After working 30 consecutive hours at a community health service center on the outskirts of Shanghai, Ding Caixia decided to skip her lunch and rush home to check on her father, who’s been feeling unwell lately.

Family doctors like Ding spend around 80 percent of their time at these health centers, receiving outpatients two days a week and seeing inpatients, mostly seniors or the terminally ill, another two days each week. But they also must travel door to door treating elderly people with chronic diseases like high blood pressure and diabetes — visits for which they charge nothing or as little as 10 yuan ($1.45).

“It’s a less stressful job compared with medical practitioners at big hospitals, but we often work beyond regular hours to fulfill our duties,” Ding told Sixth Tone earlier this month. The 29-year-old is one of 17 family doctors whom Jinshan District has recruited since Shanghai became one of the first cities in China to pilot a new family physician policy in 2011.

The family doctor role was officially introduced in China six years ago, after the country saw its big hospitals struggling to treat the enormous volume of patients they received every day. Family doctors serve as community-based general practitioners, diverting a significant proportion of patients with common, minor, or chronic diseases to local health service centers. By the end of 2015, a total of 10.27 million Shanghai residents had signed up to take part in the family doctor program. But the World Health Organization (WHO) recommends having four to five family doctors for every 10,000 people; with around 6,000 family doctors serving a population of 24 million, Shanghai’s ratio is about half the WHO recommendation. According to a June announcement by the State Council, China’s cabinet, the country aims to ensure the availability of family doctors to all people by 2020 as part of an effort to create a more decentralized and sustainable health care system. 

When Jinshan’s Shanyang Town was incorporated into Shanghai’s family physician pilot scheme in 2011, Wang Yifeng was one of the first doctors to transition to the new role. A Jinshan native, Wang had started his career in 1996 as a surgeon at the Shanyang Town Community Hospital, which offered comprehensive services in fields like obstetrics and gynecology, surgery, and dentistry. In 2006, the hospital was transformed into a community health center; the specialized departments were removed, leaving entire floors empty, and their doctors were required to go through training to become general practitioners. “Most of the existing family doctors used to be specialists,” Wang told Sixth Tone in an administrative building at what is now the Shanyang Town Community Health Service Center.

Shanghai’s health authority allows suburban family doctors to take on up to 2,000 patients, while their downtown counterparts can have as many as 2,500 patients. Wang has over 1,000 patients signed up with him so far. “We left [the patients] a cellphone number when they signed the contract with us. I basically keep the phone on around the clock,” he said.

Since the launch of the family doctor pilot program, the Shanyang center has lost 10 family physicians and only managed to recruit one new staff member: Ding, who started her medical career there in 2014. A native of Anqing City in eastern China’s Anhui province, Ding graduated from the department of clinical medicine at Anhui Medical University in 2011. She chose to look for a job in Shanghai because her then-boyfriend was serving as a soldier in the city. “It’s impossible for any undergraduate student, let alone a non-local, to find a job in a big hospital in Shanghai. You have to further your studies in a postgraduate school and even obtain a doctoral degree. But I was under a lot of economic pressure back then. I decided to get a job as quickly as possible, and it’s quite easy to qualify as a family doctor,” she recalled.

Even so, new family doctors must complete at least five years of study at a medical university and three years of standard training with a big hospital. The eight years it takes to license a new family doctor has made Jinshan’s health authorities anxious about the existing shortage. Given its population of 800,000, the district should have at least 320 family doctors, although it only employs 218 at present.

Over the past six years, Jinshan has recruited 17 new family doctors but also lost some 200 — mostly to neighboring districts like Fengxian and Minhang, which boast better pay. While basic monthly salaries for family doctors are generally fixed at similar rates across the board, incomes differ based on how much a locality can offer in subsidies. Jinshan now awards new family doctors a lump-sum subsidy of 100,000 yuan, but others, like Fengxian, offer up to 5,000 yuan per month for a role that typically comes with at least a five-year contract. Another suburb, Jiading, offers its family doctors a 40-percent discount on property purchases there, helping it attract around 50 new family doctors this year.

“It’s hard to turn this situation around in a short period because Jinshan’s agriculture-focused economy means the district is definitely one of the poorest — if not the poorest — areas in Shanghai,” Lu Shuijun, head of the Luxiang Town Community Health Service Center in Jinshan, said of the recruitment difficulties.

Wu Huanyun, director of the Health Affairs Office at the Jinshan District Health and Family Planning Commission, told Sixth Tone that the Shanghai health authority has acknowledged the severe shortage of family doctors in suburbs like Jinshan and Pudong, and promised to train talent specifically for these areas. “But the situation won’t be eased for another eight years,” he said. Until then, family doctors’ workloads will likely increase nationwide with the rise in two demographics most in need of personalized care: the elderly and new mothers.

In Jinshan, people over age 80 are the focus of family doctors’ home visits, and China’s population is aging rapidly. Meanwhile, the nation launched its two-child policy at the beginning of this year and has already seen an increase in the number of newborns. As of last year, family physicians in Shanghai are required to visit expectant mothers at their homes at least once during pregnancy and two or three times after delivery.

Qian Min, a family doctor in Shanyang, told Sixth Tone that on average, 80 women give birth every month in the town. “But we only have around 10 family doctors who can carry out this job,” she said. “Sometimes we pay 70 such visits a month, and we do most of these trips in our free time because otherwise we wouldn’t be able to get the job done.” Even more challenging, said Qian, is that women who have more children than the two allowed by law frequently try to hide from doctors out of fear of the consequences. “The purpose of this work is to bring down the mortality rate for pregnant women,” she said. “It’s for the sake of their health, and it’s actually not related to family planning policies.”

A 20-year Jinshan native and veteran doctor who used to specialize in gynecology, Qian now serves as the family physician for more than 1,000 patients. She said that the growing workloads and stagnating salaries are the main reasons the area has trouble retaining family doctors. “If it weren’t for my parents, who are growing old, and for my child, who is studying here, I would have chosen to leave, too,” she added.

Lu of the Luxiang community health center said he understands family doctors’ struggles. However, he has high hopes for the latest round of medical care reforms: Shanghai’s “1+1+1” policy, which assigns each resident to one community health service center, one district-level hospital, and one municipal hospital. Since the policy was announced in February last year, between 5 and 10 percent of specialists’ appointment slots at higher-level hospitals have been reserved for referrals of more complex cases from family doctors, Lu said.

Ding from the Shanyang center said that additional resources have helped her more effectively treat patients. As a new family doctor, she has just over 200 regular patients and characterizes Jinshan residents as straightforward and easygoing, making her daily interactions relatively relaxed. “I have settled down here with my small family,” she said. “I plan to remain in this job for the foreseeable future.”

(Header image: A family doctor (right) checks on an elderly resident’s health in Changning District, Shanghai, Dec. 16, 2011. Yang Shenlai/Sixth Tone)