An online survey of primary care physicians’ knowledge of common respiratory diseases in China

Primary care is the essential element of a health system and it is the first line in managing respiratory diseases. Primary care physicians’ knowledge is an extremely important factor for the goal to improve patients’ prognosis and quality of life. Some sporadic studies have evaluated the knowledge of primary care physicians on COPD and asthma, but no persuasive studies have assessed their knowledge of influenza and CAP. This was the largest national evaluation of its kind which evaluated COPD, asthma, influenza, and CAP simultaneously in China. The results provided a robust reference for the design of a series of systematic training courses on respiratory diseases for physicians in primary care in China or similar settings. Furthermore, this study may also trigger the evaluation of the use and availability of pulmonary rehabilitation, spirometry, inhaler medications, and other treatment devices.

This study represented a first step toward understanding awareness of four most common respiratory diseases among primary care physicians in China, with the underlying objective to identify weak areas in current primary care practice where further educational resources might lead to more targeted training programs and improved patient outcomes. Even though the accurate response rate was unclear, we got an impressive large sample of 7391 returned questionnaires, and 4815 (65.1%) questionnaires were eligible and analyzed.

It was clear from the results of the study that the primary care physicians’ knowledge of CAP, asthma, Influenza, COPD was inadequate. On the whole, both the average score of the whole questionnaire and the average score of each disease was <60% of the corresponding part, suggesting that the respondents did not even master the basic knowledge of these diseases. Foremost, respondents cannot correctly identify the clinical features of the four diseases. Low proportions of them were aware of the clinical manifestations of COPD (61.4%), asthma (48.7%), and influenza (42.5%). Meanwhile, less than half of them knew the cause of COPD, the common pathogens of CAP, and the epidemiological characteristics of influenza. This finding was important in view of the fact that, in primary care settings, these diseases were primarily diagnosed clinically, based on epidemiological characteristics, clinical symptoms, or signs after the exclusion of other respiratory conditions, such as tuberculosis. Although almost half (45.3%) of the respondents did not know the grade criteria for COPD, it was gratifying to see that more than 85% of them knew the diagnostic criteria of COPD in theory, while only 8.1%, 16.1%, and 1.0% of them could make the right diagnosis of asthma, CAP and influenza, respectively. The high correct rate of COPD diagnostic criteria was probably attributed to a series of policies on COPD in recent years17,18,19,20, including the national policy The 13th Five-Year Plan for Health Care which recommended the incorporation of pulmonary function tests into routine health examinations17, in 2014 COPD was included in the national chronic disease surveillance system18, in 2015 COPD was included in the national work plan for the prevention and treatment of chronic diseases19 and in 2016 COPD was included in the hierarchical diagnosis and treatment program20. Nevertheless, COPD was the only respiratory disease mentioned in the above national projects, which have increased and strengthened the relative training on COPD, but the results also indicated that further training was still needed as primary care physicians’ knowledge of COPD treatment was not optimistic.

Even though physicians in township hospitals had a better knowledge of these diseases than community health centers, the knowledge level of influenza between them was similar, which may be due to the incidence of influenza has increased yearly in China so that the government attached great importance to influenza training. There is a National Free Influenza Vaccination Program for people over 65 years old, which encourages primary care physicians to exhort patients to be vaccinated against influenza in the flu seasons and also urges them to apply what they have learned repeatedly in clinic. In terms of treatment, the knowledge was even worse. Compared with the high correct rate of COPD diagnosis, a very small proportion of physicians were aware of bronchodilators for COPD. As the most two common chronic non-communicable respiratory diseases, only 8% and 3% were aware of the management of stable COPD and asthma, respectively.

Although primary care physicians had a poor knowledge of the four diseases, 75.6% of the respondents were qualified with a bachelor (67%) or even master (8.6%) degree in medicine, only 2.4% were qualified less than junior degree in total, with 2.9% in community health service centers and 0.7% in township hospitals, meanwhile, the qualification of professionalism was much higher than the national level. The National statistics data showed that there were 25% of primary care physicians in community health centers and 42% of those in township hospitals had less than a junior medical college level of education (junior medical college was lower than Bachelor degree, it was the basic requirement for a licensed assistant physician) in 201815. It indicated that the respondents of the study should be proficient in this knowledge.

What should be mentioned here was that the medical education system was different in China from most western countries, where physicians were required to complete training at universities including completion of master’s degree, while primary care physicians refers to people with not a bachelor’s degree, but having completed a vocational training program. In China, when the person finished the 5-year systematically medical education then he/she was qualified with a bachelor’s degree of medicine. Moreover, completion of the 5-year study in medical college was basically required to become a licensed doctor or physician. They could be qualified with a master degree if they finish a 3-year advanced vocational training program after the 5-year study. However, usually, higher qualification the physicians can obtain, higher medical institutions they will choose. In the study, we can see that more than two-thirds of these physicians with a bachelor or above degree worked in primary care, which was a relatively high proportion in the context of primary care in China. Due to the new round of medical reform in China attached great importance to the development of primary care, physicians of primary care were in a period of replacement between the young and the old generation, but we also hope that more physicians with high qualifications are willing to work in primary care facilities.

General practitioners or primary care physicians are the mainstay in primary care facilities in China, the government has paid great attention to its development. In 2018, the State Office issued the policy on Reforming and improving the incentive Mechanism for the training and using of General Practitioners21, which put forward the specific goal of the development of General Practitioners or primary care physicians—by 2020, the number of General Practitioners would reach 300,000, and there would be 2 to 3 qualified General Practitioners for every 10,000 residents in urban and rural areas. By 2030, the number of General Practitioners should reach 700,000, and there will be 5 qualified general practitioners for every 10,000 residents in urban and rural areas. To achieve the above goals as scheduled, the state has formulated different post-graduate training programs. The current training model was mainly based on the “5-year college education plus 3-year standardized post-graduate resident training” as the main body, and the “3-year college education plus 2-year assistant general practitioner training” as the supplement for people without bachelor degree. In addition, the state has also expanded the approaches to train General Practitioners, such as the implementation of the special post-graduation program for general practitioners, job transfer training, free training of rural order-oriented medical students, and so on9.

In the past few decades, hypertension and diabetes were the two conditions that were heavily prioritized in primary care settings in China, respiratory diseases were in a relatively weak position15. That may lead to less opportunities for physicians to apply the relevant knowledge in the clinical practice. Although we did not explore factors affecting their knowledge, we thought that may be one important factor for the poor knowledge of the respondents.

There were studies to investigate primary care physicians’ knowledge of COPD and asthma around the world22,23,24,25,26,27, and our conclusions were consistent with them. Knowledge assessment studies of COPD have also been carried out in China, but in a relatively smaller sample size and were only regionally based28,29. Nevertheless, seldom studies focused on knowledge assessment of CAP and influenza either in the world or in China. There was one study which assessed the knowledge of CAP in China, but this was in a single city30.

Universal health coverage (UHC) is the cornerstone of good health and well-being for all, and it is underpinned by high-quality care, however, one of the biggest barriers to improved quality is the paucity of data on quality31. Training and upskilling community health workers, nurses, and physicians must remain a global priority31. All of this requires attention to developing active learning systems. But that does not just happen—it requires careful investment and design32. This study identified weaknesses in the knowledge of primary care physicians and provided precise directions for later training. An updated education program would be designed based on our findings. The model from China would be an example for other resource-limited countries.

This was the first and largest study to assess primary care physicians’ knowledge on CAP, asthma, influenza, and COPD simultaneously, with such a huge sample and broad geographical areas in China in the pre-epidemic era of COVID-19. Although only 65.1% (4815) of the questionnaires were analyzed finally, the sample size of the study was still the largest of its kind. Though the sample population was unevenly distributed, it was sufficient to get an overview of the current knowledge level of primary care physicians about these four common respiratory diseases.

The survey had some limitations. Firstly, as most of the academic activities were held in the north of China in the past two years, obviously, there was an over-representation of respondents from north China compared to south China (70.3% vs 0.3%). Thereby the generalizability of the findings for some provinces or cities was limited. Secondly, we did not have data on non-responders so we were unable to test for response bias. For a more comprehensive view to present a thorough picture of knowledge level of primary care physicians in specific areas, surveys like this but with more physicians to take part were needed so as to provide more individualized and targeted training for certain regions. Thirdly, the questionnaire revealed only theoretical knowledge and self-reported, preferred actions. Respondents may have reported what they believed to be acceptable, instead of what they actually practiced in their clinical work. What primary care physicians did in work settings remains unknown.

In conclusion, physicians in primary care in China had a poor knowledge of asthma, CAP, COPD, and influenza. This study suggested a clear need for further education for physicians in primary care on common respiratory diseases.

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