If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.
To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients' visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.
Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.
After the government's directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.
Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, "yi nao." She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 "patient encounters" in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That's about 16 patients in a nine-hour workday.
The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She's available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.
On a hot summer day, an elderly woman with white hair walked into Dr. Yang's clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. "Hey, you got a haircut!" Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang's room, talking over one another.
"I think she's really warm and considerate," said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, "The time spent interacting with doctors here is much longer."
The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.
It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.
In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine "patients." The teachers use a checklist to grade the doctors on things like making "appropriate eye contact" and "responding appropriately to a patient's emotions."
At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.
"That isn't the right way," Li Yaling, head of the center's science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient's feet instead.
Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.
In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai's Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.
Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.
"If there's more money, the good people will come," she said. "And a high economic status will elevate the social status."
The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn't optimistic.
"All these ministries need to coordinate among themselves," she said. "Our country's affairs, you know, they aren't easy."