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. 2026 Sep 23;17:621574. doi: 10.2147/AMEP.S621574

Application of the Theory-Clinical-Community Three-Stage Training Model in General Practitioner Cultivation: A Retrospective Cross-Sectional Survey of an in-Service Continuing Professional Development Program

Weilin Li 1,*, Weihong Zhao 2,*, XinYi Mei 1, Wei Zhou 3, Beibei Qin 3, Shuangyan Qiu 1, Tao-Hsin Tung 4,✉, Xiang Jin 5,✉
PMCID: PMC13616155  PMID: 42802780

Abstract

Background

Primary care general practitioners (GPs) serve as the cornerstone of primary health service delivery, and enhancing their clinical competencies is essential to addressing the growing demand for community-based healthcare.

Purpose

This study evaluated the implementation outcomes of a 16‑week in‑service continuing professional development (CPD) programme—the Theory‑Clinical‑Community (TCC) three‑stage training—and focused on participants’ satisfaction, development of self‑perceived confidence, and suggestions for programme optimisation.

Patients and methods

A retrospective cross-sectional survey was conducted among 111 primary care GPs from county and township health institutions who completed five consecutive training cohort at Taizhou Hospital of Zhejiang Province (China) from July 2022 to January 2025. Demographic data, training satisfaction, self-assessed improvements in core clinical competencies, and suggestions regarding rotation duration and department composition were collected via an online questionnaire. Descriptive statistics were employed for data analysis.

Results

Overall satisfaction with the training model reached 100% (94.6% reported “very satisfied”). Regarding self-assessed competency improvement, over 87% of participants reported “significant progress” in the diagnosis and management of common and frequent diseases, chronic disease management, and rational medication use in community settings. Regarding optimization suggestions, 67.6% of participants considered the current department configuration adequate, while some proposed the inclusion of auxiliary examination departments (9.0%) and traditional Chinese medicine/rehabilitation departments (6.3%).

Conclusion

The TCC three-stage training model is feasible and has been highly recognised by primary care GPs, with significant self-perceived confidence development reported across most competency domains. Based on participants’ self-assessments, this study offers preliminary insights for refining competency-based training systems for primary care GPs.

Keywords: general practitioners, professional training, practice, training model, continuing professional development

Introduction

The primary healthcare system serves as the cornerstone of a comprehensive medical and health system, with general practitioners (GPs) acting as the core workforce delivering essential medical services, chronic disease management, and health education to residents.1–3 With the ongoing deepening of China’s healthcare system reform, the demand for high-quality primary care has increased significantly, placing greater demands on the professional competence of grassroots GPs.4,5 However, existing research indicates that GPs in China’s primary care settings still commonly face deficiencies in clinical skills such as emergency management and differential diagnosis, alongside a disconnect between theoretical knowledge and clinical practice. These limitations constrain the improvement of primary care service quality and hinder the adequate fulfillment of residents’ health needs.4,6,7 Furthermore, GPs also encounter various challenges in the community setting, such as workload, resource constraints, or the characteristics of the patient population.4,8

Training is a crucial pathway for enhancing the professional capabilities of grassroots GPs. In response to the growing demand for primary care and to enhance the health service capacity of grassroots GPs, Taizhou City has initiated efforts to accelerate the construction of a “Healthy China”. Therefore, a 16-week intensive in-service continuing professional development (CPD) programme was carried out at Taizhou Hospital for primary care GP already in post. Traditional GPs training models often prioritize theoretical instruction, offer limited clinical rotation opportunities, and lack personalized, targeted design. This results in a poor alignment between training content and the actual needs of GPs’ daily work, leading to suboptimal training outcomes.9–11 Currently, there are multiple types of GPs training in China, such as the 5+3 standardised residency training (SRT) model, the 3+2 assistant GPs pathway, and transfer training for practising physicians.12,13 However, significant shortcomings persist in current residency training and continuing medical education (CME) programmes.14 Training remains heavily hospital-centric, with limited community practice exposure; rotation schedules are rigid, with too many departments, a lack of targeting, and an inability to learn in depth.15 Training content often mismatches community practice needs, and teaching is predominantly delivered by specialist physicians who may lack familiarity with general practice pedagogy.16 CME programmes suffer from fragmented policy implementation, insufficient coordination among executing agencies, and inadequate quantity and quality of teaching faculty.17

GP training models vary across countries, yet all offer valuable reference frameworks. For example, the Royal College of General Practitioners (RCGP) curriculum structures training around 13 specific competencies across five domains;18 the Canadian Medical Education Directives for Specialists (CanMEDS) framework organises competencies around seven key roles;19 and Australian General Practice Training (AGPT) employs a progressive competency profile with four milestones.20 These models all feature structured competency frameworks, progressive skill development, and robust assessment systems. However, due to differences in healthcare systems and resource allocation, directly replicating these models in this training programme presents challenges.

Therefore, we constructed a Theory-Clinical-Community (TCC) three-stage training model, hoping to address the aforementioned deficiencies. This model comprises 1 week of theory, 14 weeks of clinical rotations, and 1 week of community practice. This model integrates theoretical learning, comprehensive clinical competency training, and community-based practical training. The program employs a hybrid rotation mechanism combining mandatory and elective departments and implements a one-to-one mentorship system, aiming to cater to participants’ individualized development needs and provide targeted clinical guidance. Notably, this programme is positioned as an in-service CPD and refresher training model for practising GPs already employed at county- and township-level institutions, rather than as a substitute for the formal 3-year SRT pathway.

Based on this initiative, the primary objectives of this study are: (1) to investigate the demographic characteristics of the participating physicians; (2) to evaluate their satisfaction with the training model and their self-assessed improvement in clinical competencies post-training; and (3) to collect their suggestions for optimizing the training program, particularly regarding duration and department structure. Data were collected via questionnaire surveys and analyzed statistically. This study aims to provide a basis for optimizing the training system for grassroots GPs in China and to propose a novel training model for enhancing primary care service capacity and promoting high-quality development in community healthcare.

Method

Study Design and Participants

This retrospective cross-sectional survey was conducted among primary care GPs who participated in a 16-week in-service CPD program. The participating GP were recruited by the Municipal Health Commission and completed the training program at Taizhou Hospital of Zhejiang Province. Between July 2022 and January 2025, five consecutive cohort of the three-stage training program for primary care GPs were conducted at the hospital. All eligible GPs from each cohort were invited to participate in the survey (a census sampling approach), without additional random sampling. Based on predefined inclusion and exclusion criteria, a total of 111 GPs were included in the final analysis, comprising 19 from the first cohort (July-November 2022), 29 from the second (April-August 2023), 26 from the third (August-December 2023), 14 from the fourth (April-August 2024), and 23 from the fifth cohort (September-January 2024). No prior sample size calculation was performed, as the study aimed to include all available participants from the five consecutive training cohorts. This study was approved by the Ethics Committee of Taizhou Hospital of Zhejiang Province (Approval No. K20251285). All procedures were performed in accordance with the ethical standards of the institutional research committee and the principles of the Declaration of Helsinki. The questionnaire was administered using anonymized data to ensure participant confidentiality. All participants provided informed consent prior to completing the survey, and participation was entirely voluntary. The participant selection process is shown in Figure 1, and the inclusion and exclusion criteria are listed below.

Figure 1.

A flowchart of GP recruitment and analysis process from 2022 to 2025.

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Screening flowchart.

Inclusion criteria: 1. Voluntary participation in both the training program and the questionnaire survey; 2. Employment at county- or township-level medical and health institutions; 3. Position as a general practitioner.

Exclusion criteria: 1. Inability to complete the training due to physical illness; 2. Inability to participate in full-time, off-the-job training owing to clinical duties at the home institution; 3. Unwillingness to participate in the survey.

The Theory–Clinical–Community (TCC) Three-Stage Training Model

The TCC three-stage model is a 16-week (4-month) training program designed for GPs at county- and township-level institutions, aimed at enhancing clinical diagnostic, therapeutic, and community-based practice competencies. It integrates theoretical teaching, clinical rotations, and community practice, supported by one-on-one mentoring. Key features are:

Staged curriculum: 1 week of theory, 14 weeks of clinical rotations, and 1 week of community practice.

Flexible mandatory–elective rotations: general practice and emergency medicine are compulsory (2 weeks each); GPs choose five additional departments from 15 options for a 10-week individualized rotation.

Demand-driven design: content is closely aligned with primary care needs, combining theory with hands-on practice for targeted competence improvement. (Training photographs are available in Supplementary Material 3 and Figure S1).

Implementation Strategies of the TCC Three‑Stage Training Model

Stage 1: Theoretical Training (1 Week)

This stage consolidates foundational general practice knowledge, fosters a patient-centered integrated diagnostic and therapeutic mindset, and prepares trainees for subsequent modules. The specific learning objectives of this stage are: (1) to understand the core principles and scope of general practice; (2) to apply evidence-based clinical reasoning in primary care settings; (3) to master knowledge of major infectious disease prevention and control; (4) to develop skills in chronic disease management and health promotion at the community level; and (5) to demonstrate competence in medical humanities, communication, and the use of “Internet+” healthcare tools. The curriculum covers: introduction to general practice; clinical reasoning and evidence-based decision-making; prevention and control of major infectious diseases; integrated community-based chronic disease management and health promotion; early identification of acute and critical conditions; medical humanities and physician-patient communication; hospital systems and management; outpatient reception and medical documentation standards; “Internet+” healthcare applications; community public health service functions; and general practice research design (Supplementary Material 1 and Table S1). Teaching is delivered through centralized lectures by senior specialists (≥ associate chief physician) in general practice, emergency medicine, and internal medicine. Stage completion requires passing a closed-book written examination, with scores incorporated into the overall program evaluation.

Stage 2: Clinical Competency Training via Rotations (14 Weeks)

A flexible “mandatory rotations to solidify core competencies + elective rotations to develop specialized skills” model ensures both standardization and personalization. Rotations include general practice (2 weeks), emergency medicine (2 weeks), and five elective departments (2 weeks each) chosen from 15 options: internal medicine (cardiology, respiratory, neurology, gastroenterology, endocrinology, infectious diseases, dermatology, nephrology), surgery (general surgery, orthopedics, urology, ophthalmology, otorhinolaryngology), pediatrics, and gynecology. Centralized theoretical and practical skills sessions are held on two fixed afternoons per week throughout the rotation. Lectures are based on the latest primary care or specialty guidelines; skills training covers abdominal paracentesis, thoracentesis, bone marrow aspiration, urethral catheterization, debridement and suturing, tracheal intubation, cardiopulmonary resuscitation, nasogastric tube insertion, ECG interpretation, and imaging analysis (X-ray, CT). All sessions are led by clinical teaching staff from the respective specialty bases (Supplementary Material 1 and Table S2). In each department, trainees are assigned a designated preceptor and medical team, participating in morning handovers, ward rounds, medical documentation, and clinical skills learning, with outpatient observation in the afternoons or after rounds. All activities are recorded in the standardized Rotation Logbook (Supplementary Material 2 and Tables S3–S8). For each rotation, trainees are required to complete a minimum number of clinical encounters and skill procedures as specified in the logbook. Departmental exit requires submission of a rotation summary and passing both theoretical and practical examinations (with a pass threshold of ≥60%), as certified by the department.

Stage 3: Community Practice Competency Rotation (1 Week)

This stage bridges clinical skills and community services, translating clinical competency into community application capability. Training encompasses basic medical services, basic public health services, and community health service management, delivered by community-base preceptors. Key content includes: basic medical services—understanding primary healthcare operations, hierarchical medical system, family physician contract services, team building, and quality and safety management; basic public health services—standardized diagnosis and management of common community diseases, preliminary identification and emergency handling of acute conditions, chronic disease (hypertension, diabetes) health management, follow-up, patient education, home visits, family bed establishment, and community rehabilitation; community health service management—participation in national basic public health programs, including residents’ health records, health education, vaccination, health management of key populations (children 0–6 years, pregnant/postpartum women, the elderly), chronic disease management, severe mental disorder management, tuberculosis patient management, infectious disease and public health emergency reporting, traditional Chinese medicine health management, and health supervision assistance. For completion, trainees submit a community practice summary report and pass theoretical and practical exams at the community training base (with a pass threshold of ≥60%) (Supplementary Material 2 and Tables S3–S8).

Questionnaire Survey

The survey was administered immediately after the completion of the training program for each cohort, specifically during the final week of the community practice rotation. An online survey was administered via Wenjuanxing (Changsha Ranxing Information Technology Co., Ltd., China), the largest online survey platform in China, to collect demographic data, post-training satisfaction, and self-assessed competency improvements. The survey was conducted between July 2022 and January 2025, with each cohort completing the questionnaire immediately at the end of their respective 16-week training cycle. Participants accessed the questionnaire through a URL or QR code shared via WeChat or email, completing it on mobile devices or computers. Items were rated on Likert scales. The initial questionnaire was pilot-tested by two experts and revised based on feedback from the target population. No personally identifiable information was collected, and informed consent was obtained by notifying participants of voluntary participation at the beginning of the survey.

The final questionnaire included:

  • (1)

    demographics (sex, age, educational background, professional title);

  • (2)

    satisfaction with the three-stage training model, assessed through eight items (overall satisfaction, training duration, assignment plan, clinical rotation arrangements, theoretical curriculum, skills training, one-on-one mentoring, and community rotation placement) on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied);

  • (3)

    self-assessed improvement in eight competency domains (diagnosing and treating common diseases, managing emergency patients, managing chronic diseases, performing clinical procedures, diagnosing and treating undifferentiated diseases, rational prescribing in community settings, clinical reasoning, and self-learning ability), rated on a 4-point Likert scale (1 = no improvement to 4 = significant improvement); and

  • (4)

    suggestions for optimizing the model, collected via two open-ended questions on recommended training duration and additional rotation departments.

Statistical Analysis

This study was designed as a descriptive program evaluation. The survey primarily evaluates Kirkpatrick’s Level 1 (reaction/satisfaction) and Level 2a (self-perceived learning), rather than objective competency outcomes or higher-level Kirkpatrick outcomes (Levels 3 and 4). Descriptive statistics were used to summarize participants’ demographic characteristics, satisfaction with the training model, and self‑assessed competency improvements. Frequencies and percentages were calculated for categorical variables. All statistical analyses were performed using IBM SPSS Statistics version 26.0 (SPSS Inc., Chicago, IL, USA).

Results

All data are presented as descriptive statistics (frequencies and percentages), as this study was designed as a descriptive program evaluation without predefined comparative hypotheses.

Demographic Characteristics of Survey Participants

A total of 111 GP completed the questionnaire, yielding a response rate of 98.2%. All five cohort of the three-stage training program were surveyed. The proportions of GPs from the first, second, third, fourth, and fifth cohort were 17.1% (19/111), 26.1% (29/111), 23.4% (26/111), 12.6% (14/111), and 20.7% (23/111), respectively. Among the participants, 51.4% were male and 48.6% were female. The majority of GPs were aged ≤30 years (35.1%) or between 40 and 49 years (36.1%). Regarding professional titles, 38.7% were resident physicians and 35.1% were attending doctor (Figure 2A and B). The vast majority (84.7%) held a bachelor’s degree (Table 1).

Figure 2.

A composite of four charts showing GP age and title by cohort, plus training department and duration choices. The image A showing a grouped bar chart with two line series for age distribution. X axis label: cohort, unit not shown, with First cohort, Second cohort, Third cohort, Fourth cohort, Fifth cohort. Y axis label: percent, range 0.0 percent to 60.0 percent. Bars and lines by age groups: less than or equal to 30 years old, 30 to 39 years old, 40 to 49 years old, greater than or equal to 50 years old. Values by cohort: First cohort 26.3 percent, 36.8 percent, 31.6 percent, 6.3 percent. Second cohort 48.3 percent, 24.1 percent, 24.1 percent, 3.5 percent. Third cohort 42.3 percent, 15.4 percent, 38.5 percent, 3.8 percent. Fourth cohort 35.7 percent, 0.0 percent, 57.1 percent, 7.2 percent. Fifth cohort 30.4 percent, 26.1 percent, 39.1 percent, 4.4 percent. The image B showing a grouped bar chart with two line series for professional titles. X axis label: cohort, unit not shown, with First cohort through Fifth cohort. Y axis label: percent, range 0.0 percent to 60.0 percent. Legend: Medical assistant, Practitioners, Resident physicians, Attending doctor, Associate chief physician. Values: First cohort Practitioners 10.5 percent, Resident physicians 47.4 percent, Attending doctor 26.3 percent, Associate chief physician 15.8 percent, Medical assistant 0.0 percent. Second cohort Practitioners 13.8 percent, Resident physicians 48.3 percent, Attending doctor 31.0 percent, Associate chief physician 3.5 percent, Medical assistant 3.5 percent. Third cohort Practitioners 15.4 percent, Resident physicians 50.0 percent, Attending doctor 23.1 percent, Associate chief physician 7.7 percent, Medical assistant 3.8 percent. Fourth cohort Practitioners 14.3 percent, Resident physicians 0.0 percent, Attending doctor 57.1 percent, Associate chief physician 21.4 percent, Medical assistant 7.2 percent. Fifth cohort Practitioners 13.0 percent, Resident physicians 30.4 percent, Attending doctor 47.8 percent, Associate chief physician 4.4 percent, Medical assistant 4.4 percent. The image C showing a bar chart of recommendations for training departments. X axis label: department, unit not shown. Y axis label: percent, range 0.0 percent to 80.0 percent. Bars: No 67.6 percent; Support Department 9.0 percent; Traditional Department 6.3 percent; Rehab Department 6.3 percent; Nephrology Department 3.6 percent; Psych Department 2.7 percent; Rheumatology Department 2.7 percent; Peds Department 1.8 percent; Emergency Department 1.8 percent; Pain Management Department 1.8 percent; Oncology Department 0.9 percent; Intensive care unit 0.9 percent. The image D showing a bar chart of recommendations for training duration. X axis label: duration, unit not shown, with No, 3 Months, 6 Months, 8 Months, 12 Months, 6 to 12 Months. Y axis label: percent, range 0.0 percent to 50.0 percent. Bars: No 40.6 percent; 3 Months 2.7 percent; 6 Months 43.2 percent; 8 Months 0.9 percent; 12 Months 6.3 percent; 6 to 12 Months 6.3 percent.

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Data analysis visualization; (A) Age distribution of GPs; (B) Distribution of professional titles among GPs; (C) Recommendations for training departments following three-phase training by GPs; (D) Recommendations for training duration following the three-phase training program for GPs.

Table 1.

Demographic Characteristics (n = 111)

Variable Category All First Cohort Second Cohort Third Cohort Fourth Cohort Fifth Cohort
(n=111) n(%) (n=19) n(%) (n=29) n(%) (n=26) n(%) (n=14) n(%) (n=23) n(%)
Sex Male 57(51.4) 9(47.4) 13(44.8) 16(61.5) 8(57.1) 11(47.8)
Female 54(48.6) 10(52.6) 16(55.2) 10(38.5) 6(42.9) 12(52.2)
Age ≤ 30 years old 39(35.1) 5(26.3) 14(48.3) 11(42.3) 5(35.7) 7(30.4)
30-39 years old 27(24.3) 7(36.8) 7(24.1) 4(15.4) 0(0.0) 6(26.1)
40-49 years old 40(36.1) 6(31.6) 7(24.1) 10(38.5) 8(57.1) 9(39.1)
≥ 50 years old 5(4.5) 1(5.3) 1(3.5) 1(3.8) 1(7.2) 1(4.4)
Educational Background Associate Degree 17(15.3) 6(31.5) 6(20.7) 2(7.7) 2(14.3) 1(4.4)
Bachelor’s Degree 94(84.7) 13(68.5) 23(79.3) 24(92.3) 12(85.7) 22(95.6)
Professional Title Medical assistant 4(3.6) 0(0.0) 1(3.5) 1(3.8) 1(7.2) 1(4.4)
Practitioners 15(13.5) 2(10.5) 4(13.8) 4(15.4) 2(14.3) 3(13.0)
Resident physicians 43(38.7) 9(47.4) 14(48.3) 13(50.0) 0(0.0) 7(30.4)
Attending doctor 39(35.1) 5(26.3) 9(31.0) 6(23.1) 8(57.1) 11(47.8)
Associate chief physician 10(9.0) 3(15.8) 1(3.4) 2(7.7) 3(21.4) 1(4.4)
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Satisfaction of GPs with the Three-Stage Training Model

Overall satisfaction among the 111 GPs was high, with 94.6% very satisfied and 5.4% satisfied. Specific satisfaction rates (very satisfied, satisfied, neutral) were as follows: training duration (4 months), 88.3%, 9.9%, 1.8%; allocation scheme, 91.0%, 9.0%; clinical rotation departments, 88.3%, 10.8%, 0.9%; theoretical training curriculum, 97.3%, 2.7%; skills training, 96.4%, 3.6%; one-on-one mentoring, 95.5%, 4.5%; and community rotation hospital, 91.0%, 6.3%, 2.7% (Table 2).

Table 2.

Satisfaction Evaluation of GPs with the TCC Three-Stage Training Model (n = 111)

Variable Very Dissatisfied
n (%)		 Dissatisfied
n (%)		 Neutral
n (%)		 Satisfied
n (%)		 Very Satisfied
n (%)
Overall Satisfaction with the Training Program 0(0.0) 0(0.0) 0(0.0) 6(5.4) 105(94.6)
Satisfaction with Training Duration (4 months) 0(0.0) 0(0.0) 2(1.8) 11(9.9) 98(88.3)
Satisfaction with Training Assignment Plan 0(0.0) 0(0.0) 0(0.0) 10(9.0) 101(91.0)
Satisfaction with Clinical Rotation Arrangements 0(0.0) 0(0.0) 1(0.9) 12(10.8) 98(88.3)
Satisfaction with the Theoretical Training Curriculum 0(0.0) 0(0.0) 0(0.0) 3(2.7) 108(97.3)
Satisfaction with Skills Training 0(0.0) 0(0.0) 0(0.0) 4(3.6) 107(96.4)
Satisfaction with One-on-One Mentorship Arrangements 0(0.0) 0(0.0) 0(0.0) 5(4.5) 106(95.5)
Satisfaction with Community Rotation Hospital Placement 0(0.0) 0(0.0) 3(2.7) 7(6.3) 101(91.0)
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Self-Assessed Competency Improvement After the Three-Stage Training

Following the four-month three-stage training, GPs’ self-perceived improvements in clinical competencies were assessed. The proportions reporting significant, moderate, and slight improvement were: diagnosing and managing common diseases, 88.3%, 9.0%, 2.7%; chronic disease management, 88.3%, 10.8%, 0.9%; clinical procedural skills, 85.6%, 13.5%, 0.9%; undifferentiated disease diagnosis/management, 87.4%, 11.7%, 0.9%; clinical reasoning, 86.5%, 11.7%, 1.8%; rational medication use in community settings, 87.4% significant and 12.6% moderate (no slight improvement reported); self-learning ability, 84.7%, 14.4%, 0.9%. However, for emergency patient management, only 55.9% reported significant improvement, with 40.5% moderate and 3.6% slight (Table 3).

Table 3.

Self-Reported Improvement of GPs After the TCC Three-Stage Training Model (n = 111)

Variable No
Improvement
n (%)		 Slight
Improvement
n (%)		 Moderate
Improvement
n (%)		 Significant
Improvement
n (%)
Ability to Diagnose and Treat Common and Frequent Diseases after Training 0(0.0) 3(2.7) 10(9.0) 98(88.3)
Ability to Manage Emergency Patients after Training 0(0.0) 4(3.6) 45(40.5) 62(55.9)
Ability to Manage Patients with Chronic Diseases after Training 0(0.0) 1(0.9) 12(10.8) 98(88.3)
Ability to Perform Clinical Procedures after Training 0(0.0) 1(0.9) 15(13.5) 95(85.6)
Ability to Diagnose and Treat Undifferentiated Diseases after Training 0(0.0) 1(0.9) 13(11.7) 97(87.4)
Clinical Reasoning Ability after Training 0(0.0) 2(1.8) 13(11.7) 96(86.5)
Ability to Prescribe Rationally in Community Settings after Training 0(0.0) 0(0.0) 14(12.6) 97(87.4)
Self-Learning Ability after Training 0(0.0) 1(0.9) 16(14.4) 94(84.7)
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Suggestions for Optimizing the Three-Stage Training Model

After completing the training, GPs across all five cohorts offered suggestions for optimizing the model. Regarding rotation configuration, 67.6% considered the current departments sufficient. Among those suggesting additions, 9.0% recommended auxiliary examination departments (eg, ultrasound, electrocardiography, medical imaging) and 6.3% proposed traditional Chinese medicine or rehabilitation. A few GPs also mentioned nephrology, psychology, and rheumatology/immunology (Figure 2C). For training duration, 40.6% deemed four months appropriate, whereas 43.2% recommended extending it to six months; only 2.7% favored shortening to three months (Figure 2D).

Discussion

This study evaluated the implementation outcomes of the TCC three-stage training model among primary care GPs by combining satisfaction surveys with self-assessed competency improvements. The results indicate that the training model is feasible, has been highly recognised by GPs, and is associated with positive self-perceived improvements in core clinical capabilities. Furthermore, the study collected a range of pragmatic suggestions for programme optimisation, thereby providing empirical evidence to inform the refinement of primary care GP training systems in China.

Beyond direct competency enhancement, the long-term career development of GPs is of critical importance. A large-scale study of 12,767 medical graduates from 13 medical schools in China found that the type of degree programme and socioeconomic status significantly influence the career trajectories of GPs in primary care settings.21 These findings suggest that our TCC training model should also be tested within the broader context of educational pathways, professional identity, and socioeconomic factors. Similar teaching models have been observed in other professional fields, where socioeconomic background and the nature of educational programmes jointly shape labour market outcomes.22–24

Feasibility, Acceptability, and Self-Perceived Benefits

The TCC three-stage training model received universally high satisfaction ratings from GPs, with an overall satisfaction rate of 100% (94.6% reported “very satisfied”). GPs expressed high levels of satisfaction across multiple dimensions, including training duration, departmental rotation arrangements, theoretical curriculum design, and the one‑on‑one mentoring system. These findings reflect the inherent strengths of this training model. First, the curriculum is closely aligned with the practical needs of primary care, adopting a structure of “1 week of theoretical training + 14 weeks of clinical rotations + 1 week of community practice”, which effectively balances theoretical knowledge and clinical practice, meeting the competency requirements of primary care GPs. Second, the rotation mechanism combines standardization with flexibility, incorporating two mandatory departments and five elective departments, thereby accommodating the varied subspecialty interests and career development trajectories of individual GPs and enhancing the personalization of training. In addition, the one‑on‑one mentoring system provides trainees with continuous and targeted clinical guidance, helping them address real‑world challenges encountered in daily practice. Previous studies have similarly demonstrated that training models integrating mandatory and elective components with an emphasis on hands‑on clinical experience are more readily accepted by primary care practitioners and help bridge the gap between theory and practice in primary care settings.25–27

Regarding clinical competency improvement, post‑training self‑assessment results indicated that GPs achieved substantial progress in multiple domains, including the diagnosis and management of common and frequent diseases, chronic disease management, and rational medication use in community settings, with over 87% of GPs reporting “significant improvement” in these areas. This effectiveness is closely related to the configuration of clinical rotations: general practice and emergency medicine—both mandatory rotations—provided GPs with essential experience in managing conditions frequently encountered in primary care; elective rotations in internal medicine, surgery, pediatrics, and other departments further broadened the scope of their diagnostic and therapeutic capabilities. Notably, in the domain of emergency patient management, only 55.9% of GPs reported “significant improvement”, while 40.5% reported “moderate improvement”. This relatively lower proportion may be attributable to two factors: first, the emergency rotation lasted only two weeks, a relatively short period that may limit trainees’ mastery of standardized emergency procedures; second, emergency care requires rapid decision‑making and acute care skills that typically depend on accumulated clinical experience, making it challenging to achieve full competency through short‑term training alone. Therefore, future iterations of the training program should prioritize optimizing the emergency rotation module—for instance, by extending the duration of the emergency rotation and incorporating additional classic teaching cases—to enable GPs to achieve better training outcomes in this domain.28,29

Moreover, the training significantly enhanced GPs’ clinical reasoning and self‑learning abilities, suggesting that the model not only imparts specific diagnostic and therapeutic skills but also cultivates core competencies essential for the sustainable professional development of primary care practitioners, consistent with the contemporary pursuit of comprehensive and individualized GP development.9 However, if the benefits of training fail to translate into improved community health outcomes, their value is not fully realised. Although this study focused on self-perceived gains, the ultimate goal is to convert these gains into community health benefits. First, better chronic disease management (eg, hypertension, diabetes) can improve control rates and reduce preventable hospital admissions and emergency attendances. Second, more rational prescribing can curb antibiotic overuse and polypharmacy, reducing adverse events and costs. Third, enhanced clinical reasoning and diagnostic skills enable more accurate triage and timely referral. Fourth, improved communication can enhance patient adherence and trust, reducing unnecessary repeat consultations. Future studies should employ objective measures, including referral appropriateness, medication possession ratio, and patient-reported outcomes, to evaluate these pathways and provide evidence to support policy decisions on scaling up the TCC model.

The suggestions proposed by GPs provide important references for further optimization of the training program. Regarding departmental rotation configuration, 67.6% of GPs considered the existing department selection to be largely adequate and did not recommend adding additional departments. However, 9.0% of GPs suggested incorporating auxiliary examination departments (eg, ultrasound, electrocardiography, medical imaging), and 6.3% recommended including traditional Chinese medicine or rehabilitation departments. These recommendations align with evolving trends in primary care service delivery and reflect GPs’ growing recognition of the importance of proficiency in basic auxiliary examination techniques and the role of traditional Chinese medicine and rehabilitation modalities in chronic disease management.30 With respect to training duration, 40.6% of GPs considered four months appropriate, while 43.2% recommended extending the program to six months; only 2.7% supported shortening the duration to three months. These findings indicate that the majority of GPs acknowledge the appropriateness of the current training duration, yet also express a desire for more extensive clinical practice opportunities through extended training periods. Accordingly, future program designs may consider implementing flexible training durations ranging from four to six months to balance training efficiency and educational effectiveness.

Comparison with Existing GP Training Models

Compared with existing GPs training programmes in China, the TCC training model addresses the shortcomings of traditional training approaches. In contrast to the rigid, hospital-centred rotation models commonly adopted in many current residency and continuing medical education programmes, the TCC model employs a flexible rotation structure combining mandatory and elective rotations, enabling GPs to tailor their training according to their specific practice needs. Unlike the lecture-dominated theoretical instruction found in many traditional programmes, the TCC model integrates theoretical learning with immersive clinical and community practice, embodying the principles of experiential learning and workplace-based learning. Furthermore, the individualised one-on-one mentoring system adopted by this model provides personalised guidance, which is often difficult to achieve in large-scale training cohorts.

At the international level, the TCC model shares common ground with competency-based training frameworks such as the RCGP curriculum, the CanMEDS roles framework, and the AGPT programme, all of which emphasise structured professional competency development and progressive skill acquisition.31 However, unlike these comprehensive, multi-year training programmes, the TCC model is a short-term (16-week) in-service CPD intervention designed for practising GPs. Its compact format and emphasis on skills directly relevant to clinical practice make it an alternative option for resource-constrained healthcare institutions, where implementing long-term RST training programmes may not be feasible. At the same time, studies conducted in other countries have also reported challenges during implementation, including shortages of teaching faculty, variability in training quality, and difficulties in sustaining clinical practice changes after programme completion. Moreover, the principles of sustainable education suggest that training programmes must not only deliver immediate skill gains but also foster continuous professional development and adaptability in a changing healthcare environment.32 Our TCC model, with its emphasis on self-learning and clinical reasoning, aligns with this sustainability framework.

Current cohorts are small. The TCC model is feasible and acceptable in resource-rich tertiary teaching hospitals, but its scalability needs careful consideration. Its core strengths—personalised one-to-one mentoring, flexible electives, and intensive clinical training—may be difficult to replicate in settings with limited faculty, high trainee-to-mentor ratios, or fewer specialties. To enhance adaptability, we propose: (1) replacing exclusive supervision with group mentoring or peer teaching for common tasks; (2) extending core rotations and strengthening community training where electives are limited; (3) delivering theory and some skills via online or simulation modules to reduce on-site faculty demand; and (4) using shared rotation networks or regional training for institutions lacking full specialty coverage. Future studies should evaluate these adapted models in secondary/primary hospitals and rural/underserved areas to refine dissemination.

Potential Biases and Interpretation of Findings

The high satisfaction rates (overall satisfaction of 100%, with 94.6% of participants reporting “very satisfied”) and the generally reported self-perceived improvements across most competency domains may be subject to potential sources of bias. First, social desirability bias may have led participants to overestimate their satisfaction and perceived progress, particularly given that both training and evaluation were conducted within the same institutional setting. Secondly, acquiescence bias, defined as the propensity to endorse positively framed statements, may have resulted in score inflation, particularly where negatively worded items were absent. Third, the institutional context itself may have exerted implicit pressure on participants to provide favourable evaluations, as the training programme was funded by the Municipal Health Commission and implemented by a large provincial hospital. Importantly, the survey was conducted immediately after training completion (ie, during the final week of the community practice rotation). The “two-year period” refers to the overall duration of the study encompassing five cohorts, rather than the interval between training completion and survey administration. Therefore, recall bias may be relatively small in this study. However, conducting the survey immediately after training may also capture some transient positive reactions.

Limitations

Several limitations of this study should be acknowledged. First, this was a single‑center study; all participating GPs were recruited from county-and township‑level medical institutions in Taizhou City, Zhejiang Province, which may limit the generalizability of the findings to other regions. Second, the assessment of clinical competency relied primarily on self-reported measures, which are subject to potential subjective bias, and objective evaluation tools such as standardised patient assessments or clinical skill examinations were not employed. Fourth, the lack of long-term follow-up data limits the ability to evaluate the sustainability of training effects and their downstream impact on patient health outcomes at the primary care level. Future research should incorporate objective outcome measures (eg, pre-post knowledge tests, OSCEs, workplace-based assessments, clinical audits, and patient outcome data) and longer-term follow-up to verify whether self-perceived gains translate into measurable improvements in clinical practice and patient care.

Conclusions

In summary, the TCC three-stage training model is feasible and highly acceptable to practising GPs, as reflected in high satisfaction rates and positive self‑perceived competency improvements. However, given that this study employed a retrospective cross‑sectional design and lacked baseline measurements, objective assessments, and a control group, the results should be interpreted as preliminary evidence of feasibility, acceptability, and self‑perceived benefit, rather than definitive evidence of clinical effectiveness. Based on participant feedback, future programme refinements could include: (1) extending the emergency medicine rotation and incorporating simulation‑based training; (2) broadening elective rotation options to include auxiliary diagnostics (eg, ultrasound, ECG, imaging), traditional Chinese medicine, and rehabilitation departments; and (3) offering flexible training durations (eg, four to six months). Future research should involve multi‑centre randomised controlled trials incorporating objective competency measures (eg, OSCEs, written knowledge assessments, workplace‑based assessments) and long‑term follow‑up, and should also evaluate downstream effects on patient outcomes and the model’s scalability across different resource settings. This study provides practical insights for strengthening primary care GP training systems in China and other countries.

Acknowledgments

Special thanks to the Taizhou Municipal Health Commission of Zhejiang Province (China) and all survey respondents for their support. We also extend our sincere appreciation to the team members for their dedication and contributions.

Funding Statement

Wenzhou Medical University 2025 Educational and Teaching Reform Project for Resident Standardized Training (2025XZP1002).

Abbreviations

GPs, General Practitioners; ECG, Electrocardiogram; URL, Uniform Resource Locator; QR, Quick Response; TCC, Theory-Clinical-Community.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests.

References

  • 1.Sacchetti A, Berube M, Pison C, Gagnon MA, Bellier A. Impact of nurse practitioners in primary care on patients with chronic diseases in rural and underserved areas: a systematic review. Eur J Gen Pract. 2026;32(1):2613495. doi: 10.1080/13814788.2026.2613495 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Tzartzas K, Oberhauser PN, Marion-Veyron R, Bourquin C, Senn N, Stiefel F. General practitioners referring patients to specialists in tertiary healthcare: a qualitative study. BMC Fam Pract. 2019;20(1):165. doi: 10.1186/s12875-019-1053-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Higgins A, Porter S, O’Halloran P. General practitioners’ management of the long-term sick role. Soc Sci Med. 2014;107:52–12. doi: 10.1016/j.socscimed.2014.01.044 [DOI] [PubMed] [Google Scholar]
  • 4.Chen S, Sam XH, Soong A, Car LT, Lian S, Smith HE. Recruitment of general practitioners in China: a scoping review of strategies and challenges. BMC Prim Care. 2022;23(1):249. doi: 10.1186/s12875-022-01854-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Wang HH, Wang JJ, Zhou ZH, Wang XW, Xu L. General practice education and training in southern China: recent development and ongoing challenges under the health care reform. Malays Fam Phys. 2013;8(3):2–10. [PMC free article] [PubMed] [Google Scholar]
  • 6.Feng J, Jiang H, Shen X, et al. Occupational stress and associated factors among general practitioners in China: a national cross-sectional study. BMC Public Health. 2022;22(1):1061. doi: 10.1186/s12889-022-13484-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Rao X, Lai J, Wu H, et al. The development of a competency assessment standard for general practitioners in China. Front Public Health. 2020;8:23. doi: 10.3389/fpubh.2020.00023 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Dumesnil H, Lutaud R, Bellon-Curutchet J, Deffontaines A, Verger P. Dealing with the doctor shortage: a qualitative study exploring French general practitioners’ lived experiences, difficulties, and adaptive behaviours. Fam Pract. 2024;41(6):1039–1047. doi: 10.1093/fampra/cmae017 [DOI] [PubMed] [Google Scholar]
  • 9.Su Q, Hu D, Lin X, Zhao T. Preparing future general practitioners: the effects of individual, familial, and institutional characteristics. BMC Med Edu. 2023;23(1):850. doi: 10.1186/s12909-023-04857-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Li L, Gan Y, Jiang H, et al. Job satisfaction and its associated factors among general practitioners in China. J Am Board Fam Med. 2020;33(3):456–459. doi: 10.3122/jabfm.2020.03.190126 [DOI] [PubMed] [Google Scholar]
  • 11.Wang H, He J, Zhang D, Wu Y, Wang P, Cai H. Investigation and analysis of standardized training for residents of general practitioners of Gansu Province in China. BMC Fam Pract. 2020;21(1):112. doi: 10.1186/s12875-020-01185-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Lian S, Chen Q, Yao M, Chi C, Fetters MD. Training pathways to working as a general practitioner in China. Fam Med. 2019;51(3):262–270. doi: 10.22454/FamMed.2019.329090 [DOI] [PubMed] [Google Scholar]
  • 13.Zou C, Liao XY, Spicer J, Hayhoe B. Ten years’ GP training in China: progress and challenges. Br J Gen Pract. 2020;70(699):511–512. doi: 10.3399/bjgp20X712961 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Jiang J, Zhang Z, Wu Y, et al. Psychosomatic medicine service competency training in China’s GP residency programs: a national survey from a CBME perspective. BMC Med Educ. 2026;26(1). doi: 10.1186/s12909-026-09162-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Shi J, Du Q, Gong X, et al. Is training policy for general practitioners in China charting the right path forward? A mixed methods analysis. BMJ Open. 2020;10(9):e038173. doi: 10.1136/bmjopen-2020-038173 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Xin R, Li L, Qiaoli S, Xingyue W, Shuangqing L. Perspectives of general practitioners towards their supervisors over the past ten years in China. BMC Med Educ. 2022;22(1):415. doi: 10.1186/s12909-022-03442-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.You C, Wang L, Zhang J, Yao M. China’s national continuing medical education program for general practitioners: a cross-sectional survey (2016-2023). BMC Med Educ. 2025;25(1):72. doi: 10.1186/s12909-025-06682-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Capewell S, Stewart K, Bowie P, Kelly M. Trainees’ experiences of a four-year programme for specialty training in general practice. Educ Prim Care. 2014;25(1):18–25. doi: 10.1080/14739879.2014.11494237 [DOI] [PubMed] [Google Scholar]
  • 19.Ng VK, Burke CA, Narula A. Knowledge of CanMEDS-Family Medicine roles: survey of Canadian family medicine residents. Can Fam Phys. 2013;59(9):e428–434. [PMC free article] [PubMed] [Google Scholar]
  • 20.Narayanan A, Vayro C, Greco M, et al. A comparison of patient appraisal of professional skills for GPs in training participating in differing education programs. BMC Med Educ. 2022;22(1):669. doi: 10.1186/s12909-022-03733-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Zheng D, Alam GM, Bashir K, Hassan NC, Lei M. Does a degree in medicine or a specialist programme or socioeconomic status advance the career of general practitioners in primary healthcare? PLoS One. 2026;21(3):e0346026. doi: 10.1371/journal.pone.0346026 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Xiaoli D, Alam GM, Bashir K, Prisco A. Educational pathway, program type, socioeconomic status, and graduates’ labor market attainment for sustainable development. Sust Dev. 2026. doi: 10.1002/sd.71447 [DOI] [Google Scholar]
  • 23.Alam GM. Do urbanized socioeconomic background or education programs support engineers for further advancement. Int J Educ Reform. 2021;30:344–360. doi: 10.1177/1056787921998338 [DOI] [Google Scholar]
  • 24.Alam GM, Forhad MAR. What makes a difference for further advancement of engineers: socioeconomic background or education programs? High Educ. 2022;83(6):1259–1278. doi: 10.1007/s10734-021-00741-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Prazeres F, Teixeira A. Factors associated with family physicians’ perceived self-efficacy in multimorbidity management. Front Med. 2025;12:1596652. doi: 10.3389/fmed.2025.1596652 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Prazeres F, Castro L, Teixeira A. The role of social support as a moderator between resilience and levels of burden of multimorbidity management among general practitioners: a cross-sectional study in Portugal. Fam Pract. 2024;41(6):909–915. doi: 10.1093/fampra/cmad109 [DOI] [PubMed] [Google Scholar]
  • 27.Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Annals Fam Med. 2009;7(4):357–363. doi: 10.1370/afm.983 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.An K, Zhang R, Zhu B, et al. Familiarity of teaching skills among general practitioners transfer training trainers in China: a cross-sectional survey. BMC Med Educ. 2023;23(1):949. doi: 10.1186/s12909-023-04945-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Jones CL. Clinical teacher in the emergency department: how does it benefit emergency medicine trainees? Emerg Med Australasia. 2026;38(1):e70197. doi: 10.1111/1742-6723.70197 [DOI] [PubMed] [Google Scholar]
  • 30.Wei Y, Wang F, Pan Z, et al. Development of a competency model for general practitioners after standardized residency training in China by a modified Delphi method. BMC Fam Pract. 2021;22(1):171. doi: 10.1186/s12875-021-01508-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Marton GE, McCullough B, Ramnanan CJ. A review of teaching skills development programmes for medical students. Med Educ. 2015;49(2):149–160. doi: 10.1111/medu.12571 [DOI] [PubMed] [Google Scholar]
  • 32.Alam GM. Sustainable education and sustainability in education: the reality in the era of internationalisation and commodification in education—is higher education different? Sustainability. 2023;15(2):1315. doi: 10.3390/su15021315 [DOI] [Google Scholar]

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