Preamble

Review and Monograph
A Cross-National Comparative Study on Causes and Reform Strategies for Delayed Completion in General Practice Residency Training
WEN Dazhi¹, LI Zhenshu², LI Zhenji³, WANG Ni⁴, LIU Dong⁵, ZHOU Xianchun¹, XUAN Chunhua¹

¹Affiliated Hospital of Yanbian University, Yanji 133000, China
²Yanbian Korean Autonomous Prefecture Medical Education Examination Service Center, Yanji 133000, China
³Yanji City Park Community Health Service Center, Yanji 133000, China
⁴Jilin Provincial Health Commission, Changchun 130000, China
⁵Jilin Provincial Resident Standardized Training Guidance Center, Changchun 130000, China

Corresponding authors: ZHOU Xianchun, Chief Physician/Doctoral Supervisor; E-mail: xczhou@ybu.edu.cn
XUAN Chunhua, Chief Physician; E-mail: xuanls@163.com

[Abstract] This review focuses on the delayed graduation issue in standardized residency training for general practitioners (GPRT), conducting a cross-national comparative analysis of training systems, current status of delays, contributing factors, and reform strategies across 11 representative developed and developing countries. Findings reveal that delayed graduation in global GPRT programs is widespread, with postponement rates influenced by multiple factors including clinical resource shortages, elevated assessment standards, public health emergencies, and residents' mental health challenges. Developing countries face more pronounced challenges due to regional resource disparities. Nations demonstrate differentiated countermeasures: the United States optimizes training pathways through dynamic assessment mechanisms, Japan enhances grassroots physician retention via policy incentives, while China strengthens training process management through digital technologies. The study proposes that resolving this issue requires coordinated efforts across three dimensions: restructuring adaptive training models, building supportive ecosystem networks, and iterating crisis response mechanisms. This approach seeks to balance efficiency with humanistic care, standardization with personalization, ultimately enhancing the resilience of general practice education and healthcare service quality.

[Key words] General practice; Residency training; Delayed completion; Comparative analysis; Healthcare workforce reform

1. Literature Search Strategy

A comprehensive search was conducted across PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), and official policy websites of relevant countries, with retrieval dates spanning from database inception to May 2025. Chinese search terms included "general practice," "standardized residency training," "delayed completion," "cross-national comparison," and "healthcare workforce reform." English search terms comprised "General Practice," "Residency Training," "Delayed Completion," "Comparative Analysis," and "Healthcare Workforce Reform." Inclusion criteria encompassed literature addressing standardized GPRT systems, delayed completion status, and influencing factors across various nations. Exclusion criteria comprised irrelevant content, low-quality studies, inaccessible full texts, and non-official third-party reports.

2. Overview of Global General Practice Residency Training Systems

Standardized residency training systems constitute the core pathway for cultivating qualified general practitioners, aiming to equip physicians with comprehensive clinical skills, decision-making capabilities, and patient management experience through systematic theoretical learning and clinical practice [1]. In recent years, particularly against the backdrop of global public health emergencies, residency training has faced widespread delayed completion issues that have garnered international attention and impacted workforce resource allocation and healthcare service quality in general practice [2]. The causes of training delays are complex, including limited clinical rotation opportunities, healthcare resource shortages, policy changes, health issues among residents, and psychological stress. Research indicates that the pandemic's impact was particularly significant, preventing residents from completing required clinical internships and academic requirements as planned [2]. How to comprehensively address this systemic challenge remains an unresolved issue. This study aims to explore integrated strategies for resolving GPRT delayed completion by summarizing global experiences, providing effective pathways for nations to respond to public health emergencies and other challenges, and promoting the continuous development and innovation of general practice education.

Despite variations in training system design across countries, the core objective remains consistent: to cultivate general practitioners capable of fulfilling the "health gatekeeper" role and achieving equitable access to healthcare resources. An overview of national GPRT systems is presented in [TABLE:1].

3. The Universal Phenomenon of Delayed Completion in General Practice Residency

Delayed completion in GPRT has become a shared challenge across geographic and cultural contexts. Although training system designs differ among nations, data reveal that failure to complete training on schedule is widespread, with postponement rates showing dynamic fluctuations influenced by policy adjustments, resource allocation, and public health emergencies.

In Europe and North America, the UK, US, and Canada have experienced relatively stable but locally fluctuating delayed completion rates. In the UK, for instance, postponement rates rose from 8% to 12% between 2015-2018 due to curriculum adjustments and elevated practice skills assessment standards, but subsequently declined to approximately 10% during 2019-2022 through optimized course design and increased mentorship time [14]. The US exhibited similar trends: delayed completion rates increased from 10% to 15% during 2016-2020 amid medical education reforms that heightened clinical competence and research requirements, then gradually stabilized through the introduction of flexible training pathways and enhanced process support [15]. Canada mitigated some issues through rural medical rotations and subspecialty electives, yet urban-rural resource disparities continue to cause significant quality variations and fluctuating postponement rates across regions [16].

In Asia, China's GPRT scale has expanded rapidly in recent years, but delayed completion rates remain high at 15%-20% due to uneven regional resource distribution and increasingly stringent assessment standards. Specifically, inadequate infrastructure and weak faculty in grassroots training bases in central and western regions limit residents' clinical practice opportunities, while developed eastern regions face greater challenges in meeting elevated competency requirements for chronic disease management and multidisciplinary collaboration, increasing the difficulty for trainees to achieve standards [17]. In contrast, Japan's Ministry of Health, Labour and Welfare's 2024 revised Clinical Training Guidelines reduced postponement rates caused by pending rotations or assessments by clarifying mentorship support and workplace environment monitoring requirements, enabling real-time evaluation and adjustment of learning progress and competency attainment across departments [18-19].

Beyond high-income countries in Europe and Asia, developing nations such as Brazil, India, South Africa, and Mexico face significant delayed completion challenges. Brazil's Ministry of Health 2023 data indicate that postponement rates due to competency assessment failures reached 18%, concentrated primarily in remote Amazon regions [20]; India's Medical Council statistics show that 32% of residents participating in national public health programs for fewer than 120 days required 3-6 month extensions of grassroots practice [21]; South Africa's HIV/TB comprehensive prevention and treatment skills assessment pass rates result in approximately one-quarter of trainees requiring additional three-month mobile clinic rotations [22]; and 15% of trainees in Mexico's border regions experience delays due to failing indigenous language communication tests [23]. These data confirm the common issues of uneven regional development and shortage of grassroots practice resources in developing countries' general practice education, paralleling challenges faced in China's central and western regions.

Notably, global public health emergencies have exacerbated the universality of delayed completion. Multi-country studies indicate that during the pandemic, residents were extensively redeployed to pandemic response, disrupting routine training; simultaneously, reduced clinical practice opportunities and limitations of remote education models led to inadequate skill mastery, indirectly increasing postponement risk. Some residents reported that virtual teaching could not substitute for real patient interaction, suggesting that hybrid education models require further refinement [24].

4. Analysis of Main Causes of Delayed Completion

The phenomenon of delayed completion in GPRT essentially results from the interaction of individual capability, training system design, and social environment. From a global perspective, causes can be attributed to three tensions: imbalance between individual adaptability and occupational stress, contradiction between standardization and flexibility in training design, and misalignment between social support systems and healthcare resource demands.

First, residents' individual adaptability faces multiple challenges. High-intensity training and occupational stress pose direct threats to physical and mental health. Research indicates that 30%-40% of residents experience anxiety or depression symptoms, stemming not only from medical knowledge complexity but also from overload during clinical rotations (e.g., 60-80 weekly work hours) [25]. This pressure amplifies among those with family responsibilities—approximately 20% of Chinese residents experience fragmented study time due to childcare or eldercare, while in Europe and North America, up to 15% of female residents interrupt training for childbirth [26]. Additionally, lack of professional identity exacerbates psychological burden. Some residents lack clear understanding of general practice's grassroots service orientation at training onset, experiencing burnout when facing repetitive tasks or patients' complex social needs, ultimately choosing extended training periods to adjust career planning.

Second, structural deficiencies in training systems amplify individual vulnerability. Most nations' GPRT still employs a "one-size-fits-all" model that fails to accommodate differentiated needs. Some US programs overemphasize research output at the expense of clinical practice time, while Chinese grassroots training bases often suffer from outdated equipment and limited case diversity, failing to meet advanced competency requirements for chronic disease management. This supply-demand imbalance becomes particularly pronounced under insufficient mentorship—30% of residents report that mentors, burdened with heavy clinical tasks, cannot provide timely guidance, resulting in inefficient skill acquisition [27]. A more fundamental contradiction lies in assessment mechanisms that emphasize theoretical knowledge and standardized procedures while neglecting soft skills like communication and interdisciplinary collaboration essential for general practitioners. This misalignment forces residents to invest substantial energy in exam preparation rather than solving actual clinical problems, further prolonging training periods. Brazil's federal and local governments lack unified coordination in residency management authority and resource allocation, causing rotation scheduling conflicts and inadequate mentor staffing across training hospitals. In 2021, only 41,853 Brazilian physicians participated in residency training—merely 8% of the total physician workforce—with approximately 12% forced to extend training due to insufficient rotation resources [28]. India's NEET-PG examination and subsequent enrollment processes often delay new residents' start by nearly three months due to high application volumes and system verification lags, pushing training completion timelines back accordingly [29].

Finally, lagging social resource allocation and policy coordination constitute systemic barriers. Regional healthcare resource inequality significantly impacts training quality. In developing countries, remote training bases frequently face equipment shortages and limited case variety, preventing residents from exposure to complex diseases; while high-income nations, despite resource abundance, still experience quality disparities between urban and rural rotations. Public health emergencies like COVID-19 exposed training system vulnerabilities—approximately 40% of global residents had rotation plans interrupted by pandemic deployment, and remote education limitations (e.g., lack of real patient interaction) decreased skill competency rates [30]. Policy-level incentive deficiencies are also notable. Japan successfully controlled postponement rates below 8% through housing subsidies and promotion priority, yet most nations still lack career development support for general practitioners, creating a vicious cycle of talent loss and training interruption [31]. South Africa's community service is mandatory for residency completion and independent practice registration, but annual delays in position allocation and document review force some physicians to suspend training after completing requirements, affecting final registration and completion timelines [32]. Mexico's ENARM examination and Ministry of Health service agreement processes experience periodic delays, with some 2025 candidates unable to commence training on schedule due to information system updates and repeated agreement signing, resulting in corresponding training extensions [33].

Notably, these factors are interconnected and interact through a "stress transmission chain." Mental health issues, for instance, are both products of high-intensity training and are amplified by social factors like family responsibilities and career anxiety, ultimately impairing learning efficiency and training progress. Therefore, resolving delayed completion requires moving beyond single-factor attribution to coordinate efforts across three dimensions: individual resilience cultivation, training model innovation, and social support network construction.

5. Impacts of Delayed Completion

Delayed completion in GPRT represents not merely individual career dilemmas but a systemic issue affecting healthcare system efficiency and patient health outcomes. Its impacts manifest through an "individual-system-service" transmission chain, presenting multidimensional negative effects.

5.1 Individual Impact: Career Path Disruption and Psychological Capital Depletion

Delayed completion directly disrupts residents' career trajectories. Research shows that over 60% of delayed trainees miss healthcare institution recruitment windows and are forced to accept non-ideal positions, requiring career plan adjustments [34]. This career path disruption further exacerbates psychological pressure—comparison gaps with peers, social expectation pressures, and reduced self-efficacy result in anxiety and depression incidence rates 2.3 times higher than on-time graduates. More insidiously, prolonged training periods weaken professional identity, leaving residents in an ambiguous "quasi-practitioner" status that prevents complete departure from student roles while requiring clinical responsibilities. This role conflict significantly increases burnout risk. A Chinese follow-up survey revealed that delayed trainees scored an average of 18.7 points higher on the Maslach Burnout Inventory (MBI) than on-time graduates, with emotional exhaustion and depersonalization tendencies potentially persisting into formal practice, creating long-term career development obstacles [35].

5.2 Healthcare System Impact: Talent Supply Imbalance and Service Capacity Degradation

From a systemic perspective, delayed completion exacerbates human capital supply-demand contradictions in general practice. China's annual 15%-20% postponement rate has expanded grassroots general practitioner shortages by 12%-15%, forcing some regions to lower recruitment standards or extend retirement ages for practicing physicians, creating a "low-quality substitution" vicious cycle [36]. This structural talent supply imbalance further degrades service quality—delayed graduates, due to insufficient clinical experience, exhibit 9.4% higher misdiagnosis rates in complex cases than qualified physicians. Decreased team stability reduces multidisciplinary collaboration efficiency, particularly in rural areas where frequent resident rotation leads to incoherent treatment plans. More profoundly, general practitioner shortages directly impede family doctor contract service coverage—each 1% increase in postponement rates correlates with a 0.8% decrease in contract coverage, hindering tiered diagnosis and treatment system implementation [37].

5.3 Patient Rights Impact: Dual Threats to Service Continuity and Safety

As end-users of healthcare services, patients suffer implicit deprivation of health rights within the delayed completion chain. Chronic disease patients are most affected—diabetes and hypertension patients under delayed residents' care experience 23% lower blood glucose/blood pressure control rates due to treatment team turnover [38]. This service continuity interruption not only increases patients' revisit costs but may also cause medication errors due to information transmission inaccuracies. Additionally, residents' insufficient clinical competence directly impacts diagnostic quality. A US primary care comparison study showed that patients treated by delayed completion physicians had higher 30-day readmission rates [39], indicating significant correlation between training delays and clinical decision-making deficiencies. During the pandemic, this issue was amplified by remote training limitations—Australian regional data revealed that residents completing skills assessments through virtual platforms received 12% lower patient satisfaction scores than traditional training groups, highlighting that virtual teaching's effectiveness in cultivating doctor-patient communication skills remains inferior to in-person training.

5.4 Interactivity and Long-Term Nature of Impacts

These impacts are not isolated. Psychological capital depletion, for example, not only reduces residents' clinical engagement but also increases medical error risks that rebound on patient rights; decreased patient satisfaction further intensifies doctor-patient tension, forming a negative cycle of "psychological pressure-service quality decline-burnout." This cumulative systemic effect may persist for years—Japanese tracking studies indicate that delayed completion physicians have higher mid-career turnover rates, trapping healthcare systems in a high-cost "train-lose-retrain" dilemma [41]. Therefore, addressing delayed completion concerns not only individual career development but also represents a critical measure for maintaining healthcare system resilience and patients' right to health.

6. Experiences and Lessons: Evolution of National Strategies for Delayed Completion

The complexity of GPRT delayed completion has catalyzed context-specific reform practices worldwide. From policy design to technology integration, resource allocation to cultural transformation, different nations' coping strategies reveal both common patterns and localized innovations. These experiences uncover three core logics of medical education reform: systematic adaptation, dynamic resilience building, and humanistic care integration.

6.1 Systematic Adaptation: Training Model Reconstruction and Resource Integration

Confronting conflicts between standardized training and individual differences, multiple countries have enhanced training system inclusiveness through structural reforms. The US employs a goal-oriented assessment mechanism as its core, refining stage-specific objectives (e.g., University of Wisconsin's imaging specialty training system) and real-time feedback systems. This model's success lies in its "precise diagnosis-dynamic intervention" mechanism: residents' clinical performance is quantified into trackable metrics (e.g., case processing efficiency, patient satisfaction), enabling mentors to develop personalized remediation plans [42]. The UK's six-year "foundation training + general practice specialty" design strengthens competency comprehensiveness through tiered training, ensuring both rotation breadth (covering 11 specialties including internal medicine and surgery) and depth through 18 months of community clinic practice. Data show that residents receiving supervised training exhibit 9.6% higher certification exam pass rates than traditional models [43]. However, such models require substantial resource investment that developing countries often cannot replicate due to faculty shortages.

In resource-limited settings, technological innovation becomes key. China has strengthened GPRT management through information technology, with multiple provinces establishing province-wide training information management platforms that enable real-time training process recording and management, enhancing transparency and quality control. Australia leverages telemedicine to overcome geographic constraints—the Royal Australian College of General Practitioners' (RACGP) interactive simulation platform significantly improved emergency management competency rates among remote residents, though virtual teaching's effectiveness in cultivating doctor-patient communication skills remains slightly lower than in-person training. This complementarity between technology empowerment and physical practice suggests that hybrid education models require further optimization of scenario adaptation. In 2023, Brazil's National Commission on Medical Residency (CNRM) Resolution No. 2 [44] reinstated a 120-day deadline for diploma submission and mandated continuous, diversified performance evaluation mechanisms to identify teaching weaknesses early, reducing postponement rates caused by documentation delays by approximately 30%. Concurrently, the Ministry of Education's ProvMed program added 1,200 residency positions in remote areas, alleviating hospital rotation pressures.

6.2 Dynamic Resilience Building: Policy Incentives and Emergency Response Mechanisms

Public health emergencies exposed traditional training system vulnerabilities while driving nations to establish more resilient response frameworks. Japan has strengthened grassroots healthcare workforce development through multiple policy reforms. Recent implementation of the Act on Working Hours and Career Development Promotion for Physicians provides economic and professional incentives: housing subsidies up to 3 million JPY and low-rent housing for remote area physicians, reduced promotion timeframes for grassroots service years, income 20%-30% higher than urban counterparts, and childcare education subsidies [45]. Such policies have substantially improved grassroots physician retention rates. Canada's "Rural Incentive Program" attracts residents to resource-scarce areas through financial compensation (Manitoba provides additional CAD 12,000 annual allowance) and career development support, reducing rural medical misdiagnosis rates by 7.3% [46]. Notably, these policies must align with local culture—Germany embedded mental health support in interdisciplinary training, reducing postponement rates due to psychological issues by 8% through a national consultation platform, though high mentor qualification requirements (simultaneous general practice and psychology credentials) enable only 32% of rural bases to fully implement the model [47].

Public health emergencies have become touchstones for testing national emergency capabilities. The US controlled pandemic-period average postponement rates at 18%—6 percentage points lower than non-adjusted countries—by temporarily modifying rotation cycles (allowing 6-12 month extensions) and increasing simulation teaching proportions [48]. China strengthened "base-community" linkages through multi-site practice mechanisms, enabling residents to participate in pandemic response while accumulating public health experience; such trainees achieved 93% competency rates in emerging infectious disease management, 21% higher than traditional training groups [49]. These cases demonstrate that training system resilience depends not only on resource reserves but also on institutional elasticity for rapid response.

6.3 Humanistic Care Integration: From Instrumental Rationality to Value Reconstruction

Fundamental resolution of delayed completion requires transcending technical and management levels to address the humanistic core of medical education. Germany's Charité Medical School's "general practice-psychology joint clinic" model enhances residents' interdisciplinary collaboration competencies and reshapes their perception of general practice value by involving them in holistic management of psychosomatic patients. Tracking data show participating residents' professional identity scores increased by 34%, with postponement rates declining by 11% [50]. The UK embeds "reflective practice" modules in supervision systems, requiring monthly professional narrative logs from residents for mentor psychological support, reducing anxiety symptom incidence from 39% to 28% [51]. Such practices reveal that integrating "health gatekeeper" role identity into training processes effectively alleviates burnout and self-efficacy crises.

However, humanistic-oriented reforms face conflicts with quantitative assessment. Although Osaka University's "community-linked training" improved completion rates, residents' weekly work hours increased by 9 hours, causing moderate-to-severe fatigue in some trainees [52]. This suggests humanistic care must be combined with workload rebalancing. Australia attempts to resolve this contradiction through a "flexible credit system": residents can adjust training intensity based on personal status and complete core competency modules cumulatively to graduate, achieving over 95% trainee satisfaction in initial implementation [53].

7. Future Outlook: Three Major Strategies for Building Resilient Training Systems

The complexity of GPRT delayed completion demands future reforms move beyond piecemeal fixes toward systematic capacity building. Based on global practice experiences, reducing delayed completion must focus on three strategic dimensions: reconstruction of adaptive training models, cultivation of supportive ecological networks, and iteration of crisis response mechanisms. These dimensions are not isolated but form synergies through resource coordination and policy linkage.

7.1 Adaptive Training Models: From Standardization to Precision

The fundamental contradiction in current training systems lies in the conflict between uniform standards and individual differences. Future reforms must center on "precision medical education" concepts to build dynamically adaptive training frameworks. The Mayo Clinic's "competency mapping" model offers a reference: through AI analysis of residents' clinical operation data (e.g., case processing time, diagnostic accuracy), personalized competency gap reports are generated with automatic remediation course matching [54]. Such technology-driven models have demonstrably reduced postponement rates in pilot programs. However, technology empowerment requires balance with humanistic education. Heidelberg University's "dual-track" design provides a reference: residents participate in standardized clinical rotations in the morning and select thematic modules (e.g., community health promotion, geriatric care) based on interest in the afternoon, increasing professional identity scores by 28% compared to traditional models [55]. This "core competency + personalized development" hybrid pathway ensures foundational skill attainment while reducing postponement risks from unclear career positioning.

In developing countries, digital technology is becoming crucial for bridging healthcare resource gaps. China's exploration in "5G+Healthcare," particularly in chronic disease management and grassroots physician training in remote areas, has achieved remarkable results. The Sir Run Run Shaw Hospital affiliated with Zhejiang University School of Medicine collaborated with the First Affiliated Hospital of Xinjiang Production and Construction Corps to implement multiple 5G-based telemedicine projects. Through 5G networks and augmented reality (AR) technology, grassroots physicians in remote areas can complete complex medical procedures under real-time expert guidance, enhancing both service capacity and accelerating practical training. Additionally, both institutions established a regional chronic disease management system for information sharing and standardized management, significantly improving management efficiency and treatment outcomes for chronic disease patients [56].

However, extensive technology application presents new challenges. Over-reliance on virtual teaching may weaken practical skills. Consequently, the UK's National Health Service (NHS) stipulates that virtual teaching cannot exceed 30% of GPRT to ensure physicians acquire necessary clinical competencies [57]. Therefore, while promoting digital medical technology, developing countries should establish policies setting minimum thresholds for physical practice to ensure physicians maintain and enhance practical operational capabilities while mastering advanced technologies, thereby achieving overall healthcare service quality improvement.

7.2 Supportive Ecological Networks: Keys to Resolving Structural Constraints

The deep root of delayed completion lies in the disconnect between medical education and social support. In Japan, multiple local governments and healthcare institutions have implemented integrated "training-employment-service" talent retention mechanisms to address rural general practitioner shortages. Since 2023, Yokohama City has collaborated with local universities to establish a general practitioner training program targeting resource-scarce areas. The program not only provides clinical training opportunities in community clinics but also encourages physicians to continue grassroots service post-training through municipal research funding (approximately USD 33,000 annually) and university salary support. Additionally, the program includes participation in community activities such as homeless housing support and mental health day care, enhancing physicians' social responsibility and professional identity [58-59]. Such policies succeed by establishing multi-stakeholder benefit-sharing mechanisms: healthcare institutions gain stable talent supply, governments reduce grassroots healthcare investment pressure, and residents gain clear career development expectations.

Psychological support network construction is equally urgent. In Canada, resident mental health issues have gained increasing attention, with multiple provinces and healthcare institutions establishing systematic peer support networks to alleviate training-related stress and anxiety. McMaster University's residency program launched the "Resident Support Network" (RSN) in 2019, comprising trained residents, faculty, and administrative staff providing confidential listening and resource guidance services. RSN participants reported improved coping capacity, self-compassion, and sense of belonging, with overall satisfaction increasing [60]. Such informal support systems complement formal institutions. These experiences demonstrate that constructing structured psychological support networks is crucial for enhancing residents' psychological resilience and training satisfaction, offering valuable lessons for other countries' GPRT systems.

7.3 Crisis Response Mechanisms: From Passive Response to Active Defense

Public health emergencies exposed traditional training system vulnerabilities while revealing pathways for emergency capacity building. Future reforms must establish a "peace-war dual-mode" system: during normal periods, reserve emergency skills through simulation exercises (e.g., US National Board of Medical Examiners' new emerging infectious disease management modules); during crises, activate flexible training rules. During the pandemic, some Shanghai hospitals implemented a "modular credit bank" system, allowing residents to convert pandemic response work into practice credits and extending core theoretical assessment deadlines, enabling most affected trainees to complete training on schedule [61]. This mechanism's core lies in establishing a "loss compensation" principle to prevent permanent career trajectory disruption from force majeure events.

Furthermore, systematic collaboration mechanisms must be established internationally to achieve standardization, resource sharing, and crisis response capacity enhancement in residency training. Within the EU, Directive 2005/36/EC establishes automatic mutual recognition of medical professional qualifications, allowing physicians to practice freely across member states upon meeting minimum training duration and content requirements, substantially simplifying administrative barriers for cross-border training and practice [62]. Complementing this, the European Union of Medical Specialists (UEMS) European Training Requirements (ETRs) define detailed knowledge, skills, and competency standards for general practice and other specialties, providing unified quality benchmarks for member states' residency training and effectively enhancing regional healthcare system adaptability and resilience in both normal and crisis states. During COVID-19, the EU further emphasized training system crisis response capacity through the EU4Health program, which funded cross-border remote teaching and simulation exercises and supported member states in sharing best practices and resources to rapidly adjust training content and rotation arrangements, ensuring residents could complete required modules and maintain career continuity during crises [63].

Progress across these three dimensions faces multiple tensions. Technology investment may widen urban-rural gaps, requiring fiscal transfer mechanisms (e.g., Brazil's "General Practice Education Equity Fund") to ensure resource fairness. Policy incentives may induce short-term behaviors, necessitating long-cycle tracking evaluation systems (e.g., Japan's long-term career development tracking of grassroots service physicians). Deeper contradictions lie in balancing efficiency and humanism—when training cycles compress to three years, residents' communication skill competency rates decline. Therefore, reforms must establish non-negotiable baselines: the "health gatekeeper" role essence of general practitioners requires training to preserve sufficient humanistic practice space.

The delayed completion issue in GPRT represents a systemic challenge facing global medical education systems, reflecting the intersection of individual capability development, training system design, and social resource allocation contradictions. Although developed and developing countries differ in training duration, assessment standards, and other system designs, all must address the structural tension between "standardized training" and "individualized needs." Solutions require moving beyond single-factor attribution to construct a reform framework coordinating "individual-system-society" synergies. Moreover, the "health gatekeeper" role positioning demands training strengthen community engagement and interdisciplinary collaboration, requiring long-term consensus among educational institutions, healthcare organizations, and policymakers to embed grassroots service orientation into training objectives and assessment systems.

Future research must further address digital education equity issues, such as how to narrow urban-rural training resource gaps through technology普及 and how to enhance healthcare workforce allocation efficiency through cross-regional resource sharing and mutual recognition mechanisms. The deeper challenge lies in how to uphold the public welfare values of general practice through institutional design against the backdrop of healthcare marketization and efficiency prioritization, integrating humanistic care and social responsibility throughout the training cycle. Only through continuous institutional innovation and value reconstruction can the dual objectives of reducing delayed completion and improving healthcare quality be achieved, laying a sustainable talent foundation for global primary healthcare systems. This requires not only nations to optimize policy tools based on local contexts but also international collaboration to promote experience sharing and standard coordination, jointly building a more resilient and inclusive new ecosystem for general practice education.

Author Contributions: WEN Dazhi was responsible for research design, data collection, and manuscript writing; LI Zhenshu conducted literature analysis and figure preparation; LI Zhenji collected and organized literature; WANG Ni compiled policy materials; LIU Dong provided training system data; ZHOU Xianchun performed full manuscript review and quality control; XUAN Chunhua conducted international case comparisons and conclusion revision.

Conflict of Interest Statement: The authors declare no conflicts of interest.

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Received: March 31, 2025; Revised: July 2, 2025
(Edited by ZOU Lin)