Development of a medical academic degree system in China.

0.28 MB·English

by  Wu, Lijuan

(cid:2)FEATURE ARTICLE
Development of a medical academic
degree system in China
Lijuan Wu1$, Youxin Wang1$, Xiaoxia Peng1, Manshu Song1,
Xiuhua Guo1, Hugh Nelson2* and Wei Wang1,3*
1BeijingMunicipalKeyLaboratoryofClinicalEpidemiology,SchoolofPublicHealth,CapitalMedical
University, Beijing, China; 2Shekou International SOSClinic, Shenzhen, China; 3SchoolofMedical
Sciences,Edith Cowan University, Joondalup, Western Australia, Australia
Context:TheChinesegovernmentlaunchedacomprehensivehealthcarereformtotacklechallengestohealth
equities. Medicaleducation will become thekeyforsuccessful healthcarereform.
Purpose:WedescribethecurrentstatusoftheChinesemedicaldegreesystemanditsevolutionoverthelast80
years.
Content: Progress has been uneven, historically punctuated most dramatically by the Cultural Revolution.
There is a great regional disparity. Doctors with limited tertiary education may be licensed to practice,
whereas medical graduates with advanced doctorates may have limited clinical skills. There are undefined
relationshipsbetweencompetingtertiarytrainingstreams,theacademicprofessionaldegree,andtheclinical
residencytrainingprogramme(RTP).Theperceivedqualityoftraininginbothstreamsvarieswidelyacross
China. As the degrees of master or doctor of academic medicine is seen as instrumental in career
advancement,includingemployabilityinurbanhospitals,attainmentofthisdegreeissoughtafter,yetisoften
unrelated to a role in health care, or is seen as superior to clinical experience. Meanwhile, the practical
experiencegainedinsomeprestigiousacademicinstitutionsisdeprecatedbytheRTPandmustberepeated
before accreditation for clinical practice. This complexity is confusing both for students seeking the most
appropriate training, and also for clinics, hospitals and universities seeking to recruit the most appropriate
applicants.
Conclusion:Thefutureeducationreformsmightinclude:1)adomesticsystemof‘credits’thatgivesweightto
qualityclinicalexperiencevs.academicpublicationsincareeradvancement,enhancedharmonisationbetween
thecompeting streams ofthe professional degreeandthe RTP, andpromotionofmobilityofstaffbetween
areas of excellence and areas of need; 2) International (cid:2) a mutual professional and academic recognition
between China and other countries by reference to the Bologna Accord, setting up a system of easily
comparableandwell-understood medical degrees.
Keywords: medicaldegree;medicaleducation;medicallicensing;BolognaAccords;China
Received:22 October 2013; Revised:9 December 2013; Accepted:12 December 2013;Published:15 January 2014
Introduction sive healthcare reform to tackle challenges to health
Chinahasgreatdisparitiesinpersonalwealth.TheGINI equities (3).
index of wealth maldistribution has reached a figure of Medical education will become the key for the
0.47, well above the recognised warning level of 0.4 (1). successful reform of health (4). Since 1998, the govern-
China’s leaders acknowledge the threat to stability that ment has made a great effort to expand medical educa-
thisrepresentsandarepromotinga‘harmonioussociety’ tion (5). Currently, there are 159 institutions of higher
wherepeopleacceptbeing‘moderatelyprosperous’rather education for medicine in China (4). The number of
thanDengXiaoPing’s‘toberichisglorious’aspersonal students enrolled annually has increased dramatically,
goals. Meanwhile, China’s health equities exist bet- rising from 65,695 in 1995 to 149,928 in 2000, and
ween population groups. There is a clear gradient in 386,905in2005(6).Meanwhile,Chinaisintheprocessof
life expectancy, which increases with prosperity (2). In transforming its health sector from a situation in which
2009, the Chinese government launched a comprehen- less than 10% of doctors in China were graduates of
$Theseauthorscontributedequallytothiswork.
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LijuanWuetal.
collegelevelmedicaleducationintheearly1970s(7),toa China’s interactions with the outside world, particularly
situation in which 64.8% of doctors were graduates of through international trade and communications, has
university-level medical education in 2005 (8). Owing to generated a growing awareness of the importance of
the increased number of graduates with university-level medical education and cooperation in this field between
medical education, and increasing social demand for China and developed countries. This article gives a
better trained physicians, yearly enrolment into post- general overview of the evolution and present state of
graduatemedicaleducationincreased6.5-foldfrom7,280 the medical academic degree system in China. On a
in 1998 to 47,412 in 2008 (9). global level, mutual understanding of other country’s
With the rapidly expanding scale, disparities in the medical academic degree systems is invaluable to future
qualityofmedicaleducationamongmedicalschoolshave cooperation.
widenedsubstantially.Thestudenttofacultyratiovaries
from2:1to9:1indifferentschools(10).Disparitiesinthe Evolution of various medical academic degrees
quality of medical education might be helped by in- in China
creased mobility of both medical students and medical
Chinese medical education has undergone three distinct
educators,andyetvisitorsnewtoChinaareoftenstruck
periodsofdevelopmentinrecenthistory(cid:2)before,during
by the lack of portability of professionals compared to
and after the Culture Revolution (1966(cid:2)1976). These
othercountries.AlthoughfeaturesuniquetoChina,such
changes were driven largely by political rather than
as resident certificate (HuKou) and the old human
educational forces (11).
resource affiliation system (DanWei), may contribute
Before the establishment of the People’s Republic of
to this, it would currently be very difficult for a student
Chinain1949,themedicaldegreesystemwasbasedona
to transfer to another medical school mid-studies, or for western European model, introduced by the Republic of
agraduatetogetajobinahospitaltheyhadnottrained China’s 1935 ‘Degree Conferral Law’ (12). Academic
at (cid:2) because of a lack of nationwide clear standards, degrees of medicine were divided into three different
curriculumway-points,andrecognisedcreditsforquality levels (cid:2) bachelors, masters and doctoral. Meanwhile, an
of clinical experience. 8-year programme leading to the degree of Doctor of
Thesituationissimilartohowitusedtobeforwestern Medicine(DM)existedinPekingUnionMedicalCollege
childrenwhoseparents’workrequiredrelocationtoother (PUMC) established in 1917 with the support of the
cities or countries, and who suffered great disadvantage Rockefeller Foundation. Since the establishment of the
because of lack of recognition of prior learning and People’s Republic of China in 1949, the evolution of
incongruenceinprimary,middleorhighschoolcurricula. the medical degree system has been somewhat turbulent
This changedwith the development of the International anduneven.Thethree-levelsystemwasdisbandedinfavour
Baccalaureate (IB) in 1968 in Geneva. At first it served ofapre-culturalrevolutionsystem(1949(cid:2)1965).Medical
only to provide a standard for university entry of a few education was delivered by secondary medical schools
highschoolstudentsfromrichandmobilefamilies.Now (SMS) and medical universities. The SMS enrolled
it serves nearly 1 million students in 140 countries, and graduates ofjunior high (9 years) education for aperiod
more than half of these students are attending state of study lasting 3(cid:2)4 years. The medical universities
public schools rather than private elite schools. The enrolled graduates of high school education (12 years)
benefits are consistent quality and coordinated curricu- for a period of study of 5(cid:2)6 years (13). Medical
lumandeffortless personalmobility. ChinaneedsanIB- universities began to enrol postgraduates from univer-
style reform to allow increased mobility both for sity-level medical education for a period of study of 4
students,graduates,teachersandresearcherstoovercome years, equal to the Kandidate nauk degree of the Soviet
some of the geographic inequities in medical education. Union. None of these programmes awarded formal
ThismaybeavailablealreadyintheformoftheBologna degrees.
Process, which is being adopted in Europe, and other WiththeonsetoftheCulturalRevolution(1966(cid:2)1976),
countries including Russia, whose academic and medical medicaleducationessentiallyceased.Peer-chosen‘worker(cid:2)
traditions have influenced China’s past policies. peasant(cid:2)soldier’ students were enrolled to learn a cur-
China’s medical degree system appears complex to riculum emphasising political ideology and practical
newcomersfromothercountries.Therearemultipletiers training over medical science. At this stage, entrance
of health care providers, varied routes to accreditation, examinations, aswell as degrees, were abolished.
and diverse roles of personnel with medical degrees in After the Cultural Revolution, a modern medical
China.Thesepartlyreflectthetendencyofacademicsthe degree system came into effect in 1981. A three-level
world over to build and promote their own ‘silos’, but medical degree system (cid:2) Bachelor of Medicine (BM),
alsothedifficultiesoftryingtomeetpeopleshealthneeds Master of Medicine (MM), and Doctor of Medicine
in the face of the major political, economic and social (DM) (cid:2)was adopted (14). In 1988, a 7-year programme
change over the past 80 years. The ‘opening up’ of was adoptedtogive medical studentsthe opportunityto
2
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MedicalacademicdegreesysteminChina
pursue other fields alongside their medical studies with Firstly, an overview of the levels, the route and the
the aim of broadening their knowledge and appreciation form of medical degreeswill be examined. Secondly, the
of the humanities and enhancing their career skills. relationship between the clinical training provided in
Successful completion of the 7-year course led to the theprofessionaldegreestreamandtheresidencytraining
awardoftheMM.Asmasteryofclinicalskillsisessential programmes (RTPs) stream will be analysed. Thirdly, as
in the professional development of doctorswho care for inmostothercountries,alicensetopractisemedicineisa
patients,itwasdecidedin1997toseparateandrecognise separate issue from attainment of a medical degree. This
twotypesofmedicalacademicdegreeatbothmasterand section will focus both on medical degrees and medical
doctoral levels, i.e., a clinical professional degree and a licensing. Finally, the role of these qualifications in a
researchdegree(15). This meant that the medical degree doctor’s career will be considered.
systembecamemorecomplex.Totrainmedicalscientists
and medical educators for China, an 8-year programme
Medical degrees: multilevel, multiroute and
leading to the degree of DM was initiated in 2001 (16).
multiform approach
The first class of 293 graduates of an 8-year programme
In the past decade, China has struggled to balance the
obtained this degree in 2009. This degree has existed in
needofitsmedicaleducationalstrategy,asshownbythe
PUMCsince1917,althoughitsoutputwasmodest(only
scale (6, 9) and complexity of the medical academic
313 graduates between 1925 and 1949). Nevertheless, its
degree system (Figure 1).
graduates have had a profound impact on the establish-
ment of western-style medicine and scientific research in
Theclinicalprofessionaldegreestream
China (17, 18).
The medical academic degree system in China is orga-
nised around a three-level degree system awarding
Present state of medical academic degree bachelor, master and doctorate degrees. Medical univer-
system in China sitiesprovidea5-yearundergraduatemedicalcurriculum
Unlike medical degrees in the UK, e.g., Bachelor of forcandidateswhohavecompletedhighschooleducation
Medicine and Bachelorof Surgery (MBChB), which can and passed the National Admission Examination, lead-
only be awarded to medical students, medical degrees in ing to the BM.
China can also be awarded to students specialising in Holders of the BM who pass the National Postgrad-
other fields, e.g., Human Movement Science, History of uate Entrance Examination are qualified to enter the
Science and Technology, Biomedical Engineering and master’s degree programme (professional degree or
Social Medicine and Health management. This means research degree) for 2(cid:2)3 years offull-time study.
thatthemedicaldegreesysteminChinaismorecomplex After obtaining the master’s degree, a student who
than in most countries (19). For the sake of clarity in passes the National Doctor Entrance Examination may
understanding the nature of a medical degree in China, enteramedicaluniversityormedicalinstitutetopursuea
thisarticlewillfocusononespecialty(clinicalmedicine). doctorate degree. The DM is a research degree. It is
Fig. 1. Multipath toacquiremultilevelof medical degrees.
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awardedaftersuccessfulcompletionof3yearsoffurther Theresearchdegree
study: 6-month curriculum study and 2.5-year medical A professional degree differs from the research degree
research. Also, the Doctor of Clinical Medicine (DCM) in the area of professional supervision and discipline.
is a professional degree. It is awarded after successful Table 1 shows the difference between these two types of
completion of 3-year study, 6-month curriculum study medical degree. The MM and DM are all research
and 1.5-year clinical training in a hospital and 1-year degrees. Medical graduates holding research degreeswill
medicalresearch.TheDCMhighlightstraininginclinical perform research in the fields of Medicine as their pri-
mary professional activity. Publications in peer-reviewed
skills.ItisroughlyequaltotheDoctorofMedicine(MD)
national journals are considered essential requirements
intheUSA,oraFellowshipinaSpecialistCollegeinUK
formastergraduates,whilepublicationsinpeer-reviewed
or Australia. The graduates are required to have solid
international journals are considered essential require-
knowledge in the diagnosis and treatment of special
ments for doctorate graduates. The DM is roughly
diseases and have specific skills in a subspecialty, taking
equivalent to the PhD qualification in the USA or UK.
on the responsibility as chief-of-residents, supervising
They will become physician(cid:2)scientists who perform
and training junior clinical staff. They should also do
medical research as their primary professional activity.
clinical research, write a dissertation, and be proficient
in reading English. They will become physicians. The
The relationship between the professional
study period between graduating from high school and
degree and residency training programme
obtaining DCM varies from eight to 14 years in China.
streams
In addition to the 5-year undergraduate medical
It was recognised that there was a need for an indepen-
curriculum, some medical universities present 7-year
dentbodytoaccredittheclinicaltrainingofotherbodies
programmes in clinical medicine leading directly to a
acrossChinabecausemanygraduatesoftheprofessional
master’s level qualification, i.e., Master of Clinical
degree stream had inadequate clinical experience. This
Medicine (MCM). More than 40 medical schools have was due to the great disparity in the quality of medical
both 5- and 7-year undergraduate medical courses in education across China. To address this, the RTP was
China (20). initiatedin1993,undertheresponsibilityandsupervision
Thetop12leadingmedicalschoolsinChinahavebeen oftheMinistryofHealth.In1995,theMinistryofHealth
authorised by the Ministry of Education to develop a establishedtheCouncilforGraduateMedicalEducation
dedicated8-yearprogramme,leadingtotheDCM.Yearly to set the standards for residency training and give
enrolment into the 8-year programme in the 12 medical accreditation to residency training centres. There are
schools is limited to 1,300 individuals (16). 2400 such centres in 26 of China’s 34 provincial level
Table1. Differencebetweenprofessional degreesandresearchdegreesin medical sciences
Professionaldegree Researchdegree
Fieldofstudy Professionaldiscipline Academicdiscipline
Levelsofmedicaldegree Master’slevel;doctoratelevel Master’slevel;doctoratelevel
awarded
Outputs Seniordoctors,seniorpublichealthphysicians, Physician(cid:2)scientistswhoperformmedical
seniordentists,seniorpharmacist,seniornurses researchastheirprimaryprofessionalactivity
Titlesformedicaldegree ClinicalMedicine(MCM/DCM) Pre-clinicalMedicine
PublicHealth(MPH) ClinicalMedicine
Stomatology(MSM/DSM) PreventiveMedicine
PharmacologicalScience(MPS/DPS Dentistry
ChineseMateriaMedica(MCMM/DCMM) PharmacologicalScience
HumanMovementScience
HistoryofScienceandTechnology
BiomedicalEngineering
SocialMedicineandHealthManagement
(allawardedMM/DM)
MCM(cid:3)Master of Clinical Medicine; MCMM(cid:3)Master of Chinese Materia Medica; MPH(cid:3)Master of Public Health; MPS(cid:3)Mater of
PharmacologicalScience;MSM(cid:3)MasterofStomatologicalMedicine;DCM(cid:3)DoctorofClinicalMedicine;DCMM(cid:3)DoctorofChinese
MateriaMedica;DPS(cid:3)DoctorofPharmacologicalScience;DSM(cid:3)DoctorofStomatologicalMedicine.
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administrative areas. Maldistribution of equipment and medical programmes: The first is a high school level,
resources means inevitable disparity in the quality of 3-yearvocationaltrainingwhichisnowbeingphasedout.
clinical training available. The second is a university-level, 3-year programme
TheRTP is organised into twostages: stage-I includes leading to a certificate.
3 years to workon ‘medicine or surgery in general’ with In order to obtain a license to practice medicine,
accreditation before starting stage II. The trainees are graduates must pass the National Medical Licensing
expected to reach the level of Specialist Physician or Examination(NMLE)(23)andhavehospitalexperience.
Surgeon.StageIIlastsbetween2and3years.Withinthis The BM graduates must have 1 year of hospital ex-
training, the trainees are expected to become competent perience, certificate graduates have 2 years, and voca-
toindependentlyconsultandtreatroutineandemergency tionaltrainingprogrammegraduatesmusthave5yearsof
cases. hospital experience.
The professional degree structure recognises RTP
clinical training as being essential to high-level profes- The role of medical qualifications in doctor’s
sional development. The clinical training objective end- careers
point of the professional degree streamis intended to be With an excess in the production of health workers over
consistent with the RTP. The clinical skills of graduates theabsorptionintothehealthworkforce(4),itisdifficult
withMCMareexpectedtoachievestage-IofRTP.After to find a job for a medical graduate. Higher degrees are
completionofstage-IofRTP,thephysicianmayapplyfor instrumental in career advancement, including employ-
MCM, which includes a 1-year master’s curriculum, abilityinurbanhospitals(cid:2)apotentmotivatorforwould-
proficiency in a foreign language (usually English) and be doctors to obtain degree-oriented medical education.
a comprehensive examination for the master’s degree China has developed its own nomenclature for physi-
organised by the Ministry of Health, then defending a cians, i.e., juniordoctor, doctor in charge, assistant chief
dissertationinthefourthyear.Aftercompletionofstage- doctor and chief doctor. It is a stepwise system in which
II of RTP the physician may apply for DCM, which graduatesholdingtheBMprogressfromjuniordoctorto
includes completing a doctor’s curriculum in 1 year, chiefdoctorwithinaperiodof15years.Althoughdegree
passing the foreign language examination for a doctor’s qualifications are not necessary to obtain a license for
degree, and defending a dissertation. medical practice, higher level degrees are necessary for
Although the professional degree has prestige, in fact rapid promotion (24). For example, without the 8 years’
manyof its graduates must repeat training years to gain DCM study, it is not possible to be appointed as a chief
RTP accreditation. Obtaining RTP level one or two in doctoruntiltheageof39years.Ontheotherhand,DCM
Beijingrequiresacombinationofamedicaldegreeaswell degree holders might be appointed as young as 33 years
asclinicalworkingexperience(21).Itispertinenttonote (25).
thattraineeswithMCMwithoutanyworkingexperience
need to complete 2 years of the RTP stage-I before they
A need for mutual recognition of degrees has
may progress to stage-II. Traineeswith 2(cid:2)5 years’ work-
been acknowledged internationally
ing experience need to complete 1 year of RTP stage-I
InMay1998,aconferenceattendedby2000academicsto
before progression to RTP stage-II.
markthe800thanniversaryofthefoundingofSorbonne
The lack of mutual recognition of training in the
University led to a declaration which focused on a
professional degree stream and the RTP stream leads to
progressive harmonisation of framework of degree
repetition and wasteful duplication of clinical training
courses, common levels for bachelors, masters and
resources. The framework regulating the relationship
doctorates (also known as the 3(cid:4)2(cid:4)3 system), and
betweentheprofessionaldegreeandtheRTPisamatter
increased international mobility of students, teachers
of national debate. Work has been done in Peking
and researchers, to promote a ‘Europe of Knowledge’
University Health Science Centre (PUHSC) to standar-
notjustofcommerce.Otherprincipleshavebeendefined,
dise and unify the clinical training as well as the
such as life-long learning, and a system of objective
assessment of clinical skills for trainees in both Profes-
credits to lend weight to vital but non-academic accom-
sional Degree and RTP streams. Thus, the PUHSC
plishments like practical engineering or clinical medical
graduate holding MCM is allowed to proceed directly
experience(26).Thenumberofcountriessupportingthis
to RTP stage-II (22).
undertaking by signing the Bologna Declaration grew
from 26 in 1999 to 46 (27 European countries and 19
Other medical qualifications non-Europeancountries)in2009(27).Medicaleducation
A first degree is a prerequisite for entry to many in recent decades has evolved from a strict separation
professions, but a BM is not essential to apply for a between academic and clinical years, towards patient
medical license in China. In addition to the degree- orientedclinicalintegrationinthewholesyllabus.Thisis
oriented medical education, there are also two kinds of creatingbetterdoctors,butmakesimplementingBologna
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style transferable modules more challenging. However, weight the value of clinical experience for nationwide
sevencountrieshavealreadyenactedlegislationtodothis cooperation in quality assurance. Thirdly, recognised
in some form (28). The ‘3(cid:4)2(cid:4)3’ system might fit ‘way points’ during the course of study where transfer
naturallywhenapre-medicalbachelor’sdegreeisalready to another location or institution mayoccur. These ‘way
required, as in the USA and Canada and increasingly in points’ could fit the ‘3(cid:4)2(cid:4)3’ pattern. This can only
Australia, UKand Ireland medical schools. Bycontrast, happen when curricula are congruent and accreditation
France and some of Britain’s schools accept high school at each level is transparent, objective and recognised
graduates after a year of Foundation study with over across China.
50% attrition, then a monolithic study period towards These would have a powerful effect to decrease
a medical degree. Despite the challenges, all medical disparity in the qualityof medical education and quality
schoolswantinternationalrecognitionofthesignificance of service delivery across China. China’s leaders in
andqualityofthedegreestheyissue.ThereisaEuropean education already recognise the need for this kind of
consensus on the matter that harmonisation of medical process (30).
education in Europe is crucial whatever system exists
(29).
Acknowledgements
The Chinese government has always attached great
importance to enhancing the mutual understanding of
ThestudywasfundedbytheNational12thFive-YearMajorProjects
higher education sectors and advancing the exchanges
ofChina(2012BAI37B03)theAustralia-ChinaScienceandResearch
and cooperation between China and other countries. In Fund (ACSRF06444), and the Principle Fund of Capital Medical
1983,Chinasignedanagreementwith19othercountries University(13JYY24).ProfessorWeiWangandManshuSongwere
to promote regional and worldwide cooperation in the supported by the Importation and Development of High-Calibre
Talents Project of Beijing Municipal Institutions (IDHT20130213,
matter of comparability and recognition or equivalence
CIT&TCD201404185),andDr.YouxinWangwassupportedbythe
of studies and academic degrees. In addition to this
BeijingHigherEducationYoungEliteTeacherProject(YETP1671).
document, China has signed the agreement of mutual WethankHuangBaoyin,LuMinfromtheMinistryofEducation,
recognition of Studies, Diplomas and Degree in Higher Prof.ChengLimingfromTongjiUniversity,Prof.LiuZhanpeifrom
Education with 26 countries, e.g., USA since 1998. Sichuan University, Prof. Wang Ling from Fudan University and
Rebecca Ling from the University of Oxford Medical School for
helpfuldiscussionsonourstudy.
The future
China’smedical degree system has undergone significant
Conflict of interest and funding
changes of reform, readjustment and development over
The authors have not received any funding or benefits
the last eight decades. The current multilevel, multiroute
from industryor elsewhere to conduct this study.
andmultiformapproachtomedicaldegreeeducationhas
been driven by society’s demands and advances in
scientific knowledge. Compared with the readily under- References
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