Walls HL, Wolfe R, Haby MM, et al. Trends in BMI of urban Australian adults, 1980–2000. Public Health Nutr 2010; 13: 631–38. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA 2014; 311: 806–14.

Authors’ reply We welcome the Correspondence from Catherine Keating and colleagues commenting on our recent Article1 and thank them for their suggested steps to improve the quality of global obesity surveillance. We agree that stratification of trends by socioeconomic status is important and relevant to understanding the obesity epidemic. In our study, we have focused mainly on estimating the national trends and revealing the intercountry similarities and differences. Intracountry variation was not studied. To address this limitation, the Global Burden of Disease Study is gradually incorporating sub-national analysis in some countries to generate the most policy-relevant results. One challenge, however, is the scarcity of reliable data for subpopulations. Surveillance and surveys are often designed to be nationally representative. To capture subnational and subpopulation information, a comprehensive monitoring system should be developed to allow gathering of data at a more localised level. Regarding the authors’ second point, we agree that it is important to examine the composition of the obese population according to severity. Again, the scarcity of data is a substantial challenge in the estimation process. Obesity is a pressing health issue worldwide. Effective monitoring and surveillance are crucial to inform action and trace success. I declare no competing interests.

Emmanuela Gakidou [email protected] Institute for Health Metrics and Evaluation, Seattle, WA 98121, USA 1


Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766–81.

Education of health professionals in China


Hou J, Michaud C, Li Z, et al. Transformation of the education of health professionals in China: progress and challenges. Lancet 2014; 384: 819–27. Duvivier RJ, Boulet JR, Opalek A, van Zanten M, Norcini J. Overview of the world’s medical schools: an update. Med Educ 2014; 48: 860–69.

With great interest I read Jianlin Hou and colleagues’ Review (Aug 30, p 819).1 I applaud the initiative of China’s Ministry of Education to provide previously unreleased data on the number of health professional graduates and faculty by school. I respectfully request this information to be made publicly available: improved data can drive research on the quality of schools and their graduates, both in China and worldwide. We recently reported an overview of the world’s medical schools,2 and identified many challenges associated with counting schools and tracking information at school level. Nevertheless, to help meet the projected demand for health professionals in China, its government must pay attention, not only to the number and capacity of their training institutions, but also to their quality. Hou and colleagues provide observations on the quality of health professional education, but do not comment on the availability of outcome measures, such as government recognition and oversight, licensure and test scores, or process measures, such as qualifications of faculty staff. The absence of standard setting processes, accreditation, and licensing processes poses a real threat to the quality of the educational institutions of health professionals in China. Rigid and static educational methods are prevalent—incorporation of adult learning principles coupled with state-of-the-art assessment and evaluation are urgently needed to bring the education of China’s health professionals into the 21st century. What China needs are health professionals with the knowledge and skills to bring major educational reform and create meaningful and sustainable advances.

We read with interest the Review by Jianlin Hou and colleagues on the progress and challenges of transformation of the education of health professionals in China.1 We are concerned about the training of nurses. We are worried by the fact that most nurses did not receive standard nursing training. According to figure 1 in the Review,1 in 2012, only 30 000 out of 186 000 graduate nurses earned standard bachelor degrees or above. Most nurses received diplomas associated with brief training. Based on the supplementary materials,1 more than 80% of nurses working in the Chinese medical system received a diploma or lower and lack adequate training. With a 1:1 ratio between doctors and nurses1 and stressful working conditions, inadequately trained nurses could make mistakes during their medical service. The Review 1 on education transformation was accompanied by three pieces of Correspondence2–4 about violence against doctors in China. Although we agree that stronger punishments and other measures should be implemented to reduce violence against health professionals, we also believe that the education of nurses in China could also participate to some degree to the issue of violence against medical personnel.5 Nurses are intermediates between doctors and patients. In our practice, we have seen misunderstanding and mistrust between patients and doctors most probably due to of the inadequate training of nurses. A more comprehensive training system for nurses is needed.

I declare no competing interests.

We declare no competing interests.

Robbert J Duvivier

*Fengxia Liu, Ruili Zhang, Cuizhi Geng, Hong Chen, Yongjun Wang

[email protected] University of Newcastle, Callaghan, NSW 2308, Australia


[email protected] Vol 384 December 13, 2014



2 3 4 5

Hou J, Michaud C, Li Z, Dong Z, et al. Transformation of the education of health professionals in China: progress and challenges. Lancet 2014; 384: 819–27. Zhao L, Zhang XY, Bai GY, Wang YG. Violence against doctors in China. Lancet 2014; 384: 744. Xu W. Violence against doctors in China. Lancet 2014; 384: 745. Liu Y. Violence against doctors in China. Lancet 2014; 384: 745. Huang J, Yan L, Zeng Y. Facing up to the threat in China. Lancet 2010; 376: 1823–24.

Author’s reply We agree with Robbert Duvivier’s comment that both quantity and quality issues should be emphasised in the education of health professionals. Several educational measures have been taken by the Chinese Government to improve the competence of health professionals. In 2008, a draft standard for undergraduate medical education was announced and implemented by the Ministry of Education (MOE) and Ministry of Health, laying the basis for accreditation of medical schools. All undergraduate clinical programmes in the country are planned to be accredited by 2020. In the 1990s, the government also established national licensing examinations for physicians and nurses. Health professional graduates can provide health services after passing the licensing examinations. Furthermore, the MOE developed infrastructure and faculty criteria for higher education. However, noncompliance with these criteria is common because of insufficient supervision and regulation. We also agree with Duvivier that improved data are essential. Many governmental departments have introduced an information publication scheme—eg, electronic copies of some statistical yearbooks are available on governmental websites free of charge, and citizens can apply to access information. Nevertheless, more measures are needed to improve the information publication scheme. Some Vol 384 December 13, 2014

data, such as pass rates and test scores for licensing examinations are still confidential, although they can be easily obtained by the public in many other countries. The main reason that these records have never been made publicly available seems to be that because it has never been done, the authority in charge of licensing examinations is reluctant to be the first to release their records. The barriers can also come from local authorities or education institutions. For example, few universities or colleges make their financial information publicly available despite being requested to do so by the MOE. Generally, it seems easier to make aggregate data publicly available than disaggregate data. As to the MOE datasets used for our Review,1 time is needed to explore the possibility of making them publicly available because they contain detailed information for each higher medical education institution. With respect to nursing education, we share Fengxia Liu and colleagues’ concerns. Studies show that about 70–80% of medical disputes were caused by poor communication between health professionals and patients.2,3 Therefore, we re-emphasise the urgent need to strengthen training for communication skills in the education of health professionals in China. Violence against health professionals could be reduced by enhancing trust and enabling systematic reforms. We declare no competing interests.

Jianlin Hou, Catherine Michaud, Lincoln Chen, *Yang Ke [email protected] Institute of Medical Education, Peking University, Beijing, China (JH); China Medical Board, Cambridge, MA, USA (CM, LC); and Peking University Health Science Centre, Beijing 100191, China (YK) 1



Hou J, Michaud C, Li Z, Dong Z, et al. Transformation of the education of health professionals in China: progress and challenges. Lancet 2014; 384: 819–27. Liu W, Xu Y. Causes and prevention of medical disputes: a report from 240 cases. Chinese Hospital Management 2005; 11: 47–48 (in Chinese). Miao X. Analysis of medical disputes and solutions. J Inner Mongolia Univ Nationalities, 2012; 2: 59–60 (in Chinese).

Transgender patients need better protection in China Ian Lishman/Juice Images/Corbis

Nursing Department, The Fourth Hospital, Hebei Medical University, Shijiazhuang, Hebei 050011, China (FL, RZ, CG); The First Hospital of Qiqihaer City, Qiqihaer, Heilongjiang 161005, China (HC); and Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China (YW)

A rough estimate put the number of transgender people in China to 400 000, 1 yet data from the two main centres for sex reassignment (Changzheng Hospital and Shanghai Ninth People’s Hospital) suggest that less than 800 transgender patients have been treated in the past 30 years. Therefore, a proportion of transgender patients might have gone to clinics where sex reassignment surgery is not strictly regulated and incur high costs. Driven by profit, some surgeons operate unscrupulously. Moreover, when unable to afford the high price, some patients will turn to unqualified practitioners or travel abroad for cheaper services. Such situations can have terrible consequences for the patients.2,3 To tackle these issues, the Chinese Ministry of Health has provided guidelines: Technical Management Specifications for Sex Reassignment Surgery, in 2009. 4 The guidelines require that sex reassignment surgery should be done only in third-level, grade-A or plastic-surgery hospitals by senior plastic surgeons. However, the number of surgeries, particularly the less complicated male-to-female operation, continues to decrease in state-owned hospitals. Despite good intentions, the regulation4 might need substantial revision. First, the prerequisites for sex-reassignment surgery seem too demanding. The patient must get approval from direct relatives, obtain a clear criminal record from the local public security office, and have the documents notarised. These rules have raised criticisms about infringement on individual autonomy and privacy 5 and might contribute to patients seeking care outside regulated centres. Second, the regulation fails to follow 2109

Education of health professionals in China.

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