Medical Education 1992, 26, 33S339

Medical education and medical education research and development activities in modern China JIANSHI H U A N G Department of Medical Education, College .f Medicine, University of Illinois at Chicago Summary. The development of medical education in China occurred quite differently to medical education in the rest of the world. A review of the literature has been presented regarding the historical development and the evolution of medical education research and development (MERAD) units in modern China. The history of medical education in modern China has been divided into three periods: (1) the 17 years before the ‘Cultural Revolution’ (19491966); (2) the period of the ‘Cultural Revolution’ (19661976); (3) the post ‘Cultural Revolution’ period (1976 onwards). Although a number of MERAD activities had existed on China’s medical campuses since 1949, there was no formal organizational structure for MERAD before 1978. The change of the political situation in 1978 led China to seek modernization, with education as its basis. In the process ofhealth care system modernization, medical education was given priority, and the Western model of establishing MERAD units as a means of improving the training of health professionals was introduced. The evolution of medical education research and development in modern China appears to be following the Western pattern due to the multitude of Western consultants and fellowships in Western countries provided to Chinese medical education leaders. A group of people from medicine is gathering in the MERAD field and MERAD units are beginning to take shape in modern China.

Medical education in modern China

The development of China’s medical education has been quite different to that in the rest of the world. Although traditional Chinese medicine has a history of thousands of years, in which physician training took the form of apprenticeship, medical education for Western medicine was introduced in China less than 200 years ago by missionaries (Huang 1981). The first medical school in China to adopt the Western model was the Canton Medical School, established by missionaries in Guangzhou in 1866 (Chan 1972; Gong 1983). Since then, apprenticeship as the major vehicle of medical education in China has gradually been replaced by formal medical school training. Although individual medical schools sought to introduce and assimilate the Western medical education model before 1949, activities to improve medical education were organized by the government aftcr the founding of the People’s Republic of China in 1949. Although decisions about the nature of medical education usually depended excessively upon political motivations as opposed to scientific fact, considerable advances in medical education have since been made along with the development of the health care delivery system. Today, there is a relatively comprehensive medical education system composed of primary, secondary, higher, postgraduate and continuing medical education. This system has been set up over decades, and is intended to meet the people’s needs for health and medical care in two ways: by increasing the quantity and upgrading the quality of doctors and other health professions. 1986 statistics show that there are 129 medical schools training medical doctors in China. O f these, 14 are under the direct supervision of the Ministry of Public Health (MOPH), six of which are

Key words: *education, medical/trends; *research; education, medical/hist; review, academic; China Correspondence: Dr Jianshi Huang, Apt. #201, 8015-196 Street, Edmonton, Alberta, Canada T6E 5P1. 333

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Jiarishi Hiraw‘q Table 1. Chmparison o i enrolment ratcipopiilation

111

sclccred c ~ i i i i t r i c \

N umbcr of cnrolnicn t

Country

cI1111a USA Candda

(Year) 42 000 ( 1985) l(7929 (198.5-86)” 1 812 (1 98.5-86)

national key medical schools: Beijing Medical University, Shanghai Medical University, the Sun Yatscn University ofMedical Sciences, West China Medical University, Peking Union Medical College and Beijing College o f Traditional Chinese Medicine. T h e remaining 115 mcdical schools are run by either provincial o r municipal governments, or b y other ministries of the central government. These 12Y medical schools are distributed in 30 provinces, autonomous regions and municipalities. Every province, autonomous region or municipality has at least one medical school. T h e highest number o f mcdical schools in onc province is 10 Uiansu Province) (Liu 1986a). In the 1985 academic ycar, new students admitted to medical schools numbered 42000, bringing the total medical students in China close to 157000 (Huang 1987). A comparison o f the rate per population with selected countries is shown in Table 1. T h e medical education system in China has for decades been centrally administered. T h e National Education Committee (formerly the Ministry of Education) is responsible for general educational policy-making for all aspects o f education, including medical education. T h e M O P H is responsible for the professional administration of medical education (Huang 1987). T h e development of mcdical education in modern China has undergone a continuous process o f reform, readjustment and raising o f standards since 1949. It has zigzagged forward in three developmental periods (Xu 1983; Liu 1986b; Z h u 1982, 1987). ( 1 ) T h e 17 years before the ‘ C u l t u r a l Revolution’ (1949- 1966)

I n 1949, the government began to seize control

I’opulatloIl*

ILitc pcr

popiildtion

1031 88251 1

4.0702E

226.545 805 24343 1x2

74436E

- 05 7.4172E- 05 - 0.5

of all public and private mcdical schools, sonic of which were run by foreigners. T h e schools wcrc reformed and the system reconstructed based o n the experiences o f health care services in the communist liberated areas and the Soviet model. T h e result was a centralized medical education system comprised o f 44 medical schools and 228 secondary medical schools. Graduatcs of these medical colleges formed the backbone of the health care delivery system in today’s China. Despite difficulties and setbacks encountered between 1955 and 1960, a medical education system appropriate to both the domestic situation and the pcoplc’s needs was gradually taking shape.

(2) The period cfthe ‘ C u l t u r a / Revolution’ ( 1 9 6 6 1976)

T h e ‘Cultural Revolution’ extended from May 1966 t o October 1976. It was a decade ofinternal turmoil which seriously disrupted the medical education system. Normal instruction and admission of new medical students were suspended for 5 years (196G1970). Medical school teachers were forced to g o to rural and remote areas and lost the right to teach and study. Many school buildings were occupied b y factories and the military and laboratory equipment and apparatus as well as library holdings were damaged and destroyed. When the medical schools rcopended again in 1971, college entrance examinations had been abolished and the quality of teaching had deteriorated seriously. As a consequence of these 10 years of turmoil, the health care delivery system in China today suffers from a shortage o f qualified staff and an abnormal age structure of its professional personnel.

Medical educatiori RGD in Chitia (3) Post ‘Cultural Revolution’ period (since 1977)

The decade following the ‘Cultural Revolution’ was characterized by energetic rehabilitation, readjustment and an accelerated pace of reform in medical education. The downfall ofthe ‘Gang of Four’ (four radicals who oversaw the ‘Cultural Revolution’) in late 1976 marked the beginning of a new historical era in China. The fundamental change in the political situation had obvious positive influences on medical education. Wrongdoings began to be rectified. The normal high and secondary medical education system was rehabilitated. Expelled teachers returned to thc schools. The resumption of the Unified National Entrance Examination in 1977 motivated young people to study diligently and assured the quality of medical school entrants. The system was expanded to acconimodate a great number of postgraduate students. The continuing medical education system was resumed and developed. A national academic degree system was established in 1981. New standard curricula for medical colleges and secondary medical schools were designed and unified textbooks for medical students were published, and equipment, apparatus and library holdings were replenished and renewed. A normal order of teaching and learning was gradually re-established and the quality of medical education steadily improved. The National Medical Examination for Medical Graduates (NMEMG) was piloted in 1982 and adopted by many medical schools the following year. Not only has the NMEMG improved the quality of teaching and learning, it has also played an important role in the acceleration of medical education research and development activities (MERAD) in China. Enrolment in China’s medical schools increased by 49% from 1980 to 1985 (from 28 196 in 1980 to 42000 in 1985); however, this expansion is still too slow to meet the one billion people’s health needs. (According to the third population census of 1982, the total population of China was 1031882511 on 1 July 1982. [1990 data: 1 133683000] [Qiwen 1984; Encyclopedia Britannica Inc., 19911.) In realizing the dilcmma between the growing needs and limitcd funding, a multi-level, multi-channel and multi-form approach is proposed to run medical schools.

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Medical education research and development activities are also encouraged. However, their effects on Chinese medical education still need to be assessed.

Medical education research and development (MERAD) in modern China The idea of establishing a formal organizational structure within medical schools to help promote the quality of medical education gained favour after China instituted an open-door policy in 1978. Since then, China has striven to apply scientific and technological developments from elsewhere in the world to all facets of Chinese society, including the health care system and medical education. In China, MERAD units have been seen as a means for the ‘modernization’ of medical education and have been introduced and accepted by Chinese medical educators. The first MERAD unit was set up in the late 1970s and, as a ‘fashionable’ sub-unit of a medical school, other units were formed in most of China’s medical campuses in the early 1980s. Before 1978 It is quite clear that although there was no formal organizational structure for MERAD before 1978, a number of MERAD activities already existed on China’s medical campuses. These activities, supervised by the Ministry of Public Health (MOPH), were usually carried out by temporary teams consisting of the teachers and educational administrators from both medical schools and thc government’s mcdical departments. From 1949 to 1978, the MERAD teams worked in the areas of investigation and evaluation, curriculum design and development, instructional methods and materials, teacher development and innovations in China’s medical education field (Zhu 1983, 1987;Hu 1984a,b; H u 1984; Niu 1984). In 1952 a nationwide medical education survey of all 44 medical schools was conducted. Two problems were identified. One was the maldistribution of medical schools; thc other was the inadequacy of some medical schools due to very poor equipment, a lack of qualified teachers, and low enrolment. The government responded by combining some medical schools and relocating

others, laying the foundation for the dcvelopmcnt of medical education in modern China. Among other M E R A D activities were curriculum design and development of instructional materials. During 195.556, a unified curriculum, modcllcd after the Russian medical curriculum, which lasts for 6 years after high school, as in Europe generally (Rocnier 1977), was designed by nationally recognized cxpcrts appointed by the M O P H . The same approach was employed to revise and develop the curriculum in 1958 and 1962. This standard curriculum was promulgated by the M O P H as a guiding document for medical schools throughout China. After the 1954 First National Conference for Higher Medical Education, the criteria for curricula, length of schooling, objectives of medical schools, and syllabi were identified. Measures were taken to solve the language and content problenis which stemmed from using Russian medical textbooks. First, Russian medical tcxtbooks were translated into Chinese to allow more student use; second, a project to compile China’s o w n medical textbooks and syllabi was set. Many nationally and internationally recognized Chinese medical experts were mobilized to write and 8 years later, 206 medical textbooks and a series of syllabi were published. These played an important role in maintaining minim u m standards for medical schools in the absence of a licensing system. To promote teaching quality, workshops were held by the M O P H in the early 1950s to introduce Russian teaching methods to the teachers in medical schools. According to the corpus of medical educatiori data compiled by the Bureau of Medical Education of the M O P H in the 1950s, the workshop topics included ‘How to lecture in a large classroom’ and ‘How to prepare a lecture’ (MOI’H 1950). Teacher training comprised both short-term training programmes and fellowships, emphasizing professional skills and knowledge over pedagogical aspects. China experienced several innovations in medical education between 1949 and 1978. In 1950, the medical education system was reconstructed by setting higher, secondary and primary levels. Priority was placed o n secondary medical education. The First National Conference for Public Health also proposed a 2-year programme, influenced by the Russian model,

for higher medical education in an attempt to train more doctors to alleviate health personnel shortages. This programme failed and was discontinued. In 1954, the priority was shifted from secondary to higher medical education, the Russian model ofniedical education was adopted in its entirety, including a ccntrally administered system. Reforms continued in 1958, with the so-called ‘Great Leap Forward’. T h c number of medical schools w a s increased from 37 in 1958 to 204 in 1960, but this attempt a t rapid growth failed and the number of medical schools was reduced in the late 1960s from 204 to 85. Similarly, in 1975, during the ‘Cultural Revolution’, political slogans flooded medical campuses. O n e slogan, ‘Open to run the medical school’, meant that nicdical schools were to send all oftheir students to the community. However, political pressure suppressed professional training and the ‘innovation’ failed undoubtedly because it was controlled by the political situation and lacked a scientific basis (Zhu 1987).

A j e r 1978 In the late 1970s, China began to reopen the door which had been closed for nearly thrcc decades. The Chinese found many aspects of the modern Western world shocking initially. An option popular in the media at that time was that the ‘Cultural Revolution’ widened the gap between China and developed countries. In an attempt at ‘modernization’ China accelerated the rate oftechnological exchange with the West, especially in the area of medicine. The leaders in medical education were convinced that the development of medical education should precede that of health care services (Zhu 1987). Seven short-term delegations, comprised of medical education leaders, were sent to North America, Western Europe and Japan between 1978 and 1984 to observe their medical education practices. Impressed by the success of innovations in Western medical education, which had failed in China, leaders focused on education research and development as the basis for China’s modernization of medical education. Reports of the delegations were distributed to the medical schools and research in the science of pedagogy was placed o n the agenda.

Medical education RGD in China In 1978 the M O P H organized the National Seminar on Planning for Medical Education and proposed to establish MERAD units in the medical schools. Shanghai First Medical College (now Shanghai Medical University), one of the leading medical schools in China, established the first MERAD unit in China in October 1978, one month before the National Seminar (Chcn, personal communication, 1985). Soon after, Shanghai begin to publish the journal of Medicine Abroad: Medical Education to introduce intcrnational information in medical education. The complementaryjournal ofMedical Education, concentrating on domestic MERAD activities, was published by Beijing Medical College (now Beijing Medical University). Thejournal ofMedicine Abroad: Medical Education was first published in 1980, and the Journal of Medical Education appeared the following year (Editorial Dcpartment, Journal of Medicine Abroad 1980; Chen, personal communication). The establishment of the MERAD unit had only provided an organizational guarantee for the MERAD activities. It was not until 1981 that the potential application ofeducation to medicine was first seriously and systematically explored in China. In 1981, the National Medical Examination Office was set up to lead rcprcsentatives of MERAD units to develop a national medical examination system for medical graduates. The first Tentative National Medical Examination for Medical Graduates was introduced in 1982 (Liu 1986a). Through the preparation and administration of the Examination, the MERAD concept was adopted by all medical schools involved in the Examination. Sincc the Examination was the first event in the history of China’s higher education in terms of examinee’s numbers, it not only evoked nationwide repercussions, but also brought attention from the Western medical cducation world. Medical campuses were deeply stirred by it. The MERAD units in the key medical schools played a dual role in the early years ofdevelopment ofthe National Medical Examination. O n one hand, as members of the National Medical Examination steering committee, the MERAD directors were involved in the decision-making processes; on the other hand, as consultants, the Faculty members of MERAD units in parent medical schools helped to prepare for this new kind of

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examination. The workshops on medical education measurement and the introduction of the Examination were held within the parent medical schools as well as the other medical schools within the same rcgions. The sccond event critical to the evolution of MERAD in China was the National Higher Medical Education Administration Scminar held in Guangzhou from 1 November to 15 December 1982 ( M O P H 1983). Presidents, deans and other leaders from 47 medical schools participated in this five-stage seminar. The seminar covered the contents of educational scicnces, administration skills, medical statistics, and an introduction of medical education systems in the United Kingdom, Australia, the United States, France, Canada, West Germany, Japan and thc Soviet Union. A new approach of using independent study and group discussion was adapted with medical education experts’ assistance from the World Health Organization (WHO), the United States and Canada. Although thc major objective ofthe seminar was not to emphasize the concept of MERAD, it actually arose out of thc leaders’ interest in MERAD, which paved the way for the cstablishmcnt of MERAD units in most medical schools (MOPH 1983). In addition to the National Examination and the 1982 Guangzhou seminar, a series of staff training and consultation activities was sponsored by the M O P H , WHO, and the World Bank (WB). Their impact cannot be ignored in the evolution ofthe MERAD units in China. The School ofMedical Education ofthe University of N e w South Wales of Australia (one of the W H O Regional Teacher Training Centres) was cspecially influential. O n e of the first medical education delegations, consisting of the leaders from Bcijing Medical College and Shanghai First Medical College, visited the centre in the late 1970s. This was probably thc first direct exposure of Chinese medical educators to Western MERAD. Later, in 1981, the director of the centre was invited to Bcijing Medical College to conduct a workshop on teaching and learning to the M O P H medical school deans (Qian 1981). The problem-based and student-centred learning approach was well received by the deans as an alternative to traditional teaching and learning approaches (MOPH, unpublished material, 1981).

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Jianshi H u a q

The Project 011 Strcngthening Medical Education sponsored by the World Bank (WB) provided opportunities for the new MERAD units to consolidate and develop by emphasizing their role in medical education innovations and by providing financial aid for MERAD devclopment (MOPH 1985). In 1984, a three-member consultant team of the WB visited four National Centres for Medical Education Research which had been found wanting by the M O P H and the WB: China Medical University, Sun Yat-sen University of Medical Sciences, Shanghai Medical University, and Beijing College of Traditional Chinese Medicine. At each centre, the consultants met the medical school president and dean and the MERAD unit directors. The units were visited and issues regarding the MERAD units were discussed. This short-term visit had two results: first, it encouraged the leaders of key medical schools to give more attention and support to the MERAD units; second, it provided concrete advice on how to consolidate and develop the MERAD units on time (Huang, unpublished report, 1984). Sponsored by W H O and WB, doctors were sent abroad to receive MERAD training, a practice which continues today. The degree and fellowship training offered by MERAD units abroad, especially by those of the United States, transfused new blood into China’s MERAD units, and encouraged China’s MERAD activities. Sending teachers abroad is one approach to MERAD development, but it is relatively ineffectual in terms of China’s large population. In 1990, in an attempt to prepare future medical education leaders in China, the National Centre for Medical Education at Beijing Medical University and the Dcpartmcnt of Medical Education at the University of Illinois at Chicago entered an agreement whereby the Master of Health Professions Education leadership programme is offcrcd on-site for 30 Chinese doctors who are leaders in their home institutes throughout the People’s Republic of China. This programme began in March 1991 and is funded by the World Bank and the W.K. Kellogg Foundation (Department of Medical Education of the University of Illinois 1990). Fellowship training in general education in domestic normal schools for the MEHAD teachers also exists (Huang, personal note, 1986).

Two symposia described below are important in the history ofMERAD. The National Symposium on Evaluation and Innovation held in Guangzhou in 1985 was a foruni for exchanging MERAD experiences and exploring future directions for MERAD. Over 130 people attended the Symposium, two-thirds of whom were from MERAD in medical schools. During the Symposium, directors of the MERAD units met to exchange ideas and discuss issues in MERAD, and a proposal was made to design a degree programme within thc medical school for MERAD development. Four experts from the United States, Canada, Japan and Australia took part in the Symposium as both participants and consultants (MOPH 1985). In 1986, MERAD people met again at the National Symposium on Postgraduate and Continuing Medical Education held in Qingdao. Three experts from the United Kingdom, the United States and Japan were invited. Research experiences on postgraduate and continuing medical education were shared. Professor H.J. Walton, President of the World Federation for Medical Education, brought new information about MERAD activities throughout the world (MOPH 1986). Annual meetings for MERAD have been held since 1983. This meeting was sponsored by the preparatory committee for the Medical Education Committee of the China Medical Association in 1983 and by the Medical Education Committee of the China Medical Association since 1984 (Huang, personal note, 1986). In 1984, the establishment of the Medical Education Comniittee of the China Medical Association was approved by the China Association of Sciences and Technology, the highest academic authority for recognizing emerging disciplines in China. This signified the beginning of the professionalization of MERAD in China (Editorial Department, journal of Medical Education, 1984). Conclusion Not surprisingly, the circumstances of establishing MERAD units in China are different from those in Western countries. However, the pattcrn of development of MERAD units in China is similar to that of Western units. For example, both considered MERAD as a means to improve medical education. In the West, the

Medical education RGD in C h i n a

prevalent belief that social problems can be solved by applying advanced technology led to the application of new educational technology to the teaching/learning process and establishment of MERAD units. In China, a desire to modernize the health care system led to an emphasis on medical education. In turn, the Western MERAD model was introduced and accepted as likely to contribute to modernizing medical education. Like most new emerging disciplines, both Western and Chinese units have encountered similar problems, such as inadequate staffing, lack of funding, lack of academic credibility, and lack of systematic research. However, the fact is that a group of people from medicine is gathering in the MERAD field in China. The MERAD units are beginning to take shape in the People’s Republic of China.

Acknowledgement The author would like to thank Ms Merrill Cooper, Faculty of Medicine, University of Calgary, Canada for reviewing the manuscript.

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Received 20 A u g u s t 1991; editorial comments to a u t h o r 2 1 N o v e m b e r 1991;acceptedforpublication 15 January 1992