Literature Review

China’s Medical Education and Interventional Neuroradiology Training Xianli Lv, Hongwei He, Zhongxue Wu

Key words Interventional neuroradiology - Medical education - Training -

Abbreviations and Acronyms INR: Interventional neuroradiology PBL: Problem-based learning UEMS: Union Europeenne des Medecins Specialistes WFITN: World federation of interventional and therapeutic neuroradiology Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China To whom correspondences should be addressed: Hongwei He and Zhongxue Wu. [E-mail: [email protected]; [email protected]] Citation: World Neurosurg. (2015) 84, 5:1462-1465. Journal homepage: Available online: 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.

INTRODUCTION Endovascular techniques and clinical experience have matured to the point that all or a significant part of the treatment of acute ischemic stroke, cerebral aneurysms, brachiocephalic occlusive disease, and arteriovenous fistulae or malformations is performed in angiography suites by neuroradiologists, vascular surgeons, peripheral interventionists, cardiologists, neurologists, and neurosurgeons worldwide (2). The incidence of stroke is approximately 2 million per year in China and is increasing at an annual rate of nearly 8.7% (8). Neurosurgeons currently provide only a small portion of the care of these patients. It is imperative that adequate training and quality assurance be in place to ensure that the use of interventional neuroradiology (INR) procedures impact favorably on the outcomes of these patients. In 1999, Prof. Lasjaunias created, along with the Universities of Paris-Sud and Mahidol in Bangkok, a curriculum for INR training so that physicians of the Asian Pacific Rim have the opportunity to receive a unique education (10). The success of this


China’s medical education system is complex and consists of degree programs lasting from 3 to 8 years, the inconsistency across previous educational backgrounds is a challenge when implementing residency training objectives and contents. Only in several advanced medical universities, education for interventional neuroradiology (INR) is a part of a rotation in the 2-year training for neurosurgery. Advanced INR techniques are confined to big cities such as Beijing, Shanghai and Guangzhou, where most of the Chinese INRs have their 6 to 12 months fellowship to major medical centers. With a tremendous economic growth in the region, we expect that INR practice will evolve at an equally rapid pace, and information presented in this chapter may soon become obsolete. program was great, and soon it attracted doctors from around the world. To maintain and to improve the general quality level of its specialty, in 2012 discussions and multiple working seminars within the Union Europeenne des Medecins Specialistes (UEMS), a training charter to acquire such a particular qualification in INR was proposed and approved by the (UEMS 12). Both the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) and UEMS recommendations recognize that there are a number of structural and operational differences in the health care systems, and training systems in the different countries (3, 11). In East Asia, there also are governmental or nongovernmental training charters for INR in Japan, Korea, and China. There are some differences, however, between these charters of 3 countries, and the courses of medical education also are different. Education and training for specialty (residency) or subspecialty (fellowship) are on the continuing education program even though the contents (15), format, or period are different in the 3 countries. I will attempt to describe the medical education and the evolution and current practice of INR in China. UNDERGRADUATE AND POSTGRADUATE MEDICAL EDUCATION China has 268 medical schools and very large production of graduates (144,000 per

year). China’s medical education system is complex and consists of degree programs lasting from 3 to 8 years, with the longest duration usually associated with more competitive schools (5). The explanation for China’s great production system is its very large class sizes, averaging 548 graduates per school. For the clinical doctors, 5 years undergraduate classroom work usually is followed by clinical practicum at affiliated hospitals. After graduation, a young doctor needs to complete 3e6 years of residency training; some doctors need extended training for their subspecialty. Internal medicine usually takes 3e4 years of residency training, but surgical specialties may takes 5e8 years to complete. To control the medical education standard, the Chinese Ministry of Education set up a quality control regulation on medical education particularly for the Englishmedium undergraduate medical education (14). Upon graduation, the graduate must work as a resident physician for few years to be eligible to take a National Medical Licensing Examination for physician certification. This examination is conducted by the National Medical Examination Center. Without approval of registration by the Ministry of Health one cannot practice medicine in China as a physician or assistant physician. A medical graduate rotates through several departments and then assigned to a specialty department according to his or her strengths and the hospital’s needs. Specialty physician usually are attendings



who specialized in a certain specialty during the training process in a specialty hospital or in a subspecialty at a general hospital. The classification of specialties at a Chinese hospital is similar to that at American hospitals. The undergraduate curriculum for most common 5-year programs places heavy emphasis on basic biomedicine, medical technology, and clinical medicine (1). This focus also is prevalent in 3-year schools and in the more competitive 7- to 8-year degree programs. Reports across China consistently show the very little student exposure to the humanities, social sciences, communication skills, ethics, and population or public health. Early patient exposure is also uncommon. Class size and classrooms have limited application of problem-based learning (PBL), teambased learning, and case studies. There are limited facultyestudent and studentestudent interactions for creativity and innovation. A big difficulty is that faculty numbers (and also quality) might not have kept pace with numeric expansion of students (12). The national resident standardization training has not been implemented nationwide in Chinese hospitals, although almost all hospitals require their physicians to be trained as resident for few years before promotion to attending. The resident standardization training was launched in some University-affiliated hospitals. These students will complete their MD study and have to pass the National Medical Licensing Examination during the residency (14). The national resident standardization training will start in 2015, and all medical graduates are required to receive mandatory training from 2020. The primary model is a 5-year course in a medical school plus 3 years of residency training; however, it still faces significant challenges. China has a large and diverse group of 144,000 graduates. Sixty-seven thousand are 5-year medical students, 34,000 are master or doctoral-level graduates, and 63,000 graduates have only 3 years of medical education (5). The inconsistency across previous educational backgrounds is a challenge when implementing residency training objectives and contents. The resident standardization training contents issued by National Health and Family Planning


Commission (5) are heavily focused on medical technology, with little content about humanities, ethics, communication skills, and public health. Many medical graduates have lost their enthusiasm in pursuing their career because of insufficient salaries, heavy workloads, and patientedoctor tensions (14). An additional 3 years of residency training with inadequate income may prevent more talented graduates from going into this field. Efforts should focus on several aspects: a more detailed framework for differently educated individuals, a more humanistic and pragmatic training content, and acceptable salaries that will attract greater enrollment (1). CURRENT STATUS OF INR AND INR TRAINING IN CHINA Recent advances in devices and materials and therapeutic technical improvements in INR practice make it possible to use this therapeutic method for the treatment of neurovascular disease. INR has progressively become a true subspecialty at the crossroad of neuroradiology, neurosurgery, neurology, and neurosciences (12). The participation of the Far East in INR was 39.7% in 2013 (Marco Leonardi, 2013, personal communication). INR was introduced to China during the 1980s in conjunction with China’s Open and Reform Policy. Currently, there are approximately 1405 full-time and part-time INRs in China, including 833 neurosurgeons, 361 neurologists, and 211 radiologists (Feng Ling, Shanghai, 2012). In the past 10 years, INR procedures dramatically have increased in China. Advanced INR techniques are confined to big cities such as Beijing, Shanghai, and Guangzhou, where most of the Chinese INRs have their 6- to 12-month fellowship at major medical centers. Zhongxue Wu was a professor of INR of Capital Medical University and Beijing Tiantan Hospital and a pioneer of INR in China. He trained the first generation of full-time INRs in China in the 1980s and founded the first INR ward in 1992, which is the only one in China. I was trained by him since 2006 and I have been deeply influenced by his great enthusiasm and professional spirit for INR (16). INR in China is a relatively young subspecialty. It has become the largest one in the world in terms of the number of INRs.

WORLD NEUROSURGERY 84 [5]: 1462-1465, NOVEMBER 2015

The inpatient INR ward is very important to win the turf battle with other specialties. At the INR ward of Beijing Tiantan Hospital at Capital Medical University in Beijing, more than 2500 INR procedures are performed annually by fulltime INRs. The training requirement for INR in China is contained in the “Management Standard for Diagnosis and Treatment of Interventional Neuroradiology in China,” which was an official charter published by Chinese Ministry of Health in 2012. In this charter, the full training to become an INR specialist is defined as two and half years of full-time training. One of these years is to be spent in core INR and 9 months is to be spent in neurosurgery, neurology, and neuroradiology, respectively. However, there is not yet any official or national INR training in China. Only in several advanced medical universities is education for INR a part of a rotation in the 2-year training for neurosurgery. This training is designed to provide students time to become proficient with catheter-based techniques used in cerebral angiography (with a requirement of at least 100 angiograms) in addition to providing a fundamental foundation in radiation sciences (including knowledge in radiation physics and in interpretation of neuroradiological studies). The Chinese INR Coordinating Committee of the Chinese Doctor Association was founded at the beginning of 2014 and included 9 members. Every year, 3 major internal symposiums are hosted regularly each year in Beijing and Shanghai. An example is the Beijing Tiantan Neurointervention Symposium, for which the number of participants has increased to approximately 1000. Many world renowned professors, including Fernando Viñuela, Lasjaunias, Karel terBrugge, Luc Picard, Alex Berenstein, Anton Valavanis, Marco Leonardi, and Michel Mawad, have come to China to deliver lectures. All of these meetings and symposia offer good platforms for neurosurgeons to exchange ideas and broaden their views. The Chinese Doctor Association also plays an important role in continuing medical education for resident training in each specialty. Annually, many hours of courses for continuing medical education credit are available in large cities such as Beijing, Shanghai, and Guangzhou. Today’s Chinese neurosurgeons actively participate in



international events via publishing (science citation index) papers or giving a presentation in international conferences. Some doctors act as members of the WFITN and are invited to be reviewers for international journals such as INTERVENTIONAL NEURORADIOLOGY. Participation in international events helps Chinese neurosurgeons learn about the world and vice versa. The 2007 WFITN Congress was held in Beijing. Personally, I have been happy to be one of the members of WFITN since 2014. I believe another important reason for there being less competition for INRs may be attributable to insufficient training in China. The major tasks for us are to ensure the quality of the INR services. We should have national criteria for the registry of INRs, national guidelines for INR procedures, and a national registry network for INR procedures. We need a national strong INR society, which is supposed to be a regular and more professional organization like the Japanese Society of Neuroendovascular Treatment, the Korean society of Interventional Neuroradiology, European Society, the American Society of Interventional and Therapeutic Neuroradiology, the Joint Section of Cerebrovascular Neurosurgery, and the American Society of Neuroradiology. Medical insurance is still a weakness in the Chinese medical system, and some patients cannot afford INR, which is expensive. The government provides 30%e50% coverage of INR expenses for patients in cities, and less than 30% for patients in rural areas. Thus, expensive INR procedures are still a significant problem for patients and INRs, and they play a significant role in consideration of INR treatment. Physicians from remote areas have more support for their fellowship to major medical centers. INR in the Xinjiang region has been improved greatly with help from Beijing. More than 400 INR patients have been treated locally each year. DEVICE MARKET There are additional difficulties of making all devices available in China. There are legal concerns of patents and property rights and competition from domesticmanufactured devices. For the INR devices, only 5 industrial companies are



currently having a real presence in China, namely Medtronic Inc (Santa Rosa, California, USA), Cordman Neurovascular (Miami, Florida, USA), MicroVention Inc. (Tustin, California, USA), Stryker (Kalamazoo, Michigan, USA) and Balt Extrusion (Montmorency, France). In those with matured economies and established funding structures such as Japan, government regulations and conservatism have hindered the introduction of industrial devices. On the other hand, developing countries such as China have no strict regulations for devices, and there is no sufficient national reimbursement system or medical insurance. There are a number of domestically manufactured INR devices that comprise a little of the total market. The Willis covered stent (Microport Medical, Shanghai, China) is a neurostent graft made of a bare stent, an expandable polytetrafluoroethylene membrane, and a balloon catheter. It is available in diameters from 3 to 5 mm and lengths from 7 to 15 mm and is mounted on a deflated balloon catheter with an outside diameter of 3.8F (7). The company also offers a Tubridge flow-diverting device (Microport Medical, Shanghai) (17). The Jasper coils (Jasper Inc, Shanghai, China) (6) and EVAL liquid embolic system (Success, Shandong, China) (4) are similar to the GDC (Boston Scientifics/Target, Fremont, California, USA) and ONYX (ev3-Covidien, Irvine, California, USA) designs. These domestic devices are available for about two-thirds of the costs of a “Western” device and are attractive alternatives to patients. FUTURE CONSIDERATION Student-centered approaches present unique challenges in Asian countries (especially those in the Far East such as China, Japan, and Korea), which can be understood in their cultural context. Asian countries are deeply affected by the Confucian tradition, in which the authority of and respect for teachers are heavily emphasized in teacherestudent relationships. In this patriarchic paradigm, didactic lectures dominate the educational scene, where teachers impart knowledge and students listen passively. Despite such challenges, research has shown that faculty and student perceptions of PBL are positive as they recognize the benefits of

PBL in facilitating the students’ problemsolving and self-directed learning skills. Some Korean medical schools have started to pay attention to team-based learning methods to blend small-group learning activities into traditional lecture-based approaches. Neurosurgery residents in training should be inspired and motivated to learn new methods for the treatment of vascular disease in China. During the past few years, the field of INR has been expanding, and neurosurgeons, radiologists, and neurologists currently are being trained. Strozyk et al (13) took a national survey of endovascular training programs and found that when they compared the past 5 years (2003e2007) with future 5-year projections (2008e2012), the number of radiologists decreased by 37% (73 vs. 46), whereas the number of neurosurgeons (74 vs. 106) and neurologists (20 vs. 37) increased by 42.5% and 112%, respectively. Although the majority of current faculty is still composed of neuroradiologists, the number of graduates in radiology will decrease during the next 5 years, reflecting a trend toward greater subspecialization within the fields of neurosurgery and neurology. However, for the neurologist who has completed an endovascular fellowship, potential career paths are currently poorly defined, mainly because of the fact that neurologists have only recently begun to enter the field. Endovascular surgery should become an inherent rotation for the neurosurgery resident, enhancing the comprehension of endovascular skills among the neurosurgical practitioners of tomorrow and ensuring a continuum of care for patients with cerebrovascular disease. Peschillo and Delfini (9) reviewed the current state of endovascular neurosurgery in Europe and in Italy and speculate that it is time for European neurosurgeons to start training residents in INR in every other neurosurgical discipline in the near and distant future. One of the current questions is “How many specialists do we need in China?” Also, should we maintain set percentages of the members or expand naturally? We have not yet answered this question. This issue is also related to the re-registration system, and the balance of new and retired specialist members. The other issue about INR in China is the adequacy



of follow-up. Many patients who seek treatment in reputed centers are from rural areas and without means of further surveillance or communication. This alone poses a significant barrier to promulgating the many novel procedures currently done in China. Neurosurgeons in China are currently doing more than 90% of INR, and it is expected that their role will continue to dominate in future. CONCLUSION China’s medical education system is complex and consists of degree programs lasting from 3 to 8 years, the inconsistency across previous educational backgrounds is a challenge when implementing residency training objectives and contents. REFERENCES 1. Cao Z, Wang L: China’s evolving residency training. Med Teach. 2015 [Epub ahead of print]. 2. Ecker RD, Levy EI, Hopkins LN: Workforce needs for endovascular neurosurgery. Neurosurgery 59 (5 Suppl 3):S271-S276, 2006. 3. Flodmark O, Grisold W, Richling B, Mudra H, Pierot L: Training of future interventional neuroradiologists: the European Approach. Stroke 43: 2810-2813, 2012. 4. Hongwei H, Chuansheng L, Zhongxue W, Youxiang L, Chuhan J: Endovascular treatment of


cerebral or spinal arteriovenous malformations with EVAL embolization [in Chinese]. Zhonghua Shenjingwaike Zazhi 25:23-26, 2009. 5. Hou J, Michaud C, Li Z, Dong Z, Sun B, Zhang J, Cao D, Wan X, Zeng C, Wei B, Tao L, Li X, Wang W, Lu Y, Xia X, Guo G, Zhang Z, Cao Y, Guan Y, Meng Q, Wang Q, Zhao Y, Liu H, Lin H, Ke Y, Chen L: Transformation of the education of health professionals in China: progress and challenges. Lancet 384:819-827, 2014. 6. Jieqing W, Yiling F, Yaohua P, Jiyao J: Endovascular treatment of intracranial aneurysms with JASPER electrolytically detachable coils: a clinical observation [in Chinese]. Shenjingbingxue Yu Shenjingkangfuxue Zazhi 9:149-155, 2012. 7. Li MH, Li YD, Gao BL, Fang C, Luo QY, Cheng YS, Xie ZY, Wang YL, Zhao JG, Li Y, Wang W, Zhang BL, Li M: A new covered stent designed for intracranial vasculature: application in the management of pseudoaneurysms of the cranial internal carotid artery. AJNR Am J Neuroradiol 28:1579-1585, 2007. 8. Lv X, Wu Z: Robot-assisted Gait Rehabilitation after Stroke. J Rehabil Robotics 1:3-8, 2013. 9. Peschillo S, Delfini R: Endovascular neurosurgery in Europe and in Italy: what is in the future? World Neurosurg 77:248-251, 2012. 10. Picard L: Pierre Lasjaunias. AJNR Am J Neuroradiol 29:e92-e93, 2008. 11. Picard L: Interventional neuroradiology training charter. Interv Neuroradiol 15:11-15, 2009.

Tampieri D, Taylor A, Terbrugge K, Valavanis A, van den Berg R: Interventional Neuroradiology: a neuroscience sub-specialty? Interv Neuroradiol 19: 263-270, 2013. 13. Strozyk D, Hanft SJ, Kellner CP, Meyers PM, Lavine SD: Training in endovascular surgical neuroradiology. World Neurosurg 74:28-31, 2010. 14. Zeng J, Zeng X, Tu Q: A gloomy future for medical students in China. Lancet 382:2013, 1878. 15. Zhao JZ, Zhou LF, Zhou DB, Tang J, Zhang D: The status quo of neurosurgery in China. Neurosurgery 62:516-521, 2008. 16. Wu Zhongxue: Angel under X-ray. Translated by Xianli Lv. Interv Neuroradiol 20:454, 2014. 17. Zhou Y, Yang PF, Fang YB, Xu Y, Hong B, Zhao WY, Li Q, Zhao R, Huang QH, Liu JM: A novel flow-diverting device (Tubridge) for the treatment of 28 large or giant intracranial aneurysms: a single-center experience. AJNR Am J Neuroradiol 35:2326-2333, 2014.

Conflict of interest statement: The author declares that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 22 April 2015; accepted 7 June 2015 Citation: World Neurosurg. (2015) 84, 5:1462-1465. Journal homepage:

12. Rodesch G, Picard L, Berenstein A, Biondi A, Bracard S, Choi IS, Feng L, Hyogo T, Lefeuvre D, Leonardi M, Mayer T, Miyashi S, Muto M, Piske R, Pongpech S, Reul J, Soderman M, Chuh DS,

WORLD NEUROSURGERY 84 [5]: 1462-1465, NOVEMBER 2015

Available online: 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.


China's Medical Education and Interventional Neuroradiology Training.

China's medical education system is complex and consists of degree programs lasting from 3 to 8 years, the inconsistency across previous educational b...
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