2014, 36: 1043–1050
Curriculum reform at Chinese medical schools: What have we learned? LEI HUANG1, LIMING CHENG1, QIAOLING CAI2, RUSSELL OLIVE KOSIK3, YUN HUANG2, XUDONG ZHAO2, GUO-TONG XU2, TUNG-PING SU4, ALLEN WEN-HSIANG CHIU4 & ANGELA PEI-CHEN FAN4 1
Tongji Hospital, Tongji University School of Medicine, China, 2Tongji University School of Medicine, China, 3Santa Clara Valley Medical Center, USA, 4National Yang-Ming University, Taiwan
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Abstract Introduction: Curriculum reform at Chinese medical schools has attracted a lot of attention recently. Several leading medical schools in China have undergone exploratory reforms and in so doing, have accumulated significant experience and have made considerable progress. Methods: An analysis of the reforms conducted by 38 Chinese medical colleges that were targeted by the government for upgrade was performed. Drawing from both domestic and international literature, we designed a questionnaire to determine what types of curricular reforms have occurred at these institutions and how they were implemented. Major questions touched upon the purpose of the reforms, curricular patterns, improvements in teaching methods post-reform, changes made to evaluation systems postreform, intra-university reform assessment, and what difficulties the schools faced when instituting the reforms. Besides the questionnaire, relevant administrators from each medical school were also interviewed to obtain more qualitative data. Results: Out of the 38 included universities, twenty-five have undergone major curricular reforms. Among them, 60.0% adopted an organ system-based curriculum model, 32.0% adopted a problem-based curriculum model, and 8.0% adopted a hybrid curriculum model. About 60.0% of the schools’ reforms involved both the ‘‘pre-clinical’’ and the ‘‘clinical’’ curricula, 32.0% of the schools’ reforms were limited to the ‘‘pre-clinical’’ curricula, and 8.0% of the schools’ reforms only involved the ‘‘clinical’’ curricula. Following curricular reform, 60.0% of medical schools experienced an overall reduction in teaching hours, 76.0% reported an increase in their students’ clinical skills, and 60.0% reported an increase in their students’ research skills. Discussion: Medical curricular reform is still in its infancy in China. The republic’s leading medical schools have engaged in various approaches to bring innovative teaching methods to their respective institutions. However, due to limited resources and the shackle of traditional pedagogical beliefs among many faculty and administrators, progress has been significantly hindered. Despite these and other challenges, many medical schools report positive initial results from the reforms that they have enacted. Although the long term effects of such reforms remain unclear, curricular reform appears to be the inevitable solution to China’s growing need for high-quality medical doctors.
Introduction Global Minimum Essential Requirements (GMER), as defined by the Institute for International Medical Education (IIME), outlines the essential competencies that a medical graduate should possess (Core Committee 2002). Currently, the majority of medical schools in China employ a discipline-based curricular model, where theory, clerkship, and internship are completed in three isolated phases and the GMER competencies are largely neglected. Compared to medical students who are taught via the GMER, medical students who are educated under traditional curricula underachieve. As a result, some Chinese medical schools are working intensively to create integrated curricula (Xiao et al. 2007; Sherer et al. 2013). Curriculum change affects every aspect of an educational organization, whether the change is minimal or involves more fundamental reform (MacCarrick 2009). Unfortunately, very
little literature concerning the process of curricular reform in China exists. To help bridge this gap in knowledge, we have investigated the medical curriculum reform status at 38 of the leading Chinese medical schools.
Methods A comprehensive literature search was performed with the keywords ‘‘medical’’ and ‘‘curriculum’’ using the database of Chinese Academic Journals. Articles published between 2001 and 2010 were selected for preliminary screening, which consisted of browsing of titles and abstracts. About 10 948 studies published between 2001 and 2010 were retrieved from the database. Following preliminary screening, 76 publications from 49 different medical schools were selected. About 31 publications regarding clinical medicine curricular reform were analyzed further.
Correspondence: Angela Pei-Chen Fan, National Yang-Ming University, P.O. Box 22072, Taipei ROC 100, Taiwan. Tel: +886 937 190763; Fax: +886 937 190763; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/121043–8 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.918253
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Practice points
Sample representativeness
This study only examines a subset of Chinese medical schools. However, the subset that was examined is a set of schools that are on the forefront of medical education in China. Most are ranked in the top 50 best Chinese medical schools, and their annual participation in the distinguished Medical Education Conference for China reflects their sustained and profound commitment to influencing the direction of future medical education initiatives in China. Chinese medical schools are categorized into several classes by the Ministry of Education. The 38 schools for which data were collected are all categorized as ‘‘first class’’ medical schools (Table 1), and most have received the ‘‘Aiming for Excellence’’, ‘‘985’’, and ‘‘211’’ grants. The 985 grant is The People’s Republic of China’s government sponsored initiative to upgrade 30 selected research universities to internationally renowned status. The 211 project was initiated by the Chinese government in the 1990s with the specific goal of greater implementation of pro-higher education policies. ‘‘211’’ stands for ‘‘21st Century, 100 key universities’’. Currently in China, there are 152 medical schools that teach Western Medicine. Of the 152 medical schools that teach Western Medicine, 128 are classified as first class medical schools, the other 24 medical schools belong to the second class or the third class. Further description of these medical schools can be found elsewhere (Fan et al. 2011, 2013). The classification system is derived by the Ministry of Education. The length of each medical school varies considerably, with some schools offering five-year programs, others offering five and seven year programs, and a small distinguished group of schools offering eight-year programs. Figure 1 presents the geographic location and statistical distribution of our sample. As indicated by the figure, the sample is quite geographically diverse, implying that the pooled result offers an amalgamation of the happenings throughout China’s different regions. That is, as recognized leaders from all over the country, the curricular undertakings of the medical universities included in this study can be considered to reflect the future direction of the rest of the nation.
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Several leading medical schools in China have undergone exploratory reforms and in so doing, have accumulated significant experience and have made considerable progress. Although China’s leading medical schools have for the most part reached their pre-reform consensus goals, they have done so by using varied curricular models as well as by taking varied approaches at implementing the reforms. Despite a multitude of challenges, many medical schools report positive results from initial evaluations of the reforms that they have enacted, but the longterm effects of such reforms remains unclear. Medical curriculum reform in China is in its infancy and will inevitably continue to spread, but careful guidance and attention will be required to ensure that the appropriate goals are achieved.
Based on this literature review and other significant prior research regarding medical curriculum reform in China and abroad (Papa & Harasym 1999; Qiao et al. 2001; Sun 2002; McLean 2004; Gude et al. 2005; Li et al. 2005; Wang & Wang 2005; Huang et al. 2006; Watmough et al. 2006; Zhao et al. 2006; Feng & Huang 2008; Muller et al. 2008; Albanese 2009; Fan & Zhu 2009; Kong et al. 2009; Mo et al. 2009; Lieberman et al. 2010), a first draft of a questionnaire was created. The questionnaire consisted of questions concerning whether or not medical curriculum reform had been implemented, and if so, the type of reform, how the reform was conducted, and why. In addition, data concerning how the reforms have been evaluated by the schools at which they were implemented was also collected. This questionnaire was then distributed to faculty and relevant administrators at Tongji University School of Medicine. Based on data provided by this sample, factor analysis was conducted, and the questionnaire was revised appropriately. The revised version was then taken to five medical educators for verification of its reliability and validity to assess medical curricular reform. Finally, a third version was created after a thorough analysis and integration of feedback provided by the medical educators. We distributed the questionnaire and conducted direct interviews at the Sixteenth National Young and Middle-Aged Academic Conference on Medical Education hosted by the Chinese Medical Association. Administrators from 38 medical schools who were directly involved in curricular design and/or implementation completed the questionnaires. Data were analyzed using SPSS 17.0.
Objectives of medical curriculum reform Medical educators generally agreed with the seven objectives of medical curricular reform listed on our questionnaire, with most administrators stating that they ‘‘completely agree’’ or ‘‘mostly agree’’ that their institution had such objectives in mind when the reforms were instituted (Table 2).
Curriculum models
Results Of the 38 medical schools, 16 medical schools are affiliated with a larger university, while the other 22 are autonomous. Twenty-five of the 38 have already enacted medical curricular reform, while 13 have not and do not as of yet have a plan to do so. 1044
In 1999, Professor Frank J. Papa of the University of North Texas School of Medicine and Professor Peter H. Harasym of the Calgary University School of Medicine systematically reviewed both past and current medical curriculum models. They grouped each model into one of five types: (1) the apprenticeship-based curriculum model, ABCM, (2) the discipline-based curriculum model, DBCM, (3) the
South
East
Region
48.30M people in 236 700 km2
41.76M people in 394 000 km2
Yunnan
71.64M people in 102 600 km2
Jiangsu
Guangxi
45.52M people in 101 800 km2
Zhejiang
72.23M people in 179 800 km2
13.42M people in 6340.5 km2
Shanghai
Guangdong
91.08M people in 157 000 km2
Shandong
Province
Population and area
First class 6/16 ¼ 38% Second Class ¼ 0
Second class: 0/6 ¼ 0
First class: 13/38 ¼ 34%
Sample distribution by ranking
No
No
Youjiang Medical University for Nationalities Kunming Medical University
No No No
No No No
No
No
No
No Yes
No Yes
No
No
No
Guangxi Medical University
No
No
No
No
Medical School of Nantong University Yangzhou University Medical Academy Xuzhou Medical College Zhongshan School of Medicine, Sun Yat-Sen University Guangzhou Medical University Guangdong Medical College Southern Medical University
No
Yes
Medical College of Soochow University Nanjing Medical University
No No No
Yes
Yes
No No No
No
Yes
Yes
Yes
Yes
Yes
985
Yes
Yes
211
Hangzhou Normal University Shaoxing University Wenzhou Medical College
Second Military Medical University Zhejiang University School of Medicine
Tongji University School of Medicine Shanghai Medical College of Fudan University
Shandong University School of Medicine
Medical school
Table 1. Characteristics of the study sample.
years years years years
years years years years years years years years years years years years years years years
years years years years years years years 5 years
5 5 5 8 5 7 5
5 years 5 years 8 years
5 years
5 6 7 5
5 7 5 6 8 5 8 5 7 8 5 5 5 7 5
5 years 7 years 8 years
Duration of medical study programs
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No
Yes
Yes
Yes No No
No Yes
Yes
Yes
Yes
Yes
No No No
Yes
Yes
Yes
Yes
Yes
Curriculum reform
–
–
29
– – 15
37 6
41
–
7
13
43 – –
10
9
2
28
–
Basic medicine
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(continued )
–
–
30
29 – 27
37 5
44
–
20
28
– – 25
8
10
3
24
–
Clinical medicine
Rank among Chinese medical schools
Medical curriculum reform in China
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Central
North
West
Region
43.02M people in 166 900 km2
97.68M people in 167 000 km2
Jiangxi
Henan
Hubei
32.68M people in 156 381 km2 60.01M people in 185 900 km2
Shanxi
Liaoning
Inner Mongolia
Hebei
Tianjin
Beijing
Sichuan
11.54M people in 16 807.8 km2 9.32M people in 11 760.2 km2 67.82M people in 187 693 km2 23.50M people in 1 183 000 km2 41.62M people in 148 000 km2
18.89M people in 1 664 900 km2 31.30M people in 82 402 km2 85.29M people in 485 000 km2
Xinjiang
Chongqing
36.42M people in 205 800 km2
Shananxi
Province
Population and area
First class 4/21 ¼ 19% Second class 0/4 ¼ 0
First class 8/32 ¼ 25% Second class 0/8 ¼ 0
First class 4/23 ¼ 17% Second class 0/4 ¼ 0
Sample distribution by ranking
No
Hebei Medical University
JiuJiang University Medical Centre Gannan Medical University Xinxiang Medical University
No No No
No No
No
Yes
No
No
No
Hubei University of Medicine
Yes
Yes
Yes
No No
Liaoning Medical University Fenyang College Shanxi Medical University Tongji Medical College of Huazhong University of Science and Technology Wuhan University Medicine School
No No
No
Dalian Medical University
No
No
No
No
No
No
No
No
No
Yes
985
Inner Mongolia Medical University China Medical University
No
Yes
No
Yes
No
No
Yes
211
Tianjin Medical University
Capital Medical University
West China School of Medicine
Chongqing Medical University
Xinjiang Medical University
Xi’an Jiaotong University College of Medicine
Medical school
Table 1. Continued
years years years years years years years
years years years years years years years years years years
years years years years years years years years years years years years years years years years years
5 years 5 years
5 7 8 5 7 8 5
5 7 5 7 5 5 7 5 6 8
5 7 8 5 7 5 7 5 7 8 5 7 5 7 5 7 5
Duration of medical study programs
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Yes Yes
– –
–
–
No
Yes
17
8
Yes
Yes
34 –
–
16
–
–
21
No No
Yes
Yes
No
Yes
No
20
14
Yes
No
18
40
19
Basic medicine
Yes
Yes
Yes
Curriculum reform
– –
–
36
23
9
40 31
45
14
–
36
15
7
6
17
33
21
Clinical medicine
Rank among Chinese medical schools
L. Huang et al.
Medical curriculum reform in China
organ system-based curriculum model, OSBCM, (4) the problem-based curriculum model, PBCM and (5) the clinical presentation-based curriculum model, CPBCM (Papa & Harasym 1999; Kong et al. 2009). Of the 25 medical schools in our study that have already enacted medical curriculum reform, 15 (60.0%) adopted an organ system-based curriculum model, 8 (32.0%) adopted a problem-based curriculum model, and 2 (8.0%) adopted a hybrid curriculum model that includes aspects of both the
organ system-based curriculum model and the problem-based curriculum model. At 15 schools (60.0%), curricular reform involved both the ‘‘pre-clinical’’ and the ‘‘clinical’’ curricula. At 8 schools (32.0%), curricular reform was limited to the ‘‘pre-clinical’’ curricula. Finally, at 2 schools (8.0%), curricular reform chiefly involved the ‘‘clinical’’ curricula. About 20 medical schools (80.0%) ‘‘integrated courses from the old curricula into the new curricula’’, 2 medical schools (8.0%) ‘‘created entirely new curricula’’, and 3 medical schools (12.0%) maintained the old curricular structure while adding several comprehensive integrated courses.
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Teaching hours before and after curricular reform
Figure 1. Geographic location and statistical distribution of the study sample.
Following curricular reform, fifteen (60.0%) medical schools experienced a reduction in teaching hours, two (8.0%) experienced an increase in teaching hours, and eight (32.0%) did not experience any change in teaching hours. Further, the majority of medical schools reported an improvement in their students’ clinical skills (76.0%) and research skills (60.0%). Finally, teaching hours of the arts and humanities (56.0%) and of optional practice courses (52.0%) were unchanged at the majority of medical schools (Table 3).
Table 2. Objectives of medical curriculum reform.
Completely agree
Items
Mostly agree
Do not agree or disagree
Mostly disagree
Completely disagree
Number Percent Number of Percent Number Percent Number Percent Number Percent of schools (%) schools (%) of schools (%) of schools (%) of schools (%)
Number of schools Increase interdisciplinary coordination and maximize the efficiency of the curricula Decrease hours spent in lecture and increase students’ spare time Early clinical exposure Enhance clinical thinking and strategy skills Enhance research abilities Improve self-learning and independent problem solving Improve doctor/patient communication and ability to work as a team
19
76.0
6
24.0
0
0
0
0
0
0
16
64.0
6
24.0
3
12.0
0
0
0
0
20 21
80.0 84.0
3 2
12.0 8.0
2 2
8.0 8.0
0 0
0 0
0 0
0 0
12 19
48.0 76.0
11 5
44.0 20.0
2 1
8.0 4.0
0 0
0 0
0 0
0 0
17
68.0
6
24.0
2
8.0
0
0
0
0
Table 3. Lecture hours before and after medical curriculum reform.
Decreased Lecture hours Total teaching hours Arts and humanities Clinical skills Research Skills Optional lectures Optional practice
Remained the same
Increased
Number of schools
Percent (%)
Number of schools
Percent (%)
Number of schools
Percent (%)
15 3 1 2 2 2
60.0 12.0 4.0 8.0 8.0 8.0
8 14 5 8 11 13
32.0 56.0 20.0 32.0 44.0 52.0
2 8 19 15 12 10
8.0 32.0 76.0 60.0 48.0 40.0
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Table 4. Instructional methods used in reformed curriculum (%).
Form of education Lectures Problem-based learning (PBL) Case-based learning (CBL) Team-based learning (TBL) Computer-assisted learning (CAL) Medical simulation learning (MSL)
Number of schools
Percent (%)
25 25 18 13 13 16
100.0 100.0 72.0 52.0 52.0 64.0
Presented as a multiple choice question.
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Instructional methods and student evaluation Medical curriculum reform involves extensive modification to instructional methods. Although it can come in many forms, adoption of a hybrid set of instructional methods, that includes a primary emphasis on PBL, is central (Lieberman et al. 2010). All 25 medical schools that completed medical curriculum reform, in doing so, adopted multiple instructional methods. All medical schools adopted lectures and Problem-Based Learning (PBL), while Case-Based Learning (CBL) (72.0%) and Medical Simulation Learning (MSL) (64%) were also popular (Table 4). An equally important piece of curricular reform is improving the way medical students are assessed. Eighteen medical schools (72.0%) indicated that, following curricular reform, they now utilize a ‘‘formative assessment system’’, where student performance is evaluated throughout an entire course, rather than an ‘‘end-point assessment system’’, where the final examination alone determines a student’s competency. However, seven schools (28.0%) retained the ‘‘end-point assessment system’’. Eighteen medical schools (72.0%) gave their new curricula a positive review, claiming a noticeable improvement in the following student abilities: clinical thinking skills, patient– doctor communication skills, teamwork, self-learning, and overall general competence. The other seven schools (28.0%) ‘‘have yet to evaluate their medical curricula’’.
Faculty development All of the medical schools have in place various programs to provide support for their faculty to develop their teaching, research, and clinical skills. Seminars, lectures, invited speeches, and discussion sessions are offered to prepare faculty to meet the challenges of a changing world as well as to guide them towards the central direction envisioned by the nation. Training courses offer faculty practical information and relevant insights aimed at enhancing their professional competency and enriching their lives both professionally and personally. Discussion of innovative teaching models, reflection on the curriculum, and constructive suggestions are encouraged in these training courses. All the medical schools also send faculty abroad to learn from international colleagues and to participate in relevant educational programs. Creating a platform for discussion aimed at pedagogical improvement is the common goal. PBL tutor training sessions are also a part of faculty development at those schools that have adopted PBL 1048
curricula. Finally, these sessions offer faculty a chance to provide input concerning the reorganization and modification of teaching material that occurs with curricular reform.
Chief difficulties of instituting medical curriculum reform Reforming a medical curriculum requires a preparedness for some obstacles, that though predictable, are no less challenging (Muller et al. 2008). Problems that have been described in the relevant literature, including ‘‘training and organizing faculty’’, ‘‘increasing interdisciplinary coordination’’, and ‘‘changing the mindsets of faculty accustomed to antiquated techniques’’, were all viewed as ‘‘relatively difficult’’ to ‘‘extremely difficult’’ to overcome by fifty percent or more of the medical schools in our study. However, over half of the schools also claimed to have ‘‘almost no difficulty’’ to ‘‘no difficulty’’ in overcoming other obstacles including ‘‘adaptation by students’’ and ‘‘application of various instructional methods’’ (Table 5). Additionally, it is customary in Chinese schools that administrators, faculty, educators, and all relevant personnel are required to attend certain meetings and training sessions, though medical students’ involvement is limited.
Discussion Meeting the goals of medical curriculum reform The ‘‘discipline-based curriculum model’’ no longer meets the needs of physicians training in China because it causes a number of significant problems: (1) each discipline covers material that widely overlaps with other disciplines and thus topics of study can become redundant, resulting in an unnecessary increase in teaching hours for professors and learning burden for students; (2) a lack of elective courses prevents students from exploring their individual interests; (3) students do not receive sufficient clinical, research, and professional skills training and (4) assessment is limited to standardized means such as written examinations and lacks a formative component. Recognizing the need for reform, many schools updated their curricular models with the explicit purposes of ‘‘enhancing clinical thinking and strategy skills’’ training, ‘‘increasing interdisciplinary coordination’’ to ‘‘maximize the efficiency of the curricula’’, and ‘‘improving self-learning and independent problem solving’’ training.
Varying strategies between schools The core of medical curriculum reform is the integration of multiple subjects. Schools that instituted curricular reform for the most part changed their curricular models to either an ‘‘organ system-based model’’ or a ‘‘problem-based model’’. However, these schools took varying approaches at enacting the reforms. While some focused on the pre-clinical curricula, others focused on the longitudinal integration of the preclinical and clinical curricula. The majority of schools maintained several courses from their old curricula, while simultaneously integrating new courses to form a new
Medical curriculum reform in China
Table 5. Chief difficulties of instituting medical curriculum reform.
Extremely difficult
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Items Obtaining financial support Training and organizing faculty Increasing interdisciplinary coordination Changing the mindset of faculty accustomed to antiquated techniques Adaptation by students Integration of teaching content Application of various instructional methods Implementation of a formative evaluation system Preparing lecture materials
Relatively difficult
Hard to say
Almost no difficulty
No difficulty
Number of Percent Number of Percent Number of Percent Number of Percent Number of Percent schools (%) schools (%) schools (%) schools (%) schools (%) 0 1 5
0 4.0 20.0
10 12 14
40.0 48.0 56.0
2 1 1
8.0 4.0 4.0
12 10 5
48.0 40.0 20.0
1 1 0
4.0 4.0 0.0
2
8.0
12
48.0
4
16.0
7
28.0
0
0
0 2 1
0 8.0 4.0
3 9 4
12.0 36.0 16.0
9 2 4
36.0 8.0 16.0
12 12 16
48.0 48.0 64.0
1 0 0
4.0 0 0
0
0
9
36.0
7
28.0
9
36.0
0
0
1
4.0
6
24.0
8
32.0
10
40.0
0
0
curricular model. The preservation of popular or efficacious courses can breathe a sense of familiarity for both students and teachers alike into the new curricula, thus easing the transition. Very few schools completely dissolved all interdisciplinary boundaries by integrating pre-clinical coursework, clinical coursework, preventive medical courses, and the humanities in creating a new curriculum.
Emphasis on the cultivation of clinical competency Traditional medical curriculum models are greatly limited in the sense that they are designed merely to impart medical knowledge, and in so doing ignore the cultivation of professional skills that play an integral role in determining a medical student’s overall clinical competency. A vital goal of curricular reform therefore, is to cultivate medical students’ professional qualities. Most of the medical schools in this study increased teaching hours dedicated to clinical skills, research skills, optional lectures, optional practice, arts, and the humanities following curricular reform. The utilization of multiple instructional methods, establishment of a formative assessment system, and creation of the idea of a student-centered education all are geared towards nurturing students’ professional qualities.
Continued challenges Despite the large steps that the reforms described in this study represent for the small number of Chinese medical schools that have adopted them, they are just the initial stages towards an end goal of creating a mature medical curricular model. Such a model still eludes the majority of Chinese medical schools for a number of reasons. Attempting to integrate interdisciplinary curricula can sometimes lead to a piecemeal program that doesn’t fully achieve teaching goals. Such a phenomenon has already been reported by some medical schools in China. Further, administrators, organizers, professors, and tutors all have varied perceptions of what constitutes medical curriculum reform. A more unified understanding among faculty of
the goals and implementation strategies of curricular reform would benefit students and ease the transition for the school as a whole into the new curriculum. The majority of medical schools in China still employ the discipline-based curriculum model, where each discipline is taught almost completely independently of the others. If properly implemented, curricular model reform can drastically improve medical student education, teaching methods, assessment systems, and curricular efficiency. However, in order for reforms to succeed, both teachers and students must be willing to embrace an innovative educational philosophy that, in some cases, may be completely different than anything they have ever seen before. Among the schools that have instituted reforms, such an adjustment has proven difficult. Quite a large number of medical schools reported difficulties in the training of faculty. In general, schools can only offer a select few faculty members the experience of overseas training. Those faculty members can then return to China to serve as seed trainers for the rest of the faculty. Alternatively, hosting international experts can allow an entire faculty to gain exposure to ideas from abroad in one setting, though such exposure is usually temporary. Finally, the introduction of small group discussion teaching methods, which require a larger number of faculties and place an emphasis on clinical skills training, has placed an onerous financial burden on some medical schools.
What we need next Medical curriculum reform at Chinese medical schools has attracted a lot of attention in recent years. Several leading medical schools in China have undergone exploratory reforms and in so doing, have accumulated significant experiences as well as have made considerable progress. Although these leading medical schools have for the most part reached their pre-reform consensus goals, they have done so by using quite varied curricular models as well as by taking quite varied approaches at implementing the reforms. Despite a multitude of challenges, many medical schools report positive results
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from initial evaluations of the reforms that they have enacted, but the long-term effects of such reforms remains unclear. Medical curriculum reform in China is in its infancy and will inevitably continue to spread, but careful guidance and attention will be required to ensure that the appropriate goals are achieved.
Notes on contributors Dr. LEI HUANG, MD, is an internist and Ph.D. candidate in psychiatry. She is in charging of the clinical teaching education and administration of Tongji Hospital, Tongji University School of Medicine. Dr. LIMING CHENG, MD, PHD, is an orthopedist and the Deputy Dean for Medical Education of Tongji Hospital, Tongji University School of Medicine.
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Dr. QIAOLING CAI, MD, is an internist and the Deputy Dean for Medical Education, Tongji University School of Medicine. Dr. RUSSELL OLIVE KOSIK, MD, MPH, is a radiology resident at the Santa Clara Valley Medical Center, San Jose, CA, USA. He received his MD from the UCLA School of Medicine, and MPH from the National Yang-Ming University. Ms. YUN HUANG is a medical student of Tongji University School of Medicine. Dr. XUDONG ZHAO, MD, PhD, is a psychiatrist and the Director of Division of Medical Humanities and Behavioral Sciences, Tongji University School of Medicine. Dr. GUO-TONG XU, MD, PhD, is an ophthalmologist and the Dean for Tongji University School of Medicine. Dr. TUNG-PING SU, MD, is the Chairman, Dept. of Psychiatry, School of Medicine at National Yang-Ming University. Dr. ALLEN WEN-HSIANG CHIU, MD, PhD, is the Dean, School of Medicine at National Yang-Ming University, Taiwan. Dr. ANGELA PEI-CHEN FAN, PhD, is the Associate Professor of Psychiatry, Faculty of Medicine at National Yang-Ming University. She received her MS from Harvard, PhD from the Johns Hopkins University, and served on the faculty of the Johns Hopkins University before she came to Taiwan.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References Albanese M. 2009. Life is tough for curriculum researchers. Med Educ 43: 199–201. Core Committee, IFIME. 2002. Global minimum essential requirements in medical education. Med Teach 24:130–135. Fan AP, Kosik RO, Chen Q. 2013. Internationalisation of Chinese medical schools. The Lancet 381(9882):1984. Fan AP, Kosik RO, Su TP, Chen YA, Chen CH, Lee CH, Tang W, Chen Q, Guo L. 2011. Humanities and ethics education at Chinese medical schools. Med Teach 33(1):85–87.
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Fan HH, Zhu J. 2009. The shift of clinic medical qualified personnel cultivation and its embodiment in higher medical curriculum reform. Res Med Educ 8:349–351. Feng, K, Huang, JS. 2008. Inspirations from the curricula of Harvard Medical School and Johns Hopkins School of Medicine for the education reforms of 8-year medical program in China. Fudan Educ Forum 6:86–89. Gude T, Hjortdahl P, Anvik T, Baerheim A, Fasmer OB, Grimstad H, Tyssen R. 2005. Does change from a traditional to a new medical curriculum reduce negative attitudes among Students? A quasi-experimental study. Med Teach 27:737–739. Huang JS, Guan YZ, Xu ZL, Ma JY, Zheng DC, NI C. 2006. Current status of medical education and characteristics of curriculum reform in three Australian medical schools. Chin J Med Educ 26:92–93. Kong WJ, P YX, Fu Y, Tao XN, Liu YL, Zheng J, Yang GY, Shu Z. 2009. The investigation and practice of clinical curriculum. Chin J Med Educ 29(4):2. Li ZS, Wang ZY, Lu HB. 2005. Transformation of medical pattern and medical education reform. Northwest Med Educ 13:124–126. Lieberman SA, Ainsworth MA, Asimakis GK, Thomas L, Cain LD, Mancuso MG, Rabek JP, Zhang N, Frye AW. 2010. Effects of comprehensive educational reforms on academic success in a diverse student body. Med Educ 44:1232–1240. MacCarrick G. 2009. Curriculum reform: A narrated journey. Med Educ 43: 979–988. McLean M. 2004. A comparison of students who chose a traditional or a problem-based learning curriculum after failing year 2 in the traditional curriculum: A unique case study at the Nelson R. Mandela School of Medicine. Teach Learn Med 16:301–303. Mo GH, Mo Y, Zhang C. 2009. Innovation and discussion in medical curriculum under international background and China’s actual conditons. China Higher Med Educ (6):89–90. Muller JH, Jain S, Loser H, Irby DM. 2008. Lessons learned about integrating a medical school curriculum: Perceptions of students, faculty and curriculum leaders. Med Educ 42:778–785. Papa FJ, Harasym PH. 1999. Medical curriculum reform in North America, 1765 to the present: A cognitive science perspective. Acad Med 74: 154–164. Qiao M, Guo L, He J, Zhang XM, Hu XB. 2001. The trends and characteristics of medical curriculum reform in foreign countries. Med Educ (6):19–22. Sherer R, Dong H, Yunfeng Z, Stern S, Jiong Y, Matlin K, Baoping Y, Husain AN, Morgan I, Cooper B, et al. 2013. Medical education reform in Wuhan University, China: A preliminary report of an international collaboration. Teach Learn Med 25:148–154. Sun BZ. 2002. A detailed comparison of medical curriculums between the US and China and the related international standards. China High Med Educ (4):22–25. Wang TH, Wang SZ. 2005. Reflections on the minimum requirements of global medical education and curriculum reform. Northwest Med Educ 13:116–118. Watmough S, Garden N, Taylor D. 2006. Does a new integrated PBL curriculum with specific communication skills classes produce Pre Registration House Officers (PRHOs) with improved communication skills? Med Teach 28:264–269. Xiao H, Xian L, Yu X, Wang J. 2007. Medical curriculum reform in Sun Yat-Sen University: Implications from the results of GMER evaluation in China. Med Teach 29:706–710. Zhao JH, Liu P, Fan WL. 2006. Review, analysis and expectation of medical curriculum mode in higher medical schools in China. Northwest Med Educ 14:156–157.
Curriculum reform at Chinese medical schools: What have we learned? LEI HUANG1, LIMING CHENG1, QIAOLING CAI2, RUSSELL OLIVE KOSIK3, YUN HUANG2, XUDONG ZHAO2, GUO-TONG XU2, TUNG-PING SU4, ALLEN WEN-HSIANG CHIU4 & ANGELA PEI-CHEN FAN4 1
Tongji Hospital, Tongji University School of Medicine, China, 2Tongji University School of Medicine, China, 3Santa Clara Valley Medical Center, USA, 4National Yang-Ming University, Taiwan
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Abstract Introduction: Curriculum reform at Chinese medical schools has attracted a lot of attention recently. Several leading medical schools in China have undergone exploratory reforms and in so doing, have accumulated significant experience and have made considerable progress. Methods: An analysis of the reforms conducted by 38 Chinese medical colleges that were targeted by the government for upgrade was performed. Drawing from both domestic and international literature, we designed a questionnaire to determine what types of curricular reforms have occurred at these institutions and how they were implemented. Major questions touched upon the purpose of the reforms, curricular patterns, improvements in teaching methods post-reform, changes made to evaluation systems postreform, intra-university reform assessment, and what difficulties the schools faced when instituting the reforms. Besides the questionnaire, relevant administrators from each medical school were also interviewed to obtain more qualitative data. Results: Out of the 38 included universities, twenty-five have undergone major curricular reforms. Among them, 60.0% adopted an organ system-based curriculum model, 32.0% adopted a problem-based curriculum model, and 8.0% adopted a hybrid curriculum model. About 60.0% of the schools’ reforms involved both the ‘‘pre-clinical’’ and the ‘‘clinical’’ curricula, 32.0% of the schools’ reforms were limited to the ‘‘pre-clinical’’ curricula, and 8.0% of the schools’ reforms only involved the ‘‘clinical’’ curricula. Following curricular reform, 60.0% of medical schools experienced an overall reduction in teaching hours, 76.0% reported an increase in their students’ clinical skills, and 60.0% reported an increase in their students’ research skills. Discussion: Medical curricular reform is still in its infancy in China. The republic’s leading medical schools have engaged in various approaches to bring innovative teaching methods to their respective institutions. However, due to limited resources and the shackle of traditional pedagogical beliefs among many faculty and administrators, progress has been significantly hindered. Despite these and other challenges, many medical schools report positive initial results from the reforms that they have enacted. Although the long term effects of such reforms remain unclear, curricular reform appears to be the inevitable solution to China’s growing need for high-quality medical doctors.
Introduction Global Minimum Essential Requirements (GMER), as defined by the Institute for International Medical Education (IIME), outlines the essential competencies that a medical graduate should possess (Core Committee 2002). Currently, the majority of medical schools in China employ a discipline-based curricular model, where theory, clerkship, and internship are completed in three isolated phases and the GMER competencies are largely neglected. Compared to medical students who are taught via the GMER, medical students who are educated under traditional curricula underachieve. As a result, some Chinese medical schools are working intensively to create integrated curricula (Xiao et al. 2007; Sherer et al. 2013). Curriculum change affects every aspect of an educational organization, whether the change is minimal or involves more fundamental reform (MacCarrick 2009). Unfortunately, very
little literature concerning the process of curricular reform in China exists. To help bridge this gap in knowledge, we have investigated the medical curriculum reform status at 38 of the leading Chinese medical schools.
Methods A comprehensive literature search was performed with the keywords ‘‘medical’’ and ‘‘curriculum’’ using the database of Chinese Academic Journals. Articles published between 2001 and 2010 were selected for preliminary screening, which consisted of browsing of titles and abstracts. About 10 948 studies published between 2001 and 2010 were retrieved from the database. Following preliminary screening, 76 publications from 49 different medical schools were selected. About 31 publications regarding clinical medicine curricular reform were analyzed further.
Correspondence: Angela Pei-Chen Fan, National Yang-Ming University, P.O. Box 22072, Taipei ROC 100, Taiwan. Tel: +886 937 190763; Fax: +886 937 190763; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/121043–8 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.918253
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Practice points
Sample representativeness
This study only examines a subset of Chinese medical schools. However, the subset that was examined is a set of schools that are on the forefront of medical education in China. Most are ranked in the top 50 best Chinese medical schools, and their annual participation in the distinguished Medical Education Conference for China reflects their sustained and profound commitment to influencing the direction of future medical education initiatives in China. Chinese medical schools are categorized into several classes by the Ministry of Education. The 38 schools for which data were collected are all categorized as ‘‘first class’’ medical schools (Table 1), and most have received the ‘‘Aiming for Excellence’’, ‘‘985’’, and ‘‘211’’ grants. The 985 grant is The People’s Republic of China’s government sponsored initiative to upgrade 30 selected research universities to internationally renowned status. The 211 project was initiated by the Chinese government in the 1990s with the specific goal of greater implementation of pro-higher education policies. ‘‘211’’ stands for ‘‘21st Century, 100 key universities’’. Currently in China, there are 152 medical schools that teach Western Medicine. Of the 152 medical schools that teach Western Medicine, 128 are classified as first class medical schools, the other 24 medical schools belong to the second class or the third class. Further description of these medical schools can be found elsewhere (Fan et al. 2011, 2013). The classification system is derived by the Ministry of Education. The length of each medical school varies considerably, with some schools offering five-year programs, others offering five and seven year programs, and a small distinguished group of schools offering eight-year programs. Figure 1 presents the geographic location and statistical distribution of our sample. As indicated by the figure, the sample is quite geographically diverse, implying that the pooled result offers an amalgamation of the happenings throughout China’s different regions. That is, as recognized leaders from all over the country, the curricular undertakings of the medical universities included in this study can be considered to reflect the future direction of the rest of the nation.
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Several leading medical schools in China have undergone exploratory reforms and in so doing, have accumulated significant experience and have made considerable progress. Although China’s leading medical schools have for the most part reached their pre-reform consensus goals, they have done so by using varied curricular models as well as by taking varied approaches at implementing the reforms. Despite a multitude of challenges, many medical schools report positive results from initial evaluations of the reforms that they have enacted, but the longterm effects of such reforms remains unclear. Medical curriculum reform in China is in its infancy and will inevitably continue to spread, but careful guidance and attention will be required to ensure that the appropriate goals are achieved.
Based on this literature review and other significant prior research regarding medical curriculum reform in China and abroad (Papa & Harasym 1999; Qiao et al. 2001; Sun 2002; McLean 2004; Gude et al. 2005; Li et al. 2005; Wang & Wang 2005; Huang et al. 2006; Watmough et al. 2006; Zhao et al. 2006; Feng & Huang 2008; Muller et al. 2008; Albanese 2009; Fan & Zhu 2009; Kong et al. 2009; Mo et al. 2009; Lieberman et al. 2010), a first draft of a questionnaire was created. The questionnaire consisted of questions concerning whether or not medical curriculum reform had been implemented, and if so, the type of reform, how the reform was conducted, and why. In addition, data concerning how the reforms have been evaluated by the schools at which they were implemented was also collected. This questionnaire was then distributed to faculty and relevant administrators at Tongji University School of Medicine. Based on data provided by this sample, factor analysis was conducted, and the questionnaire was revised appropriately. The revised version was then taken to five medical educators for verification of its reliability and validity to assess medical curricular reform. Finally, a third version was created after a thorough analysis and integration of feedback provided by the medical educators. We distributed the questionnaire and conducted direct interviews at the Sixteenth National Young and Middle-Aged Academic Conference on Medical Education hosted by the Chinese Medical Association. Administrators from 38 medical schools who were directly involved in curricular design and/or implementation completed the questionnaires. Data were analyzed using SPSS 17.0.
Objectives of medical curriculum reform Medical educators generally agreed with the seven objectives of medical curricular reform listed on our questionnaire, with most administrators stating that they ‘‘completely agree’’ or ‘‘mostly agree’’ that their institution had such objectives in mind when the reforms were instituted (Table 2).
Curriculum models
Results Of the 38 medical schools, 16 medical schools are affiliated with a larger university, while the other 22 are autonomous. Twenty-five of the 38 have already enacted medical curricular reform, while 13 have not and do not as of yet have a plan to do so. 1044
In 1999, Professor Frank J. Papa of the University of North Texas School of Medicine and Professor Peter H. Harasym of the Calgary University School of Medicine systematically reviewed both past and current medical curriculum models. They grouped each model into one of five types: (1) the apprenticeship-based curriculum model, ABCM, (2) the discipline-based curriculum model, DBCM, (3) the
South
East
Region
48.30M people in 236 700 km2
41.76M people in 394 000 km2
Yunnan
71.64M people in 102 600 km2
Jiangsu
Guangxi
45.52M people in 101 800 km2
Zhejiang
72.23M people in 179 800 km2
13.42M people in 6340.5 km2
Shanghai
Guangdong
91.08M people in 157 000 km2
Shandong
Province
Population and area
First class 6/16 ¼ 38% Second Class ¼ 0
Second class: 0/6 ¼ 0
First class: 13/38 ¼ 34%
Sample distribution by ranking
No
No
Youjiang Medical University for Nationalities Kunming Medical University
No No No
No No No
No
No
No
No Yes
No Yes
No
No
No
Guangxi Medical University
No
No
No
No
Medical School of Nantong University Yangzhou University Medical Academy Xuzhou Medical College Zhongshan School of Medicine, Sun Yat-Sen University Guangzhou Medical University Guangdong Medical College Southern Medical University
No
Yes
Medical College of Soochow University Nanjing Medical University
No No No
Yes
Yes
No No No
No
Yes
Yes
Yes
Yes
Yes
985
Yes
Yes
211
Hangzhou Normal University Shaoxing University Wenzhou Medical College
Second Military Medical University Zhejiang University School of Medicine
Tongji University School of Medicine Shanghai Medical College of Fudan University
Shandong University School of Medicine
Medical school
Table 1. Characteristics of the study sample.
years years years years
years years years years years years years years years years years years years years years
years years years years years years years 5 years
5 5 5 8 5 7 5
5 years 5 years 8 years
5 years
5 6 7 5
5 7 5 6 8 5 8 5 7 8 5 5 5 7 5
5 years 7 years 8 years
Duration of medical study programs
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No
Yes
Yes
Yes No No
No Yes
Yes
Yes
Yes
Yes
No No No
Yes
Yes
Yes
Yes
Yes
Curriculum reform
–
–
29
– – 15
37 6
41
–
7
13
43 – –
10
9
2
28
–
Basic medicine
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(continued )
–
–
30
29 – 27
37 5
44
–
20
28
– – 25
8
10
3
24
–
Clinical medicine
Rank among Chinese medical schools
Medical curriculum reform in China
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Central
North
West
Region
43.02M people in 166 900 km2
97.68M people in 167 000 km2
Jiangxi
Henan
Hubei
32.68M people in 156 381 km2 60.01M people in 185 900 km2
Shanxi
Liaoning
Inner Mongolia
Hebei
Tianjin
Beijing
Sichuan
11.54M people in 16 807.8 km2 9.32M people in 11 760.2 km2 67.82M people in 187 693 km2 23.50M people in 1 183 000 km2 41.62M people in 148 000 km2
18.89M people in 1 664 900 km2 31.30M people in 82 402 km2 85.29M people in 485 000 km2
Xinjiang
Chongqing
36.42M people in 205 800 km2
Shananxi
Province
Population and area
First class 4/21 ¼ 19% Second class 0/4 ¼ 0
First class 8/32 ¼ 25% Second class 0/8 ¼ 0
First class 4/23 ¼ 17% Second class 0/4 ¼ 0
Sample distribution by ranking
No
Hebei Medical University
JiuJiang University Medical Centre Gannan Medical University Xinxiang Medical University
No No No
No No
No
Yes
No
No
No
Hubei University of Medicine
Yes
Yes
Yes
No No
Liaoning Medical University Fenyang College Shanxi Medical University Tongji Medical College of Huazhong University of Science and Technology Wuhan University Medicine School
No No
No
Dalian Medical University
No
No
No
No
No
No
No
No
No
Yes
985
Inner Mongolia Medical University China Medical University
No
Yes
No
Yes
No
No
Yes
211
Tianjin Medical University
Capital Medical University
West China School of Medicine
Chongqing Medical University
Xinjiang Medical University
Xi’an Jiaotong University College of Medicine
Medical school
Table 1. Continued
years years years years years years years
years years years years years years years years years years
years years years years years years years years years years years years years years years years years
5 years 5 years
5 7 8 5 7 8 5
5 7 5 7 5 5 7 5 6 8
5 7 8 5 7 5 7 5 7 8 5 7 5 7 5 7 5
Duration of medical study programs
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Yes Yes
– –
–
–
No
Yes
17
8
Yes
Yes
34 –
–
16
–
–
21
No No
Yes
Yes
No
Yes
No
20
14
Yes
No
18
40
19
Basic medicine
Yes
Yes
Yes
Curriculum reform
– –
–
36
23
9
40 31
45
14
–
36
15
7
6
17
33
21
Clinical medicine
Rank among Chinese medical schools
L. Huang et al.
Medical curriculum reform in China
organ system-based curriculum model, OSBCM, (4) the problem-based curriculum model, PBCM and (5) the clinical presentation-based curriculum model, CPBCM (Papa & Harasym 1999; Kong et al. 2009). Of the 25 medical schools in our study that have already enacted medical curriculum reform, 15 (60.0%) adopted an organ system-based curriculum model, 8 (32.0%) adopted a problem-based curriculum model, and 2 (8.0%) adopted a hybrid curriculum model that includes aspects of both the
organ system-based curriculum model and the problem-based curriculum model. At 15 schools (60.0%), curricular reform involved both the ‘‘pre-clinical’’ and the ‘‘clinical’’ curricula. At 8 schools (32.0%), curricular reform was limited to the ‘‘pre-clinical’’ curricula. Finally, at 2 schools (8.0%), curricular reform chiefly involved the ‘‘clinical’’ curricula. About 20 medical schools (80.0%) ‘‘integrated courses from the old curricula into the new curricula’’, 2 medical schools (8.0%) ‘‘created entirely new curricula’’, and 3 medical schools (12.0%) maintained the old curricular structure while adding several comprehensive integrated courses.
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Teaching hours before and after curricular reform
Figure 1. Geographic location and statistical distribution of the study sample.
Following curricular reform, fifteen (60.0%) medical schools experienced a reduction in teaching hours, two (8.0%) experienced an increase in teaching hours, and eight (32.0%) did not experience any change in teaching hours. Further, the majority of medical schools reported an improvement in their students’ clinical skills (76.0%) and research skills (60.0%). Finally, teaching hours of the arts and humanities (56.0%) and of optional practice courses (52.0%) were unchanged at the majority of medical schools (Table 3).
Table 2. Objectives of medical curriculum reform.
Completely agree
Items
Mostly agree
Do not agree or disagree
Mostly disagree
Completely disagree
Number Percent Number of Percent Number Percent Number Percent Number Percent of schools (%) schools (%) of schools (%) of schools (%) of schools (%)
Number of schools Increase interdisciplinary coordination and maximize the efficiency of the curricula Decrease hours spent in lecture and increase students’ spare time Early clinical exposure Enhance clinical thinking and strategy skills Enhance research abilities Improve self-learning and independent problem solving Improve doctor/patient communication and ability to work as a team
19
76.0
6
24.0
0
0
0
0
0
0
16
64.0
6
24.0
3
12.0
0
0
0
0
20 21
80.0 84.0
3 2
12.0 8.0
2 2
8.0 8.0
0 0
0 0
0 0
0 0
12 19
48.0 76.0
11 5
44.0 20.0
2 1
8.0 4.0
0 0
0 0
0 0
0 0
17
68.0
6
24.0
2
8.0
0
0
0
0
Table 3. Lecture hours before and after medical curriculum reform.
Decreased Lecture hours Total teaching hours Arts and humanities Clinical skills Research Skills Optional lectures Optional practice
Remained the same
Increased
Number of schools
Percent (%)
Number of schools
Percent (%)
Number of schools
Percent (%)
15 3 1 2 2 2
60.0 12.0 4.0 8.0 8.0 8.0
8 14 5 8 11 13
32.0 56.0 20.0 32.0 44.0 52.0
2 8 19 15 12 10
8.0 32.0 76.0 60.0 48.0 40.0
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Table 4. Instructional methods used in reformed curriculum (%).
Form of education Lectures Problem-based learning (PBL) Case-based learning (CBL) Team-based learning (TBL) Computer-assisted learning (CAL) Medical simulation learning (MSL)
Number of schools
Percent (%)
25 25 18 13 13 16
100.0 100.0 72.0 52.0 52.0 64.0
Presented as a multiple choice question.
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Instructional methods and student evaluation Medical curriculum reform involves extensive modification to instructional methods. Although it can come in many forms, adoption of a hybrid set of instructional methods, that includes a primary emphasis on PBL, is central (Lieberman et al. 2010). All 25 medical schools that completed medical curriculum reform, in doing so, adopted multiple instructional methods. All medical schools adopted lectures and Problem-Based Learning (PBL), while Case-Based Learning (CBL) (72.0%) and Medical Simulation Learning (MSL) (64%) were also popular (Table 4). An equally important piece of curricular reform is improving the way medical students are assessed. Eighteen medical schools (72.0%) indicated that, following curricular reform, they now utilize a ‘‘formative assessment system’’, where student performance is evaluated throughout an entire course, rather than an ‘‘end-point assessment system’’, where the final examination alone determines a student’s competency. However, seven schools (28.0%) retained the ‘‘end-point assessment system’’. Eighteen medical schools (72.0%) gave their new curricula a positive review, claiming a noticeable improvement in the following student abilities: clinical thinking skills, patient– doctor communication skills, teamwork, self-learning, and overall general competence. The other seven schools (28.0%) ‘‘have yet to evaluate their medical curricula’’.
Faculty development All of the medical schools have in place various programs to provide support for their faculty to develop their teaching, research, and clinical skills. Seminars, lectures, invited speeches, and discussion sessions are offered to prepare faculty to meet the challenges of a changing world as well as to guide them towards the central direction envisioned by the nation. Training courses offer faculty practical information and relevant insights aimed at enhancing their professional competency and enriching their lives both professionally and personally. Discussion of innovative teaching models, reflection on the curriculum, and constructive suggestions are encouraged in these training courses. All the medical schools also send faculty abroad to learn from international colleagues and to participate in relevant educational programs. Creating a platform for discussion aimed at pedagogical improvement is the common goal. PBL tutor training sessions are also a part of faculty development at those schools that have adopted PBL 1048
curricula. Finally, these sessions offer faculty a chance to provide input concerning the reorganization and modification of teaching material that occurs with curricular reform.
Chief difficulties of instituting medical curriculum reform Reforming a medical curriculum requires a preparedness for some obstacles, that though predictable, are no less challenging (Muller et al. 2008). Problems that have been described in the relevant literature, including ‘‘training and organizing faculty’’, ‘‘increasing interdisciplinary coordination’’, and ‘‘changing the mindsets of faculty accustomed to antiquated techniques’’, were all viewed as ‘‘relatively difficult’’ to ‘‘extremely difficult’’ to overcome by fifty percent or more of the medical schools in our study. However, over half of the schools also claimed to have ‘‘almost no difficulty’’ to ‘‘no difficulty’’ in overcoming other obstacles including ‘‘adaptation by students’’ and ‘‘application of various instructional methods’’ (Table 5). Additionally, it is customary in Chinese schools that administrators, faculty, educators, and all relevant personnel are required to attend certain meetings and training sessions, though medical students’ involvement is limited.
Discussion Meeting the goals of medical curriculum reform The ‘‘discipline-based curriculum model’’ no longer meets the needs of physicians training in China because it causes a number of significant problems: (1) each discipline covers material that widely overlaps with other disciplines and thus topics of study can become redundant, resulting in an unnecessary increase in teaching hours for professors and learning burden for students; (2) a lack of elective courses prevents students from exploring their individual interests; (3) students do not receive sufficient clinical, research, and professional skills training and (4) assessment is limited to standardized means such as written examinations and lacks a formative component. Recognizing the need for reform, many schools updated their curricular models with the explicit purposes of ‘‘enhancing clinical thinking and strategy skills’’ training, ‘‘increasing interdisciplinary coordination’’ to ‘‘maximize the efficiency of the curricula’’, and ‘‘improving self-learning and independent problem solving’’ training.
Varying strategies between schools The core of medical curriculum reform is the integration of multiple subjects. Schools that instituted curricular reform for the most part changed their curricular models to either an ‘‘organ system-based model’’ or a ‘‘problem-based model’’. However, these schools took varying approaches at enacting the reforms. While some focused on the pre-clinical curricula, others focused on the longitudinal integration of the preclinical and clinical curricula. The majority of schools maintained several courses from their old curricula, while simultaneously integrating new courses to form a new
Medical curriculum reform in China
Table 5. Chief difficulties of instituting medical curriculum reform.
Extremely difficult
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Items Obtaining financial support Training and organizing faculty Increasing interdisciplinary coordination Changing the mindset of faculty accustomed to antiquated techniques Adaptation by students Integration of teaching content Application of various instructional methods Implementation of a formative evaluation system Preparing lecture materials
Relatively difficult
Hard to say
Almost no difficulty
No difficulty
Number of Percent Number of Percent Number of Percent Number of Percent Number of Percent schools (%) schools (%) schools (%) schools (%) schools (%) 0 1 5
0 4.0 20.0
10 12 14
40.0 48.0 56.0
2 1 1
8.0 4.0 4.0
12 10 5
48.0 40.0 20.0
1 1 0
4.0 4.0 0.0
2
8.0
12
48.0
4
16.0
7
28.0
0
0
0 2 1
0 8.0 4.0
3 9 4
12.0 36.0 16.0
9 2 4
36.0 8.0 16.0
12 12 16
48.0 48.0 64.0
1 0 0
4.0 0 0
0
0
9
36.0
7
28.0
9
36.0
0
0
1
4.0
6
24.0
8
32.0
10
40.0
0
0
curricular model. The preservation of popular or efficacious courses can breathe a sense of familiarity for both students and teachers alike into the new curricula, thus easing the transition. Very few schools completely dissolved all interdisciplinary boundaries by integrating pre-clinical coursework, clinical coursework, preventive medical courses, and the humanities in creating a new curriculum.
Emphasis on the cultivation of clinical competency Traditional medical curriculum models are greatly limited in the sense that they are designed merely to impart medical knowledge, and in so doing ignore the cultivation of professional skills that play an integral role in determining a medical student’s overall clinical competency. A vital goal of curricular reform therefore, is to cultivate medical students’ professional qualities. Most of the medical schools in this study increased teaching hours dedicated to clinical skills, research skills, optional lectures, optional practice, arts, and the humanities following curricular reform. The utilization of multiple instructional methods, establishment of a formative assessment system, and creation of the idea of a student-centered education all are geared towards nurturing students’ professional qualities.
Continued challenges Despite the large steps that the reforms described in this study represent for the small number of Chinese medical schools that have adopted them, they are just the initial stages towards an end goal of creating a mature medical curricular model. Such a model still eludes the majority of Chinese medical schools for a number of reasons. Attempting to integrate interdisciplinary curricula can sometimes lead to a piecemeal program that doesn’t fully achieve teaching goals. Such a phenomenon has already been reported by some medical schools in China. Further, administrators, organizers, professors, and tutors all have varied perceptions of what constitutes medical curriculum reform. A more unified understanding among faculty of
the goals and implementation strategies of curricular reform would benefit students and ease the transition for the school as a whole into the new curriculum. The majority of medical schools in China still employ the discipline-based curriculum model, where each discipline is taught almost completely independently of the others. If properly implemented, curricular model reform can drastically improve medical student education, teaching methods, assessment systems, and curricular efficiency. However, in order for reforms to succeed, both teachers and students must be willing to embrace an innovative educational philosophy that, in some cases, may be completely different than anything they have ever seen before. Among the schools that have instituted reforms, such an adjustment has proven difficult. Quite a large number of medical schools reported difficulties in the training of faculty. In general, schools can only offer a select few faculty members the experience of overseas training. Those faculty members can then return to China to serve as seed trainers for the rest of the faculty. Alternatively, hosting international experts can allow an entire faculty to gain exposure to ideas from abroad in one setting, though such exposure is usually temporary. Finally, the introduction of small group discussion teaching methods, which require a larger number of faculties and place an emphasis on clinical skills training, has placed an onerous financial burden on some medical schools.
What we need next Medical curriculum reform at Chinese medical schools has attracted a lot of attention in recent years. Several leading medical schools in China have undergone exploratory reforms and in so doing, have accumulated significant experiences as well as have made considerable progress. Although these leading medical schools have for the most part reached their pre-reform consensus goals, they have done so by using quite varied curricular models as well as by taking quite varied approaches at implementing the reforms. Despite a multitude of challenges, many medical schools report positive results
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L. Huang et al.
from initial evaluations of the reforms that they have enacted, but the long-term effects of such reforms remains unclear. Medical curriculum reform in China is in its infancy and will inevitably continue to spread, but careful guidance and attention will be required to ensure that the appropriate goals are achieved.
Notes on contributors Dr. LEI HUANG, MD, is an internist and Ph.D. candidate in psychiatry. She is in charging of the clinical teaching education and administration of Tongji Hospital, Tongji University School of Medicine. Dr. LIMING CHENG, MD, PHD, is an orthopedist and the Deputy Dean for Medical Education of Tongji Hospital, Tongji University School of Medicine.
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Dr. QIAOLING CAI, MD, is an internist and the Deputy Dean for Medical Education, Tongji University School of Medicine. Dr. RUSSELL OLIVE KOSIK, MD, MPH, is a radiology resident at the Santa Clara Valley Medical Center, San Jose, CA, USA. He received his MD from the UCLA School of Medicine, and MPH from the National Yang-Ming University. Ms. YUN HUANG is a medical student of Tongji University School of Medicine. Dr. XUDONG ZHAO, MD, PhD, is a psychiatrist and the Director of Division of Medical Humanities and Behavioral Sciences, Tongji University School of Medicine. Dr. GUO-TONG XU, MD, PhD, is an ophthalmologist and the Dean for Tongji University School of Medicine. Dr. TUNG-PING SU, MD, is the Chairman, Dept. of Psychiatry, School of Medicine at National Yang-Ming University. Dr. ALLEN WEN-HSIANG CHIU, MD, PhD, is the Dean, School of Medicine at National Yang-Ming University, Taiwan. Dr. ANGELA PEI-CHEN FAN, PhD, is the Associate Professor of Psychiatry, Faculty of Medicine at National Yang-Ming University. She received her MS from Harvard, PhD from the Johns Hopkins University, and served on the faculty of the Johns Hopkins University before she came to Taiwan.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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