Medical school places unfilled: nobody in China wants to be a doctor, and there are three good reasons why they don't

In western countries there is fierce competition to get a place in medical school. Only straight A students with an impressive portfolio of extra-curricular activities need apply. In China, the picture is very different. Even the top medical schools in China are struggling to attract students.

This week, Professor Yang Jun a distinguished cardiologist and head of the First College of Clinical Medical Sciences, Hubei, notes that Shanghai's prestigious Fudan University has had to drop its entrance mark threshold by 58 marks this year. The same "dumbing down" has been seen at the city's Jiatong University medical school and other medical schools across the country. When China's top medical school at  Peking Union Medical College allotted 10 places to Guangzhou students, only four applications were received - and of these only one was deemed to make the grade.

What's happening? The fact is, nobody with any ambition wants to be a doctor in China right now, and you can see why. The three main reasons are poor pay, long hours and terrible working conditions - including the real possibility of abuse and violence.

Writing in the International Journal of Cardiology, Professor Yang notes that the average salary of a doctor in China is 72,000 yuan a year (US$11,600) -  and many doctors earn a lot less than that, especially if they work in unpopular specialities such as paediatrics or emergency medicine (the so-called ambulance riders).

Poor pay for doctors in China: paediatricians are at the bottom, with only 63,000 yuan a year

For this salary, doctors have to work long hours - more than 50% of doctors work more than the 'specified' 40 hours a week and 30% work more than 60 hours a week.  Doctors also face huge workloads - as many as 80 patients in a single morning shift. As Professor Yang observes, the Mayo Clinic in the US has fifteen times more staff than the Peking Union Medical College, and yet it has only half the patient numbers.

Doctors in China simply don't have time to practice adequate medicine - and the consequences are unhappy patients who take out their frustration on staff. A recent survey of almost 10,000 doctors found that 60% had recently experienced abuse from patients, and 13% had experienced physical assaults.

Doctors also have to study long and hard to qualify - up to ten years including undergraduate and postgraduate qualifications. On top of this they have to publish articles and to gain academic merit for promotion.  Doctors have lost the status and respect they once had - and only 6.8% of doctors say they would advise their children to follow  a career in medicine.

This is already causing problems in the less popular branches of the profession. On 27 July, the National Health and Family Planning Commission announced that it would be waiving the usual entry criteria for admission to the specialities of paediatrics and emergency medicine. Medical student candidates who did not achieve the usual pass mark would be allowed to become trainee paediatricians and emergency medicine doctors if their coursework was of sufficiently high standard, the NHFPC announced. This has caused outrage among  doctors currently working in these specialities, who say it is a desperate and self -defeating move that will further reduce the attractiveness of their branches of medicine.

They say there is a need to improve pay and conditions in their work rather than lowering the bar to entry. Paediatrics and emergency medicine and notoriously poorly remunerated and yet high pressure jobs in the Chinese healthcare system. Assaults on doctors in these departments are numerous as they are in the front line seeing critically ill patients - especially the treasured offspring in a one-child system.

The doctor's social network site DXY echoed many of the criticisms of the "dumbing down" move. As one doctor wrote: "We work longer hours for less pay in unsafe conditions, but we stick to our posts because of the duty we have to the little ones who thank us after we have care for them."

Medical schools in China: outdated and unpopular

Some insider views of the Chinese medical education system have been published as part of The Lancet special China-themed issue this week. The rather gloomy conclusion is that China's vast medical education system is failing to attract good students and failing to produce graduates who are able and willing to work as doctors.

A review article notes that China made some major reforms to medical education in 1998, greatly expanding the number of students to produce half a million would-be doctors a year. However, many of these medical graduates do not enter medicine but take up other careers. Why is this? The review authors say there "is a mismatch of health professional education and employment opportunities".

Another article in the same issue of the Lancet throws further light on the lack of enthusiasm for medicine as a career: Dr Yang Pengfei of the Changhai Hospital, Second Military Medical University, Shanghai, says most doctors now advise their children against taking up a career in medicine and only 7% would recommend it. He cites the breakdown in trust and respect between patients and doctors and the tide of violence against medical staff - 30 killings in recent years by disgruntled patients and their families. Dr Yang notes that even the best medical schools such as Peking Union Medical College are now struggling to attract high quality students.

"The national admission score for a graduate student majoring in medicine has also declined for three consecutive years, according to the Chinese Ministry of Education. It is no longer the best students who go to medical school. This is a growing concern: who will be tomorrow's doctors?" he asks.

The review article says the problem of poor relations between patients and doctors is due in part to the narrow and inflexible education system that fails to instil students with the values, ethos, and ethics of the medical profession and also fails to produce doctors with good communication skills and characteristics such as empathy.

"The curriculum system still focuses narrowly on biomedicine, medical technology, and clinical practice. Pedagogic methods are rigid: mostly teacher-controlled didactic lecturing, which requires rote memorisation by students. The increase of disputes between doctors and patients, and violence against doctors in China might be associated with these deficiencies in education," it says.

Another problem with medical education in China is that it is still rigidly hospital focused and geared towards producing narrow specialists rather than generalists who can work in the community or in rural health.

"Therefore, it is not surprising that the graduates have limited knowledge about primary care services and prevention of diseases."

Will things improve in the near future? It's hard to see how, as huge class sizes are a barrier to more innovative teaching methods such as problem-based learning, and encouraging interaction and discussion.

China's medical schools may need to take a leaf from the book of China's factories. Instead of mass producing unpopular low quality products they could adapt the best foreign know-how and methods through joint ventures to produce a wider range of higher quality sought-after products.

Daily Mail fake miscarriage | 120 seconds per patient | Dogs a hepatitis risk | Atrial fibrillation untreated

The Daily Mail has been running a fake story claiming that a pregnant Changsha nurse had 'lost her baby' after being attacked by relatives of a cancer patient who died. Chinese media reported the attack but said she was fortunate to have avoided a miscarriage.

A doctor at a Guangzhou hospital could only spend an average of one and a half minutes per patient when he was the only clinician on duty and had a waiting room of 100 patients to see in one morning.

About 20% of dogs and 6% of cats in Guangzhou are infected with hepatitis E, a new study has shown. The high rates of hepatitis infection should raise concern about the eating of dogs, warn researchers from the South China Agricultural University.

China should not copy the US private model of healthcare according to Nobel prize winning economist Daniel McFadden, of the University of Southern California. Professor McFadden said that when looking at healthcare systems around the world, the most efficient are those where the community medical providers are either employed by the government or employed by companies that are largely contracting to the government and not operating as private businesses.

Hospital staff in the Muslim Xinjiang province have been told not to fast during Ramadan. The request was made at a meeting on upholding ethnic minority unity, “in order not to affect normal work and life." Muslim hospital staff members were requested to sign their pledge of compliance in a “responsibility book.”

One in ten emergency department patients leave without being seen by a doctor, according to a study carried out in Chengdu hospitals. Those who left tended to be families who arrived on foot with children who had less serious problems.

Most Chinese people with atrial fibrillation go untreated, with only 40% receiving anticoagulants, according to a study from Fuwai Hospital and Peking Union Medical College, Beijing.The study also showed that only 26% of people treated for  atrial fibrillation received adequate treatment.

Reform of the medical school curriculum is needed in China as many medical schools are still using outdated and ineffective teaching methods that fail to keep pace with developments in medicine, according to a study from Tongji University, Shanghai.

Iron deficiency anaemia is common in rural parts of central China, where only about 40% of infants have an adequate diet, a study by the UNICEF Office for China, Beijing, shows. Malnutrition and anaemia was more of a risk for ethnic minorities and for those living in poor mountainous areas.

Impressions of an American medic on a Chinese hospital ward round

Blog post by Dr Zachary Sholem Berger: "I sat in on rounds at Peking Union Medical College Hospital, my host and one of the top-ranked hospitals in China. The General Internal Medicine Division is renowned for its ability to treat the hardest cases and consistent high reputation, which becomes a self-fulfilling prophecy in certain respects (sound familiar?).
The similarities are not all that interesting: the team sits round a table and talks about the new patients, then walks through the wards seeing the old patients. Questions are asked to put medical students on the spot (in American English we have a word for that). The differences, however, are somewhat instructive.

Roommate's poisoning meant as joke: medical student

A medical student at Fudan University who was accused of poisoning his roommate to death said at trial today it was just an April Fool's joke.
Lin Senhao, 27, denied having held a grudge against his roommate, Huang Yang, though he thought Huang was self-righteous, the Shanghai No. 2 Intermediate People's Court heard in the ongoing trial.
Lin insisted that he didn't mean to kill Huang. Instead, the postgraduate student said he had planned to just make Huang feel sick since he believed Huang would take only a little of the toxin, which shouldn't have killed him, Lin said.
Lin said he had experimented on rats and many didn't die of poisoning.
Source: Shanghai Daily

Shanghai medical student used liver toxin to kill room-mate

A medical student of  Fudan University who is accused of poisoning his roommate to death in April will stand trial next week.

Lin Senhao reportedly held some grudge against his roommate, Huang Yang, over trivial matters. Huang, 27, a postgraduate student of Fudan University Medical School, died after drinking water that was laced with N-Nitrosodimethylamine, an organic chemical highly toxic to the liver. He was diagnosed with liver failure and died of poisoning on April 16.

The chemical is often used to induce liver disease in rats in cancer experiments in laboratories.

After being arrested, Lin admitted poisoning his roommate.

Lin told police that he stole the chemical from the university and injected it into the dispenser on March 31.

Source: Shanghai Daily

Five medical students found dead in Beijing

Five students from a medical college were found dead Monday morning in a rented house in Beijing, probably due to carbon monoxide poisoning, police said.
Arriving at the rented house in Chaoyang District at around 8:30 a.m., emergency doctors found the five men, from Harbin Medical University in northeast China's Heilongjiang Province, had all stopped breathing and had no pulse, police said.
The students were immediately rushed to a nearby hospital for treatment. But they died despite doctors' efforts.
They had been working as interns at the Sino-Japan Friendship Hospital in Beijing, according to the police. Six people were living in the house, but one of them had not been present on the night the tragedy occurred.
Initial investigation showed the five were killed by carbon monoxide, although the exact cause of their deaths is still being investigated.
Source: CRI

Chinese students sent to Nebraska to study medicine

Yang Hu is one of a select few students sponsored to study medicine in the US

by Paul Goodsell
Yang Hu is one of the first Chinese students chosen to enroll in the special program at the University of Nebraska Medical Center.
Going to an American medical school is more than a great opportunity for Yang. The program she joined is also a source of pride for UNMC and an example of the med center's growing international reputation.
While thousands of Chinese students already are at American medical schools for doctoral programs, research or short-term clinical rotations, the UNMC program is different. Only in Omaha does the Chinese government pick up the tab for its students to earn a four-year U.S. medical degree or a similar professional diploma in fields like pharmacy or physical therapy.
Besides bringing in tuition revenue, university officials say, they hope the students will establish relationships with UNMC that could lead to future research partnerships and other ties with China, the economic powerhouse that is expected to continue its rapid growth and increasing influence in the coming decades.
“These students will be leaders of Chinese health care,” said Jialin Zheng, a UNMC professor who heads UNMC's Asia Pacific Rim development program. “They will be ambassadors to future collaborations.”
For now, however, they are merely 20-something students wrestling with rigorous coursework, language challenges and an unfamiliar culture.
Yang and her fellow Chinese students have had to adjust to a different educational system and adapt to the American approach to health care.
They have stared blankly at American restaurant menus, worn costumes to Halloween parties and spent Thanksgivings with new Nebraska friends.
One is exploring Christianity after growing up as an atheist. Several have learned to drive.
The experience has “really helped me to broaden my horizon,” said Xin Zhang, a 26-year-old physical therapy student from Xi'an.
Xin and Yimei Huang, a pharmacy student from Chengdu, started at UNMC in 2011. This year, Yang and Lei Yu from Chengdu both entered the medical school.
The scholarship program is one element of the Shanghai-U.S. Health Science Initiative formalized in August when Nebraska Gov. Dave Heineman was in China on a trade mission. UNMC officials describe the broader pact as one of the most extensive partnerships between U.S. and Chinese academic institutions.
UNMC Chancellor Harold Maurer said the med center has ties with China that are envied by top U.S. universities. At a recent meeting with leading U.S. medical schools and the Chinese government, he said, “it was clear that UNMC is probably one of the best known U.S. institutions in China.”

Other schools such as Duke University asked the Chinese about why they were working so much with Nebraska, Maurer said. The answer: UNMC takes good care of its Chinese students and teaches them well. In addition, the Chinese noted, it doesn't cost as much to go to school in Nebraska.
With the new program, university officials have begun slowly, carefully selecting students for their English language ability and above-average test scores.
When fully implemented, there will be 10 new students arriving in Omaha each August — two in each of five areas: medicine, pharmacy, physical therapy, dentistry and nursing.
Read more: World Herald

New 10-year medical training program will produce rural generalists

The new 10-year medical training will focus on producing 'generalists'

China has initiated a 10-year education program that aims at cultivating more high-calibre doctors and training more general medical practitioners to serve the countryside.
The program emphasizes improving medical students' capacity in clinical practices and will require them to go through training in medical ethics and a formal residency before they become doctors, according to a notice issued by the Ministry of Education on Monday.
A total of 125 Chinese universities have been designated as the first batch of higher-education institutions to lecture medical students under the scheme.
Unlike the United States, where medical graduates have to go through tough examinations and residency programs before they become doctors, the majority of Chinese medical students go straight to work after graduation.
Chinese medical graduates go through residency training as hospital employees. The quality of training is highly dependent on hospitals.
Under the 10-year program, medical students will have to go through two or three years' residency training before they become doctors or assistant to general medical practitioners in rural areas, according to the notice.
Read more: Shanghai Daily

University of Cincinnati may open medical school in Chongqing

The University of Cincinnati has been in talks with Chinese officials about adding a medical school campus in China in conjunction with Chongqing Medical University.
College of Medicine Dean Tom Boat recently updated university trustees about the discussions.
Tens of millions of dollars would be needed in donations to make the UC campus a reality, The Cincinnati Enquirer reported. But supporters point to the potential for new growth and revenue in the world's largest nation by population.
"It would allow us to have an international connection with China that would really push our globalization efforts forward," Boat told professors and students last week.
China is the leading source for international students for UC, with 962 Chinese students enrolled this year. The university already has a number of collaboration and project agreements in China.
Boat emphasized the plans are in very early stages with Chongqing Medical University, which has four hospitals with 5,000 beds and treats millions of outpatients annually.
"If the plan plays out, yes, it would be a UC-branded campus," Boat said.
Duke University, in Durham, N.C., has moved ahead with its plans for a China campus in partnership with Chinese educators. Duke Kunshan University operations are currently expected to begin in the 2013-14 academic year, pending final approval from Chinese officials.
UC's College of Medicine could use another source of revenue. The medical school lost $7 million on operating costs, while receiving a $10 million one-time payment from Cincinnati Children's Hospital and Medical Center.
UC gave out $2.66 million in institutional aid to medical students in the 2010-11 school year, compared to $5.8 million by Ohio State University, the Cincinnati newspaper reported.

Read more: Newsday