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Teri A. Reynolds, PhD; Lawrence M. Tierney, Jr, MD
University of California, San Francisco, School of Medicine

JAMA. 2004;291:2141.

Modern Chinese medical education has recently undergone 3 distinct periods of development—before, during, and after the 1966-1976 Cultural Revolution—driven largely by extra-academic political forces.

In 1965 in China, there were 298 secondary medical-pharmaceutical schools with a 3- to 4-year curriculum, which admitted students with a junior high (9-year) education; 92 medical-pharmaceutical universities, usually with a 5-year curriculum, which admitted students after high school; and 21 colleges of traditional Chinese medicine.¹ The curriculum of the secondary medical schools at the time often included general education in language, literature, mathematics, and science, as well as specific vocational training in medicine. The medical university curriculum included 3 years of basic science lectures, 1 year of clinical didactics, and a 1-year practicum (similar to an internship year in the United States). University graduates were eligible to practice with no further training, whereas secondary school graduates were usually required to complete a practical internship first.²

With the onset of the Cultural Revolution, medical education essentially ceased; between 1966 and 1970, no new students were admitted and no formal instruction was given to those already enrolled.¹ In 1970, Chinese medical schools and universities were reopened but with a new philosophy of training peer-chosen "worker-peasant-soldier" students in a curriculum emphasizing political ideology and practical training over basic science.² Entrance examinations, as well as degrees and diplomas, were abolished, and a limited 3-year curriculum was instituted, even at the upper-level medical universities. Approximately one fourth of the curriculum was devoted to political science, and students were required to complete several weeks of agricultural and factory labor each year. Priority for admission was given to peasants, factory workers, or those in the liberation army, and students were not required to have finished high school. In fact, because of the disruptions during the initial period of the Cultural Revolution, many students began medical school with no more than a junior high education. Universities themselves had limited input,³ and, while in theory students were chosen by communities and coworkers whom they would return to serve, in practice they were also often chosen by Communist party officials.^2-3

The end of the Cultural Revolution brought the reinstitution of a national entrance examination in 1977, and by 1980, university admission was highly competitive, with an admission rate of less than 10%. Many graduates of the 1970s were recalled from their jobs for remedial coursework.²

The 1980s also brought attempts to reform extrauniversity medical education, such as that of the "barefoot doctors." Begun decades prior to and expanded during the Cultural Revolution, this program gave young agricultural or factory workers a few weeks to a year of training in preventive and practical medicine. They then provided medical care in the countryside, in factories, or in urban health stations and usually continued to work alongside those they treated. They numbered in the millions, and in all, fewer than 10% of "doctors" in 1972 China were college-educated in medicine. Similar to the way that many of the worker-peasant-soldier graduates were recalled in the post-Revolution period, so were many of the barefoot doctors: most took a written examination in 1980, and by 1984, one third had been retrained to secondary school level.²

Overall, though, the restored university curriculum looked much like the pre-Revolution curriculum, with some expansion of the time spent in clinical clerkships and the practicum.² In 1988, a national conference sponsored by the World Bank and the World Health Organization⁴ suggested several reforms, including the introduction of problem-based, less didactic learning and a focus on prevention and rural health needs. Then as now, the majority of physicians in China were educated within secondary schools rather than universities, and further reform of 3-year secondary medical education and barefoot doctor programs were discussed as a means of meeting the needs of the increasingly elderly rural Chinese population.

As of 1996, there were 550 secondary medical-pharmaceutical schools, 123 medical-pharmaceutical universities, and 30 colleges of traditional Chinese medicine in China.¹ Medical curricula vary greatly, from 3 years at secondary schools to 5 to 8 years at universities. The most common course of study is 5 years and has changed little since the late 1970s. Students are placed based on the results of national entrance examinations, but there is still no national exit examination, nor is there a central accreditation body for medical schools and universities.¹ It remains to be seen whether recent regional⁵ and global^5-7 attempts to set universal standards for medical education will be incorporated in China.

REFERENCES
1. Gao T, Shiwaku K, Fukushima T, Isobe A, Yamane Y. Medical education in China for the 21st century. Med Educ. 1999;33:768-773. PUBMED 2. Fox S. Hippocrates unbound: China's medical education for the 1980s. JAMA. 1984;251:490-494. FREE FULL TEXT 3. Wen CP, Hays CW. Medical education in China in the postcultural revolution era. N Engl J Med. 1975;292:998-1005. ABSTRACT 4. Kaufman A, Hamilton JD, Peabody JW. Medical education in China for the 21st century: the context for change. Med Educ. 1988;22:253-260. PUBMED 5. Lee SH, Lee JC. Mainland China, Taiwan, and the Hong Kong region: the Second Medical Education Conference. Med Educ. 1997;31:468-472. PUBMED 6. Schwarz MR, Wojtczak A. Global minimum essential requirements: a road towards competence-oriented medical education. Med Teach. 2002;24:125-129. FULL TEXT | PUBMED 7. Core Committee. Institute for International Medical Education. Global minimum essential requirements in medical education. Med Teach. 2002;24:130-135. FULL TEXT | WEB OF SCIENCE | PUBMED

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