- Email: [email protected]
Pursuing excellence in graduate medical education in China
Comment
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WHO. Neglected tropical diseases. 2016. http://www.who.int/neglected_ diseases/diseases/en/(accessed July 25, 2016). Hotez PJ, Brindley PJ, Bethony JM, King CH, Pearce EJ, Jacobson J. Helminth infections: the great neglected tropical diseases. J Clin Invest 2008; 118: 1311–21. Feldmeier H, Krantz I, Poggensee G. Female genital schistosomiasis as a risk-factor for the transmission of HIV. Int J STD AIDS 1994; 5: 368–72. Bentwich Z, Kalinkovich A, Weisman Z. Immune activation is a dominant factor in the pathogenesis of African AIDS. Immunol Today 1995; 16: 187–91. Pearce EJ, Caspar P, Grzych JM, Lewis FA, Sher A. Downregulation of Th1 cytokine production accompanies induction of Th2 responses by a parasitic helminth, Schistosoma mansoni. J Exp Med 1991; 173: 159–66. Kjetland EF, Ndhlovu PD, Gomo E, et al. Association between genital schistosomiasis and HIV in rural Zimbabwean women. AIDS 2006; 20: 593–600. Downs JA, van Dam GJ, Changalucha JM, et al. Association of schistosomiasis and HIV infection in Tanzania. Am J Trop Med Hyg 2012; 87: 868–73.
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Nielsen N, Simonsen P, Magnussen P, Magesa S, Friis H. Cross-sectional relationship between HIV, lymphatic filariasis and other parasitic infections in adults in coastal northeastern Tanzania. Trans R Soc Trop Med Hyg 2006; 100: 543–50. Kroidl I, Saathof E, Maganga L, et al. Effect of Wuchereria bancrofti infection on HIV incidence in southwest Tanzania: a prospective cohort study. Lancet 2016; published online first Aug 2. http://dx.doi.org/10.1016/ S0140-6736(16)31252-1. Schüle SA, Clowes P, Kroidl I, et al. Ascaris lumbricoides infection and its relation to environmental factors in the Mbeya region of Tanzania, a cross-sectional, population-based study. PLoS One 2014; 9: e92032. Riess H, Clowes P, Kroidl I, et al. Hookworm infection and environmental factors in mbeya region, Tanzania: a cross-sectional, population-based study. PLoS Negl Trop Dis 2013; 7: e2408. Knopp S, Corstjens PLAM, Koukounari A, et al. Sensitivity and specificity of a urine circulating anodic antigen test for the diagnosis of schistosoma haematobium in low endemic settings. PLoS Negl Trop Dis 2015; 9: e0003752.
Unquestionably, one of China’s primary challenges in health-care reform is improving the quality of clinical services.1 Patients who seek quality of care bypass poorly staffed primary care facilities for long waits in congested hospitals. Unsatisfactory quality of care is a major source of conflict between patients and doctors. Health inequity in China is due less to a shortage of health-care workers and more to abundant yet poorly educated service providers, especially in rural areas. That is why seven Chinese Government ministries in 2013 jointly launched the Standardized Residency Training (SRT) programme, which consists of 3 years of residency training after 5 years of medical school.2 The SRT represents China’s commitment to achieving high national quality standards, backed by the government’s investment of an additional US$7 billion before 2020. Standardisation of quality of care constitutes an enormous challenge for China, where the 26 000 hospitals are stand-alone institutions without systems of accreditation, certification, or the sharing of best practices and outstanding faculty. Many groups will have to contribute to the SRT, especially leading institutions such as the Peking Union Medical College Hospital (PUMCH), arguably China’s top hospital and also the birthplace of modern graduate medical education in China.3 Established in 1921 by the Rockefeller Foundation’s China Medical Board, PUMCH adopted the Johns Hopkins model, translating the 1910 Flexner Report to integrate modern medical sciences into clinical services.4 PUMCH has produced some of China’s most distinguished health leaders and set the benchmark for www.thelancet.com Vol 388 October 15, 2016
clinical excellence.5 Like other top hospitals in China, PUMCH today has to grapple with a sheer volume of services, with 800 faculty members and 500 residents serving 2200 inpatients and 13 000 outpatients daily (Axelrod L, PUMCH, personal communication). PUMCH will attempt to fulfil its national responsibility through the two-prong strategy of reaching for the top while lifting up the bottom. As the national leader, PUMCH aims to keep pace with the world’s advancement in patient care and clinical education by achieving clinical excellence in its own residency programme. International experiences have shown that strong residency programmes are associated with the best hospitals.6 PUMCH will also participate in disseminating its quality standards nationally. Working with others, PUMCH will join in setting national standards and strengthening China’s national accreditation and certification systems, which are to be managed by national health authorities. To achieve these aims, PUMCH has launched a 5-year plan to reinvigorate its residency programme, which aims to produce competent professionals for independent high-quality clinical practice. Under continuous development are evidence-based case teaching, faculty mentoring, balanced patient workloads, and the inculcation of teamwork.7 Patientcentred learning will be blended with innovative teaching methods, interactive IT-based learning, simulation exercises, objective testing, and telemedicine. PUMCH recently announced an unprecedented postdoctoral residency programme. The first cohort starting in August, 2016, consists of 20 highly competitive
Peking Union Medical College Hospital
Pursuing excellence in graduate medical education in China
See Editorial page 1851 See Review pages 1922, 1930, and 1939 See Viewpoint page 1952
1859
Comment
residents who will receive intensified training and exceptional salaries and living quarters, with the aim to address growing concerns among residents.8 Teach-the-teachers is the PUMCH strategy for extending PUMCH’s vision of quality to other hospitals in China. Experience has shown how leading hospitals in countries that are members of the Organisation for Economic Co-operation and Development have produced and dispersed a nucleus of well trained physicians to spread high-quality standards.6 Since its founding, PUMCH has attracted and dispatched its graduating teachers for capacity-building throughout China. In 2015, 1008 doctors and 634 nurses were trained as nonresident trainees at PUMCH for 6–12 months, before returning home to their local hospitals. China’s new national accreditation and certification systems will be able to deliver improved results by harnessing the professional engagement of China’s most outstanding clinicians. At the request of the National Health and Family Planning Commission, in October, 2015, PUMCH established a consortium of China’s seven leading university hospitals, comprising Central South University Xiangya Hospital (Changsha, Hunan), Fudan University Zhongshan Hospital (Shanghai), PUMCH (Beijing), Peking University First Hospital (Beijing), Sichuan University West China Hospital (Chengdu, Sichuan), the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, Guangdong), and the First Affiliated Hospital of Zhejiang University (Hangzhou, Zhejiang). This sevenmember consortium will lead and support the 24 pilot demonstration hospitals and 559 accredited hospitals for cascading quality improvement across the country. The consortium will foster mutual learning and the teachthe-teachers strategy through propagating best practices, quality standardisation, matching of residents, faculty development, tracking of progress, and international collaboration. A major obstacle to progress will be the lack
of information, transparency, and standards of Chinese hospitals. Proposed for the consortium are a series of self-studies starting in October, 2016, as the first step in continuous quality improvement and ultimately quality diffusion to other hospitals. China’s timeline for achieving national SRT matches the 5-year approach to PUMCH’s 100th anniversary in 2021. PUMCH, in partnership once again with the China Medical Board, has the ambition to lead the improvement of quality of care in China. PUMCH recognises that quality involves both technical competency and patient-centred professionalism. PUMCH should show and spread its education of doctors and nurses beyond producing technicians, to nurturing humanistic, empathetic, and ethical professionals. These qualities were embedded in PUMCH’s values 95 years ago. PUMCH intends to build upon these core values by striving for both clinical excellence and national impact into the future. *Yupei Zhao, Shuyang Zhang, Wenkai Li, Lincoln Chen Peking Union Medical College Hospital, Beijing 100730, China (YZ, SZ); China Medical Board, Beijing Office, Beijing, China (WL); and China Medical Board, Cambridge, MA, USA (LC) [email protected] YZ is President of the Peking Union Medical College Hospital. LC is President of the China Medical Board. All other authors declare no competing interests. 1 2
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Wang HH. China’s new health department: progress and priorities. Lancet 2014; 384: 733–34. Zhu J, Li W, Chen L. Doctors in China: improving quality through modernisation of residency education. Lancet 2016; published online Jun 17. http://dx.doi.org/10.1016/S0140-6736(16)00582-1. Hospital Management Institute, Fudan University. 2014 best hospitals rankings in China. http://www.fudanmed.com/institute/news2014-3.aspx (accessed July 18, 2016). Sanders MB. Dedication exercises of the Peking Union Medical College. Boston Med Surg J 1921; 185: 672–73. Bullock M. An American transplant: the Rockefeller Foundation and Peking Union Medical College. Berkeley: University of California Press, 1980. Ludmerer KM. Let me heal: the opportunity to preserve excellence in American medicine. Oxford: Oxford University Press, 2014. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med 2006; 355: 1339–44. Wu LX, Qi L, Li Y. Challenges faced by young Chinese doctors. Lancet 2016; 387: 1617.
Harnessing China’s universities for global health See Editorial page 1851 See Review pages 1922, 1930, and 1939 See Viewpoint page 1952
1860
In 1963, China’s medical teams became its signature programme for international health outreach work.1 15 years later, the so-called barefoot doctor approach for training locals in basic medical care2 inspired the global primary health care initiative at Alma-Ata.3 Since 2015, China has launched a series of international programmes:
the Cape Town Declaration;1 a new global development fund with an initial US$2 billion;4 and the “six 100s” initiative, which aims to make available 100 programmes for poverty reduction, agricultural cooperation, trade promotion, and environment protection in addition to 100 new hospitals and clinics and 100 schools and www.thelancet.com Vol 388 October 15, 2016
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WHO. Neglected tropical diseases. 2016. http://www.who.int/neglected_ diseases/diseases/en/(accessed July 25, 2016). Hotez PJ, Brindley PJ, Bethony JM, King CH, Pearce EJ, Jacobson J. Helminth infections: the great neglected tropical diseases. J Clin Invest 2008; 118: 1311–21. Feldmeier H, Krantz I, Poggensee G. Female genital schistosomiasis as a risk-factor for the transmission of HIV. Int J STD AIDS 1994; 5: 368–72. Bentwich Z, Kalinkovich A, Weisman Z. Immune activation is a dominant factor in the pathogenesis of African AIDS. Immunol Today 1995; 16: 187–91. Pearce EJ, Caspar P, Grzych JM, Lewis FA, Sher A. Downregulation of Th1 cytokine production accompanies induction of Th2 responses by a parasitic helminth, Schistosoma mansoni. J Exp Med 1991; 173: 159–66. Kjetland EF, Ndhlovu PD, Gomo E, et al. Association between genital schistosomiasis and HIV in rural Zimbabwean women. AIDS 2006; 20: 593–600. Downs JA, van Dam GJ, Changalucha JM, et al. Association of schistosomiasis and HIV infection in Tanzania. Am J Trop Med Hyg 2012; 87: 868–73.
9
10
11
12
13
Nielsen N, Simonsen P, Magnussen P, Magesa S, Friis H. Cross-sectional relationship between HIV, lymphatic filariasis and other parasitic infections in adults in coastal northeastern Tanzania. Trans R Soc Trop Med Hyg 2006; 100: 543–50. Kroidl I, Saathof E, Maganga L, et al. Effect of Wuchereria bancrofti infection on HIV incidence in southwest Tanzania: a prospective cohort study. Lancet 2016; published online first Aug 2. http://dx.doi.org/10.1016/ S0140-6736(16)31252-1. Schüle SA, Clowes P, Kroidl I, et al. Ascaris lumbricoides infection and its relation to environmental factors in the Mbeya region of Tanzania, a cross-sectional, population-based study. PLoS One 2014; 9: e92032. Riess H, Clowes P, Kroidl I, et al. Hookworm infection and environmental factors in mbeya region, Tanzania: a cross-sectional, population-based study. PLoS Negl Trop Dis 2013; 7: e2408. Knopp S, Corstjens PLAM, Koukounari A, et al. Sensitivity and specificity of a urine circulating anodic antigen test for the diagnosis of schistosoma haematobium in low endemic settings. PLoS Negl Trop Dis 2015; 9: e0003752.
Unquestionably, one of China’s primary challenges in health-care reform is improving the quality of clinical services.1 Patients who seek quality of care bypass poorly staffed primary care facilities for long waits in congested hospitals. Unsatisfactory quality of care is a major source of conflict between patients and doctors. Health inequity in China is due less to a shortage of health-care workers and more to abundant yet poorly educated service providers, especially in rural areas. That is why seven Chinese Government ministries in 2013 jointly launched the Standardized Residency Training (SRT) programme, which consists of 3 years of residency training after 5 years of medical school.2 The SRT represents China’s commitment to achieving high national quality standards, backed by the government’s investment of an additional US$7 billion before 2020. Standardisation of quality of care constitutes an enormous challenge for China, where the 26 000 hospitals are stand-alone institutions without systems of accreditation, certification, or the sharing of best practices and outstanding faculty. Many groups will have to contribute to the SRT, especially leading institutions such as the Peking Union Medical College Hospital (PUMCH), arguably China’s top hospital and also the birthplace of modern graduate medical education in China.3 Established in 1921 by the Rockefeller Foundation’s China Medical Board, PUMCH adopted the Johns Hopkins model, translating the 1910 Flexner Report to integrate modern medical sciences into clinical services.4 PUMCH has produced some of China’s most distinguished health leaders and set the benchmark for www.thelancet.com Vol 388 October 15, 2016
clinical excellence.5 Like other top hospitals in China, PUMCH today has to grapple with a sheer volume of services, with 800 faculty members and 500 residents serving 2200 inpatients and 13 000 outpatients daily (Axelrod L, PUMCH, personal communication). PUMCH will attempt to fulfil its national responsibility through the two-prong strategy of reaching for the top while lifting up the bottom. As the national leader, PUMCH aims to keep pace with the world’s advancement in patient care and clinical education by achieving clinical excellence in its own residency programme. International experiences have shown that strong residency programmes are associated with the best hospitals.6 PUMCH will also participate in disseminating its quality standards nationally. Working with others, PUMCH will join in setting national standards and strengthening China’s national accreditation and certification systems, which are to be managed by national health authorities. To achieve these aims, PUMCH has launched a 5-year plan to reinvigorate its residency programme, which aims to produce competent professionals for independent high-quality clinical practice. Under continuous development are evidence-based case teaching, faculty mentoring, balanced patient workloads, and the inculcation of teamwork.7 Patientcentred learning will be blended with innovative teaching methods, interactive IT-based learning, simulation exercises, objective testing, and telemedicine. PUMCH recently announced an unprecedented postdoctoral residency programme. The first cohort starting in August, 2016, consists of 20 highly competitive
Peking Union Medical College Hospital
Pursuing excellence in graduate medical education in China
See Editorial page 1851 See Review pages 1922, 1930, and 1939 See Viewpoint page 1952
1859
Comment
residents who will receive intensified training and exceptional salaries and living quarters, with the aim to address growing concerns among residents.8 Teach-the-teachers is the PUMCH strategy for extending PUMCH’s vision of quality to other hospitals in China. Experience has shown how leading hospitals in countries that are members of the Organisation for Economic Co-operation and Development have produced and dispersed a nucleus of well trained physicians to spread high-quality standards.6 Since its founding, PUMCH has attracted and dispatched its graduating teachers for capacity-building throughout China. In 2015, 1008 doctors and 634 nurses were trained as nonresident trainees at PUMCH for 6–12 months, before returning home to their local hospitals. China’s new national accreditation and certification systems will be able to deliver improved results by harnessing the professional engagement of China’s most outstanding clinicians. At the request of the National Health and Family Planning Commission, in October, 2015, PUMCH established a consortium of China’s seven leading university hospitals, comprising Central South University Xiangya Hospital (Changsha, Hunan), Fudan University Zhongshan Hospital (Shanghai), PUMCH (Beijing), Peking University First Hospital (Beijing), Sichuan University West China Hospital (Chengdu, Sichuan), the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, Guangdong), and the First Affiliated Hospital of Zhejiang University (Hangzhou, Zhejiang). This sevenmember consortium will lead and support the 24 pilot demonstration hospitals and 559 accredited hospitals for cascading quality improvement across the country. The consortium will foster mutual learning and the teachthe-teachers strategy through propagating best practices, quality standardisation, matching of residents, faculty development, tracking of progress, and international collaboration. A major obstacle to progress will be the lack
of information, transparency, and standards of Chinese hospitals. Proposed for the consortium are a series of self-studies starting in October, 2016, as the first step in continuous quality improvement and ultimately quality diffusion to other hospitals. China’s timeline for achieving national SRT matches the 5-year approach to PUMCH’s 100th anniversary in 2021. PUMCH, in partnership once again with the China Medical Board, has the ambition to lead the improvement of quality of care in China. PUMCH recognises that quality involves both technical competency and patient-centred professionalism. PUMCH should show and spread its education of doctors and nurses beyond producing technicians, to nurturing humanistic, empathetic, and ethical professionals. These qualities were embedded in PUMCH’s values 95 years ago. PUMCH intends to build upon these core values by striving for both clinical excellence and national impact into the future. *Yupei Zhao, Shuyang Zhang, Wenkai Li, Lincoln Chen Peking Union Medical College Hospital, Beijing 100730, China (YZ, SZ); China Medical Board, Beijing Office, Beijing, China (WL); and China Medical Board, Cambridge, MA, USA (LC) [email protected] YZ is President of the Peking Union Medical College Hospital. LC is President of the China Medical Board. All other authors declare no competing interests. 1 2
3
4 5 6 7 8
Wang HH. China’s new health department: progress and priorities. Lancet 2014; 384: 733–34. Zhu J, Li W, Chen L. Doctors in China: improving quality through modernisation of residency education. Lancet 2016; published online Jun 17. http://dx.doi.org/10.1016/S0140-6736(16)00582-1. Hospital Management Institute, Fudan University. 2014 best hospitals rankings in China. http://www.fudanmed.com/institute/news2014-3.aspx (accessed July 18, 2016). Sanders MB. Dedication exercises of the Peking Union Medical College. Boston Med Surg J 1921; 185: 672–73. Bullock M. An American transplant: the Rockefeller Foundation and Peking Union Medical College. Berkeley: University of California Press, 1980. Ludmerer KM. Let me heal: the opportunity to preserve excellence in American medicine. Oxford: Oxford University Press, 2014. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med 2006; 355: 1339–44. Wu LX, Qi L, Li Y. Challenges faced by young Chinese doctors. Lancet 2016; 387: 1617.
Harnessing China’s universities for global health See Editorial page 1851 See Review pages 1922, 1930, and 1939 See Viewpoint page 1952
1860
In 1963, China’s medical teams became its signature programme for international health outreach work.1 15 years later, the so-called barefoot doctor approach for training locals in basic medical care2 inspired the global primary health care initiative at Alma-Ata.3 Since 2015, China has launched a series of international programmes:
the Cape Town Declaration;1 a new global development fund with an initial US$2 billion;4 and the “six 100s” initiative, which aims to make available 100 programmes for poverty reduction, agricultural cooperation, trade promotion, and environment protection in addition to 100 new hospitals and clinics and 100 schools and www.thelancet.com Vol 388 October 15, 2016