Medical students have been trained for eight years, why don't they see a doctor?

"Now that the patient's hematocrit is 21%, will you choose a blood transfusion?"


“18%。 ”

"The patient is severely anemic, and I will have a blood transfusion."

"Do you mean that 18% of the hematocrit should be transfused, and 21% should not be transfused?"

This conversation comes from the book "I Became a Doctor in America" and describes a test taker in a hospital in the United States as they take a mock exam for residency training. "The patient is alive, the surgery is ongoing, everything is dynamic, and answering questions should be dynamic. If a data is used to decide whether or not to transfuse blood, it is a clinical failure. The author writes.

In recent years, the number of medical students graduating from ordinary colleges and universities in China has increased year by year, with a cumulative total of 3.92 million graduates from 2016 to 2020. However, for a long time, the training of domestic medical students has faced problems such as multiple academic systems, mixed degrees, and the lack of unified standards for standardized training of resident doctors (hereinafter referred to as standardized training).

A few days ago, the Central Office and the State Office issued the "Opinions on Further Improving the Medical and Health Service System", which mentioned that it is necessary to strengthen the coordination of medical education, implement post-graduation education and continuing education, and improve the standardized training system for resident doctors.

"The medical education system has not been clarified. This is also the fundamental reason why the country spends a lot of effort to train many medical students, but not so many people will eventually see a doctor. Ge Junbo, academician of the Chinese Academy of Sciences and president of the First Affiliated Hospital of the University of Science and Technology of China, told China Newsweek.

There are many academic systems and mixed degrees

Zhang Man graduated from a well-known local medical school in Guangzhou with a bachelor's degree and a master's degree, and has undergone "5+3" integrated training, that is, 5 years of clinical medicine bachelor's degree and 3 years of professional master's degree. In 2021, Zhang Man graduated with a master's degree and is now a breast doctor in a local tertiary hospital in Guangzhou.

Medical education has its own special regularity, recognized at home and abroad as a continuous unity composed of college education, post-graduation education and continuing education, among which, post-graduation medical education is divided into two stages: standardized training and standardized training of specialists (hereinafter referred to as specialized training). On the one hand, medical students who specialize in master's and master's training rotate in the hospital and are managed by the hospital, and in essence, they are master's students and are under the management of the school.

During his postgraduate studies, Zhang Man had to complete the training in order to obtain the certificate of completion of the training, the qualification certificate of a licensed physician, a professional master's degree certificate, and a professional master's degree certificate, commonly known as "four certificates in one".

The "5+3" integrated academic system experienced by Zhang Man is the mainstream medical student training model in China, and this model was established in China in 2015. In that year, the Ministry of Education and other six departments jointly issued the "Opinions on Deepening the Reform of Clinical Medical Talent Training through Collaboration between Medicine and Education", which required that from that year, the enrollment of seven-year clinical medicine majors should be stopped and adjusted to a "5+3" integrated clinical medical talent training model.

On September 19, 2017, a third-year student majoring in clinical medicine at a university in Qingdao, Shandong Province, took his first local anatomy class since enrollment. Photo/Visual China

At present, the academic system of domestic medical students training also includes three-year specialty, five-year undergraduate, and eight-year undergraduate study in clinical medicine (hereinafter referred to as the eight-year program). Ge Junbo said that the eight-year program is equivalent to medical elite education, and there are only more than ten colleges and universities in the country. But in fact, eight-year students only spend about half a year writing their dissertations, and some students' thesis levels may not meet the requirements for doctoral graduation.

If you finish your master's degree and then do your doctorate, you will also face this problem. Research-oriented medical doctors generally graduate in three years, the first year to learn basic courses, the second year to do experiments, after that, prepare the graduation thesis. In Ge Junbo's view, due to time constraints, most of the papers written by medical students at this stage are repeating what others have done, and lack innovation.

Xiong Sidong, former president of Soochow University and engaged in molecular immunology and virology research, told China Newsweek that medical schools train students with medical education and medical knowledge. Now he is more worried about the trend of scientific clinical medicine. For eight-year students, in addition to learning basic courses and basic medical knowledge, they must complete 3 years of regular training after graduation before they can carry out clinical work. Standardized training should be carried out in affiliated hospitals of medical schools, and some hospitals have a limited number of students, which leads to some students may not have the opportunity to complete standardized training after medical school education, and some people will eventually choose to engage in scientific research.

Xiong Sidong said that now the medical education of many colleges and universities "grasps the eyebrows and beards", seeking high and greedy, from a three-year system to a four-year system, a four-year system to a five-year system, and now even extended to a ten-year system. On this basis, some universities also require students to obtain a double doctoral degree, namely MD and PhD, the former is a doctorate in clinical medicine, and the latter is an academic doctorate. "The one-size-fits-all medical student training system needs to be adjusted, and not all doctors need to train for 8 years or more." Xiong Sidong said.

In the United States, students should study science and engineering or other majors for four years during undergraduate studies before applying for medical school, that is, the "4+4" model. Medical students trained in the "4+4" model in the United States do not necessarily have to write papers, and graduation is equivalent to MD.

Lei Gao is a cardiology clinician in the United States, the president of the North American Chinese Physicians Alliance, and an expert member of the American College of Cardiology (FACC). He told China Newsweek that the "4+4" eight-year medical teaching model in the United States has also been criticized by the American industry. There is a view that this training method, which costs more money and takes longer, is not the best way to train doctors, and that the United States is the only one in the world to do so.

Some domestic universities are also constantly exploring a "4+4" academic system similar to that of the United States. As early as 2002, Shanghai Jiaotong University School of Medicine opened the "4+4" training model for clinical medical doctors, and has been continuously enrolled for 20 years. In September 2018, Peking Union Medical College officially implemented the "4+4" academic system reform, and in the same year, the pilot class began to enroll. However, the enrollment of the "4+4" model of the two medical schools mentioned above has been small. In 2023, Shanghai Jiaotong University School of Medicine and Peking Union Medical College will enroll 25 and 18 students respectively.

In Gao Lei's view, the complexity of domestic medical degrees is reflected in the vague requirements for medical students and doctors, overemphasizing the importance of scientific research, and ignoring the essence of doctors to treat patients and save people. China has set up too many degree systems in the training of doctors, disrupting its own training system.

In the 90s, Ge Junbo studied and worked in Germany for 10 years. In 1990, after graduating from Shanghai Medical University with a doctorate, he was sent to the University of Mainz School of Medicine in Germany for joint training. In 1995, he became Head of the Endovascular Ultrasound Department of the Department of Cardiology, Faculty of Medicine of the University of Essen, Germany. Ge Junbo believes that he has taken many detours. In his view, the training time of doctors should be reasonably shortened, so that they can master the knowledge of various subdisciplines in the shortest possible time and become a good doctor.

Ge Junbo observed that in Germany, clinical medicine is not the familiar bachelor's-master-doctoral system, but similar to a university study course with a total of 6 years and 3 months, and the graduation certificate obtained is not a general degree certificate or graduation certificate, but a medical qualification certificate. The whole clinical medical study stage is divided into 2 years of clinical preparatory course, 3 years of clinical course, and 1 year of clinical internship. In the clinical internship stage, it is necessary to rotate in each department, and when leaving the department, a certain clinical assessment index should be reached.

Ge Junbo analyzed that China should combine master's and doctoral degrees, because it is difficult to learn "real materials" simply by studying for a master's degree in medicine. A medical student who completes 5 years of medical education and 3 years of regular training can fully obtain a doctorate degree in clinical medicine. The 5-year stage is to learn the basics of medicine, and the 3-year stage is to rotate in each department to learn the diseases of each system, and the entire training period is not mandatory to do scientific research.

How should the training be carried out?

In 1994, Gao Lei graduated from a domestic university with a bachelor's degree in clinical medicine, when he applied to work in a hospital in Suzhou. "At that time, I noticed that Suzhou already had a relatively good residency training program, although there were certain limitations." He told China Newsweek.

After graduating from medical school, Gao Lei joined the cardiology department of a hospital in Suzhou, where he first experienced a three-year rotation of various departments of internal medicine, involving respiratory medicine, gastroenterology, cardiovascular medicine and other subdivisions. After completing the rotation, you have the opportunity to become a specialist. During the rotation, the hospital will issue a notebook to each person, and the medical records and clinical operations must be clearly recorded, and at the end of each rotation, the instructor will sign the book. The specific arrangement of rotation is the responsibility of the medical education department of the hospital, and the individual still belongs to the cardiology department, the salary is paid by the cardiology department, and the basic award of the cardiology department can also be obtained. Every year, the Health Bureau organizes a residency knowledge examination.

Clinical skills assessment of medical students of Guilin Medical College before graduation. Photo/Zhongxin

"This is the early prototype of local training, and the overall feeling is that the training was very formal at that time. The relationship between teachers and students is also very good, and I have benefited a lot from the willingness of teachers to teach students. In Gao Lei's impression, at that time, he could be familiar with general internal medicine operations such as chest piercing, abdominal puncture, and bone piercing.

In December 2013, the former National Health and Family Planning Commission and other seven departments jointly issued the Guiding Opinions on the Establishment of a Standardized Training System for Resident Physicians (hereinafter referred to as the "Guiding Opinions"), marking the formal establishment and implementation of a standardized training system in China. In 2014, the former National Health and Family Planning Commission successively issued a series of supporting documents such as the Administrative Measures for Standardized Training of Resident Physicians (Trial), which initially built a policy system for domestic regulation and training and made it more operational.

The "Guiding Opinions" pointed out that by 2015, all localities should comprehensively start the work of regulation and training. By 2020, all clinicians with a bachelor's degree or above who enter a new medical position must receive regulated training.

In Xiong Sidong's view, in the past ten years, domestic regulation and training has been standardized and systematic, and compared with Western countries that began to implement regulation training earlier, China has not done less. Gao Lei believes that although the overall regulation and training are doing well, there is no uniformity in various places, and the Fudan model, the West China model, the Xiehe model, etc., lack of national unified standards.

Li Zhou, who lives in a city in the south, is now the deputy chief physician of the pathology department of a tertiary hospital. It has been 20 years since he graduated from medical school. In 2007, his hospital recommended him for graduate school. Li Zhou recalled that when he graduated with a master's degree in 2010, it coincided with the first year of standardized local training, and his hospital also established two standardized training bases in pediatrics and obstetrics and gynecology that year.

Li Zhou said that some hospitals carry out standardized training, more based on their own needs, and do not give too much consideration to the issue of whether the content of the standardized training is correct when doctors return to their hospitals after the training.

In 2017, he was on a business trip to a county town when the director of a local hospital told him, "I'll send doctors to your hospital for training." At the time of training, I studied minimally invasive laparoscopic surgery at your hospital, but the county hospital did not have the corresponding conditions to carry out such surgery. After returning to the county, Dr. Guipei will have to relearn open surgery." In Li Zhou's view, such "incorrect" training has reduced the clinical significance of doctors returning to their hospitals after training.

Ge Junbo analyzed that at present, the domestic regulation and training system has been fully established, but there are problems in its implementation. For example, a clinical medical student who graduated from a bachelor's degree directly enters the training stage without entering graduate school, and needs to rotate in multiple departments such as gastroenterology and respiratory medicine, and then pass the license examination of a licensed physician and can start seeing a doctor. However, in the past 3 years, the medical student did not have a degree, and finally could only obtain a medical license. This is a bit "out of touch" with the same batch of medical students who were entering graduate school and studying for Bo at that time.

At present, the training time of different places and hospitals in different parts of the country is still inconsistent, some hospitals are two years, and some hospitals are three years. Ge Junbo proposed that the whole country should be unified in this regard, and it cannot be said that it takes three years for training in first-tier cities, and the standard will be lowered to two years in other cities.

The level of training bases varies from place to place. Xiong Sidong analyzed that the quality of hospital training with strong comprehensive strength is better, but the scale of national medical student training is very large, which leads to these hospitals being far from meeting the demand, so they will expand to lower-level hospitals. Xiong Sidong said that some departments and some doctors brought too many regular trainees, and he had the impression that the number of regular trainees in some departments reached hundreds, and even one doctor brought dozens of regular trainees, resulting in a lack of fine guidance for regulated training doctors.

"Different hospitals have different degrees of strictness in their grasp of training." Zhang Man said that some hospitals are particularly strict and strictly follow the training rotation plan; Some hospitals are very "paddling", the training doctor has been in the department of his supervisor for 3 years, if the hospital does not check at all, the training manual is filled in by himself, and the form of the final department can be passed by finding the department director to sign.

Zhao Lin, a regular training physician at a third-class hospital in Shanghai, told China Newsweek, "Now many regular training doctors have never been to the clinic, they only have things in books, but patients do not get sick according to books." ”

"The income of regular trainees is not high." Li Zhou said that in his hospital, during 2010~2012, all the income of regular trainees was only one or two thousand yuan a month. Now the monthly salary of trainees in his hospital has risen to about 5,000 yuan per month, mainly thanks to subsidies from the local government and hospitals.

Zhang Man, who works in Guangzhou, calculated that all her monthly "income" at the time of training totaled about 2,000 yuan, including the school's stipend and the school's monthly tuition refund. Zhang Man said that the treatment of training in various hospitals varies greatly, with monthly salaries ranging from a few hundred yuan to several thousand. If the hospital does not provide accommodation, this income is not enough to rent a house in a big city.

In addition to standardized training, the promotion of specialized training has gradually increased in recent years, that is, on the basis of 5 years of undergraduate education in medical specialties and 3 years of standardized training for residents, 2~4 years of specialized training is carried out according to relevant requirements.

In 2015, the former National Health and Family Planning Commission and other 8 departments issued the "Guiding Opinions on Carrying out the Pilot of the Standardized Training System for Specialist Physicians". On December 7, 2022, the National Health Commission issued a "proposal response letter" to CPPCC members, mentioning that the pilot work of the special training system was officially launched in 2016, and 10 specialties with strong representative and large social needs, such as respiratory and critical care medicine, cardiovascular disease, neurosurgery, and internal medicine critical care medicine, were selected as pilots, and a total of 224 specialized training bases were selected, and more than 7,500 specialists were trained in total.

"Doctors who have undergone specialized training do not mean that the level is higher, and most hospitals do not have mandatory rules that special training must be carried out." Ge Junbo said. Five or six years ago, in order to bring in line with international standards, he joined several other CPPCC members to call for the establishment of a pilot training program in China.

In the United States, after students earn an MD degree, they enter the residency training stage, which varies by specialty, with 3 or 4 years for the internal medicine system and 5 to 7 years for the surgical system. In addition, U.S. medical practitioners need to go through 3 medical qualification exams to obtain a physician license, which covers both theory and practice.

Now nationwide, specialized training has not been formalized. Ge Junbo believes that it is time to review and see whether a standardized system can be formulated, for which groups of people need special training, and from what stage of specialized training. Usually, medical students can apply for promotion to attending physician five years after graduating and entering the hospital. He pondered whether doctors above the rank of attending doctor did not need specialized training. However, the group of attending doctors accounts for a high proportion of hospitals, and without specialized training, this group's knowledge may not be so comprehensive.

What kind of doctor is needed?

At present, medical students are mainly trained by three types of colleges, including medical schools of comprehensive universities, traditional independent medical schools, vocational high schools and medical-related and health-related colleges and universities. Xiong Sidong pointed out that in terms of quantity, the number of medical students trained each year is enough to meet the national demand. However, not all medical school graduates are engaged in health care, so there is a phenomenon that there are more graduates than hospitals need.

A trend that Xiong Sidong obviously feels is that the way medical schools train students is homogeneous, and they are all going in the direction of cultivating top doctors. Nowadays, there are fewer and fewer doctors close to the people who are engaged in general medicine and community medical and nursing care, and going to a top tertiary hospital has become the dream choice of most medical students. The objective situation is that there is a high shortage of grassroots doctors now, and many doctors in the top tertiary hospitals squeeze their heads but cannot enter.

"It's hard for medical graduates to get into big hospitals these days." Sun Yongan, chief physician of the Department of Neurology at Peking University First Hospital, said in an interview with China Newsweek that last year, his neurology department received 70 or 80 resumes, but in the end there was only one enrollment quota. Li Zhou's hospital is a large local tertiary hospital, and more than a dozen masters have now applied for a general technician position this year.

Li Zhou believes that in some specific detailed policies for regulation and training, the National Health Commission should seek more advice from front-line clinicians. He believes that although the phenomenon of different regulatory training systems in different places has been gradually corrected, young doctors have paid a lot of energy and price for this.

According to Zhang Man, some surgeons in her hospital have very few opportunities for surgery. The larger the hospital, the more common this phenomenon becomes. Most of the work Zhang Man is doing in the breast department is actually not much different from the training stage. She said, "I can do some minor surgeries and get paid." ”

"The reform of the medical education system is not simply a matter of shortening or lengthening the training time of doctors, but requires the restructuring of medical education." In Xiong Sidong's view, on the one hand, the training of doctors should have a more solid foundation, and talents can be selected from college students who are not medical undergraduate majors to maintain the ability of doctors to continue learning; On the other hand, it allows doctors to acquire more accurate medical knowledge and equip them with the right job competencies.

Zhang Man's hospital, if you want to be further promoted, you still read more papers, how many studies have been published, and the doctor's clinical operation level ability does not dominate in the promotion assessment system. "The quality of the operation cannot be quantified, and the famous doctor may have done the operation in a mess." She said. Zhao Lin's hospital generally does not recruit doctors with "four certificates in one", but tends to recruit doctors with strong scientific research strength.

"Basically, 80% of doctors abroad do not need to do scientific research." Gao Lei analyzed that he has a double degree of PhD and MD, but he has been a doctor in the United States for more than ten years, rarely touches scientific research, and spends most of his time treating patients.

Ge Junbo believes that different hospitals have different needs for medical talents. Large tertiary hospitals have undertaken more scientific research tasks, and for county hospitals, there is no need to assess the level of doctors' theses, or set the threshold for degrees very high. Because now the people see a doctor, 80% of the people go to the county hospital, for the county-level hospital, it is more important to see the disease. Now many hospitals require doctors to be able to see doctors and do scientific research, which is actually not necessary.

Ge Junbo pointed out that taking the United States as an example, doctors of the Chinese American Heart Association generally have their own independent clinics, more daily medical treatment, less involved in scientific research, and there are some medical scientists who specialize in academic scientific research. Discipline leaders in colleges and universities such as Harvard Medical School may have both. In China, clinicians doing scientific research seems to be a norm, and it is also an important indicator of domestic talent evaluation and promotion, and it is necessary to start from the assessment mechanism to change this.

He suggested that the relevant departments should hold a seminar with the participation of the Ministry of Education, the Health Commission and an advisory committee composed of well-known scholars to discuss the development of standardized medical training procedures. Because this involves subject education, the application of medical expertise, experts in various fields need to be involved, so that we can figure out where the shortcomings are and make improvements.

Sun Yongan believes that the reform of the medical education system will take a long time and require the cooperation of multiple departments. The key now is to establish an effective clinical evaluation system as soon as possible, so that clinicians have enough time to participate in the diagnosis and treatment of clinical diseases and train more doctors who can really see patients.

Xiong Sidong analyzed that great efforts should be made in the structure and quality of medical students, especially the former. Clarify what positions of doctors are needed in the future, and then make structural adjustments to adapt to the needs of doctors in different positions and at different levels. In addition, an early warning system for doctors' posts nationwide should be established to keep abreast of which doctors' positions are short of personnel and train them to avoid too much time lag.

(Zhang Man, Zhao Lin, Li Zhou are pseudonyms)

Intern Li Jinjin also contributed to this article

Published in the 1085th issue of China Newsweek magazine on March 27, 2023

Magazine Title: Medical Education Reform, How to Train More Good Doctors?

Reporter: Niu He

Read on