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[The data in this article comes from CCTV, 21st Century Business Herald, and CBN]
Since the beginning of this year, four suicides of medical students have occurred in hospitals in Guangxi, Hunan, Shanghai and other places. First of all, on February 2, before the Spring Festival, Xiao Ji, a student of Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai University of Traditional Chinese Medicine, committed suicide by burning charcoal in a rental house, followed by Cao Liping, a 25-year-old student of Hunan Provincial People's Hospital, who committed suicide by cutting her neck in the hospital toilet in the early morning of February 24, followed by an intern and a trainee from the First People's Hospital of Nanning, Guangxi Province on March 14 and March 19.
According to public media reports, these four suicide incidents all point to the concerns of "regular trainees", "high labor intensity, less money, more things", "less learning gains", etc., and the living conditions of regular training doctors have gradually entered everyone's field of vision.
What is the "regular training system" for doctors?
Regular training is an important medical education system that has been implemented in many countries around the world for many years. Improving the average quality of doctors was the original intention of the establishment of this system, but when it landed on the mainland, some students did not feel good for various reasons. Today, there are more than 500 public hospitals in the country that exist as training bases. In 2020, the medical industry forum Ding Xiangyuan conducted a monthly income survey for trainees, and nearly three-tenths (27.5%) of the trainees said that their monthly income was less than 1,000 yuan.
On April 9, the media 21st Century Business Herald interviewed Professor Liu Jin, one of the earliest experts in China to initiate the establishment of a residency training system, and explained the reasons in detail. According to reports, 35 years ago, as the first doctor of clinical anesthesiology in mainland China, Liu Jin went to the United States to study for a postdoctoral degree. Before going abroad, Liu Jin resigned to his doctoral supervisor, Professor Xu Shouchun, who explained that in addition to doing scientific research, he also had to investigate why the level of clinical medicine in the mainland was lower than that in the United States. There is not much difference in the level of medical school graduates in the two countries, but American medical school graduates must go through highly standardized and modern training if they want to become attending physicians, compared with China, the training at the same stage is not standardized, which is one of the important reasons for the large gap in clinical knowledge and skills between China and the United States. ”
At the beginning of 1994, after Liu Jin returned to China, he served as the director of the anesthesiology department in Beijing Fuwai Hospital, and required all young doctors in the department to implement a regular training system according to the standards he had set. However, Fuwai Hospital is a specialized hospital for cardiovascular diseases, and there are no other clinical anesthesia subspecialties required for anesthesiology training. To this end, Liu Jin contacted Peking Union Medical College Hospital, Temple of Heaven, Children's Hospital and other hospitals to send young doctors to specialists. In 2000, Liu Jin applied for transfer to West China Hospital of Sichuan University, which is a comprehensive hospital that is more suitable for the implementation of the training system than Fuwai Hospital. Taking this opportunity, Liu Jin began to pilot training in the anesthesiology department of West China Hospital, and began to popularize it to other departments in 2003, and at the same time recruited "social people" to participate in the training. Also in the same year, Liu Jin began to serve as a deputy to the National People's Congress. During his tenure as a deputy to the National People's Congress, he put forward the proposal of "establishing a national standardized training system for resident doctors and including its expenses in the national budget" for ten consecutive years.
Finally, on December 31, 2013, the 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 Doctors", and in 2014, the standardized training system for resident doctors began to be implemented nationwide. At the same time, since 2014, the central government has provided special financial support for the standardized training of resident doctors, and the capital subsidy standard is 30,000 yuan per person per year. Two-thirds of the subsidy funds are used to subsidize the resident doctors, and one-third is used to subsidize the base and teachers. According to the Chinese Medical Doctor Association, a total of 120,000 medical graduates across the country will participate in standardized residency training in 2023, which is the largest number of students enrolled in the mainland since the implementation of the regular training system ten years ago.
About reducing the training time. Professor Liu Jin said that the training time of internal medicine and pediatric system in the United States is three years, anesthesia, radiology, pathology, ophthalmology and other departments are four years, and surgery is five years. In contrast, considering that the disease spectrum is roughly the same and the diagnosis and treatment principles are basically the same, the mainland has shortened the standardized training time for residents to three years, which is shorter than that of the United States. During the standardized residency training, trainees need to rotate to different departments. Only through job rotation can doctors have a more comprehensive view and understanding of the disease, and when considering patients' problems, they can minimize misdiagnosis and missed diagnosis. If the time is shortened to one to two years, it may lead to incomplete rotation of physicians, and the trained physicians are not qualified.
About the income of medical students during the training period. Professor Liu Jin said that in terms of specific trainees, according to the existing national regulations, a subsidy of 30,000 yuan/year will be provided for each resident, of which 10,000 yuan will be used to subsidize the base and teachers, and the remaining 20,000 yuan will be used to subsidize the resident doctors, that is, 1,667 yuan per person per month. As far as I know, the vast majority of hospitals subsidize residents as much as possible, and the vast majority of training bases can reach or approach the average social wage of the city where the base is located.
At present, there are three main categories of people who study medicine in hospital training bases: the first type is the resident doctors who are "social people" and study in the training bases for three years before going to work in middle and grass-roots hospitals according to the requirements of the state; the second type is the professional and master's students who have taken the systematic examination of the Ministry of Education, and the Ministry of Education stipulates that the professional and master's students will receive 33 months of resident medical training during the 36-month period; and the third category is the advanced doctors.
In fact, when I first proposed the establishment of a regular training system, the Ministry of Education did not stipulate that professional and master's students must receive 33 months of residency training, including the national policy of 30,000 yuan/year/person, and this subsidy did not enter the Ministry of Education's professional and master's system. Due to the limited number of places allocated by the Ministry of Education, only about a quarter of the new graduates of medical schools can pass the examination and be admitted to the full-time graduate management system of the Ministry of Education, and they will not receive financial subsidies from the government during the 33-month period of completing the regular training. Because, the government's financial subsidy is 30,000 yuan per person per year according to the training system of the National Health Commission. The post-secondary students belong to the system of the Ministry of Education and are not in the training system of the National Health Commission. This difference in income between regular trainees and professional and master's students only appeared after the Ministry of Education required that master's degree students in clinical medicine must participate in 33 months of regular training. If we confuse the two, we will come to the following misunderstanding: "About a quarter of the trainees in the mainland (in fact, college and master's students) have less than 1,000 yuan per month for living expenses." Some measures can be taken to solve the contradiction of low remuneration for post-graduate students, such as the education department taking the initiative to actively communicate with the Ministry of Finance and the National Health Commission, and strive to include the financial subsidies and hospital subsidies for clinical medicine master's students into the subsidy system.
On whether the training system should be improved. Professor Liu Jin said that first, the national finance should cover at least 90% of the cost of residency training. At the beginning, I mentioned 100,000 yuan/year/person, but now it may be a little higher. This will also motivate the training base to recruit more resident doctors and train residents for the country, because hospitals with independent accounting are not obliged to train talents for the country. Second, as a training base, the main task of large tertiary hospitals is education and training rather than scientific research, but now many hospitals pay more attention to scientific research than education and training, which is a common problem at this stage. In fact, hospitals should develop medical education and research in an all-round way, with clinical medicine in the first place, education and training second, and scientific research in the third. Third, teaching and learning are mutually beneficial. Teachers should improve their sense of responsibility and educational skills, medical education is mainly bedside teaching and training, next to the patient, next to the operating table, next to the diagnostic bed, next to the hospital bed or outpatient clinic, and university education is different. Fourth, residents should have sufficient mental preparation and ability, because the long-term examination-oriented education in the mainland makes a considerable number of medical students may not adapt to the current teaching and training methods.
He also said that including the improvement of the standards of the training base and the practical implementation, these will take time, but time is not our excuse. There are 1.4 billion people in China, and the grassroots need more qualified "health gatekeepers", which is an important foundation for ensuring the health of the whole people. In short, we need to look at this system of training a large number of qualified doctors for the country from the perspective of the life and health of the people of the whole country, especially the diagnosis and treatment of common and frequent diseases of workers, peasants and ordinary urban residents.
CCTV: How did the doctor become a "free cow and horse"?
There are three links in medical education, including medical student education, residency training, and lifelong continuing education for specialists. In mainland China, residency training has always been the weakest link of the three. If you want to become a clinician, you can't avoid it.
On April 1, CCTV interviewed relevant medical students. In the training topic of a mainstream medical forum, "free cattle and horses" and "cheap labor" are the most mentioned words. "When we see the news of these suicides, we are sad and angry, but we are powerless to change. Dr. Guipei is really bitter. Tang Xiaoxiao, a doctor from a large tertiary hospital in Zhejiang, said helplessly.
"I have no choice but to hold on. "Tiredness is the most direct feeling of medical students receiving regulatory training. This year is Sun Xingzhi's second year of training in a tertiary hospital in Nanchang, Jiangxi. After rotating through multiple departments such as digestion, blood, respiration, and cardiology, he found that the actual workload of the trainees was much larger than the regulations. "According to the training policy, each trainee manages 4-6 patients, which is busy enough. However, in a large tertiary hospital like ours, each doctor needs to manage more than 10 beds or even more than 20 patients at the same time. "Going through the admission and discharge procedures, asking for medical history, filling out medical records, and issuing medical orders...... Every day from 8 a.m. to 7 or 8 p.m., Dr. Guipei is in a state of high-intensity "continuous rotation". Not being able to eat is the norm, and having one day off a week is considered a luxury, and there are basically no other holidays. Last year, Sun Xingzhi only took three days off during the Chinese New Year.
Compared with regular commuting, the most headache is "night shift". According to a number of doctors, a night shift needs to be from 8 a.m. to 8 a.m. the next morning, plus the handover of work, and it is generally 12 noon before you can get off work. Such a continuous 30-hour "shift" will be rotated four or five times a month.
In addition to the clinical work in the hospital, professional and master's degree trainees also face the pressure of academic and scientific research. After work in the evening, when I go back to school, I have to spend 3-4 hours in class, reading literature, and writing papers.
Continuous high-intensity work is extremely taxing to the body. "I was healthy as an undergraduate, and I hardly ever got sick, but now I have irregular menstruation, low blood sugar, heart palpitations, acute gastroenteritis, and sudden deafness...... I go to the hospital four or five times a year. "After more than a year of training, Tang Xiaoxiao obviously felt that his body was not as good as before.
This is not matched by extremely low salaries. In accordance with national regulations, the central government provides 30,000 yuan/person/year of special financial support for regular training, 2/3 of which is used to subsidize regular training physicians, and 1/3 is used to subsidize bases and teachers. But in fact, the income of doctors in different hospitals and departments is different. According to Lin Han, a doctor in a top tertiary hospital in Beijing, in Beijing and Shanghai, the income of trainees in very few hospitals can reach 5,000-10,000 yuan per month. But in most cases, the monthly income of regular trainees is around 1,000 yuan. Based on the calculation of 60 hours of work per week, the hourly wage is only about 4 yuan. If you include expenses such as renting, taking a taxi, and eating, some regular training doctors even need to "pay for work".
The starting point of translating book knowledge into clinical practice is naturally good. However, many doctors believe that not only are they tired, but in reality, the original intention of the training system has not been well implemented.
In 2022, Dr. Zeng Qingqi from the Department of Continuing Education of Peking University People's Hospital and others conducted a survey of 15,830 teaching doctors in 310 training bases across the country. The results showed that the "competency" of the residents had been significantly improved after the regular training, but the effect was lower than expected at both the beginning and the end of the regular training. "Regulation and training are neither standardized nor trained. "Tang Xiaoxin, this is a frequent complaint of medical students in private. For doctors in regulation, in addition to living more and less money, the most torturous thing is "meaningless" and "unable to learn things".
The cities, hospitals, and departments trained by Dr. Sun Xingzhi, Tang Xiaoxiao, and Lin Han are different, but their work content is similar - 70% of the work is dealing with clerical work. For example, asking for medical history, writing discharge records, writing medical records, writing the course of the disease, issuing medical orders, signing informed consent forms with patients, talking before surgery, opening examination lists, taking patients for examinations, communicating with family members, asking for consultations, writing consultation records, explaining precautions, etc., occasionally do some basic operations such as thoracentesis, lumbar puncture, tracheal intubation, dressing change and suture removal.
"The work was useful at first, but the problem was that it was repeated mechanically every day, like screws on an assembly line. Lin Han joked that this was more like training a secretary than a doctor.
"I was a typist for a whole month when I was on the ultrasound rotation, and I typed whatever the teacher said. But I wanted to learn how to see whether a nodule is benign or malignant, how to look at the structure of the heart, etc., but I was not taught. Tang Xiaoxiao believes that compared with students, doctors are more like tool people, and what they can learn is very limited.
"Some teachers are too busy with their own affairs, they don't have time to eat, and the patients are one after another, and the teaching can only account for less than 5% of his total work. "Many doctors said that training is more self-taught.
Sun Xingzhi introduced that sometimes, he was also arranged by senior doctors to help with PPT, write reports, collect clinical data, run errands and other chores that had nothing to do with regular training.
What should a reasonable training system look like? Is there a solution?
Medical student suicides continue to occur, and the industry is constantly thinking and discussing the training system. From the point of view of public opinion, first of all, residents should not be treated as cheap labor, and residents should be rotated to each department to study; second, in addition to their own work, teachers should also assume the sense of responsibility of teachers and teach students in a real way. The time is spent on teaching services, in order to balance the teacher's energy between teaching and clinical tasks, and the trainees agree that the quality of learning during the training period is high or low, and the instructor plays a decisive role; in addition, it is urgent to improve the salary; and finally the public hospital system of the training base needs to be optimized.
The picture comes from the Internet
In the process of interviewing industry insiders, the media Yicai found that the consensus of industry insiders is that medical students receive standardized education in hospitals after graduation, and this practice process is indispensable. Regular training is a "bridge" between theory and practice, which can help medical students quickly transition from the textbook learning stage to the clinical practice stage, but the training mechanism, remuneration package, and teaching mode may have improvement paths.
Wang Chen, president of Peking Union Medical College and academician of the Chinese Academy of Engineering, made a public suggestion that the organic connection between college education, post-graduation education, and continuing education should be strengthened, and a unified and standardized post-graduation medical education system should be established. The remuneration of specialized trainees should be increased from the current 30,000 yuan to at least 50,000 yuan per trainee; the current stipulation that medical graduates must have worked in clinical practice for one year before they can take the medical examination will be changed, and medical students can take the qualification examination for medical practitioners in the year of graduation.
Zhao Dahai, executive director of the Shanghai Jiao Tong University-Yale University Joint Research Center for Health Policy, told reporters that more often than income, medical students need a reasonable expectation of employment and career development. At the same time, a healthy and stable teacher-student relationship is also the key to the quality of regular training, and the two sides should become a close community.
The improvement of the training system is not limited to this. Zhu Shunsheng, a health policy research expert and deputy director of the medical reform office of Shaxian District General Hospital in Sanming City, Fujian Province, said that while some trainees went to provincial hospitals for training, they also provided cheap labor for the hospital. ”
Zhu Shunsheng told the first financial reporter that the training system should play a role in improving the professional ability of doctors, and if the trainees are in a state of "miscellaneous" most of the time, it is not conducive to their career development, but the teaching doctors do not dare to let them operate easily, or are afraid of taking possible medical risks (including doctor-patient disputes that may be caused by improper handling).
"Only after determining the development department can medical students really begin to grow and develop their patients, and can they bring problems to training and achieve progress. However, there are still many medical students who go out as soon as they are assigned to the hospital, and there is no difference between regular training and internship, which is actually a waste of time. Zhu Shunsheng said that it is recommended that regular trainees need to have corresponding work experience, and they must work for 1 to 2 years after completing the rotation of this hospital before they can go to regular training.
"It is suggested that the quota of regular trainees can be voluntarily and reasonably arranged by grassroots hospitals, so as to avoid the apportionment of regular trainee quotas by higher-level hospitals to primary hospitals. Grassroots hospitals have difficulty recruiting and are already short of manpower, and if they have to send new people out for three years of training, it will also bring certain difficulties to grassroots health work. Zhu Shunsheng said.