Reform direction of medical education in China: implementing “competency-based” medical education

For over 100 years, medical education has achieved continuous development and progress all over the world. Flexner's report in 1910 brought modern science into the curricula of medical schools. In the 1960s, problem-based learning (PBL) was born in Canada and quickly achieved wide use. From the beginning of the 21st century, with increasing specialization in medicine, the “silo effect” has become more apparent. The inequality in healthcare and low efficiency of the entire health system has become prominent problems. These have brought about new challenges for medical education—how to implement accountable medical education so as to rectify the current situation. Therefore, “competency-based” medical education, as an important feature of the third generation medical education reform, has gradually become the trend.1 However, currently in most medical schools in China, PBL is still flourishing, which indicates that we are still at the second generation of medical education reform. The public's desire for equality in healthcare as well as the glaring conflicts in the doctor-patient relationship2 requires us to take swifter action to implement “competency-based” medical education. Presently, throughout the world, mature “competency-based” training is mainly conducted during the residency training stage. These include America's Accreditation Council for Graduate Medical Education (ACGME) core competency4 and Canada's Royal College of Physicians and Surgeons of Canada (RCPSC) CanMEDS framework.5 Training objectives such as “practice-based learning and improvement, interpersonal and communication skills, and systems-based practice” from the ACGME's core competency and the roles of “communicator, manager, collaborator, health advocator” from CanMEDS framework, all place more emphasis on the competency of doctors, so that they can play an important role in the entire health system in the future. The intent is to break the silo effect through progress in medical education, and improve medical efficiency and equality in healthcare so that the entire population can benefit from the fruits of medical development. At the same time, through the cultivation of the above-mentioned competency, we hope doctors can better recognize the existing problems within the current medical and health systems and the urgency of these problem, acquire leadership skills for coping with these problems, thus allowing medical education to better shoulder its responsibilities. Based on the requirements of “competency-based education”, we need to analyze the status quo of medical education in China so as to understand the adjustments and improvements we have to make now. The goal of competency-based medical education is to produce competent doctors with solid knowledge and skills in medicine, as well as adequate abilities in communication, collaboration, self-learning and critical thinking. They are also expected to be competent health advocators with sound professionalism. To achieve such goals we need to take the following actions now. (1) Construct reasonable objectives and schemes for knowledge and skills. Current medical education in China can be roughly divided into two stages: basic medicine and clinical medicine. In most cases, teaching hospitals and medical schools in China are not conveniently located adjacent to each other, and their modes of management differ too. This results in the insufficient communication and cooperation between basic and clinical medicines. Furthermore, different disciplines within both basic and clinical medicine themselves do not communicate much. Such fragmentation and isolation point to the absence of a “top-down” design which can integrate basic medicine and clinical medicine and dictate what to include in the overall curriculum. Unfortunately, this lack of overall planning for medical education brings about premature specialization, blurred boundaries between under-graduate medical education and post-graduate medical education. The amount of total knowledge students are required to learn and grasp is gradually increasing while the time and space for capability training is severely compressed. The urgent work now is to organize multi-disciplinary teacher teams from basic and clinical medical education, and to analyze in detail the essential knowledge, skills and competency required for clinical doctors in the future. Then an overall objective and objectives for different training stages can be designed accordingly based on the principles of medical education. Students' burden of knowledge and skills learning should be reduced the so as to enable them to acquire extensive general knowledge rather than fragmented, specialized knowledge. If these actions are taken, there should be more time for competency-based training, which will lay a solid foundation for post-graduate medical education. (2) Clarify the objectives and methods for competency training. Medical science is dually characterized by science and humanity. However, due to the rapid development of medical science, the scientific aspect in medical education has been greatly enhanced and the curriculum focuses rigidly on disease and not sufficiently on the humanity aspects, such as relationship with patients, or integration of public health into clinical medicine.3 Teaching investment for postgraduates clearly outweighs that for undergraduates. High-quality teaching teams focus more on the postgraduate level training. At the same time, in many medical school and teaching hospitals, faculty's promotion is based more on their scientific research capability rather than their teaching capability. Undergraduate education lacks overall vigor and enthusiasm, and research in medical education is inadequate. As a result, medical students are apt to become “technocrats”. To improve the humanity quality of medicine is to pay more attention to the quality of humanity cultivation of the medical students. This covers communication, cooperation and critical thinking of the competency-based training. It is worth researching how to integrate the experience from countries well developed in medical education with the status quo in China, to design feasible curricula, schemes, and evaluation methods. Lectures and paper-based tests alone are not sufficient for competency-based training and evaluation. Teachers will be required to put in more time for frequent and in-depth discussion and communication with medical students. Such increased time and efforts will have a direct effect on the teaching outcome. The attention paid to the humanity aspect in teaching also has the potential power to help improve the culture of the teaching hospitals. If medical students are kindly treated and cared by their teachers (the senior doctors), they will learn to relay such kindness to their colleagues and patients. Medical students and patients should be valued as “humans” rather than the receptacles of knowledge or carriers of diseases. Only when doctors are trained in this way can they competently practice the “bio-psycho-social model” of medicine. (3) Develop information technology. Information technology plays an important part in “competency-based” medical education. First, competency-based medical education is steeped with small group learning, bedside teaching and formative assessment. Recording the teaching process and formative evaluation plays an important part in student growth and teaching adjustment. Second, medical education increasingly benefits from the development of information technology. Future medical education emphasizes improving self-learning and lifelong learning, both of which require the strong support of information technology. The solution of clinical problems will depend more on the results and conclusions of evidence-based medicine. The timely application of new research findings entails accurate and dependable databases. The current application of databases such as UpToDate6 and Bestpracice shows the increasing impact of information technology on the improvement of clinical outcome and efficiency. It will also have significant impact on postgraduate medical education and continuing education. Learning from resources in English and information retrieving can be done conveniently in most medical schools in China. How to tap the potential of such resources and to cultivate students' learning and d reading habits is good topic for research. The construction of high-quality databases for medical practice and education will undoubtedly improve the overall quality of these two spheres. Medical education is closely related with population well-being. Whether or not doctors are moral models for society reflects the level of civilization of that society. To provide strong guarantee for the continuous development of medical and health services in China, we should conduct “competency-based” medical education, cultivate future doctors with good humanist spirit and leadership capability for improving the efficiency and equality in healthcare. We should make efforts to accomplish this end.

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