A Standardized Pediatrician Residency Curriculum Across China?
Standardizing Pediatrician residency curriculum across China was the hope of leaders from China, Taiwan and Hong Kong (两岸三地) as they gathered at Shanghai Children's Medical Center (SCMC) over a weekend in June. The collaboration brought together key leaders from all sections of China including hospitals, government and universities to examine current practices and experiences, understand challenges, and discuss opportunities. One key challenge these leaders agreed on is that the general Pediatrician profession is not attracting residents let alone top talent which can be tied to unattractive conditions and benefits. Dr. Zhu, Chairman of China Association of Pediatricians and Vice Chairman of the China Association of Woman and Children Health, shared that China has 267 million children between the ages of 0-14 and about 61,700 pediatricians which creates both a significant shortage and a critical problem for China. He also noted that “the first 1000 days of life” for a child is the critical period as it is the “window of opportunity” to address problems and set the course for a healthier future.
Professor Louis Low, past president of Hong Kong College of Pediatricians (http://paed.hku.hk/menu/staff/lcklow/lcklow.html), shared the Hong Kong model and best practices which contains a highly structured training curriculum. The model incorporates general and specialty rotations, a life-long self-learning discipline, and a curriculum that not only covers medical competency and practice-based learning but professional people skills such as counseling, presentation, attitude, teamwork, leadership, organization, and teaching capabilities. He noted that contrary to China, hospital pediatricians only see 10% of the outpatient populations. This was also a consistent observation made by Dr. Mei-Hwan Wu who leads the Taiwan Pediatric Society and Resident Training Program at Taiwan University Affiliated Hospital in Taipei (http://www.mc.ntu.edu.tw/main.php) Dr. Wu noted a more distributed practice in Taiwan with about an equal split of Pediatricians practicing in hospitals and private practices where private practices cover much of the outpatient visits. She also spoke of new areas that the mature Taiwan program is exploring such as the ‘No blame medicine” with specific criteria to protect doctors acting properly from unjust prosecutions. Different models and experiences were shared throughout the event; however, one that looked promising and scalable is the Chongqing (重庆) model that appears to be turning out well-trained pediatricians. The model went through a three-stage development process that started in 1993. Lily Hsu, Project HOPE's Program Director in China, noted that this is a good model as it incorporates key elements such as a 360 degree resident’s feedback and evaluation process for trainees and mentors, an integrated rotational training curriculum using a network of secondary hospitals as well as practical characteristics to scale across China. The Chongqing model adopted a key practice from the U.S. that uses a network of integrated advisors and take on a gradual approach to residency training with supervision and support that allows the resident to take on more responsibility as the resident progresses through the stages of the residency program. What first appears to be a simple problem is quite complex and I’m coming to appreciate the difficulty of this topic as there are many underlining challenges that I didn’t even touch on. The sheer size of China alone presents many unique and complex factors let alone factors such as the lack of an integrated government policy to support hospitals leaving them to develop hospital centric programs with limited resources and innovation to scale beyond the individual hospital. All the discussions suggest to me that any good model in China must integrate collaboration between the different levels of hospitals (Tertiary, Secondary and Community Hospitals) and be supported by strong government policies to put general Pediatricians on the proper professional standing. As SCMC Party Secretary Jiang Zhongyi alluded to in his closing remarks for the event, there are multiple levels of changes required to create the proper collaboration reform that is needed whether it is making this profession its own specialty, elevating the profession within the three levels of medicine or enhancing benefits for the profession, the child will always come first. He stated that preventive and comprehensive care for children in the first five years of life is an investment with enormous financial returns that last the next 30 years in addition to easing the burden on the nation’s health care system in the long run. It certainly was an eye opener for me as what appears to be a simple question of what should be included in a standard residency curriculum, resulted in me learning so many related medical challenges and complex interdependencies that this nation is working hard to address to provide an effective and comprehensive national solution which actually is the same goal of other nations around the world. Participating in this collaborative exchange has helped validated many of the components that I’ve outlined for the manual to guide the development and implementation of new NCD (non-communicable diseases) programs such as Cardiovascular diseases and Diabetes, This manual will provide program managers and implementers a roadmap to design and implement new programs on NCD in new developing countries or regions as the World Health Organization estimates that NCDs could cost the global economy $35 trillion from 2005 to 2030. The roadmap will guide program managers through a framework based on experience and learning to increase their success; it will help ensure key factors such as those we touched on above and local partnerships are addressed appropriately as well as proper indicators are defined and measurable for assessing effectiveness and outcome.