Preparedness of medical education in China: Lessons from the COVID-19 outbreak

Abstract

The COVID-19 outbreak can be seen as a ‘big test’ for China; a summative assessment of its preparedness on multiple fronts, including medical education. Being intimately involved in the coordinated response, the First Affiliated Hospital of Sun Yat-sen University has been a first-hand witness to the strengths and weaknesses of the current medical education system in China. On the one hand, we believe that the distinguished contributions in disease containment efforts by healthcare professionals indicated that our medical education system has achieved its intended outcomes and is socially accountable. On the other hand, we have also identified three major issues that need to be addressed from an educational standpoint: insufficient emphasis on public health emergency preparedness; unsophisticated mechanisms for interdisciplinary cooperation; and inadequate guidance in medical ethics. Whilst these reflections might be seen in its summative form, we would suggest changing it to that of a formative process, where we learn from our assessment through observation and feedback of the gaps, upon which improvement of our present situation can be made. We hope that these lessons may be helpful to our colleagues in the rest of China and around the world, who are engaged in medical educational reform.

Keywords:

• COVID-19
• public health emergency
• medical education
• preparedness
• medical ethics

The ongoing COVID-19 pandemic is becoming a global health crisis of epic proportions. As of 3rd May 2020, it has spread to over 200 countries with over 3.3 million confirmed cases and over 238,000 deaths worldwide (WHO 2020b). Currently, the outbreak has largely been contained in China, thanks to what has been lauded by the World Health Organization (WHO) as ‘the most ambitious, agile, and aggressive disease containment effort in the history of infectious disease control’ by the Chinese government (WHO-China Joint Mission 2020). When the healthcare system in Wuhan was gradually being overwhelmed early during the outbreak, thousands of medical professionals from around China heeded the call of duty. Within days, a total of 42,600 healthcare workers (HCWs) were dispatched from all over the country to the epidemic epicentre and joined hands in the fight against the deadly virus (Hubei Daily 2020). After two months of hard work in demanding situations, these relief team members have now completed their mission and returned back home, safe and sound (China NHC 2020). Of course, they are but the tip of the iceberg in the medical cohort of the ‘China response’ (WHO-China Joint Mission 2020). Workers in Centres for Disease Control (CDC), Schools of Public Health, Research Institutes of Virology, Pharmacology and other basic sciences, big data centres at various levels, Primary Care facilities, and general or designated hospitals across the nation have all participated in the coordinated response to safeguard the lives of the people. Serving with professionalism, dedication, courage, and self-sacrifice, they are truly the faces of national heroes of our time. Similar heroic acts are now to be found in all parts of the world, as countries struggle with this disruptive pandemic.

Practice points

• The COVID-19 outbreak revealed the strengths as well as exposed the weaknesses of current medical education in China.

• The distinguished contributions in disease containment efforts by healthcare professionals indicated that medical education in China has achieved its intended purposes and is socially accountable.

• Insufficient emphasis on public health emergency preparedness, unsophisticated mechanisms for interdisciplinary cooperation, and inadequate guidance in medical ethics, were three important issues in need of substantive improvement for the medical education system in China.

The COVID-19 outbreak can be seen as a ‘big test’ for China; a summative assessment of its preparedness on multiple fronts. As a national-level medical centre being intimately involved in the coordinated response to COVID-19 outbreak, the First Affiliated Hospital of Sun Yat-sen University (FAH-SYSU) has been a first-hand witness to the strengths and weaknesses of our current medical education system. On the one hand, we believe that the distinguished contributions in disease containment efforts by healthcare professionals indicated that our medical education system has achieved its intended outcomes and is socially accountable. On the other hand, several areas that warrant substantive improvement were also exposed in the process. Specifically, we have identified three major issues that need to be addressed from an educational standpoint: insufficient emphasis on public health emergency preparedness; unsophisticated mechanisms for interdisciplinary cooperation; and inadequate guidance in medical ethics. Whilst these reflections on medical education preparedness might be seen in its summative form, we would suggest changing it to that of a formative process, where we learn from our assessment through observation and feedback of the gaps, upon which improvement of our present situation can be made. Since most discussions of medical education in relation to COVID-19 seem to focus on teaching, learning and assessment activities during the present outbreak (Ahmed et al. 2020; Alsafi et al. 2020; Li et al. 2020; Moszkowicz et al. 2020; Rose 2020; Taylor et al. 2020), taking a step back and reflecting upon these upstream issues, we believe, would be of immense value for moving forward in medical education reform for our colleagues at home and abroad.

Insufficient emphasis on public health emergency preparedness

During the 1970s, there was a prevalent belief in the field of medicine and public health that infectious diseases had already been conquered and that global pandemics would be relics useful for historical studies only (Bloom et al. 2020). Meanwhile, since the incidence, morbidity and mortality of non-communicable diseases such as cardiovascular diseases and neoplastic diseases are on the rise, they have gradually become the primary, if not exclusive, focus for clinical medicine and scientific research. Over the years, despite the breaking out of major epidemics such as Acquired Immunodeficiency Syndrome (AIDS) in the 1980s, Ebola Virus Disease (EVD) in the 1990s, Severe Acute Respiratory Syndrome (SARS) and highly pathogenic avian influenza A (H5N1) in the 2000s, as well as Middle East Respiratory Syndrome (MERS) and Zika virus disease (ZVD) in the 2010s, curricular content related to public health emergency response continue to be relegated as non-essential in most medical schools and postgraduate training. For example, in the 5 year programme for medical undergraduates in the School of Medicine of Sun Yat-sen University, there is no dedicated course for public health emergency response. Courses immediately relevant to this subject may include Microbiology, Epidemiology and Evidence-based Medicine and Infectious Diseases. Albeit mandatory, these three courses take up only a small fraction of total required hours (81 + 54 + 68/4440) and credits (3.5 + 2.5 + 3/251.5) in the curriculum. In the FAH-SYSU as well as other affiliated general hospitals, postgraduate and residency training programmes for internal medicine usually schedule 1–2 months of rotation at Infectious Diseases department at the Third Affiliated Hospital of Sun Yat-sen University, but most admitted patients there are chronic cases such as hepatitis B. In addition, prior to the COVID-19 outbreak, there was no regular hospital-level training for staff with regards to public health emergency responses. Anecdotal evidence suggests that this situation is not unique for China and may exist globally in resource-rich as well as resource-constrained countries.

The subtle marginalisation of public health emergency response training may have, to some extent, contributed to the relative unpreparedness among medical institutions in terms of hospital infrastructure, resource supplies and HCWs early in the COVID-19 outbreak. One probable consequence from such unpreparedness is of course HCWs becoming infected, with a consequent mortality rate and immediate or long-term effect upon the workforce. According to a situation report from the WHO, 22,073 cases from 52 countries of COVID-19 among HCWs had been reported as of 8 April, 2020 (WHO 2020a). In a recent report by the Chinese CDC, 3,387 HCWs among 476 healthcare facilities across China contracted COVID-19 (WHO-China Joint Mission 2020). Another probable consequence was psychological stress among HCWs. Among relief team members sent to Wuhan from our hospital, 92.7% reportedly felt stressful during work shifts, and approximately 40% reported symptoms of insomnia, anxiety or depression, especially among staff from specialties other than infectious disease or intensive care (unpublished data). Thankfully, FAH-SYSU managed to overcome these challenges through a series of effective measures, including the consolidation of organizational leadership, implementation of a stringent infection prevention control protocol, establishment of a logistical support system that secures equipment and supplies for healthcare workers, introduction of COVID-19-related training for all personnel, provision of psychological support for frontline HCWs, and so on. However, in hindsight, such misfortune may have been prevented, to some extent, by revisiting our curriculum design and assign a proper priority to core competencies of public health emergency response. A detailed proposal to incorporate such preparedness into the medical curriculum is beyond the scope of this article. To start with the simple and obvious, broad discussions about what constitutes public health emergency preparedness should be encouraged. And from the conceptual framework of ‘curriculum as praxis’ (Grundy 1987), an informed and committed action by various stakeholders should be sought, within the realm of medical education and beyond, towards building a healthcare system well-prepared for challenging times like this.

Unsophisticated mechanisms for interdisciplinary cooperation

During the initial phase of the COVID-19 outbreak in Wuhan, there was a costly deficiency in the communication and collaboration between primary care, general hospitals and CDCs, which resulted in local hospitals being overrun by frightened members of the community on the one hand, and COVID-19 patients and close contacts not being properly tracked, tested, and isolated on the other. In addition, testing capacity was seriously lagging behind at that time, despite the privileged presence of advanced virology research institutes, P3 laboratories, Schools of Public Health, and top-tiered hospitals. Furthermore, the scientific community at large was not expediently mobilised due to the absence of a strategic roadmap for research and development. Guangzhou and other metropolitan areas in China faced similar circumstances, albeit on a smaller scale.

Notwithstanding the COVID-19 outbreak being an unparalleled situation, one could argue that this was probably a result from the structural issues within the healthcare system in China, including an under-appreciated public health system (Sina 2020; Chinese Science Newspaper 2020) and an underdeveloped primary care system (Li et al. 2017; Yip et al. 2019). And as such, these weak links might also be the natural extension of the current medical education landscape. First, as mentioned above, an integrated course on public health emergency response is virtually non-existent in medical school curricula. Second, the training of competent and caring General Practitioners (GPs) at both undergraduate and postgraduate levels remains an uphill struggle against the ever-increasing trend of overspecialisation. Third, public health education is insufficient in its horizontal connectedness with clinicians both in classroom settings and real-world scenarios. In general, there seems to be a subtle but profound system-wise disciplinary territorialism that encourages a competitive, rather than cooperative, relationship between different sectors, institutes and departments.

The way forward, we believe, involves the development of a framework of collaboration mechanisms between different disciplines, preferably as early as in undergraduate medical education. For examples, stakeholders from various sectors may come together for a joint effort to create an integrated curriculum that addresses public health emergencies with system thinking. Furthermore, the possibility of capitalizing on successful precedents of M.D. + M.P.H., M.D. + Ph.D. and other relevant double-degree programmes may also be explored, in order to secure interdisciplinary leadership of the future for challenging times like this.

Inadequate guidance in medical ethics

As with other infectious disease pandemics, the COVID-19 outbreak was associated with various social problems of ethical significance. For example, fear, stigmatisation and discrimination against Asians, against people who have recently travelled, and even against emergency responders or healthcare workers have been reported (CDC 2020; Time 2020). Another very specific issue was striking healthcare workers. Healthcare workers in several cities went on strike over grievances related to COVID-19 (Eyewitness News 2020; Radio Free Asia 2020). Also noteworthy is the allocation of critical care resources such as ICU beds and ventilators, which was extremely difficult in countries where available resources were stretched thin (White and Lo 2020). These social problems transcend culture and are of urgent importance both for frontline clinicians and healthcare policymakers. We believe a clear, defensible, and context-specific moral compass to equip HCWs in their decision-making should also be considered as a key component within the fabric of public health emergency preparedness. On 6 April 2020, the International Bioethics Committee (IBE) and the United Nations Educational, Scientific and Cultural Organization (UNESCO) World Commission on the Ethics of Scientific Knowledge and Technology (COMEST) jointly issued a statement on the ethical considerations on COVID-19 from a global perspective (IBC and COMEST 2020). In this document, the IBC and COMEST have highlighted several pressing ethical issues to be globally recognized, including the enactment of interdisciplinary dialogue among scientific, ethical and political actors, healthcare policymaking based on sound scientific knowledge and practices, the allocation of resources amidst the weaknesses of the healthcare system, the protection of vulnerable individuals, our right to health being guaranteed by our duty to health, and so on. Meanwhile, the advisory bodies appealed for urgent, collective actions by governments to search for ethically acceptable solutions.

Speaking from our own experiences, as a response to the outbreak, FAH-SYSU implemented a tactical training protocol for all staff, the content of which covers almost all aspects of COVID-19. This training programme did result in a zero infection rate among our HCWs both at the frontline in Wuhan and at our home base in Guangzhou. Nevertheless, in retrospect, it was relatively insufficient in addressing the social dimensions of the epidemic with practical guidance in medical ethics. Overall, the educational and scholarly endeavours by the medical community in China as a whole to deal with these issues appeared ‘too little, too late.’ We believe this may also be the natural extension of how the teaching of medical ethics fits in the overall curriculum at present.

In undergraduate education, it is not uncommon for medical ethics to be rendered a peripheral status in the medical curriculum. For example, in the 5 year programme for medical undergraduates in the School of Medicine of Sun Yat-sen University, Medical Ethics is a non-mandatory course with a miniscule portion of required hours (36/4440) and credits (2/251.5) in the curriculum. In addition, it is taught within a concentrated time slot, mostly in the traditional lecture format, and without proper assessment of its translation in clinical care. The situation is similar for postgraduate and continual medical education. In order to address this unpreparedness, new avenues to teach medical ethics can be explored. Earlier, a novel framework of integrating bioethics vertically throughout the years of medical education has been proposed and piloted in India with promising results (D’Souza et al. 2018). Just recently, one of the authors (Kuang M.) attended a webinar on Ethical Issues in Medical Education in the wake of COVID-19 hosted by the UNESCO Chair in Bioethics to discuss topics such as Technology and Medical Education Interface and Preserving the Doctor-Patient Relationship. In general, medical educators in China ought to make the most of these experiences and opportunities to advance curriculum reform for medical ethics so that future generations of clinicians can be adequately trained to provide value-based health care, in particular during challenging times like this.

Conclusion

The COVID-19 outbreak revealed the strengths as well as exposed the weaknesses of medical education in China. Insufficient emphasis on public health emergency preparedness, unsophisticated mechanisms for interdisciplinary cooperation, and inadequate guidance in medical ethics, were three important issues in need of substantive improvement. It must be pointed out, however, that we are seeing these from the perspective of the product rather than the process. Although the issues and observations are related to one group of individuals from one major hospital in China, we hope that these lessons may be helpful to our colleagues in the rest of China and around the world, who are engaged in medical educational reform. Since epidemics like COVID-19 may continue to exist for many years to come, the importance of making these future-proofing efforts cannot be overstated.

Acknowledgements

The authors would like to thank Prof. Trevor Gibbs, for providing valuable help for this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Da-Ya Yang

Da-ya Yang, M.D., Ph.D., The First Affiliated Hospital of Sun Yat-sen University and Key Laboratory of Assisted Circulation, National Health Commission.

Shu-Yuan Cheng

Shu-yuan Cheng, Dr PH Candidate, The First Affiliated Hospital of Sun Yat-sen University.

Shu-Zhen Wang

Shu-zhen Wang, Ph.D., Office of Education Administration, Sun Yat-sen University.

Jin-Song Wang

Jin-song Wang, M.D., Ph.D., The First Affiliated Hospital of Sun Yat-sen University.

Ming Kuang

Ming Kuang, M.D., Ph.D., The First Affiliated Hospital of Sun Yat-sen University and Zhongshan School of Medicine, Sun Yat-sen University.

Ting-Huai Wang

Ting-huai Wang, M.D., Ph.D., Xinhua College of Sun Yat-sen University and Zhongshan School of Medicine, Sun Yat-sen University.

Hai-Peng Xiao

Hai-peng Xiao, M.D., Ph.D., The First Affiliated Hospital of Sun Yat-sen University.