Studying medicine in China

20 july 2008--British medical student Huza Zhang discovered some surprising similarities on a recent visit
Like everything else these days in China, the health care and medical education systems in the world’s most populous country are undergoing massive change. Gone are the relatively carefree days, when graduation from medical school meant a post for life at a government assigned hospital or surgery. In its place is a rather unplanned system where the market economy is king.
As a UK medical student with Chinese origins, I have always been curious to know the work, life, and prospects of my counterparts in China. Last year I was delighted to have the opportunity to spend a few days at a Chinese medical school. This was organised through family contacts, with the help of my university.
When I arrived I arranged interviews with about 10 medical students with the help of a lecturer, who was not present during the interviews. I had the opportunity to attend lectures as well as enjoy informal chatter with the students. I was able to interact with them freely and naturally, without supervision. So I began to see what it was like to be a medical student in China.
Most medical schools in China offer a five year course that leads to a bachelor of medicine degree or a seven year programme with a master of medicine degree or both. My time was mainly spent with third year students on the seven year course. My host was Capital Medical University, based in Beijing. It does not teach traditional Chinese medicine, which is offered at specialised academies, except at a superficial level to give students an awareness of the principles.
Surprisingly familiar
Attending the lectures of the students was an interesting and baffling experience. Although fluent in Mandarin, my arsenal of Chinese medical lingo was limited to “cold,” “fever,” and “I think I ate something funny,” all of them useful on previous visits to China. Although I found the language a challenge, I was nevertheless struck by the similarity of the course to mine at Oxford. Both are primarily based on a traditional medical curriculum, strict regimentation, and clear distinctions between the preclinical and clinical years (years three and four at the Chinese school).
Most UK medical schools have now moved to courses with more integration of basic science with clinical experience, however, it seems that traditional courses still dominate Chinese medical education. Like Oxford medical students, many of the third year students in Beijing at the end of their preclinical studies wondered whether the flood of facts about receptors, ion channels, and chemical pathways so enthusiastically bestowed upon them would indeed help them as future clinicians.
Rote learning is something that medical students have to endure in every country. But it is taken to a new level in Chinese medical schools. At the Beijing university there is almost no homework set other than to learn and memorise. Furthermore, I found that every student has almost exactly the same set of standard textbooks, all recommended by the university. Reading around the subject is not discouraged, but it seems that only the opinion of the standard textbooks counts on exam day.
The gruelling schedule of up to eight hours of lectures a day (similar to lectures at Oxford, with 100-200 students), and many laboratory and self study requirements, means that many students find it hard to socialise outside the medical student population. To be fair, many medical students in the United Kingdom also fail to stray beyond their medical social networks, despite their less demanding schedules.
The Communist Party
Chinese students nowadays are a far cry from those in the 70s waving “little red books” and cheering at images of Mao. But it seems that politics is still a big part of their lives. Every student has to attend politics classes at university, where they learn Marxist and socialist theory and history. Examinations on these classes count as part of their final marks. No politics lectures were running during my visit, but I did encounter the influence of the Communist party at an ordinary medical ethics lecture.
The lecture included a documentary about the outbreak of severe acute respiratory syndrome (SARS) in 2003. It began with stories of brave doctors and nurses committed to their posts in spite of an almost non-existent understanding about the SARS virus and consequently wholly inadequate protection against infection. The film took a subtle turn and moved away from the talk of professionalism, duty, and humanitarianism as driving forces for the incidences of self sacrifice. It suggested that the Communist Party and its ideology was the main motivation for these health workers. Continuing with scenes of doctors who were members of the party volunteering to be sent “to the front lines,” the show ended with survivors thanking and praising the party. The widely reported mismanagement by party and government cadres that exacerbated the outbreak was not mentioned.
The film sparked an interesting class discussion. A couple of students who were party members vocally pledged their service to the party and people, but many other students emphasised that it is the duty of doctors to do their utmost at times of crisis, regardless of party membership.
None the less, it appears that being a party member is of vital importance in a doctor’s career development, especially as most hospitals are still state run. Hospital interview panels may take into account more than just professional ability; there are rumours of non-party members being passed over for the best posts. Many medical students apply for membership during their university years, but the motivation of this generation’s medical students may have less to do with ideology than personal incentives.
Job prospects
Every medical graduate was guaranteed a government assigned job in the past. But the “iron rice bowl” days of guaranteed job security and a steady income and benefits are long gone, although the healthcare system remains a state run enterprise. The job market for doctors is as competitive as any other. There are three levels of employment, based on the affluence and importance of the geographical area—firstly, big cities such as Beijing and Shanghai; secondly, provincial cities or towns; and finally, the countryside. The rate of pay and career prospects undergo freefall as you get further away from the bigger cities, and it is understandably the goal of every medic in the big city schools to stay and students from the smaller cities to push their way in.
Most students are not confident of landing good jobs upon graduation, which in their view is concentrated in large city hospitals. Many expect to end up in the lower paying community hospitals. Several students revealed that many of their seniors are now opting to study to doctor of philosophy (PhD) or doctor of medicine (MD) to improve their employability. Many students consider emigrating to Western countries that have better pay but are hindered by the requirement for English skills. Ironically, the UK National Health Service seems like a socialist paradise in comparison because most medical students land similarly paid jobs after graduation.
The employment concerns of the medical students I met appear to be widespread. A survey of practicing Chinese doctors in 2003 found low levels of satisfaction across a range of factors.1 A particular disheartening finding was that only 8% of the doctors covered by the survey were satisfied with their pay and the same survey reported that 83% of doctors were paid less than ¥30 000 (£2200; €2800; $4300) a year, the same as a young worker in a city office. Some medical students in the UK are dissatisfied and protesting about the loss of free housing for their first year of work: it would be interesting to compare doctors’ job satisfaction in different countries.
In the same survey, other areas of disappointment were the 31% satisfaction of doctors on their level of skill and an 18% satisfaction rate on continuing education after graduation. The only silver lining was the 60% satisfaction rate expressed by doctors about their relationship with patients. Then again, this too is being eroded by constant media reports of “black hearted” doctors taking bribes from patients and refusing treatment to those who cannot afford it. Some students seemed to think that bribe taking was going to be an important supplement to their incomes. On the other hand, most students I met thought that taking bribes affects only a minority of the health workers in the country. I wonder what the true situation is like on the ground? Perhaps I will be able to make up my own mind if I have the opportunity to return some day for hospital placements.
Final thoughts
I found my time with the students of Capital Medical University interesting and enlightening. With increased globalisation and the economic development of China, its doctors are bound to have an ever bigger role to play in the international discipline of medicine.
I thank all the students I met and wish them the best of luck in their studies and careers. Who knows, they could be my colleagues and international collaborators in the future.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.Huza Zhang third year medical student St Peter’s College, University of Oxfordhuza.zhang@spc.ox.ac.ukStudent BMJ 2008;16:235 18
Lim MK, Yang H, Zhang T, Zhou Z, Feng W, Chen Y. China’s evolving healthcare market: how doctors feel and what they think. Health Policy 2004;69:329-37.