Medical Education Reform in Wuhan University, China

Teaching and Learning in Medicine An International Journal

ISSN: 1040-1334 (Print) 1532-8015 (Online) Journal homepage: http://www.tandfonline.com/loi/htlm20

Medical Education Reform in Wuhan University, China: A Preliminary Report of an International Collaboration Renslow Sherer , Hongmei Dong , Zhou Yunfeng , Scott Stern , Yang Jiong , Karl Matlin , Yu Baoping , Aliya N. Husain , Ivy Morgan , Brian Cooper , Feng Juan & Sujata Mehta To cite this article: Renslow Sherer , Hongmei Dong , Zhou Yunfeng , Scott Stern , Yang Jiong , Karl Matlin , Yu Baoping , Aliya N. Husain , Ivy Morgan , Brian Cooper , Feng Juan & Sujata Mehta (2013) Medical Education Reform in Wuhan University, China: A Preliminary Report of an International Collaboration, Teaching and Learning in Medicine, 25:2, 148-154, DOI: 10.1080/10401334.2013.770745 To link to this article: http://dx.doi.org/10.1080/10401334.2013.770745

Published online: 26 Mar 2013.

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Date: 29 January 2016, At: 23:32

Teaching and Learning in Medicine, 25(2), 148–154 C 2013, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.770745

DEVELOPMENTS Medical Education Reform in Wuhan University, China: A Preliminary Report of an International Collaboration Renslow Sherer and Hongmei Dong Department of Medicine, University of Chicago, Chicago, Illinois, USA

Zhou Yunfeng Health Sciences Center, Wuhan University Medical School, Wuhan, China

Scott Stern

Downloaded by [183.111.169.204] at 23:32 29 January 2016

Department of Medicine, University of Chicago, Chicago, Illinois, USA

Yang Jiong Health Sciences Center, Wuhan University Medical School, Wuhan, China

Karl Matlin Department of Surgery, University of Chicago, Chicago, Illinois, USA

Yu Baoping Health Sciences Center, Wuhan University Medical School, Wuhan, China

Aliya N. Husain Department of Pathology, University of Chicago, Chicago, Illinois, USA

Ivy Morgan and Brian Cooper Department of Medicine, University of Chicago, Chicago, Illinois, USA

Feng Juan Health Sciences Center, Wuhan University Medical School, Wuhan, China

Sujata Mehta Department of Medicine, University of Chicago, Chicago, Illinois, USA

Background: In 2008 Wuhan University Medical School in China proposed to reform its curriculum by adapting the curriculum of the University of Chicago Medical School. Description: An assessment of Wuhan University Medical School’s traditional curriculum conducted in 2009 informed the reform directions, which

We acknowledge the invaluable contributions to the WUMER Project by the faculty and students at Wuhan University Medical School and the University of Chicago Pritzker School of Medicine. We also acknowledge the primary sponsor of the WUMER Project, the Alphawood Foundation, Chicago, Illinois. Correspondence may be sent to Renslow Sherer, Section of Infectious Diseases and Global Health, Department of Medicine, The University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA. E-mail: [email protected]

included course integration, use of clinical cases, improved relevance of basic sciences to clinical medicine, reduction of lecture time, increase in group and independent learning, and the use of formative assessments. Fifty student volunteers per year were chosen to participate in the reform, and the rest remained in the traditional curriculum. Evaluation: A student survey was conducted in 2011 to evaluate the reform by comparing the attitudes of those in the reform and standard curricula. Conclusions: The reform met the needs of the school, was generally well received, improved satisfaction in reform participants, and had a positive impact on students. Areas needing improvement were also identified.

INTRODUCTION Medical education in China is in a period of transformation.1,2 The structure and curricula of medical education have

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largely remained unchanged over the past 40 years and are in need of extensive revision and reform.3 The current system of extensive traditional didactic training and passive clinical teaching for medical students is insufficient to meet the needs for modern health care and disease prevention. In recognition of these shortcomings, the Ministry of Health established a Medical Education Reform Task Force in 2000 to assess the current situation in China.4 In the same period, the China Medical Board provided support for innovations in medical education at several universities in China.5 Reform efforts so far have displayed some shared characteristics such as curricular integration, increased emphasis on clinical training and analytical and problem-solving abilities, and more use of group and independent learning.4,6 In this process, some schools have drawn upon the experience of medical schools in North America or Europe (e.g., see Qiao et al.7). Herein we report on an extensive collaboration between Wuhan University (WU) and the University of Chicago’s (UC’s) School of Medicine to reform medical education at WU. Specifically, we describe the initial reform implementation and the preliminary results of a general survey of students regarding their attitudes towards the reform. This research was approved by the WU Ethics Committee and UC Institutional Review Board in 2009. THE WUHAN UNIVERSITY MEDICAL EDUCATION REFORM The Wuhan University Medical Education Reform (WUMER) project is a 5-year collaboration between WU and UC to reform the former’s medical curriculum by adapting the curriculum of the UC Medical School. From 2008 to 2009, UC and WU faculty conducted an assessment of the WU curriculum and teaching methods. The assessment included a survey of WU medical faculty and students in 2009 to gauge their perceptions of their traditional curriculum. A total of 79 faculty members and 72 students from Years 4 to 6 volunteered to participate in the surveys. It was found that only half of faculty and students felt that curriculum was satisfactory. Most faculty and students believed that earlier patient contact was needed, whereas only less than 20% of students and faculty thought that students’ clinical experience had been adequate. Regarding suggestions for improving instruction and learning, about 50% of faculty and students wanted to see a decrease in lecture time, and most (between 70% and 90%) students and faculty suggested an increase in small group activities, clinical case discussions, and opportunities for independent learning. UC’s current medical education curriculum was the result of a comprehensive reform that culminated with the introduction of a revised curriculum in 2009.8 Key elements of the UC medical curriculum include • •

integrated basic science courses in both Years 1 and 2; the integrated Clinical Patho-Physiology & Treatment course in Year 2;

•

• •

• •

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preparatory courses at the end of Year 2 that help students transition to clinical clerkships, and again at the end of the 4th year prior to internship; communication, clinical skills, and patient contact training in all years; longitudinal immersion in scholarship and research in the “Scholarship and Discovery” program, starting in Year 1; ongoing immersion in the social dimension of medicine and health care; and a strong emphasis on formative assessment.

Both the UC reform process and the curricular content from this initiative served as templates for modification and adaptation at WU. Key WU faculty members were introduced to the UC medical curriculum and pedagogical approaches. Leadership at WU medical school identified reform course directors for each discipline and convened them into a WU Medical Faculty Reform Committee, whereas WU convened a larger university-wide WU Oversight Committee. Protected time for reform activities was provided for the course directors, who led iterative curriculum review and redesign initiatives within each discipline. Leadership at UC was provided by faculty in the Section of Infectious Diseases and Global Health and by faculty at UC Medical School. Based on the UC model and in part on the aforementioned survey findings, WU made adjustments to their traditional curriculum starting in fall 2009. Overall, lecture time was reduced by 38%, with a corresponding increase in small-group learning and time for self-directed study that would be closely monitored in the trial years. Other prominent features of the reform curriculum included the introduction of earlier patient contact (in the 1st year along with earlier clinical skills courses), interdisciplinary integration, increased emphasis on clinical application of basic sciences, and the use of formative assessments to provide students feedback on their learning. Three separate courses—Biochemistry, Cell Biology, and Genetics—were integrated into a single course entitled Cells, Molecules, & Genes. Histology and Physiology, previously taught separately, were combined into Tissue Structure & Function. The broadly inclusive course entitled Response to Injury included pathology, pharmacology, immunology, and microbiology. The Human Body course replaced the traditional Anatomy course and incorporated lectures and training materials from radiologists and surgeons. All basic science courses used clinical vignettes to emphasize clinical relevance and to engage students. At the time of the writing of this article, the adapted UC course Clinical Patho-Physiology & Treatment (CPPT) is being piloted at WU. The CPPT at the UC is a 4-month-long course (for Year 2 students) that integrates pathology, pathophysiology, concepts in therapeutics, and the introduction to clinical medicine. It is organized by organ systems and is jointly taught by pathologists and clinicians. Teaching materials include more than 180 hr of online lectures and about 200 web-based clinical

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cases. The teaching materials are used in real time in lecture halls and labs and are available for student and faculty use online at any time during the school year.9 The WU-adapted CPPT, which is 1 year in length, was first implemented at WU in fall 2011 with 3rd-year medical students. Access to the online UC CPPT-web and course materials is now available to all WU reform faculty and students.

METHODS OF PROJECT EVALUATION The WUMER Project Evaluation is a longitudinal study of WU student and faculty attitudes regarding medical education reform and of the outcomes of reform on student learning. The hypotheses of the overall project were that (a) the WU reform curricula would result in improved learning of the basic sciences, clinical knowledge and skills, professionalism and patient communication, and greater student satisfaction compared to the standard curriculum, and (b) initial resistance to medical education reform among students and faculty would change over time, with greater acceptance and adoption of the new curriculum and teaching methodologies. Each year, volunteers were sought from the incoming freshman class for participation in the reform curriculum, and about 50 students were selected to participate from this group. Since fall 2009, about 150 students have joined the reform. As a means to monitor students’ response to the reform, we developed and administered a general survey in December 2011 that consisted of 64 items, the majority of which were Likertscale-type questions for measuring students’ satisfaction with various curricular dimensions. There were also items that asked students to give suggestions as to how to improve teaching and learning, items for measuring students’ self-perceived engagement as learners, items for measuring their opinions of professionalism, and items regarding demographic information and career intentions. The Likert scale had 5 points: 1 (strongly disagree), 2 (somewhat disagree), 3 (neither agree nor disagree), 4 (somewhat agree), and 5 (strongly agree). This report focuses on students’ evaluation of the reform and the traditional curricula and their suggestions for improvement. The main categories of the curricular evaluation items included structure, instruction, interdisciplinary connections among basic science courses, clinical relevance of basic science courses, clinically related knowledge and experience, assessments, and textbooks and other materials. Students gave suggestions for improvement by indicating whether they wanted to increase, decrease, or “not change” the use of certain teaching and learning methods. It is important to note that by the time of the survey, the students’ experience with their curricula ranged from about a half year to 2 12 years. Three types of analyses were employed. First, for reform students’ evaluation of their curriculum, ratings of somewhat agree and strongly agree were combined into agree, as were ratings of somewhat disagree and strongly disagree into disagree, in order to obtain frequency distributions for each variable in some main

categories. Second, for each category of items (such as “structure”), composite scores were obtained and independent samples t tests were used to compare the reform curriculum (RC) and traditional curriculum (TC) students’ attitudes. Multiple-group comparisons were done using an analysis of variance. Finally, chi-square tests were applied to categorical items where students indicated the types of changes they would suggest to improve their respective curricula to find whether RC and TC students differed with respect to their suggestions. Test statistics were considered significant at the .05 level. PRELIMINARY RESULTS Altogether 147 students in the reformed program (Year 1 = 50, Year 2 = 48, Year 3 = 49) and 149 in the traditional 5-year program (Year 1 = 50, Year 2 = 49, Year 3 = 50) voluntarily participated in the survey. Among the participants, 48.3% were female and 51.4% were male (one student did not give gender information). The RC participants consisted of 50.3% female and 49% male students, and of the TC participants 46.3% were female and 53.7% male. The survey response rate was 100%. Next we report findings regarding students’ evaluation of their curricula and suggestions for improvement. Overall results showed that RC students were rather satisfied with most of the main aspects of the reform and were more positive than TC students toward their respective curricula. Reform Curriculum Students’ Evaluation of Their Curriculum, Teaching, and Assessment As shown in Figure 1, the majority of students were satisfied with their curriculum’s content and structure (note that numbers in the figures were rounded to the nearest whole number). The satisfaction rates were the highest (with agree rates of 80% to 90%) in terms of clinical relevance of basic science courses (Item 6), usefulness of clinical contact they had so far (Item 7), and the extent to which courses helped them develop independent learning ability (Item 11). This is evidence that three of the reform curriculum’s key features—clinical application of basic sciences, earlier clinical experience, and emphasis on independent learning—were effective and welcomed by students. Also rather high (70–76%) was their satisfaction with course sequencing (Item 1), coherence between lecture and lab sessions (Item 3), no unnecessary course duplication (Item 4), interdisciplinary connections (Item 5), and the extent to which courses helped students develop analytical skills (Item 12). The aspects that were least satisfactory were course schedule, coursework in communication skills, the amount of patient contact, and course materials, all with satisfaction rates of 47% or lower (Items 2, 9, 10, and 13). The fact that students found clinical contact helpful (Item 7) and the fact they deemed the amount of clinical contact inadequate (Item 10) might suggest that earlier clinical contact was highly valued and desired by students. Figure 2 shows students’ evaluation of teaching and assessment. The use of case discussions (2), technology use (3), students’ participation in lab activities (4) and the guidance they

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Item number Key to statement numbers in Figure 1: 1. Current courses follow a logical order that builds upon the contents of previous courses 2. Courses are appropriately scheduled (e.g. difficult courses are not grouped together in one single semester 3. Lab sessions are properly connected with lectures


4. There is no unnecessary duplication among courses 5. Necessary connections are made among related disciplines 6. Basic science course contents are clinically relevant 7. The clinical contact I had was useful to my learning 8. Courses prepare me to have proper patient contact 9. Course prepare me with necessary communication skills with patients 10. Current curriculum provides necessary patient contact opportunities 11. Courses help me develop independent learning ability 12. Courses help me develop analytical skills 13. Course materials (textbooks etc.) are appropriate 14. Course materials are at an appropriate level of difficulty.

FIG. 1. Items evaluating overall curriculum content and structure: Percentage of reform students reporting agree or disagree with given statements (General Student Survey, 2011). (Color figure available online).

received (5), and students’ participation in class activities (6) were satisfactory to most students (73% or higher). Students’ relatively high satisfaction with the use of quizzes as feedback tools (Item 9) suggests that formative assessment, one of the reform curriculum’s key features, was used effectively. It is worth noting that students were more satisfied with formative assessment than with summative assessment (exams, Item 8). Finally, students’ position toward the ratio of lecture time to small group to independent study was divided (see Item 1): 32% thought it was not appropriate, 38% believed it was appropriate, and the remaining held a “neutral” position.

Comparing RC and TC Students’ Attitudes Toward Their Respective Curricula RC students were overall more positive than TC students toward their respective curricula. Table 1 shows that in four areas, RC students rated their curriculum in a more positive light.

When all 3 years’ students were included in analysis, RC students reported that their curriculum displayed better connections (coherence) among courses, made basic science teaching more clinically relevant, provided more clinically related knowledge and experience, and offered better instruction. When only Year 3 students, who had more experience with their curricula, were included in the comparison, these differences still existed. In addition, two more significant differences were found with Year 3 students: TC students were more positive about their textbooks and other course materials, t(97) = –2.038, p = .044, whereas RC students were more positive about how they were assessed, t(97) = 2.249, p = .027.

RC and TC Students’ Suggestions for Improvement Students were also asked to indicate what changes they would like to see in their respective curricula. Chi-square analyses showed that there was significant difference between RC and

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90 80 70 60 50 40 30

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Item number Key to item numbers in Figure 2: 1. There is an appropriate ratio of lecture time to small groups to independent study 2. Use of clinical case discussions in basic science subjects is helpful to my learning


3. The courses I attend use technology effectively 4. In lab sessions students have sufficient opportunities to do hands-on activities 5. Students receive adequate guidance in labs 6. Student participation is encouraged in class activities 7. Classroom instruction is engaging 8. Exams are a fair evaluation of what is taught to me and what I should know 9. Periodic quizzes give me timely feedback to help improve learning

FIG. 2. Items evaluating teaching and assessment of students: Percentage of reform students reporting agree or disagree with given statements (General Student Survey, 2011). (Color figure available online).

TC students with respect to their suggestions. Specifically, more TC students would like to see increases in small-group discussion time (81.3% of TC students vs. 36.8% of RC students; p < .0001), case-based learning (92.6% of TC students vs. 52.1% of RC students; p < .0001), and lab sessions (72% of TC students vs. 40 % of RC students; p < .0001). There was no difference regarding the two groups of students’ suggestions for independent study time and lecture time. The majority of both groups wanted to have more time for independent study (75.2% and 68% of RC and TC students, respectively), but their opinions regarding lecture time were divided. Overall, the new teaching and learning methods seemed desirable to students in TC.

Three Years of RC Students Compared When the 3 years of RC students were compared regarding the aforementioned curricular subtypes using an analysis of variance, there was only one significant difference—their evaluation of clinically related knowledge and experience that their curriculum provided (F = 15.267, p < .0001). Means for Years 1, 2, and 3 were 2.983, 3.4777, and 3.949, respectively (SD = .989, .899, and .692, respectively). Year 3 students’ rating was significantly higher than that of Year 2 students ( p = .008), whose rating in turn was higher than that of Year 1 ( p = .006).

DISCUSSION AND CONCLUSION This collaboration between WU and UC led to the implementation of an intensive reform of the medical education curriculum and teaching methods at WU. The direction of the reform effort has been informed by our knowledge of the best practice in medical education and by the weaknesses in the traditional curriculum as perceived by WU faculty and students. In particular, the curricular limitations that faculty and student surveys identified provided direction for the curricular redesign for the basic sciences years. In addition, the UC medical curriculum, which was based on the generally accepted principles in the United States such as integration, independent learning, and clinical application of basic sciences, provided an appropriate model for WU to adopt and adapt. As a result, some issues identified by the 2009 surveys were addressed by the reform: There was a substantial decrease in overall lecture time and an increase in small-group learning and case discussions, earlier patient contact experience and knowledge were introduced, formative assessment was used, and basic sciences were integrated and more closely related to clinical medicine. Our recent project evaluation survey suggests that the reform has been well received by WU students in the new curriculum. The survey results revealed that key features of the reform, such as application of basic sciences to clinical medicine, earlier

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TABLE 1 Comparison of RC and TC students’ evaluation of their respective curricula (all participants, general student survey, 2011)

Overall Structure N RC N TC M RC M TC SD RC SD TC 95% Confidence Interval


t Test (Two-Tailed)a

145 150 3.572 3.417 .754 .786 .021 .332 Not significant

Relevance of Clinically Connections Basic Sciences Related Teaching Course Texts Among to Clinical Knowledge Methods and Other Assessment Courses Medicine and Experience and Style Materials of Students 145 150 3.793 3.560 .849 .855 .038 .428 t = 2.349 p = .019

145 150 4.32 3.43 .897 1.143 .662 1.133 t = 7.486 p < .0001

145 150 3.456 2.373 .953 .826 .879 1.287 t = 10.440 p < .0001

147 149 3.809 3.307 .622 .695 .35 .65 t = 6.538 p < .0001

145 150 3.255 3.410 .884 .875 −.356 .047 ns

145 150 3.607 3.483 .938 .864 −.083 .330 ns

Note. RC = reform curriculum; TC = traditional curriculum. a df = 293.

clinical knowledge and contact, interdisciplinary connections, and independent learning, were prominent in the new curriculum and welcomed by students. The new teaching, learning, and assessment methods—use of case discussions, more active student participation, and formative assessments as feedback tools—were also used somewhat effectively and appreciated by students. A comparison of the 3 years of RC students showed a difference with regard to their satisfaction with the adequacy of clinically related knowledge and experience, suggesting that as students progressed in their education, they were exposed to significantly more clinical knowledge and/or experience. It has also been found that students in the reform were generally more positive about their main curricular elements than the other students about their traditional curriculum. Results from the comparison of RC and TC students’ evaluation of their respective curricula suggested that the emphases on integration, clinical application, and clinical knowledge were more prominent in the reform courses than in the traditional courses. RC students were more satisfied with the teaching they received. It provided evidence that the new curriculum and pedagogy were well implemented and valued by RC students. In addition, students’ suggestions for improvement showed that small-group discussions and case-based learning, two of the key features of the new curriculum, were appealing to TC students as well. The fact that significantly fewer RC than TC students wished to increase lab hours was possibly due to RC courses’ inclusion of much case discussion in the lab. Finally, the fact that about 37% and 52% of RC students would like to see more use of small-group discussion and case-based learning, respectively, might indicate that these two features could be implemented more widely in the reform courses. These results suggest that the reform is heading in the right direction and that it has the potential of improving the overall educational quality of WU Medical School. There is much

room for improvement, however. For the reform curriculum, more work needs to be done in several areas. Overall RC students’ satisfaction with course sequencing is not significantly higher than that of TC students. Course schedules need adjusting so that difficult courses are not offered together in a single semester. Coursework work in communication skills may need improvement. RC students were quite divided as to whether the lecture to small group to independent learning ratio is appropriate, which might mean that a better ratio is yet to be achieved. Textbooks and other course materials were rated lower by Year 3 RC students than TC students. To date, some faculty members are providing remedies by developing their own handbooks and textbooks to match the novel reform curriculum. Students’ relatively low satisfaction with summative exams, which was reflected in earlier survey results, continued in 2011, and thus additional work on summative examinations is also in process. More opportunities for clinical experience are also called for by students. In response, additional development of clinical skills training using simulations and patient access at local community health centers is under way. Limitations of This Study One limitation of this study lies in the use of volunteer participants in the reform. Students were not randomly assigned to the reform and the traditional curricula. It is unclear whether differences in the two groups’ of students’ evaluations of the two curricula were attributable to differences in the students’ characteristics. Thus, it is possible that the comparison between the two groups’ evaluations of their respective curriculum might be biased by some students’ enthusiasm about reform. Another limitation is that the new WU curriculum and the analysis of its effectiveness are at an early stage. The project is still young, and because of the preliminary nature of this analysis, no durable conclusions related to our hypotheses are

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possible. Reform participants have had only 2 12 years’ experience with their new curriculum and their assessment of it is far from thorough. Thus, the recent general survey only obtained students’ perspectives on a portion of their 5-year-long curriculum. More in-depth and prolonged research is needed before the merits of the reform can be determined in terms of its impact on students’ learning and professional performance. Future use of the WUMER project design may allow for measures to test the translation of certain learning strategies into improved clinical behaviors, such as the assessment of clinical reasoning in the medicine clerkship and the measurement of students’ capacity against the Global Minimum Essential Requirements developed by the Institute of International Medical Education.10


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