Medical Education in Hong Kong -Past, Present, and FutureProf. Tai-fai FOKDean of Medicine, The Chinese University of Hong KongThe PastHistorically, mainstream Western medicine was closely
associated with religious activities. Dating back to the
early Middle Ages, the church played a dominant role in
the provision of medical education in Europe. Physicians
were trained as apprentices in monastery infirmaries and
hospitals. With the development of universities in
western Europe, medical training gradually shifted to the
medical schools. However, the mentor-apprentice
relationship between medical teachers and students
continued for many centuries until the 17th and 18th
centuries when medical education began to assume its
modern characters. Basic sciences teaching and
application of scientific principles to patient management
started to be incorporated into the medical curricula. In
Britain, the establishment of the General Medical Council
following the passage of the Medical Act in 1858 allowed
a statutory regulatory body to exert greater control and
influence over medical education, as well as to ensure
better quality assurance of medical practice. This had
resulted in significant improvements in medical
education standard across the country.
The improvement in the quality of medical education in
Europe was however not seen in the United States
where medical schools were mainly profit-driven with
profits being derived from hefty school fees. Standards
were very variable and in general quite low. Many
medical schools did not provide patient-based
education. This abysmal situation lasted until the turn of
the last century when Abraham Flexner published the
historic Flexner Report that revolutionised medical
education in the US. A school teacher-cum educational
researcher, Flexner was impressed by the medical
schools he saw during his tours around Europe,
especially those in Germany. After returning to the US,
he was commissioned by the Carnegie Foundation to
make recommendations on the way forward for medical
education in the US. He visited all the 155 medical
schools in the US and Canada, and published a report
which severely criticised the medical schools for their
lack of standard, poor evaluation method and lack of
clinical teaching. He pointed out that medical education
should be a form of formal university education rather
than an enigmatic process of apprenticeship. He
recommended the introduction of robust basic sciences
training in the laboratories, to be followed by clinical
teaching in teaching hospitals. He believed that the two
sets of training should be very distinct with no
overlapping in between. The Flexnerian curriculum was
adopted by most medical schools and became the
mainstay of medical education for a few decades,
including that in Hong Kong, until the late 20th century.
The PresentDuring the 1990's, the Flexnerian model was challenged
because of the compartmentalisation of basic sciences
and clinical training, and the lack of skills training.
Many medical educationists were of the opinion that
because of these deficiencies, the curriculum was
inadequate in preparing students to become
practitioners who were capable of meeting the demands
of the patients and the society in the present days. The
Flexnerian model gradually lost its dominance as many
medical schools underwent curriculum reforms in the
late 1990's. In all these reforms, "integration" became
the buzzword. HKU introduced a new integrated
curriculum with a heavy element of PBL (problembased
learning) in 1997 while CUHK adopted an
integrated curriculum with less elements of PBL in 2001.
In the design of the new medical curriculum in CUHK,
we have made reference to the famous book
"Tomorrow's Doctors" published by the General
Medical Council in 1993. We agreed with the GMC's
observation that the then existing curriculum burdened
the students with excessive factual information and
unnecessary memorisation, and lacked training in the
skills that physicians needed to acquire before they
could provide holistic and compassionate care to their
patients. The new curriculum significantly trims down
the core teaching content by 30%, and introduces
student-selected components that allow in-depth
studies in areas of particular interests to the students. It
also places significant emphasis in three areas: firstly
the training of skills in communication, secondly the
methodologies for searching and critically appraising
evidence in medical practice, and thirdly the
development of proper attitudes and behaviours as a
responsible medical practitioner. Replacing a subjectbased
curriculum that segregates basic sciences from
clinical teaching, the new curriculum is system-based
with horizontal (among disciplines) and vertical
(between basic sciences and clinical) integration.
Students are given opportunities to have clinical contact
as early as in their first year of studies. Many of the
large-class lectures are replaced by small group
teaching. Student assessments have also been
revamped with the introduction of formative and
summative components. In short, the curriculum has
become much more structured in terms of teaching and
learning as well as assessments.
In introducing major changes to our curriculum, we
recognise the importance of keeping under review its
effectiveness. The new curriculum at CUHK has now
been implemented for a total of seven years. Throughout
this period the Faculty has been diligently collecting
student feedback through a number of channels. While
there is still much room for improvement, the new
curriculum has so far received very positive feedback
from our students. There is a general feeling among the
students that they can now spend more time taking part
in extracurricular activities which make them feel more
like "receiving university (as opposed to vocational)
education". They also feel that with early clinical contact
and the integrated approach to basic sciences and clinical
learning, they now have a better understanding of the
clinical applications of the scientific principles.
Comments from external examiners have in general been
very favourable. The evaluation scores given by the
intern supervisors to the first two batches of interns who
have graduated from the new curriculum also compared
favourably with their predecessors.
The FutureAlthough we are pleased with the initial outcome of the
curriculum reform and are convinced that the direction
of our change is correct, we are fully aware that there
are still deficiencies in the design as well as our
execution of the new curriculum. After a few years
experimenting with the new curriculum, it is apparent
that some of our colleagues still do not embrace the new
concept of the reform. They are concerned that the
reduction in the teaching of factual information would
produce a generation of medical students and doctors
who do not possess the full range of knowledge
necessary to enable them to become safe medical
practitioners. With this perceived knowledge gap, the
skeptics fear that the new curriculum is going to
produce a group of second class doctors. To ensure the
success of the new curriculum, it is our duty to convince
these colleagues that in this day and age, there are more
important things and skills that students need to
acquire other than pure factual knowledge. As an
example, with the rapid advances in medicine, it is
more important for the students to equip themselves
with the skills that would enable them to access new
knowledge on their own rather than memorising
voluminous amount of factual information fed to them
which may have no direct relevance to their practice.
This is particularly true when much of this information
may become out-of-date within a very short period of
time. To give students more time to learn these new
knowledge and skills, it is only appropriate to reduce
much of the "over-teaching" that was so prevalent in the
past. In fact, even with the trimming of our core
teaching, our curriculum may still be too broad and the
scope too ill-defined so that the students might lose
their focus in their studies. They would certainly run
the risk of "missing the forest for a tree" if they are
unable to differentiate the essential information from
the less important ones. In compliance with the
requirements of the University Grant Committee, our
Faculty is now putting a lot of effort in devising a set of
outcome-based guidelines for teaching and learning.
Hopefully this will provide the students and teachers
with a more clear-cut indication of what the students
are expected to achieve upon completion of every stage
of their medical studies.
In the review of our new curriculum, I believe that we
are still deficient in two areas that need improvement.
The first is the imbalance between hospital-based
specialty teaching and teaching in primary health care.
Primary health care has been hailed as the gate-keeper
of the health care system by international authorities
such as the WHO, our own government, and to some
extent the public. Primary care teaching has however
not been given its fair share of emphasis in the curricula
of our medical schools. The family medicine units are
underprovided when compared to their counterparts in
countries where primary health care is well established.
There are historical reasons for this lopsided
phenomenon. The academic clinical units are duty
bound to provide clinical services to hospital patients
and there is therefore a need for a sufficient number of
clinical professors to shoulder this service load.
Primary health care in the past was not considered a
specialised field in Hong Kong as it was provided
mainly by general practitioners who had little or no
postgraduate training. However in this day and age,
we all recognise the importance and sophistication of
primary care, so much so that the Hong Kong College
of Family Physicians requires its trainees to go through
6 years of structured post-internship training. Yet the
teaching of primary care to medical students, which we
all agree should be in the community rather than in the
hospitals, still depends to a large extent on the good
will of primary care physicians in the community who
are providing free teaching services to the faculties.
Given this arrangement, quality assurance would not be
easy, and little can be done to stimulate the interest of
our students in considering primary health care as their
future career. In all the other developed countries
where primary health care is well organised, such as the
UK, Canada, and Australia, their governments have all
injected substantial resources into primary health care
teaching in medical schools. Primary care physicians in
the community are reasonably remunerated so that they
can dedicate a certain number of sessions every week to
providing structured undergraduate teaching. It is only
through the support of our Government that we can
bring life to primary care teaching, and prepare our
students properly for a career as primary care
providers. It is now time for the two medical schools at
HKU and CUHK to work together towards a better
primary care service for our community.
Another area of deficiency in our medical education is
character building of our students. From time to time,
we hear criticism about our junior doctors being
immature, self-centred, emotionally fragile, and lack of
compassion for their patients. It seems that our efforts
in enhancing teaching on communication skills, ethics
and attitudes in the new curriculum have not helped
building the character of some of our students. This is
not surprising since 'Rome was not built in one day'. It
would be unrealistic to expect that we can shape, or
change, these young people's attitude and character
through classroom teaching of some ethical principles
or a glossary of technical jargons. It is through life
experiences and wider exposure to humanity issues that
students can learn the ways to improve their
interpersonal skills as well as their emotion and
adversity quotients, to cultivate a demeanour that can
gain them the trust of their patients, to be sensitive to
the special needs of their patients, and to understand
the dimensions of life and personality of their patients
beyond their physical illnesses. Lack of such exposure is
a major deficiency in disciplines with a strong emphasis
in vocational training, such as medicine. While character
building should have begun during the early formative
years of the individuals (primary and secondary schools),
the introduction of the 3+3+4 curriculum may provide us
with an opportunity to correct, to a certain extent, the
deficiency since medical students will join the university
at an earlier age and for an additional year. We should
make use of this extra year to implement a programme
for character building and training appropriate for future
medical practitioners. More emphasis on general
education to enhance the exposure of our students to
philosophy, literature and culture, traditional values, and
ethics may also help.
No medical education programme can claim to be
perfect. There is more to being a good doctor than being
able to make an accurate diagnosis or design an effective
treatment plan. We expect a good doctor to be confident,
empathetic, compassionate, humane, personal,
responsible and forthright. To keep up with rapid
advances in medicine, the doctor also needs to be a lifelong
learner. To design a curriculum that helps students
to acquire all these diverse attributes is indeed a great
challenge. Despite the deficiencies mentioned above, I
believe we are moving in the right direction with our
new curriculum. We will need however to be vigilant to
ensure that we will not derail. Through continuous self
reflection and improvement of our curriculum we hope
to achieve our mission of providing education to our
students who are ready to provide quality health care to
our community upon their graduation.
