Successful medical education is essential for an efficient healthcare system in China.1 Ophthalmology, one of the first western medical specialties introduced to China in the 1800s, is a fast and growing field. The development of competent and qualified ophthalmic professionals requires robust medical education, which may be challenging for large countries such as China.
Since 2006, the International Council of Ophthalmology (ICO) has published standardized curriculum content outlines based on analysis of curricula from >30 countries.2 These outlines represent an international consensus on what residents are expected to learn and have been translated into multiple languages, with opportunities for adaptation to suit the needs of different countries and cultures. These outlines are continuously undergoing modification, with a major update in 2012 to include more specific detailed requirements.3
In this article, we aim to provide a thorough review of the Chinese ophthalmology residency training and promote development of a better-executed standardization process that matches international standards to train future Chinese ophthalmologists. To our knowledge, this is the first comprehensive review of ophthalmology training in China that draws information both from literature and onsite data collected from Chinese ophthalmologists.
PREMEDICAL AND MEDICAL EDUCATION
In contrast to medical training after undergraduate (or college) degrees in the United States (US), medical training in China starts immediately after high school. In China, medical school training generally takes 5 years, comprised of basic and clinical science courses in the early years followed by clerkship and internship training during the last 2 years. Students graduate with a Bachelor in Medicine (MB) degree and may start residency training with the possibility of pursuing a Master's (usually 3 years) or Doctor of Philosophy (PhD) degree (usually 3+3 years or more) in clinical medicine concurrently. Applicants for these special combined programs will need to undergo national examinations and interview processes for both the advanced degree programs and the standardized residency training programs separately. Recently, several prestigious Chinese medical schools have piloted “8-year programs” that combine undergraduate and PhD degrees (4 + 4 model), with different programs varying from the amount of time dedicated to liberal arts study, basic science classes, clinical exposure, and research.4 In 2017, the Chinese State Council issued a document emphasizing that the traditional 5-year medical undergraduate program will remain the norm while strictly controlling the number and enrollment scale of the 8-year programs.5
The concept of residency training is relatively new to China. Ophthalmologists traditionally obtained their skills on the job without formal training. In 1988, the city of Beijing initiated standardized residency training in its teaching hospitals.6 The Chinese Ministry of Health in 1993 began requiring all teaching hospitals to provide standardized training and evaluation of junior physicians, which led to creation of residency programs similar to those in the US.7 The goals of standardized residency training in China are to improve the competence of ophthalmologists and the quality of patient care and to meet international standards.
In 2006, the Chinese Ministry of Health designated Beijing as the official pilot region for national standardization of ophthalmology residency.8 Ophthalmology residency guidelines were subsequently updated in the city of Shanghai and the province of Guangdong as well. Since then, there have been increasing efforts to standardize residency training in different regions of China; however, there is still a lack of updated and unifying national guidelines.
Program Accreditation and Oversight
Ophthalmology residency programs in China are accredited by the Ministry of Health. Accreditation is determined at a local level by the provinces’ Departments of Health. In contrast, in the US, the Accreditation Counsel of Graduate Medical Education (ACGME), a not-for-profit private organization, sets standards for graduate medical education and accredits residency programs. Comparison and contrasts of specific accreditation requirements can be found in Table 1.
In China, after an initial onsite inspection, evaluation and certification are also conducted by an expert committee organized by the provincial Departments of Health at each review cycle.7 The committee has the right to revoke accreditation from hospitals, which must then send residents elsewhere for training.9 The Ministry of Health can also reduce the number of training centers in a specific region as a result of multiple programs losing accreditation. This makes the imbalance in availability of training programs even worse, as training programs tend to be concentrated in large metropolitan areas such as Beijing.
Thus far, there are a total of 450 training centers accredited across the country.10 However, the number of ophthalmology residents in training nationwide is unclear given the lack of specialty data and ongoing monitoring.
Resident Selection Process
The Ministry of Health determines the number of all medical residency positions based on the anticipated needs and growth of each hospital. The hospital administration then allocates positions among the specialties, taking into consideration requests from each department. Thus, the number of ophthalmology residency positions in a hospital varies year to year and may even be as few as one position in any given year. However, there are no regulatory limitations on how many “outside trainees” each qualified training center can accept from nontraining center hospitals. These “outside trainees” are typically practicing ophthalmologists from hospitals that do not have training centers, who wish to pursue more standardized training. They typically do not have to go through the “standardized residency training program” selection process and therefore do not count toward the “program quota,” but are allowed to participate in program activities. This concept of “outside trainee” is similar to that of “US trainees outside the Match,” although the latter is less common.
Criteria for resident selection in China includes academic performance during medical school, the major criterion, and English proficiency.8 There is no equivalent to the US “Match” process, and personal statements or letters of recommendation are not required, although more selective programs may require interviews. Additionally, teaching hospitals are prone to admit students from their affiliated medical schools, as there does not exist a standardized medical school graduation examination.
Training Duration and Overview
In China, ophthalmologists must first complete at least a 5-year undergraduate curriculum emphasizing basic biomedicine, medical technology, and clinical medicine. Afterwards, they may complete ophthalmology residency training.11 Individuals can enter residency with an MB degree, an MS degree, or a PhD degree in clinical medicine. Residents with an MB degree are allowed to pursue higher degrees of education (MS or PhD) during their training. The duration of residency training in China is generally 3 years for trainees with an MB degree. For those pursuing an additional graduate degree during residency training, the residency component should be no less than 33 months.12 Trainees with previous ophthalmology experience or advanced degrees may shorten their training duration at the discretion of their specific training center. Graduates of the standardized residency training programs are regarded as general ophthalmologists and can perform clinical, surgical, and consultation duties independently.
In comparison to the US, where ophthalmology residency training programs are expected to organize formal didactic lectures as part of their core requirements, formal teaching at residency training programs in China is highly variable. The large clinical volume has been cited as a limiting factor in the ability to carry out formal teaching. Based on our onsite interviews, it appears that only elite Chinese training programs, such as Peking University (PKU)'s program, assemble regular teaching conferences. PKU residents are expected to actively participate in these conferences and are required to give annual case presentations. However, formal didactic lectures on ophthalmic principles and clinical knowledge are infrequent.
The most recently published Chinese guidelines for ophthalmology residency training in 2015 established basic requirements for length of rotations, surgical case exposures, and volume of procedures, and research, bioethics, and teaching expectations.13 However, the specific curriculum at each training center varies considerably.
In the US, comprehensive, subspecialty, and surgical trainings are interspersed throughout 3 years of ophthalmology residency with appropriately staged advancement. However, at PKU, the 3 years of residency training is a two-stage process, as illustrated in Figure 1. The initial “clinical observation” stage takes place during the first year, whereas the second “systemic training” stage takes place during the second and third years of residency (Fig. 1), with emphasis on clinical applications of fundamental knowledge.
Surgical training is typically dispersed throughout residency. At PKU, basic surgical skills training is usually conducted after case conferences for the first-year residents. The department also holds annual courses on cataract, glaucoma, and vitreo-retinal surgeries, with emphasis on the surgical principles and pearls of each type of surgery. Residents are encouraged to use the wet lab, which contains microsurgical equipment for practicing surgical skills on animal or model eyes. In Shanghai, suturing pig eyes comprises one of the mandated practical examinations for residents, who are evaluated on their strengths and weaknesses during the procedure.14 Each resident is expected to pass a surgical skills evaluation before participating in surgery.
Specific surgical skills requirements are listed in the Beijing ophthalmology training manual. Competency requirements by year are also illustrated in Figure 1. Elite programs may set a higher number of required surgical cases for graduation, although a large range of variety exists between different programs (Table 2). Although residents from different American programs may graduate with varying numbers of surgical cases due to geographic and patient population restrictions, the standard is established at a national level and individual programs do not adjust requirements at the program level. Due to regional differences in population density, economic development, and educational background, accreditation requirements vary among the different regions in China. The significant variability in surgical requirements between Chinese programs may contribute to differences in skill competency and surgical outcome. In addition to regional differences in surgical curriculum, the requirements for Chinese ophthalmological residents are generally less specific and detailed when compare with those listed in the ICO guidelines.
Teaching and Research Requirements
Both American and Chinese ophthalmology residents do not have a structured teaching requirement. Nevertheless, residents are expected to be able to teach rotating medical students. Research requirements, as in the US, vary among training programs. Ophthalmology residents in China are generally required to perform literature review and conduct parts of clinical research, including research topic selection, study design, and execution. Formal research requirements may exist for more elite programs. For example, at both PKU and Zhongshan Ophthalmic Center, residents are required to publish at least one review article before graduation. The Ruijin Hospital training program affiliated with Shanghai Jiaotong University requires at least 1 publication in a Chinese core journal. Residents pursuing concurrent Master's or PhD degrees must complete a thesis dissertation by the end of residency. These residents are also expected to write case reports or literature reviews regularly. Participation in national or international conferences is not mandated during training.
Resident evaluation involves end-of-rotation exams and a final evaluation at the end of training. Each resident is expected to pass an in-service evaluation, obtain departmental approval, and pass the National Physician Certification Examination before applying to attend the ophthalmology certification evaluation. Only those who pass the certification examination are allowed to apply for fellowship, if desired, although no standardization of fellowship training currently exists.
The final certification examination is based on the Objective Systemic Clinical Examination (OSCE) model and is comparable to a combination of the United States Medical License Examination (USMLE) STEP 2 Clinical Skills Assessment and Ophthalmology Oral Boards.15 The final certification examination is conducted at a regional level without use of national standardized testing centers. In Beijing, for example, the final assessment involves written and practical examinations at 5 stations. Clinical competency and interpersonal skills are tested with real patient interactions. Microsurgical skills are assessed with proctored procedures.
In a cross-sectional web-based survey of 87 US ophthalmology residents, 93.6% responded that they were highly satisfied with their programs, with >80% rating case volume, complexity, and variety as satisfactory or better. However, 38.5% of respondents reported insufficient exposure to low-vision rehabilitation, refraction and contact lenses prescription, and vitreoretinal surgeries. There were also reports of insufficient exposure to extracapsular cataract extraction (26.3%), refractive surgery (19.7%), and orbital surgery (64.5%), suggesting that certain curriculum modifications should be considered.16
In a study of perceived training differences among ophthalmology residents, Young et al reported that Chinese ophthalmology residents overall reported lower satisfaction, in part due to too much time completing medical charts, less supervision, and underpay.17 Currently, there is no literature directly comparing satisfaction with residency programs between American and Chinese ophthalmology residents.
Continuing Training After Residency
Approximately 65% of US graduating ophthalmologists pursue an additional 1 to 2 years of subspecialty fellowship training in glaucoma, medical or surgical retina, cornea, oculoplastics, pediatrics, and neuro-ophthalmology. US fellows often see patients independently and, throughout their subspecialty training, will progressively gain more responsibility managing patients until they are equipped to do so entirely on their own. They may initially assist in the operating room under supervision but toward the end of their training, may perform primary procedures. In China, however, subspecialty training is not available nationwide and is mainly organized by hospitals that have strengths in particular subspecialty fields. In both the US and China, practicing ophthalmologists are expected to achieve 25 hours of continuing medical education credits, including 2 hours of ethics training, annually.11
Ongoing Standardization Efforts
Constant efforts are being made in the Chinese ophthalmological community to improve training quality. For example, Jiangsu Province has organized training courses to improve faculty teaching ability and training forums for educators to share their experiences. Zhejiang Province has also launched faculty training programs. Sichuan Province has implemented detailed residency assessment programs, including a daily assessment, end-of-rotation assessment, annual in-service assessment, and final assessment administered at the time of program completion. A monitoring platform is also being built to facilitate student recruitment, teaching quality, residency examination, and evaluation in several different provinces.18
In the past 30 years, significant developments have been made in the nascent Chinese ophthalmology residency training. However, the process of standardization is still ongoing. When compared with the ICO residency training curriculum requirements, the Chinese requirements are less detailed and less specific. Large regional differences continue to exist due to the lack of a true national standard, resulting in significant variations in the competence of graduating residents. Insufficient opportunities, in the forms of limited numbers of training positions available, lack of adequate teaching by attending physicians, and difficulty in securing a job after training, are some of the consequences of the lack of standardization.
The Chinese ophthalmology community is determined to standardize residency programs to train young ophthalmologists who are competent, ethical, and compassionate. The standards set forth by the ICO serve as an excellent baseline with opportunities for modification to suit the Chinese people. Further standardization in line with the international standards will also facilitate international fellowship studies, exchange scholars, and research collaboration globally.
The authors sincerely appreciate Dr. Ta Chen Chang and Dr. Steven Gedde at the Bascom Palmer Eye Institute for their invaluable suggestions and advice when writing this manuscript.
1. Xu D, Sun B, Wan X, Ke Y. Reformation of medical education in China. Lancet
2. Golnik K, Mayorga E, Spivey B, Ritch R, Gauthier TM. International Council of Ophthalmology: refocusing ophthalmic education in the Asia-Pacific region and beyond. Asia Pac J Ophthalmol (Phila)
3. Education ICoOR. ICO Residency Curriculum 2006. Available at: http://www.icoph.org/refocusing_education/educational_programs/residency.html
. Accessed October 20, 2018.
4. M G. Discussion of the 8 year programs [article in Chinese]. Available at: http://www.h-ceo.com/html/2011/06/2011062715410000045453.shtml
. Accessed September 6, 2018.
5. Council GOotS. Opinions of the General Office of the State Council on Deepening Medical Education Cooperation and Further Promoting the Reform and Development of Medical Education [Article in Chinese]. Available at: http://www.gov.cn/zhengce/content/2017-07/11/content_5209661.htm
. Accessed July 11, 2018.
6. Health BM. Opinions on promoting the construction of standardized training system for residents in Beijing. Available at: http://zy.bjzyy.wsglw.net/OtherInfo/NewsShow.aspx?news_id=8e23160b-7c54-4de1-b4cb-a65e00adfaed
. Accessed August 10, 2018.
7. Wang XY, Rodríguez AC, Shu MR. Challenges to implementation of medical residency programs in China: a five-year study of attrition from West China hospital. Acad Med
8. Chinese Medical Doctors Association Mo and China HotPsRo. Standardized residency training requirements (editing draft) [Article in Chinese]. Chinese Medical Doctors Association, Ministry of Health of the People's Republic of China, 2011.
9. China MoHotPsRo. Notice of the General Office of the Ministry of Health on building specialty physician training program test-sites [Article in Chinese]. Document No 27. Beijing, China: Ministry of Health of the People's Republic of China, 2006.
10. General Office of National Health and Family Planning Commission. Notice of the General Office of national health and Family Planning Commission on publishing the list of the first batch of standardized training bases for residents. Available at: http://www.nhc.gov.cn/qjjys/s3593/201409/bc24d6c148794d958d7babc93f872322.shtml
. Accessed September 26, 2019.
11. Liu Z, Liu M, Chang R, Huang P, Zhang C. A comparison of ophthalmic education in China and America. Ann Eye Sci
12. Bureau BMH. Management measures for standardized training of residents in Beijing. Available at: http://zy.bjzyy.wsglw.net/OtherInfo/NewsShow.aspx?news_id=8e23160b-7c54-4de1-b4cb-a65e00adfaed
. Accessed June 13, 2018.
13. Bureau BMH. Registration Manual for standardized residency training in Beijing [Article in Chinese].
14. Zhang Z, Zhou M, Liu K, et al. Development of a new valid and reliable microsurgical skill assessment scale for ophthalmology residents. BMC Ophthalmol
15. Notice on the first batch of graduation theory and clinical practice competence assessment for standardized resident training in Beijing in 2018 [Article in Chinese].
16. Abdelfattah NS, Radwan AE, Sadda SR. Perspective of ophthalmology residents in the United States about residency programs and competency in relation to the International Council of Ophthalmology guidelines. J Curr Ophthalmol
17. Young AL, Jhanji V, Liang Y, et al. A survey of perceived training differences between ophthalmology residents in Hong Kong and China. BMC Med Educ
18. Office of Leading Group for Deepening the Reform of Medical and Health System of the Ministry of Health. Steadily advancing of the residents standardized training. Available at: http://www.nhc.gov.cn/tigs/s9661/201205/3db6210dca254b05afaa27dca1ac5d3e.shtml
. Accessed January 13, 2020.