How the humanities can ameliorate China's health-care crisis
Authors: Angela P Fan, Russell O Kosik, Selina S Lien, Yunung Hsu, Lihong Fan, Dan Li, Lei Huang, Xudong Zhao, Yuanpeng Ren, Baisheng Jiang, Qi Chen
Journal: The Lancet Psychiatry (2020)

Who wants to be a doctor when an epidemic occurs? The recent coronavirus epidemic has shown how crucial it is for medical doctors to possess strong mental health, resilience, and a spirit of self-sacrifice. This poses the question: what is the best way to cultivate medical doctors with such qualities? Over the past century, advances in the medical sciences have engendered an optimistic spirit among those in the profession. However, in addition to acute issues such as the outbreak of infectious diseases, challenging phenomena such as chronic diseases have threatened that positivity. Responding fully to these diseases will not be possible by relying solely on the sciences. Because caring for the health of mankind is the essence of medicine, the prevention of disease is in itself a social process, requiring human love that is blind to national borders. In addition, a diverse range of work in critical medical humanities has long explored the realities of medicine and health. Therefore, reflection on the nature of medicine, with special attention to the economic, social, cultural, anthropological, and historical causes of disease, is essential for reshaping medical education for the 21st century. Although these topics have been introduced into medical humanities curricula, pragmatically focused medical education systems concentrate on immediate clinical results rather than critical reflection. In many medical schools around the world, the medical humanities have thus become enclaves against the dominance of biological sciences. In this globalised world, China's health-care system is not only directly responsible for the care of the country's 1·4 billion people, but also indirectly responsible for medical issues that might affect the entire world's population—as recent events have shown. Since 2009, along with expansions in the provision of health care and technical advances, the Chinese government has vigorously promoted various policies and guidelines aimed at improving physicians' training standards and working environments, including raising their incomes and reforming medical humanities curricula. During difficult periods in Chinese history, such as the Sino–Japanese War, many Western missionaries were engaged in providing medical education and services in China. Their stories are remembered by generations of Chinese people. One of the most influential of these doctors was Dr Norman Bethune. Statues in his honor can be found in cities throughout China. Bethune emphasised that a person's motivations should be guided by principles, not profits, and he effectively brought modern medicine to rural China. His selfless attitude left a profound impression on the Chinese people, and Bethune's spirit to this day remains at the core of a Chinese medical humanities education.9Deslauriers J The medical life of Henry Norman Bethune.Can Respir J. 2015; 22: e32-e42Crossref Scopus (3) Google Scholar Despite many successful reforms in medical education in China, various problems have arisen, including physician attrition1Lien SS Kosik RO Fan AP et al.10-year trends in the production and attrition of Chinese medical graduates: an analysis of nationwide data.Lancet. 2016; 388: S11Summary Full Text Full Text PDF Google Scholar and a deteriorating doctor–patient relationship.2Li J Qi F Guo S Peng P Zhang M Absence of humanities in China's medical education system.Lancet. 2012; 380: 648Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 3Tucker JD Wong B Nie J-B Kleinman A Rebuilding patient–physician trust in China.Lancet. 2016; 388: 755Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar Some argue that the fundamental reasons behind these problems lie within misdirected medical curricula.4Tucker JD Nie J-B Cheng Y Zhu W Kleinman A Reviving medicine as the art of humanity in China.Lancet. 2014; 383: 1462-1463Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 5Wang XQ Wang XT Zheng JJ How to end violence against doctors in China.Lancet. 2012; 380: 647-648Summary Full Text Full Text PDF PubMed Scopus (67) Google Scholar Although some authors4Tucker JD Nie J-B Cheng Y Zhu W Kleinman A Reviving medicine as the art of humanity in China.Lancet. 2014; 383: 1462-1463Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 7Chen LC Reich M Ryan J Medical education in East Asia: past and future. Indiana University Press, Bloomington2017Crossref Google Scholar have commented on the relative scarcity of humanities material in Chinese medical curricula, there has been little research regarding the state of the humanities at Chinese medical schools, particularly from a comprehensive and evidence-based approach. In China, only tier-one colleges may offer an education in clinical medicine. We conducted a comprehensive web-based search of curricula to identify all medical humanities courses at all tier-one Western medicine Chinese medical schools (of which there are 138). Eight course types were identified. The most frequently offered course types are medical psychology or clinical psychology (72 [77%] of 94 schools who publicise their curricula), medical ethics (68 [72%]), hygienic and medical jurisprudence (57 [61%]), and doctor–patient communication (46 [49%]). Medical humanities courses account for 3–10% of the total credits that students are required to obtain in order to graduate, and the compulsory ideological and political theory curriculum accounts for 6–8% of the credits required to graduate. This curriculum includes Mao Zedong thought, modern Chinese history, Marxism, socialism with Chinese characteristics, and moral education and law, and it is required of all students, not solely medical students. Medical humanities courses at Western medical schools account for a greater proportion of the total credits required to graduate; for example, they make up 15% at Oxford University and 25% at Harvard University. In China, the ideological and political theory curriculum also has a humanistic intent, and when added together with traditional medical humanities content, the two together account for 9–18%. Thus, China might not be as far behind Western countries with regards to the quantity of medical humanities education as it appears on the surface. Despite continued deterioration of the doctor–patient relationship in China, only around half (49%) of tier-one medical schools offer coursework focused on doctor–patient communication, and this coursework is mostly limited to a single semester or school year. In contrast, medical schools in Western countries, such as Harvard University and Oxford University, place a much greater emphasis on doctor–patient communication, with applicable coursework running through both the preclinical and clinical years. In the past few years, Chinese medical education has been uniquely transformed in a way that reflects Chinese culture and history. A coherent and longitudinal medical humanities framework, specifically aimed at strengthening the doctor–patient relationship, is urgently needed. China's endeavours to foster medical humanities education reforms should be actively promoted at the level of research, policy, and practice. We declare no competing interests.