medical education in china

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Medical Education Systems in China: Development, Status, and Evaluation

Liu, Xihan MD 1 ; Feng, Jie MD 2 ; Liu, Chenmian MD 3 ; Chu, Ran MD 4 ; Lv, Ming MD 5 ; Zhong, Ning MD 6 ; Tang, Yuchun MD 7 ; Li, Li MD 8 ; Song, Kun MD 9

1 X. Liu is a student, Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, China.

2 J. Feng is a student, Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, China.

3 C. Liu is a student, Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, China.

4 R. Chu is a student, Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, China.

5 M. Lv is director, Department of Education, Qilu Hospital of Shandong University, Jinan, Shandong, China.

6 N. Zhong is associate professor, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.

7 Y. Tang is associate professor, Department of Anatomy and Neurobiology, School of Basic Medical Sciences, and deputy director, Office of Scientific Research and International Affairs, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.

8 L. Li is associate director, Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, China.

9 K. Song is director, Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, China

Supplemental digital content for this article is available at https://links.lww.com/ACADMED/B323 .

Funding/Support: This work was supported by the educational reform and research project of Cheeloo College of Medicine, Shandong University (grant number qlyxjy-201707 and grant number qlyxjy-201880), and the educational reform and research project of Qilu Hospital, Shandong University (grant number 2016QLJY11).

Other disclosures: None reported.

Ethical approval: All participants provided written informed consent, and the Ethics Committee of Shandong University approved the study (KYLL-202111-072).

The authors have informed the journal that they agree that X. Liu, J. Feng, and C. Liu completed the intellectual and other work typical of the first author.

Correspondence should be addressed to Kun Song, Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, 107 Wenhua Xi Rd., Jinan, Shandong 250012, P.R. China; email: [email protected] .

Since 1949, China has made many changes to develop its medical education system and now has a complex array of medical degrees. The current system comprises a 3-year junior college medical program, 5-year medical bachelor’s degree program, “5 + 3” medical master’s degree program, and 8-year medical doctoral degree program; these programs each provide a different path to earning a medical degree. The advantages and drawbacks of such complexity are open to discussion. Since the government set a strategic goal of “Healthy China” in 2019, it has sought to increase the training capacity of its medical education system to establish a high-quality health service system. This article reviews medical education reform in China, discusses the current medical education system, and presents evaluations of medical education programs based on assessments by 1,025 participants (medical students and doctors) recruited from 31 provinces of China. These assessments were compiled via a multicenter self-reported questionnaire administered July 1 to 5, 2021. Participants were training for a medical degree or practicing doctors trained in the 5-year program, “5 + 3” program, 8-year program, or “4 + 4” program. The authors assessed the medical education system to which each of the participants belong and their career stage and career satisfaction, and they requested that participants name the 3 most promising programs. The 8-year program ranked first in work satisfaction (7.92/10), education program satisfaction (7.78/10), and potential (1.91/2). Scores of the 5-year program and “5 + 3” programs were 7.25 and 7.17 for system satisfaction, respectively, and the “4 + 4” program (7.00/10) ranked the next highest. The innovations that have occurred in the Chinese medical education system have offered opportunities to meet the needs of more patients, but the lack of consistency has also posed challenges. Currently, Chinese medical education is becoming more uniform and standardized.

From 1949 to 2020, China invested in modern medical education. When the People’s Republic of China was established in 1949, only 22 medical colleges existed, with 3,800 students enrolled per year. 1 By September 2020, this number had increased to more than 200 medical colleges, with approximately 800,000 students enrolled per year. 1

China has great complexity in the levels of programs designed to train doctors. The current system comprises a 3-year junior college medical program, 5-year medical bachelor’s degree program, “5 + 3” medical master’s degree program, and 8-year medical doctoral degree program. These 4 programs were developed in response to the shortage of doctors in China from 1949 to 1976 and the lack of high-level medical talent in the late 1990s, and they have been enabled by technology and economic and social progress. 2

The diversity of the medical education system in China is largely due to historical changes. In the early 1970s, China emphasized enlarging the scale of medical education and shortened the medical education period to meet the increasing demand for health care. 3 , 4 To enhance the quality of medical education in the 21st century, longer-term programs, such as the “5 + 3” and 8-year programs, were implemented to enhance the quality of medical education. 5 In 2018, the Peking Union Medical College launched a “4 + 4” program, allowing talented college graduates from top institutions worldwide and with diverse undergraduate academic backgrounds to pursue medical careers. 6

Multiple programs coexist within the modern Chinese medical education system, but the characteristics, degree of satisfaction, and future development of each program have not been thoroughly evaluated. In this study, we examined the historical development of Chinese medical education, identified the differences and specialties of each medical education program, and conducted a multicenter survey to evaluate the programs. We also considered possible future directions for medical education in China. Specifically, we forecast that a more uniform and standardized medical system unique to China will soon be developed.

Historical Background of the Medical Education System in China

We searched MEDLINE, Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI), Web of Science, and Wanfang Data, to identify articles published on the historical development of China’s medical education system from inception to December 2020. Additionally, we searched the official websites of colleges and the Chinese Ministry of Education to obtain official information. We used the following search terms and medical subject headings: “Chinese medical education,” “reform,” “changes,” “development,” “junior college medical education,” “5-year program,” “4 + 4,” “5 + 3,” “medical educational system,” and “length of schooling.” Reference formats included research articles, websites, and official files. Subsequently, we reviewed the reference lists of the articles we found to identify and include additional eligible articles.

Reforms in Chinese medical education programs since 1949

The development of modern medical education in China can be divided into 4 stages. The first stage occurred from 1949 to 1966, when the Chinese medical education system was initially established based on the Soviet Union’s medical education system. The second stage (1966 to 1976) was a period of stagnation that saw the abolishment of the college entrance examination system. The third stage (1976 to 2012) was marked by rapid changes in medical education policy, and medical education gradually transformed into multilevel and multispecialty areas of practice. The fourth stage (2012 to the present) is characterized by a focus on high-quality medical education. 4 Figure 1 shows the major events and policy changes over this timespan.

Before 1949, the Chinese medical education system was based on the 3-level degree system. 7 Starting in 1949, the Chinese government implemented reforms to build a new medical education system. 8 In 1952, public medical colleges were established and assumed the task of cultivating medical students. At this time, medical education mainly comprised intermediate and higher training conducted by secondary medical schools and universities. 9 College students earned a medical degree in 5 years by completing 3 years of basic science, 1 year of clinical teaching, and 1 year of practice. 4 Graduates could enter clinical practice directly after completing their education. However, this extensive course of education led to an extreme shortage of medical personnel. From 1953 to 1957, the country had 25,918 medical graduates while its population was more than 614 million. 1

In 1966, to cultivate more doctors to meet the country’s rising health care needs, the Ministry of Education shortened the length of medical education from 5 years to 3 years. 10 , 11 Around this same time period, the Ministry of Health also shifted the focus of medical care to the countryside, which spawned a rural doctor system that lasted from 1965 to 1975. 12 The aim of the rural doctor system was to produce a large number of workers with medical knowledge to provide preventive health care and treat basic health problems. Rural doctors were trained to play an essential role in providing basic care to the rural population; however, their training was brief and very limited. 12 , 13

After 1976, China again refocused its medical education system, and in 1981, the country began to standardize medical degrees. The Ministry of Education promulgated the “Regulations of the People’s Republic of China on Academic Degree” and established a 3-level medical degree system: bachelor, master, and doctor of medicine (MD). 14 In this 3-level system, students must earn a previous degree to apply for a higher degree. For example, a medical doctoral student must complete 5 years of undergraduate study for a bachelor’s degree and 3 years for a master’s degree before proceeding to 4 years of doctoral study. After 1988, some schools were allowed to admit long-term medical students and get higher degrees directly; for example, in these schools, 8-year medical students can earn a doctorate without a master’s degree.

In 1988, 15 schools were approved to conduct the 7-year program that awarded a master’s degree in medicine. In 2001, the Ministry of Education stated that medical education should gradually expand the scale. 15 In the same year, the Peking Union Medical College began to recruit students for the 8-year MD degree. In 2004, the Ministry of Education officially approved 9 universities to award the MD degree. 16

The number of medical university graduates increased rapidly, especially once university enrollment expanded in 1999. To standardize medical services, in the same year, China formally passed the Law on Medical Practitioners and established national medical licensing examination (NMLE) systems. 17

In 2010, the International Medical Education Expert Committee called for a third medical education reform to meet the global health requirements, 18 and in 2012, the Ministry of Health proposed the “Excellent Doctor Education and Training Program.” 19 This reform focused on improving the quality of doctors graduating from Chinese universities and cultivating humanistic clinicians capable of conducting scientific research. In 2014, China formally established a national standard residency training system. 20 Chinese doctors were required at minimum to obtain a medical degree, pass the medical practitioner qualification examination, and finish standardized residency training. 21 In 2015, the “5 + 3” integrated training model completely replaced the prior 7-year master’s level medical degree. 22 The new model allows graduates to obtain a medical master’s degree and certificate of standardized residency training. At present, postgraduate education in China includes standardized residency, general practitioner training, and specialist training. 23

Description of different medical education programs in China

Table 1 provides an overview of different medical education programs that have been offered in China since 1949. The major medical training program in China today is the 5-year bachelor’s degree program, with 132 colleges offered this program in 2021. Figure 2 provides a comparison of the various cycles for cultivating doctors in China.

Medical education in junior colleges.

Junior colleges train practical medical professionals for primary medical services; they include secondary technical schools and junior medical colleges. Generally, the length of schooling is 3 years. In 2012, the government introduced a “3 + 2” program, which comprises the 3-year junior college medical education plus a 2-year general practitioner training. 19 Junior college medical education has a lower entry threshold and shorter training period compared with other medical education programs. This program has trained many clinicians for primary health care and heavily contributes to China’s primary medical services.

The 5-year medical education program.

The 5-year clinical medical major program is the basis of clinical medicine education. It is designed to produce qualified practicing doctors. 8 The training plan includes basic and clinical medicine courses and internships. Graduates can take the NMLE 1 year after participating in clinical work at medical institutions, and they need to complete 3 years of standardized residency training to become doctors.

With the increase in the number of 5-year medical education graduates, the requirements for working in top-ranked hospitals have become more stringent. An increasing number of undergraduates continue their studies to earn a master’s or doctoral degree for better employment opportunities. 24

The “5 + 3” medical education program.

The “5 + 3” model is designed for training high-level clinicians. 25 It combines the 5-year medical undergraduate education, 3-year standardized residency training, and postgraduate education. Qualified graduates obtain a certificate of standardized residency training and a professional master’s degree. 22 Compared with other medical students, the greatest advantage for students in this program is their ability to simultaneously participate in standardized residency training and postgraduate education.

The 8-year medical education program.

To date, 14 colleges have qualified for the 8-year medical education program in China. 16 This program aims to equip students with a humanistic spirit, extensive social and natural science knowledge, solid medical knowledge, and clinical practice skills.

The training program varies but mainly includes basic science and medical education together with scientific research training. After graduation, most students obtain an MD degree. Peking University awards a small number of excellent graduates with MD and Doctor of Philosophy (PhD) degrees. 26

Recent practice in medical education in China.

Medical education in China is becoming internationalized. The Ministry of Education pushed forward a reform of integrative-curriculum education, applied new teaching methods, such as problem-based learning, and implemented the “4 + 4” and 9-year programs.

The “4 + 4” medical education program has emerged in China in recent years. 6 Only 3 universities have adopted this program, which provides training to meet the public’s increasingly high expectations for health care services. 5 The students selected for this program are talented college graduates with multidisciplinary academic backgrounds from top institutions worldwide. Students need to complete the medical curriculum, internships, and doctoral dissertations within 4 years. Those who fail the exam are transferred to a PhD or Master of Science training program. 27

In 2019, Nanjing Medical University established a 9-year medical education program. In this model, undergraduate, graduate, doctoral education, and standardized residency training are integrated and completed within 9 years total. 28 Graduates earn an MD degree and can become qualified doctors instantly after graduation. 28 It offers the shortest cycle from start to finish among all the medical education programs.

Evaluation of Medical Education Programs in China

To learn more about today’s medical education system in China, we invited 1,025 medical students, residents, and doctors who had joined a medical education program in 79 hospitals in 31 provinces of China to participate in a self-administered questionnaire survey that took 5 to 10 minutes to complete. Participation was limited to individuals who had trained in Western medicine curriculum.

We contacted directors of hospital education departments to assist in recruiting participants and in coordinating meetings to complete questionnaires onsite. All 1,025 questionnaires were completed and collected, and the completed questionnaires were then input into our computer system for analysis.

We collected basic information for all 1,025 participants, including age, graduate school, medical program, affiliation, highest educational attainment, and current career stage. We measured job satisfaction and program satisfaction using a scoring system that ranged from 0 to 10 and calculated each program’s average score. We requested participants choose the 3 programs with the most potential, and we calculated the average weighted scores. All statistical computations were performed using the online Questionnaire Star application ( https://www.wjx.cn ). All participants provided written informed consent, and the Ethics Committee of Shandong University approved the study. Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B323 displays information about the questionnaire used in this study.

Of the 1,025 total respondents, 578 (56.39%) were from universities and hospitals in the Shandong province. The rest were from Jilin (68, 6.63%), Beijing (61, 5.95%), Chongqing (54, 5.27%), and others (264, 25.76%), including 31 provinces of China (see Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/B323 ).

Participants were uniformly distributed by career stages. The total number of students was 380 (37.07%), comprising 101 (9.9%) undergraduates, 181 (17.66%) standardized resident trainees pursuing a master’s degree, 85 (8.29%) students pursuing a doctor’s degree, and 13 (1.27%) students pursuing a postdoctoral degree. The total number of doctors was 645 (62.93%), comprising 166 (16.20%) attending doctors, 213 (20.78%) associate (deputy) chief doctors, and 266 (25.95%) chief doctors (see Supplemental Digital Appendix 3 at https://links.lww.com/ACADMED/B323 ). Of the 1,025 total participants, 809 (78.93%) attended a 5-year program, 166 (16.20%) completed the “5 + 3” program, 40 (3.90%) completed the 8-year program, and 10 (0.98%) attended the “4 + 4” program (see Supplemental Digital Appendix 4 at https://links.lww.com/ACADMED/B323 ).

When asked about the program with the highest development potential, most of the 1.025 participants chose the 8-year program. This program received the highest average weighted score of 1.91, followed by the “5 + 3” program, with a score of 1.87. The 5-year programs and “4 + 4” program scored 0.86 and 0.76, respectively (see Supplemental Digital Appendix 5 at https://links.lww.com/ACADMED/B323 ). We requested participants to rate their career and system satisfaction on a scale of 0 to 10. Participants of the 8-year and “4 + 4” programs gave nearly equal marks in career satisfaction, with average scores of 7.92 and 7.9, respectively. The “5 + 3” program obtained the lowest average score of 7.25 in career satisfaction (see Supplemental Digital Appendix 6 at https://links.lww.com/ACADMED/B323 ). As for the most satisfying medical education program in China, the 8-year program obtained the highest average score of 7.78, followed by the 5-year (7.25), “5 + 3” (7.17), and “4 + 4” (7.00) programs (see Supplemental Digital Appendix 7 at https://links.lww.com/ACADMED/B323 ).

A correlation analysis of the results revealed that students with a doctorate degree and chief doctors had generally high career satisfaction scores, averaging 7.65 and 8.24, respectively. However, postdoctors (doctors with a PhD degree who are pursuing postdoctoral training) had the lowest career satisfaction score (6.62), possibly because of the long medical schooling cycle they have to go through (see Supplemental Digital Appendix 8 at https://links.lww.com/ACADMED/B323 ).

Next, we discovered that the 5-year program cultivated the most chief doctors. This result may be affected by bias because the 5-year program is the oldest (see Supplemental Digital Appendix 9 at https://links.lww.com/ACADMED/B323 ). Finally, participants were asked to make suggestions for improving the current Chinese medical education system. In all, 316 participants made a suggestion; the most frequent suggestions were increasing clinical practice hours (n = 57), unifying the length of schooling (n = 34), developing individualized teaching (n = 23), and strengthening scientific and humanities education (n = 22; see Supplemental Digital Appendix 10 at https://links.lww.com/ACADMED/B323 ).

The Chinese medical education system is complex and diverse. Assessing these various education programs could help in addressing their shortcomings and in developing a more mature and effective system for training doctors.

The 8-year program aims to develop the scientific thinking and clinical skills of students to help them become medical scientists and physicians. As our study showed, many medical students in China consider this program the most promising path to becoming a doctor. However, the students enrolled in this program generally have a shorter time (3-year course) to obtain a doctorate degree compared with students in the normal MD–PhD programs who must complete a 3-year master’s course and 4-year doctoral course. The shorter duration of the 8-year program is problematic as students may not obtain sufficient scientific and clinical training compared with those studying for an MD or PhD degree.

The “5 + 3” program is another newly founded long-duration system. Students of this program participate in 3-year standardized residency training while pursuing a Master of Medicine degree. However, as these students do not receive integrated scientific training during heavy clinical work, they generally do not develop competitive scientific capacity in the working environment unless they continue with further studies. 29 Moreover, the 3-year residency in college hospitals restricts them from obtaining educational opportunities in medical schools of better quality. 30 This could be the reason that the students report relatively low system and career satisfaction for this program.

The 5-year program is a part of the traditional Chinese medical education system. Of the 1,025 participants in our survey, 809 graduated from the 5-year program. Of the 266 who were chief doctors, 253 graduated from the 5-year program (95.11%), and of the 213 associate (deputy) chief doctors, 176 graduated from the 5-year program (82.63%)—indicating that this program has cultivated many medical talents. 6

The “4 + 4” program was recently launched and closely matches the current international medical education system. As annual enrollment in this program is still quite low, we can only predict the program’s future. Students in the “4 + 4” program are cultivated to have a wider range of knowledge and interdisciplinary thinking, which could confer graduates from this program with unique advantages. This program holds important development potential for the future of Chinese medicine.

Our study to assess the development and current status of China’s medical education programs had some limitations. First, the number of medical students from each program differed based on the launch date of the different programs. Most study participants were from the more established 5-year and 8-year programs, and there were fewer respondents from the more recently established “4 + 4” program. Second, our study findings were based on the participants’ subjective evaluation, not objective indicators. Various work environments, age, education, and job experiences may have influenced the respondents’ opinions.

In conclusion, the development of medical education in China can be summarized by 5 major milestones: construction of the “5 + 3” program, exploration of the “3 + 2” training mode of rural medical program, promulgation of the clinical medicine professional certification system, in-depth training of health personnel in the “5 + 3” program, and the recent launch of the “4 + 4” program. 31 , 32

The innovations occurring in the medical education system in China offer opportunities and pose challenges. Training programs are designed to be both student-centered and competency-oriented. They integrate interdisciplinary learning methods to develop independent thinkers with a professional spirit. We believe that the current work happening in medical education in China will eventually lead to a system that effectively develops doctors who are well-trained and prepared to meet the needs of their patients.

Acknowledgments:

The authors thank Editage ( www.editage.com ) for English-language editing.

• Cited Here |
• Google Scholar

References cited in Table 1 only

Supplemental digital content.

• ACADMED_2022_08_02_SONG_AcadMed-D-21-02263_SDC1.pdf; [PDF] (514 KB)
• + Favorites
• View in Gallery

Readers Of this Article Also Read

A call to improve health by achieving the learning health care system, trends in nih funding to medical schools in 2011 and 2020, easing the transition from undergraduate to graduate medical education, blue skies with clouds: envisioning the future ideal state and identifying..., the undergraduate to graduate medical education transition as a systems....

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• J Grad Med Educ
• v.12(6); 2020 Dec

Medical Education Reform in China: The Shanghai Medical Training Model

Jialin c. zheng.

Professor and Dean, Tongji University School of Medicine, Shanghai, China

Professor, Department of Pharmacology & Experimental Neuroscience, Nebraska Medical Center

MD graduate, Second Military Medical University, Shanghai, China

PhD graduate, Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center

Zenghan Tong

PhD graduate, Department of Pharmacology & Experimental Neuroscience, and Member of Asia Pacific Rim Development Program, University of Nebraska Medical Center

MD graduate, Tongji University School of Medicine, Shanghai, China

Matthew S. Mitchell

Member of Asia Pacific Rim Development Program, University of Nebraska Medical Center

Xiaoting Sun

PhD graduate, Tongji University School of Medicine, Shanghai, China

Yuhong Yang

MD graduate, University of Nebraska Medical Center

Professor and Director, Scientific Research and Education Division, Shanghai Municipal Health Commission, Shanghai, China

Secretary, Scientific Research and Education Division, Shanghai Municipal Health Commission, Shanghai, China

Professor, Department of Obstetrics and Gynecology, and Former Dean, The Alpert Medical School, Brown University

In China, a growing and aging population has challenged the health care system. It is expected that China's population over 65 years old will reach 487 million, or nearly 35% of inhabitants, in 2050. 1 The burden on the health care system will be exacerbated by difficulty in accessing medical resources, especially in rural areas. The training of physicians who are qualified, respected, and trusted to serve in rural and urban communities must be increased to meet this need.

The concept of graduate medical education is relatively new in China. Traditionally, medical school graduates work directly as junior physicians without residency training after finishing medical school. With theoretical knowledge and clinical clerkships obtained in medical school, junior physicians' practical skills and knowledge were gradually acquired through an apprenticeship model, learning from senior physicians in the same department over an indefinite number of years. The training experience is variable in terms of length and quality, as there is no standardization or oversight.

This inconsistency has led to a devaluation of physicians practicing in the community, away from teaching hospitals. Many patients prefer to be treated in tertiary centers as the physicians there learned from the experts. 2 Patients may self-refer to specialists or physicians with more experience, resulting in an overloading of tertiary hospitals and underutilization of physicians practicing in community and rural areas. Given this social stigma, early career physicians tend to choose tertiary hospitals at the start of their medical career and are reluctant to work in community health care centers or regional hospitals, because they have insufficient social recognition and resources. 3 , 4 Thus, reform in health care service delivery, particularly in the medical education system, is warranted to cultivate more primary care physicians and community-based and rural providers through standardized medical training. 5 These reforms would need to incorporate improved standardization and quality while being timely and cost-effective to encourage institutional implementation and student recruitment.

In 2009, the Chinese government launched a national health care reform policy, of which medical education reform is a key part. 6 In 2010, Shanghai was chosen to be the pilot city for the national reform because it had relatively mature medical and educational resources. Several local health and education departments united and formed a special health reform leadership group to formulate plans and supervise the implementation. Shanghai's reform aims to create a better physician training system, enhance professional prestige, and promote a more harmonious medical care environment with better physician-patient relationships and improved learning environments for trainees. The 2 pillars of Shanghai's medical education reform are standardized residency training and standardized specialist training, with the aim of cultivating medical personnel of homogenized quality and high-level standards through a well-functioning postgraduate medical education system. There are 5 essential parts to Shanghai's health care reform: the “5+3+3” model (5-year bachelor's degree in medical school, plus 3-year residency training, plus 3-year specialty training), a standardized residency training, a primary care system, a health information project, and vertical integration of medical resources. 7 , 8 After graduation from the standardized residency training (SRT), trainees obtain a certificate that is recognized throughout the country, indicating that they have completed residency training and can be recruited by health care institutes of different levels all over the nation as registered physicians. In this article, we describe the 5+3+3 model and its potential for dissemination throughout China's medical education system.

Current Status of Medical Education in China

After graduation from high school, all students intending to continue their education take a national college entrance examination. It is a general examination for all majors and universities, not specific to medical school. The results of this examination largely determine which school and program students attend after high school. 9

Currently, medical education in China is highly heterogeneous, including 5-year, 6-year, 7-year, and 8-year medical education programs. Different medical schools nationwide have adopted variable curricula and distinct continuing medical education paradigms ( Table ). These various systems have been based on medical education principles from the former Soviet Union and Britain. With various instructional methods and standards to evaluate the competency of the trainees, it is likely these programs would lead to discrepancies in the quality of training.

Current Medical Education Programs in China

New Medical Education System in Shanghai

In order to meet the national goal of “Health China 2030,” China has urgently called for a reform of the primary and continuing medical educational training systems. In the United States, the model of 4 years of medical school plus a standardized length of time for each specialty's training is well-established, evidence-based, and has been adopted nationwide. 11 However, this system cannot be copied mechanically in China. The cost of a general college education before medical school could be a major financial burden for most students from lower- or middle-income families. This, in addition to the generally lower compensation for physicians in China compared with that in the United States, would be a strong disincentive for pursuing an MD training. Furthermore, China's large aging population and its urgent shortage of qualified physicians make the lengthy US model of medical education largely impractical.

To mitigate these problems, Shanghai has attempted to implement a standardized residency program aiming at training highly qualified physicians, diminishing public distrust, 3 and more importantly, improving the accessibility and affordability of medical services. Shanghai City introduced a new medical education program in 2010, 8 which includes the broad 5-year undergraduate medical education, a 3-year SRT program, and a 3-year specialized training program, also referred to as the 5+3+3 model program. Figure 1 illustrates the differences between the physician training system in the United States and the Shanghai model.

Physician Training System in the United States (a) and Under the Shanghai Model (b)

Phase 1: Standardized 5-Year Medical School Training

The degree granted after this 5-year program is Bachelor of Medicine. In the first 2 years, students study humanities, medical ethics, basic science, and basic medical courses such as medical history, biochemistry, anatomy, immunology, and physiology. In the next 2 years, students take clinical courses in specialties, including surgery, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, family medicine, emergency medicine, and traditional Chinese medicine. During these 4 years, students take several nationally standardized assessments to determine their progress. In their fifth year, students complete a 1-year clinical rotation, followed by a 2-part final examination that evaluates basic clinical knowledge and clinical skills. Graduates must then take a national medical licensing examination before they can apply for a medical license.

Phase 2: Standardized Residency Training Program

Phase 2 of the 5+3+3 model builds on the existing model for residency training in Shanghai. In 1988, various specialties and institutions began to train residents as hospital employees. In 2000, Shanghai started to standardize the program and widely implemented it in 2006. In 2009, after the national health care reform, Shanghai piloted the SRT program in tertiary hospitals, where all graduates received a standardized training program before employment. The training criteria in different tertiary hospitals were gradually established and standardized. 12

Medical school graduates holding Bachelor of Medicine, Master of Medicine (basic science), and PhD degrees who desire to become practicing physicians are required to apply for one of these 3-year programs in qualified educational hospitals (the 64 authorized teaching hospitals in the city as of 2018).

The SRT program comprises 5 specialties: surgery, internal medicine, pediatrics, obstetrics and gynecology, and family medicine, each with standardized rotation schedules. Residents choose one to train in and are assessed throughout their training by annual evaluations and comprehensive examinations, including an objective structured clinical examination (OSCE). After residency, the National Qualification Examination for Doctors is mandatory for trainees to be registered as a physician at their practicing institution. 13

Our survey in collaboration with the Research and Education Division of Shanghai Municipal Health Commission found that in 2011, 1 year after the implementation of the SRT program, only 100 trainees had completed the program. By 2018, there were 14 597 trainees who had completed the program and acquired a certification. In a 2014 survey of the Shanghai SRT program recruitment, the number of residents enrolled in the SRT program increased from 1841 in 2010 to 3400 in 2017. Graduates with a masters' or doctorate degrees accounted for more than half of the new residents.

The SRT program is gaining momentum. By 2018, 23 318 trainees had been recruited into the Shanghai SRT program, along with the 14 597 trainees who had successfully completed the program ( Figure 2 ).

Recruitment and Student Background of Standardized Residency Training in Shanghai (2010–2018)

Phase 3: Further Training

In order to acquire the SRT certification, trainees need to pass the National Medical Licensing Examination and SRT completion examination, which are both nationally standardized. Therefore, after the SRT program, trainees are well qualified to provide safe care to most patients in their specialty and understand when to transfer them for subspecialty care, especially if practicing in areas with less consulting physician support or resources. However, in the Shanghai model, the post-residency medical education programs include the Standardized Specialty Training (SST) and PhD programs.

In January 2016, the Ministry of Health announced plans to initiate a pilot SST program. In this program, participants can pursue 2 to 4 years of training in any specialty after completion of the SRT program. Those who complete the SST program will receive a Doctor of Medicine degree, a demonstration of the holder's knowledge and skill in clinical medicine, which is equivalent to a doctorate degree in other subjects. 4 , 14 However, this program has received complaints from medical students and junior doctors in China for fear of the lengthy process and limited compensation during SST.

Next Steps and Remaining Challenges

The continuing educational programs of the 5+3+3 model will gradually standardize the medical education and professional training for qualified physicians and physician-scientists in China. This is a breakthrough for Chinese medical care and brings a promising future to China's overburdened medical care system. Shanghai's reform has already led to a remodeling of the medical education system in China. In early 2014, the National Health and Family Planning Commission of China issued “Guiding Opinions on Establishing a Nationwide Standardized Resident Training System,” which proposes that by 2015, all provinces and regions will initiate SRT, and by 2020, all newly graduated clinicians with a bachelor's degree or above should receive SRT before practicing in medical facilities.

Nevertheless, there are challenges during the national adoption of this new educational system. Not every hospital likely has enough faculties to support the educational program. Since teaching hospitals in China are generally burdened with high outpatient and inpatient volumes, it is difficult for faculty to deliver effective teaching to residents, especially when there is not a good incentive mechanism in place. Residents in some of the leading programs reported issues such as variations in teaching quality and insufficient supervision. 15 , 16 Currently, the Ministry of Health and the Ministry of Education in China design and evaluate the curricula, which undergoes continual improvement. For example, an investigation on internal medicine programs found that case discussions most often occurred only once a week or less, which is likely too infrequent to provide an environment conducive to learning. 17

Since a sophisticated competency framework to guide resident education is currently lacking in the Chinese graduate medical education system, 18 it is essential to set up a nationwide standardized evaluation system with the involvement of third-party institutes, such as the Accreditation Council for Graduate Medical Education (ACGME) and the Accreditation Council for Graduate Medical Education–International (ACGME-I). The ACGME's 6 core competencies and their associated subcompetencies are useful guiding tools in terms of building and evaluating the full scope of a physician's practice of medicine. As of late 2018, Tongji University School of Medicine (TJSM) had started the process of ACGME-I accreditation in its affiliated hospitals, the first to introduce this accreditation system in mainland China. The aim of this campaign is to apply the well-recognized criteria to the Shanghai SRT program to make it more rigorous and comparable to its counterparts elsewhere. 19 Moreover, with the ongoing efforts and progress made via undergraduate curriculum reconstruction and residency training standardization (including ACGME-I accreditation), TJSM is also trying to promote a new “5+3” program of training high-quality primary care providers, which grants them with an MD degree without having to complete the SST component of the model. Together with the societal efforts of raising the prestige of the profession and financial compensation for young physicians, these solutions are aimed to optimize training length and quality, and hopefully therefore the attractiveness of and recruitment into the profession.

Conclusions

Despite challenges, Shanghai's 5+3+3 system has thus far shown promise in solving some of China's most urgent health care needs via a reformulated training model. A more reliable accreditation and oversight from an outside agency with international criteria is crucial for the persistence of the system's quality and its spread to other areas of the country.

The authors would like to thank Hong Huang, Xiaochu Shen, Jianguang Xu, and Tiefeng Xu from Shanghai Municipal Commission of Health and Family Planning; Gang Pei from Tongji University; and Gang Huang from Shanghai Jiao Tong University School of Medicine for suggestions and support. They would also like to thank Lenal Bottoms and Jaclyn Ostronic for providing outstanding administrative support.

Contributor Information

Jialin C. Zheng, Professor and Dean, Tongji University School of Medicine, Shanghai, China. Professor, Department of Pharmacology & Experimental Neuroscience, Nebraska Medical Center.

Han Zhang, MD graduate, Second Military Medical University, Shanghai, China.

Beiqing Wu, PhD graduate, Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center.

Zenghan Tong, PhD graduate, Department of Pharmacology & Experimental Neuroscience, and Member of Asia Pacific Rim Development Program, University of Nebraska Medical Center.

Yingbo Zhu, MD graduate, Tongji University School of Medicine, Shanghai, China.

Matthew S. Mitchell, Member of Asia Pacific Rim Development Program, University of Nebraska Medical Center.

Xiaoting Sun, PhD graduate, Tongji University School of Medicine, Shanghai, China.

Yuhong Yang, MD graduate, University of Nebraska Medical Center.

Kan Zhang, Professor and Director, Scientific Research and Education Division, Shanghai Municipal Health Commission, Shanghai, China.

Lv Fang, Secretary, Scientific Research and Education Division, Shanghai Municipal Health Commission, Shanghai, China.

Eli Adashi, Professor, Department of Obstetrics and Gynecology, and Former Dean, The Alpert Medical School, Brown University.

News from Brown

Chinese medical education rising unevenly from cultural revolution rubble.

A new research review chronicling the history and current state of medical education in China finds that the country’s quest to build up a medical education system to serve its massive population has produced a rapid, if uneven, result.

PROVIDENCE, R.I. [Brown University] — For scores of years after the first medical school opened in China in 1886, the country progressed in building a medical education system for its fast-growing population. Then 50 years ago, it not only came to a screeching halt, but to a full reversal with the Cultural Revolution.

“Indeed, throughout the decade in question (1966 to 1976), all extant medical schools were effectively shuttered and their faculty disbanded,” write the authors of a new paper describing the history and current status of China’s medical education system. “It was only in the aftermath of the Cultural Revolution and the passing of Chairman Mao Zedong in 1976 that the medical education enterprise embarked on a slow recovery process during which some of the schools affected were allowed to reopen.”

Since then, the pace has quickened considerably to the point where the country has more than 2.1 million practicing physicians and more than 167 civilian medical schools enrolling about 64,000 students. The restoration of a large national system for undergraduate medical education in just 40 years is remarkable, said study corresponding author Dr. Eli Adashi, former dean of medicine and biological sciences at Brown University.

“They had to go from 0 to 60 in three seconds,” said Adashi, who has visited China many times since 2008, often to study and to advise colleagues within the system. “They had to cover a lot of ground, and since they are trying to catch up to the rest of the world, they had to go about it fairly quickly. For the hardships and difficulties and hugeness that characterizes China, they’ve done pretty well on the medical school part.”

In addition to Adashi, the authors of the paper in the American Journal of Clinical and Experimental Obstetrics and Gynecology are Dr. Nan Du, a graduate of Brown University’s Alpert Medical School now at Yale, and Dr. Huanling Zhang of Fudan University in Shanghai.

Peculiar paths

Despite China’s overall progress, two overarching peculiarities remain in the system by which China’s Ministry of Education produces its physicians, Adashi said. One is the complex diversity of paths an aspiring doctor can follow to gain medical training and become a practicing doctor. The other, which Adashi said is a more serious concern, is a near-complete lack of standardized residency programs, or graduate medical education.

Chinese students can follow many paths to becoming a doctor, including curricula lasting three, five, seven or eight years. As in most places around the world (except the U.S.) enrollment in a medical education program occurs in lieu of obtaining a four-year non-medical undergraduate college education.

Instead, the vast majority of Chinese medical students (about 58,000) attend a five-year program after high school to earn a bachelor’s degree. Then they serve in a one-year clinical internship before taking the nation’s standardized medical licensure exams, which measure both knowledge and clinical skills. Upon passage, they can register as medical practitioners.

Those who pursue the more elite seven- or eight-year curricula gain additional training and research experience and earn more prestigious degrees (master’s or doctorate respectively), before taking the same licensure exams as their bachelor’s degree-earning colleagues.

Though the varied tracks offer differing levels of rigor in the classroom, Adashi said the consistency of the licensing exam requirements ensures a baseline of training and competency across the profession.

“If everybody takes the same licensing examination, I think it really doesn’t matter if you do it in eight years, or seven years or five years,” Adashi said. “If you have an equating national benchmark that allows you to compare students from anywhere in the country then you are in reasonably good shape.”

In addition, China appears to be working toward winnowing the number of different paths into the profession, Adashi said. The seven-year programs have been left out of several recent ministry reports on the future of medical education.

Residency difficulties

Where China’s medical education system urgently needs more development, Adashi said, is in creating residency programs like those pioneered in, and required in, the U.S. Residency, after all, is where newly credentialed doctors grow into truly experienced hospital physicians by way of the structured evaluation and guidance of seasoned supervising doctors.

“It’s essential to the patient to know that the doctors who are training, for instance to do surgical procedures, are carefully supervised, their progression is monitored, they take exams to prove their competence, and they acquire graduated responsibilities as they proceed,” Adashi said.

After many false starts over decades, China’s National Health and Family Planning Commission has recently defined requirements of between one and three years of graduate medical education, depending on undergraduate training and desired specialty. But the standards of evaluation vary widely by region, Adashi and his co-authors wrote. Adashi said they do not yet amount to a rigorous, nationally reliable standard.

“Their residency program is their challenge,” Adashi said. “It is unstructured and non-uniform. It is everything you don’t want it to be.”

China is clearly keen to continue building a robust residency system for its aging population of 1.4 billion, Adashi said.

“They understand the importance,” Adashi said, “but they have barely gotten underway.”

• Doctors and Medical Education in China

Doctors are one of the most respected professions in the world. They use their extensive knowledge in the field of medicine to assist and improve patients' well-being and improve health-care facilities. Together with other medical practitioners, they are heroes in fighting against diseases especially during a pandemic like Covid-19. Doctors across the world continue to work hard to contain the spread of the new coronavirus.

Since the outbreak began in Wuhan, Hubei Province in China, in December 2019, more than 40,000 medical practitioners came together from every corner of China to help Hubei. They worked around the clock to battle the coronavirus outbreak and finally bringing the epidemic under control. There were more than 3000 medical practitioners infected with some, sadly, succumbing to the virus.

To cope with the increasing health-care demand, the Chinese government launched the “Excellent Doctor Training Program” in 2012 aiming to train more doctors for the next 10 years. Most medical schools in China offer courses in English, where foreign nationals are welcome to China for higher education. Today, you will find many international students studying medicine in China.

The Typical Process to Become a Doctor in China

To pursue a career as a doctor has become a very competitive and comprehensive process. The number of years and steps involved will depend on the course and specialty you choose to pursue.

To become a doctor in China, a student must pass the standardized national exams in high school, complete seven years (or eight years for two medical schools) of medical studies, and undergo an internship. Students undertake basic science, liberal arts, and clinical science courses in the program. The program also requires mandatory hours of volunteer work.

Medical students spend the first two years of their typical seven-year program studying liberal arts and basic science courses. Medical schools compress clinical science courses into a two-year program that spans the third and fourth years of study. After that, students must undertake compulsory hours of internship. The duration of the internship differs across different universities. However, students must complete an internship and a clerkship before they graduate their seventh year.

When is Chinese Doctors' Day?

19th of August is designated the observance of Doctor’s Day in China, which marks the significance of doctors in safeguarding people's health. Doctor's Day was first celebrated on August 19, 2018.

What Is a “Barefoot Doctor” ?

“Barefoot doctors” first existed in China during the Cultural Revolution(1966-1976). The farmers who received training worked in their rural villages to bring basic health-care to areas in which urban-trained doctors would not settle. They promote basic preventive health-care, family planning, and treat common illnesses. The name "Barefoot doctor" originates from southern farmers, who would often work barefoot in the rice paddies.

Barefoot doctors act as primary health-care providers at the grass-roots level. Often, they grow their herbal medicine in their backyard. They often spend 50% of their time farming, and as a result, rural farmers perceived them as peers and respect their advice. They were also integrated into a system where they can refer seriously ill patients to the township and county hospitals.

The Pantheon of Modern Medicine in China

1. dr. wu lien-teh - the father of modern medicine in china.

Dr. Wu Lien-Teh was born in Penang in 1879. He was the first of Chinese descent to graduate as a medical doctor from the University of Cambridge.

Dr. Wu was a physician renowned for his work in public health and particularly, as the 'Plague Fighter' who stamped out the Northeastern China plague of 1910–11. He was also the first Malayan and the first Chinese-heritage person nominated to receive the Nobel Prize in Medicine in 1935.

In 1915, the National Medical Association was formed to promote western medicine in China. Wu was elected Secretary in 1915, and President in 1916–1920.

In 1930, the Chinese government created the National Quarantine Service (NQS) and appointed Wu as its first director. Headquartered in Shanghai and staffed by Chinese personnel, NQS enabled the Chinese government to regain quarantine control of all major ports in China.

His other claim to fame is as the inventor of the Wu mask, the precursor of today's N95 mask.

Source: http://drwulienteh.com/

2. Dr. Qiu Fazu-The Father of Modern Surgery in China

Qiu Fazu was born in Hangzhou, Zhejiang Province, China, in December 1914. He studied medicine as his mother had died after maltreatment of appendicitis. After his finals at the German School of Medicine in Shanghai, he went to Munich after gaining a Humboldt scholarship, graduating from the medical faculty, and receiving a German MD in 1939.

Back in China, Qiu introduced modern surgical techniques, and with his experience from Germany helped in establishing medical schools. Promoting the development of abdominal and general surgery, he is considered a surgical pioneer and the main founder of organ transplantation surgery in China. In the 1970s he began the earliest research program on liver transplantation—from experimental study to clinical treatment—founding the first institute of organ transplantation in China.

Qiu Fazu was the first Asian to receive the highest German honor, the Federal Cross of Merit, in 1985.

3. Dr. HuangJiasi -Pioneer of the Chinese Thoracic Surgery

Graduated from the Peking Union Medical College, Huang became the leading thoracic surgery specialist and medical educationalist in China. Huang went to the University of Michigan Medical School in 1941, where he was instructed by Dr. John Alexander (Michigan’s first Director of Thoracic Surgery). Huang graduated from the school with a Master of Surgery Degree in 1943. Huang returned to China in 1945 and became a Professor at the Shanghai Medical College. During his position in Shanghai, Huang helped founded the Shanghai Chest Hospital and served as the first Dean of the Hospital. After his appointment, Huang moved to Beijing, where he became President of the Chinese Academy of Medical Sciences and President of the Peking Union Medical College from 1958 to 1983. Huang’s endeavor in his career as a medical practitioner and educator helped China through the development of Thoracic Science and produced a significant number of thoracic surgeons for the country.

4. Dr. WuJieping- Pioneer of Urology in China

Born in January 1917 in Changzhou, Jiangsu, Wu studied medicine after his father said that an intellectual should strive to be either a good prime minister or an excellent doctor. Wu earned his Ph.D. in 1942 from the Peking Union Medical College, a world-class medical school at the time. He then worked at the Zhonghe Hospital before heading off to further his skills in urology at the University of Chicago in 1947. In the United States, he was instructed by Professor Charles Brenton Huggins, who won the Nobel Prize in Medicine in 1966. Wu was also the first person on the mainland to carry out kidney transplant surgery.

5. Dr. Wu Mengchao-Father of Chinese Hepatobiliary Surgery

Wu was born in Minqing County, Fujian, in southern China, and spent a few years in East Malaysia where his father worked, returning to China for education in 1940. Wu graduated from the School of Medicine of Tongji University in July 1949 and was elected the academician of the Chinese Academy of Sciences in 1991.

During his 50 years as a hepatic surgeon, Wu has performed surgery almost every day. Until June 2011, Wu had performed over 14,000 hepatic surgeries, including more than 9,300 liver tumor resections. His success rate stood at 98.5 percent. Wu maintained a steady record of more than 200 surgeries each year.

Wu was given the honor of "Leading Medical Expert" by the Central Military Commission in 1996 and was presented the 2005 National Science and Technology Award in 2006.

He served as Director of the Research Institute for Hepatobiliary Surgery and Director of the Department of Hepatobiliary Surgery of Changhai Hospital under the Second Military Medical University, and Vice President of the Second Military Medical University.

6. Dr. Lin Qiaozhi (1901-1983) - China's Pioneer Gynecologist

Known as “the Mother of Ten-Thousand Babies” and “Angel of Life,” Lin Qiaozhi, a famed obstetrician and gynecologist in China, delivered over 50,000 babies in her career, though she didn’t marry or have any children.

Born at Gulangyu Island, in Xiamen, Fujian Province in southern China in December 1901, in 1921 she entered Peking Union Medical College(PUMC). She received her Doctor of Medicine degree and became a doctor in the PUMC hospital in 1929. Lin was later sent to London and Manchester in Britain in 1932 and Vienna in Austria in 1933 for advanced training. She then entered Chicago University Medical School for further study in 1939 and was later named an honorary member of the Chicago Academy of Nature in 1940. She was elected academician of the Chinese Academy of Sciences in 1959.

7. Dr. YanFuqing-Pioneer of Modern Medical Education in China

Born in Shanghai in 1882, he graduated from Yale Medical School with a doctorate in medicine in 1909. That same year, he was elected a member of the American Natural Sciences Association. Upon completion of his studies, Yen made his way to the Liverpool School of Tropical Medicine in Liverpool, England for one semester's advanced study. For his work, Yen earned a certificate of study.

Yen returned to Shanghai in the winter of 1910 on a two-year Yale-China Association contract, where he worked with Dr. Edward H. Hume. His presence as a Chinese doctor in the leadership of a Western medical organization inspired confidence and interest among other Chinese medical practitioners.

In 1914, he founded the Xiangya Medical College (now part of the Central South University) in Changsha and served as the first principal. In 1926, Yen also co-founded and became the first Dean of the Institution that would ultimately become the Fudan University Medical School. He would go on to spearhead the opening of the Shanghai Medical Center and the establishment of the Hunan-Yale Medical School.

8. Tang Fei-fan (1897-1958)- Pioneer of the Vaccine in China

Born in Liling County, Hunan Province in 1897, he graduated from the Xiangya College of Medicine (now Xiangya School of Medicine, Central South University) in 1921. In 1925 he went to the United States to study bacteriology under Professor Hans Zinsser at Harvard University. He returned to China in 1929 and became a Professor at the Medical School of National Central University. In 1935 he was recruited as a researcher at the British National Institute for Medical Research, a position in which he remained until 1937.

After the outbreak of the Sino-Japanese War in 1937, he founded the Central Epidemic Prevention Laboratory in Kunming, capital of southwest China's Yunnan Province, and served as its director. He made China's first batch of penicillin vaccines and serum with his team for the soldiers at the frontline. After the war, he established China's first antibiotic research and penicillin production workshop, as well as the BCG vaccine laboratory.

In 1950, a terrible plague hit northern China, he developed an attenuated live vaccine of Yersinia pestis. He also developed China's yellow fever vaccine which helped eradicate smallpox in China in 1960.

In 1955, he first cultured the Chlamydia trachomatis agent in the yolk sacs of eggs.

Medical Education in China

Medical School in China is entered from high school, whereas in the US it is entered after an undergraduate degree that is usually 4 years in length.

Medical school in China takes a minimum of 5 years leading to an MBBS, sometimes followed by a 3 year MM or Master of Medicine. Another route is the 8 year MD route leading to a Doctor of Medicine that is given mainly at the top medical schools in China. In the 8-year MD program, students will typically do 3 years of “pre-med” followed by 2–3 years of “pre-clinical” and then 2-3 years of “clinical” training. Many academic physicians will later do a 3 year PhD after their MBBS or MM.

Top 7 Medical Schools in China

1. peking union medical college.

The top medical school in China, it was founded in 1917 and one of the most difficult to be admitted. For students that are pursuing university degrees in China with a focus on medicine, Peking Union Medical College is one of the top institutions to attend. Peking Union Medical College was the first medical school in China to introduce the eight-year M.D. program.

2. Peking University – Health Science Center (HSC)

Peking University Health Science Center (PUHSC) is one of the nation’s leading institutions of modern medical education in China and is recognized as a renowned medical school both at home and abroad. Established in 1912 as the first public western medical school in China, its former name was Peking National Medical School, and then Beijing Medical University, which successfully developed into a multi-disciplinary comprehensive health science center.

3. Fudan University – Shanghai Medical College (SMC)

Founded in 1927 by Dr. Fuqing Yan—a dedicated Chinese medical educator and scholar in public health, Shanghai Medical College, Fudan University (SMCFU) has a long-standing reputation of excellence in medical teaching, research training for medical professionals. Ranked among the nations leading medical universities since its establishment under the name of Shanghai Medical University, it aims high for academic excellence in addition to the advocation of integrity, devotion, and commitment of society and human beings as a whole. Shanghai Medical College, Fudan University was inaugurated since its merge with Fudan University in 2000.

4. Shanghai Jiao Tong University (SJTU)–School of Medicine

Previously known as the Shanghai Second Medical College which was established in 1952 the name was changed in 1985 to the Shanghai Second Medical University. It is comprised of Medical School of Aurora University (Shanghai), Medical School of Saint John's University, Shanghai, and Tong De Medical College. It was merged with Shanghai Jiao Tong University in 2005 and was named Shanghai Jiao Tong University School of Medicine.

5. Sun Yat-Sen University (SYSU)–Zhongshan School of Medicine

Sun Yat-sen University Zhongshan School of Medicine originated in 1957. It can be dated back to Boji Medical School founded in 1866 -- the oldest school of western medicine established in China. Zhongshan's reputation for quality education, science innovation, and social services have attracted outstanding and diverse teachers and student body with over 18,000 full-time faculties and clinicians, and 8,915 medical and health science undergraduates and post-graduate students including over 400 international students from 28 countries.

6. Central South University (CSU)–Xiangya School of Medicine

Central South University Xiangya School of Medicine dates from the specialized Xiangya Medical School, founded by the Hunan Institute of Education and the Yale-China Association of America in 1914. It is a pioneer of western medical education in China. Through a century's development, it has 8 national key disciplines, 13 provincial key disciplines and 10 undergraduate programs all top-level in China.

7. Sichuan University–West China College of Medicine(WCCM)

The West China School of Medicine, Sichuan University, was founded in 1910 as a private medical school, then named HuaxiXiehe College (West China Union College). It was established by five Christian missionary groups from the US., UK, and Canada, with disciplines in stomatology, bio-medicine, basic medicine, and clinical medicine. At present, it consists of 5 Divisions: Clinical Medicine, Laboratory Medicine, Higher Nursing Education, Maternity and Child Hygiene, and Allied Health Professions. More than 1,500 students are studying for a bachelor's degree and over 1,500 students for Masters or Doctorate. There are 165 foreign student placements to study medicine in the school. Over the last five decades, it has been regarded as one of the top 5 medical schools in the country.

• Chinese Healthcare System
• Hospitals in China
• Chinese Healthcare Insurance

8 Top Medical Schools In China For International Students in 2023

Chinese medical schools have gained the world’s attention for their excellent medical facilities, numerous scholarship offerings and well-trained, international medical faculty.

Majority of medical universities in China are recognized by the World Health Organization (WHO) and are in the World Directory of Medical Schools. Compared to medical schools in the west, Chinese medical schools have easy entry requirements and lower tuition fees.

In addition, the cost of living in China is much lower, so many foreign students are attracted to study medicine in China. So what are the top medical schools in China for international students?

Best Medical Universities In China in 2023

China has 45 medical schools that are allowed to offer English-medium MBBS (Bachelor of Medicine and Bachelor of Surgery) programs. But these are the 8 best medical schools in China for MBBS .

1. Shantou University Medical College (SUMC)

Shantou University Medical College is located in Shantou, a beautiful coastal city in the Guangdong province. Most MBBS programs in China take 6 years but the MBBS at SUMC only takes 5 years. Read: 15 Reasons to Study MBBS at SUMC .

SUMC has 2 campuses. One where you spend your first few years as a medical student and a second one where your are trained for clinical skills. Shantou boasts of a simulated medical center where you can practice your skills with the aid of virtual learning resources shared by University of Alberta and Stanford University.

Apart from medical theory, you will also get medical training at the Pearl River Delta and Hainan. The curriculum also includes units that help students learn Chinese language and culture.

Apply for the MBBS program at SUMC .

2. Nanjing Medical University (NJMU)

NJMU is located in Nanjing, a city rich in Chinese history and culture. The medical university has two campuses: Wutai and Jiangning. The MBBS program takes 6 years to complete, with only 100 students enrolled for the intake. Students can do their internship in any of the following facilities:

– The First Affiliated Hospital of NMU – The Second Affiliated Hospital of NMU – Nanjing First Hospital – Nanjing Drum Tower Hospital

*The application can be closed earlier if the targeted number of students is reached earlier. Feedback for the application is usually given within 4 to 6 weeks after application.

Apply for the MBBS program at NJMU .

3. Zhejiang University School of Medicine (ZUSM)

In Hangzhou, one of the most visited places by tourist, lies Zhejiang University. The School of Medicine offers an MBBS program that is recognized internationally. The program takes 6 years to complete including 5 years of classroom teaching and 1 year of internship.

As a student, you will go through three stages of the course which include:

– Pre-med for 1 year – Pre-clinic for 2 years – Clinic for 3 years – Internship for 1 year (you will be supervised by doctors)

Apply for the MBBS program at Zhejiang University .

4. Shanghai Medical College of Fudan University (SHMC)

Shanghai Medical College is part of Fudan University, one of the oldest and most prestigious universities in China. SHMC is located in Xujiahui, a commercial district in Shanghai. The MBBS program at SHMC takes 6 years to complete.

You can choose to do your internship in China, your home country or another country. The school will help you find a suitable hospital to do your internship.

If you choose to do your internship in China, you must pass HSK 5 before the internship so that you can communicate with patients effectively. Some hospitals affiliated with Shanghai Medical College include:

– Huadong Hospital – Shanghai Cancer Center – Eye and ENT hospital – Shanghai Public Health Clinical Center

Apply for the MBBS program at Fudan University .

5. Guangzhou Medical University (GMU)

Guangzhou Medical University is located in Guangzhou, one of the three largest cities in China. It has an amazing campus that is suitable teachers and students. The MBBS program at GMU takes 6 years to complete.

Apply for the MBBS program at GMU .

6. Capital Medical University (CCMU)

Capital Medical University is located in Beijing, China. CCMU has one of the most advanced equipment and international faculty of 994 associate professors and 548 professors. The MBBS at CCMU takes 6 years to complete:

– 1 year of foundation – 2 years of basic medicine – 2 years of clinical medicine – 1 year internship

Students can do their internship in the 14 hospitals the university is affiliated with. CCMU has outstanding reputation in scientific research including traditional Chinese medicine and basic medicine.

CCMU also has partnerships with international education institutions in more than 20 countries and many student exchange programs.

Apply for the MBBS program at CCMU .

7. Tongji University School of Medicine (TUSM)

Tongji University School of Management is located in Shanghai, the financial capital of China. The MBBS at TUSM takes 6 years to complete.

At TUSM, you will study with dedicated faculty members, undertake research and clinical rotations with national top research teams and affiliated hospitals, and receive a globally recognized medical degree.

You will also enjoy a dynamic campus life and meet students from all over the world. TUSM’s ultimate goal is to train doctors who are competent in the delivery of effective and ethical medical care in today’s rapidly changing health-care environment.

Apply for the MBBS program at TUSM .

8. Jinzhou Medical University (JZMU)

Jinzhou Medical University is located in northeastern China in the city of Jinzhou. The MBBS program at JZMU takes 6 years to complete, inclusive of one year of internship. Internship is done at the First Affiliated Hospital of Liaoning Medical University (LMU).

Apply for the MBBS program at JZMU .

Apply for MBBS in China!

Studying MBBS in China is something you will never regret. Read our MBBS guide , choose a university, apply for the next MBBS intake and get your medical career started.

• Recent Posts
• Study MBBS in China: Admissions Guide for 2024! - June 12, 2024
• 8 Universities in China with the Best Online Chinese Programs for 2024 - June 2, 2024
• Introducing The Sino-British College, USST (SBC) - June 1, 2024

Join 180,000+ international students and get monthly updates

Receive Admissions, Scholarships & Deadlines Updates from Chinese Universities. Unsubscribe anytime.

• Online Programs
• Chinese Programs
• Foundation Programs
• Medicine – MBBS
• Chinese Language
• Business (BBA)
• Computer Science
• Engineering
• Business Management
• See All PhD Programs
• How to Choose Programs
• Learning Chinese & HSK
• Internships in China
• Browse All Programs
• University Rankings
• Most Popular Universities in China
• Top 16 Chinese Universities
• See All Universities
• Online Classes
• Register an account
• Ask a question
• Join the Wechat Group
• Moving to China
• Jobs / Careers
• Studying in China
• Universities
• Fees & Finances
• Scholarships
• Why China Admissions?
• Our Services
• Book a Call with Us
• Testimonials

Request Information

Download your free guide and information. Please complete the form below so we can best support you.

• What language would you like to study in? * Select English Chinese
• What is your highest education level? * Select Secondary School High School Bachelor’s Master’s PhD
• How are your grades? * Select Below Average Average Above Average Exceptional
• How is your English level? * Select None Beginner Fluent Advanced Native
• How is your Chinese level? * Select None Beginner Fluent Advanced Native
• What is your budget for studying in China? * Select I don't have any available budget and need a scholarship to study I already have a scholarship which will cover all my fees 10,000 - 20,000 RMB per year (approximately 1,500 - 3,000 USD) 20,000 - 40,000 RMB per year (approximately 3,000 - 6,000 USD) 40,000 - 80,000 RMB per year (approximately 6,000 - 12,000 USD) 80,000 - 120,000 RMB per year (approximately 12,000 - 19,000 USD) Over 120,000 RMB per year (approximately 19,000 USD)
• First Name *
• Last Name *
• Country of Residence * Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao, People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
• Start Date * Now 6 - 12 Months 12 - 18 Months 18 Months + Other
• Level Interested In * Select Bachelor’s Master’s PhD Summer program Short term
• Program Interested In *
• Which University are you interested in? *
• I agree to the Privacy Policy

Medical Degree and Education in China

Medical education refers to education related to the practice of being a medical practitioner those who follow basic medical training become a physician, additional trainings allow medical student to specialize in one of medical area. Modern Medical Education in China started in the early 20th century. Medical Universities, Colleges and Schools accredited by China higher education council, offer six years undergraduate medical education. To control standards of medical education in china, Chinese Ministry of Education set up a quality control regulation on medical education, this regulation gives special attention to English medium for undergraduate students. At the present, there are around 50 Medical Universities and schools have been accredited to offer MBBS and BDS program in English medium, where foreign students who meet entry criteria, apply to study in those universities and schools. 

Medical Education in China have been improved in order to meet international standards, today most Chinese medical schools offer MBBS, BDS programs taught  in English medium language. Medical student who completed MBBS medical education program awarded MBBS degree, however the one who followed BDS medical education program awarded BDS degree. In Most of Medical Universities/schools or colleges in China admit students in MBBS or BDS programs with science subject’s background such as Mathematics, Biology, Chemistry, and Physics. Students must prove that they can follow medical courses in English. Those subjects are pre-requisite for being accepted to any Chinese medical schools other requirements vary by medical school. Furthermore apart from MBBS and BDS program, China Medical education system train postgraduate students in all medical fields at Masters as well as for Doctorate levels, masters in any clinical field last 3 years in most Chinese medical schools, and Doctorate last 3-4 years in most medical education institutions in china.  

Today Chinese medical universities and schools, first courses focused on basic sciences such as Anatomy, Physiology, Biochemistry, Pharmacology and Pathology. In advanced years, students cover clinical medicine subjects like Pediatrics, Obstetrics and Gynecology, Internal medicine, Psychiatry, Public health and General surgery. Those courses are for the student who undergoes MBBS program, after 5 years coursework, the medical students start their internship in one of the hospital affiliated to his/her medical university/school. The successful completion of internship allow medical student to be awarded Bachelor of Medicine, Bachelor of Surgery degree. Starting practice medical career after MBBS degree depends on the laws and regulations of the country where a graduate student want to exercise his/her medical career. 

Other medical education program offered by most of medical universities/ schools in China is BDS program. BDS medical education train skilled medical personnel who want to become medical Dentist. At the present BDS program is among the most preferable medical education program in China by foreign students. 

BDS curriculum has recently reviewed in order to meet international standards and provide a solid medical background in modern dental field. The core courses in BDS medical education in China include oral pathology, oral medicine, Human oral anatomy, Oral microbiology, Materials used in Dentistry, Histology and Tooth Morphology , Maxillofacial surgery. All those subjects are taught in English. BDS medical education in China takes 5 years including internship. A successful completion of BDS medical education allows a medical student to be awarded Bachelor of Dentistry and dental Surgery degree. Starting practice as a dentist and dental surgical operations depend on the laws and regulations of where BDS degree owner want to exercise his/her career. 

Medical Education in China continues to be successful and produce skilled future Doctors, because of having experienced and carrier devoted professors/teachers.  Modern infrastructure and use of modern technology in medical education make China medical education to be among the best around the world. Most of Chinese Medical universities, schools and colleges are recognized by World Health Organization and China Medical education is ranked at 4th by recent WHO survey, Medical degrees provided by Chinese Medical universities/schools and college are accepted and recognized all over the world. Those degrees allow a graduate who want to pursue major or minor medical specialties in any Medical university/school or colleges all over the world. 

• Medical Universities
• TCM Universities
• Medical Programs
• How to Apply
• Cost and Fees
• Scholarship
• Visa Information
• Travel to China
• Airport Pick up
• Accomodation
• Health Check Form
• International Students
• Universities & Programs

Online Application

2024 Admission is opening ! Anhui Medical University

Wenzhou Medical University

Read more ......

Medical License Examination | Medical Council | Pharmacy University | Nursing School | Dental College

• Summer Campaign
• International Communication
• Job & Work in China
• News & Events
• Primary Schools
• Universities and Colleges

• Web Stories
• Soch with Coach
• Straight Up

Affordable medical education abroad: Top countries and application tips

Pursuing a medical degree can be an expensive endeavour, but several countries abroad offer quality medical education at a fraction of the cost compared to others.

Below are outlined some of the most affordable countries for medical education and provide essential tips on how to apply for these programmes.

So, with the National Eligibility cum Entrance Test - Undergraduate (NEET-UG) irregularities tainting every exam conducted by the Centre or related bodies, students are surely looking to pursue medical education abroad. Not to forget the inflated ranks and sky-high cut-offs. Hence, this list actually might come in handy.

Why Germany?

- Free or low tuition fees: Many public universities in Germany offer medical courses either for free or with minimal tuition fees.

- High-quality education: German universities are renowned for their rigorous and high-standard medical education.

- Global recognition: Medical degrees from Germany are recognised worldwide.

Application tips :

- Language proficiency: Most medical programmes in Germany are taught in German. Ensure you have proficiency in the German language and pass the necessary exams (TestDaF or DSH).

- Pre-med course: If your qualifications do not meet the entry requirements, you might need to complete a Studienkolleg, a preparatory course.

- Early application: Apply early through uni-assist, the centralised application service for international students.

Why Poland?

- Moderate tuition fees: Medical schools in Poland charge relatively affordable fees compared to Western Europe and North America.

- English-taught programmes: Many universities offer medical courses in English, making it accessible for international students.

- Quality education: Polish medical universities are known for their high-quality education and practical training.

- Entry exams: Some universities require entrance exams in biology, chemistry, and physics. Prepare thoroughly for these tests.

- Documentation: Ensure you have all necessary documents, including high school diplomas, transcripts, and proof of English proficiency (if applicable).

- Visa requirements: Research and apply for a student visa well in advance to avoid any last-minute issues.

3. The Philippines

Why the Philippines?

- Affordable education: The Philippines offers medical education at very affordable rates compared to Western countries.

- English instruction: Medical programmes are taught in English, making it an attractive destination for English-speaking students.

- Clinical exposure: The Philippines provides extensive clinical exposure and hands-on training.

Application Tips :

- NMAT: The National Medical Admission Test (NMAT) is required for admission to medical schools in the Philippines. Prepare well in advance.

- Accreditation: Verify that the medical school you choose is accredited by relevant bodies such as the World Health Organization (WHO) or the local health ministry.

- Cultural adaptation: Familiarise yourself with the local culture and customs to ease your transition.

- Low tuition fees: China offers affordable medical education with relatively low tuition fees.

- Scholarships: Various scholarships are available for international students, reducing the financial burden.

- Modern facilities: Chinese medical universities are equipped with modern facilities and technology.

- Language requirements: Some programmes are in Chinese, so you might need to pass the HSK (Chinese Proficiency Test). However, many universities also offer English-taught programmes.

- Application platform: Apply through the official Chinese government scholarship website or directly to the universities.

- Stay informed: Keep updated with any changes in application processes or requirements by regularly checking the universities' official websites.

Map Options

Education Rankings by Country 2024

There is a correlation between a country's educational system quality and its economic status, with developed nations offering higher quality education.

The U.S., despite ranking high in educational system surveys, falls behind in math and science scores compared to many other countries.

Educational system adequacy varies globally, with some countries struggling due to internal conflicts, economic challenges, or underfunded programs.

While education levels vary from country to country, there is a clear correlation between the quality of a country's educational system and its general economic status and overall well-being. In general, developing nations tend to offer their citizens a higher quality of education than the least developed nations do, and fully developed nations offer the best quality of education of all. Education is clearly a vital contributor to any country's overall health.

According to the Global Partnership for Education , education is considered to be a human right and plays a crucial role in human, social, and economic development . Education promotes gender equality, fosters peace, and increases a person's chances of having more and better life and career opportunities.

"Education is the most powerful weapon which you can use to change the world." — Nelson Mandela

The annual Best Countries Report , conducted by US News and World Report, BAV Group, and the Wharton School of the University of Pennsylvania , reserves an entire section for education. The report surveys thousands of people across 78 countries, then ranks those countries based upon the survey's responses. The education portion of the survey compiles scores from three equally-weighted attributes: a well-developed public education system, would consider attending university there, and provides top-quality education. As of 2023, the top ten countries based on education rankings are:

Countries with the Best Educational Systems - 2021 Best Countries Report*

Ironically, despite the United States having the best-surveyed education system on the globe, U.S students consistently score lower in math and science than students from many other countries. According to a Business Insider report in 2018, the U.S. ranked 38th in math scores and 24th in science. Discussions about why the United States' education rankings have fallen by international standards over the past three decades frequently point out that government spending on education has failed to keep up with inflation.

It's also worthwhile to note that while the Best Countries study is certainly respectable, other studies use different methodologies or emphasize different criteria, which often leads to different results. For example, the Global Citizens for Human Rights' annual study measures ten levels of education from early childhood enrollment rates to adult literacy. Its final 2020 rankings look a bit different:

Education Rates of Children Around the World

Most findings and ranking regarding education worldwide involve adult literacy rates and levels of education completed. However, some studies look at current students and their abilities in different subjects.

One of the most-reviewed studies regarding education around the world involved 470,000 fifteen-year-old students. Each student was administered tests in math, science, and reading similar to the SAT or ACT exams (standardized tests used for college admissions in the U.S.) These exam scores were later compiled to determine each country's average score for each of the three subjects. Based on this study, China received the highest scores , followed by Korea, Finland , Hong Kong , Singapore , Canada , New Zealand , Japan , Australia and the Netherlands .

On the down side, there are many nations whose educational systems are considered inadequate. This could be due to internal conflict, economic problems, or underfunded programs. The United Nations Educational, Scientific, and Cultural Organization's Education for All Global Monitoring Report ranks the following countries as having the world's worst educational systems:

Countries with the Lowest Adult Literacy Rates

• Education rankings are sourced from both the annual UN News Best Countries report and the nonprofit organization World Top 20

Download Table Data

Enter your email below, and you'll receive this table's data in your inbox momentarily.

Which country ranks first in education?

Which country ranks last in education, frequently asked questions.

• Best Countries for Education - 2023 - US News
• Literacy rate, adult total (% of people ages 15 and above) - World Bank
• World Best Education Systems - Global Citizens for Human Rights
• UNESCO - Global Education Monitoring Reports
• World’s 10 Worst Countries for Education - Global Citizen
• International Education Database - World Top 20

• Open access
• Published: 09 July 2024

Analysis of barriers associated with emergency medical service activation in patients with acute stroke and acute myocardial infarction from Zhongjiang County of Sichuan Province in China

• Chengcheng He 1 ,
• Yingchun Zhang 2 ,
• Meimei Tang 1 ,
• Xiaohua Ai 1 ,
• Mingxiang Tang 1 ,
• Cheng Tang 1 ,
• Wenjin Huang 1 ,
• Xin You 1 ,
• Dewen Zhou 1 ,
• Jiming Zhou 1 ,
• Yan Shi 1 &
• Min Luo 1  

BMC Emergency Medicine volume  24 , Article number:  113 ( 2024 ) Cite this article

Metrics details

The purpose of this study was to investigate the preferred modes of transportation to the hospital among patients with acute stroke and acute myocardial infarction (AMI), as well as to identify the factors that influence the utilization of ambulances.

We conducted a cross-sectional study, including patients who were diagnosed with acute stroke and AMI, at the people’s hospital of Zhongjiang, from September 30th, 2022 to August 30th, 2023. All patients were divided into emergency medical service (EMS)-activation group and self-transportation group. Chi-square and t-tests were utilized to discern differences between groups at baseline. To screen relevant variables, we employed the Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis using R package glmnet. Subsequently, we performed a logistic regression analysis to identify predictors of EMS activation according the results of LASSO regression.

we collected 929 valid questionnaires. 26.16% of the patients required the services of EMS. 90.9% of individuals have not received any formal first aid education. 42.1% of them reported that they had no understanding of cardiovascular and cerebrovascular diseases. Diagnosed as AMI (OR 0.22, 95%CI 0.06 to 0.88) or acute cerebral infarction (OR 0.26, 0.10 to 0.68), the distance between the patient and the nearest 120 network hospital when the patient had these symptoms (OR 0.97, 0.94 to 0.99), the patient’s son or daughter was there when the patient was symptomatic (OR 0.58, 0.37 to 0.94), the patient (OR 0.19, 0.05 to 0.72) and the patient’s partner (wife or husband) (OR 0.36, 0.16 to 0.85) had decided that the patient needed further medical help, Among patients who did not seek immediate help after symptom onset, thinking that the symptoms will disappear spontaneously (OR 0.34, 0.13 to 0.92) or not wanting to disturb others (OR 0.06, 0.01 to 0.66) or believing that they are not important symptoms (OR 0.15, 0.05 to 0.42) were factors independently associated with less ambulance use. Age (OR 1.02, 1.00 to 1.04), Stroke patients have experienced symptoms of disturbance of consciousness or convulsions (OR 2.99, 1.72 to 5.2) were independent factors associated with increased ambulance use.

There is still ambulance underutilization among patients with acute stroke and AMI in county territory of China. Moreover, it is needed to raise the level of first aid education and awareness about EMS. Additionally, private clinic doctors and the public should gain adequate understanding of the severity of acute stroke and AMI, as well as their common symptoms, the crucial importance of prompt medical intervention. Finally, we propose that all township hospitals should be integrated into the 120 emergency networks and equipped with emergency first aid capabilities, pre-hospital care, and transportation abilities.

Peer Review reports

Introduction

Acute stroke and acute myocardial infarction (AMI) pose a significant threat to the health of the Chinese population [ 1 , 2 ]. According to the 2019 Global Burden of Disease study, China experienced 3.94 million new cases of stroke in 2019, with 28.76 million existing cases. Of these cases, 2.19 million resulted in death, with 82.6% being ischemic strokes [ 2 ]. Stroke exhibits high mortality and disability rates, serving as a major cause of death and disability among Chinese adults [ 2 ]. For acute ischemic stroke, prompt interventions such as intravenous thrombolysis and endovascular treatment administered within the critical time window can effectively dissolve blood clots and restore blood flow [ 3 ]. This timely approach significantly improves clinical outcomes, reduces mortality rates, and minimizes disability [ 3 ]. Similarly, AMI has a high incidence and mortality rate worldwide [ 4 ].In China, there is a high incidence rate of coronary artery disease(CAD), and the mortality rate of AMI has shown a rapid and continuous upward trend from 2012 to 2020. Specifically, the AMI mortality rate increased from 68.62 to 135.88 per 100,000 rural population, and from 93.17 to 126.91 per 100,000 urban population annually [ 5 ]. Early reperfusion therapy, including intravenous thrombolysis and percutaneous coronary intervention (PCI), is crucial for managing AMI [ 1 , 4 ].

Emergency Medical Service (EMS) play a crucial role in swiftly transporting patients and providing initial treatment, and early activation of EMS is vital for promptly diagnosing and treating acute stroke and AMI patients [ 6 ]. For patients experiencing acute stroke and AMI, the timely activation of EMS is paramount. The direct correlation between prompt EMS activation and improved clinical outcomes is crucial in ensuring optimal patient care and recovery [ 6 , 7 ]. However, in China, especially in rural or county-level areas, the utilization of ambulances for acute ischemic stroke and AMI patients remains low [ 6 ]. Some studies have explored factors influencing the non-use of ambulances by patients with acute coronary syndrome [ 6 , 8 , 9 , 10 , 11 ] and the pre-hospital delay in stroke patients [ 7 ]. However, data regarding reasons for the delayed initiation of EMS in acute stroke and AMI patients in county-level areas are lacking.

This study aims to analyze the barriers preventing the initiation of EMSS in patients with acute stroke and AMI, which could contribute to targeted solutions and improved time management for these conditions. This would subsequently enhance patient outcomes and provide greater benefits to affected individuals. Moreover, the research findings can serve as valuable references for county-level areas in China, benefiting a diverse populace and potentially contributing to socioeconomic improvements.

Study type and population

We conducted a prospective, single-center, cross-sectional study, including the patients who were diagnosed with acute stroke and AMI, at the people’s hospital of Zhongjiang, a tertiary hospital in Zhongjiang County of Sichuan Province, from September 30, 2022, to August 30, 2023. All the patients were onseted in the territory of Zhongjiang County. Some came to our hospital by call the EMS (EMS-activation group), while some came without activating the EMS (self-transportation group).

Patients were included if they were (1) 14 years and older, (2) with acute stroke and AMI symptoms occurred within 3 days, (3) presenting to the Emergency Department, (4) definitively diagnosed as acute stroke and AMI.

Patients were excluded if they were (1) unwilling to participate in the questionnaire survey, (2) patients with acute stroke or AMI who had started treatment outside of Zhongjiang County and were subsequently transferred to our hospital. (3) the patients were unable to respond to the questionnaires, and no one knew the actual situation.

Zhongjiang county and EMS setting

Zhongjiang County is located in the central Sichuan hilly region, in the northwest of the Sichuan Basin. The county covers an area of 2,200 square kilometers, including 26 towns and 4 townships, totally 522 villages (communities). According to the 2021 census data, Zhongjiang County has a registered population of 1.363 million and a permanent population of 948,000, with an urbanization rate of 42.9% for the permanent population. There are seven hospitals affiliated with the 120 emergency medical network in Zhongjiang County. Figure  1 provides a map of Zhongjiang County and its neighboring areas, highlighting the locations of these 120 network hospitals.

The map of Zhongjiang County and its neighboring areas, and the locations of these 120 network hospitals. The blue dotted line demarcates the boundaries of Zhongjiang County

The people’s hospital of Zhongjiang serves as a significant tertiary medical hub in Zhongjiang County, Sichuan Province. It provides round-the-clock services, seven days a week, for intravenous thrombolysis and endovascular intervention for cerebral infarction, as well as PCI-mediated reperfusion therapy for AMI.

Contents, development, and validation of the questionnaire

The questionnaire comprehensively covers various aspects related to patients’ experiences with acute stroke and AMI, from basic demographic details to their level of disease awareness, healthcare-seeking behavior, and potential causes of delayed EMS activation. Besides, it also explores their hypothetical actions and reasons if a similar situation were to occur again. The specific contents of the questionnaire are detailed in the supplementary document.

The design of the questionnaire initially referenced questionnaires from other studies [ 6 , 12 ] and was adjusted according to the actual situation. Following this, a pilot testing phase was conducted to evaluate its effectiveness. Based on the feedback of the pilot test and expert reviews, further revisions were made repeatedly to the questionnaire. Finally, the revised questionnaire was deemed ready for larger-scale administration.

Data collection

Patients who experienced acute stroke and AMI were initially screened upon arrival at the Emergency Department. Subsequently, they or their family member were invited by a trained investigator within 2 days to participate in the study and complete the questionnaire. The data collection was conducted on the phone using a WeChat mini-program, according to the standard data collection protocol developed by the research team.

If the patients were able to express themselves, the patients or their family members would complete the questionnaire based on the patient’s statements. If the patients were unable to respond to the questionnaires due to unconsciousness, aphasia, or being intubated, then their family members would complete the questionnaire based on the actual situation. If the patients were in the Intensive Care Unit or had passed away with no family members present in the hospital, the investigator would complete the questionnaire through a telephone interview. If the family members did not have a phone or were unfamiliar with the process, the investigator would complete the questionnaire or guide them through the process.

The questionnaire items that are most likely to lead to bias are as follows: (1) When inquiring about the symptoms of cardiovascular and cerebrovascular diseases before the onset of the illness, respondents often choose current symptoms. The investigator must clarify that the intent is to gauge understanding of these diseases before onset, not current manifestations. (2) During the inquiry about the distances patients were away from those three places, respondents frequently offer rough estimates in kilometers, which may result in significant errors. For those who are unsure of the distance, the investigator uses navigation software to measure the exact distance. (3) When inquiring about hypothetical actions and reasons in the event of a similar situation recurring, respondents often consider some factors and make choices that may not reflect their actual intentions. Based on their responses during the interview, the investigator will offer guidance to mitigate potential errors.

Statistical analysis

Categorical variables are presented as frequency (percentage) and were compared using the Chi-square test or Fisher’s exact test. Normally distributed continuous variables are presented as mean ± SD and were compared with the t-test. Non-normally distributed continuous variables are presented as median (95% confidence interval [CI]) and were compared with the Mann–Whitney test if independent or the Wilcoxon test in case of dependent variables. P value < 0.05 was considered statistically signifcant. All data were anonymized and analyzed with SPSS (version 20.0) and R (version 4.2.3).

In our study, Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis was performed to screen the most relevant variables using the glmnet package in R. This popular method avoids overfitting by incorporating the best performance parameters, resulting in a simpler and more easily interpreted model. LASSO regression was chosen for this analysis due to its ability to efficiently perform variable selection and handle multicollinearity. By penalizing the sum of absolute coefficients, LASSO automatically shrinks some coefficients to zero, selecting only the most relevant variables and reducing the influence of less correlated predictors. Furthermore, LASSO’s computational efficiency allows it to handle large datasets effectively. In comparison to other regression methods, LASSO offers a unique combination of variable selection, regularization, and prediction accuracy, making it a robust choice for this analysis.

Subsequently, we conducted a logistic regression analysis to further examine the predictors of EMS activation according the results of LASSO regression. In selecting the final logistic regression model, we incorporated variables that were selected by the LASSO regression procedure and those that demonstrated statistical significance. We comprehensively evaluated the model’s goodness of fit and predictive performance using Nagelkerke’s R² value, the p value and the prediction accuracy across different groups. The Harrell’s C-index was used to quantify and validate the concordance performance of the model. To obtain a relatively corrected estimate of the C-index, the model was subjected to bootstrapping validation with 1,000 bootstrap resamples. Through the multivariable logistic regression analysis, we obtained some results that more accurately depicts the relationship between the predictors and the EMS activation outcome.

During the study period, 1082 patients with acute stroke and AMI were admitted to our hospital. Among them, 582 patients had acute cerebral infarction, 354 patients had acute cerebral hemorrhage, 48 patients had acute spontaneous subarachnoid hemorrhage, and 98 patients had AMI. However, a total of 153 patients were excluded from the study for various reasons, including unwillingness to participate in the questionnaire survey, failure of the investigator to complete the survey, invalid questionnaires, and patients with acute stroke or AMI who had started treatment outside of Zhongjiang County and were subsequently transferred to our hospital, as they met the exclusion criteria. The final result was that we collected 929 valid questionnaires. Among them, 243 (26.16%) called for EMS (EMS-activation group), while the remaining did not call for EMS (self-transportation group).

Social demographics, cardiovascular history, risk factors

Table  1 lists social demographics, cardiovascular history, risk factors in the overall population and comparison between EMS-activation group and self-transportation group. No statistical differences were observed in age, gender, educational level, marriage status, risk factors and previous cardiovascular or cerebrovascular diseases. Only the answers regarding whether they have ever received first aid education showed statistical differences between the two groups. The self-transportation group was more likely to report not knowing the 120 emergency phone number (11.4% vs. 6.2% P  = 0.02), whereas the EMS-activation group was more likely to have studied first aid through media or the Internet (9.5% vs. 5.2% P  = 0.02).

Understandings of cardiovascular and cerebrovascular diseases

Table  2 lists understandings of cardiovascular and cerebrovascular diseases in the overall population and comparison between EMS-activation group and self-transportation group. The EMS-activation group was more likely to believe that cardiovascular and cerebrovascular diseases have symptoms such as disorders of consciousness or convulsions (11.1% vs. 6.7% p  = 0.03) and chest pressure (7.8% vs. 3.8% p  = 0.02). In addition, it is worth noting that 42.1% of them reported that they had no understanding of cardiovascular and cerebrovascular diseases.

Symptom characteristics

Table  3 lists symptom characteristics when the symptoms occurred in the overall population and comparison between the two groups. The most common symptom in patients with acute stroke was that one side of the limb is weak or numb or clumsy, which occurs in 58.0% of cases. Meanwhile, chest pain was the most common symptom occurring in 73.3% of patients with AMI. One side of the limb is weak or numb or clumsy (50.7% vs. 60.7%, p  < 0.01) was associated with decreased use of ambulance. At the same time, chest pain(78.6% vs. 50.0%, p  = 0.03) was associated with increased use of ambulance.

The situation when the symptoms occurred

Table  4 lists informations regarding the situation when the symptoms occurred in the overall population and comparison between the two groups. The median time of the onset to hospital arrival in EMS-activation group was 2.5 h, whereas in the self-transportation group, the median time was 5.0 h, with p  < 0.001. Additionally, in EMS-activation group, the median time of the onset to EMS calling was 2.00 h (Interquartile Range [IQR]: 0.67–5.00 h) and the median time of EMS calling to hospital arrival was 0.81 h (IQR: 0.48–1.31 h).

Patients diagnosed with acute cerebral hemorrhage (43.6% vs. 26.7%) and acute spontaneous subarachnoid hemorrhage (5.8% vs. 2.2%) exhibited significantly higher utilization of ambulances compared to those diagnosed with acute cerebral infarction (44.0% vs. 60.9%) and AMI (6.6% vs. 10.2%), with a statistically significant difference ( p  < 0.001).

The distribution of symptom onset times among patients also had statistically significant implications for their decision to call an ambulance ( p  < 0.01). There were higher numbers of ambulance calls from 5 pm to 8 pm (22.6% vs. 14.9%), 9 pm to midnight (7.8% vs. 7.3%), 1 am to 4 am (8.6% vs. 7.3%), and 9 am to 12 pm (28.8% vs. 25.1%). Conversely, lower numbers of ambulance calls were observed between 5 am and 8 am (18.5% vs. 27.0%), 1 pm and 4 pm (13.6% vs. 18.5%).

When the patient had these symptoms, the median distance to the nearest township hospital was 2 km for the EMS-activation group and 3 km for the self-transportation group ( p  = 0.03). The median distance between the patient and the nearest 120 network hospital was 10 km for the EMS-activation group and 14 km for the self-transportation group ( p  < 0.001). Meanwhile, the median distance between the patient and the people’s hospital of Zhongjiang was 15 km for the EMS-activation group and 20 km for the self-transportation group ( p  < 0.001).

When asked where was the patient when these symptoms occur, patients who were in a public place (11.5% vs. 7.0%) had a higher utilization of ambulance services compared to those who were at home (75.3% vs. 82.7%) ( p  = 0.03).

Before making an emergency call or going to the hospital, the patient’s relatives (77.4% vs. 71.6%), friend (6.6% vs. 3.6%), doctors in a private practice (2.1% vs. 1.0%), and other individual (6.6% vs. 3.3%) who realized that this was a serious problem were associated with increased use of ambulance compared to the patient (6.2% vs. 16.6%), and no one (1.2% vs. 3.8%) ( p  < 0.001). While, when doctor from a nearby township hospital (10.3% vs. 9.8%), other doctor (1.6% vs. 1.5%), the patient’s friends (3.7% vs. 1.2%), colleagues (1.2% vs. 0.9%), and other individual (9.5% vs. 3.6%) who decided that the patient needed further medical help, there were higher numbers of ambulance calls than the patient (2.1% vs. 10.8%), the patient’s partner (18.1% vs. 18.5%), and private clinic (0.4% vs. 1.3%) ( p  < 0.001).

When asked what caused them not to seek help immediately after symptoms appeared, the self-transportation group was more likely to believe that the symptoms would disappear spontaneously (18.4% vs. 7.4%), they were not important symptoms (17.8% vs. 6.6%), didn’t want to disturb others (3.4% vs. 0.4%) compare to the EMS-activation group. While, the EMS-activation group was even more likely to think that it wasn’t a heart or brain problem (2.1% vs. 1.6%) ( p  < 0.001).

Information of the self-transportation group: how to hospital, reasons, choices and strategies for future situations

Table  5 lists Informations about how patients arrived at the hospital, their reasons for this choice, and their actions if such a situation were to occur again among the 686 patients in the self-transportation group. The results of the survey show that the majority of patients arrive at the hospital by private transportation, either driven by a relative or friend (56.6%) or by the patient themselves (24.2%). Meanwhile, a minority chose to charter a private vehicle (11.5%).

When asked why they didn’t call 120 EMS, the most common reasons were that patients believed a private transport would be faster (38.9%), they didn’t think the health issue was severe enough to require an ambulance (24.9%), some patients didn’t consider it (13.4%), and some were already in a private vehicle (9.3%).

When asked if they would call 120 or use private transportation to return to the hospital in the event that the time were to go back and the patients became ill again or displayed the same symptoms, the results were that 45.3% would call 120, while 54.4% would still choose private transportation to go to the hospital. The main reason for preferring private transportation was that it was faster (73.2%), more convenient (26.8%), or patients thought that the disease wasn’t serious (12.8%). Some also believed that driving themselves was more economical (2.9%). For those who would call 120 again, the top reasons were that the medical staff in the ambulance was more professional (29.1%) and that ambulance was faster (25.6%). Other reasons included thinking the disease was serious (21.7%), believing the ambulance service was more convenient (8.9%).

Result of Lasso regression analysis

Figure  2 demonstrates the results of LASSO regression analysis, which was performed to screen variates to avoid overfitting and to generate a simpler interpreted model. Finally, 32 prognostic variates were selected, including diagnosis, the distance between the patient and the nearest 120 network hospital, the distance between the patient and the people’s hospital of Zhongjiang, the question of whether you have ever received first aid education (I didn’t even know the 120 emergency phone number, I had studied it in my compulsory education courses, I had studied in the media and on the Internet), the understanding of the symptoms of cardiovascular and cerebrovascular diseases prior to this illness (chest pressure, headache, headache associated with nausea and vomiting, one side of the face numbness or askew of the mouth, both eyes are fixed and can not rotate, disorders of consciousness or convulsions, having no understanding of cardiovascular and cerebrovascular diseases), the symptoms experienced by the patient with AMI (chest pressure, sweating, nausea and vomiting), grades of chest pain, the symptoms experienced by the patient with acute stroke(headache, headache associated with nausea and vomiting, dizziness, one side of the limb is weak or numb or clumsy, loss or blurred vision on either one side or both eyes, optic rotation or balance disorder, disorders of consciousness or convulsions), the place where the patient was when these symptoms occur, the person who was there when the patient was symptomatic(no one, the patient’s son or daughter), the person who realized that the problem was serious before making an emergency call or going to the hospital, the place where the patient sought medical attention in the first instance, the person who had decided that the patient needed further medical help, the reasons that caused the patient didn’t seek help immediately after symptoms.

The least absolute shrinkage and selection operator (LASSO) regression analysis. Prognosis-related variates selection in the LASSO regression ( A ). The selection of LASSO regression truncation value ( B ). The dotted line a represents the lambda corresponding to the lowest error mean. The dotted line b represents the maximum lambda corresponding to the error mean within one standard deviation of the minimum

Result of multivariable logistic regression analysis

Table  6 lists the final result of multivariable logistic regression analysis. It showed that diagnosed as AMI (OR 0.22, 95%CI 0.06 to 0.88) or acute cerebral infarction (OR 0.26, 0.10 to 0.68), the distance between the patient and the nearest 120 network hospital when the patient had these symptoms (OR 0.97, 0.94 to 0.99), the patient believed that the symptoms of cardiovascular and cerebrovascular diseases included headache accompanied by nausea and vomiting(OR 0.35, 0.18 to 0.69), one side of the face numbness or askew of the mouth (OR 0.51, 0.28 to 0.91) before the onset of this illness, the patient’s son or daughter was there when the patient was symptomatic (OR 0.58, 0.37 to 0.94), the patient (OR 0.19, 0.05 to 0.72) and the patient’s partner (wife or husband) (OR 0.36, 0.16 to 0.85) had decided that the patient needed further medical help, Among patients who did not seek immediate help after symptom onset, thinking that the symptoms will disappear spontaneously (OR 0.34, 0.13 to 0.92) or not wanting to disturb others (OR 0.06, 0.01 to 0.66) or believing that they are not important symptoms (OR 0.15, 0.05 to 0.42) were factors independently associated with less ambulance use. Age (OR 1.02, 1.00 to 1.04), and stroke patients have experienced symptoms of disturbance of consciousness or convulsions (OR 2.99, 1.72 to 5.2) were independent factors associated with increased ambulance use. The model is statistically significant with a p-value less than 0.001, and its Nagelkerke’s R 2 is 0.34. Meanwhile, the model’s overall comprehensive prediction accuracy is 80.0% (for the self-transportation group, the prediction accuracy is 93.9%, while, for the EMS-activation group is 40.7%). The C-index for the model was 0.812 (95% CI: 0.810–0.814), and upon bootstrapping validation, it was validated to be 0.744, indicating moderate accuracy of the model.

There is still ambulance underusage among patients with acute stroke and AMI in county territory of China. In our study, 26.16% of the patients required the services of EMS, which is comparable to the findings of a study conducted seven years ago by Qilu Hospital of Shandong University, where 21.6% of patients with acute coronary syndrome (ACS) were transported to the hospital via ambulance [ 6 ]. However, in Northern Italy, 65.2% of patients with ST-segment elevation acute coronary syndromes called for EMS [ 12 ]. Meanwhile, in Ireland, the percentage of ACS patients using ambulances was 27% [ 8 ] or 40.1% [ 10 ]. Therefore, the proportion of our patients with acute stroke and AMI who call the 120 still requires enhancement.

It is worth noting that 80.9% of individuals only know that they can call the 120 when they need first aid, and they have not received any formal first aid education. In addition, 10% of individuals are unaware of the 120 emergency phone number altogether. This also shows that the level of first aid education in China remains low [ 13 ]. Furthermore, the EMS-activation group tended to have a higher likelihood of having studied first aid through media or the Internet. In addition, 40.9% of overall patients didn’t seek help immediately after symptoms appeared. When asked what caused this, 15.5% of overall patients believed that the symptoms would disappear spontaneously, while 14.9% thought that they were not important symptoms. These revelations highlight the importance of not only promoting awareness of EMS but also enhancing public education on common health issues related to cardiovascular and cerebrovascular diseases. Such efforts would contribute significantly to improving the level of emergency first aid for acute stroke and heart attacks.

To enhance first aid education, there are multifaceted approaches encompassing mandatory school programs, community workshops, mass media campaigns, and partnerships with non-governmental organizations and private sectors to ensure widespread knowledge and skills.

Moreover, due to the widespread ownership of cars currently, many individuals opt to drive themselves, relatives, or friends to the hospital. The most common reasons for not calling the EMS were patients’ belief that private transportation would be swifter (38.9%) and their assessment that the health issue was not severe enough to necessitate an ambulance (24.9%). In addition, among those in the self-transportation group, 54.4% would still opt for private transportation if the situation arose again, citing the primary reasons for believing that the private vehicle was faster (73.2%), more convenient (26.8%), and the disease wasn’t serious (12.8%). On the other hand, those who would call the 120 in similar circumstances primarily cite the ambulance’s professional medical staff (29.1%), its speed (25.6%), and the seriousness of the illness (21.7%) as reasons for their choice. Correspondently, in Italy, Among those who did not activate EMS, 45.5% believed their symptoms were unrelated to a significant health issue, and 34.7% thought the private vehicle would be faster than an ambulance [ 12 ]. In summary, our stroke/chest pain center must diligently strive to enhance public awareness regarding acute stroke and heart attacks, and to popularize first aid education.

On the other hand, when patients presented these symptoms, the EMS-activation group had a median distance of 2 km to the nearest township hospital, 12 km to the nearest 120 network hospital, and 20 km to the people’s hospital of Zhongjiang. Notably, the EMS-activation group tended to have shorter distances to these three locations compared to the self-transportation group. Based on this, we propose that all township hospitals should be integrated into the 120 emergency networks and equipped with emergency first aid capabilities, as well as pre-hospital care and transportation abilities. Furthermore, the implementation strategies for this integration involve Securing government backing, obtaining administrative directives, establishing a coordination mechanism, standardizing protocols, upgrading infrastructure and equipment, training staff, and establishing communication links, among other steps. This integration is expected to increase efficiency in emergency response, improve resource utilization, enhance patient experience, and strengthen public trust in the healthcare system, among other benefits.

Patients were more inclined to opt for an ambulance when symptoms occurred at night, this is similar to another study on ACS [ 6 ]. When symptoms occurred, 80.7% of patients were at home, exhibiting a lower utilization of EMS compared to those who were in public places. Additionally, 45.1% of them were accompanied by their partner, and 28.1% were with their son or daughter. Notably, those accompanied by family members also tended to have a lower utilization of EMS. This might be caused by the perception that it wasn’t a serious problem. Prior research has demonstrated that patients tend to call an ambulance when they perceive their symptoms as being sufficiently serious [ 6 , 11 ]. Furthermore, in our study, before making an emergency call or going to the hospital, the patient and no one who realized that this was a serious problem were associated with decreased use of ambulance compared to when the patient’s relatives, friends, or doctors in private practice were involved. While, when the patient, the patient’s partner, and the private clinic decided that the patient needed further medical help, there were lower numbers of ambulance calls. These further indicate that patients, their families, and private clinic doctors lack adequate understanding of the potentially grave consequences of acute stroke and AMI, as well as the critical importance of prompt medical intervention.

Finally, in discussing our findings, we must address the potential issue of selection bias and its impact on the generalizability of our results. Our samples originated from a central hospital in Zhongjiang County, and neighboring hospitals may have also included minor patients. Selection bias may also arise due to voluntary participation, a unique patient population, and investigator variations. Given that there are over 2,000 county units in China, the specific socioeconomic, demographic, and healthcare context of Zhongjiang County may limit the generalizability of our findings. However, we believe that many of our findings can still provide valuable insights for many other regions with similar characteristics. We recommend improved training for investigators and enhanced research methods to mitigate bias and improve the reliability and generalizability of future studies.

Conclusions

In summary, Ambulance underutilization persists among patients with acute stroke and AMI in county territory of China, coupled with low levels of first aid education. Our findings underscore that it is needed to raise the level of first aid education and awareness about EMS. Moreover, it is crucial for private clinic doctors and the public to recognize typical symptoms and potential dangers of acute stroke and AMI, as well as the significance of prompt EMS services and timely treatment at chest pain/stroke centers. Finally, we propose that all township hospitals should be integrated into the 120 emergency networks and equipped with emergency first aid capabilities, pre-hospital care, and transportation abilities. These efforts would contribute significantly to improving the level of emergency first aid for acute stroke and heart attacks.

Data availability

The datasets that were used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Emergency Medical Service

Acute Myocardial Infarction

Least Absolute Shrinkage and Selection Operator

Acute Coronary Syndrome

Percutaneous Coronary Intervention

Interquartile Range

Hu C, Tkebuchava T, Hu D. Managing acute myocardial infarction in China. Eur Heart J. 2019;40(15):1179–81.

Article   PubMed   Google Scholar  

Wang YJ, Li ZX, Gu HQ, et al. China stroke statistics: an update on the 2019 report from the national center for healthcare quality management in neurological diseases, China national clinical research center for neurological diseases, the Chinese stroke association, national center for chronic and non-communicable disease control and prevention, Chinese center for disease control and prevention and institute for global neuroscience and stroke collaborations. Stroke Vasc Neurol; 2022.

Hankey GJ, Stroke. Lancet. 2017;389(10069):641–54.

Reed GW, Rossi JE, Cannon CP. Acute myocardial infarction. Lancet. 2017;389(10065):197–210.

Hu SS, Writing Committee of the Report on Cardiovascular H. Diseases in C. Epidemiology and current management of cardiovascular disease in China. J Geriatric Cardiology: JGC. 2024;21(4):387–406.

Article   PubMed Central   Google Scholar  

Ma J, Wang J, Zheng W, et al. Usage of ambulance transport and influencing factors in acute coronary syndrome: a cross-sectional study at a tertiary centre in China. BMJ Open. 2017;7(8):e015809.

Article   PubMed   PubMed Central   Google Scholar  

Nagao Y, Nakajima M, Inatomi Y, et al. Pre-hospital delay in patients with acute ischemic stroke in a multicenter stroke registry: K-plus. J Stroke Cerebrovasc Dis. 2020;29(11):105284.

Ahern S, Vaughan C. Factors influencing ambulance usage in acute coronary syndrome. Ir Med J. 2022;115(2):539.

CAS   PubMed   Google Scholar  

Lavery T, Greenslade JH, Parsonage WA, et al. Factors influencing choice of pre-hospital transportation of patients with potential acute coronary syndrome: an observational study. Emerg Med Australasia: EMA. 2017;29(2):210–6.

Article   Google Scholar  

Mooney M, O’Brien F, McKee G, et al. Ambulance use in acute coronary syndrome in Ireland: a cross-sectional study. Eur J Cardiovasc Nurs. 2016;15(5):345–54.

Thuresson M, Jarlov MB, Lindahl B, et al. Factors that influence the use of ambulance in acute coronary syndrome. Am Heart J. 2008;156(1):170–6.

Baldi E, Camporotondo R, Gnecchi M et al. Barriers associated with emergency medical service activation in patients with St-segment elevation acute coronary syndromes. Intern Emerg Med. 2021.

Xu F, Zhang Y, Chen Y. Cardiopulmonary resuscitation training in China: current situation and future development. JAMA Cardiol. 2017;2(5):469–70.

Download references

Acknowledgements

Colleagues including Kai Long, Tao Xu, Bin Liu, Bin Tang, Jianwei Xu, Shan Chen, Huan Yang, Xueqin Wang, and Xiaoju Wang, as well as intern doctors Guo Hu, Muxiaolong Li, Miao Zhou, Wen He, and Liang Wang, partially contributed to the questionnaire survey or enrollment process. Thanks to them and to all the other individuals who have assisted in this study.

This study was supported by Deyang Science and Technology Program (2022SCZ103).

Author information

Authors and affiliations.

Department of Emergency Medicine, People’s hospital of Zhongjiang, Deyang, Sichuan, China

Chengcheng He, Meimei Tang, Xiaohua Ai, Mingxiang Tang, Cheng Tang, Li Li, Wenjin Huang, Xin You, Dewen Zhou, Jiming Zhou, Yan Shi & Min Luo

Department of Neurology, People’s hospital of Zhongjiang, Deyang, Sichuan, China

Yingchun Zhang

You can also search for this author in PubMed   Google Scholar

Contributions

He Chengcheng, Ai Xiaohua, Tang Mingxiang, and Tang Meimei conceived the study and supervised the conduct of the study. He Chengcheng designed the trial and obtained research funding. He Chengcheng, Tang Cheng, Li Li, and Huang Wenjin undertook the recruitment of participating patients. He Chengcheng, Zhang Yingchun, Tang Cheng, Li Li, Huang Wenjin, You Xin, Zhou Dewen, Zhou Jiming, Shi Yan, and Luo Min conducted data collection. Ai Xiaohua chaired the data oversight committee, while He Chengcheng, Tang Meimei, and Tang Mingxiang managed the data and conducted quality control. He Chengcheng and Zhang Yingchun analyzed the data and drafted the manuscript and all authors contributed substantially to its revision.

Corresponding authors

Correspondence to Chengcheng He or Xiaohua Ai .

Ethics declarations

Ethics approval and consent to participate.

The ethical approval, with approval reference number JLS-2022-034, was obtained from the Ethics Committee of the People’s Hospital of Zhongjiang before initiation of the study. Prior to administering any questionnaire survey, informed consent was obtained from all patients capable of expressing themselves, or from their family members if patients were unable to do so. The Ethics Committee of the People’s Hospital of Zhongjiang is affiliated with the People’s Hospital of Zhongjiang.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

He, C., Zhang, Y., Tang, M. et al. Analysis of barriers associated with emergency medical service activation in patients with acute stroke and acute myocardial infarction from Zhongjiang County of Sichuan Province in China. BMC Emerg Med 24 , 113 (2024). https://doi.org/10.1186/s12873-024-01035-5

Download citation

Received : 28 March 2024

Accepted : 02 July 2024

Published : 09 July 2024

DOI : https://doi.org/10.1186/s12873-024-01035-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Emergency medical service
• Acute stroke
• Acute myocardial infarction
• Barriers self-transportation

BMC Emergency Medicine

ISSN: 1471-227X

• General enquiries: [email protected]

• China Daily PDF
• China Daily E-paper

Global medicine takes cue from Chinese patients

Agreements boost nation's r&d status in field of pioneering research dealing with a wide range of diseases.

German pharmaceutical company Boehringer Ingelheim signed framework agreements with three major domestic hospitals during the fourth China International Import Expo held in Shanghai in early November to include them in the company's early-stage clinical research of innovative compounds it developed globally.

The collaboration with Shanghai Huashan Hospital, Shanghai Cancer Center and Shanghai Mental Health Center brought the total of Chinese medical institutions that reached such agreements with the company to 19. This follows the company's China Key initiative to include Chinese patients' needs in its global research and development strategy, which started in 2019.

Such collaboration allows Chinese patients to share the latest results of new drug R&D at the same time as patients elsewhere. More importantly, diseases that are more prevalent in China will get more attention, industry insiders said.

"Periodic results have been achieved in the tumor, immunity, central nervous system, metabolism and cardiovascular fields from existing collaboration with Chinese hospitals," said Zhang Wei, head of medicine at Boehringer Ingelheim.

Also, based on the clinical needs of local patients, some clinical trial projects, including innovative therapies for the treatment of solid tumors as well as obesity and fatty liver disease, were already ongoing, he said.

While Chinese institutions are increasingly participating in the international R&D network of multinational pharmaceutical companies, and clinical research programs in China are more synchronized with the world, the particular needs of Chinese patients are more visible and better represented today than ever before, experts said.

Wang Bin, general manager of Boehringer Ingelheim Biopharma China, said that one obvious change in the domestic biopharma industry over the past decade is that the R&D focus shifted toward disease categories that afflict Chinese more often.

The change has become evident in the number of company clients included in the contract development manufacturing organization model, which allows research-oriented companies to focus on R&D while outsourcing drug development and manufacturing to Boehringer Ingelheim, he said.

"A decade ago, the most common practice in the domestic biopharma field was to produce generic drugs, and therefore most drugs were for the treatment of diseases with a high incidence in the West－but not necessarily high in China," Wang said.

"However, drug development tailor-made for China and Asia is a growing trend. More drug R&D programs are focused on lung cancer, intestinal cancer and some other diseases that severely affect Chinese people's health," he said.

At Draeger Medical Equipment, based in Germany, there are around 100 Chinese scientists and engineers working at its China R&D center, accounting for 10 percent of the company's global R&D effort, said Gabor Polivka, CEO of the company's division in China.

"Chinese researchers played a big role in incorporating 4G technologies and network connections in our medical devices for doctors to monitor the condition of patients, the application of which was remarkable when treating COVID-19 cases in quarantine wards," Polivka said.

Another example was masks, he said. When the company started producing masks in China last year, the China team made changes in the design to make them better fit Asian faces.

"Today, masks made in China are sold not only in China but also in some other regions of Asia," Polivka said.

For Swiss pharmaceutical company Novartis, the new arrangement ensures that China teams provide input to its global development programs much earlier.

"We now consider feedback from our local China team as well as Chinese regulators. At the same time, we consider feedback from other major global regulators in designing our phase 3 studies," said Vas Narasimhan, Novartis CEO.

Johan Kahlstroem, head of the cardiovascular, renal and metabolism business unit at Novartis Pharma (China), said 100 percent of its clinical trials in relevant disease areas in China take place simultaneously with global trials today.

"The inclusion of Chinese patients directly in our trials does not mean only a minimized gap between the launch of a new drug in the West and in China. Starting trials earlier also means that we can use the insights from a clinical program as early as possible and implement them in others," Kahlstroem said.

Early insights may also give clues to R&D teams on the treatment patterns of a potential new therapy and how it actually interacts with the standard therapy in China, he said. "Early insights help us really drive clinical preparedness for using a drug," he said.

Edwards Life sciences, which has been introducing heart valve and critical care products to China over the past two decades, said that it shares the vision of having Chinese clinical teams involved in R&D on its therapies.

Michael Mussallem, chairman and CEO of Edwards Life sciences, said the company is encouraged that research teams at Chinese hospitals have been increasing their capabilities, and the company is also improving its in-country clinical resources.

"For example, we conducted field research with Chinese physicians on a key pipeline technology for surgical treatment of heart valve disease so that their voices can be better heard in this important therapeutic area," he said.

One recent example was the recent publication of the first 200 commercial case results of the company's transcatheter aortic valve system Sapien 3 performed by Chinese doctors in real-world settings, which demonstrated exciting results, said Mussallem. Transcatheter procedures are minimally invasive surgeries that can be used to replace heart valves.

"We look forward to continuing our work with hospitals and clinicians around China to address the unmet needs in the treatment of aortic, mitral and tricuspid valve disease, and to generate early data and evidence that'll be relevant globally," he said.

To have Chinese patients' needs better represented, United States-based pharmaceutical company Bristol Myers Squibb recently made a change in the reporting procedures of its China R&D departments.

Instead of reporting to their respective global departments, they now report to the company's R&D head in China, who then reports to the company's global executive vice-president in charge of drug development.

The company has over 30 clinical trials ongoing in China of immuno-oncology treatment, which uses a person's immune system to fight cancer. They cover cancers of the lung, liver, stomach and esophagus, which are more common in China.

In the field of immunology, the company said it has eight clinical trials in different phases, covering illnesses such as Crohn's disease－an inflammation of the bowel－the skin disease psoriasis and lupus nephritis, a kidney condition brought on by the autoimmune disease lupus. These are illnesses for which patients have long awaited new therapies.

Today's Top News

• Report: Critique of the South China Sea Arbitration Award
• CPI heralds modest price rises in H2
• Expats hail new mainland travel permits
• China right to pursue its modernization path
• Nation's progress in transportation sector highlighted
• Beijing, Dhaka elevate ties, vow more BRI cooperation

Most Viewed

• Skip to main content

Update your browser for the best possible experience

As of January 1st, 2020, Internet Explorer (versions 11 and below) is no longer supported by Evolve. To get the best possible experience using Evolve, we recommend that you use another web browser. For HESI iNet users click here .

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Analysis of barriers associated with emergency medical service activation in patients with acute stroke and acute myocardial infarction from Zhongjiang County of Sichuan Province in China

Affiliations.

• 1 Department of Emergency Medicine, People's hospital of Zhongjiang, Deyang, Sichuan, China. [email protected].
• 2 Department of Neurology, People's hospital of Zhongjiang, Deyang, Sichuan, China.
• 3 Department of Emergency Medicine, People's hospital of Zhongjiang, Deyang, Sichuan, China.
• 4 Department of Emergency Medicine, People's hospital of Zhongjiang, Deyang, Sichuan, China. [email protected].
• PMID: 38982343
• DOI: 10.1186/s12873-024-01035-5

Objectives: The purpose of this study was to investigate the preferred modes of transportation to the hospital among patients with acute stroke and acute myocardial infarction (AMI), as well as to identify the factors that influence the utilization of ambulances.

Methods: We conducted a cross-sectional study, including patients who were diagnosed with acute stroke and AMI, at the people's hospital of Zhongjiang, from September 30th, 2022 to August 30th, 2023. All patients were divided into emergency medical service (EMS)-activation group and self-transportation group. Chi-square and t-tests were utilized to discern differences between groups at baseline. To screen relevant variables, we employed the Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis using R package glmnet. Subsequently, we performed a logistic regression analysis to identify predictors of EMS activation according the results of LASSO regression.

Results: we collected 929 valid questionnaires. 26.16% of the patients required the services of EMS. 90.9% of individuals have not received any formal first aid education. 42.1% of them reported that they had no understanding of cardiovascular and cerebrovascular diseases. Diagnosed as AMI (OR 0.22, 95%CI 0.06 to 0.88) or acute cerebral infarction (OR 0.26, 0.10 to 0.68), the distance between the patient and the nearest 120 network hospital when the patient had these symptoms (OR 0.97, 0.94 to 0.99), the patient's son or daughter was there when the patient was symptomatic (OR 0.58, 0.37 to 0.94), the patient (OR 0.19, 0.05 to 0.72) and the patient's partner (wife or husband) (OR 0.36, 0.16 to 0.85) had decided that the patient needed further medical help, Among patients who did not seek immediate help after symptom onset, thinking that the symptoms will disappear spontaneously (OR 0.34, 0.13 to 0.92) or not wanting to disturb others (OR 0.06, 0.01 to 0.66) or believing that they are not important symptoms (OR 0.15, 0.05 to 0.42) were factors independently associated with less ambulance use. Age (OR 1.02, 1.00 to 1.04), Stroke patients have experienced symptoms of disturbance of consciousness or convulsions (OR 2.99, 1.72 to 5.2) were independent factors associated with increased ambulance use.

Conclusion: There is still ambulance underutilization among patients with acute stroke and AMI in county territory of China. Moreover, it is needed to raise the level of first aid education and awareness about EMS. Additionally, private clinic doctors and the public should gain adequate understanding of the severity of acute stroke and AMI, as well as their common symptoms, the crucial importance of prompt medical intervention. Finally, we propose that all township hospitals should be integrated into the 120 emergency networks and equipped with emergency first aid capabilities, pre-hospital care, and transportation abilities.

Keywords: Acute myocardial infarction; Acute stroke; Barriers self-transportation; Emergency medical service.

© 2024. The Author(s).

PubMed Disclaimer

• Hu C, Tkebuchava T, Hu D. Managing acute myocardial infarction in China. Eur Heart J. 2019;40(15):1179–81. - DOI - PubMed
• Wang YJ, Li ZX, Gu HQ, et al. China stroke statistics: an update on the 2019 report from the national center for healthcare quality management in neurological diseases, China national clinical research center for neurological diseases, the Chinese stroke association, national center for chronic and non-communicable disease control and prevention, Chinese center for disease control and prevention and institute for global neuroscience and stroke collaborations. Stroke Vasc Neurol; 2022.
• Hankey GJ, Stroke. Lancet. 2017;389(10069):641–54. - DOI - PubMed
• Reed GW, Rossi JE, Cannon CP. Acute myocardial infarction. Lancet. 2017;389(10065):197–210. - DOI - PubMed
• Hu SS, Writing Committee of the Report on Cardiovascular H. Diseases in C. Epidemiology and current management of cardiovascular disease in China. J Geriatric Cardiology: JGC. 2024;21(4):387–406. - DOI - PMC
• Search in MeSH
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.