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A helpful exchange

Partnerships between Yale School of Medicine and Chinese medical schools may have played a key role in reforming medical training throughout China.

When a group of doctors at Yale came up with an idea to improve health care in China, they thought they’d help one university. But thanks to some incredible work and a perhaps even more incredible coincidence, their idea spread throughout China and beyond. “From a little seed grew this huge forest,” said Barry Wu, MD, professor of clinical medicine and chair of the health committee for the Yale-China Association, a group that fosters cooperation between Yale and China.

For much of its history, China relied on traditional Chinese medicine. Over the 20th century, however, China rapidly modernized its health care, including the adoption of Western techniques of surgery. But in the early 2000s, it still lagged behind in one important area: residency training. In China, medical trainees went straight from student status to independent medical practitioner with no residency period in between. Yale-China came up with a plan to create a residency program at the Xiangya School of Medicine in Changsha, the capital of China’s Hunan province.

Working with Xiangya is nothing new: Yale-China founded Xiangya (then called Xiangya Medical College) in the first place in 1914. In Chinese, Xiangya means Hunan-Yale. “It’s really the longest, oldest, most productive relationship of any university in the U.S. with China,” said David Youtz, president of the Yale-China Association.

For a year, health care professionals from Xiangya and Yale went back and forth between Changsha and New Haven to study each other’s health care systems. The Chinese professionals were particularly impressed with one feature of the American system: core competencies. The U.S. health care system (and many other international systems) uses set areas of study called core competencies or milestones to measure student abilities. China had no such equivalency. The colleagues at Xiangya liked the idea of competencies, but they weren’t fans of the particular milestones used in the United States, so they worked with Yale to create their own.

“I actually like theirs better than ours,” said Robert Rohrbaugh, MD '82, professor of psychiatry and associate dean for global health education, who worked on the collaboration. China decided to focus on competencies like patient safety, medical ethics, innovation, self-development, and team spirit in its new residency program.

Previously, health care in China was a mostly top-down affair. Lead doctors would diagnose patients, and residents and nurses would run off to do their bidding. Yale, on the other hand, has a different approach: physicians, residents, and nurses all give their input on a patient. Young doctors learn from older ones, but older doctors also listen to younger ones. China was impressed with Yale’s teamwork-driven approach, which is why they made team spirit one of their competencies.

“I love the idea of team spirit as a competency,” Rohrbaugh said. “Instead of faculty saying, ‘This is how it is,’ it was faculty saying to residents, ‘Well, what do you think is going on? Why do you think that?’ ”

Decreasing the power of hierarchies became a central theme throughout the project. When the Yale team first sat in on Xiangya lectures, they noticed something odd: after the lecture, no one raised their hands when a teacher asked if there were any questions. Information went in only one direction: from teacher to student. Students were afraid to speak up or make mistakes. But as Wu pointed out, “Real learning is when you get things wrong.” Health care workers must be inquisitive and skeptical. They have to question current dogma.

Xiangya decided to soften its approach and encourage students to feel more comfortable speaking up. Yale taught Xiangya the so-called sandwich model of feedback: giving a compliment, a criticism, and another compliment. “Being kind can help the learner,” Wu said.

On a similar note, Chinese medical schools didn’t typically ask students to evaluate teachers— that would go against the hierarchy of teachers being above students. But after seeing Yale do so, they implemented this idea. These faculty evaluations were “really radical,” Rohrbaugh said.

Xiangya put its own spin on this change. American schools use computer programs for their faculty evaluations, and they often have trouble getting people to complete them. But Xiangya decided to conduct its evaluations on WeChat, an app Chinese people use to do everything from chatting with friends to paying electric bills. Chinese people use WeChat constantly, so it is easy to get the Chinese health care community to complete evaluations.

Xiangya was also intrigued by Yale’s approach to research. After seeing a new patient, Yale residents dig into research to learn about new diagnoses and treatments. In addition to widening the students’ medical perspectives, this process inspires them to contribute their own research to the medical literature. Xiangya loved this idea. “When I saw our program through their eyes, I recognized that it is pretty cool that our trainees do this,” Rohrbaugh said.

Ultimately, Yale didn’t simply drop its existing system into China. The two cultures worked together to create a new system—one that meets international standards but remains uniquely Chinese. “It’s not what either party pictured at the beginning,” said Youtz.

Their creativity paid off. Xiangya’s program was a success, one that spread far beyond the province of Hunan. By sheer coincidence, about a year after Yale-China came up with the idea, the Chinese government announced its plans to institute residency programs throughout the country. The government selected six pilot sites for residency programs, including Xiangya.

The government ultimately decided to implement many aspects of Xiangya’s residency program throughout the country, including four or five of the six milestones Yale helped inspire, said Rohrbaugh. The medical professionals at Xiangya have been “recognized as national leaders,” Rohrbaugh added. Many of their changes are becoming standard practice throughout China.

That means Yale-China’s contributions continue to affect over 1.3 billion people. And that’s just within the country’s borders. China is also heavily investing in infrastructure in Africa, so the approach is spreading there as well. In fact, some Xiangya techniques made their way back to Yale. The Yale doctors learned a lot from their Chinese colleagues. “I was in awe at how fast they get things done,” said Wu, who watched China implement new programs practically overnight. “When they decide to do something, they just do it,” he added.

Chinese medicine was far from modern in the early 20th century. But today, China is catching up to and even surpassing American medicine in some areas. “There are things Americans should and will learn from the Chinese,” Youtz said. So it’s all the more important that these medical powerhouses develop relationships with one another.

“This would not have succeeded without the mutual respect and integrity of the people we worked with,” Wu said. “We had a common goal. It wasn’t we and them. It was us.”