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Establishing Pulmonary and Critical Care Medicine in China: 2016 Report on Implementation and Government Recognition: Joint Statement of the Chinese Association of Chest Physicians and the American College of Chest Physicians FREE TO VIEW

Renli Qiao, MD, PhD, FCCP; Darcy Marciniuk, MD, FCCP; Nicki Augustyn; Mark J. Rosen, MD, Master FCCP; Huaping Dai, MD; Rongchang Chen, MD, FCCP; Sinan Wu, MD; Chen Wang, MD, PhD, FCCP
Author and Funding Information

aDepartment of Pulmonary, Critical Care, and Sleep Medicine, Keck School of Medicine, University of California, Los Angeles, CA

bDepartment of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

cAmerican College of Chest Physicians, Glenview, IL

dDepartment of Pulmonary, Critical Care, and Sleep Medicine, North Shore University Hospital, Manhasset, NY

eCapital Medical University, Beijing Chao Yang Hospital, Beijing Institute of Respiratory Medicine, Beijing, China

fBeijing Chao Yang Hospital, Beijing Institute of Respiratory Medicine, Beijing, China

gDepartment of Critical Care and Respiratory Medicine, State Key Laboratory of Respiratory Disease at The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Medicine, Guangzhou, China

hMinistry of Health, Beijing Hospital, Beijing Institute of Health, and Key Laboratory of Geriatrics, Beijing, China

CORRESPONDENCE TO: Darcy Marciniuk, MD, FCCP, Division of Respirology, 5th Floor Ellis Hall, Royal University Hospital, Saskatoon, SK, S7N 0W8 Canada


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(2):279-282. doi:10.1016/j.chest.2016.05.005
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Published online

This article provides an update on progress toward establishing pulmonary and critical care medicine (PCCM) fellowship training as one of the first four subspecialties to be recognized and supported by the Chinese government. Designed and implemented throughout 2013 and 2014 by a collaborative effort of the Chinese Thoracic Society (CTS) and the American College of Chest Physicians (CHEST), 12 leading Chinese hospitals enrolled a total of 64 fellows into standardized PCCM training programs with common curricula, educational activities, and assessment measures. Supplemental educational materials, online assessment tools, and institutional site visits designed to evaluate and provide feedback on the programs’ progress are being provided by CHEST. As a result of this initial progress, the Chinese government, through the Chinese Medical Doctor’s Association, endorsed the concept of subspecialty fellowship training in China, with PCCM as one of the four pilot subspecialties to be operationalized nationwide in 2016, followed by implementation across other subspecialties by 2020. This article also reflects on the achievements of the training sites and the challenges they face and outlines plans to enhance and expand PCCM training and practice in China.

In 2014, Qiao et al outlined the case for working toward the establishment of formal subspecialty training in the combined fields of pulmonary and critical care medicine (PCCM) throughout China. A group of leading Chinese pulmonary specialists recognized the increasing demand for high-quality critical care to serve a vast and aging population. They recognized that structured and standardized training across China in this and all other subspecialties was lacking and that, as in the United States, the combined subspecialty of PCCM is well placed to meet these clinical and educational needs. As a result, the Chinese Thoracic Society (CTS) proposed collaborating with the American College of Chest Physicians (CHEST) to design and establish fellowship training in PCCM in China.

In September 2013, a joint steering committee was constituted to face the challenges of establishing this new subspecialty, starting with launching 3-y training programs with common curricula, educational processes, and evaluation systems. These programs have since been referred to as “China-CHEST PCCM.” Renli Qiao, MD, PhD, FCCP was designated the CHEST PCCM Medical Director to lead the joint effort in China. Dr Qiao is uniquely qualified to facilitate these activities because he is trained and experienced in both the Chinese and American clinical and education systems, serves as senior faculty in a major US medical center, and is recognized in China as a leader in educational design and reform.

With the vision of establishing PCCM as the first subspecialty with standardized training pathways in China, the steering committee embarked on an ambitious set of tasks. Eight leading Chinese institutions were initially identified to launch the programs and graduate the first “class” of 18 in 2016; 4 additional hospitals joined within the following year for a total of 12 pilot programs. These programs officially launched in September 2013 (Table 1).

Table Graphic Jump Location
Table 1 China-CHEST PCCM Pilot Programs

PCCM = pulmonary and critical care medicine.

Using elements of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Medical Education in Pulmonary Disease and Critical Care Medicine (Internal Medicine), the committee identified areas of study and training that would best and most immediately serve the needs of Chinese intensivists, with requirements that Chinese institutions could rapidly adopt while adhering to central and local governmental policies.

The steering committee developed standard requirements for institutional resources, attributes, and responsibilities of program directors and faculty, experiences and supervision of fellows, and feedback and evaluation processes for fellows, faculty, and program directors alike. They defined a detailed curriculum for participating programs to use in designing their own training plans. Outlines for clinical rotations and teaching conference schedules were developed, along with recommendations for assessing competence in specific procedures. These recommendations were based in part on ACGME criteria and modified to account for the needs of the Chinese patient population and capabilities of the institutions. These requirements were in turn refined and approved by the program directors of each site (e-Tables 1, 2).

To assess adherence to requirements and to identify and address problems in implementation, representatives from CHEST conducted site visits to each of the participating programs. Starting with assessment of materials related to faculty qualifications, adherence to the curriculum, clinical exposures, conference schedules, and procedure logs, the site visitors then interviewed institutional leadership, program directors, faculty, and fellows to review the accomplishments and challenges faced by each program. These were followed by comprehensive tours of each hospital’s intensive care, inpatient, and outpatient settings. The site visitors also participated in teaching conferences and patient care rounds and offered feedback and recommendations to the program directors based on these observations.

One of the common issues recognized before the launch and confirmed by site visits involved the conduct of teaching experiences. In the traditional hierarchical structure of Chinese medical education, senior faculty offer didactic experiences while learners assume a passive role. For example, case discussions are structured to have the trainees present the history and physical examination, pertinent results of diagnostic tests, and summary of the clinical course. This is usually followed by discussion of the differential diagnosis and recommendations for next steps by senior staff and usually the department chair. This approach was deemed by the steering committee to be antithetical to the development of independent thinking skills and evidence-based practice. Feedback to the sites about how to improve these educational experiences to promote active learning was provided, and the conduct of teaching rounds and conferences will be assessed again in future site visits.

To augment the existing clinical experience, twice-weekly internet case discussions were developed, conducted, and facilitated by Dr Qiao in his role as the PCCM medical director; remote events were conducted in the manner of similar US conferences. Participation is mandatory for all PCCM fellows. The sessions proved so popular that they are regularly accessed by hundreds of trainees and senior staff around China.

Another common barrier to subspecialty clinical training is the Chinese system of financial and other incentives for professional advancement, which promotes achievements in research and publication to the detriment of pursuit of clinical excellence. The Chinese Medical Doctors Association (CMDA) is the operational arm of the Chinese Committee of Health and Family Planning (formerly Ministry of Health) overseeing the conduct of medical practice and education in China. In January 2016, CMDA recognized the pull between devoting time and effort in research and clinical careers and for the first time formally endorsed the importance of establishing clinical training pathways for subspecialties. Recognizing the accomplishments and transformative potential of the PCCM efforts, they designated this discipline, along with orthopedics, geriatrics, and neurosurgery, as the first wave of standardized training programs across all the subspecialties in China. As PCCM medical director, Dr Qiao has emerged as a leader in Chinese education and clinical practice. He writes a regular column reporting on PCCM and postgraduate education for MD Weekly, the official publication of CMDA, and was appointed to the Advisory Board for Postgraduate Medical Education of the Chinese Committee of Health and Family Planning.

The Chinese Association of Chest Physicians (CACP) is the respiratory arm of the CMDA and is now charged with oversight of the broad implementation of PCCM programs. CACP estimates that approximately 8,000 PCCM subspecialists are needed to meet the enormous demands of the Chinese population. Discussions among representatives of the PCCM steering committee program, the program directors, and CACP culminated in an agreement to establish an exclusive collaboration between CHEST and CMDA aimed at implementing the expansion of the China-CHEST PCCM programs as the first accredited fellowships in China. The comprehensive agreement importantly covers training in clinical care, leadership, and research and is intended to ensure that graduates are fully capable experts in their field. This agreement was signed by both parties in the opening ceremony of the CHEST World Congress 2016 in Shanghai before an audience of more than 1,000 delegates from around the world.

Accordingly, the number of China-CHEST PCCM programs is expected to grow from 12 to 30 in the coming year, with the number of fellows in each class growing in parallel. Training sites will be accredited jointly by CACP and CHEST under the auspices of the Chinese government. In this way, it is anticipated that as many as 1,000 China-CHEST certified specialists can be practicing by the year 2020.

CHEST supports the China-CHEST PCCM effort not only by funding the operational expenses of the PCCM medical director, steering committee, and staff but also by technological support to provide CHEST-derived educational materials along with tools for data collection and ongoing evaluation of programs and fellows. Establishing new educational activities is also currently under discussion: These include train-the-trainer and hands-on simulation programs in China, along with 2-way exchange programs to provide both Chinese and North American PCCM fellows the opportunity to be exposed to each others’ patient populations and clinical practices.

Over 3 y, the China-CHEST PCCM effort has resulted in great strides in advancing the unification of the disciplines of pulmonary and critical care medicine in China into a single subspecialty that is now recognized by the Chinese government and with the active participation of 12 pilot sites. With successful expansion of the number of PCCM programs and trainees, we anticipate this model of subspecialty training will become the standard for Chinese medical education and transform medical care in the nation. This progress will help achieve our common goal of providing the very best possible care for our patients.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following: D. M. is employed by the University of Saskatchewan. N. A. is employed by the American College of Chest Physicians. None declared (R. Q., M. J. R., H. D., R. C., S. W., C. W.).

Collaborators: China-CHEST PCCM Steering Committee Members: Darcy D. Marciniuk, MD, FRCPC, FCCP (co-chair); Chen Wang, MD, PhD, FCCP (co-chair); Renli Qiao, MD, PhD, FCCP; Mark J. Rosen, MD, FCCP; Stephanie M. Levine, MD, FCCP; Jack D. Buckley, MD, FCCP; Rongchang Chen, MD, FCCP; and Huaping Dai, MD.

Additional information: The e-Tables can be found in the Supplemental Materials section of the online article.

Qiao R. .Rosen M.J. .Chen R. .et al Establishing pulmonary and critical care medicine as a subspecialty in China: joint statement of the Chinese Thoracic Society and the American College of Chest Physicians. Chest. 2014;145:27-29 [PubMed]journal. [CrossRef] [PubMed]
 
ACGME Program Requirements for Graduate Medical Education in Pulmonary and Critical Care Medicine (Internal Medicine).https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/156_pulmonary_critical_care_int_med_2016.pdf. Accessed April 28, 2016.
 

Figures

Tables

Table Graphic Jump Location
Table 1 China-CHEST PCCM Pilot Programs

PCCM = pulmonary and critical care medicine.

References

Qiao R. .Rosen M.J. .Chen R. .et al Establishing pulmonary and critical care medicine as a subspecialty in China: joint statement of the Chinese Thoracic Society and the American College of Chest Physicians. Chest. 2014;145:27-29 [PubMed]journal. [CrossRef] [PubMed]
 
ACGME Program Requirements for Graduate Medical Education in Pulmonary and Critical Care Medicine (Internal Medicine).https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/156_pulmonary_critical_care_int_med_2016.pdf. Accessed April 28, 2016.
 
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Supporting Data

e-Tables 1 and 2

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