Western medicine and the Western medical education system were introduced to Asia several hundred years ago. The curricula and the teaching methods of medical education in Asia are based on the traditional Western model, which stresses a teacher-centered, didactic, discipline-specific, lecture-based approach. As a result of changing health care needs of local communities and the learning needs of the students, Asia, like other parts of the world, is haunted by a mismatch between what is taught at medical school and the actual skills that are needed by doctors to provide health care service.1 To overcome the deficiencies, many Asian medical schools have followed the footsteps of their Western counterparts in pursuing medical education reform which is now recognized as an integral part of medical education.
Asia, the world’s largest and most populous continent, contains nearly three fifths of the world’s total population.2 According to the United Nations, Asia is divided into five subregions. China, Hong Kong, Macau, Japan, North Korea, South Korea, Mongolia, and Taiwan are known as Eastern Asia. Southern Asia includes Afghanistan, Bangladesh, Bhutan, India, Iran, Maldives, Nepal, Pakistan, and Sri Lanka. Brunei, Cambodia, East Timor, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam belong to Southeastern Asia. Central Asia is composed of Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. Armenia, Azerbaijan, Bahrain, Cyprus, Gaza, Georgia, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates, Palestine, and Yemen are located in Western Asia. With such a huge population, varied racial and cultural backgrounds, and diverse social developments, it is not surprising that variation instead of uniformity is found in the Western-inspired medical education reforms that span over Asia in spite of their common origination from the West. As Hays and Baravilala3 pointed out, any reform effort in Asia’s medical education must take into consideration the need for adjustment and adaptation in the local context. In other words, the direct and outright application of a Western medical education model or reform may not be viable in the Asian context.
Despite the challenge of geographic and cultural differences, international efforts, like that of the World Health Organization, promote medical education reform, especially in Southern Asia, with the aim to upgrade local curricula to meet global standards.4,5 The question is how to understand and assess the effectiveness of medical education reform in Asia if localization and adaptation of Western models are necessary, given the multiplicity and complexity of the Asian experience.
In this article, we review the extent and ways the medical education reforms borrowed from the West have been adapted to the local contexts of Asian communities and Asian medical students. Have the reforms brought improvement to the local medical curricula and effectively fulfilled the cultural and social needs of Asian countries?
Being a comparatively developed region in Asia, countries in Eastern Asia have better access to medical information and practices, which enable them to adopt and launch medical education reforms on a more extensive scale. However, the fact that the traditional education system in Eastern Asia is deeply rooted in Confucianism—an educational tradition characterized by rote learning, an examination-oriented mindset, and the superior status of the teacher—may present as a barrier to the implementation of education reforms. The experiences in applying problem-based learning (PBL) in the Asian setting, regardless of the facts that PBL is itself facing challenges6 and that evidence of its effectiveness is still limited, provide insights on how cultural differences and barriers which limit the application of Western-based reform may be overcome by indigenous solutions.
Established in 2000, the Fu-Jen Medical School in Taiwan has adopted PBL across its entire curriculum. The emphasis PBL puts on student-centered learning signifies a significant deviation, if not violation from the traditional Asian model,7 which places the teacher in a superior position. Because of these traditions, students in Asia, especially Eastern Asia, expect high-quality teachers. Besides teaching abilities, the Eastern Asian society also expect their teachers to possess a positive personality.7 Fu-Jen’s experience suggests that studies on the quality of PBL tutors from the perspective of Asian medical students are important.
In Korea, the traditional education system in medical schools also faces challenges in meeting new societal needs. Korean medical students feel that they are not competent enough to perform solo practice unless they have undergone task-based training. For them, changing the style of learning is as important as changing the style of teaching. They believe that certain traditional psychological and behavioral traits, such as extreme politeness, passiveness, and blind respect for teachers are hindrances to student learning in higher education, especially in modern Western medical education.8 The Korean experience indicates that integration of the Western teaching methodologies and the Eastern learning attitudes should be taken into more serious consideration.
The tradition of a teacher-directed rather than a learner-directed education is also prevalent in Japan. In a study conducted by the Tokyo Women’s Medical University, where PBL has been integrated as a component of the preclinical curriculum for more than 10 years, it was found that PBL learners early in their training encountered difficulties in extracting problems under the influence of a teacher-directed tradition.9 To combat the situation, strategic interventions aimed to motivate and facilitate freshman students to extract problems and derive learning objectives were employed to modify the conventional PBL program. The results were positive, and students’ problem-finding skills were significantly improved.
The Hong Kong example offers further insights into the positive outcomes of a reformed medical curriculum in an Asian context. Introduced by the University of Hong Kong in 1997, the new medical curriculum focuses on integrating the basic and clinical sciences; courses in the traditional disciplines have been removed from the curriculum.10 The curriculum’s system-based approach with small-group, PBL is probably the most revolutionary of its kind in Asia today. The new curriculum encourages first-year medical students to transform their passive learning style into a self-directed, problem-based mode. To facilitate this change, a transitional course from high school to medical school was developed and has been found to be helpful.11 During clinical training, the problem-based medical curriculum has been a successful model for the Hong Kong students.12 The University of Hong Kong’s experience in incorporating PBL as an integral component in their new medical curriculum may serve as a useful reference for other medical schools in the Eastern Asian region where Confucianism is the principal culture of learning.
In China, medical education reform lags behind its economic reform in depth and in scope. To cope with increasing societal needs, the innovation of medical education in China has become an urgent and important issue.13,14 In its attempt to adopt Western methodology in medical education, differences in social and cultural background have created considerable obstacles to the reform effort. Learning by rote has been widely accepted and practiced for hundreds of years in China, nourished by the exam-oriented mindset that has historically flourished in China.15 Because Confucian teaching emphasizes self-control, the development of personality and creativity is neglected and even suppressed. The result is a general mindset in China of being overcautious and fearful of risk, which limits imaginative thinking.
Since the 1990s, tertiary colleges in China adopting PBL have gradually increased, and the results are encouraging.16 Nevertheless some participating scholars and instructors are still showing reservations about the educational results of PBL. One concern is that teachers have struggled to integrate PBL within a short period of time.17 For schools that practice PBL, traditional didactic teaching methods still remain their major practice, with PBL treated as a supplement.18 A recent study also pinpointed that because of different cultural backgrounds between the Chinese and the Western students, despite the similarity of the teaching process and outcomes to Western experience, notable differences are found in the adoption of PBL in China.19 These differences stem from the subconscious of the Chinese students not to transcend their status through open discussion, which probably is related to the Confucian belief of self-control. Moreover, teaching and educational resources are insufficient in China, which also limits the development of PBL.16,17,20
Apart from cultural barriers, limited economic conditions, a huge population with a large percentage of rural inhabitants, a growing manpower shortage in the health care industry of rural China, and variations in training standards are ruling factors that hinder the development of medical education reform in China.15 As Gao et al13 proposed, medical education reform in China should focus on improving educational quality, solving the uneven distribution of doctors, and continuing to develop innovations in medical education.
Medical schools in Southern Asia have traditionally modeled their education systems on their colonial, European roots. The curriculum, as a result, is a direct imitation from the West, which neglects local cultures and practices and often falls short of community expectations. The medical training is inadequate so physicians in Southern Asia are unable to understand and respond to community needs in the region.1,21
Faced with a lack of resources, developing countries in Southern Asia have focused on reforming medical education to fulfill the health care needs of their communities. In recent years, many medical schools in the region have undergone bold changes. Some of these reforms are carried out with help and support of international organizations. They have reoriented the traditional curricula which emphasize didactic, teacher-centered teaching and a discipline-based approach to a curriculum which is responsive to the specific needs of the community.20,22 The development of community-based educational programs,1,20,21,23 which focus on learning in community settings and understanding the health needs of local population groups as well as individuals in the community, is seen as a viable direction.24 The goal is to equip health personnel with the necessary knowledge and skills to render quality care for the community.
Although variations in manpower and resources exist, tentative steps have been taken by medical schools in the region to introduce problem-based, community-oriented, integrated teaching for basic and clinical sciences in their curricula. Furthermore, it is also essential to establish a regional network of community-based educators that facilitates communication and research collaboration among educators in the region.1 Apart from medical education, health education is also deemed important in the community. The interaction of better-informed patients and well-qualified doctors may significantly improve community health.25
Despite political and social challenges, Pakistan has a long history of practicing community-based medical education. Aga Khan University introduced a medical education curriculum 20 years ago that addresses the health care needs of the community at large. Medical training is carried out in the communities at the grassroots level—community-based organizations and groups identify their own needs. On the basis of Aga Khan University’s successful experience, the Pakistani authority has formally extended its community-oriented teaching model to all medical colleges in the country.22
Elsewhere, the practice of community-based medical education has also reaped impressive results. In 2005, the demand for medical education curricular reform emerged in Sri Lanka, and emphasis was put on community-based training. India’s Kerala state experienced similar medical education reform. Both Sri Lanka and the Indian state of Kerala have maintained policies to achieve gender and social equity. As a result, Sri Lanka and Kerala have the best health indicators, with high life expectancy, low infant mortality, and low maternal mortality in the region. Even though the Sri Lankan and Indian governments spend limited resources on education and community-based primary care, the health care needs of the community are still adequately catered for because of the medical education reform movement.26
The need for medical education reform in India, the second most populous country in the world, has sparked the urge for a more comprehensive approach to health care delivery.27 Although the Indian economy has grown steadily over the last two decades, its wealth distribution is uneven.1 Furthermore, the Indian communities are culturally, linguistically, and ethnically diverse. Special attention and cultural sensitivity are essential when addressing the unique problems of different communities. The research, training, and service missions of academic medicine in India need to be better linked up to provide appropriate health care services.26
In Nepal, though community-based learning has been carried out for many years, the majority of teaching is still conducted in acute hospital settings because of ongoing political conflicts within the country.28 Apart from the community diagnosis programs organized by the Institute of Medicine in Kathmandu, Kathmandu University School of Medical Sciences has revised its medical curriculum to include an emphasis on community-based learning by having students visit remote areas and neighboring districts to interact closely with local communities. Dismayingly, the community field trips have been gradually curtailed because of the waves of insurgency.28
In the past, postgraduate medical training programs in Southern Asia were rarely subjected to external review or internal quality control.29 However, medical schools in Sri Lanka and Pakistan have begun to invite external examiners from the United Kingdom, Australia, Singapore, and New Zealand to oversee their final exams. External examiners also review study programs and provide training to local educators.29 It is believed that this growing trend will enhance meaningful adaptation of Western medical teaching in the Asian context.
As Amin et al22 remark, medical schools in Southeastern Asia are moving towards curriculum integration, though most of the countries in the region are facing financial constraints and resistance to change. PBL is part of the hybrid curriculum in at least half of the medical schools in the region.21 Early clinical exposure and community-based education are also gaining ground, and assessment reform is under way.30
Malaysia, a newly industrialized country in Southeastern Asia, puts emphasis on the provision of community-based health care service because of its multiethnic, multicultural, and multilingual society. Specific health care services are geared towards different Malay communities. The integrated curriculum of basic medical sciences and clinical skills at the Universiti Malaysia Sabah School of Medicine, newly established in 2003, was tailored for the local community of Sabah.31 The medical school of Universiti Malaysia Sarawak adopted a PBL, integrated, community-based curriculum that reflects the specific health care needs of the people of Sarawak. For example, doctors have to be familiar with and sensitive to the beliefs and cultural practices of the 26 ethnic groups in Sarawak.32
Starting in 1999, the National University of Singapore’s Faculty of Medicine (today known as the Yong Loo Lin School of Medicine) implemented a new hybrid curriculum which shifted from a teacher-centered, lecture-based, discipline-oriented curriculum to a more student-centered, integrated, interactive, faculty-directed curriculum. Compared with its traditional British-style curriculum, the school hopes the new curriculum can better prepare students to meet the challenges of health care needs for the people of Singapore. PBL is the key feature of the new hybrid curriculum and takes up 20% of the curriculum. But because of an environment deeply entrenched in traditional education, the Singapore medical school has decided not to fully adopt the PBL curriculum.33 Experiences of both teachers and students have been positive, but appropriate training for both groups and further research on the efficacy of the new curriculum are needed.34
Worthy of note is the emerging phenomenon of private medical schools among the Southern and Southeastern Asian countries such as the Philippines, Indonesia, Malaysia, Pakistan, and Bangladesh. While private medical schools enjoy the advantage of quick adaptation to education innovations such as problem-based, community-oriented teaching without hindrance from government bureaucracy, quality of training is a serious concern.25,35
Central and Western Asia
In Central Asia, attempts have been made to reach international standards of medical education after the collapse of the former Soviet Union’s centralized medical education system.36 The development of medical education reform in the region is facilitated by assistance from international agencies and the formulation of regional guidelines for future reform. In Western Asia, even though the undergraduate curricula in most of the medical schools remain lecture-based and teacher-centered, comparative studies with Western innovative medical schools have been done, and the appropriateness of curriculum reform is substantiated.37 In Bahrain, the College of Medicine and Medical Science of Arabian Gulf University adopted a full-scale PBL curriculum at its inception in 1982 and continues to refine the curriculum. Positive outcomes are noted from a recent innovation using senior students as tutors in the PBL medical curriculum. The impact of peer tutoring on student performance is impressive, though student tutors require special training before adopting such an approach in the PBL programs.38
Asia contains a vast number of countries with different races, ethics, social customs, cultures, resources, and health care developments. It is inevitable that different countries would place different emphases on their medical education agenda. In developed countries where the health care systems are relatively well established, attention is directed more to improving the standards of medical education by refining the curricula to better suit the students’ needs. Student-centered learning approaches such as PBL are widely adopted or adapted. However, experiences in developed Asian countries have shown that what has worked well in the West may not necessarily be successful in Asia because of different social and cultural dispositions. Even in the West, it is argued, different students have different styles of learning, so teaching programs need to be designed to match students’ personalities and preferences.39 All medical schools should provide a wide range of teaching strategies that satisfy the learning needs of students.6,40
Despite the challenges, a number of important insights are revealed in the reform effort undertaken by different regions in Asia. More importantly, the successful experiences in medical education reform cited here demonstrate the significance of local initiatives vis-a-vis Western-inspired reforms, the integration of which would greatly enhance the applicability and outcomes of the medical education reform in the Asian context. In the developing countries, top priority is placed on fulfilling the health care needs of the community. In response, health care personnel should be trained in community-based environments so that they will be able to understand the needs of the local population and be able to work more closely with the local community. While this is already a growing trend in the West, the need to place medical education reform in the context of local community seems more pressing in Asian societies in view of the scarcity of resources and the greater complexity in ethnic and cultural composition.
Moreover, promoting research in medical education and bridging the gap between research and education are crucial areas that Asian medical schools should seriously consider.34 While data pertaining to medical education in this region are limited,24 it is encouraging to see that research findings in education are gradually being incorporated into the practices of Asian medical schools.34 A survey of 30 medical schools in Southeastern Asia showed that 72% of the respondents have existing medical education units, most of which were established after 1990.21 Hopefully, these existing and newly formed education units will invest and devote themselves to the study and expansion of medical education reform in the region.
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