Medical education in Vietnam

2012; 34: 103–107

AROUND THE WORLD

Medical education in Vietnam A. P. FAN1, D. T. TRAN1, R. O. KOSIK2, G. A. MANDELL1, H. S. HSU1 & Y. S. CHEN1 1

National Yang-Ming University, Taiwan, 2UCLA School of Medicine, USA

Med Teach Downloaded from informahealthcare.com by HINARI on 03/06/12 For personal use only.

Abstract Background: Vietnam is one of the most populous countries in Southeast Asia, yet it displays an unsettling lack of doctors. Aims: Medical education is an important factor contributing to this issue, yet little is known about the system currently in place in Vietnam. Methods: Through an extensive literary search of medical schools’ and Ministry of Health’s data, we have examined the current medical education system in Vietnam. Results: At present, there are 12 medical universities, and the general curriculum at each university follows a national framework but tends to vary from university to university. Medical training lasts either 4 or 6 years, with competitive graduates attending residency programs following graduation. While examinations are required to graduate, the lack of a national licensing exam makes it difficult to ensure that a nation-wide standard of quality exists, both at the medical universities themselves as well as amongst the doctors graduating from them. Conclusions: The development and institution of a national exam would introduce a standard of training throughout Vietnam’s medical education system. Further, a substantial portion of a doctor’s education is in subjects that are loosely related to medicine. When looking forward it will be important to evaluate whether or not these non-medical subjects detract from the quality of medical training.

Introduction With a population of 85,789,573 as of 2009, Vietnam is the third most populous country in Southeast Asia, and the 13th most populous country in the world (General Statistics Office of Vietnam (GSO) 2010a). Although the number of doctors has increased over the past 5 years, there are still only 60,807 doctors or 7.1 doctors per 10,000 people in the entire country (GSO 2010b). Despite such an incredible shortfall of doctors, there has been little published concerning the current state of medical education in Vietnam. This article looks at the medical education system currently in place in Vietnam and sheds insight into the problem of creating enough competent doctors to serve its growing population including foreign businessmen and tourists.

Practice points . Vietnam faces a serious shortage of doctors, with currently only 7 doctors per 10,000 people. . Each medical university has its own specific graduation exam, which usually is not comparable to other universities’ graduation exams. . Quality of care could be greatly improved in the future by the development and institution of a national exam, which would set a national standard of training for doctors.

Results Methods

Location and distribution of medical schools

We used PubMed and Google with search terms such as ‘‘medical education’’, ‘‘medical curricula’’ and ‘‘Vietnam’’ both in English and Vietnamese. Data from the web pages of Vietnamese medical schools were also gathered. Additionally, academic and gray literature were obtained from government agencies, such as the Vietnamese Ministry of Health and the Ministry of Education and Training.

Currently, 12 medical universities offer training programs for generalists who are expected to practice at community level after graduation (Table 1). All 12 schools are public and distributing in the following regions: one in the North, four in the Red River Delta, two in the Central Coast, one in the Central Highland, three in the Southeast, and one in the Mekong Delta.

Correspondence: A. P. Fan, Faculty of Medicine, National Yang-Ming University, P.O. Box 22072, Taipei, Taiwan, ROC 100. Tel: 886 937 190763; fax: 886 2 2828 7103; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/12/020103–5 ß 2012 Informa UK Ltd. DOI: 10.3109/0142159X.2011.613499

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Table 1. Medical schools in Vietnam.

Region North Red River Delta

Central Coast Central Highlands Southeast


Mekong Delta

University

Number of places in 2010

Residency training

Specialized Level 1

Specialized Level 2

Master’s

PhD

Thai Nguyen Medical University Hanoi Medical University Hai Phong Medical University Thai Binh Medical University Vietnam Military Medical Academy Hue College of Medicine and Pharmacy Medical Faculty of Da Nang University Medical Faculty of Tay Nguyen University Ho Chi Minh University of Medicine and Pharmacy Pham Ngoc Thach Medical University Medical Faculty of Ho Chi Minh University Can Tho Medical and Pharmaceutical University

250 550 450 450 105 450 50 150 500 500 100 150

Yes Yes Yes Yes No Yes No No Yes No No No

Yes Yes Yes Yes No Yes No Yes Yes Yes No No

Yes Yes Yes Yes No Yes No No Yes No No No

Yes Yes Yes No Yes Yes No No Yes No No No

No Yes No No Yes Yes No No Yes No No No

Admission Prior to 2008, medical student quotas for each school year were mainly set by the Ministry of Education and Training and the Ministry of Health. Since 2008, in accordance with Directive 06/2008/CT-BYT aimed at strengthening the quality of health worker training, medical schools determine on their own the number of students that they wish to admit each year (Vietnam Ministry of Health (MOH) 2008). In addition, Decree 43/2006/N-CP increased the autonomy and financial responsibility of state agencies (Government 2006). As a result, medical schools have increased the admission of students who pay full tuition and receive no subsidy out of the state budget (MOH, Health partnership group 2009). Currently, two programs for generalist training exist in Vietnam: a 6-year program and a 4-year program. The 4-year program was recently established by the Ministry of Health in response to the shortage of community physicians. Students in both programs are admitted based on their examination scores, direct recruitment without examination, or by signing a contract with the locality where the student agrees to practice in following graduation. Students admitted to the 6-year programs are high school graduates who have passed the National Entrance Examination. Students admitted to the 4-year programs are usually assistant doctors who have passed the medical university’s in-house examination. None of the medical universities currently use interviews to select students for admission.

professional education. In this stage, students do clinical rotations in the morning, attend lectures in the afternoon, and spend on average one night shift per week on overnight call. Individual curricula vary significantly from university to university, with some universities offering general education courses during the professional education stage (Ho Chi Minh University of Medicine and Pharmacy 2010). The general education stage can be further subdivided into general and basic science courses (Table 2). The framework curricula stipulate that approximately 25% of general education credits should be devoted to political education. Political education courses include History of Philosophy, Marx and Lenin Philosophy, Political Economy: Marx and Lenin, Socialism Science, History of the Vietnamese Communist Party, and Ho Chi Minh Ideology (MOET 2001a, 2001b). Political education is required for all students in Vietnam, not solely those matriculating at medical schools. The professional education stage is subdivided into basic and professional medicine courses (Table 2). Generally, 6-year programs and 4-year programs offer similar courses. Although 4-year programs have less coursework overall, 4-year students spend double the credit hours in Community Practice, National Health Program, and Population – Maternal and Child Health Care – Reproductive Health Issues courses than 6-year students, because the 4-year students are mostly physician assistants who already have work experiences in such areas and are expected to go back to their original work with advanced knowledge (MOET 2001a, 2001b).

Curricula Each medical university bases its individual curriculum on the framework curricula. The framework curricula were developed and approved by the Ministry of Education and Training and the Ministry of Health, respectively. The university must receive approval from the Ministry of Health prior to putting its curriculum into practice (Ministry of Education and Training of Vietnam (MOET) 2001a, 2001b). The framework curricula for both 6- and 4-year programs have two stages of training. The first stage is general education. It comprises the first 2 years at 6-year programs and the first year at 4-year programs. The second stage is 104

Assessment Students are assessed by either essay or multiple-choice exams. Clinical case testing is used when students complete hospital rotations. At the completion of their medical training, students must pass their university’s in-house graduation examination. No national examination or independent accreditation examinations exist in Vietnam, thus limiting health officials’ ability to objectively assess the training of recently graduated doctors and of the medical education system as a whole.

Medical education in Vietnam

Table 2. Undergraduate medical education courses. Year 1–Year 2: General education General courses: History of Philosophy, Marx and Lenin Philosophy, Political Economy: Marx and Lenin, Socialism Science, History of the Vietnamese Communist Party, Ho Chi Minh Ideology, Psychology (Psychological Medicine – Medical Ethics), Foreign Language (including medical foreign languages), Physical Education, Defense Education & Army Medical Basic sciences: Advanced Mathematics, Statistics/Probability, Informatics, General Physics, Biophysics, General Chemistry, Inorganic Chemistry, Organic Chemistry, General Biology, Genetics Year 3–Year 6: Professional education Basic medicine courses: Anatomy, Embryonic Tissue, Physiology, Biochemistry, Microbiology, Parasites, Pathology, Pathophysiology – Immunity, Pharmacology, Surgical Practice, Imaging Diagnostics, Nutrition – Food Safety and Hygiene, Basic Nursing, Environmental Science – Environmental Health, Epidemiology, Health Promotion Education, Community Practice Professional medicine courses: Basic Internal Medicine, Basic Surgery, Internal Diseases, Surgical Diseases, Obstetrics & Gynecology, Pediatrics, Infection, Traditional Medicine, Tuberculosis - Lung Disease, Odonto-stomatology, Otolaryngology, Ophthalmology, Dermatology, Rehabilitation, Neurology, Mental Health, Basic Cancer, Forensics, National Health Program, Population – Maternal and Child Health Care – Reproductive Health Issues, Economic Health – Health Insurance, Health Organizations


Table 3. Graduate medical education. PhD

Subject General Basic and supporting Specialty Thesis related topics Thesis Duration (years) Total credits

Residency

SL1

SL2

15% 14% 50% No 18% 3 150

20% 10% 60% No No 2 100

12% 12% 50% No 25% 2 100

Master’s 10% 70% No 20% 2 30–55

Undergraduate degree holder

SL2 degree holder or Master’s from unrelated PhD’s field

Yes Yes Yes Yes Yes 4

No No Yes Yes Yes 3

Master’s degree holder No No Yes Yes 2

Source: MOET (2008, 2009), MOH (2001a, 2001b, 2006). Note: %, Percentage of total training credits.

Graduate medical education There are three tracks of graduate medical education in Vietnam: clinical training, academic training, and residency training (Table 3). Clinical training. This clinical training track can only take two forms, Specialized Level 1 (SL1) and Specialized Level 2 (SL2). In order to apply for SL1 clinical training, applicants must have at least 1 year of clinical experience following medical school. In order to apply for SL2, applicants must have at least 6 years of clinical experience following completion of their SL1 degree. The SL1 and SL2 curricula at each university must be approved by an institutional specific scientific council and the Ministry of Health. Academic training. Academic training includes Master’s and PhD programs. To enroll in a PhD program, students are required to have published at least one to three scientific papers, depending on the degree(s) that they have already obtained. Residency training. Training of resident doctors started in 1973. As of 2010, six medical universities offer residency training (Table 1).

As stated by Decision 19/2006 QD-BYT, residency training is a special form of training young and talented health care workers (MOH 2006). Unlike in the USA, Resident Physicians are expected to become experts in not only clinical practice but research as well. Vietnamese residents are also expected to become medical school faculty following completion of their residency training. Therefore, residency training is highly competitive and only available to a small number of students with outstanding credentials, including having graduated in the past year, a degree from a reputable institution, being less than 27 years old, and high examination scores. Residents are given both the Resident Physician degree and a Specialize Level 1 degree upon successful completion of their programs. They also can claim Master’s degree from Ministry of Education and Training. In addition, they are always invited to work by tertiary or National hospitals.

Medical education reform In recent years, medical education in Vietnam has undergone changes with the support of international donors. For example, the ‘‘Strengthening Medical Skills Training at Eight Universities’’ (Nuffic 2007) project, which was sponsored by the Netherlands’ NUFFIC program from 2004 to 2008,

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has supported schools in establishing and developing medical skills training units and new medical skills training curricula. The Dutch government, through the Royal Netherlands Embassy in Vietnam, also supported another project aimed at strengthening community-oriented education. A Knowledge, Attitudes, and Skills book was the result of this project, which was approved in 2006 by the authority as the basis for a standard curriculum across all medical schools in the country (Hoat et al. 2007). In 2006, the Objective Structured Clinical Examination (OSCE) was introduced first time for the fourth year medical students in Obstetrics and Gynecology rotation at Hue Medical and Pharmaceutical University by Pathfinder and its partners. Its success has led the sixth year students at this school and several other schools to launch the OSCE (Jeffrey Smith et al. 2008; Pathfinder International Vietnam 2008a). Evidencebased learning and problem-based learning have been introduced since 2007 (Pathfinder International Vietnam 2008b). To strengthen the primary care at the community health centers, SL1 training in Family Medicine was initiated in 2003 by US partners allying with the Ministry of Health (Montegut et al. 2007).

Discussion Medical training is one of the most important factors affecting doctors’ competency. Although each university develops its own curriculum based on the MOET’s curricula framework (which emphasizes on community training), it is very difficult to evaluate the overall quality of teaching and training. In addition, most people still think the doctors at tertiary or national hospitals are more competent than those in the community hospitals that leads to the chronic volume overload at those tertiary hospitals. In fact, 94% of children admitted to the National Pediatric Hospital could be treated at community hospitals, while 33% could be treated at the provincial level. Further, around 50% of patients treated at Tu Du Hospital (the biggest Obstetrics and Gynecology Hospital in Southern Vietnam) could be treated at the community level. Approximately, 80% of patients select doctors’ competency and health facilities infrastructure as the reasons that they sought treatment at those hospitals (Cuong 2007). Therefore, the institution of a national exam following the completion of training would be a good solution. A national exam is a valuable tool that not only evaluates student performance but also teaching quality. The establishment of an independently operated National Medical Examination Board is the first step. This agency could then determine the content of the exam. Passing a national exam would provide objective evidence that students have fulfilled the same criteria required to graduate without taking into account which school they studied as well as give patients confidence in young doctors whom they may otherwise be hesitant to obtain care from. As a result, volume overload at tertiary and national hospitals could decline over time. With the resources saved from a decreased patient burden, hospitals would then be able to make investments into new equipment and infrastructure. Additionally, a national exam would pressure medical universities to improve teaching. By examining 106

the percentage of their students that pass the exam each year, university administrators would know how and when they should modify their curricula and training practices. Furthermore, funds could then be allocated to universities that require resources to improve their curricula. Currently, universities receive state funds based solely on the number of students that they enroll. The current framework curricula stipulate that medical schools must devote approximately 25% of their general education credits to political training. Thus, students spend quite a large amount of time studying politics. This time may be better used on courses more relevant to a career in medicine, such as medical humanities, ethics, medical English, mental health, and research methods. In fact, attitude and behavior of the health works have been a big concern in Vietnam’s public hospitals. According to the survey of National Hospital of Pediatrics which collected parent’s feedback, at least 55% of parents or caregivers of children were not satisfied with their medical staff’s attitude and behavior (World Bank 2010). The authority for Vietnam’s medical education and training, including the Ministry of Health and the Ministry of Education and Training, should be aware that the general education for a future doctor, who will take care of the sick human being, would be different from other specialties, needs enhanced trainings in empathy and humanities.

Conclusion Medical training in Vietnam is extremely costly both in terms of time and money. Medical educators should consider limiting the number of mandatory course hours devoted to non-medical subjects, such as politics or even the basic sciences. Such time could then be used to teach more contemporary medical topics, such as genetics, molecular medicine, humanities, and mental health. In addition, the development of a way to objectively assess the quality of medical training in Vietnam is urgently needed. One possibility is the institution of a national exam. Such an exam would allow educators to improve medical education in disadvantaged areas by determining precisely which subjects schools in those areas are weak in as well as to assess the efficacy of their changes over time.

Notes on contributors ANGELA PEI-CHEN FAN, PhD, is an associate professor of Psychiatry, Faculty of Medicine at National Yang-Ming University. She received her MS from Harvard, PhD from the Johns Hopkins University, and served on the faculty of the Johns Hopkins University before she came to Taiwan. DONG TRIEU PHUONG TRAN, MD, is a pediatrician in Vietnam and an MPH student at the National Yang-Ming University International Health Program. RUSSELL OLIVER KOSIK, MPH, is an MD student at the UCLA School of Medicine. GREG A. MANDELL is an MPH student at the National Yang-Ming University International Health Program. HAN-SHUI HSU, MD, PhD, is in charge of the clinical education training at the National Yang-Ming University teaching hospital.

Medical education in Vietnam

YING-SHEUE CHEN, MD, is in charge of the clinical education training at the National Yang-Ming University teaching hospital.

Acknowledgement This study is supported by National Science Council Grant 99-2511-S-010-004. The funding source had no involvement in study design, data collection and analysis, interpretation of the results, writing of the report, and the decision to submit the paper for publication.


Declaration of interest: There are no conflicts of interest to report. The manuscript represents the full results of the study and all the data collected from that study. All those listed as authors are qualified for authorship, and all those who are qualified to be authors are listed as such in the author byline. All authors have confirmed that no conflict of interest, financial or other, exists.

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