High Altitude Medicine Education in China: Exploring a New Medical Education Reform

Abstract

Luo, Yongjun, Rong Luo, Weiming Li, Jianjun Huang, Qiquan Zhou and Yuqi Gao. High altitude medicine education in China: exploring a new medical education reform. High Alt. Med. Biol. 13:57–59.—China has the largest plateau in the world, which includes the whole of Tibet, part of Qinghai, Xinjiang, Yunnan, and Sichuan. The plateau area is about 257.2×10⁴ km², which accounts for about 26.8% of the total area of China. According to data collected in 2006, approximately twelve million people were living at high altitudes, between 2200 to 5200 m high, on the Qinghai–Tibetan Plateau. Therefore, there is a need for medical workers who are trained to treat individuals living at high altitudes. To train undergraduates in high altitude medicine, the College of High Altitude Military Medicine was set up at the Third Military Medical University (TMMU) in Chongqing in 1999. This is the only school to teach high altitude medicine in China. Students at TMMU study natural and social sciences, basic medical sciences, clinical medical sciences, and high altitude medicine. In their 5^th year, students work as interns at the General Hospital of Tibet Military Command in Lhasa for 3 months, where they receive on-site teaching. The method of on-site teaching is an innovative approach for training in high altitude medicine for undergraduates. Three improvements were implemented during the on-site teaching component of the training program: (1) standardization of the learning progress; (2) integration of formal knowledge with clinical experience; and (3) coaching students to develop habits of inquiry and to engage in ongoing self-improvement to set the stage for lifelong learning. Since the establishment of the innovative training methods in 2001, six classes of high altitude medicine undergraduates, who received on-site teaching, have graduated and achieved encouraging results. This evidence shows that on-site teaching needs to be used more widely in high altitude medicine education.

Introduction

In China, 3000 meters above sea level is considered high altitude. China has the largest plateau in the world, which includes the whole of Tibet, part of Qinghai, Xinjiang, Yunnan, and Sichuan. The plateau's area is approximately 257.2×10⁴ km², which accounts for approximately 26.8% of China's total area (Zhao et al., 2008). As of 2006, approximately 12 million people were living at high altitudes (i.e., between 2200 to 5200 meters) on the Qinghai–Tibetan Plateau (Wu and Kayser, 2006). Most of this population is situated around the 3000 to 4500 meters level, but some soldiers live at an altitude of more than 5000 meters. Therefore, there is a need for medical workers who are trained to treat individuals living at high altitudes. When people quickly ascend to a high altitude or have lived at a high altitude for an extended period of time, they risk acquiring acute mountain sickness (AMS) or chronic mountain sickness (CMS). The former medicine education system in China was perceived and documented to be lacking in medical training specific to high altitude conditions. To train undergraduates in high altitude medicine, the College of High Altitude Military Medicine was set up at the Third Military Medical University (TMMU) in Chongqing in 1999. This is the only school in China that teaches high altitude medicine.

Methods

Students at TMMU study natural and social sciences in their first and second terms, basic medical sciences from their second to their fifth term, clinical medical sciences in their sixth and seventh terms, and high altitude science in their eighth term (Table 1). In their fifth year, students work as interns at the General Hospital of Tibet Military Command in Lhasa for 3 months, where they receive on-site teaching. The method of on-site teaching is an innovative approach for training high altitude medicine undergraduate students. Three improvements were implemented during the on-site teaching component of the program: (1) standardization of the student's learning progress, (2) integration of formal knowledge with clinical experience, and (3) coaching students to develop habits of inquiry and to improve for the purposes of lifelong learning. Since the establishment of the innovative training methods in 2001, a total of 11 classes of high altitude medicine students were enrolled, and 6 classes of high altitude medicine undergraduates, who received on-site teaching, have graduated.

Table 1.

Core Curriculum for High Altitude Medicine Students

Classify	Subjects	Term	Total Study Time	Aim
Natural and social sciences	Chinese, Medical History, Medical Mathematics, Medical Physics, Medical Chemistry, English, Computer, Medical Statistics, Literature Index	First, second	540 hours	Familiarity with natural science, basic knowledge of humanities, social sciences
Basic medical sciences	Human Anatomy, Histology and Embryology, Human Physiology, Biochemistry, Molecular Biology, Medical Microbiology, Medical Immunology, Human Parasitology, Pathophysiology, Pathology, Pharmacology, Medical Psychology, and Medical Genetics	Third–fifth	840 hours	Master the basic medical and clinical bases of theory and to develop a strong ability to think analytically to solve clinical problems
Clinical medical sciences	Science of Operation, Image Medicine, Diagnosis, Internal Medicine, Surgery, Gynecology and Obstetrics, Pediatrics, Neurology, Psychiatry, Ophthalmology, Otorhinolaryngology, and Dermatology	Sixth, seventh	583 hours	Has the ability to collect medical history, communicate effectively with patients, and the skills to diagnose and treat common diseases
High altitude medicine	High-altitude Diseases, High-altitude Pathophysiology, High-altitude Medical Geography, High-altitude Epidemiology, and High-altitude Military Hygiene	Eighth	323 hours	How to treat and prevent high-altitude diseases when people ascend quickly or live at a high altitude
High altitude on-site study	Train as an intern, receive clinical training and practice in mountain sickness, become familiar with common high-altitude medical conditions, including those requiring surgery, and attend social practice events	Ninth	3 months	How to deal with the most common diseases at high altitudes; specific treatment of high-altitude diseases such as acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), high altitude cerebral edema (HACE), and chronic mountain sickness (CMS), and to clarify what educational topics the students need to master in school

Results and Discussion

Standardization of the learning process

According to the needs of the plateau's military force, we highlighted the characteristics of high altitude medicine and defined the various relevant disciplines to develop professional curriculum standards. The first high altitude medicine textbooks were published in 2005 and included information about high altitude disease, high altitude physiology, high altitude medical geography, high altitude epidemiology, and high altitude military hygiene. The plateau on-site teaching model became the main teaching method in high altitude medicine education. Every year, all students must move to Lhasa to be trained as interns and to attend social practice events on the plateau.

Integration of formal knowledge with clinical experience

During the 3-month on-site term, students trained as interns to master the skills needed to manage the diseases most commonly found at high altitudes. Specifically, they must know how to treat high altitude diseases, such as acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), high altitude cerebral edema (HACE), and chronic mountain sickness (CMS). Many medical conditions require the attention of doctors who are resourceful and have practical ability, comprehensive analytical skills, and clinical application capabilities. Therefore, we increased the time spent teaching practical skills during the plateau on-site teaching term. For example, we combined theory and experimentation by combining on-site teaching with research activities. When the students moved to Lhasa in 2009, they participated in an AMS survey; during the journey, students' vital signs were monitored as they ascended to Lhasa via the Qinghai–Tibet train (Luo et al., 2011). As a result of this research activity, the students understood that headaches, dizziness, and poor appetite were the most common symptoms of AMS, and many personally experienced symptoms related to hypoxia. A flexible approach was also used in the organization of on-site teaching. Students were not limited to classroom teaching and were able to go to the army base, the plateau's native community, and the local temple to study the most common diseases found among this high altitude population and to familiarize themselves with the climate and cultural characteristics of the plateau. For example, after they visited the army base and plateau community, they clarified for themselves what educational topics they needed to master in school.

Coaching students to develop habits of inquiry and to improve for the purposes of lifelong learning

We reformed common teaching methods by using new methods during lectures on theory, such as discussing problems and including participatory teaching by the students themselves. For example, when studying a chapter about AMS, the students were asked to give a seminar about how to prevent the condition. Each student provided the following information: How to prepare the materials before moving to Lhasa, which precautions must be taken during the journey to a high altitude destination, and what must be done upon arrival. The teacher then gave a summary after the students' presentations. The classroom atmosphere was enlivened by these methods, and the teaching effectiveness and students' ability to learn independently were also enhanced.

Since 2006, many students have graduated from the school of high altitude medicine and served with the plateau forces. After their graduation, 95% of the students continued to work on the plateau, providing medical services to the soldiers and citizens in the local area. They succeeded in treating many HAPE and HACE cases in the remote region with little medicine. Among the graduated students, nine students have been the lead authors on published research papers about high altitude medicine, and nine students continued their studies to pursue a Ph.D. in high altitude medicine. One year after the students graduated, peer evaluations (conducted by an outside, independent survey body) were conducted among army personnel who received care from the graduates. The survey showed that 99% of the army personnel were satisfied with the quality of care provided by the graduated students because they had mastered not only traditional medical knowledge but also the high altitude medicine specialty (Zhou and Luo, 2008). Now, there are many freshmen entering the school of high altitude medicine every year. Therefore, the on-site teaching method needs to be used more widely among high altitude medicine education to increase the quality of high altitude medical care.

Footnotes

Acknowledgments

We are grateful to all the people who participated in this study.

Author Disclosure Statement

The authors reported no conflicts of interest or financial ties.

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