Comparison of Plastic Surgery Training Programs Between Hong Kong and Shanghai

Manhon CHUNG ,Xiang LIAN ,Bin GU,Zhichao WANG

Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200011,China

ABSTRACT The field of plastic surgery has developed rapidly in the last couple of decades in Hong Kong and Shanghai,China.Both cities have their own educational system for training plastic surgeons.Their training programs differ in many ways,including the surgical exposure of undergraduate studies,the structure,curriculum,and operative requirements of residency training.In general,Hong Kong has a single pathway of residency training with more early clinical exposure in an undergraduate study.On the contrary,Shanghai has multiple pathways of residency training that are heavily emphasized in academic research.Both Hong Kong and Shanghai should complement each other to modify their plastic surgery training programs that will eventually benefit the field of plastic surgery education.

KEY WORDS Plastic surgery; Residency training; Hong Kong; Shanghai; China

INTRODUCTION

Plastic surgery has gained revolutionary advancements in recent decades.The existence of plastic surgery in China dates to the 19th century when Peter Darker,an American medical doctor,first performed an entropion repair surgery in Guangzhou in 1835[1].However,the first plastic surgery training was a century later when Baochun Ni,the first medical doctor of plastic surgery in China,set up the first Department of Plastic Surgery and served as teaching staff in St.Luke’s Hospital,St.John’s University-affiliated hospital in Shanghai in 1929[1].After the Second World War,plastic surgery in China continued to blossom as JP Webster,former president of the American Board of Plastic Surgery,held the first Plastic Surgery training class in Shanghai in 1948[1].Ti-Sheng Chang established the Department of Plastic and Reconstructive Surgery in Shanghai Ninth People’s Hospital in 1961.Since then,Shanghai has been gradually established as one of the cornerstones of modern plastic surgery in China.In comparison,the modern development of plastic surgery in Hong Kong came into the picture later.The Association of Plastic and Reconstructive of Surgeons in Hong Kong was founded in 1967[2].As cosmetic surgery became a compulsory subject,courses were gradually conducted in public hospitals,including the Queen Mary Hospital,the Prince of Wales Hospital,and the Princess Margaret Hospital.Hong Kong gradually became an international center of medical education and hosted its first international conference on Plastic Surgery in 1998[2].There are distinct differences between the two places in plastic surgery training.Therefore,this article outlines the significant differences in undergraduates’ surgical exposure and the structure and curriculum of residency training in plastic surgery training in Hong Kong and Shanghai.

STRUCTURE OF UNDERGRADUATE STUDY IN HONG KONG AND SHANGHAI

Medical students from Hong Kong and Shanghai must complete pre-clinical studies and clinical subjects upon completing their undergraduate degree,but the courses differ in duration,structure,and teaching language.All Hong Kong medical students who pursue a career as a plastic surgeon must have completed a six-year degree of MBBS before entering residency training[3-4].Students take pre-clinical studies in this training period,consisting of basic science subjects in the first two to three years,and complete the clinical subjects for the rest of the MBBS degree.They then apply for housemanship in the hospital after graduation.All courses are taught in English throughout the study period.

Undergraduate medical training in Shanghai differs slightly from Hong Kong as medical schools offer mainly five-year degrees[5].Medical students also take pre-clinical subjects before spending the last two to three years in clinical studies.However,they go for an internship before graduation.Another critical difference between the two places is that elite medical schools in Shanghai offer an eight-year medical training that consists of five years of pre-clinical and clinical studies,plus another three years of medical research and further clinical studies[6].Students who complete this eight-year training program achieve a Doctor of Medicine (MD) degree[6].Regarding teaching languages,many Shanghai medical schools offer both Chinese and English undergraduate courses,and some even have French courses.

SURGICAL EXPOSURE IN UNDERGRADUATE STUDY OF HONG KONG AND SHANGHAI

Under the undergraduate program of Hong Kong,students must go to different hospital rotations throughout the last three years of study,known as clinical clerkships.For example,the clinical clerkship at the Chinese University of Hong Kong (CUHK) spans over two phases:Junior clerkship (year 4) and Senior clerkship(year 6)[7].Regarding surgical exposure,medical students are assigned to three surgical modules and have a twelveweek teaching block in year 4[7].They are required to attend lectures,bed-side tutorials,and teaching sessions during ward rounds,and operating sessions during this rotation.Students have a twenty-week teaching block in the senior surgical clerkship in which they rotate in general surgery and different surgical subspecialties,including plastic and reconstructive surgery[7].They are encouraged to get a closer involvement in surgical ward activities and even practice some practical skills under supervision.

In Shanghai,clinical clerkships occur in the third and fourth year.The teaching model mainly consists of lectures and bed-side tutorials.Students have little involvement in ward activities apart from history taking.However,their internship occurs in the final year of undergraduate study.For surgery,they must rotate for three months,wherein they participate in daily surgical ward activities.They are also allowed to join surgical operations as either observers or participants.During this period,the compulsory rotation to various surgical specialties does not include plastic and reconstruction surgery.Finally,some medical schools in Shanghai offer elective courses in plastic surgery for medical students.It is an introductory course that aims to provide early exposure to students who are interested in plastic surgery.

STRUCTURE OF RESIDENCY TRAINING OF HONG KONG

Hong Kong and Shanghai have different paths regarding residency training in plastic surgery.In Hong Kong,medical graduates will have to complete a year of supervised practice known as housemanship.After completing the houseman year,they can practice as general practitioners with full registration and apply for a training post in the approved hospitals to be eligible for basic surgical training.Trainees will have at least two years of general surgical and subspecialty training under the basic surgical training program[8].They are also required to register with one of the four Surgical Colleges of Hong Kong and the Hong Kong Intercollegiate Board of Surgical Colleges (HKICBSC) during this period[8].As they complete the basic surgical training,they need to pass the HKICBSC membership examination before entering higher surgical training[9].They must obtain an ordinary member of the College of Surgeons of Hong Kong (CSHK) and apply for a higher surgic al training post from the approved hospitals[10].Under the higher surgical training program,trainees of the plastic specialty have four years of training duration[11].This training includes the rotation of various plastic subspecialties.Once they complete four years of training,they can apply for the fellowship examination held by the CSHK to become fellows.

STRUCTURE OF RESIDENCY TRAINING OF SHANGHAI

In Shanghai,there is more than one pathway for a medical graduate to become a plastic surgeon.The most common pathway is to obtain a three-year postgraduate master’s degree before applying for a full-time job in hospitals.There are two types of master’s degrees,professional and academic degrees[12].Professional-master-degree (PMD)students spend most of their time in clinical work without much academic participation.They also enroll in the three-year standardized residency training (SRT) program,the basic residency training in China[13].By the time they graduate,they must pass the SRT examination and the National Medical License Examination (NMLE)[13].As research publications favor career promotion in Shanghai,academic master’s degrees (AMD) retain many students’ favorites.AMD students spend most of the time participating in academic research related to their specialty.They also need to publish a certain number of research papers or review articles to graduate.Once they complete the degree,they can enroll back in the SRT program for another three years.

Because of Shanghai’s intensely competitive environment,many students also consider a doctoral degree to aim for even better career promotion.They can either apply after the graduation of a Master’s degree or apply for a five-year degree right after undergraduate study.Other forms of doctoral degrees include an eight-year degree and a “4+4” degree[6].The former comprises fiveyear undergraduate medical training plus another three years of further academic research training.However,the latter requires students to study for a non-medical undergraduate degree before applying for a four-year medical degree[6].Regardless of the eight-year degree or“4+4” degree,all students achieve an MD degree when they graduate.Similar to AMD graduates,they enter the SRT program for another three years.

After passing both the SRT exam and NMLE,trainees enter the other three years of specialized residency training in plastic surgery,including rotations in different surgical specialties and plastic surgical subspecialties.Once they complete specialized residency training,they are assessed by their hospital.They are also eligible to apply for the National Health Professional Technical Qualification Examination (NHPTQE) held by the Health Human Resources Development Center of the Ministry of Health[13].Trainees who pass the NHPTQE will become an attending surgeon in plastic surgery,though those who fail can remain resident physicians[13].

CURRICULUM OF RESIDENCY TRAINING OF HONG KONG AND SHANGHAI

In the 2-year basic surgical training program,Hong Kong trainees attend core training in general surgery for six months and an emergency module for the other six months during the first year[9].The emergency module may include accident and emergency (A&E),intensive care unit (ICU),or any other surgical specialty with emergency calls.The remaining year of basic training includes two to three other specialties lasting for at least three months for each of them,choosing from orthopedic surgery,otorhinolaryngology,neurosurgery,cardiothoracic surgery,pediatric surgery,urology,and plastic surgery[9].During this period,trainees are expected to participate in workshops and courses based on basic surgical skills,communication skills,or medical ethics.There are continuous assessments for trainees,including Mini-Clinical Evaluation Exercise (CEX),Direct Observation of Procedural Skills in Surgery and Endoscope,and Case-based Discussion (CBD)[9].In the four-year higher surgical training,trainees must meet specific rotational requirements[11].For instance,they must rotate out of the parent training center for at least a year,with each rotation lasting for at least six months.During the period in the parent center,trainees must rotate to different trainers every six months.They also need to be exposed to a 3-month rotation of hand surgery and 12 cosmetic surgery sessions in the last year of training[11].There are midterm and half-yearly assessments throughout higher surgical training.The midterm assessment is evaluated by the training mentor every three months,whereas the respective specialty boards assess the latter.

Unlike the Hong Kong training model,most Shanghai trainees apply for postgraduate degrees before entering the three-year SRT program.Almost all postgraduate choices are academic-oriented,with high requirements for research publications.Students must devote much attention to academic research.Once they enter the SRT program,they are rotated to general surgery for sixteen months with two months in surgical A&E and orthopedics for six months with one month in orthopedic A&E.Other surgical rotations include three months each for Urology and Cardiothoracic surgery,two months each of Neurosurgery and Anesthesiology,and one month in the Surgical ICU (SICU)[14].Similarly,specialized plastic surgical training comprises three years of rotation,consisting of five stages[14].The first stage lasts for six months and includes specialties closely relevant to plastic surgery,such as dermatology,ophthalmology,otorhinolaryngology,gynecology,and oral maxillofacial and burn-wound surgery.Trainees can choose all or at least two of them for rotation.The second stage also lasts for six months and is mainly general plastic surgery,which includes scar and superficial mass management.In the third stage,plastic surgical subspecialties are more emphasized,including microsurgery,hand surgery,plastic surgery of the extremities,genitalia,vessels,lymphatics,and craniomaxillofacial organs,each lasting for two months.In the last semester of the specialized training program,trainees rotate to cosmetic surgery for six months[14].Besides,the assessment of the trainee’s performance is based on the Assessment Logbook of plastic surgical training.Trainers evaluate trainees’ performances during and after each rotation.All assessments were undertaken within each hospital.

OPERATIVE REQUIREMENTS OF HONG KONG AND SHANGHAI

In Hong Kong,there are some guidelines for plastic surgical trainees regarding the operative requirements according to the CSHK[15].All higher surgical trainees must have a procedure-based assessment during the four years of training.This assessment comprises three levels:basic,intermediate,and advanced[15].Trainees must fulfill the minimum requirement of two basics,two intermediate,and one advanced topic,with no limit on the number of operations performed.Trainees must operate on at least one advanced topic as a chief surgeon,independently or under supervision.Furthermore,there is a minimum requirement of 50 major operations involvement per six months for each higher surgical trainee of plastic surgery[15].

Shanghai’s requirements are more detailed in the minimum number of cases required than that of Hong Kong.During the three years of specialized training,trainees must complete around 100 primary cases and participate in around 60 advanced cases at the first stage[13].In the following stages,they must participate in at least 85 cases of surgery from general plastic surgery to the plastic surgical subspecialties mentioned previously,either as chief surgeons or first assistants.Moreover,trainees must complete a minimum of 56 cases and participate in at least 262 cosmetic surgery cases during the last stage of specialized residency training[13].

DISCUSSION

Training programs of plastic surgery in Hong Kong and Shanghai differ in various aspects,including surgical exposure in undergraduate studies,the structure,curriculum,and operative requirements of residency training.Regarding undergraduate training,most Shanghai medical schools offer a five-year model with an internship year included,whereas medical schools in Hong Kong have a six-year model with an internship taken after graduation.Shanghai’s model shows a significant advantage of having an internship before graduation.This model allows students to have at least three months of in-ward and operative surgical experience before graduation.However,before the internship,surgical exposure is insufficient as clinical clerkships in Shanghai do not encourage much ward involvement.Although Hong Kong students do not have an internship within the undergraduate study,their surgical experiences are compensated with sufficient clinical clerkship sessions in different rotations.Most importantly,the surgical clerkship rotation includes plastic and reconstruction surgery,which provides students with early clinical exposure to this surgical specialty.

The structures of residency training programs differ significantly between Hong Kong and Shanghai.There is only one path in plastic surgery residency training in Hong Kong.After registration,trainees take two years of basic surgical training and then three years of higher surgical training to become plastic surgical specialists.In contrast,multiple paths are available in Shanghai.Students can choose to study a PMD or AMD after graduation.The PMD is a faster track as students can enroll in the SRT program simultaneously,whereas AMD is more career-favorable owing to higher academic publication requirements.Apart from master’s degrees,other choices include a five-year doctoral degree,a “4+4” degree,and an eight-year MD degree.Therefore,Shanghai clearly shows a large variety of choices in terms of residency training.The disadvantage in Shanghai is that students need to enroll back in the three-year SRT program in most pathways.These pathways require a long period to become plastic surgeons,reducing the incentives to study plastic surgery in Shanghai.

The variety of choices is also seen in the teaching language of undergraduate courses.Some Shanghai medical schools offer multiple language classes,including Chinese,English,and French.However,they only offer Chinese classes in residency training,whereas the teaching language in Hong Kong has always been English from undergraduate to residency training.Foreign language,especially English,is a massive part of modern world communication.It enables students to be more international and equipped with international academic exchanges.This advantage in Hong Kong also helps the place become a global educational center.

Furthermore,residency training in Shanghai is more academic-oriented than that in Hong Kong.As most postgraduate degrees require high academic research requirements,Shanghai students devote more time to academic work than clinical work.On the contrary,Hong Kong trainees need minimal publication during basic training and devote most of the time to clinical work.Less academic work may have a negative impact on their understanding of the current evidence of practice.Both places share a similar training fashion in terms of the primary clinical training curriculum,which goes from general to specific.They both start from rotation in general surgery and emergency surgery to other surgical specialties,plastic surgical specialties,and cosmetic surgery.In the aspect of operative experience,both Hong Kong and Shanghai have specific operative requirements.However,the number of plastic surgical operations participation required in Hong Kong is less than that in Shanghai.The reason could be the lack of patients in plastic surgery in Hong Kong in general,whereas the number of patients is never a concern in Shanghai,as the population is much larger than that in Hong Kong.

Being two of the most modern cities in China,Hong Kong and Shanghai have their advantages and weaknesses in plastic surgery training.The training program in Hong Kong comprises many Western educational experiences that Shanghai can learn.The use of English throughout the whole training gives Hong Kong students a massive advantage in either international communication or academic publications.Early clinical exposure also benefits the students as they are more prepared before entering the residency.The Shanghai training model,on the contrary,has Chinese characteristics that Hong Kong does not equip.Various paths in residency training provide different options for medical students to choose from according to their interest.The academicoriented atmosphere further enhances students’ vision in the specialty and enriches their career profiles.These altogether favor not only the individuals but also the general field of plastic surgery.

In terms of improvement,Shanghai and Hong Kong can learn a lot from each other.As Shanghai medical students lack early clinical exposure in undergraduate studies,medical schools should consider adopting a clinical clerkship model similar to that of Hong Kong.An earlier ward involvement and more bed-side tutorials provide students with better knowledge and preparation when entering the internship at a later stage.They should also consider adding English as a second teaching language in residency training.This suggestion can be applied on many occasions,including journals and experiment presentations,ward rounds,history presentations,and case discussions.By adding English to training on a regular basis,trainees can be more prepared for international academic exchanges and conferences.

On the contrary,Hong Kong should consider adding more academic elements into residency training.The current curriculum in Hong Kong is heavily clinicaloriented.Trainees need only five years to be a fellow in plastic surgery.Adjusting the eligibility of fellowship applications by adding some academic research requirements can certainly increase trainees’ incentives to devote more to research work.Based on this suggestion,adding an extra year for academic research can be considered to the current curriculum so that trainees have sufficient time to publish research articles of better quality.Hong Kong should also consider borrowing ideas from Shanghai’s model by initiating an eight-year degree for students interested in research.Opening more space for plastic surgery trainees also improves plastic surgeons'shortage,as there are less than seventy in Hong Kong.In addition,information and experience exchange could be beneficial between the two modern cities.By holding more joint conferences or short-term exchange programs,both Hong Kong and Shanghai students can have the opportunity to share information and experience with each side,thus benefiting the development of both sides.

CONCLUSION

In conclusion,plastic surgery has become increasingly popular throughout the years.Being two of the most modern cities in China,Hong Kong and Shanghai have significant differences in plastic surgery training.The learning experience and educational system of both sides must surely improve and benefit their plastic surgery training programs.

FUNDING

This work was supported by grants from the Youth Doctor Collaborative Innovation Team Project (QC201803)of Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine; the Project of Biobank (NO.YBKA201901) from Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine; the Shanghai Youth Top-Notch Talent Program (201809004); “Chenguang Program” supported by Shanghai Education Development Foundation and Shanghai Municipal Education Commission (19CG18)and Science and Technology Commission of Shanghai Municipality (19JC1413),Shanghai Rising-Star Program(20QA1405600).

ETHICS DECLARATIONS

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Competing Interests

The authors declare that they have no competing interests.The authors state that the views expressed in the submitted article are their own and not the official position of the institution or funder.