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830 J Formos Med Assoc | 2009 • Vol 108 • No 11
NEWS AND PERSPECTIVES
Background
Biomedical research performed in Taiwan is pub-
lished in top medical journals, and the latest
therapeutic innovations, such as biopharmaceu-
ticals, cardiac electrophysiology and robotic
surgery are available in Taiwan. However, pri-
mary medical care in Taiwan currently is inade-
quate, and as the population of Taiwan ages, the
need for primary care will increase. Good pri-
mary care is necessary to ensure that diseases
such as hypertension, diabetes and cancer are
detected and treated early, to identify people
who might benefit from the latest therapeutic in-
novations, and to identify rapidly and respond
effectively to emerging health threats such as
multidrug-resistant pathogens.
Here, we report briefly a pathway of accelerated
medical education that reduces the time spent in
the classroom and increases the time spent learn-
ing clinical fundamentals. We propose widespread
adoption of similar educational pathways and
reform of other aspects of medical education in
Taiwan, to facilitate the training of doctors who
can provide the primary care needed by the people
of Taiwan.
Six aspects of medical education in Taiwan
contribute to the poor preparation of doctors to
provide primary care. (1) Insufficient training
in clinical fundamentals including humanism,
history taking, physical examination and the
biopsychosocial model of medical care. (2) Ins-
ufficient training in quality improvement, includ-
ing how to recognize improvement opportunities,
how to motivate change, and how to improve
quality by making systemic changes. (3) No formal
training in teamwork. Teamwork is essential for
quality medical care, but medical students are
graded on individual performance. Similarly,
teamwork is disregarded at more advanced levels
of medical training. Consequently, teamwork is
neglected in medical practice, which results in
poor coordination among health professionals
and therefore poor medical care.1 (4) Insufficient
outpatient primary care training. Current med-
ical training primarily is hospital-based. Doctors
have the knowledge and skills to provide high-
intensity, high-technology, high-cost and acute
medical interventions, but not to provide primary
care. (5) Early specialization. When trainees spe-
cialize early, they truncate their education in fun-
damental clinical skills and focus on acquiring
the knowledge and techniques of a narrow field
of practice. As a consequence, they never gain
the knowledge or the skills needed to provide
primary care, or to teach it. (6) Finally, faculty
physicians depend on fee-for-service National
Health Insurance for their income, but this
©2009 Elsevier & Formosan Medical Association
.......................................................
1Departments of Primary Care Medicine and 2Internal Medicine, National Taiwan University College of Medicine and
Hospital, Taipei, Taiwan; 3Division of General Internal Medicine, The Ohio State University College of Medicine,
Columbus, Ohio, USA.
*Correspondence to: Dr Tzong-Shinn Chu, Department Internal Medicine, National Taiwan University Hospital,
7 Chung-Shan South Road, Taipei, Taiwan.
E-mail: tschu@ntu.edu.tw
Recommendations for Medical Education in
Taiwan
Tzong-Shinn Chu,1,2* Harrison G. Weed,3Pan-Chyr Yang2
reimbursement system does not compensate them
for teaching or developing their teaching skills.
Consequently, the teaching practices and skills
of faculty physicians are poor,1,2 and a system of
compensating them for teaching is needed.
Six structural aspects of medical training in
Taiwan have contributed to a health system that
provides high-technology acute care, but not com-
prehensive primary care. We must reform med-
ical training to improve primary medical care in
Taiwan. One aspect of reforming medical train-
ing is to reduce the time that students spend in
classroom-based learning and thereby allow more
time for learning clinical fundamentals, quality
improvement, teamwork and outpatient care.
The National Taiwan University College
of Medicine Experience
In 1998, the National Taiwan University College
of Medicine (NTUCM) initiated an ongoing two-
step program to accelerate undergraduate med-
ical education and to teach students in general
clinical care before they commit to specialist train-
ing. In the first step, selected students entering
their fifth year of medical school undergo 1 month
of clinical skills preparation, and then undertake
the clinical rotations usually done in the sixth
and seventh years. In addition, more than half of
these clinical rotations are designed to teach fun-
damental clinical skills, quality improvement
and teamwork. At the end of the sixth year (instead
of the usual seventh year) students graduate and
are qualified to sit for the National Medical
Certifying Examination. The second step of the
program is a compulsory year of postgraduate
training in general clinical skills in one of three
specialties: internal medicine, surgery or pedi-
atrics. Broad training continues during the year,
for example, residents in surgery spend 1 month
as internal medicine residents and 1 month as
community medicine residents. Compared with
students who receive traditional instruction,
those selected for the two-step program are
more likely to pass national board examinations
(100% vs. 80–97%), and have been rated as
more proficient by their teachers for nine different
parameters of clinical performance (p<0.001).3
Although the outcomes of the NTUCM two-step
program have not been analyzed to assess the
impact on primary care, there is evidence that
the classroom portion of undergraduate medical
education can be shortened by 1 year, which al-
lows an extra year for students to develop practi-
cal clinical knowledge and skills.
Recommendations
Implement the Postgraduate Year Residency
(PGY) program nationwide by 2011
From August 2003, the Department of Health in
Taiwan promulgated a program of 3 months of
broad education in the first postgraduate year,
which consisted of at least 36 hours of basic train-
ing, and 1 month of training in general surgery,
internal medicine and community medicine. From
August 2006, residents began participating in
the formal PGY program. The program is divided
into two halves of 6 months each. The first half
consists of 1 month of general clinical training,
1 month of basic community medicine, 1 month
of community-related medicine, and 3 months
of specialty training in internal medicine, surgery
or pediatrics. To date, two-thirds have chosen in-
ternal medicine.2This half of the PGY program is
organized and overseen by the Taiwan Joint
Commission on Hospital Accreditation (TJCHA).
The second half of the PGY program consists of
6 months of medical training in the resident’s
chosen specialty, and is organized and overseen
by individual hospitals with reference to official
guidelines.
We recommend the following: (1) Fully im-
plement the PGY program in 2011. (2) Do not
allow specialty training programs to offer trainees
positions, and do not allow trainees to commit
to specialty training programs, until after they
have completed the PGY program. (3) Grade
trainees in the PGY program (A, B, C and D, where
A is “excellent” and D is “failing”). Explicitly
Recommendations for medical education
J Formos Med Assoc | 2009 • Vol 108 • No 11 831
define grading criteria and apply them consistently
across programs. (4) Encourage teaching hospitals
to submit proposals for participation in the PGY
program to the Department of Health or another
suitable authority for official review and oversight.
(5) Provide half of the salary of a trainee in the
PGY program through the Department of Health.
(6) Include the PGY program in the residency
matching process. (7) Administer the PGY pro-
gram through departments of medical education
at teaching hospitals.
Reform teaching, certification and training
program accreditation
Traditionally, medical students in Taiwan have
been taught by lectures and graded by written
examinations. These methods of teaching and
grading devalue curiosity, creativity, humanism
and teamwork, which are all critical aspects of
providing good healthcare.
Supervising doctors, clinical teachers and
program directors report that many trainees do
not take an active role in learning, and encourag-
ing trainees to do this will require changing the
learning environment. The TJCHA has established
a nationwide system for development of medical
teachers, which includes a core curriculum and
materials designed to help medical educators de-
velop their skills in student assessment and pro-
viding feedback. Based on data collected by the
TJCHA, when medical educators use these mate-
rials, trainees feel that their clinical experience
is enhanced and their learning environment is
improved.2
To enhance the clinical experience and im-
prove the learning environment, there must be
substantial changes in examination, certification
and accreditation. Trainees must be held to spe-
cific, high standards to progress to the next level
of training. Teaching hospitals also must be held
to specific, high standards to maintain certifica-
tion of their residency programs.
Medical education reform must start with
undergraduate education. The recently published
Medical School Objectives Project, a series of re-
ports from the Association of American Medical
Colleges, could be a useful reference in this
process.4Also, in the same way that certification
should be used to enforce specific standards on
postgraduate teaching programs, medical school
accreditation should be used to enforce specific
curriculum and teaching reforms. Medical schools
in Taiwan should replace the traditional curricu-
lum and lecture-style teaching with integrated,
problem-solving, active learning and learner-
centered programs, to improve undergraduate
medical education and teach students life-long
learning habits. Research has demonstrated that
such programs can increase self-directed learning
and improve educational outcomes.
The current national medical licensure exam-
ination in Taiwan focuses on pathophysiological
medical knowledge, without addressing medical
ethics or the doctor–patient relationship, and no
requirement for demonstration of clinical skills.
For certification, the Department of Health should
require trainees to pass a core clinical skills ex-
amination similar to step 3 of the United States
Medical Licensing Examination. This examina-
tion should be administered at the end of the
PGY program and passing it should be a require-
ment, both for certification and entering specialty
training. The core clinical skills examination
should use standardized patients and objective
measures of clinical performance, such as those
in an objective structured clinical examination
(OSCE). The Taiwan Association of Medical Edu-
cation has established an OSCE task force, and is
promoting actively OSCEs nationwide. A core
clinical skills examination currently is required
in the United States, Canada and Japan, and it is
time for Taiwan to adopt modern methods of
assessing qualifications for medical licensure.5,6
Shorten medical school education to 6 years
Six years of medical school followed by 2 years
of general clinical training is standard in many
countries including the United Kingdom and
Japan.6Adopting a similar system in Taiwan has
the potential to improve the quality of medical
education and the medical care that is provided
to the people of Taiwan (Figure).
T.S. Chu, et al
832 J Formos Med Assoc | 2009 • Vol 108 • No 11
Reform reimbursement
Specific barriers to providing medical education
are that there are too many patients seen per
clinic in a teaching setting, and that long work
hours do not allow time for learning or teaching,
or for teachers to develop their teaching skills.
The fundamental reason for this work overload
is that reimbursement for clinical care provided
in teaching settings is insufficient. Therefore, to
improve medical education, the National Health
Insurance system will need reform, including
that specific to the special needs of clinical care
provided in a teaching setting. The Department
of Health could subsidize the cost of clinical
teaching.2
Of course, medical education is not responsi-
ble exclusively for poor primary care in Taiwan,
and changes in medical education will not by
themselves improve primary care in Taiwan.
However, we think that the above changes in
medical education are necessary to reach the
goal of providing the primary care that the peo-
ple of Taiwan deserve.
References
1. Chu TS. Health professions education. Taipei: Taiwan
Joint Commission of Hospital Accreditation 2007:205–11.
[In Chinese]
2. Hsieh BS. General medical education, 2nd edition. Taipei:
National Taiwan University College of Medicine 2006:
159–88. [In Chinese]
3. Chu TS, Weed HG, Wu CC, et al. A program of accelerated
medical education in Taiwan. Med Teach 2009;31:e74–8.
4. The Medical School Objectives Writing Group. Learning
objectives for medical school education: guidelines for
medical schools. Report I of the Medical School Objectives
Project. Acad Med 1999;74:13–8.
5. Association of American Medical Colleges, Task Force on
the Clinical Skills Education of Medical Students. The
AAMC project on the clinical education of medical stu-
dents. Washington DC: American Association of Medical
Colleges 2005:1–38.
6. Teo A. The current state of medical education in Japan: a
system under reform. Med Educ 2007;41:302–8.
Recommendations for medical education
J Formos Med Assoc | 2009 • Vol 108 • No 11 833
Figure. Proposal for a new clinical training system. (I)
Shorten medical school education to 6 years, with general
education and humanities in the 1st and 2nd years; inte-
grated basic medical sciences in the 3rd and 4th years; and
clinical teaching in the 5th and 6th years. Internship will be
provided after graduation. (II) A 2-year compulsory post-
graduate training. The first year will be general clinical
training comparable to the current intern year, but with
higher standards. The second year will be clinical training
in community medicine and general internal medicine,
general surgery, or general pediatrics. (III) Successful com-
pletion of the 2-year program will be required for a doctor
to enter general medical practice or to start specialty train-
ing. (IV) Determine the number of positions available for
subspecialty training based on national needs.
(I) Medical school education (6 yr)
(II) Postgraduate training (2 yr)
(III) Specialty training (2–3 yr) Primary care
(IV) Subspecialty training (2–3 yr)
