Surgery in taiwan FREE

The development of health care in taiwan can be divided into 3 periods corresponding to changes in government leadership.¹ Before 1895, when taiwan was under the regime of the chin dynasty, wounds and skeletal injuries were managed by the application of herbs and wooden splints. the introduction of christianity by missionary persons in 1865 also introduced western medicine into taiwan. treatment of malaria with quinine, cataract removal, nephrolithotomy, and tooth extraction with dramatic health care effects were regarded as miracles by the population. the increasing popularity of christianity related very much to the function of the medical missionary society. in the makuan treaty, signed in 1895 between chin and japan after a period of war, chin lost this territory to japan, and the second period of health care began, remaining until 1945. during this period, several hospitals were established according to the japanese style. medical and surgical services were provided by domestic and japanese physicians and by medical missionary persons. the first medical school was founded in 1899 for the training of local physicians. thyroidectomy, trachoma surgery, and gastrointestinal surgeries were gradually developed. after world war ii, japan gave up the sovereignty of taiwan, and, subsequently, the civil war between kuomintang and the communist chinese led to the withdrawal of kuomintang troops and medical staff from china to taiwan. many of the physicians were military staff and had some training from american physicians sponsored by the china medical board division of the rockefeller foundation, formed in 1914. local physicians and physicians from the mainland merged and formed a new health program. today, more than 80% of the surgeons in taiwan have had some training in the united states through the support of the china medical board, the american bureau of medical aid to china, government funds, or foundations. this support contributed to the continuing infusion of new ideas, especially in the field of surgical research, and the development of new techniques, dramatically improving the quality of surgery in taiwan.

The medical educational system in taiwan is changing. currently, there are 11 medical schools, 4 of which are public. the other medical schools are private and are associated with either independent medical universities or schools of medicine in universities au thorized by the department of education of the central government in taipei. the medical schools admit approximately 1200 high school graduates annually for a 7-year medical education. in the first 2 years, a premed course provides students with knowledge of medical ethics, history, and a foreign language and includes courses in advanced biology, physics, chemistry, etc. the students are required to complete the medical courses in the subsequent 5 years, leaving the last year for a rotating internship. on graduation, the students are awarded the bachelor of medicine degree. recent system reforms allow selected students to complete their medical education in 6 years.

In 2002, the national committee on foreign medical education and accreditation (washington, dc) determined that the current accreditation standards of the taiwan medical accreditation council are comparable to those of the programs leading to the doctor of medicine degree in the united states (r. paige, phd, national committee on foreign medical education and accreditation, in a letter to k. y. huang, md, phd, taiwan medical accreditation council, may 6, 2002). training in basic surgical skills for the undergraduate is provided in the course of experimental surgery. dry and wet laboratories with computer simulations of gastrointestinal and orthopedic surgeries are available in some universities.

Surgery is among the 21 specialties recognized by the department of health (doh). medical graduates are accepted into surgical training programs on a competition basis and by interview. trainees must complete at least 4 years of a general surgical residency to be eligible for a board examination consisting of written and oral tests. a 5-year residency program based on the halstedian model of progressive responsibility is available in training centers for general surgery. approximately 130 to 170 surgeons are certified as general surgeons each year. however, trainees may choose a subspecialty such as orthopedic surgery or urology after 2 years of general training and continue their rotation until the fourth year is finished.

The doh accredits hospitals in taiwan every third year and categorizes them as medical centers, regional hospitals, and community hospitals according to facilities, competency, and capability for dealing with diseases. accreditation of the surgical departments is an important part of the system, with a weight of 15% of total scoring. only medical centers and their branch hospitals as well as regional hospitals have surgical residency training programs. there are currently 17 medical centers and 66 regional hospitals in taiwan. the taiwan surgical society (tss) is authorized by the doh to approve and evaluate the qualification of each surgical residency program.

A typical department of surgery in a medical center consists of divisions of neurosurgery, urology, and general, orthopedic, plastic, cardiovascular, chest, and pediatric surgery. urology, neurosurgery, and orthopedic surgery are independent departments in several medical centers. the division of general surgery is subdivided into breast, colorectal, endocrine, gastrointestinal, hepatobiliary, trauma, and transplantation teams in some medical centers.

Surgical residency training includes basic sciences, cognitive and technical skills, development of clinical knowledge, maturity, judgment, and clinical applications. the principal training consists of rotations on these services, with residents having the primary responsibility of caring for patients. this exposure enables our residents to become competent in the management of problems involving the head and neck, breast, skin and soft tissues, alimentary tract, abdomen, vascular system, and endocrine system and in the comprehensive care of trauma and emergency patients.

Surgical residents should also become familiar with evolving diagnostic and therapeutic interventions such as laser surgery, distal common duct dissection by endoscopic retrograde cholangiopancreatography, sentinel lymph node biopsy, gastrointestinal tract motility studies, noninvasive diagnostic evaluation of the vascular system, interventional radiology such as sonoguided pigtail drainage for abscess, percutaneous transhepatic biliary drainage, and transcatheter vascular interventional techniques. surgical training also includes experience in an emergency department and in an intensive care unit to enable residents to treat acutely ill and critically ill patients and patients with major injuries requiring urgent care.² Residents acquire the following knowledge and skills during their training:

All of taiwan's teaching institutions have research facilities and libraries. learning operative techniques is essential for surgeons. residents learn these skills by observing, assisting, and then working as the surgeon assisted by a faculty member according to his or her ability and training level. during the fifth year of residency, the chief year, residents may be assigned by the faculty to operate on selected patients and thus develop their own operative experience. the training program must provide sufficient operative experience to train and educate qualified surgeons. general surgery programs are required to have the residents perform a minimum number of surgeries during 5 years of training. all surgeries are tabulated and recorded. all faculty members have an ethical and legal responsibility for the overall care of each patient and for the supervision of the resident involved in the patient's care. all aspects of the resident's training are supervised. all residents also spend about a half day each week in outpatient clinics to gain experience with a diverse mix of patients and to become experienced in preoperative diagnostic modalities and care as well as the successes and complications of surgery. residents are encouraged to attend regional or national meetings and to present and publish scientific studies under the supervision of their teaching faculty members. for board certification, the candidate surgeon must show competencies in patient care, medical knowledge, and documented evidence of experience in major operations.

The tss and the international college of surgeons, taiwan chapter, are 2 major general surgical societies on the national level. other societies include those for endocrine, digestive disease, breast, chest, cardiovascular, plastic, pediatric, urologic, orthopedic, transplantation, colorectal, and pancreatic surgery and neurosurgery.

The local chapter of the international college of surgeons recruits only senior surgeons. it has an annual meeting, and an award is given for the best scientific paper. the local chapter also acts as a bridge in communicating and coordinating with the international college of surgeons. the taiwan chapter successfully hosted the 33rd world congress in taipei in december 2002.

More than 4500 surgeons belong to the tss. every march the tss organizes a scientific program supported by the subspecialty societies. members of the tss can attend the invited lectures and paper presentations for free. the society also organizes workshops and continuing medical education courses such as advanced trauma life support and laparoscopic surgery each year. local meetings are held every month in 10 districts.

The tss publishes a scientific journal, the Formosan journal of surgery, bimonthly. it is also an official journal of endocrine, pediatric, transplantation, and digestive surgical societies. trainees receive extra credit on the final score of the board examination for publication of scientific articles in the Formosan journal of surgery or other related journals listed in the scientific citation index. board-certified surgeons are required to renew their qualification every 6 years by accumulating a total of 600 continuing medical education credits during the period since last certification. the tss awards 60 continuing medical education credits to each member who attends the annual congress. additional credits can be obtained by attending international surgical meetings, subspecialty conferences, and local meetings that offer recognized credits by the tss.

According to an epidemiologic study³ by the doh, cancer has been the number one killer for decades, with a progressive increase in incidence per year. the cancer registry in taiwan documented that lung, colorectal, and prostate cancer in men and cervical, breast, and lung cancer in women are the most common cancers. however, primary cancer of the liver (or hepatoma), gastric cancer, nasopharyngeal cancer, and cholangiocarcinoma are seen more frequently in this part of the world.

For unknown reasons, women with breast cancer in taiwan are 10 years younger at diagnosis than those in other countries. most of the primary cancers of the liver in taiwan are combined with postnecrotic liver cirrhosis, which is a result of chronic viral hepatitis. the ability to treat a patient with primary liver cell carcinoma is important for gastrointestinal surgeons in taiwan. this cancer may manifest with fever of unknown origin, spontaneous hemoperitoneum, obstructive jaundice, or acute abdominal pain. earlier diagnosis may help decrease emergency presentation. vaccination of hepatitis b virus for newborns in taiwan has greatly reduced the virus carrier rate in the past years. because the occurrence of primary cancer of the liver is related to the status of hepatitis b virus carrier, it is expected that the incidence of this cancer will eventually decrease.

Nasopharyngeal cancer is also a common malignant disease in the chinese population. patients usually have enlarged lymph nodes in the neck. nasopharyngeal cancer must be included in the differential diagnosis for patients with cervical lymphadenopathy, especially when epistaxis and diplopia occur.

Hepatolithiasis or intrahepatic ductal stone formation is a type of gallstone disease in which these stones are formed primarily in the intrahepatic ducts. it may be confined to one segment, one lobe, or both lobes of the liver. because of bile stasis and repeated infection, stenosis of the intrahepatic bile ducts is common. after stone removal, re-formation may occur until the involved hepatic segment or lobe is resected. in some of these patients, cholangiocarcinoma coexists with hepatolithiasis. endoscopic surgery is popular in taiwan. at present, most of the uncomplicated cholecystectomies and some of the appendectomies, hernia repairs, and adrenalectomies are performed laparoscopically.

Surgical research covering basic and clinical sciences is encouraged in every medical center and regional hospital. it is also one of the items required for accreditation by the doh. most of the financial support for surgical research is from the government or foundations. the national science council is the major resource supporting medical research in taiwan. only surgeons working in teaching hospitals are eligible to submit research proposals for possible funding. approximately 60% to 70% of the proposals are funded via a peer review process every year. between 1999 and 2002, the number of surgical research projects and the total budget for research have increased (Figure 1 and Table 1). the number of scientific papers published in scientific citation index journals has also increased (Figure 2 and Table 2).⁴ Besides the national science council, the academia sinica, the doh, and the national health research institute also support collaborative research projects on specific topics. the national health research institute has sponsored programs in surgical oncology since 1992.

Currently, most basic surgical research is conducted in medical centers or universities. many academic surgeons are involved as primary investigators in research studies of malignant diseases. at present, study groups for breast, colorectal, gastric, liver, lung, nasopharyngeal cell cancers, etc, have been organized in the taiwan cooperative oncologic group of the national health research institute. all projects involving human genetic or experimental study must report to the doh and require informed consent from the patients. access to tumor specimens is limited to specifically approved studies, and patient privacy is protected.

Kidney transplantation began in taiwan in 1968, followed by liver transplantation in 1984 and heart transplantation in 1987. the successes of these programs were considered milestones in the history of surgery in taiwan.¹ Most medical centers in taiwan have kidney transplantation programs with acceptable results. six cadaveric liver transplantation programs have been approved by the doh. one program has had more than 100 successful cadaveric liver transplantations in addition to the use of living related split liver transplants. heart transplantation programs are present in a regional hospital in taipei and in 4 medical centers. the success rate of these programs has been excellent. to date, there has been only limited experience with lung, heart-lung, pancreas, and kidney-pancreas transplantations.

Clinical transplantation has been limited because of a shortage in cadaveric organ donation. clarification of brain death in 1987, however, has helped procure donors. organ donation remains uncommon, increasing the need for transgenic pig donors in an effort to establish a rich source of human organ substitute. preliminary success has been achieved. tissue and organ fabrication from stem cells is also under investigation. it is now possible to reconstruct damaged corneas by transplantation of autologous limbal epithelial cells.⁵ Meanwhile, before organ donation is available, dying patients need artificial organ support. for this purpose, an artificial heart was developed and has proved to be helpful in clinical transplantation. research in immunotolerance and immunoisolation by microencapsulation of graft cells is ongoing.

Recent developments in molecular neurobiology have resulted in a new era of novel central nervous system repair with functional recovery. through the use of peripheral nerve grafts supported by growth factor containing fibrin glue, animal studies have demonstrated partial restoration of hind limb function in adult paraplegic rats. using similar methods, substantial recovery of forelimb function was achieved in adult rats with avulsed cervical roots. since 2000, clinical trials^6- 7 on neuron repair of the spinal cord, the brachial plexus, and peripheral nerve injuries have been performed, and the results of these experiments are encouraging.

The health care system in taiwan is predominantly a closed-staff system; physicians are either independent practitioners (practicing at clinics) or are hired by hospitals. availability of health care resources has improved during the past 2 decades. in 2001, there were 15.4 physicians and 51 hospital beds per 10 000 population. health care expenditures account for 5.77% of the gross domestic product.⁸ Access to care has improved dramatically since the inception of national health insurance (nhi) in 1995. national health insurance is a compulsory, government-run, comprehensive health insurance program, with 96% of the population enrolled in 2003. benefits of nhi include inpatient care, outpatient care, emergency care, home care, dental care, traditional chinese medicine, day care for the mentally ill, preventive care, prescription drugs, and major high technologies, including computed tomography, magnetic resonance imaging, lithotripsy, gamma ray knife, and organ transplantations (kidney, heart, and lung). patients are allowed to have free choice of providers with a copayment (10% for inpatient care, <20% for outpatient care, and no deductible). extra copayments are required for ancillary tests and medicines exceeding certain amounts. also, providers, including hospitals, are paid mainly based on an itemized fee-for-service payment system. therefore, unless patients seek inpatient care or surgery from a specific medical center or hospital, queuing is usually not a major issue in taiwan.

The fee schedules of nhi were criticized for providing incorrect incentives to providers and inequitable payment to specialists. for example, most general and cardiac surgeries were underpaid compared with ophthalmology and otolaryngology procedures, whereas most laboratory tests, radiographs, and high technologies were overpaid and created great incentive for abuse.⁹ The bureau of nhi (bnhi), the agency responsible for nhi administration, has tried to solve these problems during the past 7 years. in 2003, a new version of the fee schedules based on modified resource-based relative value scales (a method developed by a harvard team lead by william hsiao, phd)¹⁰ will be introduced. therefore, it is hoped that a fairer payment scheme for specialists will be developed.

The inequitable payment scheme has already had a substantial impact on medical manpower. according to data provided by the medical association of the republic of china,¹¹ the total number of general surgeons was 3217 in 1994 and 3027 in 1998 (a 6% decrease), before and after the launch of nhi in 1995, respectively. the number of general surgeons increased slightly recently (n = 3120 in 2001) but was still less than that in 1994 (Figure 3). the situation was also true for obstetricians-gynecologists. the number of physicians choosing to practice family medicine, neurosurgery, cosmetic surgery, and rehabilitation medicine increased more than 10% per year after nhi. lower fees, higher-risk patients, longer periods of training, practice difficulties, lower patient volume, and less likelihood to induce demand are some of the major reasons that seem to have discouraged medical students from becoming surgeons.

In addition to fee for service, a case payment pilot project was introduced in 1995 based on either procedures or diagnosis related groups. pilot studies primarily concerned maternal deliveries, popular surgical procedures, or obstetric and gynecologic procedures for which surgeons were paid a fixed amount, regardless of the characteristics of the providers, unless they qualified for outliers, which are still paid on a fee-for-service basis. meanwhile, minimal requirements for admissions and procedures (treatment guidelines) and readmission policies (hospitals take the responsibility for readmission within 2 weeks) were also developed by the bnhi to ensure quality of care. to cope with the case payment system, most hospitals soon developed clinical pathways to control length of stay and to reduce unnecessary services and drugs in order to control cost. overall, these reforms have resulted in improved efficiency and care. institution of clinical pathways and enforcement of treatment guidelines and readmission policies regulated by the bnhi has improved care in some but not all studies.¹² However, more investigations are needed to determine whether quality of care was improved by these programs.

The global budget payment system (gbps), introduced recently, has also had tremendous impact on providers' behavior. the objectives of the gbps are to control costs, to improve the efficiency and quality of health care, and to enhance professional autonomy. the gbps was first applied to dental care in 1998, to traditional medicine in 2000, to western clinics (general practitioners) in 2001, and finally to hospitals in 2002. this reform set a cap for total health care expenditures and for appropriate distribution among the participating groups. providers of different sectors were invited by the bnhi to work together under a so-called comanagement model to control cost and to improve the quality, efficiency, and effectiveness of health care. to achieve the goal, conversion factors of the fee schedules were floating and were computed retrospectively at the end of each quarter (conversion factor_i = budget for quarter i/total points claimed by all providers at each sector at quarter i). in addition, providers led by physician associations (eg, the medical association of the republic of china) or the hospital association will collectively develop strategies to improve the quality and efficiency of health care and to prevent fraud and abuse.¹³ The budget allocation (to different sectors), it is hoped, will help the government develop improved policies and better use of health care resources. for example, before the gbps was introduced, numerous regulations had prevented clinics from providing many ancillary services and procedures and even necessary care to patients. therefore, most physicians, including surgeons, practicing at clinics would act like general practitioners and treat only minor diseases. to prevent clinics from shrinking and to enhance the accessibility of the insured, the caps for all the clinics for the first 1½ years was near 5% growth, compared with a 5% reduction during the previous period, and it actually created great incentive for general practitioners to provide more preventive and necessary care and to improve the quality of and access to care. clinics were allowed to provide 82 additional procedures and have incentives for joint disease management programs, such as for diabetic patients, to improve quality of care. preliminary results showed that, as expected, clinics provided 16% more preventive care, 5% more surgical procedures, and 14% more visits for chronic patients during the first 2 quarters after institution of the gbps. consultation fees increased, whereas costs of drugs decreased during the same time. more patients rated overall quality of care in the clinics as acceptable after the gbps vs before (96.6% vs 94.6%).¹⁴

Most hospitals have not yet developed strategies to control patient volumes and intensity of service. instead, the volume and intensity of care almost doubled compared with the funding predicted by negotiation. furthermore, because of financial pressures, many hospitals decreased physicians' salaries despite a us $280 million per year increase in funding for a total of 553 hospitals (a 4.8% increase) compared with the previous year. in addition, it seemed that new technology was introduced at a lower rate. whether the quality of care will be adversely affected in the long run will need to be investigated. most services remain paid in the fee-for-service system, and services for the severely ill are protected by applying a fixed conversion factor of 1. providers are less likely to reduce necessary care unless a new policy, if any, is introduced in the future.

In the past century, great contributions have been made by surgeons to restore patient health. with the progress in biologic science, surgeons are expected to develop more and more new ideas and new techniques in the new century. it is necessary, therefore, to recruit the best and brightest medical graduates into surgery. however, in taiwan, owing to insufficient reimbursement for the major and new surgical work from the bnhi, potentially higher risk of litigation, prolonged working hours, stress, sleeplessness, and overproduction of surgeons, fewer and fewer medical graduates consider surgery as a career. meanwhile, rapid expansion of hospital beds in the past 10 years has increased the need for house staff to cover the clinical work on the floors and for assistants in the operating room. many hospitals started using nursing specialist practitioners for timely implementation of routine work when most residents are in the operating room. a recent regulation developed by the doh requiring a trainer-trainee ratio of 4:1 is intended to limit the production of surgeons each year, to ensure the quality of surgical training, and to balance the demand and provision. however, more than half of the surgical trainees entered subspecialties after 2 years of general surgical training. even those staying in general surgery are looking forward to being respected as specialists instead of as general surgeons, who are frequently mistaken for "nothing special" surgeons. this trend of early and high subspecialization may be positive for longer career life but will seriously endanger comprehensiveness and experience in the care of patients. in the long run, these upcoming subspecialists may provide superior care in their specialty but will not have knowledge and experience in many complex problems.

Multiple consultations from other subspecialties may share the responsibility and liability, but synthetic care can never replace holistic care. on the other hand, too much time spent in the operating room and relatively less time for preoperative and postoperative care in the residency threaten to produce a surgical technician rather than a surgeon. a new training program with efficient core content of training, including knowledge, skills, and ethics, without prolongation of the training period, and with improved work and education experience, is needed to provide the best surgical care in the future.

Corresponding author and reprints: chen-hsen lee, md, department of surgery, taipei veterans general hospital, 201 shih-pai rd, sec 2, taipei, taiwan 11217 (e-mail: chlee@vghtpe.gov.tw).