A programme of accelerated medical education in Taiwan

Abstract

Background: Graduates of the 7-year undergraduate medical curriculum in Taiwan are often deficient in clinical skills.

Aims: To implement and assess a programme of accelerated clinical education.

Method: The Department of Primary Care Medicine at the National Taiwan University College of Medicine implemented a programme shortening the undergraduate clinical curriculum from 3 to 2 years and giving students more clinical responsibility. Students were prepared for clinical rotations with a 1-month clinical skills course. Core clinical rotations were redesigned to be more participatory. The programme included 1 year of a postgraduate, rotating residency. Self-selected students with adequate grades, recommendations and performance on an interview participated in the programme. None of them dropped out.

Results: Compared with their traditionally instructed cohorts, graduates of the accelerated programme (∼10% of each class) were more likely to pass national boards (100% versus 80–97%) and were rated as more proficient on 9 of the 10 different clinical performance parameters (p < 0.01 by sign test). Sixty-nine percent reported being satisfied or very satisfied with the programme.

Conclusion: A pilot programme of accelerated medical education at National Taiwan University that included clinical skills instruction, mentor-style classes and active learning techniques resulted in satisfactory outcomes for the students selected for the programme.

Introduction

In 1945, Taihoku (Taipei) Imperial University was renamed as National Taiwan University and the Japanese teaching system was replaced with a system implemented by the Ministry of Education of the Republic of China. In 1949, the 1-year pre-medical curriculum was expanded to 2 years (Chen 2005). Thereafter, the 7-year Doctor of Medicine degree programme at National Taiwan University College of Medicine (NTUCM) was divided into three separate stages: 2 years pre-medical, 2 years basic sciences and 3 years clinical. The clinical stage consisted of 2 years of clerkship–observership followed by a final year of rotating internship. Over the past 20 years, a number of both content and process innovations have been introduced into the MD degree programme at NTUCM including a core curriculum in humanism, integration of the basic and clinical sciences, active-learning, student-centred learning and small-group, problem-based tutorials (Chen 2005; Leung et al. 2006).

In spite of the teaching innovations and 3 years of clinical rotations, graduates have generally been deficient in fundamental clinical skills. Three factors may contribute to this deficiency. First, the fifth- and sixth-year students on clinical rotations do not have any direct patient care responsibilities. They spend their time in the classroom and in observing patient care, but they do not directly provide patient care. Second, seventh year students, ‘interns’ assume so many routine patient care duties, including record-keeping, the performance of procedures and the administration of intra-venous medications, that they do not have the time to develop their fundamental clinical skills. Third, after graduation, residents immediately undertake specialty training, thereby precluding further education in generalist skills and knowledge. Therefore, to improve education in generalist clinical skills and knowledge, the Department of Primary Care Medicine at NTUCM designed, implemented and tested a two-step, accelerated, clinically oriented, medical education programme.

Table

Practice points
The clinical education of medical students can be accelerated through the use of clinical skills instruction, mentor-style classes and active learning techniques. A clinical skills curriculum can help medical students make the transition from the classroom to the clinic.

Methods

In 1998, the Department of Primary Care Medicine at NTUCM implemented the two-step programme with the goal of improving generalist clinical skills. The fundamental innovations of the programme are: (1) to accelerate early clinical education by eliminating 1 year of observer status – clerkship and (2) to prepare students for the ward experience with 1 month of intensive clinical skills instruction comprised of small, mentor-style classes with active student involvement, in contrast to the traditional, lecture-style classes. The tactical underpinning for the two-step programme is that learners will: (1) be exposed to authentic tasks, such as those they would encounter in practice; (2) actively engage in learning, not just sit for lectures or observe others practice; (3) have opportunities to apply their learning in practice to build knowledge and develop skills and (4) be responsible for using resources appropriately (Gordon et al. 2000; Mann 2002; Daelmans et al. 2004). The critical responsibility of the faculty is to ensure that the learners received adequate supervision and support. The American Association of Medical Colleges (AAMC) has suggested that the goal of medical student education should be to produce physicians who are altruistic, knowledgeable, skillful and dutiful (Medical School Objectives Project Writing Group 1998). The learning objectives of the two-step programme are modelled after these AAMC goals. The Institute for International Medical Education has developed global minimum essential requirements for medical education that are grouped into seven broad educational domains: (1) Professional values, attitudes, behaviour and ethics, (2) Scientific foundation of medicine, (3) Communication skills, (4) Clinical skills, (5) Population health and health systems, (6) Management of information and (7) Critical thinking and research (Wojtczak, Core Committee, Institute for International Medical Education 2002). The two-step programme is designed to address these seven domains as are the instruments used to guide and evaluate students in the programme.

The two-step programme students graduate from medical school in 6 years instead of 7 years (Table 1). To accomplish this, they forgo more than 14 weeks of vacation in their fifth and sixth years; they do not take the 3-week winter vacations, and they take only 1 month, instead of 2 months for each of the two summer vacations. To enable ‘learning by doing’, students in the two-step programme assume the role of ‘Interns.’ That is, when they are on core ward rotations during their fifth and sixth years they assume the responsibilities of a seventh-year student in the traditional programme. The core rotations in the two-step programme are internal medicine, surgery, paediatrics, obstetrics/gynaecology and a special rotation at a secondary hospital. In the two-step programme the time spent, both in internal medicine and in surgery is increased from 9 to 12 weeks (Table 1).

Table 1.  Schedules of the traditional and the two-step programmes

Stage	Traditional programme	Two-step programme
Pre-medical	2 years	2 years
Basic sciences	2 years	2 years
Clinical medicine	Fifth year: all as clerk	Fifth and sixth years
	6 weeks ambulatory medicine
	6 weeks family medicine	Rotations as clerk
	9 weeks internal medicine	6 weeks ambulatory medicine
	9 weeks surgery	6 weeks family medicine
	9 weeks electives	4 weeks psychiatry
	3 weeks neurology
	Sixth year: all as clerk	3 weeks rehabilitation medicine
	4 weeks psychiatry
	3 weeks neurology	Rotations as intern (step 1)
	3 weeks rehabilitation medicine	12 weeks internal medicine
	6 weeks paediatrics	12 weeks surgery
	6 weeks obsetrics/gynaecology	6 weeks secondary hospital
	16 weeks electives	8 weeks paediatrics
	8 weeks obstetrics/gynaecology
	Seventh year: all as intern
	12 weeks internal medicine	Rotations as clerk or intern
	12 weeks surgery	20 weeks electives
	6 weeks paediatrics
	6 weeks obestetrics/gynaecology
	12 weeks electives
Graduation	End of seventh year	End of sixth year
First-year postgraduate residency training (PGY1)	1 year – first year residency in the new doctor's chosen specialty	1 year – a rotating, first-year residency in internal medicine or surgery or paediatrics (Step 2)
Subsequent residency training	The doctor's chosen specialty	The doctor's chosen specialty

The two-step programme begins with a 1-month preparatory course in fundamental clinical skills, including history taking, physical examination, clinical reasoning and the doctor–patient relationship. Two weeks of the course are spent on internal medicine, and 2 weeks on surgery. The topics covered during the internal medicine section are: cardiac diseases, endocrine diseases, kidney diseases, liver diseases, gastrointestinal diseases, infectious diseases, pneumonia and COPD, stroke and lymphoma. The topics covered during the surgery section are: gastrointestinal surgery, cardiac surgery, chest surgery, vascular surgery, breast surgery, endocrine surgery, hepatobiliary surgery and hernia surgery. Teachers first present the topic of the day to all of the two-step students in a 30-minute outline. Students then break into groups of two or three. Each group interviews and examines a patient. The teacher observes and coaches each group intermittently. The students then reconvene, present and discuss their findings, and construct a differential diagnosis and treatment plan guided by the teacher. Direct teaching time is about 2.5 hours daily. On the final day of each section, each student is observed and evaluated while performing a patient interview, examination and case presentation. Teachers in the two-step programme also teach students in the traditional programme.

The second step of the two-step programme consists of 1-year of postgraduate training. The postgraduate training is in one of three different specialties: internal medicine or surgery or paediatrics. Broad training in clinical skills continues during this rotating Post-Graduation Year (PGY) 1. For example, residents in the surgery specialty spend 1 month as internal medicine residents and 1 month as community medicine residents.

Students matriculate to the two-step programme by applying for available positions during their fourth year of medical school. The number of positions is limited by the availability of staffing. An average grade of more than 80 of the 100 in pre-clinical years is required. Candidates are also evaluated by review of comments from their pre-clinical tutors and by a 10-minute interview with an admissions committee comprised of faculty from the two-step programme. Few (0–3 per year) students who have applied for the two-step programme have not been admitted and the performance of these students have not been tracked separately from that of other students in the traditional programme.

In January 2006, we evaluated the programme using two questionnaires and the students’ national licensure examination pass rates. One questionnaire was sent to the 55 students who had completed both steps of the programme and the other was sent to 80 faculty members and chief residents who had taught both two-step and traditional students. The faculty members and chief residents compared students performing the same roles. That is, two-step students in their fifth and sixth years were compared with traditional programme students in their seventh year, and two-step students in their first year after graduation were compared with traditional program students in their first year after graduation. Statistical analysis was with the sign test (Daly & Bourke 2000).

Results

In January 2006, we evaluated the two-step programme. Approximately 10% of each class entered the two-step programme. Twelve students entered in 1998, 12 in 1999, 15 in 2000, 12 in 2001, 8 in 2002, 12 in 2003, 12 in 2004, 12 in 2005 and 10 in 2006. Of the 59 students who had entered the programme prior to 2004, four had completed the first step of the programme and entered graduate school, and 55 had completed both steps of the programme. None had dropped out. Twelve (20.3%) of the 59 students in the two-step programme were female, as were 118 (20.5%) of the 457 students in the traditional programme. The mean age of students graduating from the two-step programme was 24 years and 4 months (SD ± 25 months) and the mean age of students graduating from the traditional programme was 25 years and 4 months (SD ± 24 months).

In January 2006, we sent a questionnaire to the 55 students who had completed both steps of the programme. The response rate was 49/55 (89%). The students generally reported satisfaction with the two-step programme, including with the teachers and with their own performance (Table 2).

Table 2.  Survey of the 55 residents who have completed the two-step programme

Item	Very satisfied	Satisfied	Acceptable	Unsatisfied	No response
Teachers’ attitudes	19 (35%)	29 (53%)	1 (2%)	0	6 (11%)
Course content	13 (24%)	29 (53%)	6 (11%)	0	7 (13%)
Pregraduate course	7 (13%)	29 (53%)	11 (20%)	2 (4%)	6 (11%)
Postgraduate course	5 (9%)	19 (35%)	18 (33%)	4 (7%)	9 (16%)
Entire programme	13 (24%)	25 (45%)	11 (20%)	0	6 (11%)
Own performance	7 (13%)	17 (31%)	23 (42%)	2 (4%)	6 (11%)

We also sent a questionnaire to 80 teachers asking them to evaluate the performance of the two-step students after graduation. The teachers included both faculty members and chief residents. The response rate was 72/80 (90%). The 72 respondents included 8 department chiefs, 21 programme directors, 17 clinical teachers and 26 chief residents. In general, the teachers reported that students in the two-step programme were superior to students in the traditional programme on nine AAMC measures of performance, including overall performance. Although they found individual variation, they generally found two-step students as mature as traditional students, despite the fact that two-step students were an average of 1 year younger (Table 3). Comments from the teachers included the opinion of several that having two programmes at one medical school created conflicts and inconvenience and that a single programme was, therefore, preferred.

Table 3.  Survey of teachers on the performance of residents from both programmes

Residents from two-step programme vs. residents from traditional programme	Much better	Slightly better	About the same	Slightly worse	Much worse	Not applicable	p-value^a
Medical knowledge	7 (10%)	30 (42%)	30 (42%)	3 (4%)	0	2 (3%)	<0.01
Clinical skills	6 (8%)	24 (33%)	32 (44%)	7 (10%)	0	3 (4%)	<0.01
Performs independently	8 (11%)	28 (39%)	31 (43%)	2 (3%)	0	3 (4%)	<0.01
Reliability	15 (21%)	26 (36%)	24 (33%)	3 (4%)	1 (1%)	3 (4%)	<0.01
Problem-solving skills	5 (7%)	26 (36%)	35 (49%)	2 (3%)	0	4 (6%)	<0.01
Patient-centered care	9 (12%)	16 (22%)	41 (57%)	3 (4%)	0	3 (4%)	<0.01
Maturity	5 (7%)	17 (24%)	36 (50%)	8 (11%)	2 (3%)	4 (6%)	N.S.
Doctor–patient relationship	11 (15%)	14 (19%)	43 (60%)	1 (1%)	0	3 (4%)	<0.01
Relations with colleagues	3 (4%)	21 (29%)	37 (51%)	7 (10%)	1 (1%)	3 (4%)	<0.01
Overall performance	7 (10%)	37 (51%)	22 (31%)	3 (4%)	0	3 (4%)	<0.01

Note: ^aBy the sign test.

To date, 100% of two-step students have passed the national licensure examination. The pass rate for NTUCM students in the traditional programme has varied annually, ranging from 80% to 97% in recent years (Leung et al. 2006).

Discussion

In 1992, New York Medical College initiated an accelerated internal medicine programme that allowed selected senior-year medical students to obtain credit for their first year of an internal medicine residency while completing the requirements for their MD degree. In a comparison of six classes of graduates, there were no significant differences in performance between trainees in the accelerated and in the traditional internal medicine residency programmes in mean scores on the Intern Clinical Evaluation Exercise, standardized in-service exam, monthly attending evaluations or in Board pass rates (Chang et al. 2004). In 1993, the Faculty of Medicine of Ribeirão Preto at the University of São Paulo in Brazil initiated a new curriculum for undergraduate medical education. One of the most significant curricular changes was ‘to allow early contact of the students with the health system’. The average score on a multiple-choice written test for students graduating from the new curriculum was significantly higher than for students in the old curriculum. Furthermore, in Observed Clinical Exercises (OSCEs) the new curriculum was associated with significantly improved performance in procedural and clinical skills (Figueiredo et al. 2004). In 1997, a new curriculum based on the multidisciplinary integration of basic sciences and clinical medicine was introduced at the University of Hong Kong. Nearly 62% of respondents felt that better graduates were being produced with the new curriculum. The majority of them rated the new curriculum students better in nearly all of the major goals of the new curriculum, including self-directed learning initiative, problem solving skills, interpersonal skills and clinical performance in patient care (Lam et al. 2004).

One advantage of our implementing the two-step programme in a subset of students at one institution is that the co-existenceof the two-step programme and a traditional programme in one institution facilitates comparisons. As with accelerated medical education programmes in other countries, students in the two-step programme at NTUCM preformed well or better than their peers in the traditional programme on both written tests and in clinical settings. Some of this good performance was likely due to the selection of well-performing students for the programme. Two-step students were required to have an overall grade of greater than 80 in their pre-clinical years. Although this requirement likely contributed to the greater National Board pass rate of the two-step students, 70% of the medical students at NTUCM meet this requirement. Also, two-step students had favourable tutor evaluations and were judged favourably during a 10-minute interview. These requirements are likely selected for students who were more appealing to faculty, and who would therefore be evaluated more favourably. Finally, two-step students were self-selected, that is, they chose to enter the programme, and therefore might have been more motivated to devote themselves to achievement. However, most medical students at NTUMC are already selected as good performers on written tests, as appealing to teachers, and as motivated enough to matriculate at medical school. Nonetheless, the selection biases and the lack of randomization limit conclusions about the relative performance of two-step and traditional students.

Some of the extra teaching time required by the two-step programme is contained in the 1-month preparatory course and can be estimated as [(20 days × 2.5 hours/day) + 16–30 hours evaluation]/8–15 students = 8.25–5.3 hours/student. In addition, daily teaching time in the core rotations averages an estimated 2 hours daily compared to about 1.5 hours on a clinical rotation in the traditional programme. Also, ‘teacher’ time is required to design and maintain the two-step programme. However, all of this extra teaching time is more than counterbalanced by the 37 fewer weeks of undergraduate ward teaching needed by the two-step students who graduate an entire year earlier than traditional students. Therefore, when considered as a 6-year compared to a 7-year undergraduate medical programme, less teaching time is required in the two-step programme. However, when considered in terms of a single clinical rotation, more teaching time is required to supervise and support students in a mentoring-style that incorporates active student participation than to teach a larger group didactically. Teachers who had taught in both programmes estimated spending about 50% more time per student when ward teaching in the two-step programme. In addition, extra time is also required for teachers to acquire and to maintain their skills in supervising and supporting students in a mentoring-style that incorporates active student participation. We found this extra time required of teachers to be the primary barrier to implementing the programme.

Experience gained from the two-step programme has informed, and has been accompanied by changes in medical education at the NTUCM and in Taiwan. As encouraged by the Taiwan Medical Accreditation Council, the trend in education of fifth and sixth year medical students has been towards active participation in learning. That is, early clinical training has become more ‘learning by doing’ instead of ‘learning by watching.’ In August 2003, a 3-month post-graduation general medicine training programme was implemented throughout Taiwan, and in August 2006 1-year of post-graduation general medicine training became standard. The current goal for the structure of medical education in Taiwan is for 6 years of undergraduate medical education, followed by 2 years of post-graduate general clinical training, similar to the systems in Japan and in the United Kingdom (Beard et al. 2005; Teo 2007).

Conclusion

In Taiwan, a pilot programme of accelerated medical education that included the application of clinical skills instruction, mentor-style classes and active learning techniques resulted in satisfactory outcomes for the students selected for the programme.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Tzong-Shinn Chu

TZONG-SHINN CHU, MD, PhD, Secretary General of the Taiwan Association of Medical Education and Associate Professor of Primary Care Medicine and Internal Medicine, National Taiwan University College of Medicine.

Harrison G. Weed

HARRISON G. WEED, MD, MS, FACP, Professor of Internal Medicine, Division of General Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio.

Chau-Chong Wu

CHAU-CHONG WU, MD, PhD, Associate Professor of Primary Care Medicine and Internal Medicine, National Taiwan University College of Medicine.

Hong-Yuan Hsu

HONG-YUAN HSU, MD, PhD, Professor of Primary Care Medicine and Pediatrics, National Taiwan University College of Medicine.

Jaw-Town Lin

JAW-TOWN LIN, MD, PhD, Professor and Chief of Internal Medicine, former director of the Department of Primary Care Medicine, National Taiwan University College of Medicine.

Bor-Shen Hsieh

BOR-SHEN HSIEH, MD, PhD, Professor of Internal Medicine and former dean, National Taiwan University College of Medicine. He has been an innovator and reformer of medical education in Taiwan.