대만 의학교육 (Med Teach, 2012)

대만 의학교육 (Med Teach, 2012)

Medical education in Taiwan

JEN-YU CHOU, CHIUNG-HSUAN CHIU, ENOCH LAI, DUUJIAN TSAI & CHII-RUEY TZENG

Taipei Medical University, Taiwan

동아시아 위치. 2천3백만 인구. 의학교육 발전은 식민지 시대와 식민지 후 시대와 밀접한 관련. 오랜 역사동안 다양한 형태의 전통적 치유자가 존재하여왔다. 최초 서구 의학교육기관은 1865년의 Presbyterian Scottish- Canadian missionaries 였음. 이후 1895년부터 시작된 50년의 일본 식민지 기간동안 대만에 근대 정부가 들어서고, 서구의료를 선호하였다. 2차세계대전 이후 중국의 국가주의자들이 대만을 지배했을 때 전통의학이 재등장하고 국가의학교육시스템 안으로 들어왔다.

Taiwan is located in East Asia with a population of over 23 million. The development of the country’s medical educa- tion system bears a close relationship with its colonial and post-colonial history. While various forms of traditional healers have a long history of practice, the first Western medical education institutions emerged with the Presbyterian Scottish- Canadian missionaries in 1865 (Cheng 2001; Tsai 2001). Subsequently, the 50 years of Japanese colonization starting from 1895 brought to Taiwan a sense of modern governance, which favored Western medicine over traditional medicine. It was after the Second World War when the nationalist Chinese ruled Taiwan that traditional medicine re- emerged and began to be included in the national medical education system.

1개의 군사, 3개의 공립, 8개의 사립 의과대학. 총 1300명 이상의 학생이 매년 졸업. 주류의 서구의학교육에 더하여 2개 의과대학에서 270명의 학생은 전통의학과 학위를 받음.

Taiwan currently has one military, three public, and eight private medical schools, from which over 1300 students 1). graduate annually (Table The stable supply of new physicians has been keeping the physician/population ratio steady at its present ratio of 1/600 (National Statistics 2010). In addition to mainstream Western medical education, there are also 270 students graduating from Departments of Traditional Medicine in 2 of the 12 medical schools.

일반적으로 7년 프로그램. 2년의 의예과, 2.5년~3년의 임상교육, 2.5~3년의 임상실습과 인턴십. 

All the medical schools offer a 7-year program leading to the degree of Doctor of Medicine (MD). The curriculum includes 2 years of pre-medical courses, 2.5–3 years of clinical courses, and 2.5–3 years of clerkship and internship training. 

한 의과대학은 5년짜리 프로그램도 운영하는데, 2.5년동안 기초-임상 통합된 과정으로 압축시켜 교육하고 2.5년동안 임상실습과 인턴십. 매년 50명의 의사가 이렇게 졸업함.

One of the medical schools also provides a 5-year graduate program whose curriculum comprises 2.5 years of integrated, basic and clinical courses, and 2.5 years of clerkship and internship training. Annually only 50 physicians (about 3.8% of the total medical students) are presently graduating from this route.

대만 의료의 간략한 역사

A brief history of medicine in Taiwan

최초의 서구 의학교육 기관은 Scottish-Canadian Presbyterian missionaries 에 의해서 1865년 설립됨. 이미 서구의료를 제공하는 몇몇 병원이 있었지만 대부분 농촌제 위치하였음. 이 시기에는 - Goto Shimpei가 civil administrator가 되기 전까지는 - 의사는 하층 직업이었고, 인기가 없었다.  goto는 의료와 공중보건을 중시하여 그 당시에 위협적인 전염병을 통제하려고 했고, 일본의 첫 식민지로서 쇼케이스를 보여주고자 했다. 이 노력으로 의학은 대만인들이 상류사회로 진입할 수 있는 몇 개 되지 않는 "안전장치"가 되었다.

The first Western medical institutions were established by Scottish-Canadian Presbyterian missionaries in 1865 (Cheng 2001). While there were already several hospitals providing Western medical services during this period of time, most of them were located in rural areas. Regarded as a low-grade occupation, medical education attracted few Taiwanese during this period of time until Goto Shimpei, a German-trained physician, took the office of civil administrator. He emphasized medicine and public health in an attempt to control the then threatening epidemics and to build a showcase out of the Japan’s first colony. Through his efforts, medical education became one of the few ‘‘safety valves’’ through which Taiwanese could seek upward mobility (Lo 2002).

개인병원 의사가 된 대만 의대 졸업생들은 지역사회에서 특권층이 되었고, 비록 일본 식민지의 결과물이었지만 대만 의사들은 식민지에 저항하여 국가를 근대화시키기 위한 캠페인을 벌였다. Lo의 지적처럼 이 두 가지 역할 - 근대화의 심볼과 윤리적 지도자 - 은 전문직 정체성에 상당히 오랜기간 큰 영향을 주었다.

Taiwanese medical graduates who became private practi-tioners eventually occupied a privileged position in their local communities. Although being a product of the Japanese colonization, the Taiwanese physicians initiated campaigns to modernize the nation in an attempt to resist colonization. AsLo (2002) succinctly points out, these two roles, symbols ofmodernity and ethnic leaders, had profound and lasting impacton the professional identity of medical doctors in Taiwan. 

2차대전 이후 지역사회를 대표하는 다수의 의사가 죽임을 당하거나, 감옥에 갖히거나, 국민당에 의해서 추방당했다. 인종투쟁이 불가능한 상황에서 대만 의사들은 '근대화'를 강조하는 것으로 방향을 바꿨다. 또한 많은 중국 지도자들이 중국에서 대만의 의료기관으로 옮겨왔다. 대만과 중극 의사들은 전후 국제 의료 선교사들의 도움을 받아서 대규모의 공중보건운동을 시작하였고 여기에는 1950년대의 유명한 말라리아 퇴치운동과 1970년대의 가족계획 운동 등이 포함된다. 이러한 과정에서 의사들은 엄청난 정치적 압박 속에서도 자율적인 전문직의 위치를 성공적으로 유지할 수 있었다.

After the Second World War, a large number of physicians representing their communities were killed, imprisoned, or exiled by the Chinese Nationalist Party (known as Kuomintangor KMT). When the ethnic struggle was not possible, the Taiwanese physicians turned their emphasis to modernization.Besides, many Chinese medical leaders also moved with their medical institutions from China to Taiwan (National Defense Medical College 1984; Department of Health 2005). Together,the Taiwanese and the Chinese physicians, with the help of the post-war international medical missionaries, initiated a series of large-scale public health movements, including the famous campaigns to eradicate malaria in the 1950s (Chen et al. 2003)and a family planning initiative in the 1970s (Medical Professional Alliance in Taiwan 2008). Through these move-ments, the physicians successfully maintained an autonomous professional space in the face of severe political suppression(Tsai 2010). 

전문직의 integrity와 사회적 헌신의 전통은 이 근대화 프로젝트 속에서 성립되었고, 그들의 민족의 지역사회 지도자로서의 전통적 역할에 더하여 1980년대와 1990년대의 민주화 과정에서 의사들이 중요한 위치를 차지하게 되었다. NHI시스템은 1995년 도입되었는데, 이는 이 과정의 결과물이었다. 이 시스템에는 모든 대만 시민이 포함되었고, 정부와 근접한 관계에 있던 사람들에게만 지원되던 기존의 차별적 복지시스템이 종료되었다. 의사들은 꿈을 이룬 것으로 보였다.

This tradition of professional integrity and social commit-ment established in these modernization projects, in addition to their historical role as ethnic community leaders, contrib-uted to the significant place that physicians occupied during the democratization process in the 1980s and 1990s (Huang1993; Tsai 1996; Tai & Lee 2007). The National Health Insurance (NHI) system, inaugurated in 1995, was a productof this process. It included all the citizens of Taiwan and ended the previously discriminating welfare system that care for onlya small portion of people closely related to the government.The physicians seemed to have fulfilled their dreams (Lin &Tsai 2006). 

반대로, 그러나 NHI는 악몽이 되었다. 의사와 대중간의 사회적 계약에 심대한 도전이 되었는데, 생의학기술이 복잡해지고, 의료가 상업화되고, 진료에서 전문직의 의사결정보다 비용을 더 중요시하면서 다른 developed countries와 마찬가지로 대만 대만의 젊은 의사들도 점차 전문직으로서의 이상에 헌신하는 정도가 줄어들고 있다. 의료기업이 생겨나고 환자-의사 관계가 변하면서 대만 의사들은 다시 한번 또 다른 근대화 프로젝트를 마주하게 되었고, 이번에는 '프로페셔널리즘'의 이상을 재구성할 시간이 된 것이다.

Conversely, however, NHI has instead become a night-mare, posing serious challenges on the social contractbetween physicians and the general public (Tsai 2007). Dueto the increasing complexity of biomedical technology, com-mercialization of medical care, and the mandates of health caremanagement that prefer cost concerns over professionaldecisions, it has been observed that young Taiwanese physi-cians are reducing their devotion to professional ideals, as inother developed countries (Sullivan 2000; Hafferty 2002).Challenged by the rise of health entrepreneurs and thechanges in doctor–patient relationship, the Taiwanese physi-cians again sought to confront this situation with anothermodernization project, this time reconstructing the idea ofprofessionalism (Kassirer 1995). 

1998년 NCFMEA에서 상당한 비판을 받은 이후 대반은 즉시 자신의 인증기구를 만들었고, 의학교육시스템의 개선을 계획하였다. NCFMEA는 대만 의학교육의 부족한 부분을 지적하고 고유의 인증시스템이 없는 것을 지적했다. MOE와 대만 의학교육자들의 대응은 즉각적이었다. Dr Kun-Yen Huang 이 즉시 인증 메커니즘 계획을 수립하고, 11개 의과대학의 대표가 1998년 12월에 만나서 의학교육인증의 목표와 TMAC의 설립을 승인하였다. 1999년 봄, MOE는 NHRI를 의뢰하여 TMAC를 설립하게 하였고, DOH가 자금을 지원하게 하였다. NCFMEA의 비판이 있은 2년 후 TMAC는 2000년 8월 설립되었다.

After National receiving a critical review in 1998 from the US and Committee on Foreign Medical Education Accreditation (NCFMEA 1998), Taiwan immediately formedits own medical education accreditation council and plannedto reform Taiwan’s medical education system (Huang 2002).The NCFMEA highlighted deficiencies in Taiwan’s medicaleducation and questioned the absence of its own accreditationsystem for medical education. The response from the Ministryof Education and Taiwanese medical educators was prompt.After Dr Kun-Yen Huang was requested to immediately draftan accreditation mechanism plan, representatives of the then11 medical schools met in December 1998 to approve theobjectives of medical education accreditation and the estab-lishment of the Taiwan Medical Accreditation Council (TMAC;Huang 2008a, b; TMAC 2008). In the spring of 1999, the Ministry of Education commissioned the National HealthResearch Institute to set up TMAC, with funding provided bythe Department of Health. Within 2 years after the NCFMEA’scritical review, TMAC was inaugurated in August 2000 (Chiu &Tsai 2009). 

의과대학 입학

Admission to medical school

세 가지 방법이 있다. (1)국가 대학입학시험, (2)개인별 지원 (3)고등학교 추천

There are presently three ways that medical students in Taiwan are recruited: (1) the National college entrance exam, (2)personal applications, and (3) recommendations made by senior high schools. 

의과대학들은 기존에 (1)로만 학생을 모집하였고 인성이나 전문직업성에 대한 평가가 없었는데, NCFMEA의 지적 이후 다른 수단들이 도입되었다.현재 16~52%의 의과대학생이 지원을 거쳐 면접/인성검사/학업기록 등을 통해 선발된다.

Medical schools previously recruited medical students only through the national college entrance exam, including no measurements regarding personality or medical professional-ism. Severely criticized by the NCFMEA in 1998, medical schools started to select students by other means. Currently,16–52% of the medical students are selected through applica-tion, which includes interviews, a personality test, and academic records

학부교육과정

The undergraduate curricula

7년 프로그램

The 7-year medical education program, similar among all the 12 schools, include 2 years of pre-medical courses, 2.5–3years of clinical courses, and 2.5–3 years of clerkship and internship.

• The pre-med curriculum provides a wide range selection of courses in humanism, general education, and professional ethics. It is also designed to help students be familiar with humanism through service learning and com-munity participation. 
• Medical courses contain problem-based learning (PBL) and are delivered in multiple ways, including problem solving, case study, and lectures. Humanity courses during medical the clinical years the include communication skills,ethics, and physician–patient relationship.
• Clerkship and internship focus on experience and practice.Medical schools, therefore, need to work closely with affiliated hospitals. 

면허정책

Licensing policies

면허시험은 MOE가 주관하며 두 단계로 되어있다.

The licensing examination, administrated by the Ministry of Examination, contains two stages. 

• The first-step licensing examination, focusing on medical knowledge, is open to fifth-year medical students or above. 
• Second-stage licensing examination is open to seventh-year students or above who have already passed the first licensing examination. 

1단계 통과율 47.62% , 2단계 통과율 68.94%. 2012년부터 OSCE 도입 예정.

The pass rate was 47.62% for the first-step exam and 68.94% for the second-step exam in the year of 2010. To further insure clinical competency with humanistic concerns, a standardized OSCE examination program will be adopted for the second-step exam in 2012.

그 뒤에 MOE는 의과대학에 윤리를 강조할 것을 요구했다. "먼저 좋은 시민이 되고, 그 뒤에 좋은 의사가 된다"가 목표였고, 의예과 교육을 제도화할 것을 권고했다. Huang은 모든 의과대학에 면접을 선발의 중요한 도구로 쓰라고 요구했다. 또한 다양한 대학을 졸업한 의과대학생들이 의료인문학 교육에 있어서의 개혁을 요구했다.

Subsequently, the Ministry of Education requested medical schools to further emphasize ethics in medical educa-tion, aimed at making students ‘‘first good citizens, then decent physicians,’’ and recommended that pre-medical education similar to that in the USA should be institution-alized. Huang (2008a, b) asked all the medical schools to use interview as a major means in recruiting students. Furthermore, medical students from various universities also embarked upon campaigns calling for an education reform in medical humanities (Chen 2002a, b). A broad consensus for emphasizing humanities in medical education was evident. 

교수개발

Faculty development

TMAC의 요청에 의해서 각 의과대학은 센터 설립

Requested by TMAC, each medical school is equipped with aCenter for Faculty Development, designed for PBL implemen-tation, course evaluation, and continue education for teachers.

Supervising body

TMAC의 목표

TMAC (2008) founded in the year of 2000 evaluates medical schools regularly. The specific objectives of the TMAC are: 

(1) to draft protocols for the process of accreditation and carry out on-site visits and evaluation reporting; 

(2) to insure that medical school graduates meet the standard for the care of patients; 

(3) to insure that the standard of medical education will keep up with contemporary advances in research and treatment; and 

(4) to maintain close relations with international accreditation institutions.  

국제교류에도 노력함.

Aside from its evaluation and accreditation work, the TMAC also engages in international exchange, on the model of the US Liaison Committee on Medical Education or the Australian Medical Council (TMAC 2008). 

전문의 수련은 2년(가정의학)~6년(신경외과)로 다양함

Professional societies, supervised by Bureau of Health Affairs, latter the Department of Health Affairs, provide specialty training and certification, which require various number of years, for example, 2 years in family medicineand 6 years in neurosurgery.

새로운 PGY1 프로그램이 2012년 도입예정. 모든 졸업생이 전공과목 수련 전 최소 1년간 일반의로서 수련을 받도록 하는 것.

To insure professional competency on holistic and humanistic care, a new PGY1 program will be implemented in 2012 wherein all medical graduates have to receive general practitioner training for at least 1 year before further pursuits for advance specialist training. With awareness of human rights issues and medical humanities engagement, there are debates in reforming medical education system into 6 years with internship after graduation or into 4-year graduate programs.

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Med Teach. 2012;34(3):187-91. doi: 10.3109/0142159X.2012.652238.

Medical education in Taiwan.

Chou JY1, Chiu CH, Lai E, Tsai D, Tzeng CR.

Author information

• 1Department of Medical Humanities, Taipei Medical University, Taiwan.

Abstract

Taiwan's medical education system bears a close relationship with its colonial and post-colonial history. Since the late nineteenth century, Western medicine, Chinese medicine, and the practice of the other forms of traditional healing have encountered complex transactions with the state and one another, eventually evolving into the present medical system. Nowadays, the mainstream form of medical education in Taiwan is a 7-year Western program; other forms of medical education include a 5-year graduate program and traditional medicine programs. Challenged by the National Health Insurance that emphasizes cost management since 1995 and criticized by the US National Committee on Foreign Medical Education and Accreditation in 1998, medical education reform was implemented by the Taiwan Medical Accreditation Council established in 2000. The reform tries to bring humanities into various aspects of medical education, including student recruitment, curriculum, licensing, and continuing education. Similar to other modernization projects, the reform transplants the American and British standards to Taiwan. These changes hope to insure the reflective capabilities in physicians on the welfare of patients. However, frustration of current and future physicians may be deepened if the reform is insensitive to local issues or incapable of addressing new global tendencies.

PMID:

 

22364449

 

[PubMed - indexed for MEDLINE]