MEDICAL EDUCATION
Correspondence: Professor Ching-Yu Chen, Department of Family Medicine, College of Medicine, National Taiwan University, Taiwan.
Email: cychen@ha.mc.ntu.edu.tw
Accepted for publication 15 November 2002.
MEDICAL EDUCATION
Evaluation of the present status of academic
family medicine in Taiwan
Kai-Kuen LEUNG and Ching-Yu CHEN
Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Abstract
Aim: To evaluate the status of academic family medicine in Taiwan in terms of the development of the Association of Family Medicine, family medicine residency programs, and continuing medical edu-cation programs.
Methods: A structured questionnaire was mailed to the chairs of the departments of family medicine
in nine medical schools to collect information about faculties and family medicine curricula. Infor-mation about family medicine residency training programs, board certified family physicians, and con-tinuing medical education (CME) programs were obtained from records of the Association of Family Medicine.
Results: There were 40 full-time family medicine faculties in nine medical schools. The largest group
of them (40%) are instructors. Professors were most productive in terms of research publication. All the medical schools have family medicine courses in their curriculum. Most of the lectures are given in the fifth year and practices begin in the sixth and seventh year of 7-year training for medical students. There were 65 family medicine residency training programs with 315 teaching staff in 2001. Most pro-grams are small with only approximately four people on staff. The Taiwan Association of Family Med-icine was founded in 1986. Shortly after its establishment, membership rose rapidly to 4993 by the end of 2001. The Taiwan board of family medicine was established in 1988. At the end of 2001, there were 4145 board certified family physicians in the country. The volume of CME delivered by Departments of Family Medicine reached its peak in 1992, and has gradually decreased to less than half of that num-ber in 2000. However, opportunities for continuing education have been substituted by programs pro-vided by others specialties.
Conclusions: Family medicine is a rapidly growing specialty in Taiwan. Past efforts have laid a
con-crete foundation for future development. Expansion of residency training and the improvement of academic achievements are important for the future development of our specialty.
© 2003 Blackwell Publishing Asia and Wonca Key words: continuing medical education, curriculum, family medicine, training program.
Introduction
Taiwan is an island with a population of approxi-mately 22 million people. There are 11 medical schools, which graduated approximately 1300 medical
students each year. Family medicine became an aca-demic discipline approximately 20 years ago. General practice was originally the major source of medical care on this island. With the emergence of medical subspecialties, many physicians were trained as spe-cialists and provided medical services in large hospitals instead of local communities. Medical services were unevenly distributed, resulting in an undersupply of medical services in many rural communities. Respond-ing to the medical needs in our society, an experimen-tal project to train family physicians and allocate them to rural areas was established in 1979. As part of this
project, two family physicians were trained to provide medical services in a small village at the north east coast of Taiwan’s main island. This project turned out to be very successful and opened the way for subse-quent development of family medicine in Taiwan. The government began to fund family physician training programs in teaching hospitals beginning in 1985. With the incentives from the government, the progress of family medicine was rapid and fruitful. An academic association for family medicine was estab-lished in 1986. In 1989, family medicine was recog-nized as a medical specialty by the Department of Health. At the end of 2001, most of the 11 medical schools in Taiwan had a family medicine department that was responsible for family medicine education to undergraduate students. Family medicine departments and residency training programs were set up in many teaching hospitals to provide postgraduate training and continuing medical education (CME). After 20 years of hard work, family medicine has become a well established medical specialty. As an academic dis-cipline, faculty development, undergraduate and resi-dency programs, and scientific research are crucial for the growth of family medicine. In order to evaluate our efforts and to plan for the future, a country wide survey on family medicine curricula in medical schools was carried out in 2001. The status of the Asso-ciation of Family Medicine, family medicine residency programs, and CME were reviewed. The results of these studies are analyzed in the present study.
Materials and methods
Data analyzed in this study came from two sources. A structured questionnaire was mailed to the chairs of the departments of family medicine in nine medical schools (two of Taiwan’s 11 medical schools do not have family medicine departments). Questions asked included: (i) number, title, research interest, and pub-lications of the faculty; and (ii) type of curriculum of the undergraduate family medicine courses.
Informa-tion on family medicine residency training programs, board certified family physicians, and CME programs were obtained from records of the Association of Fam-ily Medicine. Frequency statistics and line charts were used to analyze the research data.
Results
Undergraduate training in family medicine
(1) Faculty
There are 40 full time family medicine faculties in the nine medical schools. Of this group, five (12.5%) are professors, 14 (35%) are associate professors, five (12.5%) are assistant professors, and 16 (40%) are instructors. Associate professors published the most research articles from 1998 to 2000. However, profes-sors were most productive, with an average of 13.8 articles per person within 3 years (Table 1). Regarding the quality of publications, professors published an average of 8.4 articles in Science Citation Index jour-nals within 3 years. Faculties of family medicine have a very wide range of research interest. Table 2 is a tabulation of research interest for family medicine authors. Family practice, community medicine, and preventive medicine were the top three research areas of the family medicine faculty.
(2) Undergraduate family medicine training Table 3 shows the titles and characteristics of under-graduate family medicine curriculum in different med-ical schools. In Taiwan, medmed-ical training is a 7-year program including 1 year of internship in the final year. The first to fourth years focus on basic medical training and the fifth to seventh years concern clinical medical training. Most family medicine lectures are in the fifth year with practical courses in the sixth or sev-enth year. All the lectures are required and most of the practical courses are electives. In the National Taiwan University College of Medicine, all clinical courses are
Table 1 Publication pattern of family medicine faculties from 1998 to 2000
Title Research articles SCI articles
Number % Average Number % Average
Professor 69 19.6 13.8 42 30.7 8.4
Associate professor 147 41.8 10.5 49 35.8 3.5
Assistant professor 16 4.5 3.2 8 5.8 1.6
Instructor 120 34.1 7.5 38 27.7 2.4
Total 352 100.0 137 100.0
arranged in a rotation base. For family medicine courses, fifth year students are divided into six groups and rotated for a training of 6 weeks in an integrated course called ‘Family, society and medicine’.
(3) Family medicine residency programs
There were 65 family medicine residency programs around the country in year 2001. A total of 66% of the programs were located in district hospitals (Table 4). Each training program must pass accreditation from the Association of Family Medicine before they can accept residents, and must receive reaccreditation every 3 years. A total of 315 teaching staff administer the 65 programs (Table 4). Although most of the staff work in district hospitals (52.7%), medical centers have the largest staff in each program (an average of 7.9 on staff per program).
(4) Family physicians and continuing medical education
The Association of Family Medicine was founded in 1986. Shortly after being established, membership grew rapidly from 1986 to 1997; it has plateaued for the past 4 years. There were 4993 members at the end Table 2 Research areas of family medicine faculties
Research area Number %
Family practice 34 85.0 Community medicine 16 40.0 Preventive medicine 15 37.5 Geriatrics 9 22.5 Medical education 9 22.5 Palliative medicine 7 16.5 Occupational medicine 6 15.0 Behavioral medicine 6 15.0 Adolescent medicine 5 10.5 Health management 3 7.5 Obesity 3 7.5 Medical informatics 3 7.5 Practice management 3 7.5 Women’s health 2 5.0 Medical ethics 1 2.5 Travel medicine 1 2.5 Others† 3 7.5 Total 130 100.0
†Rheumatology, nephrology, and epidemiology. (Research areas reported from family medicine faculties. Each faculty can report more than one area.)
Table 3 Family Medicine Curriculum in Taiwan Medical Schools
Medical schools Title of Teaching Programs Duration Type Grade National Taiwan University College of
Medicine
Family, society, and medicine 6 weeks Compulsory 5 Family medicine practice (I) 6 weeks Elected 6 Family medicine practice (II) 6 weeks Elected 7 Kaohsiung Medical College Family medicine 1 semester Compulsory 6 Family medicine practice (I) 3 weeks Compulsory 5,6 Family medicine practice (II) 2 weeks Elected 7 National Cheng Kung University College
of Medicine
Family medicine 1 semester Compulsory 5 Family medicine practice (I) 3 weeks Compulsory 5 Family medicine practice (II) 2 weeks Elected 7 National Yang-Ming University College
of Medicine
Community medicine 1 semester Compulsory 4 Community medicine practice 2 weeks Compulsory 4 Family medicine practice (I) 1 week Compulsory 6 Family medicine practice (II) 4 weeks Elected 7 Taipei Medical College Family medicine 1 semester Compulsory 5 Family medicine practice (I) 3 weeks Compulsory 6 Family medicine practice (II) 2 weeks Elected 7 China Medical College Introduction to family medicine 1 semester Compulsory 5 Family medicine practice 2 weeks Elected 6,7 Chung Shan Medical and Dental College Family medicine 1 semester Compulsory 6
Family medicine practice 4 weeks Elected 7 National Defense Medical College Family medicine 1 semester Compulsory 5 Family medicine practice 2 weeks Elected 6,7 Buddhist Tzu Chi Medical College Family medicine 1 semester Compulsory 5
Family medicine practice (I) 2 weeks Compulsory 6 Family medicine practice (II) 3 weeks Elected 7
of 2001 (Fig. 1). The Taiwan Board of Family Physi-cians, the first specialty board examination in Taiwan, was established in 1988. The number of board certified family physicians grew in proportion parallel to the number of members of the association. From 1988 to 2001, 4145 family physicians passed the board exam-ination (Fig. 1). After passing the board examexam-ination, board certified family physicians must complete 240 CME credits for recertification every 6 years. With the growth of the number of family physicians, came a huge demand for CME courses. Family physicians can earn CME credits from two sources, courses provided by family medicine faculties or courses provided by faculties of other subspecialties. Both kinds of courses must be approved by the Association of Family Medi-cine for the CME credits to be valid. Figure 2 shows the number of approved CME courses from 1989 to 2000. We can observe a trend of increasing CME courses pro-vided by family medicine faculties from 1989 to 1992, followed by a marked decrease. However, the number of CME courses provided by other medical specialties increased rapidly from 1991 and became a major source of CME credit in recent years.
Discussion
Nine of the 11 medical schools in Taiwan have family medicine departments. Of the two medical schools without a family medicine department, one school was newly established 3 years ago so that many of its clinical departments were not fully set up by the time of the survey. The development of family medicine in medical schools benefitted from government policy. The presence of family medicine departments adds credits to the accreditation of medical schools. As a result, practically all medical schools should have fam-ily medicine departments in their structure. However, most family medicine departments are very small, with only an average of 4.5 faculty members in each department. The size of the department may constrain further development. According to our survey, family medicine is a required course in early clerkship, the fifth grade for medical students, in all medical schools. Information not shown in our quantitative data is that many family medicine faculties are also involved in many other courses such as medical informatics, med-ical ethics, geriatrics, and community medicine. This Table 4 Family medicine residency training programs in different levels of hospital (2001)
Type of hospital Training programs Teaching staff Staff/program
Number % Number %
Medical center 17 26.1 134 42.5 7.9
District hospital 43 66.2 166 52.7 3.9
Community hospital 5 7.7 15 4.8 3
Total 65 100.0 315 100.0 4.8
Figure 1 Number of members of the Taiwan Association of Family Medicine and the number of board certified family physicians. (––), number of members; (––), no of board certified family physicians.
0 1000 2000 3000 4000 5000 6000 1986 1987 1988 1989 1909 1991 1992 1993 1994 1995 1996 1979 1998 1999 2000 2001 Calender year Number of persons
wide involvement can be reflected on the diversity of research interests of the faculty members.
Compared to their colleagues in other clinical spe-cialties, faculty members of family medicine depart-ments were less productive in the quantity and quality of medical research.1 A study revealed a total of 101
articles written by family physicians published from 1979 to 1992. Most of these studies were observational studies with a cross sectional study design. All research articles were contributed by 37 physicians.2 Although
no one denies that academic research is important for the development of a specialty, there are many obsta-cles that prevent family physicians from doing medi-cal research. A study of 115 family medicine faculties about the influencing factors on current research activ-ity and productivactiv-ity was conducted in 1997. Seventy-one faculty members (61.7%) were engaged in 124 research projects during the survey period. The only significant influence identified in the study was incompetence in research skills.3 As one article can be
written by more than one author, there were repeated counting of articles in the present study because authors listed the number of articles independently. However, the quantity of medical research seemed to improve in recent years as more research articles have been published in the past 5 years than in the early 13 years. The number of articles published in SCI jour-nals also reflect an improvement of quality of research. Nevertheless, the gap in academic achievements between family medicine and other clinical specialties is still present and continues to challenge the family medicine practice.
According to the regulations established by the association and approved by the Department of Health, the training capacity of a residency training program is limited by the number of teaching staff and
facilities. In 2002, the total training capacity of all pro-grams is 150 residents. Will the flux of family physi-cians meet the future needs of our country? A primary care physician manpower research study funded by the Department of Health is being carried out. We hope that such research provides some useful data upon which to develop future policy for family med-icine residency training.
Continuing medical education credits are required in the certification and recertification by the family medicine board. This has created a huge demand for CME courses in the initial few years after the establish-ment of family medicine specialty. To meet the needs of family physicians, the number of CME courses increased rapidly. Since 1994, when other medical spe-cialties began their board certification regulations, the number of family medicine specific CME courses markedly decreased to approximately half of its peak. We can explain this phenomenon in two parts. First, the demand of CME credits declined as most primary care physicians in the practice have already received board certification. Second, many other medical spe-cialties began their own CME courses and credits offered by other medical specialty programs are nor-mally accepted by the Association of Family Medicine after review. The higher number of CME courses in the academic medical society eased the pressure of the family medicine association to provide more CME courses for its members and the association can refo-cus its attention to other academic and educational missions. Although CME is a common tool to update medical knowledge for practicing physicians, its effec-tiveness in changing physicians’ practicing behavior has not been observed.4,5 Other educational strategies
should be developed and evaluated for the continuing education of family physicians.
Figure 2 Continuing medical education (CME) programs from 1989 to 2000. (––), family medicine CME; (––), CME provided by other specialties. 0 100 200 300 400 500 600 700 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Calender year Number of programs
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