Students from U.S., Taiwan see how systems shape medicine

Some aspects of medicine are universal, but the local environment in which medicine is practiced greatly influences patient care. A student exchange program between Harvard Medical School (HMS) and National Taiwan University College of Medicine (NTUCM) allows several students from each school to see how a different medical system can determine clinical practice. The program, administered by HMI with financial support awarded by NTUCM and the Ching-Shing Medical Foundation in Taipei, has been fostering reciprocal exchanges for more than a decade.

This spring, four HMS students participated in one-month clinical rotations at NTUCM’s teaching hospital, while four NTUCM students spent two months at several Harvard-affiliated hospitals. Beyond the clinical knowledge the students gained, they were able to see how cultural, organizational, and regulatory factors shape the day-to-day practice of physicians.

HMS student Jerry Tsong, left, stands at a nursing station with the chief resident of the Family Medicine Department at NTUCM Hospital.

The impact of insurance
All of the students were struck by how the insurance system of a country influences medical care delivery. Taiwan, with its national health insurance that covers the entire population, is quite different from the U.S. system, where a mix of rivate and public insurance leaves some uninsured. Chen Kun Chen of NTUCM, explained: “[in Taiwan,] we don’t have to argue with the insurance companies very often on business matters or let the different insurance companies change the treatment rules on different patients. The general rules of the insurance system are easy for both patients and doctors to follow.” NTUCM student Shih-Hsiu Wang agreed that the U.S. system was more complex: “I felt that insurance companies in the U.S. require doctors to complete lots of paper work, which inevitably sacrifices some time for real patient care,” he said.

HMS student Charles Hsu, whose clerkship was based in the dermatology clinics of NTUCM Hospital, found that not having to think about insurance “can be gratifying to a doctor, because fewer social issues impede the delivery of health care.” Furthermore, Hsu noticed that “access to health care seems to be better in Taiwan, and I saw more seemingly indigent patients during my time there than I had in the U.S.”

However, while universal coverage can be an important equalizer of health care, it can also limit the kinds of procedures and technologies allowed. HMS student Ma Somsouk, who completed a GI rotation at NTUCM, said: “I could see limitations of a national health care insurance system, particularly in the cardiac department.” For instance, stents are not used very often at NTUCM because the cost is not reimbursed by the national insurance plan, and many cannot afford to pay for them individually.

The insurance system of Taiwan also allows patients to choose freely among doctors and clinics, unlike the managed care system of the U.S. that designates a single primary care physician. Again, students saw the advantages and disadvantages of both systems. “Unlike the current American insurance system, the Taiwanese national health care insurance program allows for patients to ‘doctor shop’ as much as they want,” said Jerry Tsong, an HMS student who completed a rotation in Family Medicine at NTUCM. “This freedom is wonderful, but the concept of trying to maintain continuity of care with one primary provider suffers as a result.”

A different pace of patient care
The students also found that the structure of care delivery was different in Taiwan and the U.S. In Taiwan, doctors see many more patients—sometimes 30 or 40 in a morning—and visits are often shorter. Taiwanese clinics are extremely efficient. For example, in the NTUCM Hospital dermatology clinics where Charles Hsu (HMS) was assigned, the attending doctor sat in a single small room, with either a single resident or nurse helping with administration. Patients are called into the room by number, whereas in the U.S. the doctor moves from room to room.

Some of the U.S. students found this style disconcerting, as it could compromise patient privacy, which is highly valued in the U.S. “Occasionally a new patient will be called into the room and begin speaking to the doctor while another is still waiting for a prescription,” Hsu said. On one busy morning, he recalled, a doctor called the wrong patient into the room. When the mistake was realized, the correct patient came into the room, but the other patient remained. A previous patient was also still in the room waiting for a prescription from the resident. In the end, the patient to be seen allowed the doctor to examine him as the other patients looked on—even though his complaint, a rash on his groin area—was a particularly private one.

“The culture in the U.S. and Taiwan is noticeably different with regards to confidentiality,” agreed Ma Somsouk (HMS). “Patients in Taiwan show much greater interest in the care of their neighbors.” Chen Kun Chen (NTUCM), who spent time at Brigham and Women’s Hospital and Massachusetts General Hospital, felt that the faster pace of Taiwanese medicine, though it may compromise confidentiality, is appropriate to the culture there. “Though some people argue it reduces the quality of doctor consultations, I think it’s a suitable practice for the more efficient lifestyle in Taiwan,” she said.

Going out or staying in
Though office visits felt more rushed to U.S. students in Taiwan, inpatient stays at the hospitals seemed much longer. “In America, the goal of any inpatient team is to take care of the patient and discharge them as soon as possible,” said Jerry Tsong of the U.S., “often sending them to a rehabilitation hospital or setting up an adequate follow-up plan. While the Taiwanese health care system is under significant financial strains, at NTUCM Hospital I did not notice such a pressure to discharge patients quickly.”

Shih-Hsiu Wang (NTUCM), who completed rotations in neurology at Massachusetts General Hospital and geriatrics at Beth Israel Deaconess Medical Center, appreciated the rehabilitation system in the U.S.: “It reserves medical resources for patients that really need them, while providing adequate medical care for those that have partially recovered but are still not ready to return home.”

Ma Somsouk (HMS) noted that the emphasis on outpatient care in the U.S. is reflected in student training. In Taiwan, “only rarely would a resident need to cover or assist an attending in the clinics. But it is more and more important in the U.S. to be comfortable and adept in the outpatient clinical wards,” she said.

HMS students Jennifer King and Jerry Tsong take a break from their rotations to tour Taipei.

Although some of the differences the students witnessed made them appreciate their health care back home, all of the students left with an appreciation for how fluid the standards of medical practice can be. Shih-Hsiu Wang (NTUCM) said: “It was an extraordinary learning experience and I believe that it would definitely have a profound impact on my future career as a doctor.” Charles Hsu (HMS) said that brief exchange helped reinforce his interest in returning to Taiwan. “I feel that this short experience in NTUCM, my first in a medical setting in Taiwan, was invaluable in giving me a better understanding of the challenges I will face at both the personal and health-care-system level, should I decide to come back to practice,” Hsu said. “At this point, I feel surer that I will in fact pursue this goal.”