According to statistics published this past March by the Surgical Society of Gastro- Enterology, ROC, the shortage of residents in the field of surgery in Taiwan had reached 49%.

Graduates of Taiwan medical schools have training in internal medicine, surgery, pediatrics, maternity, and other fields, and are qualified physicians. But to qualify as a specialist, a doctor must serve a "residency" (training period) in a hospital. In the past, surgery was always the top choice for hospital residencies. But in recent years there has been a dramatic drop in the number of medical school grads who choose surgery, creating a serious shortfall in residents in local hospitals.

Take for example Taipei Municipal Chung Hsiao Hospital, classified as a "regional hospital" (second only to a "core medical center" in the national health organization scheme). According to the hospital staffing chart, there should be 28 residents in surgery. But currently there are only seven. Hu Wei-ming, vice-superintendent of the hospital, says that demand for residents in surgery has exceeded supply since 1991. Indeed, since 1994, despite several recruitment drives, the hospital has not found a single new resident in surgery.

Things are even worse at the Tzu Chi Buddhist General Hospital, another regional hospital, in Hualien in eastern Taiwan. While the department of surgery has 14 attending physicians, there is only one resident.

Even at core medical centers, such as Cathay General Hospital, it has been impossible to recruit a full complement of surgical residents. Given its size and ranking, Cathay's department of surgery should have 33 residents, but it has been hard going even coming up with the 27 there now. This is the first time this has ever happened since the hospital was established 19 years ago.

This year National Taiwan University Hospital (NTUH) had to hold three recruitment drives to fill its quota of 13 first-year residents in surgery. Hospital vice- superintendent Chu Shu-hsun says that NTUH has traditionally held only two exam sittings each year. He explains that a third one had to be held this year because many doctors who were accepted into the hospital turned down the offer, and went elsewhere-something that had rarely happened in the past at this core medical center. Though NTUH has managed to fill its quota of residents in surgery, there has been a marked decline in the number of applicants for such posts, from 40-plus three years ago to 30-plus two years ago and only twenty-something last year.

As a general rule it is said that there should be one physician for each 1000 people in the population, and the figure in Taiwan in 1.1 per 1000. Thus Taiwan is not short of physicians. But doctors have preferred to go into pediatrics, ear-nose-and-throat (ENT), or other specialties rather than surgery.

Not only is it hard to find new recruits, there are many stories of current surgery residents or even attending physicians leaving the field. Given that they have been able to earn large amounts of money, some choose to emigrate and live lives of leisure abroad, or perhaps to just become GPs (general practitioners). Hu Wei-ming points out that in the past two years alone three surgeons have left Chung Hsiao to open clinics as GPs or pediatricians.

Success depends not just on the surgeon, but on the whole medical team.

Surgeons needed, chop-chop

While residents do not do the main cutting in the surgical theater, they are the "hothouse seeds" being cultivated as future surgeons. The current difficulty in recruiting surgery residents not only may lead to the future shortfall that Shih Hsien-yen worries about, it is already having countless side-effects in the present day.

Now at the peak of his career-mature, stable, and with vast experience-Hu Wei- ming (who has an excellent reputation as a specialist in rectal surgery) admits that he is "slowly withdrawing" from the field of surgery.

Because surgery patients need a great deal of follow-up care, and because there are often emergencies, there always has to be someone on duty. Given the current shortage of hands, now all residents, chief residents, and attending physicians have to put in extra shifts. This month one surgeon handed Hu his resignation and went back to his hometown, leaving Hu to say: "Now it looks like even I, as the assistant chief of the hospital, will have to take some shifts." With few residents to cover the downstream tasks of surgery, Hu, who is too tied down with administrative tasks and a peak work period to do post-op care himself, asks "Do you expect me to go do surgery without taking that into account?"

Even worse, hospitals have no choice but to send those patients most in need of complex care to the core medical centers. One old woman slipped and fell, suffered brain damage, and went into a coma. She was refused at four hospitals before being sent to Cathay General Hospital. By then she was slipping away, and the opportunity to save her had very nearly been missed.

Doctors must continually learn. At morning meetings at Cathay General Hospital, MDs discuss their cases and get advice from consulting professors.

Shortage of beds

The surgeon shortfall now being faced by larger hospitals was in fact already evident in small clinics three or four years ago. According to statistics of the Department of Health, in the last three to four years, of hospitals with 50 beds or less, about 10% per year have closed their doors. Because they have had trouble finding surgeons, some small hospitals have closed outright, while others commonly send complicated cases on to regional institutions.

Now even medium-sized regional hospitals, coping with the shortage of cutters, are passing problem cases along to medical centers.

Chu Shu-hsun notes that in the past, National Taiwan University Hospital had to send its residents to smaller hospitals to give them a chance to practice relatively minor operations like appendectomies. But now they don't have to, since everybody is sending their patients up to NTUH.

Given that beds have always been hard to get at the core medical centers, the current situation of all surgical cases large and small going to the big hospitals has further stretched capacity. Each day, on average, there are 68 patients temporarily staying in the emergency ward at NTUH, most of whom are waiting for beds in the main hospital.

Right now, the middle-ranking regional hospitals, while trying very hard to fulfill their responsibilities, are starting to face a doctor shortage. Hu Wei-ming anticipates that in three to five years even the largest hospitals will be unable to accommodate all the patients, at which point high-priced private hospitals for the elite will spring up. Then it will be apropos to apply this joke from Canada: A patient came in wanting to have surgery to remove a tumor from his hand. The surgery was put off for two months because the doctor was going out of the country on vacation. However, if the patient were willing to pay himself, the doctor would fly back the next day and do the operation.

Many doctors think "there isn't much of a life to speak of" for surgeons. The photo shows staff grabbing a boxed lunch outside the operating room during a break; there are several procedures still to go in the afternoon.

Fighting the angel of death

Surgeons have always had fame, fortune, and social status-so why are so few willing to take up this calling?

In the past, surgeons were considered the cr鋗e de la cr鋗e of the medical community, and this field was frequently the first choice of the top graduates of medical schools. Thus it was not easy to be admitted to this specialty.

Chang Chin-wen, a director of the Hospital Association of the ROC, recalls that, 30 years ago when he was assistant director of Mackay Memorial Hospital, one prospective resident came to him begging for a chance to put in four years of hard work without a penny in compensation in order to study surgery. Because so many people wanted to study surgery, only the top ten graduates of the major medical schools even had the chance to enter the field. This young doctor who professed himself willing to serve for nothing was not able to fulfill his wish because his grades were not up to snuff.

Chu Shu-hsun, who was the first surgeon in Taiwan to do a heart transplant, says that he had to give up his beloved drawing and all other amusements beginning from his fifth year of university, and do nothing but academics, in order to get into surgery.

Lin Ching-yun, the first woman surgeon in Taiwan, still can't forget how, when she was a third year resident at NTUH, because she gave birth to a baby just a week before the selection of the chief resident for surgery, she missed the chance to go into heart surgery. For this reason, she stayed awake nights, unable to sleep, for three months.

For the most part, patients are only operated on when they cannot be treated in other ways. The ability to eradicate an otherwise intractable problem provides the "sense of accomplishment" in surgery, and that is what attracts people to the field. "You can see the results of surgery immediately." "A surgeon is more like what a doctor should be." Such sentiments explain why many students choose surgery as their specialty. Chu Shu-hsun describes ordinary medical practice as being like "diplomacy," with the physician "negotiating" with the enemy-the angel of death. When that fails, the only recourse is war, with the surgeon in the role of warrior, who must win total victory or face ignominious defeat, with the outcome immediately evident.

However, today, 20 years down the road, not only do the grads with the grades not flock to surgery, "someone only has to say that they want to go into surgery, and they are accepted. Hospitals don't ask about grades, and don't dare risk giving applicants an exam," says Hu Wei-ming, explaining, "It is hard enough to get anyone to sign up in the first place-they don't want to scare them away!"

Surgery is like a battle with the angel of death--the last line of medic al defense. If one day there are no surgeons to be found, then what?

The "clean" choice

There are also doctors who, only half in jest, say that these days it isn't important if surgeons have skilled hands or the ability to stay cool under pressure-requirements have been reduced to being able to "stay steady in a standing position." There is already little room to assess the surgeon's skills or consider the patient's rights.

Chu Shu-hsun points out that when he graduated from medical school, he couldn't believe it when he heard that in the US new MDs had to wait years for a residency in dermatology or ophthalmology. Now, two decades gone, the same situation can be seen in Taiwan. It is common for the best students to choose things like dermatology or ane-sthesiology.

Li Hsin-ling, a physician in the emergency ward at National Chengkung University Hospital in Tainan, explains that when doctors choose specializations, they consider several factors: personal interest, future career prospects, potential market demand. Its just that these days fewer young MDs give the greatest weight to personal interest. In contrast, those fields with greater markets (like ENT or pediatrics) or "clean" specialties-where doctors hardly ever need fear the sight of blood-are the hottest fields.

Surgery is often done under emergency conditions, with the patient hanging between life and death--there is not a second to spare.

Mission impossible

"I have talked with a lot of younger people, and they always emphasize 'quality of life.' And there isn't much of a life to speak of for a surgeon," avers Chu Shu-hsun.

The training period for surgery is certainly more difficult than for other fields. A specialist in internal medicine, for example, can take the qualifying exam after merely three years of residency. For a surgeon, residency takes five years. For cardiac- or digestive-system specialists, it takes six years, and as much as seven or eight for those specializing in the nervous system. Besides facing a long training period to become a certified cutter, surgeons must also be in better-than-average physical condition and be able to remain cool under intense pressure. Only thus can they cope with crises rarely seen in other fields.

Take for example transplant surgeries, which are held on short notice whenever an organ becomes available-even in the middle of the night-for maximum effectiveness. As Chu Shu-hsun notes, when organ donors become brain dead, the organs begin to deteriorate right away. Thus the moment must be seized.

After years of rigorous training, surgeons are under no less pressure after they qualify, for they face life and death crises at any time. Hu Wei-ming says that surgeons are at "red alert status" constantly. When something comes up, even if the doctor is not in town or is on vacation, he or she will be called back. The only way one can really relax is by going abroad. No wonder the average life expectancy of a surgeon is only 60, the shortest of any medical professional.

Li Hsin-ling states that she was torn between doing internal medicine and surgery. In the end, she decided that she wouldn't be able to cope with the physical demands, so she chose internal medicine.

For young people today, extended training followed by a high-pressure existence looks more and more like "mission impossible."

Residents have to do "rounds" every morning, visiting in-patients, giving injections, and changing dressings. Only then can they head to the operating theater without any lingering worries.

Heads you win, tails I lose

This is especially so when compared to such specialties as internal medicine or ENT, where there is no need for cutting or gore. Not only is surgery physically demanding and a bloody mess, it includes a number of hidden pitfalls.

Chu Shu-hsun points out that every surgeon has been accidentally cut, stuck with a needle, or splashed with blood during surgery. If by chance the patient has a communicable illness, it can be passed on in this way. Today, with rising numbers of cases of AIDS and hepatitis, the dangers faced by surgeons are growing.

And this high-risk, high-pressure "knife- edge" existence also carries with it a good chance of being sued.

Tsai Chin-hung, a chief resident at Chung Hsiao Hospital, says that today there is a lack of trust between patient and doctor, paralleling the growing mistrust in interpersonal relations in society as a whole. The situation is one of "heads you win, tails I lose": The patient walks away from a success, with no special rewards for the doctor, but physicians must pay compensation if they err. Compared to the past, he says, every time he picks up the scalpel now it is like walking on a tightrope, and he is constantly afraid of disputes over treatment that may drop on him out of nowhere at any time.

Ordinarily, surgical patients need care urgently, so there are more disputes than in other specializations. Doctors in Taiwan, meanwhile, are not like their foreign counterparts who have insurance to cover compensation payouts: When there are disputes in Taiwan, doctors usually have to come up with the money themselves.

Compared to exhausting surgery, pediatrics--"lots of money, little trouble, suited to private practice"--is a more likely career choice for today's MDs.

All dressed up and no place to go

Compared to dermatology, ENT, ophthalmology, or rehabilitative medicine, in which specialists can easily open their own clinics and be independent, surgery is much less appealing to young MDs.

For a surgeon, to open private practice is tantamount to giving up the field altogether. For example, an internal medicine doctor needs only a blood-pressure gauge, a stethoscope, and such simple items, and he or she can hang out their own shingle. Surgeons require not only pristine operating rooms and advanced equipment, they need the help of anesthesiologists, assistants, and nurses, making it virtually impossible to go into private practice.

Chang Chin-wen says that a surgeon can only "live parasitically" through a large hospital. However, there are only a limited number of positions for attending physicians. When a resident is finished with training, there are few opportunities for advancement, yet no chance to go out on his or her own. It's really a case of being "all dressed up with nowhere to go."

Lien Heng-hui has been a resident in surgery at Cathay General Hospital for six years. Because no attending physicians have left, while the hospital is short of residents, all he can do is continue to "apprentice" as a resident.

Not only are surgeons unable to open their own clinics, within many large hospitals there is a system of "different jobs, same rewards." Salary is determined entirely by rank, without regard to the ease or difficulty of a post. Although all doctors are still in the "high- income bracket" compared to ordinary folk, among physicians there is naturally a tendency to "pick the softest persimmon" (as the old saying has it), meaning that relatively few will opt for surgery, the most arduous specialty.

For example, at the Cathay General Hospital, a chief resident (i.e. an MD in the fifth year of residency) in surgery earns about NT$110,000 (US$4000) per month in salary and bonuses. Not bad, but a pediatrician in Neihu reveals that within half a year of opening his own office he was pulling in NT$2 million per month. Given the situation, no wonder so many abandon the surgical field.

NTUH vice-superintendent Chu Shu-hsun knows that surgery is a high-pressure field. Though inundated with administrative work, he still keeps abreast of procedures by video recordings.

No longer the top of the heap

On top of it all, unexpectedly, universal health insurance has become "the straw that breaks the camel's back" in the shortage of surgeons.

Before the implementation of universal health insurance, except for persons covered by civil service or labor insurance, doctors could charge patients individually. Surgical fees were very expensive, so surgeons ended up with the highest incomes. Indeed, their total incomes could be as much as double a specialist in internal medicine.

Chuang Yi-chou, director of the Hospital Management Center at the Chang Gung Memorial Hospital, agrees that universal health insurance payments are unreasonably low. He notes that incomes in "easier" spe-cializations like rehabilitative medicine or ophthalmology are higher than in surgery, which requires a higher degree of skill.

Take for instance one of the most basic surgical procedures-appendectomies. Two doctors, two nurses, and an anesthesiologist must work for nearly an hour, yet the universal health insurance "technical value" payment comes to only NT$4910.

Intensive-care units, closely related to surgery, are also in short supply because payments do not cover costs. Most hospitals only set up the minimum number of ICU beds required by law, and are unwilling to expand the number to meet demand. This has led to a situation in which many patients who need intensive care cannot find ICU beds. Chu Shu-hsun points out that, because beds are filled day in and day out, 80% of patients requiring open heart surgery must put off their operations.

Chang Chin-wen states that surgical pay in Taiwan is lower than in Japan, Singapore, and the US. For instance, payment for an appendectomy is only half that of the States. "Everything-housing, food, clothes-is cheaper in the US than in Taiwan. The only things that command higher prices are university education and medicine."

"Unreasonably low payments have already seriously distorted the whole medical system," says Huang Ching-shui, chief of surgery at Cathay General. Given how low universal health insurance "technical value" is for surgery, "compared to what it costs for devices like an ESWL [for breaking up kidney stones without surgery], human labor is really undervalued," he avers.

Cheap health care

Facing the shortage of surgeons, the Surgical Association of the ROC is preparing a survey of the problem, and will provide the results to the Bureau of Medical Affairs of the Department of Health to study policy options. But, with no policy yet decided, each hospital must fend for itself to keep the surgical staff complete.

Raising pay for surgeons, so that arduous tasks are amply rewarded, is a method many hospitals have adopted to attract people. Cathay General Hospital has adopted a "grading" system. Aside from basic salary, doctors are awarded bonuses depending upon their accomplishments-those who do more, earn more. National Taiwan University Hospital is also studying a similar system, and is also trying to improve the handling of disputes over treatment.

Chu Shu-hsun takes the example of the US, where there is no shortage of surgeons. "Fees in the US are determined by cost analysis. They take into account the doctor's training process, working hours, and risk level. Therefore fees are higher there," he explains.

Parng I-ming, division chief of the Medical Payments Scheme of the National Health Insurance Bureau, notes that the current fee schedules have simply been carried over from the days of the labor insurance system, plus some consideration of figures abroad. "There is definitely a need to revise the standards," he concludes. In fact, there have been two adjustments in the past half year. Of the more than 200 items revised in October, most were in surgery. While the rates of adjustment varied, they could be as high as 100%-for example, the fee for "partial liver removal" was raised from NT$4000-plus to NT$8000-plus. As for complaints by surgeons that they are "low-wage labor," Parng states that in the future the main focus of adjustments in universal health insurance pay schedules will be on respecting doctors' special skills.

Many generals, few soldiers

Meanwhile, the problem of a shortage of surgery residents remains. To solve this in the short term, suggests Hu Wei-ming, regulations governing medical organization can be amended to increase provisions for physician's assistants, who can take over for surgeons in tasks like changing dressings and giving injections. This could help resolve the current shortfall in residents.

In fact, many hospitals have begun to train senior nurses as "nurse practitioners," who can fulfill some surgical functions. During operations, they can apply clamps, stem blood flow, sew stitches and so on.

But, in the end, assistants can only assist, they cannot wield the scalpel. Although right now there is only a shortage of "soldiers" and not of "generals," today's soldiers are, after all, tomorrow's generals. Thus to fundamentally resolve the looming shortage of surgeons, it is necessary to attract more people into the field.

Besides raising compensation, another idea, favored by Chang Chin-wen, is to implement a system of "joint clinics" and "semi-open hospitals." These can remove obstacles to surgeons going into private practice.

"Joint clinics" bring together private specialists in a single place-something like a medical department store. They are similar to existing civil service insurance health centers, which have offices for internal medicine, surgery, ophthalmology, dermatology, pediatrics, rehabilitative medicine, and diagnostics, and even have a pharmacy to boot. Not only are they convenient for referring patients to other doctors, allowing more efficient use of medical resources, they resolve the problem of separating responsibility for writing and filling prescriptions. For surgery, which requires more equipment than other fields, having other specialists right on the spot greatly reduces the difficulty of opening a private practice.

Further, public hospitals could be opened to allow private practitioners to use hospital facilities to treat patients. Not only would this increase use rates of hospital equipment, it would allow surgeons to go out on their own, opening up channels for advancement within hospitals. Chang Chin-wen, who is also a consultant to the Taipei City Government, has been actively promoting this idea, and three municipal hospitals (Jen Ai, Chung Hsing, and Chung Hsiao) will soon begin experimental implementation of the scheme.

Nobody there when you need help?

But even if universal health insurance payments are raised and opportunities for private practice increased, many physicians feel that it will be hard to completely reverse the declining popularity of surgery. "This is related to the overall atmosphere in society-it is not just limited to medicine or surgery."

Tsai Chin-hung reveals, "If I had to do it all again, I would take more pragmatic considerations into account, and I wouldn't necessarily choose surgery." Hu Wei-ming says that his son, now a senior in high school, is very interested in medicine. Though Hu duly avers that he will respect his son's choices, he deeply hopes that his son will not follow the same pathway and choose surgery.

It looks like the specialization of surgery is really on the decline in Taiwan. No one wants the job. No wonder doctors themselves are worried that if they need an operation, they won't be able to find anyone to do the cutting.

Yet, some people say, in the past those with the best grades always went for surgery, leaving many who were interested in the field out in the cold. In this era when surgery is not exactly a popular field, this might be just the chance for those with the desire to become surgeons.