E-Da Hospital I-Shou University School of Medicine and GME

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E-Da Hospital/I-Shou University School of Medicine and GME programs: Brief Introduction & Overview Director Cheng-Loong Liang, M. D. , Ph. D. James (Tao. Qian) Tang, M. D. E-Da Hospital/I-Shou University

Outline l l l l l Founder’s Philosophy Business Sectors in E-United Group Visions, Missions, and Core Values Strategic Goals Differences in Terminology Between U. S. and Taiwan GME Training Programs I-Shou University Medical Education Program Postgraduate Combined Training Programs (Internship and Residency Programs) Sample Budget The Future…

Founder’s Philosphy Contributing to the Community □ Creating a comfortable, healing environment for patients □ Providing humane, highquality, and safe patientcentered care □ Importing advanced medical technologies Board Chairman Mr. I-Shou Lin “An ordinary man with an extraordinary vision”

Business Sectors in E-United Group Education I-Shou University I-Shou International School Manufacturing 7 Stainless steel manufacturing companies E-United Group Medical Education foreign students Medical Services and Health Care E-Da Hospital E-Da Cancer Hospital Da-Chang Hospital Real Estate and Leisure Business Eliter International Corp. E-Da Development Corp. E-Da World

Visions, Missions, and Core Values Missions Quality, Excellence, Innovation Visions To become a world-class medical center Core Values Kindness, Caring, Responsibility, Continuous Refinement

Organization Chart Board of Directors (9) E-Da Strategy-Decision Committee Administrative Center Superintendent Medical Affairs Management Office Committees Hospital Operation Assistants Office Human Resources Office Medical Vice Superintendent Ancillary Vice Superintendent Education Vice Superintendent Research Vice Superintendent Medical Quality Vice Superintendent Information Technology Dept. Medical Engineering Dept. Medical Affairs Paramedical Services Medical Education Medical Research Medical Quality and Patient Safety Administration Affairs Department Occupational Safety and Health Office

Strategic Goals To be a beacon of medical care for the Strategic community Goals To become the best healthcare provider in southern Taiwan To provide patient-centered and high quality healthcare To inspire and encourage advanced medical research and education To train domestic and international medical professionals and promote international academic exchange

Strategic Goals To be a beacon of medical care for the Strategic community Goals To become the best healthcare provider in southern Taiwan To provide the patient-centered and high quality healthcare To inspire and encourage advanced medical research and education To train domestic and international medical professionals and promote international academic exchange

Location of E-Da Hospital Located in Northern Kaohsiung City – As the biggest hospital in this area, we provide timely medical services for patients in northeastern rural districts and surrounding counties. I-Shou University Medical School

Bed Allocation Beds Staffed Beds Acute Psychiatric Care 30 74 Burn Care Special Beds 900 Intensive Care General Beds Acute General Care 1 Recovery 21 Sick-Baby Room 15 Respiratory Care 10 Emergency Room 60 Total 1111

Staff Types of staff Physicians Number 389 Nurses 1093 Paramedical staff 539 Administrative staff 577 Total 2, 598

38 Medical Specialties 1 General Medicine 11 Cardiac Surgery 21 Family Medicine 31 Diagnostic Radiology 2 Cardiology 12 Thoracic Surgery 22 Neurology 32 Radiation Oncology 3 Chest Medicine 13 Neurosurgery 23 Pediatrics 33 Nuclear medicine 4 Nephrology 14 Plastic Surgery 24 Dermatology 34 Anatomical Pathology /Clinical Pathology 5 Infectious Diseases 15 Pediatric Surgery 25 Psychiatry 35 Pain Clinic 6 Gastroenterology 16 Urology 26 Otolaryngology 36 Health Screening 7 Hematology & Oncology 17 Proctology 27 Anesthesiology 37 Occupational medicine 8 Endocrinology & Metabolism 18 Orthopedics 28 Emergency Medicine 38 Chinese Medicine & Acupuncture 9 Allergy Immunology 19 Rheumatology Ophthalmology 29 Dentistry 10 General Surgery Obstetrics & Gynecology 30 Rehabilitation Medicine 20

Facilities Gamma Knife Radiosurgery PET Center Rapid-Arc Thulium Laser 640 -Row CT Scanner

Total Laboratory Automation Aims Process 1. Reduce laboratory 1. Automatic processing human errors 2. Reduce turnaround time of laboratory tests 3. Offer more effective work environment for lab staff 3. Enhance patient safety systems (APS) 2. Auto-verification 3. Computer-assisted Barcoding System

Strategic Goals To be a beacon of medical care for the community Strategic Goals To become the best healthcare provider in southern Taiwan To provide the patient-centered and high quality healthcare To inspire and encourage advanced medical research and education To train domestic and international medical professionals and promote international academic exchange

Hospital Statistics Number of outpatients / month Number of inpatients / month Number of emergency visits / month Number of surgeries / month

Top-five Diagnosis and Procedures Diagnosis • Pneumonia • Malignant neoplasm of liver, primary • Urinary tract infection • Unspecified cerebral artery occlusion with cerebral infarction • Osteoarthrosis • Lumbar and lumbosacral fusion, posterior technique • Total knee replacement • Transurethral removal of obstruction from ureter and renal pelvis • Insertion or totally implantable vascular access device (VAD) • Other repair or plastic operations on bone, other site

Health Care for Community Service Education －Free Services －Raising Awareness －Disease Screening －Home Care －Health Checkup －IDS (Integrated Health Care Delivery System) －Health Promotion and Medical Alliance & Survey －Family Support delivery system －Public Health Information －Medical Alliance －Intern/Resident training －Survey of Community Health demand

Milestones p Received JCI Hospital Accreditation 3 times in a row and became the first international accredited hospital in southern Taiwan, 2011 p Our therapy team for morbid obesity acquired the Symbol of National Quality (SNQ), 2011 p Bronze medal was awarded to our Hospital Information Management Group (Hospital Category) in National Biotechnology & Medical Care Quality Award of 2012, 2012

Research Programs ※ Numbers of currently ongoing Human Clinical Trials Research Project ： 43 2011 2012 2013 2014 Human Clinical Trials Research Project 20 10 23 18 Translational Research Project 65 69 101 110

Publications (2004 -2016): 1195 articles 1. Risk of leukaemia in children infected with enterovirus: a nationwide, retrospective, population-based, Taiwanese-registry, cohort study. Lancet Oncol. 2015 Oct; 16(13): 1335 -43. 2. Adjuvant chemotherapy in locally advanced bladder cancer. Lancet Oncol. 2015 Mar; 16(3): e 103 -4. 3. Renal transplant recipient infected with Penicillium marneffei. Lancet Infect Dis. 2010 Feb; 10(2): 138. 4. Near-fatal sore throat. Lancet. 2008 Mar 29; 371(9618): 1136. 5. A girl with episodic abdominal pain. Lancet. 2007 Jun 2; 369(9576): 1890. 6. Clonic Perseveration vs Stereotypy Phenomenology. JAMA Neurol. 2016 Feb 1; 73(2): 241. 7. Intermittent bolus or continuous infusion of proton pump inhibitors for ulcer bleeding? JAMA Intern Med. 2015 Mar; 175(3): 461. 8. Images in clinical medicine. Congenital adrenal hyperplasia. N Engl J Med. 2015 Jun 11; 372(24): e 32. 9. Images in clinical medicine. Intestinal infestation with Ancylostoma ceylanicum. N Engl J Med. 2012 Mar 29; 366(13): e 20. 10. Images in clinical medicine. Patent urachus. N Engl J Med. 2011 Oct 6; 365(14): 1328 11. Images in clinical medicine. Falciform-ligament sign of pneumoperitoneum. N Engl J Med. 2004 Oct 28; 351(18): e 16.

Organization of Medical Education Department in E-Da Hospital Responsible for: Director of Medical Education Dept. Ø Curriculum Ø Clinical rotations Ø Patient safety in education Ø Faculty training

Differences Between U. S. and Taiwan Graduate Medical Education Training Programs

U. S. System Students have to complete a baccalaureate degree, 2 years of pre-medical courses, and take the MCAT prior to entry to medical school. Medical school education is 4 years. Upon graduating from medical school, a trainee would usually enter a transitional year program, preliminary year program, or a categorical training program (Family Practice, Internal Medicine, General Surgery, OBGYN, etc).

U. S. System For example, if you are training in internal medicine in the U. S. , you do not have to go through a one year transitional program or preliminary year program. You go straight into a 3 year categorical Internal Medicine Residency program. In the U. S. medical training terminology, R 1 = PGY 1 = intern.

Taiwan System Students go through 7 years of medical school upon graduating from high school. In their 5 th and 6 th years of medical school, they are called “clerks. ” In their 7 th year, the students are called “interns. ” Upon graduating from medical school, a trainee is required to complete a one year training called “PGY program” regardless of his/her future specialty. 7 + 1

Taiwan System This “PGY program” is very similar to the transitional year program in the U. S. where the trainee goes through rotations in internal medicine, surgery, community medicine, ER, electives, etc. For example, in order to be a Board Certified Internal Medicine physician in Taiwan, a trainee would have to go through a one year “PGY program” + 2. 5 years of categorical Internal Medicine Residency training. In Taiwan’s medical training terminology, R 1 ≠ PGY ≠ intern.

Taiwan System l U. S. Department of Education’s National Committee on Foreign Medical Education and Accreditation (NCFMEA) has determined that the accreditation standards used by Taiwan were comparable to standards of accreditation used to evaluate medical education in the United States l. All Taiwan medical school graduates are eligible to take the United States Medical Licensing Examination (USMLE). http: //sites. ed. gov/ncfmea/comparability-decisions/

Residency Training Positions by Specialty as approved by Ministry of Health Specialty General Surgery Pediatrics Internal Medicine OBGYN Family Practice Urology Orthopedics Neurology Psychiatry ENT Nuclear Medicine Radiology-Oncology Emergency Medicine Clinical Pathology Ophthalmology Neurosurgery Anesthesiology Plastic Surgery Occupation Medicine 2015 7 2 4 1 2 2 2 6 1 1 2 1 0 2 1 1 2014 7 2 5 1 2 2 2 8 0 0 2 1 1 2 0 0 1 1 1 0

I-Shou University Medical Education Program

E-Da Hospital and I-Shou University School of Medicine is designed based on the U. S. system, where it is a postbaccalaureate education of 4 years. First 2 years consists of mostly classroom learning. Final 2 years is mostly clinical/bedside learning. This is very unique when taken in perspective to other medical school programs in Taiwan.

Medical Students’ Countries of Origin Class of 2017 (7/32): Palau-2 / Solomon Islands-3 / Marshall Islands-1 / Kiribati-1 / Swaziland-10 / Guatemala-2 / Gambia-1 / Dominican-1 / Haiti-1 / St. Vincent -2 / St. Lucia-7 / El Salvador-1 Class of 2018 (10/29): Solomon Islands-6 / Marshall Island-2 / Kiribati-2 /Paraguay-3 / Swaziland-9 / Dominican-1 / Honduras-2 / St. Kitts and Nevis-1 / St. Lucia -3 Class of 2019 (13/33): Solomon Islands-4 / Marshall Islands-5 / Kiribati-3 / Tuvalu-1 /Paraguay-1 / Swaziland-15 / Nicaragua-1 / St. Lucia-3 Class of 2020 (10/40): Solomon Islands-5 / Marshall Islands-3 / Kiritati-1 /Tuvalu-1/ Swaziland-17 / Nicaragua-1 / Honduras-3 / Belize-2 / St. Vincent-1 / St. Lucia-5 / St. Kitts and Nevis-1

Social Responsibility l. I-Shou University School of Medicine is allotted 50 spots per year. Taiwan’s Ministry of Foreign Affairs provides full scholarships for up to 40 medical students per year. l. Full scholarships are only offered to students from countries that maintain official diplomatic relations with Taiwan. l. Students must come from countries that are considered “developing. ” l. If “developing” nations who do not maintain official diplomatic relations with Taiwan (but wish to send students to I-Shou University), their students can still apply. These students may have to find funding from other sources such as WHO, etc.

Medical Education Program Simman /Simbaby Intravenous Injection Nasogastric intubation Endotracheal intubation Central venous catheterization 01 Skill Training 04 02 ACLS Training Simulation training Training program 　 03 OSCE Testing Competition

Clinical Skills Center l l l 38 Clinical Skill Classrooms 1 Surgical Simulation Room 1 ICU Simulation Room 4 Problem-based Learning (PBL) Room 1 Storage Room 模擬開刀房 1 Central Control Room

Central Control Room Monitoring Discussion Room Monitoring Simulated Consulting Room u Monitoring system u Clinical skill trainings will be recorded to provide self-evaluations.

81 Skill Sets – Based on Netherland Medical Education

81 Skill Sets – Based on Netherland Medical Education l Taiwanese medical laws require that Taiwanese clerks and interns to be proficient in these 81 skill sets. l Likewise, E-Da Hospital/I-Shou University also requires the skill sets for our foreign medical students. Each student has a “passport” documenting what skill sets they have completed. They also need to fill in patient ID, date/time of completion, etc. And it needs to be signed by a physician. l E-Da Hospital/I-Shou University sets a high bar of standard of excellence for its students, interns, and residents.

E-DA Hospital Library

Medical Education Costs l I-Shou University School of Medicine charges USD 18, 000/student/year. This covers tuition, room and board, student fees, and a monthly stipend for students. l Funded in great part by International Cooperation and Development Fund (Taiwan. ICDF)

Postgraduate Combined Residency Training Programs

Background The first class of I-Shou University School of Medicine will graduate in Spring, 2017. Just graduating from medical school is NOT enough to be qualified as a physician who can independently diagnose and treat patients (at least based on American and Taiwanese standards). Real medicine is learned through residency, where residents accumulate the necessary experiences in the specialties of their Choice. Internship is an integral, but small part of a complete graduate medical training. Many students have approached us with this important issue.

Important Questions to Ask So, in the minds of every student and his/her home country, there are some VERY important questions : 1. 2. 3. 4. 5. • What do we do next? • What factors do we have to consider? • What obstacles do we have to overcome in order to properly train these graduates? • How to let these graduates take full advantage of the state of the art medical facilities/technologies/faculty offered by E-Da Hospital? • How do we sustain these programs?

Important Factors to Consider

Possible Solution to the Legal and Cultural/Linguistic Factors (Internship) As we understand it, Palau is setting up the Internship Training Program for medical school graduates of U. S. Affiliated Pacific Islands (USAPI). However, Palau may need physicians of different specialties/subspecialties to successfully implement the Internship Training Program. It is possible that E-Da can rotate attendings of different specialties/subspecialties to Palau to help supervise and train the interns. It is also possible that interns can have a portion of their training at E-Da Hospital (especially in the specialties where special equipment are required).

Palau Internship Program (Possible Versions): 12 months (12 months at Palau) • 18 months (6 months at E-Da, 12 months at surgery + 1 4 months internal medicine + 4 months month Palau) pediatrics + 1 month OBGYN + 1 month others (neurology, rehabilitation, ER, or ICU) + 1 month electives (radiology, psychiatry, dermatology, etc) • 24 months (8 months in E-Da, 16 months at surgery + 2 5 months internal medicine + 5 months Palau) months pediatrics + 2 months OBGYN + 2 months others (neurology, rehabilitation, ER, or ICU) + 2 months electives • 6 months internal medicine + 6 months surgery + 3 months pediatrics + 3 months OBGYN + 3 months others (neurology, rehabilitation, ER, or ICU) + 3 months

Possible Solution to the Legal and Cultural/Linguistic Factors (Residency) It is possible that residents can alternate their training between their home countries/institutions and E-Da Hospital (i. e. , alternating 3 months or 6 months rotations) That way, residents can quickly apply what they learn at E-Da at their respective countries. And if they come upon a problem in their home institutions, they can use live audio/visual consultations with their teachers back at E-Da.

Possible Solution to the Legal and Cultural/Linguistic Factors (Residency) It is also possible that E-Da can rotate attendings to supervise the trainees in their respective home countries/institutions (especially with invasive procedures or surgeries). The trainees would also quickly realize what techniques or knowledge they need to improve on; so that when they rotate back to E-Da, they can work toward their specific needs and issues.

Possible Solution to the Legal and Cultural/Linguistic Factors If E-Da Hospital can serve as a referral hospital for Palau and/or other U. S. Affiliated Pacific Islands, residents and interns of the Postgraduate Combined Training Programs can help care for these patients during trainees’ rotations at E-Da Hospital.

Possible Solution to the Legal and Cultural/Linguistic Factors (Residency)

Financial Factor While E-Da is very willing to contribute its part towards providing high quality education and care for medical students/trainees of all backgrounds, creating and maintaining residency programs are costly. In 2008 in the US, the median GME cost per full-time equivalent (FTE) resident across teaching hospitals was USD $134, 803/resident/year (funded mostly by Medicare). This includes only costs that were incurred by the teaching hospital and does not include costs incurred by a medical school or other educational partners.

Financial Factor In Taiwan, for each Taiwanese resident, the government provides around USD 2, 500/resident/month. Average cost for the hospital to keep each resident per month is around USD $5, 000 (including salaries but does not include maintaining secretaries and other staff). A fraction of the costs compared to the U. S. However, Taiwan residents also help make money for the hospitals by taking calls (6 -8 overnight calls/month), having outpatient clinics, performing procedures, etc. This is how Taiwan hospitals break even in sustaining residency programs.

Training foreign interns/residents is a completely different matter: More resources need to devoted. More staff, more attendings, etc. Foreign interns/residents are less able to contribute financially to the hospitals such as independently being on call, having outpatient clinics, doing procedures, etc. , due to legal and linguistic issues. Close supervision is needed, and that incurs extra costs. Travel costs, living expenses, dormitory costs, insurance, salary for the foreign interns/residents AND the attending physicians who will be traveling back and forth. And these do not account for the lost income for the hospitals when attendings are at other countries.

Sample Budget l Each Attending can supervise a maximum of 5 interns and/or residents to ensure quality of training. Ø For 1 to 5 interns/residents = 1 attending Ø For 6 to 10 interns/residents = 2 attendings, so on… l Based on the “ 18 Months” version of internship training = 12 months at Palau and 6 months at E-Da Hospital: l Attending Physician Costs (while rotating at Palau): Ø USD 15, 000/attending/month x 12 months = USD 180, 000/year Ø Includes salary, insurance, and monthly round trip airplane tickets for rotating attendings. Does not include room and board. 5 months internal medicine + 5 months surgery + 2 months pediatrics + 2 months OBGYN + 2 months others (neurology, rehabilitation, ER, or ICU) + 2 months electives

Sample Budget 5 Interns/Residents Costs: l Fees: USD 4, 000/trainee/month x 6 months = USD 120, 000 Ø This is for the 6 months rotations at E-Da. Includes one round trip airplane tickets and medical insurance. Ø Housing/utility will be provided for free. l Salary: USD 1, 000/trainee/month x 18 months = USD 90, 000 Ø Not included in Fees l E-Da uses the lowest possible figures (same as Taiwanese intern/resident training expenses) in calculating costs. We try to absorb as much costs as fiscally possible.

Sample Budget Coordinators: l Need 2 coordinators (with medical backgrounds and fluency in English/Chinese) to collect graduates’ training data, patient numbers, patient profiles, quality control (making sure graduates meet standards of excellence with enough exposures to different diseases), compliance with Palau/Taiwan medical requirements and laws, etc. l Salary: USD 30, 000/coordinator/year x 1. 5 years = USD 90, 000 Ø Includes round trip flight tickets and medical insurance. Ø Does not include room and board. Ø Fixed Costs. Ø The more the trainees, the less fixed costs per trainee.

Financial Summary l To successfully implement an “ 18 Months” version of internship training course (including salaries for attendings/trainees, plane tickets, insurance, fees, coordinators, etc), the estimated cost is USD 480, 000/5 trainees. l About USD 5, 334/month/trainee. l If trainees come from multiple countries, costs could perhaps be shared. Versus United State resident training cost… l USD $134, 803/resident/year in 2008 dollars. l About USD 11, 233/month/trainee l If we have 10 trainees/2 Attendings in the E-Da/Palau joint program, then the costs fall to about USD 4, 833/month/trainee. l Its more cost-effective to train at increment of 5 trainees.

Financial Factor E-Da is a private institution. We are willing to help cover part of the expenses, but other financial resources are still needed to successfully fund and sustain the training programs. Other resources may have to obtained through political negotiations and/or grant applications. For example, PIHOA , WHO, etc

The Future… These Postgraduate Combined Training Programs (internship and residency) are new and unique. Many specifics are still in the planning stages. We can customize the programs to the needs of the trainees’ home countries and institutions. E-Da Hospital/I-Shou University provides costeffective, flexible, and English based education/training programs that are well-suited to the needs of U. S. Affiliated Pacific Islands.

The Future…

The Future… Due to Palau’s goal to be a leader in internship training for USAPI, Palau may consider in obtaining JCI accreditation for its hospital to gain international recognition and approval as a teaching medical center. Much “hardware” and “software” are needed. If the post-graduate combined training programs are successfully established and sustained, Palau may have taken a significant step towards this goal.

Summary The Medical Services and Health Care and the Education arms of the E-United Group are expanding and culturally diverse entities that have both the tangible and intangible attributes to provide quality training and education for people of all countries, backgrounds, and specialties. We look forward in establishing Postgraduate Combined Training Programs with other nations, hospitals, or entities.

Seeing is Believing! We welcome you to visit us and see for yourselves!

OBSTETRICS & GYNECOLOGY Residency Training Program The Department of Obstetrics and Gynecology at E-Da hospital offers a four-year residency training program designed to offer a broad exposure to all aspects of the health care of women. The four-year program offers an intense exposure to General Obstetrics and Gynecology, as well as the subspecialties of Gynecologic Oncology, Urogynecology & Pelvic Reconstruction, Maternal Fetal Medicine, Reproductive Endocrinology & Infertility, and Family Planning, contraception and abortion. Residents also gain exposure to the role of the Ob/Gyn as a provider of primary care for women.

PGY 1 PGY 2 PGY 3 PGY 4 Obstetrics 2 blocks Private Gynecology 2 blocks Obstetrics 2 blocks Gynecologic Oncology 2 blocks Gyn. at EDDC 2 blocks Gynecology 2 blocks Ultrasound/REI 1 block Gynecology 2 blocks Night Float 2 blocks Gynecology Clinics 1 block Night Float 2 blocks Night Float 1 block Call-Free Elective 1 bloc. K Women’s Health 1 block Gynecology Clinics 2 blocks REI 1 block Outpatient Medicine/Family Planning 1 block Gynecologic Oncology 2 blocks Emergency Room 1 block Obstetrics Float 2 blocks Jeopardy 2 blocks Elective 1 block Night Float 1 block