First of all, on behalf of the government of Taiwan, ROC, I like to welcome you all to Taiwan. To my knowledge, this is the first time that the Takemi Memorial Oration is held in Taiwan. As for myself, I am much privileged and honored to be the speaker for this oration today.

For many years, I have heard of Dr. Taro Takemi, a giant from our neighbour country, Japan. He had dedicated his life to the care of society and of common people, and taught us not only how to become a good physician, but also how to be a good citizen. He ever exhorted us that physicians should not forget their social responsibilities. Although 20 some years have elapsed since his departure, his illuminations will stay for generations to come. Standing in front of the giant, especially to make a speech on medical education, I am truly humbled.

My topic today is medical education in the 21st century. In medical education I had engaged professionally for 40 years without interruption till my appointment as Minister of Health in May 2000. Even during my tenure in administration as dean of a medical school and president of a university, I still continued my teaching and educational work. Being both teacher and administrator, I had witnessed the evolution of medical education in the later half of the 20th century. With my personal experience and observations gained during the three quarters of my professional career of 40 years in the United States, and a few years in Europe, I have had deep understandings of the differences of medical education in different systems of different societies with different cultures. And because of those years abroad, I have been able to approach the medical education with a broad spectrum. Most importantly, the new millennium ushers in a new age of global relation, science, technology, and medical practice which is drastically different from that of the conventional medicine. New era needs new types of physician. And the cultivation of good new physicians demands good medical education with new approaches.

What defines a medical education as new? What different path should it follow?

Firstly, our future physicians need to know how to adapt themselves to the new demands of medical practice. In the new millennium we have to face different foci of disease: new infectious agents like Ebora, Hunta and Nipah virus; new mutations of old infectious agents, such as influenza viruses, drug-resistant microorganisms; re-emergence of old diseases like small pox, hemorrhagic plague, anthrax, possibly by bioterrorism; prominence of age-related, chronic, multifactorial, etiologically complex disorders requiring medical as well as ethical decisions; and the upsurge of mental disorders including aberrant social behaviors. Ever increasing mental burdens only induce more stress, resulting in higher degree of anxiety and depression. Introductions of new types of work may also create new environmental hazards and cause new health problems.

Against those changes we should design the curriculum to prepare our future physicians. Let us forget not that infectious diseases will never be totally eradicated, no matter how potent our anti-viral or anti-microbial devices. Design of nature is such that the structure of nucleic acid is constantly altering, albeit slow and random. Physicians need thus to be fully awared of and prepared to breast the unexpected challenges, lest epidemiological disasters might occur. Similarly, human biology requires a fresh approach with particular attentions to the physiology and pathology of aging and molecular and cellular biology of mental process. Alongside the knowledge on human genome, medical genetics and genetic medicine become prerequisites for the future physicians to apprehend the disease etiology in a new light. On the other hand, preventive medicine and health promotion will weight more than the disease diagnosis and treatment in conventional medicine. As a result, public health will become an essential knowledge for medical practitioners.

How about the newly emerged environmental hazards that we have never encountered before? Asian countries in general are in amidst of transforming from agricultural to agriculture-industrial, and to industrial countries. Unseen land, ocean and air pollution causes new physical symptoms and disorders: chronic respiratory problem by air pollution, ophthalmologic and orthopedic illness by long office hours, and chronic intoxication by IT industry, just to mention a few.

But as the medical complexities increase, the decision whether to perform a particular test, to medicate or to operate, will become more uncertain than ever before, especially when physicians have to practice with limited resources, either in a free market system or in a social insurance/welfare system. They can no longer afford not to aiming at efficiency and balance of cost and benefit, failure of one or both can indeed compromise the quality of care. On the other hand, incidence of medical error already ranks 7th or 8th cause of death in the United States, and will most likely to continue to rise. In short, higher incidence of medical error and aims of efficiency and balance of cost and benefit in a better informed public with a keener awareness of physicians' legal liabilities make the practice more taxing and more time-consuming.

Secondly, new generation physicians need to learn how to learn. We had been going through knowledge explosion in the past decades, and undoubtedly, the trend is going to accelerate and its pace quicken. The knowledge we have and will have acquired is estimated to have only a half life of no more than 6 years. Its transiency will but force them to learn by themselves, continuously through life. Since the human brain has only certain capacity to manage certain amount of knowledge, the aid of an "external brain" to integrate, to analyze, and to utilize it becomes essential and indispensable. Therefore, the 21st century medical students need to be well trained in the information technology, IT. Since the degree of proficiency in the IT can very well be the determining factor in their future success, excelling in this technology becomes mandatory not only for medical academicians but also for general practitioners.

Thirdly, future physicians must realize that the integration of all medical disciplines is unavoidable, for the rapid specification and expansion of medical information have become barely humanly manageable. But the ways of biochemical reaction, physiological function, even pharmacological process and pathological development never operate independently. Since they are all parts of a holistic system which can best be comprehended in a holistic manner, basic sciences should orient toward human-as-a-unit biological science. Similarly, all branches of clinical sciences can best be appreciated when they are integrated into a bed-side oriented clinical science.

Such knowledge integration is indeed a formidable task that proposes reforms with strong administrative supports. Key persons should first be identified who are visionary, enthusiastic and knowledgeable, with no less measures of courage and resolve. These few key persons should have good, thorough trainings to function as the seeds of reform in the institution. Every department should have its own team, material reorganized, and physical settings for teaching redone if needed. Intermural collaborations and sharing of both successful and failing experiences can greatly facilitate the reform. Among all those changes, mind-set is the most difficult to alter, but financial incentive can be a key to success. Once the psychological and physiological barriers removed, the integration can ensue. To my experience, the strongest resistance comes from the faculty members, especially the seniors. The students actually very much welcome the change and found the newly formed courses logical, fascinating and stimulating.

No doubt the integration process is difficult, costly and time consuming. Individual models must be tried out, institution by institution, country by country. Nontheless, the trend is clear, the sooner the reform the easier and less costly it will be. Even though not a single ideal program has yet emerged, once the reform starts, it can never be stopped, urged on by the advance of science.

Fourthly, new physicians need good skills of communication, professionally as well as socially. "Words, words, words," Hamlet of Shakespeare said nonchalantly; but words can heal, and words can kill. Medicine is the most dynamic profession requiring much human interactions. Physicians need not only to learn in order to know, but also to teach in order to heal. They must be able to talk with genuine concerns to patients and their families, failure of which could result in disputes. With no less importance, learning how to speak must presuppose knowing how to listen. Listening well conveys a message of care and concerns. Furthermore, patient education demands accurate, and succinct presentations. For good communication, linguistic and rhetoric training is essential. Repetitive exercise and training under specialists' guidance can be the keys to success.

How about written communication in medicine? A complete, clear and accurate medical record of patient's condition should be considered as one of the most fundamental training in medical school. Medical records are often nothing but physicians' illegible scrabblings, which are illegal and unethical. Good medical writing, just like verbal communication, requires strictly supervised and carefully guided lessons. Perusal of well written medical reports can be of great help in acquiring skills of good writing.

The geographic distance diminishes steadily as the transportation become more rapid, convenient and affordable; resultingly, the diseases can no longer be chartered by boundaries. Among nations or areas with different languages, communications both verbal and written take on a greater importance. In a foreseeable future, English will stay as the international language, making good English ability another important qualifier of success.

Fifthly, new physicians ought to have a great social conscience, and stern obligation to their social responsibilities, the good lessons that Dr. Takemi has taught us. Physicians are a group of people with high social status, not because of their income, but because of their honorable profession. Whatever taken from society should be given back to society, directly or indirectly, and proportionately. They must not violate this social principle. If elites in a more and more capitalized world of the 21st century have no social conscience, the public health system will collapse, and social polarization ensue. Laurie Garrett, a well known Pulitzer Prize-winning reporter, recently published a book "Betrayal of Trust, Collapse of Global Public Health" in which he candidly illustrated this phenomenon. It becomes eminent that future medical curriculum must emphasize humanities more than ever. This is particularly true in Asia, where students are admitted to medical schools directly from high schools. Often time slots allocated to humanities are transgressed to accommodate the professional courses. The humanities, in my opinion, should include philosophy, logics, general and medical history, sociology, literature, art and ethics. Only when physicians understand society and culture can they become good healers and good teachers.

Lastly, physicians must keep themselves fit and healthy. To be a physician demands tremendous physical stamina for tremendous physical and mental pressure. The students should learn how to maintain their own physical fitness, not necessarily through vigorous exercises, but rather via their routine, regular and consistent regimens. Physicians have to keep their physical parameters (pulse rate, respiratory volume etc.) normal in order to teach it effectively to their patients. Equally important is the mental wellbeing. A hobby in art, music, drama or traveling is especially beneficial, as W. Somerset Maugham wrote of the protagonist doctor in his novel Of Human Bondage: "It always comforted him to get among pictures. He looked at none in particular, but allowed the magnificence of their colour, the beauty of their lines, to work upon his soul." Thus in their medical school years, students must be consistently encouraged to cultivate their own interests. A well-rounded human being prefigures a better and kinder physician.

May we also be mindful that in the persuing of the new and of the future, we should not forget our great teachers through ages who have inspired us. In his sacred oath, Hipocrates said, "To hold him who has taught me this art as equal to my parents," "in purity and holiness I will guard my life and my art" and "I will keep them (patients) from harm and injustice." The father of internal medicine, sir William Osler reminded us of physicians' essential virtues of imperturbability and equanimity under all circumstances. Recently deceased American physician, medical educator, and essayist Dr. Lewis Thomas reminded us that the word "medicine" itself is from the root "med," "mederi" in Latin, meaning to look after and to heal. The English words "moderate" and "modest" are also from the same root "med," implying that doctors being modest must practice with moderation because the cognate of human is humility. All those teachings are universally true in east or west, transcending time and space. Practicing medicine, they taught us, should be a humbling experience.

In conclusion, time has come that we recognize and meet the new medical and social demands in a new century. We need to understand anew genetically the human physiology and pathology. Above all, we need to prepare the medical educational system to cultivate better professionals to better undertake their shares of social responsibility.

Finally, I like to conclude this presentation with a saying from Dr. Felix Marti-Ibanez, a renowned Spanish physician, writer and medical educator, "To be a doctor is to be an intermediary between man and God." In other words, be humble, be resolved, be caring, be prepared.

I thank you very much for your attention.

Ming-Liang Lee