Perspectives in medical education. 3. Reforming medical education to change healthcare practice in Japan

Cross-cultural Comparison of Pharmacy Students' Attitudes, Knowledge, Practice, and Barriers Regarding Evidence-based Medicine

Objective. To explore cultural influences on US and Japanese pharmacy students' evidence-based medicine (EBM) attitudes, knowledge, and behavior. Methods. A cross-sectional study was conducted using a self-administered survey. Senior students in one pharmacy school in the United States and two pharmacy schools in Japan were invited to complete a 33-item survey instrument. Results. Students in both countries reported having positive attitudes and understanding of EBM concepts. In their self-evaluation, American students rated their current EBM practice, EBM skills, and access to EBM resources higher than Japanese students rated themselves in these areas. The most common barriers to EBM for American students were lack of time (84.5%), lack of statistical knowledge (63.9%), and lack of critical appraisal skills (53.1%). The most common barriers to EBM for Japanese students were lack of training (92.6%), lack of clinical knowledge (90.4%), and lack of opportunity (88.8%). Conclusion. Although barriers to implementing EBM and confidence levels in using EBM differed between US and Japanese pharmacy students, both cohorts recognized EBM as an important skillset for the pharmacy profession. Culturally specific approaches to teaching EBM to pharmacy students are needed to improve EBM use in practice.

Perspectives in medical education 9. Revisiting the blueprint for reform of medical education in Japan

Reform of medical education at Keio University has been underway since 2003. We measure the progress made since then in five specific categories that span fifteen recommendations presented in our "Blueprint for Reform" at the outset of the effort. These are effectiveness of leadership, curriculum reform, recognition of teaching, clinical competence, and comprehensive training in general internal medicine (GIM). First, effective leadership is being sustained through a succession of Deans, although a potentially crippling loss of leadership in the Department of Medical Education must be offset through timely appointment. Second, curriculum reform is awaiting the implementation in 2012 of an integrated, organ system-based curriculum with an emphasis on ward clerkships, but the introduction of PBL has been delayed indefinitely. Third, teaching is being recognized through the use of student feedback to reward good teachers and through funds for six full-time equivalent salaries dedicated to medical education, but promotions still depend exclusively on research, without consideration of teaching ability. Fourth, clinical skills training is still lacking, although enthusiasm for it seems to be building, thanks to the presence on the wards of a (still miniscule) cadre of dedicated teachers. Finally, exposure to GIM remains non-existent; however, visionary leadership in a newly-independent Emergency Department and the wide variety of medical problems seen there provide a remarkable opportunity to craft a uniquely Japanese solution to the problem. The changes implemented to date are impressive, and we remain enthusiastic about the future, even as we recognize the magnitude of the task that lies ahead.

Perspectives in medical education 8. Enhancing preclinical education in Japan with a clinically focused, interactive anatomy curriculum

Reform of preclinical medical education in Japan requires changes in the curriculum to make it more clinically focused and interactive. At present, course content in Anatomy is usually designed and taught with little or no clinical direction and involves a heavy emphasis on by-rote learning to memorize often minor facts that have little importance in clinical medicine. As a result, the content is boring, it is learned solely for the purpose of passing exams and it is promptly forgotten, with little sense of its need in clinical practice. Successful reform of the curriculum in Anatomy requires two critical changes. The first is that content must be made interesting to students by emphasizing its clinical importance, through a close collaboration between preclinical and clinical departments, Thus, the Surgical Faculty must be incorporated in the organization and teaching of the Anatomy curriculum. Core content can thereby be pared down to only what is considered essential to provide a foundation for the later clinical years, and the clinical importance of that content will, in turn, be self-evident to students. The second change that must be implemented is to make the learning process more appealing to the students. This can be facilitated by the use of any of several commercial IT programs that make learning in Anatomy both dynamic and engaging. These dual strategies will considerably enhance the learning of one of the most basic subjects in the medical school and ensure that the review and retention of the material are enhanced.

Perspectives in medical education: 6 reflections on the state of clinical training for residents in Japan

The Muribushi Project in Okinawa, Japan, is breaking new ground for residency training in Japan by explicitly emphasizing clinical skills training and primary care. The core philosophy of the Project is defined by seven "concepts" that commit to (i) establishing cooperation between several hospitals to educate good clinicians; (ii) providing the best learning environment at multiple training sites; (iii) following global standards of practice; (iv) focusing on primary and emergency care of common diseases; (v) emphasizing faculty development through international exchange; (vi) providing residents with opportunities to obtain training abroad; and (vii) improving the quality of medical care through residents. Observations by the author during two week-long visits, one year apart, reveal that the Muribushi Project is fulfilling conceptual goals (iv), (v) and (vi) by emphasizing primary care and encouraging international exchange for faculty and students. The opportunity exists to fulfill goals (i) and (ii), but it is not being exploited because programs at member hospitals are not integrated, so that residents spend the duration of their residency at one location, and there is no formal system of rotations that would broaden their clinical experience. The Project is failing to meet a sixth goal of following global standards of care (goal #iii) and it is too early to say if it's pioneering approach to residency training is having an impact on healthcare in Japan (goal #vii). On balance, the Project's success in implementing elements of its core philosophy for residency training in the tradition-bound environment of Japan is particularly laudable.

Perspectives in medical education 5. Implementing a more integrated, interactive and interesting curriculum to improve Japanese medical education

Exact parallels can be drawn between the shortcomings in medical education in the US in the 80s and those prevalent in Japan today. Research and clinical practice had primacy over teaching, and primary care medicine, with its focus on humanistic principles, was subordinated to specialization and tertiary care. US medical schools undertook a wide-ranging reform of the traditional curriculum, recognizing its four major shortcomings. These were (i) an institutional failure to accord academic status to teaching, resulting in a disincentive to teach, (ii) a failure by faculty to perceive a shared interest in education, resulting in teaching that was fragmented and even contradictory, (iii) a failure to integrate preclinical and clinical material, resulting in fragmented learning, (iv) a failure to encourage the development of the most important attributes of a physician (independent thinking, problem solving, and self-directed learning). The reform of medical education in the US was achieved through a wholesale restructuring that (i) integrated basic science with clinical medicine across the curriculum; (ii) coordinated teaching across departments by organizing the curriculum into "blocks"; (iii) integrated problem based instruction into the curriculum to encourage active learning; and (iv) elevated the importance of both teaching and primary care. The successful effort to reform medical education in the US can serve as a source of encouragement and a road map for academic institutions in Japan, like Keio University, who recognize the same shortcomings in Japanese medical education and are attempting to develop and implement a curriculum that is more integrated and problem-oriented.

Perspectives in medical education - 4. A "global" dimension to reform at Keio University

Keio University School of Medicine is awakening to the realization that it will achieve international recognition as a center of excellence in medical education and healthcare only by inculcating clinical skills and critical thinking in its medical graduates. A new "global" perspective identifies the traditional failure of Japanese medical education to provide its graduates with clinical skills training as the root cause of a number of deficiencies. These include (i) the reluctance of Japanese medical graduates to seek global experience; (ii) the absence of interest in the global healthcare marketplace for Japanese medical graduates as potential recruits; (iii) the failure to incorporate globally accepted innovations, like problem-based learning, in Japanese medical education; (iv) the failure to follow globally accepted standards of clinical practice in Japan; (v) the lack of instruction in general internal medicine in Japan; and (vi) the neglect of evidence-based medicine in Japanese healthcare practice. Keio University is embarking on an ambitious effort that commits both the will and resources necessary to reform medical education at Keio in accordance with global norms. The initiatives currently underway include (i) incorporating PBL into the curriculum to foster active learning, (ii) implementing measures to promote interactive teaching techniques among the faculty, and (iii) granting recognition to teachers through new promotion policies. Wider implementation of these initiatives across the country will enable Japanese healthcare and Japanese physicians to occupy their rightful place of respect in the global healthcare market, comparable to the widespread international recognition given to Japanese medical researchers.