일본의 의학교육 현황: 시스템 개혁중 (Med Educ, 2007)
The current state of medical education in Japan: a system under reform
Alan Teo
학부의학교육
UNDERGRADUATE MEDICAL EDUCATION
6년, 2+2+2, 6학년은 국가시험 준비기간. 매년 약 7800명의 학생, 80개의 의과대학
Medical school in Japan begins immediately after graduation from high school and lasts 6 years. In general, the first 2 years are designated for liberal arts education, the middle 2 for pre-clinical studies, and Year 5 for clinical clerkships. Year 6 is typically reserved for graduation examinations and prepar- ation for national board examinations. Each year, approximately 7800 students enter 1 of the 80 public and private medical schools in Japan.
교육과정은 다양하지만 보통 학문단위중심 접근. 1학년은 general education, 2학년과 3학년은 기초의과학, 3학년과 4학년은 계통중심 교육. 학기당 10~15과목을 수강하나 보통 1주일에 1~2시간에 그친다.
Curricula vary but in general adhere to a traditional discipline-based approach. Typical classes during the first year of medical school include general education requirements and what would be prerequisites for medical school in the USA (e.g. biology, chemistry, English). In Years 2 and 3, students often take classes in the basic medical sciences (e.g. anatomy, immu- nology, pathology, pharmacology and physiology). In Years 3 and 4, students remain in the classroom but begin taking courses organised around specialties (e.g. cardiovascular medicine, gastroenterology, infectious disease, neurology, obstetrics and gynaecology, and public health). Japanese medical students take some 10–15 classes per term, but each class typically meets for just 1 or 2 hours a week.
North American reforms in medical education have also found their way to Japan. The 1990s saw the introduction of the objective structured clinical examination (OSCE), problem-based learning (PBL) and introductory courses in clinical medicine.2 All medical schools now utilise the OSCE bundled with a computer-based test to form a national Common Achievement Test (CAT), launched in 2005.2 Some schools, such as the private Tokyo Women’s Medical University, have also reorganised curricula from the traditional, academic, discipline-based approach to a format that is organ-based.3
Medical students usually gain their first ward experi- ences during Year 5 of medical school. Although patient interaction and clinical teaching at the bedside may be included, it is far less emphasised than performing literature reviews, writing weekly reports on patients’ medical conditions and attend- ing lectures. Medical students on clinical rotations observe rather than actively participate in clinical care (a respected form of learning called minarai). Students are not considered an integral part of the medical team, nor do they themselves consider patient care among their learning objectives.
6학년때에는 각 전공과에 대한 십수개의 시험을 위해 공부하며, 몇 달에 걸쳐 의사국가시험을 준비해서 본다. 2004년까지는 의사면허시험에 합격해도 postgraduate training을 받지 않아도 되었으나 85% 정도는 자발적으로 수련을 받았다.
During the last year of medical school, students study intensively for dozens of examinations covering each specialty in medicine. At the end of Year 6, students take the Ishi Kokka Shiken, the Japanese national board examination, for which they prepare many months in advance. Until 2004, those who passed the national boards were not required to pursue a postgraduate training programme to practise medicine, although approximately 85% of graduates did so voluntarily.
졸업후 의학교육
POSTGRADUATE MEDICAL EDUCATION
2004년 이전에는 GME 구조는 원래 독일의 형태를 따랐으며 교육원칙은 중국의 것을 따른 것으로 보인다면, 조직과 운영은 전통적인 일본의 위계 모델을 따른다. '의국'이라 불리는 임상과는 과장이 사실상 모든 측면에 대한 통제를 지니는 형태이다. 과장은 다양한 지역병원들과의 관계를 유지한다. 그(여자가 과장인 경우는 거의 없다)는 제자를 어디에 보낼지 결정하는 일방적인 권한을 가지고 있다. 이러한 시스템은 고착화된 공생관계에 의해서 유지되는데, 지역의 병원은 지속적으로 새로운 인력을 지원받을 수 있고 젊은 의사들은 과장의 비위를 맞춰서 고용의 기회를 보장받는다.
To understand postgraduate clinical education be- fore the 2004 reforms, one must understand the structure of Japanese clinical) academic departments. If the format of medical school in Japan originally hailed from Germany4 and the pedagogical princi- ples utilised seem Chinese,5 then the organisation and operation of these clinical departments derive from a traditional Japanese hierarchical model. Clinical departments, known as ikyoku,6 are headed by a department chair who single-handedly controls virtually every aspect of the department. In this traditional system, the influential department chair fosters and maintains relationships with various community hospitals. He (women are exceedingly rare in such positions) also wields unilateral authority in determining to which hospital to send his young doctor trainees and even junior faculty. The systemis sustained by an embedded symbiosis: community hospitals benefit from a constant source of new employees to replace doctors who leave to establish their own practices; young doctors receive guaran- teed employment and a chance of advancing in academia by pleasing the department chair.
이 시스템 내에서 PGME가 전통적으로 다양한 배경과 경험을 제공하지 않는지에 대한 두 가지 이유가 있다. 한 가지는, 구조적으로 입원환자든 외래환자든 다양한 과를 돌지 않았다. 두 번째로, 수련과정은 주로 세부전문과목의 연구에 통달한 멘토에 의해서 좁고 긴 도제식 과정으로 이뤄졌다.
Within this system, there are 2 reasons why postgra- duate medical education (PGME) did not tradition- ally provide a broad background and experience. First, systematic, structured rotations through various departments in both inpatient and outpatient set- tings usually were not included.7 Second, training was skewed by a narrow, longitudinal apprenticeship with a single mentor who was typically a research-trained subspecialist.4,8,9
의국이 대학병원에 존재하는 것이라서 학문단위(교실, koza)과 기능적으로 연결되어 있다. 또한 의국과 교실은 동일한 한 명의 과장이 이끈다. 이러한 연결관계는 임상 수련과 연구 수련의 구분이 불분명함을 보여주는 것이기도 하다. 의국과 교실은 의사-과학자가 지배하고 있으나, 의사-교육자는 매우 부족하다. 실제로 일본에는 clinical professorship 시스템이 없다. 의국-교실 에서는 의사-과학자 양성을 강조하므로, 대부분의 의대 졸업생들은 박사학위나 연구를 위해서는 수년간 의국-교실에 머물러야 하며 일부 시간만을 임상 업무에 할애한다.
Because ikyoku are located in university hospitals, theyare functionally linked with academic departments, or k oza, and the same chairman runs the combined ikyoku-k oza. This linkage is evidence of a lack of delineation between clinical and research training; the ikyoku-k oza is dominated by doctor-scientists but apaucity of clinician-educators.10,11 Indeed, there is noclinical professorship system in Japan.4 Given the ikyoku-k oza’s emphasis on training doctor-scientists,1 medical graduates may stay in the ikyoku-k oza for many years to pursue a PhD or research, spending only limited time on clinical duties.
Teaching conferences like morning report, noon conference, morbidity and mortality, and grand rounds rarely occur or lack resident and student participation.12 More ritual than substance makes up the uniquely Japanese tradition of weekly depart- mental chair rounds. The chair makes what amounts to a polite social visit to each patient on the service with a phalanx of junior clinicians and students in tow. Depending on the style and inclination of the professor, he may discuss aspects of a patient’s care or make teaching points while rounding.
PGME의 이러한 환경에서 일본 전공의의 임상술기 수준이 미국의 의대생 3~4학년 정도에 머문다는 것은 놀랄 일도 아니다. 일본을 방문하는 의사들은 병력청취나 신체진찰에서 상당한 수준 차이를 느낀다. 다른 나라에서 의대생 시기에 해보는 경험을 레지던트 기간에조차 못하기도 한다.
Given this context for PGME, it may not be surprising that the clinical skill of Japanese residents has been compared with that of American medical students in Years 3 and 4.2,13,14 Clinicians visiting Japanese teaching hospitals have observed major gaps in competency in taking a thorough history and per- forming a physical examination.12,13,15,16 Skills that medical students elsewhere develop during their clinical years are often not practised until postgra- duate training in Japan.
PGME에서 일본의 인턴과 레지던트는 오랜 시간을 일한다. 미국과 달리 - 주당 80시간으로 정해진 - 일본 의사들은 sign-out system, cross-cover, floating schedule 없이 근무하며 늦은 밤까지 일하고 아침 일찍 돌아와야 한다. 보통 하루에 15시간을 일하며 온콜이 아니어도 늦게까지 일하고, 퇴근 없이 몇 주씩 일하기도 한다. 병원에서 일하는 시간이 진료하는 시간을 의미하는 것은 아니다. 젊은 의사들은 연구도 해야하고 케이스 보고도 해야한다.
During postgraduate training, Japanese interns and residents work long hours. Unlike in the USA, where duty time is limited to 80 hours per week by mandate and shift work is more standard, Japanese doctors in training work without a sign-out system, cross-cover or floating schedules because they are expected to stay in the hospital until late at night and return early each morning. Residents typically work 15-hour days, stay overnight even when not on call, and may go for weeks without a day off. Time spent in the hospital, however, does not always mean time spent on patient care. Young doctors in Japan are expected to publish, and many in-hospital hours are spent researching and writing case reports and other manuscripts.
PGME 개선
POSTGRADUATE MEDICAL EDUCATION REFORM
2004년 4월, MHLW는 공식적으로 2년의 PGME를 도입했다.
In April 2004, the Ministry of Health, Labour and Welfare (MHLW) officially implemented 2 major changes to Japan’s postgraduate clinical education.17
처음으로 2년의 로테이션 구조가 의무화되었다. 이 법은 1968년 단순히 독립적 진료를 하기 전 최소한 2년의 PGME를 권고한 법을 대체하는 것이며, 초기연수(shoki kenshu)이라 불리는 2년의 기간은 종종 레지던트 라고 번역되기도 한다. 그러나 이 시간은 미국의 의대 졸업생의 인턴 기간, 혹은 영국 졸업생의 foundation program과 비슷하다. 여러 과를 도는 것이며 하나의 과에 국한된 것이 아니기 때문이다. 이 인턴십이 끝나야 진정한 의미의 전공의(후기연수)를 할 수 있다. 첫 2년간의 PGME에서 일본 인턴은 7개의 과를 돈다. 지역기반의료 로테이션은 일차의료를 강조하기 위한 것이며 소규모 혹은 중규모 병원, skilled-nursing facility, 적십자병원, 농촌지역병원 등에서 반드시 수행되어야 한다.
First, a 2-year-long structured set of rotations became mandatory. This law replaced a 1968 regulation that merely advised graduates to pursue at least 2 years of postgraduate training before setting up an inde- pendent practice. This 2-year experience, known as shoki kensh u, is often translated as a residency , but it is actually more akin to the internship year of American medical graduates or foundation pro- grammes in the UK as participants rotate through numerous departments and are not yet attached to any single specialty. Only after the internship can young doctors enter k oki kensh u, true specialty-based residencies. During the first 2 postgraduate years, Japanese interns rotate through 7 specialties (inter- nal medicine, surgery, emergency medicine or anaesthesiology, paediatrics, psychiatry, community- based medicine, and obstetrics and gynaecology), spending at least 6 months in internal medicine. Community-based medicine rotations are supposed to emphasise primary care and must take place at small- to mid-sized hospitals, skilled-nursing facilities, Red Cross blood centres, health centres or rural clinics. Activities might include home visits, public health education events, health fairs, psychiatric counselling, vaccination campaigns or disease screening.17
대부분의 수련 프로그램은 두 개의 트렉이 있다. 내과계 인턴십 / 외과계 인턴십
Most training programmes offer 2 basic tracks for the internship: 1 for those interested in internal medicine and another for those interested in surgery (Figs. 1 and 2). Programmes have been given substantial leeway in designing schedules tailored towards a student’s potential specialty and many programmes, particularly those for future surgeons, shorten non-surgical rotations to a single month.
2년짜리 인턴십의 초점은 기본적 임상술기를 익히는 것이다. MHLW는 세 가지 원칙을 제시했다.
The focus of the 2-year internship is on teaching basic clinical skills; the new curricula emphasise treatment of the most common disorders and symptoms and development of physical examination skills. In planning the new system in 2000, the MHLW first declared 3 guiding principles for the new required internship:
1 to cultivate physicianship;
2 to deepen understanding of primary care and
3 build core clinical competency in evaluating a patient as a whole, and to create an environment in which interns can 3 devote themselves fully to their internship without moonlighting .17
MHLW가 도입한 두 번째 주요 변화는 매칭 시스템을 도입한 것이다. 미국의 것과 비슷하나 두 가지 큰 차이가 있다. 일본의 시스템은 단순히 프로그램만 매칭해주며 전공까지 매칭해주지는 않는다. 전공과목 수련은 후기연수에서 이뤄진다.(3년차), 둘째로, 일본에서는 중간에 얼마나 많은 지원자들이 있었는지 알려준다. 이 중간발표는 경쟁률이 높은 프로그램에 지원한 사람이 다른 프로그램을 지원할 수 있게 정보를 주는 것이다.
The second major change made recently by the MHLWis that, for thefirst timeever, a matchingsystem administeredby the newJapanese Residency Matching Programme went into effect. The systemis similar to that in the USA, with a computer algorithmthat attempts to match candidates to 1 of their top training programme choices. There are 2 important differ- ences, though. First, applicants in Japan match simply to a programme and not a specialty. Specialty training comes inthe k oki kensh u residency, starting inthe third postgraduate year. Second, the Japanese have added a midpoint announcement of how many applications have beenreceivedat eachtrainingprogrammebefore the final deadline. This so-called ch ukan k ohyo19 is intended to allow applicants who have selected highly competitive programmes to make an informed decision as to whether to apply to more programmes.
2003년 가을, 첫 번째 결과가 보고되었다. 전체 참여자 중 96% 가까이가 매칭되었고, 70%는 1차 지망에 매칭되었다. 대학병원에 매칭된 사람은 전체 매칭된 사람의 60%였고, 이 전 년도에 비해서 10%가 준 것이며, 1980년대에 비하면 20%가 준 것이다. 2004년 자료를 보면, 이는 52.7%로 더 감소하였다. 2005년에는 처음으로 지역병원에 매칭된 졸업생이 대학병원 프로그램에 매칭된 비율보다 더 높았다.
In the fall of 2003, the results of the first match were released. Nearly 96% of the 7756 participants were successfully placed and over 70% matched with their first choice.20,21 A total of 60% of those matched entered university hospitals. This was a notable 10% drop from the year before, and an impressive 20% below the 80% of medical graduates who entered university hospitals in the 1980s.1 Data released in 2004 about the second match group revealed that the number entering university hospital programmes had dropped even further to only 52.7%, leaving 1848 of the 6064 slots ) some 30% ) for university hospitals unfilled.22 And in 2005, for the first time, more graduates were matched with community hospital rather than university programmes (51.6% to 48.4%).21 Thus, over the last 2 decades and particularly in the last few years, there has been a sharp drop in the number of graduates choosing university hospitals for their training.
이처럼 새 전공의들이 비-대학병원에 쏠리는 것은 몇 가지 설명이 가능하다. 중요한 것 하나는 대학병원에서는 기본적 기술을 충분히 익힐 수 없다는 점이다. 의사가 과도하게 많고, 기회가 적다. 그러나 잡일은 더 많다. 보상은 적으나 쉬는 시간도 적다.
The gravitation of new residents to non-university hospitals has several explanations, not the least of which is that interns and residents tend to gain less experience in honing basic clinical skills at university hospitals.23 Recent medical graduates revealed to the author other practical reasons why fewer are choos- ing university hospitals. Compared with community hospitals, university hospitals tend to be overstaffed, leading to fewer opportunities to practise procedures for residents. Ironically, however, these residents are given more scut work by their seniors, such as having to transport items around or perform finger stick blood glucose checks. They receive less time off despite poorer remuneration.
A survey in 2005 of 2505 entering interns showed that the top 3 criteria applicants used to rank programmes were:
- the quality of the hospital’s track record and teaching (64%);
- the residency programme’s connection with a hospital at which the graduate might want to work in the future (59%), and
- the quality of the content of the residency programme (43%).19
The new regulations have not come without criticism. Students planning surgical careers feel the required internship delays their entry into a specialty that already demands many years of training. Board certification requirements in effect since 2002 for general surgical residents require 5 years of training, which is supposed to include all of the first 2 postgraduate years.24 In addition, under the new system, verbal agreements between applicant and residency programme to rank each other number 1 occur, although the practice is technically forbidden. Finally, despite insistence that PGME training programmes follow national guidelines,17 each institution is left to its own devices to implement and monitor them.
DISCUSSION
미국에서 수련을 받은 일본인 의사-과학자들은 미국식 접근법을 긍정적으로 평가하며, 최근 일본에서 벌어진 의료과오 사건들이 일본 의료시스템에 대한 지적을 불러왔다. 또한 일본 법에서 2년의 인턴십을 강제한 시기에 영국에서도 비슷하게 2년의 foundation program을 도입한 것은 흥미롭다.
Many Japanese doc- tor-scientists who trained in the USA frequently talk favourably of the American approach to medical education,10,11,14 and in recent years media attention on medical malpractice has put the Japanese medical system under increased scrutiny.25 It is also interest- ing to note that the law requiring a 2-year internship in Japan was passed at about the same time that the UK’s Chief Medical Officers proposed a similar 2-year foundation programme focused on developing core clinical competencies.
전국적 매칭 시스템은 PGME 교육과정의 혁신에도 상당한 자극이 되었으며, 전통적인 의국-교실 시스템이 전공의에 미치는 영향을 크게 감소시켰다.
The recent reforms demonstrate a major step towards enhancing clinical skills training in postgraduate education. The new 2-year internship is bolstering core clinical skills by giving young doctors hands-on experience in evaluating and managing patients across a variety of specialties. More than half of graduates now enter community hospitals, rather than tertiary level university hospitals, which will give them much more experience with common clinical conditions. Moreover, trainees at non-university hos- pitals hold much more autonomy in making deci- sions about patient care.23 Effectively, the new requirement ensures that Japanese students benefit from the same broad, hands-on clinical experience that those in many Western countries receive during the clinical years of medical school and the intern- ship year. Moreover, the ability of medical graduates to choose an internship programme through the new national matching system is a powerful stimulus for innovation in the postgraduate curriculum, thus decreasing the stymieing influence of the traditional ikyoku-k oza system on residents.
일본이 초기 PGME를 개혁의 주 대상으로 삼은 것은 현명한 선택이었다. PBL이나 OSCE를 학부에 도입한 것은 주목할 만 하지만 이것은 단편적이고 전체적인 일본 의과대학의 교수-학습의 경향에 영향을 주지는 않았다. 왜냐하면 대부분의 의대생들은 고등학교를 갓 졸업하였고 자기주도적 학습능력이 부족하고 익숙하지 않기 때문이다.
Japan has wisely chosen to focus on early PGME as an area in which reform can significantly improve the training of doctors. Reforms such as those introdu- cing PBL and OSCE at undergraduate level, although noteworthy, are more piecemeal and unlikely to affect the overall flavour of how learning and teaching occur in medical school in Japan. Because the vast majority of students enter medical school directly from high school, medical schools have experienced difficulty in developing self-directed learning skills, such as critical thinking and problem- solving, with which medical students are unfamiliar.26
교육에 관한 일본식 접근법에 익숙한 사람들에게 이런 역사적 흐름은 놀랍지 않을 것이다. 이러한 철학은 선생 중심의 시험에 의해서 결정되는 다른 동아시아 국가에서도 비슷하며 수동적 학습을 유도한다.
For those familiar with the Japanese approach towards education, which stresses didactic lectures, book-learning and memorisation, this historical trend may not be surprising. This philosophy is much like those of other East Asian nations in that it is teacher-centred and examination-driven, and it encourages passive learning.5
학부의학교육에서 학생들의 직접임상경험을 막는 두 가지 장애물. (1)학생들은 미국의 3학년보다 더 많은 과를 순환하며 고작 2주씩만 보낸다. 이는 일상 업무에 충분히 익숙해지기에는 짧은 시간이나, 학생들이 임상적 책임을 맡기에도 연속성이 부족하다. 3개의 의과대학만이 최소 4주이상씩 진행되는 핵심임상실습을 도입했다. (2)일본은 환자를 돌보는 진료팀의 모델을 도입하지 않았다. 대싱 각 환자는 1명의 의사를 배정받는다. 이로 인해서 일본 의사들은 back-up system없이 면허가 없는 학생이 독립적으로 환자 평가에 동참하는 것이 위험하다고 느낀다. 미국은 3층의 구조가 있다. 짧게 말해서, 의과대학 교육의 근본적 변화가 필요하고, 적어도 가까운 미래에 다층적 변화가 필요할 것이다.
From observations at Japanese university hospitals, the author identified 2 major practical barriers to giving undergraduate medical students hands-on clinical experience in Japan. First, students rotate through many more specialties than an American Year 3 medical student and therefore typically spend just 2 weeks in a department. This is just enough time for the student to get acclimatised to the daily duties and peculiarities of the rotation, but it does not give enough continuity to allow the student to assume clinical responsibility. Just 3 medical schools have adopted a core clinical clerkship in which medical students work in a ward setting for at least 4 weeks.27 Second, Japan does not endorse a model of a whole medical team following a cadre of patients. Instead, each patient is usually assigned to 1 doctor. This leads to a fear among some Japanese doctors that allowing unlicensed medical students to evaluate independ- ently patients is dangerous because there is no back- up systemin place should the student make an error, unlike in the USA, where there is a 3-layer system of intern, resident and attending doctor.10 In short, fundamental change in medical school curricula is impractical in Japan, at least in the near future, and it would require substantial reform at multiple levels of education preceding medical school.
Many challenges remain for Japan’s PGME system too.
First, Japan has been very successful in training subspecialists, but not generalists and primary care doctors. Of Japan’s 230 000 doctors, 60 000 are community-based private practitioners, who, although they function as general practitioners, have almost exclusively had subspecialty training rather than the primary care training they would be required to have in the UK.7
Second, general internal medicine and family medi- cine are virtually non-existent specialties in Japan. Few students are even aware of primary care as a legitimate career option.7 Aware of longstanding criticisms pertaining to insufficient education in primary care, the Ministry of Education, Culture, Sports, Science and Technology has strongly supported a movement to create departments related to primary care and the number of such departments in university hospitals has quadrupled from 8 in 1990 to 32 in 2000.2 These general medicine departments ) called s og o shinry obu ) are growing, and can be found in nearly 100 of Japan’s 2200 PGME training programmes.15,17
Third, although the gender gap has narrowed, there is still a significant discrepancy. In 2000, less than 1 in 6 doctors in Japan were women, compared with about 1 in 3 of recent medical graduates, suggesting the impact on the overall doctor workforce is yet to come.28
Fourth, accountability and objective assessment of medical school and PGME curricula are conspicu- ously lacking in Japan compared with its peers. For instance, in the USA the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) expressly exist to provide accreditation. In the UK, the Joint Committee on Higher Education Medical Training (JCHET) and the Postgraduate Medical Education Training Board (PMETB) perform parallel functions.
Fifth, boosting basic clinical skills of students and residents depends on the teaching skills of faculty members. Unfortunately, the new regulations do not include funding for curriculum development; there will be little incentive for excellence in teaching until the prevailing ikyoku-k oza departmental system is altered to reward clinician-teachers with advance- ment as doctor-scientists currently are.
5 Song G, Kwan CY, Bian Z, Tai B, Wu Q. Exploratory thoughts concerning educational reform with prob- lem-based learning in China. Teach Learn Med 2005;17 (4):382–4.
26 Yoshioka T, Suganuma T, Tang AC, Matsushita S, Manno S, Kozu T. Facilitation of problem finding among first year medical school students undergoing problem-based learning. Teach Learn Med 2005;17 (2):136–41.
15 Murai M, Kitamura K, Fetters MD. Lessons learned in developing family medicine residency training pro- grammes in Japan. BMC Med Educ 2005;5:33.
The current state of medical education in Japan: a system under reform.
Author information
- 1School of Medicine, University of California San Francisco, San Francisco, CA 94131, USA. alan.teo@ucsf.edu
Abstract
CONTEXT:
DISCUSSION:
CONCLUSIONS:
Comment in
- The necessity for further reform in primary care training in Japan. [Med Educ. 2007]
- PMID:
- 17316216
- [PubMed - indexed for MEDLINE]
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