일본의학교육 (Acad Med, 2006)
Medical Education in Japan
Tadahiko Kozu, MD
의과대학
Medical Schools
There are currently 79 Japanese medical schools, representing approximately one school for every 1.6 million people. There are 42 national, 8 prefectural (founded by a local government), and 29 private medical schools. There is an additional medical school, the National Defense Medical College of the Japan Defense Agency, which is sometimes included as one of the national medical schools, bringing the total to 80 schools.
MEXT가 관리함. 특수목적의 의과대학 두 개. Jichi 의과대학, UOEH 대학.
The regulating body over all of the medical schools is the Ministry of Education, Culture, Sports, Science, and Technology (MEXT). Two of the private medical schools have unique missions:
- the Jichi Medical School educates all physicians for community care, and
- the University of Occupational Environmental Health educates physicians for industry, such as occupational physicians (employed by companies with more than 50 employees to care for themand foster a safe work environment), physicians for 34 hospitals of occupational diseases, medical officers of the organizations related to laborers’ health, and researchers of occupational and environmental health.
A few years ago, the Japanese government decided to convert the national universities to nongovernmental institutions, in an effort to reduce the number of government employees and save money. In 2003, the National University Corporation Law3 was legislated, and on April 1, 2004, all of the national universities, including 42 national medical schools, became “national university corporations.”4 This change required the universities to take responsibility for their own finances and financial management. To cope with this change, by 2006, 7 of the 12 stand-alone national medical schools had merged with their neighboring national universities.
학부의학교육
Undergraduate Medical Education
고등학교 졸업자 전형
Programs for high school graduates
보통 6년
The standard Japanese undergraduate medical education programis six years long. Typically, there are four years of preclinical education and then two years of clinical education. High school graduates are eligible to enter medical school.
4월부터 3월까지
The academic year starts on April 1 and ends on March 31.
대졸자 전형
Programs for college graduates
1975년 오사카대학에서 처음 시행되었고, 2006년에는 36개 의과대학에서 하고 있으나, 총 10% 이하이다.
Programs for college graduates were implemented for the first time at Osaka University in 1975, and by 2006, they had been adopted by 36 (46%) of the 79 medical schools,5 but they account for fewer than 10%of the available positions.
21개에서는 4년, 11개에서는 5년이다. 나머지 4개 의과대학은 MD-PhD 프로그램을 운영함.
The graduate- entry programs are four years long in 21 schools and five years long in 11 schools. For the remaining four schools, MD– PhDprograms are provided as a part of their graduate-entry programs; the number of seats for the MD–PhD programis limited to five or fewer at each of these schools.
학생선발
Student selection
다양한 방법을 사용하나 지필고사와 면접, 고등학교 내신, 추천서, 자기소개서 등
Approaches to student selection vary,6 but all include some combination of paper-based achievement tests, interviews, reports of high school grade- point averages, recommendations from students’ high school principals, and writing essays.
2005년 모든 43개 국립대학과 8개 도립의대가 NCUEE가 관장하는 국가시험을 활용함
In 2005, all 43 of the national and 8 of the prefectural medical schools used a national test administered by the National Center for University Entrance Examinations, which was established in 1988.7
주요 과목
The required subjects are Japanese language, English, mathematics, two natural sciences (biology, physics, chemistry, geoscience, etc.), and two social studies subjects (Japanese history, world history, human geography, etc.). Private schools require English, mathematics, and two of three natural sciences (biology, chemistry, and physics). The test items are created primarily by the individual schools. There are admission offices in 7 of the 79 schools.
의대생
Medical students
2006년, 약 10만명 지원자 중 7282명 입학함. 전체 의대생 수는 2006년 기준 46800명이고, 여성은 32.8%
In 2006, out of 103,384 applicants, 7,282 matriculated in the 79 schools.8 In that year, there were fewer than 5%of graduate-entry students per school in 26 schools, 10%in 7 schools, 15%in one school, 20%in another school, and 40% in one other school.5 The total number of medical students in Japan was 46,8008 in 2006, of whom15,331 (32.8%) were women.
표준 핵심 교육과정
The model core curriculum
2001년 보고서에서 일본의학교육의 변화를 권고함.
In 2001, the Report of the Coordinating Council on the Reformof Medical and Dental Education9 of the MEXT advocated guidelines for innovative changes to Japanese medical education.
"표준 핵심 교육과정"의 예를 들었다.
The report proposed an exemplary model of an integrated medical education curriculum, a “model core curriculum,” which was developed by the Subcommittee for Research and Development of Medical Education Programs.
1218개의 SBO가 들어간 교육내용 가이드라인
The model curriculum outlined essential core components of the undergraduate medical education program; these were presented as educational content guidelines with 1,218 specific behavioral objectives.
모든 일본 의과대학은 약 70%의 교육시간을 핵심교육과정에 할당하였으며, 30%는 학교별로 다르다.
All Japanese medical schools were expected to implement the core curriculumusing 70%of the existing contact hours, leaving 30%of contact time to achieve their school-specific curriculumgoals.
일련의 변화를 가져왔다.
In response to this report, a series of remarkable changes have occurred in Japanese medical education.
교육과정 구조
Curriculum structure
통합교육
Integrated curriculum.
32개 학교가 통합교육을 다양한 방식으로 도입. 38개 학교는 부분도입. 9개 학교는 학문중심교육
In 2005, 32 schools (41%) had implemented an integrated curriculumin various ways.12 In another 38 schools (48%), the curriculumwas only partially integrated. The remaining nine schools (11%) of Japan’s 79 schools maintained a discipline- oriented curriculum.
PBL
Problem-based learning.
PBL은 TWMU에 1990년 처음 도입됨. 2004년 10월 기준 63개 의과대학에서 사용하고 있음.
Problem-based learning (PBL, or tutorial education) was systematically incorporated into an integrated organ- and system-based curriculumfor the first time at Tokyo Women’s Medical University in 1990.13 In October 2004, a survey indicated that PBL was the prevalent educational method at 63 of the 79 Japanese medical schools (80%),14 and PBL was planned in an additional 13 schools (16%). Two schools (3%) expressed no intention of adopting PBL at the time of the survey, and one school (1%) did not reply to the questionnaire.
학생평가
Student assessment
CAT
The Common Achievement Test.
도입목적. 2005년 12월 공식도입.
The Common Achievement Test (CAT) is a new quality-assurance measure of students’ mastery of the preclinical core curriculumat their medical school. After several nationwide yearly trials since 2002, the CAT was officially implemented in December 2005.
임상교육 전에 CAT에 합격해야 함.
Students must take and pass the CAT before starting their clinical education. The content of the CAT and the expected level of achievement have been developed in accordance with the model core curriculumof 2001.
CBT와 OSCE로 구성
The CAT is composed of two phases: a computer- based testing (CBT) phase and an objective structured clinical examination (OSCE).
300개 문항, 6시간
The CBT is composed of 300 items, and the testing time is six hours.
구성
Subject areas, and the proportion of each for the CBT, are
▪ principles of medicine, 5%;
▪ general principles of biomedical sciences, 20%;
▪ organ-based normal structure, function, pathophysiology, diagnosis, and treatment, 40%;
▪ systemic physiological/pathological changes, 10%;
▪ introduction to clinical medicine, 15%; and
▪ health promotion/patient care/society, 10%.
2001년 이후 10,000개의 새로운 문항이 79개 의과대학에서 제공되었다. 시험, 재평가를 거쳐 문제은행에 들어간다.
Every year since 2001, approximately 10,000 new items have been collected fromall 79 medical schools, then reviewed by the education committee of CATO, edited, tested in trials, reevaluated, and pooled when regarded as appropriate.
OSCE는 다음과 같이 구성됨.
The second part of the CAT is the OSCE. The OSCE assesses clinical competencies in six stations: medical interviewing (10 minutes), head and neck (5 minutes), vital signs and chest (5 minutes), abdomen (5 minutes), neurological examinations (5 minutes), and basic minor surgical procedures and life support (5 minutes). Because of the constraints in facilities and budget, the number of stations was restricted to six in 2005.
CAT는 USMLE의 Step 1과 비슷함.
The CAT is similar in format to the Step 1 examination of the United States Medical Licensing Examination, although it is not actually a licensing examination. Each school establishes its own policy for use of the test results.
임상술기 연습실
Clinical skills laboratory.
CAT 도입과 함께 많은 의대에서 도입함.
With the implementation of the CAT, many medical schools were under pressure to provide clinical skills laboratories for their students. By 2005, 50 schools (62.5%) had developed clinical skills laboratories,17 and an additional 14 schools (17.5%) were preparing to develop them.
임상실습
Clinical clerkship
일본의 JMPL 법에 의해서 의사면허 없이 어떤 사람도 의료행위를 할 수 없다.
The Japanese Medical Practitioner Law (Ishi-hou) Article 17 prescribes that no one will be allowed to performmedical acts without a physician’s license, and Article 37 determines that a person who violates Article 17 will be sentenced to no more than two year’s penal servitude or be punished with a fine of no more than ¥20,000 ($170).
For many years, this legislative control inhibited medical educators fromdeveloping and implementing clinical clerkships. Because of the restrictions, undergraduate clinical education had consisted either of observing what the instructors did in actual medical acts (bedside teaching) or of practicing simulations of history taking or physical examinations with the consent of patients (bedside learning).
1991년 MHW는 JMPL법의 개정을 요구하는 보고서를 냈다.
In 1991, a study committee for clinical education of the Ministry of Health and Welfare issued a report18 arguing that the purpose of Article 17 was to protect the life and safety of patients. Therefore, medical procedures performed by medical students would not be deemed unlawful when the purposes, contents, and processes were reasonable froman educational standpoint and when the procedures would be as safe as when performed by a certified medical doctor.
보고서에서는 다음의 조건하에 의과대학생의 의료행위 참여를 허용하도록 제안했다.
The study committee also proposed four requirements to allow medical students to performcertain limited medical acts during their clinical training:
▪ The acts should not be highly invasive, which should be stipulated explicitly.
▪ The acts should be carried out under the meticulous guidance and watchful supervision of teaching faculty.
▪ The clinical competence of the students should be evaluated/qualified in advance.
▪ Informed consent of the patients/families should be obtained.
의료행위를 세 단계로 구분햇다.
The committee developed the following classification of medical acts:
- level 1, low- invasive medical acts, to be performed by ordinary-level medical students;
- level 2, moderately invasive medical acts, to be performed only by selected students deemed capable; and
- level 3, highly invasive medical acts, which should not be performed by medical students.
2005년, 임상실습은 66개 의과대학에 도입되었고, 학교마다 중요시하는 정도는 다르나 13개 대학에서도 고려중
In 2005, clinical clerkships were implemented in 66 medical schools (84%), although their degree of emphasis within each school’s entire clinical education programvaried. Clinical clerkships were under consideration in an additional 13 schools (17%).19
의학사
The MD degree
6학년 졸업시험
At the end of the final academic year, there is a graduation examination designed by each medical school.
의사국가시험
National Examination for Physicians
2월 중순에 3일간 치러짐. 졸업(예정)증명서를 제출해야 함.
The Japanese National Examination for Physicians is conducted once a year for three days in mid-February by the Ministry of Health, Welfare, and Labor20 at 12 sites covering the Japanese archipelago. The applicant must submit a certificate of completion of formal undergraduate medical education in Japan or in a foreign country. All students eligible to graduate on March 31 of the same year may sit for the examination. Those who pass this examination are granted a National License for Physicians and are eligible for residency training (discussed in the next section).
The examination is a paper-based test with 500 multiple-choice questions. There are 100 required items containing a number of essential questions designed to reveal possible contraindicated behaviors of a physician. The “blueprint” for the examination (i.e., its composition and the proportion that each topic area contributes to the examinee’s grade on the required items) is publicized and available for all candidates to view before taking the examination21
The passing level for these required questions is 80%or more correct answers.22 There are an additional200 items of general questions and 200 items of clinical vignettes. The blueprint for these general questions and clinical vignettes is also publicized.
모든 학생은 구체적인 결과를 제공받고, 합격기준, 합/불합 여부, 영역별 점수, 전체에서의 위치 등을 제공받는다.
Each individual is informed of the exact results of his or her examination performance, the pass level of the examination, whether he or she passed or failed, his or her scores on each category, and his or her position in the distribution of total applicants.
2006년 8602명이 시험을 치르고 90%가 합격하였음.
In 2006, the total number of applicants taking the examination was 8,602, and the number of successful candidates was 7,742 (90.0%): 5,213 men and 2,529 women. Success rate was 93.9%for the new graduates and 57.3%for the others; the success rate was 88.5%for men and 93.3%for women23.
초기연수와 매칭 시스템
Initial Postgraduate Clinical Training and the Matching System
의사면허에 합격하면 2년간의 인턴을 할 수 있음. 1946년 의무적 1년 인턴십으로 시작하여, 1968년 사라졌으나, 지금은 비의무적 2년 프로그램이 되었음.
Those who obtain a National License for Physicians may proceed to the next step, an obligatory initial postgraduate clinical training program(i.e., residency training), which lasts two years. Japanese formal postgraduate training originated in 1946 as a compulsory one-year internship, but it was eliminated in 1968 because of the inappropriateness of the curricula and the lack of financial support for the interns. It was replaced by a noncompulsory two-year postgraduate clinical training system.
MHLW는 새로운 PGME를 2004년 시작할 예정
An ordinance fromthe Ministry of Health, Labor, and Welfare, Number 158, was legislated24 in 2002, and a new two-year postgraduate clinical training systemstarted in 2004.
교육과정은 향후 전공과 무관하게 일차의료와 일반진료에 대한 효과적 수련에 목적을 두고 있다. 구성은 아래와 같음.
The curriculum focuses on providing a solid grounding and effective training in primary care and general medicine, regardless of the possible future specialty choice of the physician. The curriculum stipulates that the first year of training should be devoted to general internal medicine (no less than six months), general surgery, and emergency medicine (including anesthesiology). Additional required training (done in the second year) includes education in pediatrics, obstetrics and gynecology, psychiatry, and community medicine. Training under the new systemis a requirement for any physician who was registered on April 1, 2004 and thereafter, if he or she intends to engage in patient care.
The teaching hospitals for the postgraduate training are classified into three types.
- Independent hospitals train residents independently; these hospitals are university hospitals and principal, large teaching hospitals.
- Administrative hospitals train residents in collaboration with cooperative hospitals, each of which plays a supplementary role in cooperation with an administrative hospital.
효과적인 수련을 위해서 수련의는 충분한 월급을 지급받아야 하며, 아르바이트는 엄격하게 금지된다. 근무시간 관련 규제. 판결에 따라 한 주에 40시간만 근무해야 하지만 이는 첫 2년에만 해당하는 것.
To make residency training effective, trainees must be paid reasonably, and so-called “moonlighting” is strictly prohibited by law. The work hours of residents are limited to prevent overwork. On June 3, 2005, the Supreme Court of Japan ruled that one resident’s death had been the result of overwork in a university hospital. The court stated that although the trainee could be regarded as a learner on the one hand, in Japan, trainees must also be regarded as laborers under the Labor Standards Law when they are engaged in medical services under the supervision of teaching faculty. This definition of a resident’s status fostered a new rule by the Supreme Court, mandating that a trainee’s formal working hours should be principally limited to 40 hours a week, as is the case with all ordinary workers in Japan. However, such limitation of labor hours is applied only for the initial required two years, and not to the senior residents of the third year or higher, or to faculty.
2004년 매칭 시스템이 도입됨. 그 결과.
In 2004, a matching systemwas implemented and organized by the Council for Matching,25 a nongovernmental organization. Previously, there had been no nationwide matching system, and the residents had applied arbitrarily to the individual training programs in which they were interested. In 2005, there were proposals of 1,261 training programs, with 11,228 total positions available at 1,016 hospitals. Among 8,472 applicants, 8,100 (95.6%) were matched (46.2%for the university hospitals, 49.4%for other teaching hospitals). Of those who were matched, 2,496 (30.8%) matched to his or her own university hospital, 1,420 (17.5%) matched to another university hospital, and 4,184 (51.7%) went to other teaching hospitals that were approved by the Ministry of Health, Welfare, and Labor. The remaining 372 applicants who did not match to programs probably found positions on their own, through direct negotiation with individual hospitals. After the initial required two- year postgraduate training, the trainee advances in his or her own career path and may enter graduate school, proceed to an advanced clinical training course for a specialist, or serve as a general physician in the community
후기연수(전공의)
Advanced Postgraduate Clinical Training Programs for Medical Specialists
The advanced postgraduate clinical training programs for medical specialists are between four and six years in length. During or after finishing this advanced clinical training, the trainee may sit for the board examination for a basic specialty approved by the academic societies.
전공과목 시스템은 JBMS에 의해서 조직되며, 18개의 기본전공과목이 있으며 각 전공과목에 따라 학회가 보드시험을 책임진다. 의사들은 한 가지 기본전공만 할 수 있다.
The system of medical specialties is organized by the Japanese Board of Medical Specialties,26 which was established in December 2002 under the auspices of the Japan Medical Congress, the Japan Medical Association, and the Council of Medical Specialties. Eighteen fields were designated as the basic specialties, and the corresponding academic medical societies/associations are responsible for their specialties’ board examinations. A physician is allowed to practice in only one basic specialty.
In addition to the basic specialties, there are 26 subspecialty societies/associations and seven societies/associations that cover multiple areas. A physician may practice in multiple subspecialties as long as he or she has already qualified as a specialist in either internal medicine or surgery.
대학원교육
Education at Graduate Schools
2005년 3월까지 43개 국립대 중 23개, 그리고 8개의 도립의과대학 중 4개에서 '의과대학'에서 '의과대학원'으로 중심을 이동하였다. "대학원 우선화"로 알려진 이 전략은 MEXT의 정책에 따른 것으로, 그 결과 교수들은 주로 대학원에 소속되게 되었다. 그러나 모든 의과대학 대학원은 의과대학을 가지고 있기 때문에 의과대학-의과대학원 두 가지 위치를 모두 유지하고 있다.
Until March 2005, 23 of the 43 national university corporations for medicine and four of the eight prefectural medical schools had changed their principal focus from“school of medicine” to “graduate school.” This movement was known as “prioritizing graduate school,” following a policy of the MEXT. As a consequence, the faculty belong primarily to the graduate school. However, all medical graduate schools also have undergraduate schools of medicine, and all the faculty of any graduate school concurrently hold positions in the undergraduate schools of medicine.
대학원 과정 설명
Both medical and nonmedical graduate courses are provided in all 79 medical schools. The master’s degree courses are for two years, and the PhDdegree courses are for the succeeding two years. Thirty- seven schools offer master’s courses for graduates who have completed a nonmedical undergraduate education. The only schools of public health are at Kyoto University and Kyushu University; in 2007, Tokyo University will be added.
현 이슈와 미래
Current Issues and Future Perspectives
표준 핵심 교육과정을 기준으로 학부 의학교육이 크게 바뀌었다.
Stimulated by the model core curriculum as the benchmark, undergraduate medical education curricula have significantly changed in most medical schools in Japan. Eighty-three percent of the schools have implemented a standard core curriculum, and 80%have implemented PBL education in recent years. The nationwide CBT may have accelerated innovation by serving as evidence of effective education. The nationwide OSCE in the CAT also seems to have enhanced the quality of clinical education, judging fromthe rapidly increasing number (in 49 to 62%of 79 medical schools) of clinical skills laboratories and by the prevalence of teaching skills workshops. The CAT also seems to have influenced the National Examination for Physicians.
표준 핵심 교육과정은 원래 질관리와 최소기준 설정을 위한 것이엇다. 그 다음 단계는 각 학교의 의학교육프로그램의 향상이며, 나머지 30%를 잘 활용해야 한다.
The proposed model core curriculumwas originally intended for quality assurance and to set a minimumrequirement for physicians. The next step will be the further enhancement of each individual school’s medical education program, using the remaining 30%of school hours that are focused on the individual school’s mission.
의학전문대학원은 일본에서는 마이너한 움직임이다. 두 개의 상반된 사례.
Graduate-entry programs represent a minor movement in Japan; they offered fewer than five seats in 23 (or 63%) of 36 medical schools in 2006.5 There are two contrasting examples.
- Since 1975, Osaka University provided graduate entry for 20 seats (20%of the 100 new enrollees) focused on fostering medical scientists. But the experiences in the past 24 years proved that the number of 20 graduate- entry students was ineffective for that purpose and not necessarily satisfactory (M. Tohyama, personal communication, 2006). Beginning in 1999, the number was reduced to 10 seats, and later in 2000 it was split into five seats for the ordinary graduate-entry course and five seats for the MD-PhDcourse.
- On the contrary, Tokai University started graduate entry in 1987 for 15 seats to enroll students who were more mature and more motivated to be good physicians; Tokai University has increased the number of positions available to 40 students among 100 seats, beginning in 2006.
Previously, university hospitals were the principal sites for pre- and postgraduate clinical education. However, too much specialization of university hospitals as tertiary hospitals caused the basic clinical education for undergraduate medical students to be inappropriate and insufficient. To cope with this situation, 66 (84%) of 79 university hospitals sent their students to teaching hospitals in the community as part of their formal clinical education. The new nationwide matching system also revealed that a little more than half (51.7%) of the trainees in 2005 preferred a training site outside of the university hospitals, presumably seeking a more appropriate environment for primary care training.
2 Onishi H, Yoshida I. Rapid change in Japanese medical education. Med Teach. 2004;26:403–408.
Medical education in Japan.
Author information
- 1Department of Medical Education, Tokyo Women's Medical University School of Medicine, Tokyo, Japan. kozu@research.twmu.ac.jp
Abstract
- PMID:
- 17122471
- [PubMed - indexed for MEDLINE]
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