일본의 의학교육: 의료시스템에 관한 과제(Med Teach, 2008)

일본의 의학교육: 의료시스템에 관한 과제(Med Teach, 2008)

Medical education in Japan: A challenge to the healthcare system

YASUYUKI SUZUKI1, TREVOR GIBBS2 & KAZUHIKO FUJISAKI1

1Gifu University School of Medicine, Japan, 2Chinese University of Hong Kong, Hong Kong

일본의 지리적 특성(면적 등), 인구, 지형

Japan is located in Far East Asia, and is composed of four major islands and more than 6800 smaller islands. With a land mass the size of Germany (378,000Km2) and a north-south distance of 3000km, its 128 million population live in a country that is 70% mountain, forest and rural areas.

일본의 인구구조 변화(노령화 등)

Japan’s elderly population is growing fast (20.8% of population over 65 years in 2006), whilst the percentage of children less than 15 years is decreasing (13.6% in 2007) (Annual Report on Health, Labour and Welfare in Japan 2007). It is estimated from the same report that in 2055, more than 40% of the population will be greater than 65 years, whilst children and teenagers, less than 15 years, will constitute only 10% of the population. These changes will have an effect upon the health needs of the Japanese population. At present, 98% of Japan’s residents are Japanese, the other 2% being of Korean, Chinese or Brazilian extraction.

일본 의학의 역사

History of medicine in Japan

한의학과 중의학

Korean and Chinese medicine

One of the first descriptions of medicine in Japan was in the 5th century, when Koreans introduced their approach to medicine. In the 7th century, Japanese intellectuals journeyed to China to study economics and medicine. The first official facility for ill patients was built in the 8th century and the first medical system was introduced. The disabled, the severely ill and their care-givers were given exemption from tax, labour and military service!

서양의학의 도입

Introduction of western medicine

The first contact with European medicine was in the 16th century, when Portuguese monks introduced new surgical techniques and built the first western-style hospital. However, the Tokugawa feudal government feared the Christian religion and closed the country except for visitors from Holland, China and Korea. As could be expected, Dutch medicine reigned in the 17th and 18th Centuries the first anatomical text translated for use by Japanese doctors was ‘Tafel Anatomie’ in 1774.

Seishu Hanaoka, a Japanese surgeon, who learned both Dutch and traditional medicine, developed general anaesthetic agents from herbal material, performing breast surgery using these agents. This was 40 years before ether anaesthesia was introduced by Morton in Boston, USA.

The first western style medical school was established in Nagasaki in 1857, under the direction of two Dutch doctors, Pompe and Bauduin.

근대의학

Modern medicine

1868 brought the new Meiji Government, effectively abolishing the Tokugawa feudal and samurai system and replacing it with a western-style culture. English and German doctors were invited to teach and related to the politics at the time, the German system dominated and strongly influenced the system of medical education. Nine imperial (Tokyo, Kyoto, Osaka, Kyushu, Hokkaido, Nagoya, Seoul in Korea, and Taipei in Taiwan) and 6 national medical schools were established in the late 19th, early 20th centuries.

2차대전 이후

Post World War II

After 1945 the governments of the Allied Forces reconstructed the political and social structure of Japan, and new laws and actions were implemented, having a great and positive effect upon health. In 1961 a new insurance scheme was introduced for all Japanese people ensuring that all were at least partly compensated for their healthcare. The Ministry of Health, Labour and Welfare controls healthcare policy, whilst the Ministry of Education covers the educational policy. In 1969, out of a group of faculty with similar interest, the Japanese Society for Medical Education (JSME) was established.

일본의 헬스케어

Healthcare in Japan

The World Health Organization report of 2000 (WHO 2000) ranked Japan’s healthcare system the highest in the world. The infant mortality rate had fallen to 2.8 per 1000 births from the previous century, life expectancy had increased (females: 85.8 years, males: 79 years) (Journal of Health and Welfare Statistics 2007). At the beginning of the millennium, life was looking good for Japan.

However, serious problems are beginning to arise. Japan is becoming the most aged population of the world; major causes of morbidity and mortality are malignancy, cerebro- vascular and cardiovascular disease all of which strain the health economics of the country. New but expensive preventative approaches are needed and the increase of the nuclear family means an increase in support institutions (Annual Report on Health, Labour and Welfare in Japan 2007). Conversely there is a decrease in the total fertility rate from 3.65 in 1950 to 1.32 in 2006 (Journal of Health and Welfare Statistics 2007). Psychological illness is increasing, possibly related to the pressures of a modern life-style and its financial strain.

Healthcare system

The National and local governments, employers (companies), and their employees financially support the Japanese social health insurance scheme. Employees pay around 5%–10% of their earnings into an insurance scheme that pays for anything over 30% of adults’, 20% of children’s and 10% of the elderly’s healthcare. However, this scheme is only available to those who can pay into it and leaves may people without healthcare cover. This scheme unconventionally covers both the private and public systems of healthcare delivery. At present Japan lies 21st out of 30 in the league table of OECD countries for health expenditure (OECD 2007).

Medical staff

The total number of doctors in Japan is around 270,000, with a ratio of 2.1 doctors per approx. 1000 population. Although this ranks 27th out of 30 OECD countries (OECD 2007) it is made even worse by the diverse distribution of medical staff (11 per 1000 in Tokyo, 0.4 per 1000 in North East Japan). Healthcare in the remote and rural areas is critical and has led to the development of one school especially designed for training rural doctors (Jichi Medical University 2008).

General practitioners are still very few in Japan and a new training programme and academy for family medicine is about to be introduced (Yoshimura et al. 2008).

Japanese tend to select their own practitioner, by word of mouth and professional recommendation, and often in a private clinic if they can afford it. A heavy workload, an increase in medical litigation, and a limited income in the public sector have led the doctors to the private sector, and this has led to a shortage in public facilities. A shortage of obstetricians causes labouring patients to travel far from their hometown. The lack of staff such as paediatricians and anaesthetists is putting a major strain on healthcare and medical education alike.

의과대학과 의과대학생

Medical schools and students

There are 80 medical schools in Japan, of which 43 are national (including National Defense Medical College), 8 are public (belonging to a specific prefecture or municipality), and 29 are private.

All of the schools adopt a six year course for those doing well from secondary school; all tuition is in Japanese. In 2004, all of the national schools were reorganized into independent organizations under the National University Corporation, which however is still under Governmental control.

Jichi Medical School, formed by an alliance of 47 local governments is a unique school, solely for the purpose of training rural doctors. The numbers of students entering medical schools has changed over the years. The 1960s saw an increase to cope with the shortage of doctors. A perception that there would be too many doctors for the 21st century, led to the number falling again, but then rising in the early part of this century to cope with the impending healthcare problems. 2006 saw a governmental policy actively recruiting and supporting students from each schools’ local area, offering financial support from local government if students continue to work in that area, post graduation. 

Tuition fees for national and public schools are approx. 500,000 JPY (£2500) per year, much higher in the private schools. Jichi Medical School’s fees are exempt for students who continue to work in a rural area. The average staff number in most schools is about 250 (Medical School White Paper 2005), inclusive of basic science and clinical staff. This is much lower than seen in western schools and each school relies heavily on part-time staff.

학생선발

Student selection

Medicine is extremely popular as a career choice in Japan making the entrance examination highly competitive. Ninety percent of students are from secondary school, 10% are from college graduates (36 schools offer a 4 or 5 year graduate entry programme, to a total of 250 students (Yagi 2006)).

Most students are accepted through a common national entrance examination (National Centre for University Entrance Examinations 2008), whilst 13% are accepted through combi- nations of interview, written work, recommendations and previous community activities. Student places for working in rural areas is increasing (56 in 2005, to over 500 presently). Female students, although increasing in number, still only constitute 30% of the total number, and foreign graduate are rare because of the language problems.

학부의학교육

Undergraduate medical education

Pre 1980s

The curriculum tended to be very traditional: 

• 2 years for general education in basic science, arts and language; 
• two and half years pre-clinical medical sciences and 
• one year clinical training in an observational style. There was very little hands- on skill learning.

Post 1980s

As in many schools throughout the world, Japan underwent major reforms in its curricula in the 1990s. There was a blurring of the pre-clinical divide, learning became more contextual and opportunities to learn in different environments were created (Goto 2006).

Problem – based learning (PBL)

Again, like many western schools, PBL was introduced as a vehicle for learning. Tokyo Women’s’ Medical School was the first to adopt PBL in 1990, followed by Gifu (Suzuki et al. 2003) and Mie in 1995, so that now 75 (94%) of the schools in Japan use PBL, the length of time it is used varying from 10 weeks only, up to more than 60 weeks (Med School White Paper 2005). As per most schools the number of staff required for PBL is proving difficult, and not always accepted in a population very much used to didactic teaching.

Common Achievement Test (CAT)

The CAT was introduced in 2005 to ensure a common level of competency before the students enter the clinical years. Although operated through an independent organisation, supported CAT is by all Japanese medical schools. The summative process consists of a computer based test (multiple choice) and an Objective Structured Clinical Examination (OSCE) (Sato 2002; Onishi & Yoshida 2004; Kozu 2006). Medical Schools throughout Japan contribute to the questions and act as external examiners.

Medical simulation

Driven by a need to improve competency and real-life medical learning, most Japanese schools have developed clinical skills laboratories together with cohorts of simulated, standardized patients (Ban 2006); more than 59 simulated patient groups are operative at present. (Abe et al. 2007).

Clinical teaching and learning

The extension in time and the new approaches to clinical teaching has been a significant event in Japanese medical education (Abe 2006). The total period of clinical learning averages about 46 weeks (32–69), and although still shorter than most western schools, it represents a major achievement and fulfils many of the learning gaps highlighted by Kozu (Kozu 2006) in describing the clinical deficits of graduating students. At the present time, ‘clinical clerkships’ are still too short (Suzuki et al. 2008) and learning opportunities to superficial.

The teaching environment

Teaching traditionally has taken place in large teachinghospitals, but the introduction of a new residency programmein 2004, which accepted community hospitals and clinics as viable training areas, has led to undergraduate educationmoving in to these newenvironments. However, again a majorhurdle is the availability of trained staff to teach as moredoctors become dissatisfied with the public sector. 

National licensing examination

In 1946, under the jurisdiction of the General Headquarters of Allied Forces, a National Medical Licensing Examination was introduced, and is still in place. At the end of year 6, allstudents embark on a major examination over three days. Fivehundred MCQ questions are set, covering public health toclinical medicine; 50% of the questions are basic clinical knowledge and 50% are case based clinical vignettes. The passrate is around 90% under and the introduction of an OSCEexamination is discussion (Hatao 2006). As oneimagines, the final year of medical school is often dominatedby this high stakes examination, and at the expense of clinicallearning. 

Postgraduate medical education

From 1968 until the reform of 2004, there was no internship or pre-registration year. Prior to 1968, medical students spent one year post graduation as an intern; the system eventually became unstable and collapsed. From 1968 until 2004, it was possible to progress from university graduation straight into specialty training, a situation which only changed after public criticism of the general competencies of Japanese doctors.

The new residency programme was introduced in 2004(Tanabe 2006), when all graduating medical students have to spend two years rotating through the main specialties, in approved teaching and community hospitals. Salaries are about 4 million Yen per year and ‘moonlighting’ is prohibited. However, these new internships created a serious phenomenon of lack of staff both in the local university teaching hospitals and in rural hospitals, as more residents seek work in well-known teaching hospitals in urban areas. 

Upon completion of the two year residency programme, the interns enter into one of many higher training schemes,and as is common in many other countries, certain specialties, paediatrics, obstetrics, anaesthesia and accident and emergency medicine fail to attract many applicants. At present Japan is witnessing the closure of many smaller hospitals, with patients traveling long distances for consultation and treatment.

Graduate School of Medicine

Japanese medicine has previously been dominated by universities and research orientated programmes. So much so that all Japanese medical schools have a graduate school with 4 year PhD programmes. The total number of places is about 5000 per year, with approximately 3400 gaining their PhD yearly (Kitamura 2006). Applicants are either post residency doctors, foreign graduates from mainly Asian countries and para-medical scientists. This healthy situation continues to place Japan high amongst the world rankings formedical research, but as younger doctors now prefer a quick acceleration into a clinical specialty, it is hard to predict how long such a status will exist.

Faculty training

The Japanese Society of Medical Education (JSME) and the Japan Medical Education Foundation have been the two major organizations responsible for faculty training and have shared their work. Additionally, these last ten years have seen 50 medical schools develop their own units or departments of medical education, along with the reform of medical education. Two national centres have also been established;the Medical Education Development Centre (MEDC) at Gifu,mainly involved with faculty training in teaching methodology,and the Tokyo Centre for Education Research in Medicine and Dentistry (CERMeD), mainly dealing with student assessment.The Tokyo International Research Centre for Medical Education (IRCME) contributes to international collaborations.

Research activities

At present the membership of JSME is approximately 2000 and at their annual meeting, 300 papers on educational research are presented. The official journal of JSME is published presented bi-monthly with 30–40 peer reviewed articles every year. At present the journal is published in Japanese,causing difficulty in attracting international authors, or disseminating the journal more widely. However recent times have seen a call for papers written in English, and a new international section of both the annual meeting and the journal has been introduced. 

The future of Japanese medical education

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Med Teach. 2008;30(9-10):846-50. doi: 10.1080/01421590802298207.

Medical education in Japan: a challenge to the healthcare system.

Suzuki Y1, Gibbs T, Fujisaki K.

Author information

• 1Gifu University School of Medicine, Yanagidol-l, Gifu, Japan. ysuz@gifu-u.ac.jp

Abstract

In response to a change in health and societal need, the system of medical education in Japan has undergone major reform within the last two decades. Although the general health status of Japanese citizens ranks amongst the highest in the world, a rapidly increasingly elderly population, a social insurance system in crisis and a decrease in the number of practicing physicians is severely affecting this enviable position. To compensate, the Government has reversed its previous decision to reduce the number of doctors. Concomitantly, public opinion is changing to that of support and sympathy for the practicing physician. In order to produce a new breed of future doctors, Japanese medical education has undergone major reform: problem-based learning and clinical skills development has been instituted in most medical schools, more rigid assessment methods, ensuring competency and fitness to practice have been introduced, and there has been an increase in purposeful clinical attachments with a hands-on approach rather than a traditional observation model. A new postgraduate residency programme, introduced in 2004, hopes to improve general competency levels, while medical schools throughout the country are paying attention to modern medical education and faculty development.

PMID:

 

19117222

 

[PubMed - indexed for MEDLINE]