일본 의학교육의 현실에 대한 성찰(Keio J Med, 2006)

일본 의학교육의 현실에 대한 성찰(Keio J Med, 2006)

Perspectives in Medical Education 1. Reflections on the state of medical education in Japan

R Harsha Rao

Professor of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, U.S.A.

Introduction

일본은 전국민에게 universal health insurance를 제공한다. 반면 미국은 그렇지 않는데, 일본의 GDP대비 총 건강 지출이 미국의 절반정도에 불과함에도 의료의 상대적 질에는 의심의 여지가 없다.

After all, Japan provides its citizens with universal health insurance, while the US does not, despite the fact that Japan’s total health expenditure as a percentage of the gross domestic product is approxi- mately half that of the United States!3,4 Nor can the quality of the health care be called into question, in comparative terms.

이러한 성공에도 불구하고, 지나치게 전문과목을 강조하는 일본의 의료가 공공의료, 의료시스템에 안 좋은 영향을 미치고 이것이 바뀌어야 한다는 인식이 늘어나고 있다. 안타깝게도 기존의 전문과목 시스템은 의학교육에 일차의료 수련의 중요성을 전혀 강조하고 있지 않다.

Notwithstanding this success, there is now a growing recognition in Japan that the overwhelming emphasis on specialty care is detrimental to both the health of the system and the health of the public, and that this must change.1,2 Unfortunately, the existing system of spe- cialty care is sustained and perpetuated by a system of medical education that places no value on primary care training.2

그러나 의학교육에게 요구되는 변화는 전문과목 위주의 수련을 일반내과 진료로 바꾸는 것에 그치지 않는다. 이를 위해서는 전통적인 의국-교실 시스템에 기초한 학생과 전공의 수련 접근법에 혁신적 변화가 필요하다. 이러한 시스템이 낯선 외부인들에게는 이것이 오래 전 독일의 도제식 전통과 유사함을 발견할 것이다. 하지만 지나간 옛날의 유물이 일본에는 여전히 남아있으며, 심지어 독일에서조차 더 이상 존재하지 않음에도 그러하다.

However, the need for reform in medical education goes beyond changing the emphasis from specialty training to general internal medicine training. It involves a radical departure from the traditional Japanese approach to student and resi- dent training, based on the feudal ‘‘ikyoku-koza’’ sys- tem.5,7 To an outsider unfamiliar with Japanese tradi- tion, it bears a striking resemblance to an older Germanic tradition of apprenticeship. However, that remnant of a bygone era remains in place in Japan even though it is so antiquated as to be no longer extant even in Ger- many!

그러나 가장 큰 걱정거리는 피라미드의 가장 상위에 있는 레지던트 수련이 아니다. 반대로 피라미드의 가장 저층에 위치한 의과대학생 교육의 관성이 가장 문제이다. 일본 의학교육에서 가장 앞서나간다는 곳 조차, 변화에 대한 인센티브를 전혀 느끼지 못하고, 임상 교육은 사실상 존재하지 않는다. 최고의 학생들을 모집하기 위한 경쟁이 존재하지 않는데, 학생들에게는 미래의 자신의 진로에 큰 도움을 줄 수 있는 교수들을 만날 수 있는 기회 자체로 교육의 질이 낮은 것을 감수하게 되기 때문이다.

So it is not residency training – the apex of the pyramid – that causes the greatest concern. It is the in- ertia to change at the base of the pyramid – medical student education – that is of greatest concern. This is no more evident than in some of the leading centers for medical education in Japan, where the well-entrenched interests see no incentive to change, and clinical in- struction remains virtually non-existent.5 There is, after all, no competition for the best students at these insti- tutions, since the cachet of graduating from the top universities, and the opportunity such places provide for contacts with faculty who can provide significant help in future academic careers, far outweighs any deficiencies in the quality of education that is provided.

1. The skills of Japanese Medical Students 

2. The status of Bedside Clinical Instruction Clinician-Teachers 

3. The attitude towards Teaching among the Faculty 

4. The applicability and promise of Problem Based Learning

1. 일본 의대생들

1. Japanese Medical Students:

그토록 우수한 학생들임에도 비슷한 미국 학생들의 평균에도 미치지 못한다.

They are as bright and incisive as any of the best students I have encountered over three decades and across three continents, thirstily soaking up instruction like sponges. Having said that, however, I have to say also that, for the most part, (and through no fault of their own!), they would not measure up to even the most average student of comparable chronologic seniority in the US (i.e. 3rd and 4th yr medical students). This is because of several factors:

(a) 임상교육의 부족

(a) Lack of Clinical Instruction:

의대생들에게 강조하는 임상술기는 립서비스에 그친다.

And the cause of this is not difficult to find: Japanese medical education pays no more than lip service to the development of clinical skills in medical students.

그럼에도 이 학생들에게 어떤 임상징후의 원인을 물어보면 엄청나게 긴 목록을 다 말할 수 있다.

And yet, ask them what the causes of any physical sign are, and they can rattle off a list as long as your arm!

사례발표도 거의 존재하지 않는다.

Case presentations (at least as I understand them) are non-existent.

(b) 수동성

(b) Passivity:

이들은 질문을 하지 '않도록' 교육받아왔다.

It constantly drove me crazy to see these incredibly brilliant and knowledgeable young minds go into limbo because they were taught not to ask ANY questions.

이렇게 문화에 뿌리깊게 박힌 수동성때문에 임상술기의 부족함을 교정해주는 것이 더 어려워진다. 이는 극도로 형식을 중요시하고 일방적 훈계식 교육과 연결되어 있다. 처음부터 쌍방향의 상호적인 것이라기보다는 일방적이고, 수동적이었다. 관행에 따르지 않는 것은 용납하지 않았다.

This passivity of Japanese students is a failing that may be much harder to correct than their lack of clini- cal skills, because it appears to be culturally ingrained. It is inextricably linked to an extremely formal and di- dactic educational system, which is, from the very be- ginning (in grade school), one-way and passive, rather than two-way and interactive, and discourages non- conformity.

(c) 영어 말하기 기술

(c) English speaking skills:

(d) 의학용어

(d) Medical Terminology:

큰 문제는 아니지만, 단기간적으로는 상당한 핸디캡이다.

This is not a widespread limitation, but might be potentially a significant handi- cap in the short term, even for those who speak fluent English.

2. 임상교육

2. Bedside Clinical Instruction:

한마디로 말하면, 없다!

In a word, NONE!

이는 일반내과 수련의 개념이 존재하지 않는 것에 직접적으로 연관된다.

This is a problem that stems directly from one fact: there is NO(as in ‘‘zero’’) understanding of the concept of training in general internal medicine.

이 문제를 언급한 사람은 이 전에도 있었지만, 얼마나 심각한지는 일본에 가보기 전까지는 모를 것이다. 모든 의사가 대학병원에 전문의로서 존재하며, 매우 제한된 영역에서만 환자를 보는데, 의과대학 졸업 직후부터 이런 식이다.

Others have described this before,3,4 and I went to Japan fully fore- warned to expect this, but until one actually goes to Japan, it is impossible to comprehend the immensity of this problem. The fact is that every physician in a University Teaching Hospital is a specialist who sees patients exclusively within a very circumscribed sphere of interest, starting from the very first day out of medi- cal school.15,16

교수들이 이러니 이후에 배출되는 수련의들도 임상기술이나 일반내과에 대한 개념이 없고, 그 상태로 '일반 내과의'로서 진료를 해나간다. 따라서 이러한 '일반의'들이 짊어져야 할 짐은 단순히 임상술기 부족이 아니라 극도로 전문과목에 초점을 맞춘 관점에서 생겨난 mindset이다.

And so it transpires that successive batches of trainees leave their teaching hospitals without any training in clinical skills or concept of general internal medicine, and go into practice to function as.... general internists! Thus, these generalists are burdened forever by not only a lack of clinical skills, but also a mindset bred from an exclusive focus on a subspecialty viewpoint.17

전문과목에만 국한된 mindset의 다른 문제는 환자를 전인적 관점에서 조사해야 한다는 개념의 부족이다.

A mind-set dedicated exclusively to specialty care breeds another problem: even with the eventual acqui- sition of clinical skills through experience, the concept of examining the patient as a whole is nonexistent.

레지던트는 사실상의 노예와 같다.

But the descriptions of resident life given to me by several of the latter, coupled with my own limited observations, lead me to conclude that the resident is almost an indentured slave in the unit in which he/she elects to work after gradua- tion (remembering of course that there is nothing known as ‘‘general internal medicine training’’ in Ja- pan).

봉건적인 시스템아래서 '보스에게 잘 보여야 하는' 엄청난 압박을 받는다.

But there is another equally powerful and at times even destructive effect of such a feudal system: it gen- erates incredible pressure to ‘‘impress the boss’’.

3. 의사-선생님과 임상교육

3. Clinician-Teachers and Clinical Teaching:

Keio대학에서 의학을 어떻게 가르치는가?

How is Medicine taught at Keio University?:

일방적 강의가 거의 주 교수법이다.

Didactic lectures are the major modality of instruction at Keio University (since there is little or no clinical instruction and no concept of small group discussion or PBL).

강의슬을 보면 90%는 자고 있다.

And repeated glances around the lecture hall showed also that 90% of the students were asleep at any given time.

대부분의 강의는 임상 상황과 관련성이 거의 없어서, 교수들은 학생들이 실제로 무엇을 배워야 하는가에 관심이 없어 보인다.

While the absence of any clinical relevance to most of the lectures was the most glaring of the defects I noted, it was clear also that the teachers I observed seemed to have no sense of (or interest in?) what it was the students really needed to know.

또한 교육에 대해서 거의 인정해주지 않고 연구가 학문적 성공의 유일한 결정요인이다.

A close second to it, though, is the lack of recognition of teach- ing as a scholarly activity in Japan. Research (both grant getting and publication record) is the SOLE de- terminant of academic success.

따라서 교육에 노력을 쏟고 싶어도 하지 못하는 의사들이 많다.

It comes, therefore, as no surprise, that several clini- cians openly, if somewhat ruefully, declared that they could not teach even if they wanted to, because teach- ing was identified as an indulgence that wasted valuable clinical time (i.e. hindered revenue generation!). And it seems obvious that the Division Chiefs place little or no value on clinical or teaching activities.

왜 Keio대학의 교수들은 교육에 참여하지 않는가?

Why are Faculty at Keio University Reluctant to Teach?:

의사를 양성하는 의과대학에서는 교육은 적어도 연구와 비슷한 대우를 받아야 한다.

But a medical school is, first and foremost, a revered place of Higher Learning where future doctors are trained. This means that teaching must be accorded a status that is at least equal with research.

그러나 일본에서는 그렇지 않다. 승진은 거의 연구 성과에 따라 이뤄진다.

This is just not true of Japanese academic institu-tions, notwithstanding protestations to the contrary.16 In Japan, promotions policy is based exclusively on re-search output and faculty who teach are accorded no recognition and given no status.

이러한 엄청난 핸디캡에도 불구하고, '교육'이 여전히 유지되는 것은 몇몇의 희생 덕분이다.

That teaching still occurs at Keio University Hospi- tal, despite this terrible handicap, is a testament to the selflessness of the few dedicated souls who soldier on without hope of recognition or reward.

의미있는 피드백의 부족

Absence of Meaningful Feedback:

학생에게 솔직한, 익명의 피드백을 구하지 못한다.

Yet another major obstacle to meaningful change in medical education in Japan is a failure to get honest, anonymous feedback from students.

4. Problem Based Learning:

보람된 의미있는 교육경험이었음.

The jubilation I felt at the end was as great as any I have experienced in my teaching career, and I con- veyed it to the students.

다만 교수나 레지던트 중 단 한사람도 참석하지 않은 것은 실망스럽다.

My only abiding dis- appointment is that not a single Keio University faculty member or resident attended the PBL sessions, despite repeated invitations. Had they been there, not one would have walked away without being impressed by the excitement and enthusiasm for interactive learning that was on display.

그러나 오히려 그렇기 때문에 학생들이 자유롭게 이야기할 수 있었던 것일 수도 있다.

On second thoughts, maybe it was good that they did not come! I suspect the session would have ended in dismal failure. I doubt that the students would have felt free – or even dared! – to be spontaneous had they known their ‘‘sensei’’ were watching them and listening to their every word. I have observed that Japanese stu- dents are quite intimidated by the very thought of interacting with their teachers (with a few selected exceptions).

Summary of Observations Regarding Medical Education at Keio University School of Medicine

약점

A. Observed Weaknesses:

1. The absence of any concept of a generalist who has a broad-based understanding of disease processes. 

2. The absence of any bedside clinical instruction. 

3. The absence of any recognition of teaching as a le- gitimate academic pursuit (and the absence of any rewards for engaging in teaching) 

4. The absence of any mechanism for evaluation of teachers in an honest and anonymous manner 

5. The overwhelming dependence on passive learning (didactic lecturing) for medical education 

6. The absence of clinical relevance in the didactic ma- terial (with the exceptions noted) 

7. The widespread attitude of deference that leads to unquestioning acceptance by students of all that is or isn’t sent their way by seniors 

8. The resultant a. absence of any sense of participation by students in active and interactive learning b. deeply ingrained attitude of passivity and defer- ence in students.

강점

B. Observed Strengths:

1. The quality of the students! What a marvelous re- source, and if exploited in the appropriate manner, it could be the engine for long-lasting change. 

2. Professor Takahiro Amano as Head of the Depart- ment of Medical Education, the perfect person to guide them through the difficult changes to come 

3. The will to change as articulated by Dr Amano and endorsed by Dean Kitajima 

4. A core group of faculty who I suspect may be willing to become clinician-teachers, given the right incen- tive 

5. The Pittsburgh-Japan Program as a facilitator of change; it can contribute mightily by exposing stu- dents in Japan to the wonders of clinical training, and by exposing teachers from Japan to the joy of teaching. A free and frequent exchange of both per- sonnel and ideas will help cultivate the right atti- tudes for the changes to take place. The best way to have an impact is to send clinical instructors to Japan on a frequent basis, to cover as many institutions as are willing to consider radical changes in their teaching methods. The more that both students and teachers are exposed to the excitement and rewards of bedside clinical instruction, the more likely it is that there will be inculcated a desire to teach in fu- ture generations of teachers.

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Keio J Med. 2006 Jun;55(2):41-51.

Perspectives in medical education--1. Reflections on the state of medical education in Japan.

Rao RH1.

Author information

• 1University of Pittsburgh School of Medicine, PA 15213, USA. rao@dom.pitt.edu

Abstract

The current shortcomings in Japanese medical education are highlighted by identifying four major areas of concern, based on the author's personal observations at Keio University Hospital. The first of these is a woeful lack of clinical skills among Japanese medical students and residents. This lack springs directly from the complete absence of any bedside clinical instruction, which constitutes the second area of concern. The third is the attitude of faculty towards teaching as a burden that detracts and diverts them from their primary goal of academic advancement through research. Finally, there is no recognition of the value of a problem-based approach to teaching clinical medicine, so that clinical problem-solving skills have atrophied to the point of near-extinction in the current generation of Japanese physicians. The promise of problem-based learning (PBL) provides a crucial starting point for efforts to change the system. PBL emphasizes the importance of an integrated approach to clinical problems, and a reliance on critical thinking--the basis of primary care. This contrasts with the selective and highly specialized approach to disease, and reliance on sophisticated technology, which are hallmarks of specialty care. The effort to reform medical education will fail without visionary leadership and without the willingness to confront the truth, as unpleasant as it may seem to be. Both these crucial elements exist at Keio University at this critical juncture. It is this happy confluence that emboldens the author to hope that the future of reform is in good hands at this august institution.

PMID:

 

16823259

 

[PubMed - indexed for MEDLINE] 

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