일본 의학교육의 트렌드(Medical Education, 1985)

일본 의학교육의 트렌드(Medical Education, 1985)

Trends of medical education in Japan 

D. USHIBA

Historical background

중의학이 오랜 시간동안 우위를 점하고, 고립정책 아래서 200년 이상 포르투갈과 네덜란드에 의한 서구 의학의 영향을 받아온 일본은 공식적으로 1870년 독일 의학교육시스템을 도입하기로 결정한다. 이러한 결정에 저항이 없었던 것처럼 보이는데, 전통적 가족 시스템으로 대표되는 기존의 봉건주의가 '수장'을 기반으로 하는 전통적 독일의 시스템과 유사했으며, 즉 일본의 '교실' 시스템은 지금까지도 바뀌지 않고 교육의 여러 분야에 영향을 주고 있다.

After a long -period of nationwide predominance of Chinese medicine and more than two centuries of the influence of western medicine through Portugal and Holland under the isola- tion policy, Japan officially introduced the German system into medical education in 1870. This decision seemed to have been made with- out resistance, since the existing feudalistic atmosphere exemplified in the old family sys- tem could easily accept the old German system based on chairs, Koza in Japanese, which exists unchanged in principle even now and influ- ences every aspect of research and education.

UME의 첫 번째 혁명은 전후에 일어나는데, 북미의 영향 때문이었다. 두 가지 대표적인 것. 하나는 1년짜리 인턴십이 생긴 것이고, 두 번째는 이 1년짜리 인턴십 이후 치르게 되는 의사면허국가시험이 생긴 것이다. 

The first revolutionary change in under- graduate medical education in Japan followed soon after the war, under North American influence. It was represented by two important events, namely the introduction of the one-year internship for clinical training following gra- duation and the setting up of the national examination for physicians’ licensure to be taken by medical graduates after thcir in- ternship.

두 가지 모두 부드럽게 진행되는 듯 보였는데, 실제로는 인턴십의 운영은 여러 문제를 가져왔고 학생들이 불만스러워했다. 그 결과 인턴십은 도입 20년쯤이 지나 1968년 결국 폐지되었고 이는 정부나 교육을 담당하는 교수들 모두 인턴에게 생필품이나 재정지원에 인색했기 때문이었다. 인턴이 없어진 이후, 학생들은 졸업 직후에 의사면허시험을 보게 되었고, 일반의학에 관한 2년의 임상수련 - 의무는 아니었지만 - 이 MHW에 의해서 권고되었다.

These two processes appeared to be proceed- ing smoothly, but in reality the operation of the internship involved many problems that caused student dissatisfaction. In consequence the in- ternship was finally abandoned in 1968 after a period of some 20 years, because of a lack of action by both the government and medical teachers at that time about providing amenities and financial rewards for the interns. Since the abolishment of the internship, students take the national examination immediately after gradua- tion. At least 2 years’ postgraduate clinical training in general clinical medicine, although not mandatory, is strongly recommended by the Ministry of Health and Welfare to graduates who have passed the examination.

1970년 이후의 의과대학 증가

Increase in medical schools since 1970

1969년 4040명이던 학생 정원은 1981년 8360명까지 늘어났다.

The total enrolment of first-year students in medical schools naturally increased at the same pace, from 4040 in 1969 to 8360 in 1981.

이러한 증가 이유는 복잡하다.

The reasons for and result of this rapid increase are rather complicated. 

1970년대 초반, 더 많은 의사를 키워야 한다는 요구가 있었는데, 특히 1961년 전국민을 포괄하는 국가 건강보험시스템이 도입된 이후 이러한 요구가 더 세졌다. 동시에, 의사의 불균등한 분포가 또 다른 이유가 되었다.

In the early 1970s there was certainly a need for more doctors because of the growing demand for medical care, particularly since 1961 when a national health insurance system was instituted to cover the entire population. At the same time, the maldistribution of doctors was another reason.

다른 한편으로는, 여당이 의학교육의 문제점을 지적한 보고서에서 10만명당 160명의 의사를 1986년까지 목표로 삼아야 한다고 권고했고, 의사의 불균등 분포 해결을 위해서 한 prefecture당 의과대학 하나 이상 있어야 함을 주장했다. 이러한 계획은 일도일의과대학 정책으로 불리며, 이 정책에 따라서 정부는 1973년부터 17개의 국립의대를 신설한다.

On the other hand, a committee of a leading political party (Liberal-Democratic) re- commended in a report of a survey of medical eduation problems that a ratio of 160 doctors per IOO,OOO population should be a goal to be reached by 1985, and also that for correcting maldistribution of doctors at least one medical school should be located in each prefecture. This plan became known as the concept of ‘one medical school per prefecture’, and complying with this policy, the government has opened seventeen new national schools since 1973.

그러나 의사를 더 양성하려는 목적은 기대보다 훨씬 일찍 달성되었음에도, 의사의 과잉공급에 대한 우려는 이미 의사나 국민들 사이에서 더 커지고 있었다는 점은 아이러니하다.

It is ironical, however, that while the target of producing more doctors has been achieved much earlier than expected, as indicated by the estimated number of 165 per IOO,OOO popula- tion in 1985, anxiety about over-supply of doctors occurring in the near future has already become evident in the medical profession and even among members ofthe public.

학부의학교육의 변화

Changes in the undergraduate medical curriculum

앞에서 언급한 두 가지 변화

The two main changes in the system of medical education after the war,

사실 일본은 6-5-3 시스템에서 6-3-3시스템으로의 변화를 겪고 있었다.

In fact, at that time Japan was confronted with a fundamental change in the school year system, by which the so-called 6-3-3 system (6 years for primary, 3 years for middle and years for high school 3 education) replaced the previous 6-5-3 system.

6년의 의과대학과정은 일본 시스템의 가장 큰 특징 중 하난데, 이는 법적으로 2년의 의예과와 4년의 의학과가 구분되어 있기 때문이다.

This 6-year medical educa- tion course has become one of the most charac- teristic features of the Japanese system because it was clearly divided by law into two stages, a 2-year premedical and a 4-year medical stage (the 2-4 system).

그러나 6년 교육의 연속성에 대한 논의가 활발해지면서, 1973년 의무적인 2년-4년 구분이 사라졌다. 의과대학은 이제 6년제 혹은 2+4년제를 모두 할 수 있다.

However, a greater continuity throughout the 6 years was discussed exten- sively, resulting in the abolition of the nianda- Y tory distinction between the two stages in 1973, Medical schools can now adopt either a continuous 6-year or a segmented 2-4 system.

이러한 경향은 교육과정의 유연화를 가져왔는데, 여전히 6년 교육과정을 하는 데에는 어려움이 있었다. 예를들어 많은 의과대학이 예과-본과 캠퍼스가 달랐다. 또한 '교양교육'을 의예과에서 담당하는 교수들은 보통 의과대학 교수들과 커리어가 달라서 의예과-의학과 교수들간의 의사소통을 가로막는 장애가 되었다.

This trend seems to indicate progress towards flexibility of the curriculum, but there are still some difficulties for the continuum of the 6-year curriculum. For example, a number of older medical schools have different campuses remote from each other for premedical and medical courses. Moreover, premedical course teachers in charge of ‘general’ education (which includes the humanities, physics, chemistry, biology, mathematics and foreign languages) usually have careers entirely different from those of medical course teachers, which tends to inhibit close communication between teachers of the two courses.

어떻게 6년 연속체가 더 촉진될 수 있을지, 아니면 반대로 의예과 교육이 의학과 교육과 완전히 구분되어야 하는지는 의학교육자들 사이에서 뜨거운 논쟁 주제였다. 지금까지는 그러나 일본 의과대학은 둘로 나뉘어 있다. 다만 눈여겨 볼 점은 6년을 하는 의과대학은 물론 2+4를 하는 대학에서도 의예과 교육을 하는 교육시간은 점차 줄어들고 있으며, 이렇게 줄어든 시간은 의학과 과목을 가르치는데 쓰이고 있다.

How the ‘-year continuum can be further promoted, or conversely, whether the pre- medical course should be completely separated from medical school, is being hotly discussed among medical educators. Presently. however, medical schools in Japan can be divided into two types in this regard: one is the 6-year and the segmented ‘continuurn type and the other the segmented type in which the 2-4 system is set by the school’s regulations. It must be pointed out, however, that in schools with the continuum type and, even in segmented-type schools, teaching hours of the premedical course are gradually shortened, and hours thus saved are generally used for medical course teaching.

UME의 한 가지 문제는 - 전 세계적인 문제이기도 한 - 교육과정 통합의 문제이다.

With regard to the content of the under- graduate medical curriculum, one problem, which seems to be a matter of world-wide concern in medical education at present, is that of curricular integration.

통합교육을 하는 의과대학은 많지 않다. 증가하고 있기는 하다. 옛날 학문단위 교육 시스템이 아직도 널리 퍼져있는 이유는 Koza 시스템 때문인데, 학부의학교육은 여전히 많은 수가 강의식이다.

The number of schools having the integrated curriculum is in general not large, although an increase to some extent is seen between 1977 and 1983 (17~/0+25%). It can be said that in more than half the schools almost all subjects are being taught independently of each other on a disciplinary basis. The prevalence of this old style seems to be due to the influence of the Koza system. Undergraduate medical educa- tion in Japan, however, is still being carried out with many didactic hours, in spite of the strong recommendation after the war for laboratory practice and bedside teaching.

또 다른 문제는 필수(고정, fixed)과목 외에 특과(special subject)로 가르치는 내용의 문제이다.

Another problem is the so-called special subjects to be taught in the medical course besides the customary fixed subjects.

새로운 의과대학들

New schools with unique organizational structure or special aims in the curriculum

쯔쿠바 의과대학: 통합과 PBL, 자율학습, 소그룹 학습 강조

The University of Tsukuba School of Medi- cine, a national school established in 1974, is unique in having no Koza system, for the first time in the history ofJapanese universities. The curriculum is a complete departure from the classic style, being extensively integrated, and emphasis in teaching is placed on problem- solving, self-learning and small-group instruc- tion. There is almost no teaching by individual disciplines and the method of evaluation is decided by a special central committee. Tsuku- ba School of Medicine has a curriculum which makes the most extensive use in Japan of modern education technology. The University of Tsukuba School of Medicine is now an associate member of the Network of Community-oriented Educational Institutions for Health Sciences, with innovative problem- based curricula.

사가의과대학: 대규모의 융합형 Koza 시스템(독립적 Koza 시스템 대신)을 운영.

Saga Medical School, a national school estab- lished in 1977, is also unique in having a structure in which a large amalgamated KOZA system is used instead of an independent KOZA system for each discipline. Under this new system the curriculum is integrated, with spe- cial emphasis on self-learning and self- evaluation of students. Here, community medi- cine and primary care are particularly empha- sized.

가와사키의과대학: 일반임상의학 교실을 열고, 일차의료와 지역사회 포괄적 의료에 초점을 둠. 이러한 분야에 대한 일본 최조의 Koza system.

Kawasaki Medical School, a private school established in 1970, has recently opened a new department of general clinical medicine for the purpose of promoting primary care and com- prehensive medicine in the community. The department has the special objective of primary care in the curriculum of undergraduate as well as postgraduate education. This department is the first one of its kind organized under the KOZA system in Japan.

지치의과대학

Perhaps the most community-oriented medical school is Jichi Medical School. The school, established in I972 by local self- governing bodies, has been responsible for training doctors to practice in rural areas. Applicants are selected first in each prefecture, and two or three students from each of the prefectures are finally admitted through selec- tion by the school. All students receive a full scholarship during the entire period of the 6-year course, and are exempted from reini- bursement if they agree to work for 9 years at an institution designated by the governor of the prefecture from which they were selected. The curriculum has the particular objective of train- ing students in community medicine, and the graduates have now been working, with good reputations, in local communities since 1978. The school has recently opened a centre for community medicine, where teaching and re- search on community medicine are systemati- cally conducted.

직업환경의학(산업의학) 의과대학

Also of interest is the University of Occupa- tional and Environmental Health, School of Medicine (Industrial Medical School). It was established in 1978 by a private foundation connected with the Ministry of Labour with the purpose of training doctors lvho arc cx- pected to work in industry-related fields aftcr graduation. Their curriculum includes many hours of ‘Instruction in Medicine’ with a wide range of subjects in which outside lecturers, including those from social sciences, participate.

국방의과대학

Another medical school established with a particular aim is The National Defence Medical College. It has the special mission of training doctors for the Defence Forces under the control of the Defence Agency. Although the school is beyond the jurisdiction of the Ministry of Education, its graduates are qualified to take the national examination for licensure.

PGME, CME

Postgraduate and continuing medical education

진료를 하기 위해서 일본 학생들은 2년의 임상수련을 거쳐야 한다.

As mentioned before, if they want to practice medicine, medical graduates in Japan are now strongly recommended to receivc clinical train- ing for at least z years immediately after passing the national examination for licensure.

이 과정은 의무는 아니지만 사실상 모든 졸업생이 수료하며, 일부는 봉급을 받기도 한다. 80%는 대학병원을 선택하며, 20%는 MHW가 지정하는 병원을 선택한다. 200개 이상의 병원이 선택가능.

This postgraduate training, although not niaii- datory, is taken by almost all graduates and some trainees receive a stipend. Approximately 80% of them choose university hospitals as the place for training, while the remaining 20% are trained at the teaching hospitals designated by the Ministry of Health and Welfare as approved for postgraduate clinical training. There arc now nearly 200 such designated hospitals and a conference has recently been organized among them for improving the content of their train- ing programmes.

일반 졸업후 수련에 대해서, 전문과목 시스템은 잘 발달하고 있지 못하다. 내과 전문과목 시스템은 1968년 만들어졌는데, 이후 17개의 학회가 만들어졌고 7개가 더 만들어질 예정. 그러나 전문의로서 적절한 수준에 있는가에 대해서는 학회 사이에도 차이가 명백하고, 이 문제를 해겨랗기 위해서 1982년 다른 학회가 만들어졌음. 

Regarding general postgraduate clinical train- ing, the development of a specialty sysrcm in Japan is not progressing well. Since the speci- alty system in internal medicine was establishcd in 1968, seventeen professional societies have developed some systems for specialists or reg- istered doctors and seven more are planning the development of such systems. However, an apparent inequality in the level of certification as specialists has become evident among the societies concerned, and in order to solve this problem a body was set up among professional societies in 1982. The issue of recertification as specialists has so far only been taken up by a few societies.

CME는 사실상 자율에 맡겨져 있음

Continuing medical eduation in Japan as presently conducted is almost voluntary.

의학교육 관련 워크숍

Workshops on medical teacher-training

많은 국가에서와 마찬가지로, 대학의 교수들은 교육 기술에 대해서 배울 기회가 별로 없다. 1970년대 초반, 일부 의학교육자들이 시드니의 RTTC로 국제워크숍에 참석한 이후, 일본의 의학교육에 대한 관심이 높아졌다. RTTC 워크숍 참석자들이 국가단위 워크숍을 진행하여 1974년부터 매년 하고 있으며, 이에 반응하여 여러 작은 단위의 워크숍이 전국적으로 열리고 있다.

As in most countries, medical teachers in university or teaching hospitals in Japan used to have no opportunities for training in education technology or for studying education science. However, since the early ry7os, when several medical educators in Japan participated in the international workshops at the Regional Teacher Training Centre of the World Health Organization in Sydney, Australia, concern about teacher training in medical education in Japan has gradually developed. Under the lead- ership of participants in the RTTC workshops, nationwide workshops on teacher training have been held annually from 1974 and, echoing these central events, many other small-scale workshops have been conducted in various places throughout the country.

이러한 워크숍의 평가는 일반적으로 좋으나, 중앙조직이 필요하다.

The evaluation of these workshops is gener- ally good, but the establishment of a central organization to conduct teacher training is certainly necessary to disseminate its effect more rapidly.

의학교육관련 단체의 활동

Activities of medical education-related institutions

일본 의학교육학회

The Japan Society for Medical Education was established voluntarily in August 1969 by a group of medical educators and now has IOO institutional members, including medical schools and teaching hospitals, and more than 800 individual members.

일본의학교육학회지

The Society publishes a bimonthly official journal, Medical Education, in Japanese and holds an annual congress as well as many small conferences or workshops concerning particu- lar topics from time to time. Among its standing committees are an undergraduate medical education committee, a student selec- tion committee, a continuing medical education committee, a postgraduate clinical education committee and a teaching methods committee. Several working groups on general professional education, behavioural science, national ex- amination for licensure, etc. have also been formed. Up to now it has proposed many recommendations to promote various aspects of medical education and has published mono- graphs including ‘medical education manuals’ and ‘white papers’.

NTTC 설립(1977년)

In 1977 and for several years thereafter the Society strongly urged the establishment of a National Teacher Training Centre. Since 1974 key members of the Society have acted every year as task force persons in operating nation- wide teacher training workshops as well as short course workshops.

일본의학교육재단

The Japan Medical Education Foundation was founded in April 1979 with the assistance of all medical schools. It holds symposia on medical education, inviting medical educators from home and abroad, grants research funds for medical education to individuals or groups, forms inspection tours to domestic schools and sends study groups to institutions abroad.

의학교육 변화의 장애물

Obstacles to changes in medical education

WHO의 선언 이후 많은 노력이 이뤄지고 있다.

It is obvious that under the policy of the World Health Organization, ‘Health for All by the Year ~OOO’, many new efforts to reach this target are now required in the field of medical education.

여러 전략을 다 시행하긴 쉽지 않으나 진전은 있다. 그러나 장애물도 있다. Koza시스템이 장애가 되는데, 의지만 확실하다면 새로운 정책을 시도할 수 있는 시스템이기도 하다.

It is not easy to introduce these strategies into medical education in Japan, although prog- ress is being seen in some areas. There are several strong obstacles to the changes in present-day Japan, first of all the Koza sysiem. The Koza system is actually a traditional de- partmentalized system in universities. It is a strong hierarchical structure maintained for a long time under the authority of the professor. Under this system, changes such as those mentioned above are apt to be thought of as interference in academic freedom which may undermine Koza’s prestige. Also, the auton- omy of the Koza system puts emphasis on medical science or research, sometimes neg- lecting the importance of education in general. The introduction of curricular integration is frequently difficult under this separate depart- mental system. On the other hand, the Kora system has some advantageous features. It is a stabilized system in which a certain amount of research and teaching money is secured, and a new policy, if it is really intended, could be rather easily carried out on the professor’s decision.

보상이 주로 연구에 치우쳐있다.

As in other countries the academic reward system in Japan usually favours scientific re- search achievement shown by published papers over -teaching ability health services or research.

의과대학생 선발과 진로선택 전통적으로 일본에서 의과대학 입학 경쟁은 매우 치열했는데, 여전히 지필고사에 매우 의존하고 있다. 1979년부터 국가단위의 1차 스크리닝(시험) 이후에 대학 단위의 2차 시험이 도입되었고 여기서 인성이나 성격을 평가해야 할 것을 권고하고 있고, 여러 대학에서 면접, 논술, 토론 등을 도입했다. 그러나 지필고사에서 평가하는 것 중 큰 비중은 여전히 지식 평가에 치우쳐 있는 것이 사실이다.

Another problem is that of medical student selection and career choice of medical school graduates. Traditionally in Japan, the competi- tion for entrance to medical schools is very keen and selection used to be, and still is, based on the results of written examinations on cognitive knowledge only, particularly in national and public schools. For those schools the nationwide first screening test has been conducted since 1979, the second examination being given by each school for a final decision. It has been recommended that these second examinations should assess the applicants’ per- sonal qualities which are adaptable to each school’s particular character; therefore, some schools administer various types of tests such as interviews, short essays or group discussions.

Generally speaking, however, in all schools very little weight is given as yet to matters other than the results of the written test for cognitive knowledge. More reliable methods for selecting students who have a suitable personality and adaptability to the medical profession should be developed in order to train good doctors.

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Med Educ. 1985 Jul;19(4):258-65.

Trends of medical education in Japan.

Ushiba D.

Abstract

This article introduces recent trends in medical education in Japan, from undergraduate education through continuing education, and explains changes in the number of medical schools and in the content of the curriculum. Some obstacles to the implementation of changes, particularly in undergraduate medical education, are discussed. Now that Japan has become relatively developed in the quantity of its health manpower and also socioeconomically, a change must be directed towards qualitative reorganization and rearrangement in medical education in line with the objectives posed for the new century. The establishment of something new is difficult; to change something old and established, however, is much more difficult. In Japan, while some new designs in the curriculum are found in almost all the new schools, any fundamental change in the established curriculum in the old schools can be found only rarely, and attempts at changing the established curriculum frequently encountered resistance in the old schools.

PMID:

 

4021851

 

[PubMed - indexed for MEDLINE]