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.

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.

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.

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.

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.

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

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.

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.

Med Educ. 1985 Jul;19(4):258-65.

Trends of medical education in Japan.

현재 전 세계 의학교육 시스템(J Med Dent Sci 2011)

The Current Medical Education System in the World

Nobuo Nara1), Toshiya Suzuki1) and Shuji Tohda2)

Introduction

세계 의과대학의 교육시스템

Education system in the overseas medical schools

세 그룹으로 구분가능

We can divide the overseas medical education system into 3 groups.

Curriculum

의예과학, 기초의학, 임상의학 으로 구분된다.

The curriculum of medical school is composed of premedical science, basic medicine and clinical medicine. 

In type 1 medical school, 

• students learn liberal arts including philosophy, ethics, mathematics, physics, chemistry, biology, foreign language, etc. in premedical course for 0.5 ~2 years. 
• After the premedical course, students learn basic medicine such as anatomy, histology, biophysics, biochemistry, bacteriology/virology, pathology, hygiene, public health, physiology, pharmacology, etc. for 1.5 ~2 years. 
• Finally they learn clinical medicine such as internal medicine, pediatrics, surgery, obstetrics, gynecology, orthopedics, urology, otorhinolaryngology, ophthalmology etc. for 2 ~3 years including clinical clerkship.

type 2에서는 premedical course는 불필요.

It is not necessary for students in type 2 medical schools to take premedical course because they have already learned before admission. In 4 years education, students learn basic medicine for two years and clinical medicine for two years.

Education methods

Formally, the knowledge of medicine has been taught by teachers through lectures in a large theater.

Clinical clerkship system is reasonable to master clinical skills. Students belong to the medical team as a staff and do medical practice under the supervision of attendants. This clinical clerkship system is most advanced in USA and Canada.

Medical schools of the other countries have also introduced actively this system. Before entering clinical clerkship, students usually take simulation-based learning using standardized patients and/or models7.

독일의 Charité University 의 실험. 매년 603명의 입학생. 540명과 63명으로 나누어 교육과정 다르게 진행함.

Very attractive and important pilot study is under way in Charité University in Berlin, Germany. It accepts approximately 603 students per year. Students are divided into two classes by lot; 540 students for regular course and 63 students for reformed course. Informed consents are obtained from students of both groups. Students of either group can take appropriate education to be medical physicians; they do not think unfair even if they belong either class.

• The first five years of the reformed course are divided into two phases.
• At the first phase, the students l earn organ- based medi ci ne
• At the second phase, they learn basic medicine and clinical medicine chronologicallysuch as pregnancy, new born, baby, infant, schoolchild, adolescent and adult. Clinical clerkship is also included in this phase
• The last 6th year is a clinical clerkship year where students rotate internal medicine for 4 months, surgery for 4 months and elective department for 4 months.

6. Thompson BM, Schneider VF, Haidet P, et al. Team-based learning at ten medical schools: two years later. Med Educ 41: 250-257, 2007.

J Med Dent Sci. 2011 Jul 4;58(2):79-83.

The current medical education system in the world.

의학교육 세계화의 빈틈(Med Teach, 2009)

Cracks and crevices: Globalization discourse and medical education

BRIAN DAVID HODGES1, JERRY M. MANIATE2, MARIA ATHINA (TINA) MARTIMIANAKIS2,3, MOHAMMAD ALSUWAIDAN2,3 & CHRISTOPHE SEGOUIN2,4

의료에서 국제화 관련 담론은 매우 흔하나, 의학교육자들이 여기에 관심을 가지기 시작한 것은 비교적 최근의 일이다.

While the discourse of globalization is very common in health care, it is relatively recent that medical educators have taken up these ideas and language.

의학교육에서의 세계화

Globalization in medical education

많은 국가들이 의사가 부족하여 의료인을 '수입'한다. 예를 들어 캐나다의 한 신문에서는 '캐나다가 의사를 수입하는데, 종종 캐나다보다 더 의사를 필요로 하는 개발도상국에서 의사를 들여오기도 한다. 캐나다에서 진료하는 의사의 23~25%는 해외에서 수련받은 의사이다' 라고 하며, 한 캐나다 의과대학 학장의 말을 빌어 '캐나다는 의사를 수입하고 있으며 처음부터 의사가 부족했다' 라고 하였다.

Consider for instance that many countries with a shortage of physicians speak of ‘importing’ medical trainees. For example, a Canadian national newspaper recently reported that, ‘Canada imports doctors, often from developing countries that may need them more. Between 23 and 25% of doctors practicing in Canada are foreign-trained’ and quoted a Canadian medical school dean who said, ‘Canada has relied on importing physicians, so [our schools] have under-produced from day one’ (Spencer 2008).

어떤 나라에서는 여러 이유에서 의사의 수련을 다른 나라로 '아우소싱'한다. 일부 국가 - 특히 동유럽이나 캐리비안 국가는, 의과대학을 사업모델로서 개발하였는데, 이 의과대학의 목적은 의학교육에 대한 국제적 수요에 맞춘 것이며, 가장 최근에는 다른 국가에서 의과대학 전체 교육과정을 사들여오는 경우도 있다(the Cornell Weill-Qatar Medical Schools)

Other countries talk of ‘outsourcing’ the training of doctors to other countries for various reasons including economic ones. Some countries – notably in Eastern Europe and the Caribbean have developed medical schools with business models that are specifically aimed at meeting a global demand for medical education and most recently there are instances of countries buying entire medical school curricula from other countries (e.g. the Cornell Weill-Qatar Medical Schools discussed in detail later).

On the other side of the globe, a recent article in a national Singaporean newspaper reported that the Singapore of government of was increasing the number recognized international medical schools to 160 to addressSingapore’s MD shortage. The article noted that many studentspursuing medicine were unable to secure a place at the solenational medical school (Docs trained abroad working inS’pore 2007). 

의학교육 외 분야에서의 세계화 연구

Studies of globalization outside of medical education

세계화에 관해서 가장 많이 인용되는 저자 중 하나는 Thomas Friedman이다. 그는 ‘The World is Flat’ 이라는 책에서 저지할 수 없는 국제적 통합이 진행중이며, 그러나 긍정적인 측면이 부정적인 측면보다 많다 라고 했다.

One of the most widely cited authors on globalization is Thomas Friedman. In his book, ‘The World is Flat’ he argues that there is an unstoppable global integration process underway, but that the positive benefits outweigh the negative ones.

Certainly an examination of the economic pros and cons of projects of globalization is important, but we wonder if this economic discourse of globalization is not obfuscating other important issues with particular relevance for our field.

마지막으로, 기존에 힘 있는 국가의 전통과 문화가 압도할 수 있다는 우려가 있다. 각 전통이나 문화에 따라 의료 및 다른 의료전달체계들이 발달해왔으며, '의료 문화'란 어느 곳에나 적용가능한 균일한 제품이 아니고, 국가나 지역 문화에 맞춰서 적용되어야 한다. 의학교육자들은 마치 의학에는 단 하나의 문화만 있는 것처럼 행동하며, 비교연구에는 별다른 노력을 기울이지 않는다.

Finally, there are authors who raise a third set of concerns about the degree to which dominant countries can overwhelm national traditions and cultures. The practices of medicine and of health care delivery arise from centuries of tradition and refinement in cultures around the world. ‘Medical culture’ is not a homogenous product that can be simply taken up anywhere, but must be adapted to the context of national and regional cultures (Abbott 1988; Freidson 2001). As we will discuss later, medical educators are prone to act as though there is only one culture of medicine (Taylor 2003) thereby investing almost no effort in comparative studies (Segouin et al. 2007).

국제화 연구를 의학교육에 적용하기

Applying globalization research to medical education

국제화의 이익이 비균등하게 분포되고 있는가?

Are the benefits of globalization in medical education uneven? Is the world getting spiky?

Sullivan 은 지난 몇 년간 영리 의과대학이 네 배 이상 증가했으며, 조만간 비영리 의과대학의 숫자를 넘어설 것이라 예측했다.

Sullivan has noted that the number of for-profit medical schools has quadrupled in the last few years and probably exceeds the number of non-profit schools (Sullivan 2007). In

For example, speaking of the new Cornell-Qatar venture, Greene commented, ‘Although we are the first, we won’t be the last medical school to do this ...It is a revenue stream...Our school has been in the black for nine straight years, but we can’t afford to lose money [with the international school]’ (Green 2007).

교육 서비스와 물품으로서 이득을 보는 이러한 의과대학은 어떤 결과를 가져올 것인가?

What is the impact of this rising imperative for medical schools to make money and commodify their educational products and services?

The presumed impacts are not only on medical schools. As medical students become global consumers of education, we need to ask what effects this will have on the opportunity to become a medical student. Does deregulated, free market medical education create disparities? In this area there is some worrisome research.

Increases in tuition have important implications for those of lower socioeconomic status and disadvantaged communities. The Association of American Medical Colleges in its 2005 report noted that for the past two decades, over 60% of medical students come from families with total incomes in the top quintile of all American families, while only 20%of medical students are from families with incomes in the lowest three quintiles (AAMC 2005).

In an era of mobility of students, faculty, curricula and even entireinstitutions, which patients and societies are today’s medicalsschools serving: local, regional, national or international?

한 웹사이트에서 폴란드 학생들은 이렇게 말했다 '내가 폴란드에 온 이유는 돈 때문이야', '언어는 좀 어렵고 초반에는 정말 힘들다' '폴란드는 외국 학생들에게 익숙하지 않고, 그들에 대한 질투가 있다' '우리에 비하면 걔네들(폴란드 학생)은 상당히 가난하다'

On visiting one site with a number of comments about medical schools in Poland we found medical students writing such things as: ‘I came to Poland because it’s good value for money’; ‘The language is difficult and makes no sense in the beginning’; ‘Poland is not used to foreigners and there is jealousy amongst them’; and ‘They are quite poor in (The Student Doctor Network Forums comparison to us’ 2008; http://forums.studentdocter.net/showthread.php?p¼ 6436557).

In a Canadian article sub-titled ‘Do our development and immigration policies amount to foreign aid in reverse?’ Krotz writes, ‘it costs $200,000 (US) to train a doctor in Zimbabwe or South Africa, and they end up in places like Manitoba (Canada), where one in three rural doctors is from Africa’ (Krotz 2008).

• Medical schools must consider social responsibility to the society in which they are located, but also to the societies their graduates will serve. 
• Medical schools should track the socio-demographic characteristics of their students and explore inequities in relation to admissions policies. 
• In deregulated systems, rising tuition fees should be meaningfully countered by measures to allow student from all classes and backgrounds to enter the profession. 
• National governments must invest in realistic health-human resource planning – building national capacity without decreasing capacity of other countries (poaching).

국제적 의학교육 규제 기구, 표준, 안전장치는 나아지고 있는가?

Are global medical education regulatory structures, standards and safeguards evolving?

In the domain of globalization and healthcare one of the most hotly discussed topics is global mechanisms of regulating quality (Segouin et al. 2005). There are two basic approaches to quality assurance: 

• evaluation (against a set of standards) of the ‘outcomes’ (e.g. examinations) or 
• evaluation of ‘processes’ (e.g. accreditation). 

의학교육에 있어서 outcome 측정은 역량 평가, 진료지역 평가, 진료형태 평가 등이 있다. process 평가는 의학교육을 하는 방법 그 자체(교육과정, 교육법, 교수 구성과 교육 기술)가 있다.

Translated to medical education, outcome measures include assessment of competence (examinations), and also location of practice, practice patterns, etc. Measures of process, on the other hand, include such things as the means of delivering medical education itself, including curricula, pedagogy, faculty configuration and skills, etc.

In recent years, there has been a movement to advocate identifying/creating ‘international standards’ for medical edu- cation that could theoretically be applied everywhere in the world. However, there is a body of literature emerging that suggests a significant problem with this approach.

In terms of efforts to create international standards, the World Federation for Medical Education proposed, in 2003, three sets of standards that were elaborated by an international panel of experts

These standards were based on pre-existing ones taken especially from North America, though the WFME states that that cultural specificities must be taken into account. There are steps underway to further refine these standards to ensure a broad view, such as the recent efforts to adapt them to European countries as part of a project called MEDINE (Medical Education in Europe), founded and supported by the Commission of the European Union. The goal it to Europe, an harmonize medical education in imperative flowing from the Bologna Process which aims to harmonize credits and standards in higher education across the European Union (Segouin & Karle 2007).

Ralston Saul에 이어서 우리는 '국제 기준을 개발하는 것이 어렵다면, 세계화된 의학교육이 규제의 무풍지대로 존재해야 하는가?'라는 질문을 던지고자 한다. 흥미롭게도, 이 질문에 대해서 WFME는 국가적으로 인정받은 기관만이 그 인증절차에 대한 책임이 있다는 입장을 폈다. 그러나 여전히 카타르의 new Cornell과 같은 경우는 그 영향력 바깥에 있다. 교육과정이나 교육법, 평가법, 심지어는 교수까지도 뉴욕에서 바로 수입했는데 그 캠퍼스가 미국 바깥에 있는 경우에 누가 이 대학에 대한 인증작업을 할 것인가?

Following Ralston Saul, we might ask, if it is difficult or impossible to develop global standards, must globalized medical education exist in an unregulated space? Interestingly, after deliberation on this question, the WFME has taken the position that only nationally appointed agencies can be directly responsible for accreditation procedures. This raises important questions that are illustrated by the new Cornell medical school in Qatar. For the moment, it finds itself in an accreditation vacuum. While the curriculum, pedagogical approaches, evaluation methods and even many of the faculty members are taken directly from the New York school, the actual campus is not in the United States. Who is going to accredit this school?

The questions arising: Is it possible to consider global accreditation without reverting to colonialism and all of the problematic baggage associated with homogenization and cultural dominance?

의학교육 바깥을 보면, 흥미로운 모델들이 있다. 한 예는 ISO 인증 시스템이다.

If we look outside of medical education there are some interesting models of less problematic ‘meta’ accreditation systems. An example is the ISO certification system. Based in Geneva, the ISOgroup elaborates standards at an international level but the certification is issued by national organizations that are themselves accredited by their national ISO umbrella organization.

유사하게, 의료와 관련해서는 다음과 같은 것들이 있다.

In the same vein, but dedicated to the health care system, an international project dealing with recognition of the quality of the local accreditation process for hospitals started in the mid 1995 aiming to accredit the accreditors around the world (Heidemann 1999) and the Joint Commission International (http://jointcommissioninternational.org) which accredits hos- pital all over the world.

Finally, it might seems obvious that a practical approach dealing with the twin challenges of global mobility of medical graduates and the need for international standards would be international examinations.

We might add that the whole concept of national exit examinations is a rather Anglo-Saxon phenomenon and that many countries of the world, including many in Europe do not have licensure or post training certification examinations at all(Hodges & Segouin 2008). As with the French–USA study, the context of training, familiarity with testing formats and content issues are so important that it is difficult to interpret scores of such international exams. For example, 90% of the US medical graduates pass the USMLE (national examination taken at the end of medical school in the US) while only 53% of American students who studied at an overseas school do. What do we conclude from this result? That the internationally trained students are less competent? Or that such variables as the examination format, content and administration are so different that the examination itself is an invalid comparison?(As with the French–US study)

• There should continue to be support the development of robust national accreditation systems for all countries/ regions, but also work towards some kind of international process for accreditation of accreditors (‘meta- accreditation’). 
• In creating specific standards for schools that train interna- tional students, or students likely to practice in countries other than the one in which the medical school is located, standards should address the socio-cultural relevance of curricula to eventual practice location of their graduates. 
• Specific attention must be given to avoiding the imposition of standards from economically or culturally dominant countries that do not fit with the cultural, economic or health-human resources needs of other countries.

Are important national or cultural differences threatened by globalization projects?

문화로 돌아와보자.

We now turn to the third areas of concern – culture.

의학교육 바깥의 문헌을 보면, 다양성의 축소되고 전통적 지식과 접근법이 억압받는 것을 우려한다.

Much literature on globalization outside of medical education warns of a risk of reduction of diversity and a suppression of traditional knowledge or approaches, by dominant groups or countries (Navarro 1999).

인류학자 Janelle Taylor 는 의학에 있어서 특히 문화별로 특징적인 측면들이 있는데, 의학교육은 이러한 차이에 무지하며 마치 '무문화의 문화'인 것처럼 행동한다고 지적했다.

Indeed, anthropologist Janelle Taylor has argued that while there are quite distinct cultural aspects to medicine, medical education tends to be blind to these differences and act as a ‘culture of no culture’ (Taylor 2003).

• China graduates 100,000 medical graduates a year from medical schools of 3-, 4-, 5-, 6-, 7- and 8-year curricula tailored to different kinds of practice. 
• Scandinavian countries have a cultural value called ‘Jantelov’—(loosely the idea of not considering oneself to be too important) – that render the idea of competitive examinations inappropriate, and thus these countries have very few exams. 
• Japan has a strong value of respect for elders that renders student evaluation of teachers inappropriate. 
• Germany understands the purpose of medical education to be the development of in-depth scientific knowledge and until very recently did not introduce clinical skills in a significant way during the 6 years of medical school training. 
• Scotland was the country in which the Objective Structured Clinical Examination first emerged and yet they have never adopted it as a licensure or certification examination partly because the discourses and practices of psychometrics are not as highly valued as the idea of conducting assessment in ‘authentic settings’.

효과에 대한 확실한 근거 없이, 모든 사람이 의학교육을 비슷한 방식으로 접근하게끔 하는 공식적인 프로세스 개발을 목표로 삼는 것은 진행되지 않아야 한다. 모든 사람이 신발을 신을 때 신발끈을 묶어주어야 한다는 것에는 동의할지 모르나, 왜 모든 사람이 어떻게 끈을 묶고 어떤 매듭을 지어야 하는가에까지 동의해야 하는가?

In the absence of convincing evidence to that effect, perhaps the goal should not be to develop formal processes that bind everyone into similar approaches to medical education, or even similar approaches to treatment and care of patients across the globe. We might all agree that tying our shoelaces is a ‘best practice’ (if one wears shoes!), but why do we have to agree on howto hold the laces or what knots to use?

Boelen C. 2002. A new paradigm for medical schools a century after Flexner’s report. Bull World Health Organ 80(7):592–593.

Cracks and crevices: globalization discourse and medical education.

의학교육: 대서양을 가로지른 대화가 필요한 시기(Med Educ, 2008)

Medical education: its time for a transatlantic dialogue

Brian D Hodges & Christophe Segouin

의학교육은 북미에서 최고의 번영을 이루었다. Academic Medicine 이나 Teaching and Learning in Medicine 같은 저널, National Board of Medical Education s Stemmler fund, 여러 관련 학회 등. 대부분 미국인들이지만, 캐나다인의 참여 덕에 약간의 세계화가 첨가되어 있다.

Medical education is in full bloomin North America. Journals such as Academic Medicine and Teaching andLearning in Medicine, grants such as the National Board of Medical Education s Stemmler fund and education conferences in all medi- cal specialties give North Americanmedical educators the opportunity to present work and ideas in a richarray of venues. Although largely American, these institutions have a dab of internationalism about them because of the participation of Canadians

유럽에서도 의학교육은 점차 그 꽃을 피우고 있다. 유럽 대학들은 의학교육자들에게 자리를 새롭게 만들어주고 있으며 Medical Education 이나 Medical Teacher 같은 저널들도 있다.

In Europe, medical education is also blossoming. European univer- sities are creating new posts for medical educators, and journals such as Medical Education and Med- ical Teacher enjoy growing circula- tion and impact factors.

북미의 관할 기관들이 끊임없이 늘어나는 외부 평가에 더 많은 재인증 시험을 추가하느라 정신없는 반면, 유럽의 의학교육자들은 최종평가는 더 축소시키고 프로그램 중 평가를 더 강화해야 한다고 요구한다.

While some North Americans’ jurisdictions are busy adding more recertification examinations to the ever-growing regime of external assessment, some European medical educators are calling for a further move away from final testing and towards in- programme assessment.4

이러한 차이는 '질'이 무엇인가에 대한 기본적인 생각의 차이에서 비롯한다. 프랑스 의학교육자들은 의학교육의 질을 확보하기 위해서 교수를 고용하는 기준(미국에서는 거의 상상도 할 수 없는 수준으로) 과 교육과정을 표준화(모든 의과대학이 동일한 중앙 개발된 교육과정을 가르친다)한다. 미국과 캐나다는 의과대학과 레지던트 프로그램에게 거의 완전한 교육과정 개발의 유연성을 부여하고, 교수를 고용하는 것에 있어서도 마찬가지다. 다만 졸업생을 매우 high stake의 최종시험을 통과하게 만들어서 의과대학 산출물의 질을 확인한다.

We have suggested these differences are based on fundamentally different ideas about what quality is.3 French medical educators, for example, aimto ensure the quality of medical education by standardising the hir- ing of professors (with a rigor that would be unimaginable in North America) and of curricula (all medical schools deliver the same, centrally created curriculum). The USA and Canada, however, allow medical schools and residency pro- grammes almost complete flexibil- ity in curriculum design and in hiring faculty but submit their graduates to very high stakes final examinations that serve as a quality check on the output of the medical school in question.

In another example, Woodrow et al. reported recently on the vastly dif- ferent approach to work hours for doctors in training in Europe and North America.2

European colleagues find it slightly disconcert- ing, if perhaps not surprising, that Americans consider an 80-hour working week acceptable. Mean- while, American colleagues roll their eyes about the dedication of European professionals who work an official week of only 35)40 hours. Although this issue might be dismissed as a quaint cultural difference, we believe the stakes are higher. At a recent con- ference, one of our American col- leagues presented a framework on professionalism and told a story about a doctor who came in after hours to deliver a baby. He framed this as a compelling example of the professional value of altruism .In the row in front of us, 2 Scandina- vian medical education colleagues whispering between themselves described this as: …the most glar- ing example of unprofessional behaviour I can imagine . Intri- gued, we learned that they consid- ered the idea of altruism to be a puritan religious construct and that, for them, professionalism is more aligned with maintaining a balance between one s personal and working lives. They argued that an ethically organised education and health care system would obvi- ate the need for anyone to come in from home in the middle of the night.

Rather than assuming that universal principles underlie medical education, it is time to embrace and examine differ- ences and discontinuities in the goals, practices and values of medical education in different countries and cultures.

국제 표준을 찾기 위한 몇몇 노력에 동참하면서 우리는 기본적인 역량에 대한 합의의 가능성을 보았다. 그러나 우리는 또한 의학교육의 목표와 실천에 대한 공통의 합의가 존재한다는 가정이 과장된 것임을 확신했다.

Having participated in a few efforts aimed at finding global stan- dards ,5 we can see that it may be possible to attain consensus about the basics of medical competence. However, we are increasingly convinced that the assumption of shared agreement about objectives and practices in medical education (and, indeed, medical education research) is wildly overstated.

More attention and funding needs to be given to international, comparative education research by medical education journals, conferences and organisations.

As Schuwirth and van der Vleuten wrote: …we start from the assumption that the universe is homogenous, where in fact the more logical conclusion would have been that the universe is more variant. 6

6 Schurwirth LWT, van der Vleuten CPM. A plea for new psychometric models in educational assessment. Med Educ 2006;40:296–300.

Med Educ. 2008 Jan;42(1):2-3. Epub 2007 Nov 22.

Medical education: it's time for a transatlantic dialogue.

일본 의예과 교육의 일반(Journal of Medical Education, 1962)

General View of Premedical Education in Japan

YUTAKA SANO and HISAO FUJITA

일본 의학교육의 목적과 특성

Aim and Particularity of Japanese Premedical Education

고대부터 일본과 중국, 그리고 다른 나라에서도 "의 는 덕 이다"라고 여겨졌다. 의사에게는 높은 수준의 윤리와 휴머니즘이 요구되었고, 이것이 일본 의예과 교육의 가장 큰 목적이다.

From ancient times it has been considered, in Japan and China and in other countries, that "Medicine is virtuous." High morality and humanism are needed by medical doctors. This is the greatest aim of Jnpanese premedical education.

또 다른 중요한 것 중 하나는 외국어 학습니다. 일본의 근대 의학교육은 독일과 호주에서 약 90년 전에 들어왔다. 이들 국가에서 근대 의과학 교육의 토대를 구성하기 위해 의사들을 초청했는데, 동시에 많은 일본 학자들이 해외로 나가서 과학의 교육과 연구 방법론을 배워왔다. 이런 이유로 일본 학생들에게 독일어와 라틴어를 읽고 쓰는 것은 가장 중요한 일이 되었다.

Another requirement that is par­ ticularly important for Japanese pre­ medical education is the learning of foreign languages. The system of mod­ ern medical education in Japan was brought from Germany and Holland about 90 years ago. We invited many doctors from these countries to for­ mulate the basis of teaching modern medical science. At the same time, many Japanese scholars have gone abroad to learn methods of teaching and research in the sciences. For this reason, for Japanese students, it has been a most important thing to be able to read and to write German and Latin.

1948년 이전의 의학교육시스템

Medical Education System before 1948

The high schools were distributed in Japan without rela­ tion to the medical schools. There were two courses in high school. 

• One was the course for literature, law, and economics, and the 
• other was the course for sciences, agriculture, tech­ nology, pharmacy, and medicine.

1948년 이전에는 중등학교 이후에 의과대학에 들어가는 다른 시스템도 있었다.

Before 1948, we had another system for training medical doctors; one could enter the medical college after middle school. In this case, premedical educa­ tion was combined with the medical curriculum. This system was abolished in 1949.

1949년 이후의 의학교육시스템

Medical Education System after 1949

46개의 의과대학이 있고, 전체 대학의 10%에 해당된다. 매년 3000명의 학생이 입학하고 5%는 여성

Now there are 46 medical schools, which represent 10 per cent of all universities, schools, and colleges in our country. E\·cry year about 3,000 students, of whom about 5 per cent are females, enter the pre­ medical schools.

의과대학에 가고자 하는 전체 학생 중 10~20%만이 의예과에 들어갈 수 잇다.

In Japan it is very difficult to enter premedical school. Only about 10-20 per cent of nil high school students who desire to become medical doctors can enter the premedical school.

의예과를 마치면 90%는 의학과로 진입하고 나머지는 의예과 2학년을 한 차례 더 반복한다.

After finishing premedical school, 90 per cent of the students can enter med­ ical school; the remaining 10 per cent may gain entrance to a medical school by successfully repeating the second premedical year.

필수와 선택과정

Required and Elective Courses

1948년 이전에 독일어 과목이 많았다. 졸업 후에 읽을 수 있는 책들은 아래와 같았다.

Before 1948, we had many lessons in the German language. After graduation, most students could read the short no,·els of Storm, Carossa, Keller, and so on with the aid of a dictionary. We used "Immensee" (Storm), Die Schicksalc Dr. B1lrgcrs (Carossa), and so on, as text books.

이차대전을 전후로 중, 고등학교에서 영어 수업이 많았다. 그러나 의예과에서는 영어를 공부할 시간이 많지 않았고, 독일어보다는 영어를 잘 읽었다. 그러나 읽고 쓰는것이 대부분이었고, 말하는것은 잘 못했다.

Before and after the war, we had many hours for English lessons in mid- die or high school. Though we have not always sufficient time to study Eng­ lish in premedical school, most stu­ dents read English more easily than German. However, since most lessons are for reading and writing rather than for con\'ersation, the students cannot speak these languages as well as they can read or write them. Thomas Hardy, Washing­ ton Irving, and Nathaniel Hawthorne are famrites among our English authors.

앞에서 언급한 바와 같이 외국어 공부는 일본에서 의예과 교육에서 큰 부분을 차지한다. 우리는 언어 공부에 할당된 시간을 줄일 여유가 없다. 일본 의사들은 새로운 지식을 수많은 해외 학술지로부터 학습해야 하며, 다른 많은 언어로 연구성과를 발표해야 한다. 이러한 차원에서 보면 2년제 의예과는 너무 짧다. 의예과가 너무 짧으므로 효율성을 위하여 의학과에서 다뤄지는 내용을 반복하는 교육은 지양해야 한다.

As mentioned above, the study of foreign languages occupies a large part of the premedical education in our cc.untry. We cannot afford to decrease the number of hours for language study; Japanese doctors must deri\'e new knowledge from numerous foreign journals, and also be able to publish original work in many other languages. For this purpose the u2-year" premedical course i• too short. Since premedical education is too short, we think, duplication in lectures must be avoided in order to make all courses most effecti\ ·e. For instance, at the present time, cytology and embryology are taught in premedical school, and again in anatomy, in the medical schools.

General view of premedical education in Japan.

일본 의학교육시스템의 발전과정: 역사적 관점(Hawaii J Med Public Health. 2015)

The Evolution of the Japanese Medical Education System: A Historical Perspective

Norimitsu Kuwabara MD; Miu Yamashita BS; Keolamau Yee; and David Kurahara MD

서양의학의 도입

Introduction of Western Medicine to Japan

에도시대

During the Edo period (1603-1867) and starting from 1633, Japan was isolated from the rest of the world.2 Travelling abroad was forbidden and trade with the outside world was restricted by limited ties to China and the Netherlands.2 During this time period, Japan learned about western medicine primarily from physicians at the Dutch merchants’ office or from Dutch medical books. Japanese medicine otherwise consisted of eastern Chinese medical teachings that utilized crude drug preparations and herbal medications. All foreign books were banned during this time. This mandate lasted nearly a century until the year 1720. When this ban was lifted, the primary influence on literature from Europe was Dutch, as trading patterns were well established with this country even during the period of isolation. Japan realized the importance of the scientific method through exposure to both Dutch and German medicine following the Edo period. In the latter part of this period, interactions with Dutch traders and physicians occurred initially through the port of Nagasaki. The influence of Western medicine was quickly felt all throughout Japan.

메이지유신

During the start of the Meiji restoration of 1868, a new era (1868-1912) began in Japan’s history. Trade and interactions with the western world were now encouraged and the government imported German medicine as a national policy. In 1871 they started to invite physicians from Germany to lecture at the precursor of the University of Tokyo. This event demonstrated a significant change from the isolationist policies of the previous regime. 

독일의 영향: 교육시스템, 의학용어, 서적

The extent of German influence on Japanese medical education can still be seen today. 

• The six-year training system used in Japan today is actually derived from German medical education systems (Figure 1). 
• Many words used in Japanese medical literature are Germanic in origin. 
• For example, German medical terms like adrenalin and allergy have Japanese words similar to them like “adorenarin” and “arerugii.”3 
• It is interesting to see that some of these words with Germanic origin are also used in American medicine. 
• Following the lifting of the ban on Western books, scientific books were some of the first imported into Japan. 
• As an example of the influence of the Netherlands on Japan and area of study relating to the Dutch language was called “Rangaku,” or Dutch Learning.4 
• One of the earliest scientific works translated was a book titled “Ontleedkundige Tafelen,” a complete work on the subject of anatomy and was translated in 1771-1774 and renamed the “Kaitai Shinsho.”4 

독일과 네덜란드의 영향은 아직까지도 남아있음

The influences on the Japanese training system for physicians by both the Germans and Dutch remain today. During the following years of Japanese medical history western medicine was rapidly introduced into Japan. Using the scientific method Japanese medical doctors worked on treatment for tetanus and syphilis, studied the plague and dysentery bacilli, as well as the neurosyphilis spirochete.5

국가 의사시험의 역사

History of National Medical Examinations in Japan

메이지유신때 면허시험 도입. 동양의학에서 서양의학으로 옮겨가는 계기/초창기에는 아무나 응시가능-나중에는 의학교육을 받은 사람만 가능하게 됨. 현재 국가시험의 선조격이며, 일본 전통의사 수가 감소함.

In 1875, during the Meiji era, the government began to administer national examinations to license medical practitioners.6 

• This requirement furthered the shift away from Eastern medicine in favor of a more Western style. With this shift, there began an attempt to standardize medical care in Japan. 
• Surprisingly, this initial exam was available to anyone who wanted to become a doctor whether or not they had undergone any formal training. 
• In 1906, the government mandated that applicants for the national examination must be physicians who had graduated from a medical school-mirroring the Western process of formal medical education before licensing. 
• This licensing exam became the predecessor of the current national exam. 
• During this period, the number of Japanese traditional herbal doctors dwindled as the population of modernized doctors grew.

2차대전을 지나면서 미국식의 의료와 수련이 도입되고, 1946년에는 인턴제도와 면허시험이 도입됨.

During World War II, the necessity of advanced medical and surgical knowledge became apparent to those on the battlefield. Following this war, with the reparations of Japan directed by the United States, the dominant Western influence on an area of Japanese society was US type Medical care and training of physicians. In 1946, a medical internship system and the current national medical license examinations were introduced. As we will see below, American based resident training programs are increasing in popularity in Japan.

초기 인턴제도

Early Internship Program

1년차의 극심한 노동. 보상은 적었고, 인턴 시스템은 인기가 없었음. 학생운동이 늘어나면서, 공정한 보상을 요구했고, 환자안전은 주된 이슈였는데, 미국에서는 주당 80시간이 의무화 되었음.

Despite developing this internship system to train physicians there were some significant hardships on the Japanese Interns of this era.7 These first year residents worked long and arduous hours and were not compensated for their efforts. They were required to work volunteer for a year in order to take the national medical license examination. This system caused many young physicians substantial financial hardship. This system was highly unpopular among young trainees. During the 1960’s when many student movements actively denounced the Vietnam War in the United States, a similar type of student protest moved to Japan in 1968. Medical students went on strike demanding to be fairly compensated for their work during their training programs. The students viewed the internship training as detrimental to good clinical practice. They recognized that the system in place put patient safety at risk due to an increased likelihood of mistakes by exhausted and overwhelmed interns. This patient safety issue remains an active source of debate in the training of physicians for both Japan and the United States, and has led to the mandatory 80 hour work week in American residency training programs.

도쿄대학에서 시작한 저항운동은 Zenkyoto라는 단체가 주도하여 대규모로 커짐. 폭력적이고 안타까운 사태 이후 인턴 프로그램에 큰 변화가 생김

Protests that began at the University of Tokyo quickly spread to other medical universities.8 The protests led eventually to a nation-wide boycott of the national medical license examination. This movement also triggered the development of a radical group named “Zenkyoto” (All-Campus Joint Struggle Committee) that also protested the US safety treaty and the Vietnam War. The event ended when Zenkyoto forcibly occupied Yasuda Auditorium which was the symbolic center of the University of Tokyo. Eight thousand riot police were dispatched to secure the Auditorium. A violent battle transpired. Some students lost their lives, and many more were severely injured during this event. Shock and grief over these violent protests radiated across Japan. Following this event, significant changes were made to the internship program. Students could finally take the medical license examination after graduation from their medical university. The year of uncompensated internship was removed from being a part of the training requirements, and was replaced by the current system of residency training in Japan.

현재 의사 국가시험

Current National Medical Examination: Japan and the United States

1년에 한 차례, 2월 중순에 3일간. 500문항. 평균 합격률은 90.6%인데, 합격률에 따라 정부 지원금이 달라져서 민감한 문제임. 일부 사립의대에서는 탈락할 것 같은 학생을 일부러 유급을 시키기도 함.

The current national medical license examination in Japan is held once annually during mid-February for three days (Figure 1). It is comprised of 500 questions covering basic medicine, clinical medicine, and social medicine. During the most recent examination (2014) the pass ratio was 90.6%.9 This examination is held in twelve prefectures: Hokkaido, Miyagi, Tokyo, Niigata, Aichi, Ishikawa, Osaka, Hiroshima, Kagawa, Fukuoka, Kumamoto and Okinawa. The pass ratio in each university is critical to medical schools.10 The level of government subsidies the universities receive is related to the pass ratio. National financial subsidies to the universities are cut if the pass ratio does not meet 70%. Some private medical universities require students to repeat a year if they are expected to fail the national medical license examination. These universities may benefit financially from the extra tuition fees from these students, however, this may add additional stress to the struggling student as they are forced to finance an additional year of schooling. This pressure to pass the examination provides further incentive for the students to study more diligently through their medical school years. Once the medical students pass this examination they can obtain a medical license to practice.

OSCE와 같은 실기시험은 없음

This exam and the students training do not include clinical skills evaluation like Objective Structured Clinical Examinations (OSCE), which is a part of medical training in the United States. For much of Japanese student’s medical school training they are simply observing rather then conducting hands on training as medical students in the United States. This point is of concern to the Educational Commission for Foreign Medical Graduates (ECFMG) in the United States. Changes are being implemented in the requirements for Japanese medical students to apply to US residencies such as having more clinical exposure and testing in Japan.

의국 시스템의 역사

The History of the Ikyoku System

인턴제도가 없어진 이후, 2년의 (의무는 아닌) 권고 임상수련 프로그램을 도입함. 미국과 일본이 달라서 일본은 의과대학이 의과대학병원을 보유하고 있는데, 의국은 이러한 일본 의과대학병원의 상징과 같다. 원래는 독일에서 유래한 것.

Once the internship system was abolished, the government recommended but did not require a two-year clinical training program. These apprentice style programs do not have a standardized curriculum nationally as the content of medical education is based on the individual university or department. Most of the Japanese medical graduates went into a training program named Ikyoku after graduation from their own or other universities.11,12 Ikyoku translates to: “medicine – office/department.” American medical universities develop contracts with teaching hospitals and send medical students and residents to both learn and service the patients in those hospitals. In comparison, every Japanese medical university has its own university hospital and has the Ikyoku physician group serving its patients. Ikyoku is symbolic of the Japanese university hospital. Grasping the idea of Ikyoku is extremely important in understanding the Japanese medical post-graduate training system. Three primary goals of the Iyoku groups are: education, research, and patient care. The Ikyoku system originated in Germany.13 It was introduced in Japan following the Meiji restoration. Many Ikyoku based medical departments viewed this period as the start of the modern medical system, and will thus have self-proclaimed names like the “first department of internal medicine,” or the “second department of surgery.” However, this can lead to more than one department with the same proclamation making this a bit of an artificial and sometimes redundant description of their department if compared to other hospitals across the country.

의국 시스템에서 교수가 맨 위에 있음. 미국과 달리 거의 모든 것을 결정하는 영향력 있는 자리.

In the Ikyoku system, the professor is at the top of the hierarchal totem pole, and 

• the professor will not only make the tough clinical decisions for patients but will also make many personal decisions for the trainees. Professors decide where the trainees can practice and live. 
• In contrast, the American medical system allows its residents to make these types of career decisions in an autonomous fashion. The assistant professors, lecturers, and young trainees follow the professor down the hierarchical totem pole. 
• The professor has enormous influence, and decides where to place personnel in the medical community which is sometimes based on political contracts with other hospitals and clinics, and not a choice of the individual trainee. 
• Medical students and residents in the United States are accustomed to choosing where they want to live and practice within the country. In the Ikyoku system, the medical resident’s autonomy is limited. The professor will make the decision for the trainee that will affect job placement not only in the university system, but also in any affiliated hospital. These decisions may affect the entirety of the trainees’ career. The professor decides where the trainees will find a job, where they will work, and what populations they will treat. 

하얀거탑

The Japanese best-selling book White Big Tower is based on an Ikyoku group in Osaka University.14 It is about a fictional surgeon Dr. Goro Zaizen who becomes a professor of surgery by ruthlessly gaining power within an Osaka Ikyoku group. Meanwhile, a classmate of Dr. Zaizen’s, who was more interested in caring for his patients, does not reach a similar level of prominence. White Big Tower was written more than forty years ago. The contents still remains relevant to understanding the Japanese medical system today. Both a novel and later a television series based on White Big Tower became acclaimed critically in both Japan and South Korea.

의국에서는 제휴(협력)병원에 정치적인 이유에 따라서 의사들을 보낸다. 의사들은 전문의가 된다고 진료 보상이 높아지는 것이 아니며, 임상 경험이 몇 년인가에 따라 급여가 정해진다. 의사들이 농촌 지역으로 가는 이유도 미국과 달라서 'exile'이라고 불리기도 한다.

In Japan, the Ikyoku group at times will send doctors to affiliated hospitals based on political reasons rather than their individual skills. Under universal health insurance coverage, patients pay a specified amount for their care. This fee is not based on the doctor’s skill or experience level. Even being board-certified does not increase the compensation for a physician’s care. Physicians are instead often paid based on how many years of clinical experience they had following their graduation from medical universities. Unlike the American system, pay scales between specialties are not appreciably different. Some hospitals prefer to hire young staff rather than experienced doctors in an attempt to cut costs. The Ikyoku group determines the placement of young doctors based on hospital demands. These decisions are based on political and financial issues rather then on the training level of the clinicians. Young inexperienced doctors ordered by the Ikyoku system, may be sent to rural or small local clinics or hospitals where they may not get the exposure or training they need. Physicians that would benefit from learning at large urban institutions are denied this opportunity and are instead placed in smaller clinics. This is often called “exile,” within trainee circles, and this may happen to a resident especially if they do not get along with certain professors. This differs from the American concept of some well-trained doctors choosing to go to a remote area to service a rural community once they acquire knowledge and experience after completing residency in a larger urban center. Increasing numbers of medical students are choosing to bypass the Ikyoku system of training and train in medical systems that are similar to those in the United States (Figure 2).

비의국 수련 시스템의 등장

The Rise of Non-University Hospital Training (Non-Ikyoku)

비-의과대학 병원들이 있고, 여기서도 수련을 제공함.

Besides the Ikyoku residency training system, there are a number of non-university hospitals that are offering medical students in Japan a training program similar to that offered in the United States. These non-university hospitals include Okinawa Chubu Hospital, Tokusyukai Hospital group, St. Luke Hospital, and Kameda Medical Center, which have long histories of offering US type residency programs. The John A. Burns school of Medicine in Hawai‘i has a long relationship with Okinawa Chubu Hospital.15 Visiting Professors and students from select medical schools have traveled reciprocally each way to enhance the training programs in both countries. This option of training in a residency program similar to a US residency initially attracted a minority of the medical school graduates. Subsequently, this type of residency is growing in popularity and is providing an opportunity for Japanese medical school graduates seeking to train in the American system.

의국 시스템은 new  residency system이 도입된 2004년부터 사라졌음

The Ikyoku system presence has diminished since 2004 when the new residency system was established. Recently, the number of doctors who choose non-University/non-Ikyoku training programs has been increasing see Figure 2. Over half of medical school graduates chose non-university hospitals in part to become exposed to increased clinical exposure, evidence based medicine, and education.

일본 의학교육에서 더 많은 임상경험 제공의 필요성

The Need for Medical Education in Japan to Require More Clinical Experience

인증기준에서 72주를 요구하고 있으나, 현재 일본 의과대학의 평균 실습 기간은 50주에 그침.

A major change in the amount of clinical exposure is going to be required in Japanese medical schools by the year 2023. With close to 25% of all practicing physicians in the United States being comprised of international medical graduates (IMG), the Educational Commission for Foreign Medical Graduates (ECFMG) announced that IMGs applying for ECFMG certification will be required to have graduated from a medical school that has been accredited through a formal process similar to those used by the Liaison Committee on Medical Education (LCME).16 Other accepted criteria like The World Federation for Medical Education (WFME) standards will also be recognized. This announcement has a huge impact on Japanese medical education, as currently they will need to increase significantly the number of clinical rotation hours. New guidelines stipulate that students must train at a minimum of 72 weeks of clinical rotations. The average number of clinical rotation hours in Japanese medical universities is now at only 50 weeks.17 Japanese graduates will not be allowed to participate in US training programs in the future if this lack of clinical hours continues. The first graduates who are expected to graduate in 2023 will enter medical universities in 2017, which is very close at hand. Many of these schools are scrambling to meet the ECFMG criteria. If these requirements are not met, Japanese Medical school graduates will lose their opportunities to train in US residency training programs following 2023.

The evolution of the Japanese medical education system: a historical perspective.

PMID:

 

25821652

 

[PubMed - in process] 

PMCID:

 

PMC4363931

 

Free PMC Article

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:

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.

(d) 의학용어

(d) Medical Terminology:

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.

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.

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.

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.

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.

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).

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.

Keio J Med. 2006 Jun;55(2):41-51.

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

일본 의학교육의 변화 (KJME, 2004)

Recent Changes in Medical Education in Japan

서울대학교 의과대학 의학교육실, 의학교육연수원

이 윤 성

Yoon-seong Lee, MD

서 론

일본은 1990년대 초부터 의학교육을 비롯한 교육 에 대한 개선 작업을 벌여왔다. 일본에서 의학교육 을 개선해야 할 큰 이유로 ⑴ 인구 구조의 변화, ⑵ 과학 기술의 발전, ⑶ 생명에 대한 가치관의 변화 등을 들고 있다. 요컨대 의학교육의 변화는 ①표준 화-핵심화, ②지식 양에서 문제해결 능력, ③환자 를 배려하는 태도와 기능 교육 등이 주요 내용이다.

본 론

가. 일본 의학교육 변화의 큰 틀

일본의 文部科學省에 따르면, 의학과 의료에 대한 변화의 필요성은 시대적인 요구라 하였다. 즉 생명 과학 연구의 진전을 바탕으로 ｢post-genome 의료｣ 와 ｢재생의료｣와 같은 선진 의료기술이 전개되기 시작하였고, 한편으로 출산율 저하와 고령화 사회로 대표되는 사회적 변화에 따라 질병 구조가 바뀌었 고, 사회는 환자를 주체로 하는 의료를 요구하고 있 다. 의학과 의료에 대한 국민의 요구는 점점 높아지 고 다양해지고 있다(村田, 2002).

또한 21세기 의학교육 개선 방안으로써, 6년의 의 학교육에서 구체적인 개혁 방안은 2000년 3월부터 ｢의학-치학교육에 관한 조사연구협력자회의｣(좌장; 高久史麿, 自治醫科大學長)와 4개 檢討部會에서 많 은 교수들의 협력을 받아 다음과 같은 구체적인 제 언을 얻었다.

1) 교육과정

다양한 사회적 요구에 대응하여 각 대학의 특성 에 따라 학생의 장래 목표에 맞도록 선택이 가능한 교육과정을 제공할 필요가 있다.

종래의 강의 형태를 넘어선 종합 교육과정을 수용하였다. 또한 문제해결형 학습을 기본으로 한 ｢의학교육 Model Core Curriculum｣을 작성하였다. 전문교육에 들어간 학생이 충분한 준비교육의 지식 을 갖추지 못하였다는 지적도 있어 ｢준비교육 Mo- del Core Curriculum｣으로 전문교육의 기초 교육 학 습 내용도 함께 제시하였다.

2) 임상실습 개시 전 학생의 적절한 평가 체제

지금까지 임상실습은 견학하는 방식이 대부분이 었으나, 의과대학생의 임상 능력을 크게 향상시키기 위해서는 학생을 임상 팀의 일원으로 진료에 참가 하는 것이 매우 효과적이다. 한편 졸업 전 임상실습 을 견학형에서 진료참가형으로 이행함으로써 내실 을 도모하기 위해서, 학생은 임상실습에 들어가기 전에 진료기능(clinical skill & attitude)의 기초를 습 득하였는지를 적절하게 평가하기 위한 종합시험이 필요하다. 각 대학이 공동으로 질 높은 시험을 작성 하여 실시하는 것이 효과적이며, 세계기준(global standard)을 참조하여 일본의 기준을 확립하여야 한 다. 이른바 共用試驗(Kyoyo Test)이다.

3) 임상실습의 내실

의과대학생의 질 높은 임상능력 습득을 위해서, 지금까지의 견학형 임상실습이 아니라 의료 팀의 일원으로서 진료에 참가하여 학습하는 실천적인 clinical clerkship이 도입되기를 기대한다. 이는 필수 로 지정된 졸업후 임상연수의 수준을 높이는 것과 관련이 있다.

위와 같은 의학교육 개혁의 진전과 함께 이를 담 당할 교수 개인의 자질 향상을 조직적으로 도모하 여야 한다. 교수가 개인적으로 참가하는 연수과정뿐 아니라, 학장이나 교무부학장 등의 교육책임자를 대 상으로 하는 전국적인 교수개발워크숍(faculty dev- elopment workshop)으로 핵심교육과정(Core Curri- culum)의 도입과 임상실습의 내실을 도모하여 각 대학의 개혁과 연관짓는 것이 중요하다.

나. 6년제 의과대학

일본의 의학교육제도는 역사적으로 이차세계대전 이후의 새 제도로서 2년의 진학과정 후에 입시를 거 쳐, 4년제 의과대학에 입학하는 제도부터 시작하였 으나, 1973년의 ｢學校敎育法｣을 개정하여 진학과정 (이른바 예과 과정)과 전문과정을 통합하는 6년의 一貫敎育도 가능하게 되었다. 그 후에 1991년의 ｢커 리큘럼 대강화｣ (大綱化)에 따라 6년 일관교육과정 이 되어 교양교육과 전문교육의 구별이 없는 현행 의 제도가 되었다(Table Ⅰ).

다. 학사 편입 제도

1) 학사편입학제도의 도입과 현황

a. 학사편입학제도의 도입

의과대학에서 학사편입학제도는 1975년에 오사 카(大阪)대학이 시작한 뒤로 이를 도입하는 대학이 오랜 기간 없었으나, 1988년에 도카이(東海)대학이 도입하고, 1998년에 군마(群馬)대학과 시마네(島 根)대학이 도입한 것을 계기로 전국적으로 퍼지게 되었다. 지금까지 일반 대학에서 입학생의 성적 등 을 감안하여 이 제도를 도입하기에 주저하던 대학 들도 1998년도부터 실시한 대학의 편입학생의 상황 등을 보고 도입할 것을 전향적으로 검토하기 시작 하였고, 이는 Table Ⅲ과 같다(全國醫學部長病院長 會議, 2001).

학사편입학제도를 도입하는 대학 측은 다음과 같 은 목적을 가지고 있다.

① 고등학교 졸업 후에 곧바로 의과대학에 입학 하는 학생과 비교하여, 다양한 경험을 바탕으로 폭 넓은 교양과 풍부한 인간성과 높은 윤리의식을 가 지며, 넓은 시야와 명확한 목적의식을 지닌 학생을 받을 수 있다. 

② 의학 이외의 분야를 수학한 사람에게 길을 열 어줌으로써, 다른 관련 학문 분야에 의학 영역의 학 식을 추가하여 의학과 다른 영역의 학문 분야의 융 합을 도모하며 동시에 의학의 발전을 도모할 수 있다. 

③ 일반 학생들은 풍부한 경험과 인간성을 가진 학사편입생과 함께 교육을 받음으로써, 더불어 학습 에 대하여 동기 유발이 높아질 수 있다. 한편, 다른 학부를 졸업하고 의과대학에 입학하고 자 하는 희망자들에게는 다음과 같은 이점이 있다. 

④ 이미 학사를 취득한 학생이 1학년(예과1학년) 에 입학하는 것은 시간적으로나 경제적으로 부담이 크다. 

⑤ 고등학교를 졸업하는 나이인 18살에 스스로 장래를 결정할 수 없는 학생에게 의과대학에 진학 할 수 있는 별도의 길을 열어 줄 수 있다.

b. 학사편입학제도의 현황

학사편입학제도는 1988년 이후에 도입한 대학에 서 평가가 대체로 양호하였다는 점 때문에 국립대 학을 중심으로 급속하게 많아지고 있으며, 1988년 도 당시에 3개 대학에서 35명뿐이었다가 국립의과 대학에서 받아들이면서 2003년도에는 27 대학에서 185명으로 확대될 예정이다(Tabel Ⅳ).

이처럼 학사편입학제도에는 좋은 점이 있지만, 이 제도가 나아갈 방향을 검토하여 폭넓은 사회적 인 식 없이 편입학 제도를 확대하면, 편입학생의 전체 적인 질 저하를 초래하고 이 제도의 본디 목적을 이 루지 못하고, 좋은 점을 살리지 못한다는 점을 염두 에 두어야 한다.

2) 학사편입학생 선발 방법

a. 현황

학사편입학제도는 명확한 목적의식을 가지고 풍 부한 인간성을 갖추었으며 다른 영역에 학습한 학생을 의과대학에 입학시키는 것을 목적으로 하므로, 이 목적에 따른 학생을 받기 위해서 입학자 선발의 방법은 학사편입학제도에서 가장 중요한 부분이다.

현재 각 대학의 학사편입학생 정원은 5명 내지 10명 정도로 적다. 따라서 입학자 선발은 자체 입학 정책에 따라 대학마다 달리 시행하고 있다. 특색 있 는 것으로는 다음과 같은 방법이 있다.

① 인간성을 중시하여, 1박2일의 합숙 형식으로 면접을 하거나 자원 활동의 평가를 부과함으로써 목적의식이나 인간성 등을 평가한다. 

② 생명과학 연구자의 양성을 목적으로, 대학원 석사과정 수료자만을 수험 대상으로 정하여, OHP 를 이용하여 프레젠테이션 능력을 요구하는 시험을 본다. 

③ 이공계열 학생 이외에 인문사회학 계열의 학 생이 입학하기 쉽도록, 이과 계열 과목의 이수를 수 험의 요건으로 정하지 않으며, 더욱이 이과 계열 과 목의 학력 시험을 전혀 치르지 않는다.

모든 대학이 면접시험을 보고 있음은 특기할 만 하다.

각 대학에서 편입학시험의 수험 자격을 보면, 수 학이나 생물과 같은 일정 과목의 이수를 요구하는 대학이 16 대학 가운데 3 대학으로 적으며, 적으나 마 수험 회수에 제한을 두는 곳도 있다.

입학자의 경쟁률 평균은 1988년 당시에는 약 70:1이었는데, 2001년에는 약 40:1로 낮아졌다. 이 는 학사편입학 지원자의 수는 늘어나지 않았으나, 학사편입학을 도입한 대학 수가 4 대학에서 17 대 학으로 늘어났고, 합격자 수가 크게 늘어났기 때문 이다. 앞으로 편입학생의 질을 확보하기 위한 과제 를 제기한다.

b. 편입학 시험의 수험 자격

특히 생명과학 연구 자를 양성하려는 목적으로 편입학을 수용하였다면, 일부 대학에서 시행하고 있듯이, 생명과학 연구 분 야의 석사과정을 수료하는 등 생명과학 연구의 학 문적 기초를 가진 사람을 의과대학에서 받아 양성 하는 것도 유효한 수단이 될 수 있다.

c. 편입학시험의 시험 방법

편입학시험 방법에서도 수험 자격과 마찬가지로 이과 계열 과목 시험도 중요한 논점이 된다. 현재 1 학년으로 입학하는 학생이 고등학교에서 생물 과목 을 이수하지 않은 문제가 지적되었는데, 학사편입학 시험에서 이과 계열 과목의 이수를 수험 요건을 정 하지 않고 학력시험도 실시하지 않으면, 생물뿐 아 니라 다른 이과 계열 과목도 이수하지 않고서도 의 과대학에 입학하는 일이 생긴다.

또한 의사나 연구자를 양성할 목표가 있더라도, 다른 학부나 사회에서 무엇을 배웠는지, 또는 치밀 한 의학교육과정에 대응하기 위하여 자율학습능력 을 갖추었는지 등을 면접에서 자세하게 물어 볼 필요가 있다. 이때에 충분한 면접시간을 확보하기 위 하여, 학력 시험으로 1차 선발을 한 뒤에 적은 수를 대상으로 충분한 시간에 걸쳐 면접을 하는 것도 효 과 있는 방법이다.

d. 기타 고려 사항

① 다른 대학 출신의 수용 

학부 활성화를 도모하고, 다양한 인재를 받아서, 같은 대학교 출신에 치우치지 않고 다른 대학교 출 신의 선발에도 배려하여야 한다.

② 입학자 선발에서 추천서 

대학의 지도교수나 직장의 상사 등의 추천서를 입학자 선발 자료로 요구하는 대학이 있는데, 졸업 후에 시간이 많이 지나 지도교수의 추천서를 얻기 가 어려울 수 있다는 점이나 직장의 상사나 동료에 게 입학 신청을 알리지 않고자 하는 경우도 있다는 점 등의 특별한 사정이 있을 수 있으므로, 추천서 제출은 임의로 취급해야 한다고 본다.

3) 앞으로 학사편입학제도

a. 앞으로 확충 방책

그러나 이 제도를 확충한다면, 학사편입학생의 질 이 낮아질 수 있으므로, 결국에는 의학교육의 질 향 상을 통하여 의료의 질을 높이려는 목적을 달성하 기가 어려워진다. 따라서 학사편입학을 대폭 확충하 여야 할 적극적인 검토 자료가 없는 현재에는 다양 한 입학자를 받아들이는 제도를 적극적으로 보급하 고 정착시키며, 각 대학의 교육 개선 상황에 맞추어 적절한 범위 안에서 확대하여야 한다.

b. Medical School

일본의 의학교육제도는 역사적으로 이차세계대전 이후의 새 제도로서 2년의 진학과정 후에 입시를 거 쳐, 4년제 의과대학에 입학하는 제도부터 시작하여, 1973년의 ｢학교교육법｣ 개정 후에 진학과정과 전문 과정을 통합하는 6년의 일관교육(一貫敎育)도 가능 하게 되었다. 그후에 1991년의 ｢커리큘럼 대강화｣ 에 따라 6년 일관교육과정이 되어 교양교육과 전문 교육의 구별이 없어지고 현행의 제도가 되었다.

현재 미국이나 오스트레일리아 등에서는 4년제 medical school을 중심으로 유연하게 운용되는 제도 가 있으며, 일본이 다른 학부 출신 학생을 받아들이 는 제도를 도입한 것은 국민의 의료와 21세기의 세 계화(globalisation)에 따라 의학의 전문과정을 배우 기 전에 폭넓은 교양을 몸에 익혀 인간적으로 성숙 하며, 물리-화학-생물-수학-사회학 계열 등의 기초 학문을 충분히 학습하여 전문과정에 들어가고, 구미 에서는 최근에 의학 전문과정에 들어가기 전에 2개 의 학제적인 과정을 이수하는 것도 가능하게 되었 다는 점 등을 고려하면, 일본에서도 이런 제도를 도 입하는 것이 바람직하다는 의견도 있다.

어찌되었든 앞으로 의학교육의 질 향상과 다양화 를 바란다면 앞으로는 medical school도 유효한 제 도 가운데 하나이므로, 

①의학교육 개혁의 진척 상 황, 

②교양교육 교육체제의 정비 상황이나 법과대학원 등 다른 전문직의 양성 방법 검토 상황, 

③미 국에서 고등학교 졸업생이나 월반한 학생의 의과대학 입학 상황 등을 참고하며, 학생에 대한 경제적 부담 등을 감안하여, 학사편입학생의 추적 조사에 따른 평가를 거쳐 전체의 제도를 검토하여야 한다.

라. Model Core Curriculum과 공용시험(共 用試驗, Kyoyo test)

각 대학에서는 과제 탐구․문제해결형 학습을 도 입하고, 정선(精選)과 통합을 원칙으로 프로그램을 고치고, 선택과목이나 Free Quarter제를 적극 도입 하여, 졸업전 임상실습을 충실하게 하는 등으로 교 육 이념에 따라 개혁을 시도함으로써 상당한 효과 를 얻었다. 그러나 개별적인 노력에는 한계가 있고, 의학교육 개혁을 전체적으로 촉진하려면 무언가의 기초가 있어야 한다는 생각에 이르게 되었다.

1999년 2월 26일에 공표된 21세기 의학-의료 간 담회 제4차 보고 ｢21세기를 향한 의사-치과의사의 육성 체제에 대하여｣에서 ｢교육 내용의 정선과 다 양화｣의 항에서 다음과 같이 제언하였다. ‘앞으로 의학-의료에 대한 요구(needs)는 점점 다양해지고, 지역의료도 복지-개호, 국제의료 협력, 제약 등의 여 러 가지 분야에서 의사와 치과의사는 더 많은 활약 을 하게 될 것으로 예상한다. 각 대학에서는, 이와 같은 사회적 요구의 다양화에 대응하여, 의료 기능 을 담당할 인재, 의료-복지-개호의 연대에 걸맞은 인재, 국제의료 협력에 일할 인재, 생명과학 등의 학 제적인 기초연구에서 일할 인재 등의 다양한 인재 를 육성하여야 한다. 다양한 학과나 과정을 적극적 으로 도입하여야 한다. 이를 위해서는 먼저 정선된 기본적 내용을 중점적으로 이수할 Core Curriculum 을 확립하고, 학생이 주체적으로 선택하여 이수할 수 있는 과목을 확충하여 다양하게 마련할 필요가 있다. Core Curriculum은 이른바 의과대학 학습목표 에 해당한다.

바라건대 가장 필요한 것은 각 대학이 나름대로 교육이념에 터 잡아 우수한 선택/고급 과정(elective /advanced program)을 책정하여 개성화와 다양화를 꾀하는 것이다. 이를 위한 전제로서 의사가 되기 위하 여 필수적인 공통 내용의 지침이 필요하게 되었다.

｢의학에서 교육 프로그램의 연구-개발 사업 위원 회(1998~2000)｣ (위원장; 佐藤達夫)는 2년 동안 기 초 조사를 하고, 이를 바탕으로 1년 동안 정선과 통 합을 원칙으로 한 Model Core Curriculum을 만들어, 2000년 11월 17일에 모든 의과대학의 대표가 모인 자리에서 시안을 발표하였다. 이어서 설문 형태로 집약한 각 대학의 의견을 참고하여, 모두 42번이나 협의를 거쳐 최종적으로 ｢의학-치의학 교육에 관한 조사연구협력자 회의｣의 보고서인 ｢21세기에서 의 학-치학교육의 개선 방책에 대해서 -학부 교육의 재 구축을 위하여-｣ 속에 ｢의학교육 Model Core Curri- culum- 교육내용 가이드라인-｣으로 수록하여 2001 년 3월 27일에 공표하였다.

2) Model Core Curriculum의 주요 내용

‘B 의학 일반’에는 생물학을 비롯한 기초과학과 밀접하게 관련된 내용을 담고 있다. 종래의 기초의 학의 총론 부분에 해당하며, 임상실습에 들어가기 전의 의학교육으로서 중핵이 되는 내용이다.

‘C 인체 각 기관의 정상 구조와 기능, 병태, 진단, 치료’에서는 순환계통, 호흡계통, 소화계통 등의 15 기관계통을 각각 통합적으로 학습하도록 정리하였 다. 학문 체계에 따른 분류라면 ｢정상 구조와 기능｣ 은 B에 남는 것이 보통이다. 그러나 이른바 기초의 학에서 총론적인 사항은 B에 남지만, 각론적인 사 항은 C에서 병태와 연결고리로 삼아서 진단이나 치 료와 함께 학습하도록 정리하였다.

‘D 전신에서 일어나는 생리적 변화, 병태, 진단, 치료’에서는 감염증이나 면역-알레르기 질환처럼 C 의 기관계통에 포함되지 않는 내용을 포함한다. 기 본적인 정리 방침은 C와 같다. 다만 성장, 발달, 가 령(加齡), 노화, 죽음처럼 사람의 일생에 관한 사항 도 여기에 담았다.

‘E 진단의 기본’에서 ‘1. 증후-병태에서 접근’은 환자의 증후(쇼크, 발열, 경련, 의식장애와 같은 주 요 증후 36항목)로부터 병태를 찾아나가는 진료 추 론의 과정(clinical reasoning)을 중시하였다. C와 D 가 씨줄이라면 E의 1은 날줄에 해당한다. 또 ‘2. 기 본 진료 지식’, ‘3. 기본 진료 기능(skill)’에서 제시 한 도달목표는 임상실습을 시작하기 전에 습득해야 할 내용이고, 시청각 교재, 모형, 인형(dummy), 역 할극(role play), 모의환자 등을 이용하여 몸에 익혀 야 할 내용을 기재하였다.

‘F 의학-의료와 사회’는 종래에 저학년부터 고학 년에 걸쳐 학습하는 대학이 많은 내용으로 질병에 대한 지식을 가지고 있으면, 학습이 효과적일 수 있 는 내용을 고려하여, 임상전교육(B~E)과 ‘G 임상실습’ 사이에 배치하였다.

‘G 임상실습’에서는 진료참가형 실습(clinical cl- erkship)을 목표로 삼았다. 따라서 내과, 정신과, 소 아과, 외과, 산부인과를 중핵 실습과목으로 하고, 기 타 과목은 선택하거나 또는 단기간의 순환과정으로 다루도록 하였다. 응급의료는 중핵 실습으로 지정하 여 보완하였다.

‘H 준비교육’에서는 의사로서 필요한 풍부한 인 간성을 함양하기 위하여, 교양교육의 역할은 중요하 다. 그러나 교양교육의 내용이 대학의 특색이나 독 자성에 관련된 것도 있으므로, 의학교육의 전제로서 습득해야 할 기본 사항만을 정리하였다.

4) Model Core Curriculum이 지향하는 바

Model Core Curriculum은 ‘국민이 기대하는 좋은 의사 양성’이라는 개념으로 전국 공통의 기준선(bo- ttom line)을 제시하는 것에 불과하다.

임상실습이 진료참가형이라면 임상실습을 하기 전에 학생들은 적절한 평가를 받아야 한다. 1991년 에 ｢후생성 임상실습검토위원회｣의 최종 보고에서 는 의과대학생의 의료행위가 허용되는 요건으로서 ‘임상실습을 하려면 사전에 의과대학생의 평가를 해야 할 것’을 제시하였다.

학생이 진료에 참가하려 면 최소한 필요한 태도, 기능, 지식을 갖추었는지를 평가하여야 한다. Core Curriculum이 정선된 표준화 를 지향한다면, 그 평가는 각 대학에 맡길 수 없고, 대학들의 합의에 따라 공동으로 질 높은 종합 시험 문제를 작성하여 실시하여야 한다.

지식에 대해서는 컴퓨터를 사용하는 시험(CBT; computer based testing)을 개 발하고, 태도와 기능에 대해서는 객관구조화진료능 력시험(OSCE; objective structured clinical examin- ation)을 실시하기로 하였다. 모든 의과대학의 찬성 을 얻어, 2004년에 본격적으로 운용할 목표로 2002 년 2월~5월에 각 대학에서 제1회 시험적 운용(trial) 을 시행하였다. 앞으로는 공용시험 실시 기구가 이 를 담당할 것이나, 2002년 4월 1일에 동경의과치과 대학에 설립된 의치학교육시스템연구센터도 공용시 험 체제의연구-개발-관리에 협력한다.

마. 졸업후 임상 연수(卒後臨床硏修, Postgra- duate clinical training) 필수화

일본의 졸업 후 교육은 통일되지 않았다. 원칙적 으로 교실-의국 중심의 교육이고, 교육 연한에 대한 규정도 없고, 인턴도 없으며 전문의제도도 없다. 최 근에 몇몇 전공과목에서는 전문의 제도를 설립하였 으나, 호응이 크지 않다.

2004년부터 후생성이 주관하여 진료를 담당할 의 사에게는 모두 졸업후에 임상 연수를 받도록 규정 하였다. 기본 원칙은 다음과 같다. 즉 

① 2년 간의 연수 기간 가운데, 공통 커리큘럼에 18개월을 사용 하고 6개월은 전공하려는 과목에 쓸 수 있다. 

② 내 과, 외과, 소아과, 산부인과, 응급의학과(또는 마취 과)를 순환(rotation)한다. 

③ 필요에 따라 여러 병원 을 포함하는 그룹 단위로 연수를 받는다(의료관계 자심의회 의사임상연수부회, 1988).

1) 취지

임상연수를 필수화함으로써, 오늘날 의료 제공에 대한 국민의 요청에 부응하도록 그 내실을 도모한 다. 구체적으로 연수 중의 의사가 연수에 전념하도 록 하며, 연수 수료를 적절하게 평가하는 등으로 연 수 효과를 높인다.

- 임상연수 중 의료행위의 내용이나 종류는 제한 하지 않고, 의사법(醫事法)에 있는 의무(처방전의 교부 의무, 진료기록부의 기재․보존의무)에 대해서 도 통상의 취급을 받는다.

- 병원․진료소(醫院)의 관리자는 연수를 수료한 사람이어야 하며, 진료소를 개설할 때에 연수 미수 료자는 허가를 받을 수 없다.

- 연수 중인 의사에 대하여, 수당이 적절하게 지불되도록 필요한 조치를 강구하며, 지도의 (指導醫)의 처우에 대해서도 검토한다. 구체적인 비용 부담에 대해서는 국가나 의료보험이 부담하고 있는 현상을 바탕으로 앞으로 그 원칙을 정리한다.

3) 연수 내용

- 연수 도달 목표는[졸업후 임상연수 목표(卒後 臨床硏修目標)]를 기본으로 하되, ‘설명 받은 동의’ 나 의약품의 적정 사용 등 과학적 근거를 바탕으로 한 의료의 제공 등의 관점에서 수정한다.

- 내과 계열 및 외과 계열 모두를 포함한 복수의 진료과에서 연수를 받으며, 응급의료 등의 연수 기 회 확보에 대해서는 [연수프로그램] 속에 명확하게 정한다.

- 연수의 장소를 임상연수병원등에 국한하지 않 고 ‘병원군(病院群)’이나 ‘연수시설군(硏修施設群)’ 으로 다양하게 한다.

4) 질(質) 확보

- 현행 임상연수병원의 지정 기준에 대해서는 연수지도체제를 포함한 새로운 기준을 제시하며, 지도의의 질 향상을 도모한다.

- 각 임상연수병원 등은 졸업후 임상연수 목표를 바탕으로 연수 기간 2년 동안에 일관된 연수프로그 램을 작성하도록 한다. 임상연수병원 등을 지정할 때에 당해 프로그램의 내용에 대해서 당해 병원의 특색이나 다양성을 존중하여 심사한다.

- 연수의가 폭넓게 선택할 수 있도록 연수프로그램에 관한 정보는 공개한다.

- 임상연수병원 등의 지정은 정기적으로 확인한다. 당해 결과를 바탕으로 개선 지도나 취소 등으로 임상연수병원 등의 질 확보를 도모한다.

5) 연수 수료의 인정

- 연수 수료는 다음 방법으로 인정한다.

바. 대학원 중심 대학

일본은 80개 의과대학 가운데 90년대 중반부터 홋카이도(北海道)대학, 토호쿠(東北)대학, 도쿄(東 京)대학, 나고야(名古屋)대학, 교토(京都)대학, 오사 카(大阪)대학, 큐슈(九州)대학 등 7대학의 의학부 (醫學部)를 대학원중심대학을 지정하였고, 현재에는 12대학, 최종적으로는 30대학을 대학원 중심으로 변환하고자 한다.

대학원은 기존의 교실 체제를 벗어나 10개 이내의 큰 계열 전공 단위로 개편하고, 계열 전공 단위 안에 학문 분야를 소속시킨다. 예를 들어 교토 (京都)대학은 ⑴대학원 의학연구과와 ⑵의학부로 구성되며, 교수들은 대학원과 의학부(의과대학)에 겸 임한다(Table Ⅴ). 대학원 의학연구과에는 8 전공에 77 전공분야-연구영역이 있다. 오사카대학에도 대학원 의학계연구과가 있고 9전공 38강좌를 개설하였다.

사. 국립대학의 공사화(公社化)

2004년에 일본의 국립대학은 모두 공익법인으로 서 공사(公社)가 된다. 이에 대한 일본 정부의 공식 적인 방침은 다음과 같다(문부과학성 고등교육국, 2001).

특히 국비로 운영되는 국립대학은 지금까지 학술 연구, 인재 육성, 지역에 대한 공헌 등의 여러 측면 에서 일본의 발전에 기여하였지만, 한편으로는 국립 대학에 대해서 각계에서 여러 문제를 제기하여 세 금부담자(tax payer)인 국민의 기대에 충분히 부응 하지는 못하였다.

국립대학의 법인화가 진행되면서 계속해서 국가 가 세운 대학으로서 국민의 지지를 얻어 국비를 받 아 그 사명을 완수하기 위해서는, 최첨단의 연구 추 진과 우수한 인재 양성 등과 함께 일본의 대학 전체 를 이끌어나갈 견인체로서 긍지를 가지고 더욱 개 혁에 노력해야 한다.

c. 방침의 취지

이 방침은 ‘대학의 구조개혁 없이 일본의 발전과 재생은 없다’는 인식으로, 지금까지의 대학 개혁에 가속이 붙어 일본의 대학 특히 많은 국비로 유지되 는 국립대학이 부과된 중요한 역할을 수행하기 위 하여 각각의 특징을 살리면서 교육이나 연구를 더 욱 활력을 돋우고 국제경쟁력을 지니라는 요청을 받는다.

2) 국립대학의 재편-통합에 대한 기본 취지

a. 재편-통합을 추진하는 이유

국립대학의 법인화를 앞두고 자원을 최대한으로 활용하여 전략적인 경영을 추진하면서 어느 정도 규모의 이점(scale merit)을 확보하는 것도 효과적이 다. 이를 위하여 지금까지 경위에 집착하지 않고, 장 래의 발전을 예측하여 과감하게 재편-통합을 검토 하는 것도 필요하다.

국립대학의 재편-통합의 목적은 대학의 수를 줄 이는 것만은 아니다. 종래의 대학의 틀 속에서는 불 가능할 수도 있는 교육과 연구의 근본적인 개혁과 발전도 재편과 통합을 통하여 사회에 대한 적극적 인 공헌을 목표로 삼아 국민의 지지를 확보하면서 국립대학 전체의 재생과 새로운 비약을 기대한다.

b. 재편-통합의 검토 방향

① 개성과 특색 있는 대학 만들기

② 재편-통합의 형태; 지리적으로 가까운 것도 고 려해야 할 요소이지만, 교육이나 연구에서 이점이 있다면 지역의 경계를 넘어선 재편과 통합도 과감 하게 검토해야 하리라. 또한 대학 단위의 통합뿐 아 니라, 예를 들어 대학 사이에 학부 수준의 기능 분 담의 관점에서 재편-통합, 나아가 공립이나 사립대 학을 포함하여 가까이 있는 대학 사이에 역할 분담 이나 제휴 협력을 강화하고, 가능하고 적절하다면 지방으로 이관하는 것도 검토할 필요가 있다.

③ 국립대학에서 시행할 성과 있는 재편-통합; 교 육과 연구 등이 풍부화-고도화, 새로운 학문 영역으 로 전개, 인재의 유동화, 자원의 중점적 투자 등이 가능해지고, 국립대학에서 행할 수 있는 성과 있는 재편-통합을 지향하는 것이 중요하다.

3) 국립대학의 법인화

a. 법인화의 의의

한편으로는 구미 여러 나라에서 국립대학이나 주 립대학을 포함하여 대학에는 법인격을 부여하는 것 이 일반적인데 비하여, 일본의 국립대학은 그대로 국가행정조직의 일부로 위치하여 독립적인 법인격 없는 현재의 설치 형태에서는 개혁에 한계가 있다. 

◦문부과학장관(文部科學大臣)의 광범한 지휘 감 독 아래에 두고, 대학 스스로 권한과 책임을 지고 운영하는 것에 따른 한계가 있다. 

◦예산, 조직, 인사 등의 측면에서 국가의 행정조 직으로서 다양한 규제가 남아있으므로, 교육연구의 유연한 전개에 제약이 있다.

b. 법인화의 검토 관점

국립대학의 법인화는 대학의 자율성을 확대하고 우수한 교육과 연구의 전개라는 국립대학 본래의 기능을 충실하게 하기 위한 것이다. 이 제도 설계에 서 예산, 조직, 인사 등의 여러 규제를 완화하여, 스 스로의 노력에 보상이 있는 법인화의 이점을 최대한 활용하는 대학 개혁을 촉진하는 관점이 중요하다.

4) 제3자 평가에 의한 경쟁 원리 도입

a. 경쟁적 환경의 조성

이를 위하여 제3자 평가에 의한 경쟁논리로써 세 계적 수준의 교육-연구를 전개할 수 있는 대학을 중 점적으로 지원할 필요가 있다. 이를 위하여 국립-공 립-사립을 막론한 경쟁적 환경에서 활력 있고 국제 경쟁력 있는 대학 만들기를 지원하기 위해서는 2002년부터 세계 최고 수준의 대학 만들기 프로그 램｣ (이른바 `國公私 top 30')의 실시를 예정하고 있 다(211억 엔을 신규 개산 요구 중).

b. 제3자 평가에 의한 중점적 지원 조치의 목적

‘Top 30'는 중점성을 표명한 것으로 30이라는 숫 자는 상징적일 뿐이다. 따라서 대학을 골라서 대학 의 서열을 붙이는 것은 아니다. 신청을 받아 동료평 가(peer review)에 의한 심사 결과로, 대학의 교육연 구조직 등을 지원하며, 선정 결과는 고정하지 않고 앞으로 평가에 맞추어 변화할 수 있는 형태를 예정 하고 있다.

c. 구조의 개요

선정 구조는 중앙교육심의회 대학분과회 및 과학 기술-학술심의회 학술분과회의 위원으로 구성한 대 학개혁협의회(大學改革連絡會)에서 검토하고 있으 며, 예산의 사정 상황 등에 맞추어 변경도 가능하다.

심사는 문부과학성이 직접 시행하지 않고, 과학 연구비 보조금의 심사방식을 준용하여, 전문가와 식 견 있는 사람 등이 교육연구 활동 실적이나 앞으로 발전 가능성 등에 대하여 객관적으로 공평하고 공 정하게 제3자 평가를 실시할 것이다. 나아가 일본에 서 대학에 대한 제3자 평가 시스템의 육성-정착 여 부는 앞으로 더 검토할 것으로 본다.

결 론

일본의 의학교육도 전 세계의 의학교육 변화에 발맞추어 꾸준히 개선하고 있다. 이는 의료에 대한 사회적 요구(needs)가 급격히 달라지고 있고 달라 질 것에 대비한 당연한 변화이다. 1990년대 초부터 일본 의학교육이 제도나 내용에서 변화한 것을 

⑴ 6 년제 의과대학, 

⑵ 학사 편입 제도, 

⑶ Model Core Curriculum과 공용시험, 

⑷ 졸업후 임상연수의 필수 화, 

⑸ 대학원 중심대학으로 나누어 설명하였고, 더 불어 의학교육에 국한할 것은 아니나 

⑹ 국립대학 의 공사화를 소개하였다.

앞에서 든 일본의 의학교육 변화의 특징을 살피 면, 일본의 변화는 비교적 오랜 기간 준비하고 많은 전문가의 의견을 모으며 차츰차츰 실행하는 경향을 느낄 수 있다. 그러나 전국적으로 실시할 필요가 있 는 사항은 전폭적인 지지와 추진력으로 이를 실행 하였다. 우리라 의학교육에 일본의 경험을 반드시 반영해야 할 것은 아니지만, 우리와 비슷한 문화를 가지고 공유할 문제점이 많으며, 실제로 우리보다 여러 측면에서 몇 년 앞선 점이 있으므로 타산지석 으로 삼을 가치는 있다. 앞으로 우리나라 의학교육 의 개선에 참고할 수 있으리라 기대한다.

Korean J Med Educ > Volume 16(2); 2004 > Article

학습유형에 문화적 차이가 있을까? (INT J INTERCULT REL, 2008)

Are there cultural differences in learning style?

Simy Joy *, David A. Kolb

2. 문화적 차이를 보여주는 특징들

2. Characterizing cultural differences

문화란 다음과 같이 정의된다. 

Research on culture spans many disciplines such as Anthropology (Benedict, 1946; Hall, 1976; Kluckhohn, 1962), Psychology (Markus & Kitayama, 1991; Triandis, 1994) and Management (Hofstede, 2001; House et al., 2004). Irrespective of the discipline, the scholars have come to more or less a common ground with respect to defining culture. Culture can be conceptualized as ‘shared motives, values, beliefs, identities, and interpretations or meanings of significant events that result from common experiences of members of collectives that are transmitted across generations’ (House et al., 2004, p. 15).

그러나 이러한 공통적 개념에도 불구하고 분석의 단위는 연구자마다 다르다. 

초창기, 특히 인류학에서는 사회나 커뮤니티를 연구했다. 

This common understanding notwithstanding, the units of analysis chosen by culture researchers vary. The earlier researchers on culture, especially in the field of Anthropology, studied societies or communities. 

• For example, Kluckhohn and Strodtbeck (1961) studied five communities in America discovering differences in their value orientations. 
• There have been studies that focused on countries like Benedict’s (1946) research on the Japanese culture. 

20세기 중후반에는 국가에 대해서 연구했다. 국가가 지배구조, 법, 사회 기관 등을 정의하는 것에 따른 결과일지도 모른다. 호프스테드의 연구, 더 최근의 GLOBE 연구. 

Research in the latter half of the 20th century increasingly focused on country differences in culture, perhaps resulting from the development of nation states that defines boundaries for governing structures, law and social institutions that paved the way for increased cultural homogeneity within nations. 

• Hofstede’s (2001) research on differentiating between the cultures of around 40 countries reinforced the use of country names as the surrogates to represent culture. 
• The more recent Global Leadership and Organizational Behavior Effectiveness (GLOBE) study (House et al., 2004) followed suit. 

역사적 진화를 바탕으로 문화적 클러스터를 제안하기도 했다.

There have also been scholars who looked at the historical evolution of different regions of the world and suggested the possibility for cultural clusters that transcend national boundaries. 

• Huntington’s (1996) classification of the world cultures into Western, Latin America, African, Islamic, Sinic, Hindu, Orthodox, Buddhist and Japanese is an example. 
• The GLOBE study empirically arrives at ten cultural clusters – Anglo, Latin Europe, Nordic Europe, Germanic Europe, Eastern Europe, Latin America, Sub-Saharan Africa, Middle East, Southern Asia and Confucian Asia – wherein the countries within a cluster are more similar to each other while being significantly different from countries in other clusters.

문화 연구자들은 특정 문화에 담긴 풍습과 실제를 이해하기 위해서 노력했으며, 문화간 비교를 위한 노력도 기울였다.

Culture researchers have endeavored to build in-depth understanding of the customs and practices within certain cultures and also to develop meaningful ways to enable comparison between cultures. This has resulted in a number of cultural typologies based on the salient features identified by the researcher. Some examples include 

• 고맥락과 저맥락 high context and low context cultures (Hall, 1976) based on the amount of dependence on the context used in determining the meaning of messages, 
• 고신뢰와 저신뢰 low trust and high trust cultures (Fukuyama, 1995) based on the relationship between trust and social structures, 
• 독립적과 상호의존적 independent and interdependent self cultures (Markus&Kitayama, 1991) based on the extent to which definition of self is in relation to the larger society, and 
• 부끄러움과 죄책감 shame and guilt cultures (Benedict, 1946) based on whether the standards for behavior are internal or external to the individual. 

그러나 이러한 방식은 이분법적이다. 호프스테드는 연속적인 개념을 도입했다.

These typologies tend to be dichotomous in nature. Hofstede (2001) introduced the concept of continuous cultural dimensions as the basis for comparison. Dimensions are various categories into which the salient features of the cultures are grouped. Hofestede identified 

1. power distance, 
2. uncertainty avoidance, 
3. individualism-collectivism and 
4. masculinity-femininity (later long versus short term orientations) 

as the major aspects on which cultures differ. 

GLOBE연구는 호프스테드의 작업을 더 정교화하여 아홉 개 차원으로 구분함.

The GLOBE study (House et al., 2004) refined Hofestede’s work suggesting nine dimensions: 

1. in-group collectivism, 
2. institutional collectivism, 
3. power distance, 
4. uncertainty avoidance, 
5. future orientation, 
6. performance orientation, 
7. humane orientation, 
8. assertiveness and 
9. gender egalitarianism. 

문화 차원적 접근법을 지지하는 사람들은 각 차원에 대한 점수를 산출하는 방법을 도입했고 순위를 매겼다.

The proponents of the cultural dimensions approach introduced the practice of calculating scores on each dimension for each culture enabling relative ranking among them. These typologies and dimensions are especially useful in providing explanations when we encounter differences in outcomes that seem to originate from the differences in cultural values and practices. Researchers in variety of fields that range from education to epidemiology have explored the potential impact of cultural variables on outcomes that vary from educational accomplishments to depression.

3. 경험학습이론과 학습유형

3. Experiential learning theory and learning style 

ELT는 인간의 학습과 발전에 있어서 경험의 중요성을 주창한 20세기의 유명 학자들의 업적에 근거한다. 

Experiential learning theory draws on the work of prominent 20th century scholars who gave experience a central role in their theories of human learning and development —notably John Dewey, Kurt Lewin, Jean Piaget, WilliamJames, Carl Jung, Paulo Freire, Carl Rogers and others — to develop a holistic model of the experiential learning process and a multi-linear model of adult development (Kolb, 1984). 

ELT는 학습을 다음과 같이 정의한다. "경험의 변형을 통해 지식이 생성되는 과정으로서, 경험을 grasping하고 transforming하는 것의 종합적 결과로 지식이 생성된다."

ELT defines learning as ‘‘the process whereby knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience’’ (Kolb, 1984: 41). 

Grasping에 대한 대한 두 가지 형태, Transforming에 대한 두 가지 형태가 있다.

The ELT model portrays 

• two dialectically related modes of grasping experience – concrete experience (CE) and abstract conceptualization (AC) – and 
• two dialectically related modes of transforming experience— reflective observation (RO) and active experimentation (AE). 

경험학습의 과정은 이상적으로 순환(cycle)혹은 나선(spiral)한 것으로 묫되는데, 여기서 학습자는 "모든 베이스를 밟아간다". 이 과정은 반복적인 과정으로서, 학습 상황과 배우는 내용에 따라 달라진다. 

Experiential learning process is portrayed as an idealized learning cycle or spiral where the learner ‘‘touches all the bases’’ – experiencing, reflecting, thinking, and acting – in a recursive process that is responsive to the learning situation and what is being learned. 

• Immediate or concrete experiences give rise to observations and reflections that are assimilated and distilled into abstract concepts from which new implications for action are drawn. When these implications are actively tested new experiences are created again (See Fig. 1). 

반드시 모든 사람이 같은 순서로 각 지점을 밟아나가는 것은 아니다. 개인마다 유전적 특성과 과거의 경험, 현재의 요구가 다르기 때문에 네 가지 학습모드 중에서 선호하는 것이 있다. 

It is not necessary that each person starts his/her learning cycle in the same mode, say for example, concrete experience, and goes through all other modes in a uniform manner. Because of our hereditary equipment, our particular life experiences, and the demands of our present environment, we develop a preferred way of choosing among the four learning modes. 

• 구체적인 경험에 의존하는 사람 (정보를 모으고 직관적으로 판단을 내린다)Those who rely on concrete experience for grasping are open to new experiences, depend on people contact for gathering information, are intuitive and make feeling based judgments (Barmeyer, 2004; Kolb & Kolb, 2005). 
• 추상적 개념화에 의존하는 사람(이론과 일반화를 추구한다) Those who rely on abstract conceptualization are logical and analytical in their approach to a learning situation and seek theories and generalizations (Auyeung & Sands, 1996). 

A person may transformthe experience either through reflective observation or active experimentation. 

• 성찰적 관찰을 선호하는 사람(의미를 이해하려면 모든 측면을 다 봐야하며, 행동에 옮기기까지 시간이 걸린다.)Those who prefer reflective observation watch and observe all sides of an issue in order to understand its meaning and take time to act. 
• 능동적 실험을 선호하는 사람(무언가를 해보기를 좋아하고, 위험을 감수하는 특성이 있으며, 실용적이다.)Those who prefer active experimentation like to try things out, are more willing to take risks and are practical and application oriented (Barmeyer, 2004; Kolb & Kolb, 2005). 

학습유형의 개념은 이 네 가지 모드의 조합 중 어떤 것을 선호하느냐에 대한 것이다.  

The concept of learning style refers to the individual differences in approaches to learning based on an individual’s preference for using a combination from these dialectic modes. The four basic learning style types are Diverging, Assimilating, Converging and Accommodating. 

• Diverging learners prefer to make more use of concrete experience and reflective observation, 
• Assimilating types prefer to learn through reflective observation and abstract conceptualization, 
• Converging types rely on abstract conceptualization and active experimentation and 
• Accommodating types use active experimentation and concrete experience. 

Kolb의 학습유형검사는 개인의 학습유형을 측정하기 위한 것이다. 12문항. 점수 범위는 -36에서 +36.

The Kolb Learning Style Inventory (KLSI, Kolb, 2005) is an instrument ‘designed to measure the degree to which individuals display different learning styles’. It contains 12 items that ask the respondents to rank four sentence endings that correspond to the four learning modes—CE, RO, AC and AE. Because of this forced choice format, the cumulative ranks reflect the relative preferences among the dialectic modes. 

• The combination score AC-CE (i.e., cumulative rank for CE subtracted fromthe cumulative rank for AC) represents the preference for abstract conceptualization over concrete experience and AE- RO(i.e., cumulative rank for RO subtracted fromthe cumulative rank for AE) the preference for active experimentation over reflective observation. 

• The combination scores may range from 36 to +36. 

• 높은 AC-CE 점수(Abstractness 선호(Concrete보다)) A higher AC-CE score implies a relatively greater inclination for abstractness (AC) and lesser inclination for concreteness (CE), whereas a lower AC-CE implies the opposite. 
• 높은 AE-RO 점수는(Action 선호(Reflection보다)) Similarly, a higher AE-RO score would mean preference for action (AE) over reflection (RO) and a lower score the reverse. 

• One’s learning style type can be determined by taking both combination scores together and comparing themwith the cut- off values from the normative group. 

ELT는 학습유형이 고정된 심리학적 특성이 아니라 사람과 환경 사이의 시너지에 의해 변화하는 상태라는 것을 강조한다. 이 유동적인 상태가 얼마나 지속되느냐는 유전, 성격, 환경 등에 의해서 결정된다. 

ELT emphasizes that learning style is not a psychological trait but a dynamic state resulting from synergistic transactions between the person and the environment. The stability and endurance of these dynamic states depend not only on the genetic qualities or characteristics of human beings but also on the demands of the environment they are in. The way we process each emerging event determines our choices and decisions, which in turn determine the future events we live through (Kolb, 1984: 63–64). The environment in which this process of self-creation takes place is shaped by the pervasive influence of culture.

집단주의

4.2.1. Collectivism 

Collectivism perhaps is the most widely used dimension to differentiate between cultures, to the extent that both scholars and laymen often think of it as the only way to explain cultural differences. A number of scholars agree that collectivismis not as simple and straightforward as it is portrayed and have made attempts to fine-tune the concept. House et al. (2004) found out in the GLOBE study that collectivism can be differentiated into in-group collectivism and institutional collectivism. 

일반적으로 이해하는 집단주의와 유사함. 집단주의적 사회에서 사회적인식의 기본단위는 '집단'이다. 역할, 책임 등이 그룹 멤버에게 주어진다. 그룹 멤버들간에 조화를 이루고 체면을 유지하는 것이 중요하다. 

In-group collectivism is ‘The degree to which individuals express pride, loyalty and cohesiveness in their organizations or families’ (House et al., 2004, p. 12). In-group collectivism is similar to the concept of collectivism as it is generally understood. In collectivistic societies, the group is the basic unit of social perception. There are roles, duties and obligations attached to the group membership. It is important to maintain harmony and save face of the group members. The choice of action and communication depend heavily on the context (Hall, 1976). While communicating, they pay attention to the non- verbals to grasp the full meaning of what is being communicated. The pace of life is slow allowing for reflection (Hofstede, 1997; House et al., 2004; Triandis, 1994). To be an acceptable member of such a culture one needs to constantly pay attention to the experiences and develop intuitionand reflection. Ina less collectivistic and more individualistic culture, the individual is the recognized social unit. These cultures believe in the individual’s intellectual and affective autonomy (Schwartz, 1999). Freedom, pursuit of individual pleasure, individual initiative and achievement are accepted values. Cognition and communication are context independent. Verbal articulation is essential to communicate, silence is embarrassing. They are objective and use explicit logic, proofs and linear argument. They have a positive attitude to trying out newthings (Hofstede, 1997; House et al., 2004; Triandis, 1994). Being a member in individualistic culture may guide a person towards abstract conceptualization and active experimentation. 

조직과 사회가 자원의 집단 차원의 분배와 집단 차원의 행동을 격려하고 보상하는 정도

Institutional collectivism is ‘the degree to which organizational and societal institutional practices encourage and reward collective distribution of resources and collective action’ (House et al., 2004, p. 12). Institutional collectivism is ‘part of a cultural syndrome that is future and performance oriented’ and that tries to achieve them through collective efforts that are not assertive or dominating. It seems to originate more froma sense of justice, equality, collective action and camaraderie, the basis of which is rationality rather than feeling of kinship. The members of the societies that are high on institutional collectivism may have a preference for abstract conceptualization.

불확실성 회피

4.2.2. Uncertainty avoidance 

Uncertainty avoidance refers to ‘the extent to which the members of an organization or a society strive to avoid uncertainty by relying one stablished social norms, rituals, andbureaucratic practices’ (House et al., 2004, p. 11). Uncertainty avoiding societies resort to creating laws and rules and/or following rituals and religion in order to reduce ambiguity and unpredictability. In the laws they create, they aim to see clarity, structure and purity. In scientific pursuits, they favor deduction, formulating general principles first to apply themto specific situations (Hofstede, 2001). There is a tendency to consider what is different as dangerous. Breaking rules is not tolerated (House et al., 2004). They are more resistant to change. There is fear of failure and preference for tasks with sure outcomes, clear guidelines and less risk. Children are actively protected fromexperiencing unknown situations. In education, both teachers and students are more comfortable with the structured learning situations with clear objectives and timetables. They like learning situations with one correct answer and reward accuracy (Hofstede, 2001). The methods by which such societies deal with uncertainty may predispose its members to resort to abstract conceptualization and reflection and refrain fromexposing themselves to newexperiences and experiments while learning. Hoppe (1990) and Yamazaki (2005) have found evidence for a positive relation between uncertainty avoidance and reflective observation. Members of the less uncertainty avoiding societies are more comfortable with ambiguity, chaos, novelty and convenience. They take every day as it comes. In scientific logic they favor induction, taking note of the empirical facts first to reach general principles. They view what is different as curious. They are more tolerant of breaking rules, less resistant to change and innovation, and willing to take risks. They believe in one’s ability to influence one’s life and others. Children are encouraged to experience novel situations. In education, they prefer open ended learning situations where there is room for sense of empiricism, relativity and original and unconventional ideas. The members of such societies may find it easier to learn from concrete experiences and active experimentation.

미래지향성

4.2.3. Future orientation 

Future orientation implies ‘the degree to which individuals in organizations or societies engage in future oriented behaviors such as planning, investing in the future, and delaying individual or collective gratification’ (House et al., 2004,p. 12). Future orientated societies engage in planning. This requires the cognitive ability to see ‘the world beyond its present physical state’. These societies are cautious in initiating new tasks. They want to ensure that there are strong and positive links between the current tasks and the desired future state (House et al., 2004). Thus abstract conceptualization is a necessary condition to envisage the future (Trommsdorff, 1983). Future orientation requires being flexible (Tendem, 1987), open to taking risks and persistent. Leaders of such societies expect their members to be more innovative and tolerant of change (House et al., 2004). Future orientation thus fosters abstract conceptualization and active experimentation. Less future oriented societies are able to engage more in the present and enjoy the moment. They may show incapacity or unwillingness to plan to accomplish goals in the future. While planning, the thrust is to ensure that they are compatible with the customs and traditions. Only past experience can legitimate innovation and experience (House et al., 2004). This attitude towards the future may develop in members of such societies, habits of absorbing the experiences and reflecting on themin order to have guidelines for the future.

성취 지향성

4.2.4. Performance orientation 

Performance orientation is ‘the degree to which an organization or society encourages and rewards group members for performance improvement and excellence’ (House et al., 2004, p. 13). Highly performance oriented societies are found to value self-reliance, independence and achievement. The achievement orientation in themmay make themfocus on future, take initiatives and are persistent in the pursuit of goals (Fyans et al., 1983). They have a ‘can-do’ attitude and a sense of urgency. The emphasis is more on results than people. What one does matters more than what one is (House et al., 2004). The individuals and groups that produce results and accomplish assignments are appreciated (Parsons & Shils, 1951; Trompenaars & Hampden-Turner, 1998). Thus the societal attitude is one that favors action. The societies that are less performance oriented focus on maintenance of tradition, family, affiliation and social ties than on individual achievement. They value one’s role and position in society. In communication, they prefer subtlety and pay attention to context (House et al., 2004). Such an attitude may favor concrete experience. Such an attitude may favor less action and demand more reflection from the members of those societies.

자기주장

4.2.5. Assertiveness 

Assertiveness implies ‘the degree to which individuals in organizations or societies are assertive, confrontational and aggressive in social relationships’ (Houseet al., 2004, p. 12). Highly assertive societies appreciate assertive, dominant and tough behaviors from all of its members. They are direct in communication. They believe that anyone can be successful through hard work, take initiatives and are competitive in nature (House et al., 2004). They may have a ‘doing’ orientation (Kluckhohn & Strodtbeck, 1961). Assertive behavior indicates pragmatism(Rakos, 1991) and adaptiveness. The accepted behavior in assertive societies is one that is oriented towards action and taking charge. Societies that are low on assertiveness consider assertiveness unacceptable and endorse modesty and tenderness. They cherish people and relationships and are cooperative. They value self-possessed conduct. In communication, they are indirect (House et al., 2004). They have a more ‘being’ orientation than ‘doing’ (Kluckhohn & Strodtbeck, 1961). In learning, they may be more attuned towards using reflection than action.

권력거리

4.2.6. Power distance 

It is ‘the degree to which members of an organization or society expect and agree that power should be stratified and concentrated at higher levels of an organization or government’ (House et al., 2004, p. 12). Societies that are high on power distance tend to value social hierarchies. They don’t give the individual the freedom to do whatever they want or make own decisions. It is important for them to do what is socially correct and proper. However, the hierarchical systems of such societies assign roles to ensure socially responsible behavior (Schwartz, 1999). There are reciprocal obligations between those who occupy high and low positions in the hierarchy (House et al., 2004). A certain level of thoughtfulness and reflection is required from the members of such societies for them to understand their roles and behave suitably. In such societies, the education system places a value on the wisdom and authority of the teacher. The students are expected to obey the teacher and take in the lessons offered (Hofstede, 2001). The social norms combined with the education system appear to promote reflection rather than active experimentation. In the societies that are low on power distance, the social relationships are not hierarchically arranged. An individual is respected and appreciated for what he or she can offer (House et al., 2004). The education system is student centered where the students are encouraged to question and experiment. The members of such societies may not hesitate to engage in active experimentation (Hofstede, 2001).

성 평등

4.2.7. Gender egalitarianism 

Gender egalitarianism is ‘the degree to which an organization or society minimizes gender role differences while promoting gender equality’ (House et al., 2004, p. 12). In cultures that are more gender egalitarian, gender stereotypes and gender roles may be less pervasive, making the lived experiences of both men and women more homogeneous. Women may be as educated and employed in same occupations as men. In such cultures, there might be heightened notions about human equality and justice. It is likely that the sense making is more dependent on such abstract concepts than through relating to the heterogeneous experiences of self and others.

인간지향성

4.2.8. Humane orientation 

Humane orientation refers to ‘the degree to which individuals in organizations or societies encourage and reward individuals for being fair, altruistic, friendly, generous, caring, and kind to others’ (House et al., 2004, p. 13). In more humane oriented societies, others (family, friends, community and strangers) are very important. The members of the society are responsible for ensuring the well-being of others. They provide the social support for each other (Houseet al., 2004). They value being for giving, loving, cheerful and helpful (Bigoness &Blakely, 1996). They are motivated by altruism, benevolence, kindness and generosity (Triandis, 1994). The need for belongingness is high. The members of such societies are likely to develop the faculties for intuition and reflection and may make judgments based on feelings than logic. In less humane oriented societies, the members are not expected to look out for others. People are expected to solve their problems by themselves. There might be state structures to offer social and economic security(Houseet al., 2004). Therefore, the members can focus on self-enhancement (Schwartz, 1992) by promoting self-interest and self-gratification. They might feel freer to experiment with own lives. Since affiliation is neither a need nor a motivating factor, they might be more objective in their judgments and rely on logic and reason.

7.1. Conclusion 

문화가 영향이 있는 것은 자명해보인다. AC-CE에 대한 영향은 유의했고, AE-RO에 대한 영향은 그보다는 작았다.

From the above results, it is evident that culture has an impact on the learning style scales that is comparable to that of some of the demographic variables. Culture has a significant effect in deciding a person’s preference for abstract conceptualization versus concrete experience. The significance of its effect on the preference between active experimentation and reflective observation is marginal. 

문화에 의한 영향과 인구통계학적 변인에 의한 영향 비교. 어떤 분야를 전공하였느냐가 AC-CE에 영향을 준다.

On comparing the effect of culture and that of the demographic variables, the area of specialization seems to have a slightly larger effect on determining a person’s liking for abstraction or concreteness than culture does. This may be because of the fact that educational specialties are particularly focused on the development of and socialization into the ways of learning needed to meet the performance demands of the discipline. In case of culture, the socialization with respect to learning may be more indirect. Level of education seems to have as much of effect as culture and gender slightly less. In case of developing a preference for active experimentation or reflective observation age and area of specialization had more impact than culture. Age appears to have the greatest impact in inculcating the habit of refection than any other variable. If we take the marginal significance level of culture as acceptable, it has equal effect as level of education on developing a preference for active experimentation or reflective observation. Overall, we can see that it is culture and variables related to education, i.e., level of education and area of specialization that have the largest impact on learning styles. 

이 연구결과는 교육과 경영에 모두 중요한 의의를 지닌다.

This finding is of particular importance to the fields of education as well as management. 

• Educators need to be aware that conditioning by certain cultures may complement the learning style requirements of certain areas of specialization where as it might be clashing with some other specializations. Also, in the first years of higher education, say before graduation, where discipline specific conditioning is yet to take root, the culture-based differences may be even more pronounced. Therefore, higher educators in each area of specialization may have to ensure that the learning situations they design have elements that the students from different cultures can comprehend. 
• In management, multicultural teams became prevalent with globalization. Now with the new challenges facing organizations such as sustainability, that require paradigm shift in understanding and resolving the problem, these teams are becoming much more multidisciplinary as well. In order for these multicultural multidisciplinary teams to engage with each other effectively, they may have to understand each other’s sense making and problem solving approaches and how their cultures and areas of specialization might have predisposed them to certain approaches. Our findings from the analysis of the dimensions of culture that impact learning style differences may prove useful for these managers—the individuals tend to have a more abstract learning style in countries that are high in in- group collectivism, institutional collectivism, uncertainty avoidance, future orientation and gender egalitarianism and the individuals may have a more reflective learning style in countries that are high in in-group collectivism, uncertainty avoidance and assertiveness.

의학교육에서 신식민지주의 대 건전한 세계화 정책(Med Educ, 2008)

Neo-colonialism versus sound globalisation policy in medical education

Hans Karle, Leif Christensen, David Gordon & Jørgen Nystrup

의학교육에서 국제적 혁신에 대한 분석을 통해 Bleakley 등은 서양에서 시작한 방법이 신식민지주의 방식으로 전파되는 것에 대해 경고했다.

In a critical analysis of the global spread of innovations in medical education concepts and methods, Bleakley et al.1 rightly warn against the emergence of a form of neo- colonialism inherent in the practice of exporting ideas and methods of Western origin to other cultures in which their relevance may be limited.

PBL과 같은 교수법이나 OSCE와 같은 평가법이 다른 교육현실과 전통의 국가, 혹은 자원적으로 취약한 국가에 전파되는 것에 대해 생각하지 않았던 부분에 대한 관심을 유도하였다. 세계 여러 국가에서 의학교육의 문제는 더 근본적인 것에 있고, 재정자원과 인적자원의 부족과 연관되어 있다.

The authors draw attention to the unreflecting focus on advanced pedagogic methodology and the trend to disseminate modern instructional methods, such as problem-based learning, or assessment technologies, such as objective structured clinical examinations, to countries with other pedagogic practices and traditions in the education system in general and in medical school programmes in particular, or to countries with weaker resource profiles. In many parts of the world the problems in medical education are of a more fundamental nature and are related to lack of financial and human resources.

더 나아가서 Bleakley 등은 성과- 역량바탕 교육과정의 문제도 지적했다. 우리는 의학교육의 '성과'가 서구적 관점의 '필수 성과'에 의해서 정의되면 안된다는 것에 동의한다. 왜냐하면 의대 졸업생의 역량은 그 어떤 곳이든지 지역의 정치적, 사회경제적 환경, 건강요구, 전달체계를 반영해야 하기 때문이다.

Further, Bleakley et al.1 find the introduction of new concepts such as outcome- or competency-based curricular principles problematic. We agree that outcomes of medical education should not be defined by transferring Western ‘outcome essentials’, as the competencies of graduates everywhere must reflect local political and socioeconomic circumstances as well as the health needs and health care delivery sys- tem(including the roles of medical doctors) of local society.2,3

어떤 나라에서는 의학교육의 특성과 보건의료시스템의 질에 대한 인과관계를 해석하는데는 조심해야하는데, 이 것에 관여하는 수많은 요인들이 사실 진정으로 인과성이 있지 않기 때문이다.

Care needs to be taken in argu- ments based on any causal link between the nature of medical education and the quality of the health care system in any particular country, because multiple factors make any such linkage not truly causal.

The authors seem wrongly to iden- tify global standard setting with necessarily introducing an interna- tional medical ‘core curriculum’ based on common ‘core compe- tencies’. However, their concern underlines the necessity of the cautious use of global standards in medical education. Whenthe World Federation for Medical Education (WFME) published Global Standards for Quality Improvement of Basic Medi- cal Education,6 it emphasised that these standards (which cover all aspects of medical education, including the organisation, struc- ture, content, process, environment and outcome of education) should be used as a template for the devel- opment of regional, national and institutional standards. The requirement that these standards be applied as a template in the context of local cultural and socioeconomic circumstances is an integral part of the Standards, which cannot be regarded as an ‘international text’, as described by Bleakley et al.1

WFME 기준을 개발한 국제 테스크포스는, 모든 WFME 지부에서 총 30개국 이상이 참여했으며, 명백하게 교육 프로그램에 있어서 지역적 국가적 차이를 인정하는 방식으로 구성되어야 하며, 개별 의과대학의 서로 다른 특성을 허용해야 한다는 것을 기술하고 있다. 또한 교육목적과 교육목표가 의사들이 그 지역의 보건의료시스템에서 해야 할 역할을 지키는 가운데 정의되어야 함을 기술했다.

The international task forces behind the development of the WFME standards, which included experts from more than 30 countries representing all WFME regions, clearly stated that global standards should be formulated in such a way as to acknowledge regional and national differences in education programmes and to allow for the different profiles of individual medical schools. They also stated that mission and objectives must be defined in keeping with the roles of doctors in the local health care system.

첫째로, 서양 문화에 의해서 변질되거나 지배당하지 않으면서 의학교육에서 공유될 수 있는 중요한 가치를 개발하는 것은 어디까지 가능할까? 어떤 특징들은 전 세계적으로 의학교육에서 필요한 것들도 있다.

Firstly, to what extent is it truly possible to develop and agree meaningful and shared values and goals for medical education that are not tainted by imposition from dominant Western cultures? Some characteristics of medical educa- tion may represent universal needs.

둘째, 지역적 혁신과 외부적 도입의 균형이 중요하다. 문화적, 사회적 변화가 '전파'되는 것인지 '독립적 혁신'에 의한 것인지에 대한 연구가 많다 (진화론에서 선형 진화와 평행 진화에 비유될 만 하다). 비슷하게 의학교육에서의 발전도 한 나라에서 다른 나라로 전이되는 것일수도 있고(diffusion), 지역적 조건과 요구에 따라서 만들어지는 것일수도 있다.

Secondly, we believe that the bal- ance between local innovation andexternal imposition (‘colonialism’)in the development of the culture and practices of medical educationdeserves proper study. There is extensive research9 documenting the fact that cultural and social changes arise either by diffusion orby independent innovation (in a manner analogous to linear as opposed to parallel evolution in biology). Similar developments in medical education may represent the result of transfer from one country to another (‘diffusion’ in the above sociological terminology)or the result of local responses to similar conditions or needs.

변화가 전이의 결과로서 나타나는 것이라면, 공여국의 개념없는, 나쁜 동기에서 비롯된 활동은 마땅히 신식민지주의라 불려야 한다. 만약 독립적 혁신이 일어난다면, 그것을 일으키는 요인을 이해해야 한다. 왜냐하면 그것이 진료 양상을 변화시키기 때문이며, 어쩌면 진료 양상 자체가 제국주의적 형태로 전파되는 것일수도 있다.

If changes are the result of transfer, then thoughtless or badly motivated actions by the donor country are rightly described as neo-colonial- ism. If there is independent inno- vation, then we need to understand the factors that cause it, which may well be related to changes in med- ical care: perhaps it is medical practice itself that is spreading in an imperialist fashion.

Rogers EM. Diffusion of Innovations. New York: Free Press 5th Edition, 2003.

Neo-colonialism versus sound globalization policy in medical education.

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

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

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

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

한-중-일 의학교육 시스템 비교(Neuroint, 2013)

Comparison of Medical Education and Requirements for Training in the Interventional Neuroradiology in China, Japan and Korea

Lin Bo Zhao, MD1, 2, Shigeru Miyachi, MD3, Hai Bin Shi, MD2, Dae Chul Suh, MD1

The difference between China and the other two countries is that there are several education paths in Chinese medical schools, which are listed in Table 1 [8].

Similar with Japan, there is an obligatory initial postgraduate clinical training program which lasts two years.

Comparison of medical education and requirements for training in the interventional neuroradiology in china,Japan and Korea.

PMID:

 

23515458

 

[PubMed] 

PMCID:

 

PMC3601278

 

Free PMC Article

전통적 임상의학교육의 개선: TMDU의 경험 (Med Teach, 2009)

Reform of a traditional clinical curriculum in Japan: Experiences at Tokyo Medical and Dental University

SUSAN E. FARRELL1, KAZUKI TAKADA2, ELIZABETH G. ARMSTRONG1, YUJIRO TANAKA2 & H. THOMAS ARETZ1

1Harvard Medical School, USA, 2Tokyo Medical and Dental University, Japan

Introduction Historically, Japanese undergraduate clinical training has consisted of students’ observations of clinicians’ work. Under the direction of the 1948 Japanese Medical Practitioner Law, any one who did not hold a physician’s license could not perform medical acts. As a result, the traditional clinical learning environment was akin to an observership. Traditional societal expectation has been that students will not be involved in direct patient care. In 1991, the Japanese Ministry of Health and Welfare redefined the medical acts in which medical students were allowed to legally participate (Ministry of Health and Welfare 1994). This legislative change provided incentives for the creation of clerkships in which students could participate in clinical medicine under structured guidance (Kozu 2006; Coordinating Council on Medical and Dental Education 2007; Plotnikoff & Amano 2007).

Tokyo Medical and Dental University (TMDU), established in 1946, enrolled over 200 students at the time of this study. In 2006, TMDU, in collaboration with Harvard Medical International (HMI), initiated a reform of TMDU’s traditional undergraduate clinical curriculum.

Med Teach. 2009 Oct;31(10):947-9. doi: 10.3109/01421590902799302.

Reform of a traditional clinical curriculum in Japan: experiences at Tokyo Medical and Dental University.

왜 학생들이 의학교육에 참여하는가? (Clin Teach, 2015)

Why do students participate in medical education?

Hirohisa Fujikawa 1 , Jeffery Wong 2 , Hiroki Kurihara 3 , Kiyoshi Kitamura 4 and Hiroshi Nishigori 5

1 Department of Medicine , Suwa Central Hospital , Nagano , Japan

2 Division of General Internal Medicine & Geriatrics , Medical University of South Carolina , Charleston , USA

3 Department of Molecular Cell Biology , University of Tokyo , Japan

4 International Research Center for Medical Education , University of Tokyo , Japan

5 Center for Medical Education , Kyoto University , Japan

Medical education in Japan has experienced rapid change in recent times. Some of these changes include the institution of formal rotating internships in postgraduate training, beginning in 2004, and the introduction of a nationwide objective structured clinical examination (OSCE) and computer- based test (CBT), beginning in 2005. 1 In 2013, work began on developing a national accreditation system for undergraduate medical education. These changes have infl uenced the way that faculty members approach curriculum reform. As an example, medical students have recently become more involved in curriculum development in some, but not all, Japanese medical schools. Furthermore, the importance of student engagement in curriculum development is one of the basic tenets stated in the World Federation of Medical Education (WFME) global standards for quality improvement (World Federation of Medical Education; 2012). 2

THE UNIVERSITY OF TOKYO STUDENT GROUP FOR MEDICAL EDUCATION

Previously, student engagement at the University of Tokyo was not the norm because of strained relationships between students and faculty members, stemming from protest incidents in the 1960s. 3 After nearly 50 years of little to no involvement in curriculum planning, medical students at the University of Tokyo formed a group whose aim was to actively contribute towards planning and improving medical education at their school, with a little assistance from faculty members at the Centre for Medical Education. The University of Tokyo Student Group for Medical Education (UTSME) comprised between fi ve and 10 volunteer members in total from every year.

METHODS

A grounded theory methodology was used for this preliminary qualitative study. 5 From January to May 2012 at the University of Tokyo, the fi rst author (HF), who was a member of the UTSME, conducted individual semi- structured interviews with all seven members working for the group in 2012 with their consent. The interviews varied in length from 40 to 120 minutes, and the students were asked about what motivated them to participate in the process of medical education reform. All interviews were tape- recorded and transcribed verbatim. The transcriptions were fi rst iteratively read by HF and then analysed by the thematic synthesis method. In this method, text coding was performed fi rst, followed by the development of descriptive themes and then, in the last stage, analytical themes were generated. 6 We chose this approach because it is suitable for analysing relatively unstructured, text- based data in an inclusive and rigorous manner. 7 The last author (HN) read the transcripts independently, and through this triangulation process the identifi ed themes were reconciled to achieve higher reliability in the data analysis.

RESULTS

Three main themes emerged as potential explanations describing what motivates medical students to participate in the process of medical education reform: 

(1) extracurricular interaction with faculty members; 

(2) engaging with highly motivated peers; and 

(3) student values for serving the public. 

The students’ narratives were serially numbered using the code numbers S1–S7.

Why do students participate in medical education?

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

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.

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.

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.

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

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

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.

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.

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

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.

일본에 새로운 의과대학 도입하기(Ann Acad Med Singapore, 2008)

Introducing a New Medical School System into Japan

Yasuharu Tokuda,1MD, MPH, Shigeaki Hinohara,1MD, Tsuguya Fukui,1MD, MPH

일본의 대입

Admission to Universities in Japan

입학시험에서의 점수가 대입에 가장 중요하다. 고등학교 성적, 교사 추천서, 교외활동, 봉사활동, 인성 등은 입학과정에 그렇게 중요하지 않다.

Performance in the entrance examination is the key determinant to university admission. Other criteria, such as high school grades, teachers’ recommendations, extracurricular activities, community services and personal character, are usually not considered as important in the admission process.2

최근 입학시험 준비의 강도가 심각하게 높아졌다.

Recently, the intensity of preparation for entrance examinations has severely escalated.

그러나 사회경제적 불균형이 높아지면서, 그리고 일본 내 "working poor"에 해당하는 인구가 많아지면서, 고등교육에 있어서 불평등하고 불균등한 기회에 대한 문제가 제기되고 있다.

However, as socioeconomic disparity increases, with a growing subpopulation of the “working poor” in Japan,4 there is growing concern regarding the unequal and unfair opportunities for children or young persons to pursue higher education.

일본의 의과대학 

Undergraduate Medical Schools of Japan

현재 79개의 의과대학이 있으며, 50개는 국립/도립이며, 29개는 사림이다. 의학교육은 6년이며 보통 2년의 교양, 2년의 전임상, 2년의 임상교육으로 이뤄진다. 대부분의 의과대학생은 고등학교 졸업 후 바로 의대에 들어간 학생들이며, 대학졸업자도 36개 학교에서는 선발하고 있지만 전체의 10% 미만이다. 기초과학에서 연구자를 선발하는 것이 더 어린 학생들을 뽑는 이유이다. 또한 6년제 교육과정이 4년제 교육과정보다 더 이득이 된다.

There are currently 79 undergraduate medical schools in Japan, including 50 national/prefectural ones and 29 private schools.5 The medical education is 6 years in duration, typically comprising 2 years of general liberal arts, 2 years of pre-clinical education and 2 years of clinical education. Most medical students in Japan are immediate graduates from high schools. Although college graduates are also offered admission in 36 schools, they account for fewer than 10% of the available positions.5 Recruiting researchers from the basic sciences may be one reason for admitting younger students (18 years old) to medical schools in Japan. Furthermore, a 6-year curriculum is more profitable for universities compared with a 4-year one.

의과대학 입학

Entering Undergraduate Medical Schools

여러 단과대학 중 의과대학 입학이 가장 어렵다. 

Among all the departments in the universities, entry to undergraduate medical school is the most difficult yet the most prestigious.6 Thus, Japanese students who aspire to enter into medical schools prepare arduously for the entrance examinations.

고등학생은 1학년을 마치고 먼저 이과(Rikei) 혹은 문과(Bunkei)를 선택한다. 이과는 고등학교 수학을 3년간 하고 문과는 추가적인 수학교육을 받지 않는다. 대부분의 일본 의대생은 이과출신이며 문과에서는 거의 입학하지 않는다. 따라서 의과대학의 입학시험은 주로 이과 과목을 중심으로 하며, 따라서 문과출신 학생은 거의 들어오는 것이 불가능하다.

High school students must choose either the Mathematics/ Physicochemical Science (Rikei) or Humanities/Social Science track (Bunkei) after completing their first year of high school. Rikei students take 3 years of high school mathematics, whereas Bunkei students are not required to study any additional mathematics.7 Most medical students in Japan come from the Mathematics/Physicochemical Science track and not from the Humanities/Social Science track,6 as the entrance examinations of medical school are traditionally based on the content of the Mathematics/ Physicochemical Science track. Thus, very few students from the Humanities/Social Science track are able to enter into medical schools in Japan.

프로페셔널리즘, 휴머니즘, 윤리교육

Professionalism, Humanism and Ethics Education for Medical Students

그러나 프로페셔널리즘, 휴머니즘, 윤리에 관한 문제는 의대생과 젊은 의사들 사이에 최근 심각한 이슈가 되고 있으며, 의학교육자와 대중의 관심도 몰리고 있다. 프로페셔널리즘에 어긋나는 행동을 한 일부 학생들도 실제로 의과대학에 입학하곤 한다. 성격이나 인성이 의과대학기간동안 형성되기는 어려우며, 일부 학생들은 프로페셔널리즘, 휴머니즘, 윤리를 배우고자 하는 의지가 부족하고 이는 사회경험이 적거나 엘리트주의에 빠져있기 때문으로 보인다.

However, issues in professionalism, humanism and ethical behaviour among medical students and young physicians have recently become a widespread serious concern to medical educators and the general public in Japan.12,13 Some students with unprofessional attitudes and behaviours are indeed allowed to enter into medical schools.12,14,15 Formation of character and promotion of virtue may be difficult during the medical education period, as some students are poorly motivated to learn professionalism, humanism and ethics because of a lack of social experience, as well as an exaggerated perception of elitism.

많은 문과 학생 중에도 미래에 좋은 의사가 될 사람이 많을 수 있고 환자와 의사소통을 잘 할 수 있다. 처음에는 생화학, 분자생물학, 생물통계학 등을 배우기 어려워 할지도 모르지만, 이 과목들이 대부분 어려운 수학을 몰라도 이해할 수 있다.

There may also be many students from the Humanities/Social Science track who could be good candidates as future physicians, and are highly skilled at communications with patients. While they may initially find it difficult to learn biochemistry, molecular biology and biostatistics, they can comprehend most of these subjects without advanced mathematics.

의사양성의 새로운 시스템으로는 다른 학과를 졸업한, 특히 인문계열 학과를 졸업한 학사학위자를 선발하는 방법이 있다. 실제로 최근 의과대학의 3993명의 교수들을 대상으로 한 설문에서 60%의 교수들은 Graduate medical school도입에 찬성하는 것으로 나타났다.

A new system for cultivating physicians might include recruitment of graduates from other departments and particularly those from the Humanities/Social Science trackIndeed, a recent survey among 3993 faculty members of medical schools throughout Japan also showed that about 60% of them were in favour of introducing graduate medical schools.6

graduate medical school을 도입하는 것이 일본 사회에 큰 도움이 될 것이다.

Introducing graduate medical schools will provide substantial benefits in Japanese society.

12. Sabalis R, Shiina K, Ishii H, Yanai H, Nara N, Saitou N. Medical Education in Japan: Changes and Challenges. Igaku Kyoiku (Medical Education) 2004;35:221-8.

Ann Acad Med Singapore. 2008 Sep;37(9):800-2.

Introducing a new medical school system into Japan.

일본 의학교육에 대한 오해: 어떤 변화가 진행중인가(Keio J Med. 2007)

Misperceptions of medical education in Japan: How reform is changing the landscape

Alan R. Teo

Department of Psychiatry, University of California, San Francisco, CA, U.S.A.

Rao는 일본 의료의 오래된 패러독스를 지적했다. 어떻게 부실한 의학교육에서도 건강지표는 이토록 우수한가? 그가 내린 결론은 이전 문헌에서 내린 결론과는 다르지 않았다. 의학교육에 관심을 가지고 개혁을 요구한 것이다.

Rao correctly identifies a lingering paradox of medicine in Japan: Why such enviable health outcomes despite a dysfunctional medical education system? His ultimate conclusion is not unlike predecessors in the lit- erature who call attention to, and plead for reform of, striking deficiencies in medical education in Japan.

Rao와 다른 일본의 의학교육계가 지적하는 공통된 의견은 다음과 같다.

Commonly heard opinions that Rao and others make of medical education in Japan can be divided into four cate- gories: 

1. The Japanese medical education system is stagnant. 

2. Undergraduate medical education should be the primary target for reform. 

3. Japanese physicians are trained as subspecialists and lack the ability to practice general internal medicine. 

4. Japanese medical students have poor spoken English.

오해 1. 일본의 의학교육은 정체되어 있다.

Misperception 1. The Japanese medical education system is stagnant.

First, the Japanese Residency Match Program (JRMP) was established. This system, which is similar to that of the US, is a very important development because it of- fers graduates the opportunity to self-determine their site of residency training,

Rao는 일본 의과대학생들의 수동성에 혀를 내둘렀다.

Rao eloquently describes the frustrating passivity of his Japanese students,

나는 일본의 한 국립대에서 영어를 가르치며 동일한 고통을 느꼈다. 불행하게도, 비판적 사고와 그룹 토의에 관한 미국의 모델에 몇 주간 노출된 것 만으로는 "문화에 뿌리박힌" 수동성을 극복하기 어려웠다.

I endured identical pains in my tenure teaching medical Eng- lish at one of Japan’s national universities. Unfortunate- ly, a few weeks’ exposure to an American model of criti- cal thinking and group discussion is woefully inadequate to overcome a passivity that he acknowledges to be “cul- turally ingrained.”

이러한 상황에서, 의과대학을 대상으로 개혁을 시작하는것은 비참할 정도로 지지부진할 것이며, 전체 교육을 바뀔 것을 기대하는 것도 웃기다. 

Given this, starting reform at medical school is tragi- cally tardy, and expecting wholesale reform in education so easily is farcical. Take one example: Trying to get Japanese undergraduates, which includes medical stu- dents, to take their studies more seriously would require eliminating the preceding years of so-called “entrance exam hell” that cause them to relax once reaching the “Disneyland” of college life.

물론, 학부의학교육의 혁신이 이루어진 부분도 잇다. 이러한 개혁을 강화하고 더 넓히는 것이 더 단순하고도 현실적인 접근법이다. Roa는 "bedside 교육이 거의 없다"라고 했다. 그러나 OSCE는 모든 일본 의과대학의 requirement이다. 일본의 OSCE는 여전히 내용보다는 형태가 강조되고 있고, 학생들은 쉽게 통과하는 것으로 생각하면서 실제 임상상황을 거의 반영하지 못하며 동료들과 연습한다. 그럼에도 불구하고 OSCE에 대한 진지한 준비는 더 많은 임상교육의 기회가 될 것이다.

Of course, there are piecemeal areas of undergraduate medical education reform in Japan. Focusing on enhanc- ing and broadening these reforms is also a simpler and more realistic approach. For instance, Rao deplores the “absence of any bedside clinical instruction.” However, the Objective Structured Clinical Exam (OSCE) is a re- quirement in place at all Japanese medical schools.3 OSCE in Japan is still more form than substance－stu- dents view it as easy to pass and perform exams on peers, hardly mimicking real clinical practice. Nonethe- less, serious preparation for OSCE would be an excellent opportunity for more clinical instruction.

오해 3. 일본 의사들은 전문의 수련을 받았고, 일반의 진료 역량이 부족하다. 

Misperception 3. Japanese physicians are trained as subspecialists and lack the ability to practice general medicine.

최근의 한 가지 변화는 'general medicine department'에 대한 것으로, 일차의료에 대한 교육이 부족하다는 오래된 지적을 인식하여 MHLW는 일차의료와 관련한 부서 신설의 움직임을 지원하였고, 그 숫자는 대학병원과 지역사회기반 병원 모두에서 빠르게 증가하고 있다.

One development in recent years is of general medicine departments -- called sōgō shinryōbu in Japanese. Aware of longtime criticisms of insufficient education in prima- ry care, the MHLW has supported the movement to cre- ate departments related to primary care, and their num- bers are growing rapidly in both university and commu- nity settings.6

오해 4. 일본 학생들은 영어를 못한다.

Misperception 4. Japanese medical students have poor English.

대체로 일본 의사들은 최신의 논문을 접하고 논문을 출판하는 것에 관심이 많으며, '영어로 읽고 쓰는 것'이 그들에게 더 중요하다.('영어로 말하고 듣는 것보다'). 실제로 의사들의 '읽고 쓰는 능력'은 평균 이상이다. 비록 '영어로 말하고 듣기'가 많은 일본 의대생과 의사들이 잘 못하는 부분이지만, 모든 영여 실력을 낮춰 보는 것으 부당하다.

However, by and large academic physicians in Japan are most concerned with publishing and staying current with the literature, meaning that written English is of much more importance to them. And indeed their written skills when isolated to medical English is more than ade- quate. Although the spoken English of most Japanese medical students and physicians is poor, it is unfair to categorize their entire English language level as such.

3. Onishi H, Yoshida I: Rapid change in Japanese medical education. Med Teach 2004; 26: 403－408

Misperceptions of medical education in Japan: how reform is changing the landscape.