FINAL REPORT WONCA ACCREDITATION VISIT

Japan Primary Care Association (JPCA)

Report of visit to accredit Japan Primary Care Association’s Postgraduate Training
Programme against the WONCA Postgraduate Training Standards1.
November 3rd-5th 2019:

Dr Garth Manning
Chief Executive Officer, World Organization of Family Doctors (WONCA)

Professor Marie Andrades
Professor Institute of Family Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
Professor Val Wass
Chair WONCA Working Party on Education; Professor of Primary Care Medical Education,
Aberdeen University; Emeritus Professor of Medical Education, Keele University, UK1
http://www.globalfamilydoctor.com/site/DefaultSite/filesystem/documents/Groups/Education/WONCA%20ME%20stds_edit%20for%20web_2507
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Acknowledgements:

We acknowledge, and are grateful for, the detailed comprehensive preparation undertakenby the Japan Primary Care Association and the staff at the hospitals and training sites.
Throughout the visit we were made welcome, kept well informed and offered an opentransparent environment for information gathering and discussion. This greatly aided theaccreditation process. It reflected the overall transparent learner centred philosophy andcaring, safe atmosphere of the training programme. We thank all staff and trainees for theirtime interest and understanding and Atsushi Igaki, Chief Administrative Officer, for his
efficient organisation before and throughout the visit.

GlossaryCEO

Chief Executive Officer

CFMD

Centre for Family Medicine Development

FM

Family Medicine

JPCA

Japan Primary Care Association

JMSB

Japanese Medical Specialty Board

MCQ

Multiple Choice Question

MHLW

Ministry of Health, Labour and Welfare

OSCE

Objective Structured Clinical Examination

PC

Primary Care

PG

Postgraduate

UG

Undergraduate

VT

Vocational TrainingWBA

Workplace Based Assessment

WONCA

World Organization of Family Doctors

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EXECUTIVE SUMMARY:
1: Background:Internationally developing primary care (PC) to meet rapidly changing health care demands
is a major problem. Japan is no exception. It faces a serious recruitment challenge; of 9,000
new graduates annually, less than 2% choose to train as a Family Medicine (FM) physicians.
When three organisations merged to form the JPCA in 2010, the Association developed aformal three-year vocational training (VT) programme. On successful completion of final
assessments, trainees are certified by JPCA as FM specialists. From 2010 to 2018 inclusive,
this was the single track for FM VT but not compulsory.
In 2014 the Japanese Medical Specialties Board (JMSB) was established. In the fiscal year of2018 JMSB introduced a three-year FM VT pathway differing from the JPCA track; internal
medicine placements increased from 6 to 12 months and the JMSB introduced a compulsory
12-month rural attachment. The qualifying final assessment for exit has not yet beenannounced.
Thus, currently two programmes run simultaneously. Beyond this JPCA plan a new
curriculum, blended with the JMSB FM content but extended by a fourth year to assure VT
as a JPCA certified FM physician maintains equivalency to the current programme.
2: Aim of visit: To assess the 2010-18 JPCA VT programme for accreditation against the
WONCA PG standards and review the proposed new four-year programme.
3: The accreditation process: The WONCA team (MA, GM, VW) visited JPCA
headquarters in Tokyo over four days. Comprehensive pre-visit information was available
and informed an initial half day briefing meeting with senior JPCA members and three
trainees. Visits to two Tokyo contrasting training sites enabled broader assessment of the VT
course. Lead educators, tutors and a range of trainees (from both JPCA and JMSB
programmes) were interviewed. Further discussion for clarification with JPCA was held
before the team met to agree the outcomes. Preliminary findings and recommendations
were communicated verbally to JPCA senior members to conclude the visit.
Findings: JPCA VT programme 2010-2018 entry:
Good practice: We commend the strong commitment of the JPCA Board to FM VT and thestandards set. Several trainees had been attracted through the JPCA Summer Workshops
held for medical students where they met inspiring FM doctor role models. Trainees felt wellsupervised and mentored and valued the autonomy of choice with placements and electives.
The use of a portfolio as a record of self-directed learning is in line with current international
practice. The scenarios used for the final clinical skills assessment were truly reflective ofcases FM doctors meet.
Areas of concern moving forward to be addressed in the new JPCA curriculum:
1: The impact of uncertainty: We learnt that graduates were being deterred fromentering the JMSB programme by (a) lack of detail of the outcomes and assessment format(b) the unpopular compulsory 12-month rural attachment.

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2: Covering the FM Curriculum: Trainees were concerned there was too much time oninternal medicine in the JMSB programme. To meet international standards exposure acrossa wide range of specialties, with at least 18 months in supervised FM practice, is essential.
3: The service versus training ratio in the JMSB programme: FM is an increasingly
challenging very broad specialty. These doctors are relatively inexperienced and need aclosely supervised training structure, regular seminars etc. We found little evidence of plans
to provide this in the rural year. Patient safety may arguably be at risk. This year without
supervision cannot count towards training. The revised JPCA curriculum needs extending tofour years if VT is to meet international WONCA standards.
Conclusion:
WONCA accredits the JPCA VT programme 2010- 2018 which meets the WONCA PG
standards for accreditation. We make four recommendations to be addressed in the new
curriculum.
We strongly agree that the new JPCA course must be extended to four years with carefulattention to balance service and training, exposure across specialties and quality assuranceof the placements. We commend the ongoing development of the portfolio and planned
workplace-based assessment (WBA).
WONCA cannot accredit a programme in planning. We endorse the proposed four-year
extended programme for three years provided the four recommendations for the current
programme are addressed within the new curriculum and the following requirement is met.
Recommendation 1: Training must be explicitly included for all trainees: (i) Mental Healthincluding time with psychiatrists and related services; (ii) Women’s Health; (iii) a formal
communication skills training programme for difficult situations.
Recommendation 2: The portfolio develops greater emphasis on personal reflection andself-directed learning. JPCA with its stakeholders, should agree an explicit definition of
professionalism to ensure trainees have clear guidelines on the values and standards expectedof them professionally and how it is explicitly assessed.
Recommendation 3: The assessment programme is mapped to the curriculum in moredetail stating the level of achievement expected of trainees for each competency. The final
Multiple Choice (MCQ) and Objective Structured Clinical Examination (OSCE) are extended toensure there is adequate curriculum coverage (current international practice suggests 200
MCQs and 12-14 OSCE stations)
Recommendation 4: Plans for quality assurance of sites against a written protocol are set
in place as a priority initially targeting current training practices where quality is a concern.
Requirement: Annual reports are received by WONCA in December 2021 and December
2022 on the new course outlining progress made in the design and implementation of the
programme and how the recommendations have been met. We anticipate a “virtual”
interview for any necessary clarification. A full accreditation visit is recommended for late
2023.

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FULL REPORT
1: The Accreditation Process:
1:1 In early 2019 the JPCA approached WONCA seeking accreditation of their Family Medicine(FM) training against WONCA Global Standards for Postgraduate (PG) FM Education.1
1:2 A team of three WONCA members with the appropriate expertise was appointed to visit
Tokyo in November 2019: (i) Garth Manning (WONCA CEO) (ii) Marie Andrades (Professor,
Institute of FM, Jinnah Sindh Medical University, Karachi, Pakistan), (iii) Val Wass (Chair
WONCA Working Party on Education: Professor of PC Medical Education, Aberdeen
University UK: Emeritus Professor of Medical Education, Keele University UK).
1:3 We acknowledge that internationally developing primary care (PC) to meet rapidlychanging health care demands is a major problem. Japan is no exception. It faces a serious
recruitment challenge; of 9,000 new graduates annually, less than 2% choose to train as FM
physicians.
1:4 The JPCA faces a challenging, rather complex situation. Formed in 2010 by merging
three FM organisations, it established a three-year programme offering formal training withcertification (by JPCA) on completion as a FM specialist. Formal training was not compulsory
until 2018. Before this date, on completing six years at medical school and a two-year
residency, it was possible to offer unsupervised FM services without VT.
1:5 In 2014 the Japanese Medical Specialties Board (JMSB) was established. JMSB
introduced a new three-year FM Vocational Training (VT) pathway which differedsignificantly from the JPCA track; internal medicine placements have been increased from 6
to 12 months and the JMSB has introduced a compulsory 12-month rural attachment. The
qualifying final assessment and exit qualification have not yet been announced. Trainees inthis programme are now in the second year of VT and face the uncertainty of how they will
be certified on completion.
1:6 The WONCA team (GM, MA, VW) visited JPCA headquarters in Tokyo over four days.
Comprehensive pre-visit information was available and informed an initial half day briefing
meeting with senior JPCA members and three trainees.
1:7 Visits took place on days 2 and 3 to two Tokyo contrasting training sites; the Tama
Hospital a central Tokyo site and the more peripheral suburban Centre for Family Medicine
Development (CFMD). This enabled broader assessment of the VT course. Lead educators,
tutors and a range of trainees (from both JPCA and JMSB programmes) were interviewed.
1:8 We meet Takuma Kato, at the Ministry of Health, Labour and Welfare who provided ahelpful overview of the Ministry’s overall aims and objectives relating to PC. Further
discussion with the JPCA for clarification took place before the team met to agree theoutcomes. Preliminary findings and recommendations were communicated verbally to JPCA
senior members to conclude the visit.
WONCA PG ACCREDITATION STANDARDS1:
2: Standard 1: Mission and outcomes
2:1 The mission, vision and values for the JPCA as an organisation truly impressed us.
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2:2 JPCA has achieved much since 2010 to develop FM VT in the face of many challenges.
Currently under the leadership of President Tesshu Kusaba and Vice President Tetsuhiro
Maeno (responsible for the JPCA certification system), the Board strive to maintain their vision
for high quality education standards for both trainees and trainers.
2:3 We appreciate this is currently a critical time. When recruitment is under pressure, thetemptation is to lower the bar. We strongly support the JPCA’s stand to ensure that FM VT
training remains in line with international standards in length, range of exposure to specialities
relevant to FM practice and, above all, a minimum of 12 months (preferably 18 months)
supervised training time in FM residency.
2:4 We consistently noted across our visit a strong ethos to establish education and researchscholarship. A respectful, caring culture where students feel valued was evident throughout.
They value autonomy of choice with placements and electives and feel well supervised andmentored.
2:5 The JPCA hold summer workshops for medical students aimed at promoting FM as avocation. We learnt this had had a constructive and affirmative influence on some of the
trainees we met. FM doctors on the course were seen as positive and powerful role models.
We highlight this as an area of good practice.
3: Standard 2: The training process:
JPCA trainees:
3:1 There was a clear differential in experience between the trainees completing the threeyear JPCA training with certification in 2020. At the site visits we explored their experienceand triangulated it with that of their trainers in hospital and PC settings.
3:2 The JPCA trainees had had fairly well-balanced rotations through hospital specialities
relevant to FM practice. They felt well supported and valued within the hospital context.
3:3 WONCA acknowledges that approaches to illness can differ culturally. However globally
there is strong move to offer more support for mental health and women’s health; key roles
for FM doctors. Trainees confirmed they felt relatively poorly prepared to address mental
health problems e.g. dementia and depression. This is a notably gap in the current rotations
which needs addressing in the new four-year curriculum.
3:4 Formal communication skills training takes place, but we felt this was relatively basic
judged against international standards. More challenging patient centred contexts anddifficult situations e.g. breaking bad news and challenging negotiation would benefit
trainees.
Recommendation 1: Training must be explicitly included for all trainees: (i) Mental Healthincluding time with psychiatrists and related services; (ii) Women’s Health; (iii) a formal
communication skills training programme for difficult situations.
3:5 On FM attachments JPCA trainees reported a high quality, well supervised experience
with an emphasis on continuity of care. They valued the autonomy they held in selecting
their placements. We were particularly impressed by the reflective seminars offered at CFMD
and the blended approach to teaching. We highlight this as good practice.
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JMSB trainees:
3:6 JMSB trainees faced the uncertainty of lacking detail of expected training outcomes andhow they would be assessed; we appreciated how challenging this was for them. The
challenge of 12 months in rural practice relatively unsupervised and its impact on theirpersonal lives was unpopular. They reported both these challenges had become a deterrent
to their peers considering FM VT. We highlight this as a powerful direct conflict with the
MHLW recruitment imperative; an important area of concern
3:7 JMSB trainees reported their rotations were unrepresentative of FM practice; they felt 12months in internal medicine was far too long. To meet international standards exposure
across a wide range of specialties with at least 18 months in supervised FM practice isessential. With the impact of ageing, increased disease co-morbidity and non- communicabledisease it is increasingly important to train in less specialised contexts. We felt, with thereservations expressed, that rotations in the JPCA were more representative and need to besustained. We highlight this as an area of concern.
3:8 We were concerned by the service versus training ratio in the JMSB programme: As
highlighted patients’ presentations in FM are increasingly complex. These trainees are
relatively inexperienced and need a closely supervised training structure. We found little
evidence of plans to provide this in the rural year. Thus, this cannot count as time intraining. The focus on unsupervised service delivery opens a potential risk to patient safety.
We highlight this as a serious area of concern.
4 Standard 3: Assessment
4:1 We commend the development of the portfolio throughout training to monitor progress
and professional development. The new curriculum has the potential to place greater
emphasis on personal reflection and self-directed learning. We fully support the introductionof workplace-based assessments (WBAs) across training to assess what a trainee does andgive formative feedback. It offers a route to identifying students who are under performing.
We highlight this as good practice.
4:2 Assessing professional behaviour is gaining increasing importance. Defining JPCA’svalues and expectations for professionalism would enable professional behaviour to be morerobustly assessed both to encourage positive behaviour and identify and act when a trainee
behaves unprofessionally.
Recommendation 2: The portfolio develops greater emphasis on personal reflection, selfdirected learning and WBA. JPCA with its stakeholders, should agree an explicit definition of
professionalism to ensure trainees have clear guidelines on the values and standards expectedof them professionally and how it is explicitly assessed.
4:3 To successfully complete the current JPCA VT trainees must pass a 120-item multiplechoice question paper (MCQ) and a six station Objective Structured Clinical Examination(OSCE). We did not see the MCQs. The current OSCE scenarios are valid representations ofFM practice; we highlight this as good practice.
4:4 International experience of mapping (blueprinting) VT learning outcomes across thecurriculum consistently confirms an MCQ applied knowledge test of circa 200 items and an
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OSCE clinical skills test of circa 14 stations are needed to reach the reliability level requiredof this high-stake exit assessment.

Recommendation 3: The assessment programme is mapped to the curriculum in detailstating the achievement level expected of trainees for each competency. The final Multiple
Choice Question paper (MCQ) and Objective Structured Clinical Examination (OSCE) areextended to ensure there is adequate curriculum coverage (current international practicesuggests 200 MCQs and 12-14 OSCE stations). Successful completion of the portfolio should
be mandatory.
5 Standard 4: Trainees:
5:1 The JPCA trainees interviewed were uniformly positive about their experience. They
valued their contact with patients, empowered to self-direct their training, listened to andwell supervised. We had no concerns.
6: Standard 5: Staffing
6:1 Recruitment into FM VT remains below training capacity creating a significant underuseof trainers. We learnt of 400 training programmes only 25% were active (100 trainees). Those
we witnessed in active practice were of high quality. Measures were in place to keep trainers
up to date; a training the trainer course delivered by the UK Royal College of General
Practitioners was due to take place at the end of the month. We had no concerns.
7: Standard 6: Training setting and resources.
7:1 Within the inevitable limits of the visit which restricted the range of sites seen, we
concluded the setting, programme structure and allocation to training placements met the
curriculum requirements and WONCA standards.
7:2 JPCA are moving towards a five-year cycle of quality assurance of training sites and theirprogrammes. We commend this move and assurance that it will be intrinsic to the newprogramme. JPCA openly acknowledged that quality of training settings across the country
varied. We recommend that quality assurance of practices is a priority.
Recommendation 4: Plans for quality assurance of sites against a written protocol are set
in place as a priority initially targeting current training practices where quality is a concern.
8: Standard 7: Evaluation of training process
8:1 We were satisfied that the JPCA programme had followed a continuum of regular feedback,evaluation and change as they moved to address the implications of the introduction of the
JMSB VT programme. Our observations support JPCA’s evaluation of JMSB’s FM VT that (i) ayear in unsupervised rural practice without a formal training structure cannot count towards
formal training (ii) the specialty rotations must remain appropriate to FM practice and be
reinforced by our recommendations.

89: Standard 8: Governance and Administration
9:1 Training on the 2010-2018 programme has been conducted in accordance with thestandards set by the JPCA. The Association continues to collaborate and work towards
ensuring compatibility with the JMSB and MHLW.
10: Standard 9: Continuous renewal
10:1 The JPCA are in the process of designing a new four-year competency-based
curriculum. In view of the serious concerns about the current JMSB VT programme
emerging from this accreditation process, we strongly support this move.
Conclusion:
The programme JPCA VT programme 2010- 2018 meets the WONCA PG standards foraccreditation. We make four recommendations to be addressed in the new curriculum.
We strongly agree that the new JPCA course must be extended to four years with carefulattention to balance service and training, exposure across specialties and quality assuranceof the placements. We commend the ongoing development of the portfolio and planned
workplace-based assessment (WBA).
WONCA cannot accredit a programme in planning. We endorse the proposed four-year
extended programme for three years provided the four recommendations for the current
programme are addressed within the new curriculum and the requirements for monitoring of
the development are met.

Professor Val Wass

Dr Garth Manning

Professor Maria Andrades

Report accepted and approved

Dr Donald Li
WONCA President

27th April 20209