REVIEW
Perspectives in Medical Education
2. A blueprint for reform of medical education in JapanR Harsha Rao

Professor of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, U.S.A.
(Received for publication on September 15, 2005)(Revised for publication on March 16, 2006)(Accepted for publication on April 20, 2006)

Abstract. A blueprint for reform of medical education in Japan is presented, with the goalof training well rounded physicians who possess the ability to think critically and the clinical skill to function as generalists before they enter specialty training. Practical solutions
are offered in three problem areas that lie at the heart of the shortcomings in Japanese
medical education. They have to do with (i) the way Japanese students learn, (ii) the way
Japanese teachers teach, and (iii) the material that students are taught. The inherently
passive nature of Japanese students can be changed by emphasizing “active learning” and“critical thinking at the bedside” through a problem-oriented approach, both in the classroom and in the wards. Changing student learning, however, requires a commitment toteaching. At the present time, there is no incentive to teach at all, let alone teach in a constructive or interactive way. Teaching is widely perceived as a burden that takes time awayfrom research, rather than as a credible and rewarding academic pursuit. Thus, promotion policies must be altered to reward teachers and accord teaching its rightful place as a
primary function of the faculty. Finally, the introduction of active learning and interactive
teaching depends on reducing the current emphasis on didactic instruction, which is passive and unidirectional. Thus, medical school curricula must be restructured to emphasize
a problem-oriented, organ system-based approach throughout medical school, starting fromthe preclinical years. Reforms in all three areas must be implemented in concert for them tosucceed. (Keio J Med 55 (3): 81－95, September 2006)
Key words: Japanese medical education, problem based learning, curriculum revision, active learning, teaching in Japan

Introduction

implementing far-reaching changes that I believe are
essential to meet the challenges facing those who areattempting to reform Japanese medical education. That
these changes are critically important should be selfevident to anyone familiar with the state of Japanese
medical education in general, and at Keio University
School of Medicine specifically. The solutions I propose
are based on my own experiences at that institution, but
their sum and substance are derived from exhaustive
discussions with my hosts at the Department of Medical
Education, and the very clear directives that I received
from Dean Kitajima and his team of deputies at Keio
University School of Medicine.

In an earlier paper, I was able to present my highly
subjective insights into the problems that bedevil thetraining of physicians in Japan,1 based on observations
made during a first visit in 2003 to Keio University
School of Medicine, one of Japan’s premier institutionsof medical education. Since then, over successive annual
trips to Tokyo, I have had the opportunity to further refine and expand those initial observations on the qualityof medical education at that institution.
In this paper, the second in a planned series of papers
on the subject, I will present my personal blueprint for

Reprint requests to: R. Harsha Rao, M.D., Room 580 Falk Medical Building, 3601 Fifth Avenue, Pittsburgh PA 15213, U.S.A., E-mail: rao@dom.pitt.edu

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I must state at the outset how grateful I am to this visionary group of medical educators at Keio University
for their genuine and wholehearted eagerness to embrace
reform. I must confess that, after my first visit, I wasquite dubious about the reception that my first report
would receive, given the withering criticism it contained
regarding the state of medical education at Keio University School of Medicine.1 The fact that it was the truth
could not have made it any the less hurtful! So I had actually doubted that I would even receive an invitation to
return.
How wrong I was! Not only did they invite me back,but they did it with an openness and respect that defines
the academician, in the loftiest sense of the word. I say
that because the hallmark of the true academician, in mybook, is something that I call “intellectual generosity”:
the ability to not just accept criticism, but to see pastit, to actually appreciate it, and to then correct the root
cause. Dean Kitajima and his trio of able deputies displayed these traits to an astonishing degree, praising thehonesty and detail that went into that first report. Dean
Kitajima went so far as to thank me for giving him sucha powerful and important tool in his fight for reform,
which was meeting unrelenting resistance!
Make no mistake about it; it is that enthusiasm, comingfrom the very top, that constitutes the force that drives
this blueprint. Without such forceful and unstinting
support, I doubt that I would have had the desire or theenergy, to go through with this difficult and exhausting
exercise. I can say with complete certainty that, without it I would not have been able to even think of themonumental problems facing them with a constructive
mindset. Had I sensed the outlook was hopeless, it isentirely possible that I might have been demoralized andrendered incapable of anything other than repetitive andfutile criticism.
If that had happened, I would never have put in theintellectual effort necessary to develop my vague andunformed ideas and turn them into something that was
concrete. I know that I needed that sense of unstinting
enthusiasm in order for those ideas to evolve from an
unthinkable pipe-dream into something approaching reality. Even more importantly, I would not have been able
to muster the will to write, edit and rewrite this lengthy
blueprint into something that was both comprehensive
and comprehensible. It is presented, therefore with all
humility and with a deep sense of gratitude to the fourindividuals who have made it possible for my opinions
and advice to be heard.
Attached to this paper are two appendices. The first isa point-by-point enumeration of the various componentsof the Blueprint, presented in concise form and without
any descriptive expostulations so as to make them generally applicable anywhere in Japan. The other is a set ofbrief recommendations that are specifically applicable

Rao RH: Reforming Japanese Medical Education

to KeioUniversity School of Medicine from my perspective.
Overall Objective: To improve the quality of medical education with the ultimate goal of producing wellrounded physicians who possess the ability to think critically and the clinical skill to function as generalists before they enter specialty training.
Specific Problems That Must Be Addressed to Improve Medical Education at Keio University School of
Medicine:
I have no intention of enumerating the reasons for myfocus on these problems individually in this paper. I havedetailed the observations underlying my reasoning atgreat length in the first paper in this series.1 That paper
must be considered an integral preamble to this one, andthe reader who is interested in how I reached my conclusions is directed to that paper. The problems that I identify, based on those observations, can be grouped into
three broad areas:
1. Problems in Learning (i.e. how students learn)
2. Problems with Teaching (i.e. how students are taught)
3. Problems with the Curriculum (i.e. what students aretaught)
It is essential to address these problems on all threefronts simultaneously, for the reform effort to have any
hope of succeeding, as will become clear.
Specific Goals Of The Blueprint For Reform:
A. To change the way students learn by emphasizing“active learning” and “critical thinking at the bedside” through a problem-oriented approach to clinicalinstruction.
B. To change the attitude towards teaching among faculty by establishing its value as a credible and rewarding academic pursuit
C. To change the medical school curriculum by restructuring it to emphasize a problem-oriented approachto learning and instruction at all levels in medical
school, starting from the preclinical years.
Overview
The reforms I advocate are divided into three sections,each of which is directed towards one of the specificgoals noted above. Those specific goals were, in turn,formulated by me after considerable introspection, basedon requests I received from each individual member ofDean Kitajima’s highly dedicated team. I am not surethat those requests used exactly the same phraseologythat I employ; for taking that license, I beg their collective pardon. But the spirit of their requests is reflectedin the recommendations I make. The specific content ofeach of the three sections is as follows:Keio J Med 2006; 55 (3): 81－95

Section A, Changing the Emphasis in Student Learning
Section B, Changing Attitudes towards Teachingamong the Faculty
Section C, Changing the Medical School CurriculumThus, the division of the Blueprint into 3 sections is
intended to satisfy an organizational need at Keio University School of Medicine, and the temptation to view
them as individual solutions to separate problems must
be resisted. They are heavily inter-dependent, and are
integral and inseparable parts of a single whole.
I am humbled by the trust and confidence that went
into the requests I received from all four visionaries. In
that spirit of humility, I am compelled to admit that I am
not under any illusion that my recommendations are theonly way to achieve the same—or possibly even a better?—result. They merely constitute the honest, unbiased
and apolitical views of one outsider regarding the critical
initial steps that must be implemented in order to generate sufficient momentum for change that hopefully willthen become self-sustaining.
SECTION A
CHANGING THE EMPHASIS INSTUDENT LEARNING
Changing the paradigm of instruction for medical
students (the core of medical education) from a passive
to an active format of learning and teaching requires acommitment to reform on several fronts. Thus, changing
the paradigm for learning will be virtually meaninglessunless the paradigm for teaching is changed simultaneously. The degree to which this change is achieved iscontingent upon reforms being implemented to recognize
and reward good teachers (Section B), and change thecurriculum to accommodate these reforms (Section C).
That having been said, I am aware that several medical schools in Japan have implemented the principles ofactive learning in their curricula, with good success.2 , 3
It would be invaluable for those in charge of reforming
medical education at Keio University School of Medicine to identify one or more of these and to draw on theirexperiences to guide them regarding how to implement
similar changes in medical education at Keio University.
As I noted earlier, the major drawback in medical education that I have observed time and time again at Keio
University is that student learning is passive and unidirectional.1 Students remain trapped in a heavily paternalistic system that does not expect them to participate
in their learning. More than that, it actually discourages
student participation, and penalizes independent viewpoints that might challenge the teacher.
The result is that students are so accustomed to having
everything spoon-fed to them, that they are almost like
automatons. They stay mute and seem incapable of asking questions unless prodded almost painfully to do so.

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What a terrible waste of such unlimited potential!
From my own experience, I know that they are anything but automatons. These gifted and truly exceptional
young minds are just waiting to be released from thesystem that keeps them passive and mute. I will personally verify that, once they get a taste of active learning,they are among the most vigorous participants I have
had the privilege to teach. And lest it be thought that thisverification is an attempt by me to credit their participation to some personal dynamic that applies to only me, I
will make it clear that I am taking no credit for it. I haveseen the same dynamic at work with some of the morecourageous members of the faculty at Keio University
Hospital who I have previously identified (in my earlier
report). Thus, the students are NOT the limiting factor.
It is the system. And systems can be changed, given thewill and the resources.
My experience shows that the authorities in charge of
medical education at Keio University School of Medicine have the will and are willing to commit the resources to this monumental task. The only question in mymind is: Are the faculty willing to cooperate and followthrough with the equally monumental effort to change
their own behavior, which is ingrained in them throughseveral generations’ worth of tradition? If they are, thenthe system can be changed to encourage, rather than discourage, active learning.
Active learning in medicine requires that the focus
be placed on a problem-oriented approach to clinicalinstruction in BOTH the wards and the classroom. At
Keio University School of Medicine, as I noted above,
students are not given the opportunity to learn in anenvironment that encourages their participation. Thereis such a heavy emphasis on didactic learning in theclassroom that passive learning is firmly established as
the “desired” format! The direct consequence of this isa mindset that perpetuates passive learning even in the
one place where, one would think, it is impossible tobe passive: the wards! Changing that mindset will require curriculum reform, which is no easy task. But one
place where this could be changed very quickly is on thewards.
1. Change the focus in the wards from Passive to Active Learning:a. Students must be encouraged to vocalize opinions,and ask questions. To achieve this, daily bedsideteaching rounds must be introduced with the exclusive focus being on the students. In other words,
student rounds must be held separately from ward
rounds with residents. This is because students become overwhelmed when confronted by their own
lack of knowledge in comparison to ward residents,and so remain mute during rounds. The result? Passive students who listen but do not say a word! If

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however, they are taught in a forum of their own
peers, they are less likely to fear that they will lookfoolish if they ask a question and be much more
willing to supply the answer to a question from theteacher.
b. Students must be made to think critically about clinical problems at the bedside: Active learning in medicine requires that the student think critically on his
or her own behalf about the patient. Integral to thisprocess is the understanding that students must nothave any preformed opinions regarding any aspect of
the case when they see the patient. Without any suchpreconceived notions regarding diagnosis or management, bedside medicine becomes a process of discovery that is both exciting and challenging.
I define this approach as “problem based learningat the bedside”, to distinguish it from what is traditionally called PBL. But the purpose is the same: toengage students in active learning by forcing them toapply their minds in a way that views every case as
an “unknown” even if it is “known” to the teacher!
Only when problems are approached as “unknowns”
does clinical instruction become “problem-oriented”
and based at the bedside, where it belongs, instead ofbeing “disease-oriented” and stuck inside a textbook
or a classroom.
In other words, every patient admitted to the wards
becomes another PBL, when viewed from the perspective of the patient’s clinical problems and theneed to solve (i.e. diagnose and manage) the problems. Obviously, these may be known to the ward
attending and resident (the teachers), but is that nottrue of every PBL? And a PBL approach, as I havesaid time and again, can be extremely successful asa means of instruction at Keio University School of
Medicine.
I would go so far as to argue that the classroom
variant of PBL, which forms a key component of thereforms that I advocate (see below) are really meaningless unless paired with this kind of bedside clinical instruction. The PBL method in the classroom,
after all, is nothing more than a way of introducing
students to the kind of critical thinking that is vital togood clinical practice when it comes to patient care.
That kind of critical thinking does not come naturally: it must be acquired at the bedside throughproblem-oriented instruction. And that kind of criticalthought process is the source of the excitement andchallenge that is inherent in bedside clinical medicine.
At the present time, it is fair to say that the words“excitement” and “challenge” are nowhere in evidence in the medical education that students receiveat Keio University School of Medicine. As a matterof fact, the approach that prevails at the present time
is completely contrary to this philosophy. The focus

Rao RH: Reforming Japanese Medical Education

is primarily on disease based learning at the bedside. That is because patients admitted to the wards
at Keio University Hospital almost invariably have adiagnostic label already attached to them. From what
I have observed, and from what my students tell me,
it is apparent that student learning consists almost
entirely of reading the patient’s chart, ascertaining
the diagnosis, and then reading a text book to learn
all the details regarding the particular disease that thepatient has.
Even on those occasions when students discuss thecase with the ward resident or attending, the discussion is primarily related to management, with little orno emphasis on “discovery”. After all, there is nothing to discover, as far as the residents and attendings
are concerned! The diagnosis is well known to them.
As a result, no attempt seems to be made to engage
students in a discussion of differential diagnosis or
any other component of critical clinical thinking.
Even more destructive to student participation isthe absence of any appreciation of what constitutes
evidence-based medicine. It seems almost universally
accepted by students that they cannot question the anecdotal approach to medicine of their teachers, evenwhen the evidence is to the contrary. Attempts to introduce evidence-based medicine in the curriculum4
will succeed only if the value of evidence is accepted
at all levels.
If this is to change, students must be compelled toengage in active learning at the bedside with teachers
who understand the importance of teaching students a
problem-oriented approach to diagnosis and management. It may come as a surprise that I say this, but I
think it is relatively easy to change this—this—provided
that teachers can be found who have both the willingness to teach and the right attitude toward teaching.
It starts with the recognition that ward-based learning for students must be an exercise in active discovery, not passive book learning. Then, students
who are assigned to the wards must be told that theyshould not read the chart, but should interview thepatient without any preformed ideas regarding the diagnosis. After taking a history and doing a physical,
they should then present the case to the ward attending and he/she should engage them in a discussion of
the case, with the focus being on discovery (clinicaldiagnosis and investigation). This will lead to problem based learning at the bedside instead of disease
based learning, as is currently being followed.
c. Students must be encouraged to participate in thelearning process: Active learning is a two-way interaction. Only if teachers are willing to be challenged,
will students feel free to challenge them. Thus theprimary onus is on the teachers to foster a climate ofactive learning. If teachers accept the need to change
and if they encourage active student learning (bothKeio J Med 2006; 55 (3): 81－95

are very big “Ifs”), that will go a very long way to
encouraging students to ask questions.
d. Students must be evaluated for participation: The
only way that participation by students can be effective is if they are subject to evaluation! It is vitalthat performance and participation at bedside clinicallearning sessions become key components in the evaluation of students during clinical rotations. It is essential to change the present focus from “attendance”,
to “performance evaluation”.
2. Changing the Focus in the Classroom from Passive
to Active Learning:This can be summed up with three letters: PBL. Thisis the key to changing the focus to active learning.
Implementing the change requires two essential steps.
The first step is to make a firm commitment to establish
PBL as an integral component of the medical school curriculum: The second is to greatly reduce the number of
didactic lectures to create room in the curriculum for the
PBL exercises.
The PBL method is the classroom equivalent of the
problem-oriented instruction at the bedside, and it shares
all the same elements that go into active learning. It
teaches students to think critically about the clinical“discovery” process even before they get to the wards. It
should be incorporated into the medical school curriculum as early as possible, starting from the students’ first
exposure to the core medical school curriculum (subjects
like Anatomy, Physiology etc lend themselves very wellto the PBL format, as I proved with the Neuroanatomy
PBL that I conducted). It is an extremely time efficient
way of teaching and learning, because one PBL exercise
can take the place of 6 or 8 utterly boring didactic lectures (that fewer than a third of students attend at Keio
University, anyway!)
Under the PBL format, students become enthusiastic
and excited partners in the learning process. My own experience leads me to believe that PBL may be the single
most effective way of promoting active learning and participation by the students. Given the chance, the students
will become outstanding at this form of active learning.
I will go so far as to guarantee, based on my own experience, that Keio students will attend PBL sessions
with a degree of excitement and enthusiasm that none of
the faculty have seen to date. Moreover, I am confident
that they will retain the material far better than they donow, provided their teachers embrace the philosophy of
the PBL and apply themselves to it with the proper spirit,and do not turn the PBL into yet another form of didactic
teaching. I would even go so far as to challenge those
doubters who oppose reform and argue against changing
the system on the grounds that “it has worked well for allthese years”, and ask them if they have the confidence toprovide the same guarantee that I do.

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I am confident that they cannot! All you have to do islook at the attendance at the lectures at Keio University,and you know that such a guarantee by the doubters is
impossible.
For my guarantee to work, though, it is essential toaddress four obvious limiting factors at Keio Universitythat would negate the effectiveness of PBL as a tool for
active learning if they are not resolved. One is the lack ofa critical mass of teachers on the faculty who know how
to use this format effectively. A second is the fact thatfew members of the faculty have any interest in learning
about it. A third is the fact that there is no incentive foranyone (other than Prof Amano and his small but dedicated team) to invest the time and effort to develop theappropriate PBL material that can be used throughout
the curriculum. Finally, the curriculum as it stands rightnow has such an incredible emphasis on didactic instruction (i.e. lectures that few students attend anyway!) that
there is no time available in it to add the PBL sessions.
The third and fourth factors (lack of incentive for teaching and lack of space in the curriculum to add PBL) canonly be addressed through reform of teaching attitudes
and reform of the curriculum respectively, and are covered below (Sections B and C). But the first two factors(a lack of familiarity and a lack of faculty interest among
the faculty) do bear some examination here.
a. Addressing the Lack of Familiarity with PBL Facilitation among Faculty: There is an acute need toeducate faculty in the appropriate method for conducting a PBL, as is witnessed by the disappointment
encountered by the students I taught on my first visit,
when they tried to perpetuate the excitement andenthusiasm they discovered with PBL. They started
a PBL club to which they invited individual faculty
members who expressed an interest/willingness toattend as moderators to create and conduct PBLs by
turn. Even though there was no lack of interest, theso-called PBL sessions turned out to be nothing morethan didactic lectures, where the teacher spoke continuously and the students sat mute, the only difference being that it happened around a table, instead ofin a classroom.
This reflects an understandable lack of familiarity
with the PBL method. It could have been easily corrected, if the faculty had cared enough to attend any
one of the four PBLs I have conducted at Keio University. The importance of becoming familiar withthe philosophy and conduct of PBL is underscored by
the reaction of one of the faculty members who did
attend this year. He came up to me after I was done
and said, with obvious wonderment in his face, “I amamazed. There was a stretch of almost 15 minutes
during which you did not say a word! And even when
you spoke, it was only to ask a question that was really a hint to the students that they needed to think

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about what they were saying. Now I understand!”This is an unequivocal vindication of my belief thatthe lack of knowledge/experience among faculty iseminently correctable.
b. Addressing the Lack of Interest in the PBL Format
among Faculty: The lack of real interest among thefaculty presents a far more formidable obstacle to thesuccessful implementation of Problem Based Learning in the curriculum, if my experience is anything
to go by. I regret to say that I encountered a very
distinct lack of enthusiasm among the faculty for thisform of active learning. A total of four faculty members attended the PBL sessions that I have conductedon my trips, even though they were well publicized inadvance.
I hesitate to make generalizations based on one
interaction, but the reaction of one faculty member
who attended the Introduction session to my first
PBL may well be emblematic of the problem. Afterthe session he quite openly questioned the need forany change in the curriculum, let alone going so far
as to introduce anything as revolutionary as the PBL
format. He felt quite strongly that the system in place
had stood the test of time, having been good enoughto train several previous generations of Japanese physicians, including him. That, to him, was proof that
there was nothing wrong with the system, and no reason to change it! He went so far as to suggest that thereason I felt the students were so passive was because
Japanese students were incapable of participating in
any other form of instruction, and that PBL would bea failure in Japan. To him, it was the students’ fault,
not the teachers’.
It came as no surprise to me, then, that I never saw
that particular faculty member again at any of thesubsequent PBL sessions, but it still represented an
opportunity missed by him. Had he only been present
to see me actually conduct a PBL Resolution session,
during which every word spoken was in Japanese, he
may have had his eyes opened, and he would haveseen how wrong he was about the so-called innate
and inherent passivity of Japanese students. I do want
to describe that session very briefly, because even I
am staggered by the enormity of what was achieved
then.
During the Presentation session for that PBL, I
encountered a group of students who seemed to becompletely disinterested in participating actively.
After a very frustrating and difficult hour, during
which I tried every trick I knew to get them to speak
and discuss the case without prompting from me, I
resigned myself to the fact that this was one of thosetimes when one has to admit one’s failure as a teacher. Then it dawned on me that the reason the students
were saying little or nothing might be a result of a

Rao RH: Reforming Japanese Medical Education

very poor working knowledge of spoken English.
Could that be the constraint that was at work?
That was when I sensed that I was being presented
with a priceless opportunity to drive home the whole
point of a PBL to both the students and the faculty:that it was not meant for the teacher to teach, but forthe students to learn by teaching themselves as theytaught each other! What better way to show that tothem than to make the facilitator redundant? So, I
insisted that the students conduct the Resolution session entirely in Japanese.
Of course, the students first reaction was one of extreme dismay, because they thought they had failed
me in some way, But I reassured them that I was serious, and would actually prefer them to do it that way,
and so was able to override their reluctance.
I have interacted with these marvelously gifted students on enough occasions that I no longer have any
doubts about their ability to rise to any challenge, ifthey are just given a chance and get the appropriate
guidance.
And how they vindicated that confidence! Even
though my only role was to follow the material,
which mercifully for me was in English, the quality of the discussion and the intensity of the students’ participation was nothing short of exemplary
at the Resolution session. That assessment was notjust mine, which is obviously limited by my lack ofknowledge of Japanese, but also that of Dr Amano. If
ever there was total vindication of the PBL method,where success is measured by how little the facilitator speaks, this was it!
It was a roaring success, and the point was not loston the students, all of whom were amazed how muchthey learned with virtually no input from me! But theopportunity seized was also an opportunity missed. I
wish I had the forethought to ask that the session bevideotaped so that it could be shown to other members of the faculty who doubt the utility of PBL. Seeing it would have opened the eyes of doubters, anddebunked many of their misconceptions regarding theso-called passivity of their students, and the unsuitability of the PBL format for Japanese students.
That is something that I intend to address on my next
visit, if I am invited back (Dean Kitajima assures methat I will be!) I fully intend to conduct at least one
PBL exclusively in Japanese, and to make sure that it
is videotaped so that it can be shown to the teachingfaculty to observe. This may actually be preferable toinviting the faculty to attend my PBLs, for a couple ofreasons. First, given the long standing tradition of respectful timidity of the students towards their teachers,
the presence of large numbers of faculty at the PBL
sessions will only make them less likely to participate actively. Second, the videotape can be shown toKeio J Med 2006; 55 (3): 81－95

groups of faculty at times that are convenient to them,so that they will have no excuse to fail to attend.
3. Inculcate in Students the Habit of Performing aComprehensive History and Physical Examination.
This is another glaring inadequacy in medical student
training at Keio University. It is a product of two factors. One is the complete absence of any General Internal Medicine presence at Keio University Hospital.
The other is a complete disregard of the importance ofperforming a comprehensive H&P. This is, after all, asystem that pays virtually no attention to clinical skills,
and is focused on technological skills (which are of thehighest order, let me hasten to add). So exclusionary is
this focus that it even shuns elements of the physical thatare particularly relevant to the specialty of interest in the
management of a patient within that area of specialization. Thus it was that, as incredible as this may sound,no resident on the GI unit had ever performed a rectal
examination! That startling discovery said it all to me.
However, there is hope!
I discovered, to my delight that there exists on thewards at Keio University Hospital a template for a complete H&P—in German, no less! It is a relic of a past era
that was located by an enterprising resident on the Cardiology service in response to the realization that nothing
less than that would satisfy me. That template was usedby the resident to present one of the few comprehensive
case histories that I was privileged to listen to at Keio
University Hospital. This tells me, as nothing else could,
that the onus is on the attending faculty to start expecting it of the students and they will respond.
The deficiency in the faculty, however, is much more
intractable. I do not know if there are any generalists(outside the ER) who have the confidence in their clinical skills in General Internal Medicine to impart suchtraining to the students. My observations are consistent
with the belief (supported by Dr Amano) that all themembers of the faculty are superlative sub-specialists
who never have the need to practice general internal
medicine! Thus, I think it is doubtful that they would be
able to change such a lifelong habit to fulfill the need forteachers with the requisite clinical skill to make bedsideclinical medicine exciting.
What is needed, therefore, is a core of dedicated teachers who are willing to make the commitment to act as
instructors in General Internal Medicine. They exist
at Keio University Hospital, I have met them, and Dr
Amano knows who they are, but they need to get adequate recognition and compensation for their sacrifice.
The introduction of the Observed Structured ClinicalExamination in some schools 5 is a step in the right direction. But requiring it in the wards and requiring it to justpass an examination are two completely different things.
Without the latter, the former is virtually meaningless.

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Similarly, I would strongly urge the use of standardized
patients, both to teach interviewing skills and to gradestudents’ skills. As things stand, studies suggest thatJapanese schools lag behind those in other countries in
the use of these vital tools for medical education 6
In a related vein, it has also been brought to my attention that there is no textbook in Japanese on the Comprehensive H&P. Dr Amano has proposed a solution to thisproblem, in the form of an instructional video that demonstrates how to perform such an exam. Maybe it will
come to pass at some time in the future.
4. Empower students to provide honest feedback:This is an element that is so vital that, without it, everything else that I recommend is rendered meaningless. At the present time, the system that is in place islaughably ineffective in practice, if my own observations
are anything to go by. Students do not provide honest
feedback, only pro forma laudatory evaluations thatgive EVERY teacher the same grade. I heard from several students that they would refuse to give any teacher
a failing grade, no matter how bad that teacher was, because that would amount to insulting the teacher! Thiscame as a shock to me, even in the context of my own
cultural origins in India, where students are also taught
to hold teachers in an exalted position.
But not to this degree of reverence!
Students at Keio University seem unable or unwillingto grasp the concept that the bigger insult would be to,in effect, tell a really good teacher that his/her effort wasworthless because it did not deserve to be differentiatedfrom that of a bad teacher. What shocked me was theirinability to see this contradiction even after I pointed itout to them!
This mind set will have to change for any progress to
be made. Unless students provide honest and accurate
feedback, there will be (a) no way of identifying and rewarding good teachers, which means that (b) there will
be no reason for faculty to change their attitudes towards
teaching, and that in turn means that (c) any attempt toreform the curriculum to provide greater emphasis on
clinical instruction is doomed to failure!
The solution to this problem is comprised of three elements, all equally essential:
a. Create an Effective Evaluation tool: It is essential todevelop a reliable method of ranking and rewarding
teaching as an academic pursuit that is both credible
and valued. It will be necessary to create one that isreflective of the unique approaches and attitudes
towards teaching that are prevalent in Japan, but astart can be made from any one of several that can befound on the websites of accrediting bodies for Graduate Medical Education in the US and elsewhere.
Of course, each student must provide an independent
opinion; a collective/shared evaluation based on a

88

communal decision taken to provide a “unanimous”
opinion is particularly counterproductive, because of
the natural desire to conform (see below).
b. Maintain Anonymity: This is essential in order toavoid reprisals against students and preserve the integrity of the process. Therefore, students must submit anonymous evaluations that are collected, not by
the teacher, but by the Office of Medical Education,at the end of each lecture/course.
c. Insist on Honest Feedback: While it is clear thatstudents must provide honest feedback, it will not
happen simply by wishing it or telling them to do so.
Decades—centuries?—of a contrary tradition that is
so deeply ingrained cannot be wiped away so easily.
A second factor that may be of equal importance asa barrier to student honesty is a subtle but pervasive
fear of reprisal against those who buck the system. I
sense that there may be no greater outcast than a nonconformist in a society like Japan, where conformity
is a treasured and respected tradition.
If that entrenched mindset is to be overcome, thenstudents will have to be empowered by an explicit
endorsement of the value of their opinion. My experience in talking to several students leads me to believethat it will take nothing short of the direct intervention of the Dean to reassure them that their opinion
actually counts. He will have to personally convince
the students that good and bad teachers MUST be
identified, for the sake of everyone concerned. I do
not think they really understand this.
5. Reforming Residency Training to Enhance Active
Learning:
This is another daunting challenge, because I sensethat resident life is personally controlled very tightly byattending faculty, with little input or direction from theadministration. Even so, some changes are welcome, aspart of the new format of rotating residency training 7.
The implementation of a year of training at a community
teaching hospital gives residents experience in generalinternal medicine, the lack of which is a major drawbackof the otherwise stellar subspecialty training found at
Keio University Hospital. It is troubling that there is amove afoot to discontinue this very valuable part of theresidency rotation. I see that as a major step backward,
if it comes to pass, and all graduating students are compelled to spend their entire residency at Keio University
Hospital with no opportunity to ever experience the value of general internal medicine training. The past bodes
poorly for the future, if that comes to pass: residents
coming out of such programs in Japan have been shownto fare poorly compared to residents at non-university
hospitals, with regard to clinical skills and confidence inclinical decision making 8.

Rao RH: Reforming Japanese Medical Education

SECTION B
CHANGING ATTITUDES TOWARDS TEACHING
AMONG THE FACULTYThis may be the most difficult of all the reforms to implement, since it will require fundamental changes in human behavior—never an easy undertaking! But several
steps can be taken to make the environment conducive tochanging behavior.
1. Make the Faculty Accountable for Teaching: Unless faculty members are made accountable for teaching,nothing will change. Only the Dean can implement (andenforce!) the policy that will make it come to pass.
a. Step one is to get accurate and honest teaching evaluations from students (see above).
b. Step two is to then develop composite teaching evaluations of every member of the teaching faculty byadding all of those and averaging them.
c. Step three is to rank faculty according to their teaching evaluations and then let them know where theystand relative to the other members of their department. However, to preserve the integrity of theprocess, each faculty member in a department must
only see his or her position on the list relative to theothers, without knowing the names of those ranked
above or below.
2. Encourage Faculty Members who Teach: The way
to achieve this is for the Dean to sponsor a Best TeacherAward every year from each Grade. For this purpose, theDean’s office (or his surrogate in the Office of Medical
Education, Prof Amano) must solicit nominations for theaward from every student in each grade at the end of theacademic year. The names of the three teachers who get
the most nominations from a particular Grade must thenbe submitted to the students in that Grade for a vote to
select the Best Teacher for that year. The importance of
this being seen to emanate from the Dean’s Office can
not be overstated, because it must have the seal of academic authority for not only the students to participate init, but also for the faculty to take it seriously.
3. Reform Promotions Policy to Raise the Status of
Teaching: My discussions with the authorities at Keio
University School of Medicine lead me to believe that
there really may be an opportunity to enact the one reform that is the most crucial of all. If there is to be any
hope of reforming medical education at Keio University,then teachers who teach well must be accorded the same
status as researchers who publish well. That means thatthe current system of promotions cannot endure at Keio
University.
The approach that I would take is to create a newparadigm for promoting teachers that will not alter or

Keio J Med 2006; 55 (3): 81－95

compete with the way in which promotions are currently given to research-oriented faculty members. To
my mind, this is absolutely vital, because promotions toteachers must not be seen as a threat to the advancement
and status of current members of the faculty. If they see
it as impinging on their own opportunities, or diminishing their own academic status, they will vehemently oppose and subvert any attempts at reform.
Notwithstanding the effort to avoid this, I anticipate
that there will be fierce resistance to any attempt tochange promotions policy. Therefore, the reforms will
require the full force of the visionary zeal that the current administration has shown. If change is to be implemented, it must be now!
To understand the basis of my recommendations forreform in promotions policy, it is necessary to review thereasoning that I used to formulate them:a. Why are Faculty at Keio University Reluctant toTeach?: Research is a vitally important missionof any academic institution, because seeking to understand the unknown is what constitutes “Higher
Learning”. Thus, medical schools that are not at
the forefront of medical research should not expect
recognition as Institutions of Higher Learning. But
a medical school is, first and foremost, a revered
place of “Higher Learning” where future doctors aretrained, and learning is communicated to them. Thismeans that Teaching must be accorded a status that is
at least equal to Research.
The problem arises when Research takes preeminence over Teaching, and the latter is relegatedto second class status, as it is almost universally inJapan.6 Then, of course, nobody who aspires to academic success would waste their time pursuing excellence in teaching! The result is an institution where
the majority of faculty members have no interest inteaching. After all, why would anyone waste theircareers in such a fruitless and unrewarding pursuit
as teaching, when it is not considered a credible academic achievement?
The purpose of this introduction is to drive home
the point that Teaching and Research are two equallystrong pillars of academic achievement, neither one
greater or more important than the other, both supporting the academic mission and image of a medical
school. The corollary is that teachers, just as much as
researchers, are an essential and integral part of the
backbone of a Medical School. In Japan, however,faculty who teach are accorded no recognition andgiven no status, because promotions policy is based
exclusively on research output.
With research clearly defined as the only “truly
academic pursuit”, it becomes downright counterproductive to spend time in anything but research. That
breeds the inevitable attitude, so prevalent in Japan,that teaching is not just unnecessary, but actually a89

wasteful “non-academic pursuit” that carries a heavy
penalty, because it takes time away from research. No
wonder, then, that teaching is relegated to the statusof a menial task that falls on the shoulders of inexperienced or disinterested juniors, who are themselves
under pressure to succeed as researchers!6 That teaching still occurs at Keio University Hospital, despite
this terrible handicap, is a testament to the selflessness of the dedicated souls who soldier on without
hope of recognition or reward.
b. How can a Reluctance to Teach be overcome?: The
answer lies in a single word: Recognition.
In academic circles, of course, recognition means
promotion. And promotion is not something any
teacher can aspire to when the system exalts only
research. To resolve the impasse, it is necessary tocreate a new paradigm for promotions that recognizes
two categories of academic achievement, akin to thetwo “streams” in many academic centers in the US.
The first of these categories, which is equivalent to
the tenure stream in the US, is the Scientist-Researcher. The primary goal of this kind of academician is tosecure grants and to publish in high quality journals.
The second category, which is equivalent to the“non-tenure” stream in the US, is the Clinician-Educator. The primary goal of this kind of academician
is to see patients and to teach.
I would submit that the only way to gain acceptanceof this concept is to establish each stream as being
independent of the other. What I mean by this is that
there must be no competition for promotions between the two streams. That concept of independence
should not, however, preclude or discourage crossover, so that Scientist-Researchers who want to teachmust be allowed to do so, even if teaching is not the
major criterion in their evaluations, and ClinicianEducators who want to participate in research must
be encouraged to do so, even though research is not
the major criterion for their advancement.
c. What should be the Criteria for Promotion in the Clinician-Educator Stream?: In the interest of fairness,criteria in the two streams should not be philosophically different. To meet the requirements of the fairness principle, it is necessary to apply two common
criteria to academic achievement in both categories
and evaluate fitness for promotion based on thesein an objective and reasonably quantifiable manner.
These two common criteria are (a) Impact and (b)Quality of output.
i. In evaluating the academic achievements of a
Scientist-Researcher, it is possible, then, to assess(a) Impact based on the number, value and statureof grants acquired and (b) Quality of output basedon the number of publications and the impact factor of the journals in which they appear.
ii. Identical principles can be used when evaluating

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Rao RH: Reforming Japanese Medical Education

the academic achievements of a Clinician Educator. Then, (a) Impact can be assessed from thevolume of clinical activity, and (b) Quality of output from the number of courses taught, teachingevaluations received, and awards.
iii. From this, it is obvious that research faculty canbe left to do what they do best, without having toeither see patients or teach, and teaching faculty
can be left to do what they do best, without having
to chase after grants.
iv. Provided the major criteria are fulfilled, achievements in cross-over areas (teaching by the Scientist-Researcher, and research by the ClinicianEducator) can be viewed as additional validationof academic excellence (minor criteria).
This brings up one touchy subject that might be asource of the greatest resistance to change: Who willbe the Chairman if there are two Professors, one ineach stream? That is easily resolved for the foreseeable future. To all intents and purposes, the only
qualified candidates with sufficient seniority to beconsidered for such posts for several years will be
Scientist-Researchers. It will become an issue onlyin the future, when Clinician-Educators ultimately
achieve the requisite status to be even considered
for such posts. Until that time comes, I believe mostClinician-Educators will be quite satisfied with theincreased respect and recognition they will receive,
even if they have to forego being Chairmen!
4. Making it Possible for Clinicians to Teach:Time is a major constraint in any clinician’s life, andteaching calls for a major time commitment. I know that
all too well from my own experience! I am also awarethat this is particularly true also of all the clinicians at
Keio University Hospital, who will be the ones on whom
the teaching burden will fall. Even if they are given
academic recognition for their teaching, where will theyfind the time to fulfill the demands of their academic careers? Certainly not if they are also expected to see 100
patients in clinic, five days a week!
This means that accommodations will have to be madein clinical schedules for them to find the time to fulfill
their teaching obligations.
The easiest solution is to share the teaching and clinical burdens equally among a group of clinicians. Let us
assume, for instance, that there are 5 clinicians in a given department (say Cardiology), who each see 100 patients, 5 days a week. Obviously, none of the five would
have any time to devote to teaching on any of those fivedays.
But if, instead of all five clinicians seeing 100 patients
five days a week, only four go to clinic on any given day,then one would be free by turns to devote his/her timeto teach the students on the wards. That of course meansthat the four who are in clinic would have to see 120

patients, to make up for the absence of the fifth memberof the group. But the pain of a 20% increase in clinicalburden for 4 days a week will be more than offset by theluxury of one day of complete freedom from the burden
for each member of the team by turns. Viewed in thisway, teaching may actually become a sought after assignment—a welcome reprieve from the daily drudgeryof clinical activity!
SECTION C
CHANGING THE MEDICAL SCHOOLCURRICULUM:This aspect is the one that poses the greatest difficulty
for me when it comes to making specific recommendations for reform. I am not an expert in this field, and will
not pose as one. Also I have no knowledge of how muchdetail and what aspects of the curriculum are tested in
the national examinations in Japan. Changes at the local
level will have to take into account the overriding needof students to pass these exams. This limits the amountthat the curriculum can be changed at the local level.
Moreover, the Ministry of Health in Japan has developed
a comprehensive document that outlines all the curricular changes that need to be made. 9 Thus, I do recognizethat any changes at the local level must take into accountthose recommendations.
While acknowledging all these limitations, I will
nonetheless attempt to make some specific suggestions
because I was specifically requested to do so, regardless of those constraints. I want to make clear that theseare only suggestions, and are not based on any claim ofexpertise in this area, or any presumption of knowledge
regarding their feasibility. They are based on my own
sense of what needs to be done to improve the quality of
medical education at Keio University. It will be up to the
Dean and his worthy team of deputies to determine what
is feasible and what is not.
1. Shorten the Preclinical Curriculum from Three
years to Two years
The detail in which these subjects are currently being taught is almost stupefying! In particular, the overwhelming use of the lecture format in these years makes
it impossible to engage the students in any meaningfulmanner. No wonder that students retain almost nothing
when they come to the wards (I will attest to that!) Yet
the detail that they are asked to remember just to passtheir exams is incomprehensible to me. For instance, has
any physician ever actually needed to remember all thestructures under the gluteus maximus muscle? I certainly
have never had cause to do so, other than to pass theexam in Anatomy! My guess is that most surgeons could
not care less, and would not be able to recount those if
asked. And yet, that is what traditional courses in Anatomy expect from students! The same can be said of theKeio J Med 2006; 55 (3): 81－95

ridiculous detail in which Physiology and Pathology aretaught.
I acknowledge that no effort to shorten the curriculum
can succeed without the agreement of each pre-clinical
Department Chairman to reduce their perceived “importance” in the curriculum. That is not a reason to resist
change, however, because preclinical departments areheavily weighted towards research, and teaching takes
an even lowlier place in the general scheme of thingsin those departments. This is true even in the US. Thus,
shortening the curriculum can be presented as an attractive option because it will reduce teaching commitments
and actually free up faculty members to pursue their research to a greater degree.
The Chairs will take some convincing, though. I suggest that a preliminary “demonstration project” beundertaken, in which one particular preclinical subject
is shortened with the aim of eliminating unnecessary
detail. The ideal one for such a demonstration project is
Anatomy, as has been suggested elsewhere.2 The Chairman of Anatomy at Keio University School of Medicine(Professor Aiso) informs me that he has already considered shortening the course to 6 months. At his request,
I have put him in touch with individuals in Pittsburgh
for advice on how to go about this task. It would be very
helpful for him to tap into the experience at Pittsburgh,where the Anatomy curriculum has been completely restructured to incorporate PBL as an essential componentof the change-over from a traditional subject-based curriculum to one based on organ systems.
2. Make the Curriculum Organ System-based, not Subject-based.
A traditional curriculum is “subject-based”. By that I
mean, each subject (e.g. Anatomy or Physiology or Pathology) is taught separately, and almost as though theknowledge is being provided in a vacuum, without any
consideration being given to what else is being simultaneously taught in another subject. At any given point in time,
therefore, the content that is covered in one (e.g. the Thorax in Anatomy) has no relevance to what is being taught
elsewhere at that same point in time (e.g. Gastrointestinal
Physiology). The result is that the student acquires knowledge in the form of disconnected bits-and-pieces that haveno relevance to each other. It should come as no surprise,then, that the “knowledge” imparted is all but forgotten by
the time that the student is suddenly confronted with theneed to remember all the disparate elements as a single
coherent whole on the wards.
That is the reason for the conversion of most modern
curricula to an “organ system-based” format. The valueof such a curriculum lies in the fact that all the relevant
details of every organ system are taught together, so thatlearning is integrated across medical disciplines, specialties and subspecialties, to provide a comprehensive

91

understanding of all aspects of individual systems anddisease processes.
This means that courses are no longer taught as separate subjects. Instead segments of each subject are incorporated into a single organ system “block” and taught in
an integrated fashion. Thus, for example, the Cardiovascular “block” may last for 8-12 weeks, during which all
aspects relating to the heart and blood vessels, including
cardiac anatomy, cardiovascular physiology and pathology, cardiac pharmacology and therapeutics, clinicalcardiology, cardiac surgery etc etc, are taught as a single
coherent entity. This may then be followed by a similarcourse in Pulmonology, and then in GI, then Endocrinology, and so on and so on.
Achieving this is a very complicated endeavor, because
it calls for a top to bottom restructuring of the curriculum.
It will require careful thought and considerable cooperation from all departments involved. Most of all, it will callfor a major effort by the Dean, who will have to muster
the collective will of the medical school to make this areality. Obviously, a task force will have to be set up to
study the experiences of other schools in Japan 1 0 , 1 1 thathave gone through this restructuring. But it will be worth
the effort, because it will have several tangible benefits
for medical education:(a) An organ system-based approach helps retention ofmaterial by students, since its clinical relevance isimmediately apparent. Many of us, who have gone
through a traditional subject-based curriculum inmedical school, can remember wondering during
our pre-clinical years, why on earth we had to learnsomething that seemed utterly trivial and uselessat that time, only to find out, after starting clinicaltraining, that it would have actually made sense toremember it.
(b) An organ system-based curriculum is amenable tointegrating PBL instruction across the curriculum.
Thus, for instance, one PBL on a case with COPD
in the Pulmonology course is all it takes to teachstudents pulmonary physiology, pathophysiology,
alveolar gas exchange, pharmacology, and acid basebalance. How many boring didactic lectures would
it take to cover all of that?
(c) An organ system-based approach is characterizedby parallel, rather than serial, acquisition of knowledge, because of the simultaneous instruction in all
relevant clinical aspects of a problem. This reinforces the clinical relevance and applicability of thematerial. After all, when one sees a patient, all thephysiologic, anatomic, pathologic, pharmacologic
and clinical aspects of a disease entity are seen incohesion. Why should the instruction that leads tounderstanding of that disease not be similarly cohesive?
(d) An organ system-based approach is particularly ap-

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Rao RH: Reforming Japanese Medical Education

plicable in Keio University, because it draws upon
the strengths of the faculty. They are highly skilledin their individual areas of specialization and thus
will be able to provide a comprehensive understanding of the system that is being taught. Also, theywould be suited to developing the PBL material thatwould be incorporated into each course.
(e) An organ system-based approach will also inculcate
an appreciation of a comprehensive approach to theclinical application of knowledge. That mindset is essential if there is to be any fostering of the bread-andbutter approach to medicine that characterizes primary care. At present this aspect of clinical practicelanguishes as a neglected step-child of the Japanese
health care system 11-14. That is a direct result of theexaltation of specialty care, with its tunnel vision approach to clinical decision making. That will change
only when primary care, the best exemplar of a comprehensive approach to clinical decision making, isaccorded its rightful place as the crown jewel of any
medical education system.
Appendix 1
Concise Summary of Recomemndations
A. Changing the emphasis from passive to active learning
1. Change from Passive to Active Learning on the Wards

a. Create an environment that is conducive to student participation through daily bedside teachingrounds focused exclusively on students, (i.e. held
separately from ward rounds with residents).
b. Encourage critical thinking about clinical problems through “problem based learning at the bedside”.
c. Students attending bedside teaching rounds mustnot be allowed to read the chart beforehand; theymust engage in “discovery” by interviewing andexamining the patient without any preformed
ideas.
d. The ward attending who takes bedside teachingrounds must maintain the focus on “discovery”(clinical diagnosis and investigation).
e. Teachers must be told to foster a climate of active
learning by encouraging students to vocalize opinions, and ask questions on rounds.
f. Teachers must evaluate students fairly based on
their participation in the discovery process on
bedside teaching rounds.
g. The present focus on “attendance” must change to“performance evaluation”.
2. Change from Passive to Active Learning in the Classroom:a. Make a firm commitment to establish PBL as anintegral and essential component of the medical
school curriculum.
b. Reduce the number of didactic lectures to create

room in the curriculum for PBL exercises.
c. Incorporate PBL into the medical school curriculum as early as possible, starting from first exposure to the core medical school curriculum.
d. Educate faculty in the appropriate method for facilitating a PBL, so they understand how little afacilitator needs to say at a successful PBL.
e. Videotape a session with the students speaking
only in Japanese, and the facilitator who does not
speak Japanese to bring home that point.
f. Make it mandatory for faculty who teach PBL toview the videotape, so that they become familiar
with the technique of facilitating a PBL exercise
and can see how interactive and engaged their students are when they are allowed to learn actively.
3. Inculcate the Habit of Performing a Comprehensive
H&P:
a. Make all students follow the internationally accepted norms for a comprehensive H&P (akin tothe one available on the wards at Keio University
Hospital.)b. Identify a core of dedicated teachers who are willing to make the commitment to act as instructors
in General Internal Medicine.
c. Create an instructional video showing how to
perform a comprehensive history and physical examination.
d. Mandate the use of standardized patients forteaching interviewing skills and introduce the observed standardized clinical examination (OSCE)
for evaluation of clinical skills.
4. Empower Students to Provide Honest Feedback:a. The Dean must explicitly and publicly endorse thevalue of their opinions
b. Provide students with a reliable tool to evaluate
teachers.
c. Anonymous evaluations must be collected andtabulated by the Office of Medical Education, atthe end of each lecture/course.
d. Make students evaluations effective by using acomposite of all teaching evaluations earned byteachers over a year to evaluate teaching activity
both qualitatively and quantitatively.
e. Use the composites to rank and reward teaching as
a credible and authentic academic pursuit.
5. Reform Residency Training to Enhance Active
Learning
a. Make it mandatory for all graduates to complete a
year of training at a community teaching hospitalso that they gain experience in general internal
medicine.
b. Continue to maintain the emphasis on active
learning through appropriate teaching rounds forresidents during their ward rotations.
c. Ask all attendings, regardless of subspecialty, toKeio J Med 2006; 55 (3): 81－95

insist on a comprehensive H&P on the wards byresidents.
B. Changing attitudes towards teaching among thefaculty
1. Make Faculty Accountable for Teaching:a. Get accurate and honest teaching evaluations fromstudents (see above).
b. Develop composite teaching evaluations of every member of the teaching faculty by adding allof their evaluations over the year and averaging
them.
c. Rank faculty according to their teaching evaluations and let them know where they stand in therank order, but not the ranks of other individual
faculty members.
2. Encourage and Reward Faculty Members Who Teach:a. Dean must sponsor a Best Teacher Award every
year from each Grade.
b. Office of Medical Education or the Dean himself
must solicit nominations for the award from every
student in each grade at the end of the academic
year.
c. The names of the three teachers who get the most
nominations from a particular Grade must then be
submitted to the students in that Grade to vote on
for the Best Teacher Award for that year.
3. Reform Promotions Policy to Raise the Status of
Teacher:a. Create a new paradigm for promotions and recognition that recognizes two categories of academic
achievement for career advancement, akin to thetwo “streams” found in many academic centers in
the U.S.
1. The Scientist-Researcher, whose primary goal
is to get grants and publish research in highquality journals
2. The Clinician-Educator, whose primary goal is
to see patients and teach the students and residents.
b. Establish each stream as being independent of theother, so that there is no competition for promotions between the two streams.
c. Identify two objective criteria for assessing academic activity, and make them common to bothstreams in the interest of fairness, as follows: (i)Impact of activity and (ii) Quality of output.
d. Apply the two objective criteria consistently toevaluate academic activity equivalently in bothstreams and to determine fitness for promotion.
1. In the case of the Scientist-Researcher, evaluate(i) Impact of activity, form the number andthe value of grants acquired;(ii) Quality of output, from the number ofpublications and their quality (the impact

93

factor of the journal).
2. In the case of the Clinician-Educator, evaluate(i) Impact of activity, from clinical load
(number of patients seen, both inpatientand outpatient);(ii) Quality of output, from the number ofcourses taught and the teaching evaluations received.
e. Provided the major criteria are fulfilled, achievements in cross-over areas (teaching for the Scientist-Researcher, and research for the ClinicianEducator) can be used as additional validation ofacademic excellence (minor criteria).
f. The Chairman’s post in clinical departments will
be filled from the Scientist-Researcher stream forthe foreseeable future, until a Clinician-Educatorultimately reaches the requisite stature to be considered as a candidate for the Chairman’s position.
4. Make it Possible for Clinicians to Teach:a. Make accommodations in clinical schedules sothat the teaching and clinical burdens are sharedequally among a group of clinicians.
b. Each clinician is assigned a “teaching day” in theweek, on which he or she will have limited or nopatient care responsibilities, and the only responsibility will be to teach students and residents.
C. Changing the medical school curriculum
1. Shorten the Pre-clinical Curriculum from Three to
Two Years:
a. Select one pre-clinical subject for a Demonstration
Project to establish feasibility
b. Call on the experience developed in the US tohelp with the process of winnowing down the curriculum to the degree that is considered adequate
to still meet the students’ need to pass national
exams.
c. Implement the new curriculum in the selectedsubject for a trial period and re-evaluate student
performance at the end of that period.
d. Reduce the number of didactic lectures and use
the time saved to introduce PBL exercises in preclinical courses, so that the material being taught
is placed in a clinical perspective.
2. Make the Curriculum Organ System-based not
Subject-based:
This calls for a top-to-bottom restructuring of the curriculum and may need to be delayed until the Demonstration Project is implemented.
Appendix 2
Specific Recommendations for Transforming Medical

Education at Keio University School of medicine

1. Establish a sense of urgency: The reality is thatchange has been forced upon the system, but there ap-

94

pears to be no sense of urgency in implementing thesteps that are essential to make the changes work. Witness the introduction of a two year general medicine
residency program, without any general internists in existence!
2. Form a Powerful Guiding Coalition at Keio University: Of the people I met, there are four who have thestature and the expressed desire to change things. They
are Dean Katajima, Professor Amano, Professor Aiso,
and Professor Suematsu. They will have to form thenucleus of a force for change. Without the clout of institutional backing, the effort will flounder and fail.
3. Create a vision: What will be the face of medical
education at Keio University in 5 years? In 10 years? It
seems trite to say that change does not occur overnight,
but that does not make it any the less true! And yet, I did
not hear articulated a comprehensive vision of how thechanges will be implemented over the years. In particular, even though there is a very laudable aspiration for
the American model, the vast cultural differences makeit imperative to mold the model to local conditions inJapan. Only someone with a good understanding of what
will work, given those local factors, and an insight into
what in the American model will NOT work, can articulate that vision.
4. Communicate that vision: The heads of departments
must be incorporated in any effort to change. Without
their acquiescence, nothing is going to change!
5. Empower those who will be engines for change: The
views of the students, residents, and teachers on the front
lines of the struggle must be sought at every stage andtheir recommendations implemented when appropriate.
6. Develop clear strategies for Medical Student Education: To implement the vision, the changes, and theempowerment of those involved, it will be necessary, forexample, to:a. Officially recognize teaching as a legitimate academic activity
b. Encourage teaching as an essential ingredient of
academic lifec. Reward excellent teachers (academically and financially)d. Introduce a system for anonymous evaluation ofteachers by students
e. Initiate teaching rounds for students and residents
by the only physicians who possess a broad-based
perspective of medicine in Japan: the ER physicians.
f. Introduce PBLs at all levels of clinical training,
starting in the 3rd yr preclinical courses in medical school and proceeding through residency, as
a way of inculcating an ethic of clinical decision
making in patient care that is based on criticalanalysis.
g. Shorten the preclinical curriculum, starting with
the Anatomy course to establish feasibility (main-

Rao RH: Reforming Japanese Medical Education

ly because of Dr. Aiiso’s desire and willingness toshorten the Anatomy curriculum).
h. Implement the new curriculum in Anatomy for a
trial period and re-evaluate student performance atthe end of that period, in relation to their need topass national exams.
i. Introduce core courses on physical diagnosis forstudents by faculty members who commit to participating in interactive instruction without the
subliminal intimidation that appears to be omnipresent
j. Provide training in Bedside Clinical Instruction forexisting facultyk. Form a task force that will restructure the curriculum from top to bottom to make it organ system
based.
7. Renew (and maintain) a focus on General Internal
Medicine Training for Residents: At present, the twoyear rotating internship program at Keio University Hospital consists of nothing more than a series of subspecialty experiences. Since each experience only strengthenseven further the blinkered and myopic view of the subspecialist, the resident in training can never develop thebroad-based perspective that is essential for the generalinternist. The move to allow residents to spend one ofthose years at a community teaching hospital (a non-academic center), where a form of general internal medicine
exists, was a step in the right direction. The more recent
decision to rescind that move is, in my opinion, is a terrible mistake.
8. Consolidate the changes in coming years: Although the first steps in transformation must of necessity
be from the top down, real change will only occur when
a generational transformation in thinking percolates upwards from below. So it becomes imperative to quickly
induct the first few residents who have graduated fromthe new system of clinical instruction as clinical instructors of students. That will circumvent the inertia that impedes change in the existing set-up, and momentum forchange will build from the ground up.
Acknowledgements: The author wishes to acknowledge and thank
Dean Kitajima of Keio University School of Medicine, Professor
Takahiro Amano, Head of the Department of Medical Education,
Professor Suematsu and Professor Aiiso, Head of the Department of
Anatomy, for their unstinting support and encouragement to “do theright thing” regardless of the consequences. Grateful thanks are also
due to Dr Mark Zeidel, Chairman of Medicine, University of Pittsburgh School of Medicine, and to Dr Haruko Kuffner Director of thePittsburgh-Japan Program for opening the doors that made this effort
possible. Finally, the author wants to acknowledge his own limitations,so that he was unable to verify first-hand the contents of several of thereferences quoted in this paper, relying instead on statements made inauthors’ translations in abstract form. For any errors that result there
from, he is truly sorry.

Keio J Med 2006; 55 (3): 81－95

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