OPINION
Misperceptions of medical education in Japan:
How reform is changing the landscape
Alan R. Teo

Department of Psychiatry, University of California, San Francisco, CA, U.S.A.
(Received for publication on August 16, 2006)(Revised for publication on April 27, 2007)(Accepted for publication on April 27, 2007)

Abstract. A number of Western physicians have highlighted shortcomings in Japanese medical education over the years. In recent years, however, there has been dramatic change inthe system of medical education in Japan that renders some of these observations inaccurate and others worthy of several caveats. Using a recent review article in the Keio Journal ofMedicine as a starting point for discussion, the author responds to a number of historical concerns about medical education in Japan and includes updated information on recent reforms.
(Keio J Med 56 (2) : 61－ 63, June 2007)
Key words: Japan, medical education, clinical clerkship, residency

Introduction

completely agree with, and indeed I have no intent here
to question them. The few areas I must claim inaccurate
or misleading are ones that are commonly misconstrued.
Thus, the purpose of this article is to draw attention toand deepen the discussion of some intricate issues challenging the status quo of medical education in Japan.

For many years, Western-trained physicians have highlighted shortcomings in Japanese medical education.1- 5
In particular, major deficiencies in clinical skills, such ascompleting a history and physical exam have been described.2, 6, 7
The most recent contribution comes from Rao,8 a professor of medicine at University of Pittsburgh, who bases
his comments on accumulated experience from periodic
visits over three years to Keio University School ofMedicine. Rao’s manifold review is a valuable addition
to a sparse literature, and his earnest, frank commentary
adds a number of incisive insights. (Indeed, I found it remarkably stalwart of the Keio Journal of Medicine topublish a manuscript so censorious of its own medicalschool!) Rao correctly identifies a lingering paradox ofmedicine in Japan: Why such enviable health outcomes
despite a dysfunctional medical education system? His
ultimate conclusion is not unlike predecessors in the literature who call attention to, and plead for reform of,striking deficiencies in medical education in Japan.

Caveats
Rao writes from the experience of a monolingual English visiting professor at a premier private medical school
working primarily with a small set of medical students aswell as some faculty and residents. As my experience
differs, and as past experience undoubtedly colors thelens through which we make interpretations and conclusions, let me mention how my experience differs.
I write as a bilingual English-Japanese American medical student with three banks of relevant experiences. The
first is dozens of relationships since 1998 with Japanese
medical students, many of whom are now practicing clinicians, at Tokyo Medical University, Tokyo Women’s
Medical University, Tokyo University, and Keio University. The second source is one year spent employed atEhime University from 2001 to 2002, teaching medical
English to medical students and faculty. And the third is
one month spent on a clinical clerkship in internal medi-Purpose
The vast majority of Rao’s impassioned observations I

To whom correspondence should be addressed: Alan Teo, M.D., Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue,Box 0984-RTP, San Francisco, CA, 94143-0984, U.S.A., E-mail:alan.teo@stanfordalumni.org
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Teo AR: Misperceptions of medical education in Japancine at Yokohama City University in 2006.
Commonly heard opinions that Rao and others make of
medical education in Japan can be divided into four categories:
1. The Japanese medical education system is stagnant.
2. Undergraduate medical education should be theprimary target for reform.
3. Japanese physicians are trained as subspecialists
and lack the ability to practice general internal
medicine.
4. Japanese medical students have poor spoken
English.
To be sure, there is abundant supporting evidence foreach of these statements. However, these claims also deserve caveats. Here I point out some of the recent developments that render these statements unfairly extreme
and inaccurate.
Misperception 1. The Japanese medical education
system is stagnant.
A number of dramatic reforms, particularly in postgraduate medical education, have been made to Japan’ssystem in the last several years, just as Rao was beginning his experiences in Japan. Reports of these reforms
are just now beginning to make their way into the literature.9, 10First, the Japanese Residency Match Program (JRMP)
was established. This system, which is similar to that ofthe US, is a very important development because it offers graduates the opportunity to self-determine their siteof residency training, be it a narrowly focused university
hospital program or broad-based community one.
One of the surprises is the steady gravitation of more
graduates to the community-based residency programs.
In the 1980s, 80% of medical graduates began training atuniversity hospitals.11 Since the first Match results werereleased in late 2003, the percentage training at university hospital programs has dropped precipitously. By fall2005 it had dropped to 48%, and the latest figures fromfall 2006 show that percentage holding steady at 49%.10
In other words, whereas the vast majority of students
used to train in university hospitals, nowadays a slightmajority are choosing community programs.
Second, the Ministry of Health, Labor, and Welfare(MHLW) made a two-year-long internship mandatory topractice clinical medicine. This internship is essentially ageneral residency, a series of medical and surgical rotations in which the intern is unassociated with any specialty. Seven specialties (internal medicine, surgery,emergency medicine or anesthesiology, pediatrics, psychiatry, community-based medicine, and obstetrics/gynecology) are included. At six months in length, inter-nal medicine occupies the largest single portion. Observant critics will be hasty to note that the required rotations in internal medicine and surgery are usually merelya series of subspecialty rotations strung together. Nonetheless, it is a major step in standardizing clinical competency across Japan.
Misperception 2. Undergraduate medical education
should be the primary target for reform.
This is not the most appropriate target at this time, andthe reason lies within the very nature of Japanese education. A much more practical and realistic target, if lessideal, is postgraduate medical education, that is, residency training and beyond. Rao eloquently describes thefrustrating passivity of his Japanese students, and I endured identical pains in my tenure teaching medical English at one of Japan’s national universities. Unfortunately, a few weeks’ exposure to an American model of critical thinking and group discussion is woefully inadequate
to overcome a passivity that he acknowledges to be “culturally ingrained.”
Given this, starting reform at medical school is tragically tardy, and expecting wholesale reform in educationso easily is farcical. Take one example: Trying to get
Japanese undergraduates, which includes medical students, to take their studies more seriously would requireeliminating the preceding years of so-called “entrance
exam hell” that cause them to relax once reaching the“Disneyland” of college life.
Of course, there are piecemeal areas of undergraduate
medical education reform in Japan. Focusing on enhancing and broadening these reforms is also a simpler andmore realistic approach. For instance, Rao deplores the“absence of any bedside clinical instruction.” However,the Objective Structured Clinical Exam (OSCE) is a requirement in place at all Japanese medical schools. 3
OSCE in Japan is still more form than substance－students view it as easy to pass and perform exams onpeers, hardly mimicking real clinical practice. Nonetheless, serious preparation for OSCE would be an excellent
opportunity for more clinical instruction. Creating more
physical exam practice sessions including both real andstandardized patient experiences would be a good step inthat direction.
Misperception 3. Japanese physicians are trained as
subspecialists and lack the ability to practice generalmedicine.
This is one of the most distressing concerns. It has
been raised by Western general internists as well as family practitioners who have tried to introduce their respective specialties, with limited success, in Japan. 6
However, the last five years or so have shown somepromising signs.
One development in recent years is of general medicine

Keio J Med 2007; 56 (2): 61－ 63departments -- called sōgō shinryōbu in Japanese. Awareof longtime criticisms of insufficient education in primary care, the MHLW has supported the movement to create departments related to primary care, and their numbers are growing rapidly in both university and community settings.6 Nagoya University, thanks to the leadership of Dr. Nobutaro Ban, is the site of one of the mostprogressive of these departments.
Also, for the first time the majority of medial graduates
are entering community-based residencies, a setting
away from the ivory tower which should increase in thenumber of young physicians in Japan with more realworld and hands-on clinical experience.
Misperception 4. Japanese medical students havepoor English.
The same characteristic of passive diffusion of rote
factual knowledge discussed earlier, combined with ahomogenous population having little exposure to native
English speakers, results in most Japanese medical students and doctors being uncomfortable, if at times downright incapable, of functioning in a spoken English environment.
However, by and large academic physicians in Japanare most concerned with publishing and staying current
with the literature, meaning that written English is ofmuch more importance to them. And indeed their written
skills when isolated to medical English is more than adequate. Although the spoken English of most Japanese
medical students and physicians is poor, it is unfair tocategorize their entire English language level as such.
This language barrier unfortunately contributes to native English speakers’ perception of Japanese medical
students as subpar. For instance, Rao bemoans, Japanese
medical students “would not measure up to even themost average student of comparable chronological seniority in the US.” However, second-language communication is a major factor here: anyone with the experience of trying to write a creative story or explain a technical concept in her second or third language knows howutterly handicapped one feels. Personally, no matter how
fluent my Japanese, I will always sound more intelligent
giving a case presentation in English rather than Japanese.
There is a tendency to vastly underestimate the height

63of this language barrier. It is utterly unrealistic, as Raosuggests, to envision that it would be “reasonably easy”
for a typical Japanese medical student to surmount thelanguage barrier “after a few weeks of immersion inAmerican society.”
It is distressing, then, to read Rao’s discussion of Japanese student’s English skills, which smacks of American-style ethnocentrism. He writes that students had difficulty with “idiomatic English” and even those with excellent English “did have an accent.” Everyone, even
Americans, has an accent. Clinicians like Rao should
adapt to surroundings and avoid idiomatic English as
much as possible when outside the U.S. In the Netherlands, when I want tap water, I order “water withoutgas.” As silly as it sounds to me, I adjust my English to
the local expression rather than obstinately clinging to
my American preference. In short, simply knowing about
the language barrier as an American clinician venturing
to Japan is inadequate. One must also appreciate and accommodate that reality.
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