REVIEW

Perspectives in Medical Education
8. Enhancing Preclinical Education in Japan
with a Clinically Focused, Interactive Anatomy Curriculum
Kanchan H. Rao and R. Harsha Rao

University of Pittsburgh School of Medicine, Pennsylvania, USA(Received for publication on March 13, 2009)(Accepted for publication on May 21, 2009)

Abstract
Reform of preclinical medical education in Japan requires changes in the curriculum to make it
more clinically focused and interactive. At present, course content in Anatomy is usually designed and taught with little or no clinical direction and involves a heavy emphasis on by-rotelearning to memorize often minor facts that have little importance in clinical medicine. As aresult, the content is boring, it is learned solely for the purpose of passing exams and it ispromptly forgotten, with little sense of its need in clinical practice. Successful reform of thecurriculum in Anatomy requires two critical changes. The first is that content must be madeinteresting to students by emphasizing its clinical importance, through a close collaboration
between preclinical and clinical departments, Thus, the Surgical Faculty must be incorporated
in the organization and teaching of the Anatomy curriculum. Core content can thereby bepared down to only what is considered essential to provide a foundation for the later clinicalyears, and the clinical importance of that content will, in turn, be self-evident to students. The
second change that must be implemented is to make the learning process more appealing to
the students. This can be facilitated by the use of any of several commercial IT programs thatmake learning in Anatomy both dynamic and engaging. These dual strategies will considerably enhance the learning of one of the most basic subjects in the medical school and ensurethat the review and retention of the material are enhanced. (Keio J Med 58 (4) : 210－215, December 2009)

Keywords: medical education, curriculum reform, anatomy, preclinical training
Introduction
We have been privileged to be a part of the ongoing effort to reform medical education now underway at Keio
University School of Medicine, in Tokyo, Japan. During
the first four visits, from 2003 through 2006, one of us(RHR, a clinician-educator with 3 decades of experience) was closely involved in advising the former Dean
and the Head of the Department of Medical Education,
Professor Takahiro Amano, on how to approach and undertake the task of reforming the medical school curriculum to enhance clinical skills training, in keeping withthe mandate established by the Ministry of Health in Japan. 1 The main thrust of the recommendations thatemerged, based on observations made during those visits, was to de-emphasize didactic teaching in favor of
problem-based learning and the acquisition of clinicalskills.2-5 This set in motion a process that, as noted earlier, is more-or-less a recapitulation of the process that
played out in the late 80’s and early 90’s in medical
schools across the US.6-8
Once the need for such reform was acknowledged at
Keio, the next logical step in the progression towards an
integrated curriculum at Keio was to reform the preclini-

Presented at the 1575th meeting of The Keio Medical Society in Tokyo, July 14, 2008.
Reprint requests to: Kanchan H. Rao, MD, Office of Admissions, University of Pittsburgh School of Medicine, 518 Scaife Hall, Pittsburgh, PA 15261, USA,
Tel: +1-412-648-9891, E-mail: kangan13@yahoo.com
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Keio J Med 2009; 58 (4): 210－215

cal curriculum to serve the needs of this overall goal. To
this end, the authorities at Keio saw fit in 2006 to alsoseek the advice of the other author of this paper (KHR),
a medical educator in Anatomy with experience in theimplementation of an integrated and interactive preclinical curriculum at the University of Pittsburgh. Even onthat first visit, the tremendous effort that was being madeto introduce an integrated and problem-based curriculumat Keio was quite remarkable. It was obvious to us thatan excellent start had been made in conceptualizing thecurriculum and beginning the difficult and complicatedtask of developing it, and we felt privileged to provide
our input into that effort, based on KHR’s prior experience with the introduction of an integrated, problembased Anatomy curriculum at the University of Pittsburgh.
During that prior visit in 2006, we met a number of thefaculty and discussed the pedagogical details with regard
to introducing PBL in Anatomy and various ways ofhighlighting the clinical relevance of the subject. KHR
also conducted an Anatomy PBL, and her experience
confirmed earlier observations that, even in this preclinical area, the students of Keio University School of Medicine found this method of “active learning” far more interesting and exciting than the “passive learning” thatthey are used to in a traditional curriculum with its heavyemphasis on didactic teaching and by-rote learning. The
report of that visit was the subject of a previous paper inthis series, and the reader is referred to that for details of
our observations and specific recommendations.9
With this as the background, we returned to Keio in
July 2008, having been invited by Professor Amano withthe specific purpose of facilitating the further implementation of an integrated Anatomy curriculum. This paper
is based on an address made to the Keio Medical Society
during that visit, and the main points form the basis of
our report to Professor Amano of that visit.
Within the overall context of making specific recommendations on how to reform the Anatomy curriculum tomake it more interesting and interactive, there were two
specific goals of our visit. The first goal was to provide
advice on how exactly to develop a clinical focus to theteaching of anatomy, and how to incorporate clinical material in Anatomy curriculum. In addition to this objective of developing and strengthening the clinical focus of
the anatomy curriculum, the second objective of the visit
was to advise the Curriculum Committee on the incorporation of Information Technology in the teaching of anatomy in order to enhance the Teaching/Learning Experience.

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OBJECTIVE I
To Shift the Focus of the Anatomy Curriculum
so that It Serves a Future Clinical Need
There are several elements that go into the effort to incorporate clinical material into the anatomy curriculum.
Of these, the following are the ones that are, in our view,the most important from the point of view of what ismost easily achievable at Keio University School of
Medicine, and in the context of the strengths that wehave observed among the faculty:
1. Develop a Multi- and Inter-disciplinary Approach to
Teaching Anatomy
An inter-disciplinary approach to teaching anatomy
and all the other pre-clinical disciplines has been recommended as a way to increase interest level in these subjects.10, 11 Our experience at the University of Pittsburgh
School of Medicine following the implementation of an
integrated curriculum in the early part of 1992 showedthat the interest level of students in studying Anatomy
increased substantially when the clinical relevance of thematerial was highlighted by clinicians’ participation in
the course. This was achieved by involving Surgeons,Radiologists, Neurologists, Gynecologists and Urologists
as teaching faculty in the Anatomy course. Their participation included helping students in the Dissection Laboratory, and facilitating the Problem Based Sessions in
Anatomy. Surgery residents were also encouraged to assist in the laboratory as it would help them to review
their knowledge of the subject while helping the students
in their dissections. Following the dissection of each anatomical region, Radiologists taught the students the basics of reading X Rays, CT Scans and MRI scans. The
lesson to take from this experience is that the inclusionof clinical faculty in the teaching of Anatomy is essential
for the success of the integrated curriculum.
2. Establish and Maintain a Collaborative Dialogue
between the Departments of Anatomy and Surgery
It was most heartening and encouraging for us to observe the willingness on the part of the faculty members
in both the Department of Anatomy and the Departmentof Surgery to engage in a collaborative dialogue. The
importance of establishing such a collaborative dialogue
between the two Departments was recognized by the
Curriculum Committee at Keio, under whose auspices ameeting was convened during our visit, which waschaired by Dr. Takahiro Amano and attended by theAnatomy and the Surgery faculty. Even though the conversation was in Japanese, which neither of us speaks orunderstands, it was obvious to us that both departments
take very seriously their shared responsibility to teachthe subject in such a way that the students understand the212

Rao KH and Rao RH: A Clinically Focused, Interactive Anatomy Curriculum

clinical application of this basic science subject. We
could sense that the faculty members were truly engaged
in the process of conceptualizing and developing the new
medical school curriculum.
This attitude of constructive engagement across disciplines is a critical aspect of introducing an integrated
curriculum at Keio University Medical School, and of all
the collaborations that are called for in such a curriculum, there is none more important than the integration of
Anatomy and Surgery in the curriculum. This is particularly because the future direction and success of the integrated curriculum as a whole can be derived from themanner in which Anatomy is taught. Anatomy is the verybasis of Medicine and it is usually the first course that istaught in most medical school curricula. In addition tolearning the structure of the human body, medical students learn medical terminology, learn to work with a diverse group of peers in the dissection laboratory andcome to understand human mortality, perhaps for the
first time. All of these make the teaching of Anatomy aunique opportunity to set the tone for the entire curriculum.
3. Reinforce the Clinical Relevance of Anatomy by Facilitating Direct Patient Contact with the Students
One of the most interesting ways to heighten student
interest in a preclinical subject in the first year of medical school, such as anatomy, is to organize a PatientDoctor Seminar as part of the course. It is possible to illustrate the importance of using interactive live patientseminars to enhance the learning experience in Anatomy
using our own experience at the University of Pittsburgh.
During the Anatomy course there, when the students finish studying the Thorax, for example, a Thoracic surgeon
brings in a patient on whom he has performed a hearttransplant. The entire class of 145 students observes thesurgeon recount the history, signs and symptoms of thepatient before the operation was performed. The patientthen discusses his medical problem with the class andanswers any questions posed by the students. The surgeon then reviews the anatomy of the heart and shows
the students a video of the surgical procedure, after
which the patient describes the change in the status ofhis/her health and lifestyle following the operation. The
students enjoy this segment very much as they are able
to understand the clinical application of Anatomy, andalso because they are able to interact with a patient inmanner that validates the importance of the subject they
are studying.
4. De-emphasizing Didactic Teaching
It should become obvious from the foregoing discussion that lecturing is just one aspect of teaching. Lectures are important to convey difficult concepts and toteach students those areas of the subject that are difficult
to dissect. The most relevant and valuable teaching of
the subject is done in the Anatomy dissection hall.
Hence, this is where clinicians, especially surgeons cancontribute the most. It is impossible to overemphasize
the importance of involving surgeons in the teaching of
Anatomy. This is because surgeons are able to provide
students with an immediate perspective on the practicalimportance of the material they are learning. One of themost valuable resources we were able to mobilize is surgeons who have retired. They enjoy teaching young students and the students are excited to learn from people
who have spent an entire lifetime using their knowledgeof Anatomy in treating patients.
5. Re-emphasizing Anatomical Concepts in the Clinical
Curriculum
In a traditional curriculum, anatomy is taught at entry
and is never revisited after the course is finished. Thisnot only conveys the impression to the student that material learned in that course does not have direct applicability to clinical material in later years, it also assuresthat little of whatever is learned is remembered in those
years. Thus, it becomes important that an integrated curriculum should not only incorporate clinical material in
the anatomy course, it should equally incorporate anatomical material in clinical courses. To this end, the curriculum should be organized so that students are made toreview their knowledge of Anatomy on multiple occasions during their tenure in medical school following
their Anatomy course. This is achieved by reinforcing
and reviewing Anatomy at the beginning of each Organsystem/Block. Anatomical study aids like plastinatedspecimens, preserved specimens, models and prosected
specimens are useful for this purpose.
6. Set up a Surgical Anatomy Course in the Later Yearsof Medical School for Students Interested in a Career inSurgery
At the University of Pittsburgh School of Medicine,
the curriculum includes a Course in Surgical Anatomy.
It is offered in the final year of medical school, after the
students have made their career choice of specialty.
Those students who have chosen Surgery as their specialty enroll in this course. It is planned, implemented
and taught by Surgeons. They lecture on surgical techniques and procedures following which they demonstratethese techniques on cadavers. The students who are interested in reviewing basic anatomy are permitted to do
so. In the context of the curriculum at Keio, a SurgicalAnatomy course could be offered at the appropriate time
during the Surgical Residency and the Emergency Medicine Residency.

Keio J Med 2009; 58 (4): 210－215

7. Incorporating Medical Imaging into the Teaching ofThree-dimensional Anatomy
Medical Imaging plays a very prominent role in clinical medicine, regardless of specialty, so that its importance in the medical curriculum must not be underestimated.12-14 The tremendous advances in this field makeit imperative that anatomy be understood in the context
of these imaging modalities, so that the interpretation ofthese two-dimensional images in clinical medicine canthen be related to the three dimensional anatomy that has
been learned on the cadaver in the dissection hall.
The incorporation of imaging technology in the teaching of body structure can immeasurably enhance thelearning of Anatomy. Techniques such as Ultrasound,CT, and MRI enable medical students to study the human body in an entirely new way that is both exciting
and interesting, because it shows them the clinical relevance of anatomy in a way that is both visual and immediate. Thus, combining the comprehensive study of relevant CT Scans and MRIs with simultaneous dissection
establishes the clinical relevance of the subject. This is
the key to the success of the new integrated and problem-based curriculum at the University of Pittsburgh:
students study Anatomy with greater interest and retain
the material for longer periods of time because its clinical relevance is established for them.
8. Use Information Technology to Make Anatomy
Learning Interactive
A key element to making an integrated Anatomy curriculum even more interactive and interesting could be
the use of Information Technology to enhance the learning experience for students.11 Although these modalities
were not a part of the Integrated curriculum introduced
at Pittsburgh in 1992 (for the simple reason that these
programs have only become available in the recent past),
they could prove to be of great value specifically in theJapanese context.
Several excellent Information Technology programs(IT Programs) are available and these could be madeavailable to students through the Intranet at Keio University School of Medicine. They are particularly usefulwhen students are in their Medical Student Clinical Rotations in their 5th and 6th years of medical school (particularly the Surgery and Emergency Room rotations). A
review of Anatomy using these advanced IT Programs
would make the time spent in the clinical setting a far
more valuable experience. Another IT option that is now
available for incorporation into an Integrated Anatomy
curriculum is the use of simulations of the dissection of
the human body. These options are discussed in the following section, because the use of these IT tools forteaching Anatomy was the other declared focus of thisvisit to Keio University School of Medicine.

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OBJECTIVE IIThe Use of Information Technology Programs toEnhance the Teaching and Learning of Anatomy
There are a number of computer-based and internetbased programs that are available in the market today. I
would like to state at the outset that these programs,
however sophisticated, should be used as an “adjunct” todissection and not as a primary tool of learning.
Review of several IT programs for Anatomy reveals
that there are 3 programs that could prove to be beneficial to students at Keio University. All the programs
have interesting and innovative features. These programs are:
1. ADAM (Animated Dissection of Anatomy in Medicine) Interactive Anatomy
This is a software program that makes it possible forthe student to digitally “dissect” the human body layer
by layer, and thus can be used as a companion teachingtool with cadaveric dissection.1 5 It is divided into fivesections, as follows:a) Dissectable Anatomy: In this section, the students areable to peel off each layer of the body starting fromthe skin and going to the deepest organs in the bodyand can therefore visualize the relationship of structures to one another and to the body as a whole. In
addition, anatomical structures can be labeled andeach structure/organ can be “extracted” in order tostudy it in isolation from the rest of the body. It isalso possible to rotate the body so as to be able toview a particular structure/organ from the anterior, lateral and posterior aspects.
b) The Anatomy Atlas: This section is good but, by itself, it does not compare as a stand-alone Anatomy
learning tool with the online edition of Netter’s Atlasof Anatomy by Frank Netter. In combination with thefirst section (“Dissectible Anatomy”) however, The“Anatomy Atlas” is a valuable tool, particularly because of the inclusion of Radiographs in this sectionof ADAM. This makes the program quite useful forstudents both prior to dissection and subsequently toreview the material learned in the dissection lab.
c) The 3D Models: This part of the program provides
the viewer with views of the heart, lungs, skull, brain,
ear, eye and the male and female reproductive organs.
The “blown up skull” is a particularly interesting aspect of the skull model because it allows the student tovisualize the individual bones of the skull as they relate to each other, which is otherwise very difficult forthe student to conceptualize.
d) The Clinical Illustrations section includes diagramswith a brief explanation of the clinical condition thatthey depict. As stated earlier, if medical students aretaught the clinical relevance of the basic science sub-214

Rao KH and Rao RH: A Clinically Focused, Interactive Anatomy Curriculum

ject that they are studying, their attitude towards
learning changes for the better. The following 2 sections serve this purpose. Some examples are: Internal
fixation of a fracture, Lithotripsy procedure, Epidural
injection site, Coarctation of the Aorta, Graves’ Disease and Insulin Pump.
e) The Clinical Animations section is by far the most interesting aspect of ADAM, because it makes the surgical application of anatomical knowledge a reality forthe student, and thus brings the subject “to life”. A
step-by-step narration accompanies a series of animations that depict procedures such as a Coronary Artery
Bypass Graft (CABG) and a Directional Coronary
Atherectomy (DCA).
2. Primal Pictures
This is a web based resource of exceptional picture
quality.16• The visual excellence of this program is particularly
evident in the Models and Dissections. Students can
get a good grasp of the layers in which the body is arranged, much as they would in the ADAM program,but the images are of a much superior quality in Primal Pictures.
• A very interesting feature is the section on Clinical
Pathology, in which the clinico-pathologic correlatesof the anatomic structures on display are described.
This is a welcome feature of the program because itemphasizes the clinical relevance of Anatomy.
• Students are able to visualize complex anatomic relationships by rotating a model on the screen through360 degrees, while they peel off layer by layer to visualize deeper structures that are hidden by superficial
ones. This feature is especially valuable in depicting
a constricted space like the pelvis.
• The Program also has a very interesting feature ofmuscle action. The muscle groups (agonists and antagonists are shown in “different colors” as they contract and relax during specific joint movements. The
importance of this feature for the understanding of kinesiology is self-evident.

level of a particular section on the body and the actual
cross section. Thus, by scrolling up or down, it is possible to change the levels of the cross section and observe
the appearance and disappearance of various organs andstructures. All the relevant and important structures in
the cross section are labeled. This is also a very goodlearning tool for clinicians interested in learning radiologic anatomy.
4. Virtual Reality
Highly advanced virtual reality technology is being
used to create learning tools for medical education, including Anatomy.18 At present, each institution is developing its own programs and it is possible that these will
become available commercially in the future.
Conclusions
The tremendous progress being made at Keio University School of Medicine in developing and implementing
an Integrated Curriculum has impressed us. The enthusiasm for reform and the commitment to completing thedifficult task are palpable to us. In particular, the determination to forge ahead with introducing real change isevident in the manner in which the authorities are approaching the wholesale revamping of the curriculum tomake it more clinically focused and to engage the students through the incorporation of interactive technologies. Nowhere is this better demonstrated than in the approach that is being taken to change the Anatomy curriculum. Our observations will, we hope, help the facultyof the departments of Anatomy and Surgery in furthering
their collaborative effort to develop and organize theMedical Anatomy curriculum. We feel privileged andhonored to be part of that effort, and hope that our recommendations, which derive from personal involvementin the successful implementation of an Integrated Curriculum at the University of Pittsburgh, will prove to be
useful in facilitating the cause of reform at Keio University Medical School.
References

3. Touch of Life
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3-dimensional relationship of the organs and structuresin the body before viewing this program. Hence this is amore advanced program and would be very useful for reviewing Anatomy during the Organ/System blocks andduring the Clinical Rotations. The program allows thestudent to simultaneously view (on a split screen) the1.

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