REVIEWPERSPECTIVES IN MEDICAL EDUCATION
5. Implementing a More Integrated, Interactive and Interesting
Curriculum to Improve Japanese Medical Education
Kanchan H. Rao1, and R Harsha Rao2

Visiting Associate Professor of Medicine, University of Pittsburgh School of Medicine
2
Professor of Medicine, University of Pittsburgh School of Medicine

1(Received for publication on May 4, 2007)(Accepted for publication on July 19, 2007)

Summary: Exact parallels can be drawn between the shortcomings in medical educationin the US in the 80s and those prevalent in Japan today. Research and clinical practice had
primacy over teaching, and primary care medicine, with its focus on humanistic principles,
was subordinated to specialization and tertiary care. US medical schools undertook a wideranging reform of the traditional curriculum, recognizing its four major shortcomings. These
were (i) an institutional failure to accord academic status to teaching, resulting in a disincentive to teach, (ii) a failure by faculty to perceive a shared interest in education, resulting
in teaching that was fragmented and even contradictory, (iii) a failure to integrate preclinical and clinical material, resulting in fragmented learning, (iv) a failure to encourage thedevelopment of the most important attributes of a physician (independent thinking, problem
solving, and self-directed learning). The reform of medical education in the US was achieved
through a wholesale restructuring that (i) integrated basic science with clinical medicine
across the curriculum; (ii) coordinated teaching across departments by organizing the curriculum into “blocks”; (iii) integrated problem based instruction into the curriculum to encourage active learning; and (iv) elevated the importance of both teaching and primary care.
The successful effort to reform medical education in the US can serve as a source of encouragement and a road map for academic institutions in Japan, like Keio University, who recognize the same shortcomings in Japanese medical education and are attempting to develop
and implement a curriculum that is more integrated and problem-oriented. (Keio J Med 56(3) : 75 － 84, Septmber 2007)
Key words: Medical education, Curriculum reform, Problem-based learning, Anatomy, Preclinicaltraining

Introduction

Japan,3 and the very commendable progress over the past
3 years of the effort to reform clinical training at Keio.4
It has been argued in an earlier paper in this series that
progress in reforming the system of medical education in
Japan cannot occur until curriculum reform is enacted.
The fact is, however, that curriculum reform has been on
the agenda in Japan for at least two decades without
much success.5, 6 It has even received official sanction
more recently,7 despite which the pace of implementa-

This paper is the fifth in an ongoing series of articles
on the effort to reform medical education at Keio University School of Medicine, one of the premier medical
institutions in Japan. Preceding papers have dealt, inturn, with the identification of problems in clinical training for students at Keio,1 recommendations on how tosolve those,2 the justification of the need for reform in

Address for Correspondence: 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 Tel: 412-586-9701 Fax: 412-383-9586
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Rao KH and Rao RH: Implementing an Integrated, Problem-based Curriculum

tion remains painfully slow. The reasons for this resistance to change have been detailed in an earlier paper inthis series,3 and will not be reiterated here. Suffice it to
say that progress is stifled by the existing medical school
curriculum, constrained by tradition, and obstructed by
medical school authorities who fail to see a need tochange. Despite these barriers, the reform effort has taken root in places like Keio University, thanks to visionary leadership that recognized the need for change, andhad the will to proceed with reform.4
Keio University is now embarking on the arduous taskof reforming the medical school curriculum. This constitutes the next step in the natural progression of a processthat began in 2003, and derives from the series of recommendations that were put forth to guide the reform
effort.2 Incorporated into those recommendations was
the explicit recognition of an acute need to reform the
medical curriculum so that students could not only develop the proper foundation for assimilating basic sciences into a clinical framework but also develop into
problem solvers.
Explicit in that recognition, also, was a recognition thatsuch a profound change―particularly one that was widely viewed as being both unnecessary and “unproven”3 ―in an institution like Keio University, with its well-established tradition, preeminent reputation, and long trackrecord of success, would be met with resistance, at best,
or overt hostility, at worst. It was therefore recommended that curriculum reform be undertaken only after demonstrating its viability in the Keio context, using a “Demonstration Project”. Furthermore, it was suggested thatthe Demonstration Project might be best attempted in a
subject area that (a) was self-contained and thus amenable to a limited effort that did not affect other areas of thecurriculum, and (b) was blessed with the departmental
leadership essential to sustaining its viability. The department that met both these criteria was felt to be Anatomy, based on the fact that (a) it was a relatively selfcontained subject, by its very nature, and (b) because
Vice-Dean Aiso, the Chairman of Anatomy, was at theforefront of the reform effort.
In 2006, the reform effort at Keio University had progressed to the point that curriculum reform was the next
logical step in the process. At that point, Professor Takahiro Amano, Head of the Department of Medical Education sought advice from the authors on the practical aspects of implementing a Demonstration Project in Anatomy, in order to show how to achieve integration between basic and preclinical sciences in the medical curriculum. In that context, it is noteworthy that one of us(RHR) has been closely involved in the ongoing effort toreform clinical training at Keio over the past 3 years,1-4
and the other (KHR) was just as closely associated withthe highly successful effort to reform the preclinical curriculum at the University of Pittsburgh, School of Medi-cine (UPSOM) in 1992. The focus and the ultimate result of that effort was a heavier emphasis on teaching theclinical relevance of basic sciences in the preclinicalyears and on introducing problem based learning into thecurriculum at UPSOM.
This paper, which is based partly on an address (by
KHR) to the Keio Medical Society delivered during ourvisit to Keio in November 2006, traces the evolution of
the process which resulted in the formation of the new
curriculum at UPSOM, and how that experience might
be used at Keio University (and other like-minded institutions in Japan) to bring about curriculum reform.
A Brief History Of Curriculum Reform In Medicine
In The US
During the 1980’s, a number of medical schools in
America undertook a radical re-organization of the curriculum that was in place at the time. The situation thatcurrently exists in Japanese medical schools (at least, as
it is reflected in the situation that prevails at Keio) is very
similar, if not identical, to the one that existed in the US
two decades ago. Even more striking parallels may be
drawn between the barriers to reform and resistance tochange that existed at that time in the US,8 and thosefacing educators currently engaged in this same effort inJapan.
Background
The movement to reform medical education in the US
started against the backdrop of a realization that the traditional curriculum was failing to prepare physicians forthe future. In 1982, the Annual Report from the Council
on Medical Education of the American Medical Association (AMA), in discussing “those issues and forces thatvery likely will have an important impact on medical education” focused on “the balance between generalism
and specialism required to permit persons to develop into
well-educated physicians who possess a broad perspective”.8 It was felt that “many of the changes that haveoccurred in undergraduate and graduate medical education were stimulated by the growth of specialism”. The
Report went on to say that “multiple divisions of theclassic broad clinical disciplines of medicine andsurgery…(have resulted) in aggregates of semiautonomous units that… (may not share) the institution’s educational goals… (and) often become further and further
separated from the educational philosophy of the parent
discipline. Technological skills may be emphasized at
the expense of the broad education needed by graduates…to provide general medical care” (ref #8, p 3225).
The Project Panel of the Association of American
Medical Colleges (AAMC) in its 1984 report on the
General Professional Education for Physicians (GPEP),
entitled “Physicians for the Twenty First Century”,9 fo-

Keio J Med 2007; 56 (3): 75 － 84

cused on a different aspect of the problem: the growing
conflict between the three distinct roles served by medical schools, namely education, research and patient care.
The GPEP Report stated, “Despite frequent assertions
that the general professional education of medical students is the basic mission of medical schools, it often occupies last place in the competition for faculty time andattention. Graduate students, residents, research, and patient care are (all) accorded higher priorities” than medical education (ref #9, p19). The Report attributed thelack of commitment to medical education among the faculty to the fact that “institutional recognition and reward
are not perceived to be forthcoming for significant dedication to this educational mission” (ref #9, p 3).
Bloom, in a comprehensive analysis of the barriers toreforming medical education in the US in the 80s,1 0
agreed, as suggested in the GPEP Report, that the rootsof the problem indeed lay in the fact that “…researchand education, despite the sincere manifest intention to
be partners, have become rivals and sometimes even enemies.” However, he also acknowledged that increasing
specialization was a compounding factor, as suggested in
the AMA Report. He incorporated both viewpoints informulating eight interlinked “propositions” that summarized the increasingly dysfunctional state of medical education in academic medical centers in the US in theeighties. These are quoted here (in abbreviated form,
with annotations) because they apply so aptly to the dysfunctional state of Japanese medical education today.
(i)“Medical education, much like medicine itself,
tends to be perceived primarily as an intellectual
activity”, so that “the emphasis in training...isplaced on medical knowledge”, and “goals of
performance, of professional behavior, are subordinated to goals of ideation”. In other words,
the need to learn how to apply knowledge in theclinical context assumes secondary importanceto the primary goal in medical education of simply acquiring that knowledge as an end in itself.
(ii) “The curriculum has been assumed to be the educational instrument that channels and controls
the teaching of knowledge, skills, values, and attitude…The curriculum plans of medical
schools, however, have tended… to focus on the
primacy of scientific knowledge.” Thus, the curriculum is used as an instrument to reinforce theprimary goal of acquiring knowledge without
reference to its practical application.
(iii)“Reform programs assume a consensus of faculty value orientation that does not account fordifferences among educators according to theirplace in the social structure of the institution”,
which is divided into “basic scientists, specialized clinical scientists, and clinicians”. The inference here is that vastly different academic

77

goals lead to vastly different perceptions of theimportance of education between the divisions,and just as vast a difference in commitment to
its goals.
(iv) “The modern medical school has grown to include the generic characteristics of large complex social organizations”,”, which prefer to ““paper over the persistent underlying structure.” Inother words, a large organization―like any
medical school in the US or Japan―possesses abureaucratic inertia that prefers to preserve thestatus quo rather than acknowledge the need forany meaningful change.
(v)“The crisis of medical education today is basedin the clash between ideology and social structure”, so that “educational values become subordinate to the requisites of the organizational
structure.” These requisites are dedicated to preserving “resources that are allocated to support
the goals either of research or of…specialized
tertiary care typical of teaching hospitals.” Theinference is that medical education is not a priority for resource allocation, which implies thatthe mission of medical schools to provide medical education has been subordinated to the goalsof generating income from research and highly
specialized tertiary care.
(vi) “Educational values oriented toward teaching
humanistic and competent physician behavior
are subordinated to the bureaucratic requirements of the modern medical center’s corporate
structure.” This follows from proposition (v),whereby the organizational focus on activities
that preserve its financial security lead to a shift
away from the altruistic aspects of medical practice, which is, in turn, reflected in the educational focus as well.
(vii) “High-technology specialization orientations,already well-entrenched, have been reinforced,
crowding out the community-oriented primarycare perspectives.” This is the next logical progression of the sequence that Bloom outlines,
combining the consequences of the two foregoing propositions (v and vi), so that the educational focus is shifted away from primary care.
(viii) “Programs of change (must) address the structural problems of organization, the sources ofauthority and allocation of resources, the powersources of decision making”. This is self-explanatory, combining the organizational inertia
of proposition (iv) with the financial priorities of
proposition (v).
All eight of Bloom’s propositions are capable of being
applied without any alteration to the situation that exists
in Japanese medical education today. In that transposi-

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Rao KH and Rao RH: Implementing an Integrated, Problem-based Curriculum

tion, however, there is hope. Japanese medical educators
who are engaged in the difficult and frustrating task ofreforming medical education in Japan can take heartfrom the fact that the exact same difficulties and frustrations were overcome by medical educators in the US two
decades ago.
It is helpful to review the process that led to the successful introduction of the integrated curriculum acrossmost US medical schools in the 90s, despite the sameproblems, so that the same process can be followed by
medical educators who are pursuing reform in Japan.
That process can be broken into two steps
1. Recognizing the shortcomings in a traditional medical curriculum, and accepting the need for change.
2. Developing and implementing an integrated medical curriculum that meets the need to develop clinical problem solving skills in future physicians.
Step 1
Recognizing the Shortcomings in a Traditional
Medical Curriculum
The underlying motivation for curriculum reform was
generated through the efforts of a number of organizations that investigated the state of the general professional education of physicians in the US in the 1980s. Twoof these have already been referred to: the AMA Council on Medical Education,8 and the GPEP Report of the
AAMC.9 A third was the New York Academy of Medicine; it organized a Symposium whose title, “The Training of Tomorrow’s Physicians: How Well Are We Meeting Society’s Expectations?”,11 summed up the problem.
As can be expected (and has already been alluded toearlier), each of these bodies had a slightly different focus in their deliberations. As a result, they reached conclusions that were somewhat different in certain respects,
and overlapped in others, but were mutually compatible.
Taken together, these conclusions provided a comprehensive view of the problem as it existed at that time in
medical education in the US.
It is not the scope of this paper to review all of thesereports in detail, nor is it necessary to do so. However, it
is very relevant to the reform effort in Japan to summarize the major shortcomings in the traditional medical
school curriculum identified in the reports. All thosesame shortcomings are widespread in the situation thatexists in Japan today: 3, 5, 6
1. There is a failure to recognize teaching as a respectable academic discipline;9 hence,a. Good teaching does not confer academic status
or recognition;b. There is no salary support for time spent inteaching medical students; andc. No consideration is given for teaching talent at
the time of promotions.

2. There is a failure to integrate material across thecurriculum, because faculty members do not recognize the intellectual common ground in the shared
mission of medical student education by different
departments; this is particularly apparent between
the basic and clinical sciences.
3. There is a failure to coordinate the teaching of material across artificially created divisions between
different departments. Moreover, faculty members
do not stay abreast of developments in any but theirown fields, and so remain ignorant of how information in other academic areas impacts on their own.13
4. Finally, there is a failure to “engage” students in thelearning process, because the curriculum is highly
information-intensive and instruction is passive. 8,12
Medical educators in Japan will readily recognize allof these “failures” as being identical to the situation thatexists in Japan today. In order to understand their relevance, and the impact they have in a traditional curriculum, as it exists in Keio, and many other medical schools
in Japan, it is necessary to expand on each of these “failures” to some degree.
1. The Failure to Recognize Teaching as a Respectable Academic Pursuit: This meant that teachingexcellence was not one of the criteria for academic
advancement. Therefore, there was no status orrecognition given to faculty members who devoted
their time to medical education. This acted as a
powerful disincentive to faculty members to teach,so that it was just as inevitable (and completely understandable!) that faculty members should prefer
to focus on research (in the case of scientists) or
clinical practice (in the case of clinicians). In giving
those commitments precedence, faculty members
made no more than a token commitment to teaching. Among the basic science faculty, in particular,such a token commitment resulted in a tendency forfaculty members to limit their focus to their individual areas of research even when lecturing to
medical students, at the expense of broader or moregeneral concepts.
2. The Failure to Integrate Knowledge: This meantthat students never received a multifaceted understanding of any topic taught to them, since there
was a fragmentation of interests, resources and approaches between a variety of departments responsible for teaching different aspects of that topic.
With each department deciding for itself what was
important, and what was not, there was a total lackof integration of course materials throughout medical school.
A narrow focus on individual research interests
by faculty engaged in teaching also contributed tothe teaching of often irrelevant details to medical
students, with little or no reference to its clinicalKeio J Med 2007; 56 (3): 75 － 84

material being taught in other parts of the curriculum. This was particularly true between the preclinical and clinical courses. By extension, the traditional curriculum was indicted for (i) failing to emphasize the clinical relevance of the basic sciencematerial that was taught in the pre-clinical years on
the one hand, and (ii) on the other, ensuring that therelevance of the basic sciences was completely loston the students by the time they reached the wards.
The effect of these dual drawbacks was to devalue
and denigrate the importance of the basic sciencesin the minds of the students while they were engaged in learning those, and to later complicate immeasurably the important task of understanding thepathology and pathophysiology of clinical disease
processes in the context of normal anatomy andphysiology. Thus, when students in a traditional
curriculum entered their clinical clerkships, a considerable amount of whatever basic science material
they had learned was either completely forgotten or
had receded so far into the background as to be inaccessible! It was left to the students to refresh thisknowledge, depending on their individual motivation and understanding, and apply it, without any
guidance or experience, to the understanding of disease processes and patient care.
3. The Failure to Coordinate Material: The lack ofoverall integration of course materials was compounded even further by a lack of coordination ofmaterial being covered on a daily basis. For example, during the basic science years, at the time a student was studying the Thorax in the Anatomy
course, the material being taught in the Physiology
course may well have focused on the Nervous System, while the Biochemistry course was engaged inteaching Protein Metabolism! The fragmentation of
attention and interest associated with such fragmentation of learning would ensure that students failed
to develop an integrated understanding of the material. The retention of such material would also be
considerably impaired.
Consider, by contrast, if the material being taught
across the courses had been coordinated so that
Thoracic Anatomy was taught at the same time as
Alveolar Gas Exchange and Oxygen Transport inPhysiology, and Aerobic Oxidation in Biochemistry. Such coordination of material in an integrated
curriculum would engage the student’s attention by
providing a comprehensive learning experience andencourage retention, particularly if it was combinedwith material in Clinical Pulmonology to establish
the relevance of the material.
In most instances, the reason for the lack of integration of subject matter all through medical school
was because there was no coordinating body to

79

oversee the curriculum. The oversight provided bysuch a coordinating body would ensure that the material was appropriate, relevant and consistent between the departments involved in medical education. In the absence of such a coordinating bodywith the authority to enforce integration and relevance, departments were left to determine for themselves what they would teach and when they would
teach it in a traditional curriculum, without any reference to its importance or its relevance to what
was being taught in other courses at the same time.
4. A Failure to “Engage” the Medical Student inLearning: There were many reasons for this failure, and it is not within the scope of this paper todescribe all of these. The GPEP report, in recommending widespread changes in the medical curriculum, stressed that “a general professional education should prepare medical students to learn
throughout their professional lives rather than simply to master current information and techniques.”(ref #9, p 11).
The traditional curriculum was not meeting thisobjective because “Students are led to think that
their education depends on memorizing as much information as possible. Consequently, they lack aclear idea of the skills, values, and attitudes that areimportant.” (ref #9, p 5). The Panel felt that a traditional curriculum was ineffective because
a. Students became passive recipients of information, rather than active participants in their own
intellectual growth;b. They were not encouraged to develop the mostimportant attributes of a physician, namely, independent thinking, problem solving, and selfdirected learning.
c. The curriculum was information centric, notproblem based, and evaluation of student performance was based on recall of memorized information rather than the ability to analyze andsolve problems.
The third criticism is particularly relevant to theJapanese curriculum, which is focused almost entirely on didactic learning. Didactic lectures, which
form the backbone of a traditional curriculum, arenot conducive to active learning or problem solving,
because they are purely unidirectional and information-intensive and the facts taught to the students in
lectures are not necessarily relevant to the practiceof medicine. It is not surprising that the GPEP Report felt that “the educational yield from lectures isgenerally low” (ref #9, p 12). This is not to say that
didactic lectures do not have a place in a curriculum. But their role has to be de-emphasized and restricted to only to explaining difficult concepts andto clarify complicated material, rather than as a rou-80

Rao KH and Rao RH: Implementing an Integrated, Problem-based Curriculum

tine method of instruction.
It may be deduced, therefore, that the motivation forchanging the traditional curriculum in US medical
schools came from a general acceptance of the fact that
it was failing to meet the needs of future physicians. The
multiple “failures” associated with a traditional curriculum meant that future physicians were neither provided
knowledge with reference to clinical context, nor taught
how to address and solve a clinical problem in the “realworld”.
The recognition of these shortcomings provided theimpetus to reorganize and restructure the curriculum, sothat learning for medical students was integrated, interactive, and problem-based. The same recognition was
also the motivation that led to a major change in attitudes
towards teaching as an avenue for academic advancement. It is of critical importance to understand that an
integrated curriculum could never have been implemented if teaching had not been recognized as a worthwhile
academic pursuit. That fact is emphasized here but will
not be discussed further, having been discussed at somelength in two earlier papers in this series.2, 4 Therefore,
the remainder of this paper will focus on the practical aspects of implementing an integrated, problem based curriculum in general terms, and the specific issues related
to restructuring the Anatomy curriculum, to meet thosegoals.
Step 2Developing and Implementing an Integrated Curriculum
A number of medical schools across the US decided toembark on the rather daunting process of restructuring
and reorganizing their curricula during the late 1980’s
because they recognized the traditional curriculum failed
to address the needs of future physicians. The University of Pittsburgh, School of Medicine (UPSOM) was oneof them. In order to address and overcome the shortcoming in medical education outlined above, wholesalechanges had to be made to the traditional format. The
end result was a new curriculum developed, organized
and implemented in the early 1990’s at UPSOM.
The journey was a long and difficult one, but the roadmap for its successful completion was drawn up by a series of Task Forces appointed by the Dean. The tasks assigned to each of these is evident in their titles, some examples being Basic and Clinical Integration, 1st year curriculum reform, 2nd year curriculum reform, 3rd and 4thyear curriculum reform, Teaching Evaluation, DoctorPatient Relationship.
The members of these Task Forces interviewed chairmen, faculty members and students, and after considerable deliberation, they identified the deficiencies in theexisting curriculum and made a number of recommendations that were then compiled into a series of joint rec-ommendations, as follows:
A. Establish a hierarchical system dedicated to medical
education
B. Introduce Problem Based Learning in the curriculum
C. Organize the curriculum into integrated “Blocks”
D. Formalize the evaluation of teachers and teaching
The new curriculum was developed based on the above
recommendations. The following is a summary of themost important changes that were made to the system of
traditional medical education at the University of Pittsburgh, School of Medicine, which resulted in the implementation of an integrated curriculum with an emphasis
on Problem Based Learning.
A. Establishing a hierarchical system dedicated to
medical education
1. A Curriculum Committee was formed to develop,
organize, and implement a new curriculum. One of
the most important goals of this committee was tocreate a curriculum that integrated the basic sciences with clinical medicine throughout the four yearsof medical school.
2. An Office of Medical Education was set up to oversee the implementation of the new curriculum.
3. A Director of Medical Education was appointed by
the Dean.
4. Course Directors were appointed who were answerable to the Dean and the Curriculum Committee(rather than the Chairmen of the Department towhich they belonged) in all matters related to thecourses for which they were responsible, such asorganization of material, and its integration into thelarger framework of the Block in which it was to betaught.
5. Course Directors were chosen based on experienceand talent as teachers.
6. The Course Directors were responsible for:●Developing the course material based on therecommendations of the Curriculum Committee.
●
Organizing and implementing the new curriculum.
B. Introducing Problem Based Learning (PBL) into
the medical school curriculum: The goal of problem
based learning is to promote active learning. What does
active learning accomplish? It encourages students todevelop the most important attributes of a physician.
Students learn to become:●
Problem solvers●
Independent thinkers●
Self-directed learners
The most effective method for implementing active
learning is the incorporation of Problem based learning

Keio J Med 2007; 56 (3): 75－ 84(PBL) in the curriculum, because it develops problem
solving skills and encourages independent thinking. The
key features are as follows:●
It is done in small groups●
The teacher is a facilitator, who only guides the discussion but does not direct it.
●
The students identify the problem, search for ways
to solve the problem and finally, solve the problem(with the help of the facilitator).
The PBL format should be familiar to anyone who hasread earlier papers in this series. It is composed of two
sessions, as follows:
1. Session 1: Presentation●
To start the session, each group of students isgiven the case history including the chiefcomplaint/s, history of presenting illness andrelevant past, family and social history. (ThePBL cases are created such that they increasein the level of complexity with the increase in
the student knowledge base).
●
Further information is given to them in stages
such as the results of clinical investigations including lab reports, X’Rays, CT scans and
MRI’s.
●
Students discuss the clinical presentation andgenerate a differential diagnosis.
●
Students identify gaps in their knowledge andallocate different topics (“learning objectives”)
for further study. These could include: etiology, normal physiology, pathophysiology, diagnostic work-up and treatment.
2. Session 2: Resolution●
Students return with handouts showing the information they have gathered●
They share this information with their colleagues
After the completion of both sessions, the students
learn for themselves how to analyze a specific clinicalproblem and identify for themselves the gaps in theirknowledge as it relates to that problem (they become“independent thinkers”), they learn how to resolve thatspecific clinical problem (they become “problem solvers”) by directing themselves to gather the necessary information to fill in those gaps (they become “self-directed
learners”). It can be seen, thus, that PBL is the most effective way to foster those attributes that have been identified earlier as the most important for a future physician
to possess.
C. Organizing the curriculum into “Blocks”: The
new curriculum was divided into four major blocks, as
follows:
1. The Patient-Doctor Relationship Block (26 weeks):
The importance of this component of the curriculum can-81

not be overstated, if the desired outcome of medical education is a compassionate, caring and competent physician. The goal of this Block was to encourage the development of humanistic traits in the student physician.
These traits include skill in listening and establishingrapport, recognizing a patient’s perspective on illness,understanding principles of medical ethics and healthpromotion (i.e. wellness in addition to illness), and theformation of respectful working alliances with peers andother healthcare workers.13 The specific content areas ofthis block that focused on the development of these traits
in medical students were as follows:●
The Importance and the Art of Interviewing Patients●
Medicine, Ethics and Society●
Behavioral Medicine●
Clinical Epidemiology
2. The Basic Science Block (26 weeks): Some of the basic science subjects covered in this block were:●
The Human Body●
Cell Science and Metabolism●
Genetics●
Microbiology
3. The Organ/Systems Block (52 weeks): The major systems of the human body were taught during this block.
Each Organ/System Block comprised of a comprehensive review of clinically relevant aspects of basic science
subjects like anatomy, physiology, biochemistry etc., together with pathology, pathophysiology, clinical presentation and management (medical as well as surgical) of
diseases in that organ/system.
4. The Clinical Block (104 weeks): This block comprised of ward rotations in Medicine, Surgery, Obstetrics-Gynecology and Pediatrics, and electives in clinicalareas that varied depending on the preferences of individual students. (It must be noted, in regard to the selection of those electives, however, the GPEP Report recommended that “Medical faculties should encourage
students to concentrate their elective programs on theadvancement of their general professional education
rather than on the pursuit of a residency position” [ref#9, p 17])
D. Evaluation: The key to successful curriculum reorganization is a process of evaluation that, on the one
hand, lays out explicit criteria by which teachers canevaluate student performance in a wide variety of settings, and, on the other, formalizes a reward system forgood teachers and a commitment to teaching. The Task
Force for the Evaluation of the Curriculum created Evaluation Forms that had a number of pertinent questions
for students and teachers to answer with regard to eachother and the curriculum. The students, in particular,
were asked to evaluate the course and the teachers. The
information gleaned from these evaluations was tabulated by the Office of Medical Education and returned to82

Rao KH and Rao RH: Implementing an Integrated, Problem-based Curriculum

the Course Directors. The latter, after consulting withthe teaching faculty identified any changes that would
improve their courses and implemented them for the following year. The faculty was also asked to evaluate thestudents, particularly in the 3rd and 4th years of medical
school. In this way, the students were able to improvetheir academic performance and clinical skills.
To summarize all of the foregoing, the effort to integrate basic sciences with clinical medicine in the curriculum at the University of Pittsburgh, School of Medicine
had two major components:
1. Emphasize the clinical relevance of material taught
in the pre-clinical years.
2. Coordinate learning within each year of medical
school.
The best way to show what this meant in practice is bydescribing how one particular Block was re-organized inorder to meet the needs of the new curriculum. In the lastsection of this paper, we will describe how the Anatomy
curriculum was reorganized into a “Human Body Block”.
Re-designing the Anatomy Curriculum into “Blocks”
with an Emphasis on PBL
The most important task facing the faculty members
involved in the development and organization of the new
curriculum was to answer the following questions:(a) What should be taught?
(b) How much should be taught?
(c) When should it be taught?
(d) What are the National Board requirements?
By answering these questions, it was possible to create
a new problem-based curriculum that emphasized therelevance of anatomy to clinical medicine and to determine the level of anatomical detail that was to be included in the instruction of anatomy throughout the four
years of medical school.
The re-organization of the Anatomy curriculum occurred as follows:
A. The Human Body Course was the first course in the
Basic Science Block. The main goals of this course wereto:●Introduce students to Medical Terminology●
Teach students the 3-dimensional relationship of
structures to one another and to the body as awhole.
●
Teach students to correlate 3-dimensional anatomy
to the relevant X’Rays, CT Scans and MRI’s asthese imaging techniques constitute the direct application of anatomy to clinical medicine.
The course was planned with strict adherence to the directives issued by the Curriculum Committee.
1. Lectures were greatly reduced in number, being restricted to the specific goal of only explaining difficult concepts and simplifying complicated subject
matter. They were not used to teach details thatwere ideally suited to demonstration, e.g.:●
Origins/insertions of muscles●
The anatomical relationships of every structure●
The branches of every nerve and every artery inthe body
2. A number of multimodal instruction methods wereused. These were as follows:●
Dissection of the body using a dissection guidedeveloped “in-house” to fit the needs of thecourse. This guide gave clear instructions concerning the important structures that the students
needed to locate.
●
The opportunity to view sequential sections of
the body and compare them to CT Scans and
MRI’s taken at comparable levels.
●
Small group demonstrations conducted by thefaculty in order to explain those areas of anatomy that were difficult to explain in a lecture format●
The use of computer-assisted programs in orderto reinforce important concepts.
3. The clinical importance of anatomical concepts andmaterial was emphasized through the following
methods:●
Problem-Based Learning (PBL): The creation of
the PBL cases was a collaborative effort between the Anatomy Course Director and a Surgeon. There was one PBL case for each anatomical area, which conducted after the students
had finished dissecting that particular area.
Hence, there was a PBL case each on the Thorax, Abdomen, Pelvis and Neck.
●
Live Surgeon/Patient contact: This was used as
an extremely effective and interesting way todemonstrate the clinical relevance of anatomy.
At the end of each week (on Friday afternoon), a
surgeon brought one of the patients on whom hehad operated to the classroom. He gave the students the patient’s case history and explained therelevant clinical anatomy. He then went on toshow the students the operative procedures that
he had used (with the use of intra-operative videos, where appropriate) and described the postoperative recovery of the patient. At the end, heinvited the patient to the podium and asked him/
her to describe personal experiences regarding
the illness, the operation and the recovery following the operation. After the patient had finished, the surgeon and the patient invited questions from the students.
B. The Anatomy component in the Organ/System
Block. The goals of this particular segment were:a) To review and familiarize students once again withthe basic anatomy of each organ/system as it wasKeio J Med 2007; 56 (3): 75 － 84

covered in the Block, andb) To learn further anatomical details not covered in
the Human Body Course, and provide contextual
relevance relative to pathology, pathophysiology,
and treatment of diseases of that organ system.
The way in which these goals were achieved can bebest understood through an example. For instance,
during the Organ/System Block in Cardiology, the normal anatomy of the heart would be reviewed, including
the heart valves, myocardial oxygen supply, and the
conduction system, in order to provide a foundation fora better understanding of valvular disease, ischemic
heart disease, and cardiac dysrhythmias. Furthermore,
the practical clinical relevance of the basic science material would be reinforced in the context of imaging
studies, such as echocardiography and coronary angiography.
C. Surgical Anatomy Elective Course. It is important
to emphasize that this course was taught by surgeons.
The goals of these elective courses were to:●Re-introduce the students to 3-dimensional anatomy(the students got an opportunity to dissect the human body again)●
Teach the students anatomical details relevant to theclinical practice of Surgery and other specialties
such as Obstetrics and Gynecology, ENT, Neurosurgery etc.
From the foregoing, it is obvious that one of the mostimportant aspects of the new curriculum was to teach thestudents the clinical relevance of Anatomy at the start oftheir medical education. Another was to integrate it withother subjects, so that its immediate relevance was evident. Finally, students were given every opportunity toreview and refresh the anatomy that they had alreadylearned and add further details when necessary, throughout the years they spent in medical school.
Conclusion
The effort to reform medical education at Keio University School of Medicine is gathering momentum. Thevery fact that such a premier institution should havemade a serious commitment to reform is a major development, worthy of comment and commendation. That
commitment is shown in the enthusiasm and eagerness
with which we were received on our trip in November
2006. One of the highlights of that visit was the PBL
sessions in Anatomy conducted by one of us (KHR) to
show the effectiveness of this format for emphasizing
clinically relevant concepts in relation to Anatomy. Theinteraction with the students who attended the PBL sessions was similar in every regard to the multiple, incredibly fulfilling and exciting experiences with PBL thathave been recorded in previous papers in this series.1, 2, 4

83

Just as it was reported there, at the start of the presentation session, the passivity for which Japanese students
are notorious made it difficult to get some of them toopen up and participate in the discussion at first. However, as time went on, they got more animated and before long, all the students were involved in discussing
the case with a vigor and intellectual curiosity that wasamazing, given that they had no prior exposure to the
PBL format. At the end of the Presentation session, theend result was an excellent, self-generated list of learning objectives that covered all the important issues thatneeded to be covered. Each student went home with one
learning objective to research and resolve.
The Resolution session was even more interesting andgratifying. The handouts prepared by the students were
as good as any produced by students at UPSOM, and thediscussion was both lively and interactive. Most importantly, the case was resolved with the minimal of intervention on the part of the facilitator.
The success of the PBL session could be predicted,
given the established track record of Keio medical students documented in earlier papers in this series.1, 2, 4 It
only serves to reinforce the value and the appropriateness of Problem Based Learning in the Japanese medical
curriculum. There is no question in our minds that thestudents at Keio University would be enthusiastic participants in active learning through the inclusion of PBL
sessions in the Anatomy course. In addition, we feel that
it is necessary to restructure the Anatomy curriculum tomake it more clinically relevant and problem-based,rather than detail-oriented, along the lines that have been
described in this paper. Finally, at the risk of re-stating
the obvious, we cannot emphasize strongly enough that
it is critically important to have a group of dedicatedteachers at Keio University who are truly concerned
about the education of medical students at all levels.
This has been emphasized in previous papers1-4 with regard to clinical training, but it is just as relevant to preclinical instruction in an integrated curriculum.
Our visit has left us convinced that the will exists at
Keio to implement the radical reforms that are necessary
for medical education to become more dynamic and responsive to student needs. Many ground-breaking changes in medical education are already being implemented
at Keio University, as detailed in an earlier paper.4 The
Herculean efforts initiated by former Dean Kitajima andcontinued by Dean Ikeda, and implemented by Vice
Dean Aiso and Professor Amano, Head of the Department of Medical Education are to be highly commended.
Their dedication and commitment to the uphill task ofimproving medical education at Keio University could
provide a role model for other institutions in Japan thathave similar goals.

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Rao KH and Rao RH: Implementing an Integrated, Problem-based Curriculum

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