REVIEW
Perspectives in Medical Education
4. A “global” dimension to reform at Keio University
R Harsha Rao

Professor of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, U.S.A.
(Received for publication on July 18, 2006)(Accepted for publication on December 21, 2006)

Abstract. Keio University School of Medicine is awakening to the realization that it willachieve international recognition as a center of excellence in medical education and healthcare only by inculcating clinical skills and critical thinking in its medical graduates. A new“global” perspective identifies the traditional failure of Japanese medical education to provide its graduates with clinical skills training as the root cause of a number of deficiencies.
These include (i) the reluctance of Japanese medical graduates to seek global experience;(ii) the absence of interest in the global healthcare marketplace for Japanese medical graduates as potential recruits; (iii) the failure to incorporate globally accepted innovations, like
problem-based learning, in Japanese medical education; (iv) the failure to follow globally accepted standards of clinical practice in Japan; (v) the lack of instruction in general internal
medicine in Japan; and (vi) the neglect of evidence-based medicine in Japanese healthcare
practice. Keio University is embarking on an ambitious effort that commits both the will
and resources necessary to reform medical education at Keio in accordance with global
norms. The initiatives currently underway include (i) incorporating PBL into the curriculum
to foster active learning, (ii) implementing measures to promote interactive teaching techniques among the faculty, and (iii) granting recognition to teachers through new promotion
policies. Wider implementation of these initiatives across the country will enable Japanese
healthcare and Japanese physicians to occupy their rightful place of respect in the global
healthcare market, comparable to the widespread international recognition given to Japanese medical researchers. (Keio J Med 56 (1) : 1－ 13, March 2007)
Key words: Japanese medical education, problem based learning, clinical skills training, Japanese
healthcare system, global health care

Introduction

practical and realistic in their applicability.2 The third
paper provided a detailed and fact-based justification
for the urgent and critical necessity for reform, in orderto buttress support for the effort of the reformers, whoface a very determined, but understandable, reluctance tochange a system that can justifiably claim credit for the
success of healthcare in Japan.3
It is not my purpose in this, the fourth paper in the series, to belabor, yet again, the points made in the threeearlier papers with regard to the problems in the system,
their solutions, or the imperatives for reform. In this paper, I intend to detail the progress that is being made inreforming medical education at Keio. Of necessity, my

The problems in Japanese medical education, and theirsolutions, are the focus of this ongoing series of reflective articles based on my personal observations of thestate of teaching and learning in Japan. The first paper inthe series dealt with the nature and consequences of thepervasive dysfunction in the Japanese system of medical
education, insofar as it is exemplified by the conditionsat Keio University School of Medicine in Tokyo, one ofthe premier medical institutions in Japan.1 The second
paper focused on a highly subjective set of recommendations for reforming the system at Keio that are both

Reprint requests to: R. Harsha Rao, M.D., F.R.C.P., Room 580 Falk Medical Building, 3601 Fifth Avenue, Pittsburgh PA 15213 U.S.A., E-mail:rao@dom.pitt.edu
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Rao RH: A global approach to changing medical education at Keioobservations continue to be highly subjective and limited
only to those aspects that I have had an opportunity topersonally experience. Notwithstanding that caveat, theobservations do have broad relevance because they arebased on repetitive experience. It makes the changes I
have witnessed not only meaningful, but also consequential, rather than the mere window-dressing that doomed
earlier efforts at reform in Japan. It is necessary to statethat fact, because the changes are not easily recognizedwithout the experience, the interest, and the understanding necessary to look past the glaring problems that overwhelm the first-time observer.
At first glance, not much appears to have changed in
the two years since my first visit: the curriculum remains
stuck in a painfully boring didactic mode, teaching remains unidirectional and completely disengaged fromthe students’ learning needs, and clinical instruction isvirtually non-existent. Notwithstanding that seemingly
gloomy assessment, it is undeniable that change of avery promising nature is underway at Keio. The progress I have witnessed exemplifies what can be achieved,
even in the face of obdurate resistance, if an institution
is blessed with visionary leadership. The change in approach to medical education at Keio provides a tantalizing glimpse of the potential for transformational change
in the healthcare system itself. That is the central themeof this paper.
Recognizing the change in approach is also criticalfor another reason: to support and nurture the effort andwill to change at Keio, and thereby sustain and even embolden those who seek to reform the system of medical
education there. That is the subtext of this paper.
The Winds of Change
Central to the overall change in approach to medical
education underway at Keio University are two interdependent changes of major significance that I havewitnessed on my most recent visit to Keio University
in 2005. Although they are inextricably linked, they are
distinct from each other in their motivations and implementation, and the genesis of each comes from different
sources. Yet, they share much in common, not the leastof which is their shared link with the three annual visits I
have made to Keio University School of Medicine since
2003.
The first change has to do with perspective.
It comes as no surprise that, with each successive visit,
I learn more about Japan and its rich and complex culture. With that comes some faint insight into the way inwhich its traditions impact and constrain the educationaland healthcare systems, as well as the effect Japaneseculture and tradition have on the behavior patterns ofstudents, teachers and physicians. As a result, I am beginning to understand that there is much more to the

problems and their solutions than meets the eye at firstglance. I have dwelt on those problems and solutions
at some considerable length in earlier papers.1-3 They
are rampant, they occur at every level of education andtraining, and they continue to cry out for reform with adesperation that remains undiminished. They remain, inessence, unchanged from when I first described them,and their solutions are no different now than when I firstrecognized them. In that regard, nothing has changed.
What has changed, however, is the perspective withwhich I am able to view those problems. Repetitive exposure to the Japanese medical education system hasenabled me to develop a somewhat more subtle understanding of the context in which those problems occur,
together with the undercurrents in Japanese tradition andsociety that lie at their root. This still very rudimentarycultural maturation on my part has helped me appreciatethat a more refined perspective is necessary to understand the factors that maintain and sustain the status quo.
This change in perspective is the first of the changes I
will describe. Although there is no concrete outcome toreport as yet as a consequence of this change, it is bothof great importance and of great significance. It is ofgreat importance because developing the right perspective is the key to developing insight, the crucial “ratelimiting step” to devising and implementing solutions toany problem. It is of great significance because its source(who I will identify) is critical for the evolution of reform at Keio and a key determinant of the future of thateffort.
The second change of consequence that I have beenable to recognize with the benefit of repetitive exposure
is a serial evolution in attitudes towards teaching at Keio
University School of Medicine. I can now see tangible
progress in the arduous task of transforming the attitude
towards medical education in general, and teaching inparticular, at Keio. In some ways, this change in attitude excites me even more than the afore-mentioned
change in perspective. There is tangible and measurable evidence of progress here, unlike the more abstract,
though no less consequential, change in perspective thatis enabling it. The change in attitude is reflected in several concrete steps being implemented in Keio. Viewed
in isolation, each step seems small in the context of themagnitude and multiplicity of the problems. In order totruly appreciate the collective impact of those changes,
however, it is essential to view them as part of a bigger
picture, rather than in isolation. In other words, as the oldsaying goes, one must not “fail to see the forest for thetrees”.
The saying is appropriate in another related context, aswell. I must confess that, on previous visits, I have been
so overwhelmed myself by the magnitude and multiplicity of the individual components of the dysfunction (the“trees”) that I stand guilty of having fallen into the trap

Keio J Med 2007; 56 (1): 1－ 13

of failing to see the problem of medical education at
Keio as a single “whole” (the “forest”). It is not until mymost recent visit that I have found the correct perspective to see that “forest”. It has enabled me to integrate
the disparate components of the dysfunction that afflicts
both Japanese health care and medical education into asingle “whole”.
Both changes-one in perspective, and the other in
attitude-are important to the change in approach to
medical education that Keio. Without one, it is difficult,even impossible, to grasp the significance of the other.
A Refreshing Change in Perspective
Changing a Clinician-Educator’s “Focal” Perspectiveof Problems in Medical Education at Keio …:
In the first paper in this series, written after my firstencounter with the system as it existed at Keio, I described my perspective, as a clinician-educator, of the
problem of medical education in Japan.1 I identified one
glaring deficiency as a key factor in the wide prevalenceof the dysfunction in medical education at Keio University specifically, and in Japanese healthcare more generally: generalists are extinct as an academic species at
Keio University. It means that there is no one on the faculty who can teach medicine from the perspective of thegeneralist. As a result, clinical training is non-existent,
and the critical thinking and clinical skills that are thehallmark of the “well rounded” physician are nowherein evidence at Keio (and other academic institutions inJapan.)
Others have commented on the overwhelming dominance of specialists and the virtual absence of generalists
in academia in Japan.4, 5 This is a central factor in the
failure of medical education in Japan to prepare its graduates for the challenges of primary care practice. The
specialist faculty set the wrong example for trainees with
their narrow focus on the practice of medicine, which
consists of highly selective and specialized interventions
targeted to solving single problems without integrating
multiple problems into a single whole. Consequently,
learning for students becomes reduced to a tedious process of memorizing esoteric details that are of interest
only to specialists. Moreover, the specialist’s singleminded focus on a favorite disease can sometimes fail torecognize the larger, human context of disease processes.
All of these factors contribute to the Japanese medical
education system’s singular inability to meet the needsof the vast majority of its graduates who end up providing primary care to the public, without any instruction or
experience in doing so.
Nothing has changed with respect to those observations(and conclusions) regarding the practice of medicine inJapanese academic centers, the way in which that is reflected in the methods of instruction, or its downstream

3

impact on healthcare. However, I am aware that the
points made in the foregoing paragraphs, while accurate,
do not reflect the full picture. They are circumscribed by
the limited perspective of a teacher unable to see past thedysfunctional state of both teaching and learning in Japan. That focal, educator-centric mindset has undergone
a tectonic shift thanks to a discussion with Professor
Ikeda, Dean-elect at Keio University School of Medicine
and successor to Dean Kitajima.
I recall how surprised I was when Professor Ikeda, inreferring to the “Blueprint for Reform” in my second
report,2 thanked me for helping “to show how to make
Keio University competitive in the global health market”.
I was taken aback when I heard this. As a clinician
educator, I saw myself in a very limited role, which was
to observe and critique the teaching of medical students
at Keio University, and suggest ways to make it better. I
had no delusions of participating in a grandiose exerciseof “global” dimensions.
When I tried to disclaim any such intention to Professor Ikeda, he would have none of it. Very gently, butquite firmly, he explained to me his vision of Keio University graduates being eagerly sought as candidates fortraining in American medical centers. He used the word
“globalization” in connection with his desire to see Keio
University receive international recognition as a quality
institution for both healthcare and medical training. He
was very courteous and charming, in the best Japanesetradition, but I recall being struck by his quiet passion,even if I did not recognize its wellspring, nor relate it to
my own efforts. After forty minutes of a very satisfying
dialogue, he took leave of me and I was left to ruminate
over his vision, without much success, I must confess,in understanding the problem in the global context, as hedid.
It was not until much later, and after much thought,
when I was back in the US, that I began to develop anebulous concept of Professor Ikeda’s “globalizing” vision for Keio University. It has taken me several months
to flesh out the whole concept, at least as it has emergedin my understanding.
The core concept that Professor Ikeda described to me
was that the challenge facing Japanese medical education
goes beyond the obvious one that faces Keio University
School of Medicine, which is to produce a well-roundedphysician. As laudable as that may be, it is dwarfed bya larger challenge which faces the healthcare systemitself and makes reform of medical education so critical, as I have argued elsewhere.3 For opening my eyesto that single fact alone, I owe Professor Ikeda a debt ofgratitude. In that sense, the third paper of this series, inwhich I have articulated the case for reform of medical
education,3 is integral to understanding Professor Ikeda’s
concept of “globalization”. It can even be considered anessential preamble to this paper. However, the focus in4that paper was solely on justifying why medical education needs to change in Japan. The essence of the argument was that the healthcare system in Japan would beruined without reform of healthcare practice, and that inturn depended critically on reform of medical education.
Professor Ikeda’s concept, to my mind, goes muchfurther than simply defining the challenge of reform, or
justifying it from the standpoint of the healthcare system.
What makes it so important is that it ties together several
seemingly disparate components that go to make up thedysfunctional state of both the Japanese healthcare system as a whole, and the medical education system in particular. In that sense, it goes further than simply placing
the responsibility for that dysfunction squarely at the feetof the medical education system. It provides a unifying
theme, as well as a roadmap, for reform of both medical
education and healthcare in Japan.
I do not know if what follows in the next few paragraphs is exactly what Professor Ikeda had in mind when
he enunciated his vision to me. I cannot believe that it ismuch different, however. He is an eloquent proponent of
his concept of “globalization” of education at Keio, andI believe that I have been able to capture the essence ofthat concept in reasonably accurate detail. The report I
submitted to Keio, describing my sense of his vision has
been seen by him and, I presume, approved as being areasonable approximation of it, so I will assume it to beso.
…To a ‘Global’ Understanding of the Dysfunctional Stateof Healthcare in Japan:
The concept of “globalization” can be broken down
into several components, which mirror the componentsof the dysfunction that affects health care (and medical
education) in Japan. Viewed individually from a focused, “educator-centric” perspective, they appear to be
disjointed pieces of a puzzle, only loosely connectedwith one another. Some of these components have been
described in earlier reports, both by me1, 2 and by others,7
and it is not my intention to reiterate those yet again.
However, with the benefit of a better understanding,courtesy of Professor Ikeda’s perspective, more of thosecomponents are revealed, and their collective ramifications take on a far more pervasive character. By recognizing their interconnected nature, they can be seen tocome together like pieces in a jigsaw puzzle, and a single
integrated solution takes shape.
1. Understanding Why The Japanese Medical Graduate
Does Not Seek Global Experience: I have been struckby the curious absence of Japanese medical graduates
in residency training programs in the US.1 The fact thatJapanese graduates do not seek training in US residency
programs in any significant numbers is surprising in thecontext of the size of Japan and the number of doctors
it graduates every year. It is even more surprising when

Rao RH: A global approach to changing medical education at Keio

one considers how large and advanced the Japanese
healthcare system is. Yet, Japan does not rank in the top
twenty countries of origin of international medical graduates in the US, in striking contrast to the abundance of
trainees from many other countries in Asia.8 The significance of that statistic is brought into stark relief by thefact that the “top-twenty” list is rounded off by countries
like Colombia and Lebanon (each with approximately
3000 graduates in the US). For Japan to have fewer of its
graduates in training in the US than countries like Lebanon or Columbia boggles the mind!8
From the focused viewpoint of the clinician-educator,
it is easy to rationalize the absence of Japanese graduates
in US residency programs as a straightforward “causeand-effect” phenomenon: (i) the system of medical
education and training in Japan bears little resemblance
to the systems found in the West, (ii) as a result, Japanese medical graduates do not possess the wherewithal
to function as residents in any system that values anddemands clinical skills and critical thinking.9-1 1 The
reflexive conclusion would be that Japanese graduates
are unable, or unwilling, to take the risk of venturing out
into the threatening “outside world”.
While that conclusion may be valid in and of itself, it
is so in a very limited context. It does not represent thewhole truth, nor does it convey the magnitude of the
problem, its scope or its complexity. The contradictoryand confounding nature of the forces that are responsiblefor it are part of a much larger picture that is accuratelyreflected in microcosm by my own experiences in Japan.
On the one hand, I have sensed an astonishing enthusiasm for American residency training among Japanese
medical graduates. Given all the obstacles that stand in
the way, it never ceases to amaze me that there appears
to be such a great desire to train in America among theyoung people I have met at Keio. The economic andfinancial implications of pursuing such a dream are notsmall, and the linguistic barriers almost insurmountable,
in some cases. And yet they dream!
On the other hand, I have also discovered a very sobering reality in my interactions with these stellar young
people. The sad truth is that their enthusiasm is temperedwith a very strong dose of cynicism regarding the practical consequences of electing to train in the West. They
realize that time spent in residency training outside Japan will not absolve them of the need to train in Japan
as well, since it is a prerequisite for securing either anacademic or clinical appointment upon their return toJapan. In that sense, time spent outside Japan represents
time lost in starting a career in Japan, since the systemdoes not “recognize” it. As if that were not enough, somehave even acknowledged that it could be a waste of timein another sense too: any clinical skills training they may
acquire will be virtually impossible to import into Japan,
since the system actively discourages it.

Keio J Med 2007; 56 (1): 1－ 13

It is this conflict between dream and reality that leaves
me quite dumbfounded at times. I am not sure if a cynical acceptance of reality lies at the root of the apparent
unwillingness of most Japanese students to risk actuallyfollowing through on their dreams for “global” training.
After all, applications from Japanese graduates to US
residency program still constitute no more than a mere
trickle.8 Until one senses that it is acquiring the dimensions of a tidal wave, I am constrained to conclude thatthe aspiration to “American” or “global” experience inmost Japanese medical graduates, as remarkable as it
may be, remains just that: an aspiration. No matter how
strong the aspiration, it is trumped by the reality that any
skills acquired as a result are of little relevance for theJapanese medical graduate.
The deep ramifications of this mindset can be discerned at every level of the Japanese system. In medical
education, specifically, the example of virtually everyone in a position of responsibility in Japan demonstrates,
without leaving any doubt whatsoever, where the priorities lie. The exalted position given to research skills,
experience and achievement in academic circles in Japanreinforces, as nothing else can, the irrelevance of clinicalexpertise for academic advancement. So, it comes as no
surprise that, in the minds of trainees, no value attaches
to the acquisition of clinical skills, except as an intriguing (and transitory) curiosity. After all, if the systemdoesn’t pay even lip service to the principle of clinicalskills training, let alone to teaching those, why would thestudent value the acquisition of those skills?
In healthcare, the situation is equally dismal. Trainingthat has no relevance to the current practice of medicine
in Japan is of little value, since the development or useof clinical skills are of little consequence for the practiceof medicine.3 As a result, even those who venture abroad
to gain such experience know that any clinical skills
training acquired as a result constitutes little more thanan inevitable but unnecessary byproduct that will be irrelevant to healthcare practice when they return.
This collective mindset reverberates through the system, setting up and sustaining a vicious cycle that assuresthe maintenance of the status quo. On the one hand, theeducation system provides no clinical skills training to
its graduates, and penalizes the Japanese medical graduate who tries to acquire the clinical skills through “global”
exposure. On the other, the healthcare system discourages their use, and frowns upon the practice of medicine
that deviates from the “Japanese way”. Together, thetwin forces provide a very compelling disincentive forJapanese graduates to seek such training outside theshores of Japan.
2. Understanding Why The Global Healthcare Market
Shows No Interest in the Japanese Medical Graduate: The failure of Japanese medical graduates to seek
global exposure to date sets up yet another vicious cycle,

5this one outside Japan. The virtual absence of Japanese
graduates in clinical training outside the shores of Japanguarantees that the global healthcare marketplace lacks
any significant or sustained exposure to Japanese medical graduates. Without the benefit of such exposure, itcomes as no surprise that there should be virtually nointerest outside the shores of Japan in recognizing theJapanese medical education system as a potential poolof clinical talent. Contrast that disinterest with the widespread international recognition given to Japan as a poolof extraordinary research talent and the eagerness withwhich researchers from Japan are courted outside thecountry. The result of the disinterest is a reverberating
cause-and-effect phenomenon that has all the hallmarksof a second vicious cycle guaranteeing the status quo:
Japanese graduates do not seek clinical training outside
Japan in significant numbers, and the global marketplace
therefore has no interest in recruiting them, assuring
thereby that Japanese graduates do not receive the opportunity to acquire such training!
3. Understanding Why Globally Accepted Norms ofMedical Education Are Not Followed in Japan: The
failure of Japanese medical graduates to seek global
experience in any significant numbers has institutional
consequences that go far beyond the collective insularity
noted above. A lack of outside exposure guarantees that
attitudes inside Japan also become highly inbred withregard to teaching and training, so that clinical educators
in Japan have a very difficult time trying to incorporate
internationally accepted standards for medical education
into their curricula and methods of instruction.1 2 Methods of medical education that are developed and shown
to be effective outside Japan are rejected out of handon the grounds that they are not “suitable” for Japanese
students and conditions, without any evidence to back upthat reasoning. Emblematic of this inbred thinking is thestatement by one senior professor at Keio who told me
politely but quite emphatically that problem-based learning was neither necessary nor appropriate for medical
education in Japan because (a) Japanese students wereincapable of learning on there own, and (b) it was contrary to the “Japanese way” for students to question theirteachers. As far as he was concerned, it was a foregone
conclusion that PBL would be a complete failure in Japan. Moreover, there was no reason to change a systemthat had functioned so well for decades. After all, it had
trained him, and he saw nothing wrong with the way heturned out!
I saw little point in trying to convince him otherwise,
since his attitude did not brook any dissent or counterargument. Instead, I invited him to attend any one of theseveral PBL sessions I was scheduled to conduct during my visit, in order to have his beliefs regarding PBL
either validated or repudiated. I had little hope that hewould take me up on that, since he was convinced be-6yond any shadow of doubt that he was correct! Needlessto say, he proved me right by failing to show up at anyof the sessions. His obdurate conviction exemplifies theinsular mindset that constitutes the single biggest stumbling block to the implementation of new ideas and approaches to teaching in Japan.
4. Understanding Why Globally Accepted Standards Of
Clinical Practice Are Not Followed In Japan: The justification quoted in the foregoing paragraph for preserving
the status quo is not an isolated opinion; I have heard it
from others at Keio, too. There is no doubt in my mind
that it has to be widespread in Japan to account for the
resistance to reform that prevails there. As such, it has
yet another ramification that further amplifies and perpetuates the twin vicious cycles described above, with aneven more pernicious result.
Every system needs periodic infusions of talent andthought from outside to revitalize it and prevent attitudes from becoming inward looking, incestuous and,ultimately, sclerotic. Such periodic infusions occur only
when trainees bring back to their home country new
thoughts, ideas and clinical practices that are prevalentelsewhere. The Japanese healthcare system is deprivedof these infusions of new thoughts, ideas and practices
because Japanese medical graduates venture out of thecountry for clinical training so infrequently. Thus, attitudes such as the Keio professor’s described above
become a convenient camouflage for a deep sense of
insecurity and an excuse to reject the need for all that is
new or different. The result is that fundamental clinicalstandards that are widely accepted internationally are
ignored inside Japan. Two examples of this phenomenon
in Japanese healthcare that have been published in theliterature are the unfamiliarity of Japanese physicianswith the internationally accepted criteria for COPD andthe lack of acceptance of the Diagnostic and Statistical
Manual for Mental Disorders.13, 14
5. Understanding why the Globally Accepted Role of
the Generalist Is Not Recognized in Japan: There isa dismaying lack of any true commitment to the principles and practice of general internal medicine (GIM)
in academic institutions across Japan. 1 2, 1 5, 1 6 I havecommented at some length elsewhere on the fact that norespect or recognition is given to the general internist
in academia specifically, or to primary care in Japanese
healthcare more generally.2, 3 My initial shock and disbelief at discovering that this vitally important speciesof academic physician is extinct at Keio changed to resigned understanding when I discovered that the generalist occupies a position of such low esteem in academic
circles. It ensures that the cadre of academic physiciansthat is considered the backbone of medical education in
medical schools in other countries is sorely lacking inmedical schools across Japan. As a direct consequence,
the mindset that governs all discussion and instruction

Rao RH: A global approach to changing medical education at Keiobelongs exclusively to the super-specialist, while the primary care viewpoint is completely ignored at Keio (andat most, if not all, Japanese academic institutions, nodoubt!)
With virtually no instruction in primary care practicebeing provided in medical schools across the country,
the vast majority of Japanese medical graduates who end
up providing primary care as generalists acquire virtuallynone of the skills that are necessary for them to performin that role. The hardy souls who survive under that label
do so with the sad acceptance of their underclass status
in a highly super-specialized healthcare system. That
they survive at all is noteworthy, given their underclassstatus in the eyes of their colleagues. That they perform
as creditably as they have done, to ensure the enviable
health status of Japanese citizens,3 is nothing short of amiracle.
However, that miracle is purchased at a great “hidden”
cost. Many have told me, off the record, that their training leaves them so completely unprepared for the primary care role that it is only through “on-the-job” training that they finally learn to perform in that role. The
implications of those comments are frightening for thepatients who are unfortunate enough to be the unknowing participants in the learning curve of such “on-the-job”
training!
A lack of any meaningful instruction in general internal
medicine also explains why Japanese medical graduates
cannot perform a comprehensive history and physicalexamination, engage in critical thinking to solve clinicalproblems, or think in terms of integrated care.1, 9, 1 6 Inother words, they lack the unique skill of the generalist,
which is to see the “forest” as much as the “trees”. Moreover, with no academic role models in general internal
medicine to look up to, the Japanese medical graduate
sees no future in a career as a generalist, and views those
who select such a career with a disdain that mirrors thatwith which the system views them. This is yet anotherexample of a vicious cycle set up by a reverberating
cause-and-effect phenomenon.
6. Understanding Why Globally Accepted Standards Of
Evidence-Based Medicine (EBM) Are Not Followed In
Japan: The final ramification of the Japanese medical
graduate’s failure to be a factor in the global marketplace to this point is the most ominous of all. Without
a need to look outward, it is easy to ignore what is happening in the rest of the world. It is no wonder, then,that Evidence-based Medicine (EBM), as it is practiced
everywhere else, is nowhere in evidence in Japan! For
instance, Fukuhara et al write that the care of COPD in
Japan diverges from published practice guidelines on
several counts, including the frequent failure to consider COPD as a diagnostic entity in patients who meetcriteria, the inappropriate use of computed tomographyscans, particularly by specialists, and the infrequent use

Keio J Med 2007; 56 (1): 1－ 13

of bronchodilator therapy.13 Similarly, Ohno et al reportthat there is little agreement among Japanese clinicians
regarding the standards of care for the management ofrheumatoid arthritis (RA), and that drug prescription
based on little or no evidence is quite common.1 7 They
describe the treatment of RA in Japan as being “unique”
compared to Europe and the US, and conclude that thismay be responsible for the relatively poor outcomes associated with RA in Japan.17
The lack of acceptance of EBM has obvious consequences for patient outcomes, but it also plays a significant role in Japanese physicians’ “tendency to overprescribe”, according to Hirose et al.18 Since the systemitself has no institutional safeguards compelling appropriate practice, physicians are free to use diagnostic ortherapeutic interventions without regard to evidence oroutcome, and with no reference to quality of care or fiscal responsibility.18
My own personal experience validates these observations.3 Even more telling is the fact that, time and again,
my interactions with students and residents have revealed
that EBM is not used as the basis for either instruction or
medical practice at Keio. In fact, several residents told
me that preparing for the USMLE requires that they forget many of the things they learn for the National Boards
in Japan (and vice versa!), because the information theyneed to know to pass the latter in many cases directly
contradicts what they must know to pass the former! Of
all the indictments I have heard of healthcare practice inJapan that one has to rank among the saddest and mostdamning of all.
Formulating a “Global” Solution to the Dysfunctional
State of Medical Education and Health Care in Japan: It is not my intention to claim that the six points
described above are the only components of the problem
that matter. Nor do I wish to pretend that that this is the
only perspective that brings them together. There may beothers that are equally commendable in defining where
Japanese medical education stands today. The pointthat Professor Ikeda made-the point that resonated sostrongly with me-is fairly straightforward. It is thatJapan cannot demand respect as an equal partner in the
global health market if it is unable to command respect
as an incubator of clinical talent that is worthy of recognition outside its shores. Only by rising to that challenge
will Japanese medical education occupy its rightfulplace in the forefront of the globalization of medicine
as a whole and of medical education in particular. Only
then will Japanese health care enter the global market asa bonafide provider of comprehensive health care thatmeets international standards.
That is my redefined perspective, and I have Professor
Ikeda’s vision of globalization to thank for it. On anothernote, too, I am thankful to Professor Ikeda for reassur-

7

ing me that the future of medical education at Keio issecure. With Dean Kitajima’s tenure as Dean scheduled
to end in the not-too-distant future, I was uncertain of
the fate of reform when a new Dean took office. Dean
Kitajima’s visionary leadership, his force of will, and his
team of able deputies are collectively responsible for thechanges that I have witnessed at Keio (see below). However, there has been a lingering doubt in my mind as tothe durability of those changes once they no longer had
the same unrelenting drive and determination to sustainthem.
No longer!
Now I am reassured that Dean Kitajima’s legacy is safe
after his departure. His signature issue of ‘reform’ dovetails perfectly with his successor’s vision of ‘globalization’. In fact, the reform agenda of Dean Kitajima andthe globalization agenda of Professor Ikeda become one
when they are viewed from the perspective I have justdescribed. This is why I am confident that the changes
that I have witnessed in Keio under Dean Kitajima’s
stewardship over the past three visits will be nurtured
and allowed to expand under Dean-elect Ikeda.
The changes are still in their infancy, but the fact thatthey are occurring at all, and the fact that their futureis assured, are why I am so excited about the future of
medical education at Keio.
A Welcome Change in Attitude
My expectations after the first time I visited Keio
University in 2003 were minimal-almost nonexistent,
as a matter of fact. I fully expected that I would thatnever be invited back again, so blunt and honest was mydescription of the dismal state of medical education I
encountered there.1 But subsequent events have proventhat there existed an honest desire to change at Keio,so that my bluntness had a transforming impact on theauthorities in charge of medical education at that institution. During the course of two further annual visits overthe past two years, I have been witness to evolutionarychange that is not just measurable but truly consequential.
The change is nothing short of extraordinary when one
considers how difficult it is to challenge, let alone upend,a well-entrenched system that is as antiquated as it isobdurate. It is particularly noteworthy, because the effort
to reform the system extends to both facets of education:
learning and teaching. So, just as I have not held backmy criticism of the widespread dysfunction in medical
education at Keio University School of Medicine, I cannot hold back my appreciation of the improvements thatare being implemented there. Without a doubt, muchremains to be done. It is true that, given the magnitudeof the task, and the deeply entrenched opposition toreform, these changes may appear to be small, even in-8consequential. However, their collective impact is far
more powerful than the mere sum of the individual parts.
This is because every small change in the right direction
weakens the inertia to change in critical ways that cannot
be gauged. Not only that, it slowly but inexorably builds
a momentum that emboldens and swells the ranks ofthe true believers even as it weakens and diminishes theranks of the doubters and non-believers.
From my perspective, these changes are highly significant because they are occurring in the very three areasthat constituted my biggest concerns regarding medical
instruction at Keio University:2
1. A lack of commitment to fostering active learning techniques at Keio
2. A lack of commitment to teaching on the part of the faculty at Keio
3. A lack of commitment to encouraging and rewarding
teaching and teachers at Keio
On all three fronts, I have witnessed progress that istruly consequential.
1. Keio is Making a Commitment To Fostering Active
Learning Techniques By Incorporating PBL Into The
Curriculum: It is a matter of great satisfaction and excitement for me that Keio University School of Medicine
has now made an official commitment to introducing
Problem Based Learning into the curriculum. The details
have not been worked out in terms of logistics, such as
the curriculum changes that will be necessary to free uptime for PBL exercises. Nor is it clear where and how
the material will be procured and developed for use in
the PBL format. However, there can be no mistaking thecommitment. In anticipation of the proposed curriculum
revision, a wholesale renovation has been completed toconstruct rooms suitable for small group discussions,
all fully equipped with the latest technology, including
computer access and electronic “chalkboards” that permit direct printing of transcribed material.
I have made clear in the past my passionate belief that
Problem Based Learning is the quickest and surest way
of introducing several key concepts into medical student
learning.1, 2 These include critical thinking, introspective learning, clinical problem solving, and integrationof knowledge across organ systems and disciplines. Allof these are conspicuous by their absence from learningand teaching at Keio at the present time. Yet, I will attest
to the fact that medical students at Keio are ready, willing and able to grasp and apply these concepts, provided
they are given the opportunity.
In my first two visits, I conducted a total of five different PBL sessions for students at all levels in medical
school, from the second year (preclinical) to the sixthyear (clinical). I even facilitated one of those in Japanese, even though I myself speak no Japanese, just to
prove to myself and to the faculty at Keio that it is possi-

Rao RH: A global approach to changing medical education at Keioble for Japanese medical students to learn independently
without being spoon-fed! With my contribution being
practically nothing, except for an occasional nudge when
I sensed that the students were getting stalled, it was a
resounding validation of the whole concept of learningthat is driven by students themselves. This one observation alone refutes, without any prevarication or doubt,
the opinion of the senior professor, quoted above, thatJapanese students are incapable of independent learning.
Too late it dawned on me during my second visit that
we could have recorded those PBL sessions for viewing
by the non-believers among the faculty at a later date.
On my most recent visit, however, Professor Amano videotaped both PBL cases I conducted, including one that
I facilitated yet again for a group of students who spoke
only in Japanese. He intends to make both of these mandatory viewing for all faculty members.
2. Keio is Making A Commitment to Changing theMindset of its Faculty Towards Teaching: On my mostrecent visit, an event of great significance occurred. It
was a Faculty Development Workshop that I conducted.
The goal was to, in effect, “teach the teachers how toteach”! As part of that effort, I wanted to conduct a PBL
session that was witnessed by the faculty, in order todemonstrate the incredible excitement and enthusiasm
for learning that it generated in the students. I was convinced that if they only witnessed the joy the students
evinced, the resistance of the non-believers would beundermined beyond recovery.
In the months leading up to my visit, Professor Amanoand I exchanged several e-mails regarding how to deal
with the one major stumbling block to success that
seemed almost insurmountable: the refusal of the faculty
to attend any sessions that were conducted by me. Fromprevious experience, I was well aware that the faculty
had no interest in, nor did they believe in, the “heretical”
concept of student-directed learning that I was trying toconvey. Despite repeated entreaties by Professor Amano,
no faculty members other than those in the Departmentof Medical Education made the effort to attend or takeadvantage of any of the multiple opportunities that myvisits created for them to witness PBL in action.
We finally hit upon a solution. I made a plea to Dean
Kitajima to make an appearance at the Workshop so that
it would leave no doubt in the minds of the faculty thatthe effort bore the stamp of his approval. Knowing fullwell how busy he was as the Dean, I expected little morethan a cameo appearance from Dean Kitajima at the startof the Workshop, with him making a few supportivecomments.
I should have known better!
Not only did Dean Kitajima make an appearance, he stayed
for almost 2 hours (90 minutes longer than he had available on his schedule). His attendance, for which I am

Keio J Med 2007; 56 (1): 1－ 13

very grateful, was a resounding vote of approval forthe effort, and it could not have been lost on the fortyodd faculty members in attendance, most of who stayedthrough the entire day!
The result was a resounding success from many standpoints:(i)
The faculty finally witnessed Problem Based
Learning in action. This development was ofmonumental significance. I had no great hopethat anyone would be interested enough to attend,
based on past experience. But Dean Kitajima’spresence did the trick on that score. As a result,many of those who might otherwise never haveattended the Workshop had the opportunity to see
and experience first hand how exciting and rewarding it is for both the student and the teacher
when a problem-based format is used. Even more
important was the fact they got to see how skilled
and enthusiastic their students could be when they
were not spoon-fed. The result was a memorable
first experience for most of the attendees.
When the idea of conducting a “live” PBL session in public first entered my mind, my immediate
reaction was to reject it out of hand. There wereseveral compelling reasons to do so. In the firstplace, to conduct a PBL in public would suppress
the spontaneity and freewheeling discussion that
underwrite the success of a PBL format. A second and even more powerful disincentive was mydoubt over the wisdom of exposing the students
to “performing” under the critical eyes of theirdisbelieving teachers. Having witnessed the highly
paternalistic atmosphere that pervaded instruction at Keio, I worried that they might regress into
tongue-tied silence in front of their own “sensei”.
Moreover, there could be no doubt in their minds
regarding the certainty of the scorn and ridicule
they would face, were they to fail. Finally, and noless worrisome for me, I had to face the unpleasant truth that a failure on their part in such a publicforum would sound the death knell of efforts toconvince the faculty that PBL was a viable andvaluable commodity in medical education.
All of these compelling reasons notwithstanding,the one reason to do it kept nagging at me: the opportunity to show the disbelievers (like the seniorprofessor I quoted earlier) that Japanese students
are accomplished at self-directed learning, and aremost effective as learners when they are allowed toquestion their teachers and themselves. In the end,
the temptation to rebut and reject the narrow mindedness of the disbelievers overcame my reluctance.
Convinced that the potential upside far exceeded
the downside, I decided to put my faith in the abilities of the wonderful young people I have had the9privilege of teaching at Keio.
They rewarded that faith in resounding fashion.
All my anxieties were blown away within the first
five minutes of the session. Not only were they
not overawed by the occasion, they performed inthat public forum with an aplomb that I am notsure could be exceeded by my students at Pitt! In
fact, I would be surprised if the latter could evenmatch it, when one factors in the conditions. They
were confronting an audience in which there weremore than a few who were not only inimical to thewhole concept of PBL, but were actually waiting
for them to stumble. In that context, the ability ofthese first-timers to perform without even the semblance of a stumble was nothing short of incredible.
They did such a fantastic job that they surpassed
even my expectations. (I might add that those are
now very high indeed, given the exceptional quality of the students I have had the privilege to workwith over three visits.) Without any coaxing or
coaching on my part, they presented the material
they had prepared (for the PBL Resolution) with aconfidence and skill that made them appear to be
old hands at the exercise. The result was that thefaculty members in attendance were treated to a
virtual tour de force in active learning (for the students) and restrained facilitation (for me).
(ii) The faculty members in attendance had an eyeopening introduction to the joys of teaching. Afterthe session was over, several faculty members expressed wonderment at having witnessed such excitement and enthusiasm from their students. They
also commented, with evident disbelief, that boththe students and I seemed to be having a lot of fun,as if to imply that they never thought that learning(or teaching!) could ever be associated with having fun! That one reaction alone was fulfillment
enough for me, because that was the very message I wanted to convey. The fact that it resonatedproved to me that they got the message that active
learning is the essential prerequisite for effective
teaching.
(iii) The faculty members in attendance were introduced to concepts of active learning and interactive teaching. Before the PBL Resolution session,
I delivered a didactic lecture that focused on themutually interdependent concepts of “teaching tolearn” and “learning to teach”. Those twin concepts are central to my own core philosophy as aclinician educator, and I was honored that Dean
Kitajima and Professor Amano asked me to deliverit. That sense of honor was transformed into delight when Dean Kitajima, who had earlier asked
my pardon for having to leave early, actually

10

(iv)

Rao RH: A global approach to changing medical education at Keio

stayed until the very end (90 min longer than heintended), taking copious notes throughout the lecture. I have no doubt that his presence sent a verystrong message to the faculty in attendance that hewas serious about reforming the attitude towards
teaching at Keio.
I was able to show the teachers how difficult it is tobe a student. Teachers at Keio regard teaching as
drudgery or worse, and view the “ignorance” oftheir students as an irritant. This mindset is compounded by the traditional Japanese belief in theinfallibility of the teacher. The result is inevitable:
teachers possess a sense of power and arrogancewhich dictates that the failure of a student to learn
cannot be the teacher’s fault, only the student’s.
This destructive mindset has to change for teaching
to become interactive.
To jumpstart the effort to effect this change,
I conducted an exercise on “The Challenges ofTeaching and Learning” as part of the Workshop.
The attendees were divided into small groups ofabout 8-10 individuals, each with a facilitator who
was “trained” in the conduct of the group exercise.
Each small group was in turn divided into two
halves, to function in turn as either “teachers” or“students”. The material to be “taught” was a simple, everyday picture taken from a news magazine.
The task of the “teachers” was simply this: they
had to describe the picture in front of them, using
only words, while keeping it hidden from the viewof their “students”. Explicit instructions were also
given that all visual cues were forbidden, such as
facial expressions, hand gestures or body language.
The task for the “students” was equally simple:
to draw the picture as best they could from the words
being used by their “teachers”, without asking anyquestions. Then, the two subgroups exchanged
their roles as “teachers” and “students”, and theexercise was repeated using a different picture.
The purpose of the double exercise was to bringhome a critical point to the faculty in attendance.
It is fundamental to all successful instruction toappreciate that the material being taught is like a“picture” in the teacher’s mind, always perfectly
clear and easily seen by the teacher, but completely
hidden from the view of the student. It is the dutyof the teacher to draw that picture in words, withpatience, forbearance and exactitude, so that it assumes a concrete shape in the mind of the student.
The onus for making sure that it does sits squarelyon the shoulders of the teacher, not the student!
The point became eminently clear when the“teachers” saw the results of their descriptions.
The “students” drawings graphically demonstrated
how difficult it was to transpose the teachers’

words into an image that bore any resemblance
to the original. Vague elements of the teachers’
descriptions were discernable in the drawings, buteach “student” appeared to grasp only some fragments of the total content, and those were not consistent across the group. It became evident to allthat the difficulty lay not so much in the students’ability to draw the picture from the descriptions as
it did in the way the teachers described the picture.
An even more important insight was provided by
the participants themselves, without any prompting on my part. All agreed without exception that
it was much more difficult being a student than ateacher! Most telling of all was the opinion thatone participant voiced, and was almost universallyendorsed, that I had made it very difficult on the“students” by preventing them from either asking
any questions, or directing the descriptions according to their perceived needs. Had they been permitted to do so, they would have been able to draw amuch more accurate picture.
That spontaneous comment delighted me morethan anything, because it told me that the message had struck closer to home than any of theparticipants even realized. It presented me with theperfect opportunity to make the point that learning
occurs only in an environment where students andteachers engage in a free exchange of thoughts andideas. It helped me make the point that the traditional Japanese paradigm of education, in which it
is virtually forbidden for a student to ask a question of the teacher, is completely counterproductive to learning.
3. Keio is Making a Commitment to Recognizing the
Status of Teachers and the Importance of Teaching: It
is no secret that academic centers in Japan consider research output as the only criterion to judge suitability forpromotion, and place no value on teaching as an activity
worthy of recognition towards academic advancement.
Since there is no tangible reward for teaching at Keio, itshould come as no surprise that the faculty have neither
the enthusiasm nor the desire to teach.1, 2 The good news
is that this may be about to change.
(i)Teaching will be rewarded. I was informed byProfessor Makhoto Suematsu, the Chairman of
the Committee on Medical Education at Keio, that
there is general agreement in the Committee thatthe measures for rewarding teachers that I had
proposed as part of my ‘Blueprint for Reform’should be considered for implementation at Keio.2
Clearly, the actual mechanics of the system of academic advancement based on teaching have yet tobe worked out. However, it is an astonishing turnaround from the situation that prevailed earlier that

Keio J Med 2007; 56 (1): 1－ 13(ii)

the merits of teaching as a measure of academic
achievement are even being debated. I cannot wait
until my next visit to assess how much progresshas occurred in formulating and implementing the
new system of promotions for teachers.
Clinical teaching is being encouraged. An evenmore stunning new development is the recent appointment of not one, but two full-time clinicianteachers at Keio University Hospital. Both these
physicians (Dr Toru Satoh and Dr Tomoharu Yajima) are now free to teach students, with salary
support being provided by the Dean. I myself witnessed the enthusiasm of both these fine clinicians
for teaching. Of particular note, both are gentle
and kind towards their students, and do not exhibit
any of the overbearing dominance that I have witnessed in other teachers at Keio towards their students. Dr Yajima, in particular, spends all his timeon the wards, rounding with residents and students
on his unit and teaching them. I was very gratified
to learn that he is trying to teach his trainees how
to perform a comprehensive history and physicalexamination. The effort is to be applauded, even
if the results on view when I rounded on his ward
with his residents were somewhat mixed. That
does nothing to diminish, in my view, the value of
his approach. It is reflected in the enthusiasm of
the residents in his ward for good clinical practice.
I left his ward with a renewed sense of hope andexcitement.
A Yardstick to Measure Change

The challenge of reforming medical education in Japanis not one for the faint of heart, given the stubborn resistance to change that seems to be endemic in the Japanese
healthcare system as a whole, not just in medical education alone. That is why it is all the more creditable that
progress is being made at Keio in changing the culture
and the system of medical education and training.
If every journey begins with one small step, then thechanges I have described above collectively represent
a giant leap forward in the long journey of reform on
which Keio is preparing to embark. The first tentative
steps in the process that started after my initial visit in
October of 2003, are exploring new ground. Although it
would be foolish to minimize the distance yet to be traveled, it would be equally foolish to minimize how far
Keio has come in the short time since that first visit. The
best way to validate the dramatic turnaround in approachis through the turnaround in my own reaction, from thedismay evident in my first paper1 to the excitement andhope that I feel now.
Unfortunately, my reactions are not an objective or
reliable measure of the progress that is being made. It is11

necessary to measure progress in the context of the two
closely related aspects of training to which any medical
graduate must be exposed in order to perform creditably
in the role of the generalist: the acquisition of clinicalskills and the ability to think critically. As I have noted
elsewhere, five parameters define a model of medical
education that satisfies the dual requirements of providing training in both areas:2, 3(i)
It is problem-based;(ii) It is case-based;(iii) It is evidence-based;(iv) It is focused on developing clinical skills; and(v) It is two-way and interactive.
These five elements together comprise the best yardstick to measure the degree to which medical education
at Keio is fulfilling the two crucial requirements of inculcating clinical skills and critical thinking in its graduates.
By applying this five-parameter yardstick to the state of
medical education at Keio as I found it initially, and as itexists now, it is possible to measure the progress that has
been made since my first visit.
At the outset, let me state that not one of the five parameters was in evidence on my first visit. Measured
against that, of course, any change is significant. However, the true significance of the change and its magnitude become discernable if one examines each of the fiveindividual parameters that define an effective model of
medical education:(i)
The first big change at Keio that I see now is thedetermination to introduce PBL in the curriculum;
when that happens problem-based learning will
become a reality at Keio;(ii) Second, the presence on the faculty of two fulltime clinician educators is a signal that case-basedlearning at the bedside is finally making its appearance at Keio; if it becomes more widespreadit might become a reality;(iii) Third, there is hope-just a sliver at this point, butvery real-that the recognition of the clinician-educator’s role for the first time at Keio could lead tothe development of a cadre of clinician-educators
among the faculty at Keio; if and when that happens, there will inevitably be a much greater focus
on developing clinical skills at the bedside;(iv) Even more faint, but no less real, is the first glimmer of cooperation from the faculty regarding thevalue of interactive teaching, thanks to the visible support of Dean Kitajima at the workshop I
conducted; it means that, eventually, the unidirectional, didactic and dictatorial style of teachingthat prevails at Keio might give way to somethingthat actually encourages, rather than discourages,
student participation in learning.
(v) The fifth parameter, evidence-based medicine, isnoticeable by its absence in the process of educa-

12tion at this time. Even though it is the one “missing” parameter, it is my hope that teachers will beforced, of necessity, to question their own beliefs
and test the validity of those against the evidence.
if problem-based and interactive learning take rootin the medical education system. However, it is ahope that is too far in the future to contemplate inany realistic fashion.
Common to all five statements above is a liberal sprinkling of conditional qualifiers, like “if”, “could”, “might”
and “when”. They reflect my own uncertainty regarding
the durability of these preliminary efforts at reforming
medical education at Keio. The numerous conditional
qualifiers associated with the first four parameters andthe “missing” fifth parameter collectively represent the
distance yet to be traveled to achieve successful reformof medical education at Keio. That distance seems almost overwhelming, even discouraging, to contemplateat this time. I prefer, however, to concentrate on the
distance that Keio has traveled in the short time that has
elapsed since my first visit. That is what confers on thechanges their monumental significance, to my way of
thinking.
I cannot end without stating that, if I appear to be singling out Keio University for being beset with problems,
it is only because it represents the one academic institution in Japan that I have had the privilege and honor tovisit. I am fully aware that the problems I have identified
are not unique to it. I have had informal discussions witha number of leading Japanese educators who have participated in the Pittsburgh-Japan Program directed by Dr
Haruko Akatsu-Kuffner at the University of Pittsburgh.
Coming as they do from all corners of Japan, they represent the entire spectrum of academic and non-academic
teaching hospitals in Japan. This makes their opinions
particularly valuable as teachers who are familiar withconditions that prevail across Japan.
All, without exception, assure me that the situation I
encountered on my first visit to Keio is no different fromthat to be found in every other academic institution in
Japan. They admit that medical student education everywhere in Japan remains mired in the same stultifying
didactic mode. According to them, learning is just as determinedly unidirectional and passive everywhere else,
as it is in Keio. The universal nature of the dysfunction
has deep roots in the traditional Japanese approach toeducation from the earliest stages of elementary school,
and is in keeping with the feudal “ikyoku-koza” system in medicine.19 The result of those deep roots is thatrecommendations made over the past two decades to revamp the system have languished, gathering dust, without any evidence that they have any hope of resurrectionin the foreseeable future.20 More recently, there has beena push by the authorities to impose change from above
on a recalcitrant system.2 1 However, implementation of

Rao RH: A global approach to changing medical education at Keiothose initiatives has been undermined by a largely cosmetic whitewash that preserves, protects and perpetuates
the established system. That is not surprising, since theresistance to change is deeply rooted in a tradition thatpermeates all levels of Japanese society; it would benaïve to expect it to vanish or change in so short a periodof time.
Nevertheless, I am filled with hope that the progress
being made will continue at Keio, and will accelerate notjust there but in other institutions across Japan. The bestindicator of the potential for transformational change
is to be found in the excitement that I have witnessedamong Japanese students for clinical skills training. Thatfact, I can only hope, will not be lost on others (including the program at Keio, itself). With time and the commitment of resources, this could result in the gradualevolution of Japanese medical education into something
more akin to systems of medical education and trainingthat are seen in most other parts of the world.
Acknowledgements
I want to thank Dean Kitajima and Professor Amanofor their steadfast commitment to the reform of medical
education at Keio, and Professor Ikeda for his vision andthe time he spent articulating it for my benefit. I particularly want to acknowledge the encouragement, advice
and support of this ongoing effort provided by Dr Haruko Akatsu-Kuffner, Director of the Pittsburgh-Japan
Program. Her many helpful criticisms and comments
were invaluable during the writing of this manuscript.
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