REVIEW
Perspectives in Medical Education
1. Reﬂections on the state of medical education in JapanR Harsha Rao
Professor of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, U.S.A.
(Received for publication on September 15, 2005)(Revised for publication on March 16, 2006)(Accepted for publication on April 20, 2006)

Abstract. The current shortcomings in Japanese medical education are highlighted by identifying four
major areas of concern, based on the author’s personal observations at Keio University Hospital. The
ﬁrst of these is a woeful lack of clinical skills among Japanese medical students and residents. This lacksprings directly from the complete absence of any bedside clinical instruction, which constitutes thesecond area of concern. The third is the attitude of faculty towards teaching as a burden that detracts
and diverts them from their primary goal of academic advancement through research. Finally, there is
no recognition of the value of a problem-based approach to teaching clinical medicine, so that clinicalproblem-solving skills have atrophied to the point of near-extinction in the current generation of Japanese physicians. The promise of problem-based learning (PBL) provides a crucial starting point for
efforts to change the system. PBL emphasizes the importance of an integrated approach to clinicalproblems, and a reliance on critical thinking – the basis of primary care. This contrasts with the selective and highly specialized approach to disease, and reliance on sophisticated technology, which arehallmarks of specialty care. The effort to reform medical education will fail without visionary leadership and without the willingness to confront the truth, as unpleasant as it may seem to be. Both these
crucial elements exist at Keio University at this critical juncture. It is this happy conﬂuence thatemboldens the author to hope that the future of reform is in good hands at this august institution. (KeioJ Med 55 (2): 41–51, June 2006)
Key words: Japanese medical education, problem based learning, clinical instruction, bedside learninga percentage of the gross domestic product is approximately half that of the United States!3,4 Nor can thequality of the health care be called into question, incomparative terms. It actually assures better outcomesfor its citizens compared to those in the US at any
number of points along the age spectrum, based on
measures such as natal, postnatal, and total infant mortality, the prevalence of low birth weight (<2500 g), as
well as life expectancy at age 20 and age 65.5
Notwithstanding this success, there is now a growing
recognition in Japan that the overwhelming emphasison specialty care is detrimental to both the health of thesystem and the health of the public, and that this mustchange.1,2 Unfortunately, the existing system of specialty care is sustained and perpetuated by a system of
medical education that places no value on primary care

Introduction
Health care in Japan is in a state of ﬂux. The established tradition of reliance on specialty care is being
forced to accept, for the ﬁrst time, that it may have tocoexist with, and maybe even yield some of its preeminence to, primary care.1,2 To an outsider from theUS, like the author, the need for such a transition
appears, at ﬁrst glance, to be not only obvious and essential, but long overdue. And yet, on closer examination, it becomes apparent that the complexity of theissues involved is far greater than that which appears so‘‘obvious’’ to the outsider, both in quantitative andqualitative terms. After all, Japan provides its citizens
with universal health insurance, while the US does not,despite the fact that Japan’s total health expenditure as

Reprint requests to: Dr. R. Harsha Rao, Room 580 Falk Medical Building, 3601 Fifth Avenue, Pittsburgh, PA 15213 U.S.A., e-mail: rao@dom.pitt.edu
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training.2 As a consequence of these twin forces (undueemphasis on specialty care, and a virtual absence of
training in primary care), there exists in Japan today aserious shortage of physicians who possess the requisite
clinical competence to act either as providers of primary care or as educators in general internal medicine.1,5 Thus, a change in one must be paralleled by achange in the other for reform to take root.
In other words, it is mandatory that medical education adapt to support and sustain the larger and more
fundamental paradigm shift that is being nurtured in
the system of health care in Japan.6 However, the needfor reform in medical education goes beyond changing
the emphasis from specialty training to general internal
medicine training. It involves a radical departure fromthe traditional Japanese approach to student and resident training, based on the feudal ‘‘ikyoku-koza’’ system.5,7 To an outsider unfamiliar with Japanese tradition, it bears a striking resemblance to an older
Germanic tradition of apprenticeship. It is no accident,
however, that this is so, since German medical educators played a major role in the evolution of modern
medical practice in Japan.8,9 However, that remnant ofa bygone era remains in place in Japan even though it isso antiquated as to be no longer extant even in Germany!
This all-pervasive system presents a disconcerting,even forbidding, intellectual challenge to the outsider(like the author). Understanding its cultural underpinnings, however, is imperative, because only then is it
possible to understand why the pace of reform in Japan
appears so painfully slow. Societies that revere tradition
do not take kindly to change. Therefore, reform that is
as fundamental and far-reaching in its impact as tothreaten a deeply entrenched tradition is rejected insuch societies as being either unnecessary or harmful.
As a result, the reforms in health care and medical education that are being introduced and enforced throughﬁat are being met with an inertia that consists of equalparts natural anxiety, overt apprehension, covert resistance, and obdurate denial. The inertia to change is no
more than a natural successor to the overt refusal tochange that was acknowledged two decades ago, when
the ﬁrst proposals were made to modernize Japanese
medical education.10 And it is as pervasive now as it
was then, I must assume, based on my experiences andon what I have heard from several struggling teachersin Japan.
It is only by acknowledging the cultural imperatives
that drive this resistance to change that one begins tounderstand it. That change is being considered at all is atribute to the far-sightedness of those in charge of
medical education in Japan. That it needs to be forced
upon a recalcitrant system is understandable. That it
will take time and a lot of heartache on the part of all

Rao RH: The state of Japanese Medical Education

concerned is only to be expected. That it is succeedingin some centers is nothing short of extraordinary. That
it is occurring at all is attributable almost exclusively tovisionary leadership that is committed to dragging thesystem, kicking and screaming, out of its inertia.
Yet, the successes in many of the lesser known outposts, for all the richly-deserved plaudits they must anddo receive, are not the stories that bear watching. In
such centers, recognition for the need to change
requires the force of will of relatively few individuals.
This is best exempliﬁed by the pace of change in residency training programs at so many non-academic
teaching hospitals across Japan. It is there that one seesa gradual, if still reluctant, recognition of the importance of teaching basic clinical skills and clinical decision making.11 That is a self-sustaining change that will
only increase in momentum as the popularity of thematching program increases, and market forces apply
increasing pressure on hospitals to stay competitive inthe race to attract the best residents.
So it is not residency training – the apex of the
pyramid – that causes the greatest concern. It is the inertia to change at the base of the pyramid – medical
student education – that is of greatest concern. This is
no more evident than in some of the leading centers for
medical education in Japan, where the well-entrenchedinterests see no incentive to change, and clinical instruction remains virtually non-existent.5 There is, after
all, no competition for the best students at these institutions, since the cachet of graduating from the top
universities, and the opportunity such places provide
for contacts with faculty who can provide signiﬁcanthelp in future academic careers, far outweighs any
deﬁciencies in the quality of education that is provided.
I have had the privilege of closely observing andparticipating in Japanese medical education during periodic visits to Keio University School of Medicine inTokyo since 2003, at the invitation of Dean Kitajima
and Professor Takahiro Amano, Head of the Department of Medical Education. During those visits, I havelearned much that is new to me, observed even morethat is utterly fascinating, and have been rewarded,
most of all, in a way that most teachers can only dreamabout! These experiences motivate me to put down on
paper the uniquely personal perspective that I havedeveloped regarding medical education in Japan. This
article details my observations regarding the state of
medical education at one of Japan’s premier institutionsof medical education. They reﬂect my own approach to
medical education, developed over three decades andthree continents, and must be viewed in that light.
The observations described herein are not intended
to replicate the well-documented need for reforms inthe medical education system in Japan. They are, as I
noted above, highly personal and subjective, derived

Keio J Med 2006; 55 (2): 41–51

from my impressions of the state of clinical instruction
at Keio University School of Medicine, primarily for
medical students, but also for residents. There is not,therefore, any intention on my part, to portray these as
being widely applicable or comprehensive, given thefact that my observations are derived from interactions
with a relatively small number of students who werereasonably skilled in understanding English (although asigniﬁcant proportion were unable to speak it with great
ﬂuency). Although I believe that the problems andpromise that I discovered reﬂect those in the system as
a whole, I have tried to restrain my impulse to generalize, except insofar as my observations force thosegeneralizations upon me. The observations are, nevertheless, capable of being generalized to teaching practice as a whole at Keio University School of Medicine,
because their validity has been veriﬁed by both thestudents themselves as well as the authorities in chargeof medical education at Keio University.
My observations on the system of Japanese medical
education can be divided into four groups, based onfour speciﬁc aspects of the interactions I had during myvisits, as follows:
1. The skills of Japanese Medical Students
2. The status of Bedside Clinical Instruction
3. The attitude towards Clinician-Teachers andTeaching among the Faculty
4. The applicability and promise of Problem Based
Learning
1. Japanese Medical Students: If I were asked to pickon the one thing that made my trips to Japan the mostrewarding experiences I have EVER had as a teacher,
my answer without the slightest hesitation would be theincredible young people I had the privilege of getting toknow. The number was not large; that was, obviously,
because of my own limitation in linguistic skill (I speak
no Japanese!). So, per force, the only students who
could beneﬁt from my presence were those who understood and spoke English. Despite this failing on mypart, the enthusiasm and intelligence of those young
people was breathtaking. They are as bright and incisive as any of the best students I have encountered overthree decades and across three continents, thirstilysoaking up instruction like sponges. Having said that,
however, I have to say also that, for the most part, (andthrough no fault of their own!), they would not measure
up to even the most average student of comparable
chronologic seniority in the US (i.e. 3 rd and 4 th yr
medical students). This is because of several factors:(a) Lack of Clinical Instruction: Of all the reasons, thisis the one that is most glaringly obvious. In essence,
it would doom the Japanese medical graduate in the

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US system. And it explains a curious anomaly that has
intrigued me personally for years: despite the vast
number of international medical graduates in the US
from almost every country in Asia (even discounting
the English-conversant countries of South Asia) rareindeed is it to see a Japanese IMG in a residency program in the US.
And the cause of this is not difﬁcult to ﬁnd: Japanese
medical education pays no more than lip service to thedevelopment of clinical skills in medical students. Instead, the focus is almost exclusively on the memorization of esoteric details, often without any regard to theirrelevance to clinical practice (or international medical
practice, for that matter!) As a result, the students possess dazzling book knowledge, but have not even themost rudimentary understanding of how to perform an
H&P. Basic interviewing skills are absent, there is noappreciation of the value of a structured history with its
essential elements, and no one can elicit a physical sign,
let alone perform a physical. And yet, ask them what
the causes of any physical sign are, and they can rattle
off a list as long as your arm!
Case presentations (at least as I understand them)
are non-existent. Most students and residents could
not present a case to me in even the most rudimentary manner. The exceptions were the three students in
the group who had completed a wholly voluntary (and,I am told, extremely expensive!) summer externship at
a US hospital. These three performed passably wellbecause of a rare familiarity with case presentation
techniques that we consider routine. These three exceptions are important because they give me hope that,with proper instruction in History and Physical Examination skills, most Japanese students will perform
creditably.
(b) Passivity: This was the second most glaring failingin the students. It constantly drove me crazy to see
these incredibly brilliant and knowledgeable young
minds go into limbo because they were taught not to
ask ANY questions. I came to realize that it was theJapanese way when I was told by them, in fact, that toask a question was a sign of disrespect for their teacher!
So much so that a couple of students even implied thatthey were afraid to ask because they would be ridiculedfor being too dumb to ﬁgure it out for themselves!
What a travesty of the whole concept of teacher andstudent interaction! Even for me, as someone originallyfrom another Asian culture with a similar tradition ofreverential respect for the teacher, this was hard toswallow! So I made sure that, by the time I left, they
had learned to open up with me at least. By then, I had
them joking with me, and even learning to tease me. I
can remember quite clearly the ﬁrst time that happened, because I felt the room go absolutely still withtension. It was relieved only by my guffaw of laughter44

and my congratulating the student for breaking thetaboo!
This passivity of Japanese students is a failing that
may be much harder to correct than their lack of clinical skills, because it appears to be culturally ingrained.
It is inextricably linked to an extremely formal and didactic educational system, which is, from the very beginning (in grade school), one-way and passive, rather
than two-way and interactive, and discourages nonconformity. Changing that, in a society that prides itself(and justiﬁably so) on its incredible record of achievement using its own traditional, home-grown approach,is a formidable undertaking. But if ever there was a society where such fundamental change might be possible,
it is Japan, because the very desire to conform can be a
powerful sustaining force for change, once reform isgiven institutional approval. That is my hope.
(c) English speaking skills: These were highly variable,
even among those who ‘‘spoke’’ English. So my interactions were constrained on occasion by the difﬁculty incommunication. About one-third of my group spoke
excellent idiomatic English, although a couple of them
did have an accent. Another third spoke it passably welland were able to make themselves understood, although they hesitated at frequent intervals to ‘‘word
search’’. Most of this subset were also able to understand me without requiring me to repeat myself or slow
down. But they had trouble with idiomatic English. The
rest had major problems with understanding spoken
English, even with my deliberate slowing down of what
is ordinarily a quite measured speed of delivery. Thatcut both ways, because I had trouble understanding
their spoken English as well at times. And one of the
ﬂuent English speakers would have to translate fromJapanese for me. While that could represent a signiﬁcant handicap for these otherwise stellar students ifthey were to enter a US residency program, it should bereasonably easy for them to surmount in most cases
after a few weeks of immersion in American society.
(d) Medical Terminology: This is not a widespread
limitation, but might be potentially a signiﬁcant handicap in the short term, even for those who speak ﬂuent
English. I had trouble at times with terminology andwas forced to resort to mime and hand gestures to makethem understand the body part, symptom, sign or disease to which I was referring! But overall, these
instances were rare enough that they did not pose a
problem in communication that was insurmountable.
2. Bedside Clinical Instruction: In a word, NONE! Student after student told me that I was the ﬁrst person
ever to show them ANY physical signs, discuss how toapproach the history and physical, instruct them onpresentation skills, tell them how to generate a clinicaldifferential diagnosis before they got the results of tests,

Rao RH: The state of Japanese Medical Educationteach them a priori analysis using pre-test probabilities,
or to stress an evidence-based approach to treatment.
This is a problem that stems directly from one fact:
there is NO (as in ‘‘zero’’) understanding of the conceptof training in general internal medicine. Others havedescribed this before,3,4 and I went to Japan fully forewarned to expect this, but until one actually goes toJapan, it is impossible to comprehend the immensity ofthis problem. The fact is that every physician in a
University Teaching Hospital is a specialist who sees
patients exclusively within a very circumscribed sphereof interest, starting from the very ﬁrst day out of medical school.15,16 The solitary exception to this otherwise
universal rule can be found in ER physicians, who see
all-comers.
The specialists I encountered in Keio University
Hospital are admittedly highly skilled in their individual
specialties, possibly even among the best in the world atwhat they do. But they are extremely limited in what
they can do, because they only see patients with problems that fall under the purview of their own specialized interest from the moment they graduate frommedical school. These otherwise highly competent specialists have themselves never been exposed to theconcept of general internal medicine. And so, with eachsuccessive generation being incapable of providing
the next one with a comprehensive view of medicine,the highly specialized system perpetuates its narrowly
skewed view of disease processes through successive
generations of medical students and teachers. And so it
transpires that successive batches of trainees leave theirteaching hospitals without any training in clinical skills
or concept of general internal medicine, and go into
practice to function as. . . . general internists! Thus,
these generalists are burdened forever by not only alack of clinical skills, but also a mindset bred from an
exclusive focus on a subspecialty viewpoint.17 The consequences for quality of patient care are all too obvious
to be even stated here!
A mind-set dedicated exclusively to specialty care
breeds another problem: even with the eventual acquisition of clinical skills through experience, the conceptof examining the patient as a whole is nonexistent.
Thus, in all the time that I was in Japan, I did not encounter a single resident who could present a comprehensive H&P. Case after case presented to me by theresidents consisted basically of a statement deﬁning thedisease or diagnosis that brought the patient to attention, a rudimentary exam of the system relating to thespecialty of that unit, and then an immediate segue tothe slew of diagnostic tests that had been performed, allwhich were exclusively related just to the ‘‘organ label’’that the patient carried!
Lest this be interpreted as nothing more than themost extreme example of sub-specialty rotations inKeio J Med 2006; 55 (2): 41–51

American tertiary care hospitals, let me clarify. This
was not a case of a specialist who recognizes a problem
outside his/her area of interest and then says ‘‘I know
nothing about this, so let me ask for help’’. To the contrary, the ‘‘specialists’’ that I encountered probably
would not even recognize, let alone have a good understanding of a problem that fell outside their purview.
So, you have the terrible situation of a patient I saw thesecond day I was there with proven congenital heartdisease (TGV with pulmonary atresia and a single ventricle), who developed cough, fever and chills, and went
to see a pulmonologist (because of the cough!), and wasgiven oral antibiotics for chest congestion. He got
steadily worse over the next couple of days, developed
diarrhea from the antibiotic and went to a GI expert,
who gave him another course of oral antibiotics for
gastroenteritis. Yet another week went by before he ﬁnally ended up in the ER, critically ill, and thus wasseen by the only kind of doctor who sees patients of all
stripes. A diagnosis of SBE was ﬁnally made and thepatient was admitted to the ICU! Needless to say, thepatient was still critically ill when I saw him, three
weeks after admission.
And that was not even the most egregious exampleof this terminally specialized system at work. On mylast day, I saw a 34 year old patient who had been admitted to the renal unit ten days earlier with IgA
nephropathy (creatinine 1.9 and no hypertension) and
who developed acute pulmonary edema with hypotension and abrupt worsening of renal failure while inhospital. The case was presented as a diagnostic dilemma for the cause of worsening renal failure. When I
asked if the patient had had an MI, my query was met
with blank surprise from the residents. When I repeatedthe question, the possibility was dismissed by the resident because apparently (a) the patient was too young
to have an MI, (b) the EKG showed no evidence of MI
and (c) the echocardiogram report did not mention an
MI. So how could it be an MI? However, when I
reviewed the echo report myself, there was clear mention of severe segmental wall-motion abnormalities
particularly involving the anterior wall and the septum!
Having said this, I must, however, mention that myinteraction with residents (as opposed to the medical
students) was relatively limited (to a few hours eachday, when I rounded on the wards). These limited
interactions may not have been adequate for me to geta true picture of the state of affairs, so any conclusions
therefrom must be viewed with a considerable dose ofskepticism. In particular, I did not see them outside theward setting, nor did I have a chance to talk to themwithout the attending also being present. Thus, I had noopportunity to determine ﬁrst hand what their experiences were, or to ﬁnd out their reactions to my presenceor to my teaching.

45

This was probably by design, since the Departmentof Medical Education, which was hosting my visit, had
no jurisdiction over the residents. But the descriptionsof resident life given to me by several of the latter,coupled with my own limited observations, lead me toconclude that the resident is almost an indentured slavein the unit in which he/she elects to work after graduation (remembering of course that there is nothing
known as ‘‘general internal medicine training’’ in Japan). With their future in that specialty dependentexclusively on the chief of the unit, they obviously could
not afford to be seen as being disloyal-which would be
exactly how any independent interaction with me might
be interpreted!
But there is another equally powerful and at times
even destructive effect of such a feudal system: it generates incredible pressure to ‘‘impress the boss’’. I personally witnessed this destructive force in operation in
the case of two of the residents who were required
to present showpiece cases to the ‘‘Guest Professor’’.
They were in a really pitiable state, sweating and shaking visibly, and so close to nervous collapse as to renderthem almost incapable of articulating a word, even before they started presenting their cases to me. It was
clear that they were terriﬁed of making a mistake, andthat nothing would relieve them of that terror, no matter how hard I tried to put them at ease. In fairness,some of that may also have been due to the need topresent in a foreign language. But I do think that muchof it was due to pressure.
3. Clinician-Teachers and Clinical Teaching:
How is Medicine taught at Keio University?: Didactic
lectures are the major modality of instruction at Keio
University (since there is little or no clinical instruction
and no concept of small group discussion or PBL).
During my visits there I saw only one attempt to teachstudents through any other means. That was in the ER,
where students are engaged by their teacher in discussions with a distinct PBL ﬂavor, although without
the formal case descriptions that go with PBLs. Eachstudent in the group is assigned one acute ER presentation (e.g. chest pain, headache, abdominal pain,
shortness of breath etc). Subsequently, the student is
expected to give a 10 minute review of the subject(signs and symptoms, differential diagnosis and workup) to the group, while the instructor facilitates andguides the discussions between the students themselves.
I cannot begin to describe how laudable this attempt isin a system that does not reward such innovation andactually might be inimical to it.
With this solitary exception, everything else seemed
to be taught through lectures. And even those wereastonishingly narrow in their focus. The lectures I
attended showed me that the faculty views lectures as46

vehicles to present research work, rather than to present an overview of the state of the art in clinical medicine or to convey any important concepts, whether
those concepts are clinical, pathophysiologic or molecular! And repeated glances around the lecture hall
showed also that 90% of the students were asleep at
any given time. Even yours truly nodded off, which only
goes to show how stupefying didactic lectures can be!
I did experience two exceptions to this rule. The ﬁrst
consisted of a case presentation, followed by a didactic
discussion (in English) of the etiology, pathology, clinical features and management of a case of chronic active
hepatitis. Although it was a didactic session, the moderator strove actively to engage the students in a discussion, thereby making it as good a didactic teachingsession as any I have attended.
The other exception was a CPC session that was put
on for my beneﬁt (also in English). It was a case of
sudden onset of CHF with chest discomfort in an otherwise healthy male, who turned out to have amyloid
heart disease.12 It was quite well done, because thediscussions were highly relevant from a clinical standpoint. But at the risk of repeating myself, I must saythat there was little effort made to teach the students,
who formed 90% of the audience. The faculty in attendance (who obviously knew the case well and were well
prepared for it) engaged in soliloquies that did not incorporate any attempt to impart knowledge to the ignorant, or to provide pathophysiologic explanations forthe uninitiated.
During a later discussion with a group of students I
brought up the fact that both of these sessions werequite stimulating. They were surprisingly unmoved by
my enthusiasm, because those sessions seemed to themalmost to be aberrations! They raised a legitimate
question as to whether they were staged for just my
beneﬁt (since both were in English, and therefore almost unheard of). Even though I have no way of dismissing that suspicion, I cannot validate it either. But
the very fact that they should suspect that it was so only
serves to underline the rarity with which this type ofclinical approach to instruction is employed at Keio
University School of Medicine.
While the absence of any clinical relevance to mostof the lectures was the most glaring of the defects I
noted, it was clear also that the teachers I observed
seemed to have no sense of (or interest in?) what it was
the students really needed to know. Either way, it
seemed to me yet another example of the tunnel visionof the super specialist with an exceptional depth of understanding in a limited area! And that is a deﬁciency
that will not change until the concept of a generalist
with broad-based understanding of disease receives
more widespread acceptance.13
That lack seems to be the biggest obstacle to any

Rao RH: The state of Japanese Medical Education

change in the way medicine is taught in Japan. A close
second to it, though, is the lack of recognition of teaching as a scholarly activity in Japan. Research (bothgrant getting and publication record) is the SOLE determinant of academic success. And if an academic
happens to be a clinician, then the only reason for his/her existence is to see patients – until, that is, he or shegets a grant, and can escape purgatory!
It comes, therefore, as no surprise, that several clinicians openly, if somewhat ruefully, declared that they
could not teach even if they wanted to, because teaching was identiﬁed as an indulgence that wasted valuable
clinical time (i.e. hindered revenue generation!). And it
seems obvious that the Division Chiefs place little or novalue on clinical or teaching activities. Not one of themattends on the wards (the students for the most part had
never seen them!), and during my stay there, only two –the chief of ID and the chief of GI – even met me!
Thus, the message from the top seems clear: clinicalactivities (and teaching) do not count! This must change
if clinical instruction is to improve.
Why are Faculty at Keio University Reluctant toTeach?: One must answer this question in order to ﬁnd
solutions to the surprising lack of enthusiasm for clinicalinstruction that I witnessed time and time again at Keio
University Hospital. Research is a vitally importantmission of any academic institution, and medical schoolsthat are not at the forefront of medical research should
not expect recognition as Institutions of Higher Learning. But a medical school is, ﬁrst and foremost, arevered place of Higher Learning where future doctors
are trained. This means that teaching must be accorded
a status that is at least equal with research.
The problem arises when research takes preeminence, and teaching is relegated to second class status. Then, of course, nobody who aspires for academic
success would waste their time pursuing excellence inteaching. The result is an institution where the majorityof faculty members do not teach. After all, why would
anyone waste their careers in such a fruitless and unrewarding pursuit as teaching, when it is not considereda credible academic achievement? What you havethen, in my opinion, is not really a Medical School. It
deserves to be called nothing more than a ResearchCenter, and faculty members who do not ‘‘profess’’ do
not deserve the title of ‘‘Professor’’!
The purpose of this introduction is to drive home thepoint that teaching and research are two equally strong
pillars of academic achievement, neither one greater ormore important than the other, both supporting theacademic mission and image of a medical school. The
corollary is that teachers, just as much as researchers,
are an essential and integral part of the backbone of a
Medical School.

Keio J Med 2006; 55 (2): 41–51

This is just not true of Japanese academic institutions, notwithstanding protestations to the contrary.16
In Japan, promotions policy is based exclusively on research output and faculty who teach are accorded norecognition and given no status. Thus, with research
clearly deﬁned as the only ‘‘truly academic’’ pursuit, it isunderstandable that it is downright counterproductive
to spend time in anything but research. That breeds theinevitable attitude, so prevalent in Japan, that teaching
is not just unnecessary, but actually a wasteful ‘‘nonacademic pursuit’’ that carries a heavy penalty, because
it takes time away from research. No wonder, then, thatteaching is relegated to the status of a menial task that
falls on the shoulders of inexperienced or disinterested
juniors. Since these individuals are themselves under
overwhelming pressure to succeed as researchers, havebeen taught little or not at all during their formative
years, and have the unfortunate example of their own
mentors to guide them, the outcome is inevitable:
teaching receives short shrift.
That teaching still occurs at Keio University Hospital, despite this terrible handicap, is a testament to theselﬂessness of the few dedicated souls who soldier on
without hope of recognition or reward. These individuals, rare as they are, do possess the requisite enthusiasm
for teaching, and the right attitude towards student
interactions in particular. That attitude is vital in orderto encourage interactive learning without the elementof intimidation that is almost universal in Japan’s highly
deferential and hierarchical society. These individuals
would be the core group that I would start with if I werelooking to change things. If they can be instructed in
the basics of teaching physical diagnosis as a course,
and they are allowed the ‘‘luxury’’ of teaching (i.e. remuneration for time spent), that would be a great
starting point for any efforts to change the system. I
have no doubt that the students will ﬂock to such acourse and then momentum would build for others tofollow suit.
Absence of Meaningful Feedback: Yet another major
obstacle to meaningful change in medical education in
Japan is a failure to get honest, anonymous feedback
from students. The tradition of reverence I mentioned
earlier as the source of passivity is the limiting factor
here too. As one student told me, in Japanese society
no teacher can EVER be called bad: it is ALWAYS thestudent’s fault if he/she cannot learn. Add to this thepervasive fear of retribution that exists in a system thatmakes a resident completely subservient to the Chief,
and it ensures that even terrible teachers will get great
grades.
4. Problem Based Learning:
I intend to spend considerable space on this one aspect, because this is where I see the greatest hope for47

the future of medical education in Japan. I must confess
that, before I went there, I was not sure at all that the
PBL format would be even remotely successful in Japan
at this early stage in the process of revamping medical
education. But the students were so eager and so insistent about going through a PBL exercise with me, that I
agreed very reluctantly (and at almost the last minute)to bring a case for PBL discussion along with me. The
short notice I had before departure meant that I had tomake do with a case from my own experience, which I
put together into PBL format two days before I left forJapan! At that time, of course, I had no idea of theterrible clinical deﬁciencies I was to encounter, so I had
no way of knowing that the case I put together (seeAppendix 1) could not have been more suited to
exposing those deﬁciencies: it had a plethora of physicalﬁndings, and it crossed the boundaries between multiple specialties (pulmonology, neurology, endocrinology, oncology).
Once I got to Japan, and witnessed the total lack ofclinical instruction ﬁrst hand, I was convinced that myreluctance to do a PBL with the students was going tobe justiﬁed. Then, at the ﬁrst (presentation) session,even my worst fears paled into insigniﬁcance in the lightof the circumstances that confronted me. I was absolutely appalled to ﬁnd that the discussion group comprised of students from every level in medical school,
starting from one in the FIRST YEAR (right out ofhigh school and still two years away from his ﬁrst exposure to any medically relevant course), seven in thesecond year (also with no medical knowledge whatsoever), two in the fourth year (exposed to preclinicalcourses only), and seven with some modicum of clinicalexposure, such as it is in Japan (ﬁfth and sixth year)!
I almost felt like calling off the exercise then andthere, so daunted was I by the prospect of dealing with(i) such a diverse group of students, (ii) with such vastlydiffering knowledge bases (iii) and that too, of allthings, in a PBL setting. But the enthusiasm on display
brooked no denial, and I allowed myself to be carriedalong by it, against what I thought at that time was mybetter judgment. So it was with little faith that anything
could be achieved from this exercise in futility (or so I
thought!) that I let it proceed.
After I asked for volunteers to act as ‘‘reader’’ and‘‘scribe’’, the Presentation session began. Quite predictably, there was a total absence of participation fromthe students. The volunteer ‘‘reader’’ simply readthrough the ﬁrst page without a pause and then there
was total silence. This was understandable, given thefact that none of the students had the foggiest idea
about what to do. So I made them read page 1 again,
but telling them this time to focus on what was being
presented and what they thought was going on with thepatient, and most importantly, what the gaps were in

48

their understanding of what was going on. That started
a hesitant ‘‘discussion’’ that was anything but a discussion between peers, but rather a series of declarative
statements with a tiny question mark at the end,
accompanied by a sidelong glance at me! I knew thatthe students were talking to me, not to each other.
So I moved out of the circle and sat away from thegroup, exhorting them once again to think for themselves and to discuss their doubts with each other. To
my mounting frustration, they seemed unable to shake
off their inertia. The passivity that I have commented
on earlier was so evident in this setting that I almost
gave up in despair, so exhausting was it to wring out
each of the ﬁrst four learning objectives from them. To
be honest, there was a complete lack of clinical perspective, even in the seniors, so that they were unable
to analyze a case that transgressed the conﬁnes of adeﬁned subspecialty! And the ‘‘discussion’’ could noteven get past the signiﬁcance or meaning of the plethora of clinical signs!
Then, about three-quarters of the way through thecase presentation (on Page 4, see Appendix 1), just as I
was beginning to despair, something happened. I havestruggled to identify what it was, to no avail, because I
still cannot deﬁne what happened. But it seemed as
though the concept of group learning suddenly, permeated their collective consciousness. It may have been
the fact that the only ﬁrst year student in the group
actually spoke up and asked the group (instead of me!),‘‘Why is the calcium level high?’’ And one of theseniors remembered the association between lung cancer and hypercalcemia. That seemed to open the ﬂoodgates, and the awesome intellectual curiosity that ishabitually suppressed in these marvelously giftedyoung people found itself with a vengeance!
The last ﬁve learning objectives came almost effortlessly, and the ten learning objectives they ‘‘discovered’’ quite independently (at least the last 6!) were
almost identical to the eight that I had identiﬁed to begin with (see Appendix 2)! If ever there was a vindication of the whole PBL concept, this was it.
My only role after that was to sit back and watch the
fun as those highly motivated students grabbed the balland ran off with it. Observing the subsequent discussion, during which they began to talk to each other as asingle learning unit, rather than obliquely to me, was
one of the most exhilarating experiences of my teachingcareer. And I had to say very little after that. It was
only when it came to assigning the learning objectives
that I stepped in and suggested that the two fourth year
students be given the two objectives that had to do primarily with anatomic detail, and that the remainder be
divided among the 5 th and 6 th yrs according to preference. Then, everyone went home feeling happy, butalso with a quite conspicuous sense of nervous antici-

Rao RH: The state of Japanese Medical Education

pation of the uncharted territory of the Resolution session to come. No one more so than I, on both counts!
I need not have worried, given the high quality of thestudents I had the pleasure of working with. Simply put,the Resolution session two days later was a smashingsuccess. Only one relatively unimportant factor createda problem, and that too was born of total inexperienceon the students’ part: no one had any sense of the timeit took to present their material. Despite repeated urgings on my part that they should be aware of the passage of time, 100 minutes into the 150 minute session
saw only 4 of the 10 objectives completed. So I had tostep in and tell them that each subsequent speaker had
only 8 minutes to present the ﬁve most important points
in their material and to take questions from the groupon their material! It was stunning once again to see how
quickly they got the message. Each of the next 6
speakers got the job done in stellar fashion, curtailingtheir presentations to just the critical facts in their material. And that left me to be a facilitator in the truest
sense of the term, guiding and clarifying when asked,
but allowing the discussion to proceed without muchinterference from me.
I had that luxury because the material presented wasof such superlative quality that it required little or noclariﬁcation from me! It was comparable to, or possibly
even better than, any I have seen in at the University ofPittsburgh! And this from a group that was so inexperienced in this kind of learning and so diverse in
medical knowledge and clinical exposure as to daunteven an inveterate Pollyanna like me!
The jubilation I felt at the end was as great as any I
have experienced in my teaching career, and I conveyed it to the students. They had every right to be
proud of the astounding job they had done, given their
total ignorance of the PBL method. Which brings me toa personal revelation that should convince all naysayers
and doubters of the PBL method: If there is a betterway to teach critical analysis and clinical decision making to medical students, I have not seen it. Not when agroup such as mine, as unschooled, unsophisticated,
and ignorant as you can get in the science of interactive
learning and the art of clinical decision making, could
make it into such an exhilarating experience in learning(for them) and teaching (for me). My only abiding disappointment is that not a single Keio University faculty
member or resident attended the PBL sessions, despite
repeated invitations. Had they been there, not one
would have walked away without being impressed by
the excitement and enthusiasm for interactive learningthat was on display.
On second thoughts, maybe it was good that they did
not come! I suspect the session would have ended in
dismal failure. I doubt that the students would have felt
free – or even dared! – to be spontaneous had they

Keio J Med 2006; 55 (2): 41–51

known their ‘‘sensei’’ were watching them and listening
to their every word. I have observed that Japanese students are quite intimidated by the very thought ofinteracting with their teachers (with a few selected
exceptions). In such an intensely hierarchical system, it
is difﬁcult to imagine that the PBL concept will succeed,
because the teacher may be unwilling/unable to forsake
the traditional paternalistic role and become a true
facilitator of discussion. Even with the best of intentions, the PBL format may well get corrupted into
nothing more than a didactic discourse by a lecturer
speaking to a small group of mute captive listeners!
I will close this descriptive narrative on this note: myexperience gives me enormous hope for the future of
medical education in Japan, but it also gives me considerable reason to temper my enthusiasm with doubt.
My hope springs from the fact that the materials forresounding success are present, just waiting to be put inappropriate juxtaposition: highly motivated, even brilliant, young minds, thirsting for knowledge and instruction, and a highly skilled faculty with the requisiteknowledge and skills.
Unfortunately, the seeds of devastating failure areeven more widely prevalent, and are already in ominous juxtaposition: the deeply ingrained and culturally
programmed passivity in those young minds, and thecontempt and neglect of interactive instruction that
seems all pervasive among the faculty, with few exceptions, and within the system itself. It is only if these twinpillars of the current system are brought down simultaneously, that it will be possible to reform the Japanesesystem of medical education. How to achieve that willbe the focus of a succeeding paper.
Summary of Observations Regarding Medical
Education at Keio University School of Medicine
The failings in the system of medical education in
Japan are not the focus of my observations. My focus is
to identify the factors that contribute to the state of
medical education as observed by me at Keio University School of Medicine. To this end, I will enumerate
the weaknesses and strengths of the system that I feelare relevant to this discussion.
A. Observed Weaknesses:
1. The absence of any concept of a generalist who has abroad-based understanding of disease processes.
2. The absence of any bedside clinical instruction.
3. The absence of any recognition of teaching as a legitimate academic pursuit (and the absence of any
rewards for engaging in teaching)
4. The absence of any mechanism for evaluation ofteachers in an honest and anonymous manner49

5. The overwhelming dependence on passive learning(didactic lecturing) for medical education
6. The absence of clinical relevance in the didactic material (with the exceptions noted)
7. The widespread attitude of deference that leads tounquestioning acceptance by students of all that is or
isn’t sent their way by seniors
8. The resultant
a. absence of any sense of participation by students
in active and interactive learningb. deeply ingrained attitude of passivity and deference in students.
B. Observed Strengths:
1. The quality of the students! What a marvelous resource, and if exploited in the appropriate manner, it
could be the engine for long-lasting change.
2. Professor Takahiro Amano as Head of the Department of Medical Education, the perfect person to
guide them through the difﬁcult changes to come3. The will to change as articulated by Dr Amano andendorsed by Dean Kitajima
4. A core group of faculty who I suspect may be willing
to become clinician-teachers, given the right incentive
5. The Pittsburgh-Japan Program as a facilitator ofchange; it can contribute mightily by exposing students in Japan to the wonders of clinical training,and by exposing teachers from Japan to the joy ofteaching. A free and frequent exchange of both personnel and ideas will help cultivate the right attitudes for the changes to take place. The best way tohave an impact is to send clinical instructors to Japanon a frequent basis, to cover as many institutions as
are willing to consider radical changes in theirteaching methods. The more that both students andteachers are exposed to the excitement and rewardsof bedside clinical instruction, the more likely it isthat there will be inculcated a desire to teach in future generations of teachers.
Appendix 1
Problem Based Learning Case
Page 1
A 47 year old male construction worker presents tothe emergency room with a 6 week history of coughing
up blood. Until today, he has only noted blood-streaked
sputum, mainly in the early morning, which he ignored.
But today he brought out nearly a quarter cup of blood.
He is not experiencing any weakness or lightheadedness. There is no nausea, nor did he experience any
similar sensation at the time he coughed up the blood.
He has also observed that his voice is more hoarse thanusual over the past 2–3 weeks, but he puts it down to a

50

Rao RH: The state of Japanese Medical Education

worsening of his chronic smoker’s cough that he has
had for most of his adult life.
Review of systems is negative, speciﬁcally for any
dyspnea, chest pain, weight loss, anorexia, change inbowel habit, abdominal pain, nausea, vomiting, change
in stool color. He does not have any weakness or otherneurologic complaints.
He has no signiﬁcant past medical history, is not on
any medications, but he confesses to not having seen adoctor for several years.
Social history is signiﬁcant for a 100 pack-years ofsmoking (since age 16). He drinks 12–16 beers a week.
He works as a construction worker and is not aware ofany exposure he may have had to environmental toxins,
including asbestos. Family history is signiﬁcant for heartdisease in both parents.

right. Right apex shows an area of consolidation
with an air bronchogram. There is a pleural effusion on the right.
CT scan of chest and root of neck shows a large massin the apex of the right lung inﬁltrating andextending into the soft tissue of the neck. Thereis enlargement of multiple lymph nodes in the
mediastinum; the subcarinal node is >2 cms indiameter. There is a moderate pleural effusionon the right.
Sputum examination shows epithelial cells, and normal
respiratory ﬂora on culture. No AFB’s seen on
direct exam.
Pleural ﬂuid is sanguineous, with >10/100 RBC’s, <100WBC’s, but no malignant cells are seen on
cytology.

Physical Examination:
Alert and oriented, no distress, but somewhat anxious
looking male with central obesity.
Vitals: Pulse 92/min, BP 138/88 mm Hg, no orthostatis,
RR 20/min.
Eyes: There is slight ptosis on the right, but lids,
sclera, conjunctiva and extraocular movements
are all normal. Right pupil is smaller than theleft, but light reﬂex is present in both eyes (direct and consensual). Fundus exam is normal.
ENT: Normal nasal mucosa, oropharynx, tongue andlips.
Neck: No goiter, normal carotids, normal JVP. Single
palpable lymph node in the supraclavicularfossa on the right side, 3 cm diameter, nontender, very ﬁrm. Trachea deviated to right.
CV:
Normal apical impulse, normal heart sounds, noadded sounds, murmurs or rubs.
Chest: Some increase in AP diameter (slightly barrel
shaped), increased percussion note across thechest, breath sounds normal except for the rightapex, anteriorly, where bronchial breathing isheard, and the right base posteriorly where
breath sounds are absent and the percussion
note is dull. There are scattered crackles in bothlung ﬁelds.
Abdomen: Normal palpation, non-tender, no organomegaly, normal bowel sounds.
Extremities: No cyanosis, or edema. Grade 2 clubbing
in hands.
Neurologic: Normal cranial nerves, sensory and motor
exam. Normal reﬂexes.

Page 3

Page 2
Labs: Normal CBC and diff. Normal electrolytes/BUN/
Creatinine. Normal LFT’s.
CXR: Emphysematous lung ﬁelds. Tracheal shift to theBronchoscopy reveals a large endobronchial mass
obstructing the superior bronchus and biopsy of themass conﬁrms that it is a squamous cell carcinoma.
Page 4
The tumor is not amenable to surgery, and the patient is given palliative radiation therapy. Four months
later, he is brought to the ER in a state of confusion anddisorientation. His wife says that he was ﬁne until aweek ago, when she noticed that he was becoming forgetful, and urinating a lot. He stopped eating a day
earlier. PE reveals a cachectic individual, with stertorous breathing, not oriented to time, place or person.
Mucos membranes are very dry, the skin turgor is very
poor, and vitals show a pulse of 116, regular, with BP
ofr 90/60. Neurologic exam is signiﬁcant only for severemeiosis, enophthalmos and ptosis on the right side.
Chest exam shows complete absence of breath sounds
on the right.
Labs show H/H of 11/37, WBC of 10.3 K, left shift
with 4% bands, BUN of 78, creatinine of 3.1, calcium of
16 (normal 8.5–10.5), Phosphate of 2.9 (nl 3.5–5.0), alkphos of 337 (NL < 150).
Page 5
He is treated with vigorous iv rehydration: 1 liter ofnormal saline wide open, followed by 0.5 l/hr until pulse
and BP normalize. A Foley catheter is placed andintake/output are carefully monitored. Calcium level
drops to 13.9 2 hours later. When urine output reaches
3 ml/min (@200 ml/h) he is given 40 mg of furosamide,
and IV ﬂuid is adjusted to match output. Calcium level
drops 4 hours later to 12.1 and the patient wakes up.

Keio J Med 2006; 55 (2): 41–51

Page 5
Labs drawn in ER at time of presentation show:
PTH level of 3 pg/ml (normal 8–62)
PTHRP level of
25 OH-Vitamin D: 24
1:25 dihydroxy Vitamin D: 66 (normal 10–52)
IV hydration is tapered down over the next 48 hours,
but the patient’s claium level starts to creep back up to
14.1. The patient is given an IV infusion of pamidronate
1.5 mg/kg over 8 hours. 5 days later his calcium level is
10.3 and the patient is discharged with instructions tofollow-up in his oncologist’s ofﬁce for weekly calcium
estimations.
Appendix 2
PBL Learning Objectives
1. Discuss the differential diagnosis of hemoptysis
2. Identify the anatomic basis for the ocular ﬁndings in
the patient
3. Understand the diagnostic work-up of a patient withhemoptysis
4. Differentiate between the different types of lungcancer
5. Discuss the various treatment options for patientswith lung cancer, and the indications for radical surgery
6. Identify the relationship between hypercalcemia
and malignancy and the different pathophysiologic
mechanisms involved in hypercalcemia of malignancy
7. Outline the diagnostic approach to hypercalcemia
8. Outline the treatment of hypercalemia.
Acknowledgements: The author wishes to acknowledge and thank
Dean Kitajima of Keio University School of Medicine, Professor
Takahiro Amano, Head of the Department of Medical Education,
Professor Aiso, Head of the Department of Anatomy, and Professor
Suematsu, Chairman of the Committee on Academic Affairs, for their
unstinting support and encouragement to ‘‘do the right thing’’ regardless of the consequences. Grateful thanks are also due to Dr
Mark Zeidel, Chairman of Medicine, University of Pittsburgh Schoolof Medicine, and to Dr Haruko Kuffner Director of the Pittsburgh-

51
Japan Program, for opening the doors that made this effort possible.
Finally, the author wants to acknowledge his own limitations, so that
he was unable to verify ﬁrst-hand the contents of several of the references quoted in this paper, relying instead on statements made inauthors’ translations in abstract form. For any errors that result there
from, he is truly sorry.

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