REVIEW
Perspectives in Medical Education
3. Reforming medical education to change healthcare
practice in JapanR Harsha Rao

Professor of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, U.S.A.
(Received for publication on June 22, 2006)(Accepted for publication on November 16, 2006)

Abstract. The enviable health status of Japanese citizens is one of the reasons for obdurate
opposition to reform of Japanese healthcare practice. Change is widely believed to be unnecessary for a system that is both successful and profitably exploited to universal benefit.
However, societal trends are conspiring to make current healthcare practice patterns andexpenditures unsustainable in the future. In particular, Japan has undergone an unprecedented demographic shift from a society of young (and healthy) workers to one of older
retirees with a higher prevalence of obesity. As a result, an equally dramatic future increase
can be anticipated in the prevalence of age- and obesity-related disorders. The traditional
paradigm of Japanese healthcare is not conducive to the restraint necessary for preserving
its future viability, given these trends. Japanese healthcare does not reward clinical problem-solving skills, values specialists over generalists, places a heavy reliance on expensive
technology, does not require interventions to be evidence-based, and provides no incentives
to improve quality or efficiency. If this paradigm endures, Japanese healthcare faces thereal prospect of bankruptcy. The failure of Japanese medical education to inculcate clinicalskills and stress evidence-based medical practice lies at the heart of the impending crisis in
healthcare. To solve the crisis, medical education in Japan must change its focus to training
and developing a cadre of physicians with the broad-based expertise and clinical skills to
make evidence-based decisions in a medically and fiscally responsible manner. The future
health of the system and of the Japanese people depends on it. (Keio J Med 55 (4) : 141－148,
December 2006)
Key words: Japanese healthcare practice, clinical skills training, Japanese medical education, problem solving skills, evidence-based medicine

Introduction
In an earlier paper, I have described in some detail myview of the dysfunctional state of medical education in
Japan.1 My conclusions are derived from observations
made during annual visits since 2003 to Keio University
School of Medicine in Tokyo, one of Japan’s premier
medical institutions. As a follow-up to the first paper, I
have published a Blueprint for Reform of Medical Education at Keio University, based on a report submitted at
the request of the authorities in charge of medical educa-tion there, Dean Kitajima and Professor Amano, Head of
the Department of Medical Education.2 The focus of theBlueprint was on recommending a series of wide-ranging
changes calculated to emphasize clinical skills training
and inculcate clinical problem solving skills in Japanese
medical graduates.2
Notwithstanding the wide dissemination of those tworeports among the faculty at Keio University, and thestrong endorsement of their contents by the authorities
in charge of medical education there, the response of thefaculty to the recommendations has been decidedly luke-

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., Email:rao@dom.pitt.edu
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Rao RH: The case for reform of Japanese medical education

warm, at best, and covertly dismissive at worst. I realize
now that the blame for this may rest with me.
The reason for that surprising conclusion is to be foundin my failure to articulate a single coherent and cogent
argument for change in my earlier papers. I was so completely overwhelmed by the magnitude of the dysfunction I encountered that I could only focus on identifying
individual problems as and when I came across them.
Moreover, the justification for reform seemed so inherently obvious to me as a teacher and a clinician that I
suggested solutions without providing anything morethan piecemeal justification as I went along. It is clear tome now that one important deficiency in those two earlier papers is that I did not put the justification for correcting the individual problems into a single over-archingframework that applied to the system as a whole.
This paper is a belated attempt to correct that failure.
The Problem With Change
Change of any kind is threatening. As bad as it is when
it is forced on an individual, it is even more so whena society faces the pressure to change. Implementingchange in a society that reveres and respects tradition,
like Japan’s, is very difficult (as I have acknowledged[1]). In such a society, change that threatens something
as fundamental and cherished as a tradition itself can be
overwhelming. It is resisted from the outset even when
it is justified. Without justification, change of that magnitude is well-nigh impossible to achieve in a traditionbound society.
These generalities achieve monumental significancein relation to the attempts to reform healthcare in Japan.
It is easy to understand, in that context, why previous
attempts to introduce change have failed.3, 4 The failure
was quite predictable, in my opinion, because the casefor reform has been undermined by a sense that there is
no reason to change something that not only works, but
is profitably exploited to universal benefit, starting frompatients and providers to hospitals and the bureaucracy.
I have sensed that the same all-pervasive inertia is resisting the current effort underway in Japan to reform thesystem of medical education.5
Which brings us to the fundamental question that must
be answered, if the inertia to change is to be overcome:Why change something that seems to work?
That question has been asked of me more than once, indifferent ways, during my visits over the past three years
to Keio University School of Medicine in Tokyo. Given
the Japanese tradition of unfailing courtesy to a guest,
the question is never asked with belligerence or with
defensiveness, but most often as a genuine request forenlightenment. On occasion, however, it has also been
posed to me with varying degrees of disbelief and evenamusement.

It is a question that needs to be answered, if reform is
to have any hope of succeeding. After all, if there is no
justification for change, change for change’s sake is atbest an exercise in futility, and can at worst only harmthat which needs no change. Equally, though, obdurate
resistance to change, in favor of maintaining the status
quo even when the need to change clearly exists, is aguarantee of systemic failure. That the need exists toreform Japanese medical education is patently obvious
to the outsider, as I have detailed at length in two previous papers.1, 2 The justification is not quite so obvious tothose working inside the system, many of whom reject
the need for change as unnecessary and even harmful.
The justification for reform of medical education isbest understood in the context of the resistance to changethat seems to be all-pervasive in the Japanese healthcare
system. The inertia has its roots in tradition, and there
is no doubt that an innate reluctance to accept a change
from tradition is a part of it. Equally important, however,is a refusal to even consider that there is anything wrong
with the system, which is thought to be an unrivalledsuccess. Therefore, the need for reform of medical education can only be understood if it can first be justified
that there is a need to change the culture and practice of
healthcare in Japan. In order to justify such far-reachingchanges in the eyes of those who oppose reform, theundeniable successes of the past must be acknowledged.
Only then can the problems of the present be identified
and the perils that lie in the future for healthcare in Japanbe anticipated. Only then can the case be made for reforming medical education in order to change healthcare
practice in Japan.
THE PAST
An Enviable Track Record of Success forJapanese Healthcare
Japanese healthcare is rightfully lauded as the world
leader with respect to overall health system attainment.6
Japan’s universal health insurance system provides
all Japanese residents with ready access to high quality healthcare at a far more reasonable cost than mostother developed countries.7 Not only is there no Japaneseequivalent for the 43.6 million uninsured citizens in the
US.8 (“universal” really does mean exactly that!), but
Japanese citizens fare much better than their US counterparts by almost any health measure along the age spectrum, such as the prevalence of low birth weight, natal,
postnatal, and total infant mortality, and life expectancy
at age 20 and age 65.9 All of these stellar statistics are
impressive enough, but what is truly remarkable is thatthey have been achieved with a lower ratio of healthexpenditure to gross domestic product than any other developed country.10
Several societal factors account for this exemplary per-

Keio J Med 2006; 55 (4): 141－148

formance. These include the lowest rates for crime, illicit
drug use and prevalence of HIV in the developed world,the highest rates for high school and full-time university enrollment, and a literacy rate approaching 100%.11
Although all of these factors are certainly important
contributors to the overall success of healthcare in Japan,
one cannot ignore the fact that a considerable measure of
the credit for the exemplary healthcare performance must
attach to the main provider of that care: the Japanesephysician. If one accepts that undeniable conclusion,then one must ineluctably conclude that there could nothave been much wrong with the training of that physician!
So why should Japan seek to change a model for
healthcare and a system of medical education that appears to have worked so well? The answer is to be foundin the current practice of healthcare in Japan.
THE PRESENTAn Unaffordable Mix of Technology, Tunnel Vision
and Maslow’s Hammer
While there can be no arguing with the successes ofthe past, there is also considerable cause for concern
as to where Japanese healthcare stands at this point intime. It is true that Japan ranks first in overall healthsystem attainment, according to WHO, but it lags behind
many other developed countries in measures of healthsystem performance (9th) and measures of fairness ofcontribution to the health system (8th －11th).6 These two
measures-one reflecting the effectiveness of healthcare
being provided, and the other the social conscience ofthe recipients of that care-contain ominous portents forthe future. They manifest in the present as a combustible
mix of three elements, identified in the sub-heading of
this section(i) A Profligate Reliance on Technology
One point that is often ignored in the debate about
whether a need for change exists at all is that all of the
exemplary achievements in healthcare in Japan wereachieved as a direct consequence of the unprecedented
economic growth that followed the Second World War.
The luxury of unfettered expenditures funded by historically unprecedented economic growth allowed the Japanese healthcare system to achieve the enviable status ofone of the world’s most technologically sophisticated.
Unfortunately, this success may have reached levels thatare unsustainable in today’s bleaker economic climate,particularly in the context of the ageing Japanese population and the stagnant growth rate in Japan.11 The seeds offuture catastrophe lie in other statistics, many of which
also confer pre-eminent status to Japanese healthcare inareas that are less desirable for healthcare cost containment. For instance, Japan has far and away the greatest

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number of magnetic resonance imaging and computed
tomography scanners per capita, and it is worse than allother developed countries in resource utilization measures such as outpatient clinic visits and length-of-stay inhospital.12
The reason for those decidedly less-than-stellar performance measures lies in the twin pillars that prop up thecurrent abuse of the system: universal entitlement andfee-for-service reimbursement. On the one hand, universal entitlement provides patients with unrestricted accessto the most expensive tertiary care for even the simplest
problem. On the other hand, a fee-for-service reimbursement paradigm encourages profligate resource utilizationby physicians for every problem, and offers no incentive
for critical thinking to solve problems or to exercise restraint through judicious clinical decision making.
Either one of these twin invitations to profligacy byitself is bad enough as an incentive to abuse the system.
Both together are virtual guarantors of fiscal irresponsibility. With no incentive to control costs, it inevitably
induces physicians to use the most expensive technology
available and to ignore the human component of patientcare. Equally, it encourages patients to seek the most expensive care possible under the assumption that the rightto the most advanced technology guarantees the best
medical care. As a corollary to both those mindsets, it isinevitable that both parties would come to believe thatthe less technologically sophisticated methods used inprimary care are not even desirable, let alone worthy of
consideration.
The most important result of this constellation ofproblems is that responsible and thoughtful clinical decision making becomes an unnecessary part of healthcare.
This is the conclusion of Hirose et al who, in a hard hitting critique,11 decry the degeneration of the physicianpatient interaction in Japan into a “three-hour wait,
three-minute contact consultation (with an emphasis onordering tests and prescribing drugs during the threeminutes)”.
The incentive to use the most expensive technology tosolve a problem, and the disincentive to think throughthe problem are bad enough. They lead to the inappropriate use of diagnostic and therapeutic modalities. Thereis an additional problem that amplifies the consequences
several-fold: it is the inability to see the problem in thefirst place because of “tunnel vision”.
(ii) The Blindness that Results from “Tunnel Vision”
Tunnel vision is the hallmark of physicians who areunable to recognize problems outside a very narrow focus of interest. A lack of clinical judgment compounds
the problem and sets the stage for unnecessary and eveninappropriate use of technology, with minimal attention to clinical justification. Tunnel vision results whenclinical skill, critical reasoning and thoughtful, evidence-

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based decision making take a backseat in the midst of
the rush to exploit new technology. The inability/refusalof the Japanese physician to even recognize that there
might be a problem with such a “tech-heavy” approachis compounded by the culpability of patients in facilitating the over-emphasis on tertiary care and super-specialization in Japan.
There is no better way to summarize the gravity of the
problem than with the words of Kumasaka.13 With forthright eloquence, he writes, “Single-minded specialization tends to produce single track minds, which may lackbalanced judgment in approaching the appropriateness ofboth investigation and management.”
Japanese medical education creates and sustains thephenomenon of tunnel vision, since everyone in any
position of influence in academia is a “single-minded”
super-specialist and shares a very narrow focus andperspective, seeing little merit in the practice of generalinternal medicine or in the clinical problem solving skills
necessary for it. It comes as no surprise, then, that everyone in Japanese academia, almost without exception,
lacks both the desire and the ability to teach those skills.
My discussions with several internists have revealed
that patients too perceive high quality care as being thedomain of super-specialists in academic tertiary carecenters, and that both the public and academia look down
upon primary care physicians. The terrible consequencesof such a devaluation of primary care as a whole andgeneral internal medicine in particular become apparent
if one considers a hypothetical scenario of a patient withshortness of breath.
A primary care physician, such as an internist, would
perform a detailed history and physical and determine
whether the dyspnea is of cardiac, pulmonary, or otherorigin. A differential diagnosis would be generated andthe diagnostic work-up targeted to elucidating the correctcause, following a stepwise utilization of resources withthe greatest positive predictive value at each stage, basedon evidence. Finally, the patient would be referred, if
necessary, to the appropriate specialist for a specialized
test or therapeutic intervention based on the diagnosis.
In contrast, a tertiary care model (like the one that exists in academic centers in Japan), by its very nature,would not follow the stepwise paradigm outlined above.
Instead of diagnostic interventions being based on clinical diagnostic utility, the approach is likely to be determined by the specialty interest of the physician who firstsees the patient. Thus, if the patient happens to visit a
pulmonologist for shortness of breath, the “three minutevisit” described by Hirose et al11 would be devoted toscheduling a CT or MRI of the chest, pulmonary function tests, or even a bronchoscopy, without any regard
to the underlying cause (since there is neither the time
nor the incentive to perform a comprehensive H&P). If
the patient happens to see a cardiologist first, however,

Rao RH: The case for reform of Japanese medical education

the patient might be scheduled for echocardiography, athallium stress test, or cardiac catheterization, with equal
disregard to the real cause (for the same reason)!
I will defer any further discussion of this particularbehavioral phenomenon until after I justify the cynicism
that leads me to outline the hypothetical scenario above
as I have done. My cynicism is not unfounded hyperbole.
It derives from my own observations of the practice of
medicine in Japan.
Two published examples will suffice to back thatclaim.
The first of those is the patient with bacterial endocarditis that I described in the first paper in this series.1 Hewent to see a pulmonologist for a cough and fever, andwas treated with oral antibiotics for a presumed respiratory infection, after what was, no doubt, a classic “threeminute visit”! A second and equally stunning exampleof “tunnel vision” followed when the patient, who was
becoming increasingly incapacitated from the hemodynamic standpoint, then visited a gastroenterologist for
diarrhea, and was prescribed a change in antibiotics totreat “gastroenteritis” with dehydration!
Neither specialist made even the most rudimentary
effort at taking a history. If they had, they might havediscovered that the patient had a partial correction oftransposition of the great vessels, and a simple cardiac
examination would have confirmed the existence of multiple auscultatory abnormalities! The failure to performsomething so essential and fundamental resulted in an
unconscionable delay in diagnosing life-threatening bacterial endocarditis. The patient suffered a hemodynamic
collapse, and was still critically ill when I saw him three
weeks later. There is no doubt in my mind that this was a
misadventure that was preventable if a timely diagnosis
had been made.
Failure on the part of a Japanese specialist to apply
appropriate clinical reasoning is similarly evident in theclinico-pathologic conference in which I participated at
Keio University Hospital during my first visit in 2003.14
In that case, a patient with exertional “chest discomfort”
for the preceding seven months was subjected to a left
heart catheterization and an endomyocardial biopsy
without performing the most basic history or physicalexamination! When no coronary arterial disease or othermyocardial pathology was found, the patient was sent
home on a dihydropyridine calcium channel blocker for
presumed “variant angina”. Eight months later the correct diagnosis (restrictive cardiomyopathy from amyloid
heart disease) revealed itself when the patient presented
with intractable exertional dyspnea, pedal edema, rapidly
worsening renal failure, and a monoclonal IgD myeloma
protein in the serum. The patient died shortly thereafter
and an autopsy confirmed the diagnosis.
The lack of any history and physical examinationfrom the initial presentation makes it impossible to doKeio J Med 2006; 55 (4): 141－148

anything more than speculate about what might havebeen. It is not unreasonable, based on the later course,
to conclude that the patient’s “exertional chest discomfort” might really have been exertional dyspnea. Given
that the patient saw a cardiologist for this symptom,
and given that no history or physical examination was
performed, it is almost inevitable that exertional chest
discomfort would be reflexively diagnosed as angina. It
is just as inevitable that the patient would get a coronary
angiogram for a presumptive diagnosis of coronary artery disease. If, on the other hand, an H&P had pointed
to exertional dyspnea, the correct approach would havebeen for the patient to get an echocardiogram. Then,the classic features of restrictive cardiomyopathy due toprimary amyloidosis might have been discovered initially, instead of at the later presentation. In particular,
the patient would not have been given a dihydropyridine
calcium channel blocker for “variant angina”. This classof drugs is specifically contraindicated in patients withamyloid heart disease because of irreversible binding toamyloid fibrils.15, 16 It must be stated, in all fairness, thatthe final outcome would have been no different, given
the grim prognosis in such patients, but that caveat does
not justify a failure to adhere to the most basic fundamentals of clinical decision making.
The tragedy is that the mistakes made in both of theexamples cited above could have been prevented, in myopinion, in a primary care model. In the first case (ofbacterial endocarditis), the tertiary care model allowed
each specialist to dismiss the patient’s illness as a “minor
ailment” in the context of his own specialty, without performing a history or physical examination. In the secondcase (of amyloid heart disease), the tertiary care model
invited the specialist to jump to the most convenient diagnosis, and to justify the use of a favorite technology
in a futile attempt to confirm it, once again without performing a proper history.
Lest it be assumed that I cite these two examples because they are the only exceptions I have encountered toa pattern of otherwise exemplary care, let me hasten to
add that I have seen several others that fit the same moldduring my brief visits. There was the case diagnosed as“rheumatoid pneumonitis” in a patient with rheumatoid
arthritis on a Rheumatology service, and treated with hidose steroids without giving any consideration to “community acquired pneumonia”. Or the case of WernickeKorsakoff syndrome in a patient with alcoholic cirrhosis,
dismissed as “hepatic encephalopathy” on a GI unit. Or
a diagnosis of the rare variant “normotensive pulmonary
edema” being made instead of recognizing pulmonary
edema due to an acute myocardial infarction in a patientwith IgA nephropathy on the Renal service. All of theseexamples came to my attention as part of routine ward
rounds, and without my making any effort to find them.
These cases, just as much as the two described in greater

145

detail above, are all excellent examples of the behavioral
phenomenon that is referred to as “Maslow’s Hammer”.
(iii) Maslow’s Hammer
Named for Abraham Maslow, the motivational theorist
who enunciated it, Maslow’s Hammer states: “If the only
tool you have is a hammer, you tend to see every problem as a nail.”.17
The relevance of Maslow’s Hammer to healthcare (andto Japanese healthcare, specifically) is best demonstrated
through the hypothetical scenario described earlier of thepatient who has the choice of going to either a pulmonologist or cardiologist for shortness of breath. According
to the principle of Maslow’s Hammer, the true natureof the problem has little relevance to the diagnostic approach that will be followed, since the pulmonologist
will see the problem of dyspnea as a nail to be hit withthe pulmonologist’s hammer (e.g. an MRI of the chest or
pulmonary function tests), whereas the cardiologist will
see the exact same problem as a nail to be hit with the
cardiologist’s hammer (e.g. echocardiography or cardiac
catheterization).
Using that hypothetical scenario as the backdrop, it ispossible to identify Maslow’s Hammer in operation ineach of the cases cited in the previous section from mypersonal experience in Japan. Thus, a cardiologist sees
exertional chest discomfort only as angina, and evenwhen no coronary artery disease is found, labels it as a“variant” angina, a rheumatologist views pneumonia ina patient with rheumatologic disease only as an unusual“pneumonitis” of autoimmune origin, a gastroenterologist sees neurological dysfunction in a cirrhotic patient
only as “hepatic encephalopathy”, and a nephrologists
sees normotensive pulmonary edema in a patient with renal disease only as a fascinatingly rare “variant” insteadof an MI. In each case, one can see the way circumscribed thinking and tunnel vision drive the reflexive useof Maslow’s Hammer.
The behavioral phenomenon of Maslow’s Hammer is
not confined only to short-circuiting critical thinking inpatient care in Japan. It also has a direct bearing on theprofligate misuse of technology that is bankrupting thesystem in Japan. The effects are particularly devastating
because healthcare quality takes a backseat in the rush
to exploit every high-tech resource available, with orwithout clinical justification. In particular, there is little
financial incentive for hospitals to focus on quality or efficiency, and there are no oversight mechanisms in placeat any level that might invoke some form of penalty for
failure to adhere to quality control! According to Hirose
et al, the Medical Service Law does not require accreditation or review of medical institutions, physicians andnurses are licensed for life with no mandatory requirement for license renewal or continuing education, peeror utilization review in hospitals is non-existent, and146

Rao RH: The case for reform of Japanese medical educationinternal performance oversight in hospitals is negligible.
Finally, physician censure or license revocation is almost
unheard-of.11
With no institutional safeguards in place to ensure
quality, providers and healthcare institutions have taken
full advantage of the opportunity to exploit the unregulated “fee-for-service” system. Tokita writes: “Owing tolack of competition between both hospitals and powerless insurers-the outcome of too many regulationsthere is only a small incentive to improve the efficiency
and quality of medical service”.10
A picture begins to emerge of what is so wrong withthe system, and why the need for reform is so urgent, if
one combines all the separate elements described above
into a comprehensive paradigm. The Japanese healthcare system (i) does not place a premium on clinicalskills, (ii) allows unrestricted access to tertiary care, (iii)
confers pre-eminent status on super-specialization, (iv)permits the use of interventions without regard to clinical justification or evidence, (v) places a heavy relianceon technology, (vi) provides no financial incentive toimprove quality or efficiency, and (vii) does not provide
penalties for failure.
It is this combination that presages disaster for the system in the future.
THE FUTURE
Foretelling Disaster through Hardin’s“Tragedy of the Commons”
Nomura and Nakayama1 6 foresee the coming ruination of Japanese health care through Hardin’s visionof a “tragedy of the commons”. 1 7 The central thesisof Hardin’s argument was that grazing land belonging
to a community (the commons), left to individual exploitation (grazing) by a group of users (herders) was
overgrazed until it ultimately became a wasteland. The
reason was that each individual herder, seeing himself
in competition with his fellow herders for the benefits
provided by the common resource, was interested only
in maximizing his own use of the land for profit. Each
user was oblivious to or unheeding of the consequencesof his actions on the commons, because the destructive
impact of an individual act of overgrazing was seen to berelatively trivial. However, the collective impact of themany repeated acts of apparently “trivial” abuse resulted
in eventual ruin for all the users.
In essence, Hardin’s postulate can be generalized to
any collectively “owned” resource left open to unrestricted use. Human behavior dictates that it will not behusbanded or protected because individual greed andthe temptation of immediate gain trump restraint. In that
context, not even the surety of long-term harm can act asa deterrent against eventual devastation of the resource.
Hardin writes that, “Ruin is the destination toward which

all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.”17
Hardin’s postulate provides justification for the belief
that unrestricted exploitation of a common resource, likethe Japanese healthcare system, is a guarantee for tragedy. According to Nomura and Nakayama,16 the Japanese
healthcare system is headed for ruin because doctors,
pharmaceutical companies and medical equipment manufacturers (the herdsmen) are exploiting patients and thehealth insurance reimbursement system (the commons)for short-term gain. I would go even further than they do
to include the patients as herdsmen, as well: with theirsense of entitlement to tertiary care for even the smallest
of problems, they must bear a measure of culpability inthe ravaging of the commons (the healthcare system). To
paraphrase Hardin, “ruin is truly the destination toward
which all participants in the Japanese healthcare system
are rushing, each pursuing his or her own best interest.”
Matters are not going to get any better in the future.
Japan is seeing a demographic shift over the past halfcentury that is unprecedented in history, as it transitions
from a society composed primarily of young, healthypeople to one that is ageing so rapidly that it is now theworld leader in highest average population age.11 This
inevitably means that resource consumption in healthcare will undergo an equally unprecedented increase as
the population ages. Not only that, studies show that theprevalence of obesity is also on the increase in Japan,20
as are obesity-related disorders, such as diabetes andhypertension,2 1, 2 2 as well as some lesser known associations in the Japanese population like ovarian cancer.23
The magnitude of the problem will only increase with
the increase in childhood obesity now being reported inJapan.2 4 As these trends accelerate in the coming years,
the health status of the Japanese population is likely to
become less an object of envy than a cause for concern.
The future can expect to see a major increase in expenditure on interventions to treat problems like coronary
artery disease, and the complications of diabetes and hypertension.
It is safe to assume, therefore, that the Japanese healthcare system is headed for ruin unless one of two things
happens: (i) restrictions are placed on healthcare practicepatterns (i.e. restricting the “freedom of the commons”),
or (ii) changes are made in the way that physicians inJapan provide patient care (i.e. changing the patterns ofuse of the “commons”). The only question in my mindis, which of these two options should Japan choose?
Changing Medical Education To Change The
Future Of Healthcare In JapanTo summarize the points made above, there are threecrucial links in the chain of arguments that lead to theKeio J Med 2006; 55 (4): 141－148

conclusion that change is imperative. One is Nomura
and Nakayama’s belief that the financial health of theJapanese healthcare system is bleak because of profligate misuse of resources.18 The second is Hirose et al’s
conclusion that profligate resource utilization is a resultof the demise of clinical judgment in Japan.11 The thirdand final link is Kumasaka’s contention that single track
specialization is responsible for both a lack of clinicaljudgment and inappropriate use of resources for diagnosis and treatment.13
The connection between the three observations is inescapable: Japanese healthcare is headed for catastrophic
financial failure if healthcare practices are not changed.
How then to head off the inevitable?
The least favorable solution to the problem from myperspective is the first of the two options describedabove. Restricting the “freedom of the commons” would
mean imposing cost controls and penalties on institutions
or providers, or both, for failure to comply, and enforcing those by bureaucratic fiat. This option is not only
distasteful to me, but also would be wholly unacceptable to Japanese physicians, and probably to the publicat large. It would thus border on political suicide for any
government to even consider such draconian measures.
The only viable solution, therefore, is to change thepattern of use of the “commons”.
In an ideal world, all Japanese physicians would magically agree to change their practice habits and become
more clinically judicious and evidence-based, and thus
more fiscally responsible. It would mean that the systemitself would require little or no modification and that cost
control would become a matter of each individual physician’s moral obligation.
The problem is that Hardin’s postulate deals with thereal world, not the ideal! In the first place, the current
generation of physicians is not equipped to practice inthe manner necessary for this to work, given the education and training they have received. Even more importantly, the likelihood of this happening, given the realityof Hardin’s “tragedy of the commons”, is nonexistent.
Thus, it is a utopian dream and, although perfect fromthe theoretical standpoint, so impractical as to be almost
foolish to contemplate.
If draconian measures are unpalatable, and utopian
dreams are impractical, then realistic solutions are allthat are left. It leads to the only possible conclusion: thatthe problem of the future must be solved by preparing
the physicians of the future to deal with the problem theright way. Kumasaka writes, “For continuity of care andcontainment of costs… a broad medical education is aninvaluable investment”.11
The wisdom of that statement lies in the adjective“broad”, because a “broad” medical education is crucial
for primary care. It is the key to preventive interventions
in a wide variety of conditions that would otherwise re-147

sult in complications that cost several times more to treat
than to prevent. It also epitomizes the reason the medical
education system must change: without a broad medical
education, future generations of graduates will not be
equipped to face the challenges and perils that face theJapanese healthcare system. Without it, there will be no
way to save it in a form that resembles anything like thatwhich exists today.
To achieve that, it is essential to realign medical education in Japan by adopting a curriculum that is less devoted to specialty care, and more to primary care. The focus
must shift to inculcating clinical skills and encouraging
the use of evidence-based medicine to guide diagnostic
and therapeutic decision-making in the next generationof physicians. If, in the process, a greater appreciation
and respect for primary care is also instilled, so much thebetter, but the main focus should be on learning clinicalproblem solving skills that are the foundation for responsible clinical practice, regardless of specialty choice.
It is important to note that the solution does not require
major structural changes in the Japanese healthcare system. It only requires a change in emphasis in medical
education to emphasize the skills that are needed for primary care. The solution also fits well with the fact thatthe backbone of the current system is the vast majorityof graduates of Japanese medical schools who provide
primary care to the public, for the most part in non-academic settings. The great mystery is that they are doing
so without any instruction on how to provide effective
primary care. I can only imagine how much better things
will be if medical education in Japanese schools actually adapts to meet their needs, instead of being focused
almost exclusively on specialists who provide tertiarycare.
The focus of the medical education system must shift
to teaching clinical problem solving skills to its graduates. The Blueprint for Reform that I put forward in an
earlier report2 describes most of what must be done toachieve this. Four of these are obvious: (a) problembased learning, (b) case-based learning, (c) interactive
teaching to make learning fun, and (d) clinical skills
training with an emphasis on general internal medicine.
Add to these a fifth, (e) the teaching of evidence-based
medicine, and Japanese medical education will be transformed into the engine that drives the Japanese healthcare system into the twenty-first century, as a major
player on the global market.
That is the argument that must win the day. Only thenwill the naysayers and doubters be forced to give groundin the face of the determination to change. It is the reason
that the traditional approaches to medical education andpractice in Japan must be abandoned and new perspectives and attitudes must be cultivated. The alternative
does not bear consideration by anyone who has in mind
the collective good of the Japanese healthcare system,

148

Rao RH: The case for reform of Japanese medical educationand of the Japanese people.
Acknowledgements: I want to thank Dr Haruko Akatsu-Kuffner, theDirector of the Pittsburgh-Japan Program for encouragement and advice, for being friend and critic in pointing out the reason I needed towrite this paper, and for then playing Devil’s advocate to make sure I
would articulate it in a coherent manner.

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