ICP/HMD/012
ENGLISH ONLY
SUMMARY REPORT CONFERENCE ON "CHANGING COMMUNITY NEEDS AND FUTURE MEDICAL EDUCATION"
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Convened by the WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC AND THE JAPAN MEDICAL EDUCATION FOUNDATION Kyoto and Kurasiki, Japan 24 - 28 June 1986
Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines Augus t 1986
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The views expressed in this summary report are those of the participants in the Conference on "Changing Community Needs and Future Medical Education" and do not necessarily reflect the pOlicies of the World Health Organization. The full report on this Conference will be subsequently issued by the Japan Medical Education Foundation.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for participants in the Conference on "Changing Community Needs and Future Medical Education", held in Kyoto and Kurasiki, Japan, on 24 to 28 June 1986.
CONTENTS
1. 2.
PRESENT DAY ~DICA~ EDUCATION IN JAPAN AND SOME OF ~ TS PROBLEMS •••••••••••••.••••••••••••••••••••••••••••••• STRATEGIES AVAILABLE FOR MAKING CHANGE ••••••••••••••••••• 2.1 2.2 2.3 Promotion of diversity in medical education .••••• Clarification of educational objectives •••••••••• Improvement in admission procedures ....•••••..... Towards a student-oriented education •.••••••••••. Self-awareness of educators •••••••••.•••••••••••• Changes in the university hospital as an educational institution ......................................... .. Exchanges with other universities and community resources ............................................................................ ..
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2.4 2.5 2.6
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2.7 2.8 2.Y 2.10
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Reform of postgraduate education ••••••••••••••••• Role of the university president and the medical school dean ............................................................................ Fundamental reform of the national physician's examination ...........................................................................
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OUTLOOK FOR THE FUTURE ..•.••••.••••••••••••••••••••••••••
1.
PRESENT DAY MEDICAL EDUCATION IN JAPAN AND SOME OF ITS PROBLEMS
Medical education is inseparable from the higher education and health care system of the nation. The basis of medical science is common to all countries, but its particular application in anyone nation is influenced by national social, political economics and cultural considerations. Nonetheless, all countries are now facing unprecedented changes which transcend national differences in many aspects of medicine. Health and medical care are no exceptions to the need for change. Medical education is being reformed and brought into line with all such changes. Factors that accelerate the need for reform of medical education include the following: (1) deeper awareness of human rights;
(2) changes in disease patterns, especially in the aging population, Ln conditions resulting from life-style changes, and in the increasing number of patients with chronic or emotional disorders; (3) (4) (5) (6) (7) changes in health-care economics; advances in technology: developments in the information sciences and computer technology: increased awareness of ethical issues; changes in the community arising from industrialization and
urbanization.
The declarations and recommendations that emerged from the WHO 1978 Alma-Ata Conference and the 1985 Tokyo Conference, and also the experimental reforms discussed here with participants from several countries, were grounded on these same changes. A common feature of the
new strategies for reform is that their underlying principle i. responsiveness: the ability to respond to change and to community needs. Re-evaluation of medical education in Japan is timely for those who are involved in medical education in this country. Naturally, in making appropriate and realistic reforms, it is important to bear in mind the history of Japan and the characteristics of its culture and society. This Conference has given rise to the following observations about the present state of Japanese medical education, including some of its special characteristics and its most pressing problems. (1) Medical schools in Japan have all been required to meet standards established by the Ministry of Education, Science, and Culture. One result is that the education provided by the universities has attained a common minimum level everywhere. These standards have undergone some revisions,
and the individuality of each university is now recognized, but in fact Japanese medical educadon is still, generally speaking, uniform. (2) As a rule, professors are independently responsible for This education, research and the care of patients in their own department.
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departmental (koza) system has both advantages and disadvantages. It is desirable for management and for research, but in this system it is often difficult to coordinate between departments on matters of education, although such cooperation is essential these days. The reason for this is that in the ko~~ system, the content of the education that takes place depends greatly on the background and character of the professor. It is by no means rare to have a medical school in which the objectives of education
in the school as a whole and in the different departments, and also the goals set for student achievement, are only vaguely defined. (3) With few exceptions, the content of medical education emphasizes the cognitive domain. This is partly because the choice was made to import only the academic aspects of western medicine, partly because of certain
characteristics of the system of higher education, and partly because of the regard held for higher education in this society. These reasons are all historical ones; other reasons are the nature of the admissions system
and the national licensure examination. All of these things have led to criticism of the failure to nurture skills and attitudes, resulting from the trend towards single-minded cramming of knowledge in today's medical education.
(4) University hospitals have been a place where research has priority. Of course, society as a whole expects this of such hospitals, but it gives rise to a number of problems for medical education. Until now, little use has been made of affiliated hospitals outside the university for teaching. Factors that have contributed to this include the attitudes of the professors, financial considerations and the lack of government encouragement. This circumstance has hindered medical education
from making progress towards fulfilling community needs. (5) Most medical students receive their entire education at the same university, from entering medical school to reaching career status. Instructors are usually graduates of the same university. What is more, it
is not common for students to be taught by a doctor from a community hospital or clinic, or from other universities. (6) Philosophical objectives have been defined for undergraduate education, but there are still no specific objectives either for the undergraduate or postgraduate stage. Postgraduate education is not really systematic, and depends on the individual policies of each department and university. This affects the plans for undergraduate education as well. (7) Students are obliged to study in some depth every branch of medicine. This is considered necessary because by law a licensed doctor can decide to practise in any specialty. This has retarded change in clinical education and in introducing student-motivated study. (8) General education is designed to provide a base for the student to understand man and society, that is, to develop appropriate attitudes in the physician-to-be. However, general education as it is now, with still-undefined objectives, has little perceived relevance to medical education.
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(9) At all levels of medical education, there is insufficient integration of basic medical science, community medicine and clinical medicine.
(10) All Japanese universities include bedside training but compared with other countries, training is insufficient and tends to be overshadowed by the lecture programme. If development of problem-solving, clinical and communication skills and of appropriate attitudes is to be enhanced, then this imbalance should be reviewed. 'fhere 'Ire many stu<\ents who fail the ll"tioq"l licenallre or who fail to be promoted from one yaqr to the next in medical school. In one sense the student is the one responsible, but it is also true that there are complaints by faculty in national, public, and private universities alike of apathy and lack of motivation. Besides the fault of the apathetic individual in lacking self-determination, blame can be placed on faults in the process of education in Japan, from elementary school until entrance to university. In order to counteract this tendency to student apathy, many schools increase the lecture hours, which may worsen the problem. (11) e~amination
(12) Although the national physicians' licensure examination is being improved, its effect on medical education must not be ignored. At many universities, the time allocation now exceeds national standards. For the introduction of change in medical education, simultaneous reform of this examination is needed.
Thus, although medical education in this country is today maintained at a uniform standard in order to prepare the next generation of doctors who will have a leading role in a health care system based on the new concepts and who will have to adjust to changes in community and social needs, there are a number of problems that must be addressed. 2. STRATEGIES AVAILABLE FOR MAKING CHANGE
A variety of strategies will be needed to achieve change in medical education in Japan. The general views of this Conference about strategies and approaches are summarized below:
2.1
Promotion of diversity in medical education
Within the framework of established standards, medical schools can be encouraged to increase the diversity of medical education. Each medical school has its own individuality, which should be respected. But despite this, the expectations of society and the Government about universities should be taken into account. 2.2 Clarification of educational objectives
All medical universities must define their objectives for education. Furthermore, the objectives of each course must agree with those of the
school as a whole.
- 4 (1) Undergraduate education should be designed so that the student can move on to any medical career after graduation. One of its objectives must be that of providing a general professional education. (2) There should be a balanced emphasis on acquisition of knowledge, skills and attitudes. (3) Improvement must both be in general education itself and in the objectives of this education. While providing training in the scientific basics, general education must also be expanded to include the humanities, so that the future doctor will be able to provide medical treatment and health care with humanity. (4) There should be a greater degree of curriculum integration, including the integration of teaching in the basic medicine community sciences and clinical medicine subjects. (5) There must be increased emphasis on clinical skills, including communication skills, based on the behavioural sciences, to promote
understanding of the patient, his family and his environment. 2.3 Improvement in admission procedures
Many universities are now active in improving their entrance examination in particular. The trend is to change from reliance on purely academic tests to methods that judge the applicant's overall capacity to become a doctor. Their motives in wanting to be a doctor and their
aptitude to do so should also be evaluated. Each medical school should develop test methods to evaluate the suitability of students from the point of view of the defined educational objectives of that school. At the same time, there should be an organization that could develop an aptitude test to be used in the selection procedure. 2.4 Towards a student-oriented education In order to move toward a student-oriented education, the following suggestions are made!
(1) There should be emphasis on how to teach and how to learn rather than on what to teach and what to learn. (2) The challenge of each subject, the fascination of scientific inquiry and the responsibility for self-learning should be stressed to enhance the student's self-esteem.
(3) There should be a Shortening of lecture hours, emphasis on laboratory and small-group teaching, and increased unscheduled time for self-learning. In Japan, many educators mistake self-motivated learning for simply leaving the student alone. For self-learning in practice, the teacher provides guidance to students about their objectives and sources of learning, and on how to evaluate their progress.
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(4)
The opportunity for elective courses should be introduced.
(5) Student opinion and participation should be sought 1n planning curricula and other activities of the medical school. As students accumulate the benefits of self-directed learning, they learn how to consult with seniors and colleagues. This is one quality needed in a physician, who must continue to learn throughout his career. 2.5 Self-awareness of educators
Education centres on the human relationship of teacher and student. The instructor must be aware of his influence on the growth of students into doctors. In addition to the doctor's understanding of the patient, there must be human understanding, with consideration given to the family, workplace and society in the background of the patient. Students learn how to solve problems by observing the behaviour of their instructors. 2.6 Changes in the university hospital as an educational institution Medical education can also be improved if university hospitals change their emphasis from investigation and research to greater concern for
patient welfare. One possibility is for these hospitals to improve teamwork and liaison between clinical departments, both in and out of the university. If this is done, the hospital will become an integral part of the working Ioedical network. This improvement would facilitate cooperation with community medical and other service organizations.
2.7
Exchanges with other universities and community resources
At present, medical schools receive some help from part-time teachers from other institutions, but in the future more exchanges will be needed with other universities and community institutions. This should not be a matter only of instructors from outside coming to the university. The student should make use of the various social resources that are available. An obtacle to this change in Japan is the fact that funds are not currently earmarked for this purpose. This change has been recommended before, but has still not been implemented. Understanding of and support for this change must be sought from the Government and the community. To receive such support, medical schools must be seen to be contributing to the needs of the community. 2.8 Reform of postgraduate education
Reform of undergraduate education cannot be separated from improvement of postgraduate education. It has already been stated that the different educational objectives and methods must be defined. For undergraduate students, the closest model is the postgraduate resident doctor. The attitudes and orientation of the resident towards the community have a
major impact on the student. For effective postgraduate clinical training, it is necessary to use other hospitals as well as the university hospital. Other aspects of postgraduate training, including graduate schools, medical research and specialty certification, should be discussed in more detail separately.
- 62.9 Role of the university president and the medical school dean
Medical schools in Japan have a tradition of department-oriented administration. They are thus not always able to deal with the demands of society for reform of medical education with the necessary boldness and flexibility. Leadership by the university president and medical school dean is essential for reform. Selection methods, terms of appointment and other conditions at each university should be adjusted so that the necessary leadership can be secured. The educational and administrative roles of the president and dean must be fully supported within the institution and by other agencles. 2.10 Fundamental reform of the national physicians' examination
Since 1985, when this examination was revised, the need to establish a permanent body to be responsible for ongoing review has been widely advocated. The new revised examination does not as yet meet community needs, give appropriate emphasis to primary care or test problem-solving skills. A further concern is its use of mUltiple-choice questions. Other issues include the timing of the examination and whether it should be taken as a single comprehensive test or divided into sections. Because the examination has a great impact on undergraduate medical education, its reform should be carefully reviewed. 3. OUTLOOK FOR TKE FUTURE
This Conference has taken place under the auspices of the WHO Regional Office for the Western Pacific and of the Japan Medical Education Foundation. The participants here have fully understood the Declaration of Tokyo, which was adopted at the WKO Conference on "Toward future health and medical manpower" in 1985. Changes in medical education will always be needed. The following proposals are submitted for consideration: (1) At the university level
An effort must be made to achieve reform within the sphere of responsibility of the universities. Too much haste may result in failure. The reforms should be rooted in the community, learning from precedent. Bodies should be established to examine the need for and outcome of these reforms at each university. These bodies will need to obtain the understanding of the faculty and other staff, the students, and the community. (2) At the national level
The Japan Medical Education Foundation is always involved in research and inquiries into how to improve medical education. However, constructive responses are also needed from the Government and other agencies.
- 7 (3) At the international level
International exchange of information and expertise regarding medical education must be promoted. The continuing role of the WHO Regional Office for the Western Pacific is essential. To achieve continuing progress in each of these domains, domestic and international conferences and exchanges regarding medical education should be supported. Such conferences and exchanges will help maintain the enthusiasm generated at this meeting. This kind of meeting is unprecedented in Japan. It is noteworthy that all of the participants, both from Japan and other countries, discussed the issues sincerely and openly. A cooperative spirit was developed in the meeting leading to a better understanding of the difficulties and of ways to address strategies for change.