The truth lies somewhere in the middle: Swinging between globalization and regionalization of medical education in Japan

Abstract

Japan is well known as a super-aging society, with a low birth rate, and has been ranked as one of the countries having the highest quality of healthcare system. Japan’s society is currently approaching a major turning point with regard to societal and healthcare reforms, which are influenced by international trends and regional needs. Development of Japanese healthcare human resources, including medical students, is now expected to ride the wave of globalization, while resolving regional problems in the training and delivery of healthcare. Terms and global trends in medical education, such as outcome-based education, community-based education, reflective learning, international accreditation of medical education, and professionalization of educators are well translated into the Japanese language and embraced positively among the Japanese medical educators. However, these trends occasionally sit uncomfortably with cultural variations that are often a common approach in Japan; notably, “hansei” (introspection) and “kaizen” (change for the better). In the world facing a new era where people are unsettled between globalism and regionalism, Japan’s future mission is to steer a balanced route that recognizes both global and regional influences and produce global health professionals educators.

Introduction

Current changes of health care in Japan

As medical education responds to regional and global changes in healthcare (Gibbs and McLean 2011), medical schools have a social responsibility to train health care professionals to serve local communities. It has been almost a decade since the last paper describing health care and medical education in Japan (Onishi and Yoshida 2004; Kozu 2006; Suzuki et al. 2008), and medical education in Japan is now approaching a major turning point, related to the need for the reformation of society and healthcare in the past few decades (Ban 2014), and under the influence of “globalization” for the past decades. To address the current change and challenge of medical education in Japan, we have selected some major changes in healthcare as shown in Box 1.

Box 1. The factors pressing the Japanese health care change.

Extremely low birth rate and super-aging population unprecedented	• Total fertility rate is around 1.4 in the last decade
worldwide	• The population aged over 65 is expected to reach about 40% in 2040.
Advanced medical technologies and subdivision of the specialties	• The advancement of medical technologies has stimulated the subdivision of the practice of medicine and further development of physicians’ sub-specialty.
	• Variety of health professionals with various national qualifications.
Development of information communication technology (ICT)	• ICT accelerates the sophistication of citizen’s medical knowledge, and the health professionals are required to disclose information in an easy-to-understand manner.
	• ICT brings “a flat world” and enables the medical educators to create a cooperative system beyond barriers such as occupational categories and medical facilities.
International mobilization of both medical staff and patients cross-border	• The movement of doctors and patients across the border is increasing.
	• Health services targeting the domestic and foreign wealthy people is also occurring.
Need for general practitioners, geriatric medicine and home care	• The need for general practitioners who manage wide range of health issues is increasing.
	• To control an increase in medical expenses, the government is also trying to reduce beds for acutely ill patients and to develop home-care doctor services.

Box 2. Global trends, context in Japan, and its current changes.

Japan’s “translationism”

The Japanese perspectives toward internationalization are fundamental to the status quo of Japanese medical education. In “Nihon Henkyo Ron (Discussion on the Japan’s perception of peripheral nationality)”, which was written by a Japanese philosopher and one of the best-selling book in 2010, Uchida (2009) discussed the Japanese common perspectives on internationalization. Uchida claimed that the Japanese are based primarily on their perception that they are living in a peripheral situation, and tend to think that the center is located somewhere else in the world. Therefore, Uchida considers that Japanese usually accept new global trends and concepts with an open mindset (without criticisms), to catch up with international standards, interpret and implement them gradually, and finally incorporate them internally into the Japanese context. Maruyama and Kato (1998), other Japanese philosophers, stated the importance of “import” since modern Japan had achieved further transformation by importing foreign cultures after the opening of the country in the nineteenth century. Importing concepts from overseas actually requires a better understanding of another language and in the nineteenth century, the Japanese government adopted “translationism” that every foreign language should be translated into Japanese. In the process of making the decision, some people argued that English should be accepted as one of the official languages in Japan. On the other hand, others disagreed with the policy suggested, because common people who could not understand English would be excluded from the important and scholarly discussions and possibly resulting in social disparity. Such translationism might function as the breakwater against the tsunami of globalization, and maintain cultural independence. In fact, the adaptation of translationism might enable Japanese to internalize foreign concepts, system, and cultures gradually, in comparison with Japanese traditional cultures, by using Japanese language (Maruyama and Kato 1998). On the other hand, translation of Japanese products into foreign languages has been extremely limited, as many of references in this articles are in Japanese.

In this article, we focus on some “translated” concepts, current context and changes of medical education in Japan, in comparison with global trends at macro, meso, and micro level as shown in Box 2.

Macro level (international, national level)

At this level, the social system rather than culture influences the educational change. The social/disease structure in Japan has been changing due to the super-aging population and the ever-increasing uneven regional distribution of doctors. In fact, the number of physicians in Japan is ranked very low among OECD countries (OECD 2009), and urbanization and physician mal-distribution were claimed publicly (Tanihara et al. 2011). As a result, Japanese are trying to increase the physicians working in the community by various approaches as described below.

General practice as one of the fundamental medical specialty area

Training of the primary care physicians who can utilize human/social resources effectively in the community is undertaken at various levels after graduation (Ban and Fetters 2011). In 2014, the Japanese Medical Specialty Board was re-organized and re-started as an independent third party organization for standardizing programs and guaranteeing the quality of specialists, and the general practice is finally positioned as one of 19 fundamental medical specialty areas such as internal medicine and surgery and its development of nationwide programs is under development. Although Japan has a free-access system to all health care institutions, the increase in certified general practitioners as gatekeepers would contribute to the reorganization of the patients’ access to the physicians and reduction of medical expenditure.

Learning community medicine in the community

To fit with the international trends, clinical training has slowly been relocated from the university hospitals to the community at all level of medical education (Japanese Council for Community-based Medical Education 2015). As to residency training, a two year-postgraduate clinical training program was introduced in 2004 (Suzuki et al. 2008); one month training in the community is now mandatory during this program, which is also a part of efforts to cultivate the basic and comprehensive clinical competencies that can be utilized in the community. As with the trend in other countries, community-based education and primary-care-oriented education, within community clinics has been introduced in 77 out of 80 Japanese medical schools (Takamura et al. 2015). Furthermore, early exposure to the community is provided in undergraduate education; longitudinal encounters with elderly people, pregnant mothers, and infants at the community were all successfully implemented for the first year students to understand the function of the community with broadening their self-awareness as social entities (Saiki et al. 2016).

“Chiiki-waku” to resolve the maldistribution of doctors

The Ministry of Education, Culture, Sports, Science & Technology of Japan (MEXT) (http://www.mext.go.jp/en/) had implemented three policies to increase the physicians serving at community. MEXT decided to increase the admission quota of medical schools in 2008, and the nationwide medical student enrollment changed from 7625 in 2007 to 9262 in 2016 (21.5% increase). In addition to MEXT’s decision to establish two new medical schools, a new entrance examination system was introduced that specifically favored students who wished to work in community rural areas. In this innovation, medical schools are allowed to have a certain number of seats for local students living in the prefecture where the medical school exists or any students who will serve in the prefecture community. The applicants are expected to have a strong future will for working in the community. The admission decisions are made based on the examination, including the academic performance, recommendation of high schools and interviews. They can receive a scholarship from the local government, given that the graduates work in the community for an given period; usually nine years. The number of students admitted to the medical school via this “Chiiki-waku” has continued to increase and there are now over 71 medical schools, that accept about 1400 such medical students (MEXT 2016). Oguchi et al. (2015) clarified that students of “Chiiki-waku” had a positive image to regional/rural medicine throughout the period of academic years, and primary care and pediatrics are more popular among them. Eighty-three percent of the regional frame graduates have selected residency program located in the same prefecture of their graduation, compared to 45.3% of the non-regional graduates (Oguchi et al. 2015). This regional frame entrance system seems to be effective for increasing the future doctors in the local/rural community.

Establishment of JACME

International accreditation is recognized as extremely important by the Japanese leaders in medical schools due to two factors: one is Japan’s sensitivity to global trends and historical dependency on the United States to catch up with international standards, which may be partly explained by the “Nihon Henkyo Ron” (Uchida 2009) as described. Another reason is medical educators’ motivation to break through the conservative situation of medical schools in Japan. Accreditation itself is not something new for Japanese universities since the accreditation system for general higher education had already started in 2004, in which the main focus was to ensure the credibility of educational institutions as a whole. However, in 2010, the US Educational Commission for Foreign Medical Graduates (ECFMG) announced that “ECFMG requires medical school accreditation for international medical school graduates seeking certification beginning in 2023” (ECFMG 2010). Since then, a momentum to build an independent accreditation organization for medical education has rapidly increased. A pilot quality assurance program supported by MEXT and the Association of Japanese Medical Colleges (AJMC) has been organized and has carried out trial accreditation for medical schools since April 2013. As a result, the Japan Accreditation Council for Medical Education (JACME) was formally established on December 2015, and recognized by the World Federation for Medical Education in March 2017 (JACME 2015–2017). Formal accreditation activity, which is organized by JACME, has been implemented since April 2017. This can be an influential trigger of transformation of medical education in Japan.

Meso (institutional/organizational level)

At this level, some cultural factors may influence educational changes. As to curriculum reform, outcome-based education, setting self-directed learning strategies and effective teacher training is a major premise globally. Since curriculum development includes organizational change in local medical education institutions (Genn 2001), the cultural influence on the curriculum development in a particular country cannot be ignored.

Curriculum reformation

Hofstede et al. (2010) demonstrated that Japan has an intermediate score in power distance and highest score in uncertainty avoidance. Such characteristics of culture may influence the approaches to curriculum reformation such as PBL/TBL and clinical clerkship. Jippes and Majoor (2008) and Jippes et al. (2013) suggested that in countries where Hofstede's cultural dimensions such as power distance and uncertainty avoidance negatively influenced the implementation of PBL curriculum and integrated curriculum. As reported by Suzuki et al. (2008), 90% of Japanese medical schools have adopted a PBL approach in the design of their curriculum. On the other hand, some institutions reported the challenges of sustaining a PBL program, such as ensuring the sufficient number of qualified tutors, and the availability of physical resources (Okubo 2014). Due to these challenges, the number of medical schools using PBL has started to show a slight downward trend in recent years. It also has become clear that the ways of implementation are varied. For example, PBL is introduced only for the curriculum in basic medical sciences, clinical subjects only, or introduced for a few weeks in a few other curricula (Okubo 2014). Meanwhile, some medical schools in Japan began to implement, or switch from PBL to team-based learning (TBL); 31 out of 80 medical schools have adopted a TBL approach since 2013 (Okubo 2014), but its implementation is unclear and its fit for purpose still needs further research. Clinical clerkship is considered another weak point of Japan’s medical curriculum. In many medical schools, students still learn through a short (two weeks) rotation through all clinical departments, while international standard of the clerkship is more integration and the concentration of the core subjects to learn basic clinical competencies.

In Japan, there may be an open mind to accept new curricula learning strategies; however, in practice, there is an interference with the discretionary rights of each department, and a tendency toward quite unique, shortened and simplified forms. Therefore, efforts and effectiveness for the curriculum innovation are necessary to examine the research such, as action research (Genn 2001), to understand how the concept of the global trends of the curriculum are employed and internalized into Japanese medical education.

Faculty development in Japan

Faculty development began in 1969 with the establishment of the Japan Society for Medical Education (JSME). The first department/center of medical education in Japan was established in 1972 in Juntendo University. In 1973, three Japanese medical leaders participated in a Regional Teacher Training Programme provided by the World Health Organization (WHO) in Sydney, and they launched a similar 1-week Japanese program “Medical Education Workshop for Medical Educators” at the foot of Mt. Fuji in 1974. Since then, workshop-style seminars that broadly handle curriculum planning and teaching methods had been held in Japan (Science Council of Japan 1997; Ban 2014). Such workshop have now become the basic framework of the nationwide workshop for clinical teachers in 2004 launched by Ministry of Health, Labour and Welfare of Japan (MHLW) after a compulsory 2-year residency program was started. Participants in the workshop should be less than 50, the program should be run for at least 16 hours, and should contain curriculum development and practical methods such as feedback and workplace-based assessment (MEXT 2004). More than 70,000 attending physicians (about 20% of total Japanese physicians) have participated in this workshop and have been certified so far.

Specialization and qualifications of medical education

Since 1990, when curricula reform commenced, the number of departments/centers for medical education now number 75 out of 80 present medical school (http://www1.gifu-u.ac.jp/∼medc/unit/unit.htm). More than 600 full-time and part-time faculties are employed and they are collaborating under the informal organization “Society for Medical Education Units” (Hatao 1999). With the rapid increase in core faculty members who are responsible for medical education, there was increasing need to acquire certification as experts in education. This movement was accelerated by the statement from the WFME global standards document, that medical education experts are required to be assigned to each institution and to manage educational activities (WFME 2015). Only around 20 Japanese graduates from foreign Masters programs on medical education are now taking a leadership role in Japan, and no Masters program has yet been established. While the establishment of a Masters program is expected, the nation-wide need assessment survey by JSME demonstrated that the members of JSME prefer to obtain a basic certification in medical education rather than a Master degree (Suzuki et al. 2009). According to these results, expert qualification system led by JSME was established in 2014 to nurture medical education experts who are competent in the planning, teaching, managing, leading and studying of undergraduate/postgraduate/lifelong medical education. Applicants are required to participate in three two-day courses on (1) teaching and learning, (2) learner assessment, and (3) curriculum development, with analyzing their educational activities, then they make three educational practice reflective reports for the certification. By March 2017, 56 Medical Education Specialists have been certified. They are expected to take opinion leadership for further development of medical education at both institutional and national level.

At the university level, seminars and workshops on medical education have been held throughout the country, especially Medical Education Seminars and Workshops hosted by Gifu University Medical Education Development Center (MEDC), which as a National Collaboration Centre has accepted more than 6000 participants since 2001 and contributed to the development of new educational concepts and methods (Saiki et al. 2014). Moreover, Fellowship programs on health professions education have recently begun in two medical schools (Kyoto University, Gifu University). Both programs have been designed as a combination of online learning with campus learning for busy clinicians. Those fellows are expected to show their balanced clinical duties and teaching responding to the local context in each institution.

Micro (personal, philosophical)

Social constructivism is regarded as one of the global, solid theoretical foundations in contemporary teaching and learning. This view provides an account of how knowledge is socially constructed through activity. Key to successful learning is the learner’s active participation and educator’s facilitation for learning. Additionally, reflection is nowadays seen as an important phase of the learning cycle (Kolb 1984). However, the expectations of learning and concepts about what should happen in learning have been originally developed in each local context, i.e. context-dependent. In this section, how new educational concepts and practices from overseas have been accepted and assimilated into Japanese medical education are described.

Japanese approaches to teaching

The medical educators in Japan have traditionally focused strongly on students’ knowledge acquisition as the desired learning outcome and seen lecture-based teaching as a preferred educational strategy (Onishi and Yoshida 2004). On the other hand, they have also committed to developing the interactive educational strategies over 30 years, such as PBL, TBL and flipped classroom, to promote learners’ autonomous learning and problem-solving skills. Subsequent to the reforms in medical education, a shift to the educational paradigm underpinned by learner-centeredness has been made widely in Japanese higher education, especially as the Central Council for Education of the Japanese Government (Central Council for Education 2012) emphasized the importance of facilitating university students’ active learning in higher education.

In the educational paradigm shift in Japan, the “teacher” is expected to be a facilitator or coach for student learning. Saiki et al. (2013) suggested that Japanese medical educators were sometimes struggling to assume the role of the tutor/facilitator in the PBL tutorial. They tended to avoid “active” involvement when students’ discussion failed, partially because they were inexperienced and did not fully understand what to do as a facilitator. They also had a skeptical view of the educational effectiveness of PBL, which could be affected by their previous teaching/learning experiences and by a cultural characteristic of uncertainty avoidance in Japanese (Saiki et al. 2013). However, as they experienced, they were socialized into the new educational context and attempted to find a better way to facilitate student learning as a tutor.

Some shared understandings of educational philosophy do exist amongst Asian and Western cultures (Nishigori and Sriruksa 2011). For example, a concept similar to reflection in Japan is “hansei”. It is defined as “reviewing past behavior, evaluating, critiquing, and finally improving upon it” (Taylor et al. 2005). Hansei has been traditionally considered a fundamental skill that promotes a child’s social and personal development so that Japanese children are encouraged to make a habit of hansei. Hansei emphasizes particularly on the negative aspect of an experience, i.e. what people should not do, so that Japanese people prefer to learn from a mistake for better improvement; this is known as “kaizen” (change for the better) (Kato and Smalley 2010). Despite such minor difference of their perception, the “Western” concept of reflection has been widely accepted in Japanese medical education, such as portfolios in community-medicine clerkships (Miyata and Yagita 2010) and debriefing in simulation-based education (Konishi et al. 2015).

Japanese approaches to learning

Watkins and Biggs (1996) argued that learners would take different approaches to learning in accordance with its educational contexts, their previous learning experiences and conceptions of learning. For instance, Asian students, including Japanese, perceived the relationship between “memorizing” and “understanding” differently than Western students did. Specifically, Asian students do not see memorizing and understanding as separate but rather interconnecting processes, and believe that memorization can lead to understanding in the initial learning process (Watkins and Biggs 1996; Marton et al. 1997; Imafuku 2012). For instance, the flipped classroom, in which learners are encouraged to perform self-study preparation before classroom learning (Yoshyu in Japanese) is now embraced and gradually introduced into undergraduate medical education in Japan (Nishiya et al. 2014). The reason behind this rapid spreading out may be that the learning process in flipped classroom might align with an approach to learning by the Japanese.

There are still stereotypical images of Japanese learners as being quiet, non-critical recipients of information and rote learners. However, in fact, they were not always reluctant to actively make contributions in the classroom and to accept others’ opinions without a critical appraisal (Tavakol and Dennick 2010). For instance, in the interactive educational setting, Asian learners, including Japanese, did not merely regard silence in interaction as verbal disengagement. Rather, silence was seen as a productive resource, collaborative practice and platform of handling conflicting understandings (Nakane 2006; Jin 2012). Although Japanese learners appeared to feel it difficult to shape the new learning process in such pedagogical contexts, they attempted to more actively make contributions to discussions for the successful group learning, as they acquired experience of PBL (Imafuku et al. 2014).

From the viewpoint of micro level of Japanese medical education, we need to note the risk of over-generalizing the Japanese learners’ approach to learning and behavior. As Matsumoto (2002) claims, the stereotype of Japanese being more collectivistic does not clearly reflect Japanese identity and communication behavior in contemporary culture.

Conclusions

Even though medical education in Japan is still in a state of flux, successful development and reformation can be observed in response to international trends. While “translationalism” with an open mind set for international trends has been shaping Japan, translation of Japanese products into foreign languages has been extremely limited. As knowledge, educational terms, and models of medical education, which are mainly generated in the English-speaking countries surely contributes to the global progression of medical education, another view and wisdom should be produced and exported from non-English speaking countries for the equal collaboration. To realize this, active engagement of Japanese medical educators, who equip the capability to design, develop, facilitate, evaluate, and transport as well as export their wisdom through research are expected.

Notes on contributors

Takuya Saiki, MD MHPE and PhD, is an associate professor of the Medical Education Center, Gifu University. He initially introduced the concept of this paper together with the rest of the authors and performed a literature review and wrote the initial manuscript.

Rintaro Imafuku, MA, PhD, is an assistant professor of the Medical Education Center, Gifu University. He equally contributed to the conception of this paper and co-developed the manuscript.

Yasuyuki Suzuki, MD PhD, is a professor of the Medical Education Center, Gifu University. He is the current president of Japan Society for Medical Education since 2015. He equally contributed to the conception of this manuscript and co-developed the manuscript.

Nobutaro Ban, MD, is a professor of the Medical Education Center, Aichi Medical University School of Medicine. He is a former President of Japan Society for Medical Education (2009–2014). He equally contributed to the conception of this paper and edited the manuscript.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.