TMDU faculty prepare to lead change in Japan

With an aging population, a move towards school privatization, and a cultural shift changing the relationship between doctors and patients, Japanese medical schools must navigate a host of challenges if they are to remain competitive. Tokyo Medical and Dental University (TMDU) has been addressing these trends since partnering with HMI in 2002. In February, medical educators from TMDU came to Boston for a series of activities designed to prepare them to guide the evolution of the school ’s curriculum.

Dr. Jim Gordon introduced the TMDU faculty to “Stan” (or standard patient), the patient simulator used for teaching at HMS.

TMDU has already enhanced its standing within the Japanese academic community. In Japan, the quality of a school’s incoming students is a key metric for evaluation. In the past three years, according to a survey, TMDU’s ranking in this category has risen from eighth in Japan to second behind only University of Tokyo, the perennial market leader. But educators at TMDU understand that attracting the top students is only half the battle in an increasingly competitive market—they must produce graduates who meet and exceed the expectations of Japan’s changing patient population, and build upon each success.

“Currently Japan’s medical education system is undergoing a number of changes that are common to the international community,” said Tom Aretz, HMI vice president for education. “TMDU is exploring new ways to approach both the subject matter of medical education and the students. They have the opportunity to benefit from past experiences in other parts of the world and at other institutions.”

The 14-person TMDU contingent came to Boston with three main objectives in mind: to develop clerkship models, establish an integrated basic science curriculum, and institute a longitudinal patient-doctor course that would stress professional development in areas like communication, leadership, and medical ethics. Over the course of nine days, the group observed different teaching environments, participated in discussions on topics ranging from learning theory to case writing, and worked to develop their own teaching abilities, including small-group teaching and bedside instruction. A Tokyo-based film crew was on hand to capture the experience for Japanese public television.

TMDU’s alliance with HMI is bolstered by the participation of faculty from Ludwig Maximilians University (LMU), the Munich-based school that, since beginning its collaboration with HMI in 1996, has become a model for curriculum reform efforts in Germany. More than a century ago, Japanese medical education was modeled after the German system; today TMDU has the opportunity to learn from LMU’s experience leading change within a strictly regulated medical education system. Dr. Frank Christ, professor of anesthesia at LMU and a key figure in the Harvard-Munich alliance, played a large role in the TMDU program, presenting on a range of challenges he and his LMU colleagues have faced while developing their new curriculum.

Big changes mean big challenges
Today the leaders at TMDU find themselves in an environment where change is not merely the goal of a minority of eager idealists—on the contrary, change is a necessity, dictated by several factors.

First, the market for medical education in Japan is poised to become more competitive, for two main reasons. By the end of 2004, all of the 42 public medical schools in the nation will be semi-privatized. With less funding from the state, these schools will have to compete for resources to support new initiatives. Another factor, Japan’s falling birth rate, means that the competition for students will be fiercer than ever. Today there are about 1.5 million people aged 18 in Japan, but by 2050, due to a steady decline across the population, that number is projected to be cut in half. In Japan, high school graduates go directly into medical school, and TMDU knows that it must enhance its standing and its curriculum if it hopes to attract this shrinking crop of top students.

The dramatic fall of the birth rate also means, of course, that the country’s overall population is aging. About 30 percent of Japan’s people are over the age of 65, and that number is certain to climb over the next five decades. This greying of the population means an increased demand for health care services in general, and for services related to chronic disease in particular. Japanese medical educators teaching and practicing today must be aware of these evolutionary trends and ensure that medical education adjusts to address them.

Translating ideas into action—and innovation
Even as they agreed on the value of curricular elements like the patient-doctor course and the use of simulation for teaching, the visitors from TMDU acknowledged that implementing these ideas back home will be challenging. “There must be reflection upon our return so that these ideas are developed,” said Dr. Yujiro Tanaka, TMDU professor and director of the Department of General Medicine, who added that arriving at a consensus regarding the need for change, and what specific changes must be made, would require some further discussions.

The faculty from TMDU observed patient-doctor courses at four HMS-affiliated hospitals, including the course directed by Dr. Valerie Pronio-Stelluto at Mt. Auburn Hospital. Front row, from left to right: Jiro Kumagai, Tadashi Nariai, Valerie Pronio-Stelluto, Hiroko Maezawa, Kristen Mitchell of HMI, and Masa Yamawaki. Behind them are members of Dr. Pronio-Stelluto’s Patient-Doctor II course.

Dr. Elizabeth Armstrong, one of the architects of Harvard Medical School’s New Pathway curriculum, understands the challenge facing these educators. “Reaching a consensus about all of the ideas will be impossible, but initially there must be a consensus that something must be done. That’s a critical first step,” she said. “TMDU’s first challenge will be to attract teachers to this effort because they will help to communicate a compelling story about the need for these changes.” Armstrong added, “TMDU must develop a timeline to drive the implementation of different aspects of the new curriculum.”

While many of the group’s activities focused on the ingredients of a revised curriculum, the faculty were eager to discuss how they might bring those elements together. Some of them admitted that the TMDU faculty is very accustomed to planning their individual courses, and will need to adopt a team-oriented approach in order to implement an integrated curriculum.

Dr. Thomas Glick, HMS associate professor of neurology, was one of the course directors for the TMDU visit. He said, “Developing a curriculum design group is very difficult at first, because it involves different kinds of faculty who are not accustomed to working together. But we have found in our experience at HMS that the group must be allowed to evolve over time.”

Dr. Tsutomu Tanabe, TMDU professor of pharmacology and neurobiology, pointed out that future planning efforts must involve an interested party that to date has had little say in how medical education is carried out in Japan. “Students have had no voice for expressing concerns,” he said. This notion of a dialogue that includes the students—rather than a monologue in which the wisdom flows from the top down only—is also reflected in Japanese health care practice, where doctor-patient interaction is changing.