Hirotaka Onishi

Rapid change in Japanese medical education

Change in Japanese medical education has been accelerating over the last 10 years. Historically, clinical departments in each medical school played a crucial role, but reports in the mass media tried to refute the feudal ‘ikyoku-koza’ system with a number of malpractice cases, inappropriate patient–doctor communication, etc. At that time policies by the Ministries of Education and Health (rationalized in 2001) independently became more influential in medical education. In particular the network of governmental medical schools has been restructured, merged and privatized since 2001. In the 1990s several private medical schools developed distinctive curricula including problem-based learning (PBL), the objective structured clinical examination (OSCE) and introduction to clinical medicine (ICM). The curriculum for clinical medicine is still a critical issue and will be a major challenge for the management of each medical school. The effectiveness of the National Model Curriculum consisting of more than 1200 objectives might be questionable but the National Common Achievement Test (CAT) will make a strong impact on the preclinical curriculum. In the future each medical school should adopt an outcome-based education system to close the loop of curriculum development. An evaluation system based on the entire medical school or curriculum will be the key to successful education.

Research in assessment: Consensus statement and recommendations from the Ottawa 2010 conference

Medical education research in general is a young scientific discipline which is still finding its own position in the scientific range. It is rooted in both the biomedical sciences and the social sciences, each with their own scientific language. A more unique feature of medical education (and assessment) research is that it has to be both locally and internationally relevant. This is not always easy and sometimes leads to purely ideographic descriptions of an assessment procedure with insufficient general lessons or generalised scientific knowledge being generated or vice versa. For medical educational research, a plethora of methodologies is available to cater to many different research questions. This article contains consensus positions and suggestions on various elements of medical education (assessment) research. Overarching is the position that without a good theoretical underpinning and good knowledge of the existing literature, good research and sound conclusions are impossible to produce, and that there is no inherently superior methodology, but that the best methodology is the one most suited to answer the research question unambiguously. Although the positions should not be perceived as dogmas, they should be taken as very serious recommendations. Topics covered are: types of research, theoretical frameworks, designs and methodologies, instrument properties or psychometrics, costs/acceptability, ethics, infrastructure and support.

THE ROLE OF CASE PRESENTATION FOR TEACHING AND LEARNING ACTIVITIES

In most clinical teaching settings, case presentation is the most frequently used teaching and learning activity. From an educational viewpoint, the two important roles of case presentations are the presenters reflective opportunity and the clinician educators clues to diagnose the presenter. When a presenter prepares for a case presentation, he/she has to organize all the information collected from a patient. The presenter sometimes does not recall what to ask or to examine with relation to pertinent differential diagnoses while seeing a patient, and afterward he/she might note that more information should have been collected. He/she is able to note the processes by reflection‐on‐action and improve the processes the next time. Such a reflective process is the most important role of case conference for a presenter. When a clinician has a consultation with a patient, early problem representation determines the quality of differential diagnoses. Clinicians make a “big picture” while listening to the patient (sometimes only a glance is enough to diagnose a patient) as problem representation to narrow down clinical areas to ask questions. If the early problem representation is far from the optimal direction, the possibility of misdiagnosis will be higher. To correct the cognitive processes that lead to misdiagnosis, disclosure of uncertainty will be the key. If the teaching environment among residents or young clinicians is too competitive, some might feel reluctant to disclose incorrect reasoning processes to their peers. Or, if a clinician educator is too authoritative, students may hide key information from the educator. The educator should construct the best environment for students to be able to disclose such uncertainty. The main role of clinician educators is to facilitate and evaluate case presentations and to suggest points for improvement. Neher et als “five microskills” are a typical example of these processes, after a short presentation of an outpatient case. Yet, for an inpatient or for formal discussion, a longer version presentation is used. To improve the clinical reasoning processes of the presenter, the short presentation has several advantages: (1) shortening the presentation requires abstraction of information, possibly leading to better problem representation; (2) it is time‐efficient; and (3) it stimulates more informal interactions with the facilitator and the audience. In clinical settings, a presenter uses his/her time for the preparation of case presentations to reflect on the information he/she has collected. The facilitator should know how to improve case presentations to diagnose and improve the presenter. The advantages of the short presentation should be emphasized.

Psychometric item analysis and validation of the Indonesian version of the Readiness for Interprofessional Learning Scale (RIPLS).

Abstract Complex health care needs in developing countries are stimulating development and implementation of interprofessional education (IPE). To better understand IPE, it is necessary to develop and evaluate an educational program that focuses on interprofessional learning (IPL) in Indonesia. However, no instrument in the Indonesian language has been developed to measure attitudes toward IPL. The aim of this study is to describe the process of a cross-cultural adaptation of the Readiness for Interprofessional Learning Scale (RIPLS) in an Indonesian version including determining its reliability and validity. The study was conducted among students enrolled in medical, nursing, pharmacy and public health courses at the State Islamic University, Jakarta, Indonesia, in 2012. The completed responses to RIPLS were collected from 755 students. The psychometric properties were analyzed by both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). EFA on 18-items revealed three factors accounting for 59.9% of the total variance. CFA resulted in a three-factor model over 16 items with satisfactory reliability (alpha coefficients >0.7), construct validity and acceptable indices of goodness of fit. We conclude that this Indonesian version of RIPLS with a three-factor model over 16 items is a valid tool to measure students’ attitudes toward IPL.

Medical students can teach communication skills – a mixed methods study of cross-year peer tutoring

BackgroundCross-year peer tutoring (CYPT) of medical students is recognized as an effective learning tool. The aim of this study is to investigate the non-inferiority of the objective outcome of medical interview training with CYPT compared with the results of faculty-led training (FLT), and to explore qualitatively the educational benefits of CYPT.MethodsWe conducted a convergent mixed methods study including a randomized controlled non-inferiority trial and two focus groups. For the CYPT group, teaching was led by six student tutors from year 5. In the FLT group, students were taught by six physicians. Focus groups for student learners (four tutees) and student teachers (six tutors) were conducted following the training session.ResultsOne hundred sixteen students agreed to participate. The OSCE scores of the CYPT group and FLT group were 91.4 and 91.2, respectively. The difference in the mean score was 0.2 with a 95% CI of −1.8 to 2.2 within the predetermined non-inferiority margin of 3.0. By analyzing the focus groups, we extracted 13 subordinate concepts and formed three categories including ‘Benefits of CYPT’, ‘Reflections of tutees and tutors’ and ‘Comparison with faculty’, which affected the interactions among tutees, tutors, and faculty.ConclusionsCYPT is effective for teaching communication skills to medical students and for enhancing reflective learning among both tutors and tutees.

What determines medical students’ career preference for general practice residency training?: a multicenter survey in Japan

BackgroundFew studies have systematically explored factors affecting medical students’ general practice career choice. We conducted a nationwide multicenter survey (Japan MEdical Career of Students: JMECS) to examine factors associated with students’ general practice career aspirations in Japan, where it has been decided that general practice will be officially acknowledged as a new discipline.MethodsFrom April to December 2015, we distributed a 21-item questionnaire to final year medical students in 17 medical schools. The survey asked students about their top three career preferences from 19 specialty fields, their demographics and their career priorities. Multivariable logistic regression was used to determine the effect of each item.ResultsA total of 1264 responses were included in the analyses. The top three specialty choice were internal medicine: 833 (65.9%), general practice: 408 (32.3%), and pediatrics: 372 (29.4%). Among demographic factors, “plan to inherit other’s practice” positively associated with choosing general practice, whereas “having physician parent” had negative correlation. After controlling for potential confounders, students who ranked the following items as highly important were more likely to choose general practice: “clinical diagnostic reasoning (adjusted odds ratio (aOR): 1.65, 95% CI 1.40–1.94)”, “community-oriented practice (aOR: 1.33, 95% CI 1.13–1.57)”, and” involvement in preventive medicine (aOR: 1.18, 95% CI 1.01–1.38)”. On the contrary, “acute care rather than chronic care”, “mastering advanced procedures”, and “depth rather than breadth of practice” were less likely to be associated with general practice aspiration.ConclusionsOur nationwide multicenter survey found several features associated with general practice career aspirations: clinical diagnostic reasoning; community-oriented practice; and preventive medicine. These results can be fundamental to future research and the development of recruitment strategies.

Population-based survey regarding factors contributing to expectation for death at home

BackgroundIn 2015 in Japan 12.7% of people die at home. Since the government has no policy to increase the number of hospital beds, at-home deaths should inevitably increase in the near future. Previous researches regarding expected place of death have focused on end-of-life patients. The aim of this study is to clarify the percentage and factors of senior people who expect at-home deaths whether they are end-of-life or not.MethodsUsing cross-sectional questionnaire survey data which had been taken by a research group with the support from Tama City Medical Association (Tokyo) in 2014, univariable and multivariable logistic regression analyses were conducted to identify associations among factors. The dependent variable was the expected site of death and other factors were set as independent variables.ResultsOf 1781 respondents, 46.5% expected at-home deaths. Data from 1133 people were analyzed and 46.5% of those wanted at-home deaths. Factors significantly associated with expectation of at-home death were men, stand-alone houses for dwelling, expectation to continue life in Tama city, twosome life with the spouse, healthiness, and economic challenge.ConclusionPercentage of those who expected at-home deaths was much higher than the latest percentage of at-home deaths. Some factors associated with expectation of at-home deaths in this study have never been discussed.

Improvement in medical students' communication and interpersonal skills as evaluated by patient satisfaction questionnaire after curriculum reform.

Fifteen years of undergraduate medical education curriculum reform at Saga Medical School was evaluated by measuring medical students’ communication and interpersonal skills with a patient satisfaction questionnaire developed by the American Board of Internal Medicine. A multiphase cross-sectional study was conducted at the General Medicine Clinic of Saga Medical School Hospital in phase I (1998–1999), phase II (2001–2002), and phase III (2009–2010). A total of 1,963 patient ratings for 437 medical students’ performance was analyzed. The average scores of phases II and III were significantly higher than for phase I. The average score of female students showed a significant difference between phases I and II, but no difference between phases II and III. The average score of male students showed no difference between phases I and II, but significant difference between phases II and III. The phase II curriculum introduced basic clinical skills and examination and improved female students’ performance. The phase III curriculum was effective for male students because it emphasized the clinical skill program more and introduced problem-based learning. Curriculum reform at Saga Medical School is considered to have made good progress in improving students’ clinical competence and patient-centered attitudes.

Characteristics and perceptions of twice-weekly webinars for primary care physicians in Japan: a qualitative study

Objectives To explore the characteristic features and perceived value of free twice-weekly webinars predominantly focusing on the continuing professional development of primary care physicians in Japan. Methods In this qualitative study, we conducted a focus group of the webinars’ participants (n=6, a purposive sample). The discussion was recorded, with the recording subsequently transcribed, separated into meaningful segments and then open-coded until thematic saturation was reached. Concepts were generated through selective coding. Finally, the extracted concepts were grouped into categories. Results Extracted concepts were grouped into five categories: technological breakthroughs, the creation of learning opportunities, external interaction, stimulation of internal interaction, and the advantages and disadvantages of nationwide expansion. The webinars were perceived to provide a comfortable learning climate, enabling physicians to teach one another, share their experiences and become virtual colleagues. The chat system stimulated real-time interaction between both a main speaker and participants and the participants. Participants were able to ask questions or give comments in a stress-free atmosphere. The webinars were found to elicit real-time, internal interaction within participating sites without interrupting the sessions. Participants also highly valued the absence of commercial sponsorship. The expansion of the webinars raised two concerns: the possibility of speakers becoming nervous and the increased burden on the organizers. Conclusions The webinars have successfully allowed sharing of unbiased information and experiences in a comfortable, multifaceted interactive learning environment, enabling participants to feel connected. The chat system permitted interaction not feasible in face-to-face learning opportunities and has shown great promise as a means of online medical education.

Correction to: medical students can teach communication skills – a mixed methods study of cross-year peer tutoring

Author details Department of Integrated Medical Education, Graduate School of Medicine, Hirosaki University, 1 Zaifu-cho, Hirosaki city, Aomori, Japan. Division of Pediatric Emergency Medicine, Tokyo Metropolitan Children’s Hospital, 2-8-29 Musashidai, Fuchu city, Tokyo, Japan. International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan. Received: 18 September 2017 Accepted: 18 September 2017