Summary: Exact parallels can be drawn between the shortcomings in medical education in the US in the 80s and those prevalent in Japan today. Research and clinical practice had primacy over teaching, and primary care medicine, with its focus on humanistic principles, was subordinated to specialization and tertiary care. US medical schools undertook a wideranging reform of the traditional curriculum, recognizing its four major shortcomings. These were (i) an institutional failure to accord academic status to teaching, resulting in a disincentive to teach, (ii) a failure by faculty to perceive a shared interest in education, resulting in teaching that was fragmented and even contradictory, (iii) a failure to integrate preclinical and clinical material, resulting in fragmented learning, (iv) a failure to encourage the development of the most important attributes of a physician (independent thinking, problem solving, and self-directed learning). The reform of medical education in the US was achieved through a wholesale restructuring that (i) integrated basic science with clinical medicine across the curriculum; (ii) coordinated teaching across departments by organizing the curriculum into "blocks"; (iii) integrated problem based instruction into the curriculum to encourage active learning; and (iv) elevated the importance of both teaching and primary care. The successful effort to reform medical education in the US can serve as a source of encouragement and a road map for academic institutions in Japan, like Keio University, who recognize the same shortcomings in Japanese medical education and are attempting to develop and implement a curriculum that is more integrated and problem-oriented. (Keio J Med 56 (3) : 75 -84, Septmber 2007)

Reform of medical education at Keio University has been underway since 2003. We measure the progress made since then in five specific categories that span fifteen recommendations presented in our"Blueprint for Reform"at the outset of the effort. These are effectiveness of leadership, curriculum reform, recognition of teaching, clinical competence, and comprehensive training in general internal medicine (GIM). First, effective leadership is being sustained through a succession of Deans, although a potentially crippling loss of leadership in the Department of Medical Education must be offset through timely appointment. Second, curriculum reform is awaiting the implementation in 2012 of an integrated, organ system-based curriculum with an emphasis on ward clerkships, but the introduction of PBL has been delayed indefinitely. Third, teaching is being recognized through the use of student feedback to reward good teachers and through funds for six full-time equivalent salaries dedicated to medical education, but promotions still depend exclusively on research, without consideration of teaching ability. Fourth, clinical skills training is still lacking, although enthusiasm for it seems to be building, thanks to the presence on the wards of a (still miniscule) cadre of dedicated teachers. Finally, exposure to GIM remains non-existent; however, visionary leadership in a newly-independent Emergency Department and the wide variety of medical problems seen there provide a remarkable opportunity to craft a uniquely Japanese solution to the problem. The changes implemented to date are impressive, and we remain enthusiastic about the future, even as we recognize the magnitude of the task that lies ahead. (Keio J Med 59 (2) : 52 -63, June 2010)

Professor Takahiro Amano, on how to approach and undertake the task of reforming the medical school curriculum to enhance clinical skills training, in keeping with the mandate established by the Ministry of Health in Japan. 1 The main thrust of the recommendations that emerged, based on observations made during those visits, was to de-emphasize didactic teaching in favor of problem-based learning and the acquisition of clinical skills. [2][3][4][5] This set in motion a process that, as noted earlier, is more-or-less a recapitulation of the process that played out in the late 80's and early 90's in medical schools across the US. [6][7][8] Once the need for such reform was acknowledged at Keio, the next logical step in the progression towards an integrated curriculum at Keio was to reform the preclini- Perspectives in Medical Education AbstractReform of preclinical medical education in Japan requires changes in the curriculum to make it more clinically focused and interactive. At present, course content in Anatomy is usually designed and taught with little or no clinical direction and involves a heavy emphasis on by-rote learning to memorize often minor facts that have little importance in clinical medicine. As a result, the content is boring, it is learned solely for the purpose of passing exams and it is promptly forgotten, with little sense of its need in clinical practice. Successful reform of the curriculum in Anatomy requires two critical changes. The first is that content must be made interesting to students by emphasizing its clinical importance, through a close collaboration between preclinical and clinical departments, Thus, the Surgical Faculty must be incorporated in the organization and teaching of the Anatomy curriculum. Core content can thereby be pared down to only what is considered essential to provide a foundation for the later clinical years, and the clinical importance of that content will, in turn, be self-evident to students. The second change that must be implemented is to make the learning process more appealing to the students. This can be facilitated by the use of any of several commercial IT programs that make learning in Anatomy both dynamic and engaging. These dual strategies will considerably enhance the learning of one of the most basic subjects in the medical school and ensure that the review and retention of the material are enhanced. (Keio J Med 58 (4) : 210 -215, December 2009)