Abstract. A blueprint for reform of medical education in Japan is presented, with the goal of training well rounded physicians who possess the ability to think critically and the clinical skill to function as generalists before they enter specialty training. Practical solutions are offered in three problem areas that lie at the heart of the shortcomings in Japanese medical education. They have to do with (i) the way Japanese students learn, (ii) the way Japanese teachers teach, and (iii) the material that students are taught. The inherently passive nature of Japanese students can be changed by emphasizing "active learning" and "critical thinking at the bedside" through a problem-oriented approach, both in the classroom and in the wards. Changing student learning, however, requires a commitment to teaching. At the present time, there is no incentive to teach at all, let alone teach in a constructive or interactive way. Teaching is widely perceived as a burden that takes time away from research, rather than as a credible and rewarding academic pursuit. Thus, promotion policies must be altered to reward teachers and accord teaching its rightful place as a primary function of the faculty. Finally, the introduction of active learning and interactive teaching depends on reducing the current emphasis on didactic instruction, which is passive and unidirectional. Thus, medical school curricula must be restructured to emphasize a problem-oriented, organ system-based approach throughout medical school, starting from the preclinical years. Reforms in all three areas must be implemented in concert for them to succeed. (Keio J Med 55 (3): 81 -95, September 2006)

The residency program at Teine Keijinkai Hospital in Sapporo has successfully implemented a training philosophy that is focused on the development of clinical skills and critical thinking in Japanese residents. Several elements contribute to its success. The first and foremost is visionary physician leadership, beginning with the pioneers who implemented the philosophy, and continuing through the current leadership, which has sustained the original vision. A close second is the administrative and financial commitment to invest in producing more clinically accomplished Japanese physicians, long before that need was officially recognized. Third is the program's explicit aim of adhering to international norms by requiring three years of training, promulgating a benevolent, not paternalistic teaching philosophy and encouraging an interactive and interrogatory learning ethic. Fourth is the year-round presence of a US-trained Physician-in-Residence, to sustain the focus on clinical skills and international norms. Fifth is a long-term relationship with the Internal Medicine Training Program at the University of Pittsburgh, providing a conduit for ongoing academic exchange and programmatic advice. Last, but not least, is its avowed intention of being viewed as an "American-style program" with a preference for English fluent applicants, which acts as a magnet for trainees motivated to acquire clinical skills and competencies, with an eye to future training in the US. All these elements contribute to the program's unique focus on teaching clinical skills and critical thinking. Others who are striving with varying degrees of success to implement a similar philosophy in Japan may benefit from studying its example. (Keio J Med 58 (2) : 84 -94, June 2009)