Learn a Prospective Way of Medical Education from the Progressing Theory of Higher Education and Create a Practice based on It / 医学教育

Medical education had begun in the 1970s as a pedagogical science and art by the establishment of the Japan Society for Medical Education and its activity thereafter. WHO had played an important role in the backbone of the Society by introducing a new concept of medical teacher training as the shortest way in order to realize "Health for All by the Year of 2000". In 1973 the founder and first president Prof. Ushiba attended the WHO Workshop for Deans held in Sydney and was influenced with a shockingly effective experience.<br>The WHO's principle of teacher training (faculty development) came from pedagogy professor Bloom's theory of the taxonomy of educational objectives, strategy and evaluation and its practice.<br>After 40 years since then, the theory and practice of higher education have changed and improved. Of course, medical education is not an exception of higher education. Therefore, we apply its progress in medical education and it does the same each other. They say ten years make an age–old epoch; therefore accordingly, 40 years are four times.<br>A life expectancy of the theory of medical education will be 40 years. Now we have to reform medical education by change of our mind and by introducing new theory and practice.<br>Problems facing medical education such as shortage of physicians and medical and health care expenditure, national policy, education of physician scientists and successor medical educators are also discussed.

The 40 Years Achievement and Anticipation of the Japan Society for Medical Education / 医学教育

Forty Years AgoAugust,1969 in the prime of the nation-wide university strife, the Japan Society for Medical Education was founded within the Association of Japanese Medical Colleges in order to improve medical education through a long-ranged research-based activity and became an independent organization later.Achievements AfterwardOnly 62 members at the beginning have increased year after year to 2,000 and 230 organization members, including all 80 medical schools, in response to the societal summons. The Society's activities have ranged widely from the undergraduate medical education, begun at the student selection, the graduate education to the continuing education of the health professionals with and through evidence-based research.Some of the real activities during the past forty years have been as follows: (1)Various committees and working groups have worked continuously toward momentarily crucial issues facing medical education, (2)The scientific meetings have been held annually at the medical schools or teaching hospitals for forty years as well as conferences and workshops occasionally, (3)The official journal "Medical Education (Japan)" has been published bimonthly and the educational books as well, (4)Promotion and cooperation of "faculty development" have been one of the most important tasks, (5)Assistance to build the medical education centers in medical schools and hospitals and (6)many others.Future ProspectivesThe Japan Society for Medical Education will continue every activity for the people's health and welfare as an organization of "noblesse oblige".

Graduate schools of medicine in Japan: The status and problems of researcher training / 医学教育

1) Common training for the introduction of research and the elective and individual guidance for research should be devised in a manner attractive to graduate students of medicine.<BR>2) To train researchers, a graduate school of clinical medicine should be established as a professional school, separate from an ordinary graduate school.<BR>3) To promote basic medical sciences, the capacity of graduate schools of basic medical sciences should be reduced despite the number of teachers and the bold plan for the financial support of students.

Model Core Curriculum and Student Evaluation System for Entering to a Clinical Clerkship. The Stream of Renovation of Medical Education in Japan / 医学教育

Referencing to one hundred and thirty years history of the modernized medical education in Japan, the author analyzed the stream of its renovation by classified it into four phases according to an old Chinese proverb, “They who want to know what shall be must consider what have been.” The change during sixty years after the World War II (the second phase) had been much more remarkable than that of seventy years before the War (the first phase). The unified medical education at all the new-system universities in the second phase had been diversified multidirectionally at many newlyestablished medical schools in order to meet the nation-wide demand to increase the number of young able physicians who became impulsive power group to innovate the traditional conservative medical society. The third phase had begun in 1991 when the university chartering standards law was liberalized vastly and every medical school could compose its curriculum more freely depending on its and student's demands like as order-made programs. Recent ten years, the fourth phase, are continuing up to today becoming the structure reform of medical education more remarkable and the education curricula core-oriented toward tomorrow's physician training. Now time has changed, “They who want to know what shall be must consider what will be.”

The Present Condition and a Future Survey of Japanese Medical Graduate Schools (Master's Course) 1999 / 医学教育

To analyse the present condition and to survey Japanese medical graduate schools (Master's course), questionnaires were sent to all six universities in 1999. All the universities have the aim of, education of medical basic researchers, in common. This aim has high social needs. Four of the six universities also have the aim of, education of high grade specialists in the medical field. The number of applicants has increased for some national and public universities. For other universities, more public relations are necessary to increase the number of applicants. The social situation has altered, and finding employment has became difficult after completion of the course. It is therefore necessary to open new courses to match social needs. Buildings and equipment are not enough at present. As a result, a course for Master of Public Health will be established at Kyoto University.

Results of a Survey on Clinical Competence to Be Evaluated by the National Physicians' License Examination / 医学教育

The clinical competence needed by every beginning resident and the present status of such competencewere examined in August 1998 through questionnaires distributed to clinical educators and the nursing staff of university hospitals and clinical training hospitals designated by the Ministry of Health and Welfare. Completed questionnaires were returned by 576 (65.9%) of clinical educators and nursing staff. With a cluster analysis of the necessity and the present status of clinical competence, 21 items for clinical competence were identified as those most requiring evaluation by the national examination. These 21 items included 11 items for clinical competence in the cognitive domain, 8 items in the psychomotor domain, and 2 in the affective domain. In about half of the direct answers obtained from clinical educators, evaluations were considered necessary for 15 items of clinical competence, of which 13 belonged to the cognitive domain. These results were consistent with the present status. However, practical examinations have also attracted increasing attention, as the results included strong demands that the national examination evaluate some basic clinical skills, such as physical examination and measurement of vital signs. However, about 30 % of authorities governing the national examination thought no changes are needed in the national examination.

Designing the Medical Education Program towards the Next Millennium in an Environment of the Higher Education Reform and Society Changes / 한국의학교육

This lecture is based on my own experience in medical education at the new University of Tsukuba and Hospitals and also on the activities of the Japan Society for Medical Education. The former(U.T.) has only 25 year history and the latter(J.S.M.E.) has 30 year history both since establishment. Because both are younger than the traditional medical schools and the common medical community of Japan, my idea and opinion will be beyond the average of our country.

Medical education system. Reorganization of Chair System and Redistribution of Faculty Members at the Medical School / 医学教育

The chair system was introduced into the Japanese universities from Germany more than 100 years ago in the Meiji era. Since then, it made very little change and was preserved like antiquities in the medical schools.<BR>During the past 100 years, there had been two opportunities to change it: first in the early 1970s at the time when new medical schools had been established all over Japan and second in 1991 at the time of change of the university chartering standards law which was conducted by the Japanese Ministry of Education toward a liberalization of the past law in order to let the universities match to the change of society and to the progress of art and science.<BR>Although since the latter opportunity some change was observed mainly at graduate schools of the limited high-ranked universities, most of medical schools have neither changed their traditional chair system nor reformed their schools in spite of the ensured liberalization.<BR>In this paper, why reorganization of chair system is necessary, how it can be done and also why and how redistribution of faculty members is crucial and can be performed are explained by citing an example at the University of Tsukuba which has experienced during the past two and half decades from the beginning of its establishment in 1973.

Education of Doctor's Attitudes toward Patients in Medical Education in Japan / 医学教育

We surveyed in every medical university in Japan on how attitudes development is adopted in its medical educational curriculum so far. There are several universities which in some way have already adopted attitudes development into curriculum or teaching items. However, hours of lesson and the contents are so differed among them. Moreover, both evaluation of these lessons by trainees and judgement as far the educational effect by trainers are not programmed satisfactorily. Some universities complain of manpower shortage, difficulties of fixing curriculum, or shortage of total lesson hours, so that they say they cannot dare work on this attempt. But, there are still an increasing number of universities ready to start their programs, where education arranged by non-medical teachers, practical medical experience at the real front, the introduction of simulated patient (SP) into education, and so on are considerd to be carried out.<BR>Thus, we suppose it is time to have and share some guideline for adequate attitudes development education at this moment. And at the same time, a national system to encourage the medical education, including trainning SP, is urgently required to be planned.

A Survey on Undergraduate Clinical Training with Special Reference to Clinical Procedures Performed by Medical Students on Patients / 医学教育

A questionnaire survey on clinical procedures performed by medical students on patients during undergraduate clinical training was conducted in february 1996. Responses were received from 1328 clinical departments of university cospitals at 80 medical schools. Basic clinical procedures that medical students were permitted to perform on patients were recommended by a committee of the Ministry of Health and Welfare. These procedures are divided into three categories: level 1; procedures that medical students are permitted to perform under the supervision of an instructor; level 2; procedures medical students are permitted to perform with supervision under certain conditions; and level 3; procedures for which medical students are generally limited to assisting instructors or to attending and observing patients. The status of performance of the procedures was investigated. Of level-1 procedures (36 procedures), 8 were performed by medical students at more than 80 % of university hospitals, 19 were performed at from 50% to 70%, 9 were performed at less than 50%. Of level-2 procedures (15 procedures), 8 were performed at from 55% to 79% of hospitals and 7 were performed at less than 50%. For level-3 procedures (15 procedures), medical students were permitted to assist and observe 4 procedures at from 82% to 86% of hospitals, 11 at from 50% to 79%, and 1 at40%. In addition, students were permitted to perform 13 level-3 procedures at from 10% to 44% of hospitals and to perform 3 at from 6% to 9%. In many clinical departments, other kinds of procedures specific to the departments were adopted. Teaching media, such as standardized patients' computer-assisted instruction models, and animal materials, were used, and facilities in the community cooperated in training. Respondents wrote many suggestions and opinions about the difficulties and concerns with the legality of students' performing clinical procedures, patients' consent or agreement, minimal essentials of clinical competence of students, the shortage of instructors, and the training and guidelines for instructors.

Results of a Survey on the Present Status of Undergraduate Clinical Training and Plans for Its Improvement / 医学教育

We used questionnaires to study the present status of undergraduate clinical training at medical schools in Japan in February 1996. Completed questionnaires were returned by 81%(65) of 80 medical schools and approximately 54%(1, 328 clinical departments) of the schools. The results were as follows. Courses for early clinical exposure in the 1st or 2nd year were provided at 83% of the 65 schools; clinical clerkships in the 5th and 6th years were provided at 28%. Specific behavioral objectives for clinical training were clearly shown to students and teaching staff at 75% of schools. Clinical procedures that medical students were permitted to perform were listed and announced to students and teaching staffs at 66% of schools. Patients were informed and gave consent for clinical training of students at 77% of schools. Essential knowledge and skills of students were assessed before the start of clinical training at 40% of schools, and summative assessment was made at the end of the training at 72%. Training of clinical teaching staff for faculty development was conducted at 51% of schools. Eightynine percent of schools reported a shortage of clinical teaching staff. Similar results were obtained in the survey of clinical departments of university hospitals: most departments complained of a shortage of teaching staff, of students not being active, and of students not being competent to enter clinical training courses. To improve clinical training, the introduction of clinical clerkships and cooperation with community facilities outside universities were the main issues.

Factors Influencing School Choice by Medical Students / 医学教育

In order to appropriately obtain information for the purpose of reforming the school selection process, we analyzed questionaires from 1, 641 students in their first year of medical school. Twenty-five percent of the subjects were women and the 20 participating medical schools consisted of 4 newer national schools, 6 older national schools, 3 provincial or municipal schools, 4 newer private schools, and 3 older private schools.<BR>As expected the medical students admitted to a strong desire to enter the specific profession of medicine. Important factors influencing their decision to apply to a particular medical school included (1) geographical location, (2) general public reputation, (3) whether or not the school was part of a university, and (4) the cost of tuition. Students did not appear to pay much attention to specific educational programs, facilities and environment, or the teaching staff of individual schools. The Committee proposes that medical schools make a greater effort to acquaint applicants with the history, purpose, and educational environment of their institution in order to aid the students in their selection process.

Investigation on Improvement of Peripheral Circulation by Continuous Use of Prostaglandin E1 during Open Heart Surgery. Evaluation with Peripheral Blood Flow by Laser Doppler Flowmeter and Temperature Difference between the Periphery and Core / 日本心臓血管外科学会雑誌

Prostaglandin E₁ (PGE₁) was used continuously in adults from immediately after induction of anesthesia, during extracorporeal circulation, to the acute phase after open heart surgery. Using blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core as indices, the effects of afterload reduction and improvement of peripheral circulation were investigated. Subjects were 17 adults who underwent open heart surgery. PGE₁ was used in 7 patients and not used in 10. In the group using PGE₁, continuous injection of 0.015μg/kg/min of PGE₁ was started immediately after induction of anesthesia and was maintained during extracorporeal circulation until the acute phase after surgery. During extracorporeal circulation, perfusion pressure was kept at 50∼60mmHg and PGE₁ injection was controlled within the range of 0.015∼0.030μg/kg/min. At completion of extracorporeal circulation, the dose was fixed at 0.015μg/kg/min again. The degree of improvement of peripheral circulation was evaluated on the basis of hemodynamics, blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core, at induction of anesthesia (before using PGE₁) on completion of extracorporeal circulation, and in the acute phase after surgery. The value of blood flow in the toe determined by laser Doppler flowmeter was significantly higher in the PGE₁ group than in the non-PGE₁ group, from completion of extracorporeal circulation to the acute phase after surgery. Moreover, peripheral temperature was significantly higher in the PGE₁ group than in the non-PGE₁ group at completion of the extracorporeal circulation as well as immediately after surgery, and the temperature difference between periphery and core was significantly smaller. Continuous injection of PGE₁ enabled smooth control of perfusion pressure during extracorporeal circulation. Although there was no significant difference in peripheral vascular and total pulmonary resistance, the coefficients tended to be lower in the PGE₁ group. The use of PGE₁ during open heart surgery seems to be an effective method to improve peripheral circulation.

A Fourteen-Day-Old Neonate with Congenital Aortic Valve Stenosis Successfully Treated with Open Valvular Commissurotomy / 日本心臓血管外科学会雑誌

A thirteen-day-old neonate was admitted because of systolic heart murmur, tachycardia, tachypnea and sucking weakness. The chest X-ray film demonstrated remarkable cardiomegaly and pulmonary congestion. Echocardiography detected marked thickening and stenosis of the aortic valve, and left ventricular dysfunction (EF=10%). The pressure gradient between left ventricle and ascending aorta was presumed 130mmHg with pulsed Doppler echocardiography, Since he did not respond to conservative treatment, an emergency open aortic valvular commissurotomy under cardiopulmonary bypass was performed the day after admission. We made incisions of 1mm in the left side and 0.5mm in the right side commissure of the adherent bicuspid aortic valve. After the procedure, left ventricular function improved (EF=57%), and the pressure gradient was reduced to 62mmHg. He showed good recover from the congestive heart failure. There are few reports about operative treatment of congenital aortic valve stenosis in neonates. This is considered to be the third youngest successful operative case of open aortic valvular commissurotomy in Japan.

A Case Report of Successful Surgical Treatment of High Aortic Occlusion with Acute Ischemia of Intrapelvic Organs and Bilateral Lower Extremities / 日本心臓血管外科学会雑誌

This is a case report of a 57-year-old woman with high aortic occlusion (HAO) who had acute symptoms of severe ischemia of the lower extremities and the intrapelvic organs. Generally, HAO is a chronic ischemic disease of the lower extremities and the intrapelvic organs; therefore, acute HAO is relatively rare. Acute thrombotic occlusion of a major collateral artery might be the cause of acute HAO. Laser Doppler flowmetry of the sigmoid colon was useful to evaluate the ischemia of intrapelvic organs. Thrombectomy of the juxtarenal portion with the suprarenal aortic cross clamp was performed within four minutes, then the clamp was moved to the infrarenal portion. The remaining occluded aorta was replaced with a Y-shaped knitted Dacron graft. She had no symptoms after the surgery except renovascular hypertension. Seventy five percent stenosis of the right renal artery was exacerbated to 99%. Vascular clamping of the right renal artery might have been the cause of severe stenosis. Percutaneous transluminal renal angioplasty was successfully performed after the surgery. Aggressive renal artery reconstruction during surgery is recommended in cases with moderate or severe renal artery stenosis.

Causative Factors for Thrombi Formation in Mitral Stenosis / 日本心臓血管外科学会雑誌

Causative factors for thrombi formation in left atria of 38 patients with mitral stenosis who underwent mitral valve surgery (open mitral commissurotomy or mitral valve replacement) alone or in combination with other procedures were studied. There were 9 cases of left atrial thrombosis (LAT). Left atrial diameter was increased in LAT(+) group (6.1±1.6cm) compared with LAT(-) group (4.6±0.7cm). There was significant difference in the left atrial diameter between the two groups of patients (<i>p</i><0.01). Cardiac output was decreased in LAT(+) group (3.04±0.74<i>l</i>/min) compared with LAT(-) group (3.99±1.07<i>l</i>/min). Cardiac output of LAT (-) group was significantly larger than that of LAT(+) group (<i>p</i><0.05). Mean transition time of blood through left atrium (MTT_LA) was calculated using left atrial volume and cardiac output. In LAT (+) group, MTT_LA was significantly increased (6.2±3.9sec) compared with LAT(-) group (2.9±1.6sec). It is considered that, in mitral stenosis, prolongation of MTT_LA is one of the risk factors for thrombi formation in the left atrium.

A Successful Result of One Stage Operation for Atrial Septal Defect and Funnel Chest / 日本心臓血管外科学会雑誌

A 6-year-old boy underwent one stage operation for atrial septal defect (ASD) and funnel chest. The procedure began with removal of cost-sterno complex (plastron) following median skin incision. Plastron was kept in cold saline with antibiotics during ASD closure, and sterno-costal elevation method was performed. Simultaneous operation for heart disease and funnel chest is profitable in preventing postoperative circulatory or respiratory complications, in avoiding problems of two stage operation such as adhesion and mental stress of the patients. In addition, wide exposure and easy approach to the heart is available with this one stage procedure. Although current refinement both of cardiac and thoracic surgery has encouraged the possibility of simultaneous corrections for heart disease and funnel chest, much precautions against bleeding and infection are necessary for the satisfactory surgical result.

Aorto-Renal Artery reconstruction for renvoascular Hypertension Due to takayasu's disease / 日本心臓血管外科学会雑誌

Thirty-nine years old woman had a severe renovascular hyper-tension with Takayasu's arteritis Her left renal artery stenosis was treated with percutaneous transluminal angioplasty (PTA) three times. Six months after the third PTA, the left renal artery was occluded, and left renal failure occurred. Aorto-renal bypass surgery with a prosthetic graft was performed. Blood pressure dropped to normal range, and left renal function began to recover. Although PTA is an effective method in the treatment of renovascular hypertension, an incidence of restenosis after PTA is higher in Takayasu's arteritis rather than atherosclerotic lesions. Five months after renal revascularization, hypertension recurred in this case. However the aorto-renal bypass graft was patent accompanied by no symptoms. This aorto-renal bypass surgery can be considered effective in this condition.

Surgical Repair of Atrial Septal Defect in Adult Patients / 日本心臓血管外科学会雑誌

Fifty-five adult patients with atrial septal defect (ASD) were surgically treated. In the preoperative study, 6 patients showed high pulmonary artery systolic pressure (>50mmHg). However, there was no linear relation between PAP and age, nor between <i>Q</i>_p/<i>Q</i>_s and PAP. As for the additional surgical procedures, MVR (1), MAP (1), TAP (3), OPC (2) were carried out with ASD closure in 7 patients. Post-operative evaluation with echocardiography revealed increase in the left ventricular chamber size, decrease in the severity of tricuspid regurgitation and same grade mitral regurgitation compaired with pre-operative level. From these data, the prediction of the atrioventricular valve regurgitation after ASD closure seemed to be difficult just from the preoperative evaluation, Transesophageal echocardiography was useful for the evaluation of residual atrioventricular valve regurgitation during operation in the cases of ASD with over II grade regurgitation preoperatively.

A case of aortoenteric fistula associated with behcet disease / 日本心臓血管外科学会雑誌

Aortoduodenal fistula is rare complication of nonoperative abdominal aortic aneurysm. We successfully treated a case of primary aortoenteric fistula associated with Behcet's Disease with two surgical intervention. The patient was 41 years old man. He admitted to our hospital because of severe shock due to enormous gastrointestinal hemorrhage. Emergency laparotomy revealed the inflammatory abdominalaneurysm ruptured into the duodenum. As the saccular aneurysm was densely adherent with duodenum and retoroperitoneum, graft replacement was abandoned. Primary closure of the perforated area of duodenum and the neck of aneurysm were performed. Axillofemoral bypass restored blood flow of the lower extremities. Three month after the operation, aortoduodenal fistula recurred. On the second operation, abdominal aorta was divided through retroperitoneal approach. However, primary closure of the enteric perforation with graft replacement of the aorta is considered as the first choice of the surgical treatment for aortoenteric fistula. In a case of difficult condition such as this patient with severe shock or retroperitoneal fibrosis, repair of the duodenum wall and division of the abdominal aorta with axillofemoral bypass is an alternative method of choice.