What would William Osler think of
Clinical Education in Japan today?
Linda Snell MD MHPE FRCPC FACP
Centre for Medical Education
& Department of Medicine,
McGill University, Montreal, Canada
Visiting Professor,
IRCME, 2006-7
University of Tokyo
Why this topic?

Osler - Canada connection

Osler - McGill connection

Osler – Kaga connection
Purpose

To educate

To motivate

To inspire

To change
My ‘sources’
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Curriculum descriptions and curriculum reports
Reading
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Discussions
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Medical Education literature *
“The Quotable Osler” **
K Kaga proposals re curriculum change
Students
Faculty
Japanese medical educators
Observation of & participation in clinical education
*Kozu. Acad. Med. 81(12):1069-75, Dec 2006; Teo. Med. Educ. 41:302-8, Mar 2007
**Eds Silverman, Murray, Bryan. ACP. 2003
Clinical education in Japan
1. Curriculum
2. Bedside
learning
3. Postgraduate
education
4. Life-long
learning


Strengths
Challenges
Selected points,
not an organized overview!

Osler’s thoughts
Osler the person
Clinical Education, not Clinical Teaching

Teaching and the teachers

Learning and the learners

The clinical context

The curriculum
Clinical Education
1.
Curriculum
2.
Bedside learning
3.
Postgraduate education
4.
Life-long learning
The curriculum



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Discipline-based – affects
learning of clinical medicine
Late clinical exposure
Clerkships short duration,
many subspecialty areas
Emphasis on memory &
recall, vs understanding and
development of problemsolving skills
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

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PBL (4/5)
Core curriculum (4/5)
Integrated lectures
OSCE as part of CAT
Free quarter
Exposure to community
hospital-type patients (4/5)
Osler: Was not convinced that clinical work should
begin at the onset of medical school
“I do not think that, with our present congested
curriculum, it is an advantage to begin clinical work at
once. It may be good for the student morally, but I am
sure it is bad for him intellectually, and he gleans a
heterogeneous collection of isolated half-understood
experiences, instead of an orderly sequence in which
the acquired knowledge of laboratories is brought to
bear on the problems of disease.”
Insisted students go to bedside and participate in
hands-on care
“take the student from the lecture room, take him from
the amphitheatre – put him in the outpatient department
– put him in the wards.”
Osler: recognized that a combination of concurrent
‘book learning’ and clinical learning was effective
“To study the phenomena of disease without books is to
sail an uncharted sea. Whilst to study books without
patients is not to go to sea at all.”
"The student begins with the patient, continues with
the patient and ends his studies with the patient, using
books and lectures as tools as means to an end”
“Divide your attention equally between books and men”
Osler: Emphasized ‘methods’ (thinking skills) rather
than the acquisition and regurgitation of facts
“The student needs more time for quiet study, fewer
classes, fewer lectures, and above all examinations
should be lifted from his soul.”
“We try to teach the student too much. Give him good
methods and a proper point of view, and all other things
will be added as experience grows.”
The curriculum




Discipline-based – affects
learning of clinical medicine
Late clinical exposure
Clerkships short duration,
many subspecialty areas
Emphasis on memory &
recall, vs understanding and
development of problemsolving skills






PBL (4/5)
Core curriculum (4/5)
Integrated lectures
OSCE as part of CAT
Free quarter
Exposure to community
hospital-type patients (4/5)
Clinical Education
1.
Curriculum
2.
Bedside learning
3.
Postgraduate education
4.
Life-long learning
Bedside education



Students observe – little
‘hands-on’, passive
“Patients do not want to see
students”
Competing demands on
teachers - decreased time
with rounding team


Clinical skills labs
Popular professors teach
critical thinking & clinical
reasoning
Osler: Pioneer of bedside teaching – recognized its
importance for learning
“Medicine is learned at the bedside and not in the
classroom … Live in the ward.”
Emphasized the importance of taking a good history,
doing a thorough exam, spending time with the patient
“…It is a safe rule to have no teaching without the
patient for a text, and the best teaching is that taught by
the patient himself”
Osler knew active experiential was effective learning
“Observe, record, tabulate, communicate. Use your
five senses. Learn to see, learn to hear, learn to feel,
learn to smell, and know by practice alone that you can
become an expert. Medicine is learned by the bedside
and not in the classroom. Let not your conceptions of
disease come from words heard in the lecture room or
read from the book. See, then reason and compare and
control. But see first.”
Osler recognized the patient’s contribution to learning
The patient was made to feel that he was helping in the
education of medical students, and that the student was
his doctor… Dr Osler always created a friendly
atmosphere … The student was seeing in Dr Osler a
demonstration of the best sort of physician-patient
relationship and was gaining invaluable preparation for
his own independent clinical work”
Christian HA Arch Intern Med 1949
Osler: teaching on the wards is a pleasure not an
obligation
“The best life of the teacher is in supervising the
personal daily contact of the patient with the student on
the wards.”
Osler thought that outstanding teachers with practical
experience should be department Chairs
University departments should be “in the charge of men
who have, first, enthusiasm, that deep love of a subject,
that desire to teach and extend it…; secondly, a full
personal knowledge of the branch taught, not second
hand from books but from living experience …”
Bedside education



Students observe – little
‘hands-on’, passive
“Patients do not want to see
students”
Competing demands on
teachers - decreased time
with rounding team


Clinical skills labs
‘Popular teachers’ try to
teach critical thinking &
clinical reasoning
Clinical Education
1.
Curriculum
2.
Bedside learning
3.
Postgraduate education
4.
Life-long learning
Postgraduate education - PGY1-2

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Emphasis on technical
aspects
Little exposure to outpatients
Didactic education varies:
(conferences, grand rounds,
half-days, M&M rounds)
‘Core competencies’ not
formally taught
Entry level low clinical skills


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2 year internship emphasis
on hands-on skills
Learning ‘hierarchy: interns
taught by residents …
Emphasis on primary care:
GIM, general surgery & EM

Objectives:

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doctor patient relationship;
collaborative skills;
social, organizational & ethical
aspects;
case presentation;
medical problem solving
Osler: Created first residency programs

Live in the hospital
“Postgraduate study has always been a feature of our
profession”

Hierarchical & Pyramidal
“No man can teach successfully who is not at the same
time a student”
Osler: Recognized the value of experience as a
learning method
“The important thing is to make the lesson of each case
tell on your education. The value of experience is not
in seeing much, but in seeing wisely.”
Osler: Promoted the importance of learning general
medicine
“The art is getting longer and longer, the brain [of the
learner] has its limits…the time is too short for a man
already burdened to the breaking point, to study any
specialty from the standpoint of the specialist.”
Osler: Emphasis on learning to care for whole patient,
and role modeling the doctor patient relationship
the learner “should learn how to study disease and how
to treat it, or rather, as I prefer to teach, how to treat
patients.”
“Every patient you see is a lesson in much more than
the malady which he suffers.”
“Our study is man, as the subject of accidents or
disease.”
Clinical Education
1.
Curriculum
2.
Bedside learning
3.
Postgraduate education
4.
Life-long learning
Life-long learning



Reflection rarely taught
Skills of LLL not role
modeled or explicitly
discussed
Journal clubs and EBM
discussion uncommon

Emphasis in internship in
‘learning from cases’
Osler: Recognized the ‘information explosion’ and the
need to keep up to date
“Medicine is a “progressive science, day by day
receiving fresh acquisitions, opening up new fields for
investigation, and it will be your duty … to keep pace
with this progress.”
Osler was a life-long learner
“It is a good many years since I sat on the benches,
but I am happy to say that I am still a medical student,
and still feel I have much to learn”
Osler: Believed that ongoing education essential for
the life of a practitioner
“The hardest conviction to get into the mind of the
beginner is that the education upon which he is
engaged is not a college course, not a medical course,
but a life course, for which the work of a few years
under teachers is but a preparation”
Osler: Originated the first journal club
“A physician who does not read books and journals …
who does not read one or two of the best weeklies and
monthlies, soon sinks to the level of a cross-counter
prescriber”.
“For the general practitioner a well-used library is one
of the few correctives of premature senility…”
Osler the person
Osler as a role model

‘Humanitarian and teacher’:
taught medicine as a humanity and an art,
as well as a science

Renaissance man

Personal qualities
Art and Science of Medicine
“The practice of medicine is an art, based on science.”
“The practice of medicine is an art, not a trade; a
calling, not a business: a calling in which your heart
will be exercised equally with your head”
Renaissance man
“Before going to sleep, read for half an hour, and in the
morning have a book open on your dressing table. You
will be surprised to find how much can be accomplished
in the course of a year.”
“The young doctor should look about early for an
avocation, a pastime that will take him away from
patients, pills and potions …anything will do so long as
he straddles a hobby and rides it hard.”
Personal qualities
Compassionate
Respectful
Caring
Tolerant
Sense of humour
Love of fellow man
Humble
Warm
Kaga recommendations for medical education reform
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Standardized clinical curriculum
Integrate basic science & clinical medicine: “facts of
disease should relate to clinical presentation & reasoning”
Small group tutorials with case discussion for clinical links
Long core clerkships: more time learning clinical practice
Exposure to outpatients – continuity
Importance of bedside learning
Humanist – ‘listen to the patient’s story’
1969
Last words
“Medicine is a most difficult art to acquire. All the
college can do is teach the student principles, based on
facts in science, and give him good methods of work.
These simply start him in the right direction…”