Chapter Overview: Cultural Fusion as an Endless and Dynamic Process

This article first summarizes the brief history of medicine in Japan and its constant fusion with medical practices of other countries, such as China, Korea, multiple European countries, and the United States. Placing cultural fusion within such an extended historical context is essential for an in-depth understanding of how medicine and medical education evolved in Japan before World War II (mainly the Meiji period) and after World War II (contemporary Japan). The second section offers concrete examples of cultural fusion in Japanese medical education during the Meiji period. It includes cultural fusion that occurred when Western medicine was adopted and distributed and further narrows its focus to a series of educational tools (paintings, moulages [wax-skin models], and a journal, “the first edition of the Kyoto Medical Association Journal”) that reveal mixtures of Japanese and Western cultures. The third section examines three examples of cultural fusion in contemporary Japanese medical education: simulated learning and assessment (Objective Structured Clinical Examination [OSCE]), students’ self-directed learning with real case scenarios (problem-based learning [PBL]), and learning in steps rather than holistically (clinical clerkships). Lastly, since cultural fusion is not limited to Japan and Western countries, this study looks into two other examples: the outflux and influence of Japanese medicine and medical education in other Asian countries and an influx from Taiwan to Japan. Thus, this review examines Japanese medicine and medical education before World War II (particularly in the Meiji period, 1868–1912) and after World War II (referred to here as the contemporary period) to determine how cultural fusion occurred between Japanese medical education and imported practices.

The Process of Adopting Western Medicine in the Meiji Period

In the context of adopting Western medicine in Japan, invited Westerners were referred to as newcomers. These individuals taught Western medicine at Japanese universities and interacted with Japanese students and colleagues. Accordingly, Japan (the host environment) accepted the invited Westerners (newcomers) and imported Western medicine, which greatly affected Japanese medical education and practice. Previous historical studies have noted the process of selecting newcomers from the perspectives of both the host and the newcomers, indicating how cultural fusion happens under contexts and intentions of both sides. For example, in her historical studies about the emergence of nursing professions in modern Japan, Takahashi (2004) asserted that “in popular Japanese medical historiography, the modernization of medicine begins with schooling native doctors in Western medicine, their pursuit of Western medico-scientific knowledge, and doctors-centered institutional as well as intellectual medial development” (p. 17). Tokyo East College is an example of one such doctor-centered institution established to acquire Western medical knowledge, and German specialists such as army surgeon Benjamin L. Müller (1861–1934), the first German medical teacher, provided medical education at these establishments (Bowers, 1970, pp. 236–262; Ishida, 1988; Kanokogi, 1989; Kim, 2014, pp. 31–42; Ohmi, 2019; Sugiyama, 2006a).

Some possible reasons are attributed to why the host prioritized German medical education over others. Scholars often mention that one stakeholder in medical education, Sagara Chian (1836–1906), insisted on adopting the German medical education system (Ishida, 1988, pp. 308–330; Kim, 2014, pp. 20–21). Sagara was a graduate of Nagasaki Medical School, the first official Western medical school at the end of the Edo period. Reportedly, he is believed to have claimed the superiority of German medicine over that of other Western countries. Although scholars (Ishida, 1988, pp. 308–330; Kamiya, 1979; Kim, 2014, pp. 20–21) doubt the accuracy of this explanation, they assumed that Sagara’s claim was based on the knowledge and experience he had at Nagasaki Medical School, where manuscripts for textbooks were originally written in German and then translated into Dutch.

There are other political speculations as to why the German medical education system was imported. First, The Meiji government viewed the German political system as an ideal one with an emperor and wanted to emulate Germany (Sugiyama, 2006a). Second, the government decided to choose a third candidate to avoid political conflicts between Holland and Britain, as both countries had provided medical teachers and education before the Meiji government was established (Ishida, 1988, pp. 328–331; Kamiya, 1979).

Furthermore, while the host influenced the selection of new medical education, the newcomers also chose how they would affect the host. When selecting medical teachers from Germany, Prussian Minister Max von Brandt (1835–1920) requested that the Prussian government send army physicians to Japan as teachers. According to scholars (Bowers, 1998, p. 245; Kim, 2014, pp. 22–23), Brandt thought that the Japanese held these particular physicians in high esteem due to their warrior titles (bushi) and because they could influence people in upper-class groups, including bureaucrats and aristocrats. As a result, two medical teachers, Müller and naval physician Theodor E. Hoffmann (1837–1894), were dispatched to Japan. As Brandt requested that the Meiji government give them the power to design and supervise medical education, they were able to implement German medical education in the first Japanese medical school (Kim, 2014, pp. 22–23; S. Sakai, 1982, pp. 392−393; Takahashi, 2004, p. 19). Thus, at that time, the process of selecting and adopting new medical pedagogy aimed to consolidate both the host and newcomer’s political and cultural contexts and intentions.

One outcome of the consolidation could be seen in the medical education curricula. Such curricula have been the focus of previous studies on the adaptation of Western medicine around the Meiji period in Japan (Ishida, 1988; Kanokogi, 1989; Ohmi, 2019; S. Sakai, 1982). Ishida (1988) investigated how Dutch medicine and medical education influenced Japanese medical education and shed light on the curricula at Nagasaki Medical School (the first Western medical school founded by the Edo government), Tokyo East College, and their antecedents, the European army medical schools (p. 332). He argued that there are similarities between the curriculum of Nagasaki Medical School and that of Tokyo East College because both were based on European army medical school curricula (Table 1).

According to Ishida’s analysis, Nagasaki Medical School’s curriculum was similar to that of the Utrecht Army Medical School, from which Pompe von Meedervoort graduated (Ishida, 1988, pp. 325–326), and Tokyo East College’s curriculum shared features with the German Army Medical School syllabus (Ishida, 1988, p. 331). The curricula of all these army medical school had comparable characteristics: (a) compulsory subjects with omitted humanities and philosophy topics and (b) an emphasis on applying medical knowledge in practice and acquiring skills (Ishida, 1988, pp. 336–338). These characteristics were passed on from the first Western medical school in Nagasaki to Tokyo East College (antecedent of the University of Tokyo) and subsequently to other Japanese medical schools (Ishida, 1988, pp. 337–338).

Ohmi (2019) partially criticized this idea upon investigating and comparing different curricula from the University of Tokyo between 1874 and 1887 and argued that the Japanese culture at the University of Tokyo gradually influenced the curriculum derived from the German Army Medical School (pp. 441–451). Therefore, it is too simplistic to say that the curricula of European army medical schools were directly followed by the Imperial University and other medical schools. Each medical school, including the Imperial University, may have customized their curriculum depending on their contexts and resources and according to their specific culture, as cultural fusion theory suggests.

In addition to curricula that were the outcomes of the consolidation of the intentions of both sides, the host (Japan) and the newcomer (Germany), previous studies have covered a wide range of topics related to cultural fusion, such as educational environments, learning and teaching styles, languages, and policies (Bowers, 1980; Kanokogi, 1989; Kim, 2014; Ohmi, 2019; S. Sakai, 1982; Sawai, 2019; Terasaki, 2020).

Among them, languages and learning styles were completely different between the host and the newcomer, which provoked bitter conflicts. At the beginning of Tokyo East College, Japanese medical students were required to disregard their old methods of practicing and learn new styles to show their competencies and emphasize their capacities to make the necessary efforts to learn new medicine (Kim, 2014, pp. 31–42). They also needed to learn the German language to assimilate German medicine, as if they were studying at a German medical school. Those unable to follow these strict requirements were eventually expelled from the school (Kim, 2014, p. 16). However, this strict education process was quickly attenuated, as Tokyo East College (local receivers) refused to obey this intense assimilation pressure, transformed its curriculum, and generated a new course (Kim, 2014, pp. 44–45; Kira, 2012).

As outlined above, initially, the newcomer (medical education from the West) tried to assimilate and deculturize the host (Japanese medical education), who appeared willing to accept the assimilation. However, as cultural fusion theory and the historical accounts suggest, adopting a new education style was a reciprocal process that involved communication and compromise (Kramer, 2019).

Mechanisms (Structures and Individuals) for Distributing Western Medicine

In 1877, the Meiji government transferred Tokyo East College to Tokyo Medical School, unifying it with other schools, such as the Imperial Colleges of Engineering, Law, and Literature. This unified school, named the Imperial University, was the first national university in Japan. Among its faculty of medicine, German medical teachers provided all formal classes in German (Bowers, 1998, pp. 252–255; Kanokogi, 1989; Kim, 2014, pp. 37–39), forcing medical students to spend a long time learning the language before being able to study Western medicine. However, as some Japanese graduates became medical teachers who could teach Western medicine in Japanese, the university started offering a commuter program in Japanese to increase the number of Japanese doctors who received Western medical education (Ikai, 2010, p. 72; Kanokogi, 1989; Kim, 2014, pp. 44–45). Accordingly, the dependence on German teachers gradually decreased (Kanokogi, 1989; Kim, 2014, pp. 44–53; Ogawa, 1973; Terasaki, 2020, p. 40), and the Japanese professors established their departments, called ikyoku, which means a dispensary/medical department. Thus, structures such as universities, faculties of medicine, and ikyoku were developed to implement the newly imported Western medicine throughout Japan. At this stage, the distributors were Japanese professors studying medicine in Western countries rather than Western medical teachers.

In 1888, the Meiji government proceeded with this distribution process by creating a policy that Western medicine should be distributed across Japan from the Imperial University (Kitahara, 1997; Ogawa, 1973). Each medical school was required to hire at least three Imperial University graduates. Those hiring more than three could obtain a certificate declaring the institution an official medical school from which graduates were not obligated to take the national examination to become a qualified medical doctor (Ikai, 2010, p. 73; Kitahara, 1997; Okada, 1992). Therefore, the Imperial University’s graduates had the privilege of becoming teachers at medical schools all over Japan (Ikai, 2010, pp. 75–77; Kitahara, 1997). Additionally, these graduates could become hospital directors and gain opportunities to study overseas, especially in Germany or at universities in other European countries, with governmental financial support (Ikai, 2010, pp. 75–77; Okada, 1992). At this stage, Japanese graduates of the Imperial University, not German medical teachers, were expected to play the role of the newcomer importing Western medicine to Japan. In fact, medical doctors returning from Germany and other European countries became founders of many Western medicine disciplines in Japan. For example, Shuzo Kure (1865–1932), a psychiatrist who studied in Austria and Germany, developed the Japanese Association of Psychiatry. Keizo Dohi (1866–1931), who studied dermatology and urology in Vienna, learned how to make moulages (wax-skin models) and introduced Western dermatology and urology to Japan.

However, one famous doctor returnee from Germany, Ohgai Mori (1862–1922), began to seek the spirit of “Japaneseness” as a writer after his year-long stay in Munich in 1886. He became a military physician and later served as Army Medical Director. He not only had a successful career in medicine but also became a well-known writer in Japan. He initially went to Germany to study medicine; however, his encounter with the German host environment changed the direction of his career. Upon his return to Japan, he became more interested in literature, in which he sought the spirit of “Japaneseness” under the surge of Westernization (Morikawa, 1985). Interestingly, one of the theoretical assumptions of cultural fusion can explain this transformation that involved learning Western medicine and discovering Japan’s native literary culture: “Cultural fusion involves both acculturation and cultural maintenance” (Croucher & Kramer, 2017, p. 102). According to Morikawa (1985), one of Mori’s academic discussions with Naumann, who criticized Japan’s hasty modernization and abandonment of traditional Japanese culture, activated his “Japaneseness” and motivated him to integrate die Wissenschaft with Japanese literature as an expression of cultural fusion.

In addition to the newcomers and Japanese returnees from Europe, educational structures such as universities and faculties were subsequently derived from those in Europe and the United States and distributed in Japan (Terasaki, 2020). For 30 years following the Meiji Restoration (1868), the Imperial University was the only national university. However, in 1899, owing to an increasing number of returnees from Germany and other European countries, Kyoto Imperial University was founded as the second Japanese Imperial University (Committee for the 100-Year Anniversary Album of the Faculty of Medicine, 2004). After its establishment, the Meiji government began increasing the number of Imperial Universities in Japan and founded seven by 1939. These seven universities are still called Kyu-tei-dai, meaning the old Imperial Universities, and classified as universities that the Japanese government continued to provide with relatively large financial aid for their academic studies up to the 2010s (Kuroki, 2017).

In addition to Japan’s Imperial University system, Japanese physicians are traditionally expected to belong to the dispensary (Ikyoku) associated with the university from which they graduated. These medical dispensaries, a unique Japanese system, represent the doctor’s office and personnel bureau, comprising the top professors from each medical department affiliated with the university hospital. This top-down structure resembles the Japanese patriarchal, vertical system (Ie) (Kobayashi et al., 2006) and is prominent among doctors, especially surgeons (Green et al., 2017; Sur et al., 2016). Although the dominance and power that the dispensary system provides departmental professors have weakened, many doctors still belong to university hospital dispensaries.

Iwakuma and Son (2021) detailed the transformation of Japanese medical culture since the 1970s under the influence of Western practices, such as informed consent. Traditionally, under a strict chain of command, the professor, as the department’s father figure, could easily send junior doctors to different hospitals. These doctors were required to follow orders to survive in Japanese medical university culture. In the article, Iwakuma introduced the traditional Japanese dispensary system in which subordinates are protected and looked after in exchange for swearing loyalty to the departmental professor at the top of the pyramid. The dispensary creates a family-like atmosphere where the departmental professor fosters beneficial connections or environments for research, medical training, clinical experiences, or medical degree obtainment, all factors that are essential for younger doctors.

Influences of German Medicine on Kyoto Imperial University’s Faculty of Medicine

In addition to the processes of adopting and distributing Western medicine, evidence of cultural fusion can be detected by considering how medical teachers and students learned medicine and what materials were used to do so. This section examines cases from records and materials of Kyoto Imperial University, including the records on the school’s first professors (all were Japanese) and educational tools such as wax-skin models, wall charts, and pages from a medical journal.

Kyoto Imperial University (now known as Kyoto University) is one of the Imperial universities famous for Nobel Prize–winning research in medicine and physiology by researchers such as Tasuku Honjo (b. 1942, winner of the 2018 Nobel Prize in Physiology or Medicine) and Shinya Yamanaka (b. 1962, winner of the 2012 Nobel Prize in Physiology or Medicine). In 1899, Kyoto Imperial Medical University (the predecessor of Kyoto Imperial University) was established with eight departments and six specialties, including departments of anatomy, medical chemistry, physiology, and public health, and two departments for internal medicine and surgery (Committee for the 100-Year Anniversary Album of the Faculty of Medicine, 2004). The first professors were all from Tokyo Imperial University and had experience studying overseas, especially in Germany (Table 2).

Therefore, it is reasonable to assume that the German style of medical education continued to influence the curricula and teaching styles at Kyoto Imperial University, although no remaining official documents showing the curricula have been discovered. From the remaining pictures (Figures 1 and 2) available in the Kyoto University Archives and educational materials (Figures 3−6) accessible from the University Museum, one can only speculate as to how Western medicine was taught at that time.

Figure 1 shows a lecture conducted by Hayazo Ito, a professor from the second department of surgery. The classroom structure imitated universities in Western countries, while the students wore Western-style uniforms and professor Ito wore a white coat. The patient was wearing his kimono (Japanese clothing) and sitting cross-legged (a common Japanese way of sitting) on a table.

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Figure 1. Professor Ito's clinical lecture about surgery.

Kyoto University Archives, 1915.

In Figure 2, Kametaro Nakanishi, a professor from the second department of internal medicine, is shown examining his patient (also wearing a kimono) at Kyoto Imperial University’s outpatient clinic while explaining to his students how he interpreted his patient’s condition.

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Figure 2. Professor Nakanishi's Internal medicine lecture about outpatients.

Kyoto University Archives, 1915.

The university’s medical education tools were also designed to be similar to those in Germany or its neighboring countries but incorporated elements of Japanese style. For example, professors frequently used moulages (wax-skin models) as meticulous mannequins for learning about macroscopic skin lesions in dermatology. Dohi, a professor of dermatology and urology at the Imperial University in Tokyo, imported techniques for creating these moulages from Vienna University and developed a dedicated laboratory in his department. Technicians who learned how to make moulages at Dohi’s laboratory passed on their acquired skills for molding and creating them to other medical schools (Ishihara & Ohnishi, 2018). There are numerous moulages in Kyoto University’s Faculty of Medicine and other old universities in Japan. These past moulages indicate the types of skin diseases the local patients suffered from and how the patients, technicians, and dermatologists collaborated to meticulously create these pieces (Ishihara & Ohnishi, 2018).

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Figure 3. Lupus vulgaris moulage. The name of the disease is printed in Japanese “尋常性狼瘡‎,” and the plate surface is probably colored with Japanese black lacquer, which is a common material for coating accessory boxes and furniture in Japan. This is one example of cultural fusion where the method was imported, and the product was made using local materials.

Kyoto University Museum, unknown production year.

Wall charts are another educational tool that remains at Kyoto University. Wall charts emerged in European countries for mass schooling in the 19th century (Evertsson, 2014) and were imported to Japan in the Meiji era (Makino, 2018). The collection of wall charts from the Pathology Department shows that, around 1900, medicine focused on parasitic infectious diseases. The painters of the screens are unknown, but they were probably local painters or department members. These screens were hung in classrooms and replaced with others in succession during lectures.

The following picture was used in a well-known study conducted by Akira Fujinami (1871–1934), the first professor of the First Pathology Department to confirm Schistosoma japonicum is contagious through a per-oral or percutaneous route. This screen (Figure 4) and the following screens (Figures 5 and 6) were likely painted by a member of the pathology department or a local painter.

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Figure 4. A wall chart: The experiment exploring the route of transmission of Schistosoma japonicum

Kyoto University Museum, unknown production year.

In the experiment depicted in Figure 4, the cows with masks around their mouths could not drink water, but their feet were free for parasites to enter percutaneously. Cows wearing socks blocked the percutaneous route but could drink water and become infected orally. Fujinami anatomized both groups of cows and confirmed that the parasite could infect through the skin. Fujinami, a returnee from Germany, learned Western medicine and conducted experiments using local materials, animals, and Japanese rice fields. Thus, he applied his knowledge and experience from Western medicine to his local contexts with local materials and environment, which is one of the cultural fusions.

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Figure 5. A wall chart: The heart, tuberculous pericarditis. The painter likely used an ink-based painting or drawing method, as at first glance it looks like a Japanese (Chinese) ink brush painting.

Kyoto University Museum, unknown production year.

Furthermore, as the professors learned Western medicine in German, both at Tokyo Imperial University and universities abroad, they spoke and wrote medical terms in German. Foreign-educated professors believed that mastery of German was essential for obtaining new medical knowledge and advancing medical research and practices. Figure 6 shows a wall chart with German names of cells written along with color images of the cells. Although anatomical words derived from Latin and other European languages were translated into Japanese (Sawai & Sakai, 2010), a lecturer would introduce the terms (nomenclature) in German using this wall chart. Another example showing the use of both German and Japanese terminology is the title page of the Kyoto Medical Association Journal’s first issue (Figure 7a). This shows that German was the dominant language among many Western-trained medical doctors of the time.

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Figure 6. A wall chart: Differentiation of Blood cells.

Kyoto University Museum, unknown production year.

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Figure 7a & 7b. Kyoto medical journal, Kyoto Medical Association, 1904

Main Library, Kyoto University, 1888.

During the first 40 years after the Meiji Restoration, Japan enthusiastically accepted Western medicine—especially German medicine—and the related educational system. The process of adopting new medicine in the Meiji era (1868–1912) involved copying not only particular ways of learning medicine, as manifested in the educational curricula, but also the language, clothes, tools, and environments. In the early stages, the medical teachers were doctors from Germany (Müller and Hoffmann), who were later replaced with Japanese returnees who had studied medicine abroad, such as Kure and Dohi. Thus, medicine was a complex and churning environment in which the Japanese host was initially willing to adapt to the Western or German newcomers and subsequently transformed what was learned from the newcomers to incorporate both cultures as a functional and productive system. The returnees who studied medicine in Europe also played prominent roles in modernizing medicine and medical education in Japan.

However, while the pictures, educational tools, and articles show how the returnees and their students adopted Western culture in their home country’s educational environment, the patients in the pictures, drawings on the wall charts, and characters in the articles retained traditional Japanese culture. As Kramer (2019) noted, “cultural fusion is a process of mixing and accrual, the process of a person and society gaining in complexity by adding new repertoires of arts, styles and practices accumulated via exposure to others” (p. 19). Nevertheless, within the dynamic process of cultural fusion, there are still clear distinctions between what came from Germany and what originated in Japan. The processes and consequences of modernization did not involve simple assimilation but dynamic “bricological achievements” (Kramer, 2019, p. 2), as demonstrated by the system itself, the people involved in the changes during this period, and the remaining materials (pictures, educational tools, and articles).

Historical Background of Post-World War II Changes in Medical Education

After World War II (1945), medical education and health-care systems changed drastically under the directional influences of the Public Health and Welfare Section (PHW) of the General Headquarters of the Allied Powers occupying Japan (Institute for International Cooperation Japan International Cooperation Agency, 2005; Sugiyama, 2006b). The word “Imperial” was abolished from the seven Imperial Universities, resulting in Tokyo Imperial University and Kyoto Imperial University changing their titles to the University of Tokyo and Kyoto University, respectively. The other medical schools were also renamed, transformed, or closed following the PHW’s policies and recommendations (T. Sakai et al., 2010). Japanese medical education was further reformed to pursue the evolving standards of Western medical education. For that purpose, the government introduced national examinations for medical doctors to receive their qualifications and the internships that all graduates were required to attend (T. Sakai et al., 2010). Furthermore, in 1949, a new law directed toward the foundations of national universities (kokuritsu-daigaku secchi-hoh) declared that the duration of medical education should be six years (T. Sakai et al., 2010). Thus, the PHW promoted these drastic changes, which were attributed to the end of the war.

Since then, learning English has been a necessity for medical studies, and the influence of the previous German generations has gradually diminished in medical education and practice. By observing the use of the German language in medical education and clinical settings in Japan, one can track how German medicine lost its influence. For example, in the 1970s, German was still an essential language for medical students because German terms were often used in medical records (Sano, 1978). However, English was the first foreign language that students needed to learn because they read medical textbooks written in English, not German. In medical practices, even in the 2010s, doctors still used a few German words, such as karte for medical records and naht for suturing (Ito, 2018; Tanigawa, 2009); however, young doctors generally do not understand these words or other German medical terms often used by senior doctors (Ito, 2018; Matsubara, 2018; Tanigawa, 2009).

In addition to the influx of American medicine, globalization in contemporary Japan continuously replaced old forms of medical education with new ones, such as the OSCE, clinical clerkship, and PBL. These methods emphasize real-life simulations, clear steps for becoming a doctor in clinical practice, and active learning. They differ from the past German medical education system and traditional Japanese learning, in which students predominantly learned medicine passively from a discipline-based or organ-based lecture series, in laboratory experiments, by taking paper-based examinations, and by observing complete medical practices first and mimicking teachers’ behaviors in clinical settings.

Specifically, the OSCE is a type of structured examination that objectively assesses students’ competencies in simulated clinical settings. Clinical clerkship emphasizes the steps necessary for students to become doctors, during which they are required to actively be involved in patient care, taking on the role of a student doctor under teacher supervision. PBL is a learning tool based on teaching and learning philosophy in which teachers facilitate students’ self-directed learning from real-case scenarios.

Assessment Method with Simulations as a Newcomer and Simulated Patients as a Remanent of the Past: OSCE

The OSCE is an assessment tool with which examiners can observe the potential ways that students think and act in clinical simulation (Harden et al., 1975). Since 1975, when a medical educator, Ronald Harden, introduced the OSCE in the British Medical Journal (Harden et al., 1975), it has spread to multiple countries in Europe and North America (Ban, 1995; Kitagawa, 2002). During the examination, students rotate to different stations where they examine the medical history of a standardized/simulated patient (SP), perform physical exams on the SP or simulator, and present a case or interpret laboratory test results in front of examiners (Ban, 1995; Harden et al., 1975). The examiners then mark them using a list and score the students’ performances (Harden et al., 1975). According to Harden et al. (1975), this method represents a structured and objective clinical examination that differs from the conventional clinical tests conducted in hospital wards, based on the small number of cases chosen by the examiner. The OSCE was widely implemented, initially in England and then in North America, as a standard assessment for medical students (Ban et al., 1994). For example, since 2004, the Clinical Skills Test of the United States Medical Licensing Examination Step 2 has followed OSCE procedures.

In Japan, the OSCE was implemented in 2005 as a standard achievement test for all fourth-year medical students, following an international trend in which medical students’ clinical skills should be assessed before their clinical years (Association of Japan Medical Colleges, 2014). Along with this implementation, each medical school is required to administer the OSCE to their fourth-year students, the content of which is derived from the Common Achievement Test Organization, and maintain resources such as SPs and assessing teachers. Furthermore, the OSCE prompted reforms in the medical education curriculum that had been relatively well preserved from the Meiji period. As introduced in the previous section, the curriculum was discipline-based and separated into two parts: lectures and practice. The lecture series were usually structured based on a specific discipline, and medical students had few opportunities to learn clinical skills before their clinical rotations (Abe & Kurokawa, 2002; Fujisaki, 2001). They were expected to learn the skills during their rotations by observing how senior doctors examined their patients (Abe & Kurokawa, 2002). While preparing for the OSCE, students need to learn how to behave in clinical settings, attend to patients, and examine them before their clinical rotations (Fujisaki, 2001). Moreover, after passing the OSCE, students are expected to have acquired the basic skills necessary to attend to patients (Abe & Kurokawa, 2002). Therefore, the OSCE in Japan has had not only a significant impact as an innovative assessment method with simulations for medical students but also a seismic influence on learning content and ways of participating in clinical rotations. Therefore, each medical school may have experienced difficulties implementing the OSCE and reforming the previous curriculum. Cultural fusion theory could shed light on these difficulties, as it suggests that when new concepts are integrated with the previous ones, “integration recontextualizes and preserves cultural elements that remain salient as they are transferred, adopted, rejected, mimicked and so forth” (Kramer, 2019, p. 2).

Kitagawa (2002) raised one difficulty in adopting the OSCE: keeping resources such as SPs that were newly imported concepts in Japan. Examining the concept and situations of SPs from the perspective of cultural fusion theory, a remanent of an old concept could emerge: “patient for education (gakuyo kanja).”

SPs are volunteers recruited from laypeople, trained for clinical simulations, and required to act in the OSCE as simulated/standardized patients. Fujisaki (2010) noted that two kinds of “SP” should be discerned: a “simulated patient” giving feedback to medical students from a patient’s perspective and a “standardized patient” to be trained for the OSCE, depending on the teaching objective. In an OSCE setting, an SP is a trained volunteer or actor who can play the role of a patient with complaints and medical history. Some of them perform their physical signs according to their given role, but because varying SP reactions to the same ailment can influence medical students’ performances and scores, they are also trained to answer questions and react to physical examinations in a standardized manner. For this purpose, SPs must memorize the information on a patient’s role and internalize the role, which requires effort and time. Lastly, as SPs contribute to assessing their performances, they can be regarded as examiners as well.

“Patients as teachers” is a traditional phrase in medicine (Fukushima, 2004; Pitkin, 1998; Seeman & Becker, 2017; Towle & Godolphin, 2011). For a long time before the concept “SP” appeared, patients have been involved in teaching and learning in medical education (see Figures 1 and 2). Shinmura (2016) described deep-rooted ideas that doctors learned from patients using both Japanese and Western medicine adopted in the Meiji period. According to Shinmura (2016), both the experiential and experimental aspects of medicine tended to regard patients as objects for education. Therefore, ethical concerns related to “patients for education” were often raised in historical documents (Shinmura, 2016). In the Meiji period, the University of Tokyo hospital first stipulated the rules for using patients for medical education (“gakuyo kanja”) in 1877 (Shinmura, 2016, p. 312). Since then, other public academic hospitals have created their own rules for “gakuyo kanja.” Although there are some differences among the hospitals, according to Shinmura (2016), the term “patients for medical education (gakuyo kanja)” means that individuals are obliged to be involved in undergraduate education in exchange for free admission and treatment at public university hospitals (pp. 311−312). They either were presented as exemplified patients in lecture rooms and outpatient clinics (it is presumed that patients in Figure 1 and Figure 2 could be gakuyo kanjas) or had to agree to the use of their cadaver for anatomical studies after their death. This system benefited patients but restricted their human rights, as they could be utilized as educational materials for medical education (Muraoka, 2004; Shinmura, 2016). Shinmura (2016) also noted that this system was perpetuated not only for educational purposes in medicine but also for research on new medicines and medical technology, which has clear ethical ramifications (pp. 12−14). Using an SP in the OSCE is a different concept, as it encourages laypeople to educate medical students and professionals and allows them to participate in medicine as citizens in a civilized manner (Fujisaki, 2001; Muraoka, 2004).

However, it is emphasized that specific training for SPs must be standardized in the context of the OSCE (Fujisaki, 2010). Fujisaki (2010) pointed out that the training for “standardized patients” could compete with the training for “simulated patients” by providing patient perspectives. This may highlight the fact that SPs can share a feature with individuals who were considered “patients for medical education (gakuyo kanja)” or objects that served educational purposes in the past. Thus, Japanese undergraduate medical education adopted the system and function of OSCE, maintaining its original form and objectives. However, given the idea that SPs should be standardized for educational purposes, the concept of SPs and the way they are perceived appear to be close to the traditional concept of “patients for medical education.”

Cultural fusion theory suggests that the receiver is always “interpreting and appropriating the sender’s messages” (Kramer, 2019, p. 11). Accordingly, now that new educational tools (message), such as the OSCE and SPs, have been introduced to Japanese medical education (receiver), the field is adopting the terms and styles stemming from the countries of origin (sender). However, the old and similar concept of “patients for medical education (gakuyo kanja)” embedded in Japanese medical education appears to remain beneath the new SP concept. If one focuses on the background premise, including the idea of citizen participation and the civilization’s culture that is responsible for interpreting a newly imported concept, perhaps the Japanese idea of an SP is not based on the same idea as in the countries from which it originated.

Steps for Developing Clinical Skills: Clinical Clerkship

Clinical clerkship is one form of medical students’ involvement in medical practices in their clinical years (traditionally the fifth and sixth year in Japan). In the clinical clerkship, medical students belong to a medical team and have the responsibility of seeing patients while under supervision from a teacher or senior doctor (Abe & Kurokawa, 2002; N. Hashimoto, 1992; Ministry of Education, Culture, Sports, Science and Technology, Japan, 2016). They are expected to be involved in the process of patient care, including interviews, physical examinations, case presentations and diagnoses, and medical interventions (Abe & Kurokawa, 2002; Ministry of Education, Culture, Sports, Science and Technology, Japan, 2016). Supervisors instruct students on what they should be able to do and give effective feedback to them to achieve their required goals, along with articulated “steps” for developing their clinical skills (Abe & Kurokawa, 2002). According to Abe and Kurokawa (2002), this form of practice is usually held during the clinical years in the United States and is different from the traditional Japanese forms of student involvement in which they just observe clinical practices (observership) or examine “patients for education.”

Among the traditional Japanese forms of medical student involvement in clinical settings, the “observership” form has been usually called “Polyklinik” (a German word that means learning in outpatient departments/hospitals) and abbreviated as “poli kuli” in Japanese (Sato et al., 2020). This probably originated from the clinical years in the curriculum of Tokyo East College and Nagaski Medical School (Table 1; Association of Japan Medical Colleges, 2014). After learning liberal arts and basic medical knowledge in their preclinical years, medical students are expected to learn how to act as doctors in this “poli kuli” during their clinical years (Association of Japan Medical Colleges, 2014). Since they do not have enough opportunities to practice skills for seeing patients, such as conducting interviews and physical examinations, in their preclinical years, as mentioned in the previous section (OSCE), they observe how senior doctors and teachers see patients in clinical settings during the poli kuli. As in other Japanese traditional apprenticeships (Ikuta, 2007), students are expected to observe any people or things in clinical settings, including their seniors, other medical professionals and peers, materials, and environments, and situate and immerse themselves in the medical practices as an observer. Their roles and responsibilities are often not articulated. Therefore, they observe what happens in the medical field with their own intentions and interests, while some students could feel ignored or bored because of a paucity of concrete instructions by teachers and the vagueness of their role. It is a situated and holistic learning opportunity but lacks the articulated steps for developing their skills and the defined role that the students learn in the clinical clerkship.

In 1991, Maekawa report (the final report by the committee of undergraduate clinical education) (The Japan Ministry of Health and Welfare, 1991) articulated that medical students could practice medicine within a limited range and under appropriate supervisions, even though the law, Japanese Medical Practitioners’ Act has limited medical students providing medical practices to patients. Since then, medical educators in Japan have agreed that students should experience clinical skills in their clinical years and be encouraged to implement a clinical clerkship (Abe & Kurokawa, 2002; Association of Japan Medical Colleges, 2014). The guidelines for learning content in undergraduate medical education has followed trends (Association of Japan Medical Colleges, 2014), and medical schools and hospitals have developed learning environments for clinical clerkships. Thus, the newly imported clinical clerkship has ostensibly been replacing the traditional poli kuli. However, as cultural fusion theory suggests, the new and traditional forms of student involvements have been conflicting, negotiating, and combining. What we expect from the mingled consequences could be areas for further research.

Active Learning: PBL

In 1969, the first PBL was developed at McMaster University’s School of Medicine in Canada. Since then, that pedagogical innovation has changed medical students’ education worldwide (Frambach et al., 2019; Neville & Norman, 2007). Neufeld and Barrow (1974) introduced PBL and argued that “learning based on problems represents an alternative to studying blocks of classified knowledge in a strictly organized sequence” (p. 1042). Including both individual and small-group learning, the method uses real case scenarios or just an initial presentation of problems for which students need to “assemble information through free inquiry” (Barrows, 1986, p. 482). Thus, PBL can have multiple forms depending on the educational objectives. Additionally, Barrows (1986) raised four possible primary goals in PBL: (a) structuring knowledge for use in clinical contexts, (b) developing an effective clinical reasoning process, (c) developing effective self-directed learning skills, and (d) increasing learning motivation.

In the Japanese context, Yoshioka (2002) pointed out that PBL terminology is confusing and argued that PBL could represent tutorial teaching or small-group teaching in which a tutor attends a session with a small number of students to explore topics. According to Kwan (2019), confusion around the concept of PBL is a general and widespread issue. However, distortions and misconceptions regarding its principles are especially prominent in Asian countries, noting that Asian traditional didactic pedagogy opposes the PBL philosophy that students should learn based on their interests and at their own pace. Furthermore, Rao (2006), an American professor who visited a Japanese medical school, also revealed how difficult it is for medical students and faculties to understand the philosophy of PBL in Japan, although he observed a limited landscape of Japanese medical education. According to him, medical students are rather passive because they believe that asking the teacher questions is a sign of disrespect, and some are afraid that their questions would be perceived as ridiculous. Lastly, Teo (2007) examined the evolving reform in medical education to explicate how PBL had been situated in Japan. He pointed out that Japanese curricula tended to adhere to a traditional discipline-based approach, not the organ-based or system-based approach that is mainstream in medical education in Western countries. Kwan (2019), Rao (2006), and Teo (2007), all outsiders who investigated PBL in Japan from their own standpoints, argued together that it is necessary to reconstruct curricula to help medical students and teachers change their ways of thinking and behaving to properly adopt the PBL philosophy.

In the 1990s, Tokyo Women’s Medical University was the first university to introduce PBL in Japan and reform its undergraduate curriculum to organ-based (Teo, 2007; Yoshioka, 2007). Since then, other Asian medical schools, including Japanese ones, have partially introduced PBL in their curricula (Kozu, 2006; Kwan, 2019; Okubo et al., 2016), which Kwan (2019) defined as hybrid and distorted forms that are not authentic PBL. However, Shimizu and Nishigori (2020) argued that each context creates its form of PBL, which is an adaptation, not a failure. For example, they referred to the new safety management paradigm, Safety II, in which a safety manager is required not to pursue an ideal consequence but to focus on what happens. Thus, what previous medical teachers might have viewed as failed PBL might simply be adaptations and modifications relevant to the particular contexts (Shimizu & Nishigori, 2020). Accordingly, Frambach et al. (2019) proposed that PBL is a plural construct influenced by cultural and situational contexts. They introduced two PBL discourses (universalist and culturalist) and clarified their limitations after reviewing PBL literature in health professional education (Frambach et al., 2019). According to Frambach et al. (2019), “universal discourse describes PBL as a ‘singular’ concept.” In this discourse, PBL should be standardized globally and conducted in similar ways. Kwan’s (2019) arguments can be aligned with this universalistic idea. Contrastingly, “culturalist discourse operationalizes PBL as a ‘plural concept’” (Frambach et al., 2019). From a culturalist perspective, PBL should be context-dependent and modified based on each culture. Frambach et al. (2019) argued that both discourses still centralized “authentic PBL” or “original PBL” and marginalized a perspective that PBL-like approaches have a long history and global origins. They pointed out that many scholars in medical education have already noted that concepts very similar to PBL are found in local or historical contexts and have been remodeled or revived from their encounters with PBL (Frambach et al., 2019).

Their argument resonates with cultural fusion theory in that the receiver interprets and appropriates the sender’s messages (Kramer, 2019). As medical education in different contexts can integrate PBL as a new concept with its previous similar ideas, observing what PBL represents in each of these contexts could reveal further fusion and conflict between the culture of the host adopting PBL and the culture that originated the concept. Additionally, based on Frambach et al. (2019) and the exemplar idea of SPs presented in the previous section, similar concepts can be marginalized or ignored but are still embedded in the host culture.

The Outflux from Japan to Asian Countries: Knowledge and Experience of Schistosoma Japonicum Eradication

Influences from the West on Japanese medicine and medical education have diffused in each Japanese local context, which this article has so far reviewed and examined. This section briefly introduces an example of the outflux of medicine from Japan to other Asian countries: international collaborations to eradicate Schistosoma japonicum. S. japonicum is a parasite that was endemic in Japan. Akira Fujinami (1871–1934), the first professor of pathology at Kyoto Imperial University, was one of the contributors who discovered the route of S. japonicum infection by experimenting with cows in a rice field in an endemic region in Japan (Figure 4). He was a returnee from Germany who had learned from the well-known pathologist Rudolf Virchow (1821−1902) and conducted research based on Western medical knowledge. Owing to his and other researchers’ discovery of the infection and efforts of residents collaborating with the local government, educators and doctor, domestic infections of S. japonicum have not been reported in Japan since 1977 (Kiriki et al., 2015). As a result, its complete eradication from Japan was declared in 1996. For sharing the preventive measures, Japan has provided financial aid for global health collaborative programs with public health professionals in Asian countries where S. japonicum is still endemic (Kiriki et al., 2015).

The features of the outflux of the eradicating experience from Japan could be represented in the description provided by Hiroshi Tanaka, a researcher who was involved in the collaborative program for eradicating S. japonicum on Leyte Island in the Philippines (1976). He noted that cultural differences between Japan and the Philippines were challenges in making the program effective. Therefore, he claimed that the people providing the program should know the cultural contexts, including residents’ lifestyles, and perceptions of the infection so profoundly that they could introduce their program adjusted to the local context and let the residents accept it (Tanaka, 1976). Japan’s Official Development Assistance White Paper (2007) featured three characteristics: empowering the people in developing countries (supporting self-help efforts), transferring Japan’s knowledge and technology, and supporting the process of democratization and transition to market economies. As discussed in the previous sections, Japan has a long tradition of accepting new things, as the host, from the outside and transforming and adjusting them to the local context; this tradition has also been taken and articulated when Japan is the newcomer, not the host.

Mingled Cultures in the Asian Region: Learning from Taiwan in the COVID-19 Pandemic

Although people are not allowed to move around during the COVID-19 pandemic, Japan has gained much experience of preventive measures for COVID-19 from other Asian countries, especially Taiwan. Taiwan’s success in suppressing the spread of COVID-19 without locking down cities was made possible by information technology (IT) measures such as mask maps to avoid mask shortages. This measure was led by Audrey Tang, a transgender high school dropout and the youngest cabinet member of Taiwan. Tang strongly promotes the ideology of an open government, first called upon by former US President Barack Obama, which has three pillars: transparency, public participation, and public–private partnership by “Civic Tech” in utilizing technology to solve administrative service problems.

In Japan, one of the main policies of Prime Minister Yoshihide Suga, who took office in September 2020, has been to unify the systems of each ministry and agency to establish the “Digital Agency (tentative name)” as the command tower to accomplish many urgent tasks, such as to spread the use of My Number cards (the Japanese version of Social Security cards), which started in 2016 but has a grant rate of only 30% in 2021, or conduct administrative procedures online (Sasano, 2020). This project has been ignited as a result of the fact that digitization in Japan was not working at a sufficient speed to take countermeasures against COVID-19. With the establishment of the “Digital Agency,” the My Number Card is scheduled to be integrated with a person’s driver’s license and health insurance card to significantly improve convenience for the fast-growing number of people in need, such as benefit payments or one-stop administrative services. When asked for advice in a virtual meeting with Japanese politicians, Tang re-emphasized that the openness of information and government transparency are necessary for gaining public trust (Taguchi & Sugita, 2020), which is vital in proceeding with anti-COVID-19 administrative measures, such as a strict “stay-home” policy.

Ultimately, the impact of the pandemic has permeated every aspect of the lives of people in Japan and the world. The COVID-19 pandemic has established a “new normal” in how we work, eat, commute, gather, and communicate that is quite different from the pre-pandemic days, accompanied by newly coined terms such as “social distance,” “stay-home,” or “essential workers.” Actualization of a digital government led by a “Digital Agency” and equipped with digital policies inevitably brings in such necessary presuppositions as government openness, sharing more information with the public, or appointment of tech-savvy (most likely from younger generations) personnel. The age of COVID-19 has caused great pain in society, but it also may bring another cultural fusion to restructure the social milieu of Japan.