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Quantitative and qualitative problems of infectious diseases fellowship in Japan
International Journal of Infectious Diseases 17 (2013) e1098–e1099
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Perspective
Quantitative and qualitative problems of infectious diseases fellowship in Japan Kentaro Iwata * Kobe University, Kusunokicho 7-5-2, Chuoku, Kobe, Hyoto 650-0017, Japan
A R T I C L E I N F O
S U M M A R Y
Article history: Received 3 June 2013 Accepted 12 July 2013
Postgraduate clinical training in infectious diseases in Japan is still under-developed and needs further improvement. There are both quantitative and qualitative problems that need to be overcome. The system is unusual and two-layered, precluding young applicants from participating in many fellowship programs. To-date, less than half the programs actually have acting fellows involved in training. The system needs fundamental reform, with a better evaluation system for each program. ß 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Corresponding Editor: Eskild Petersen, Aarhus, Denmark Keywords: Infectious diseases Postgraduate training Japan
Board certification in infectious diseases in Japan is provided by the Japanese Association for Infectious Diseases (JAID). Since 2007, JAID has mandated 3 years of postgraduate training at an accredited institution for those who wish to become an infectious diseases specialist. To be certified as an accredited institution, there must be at least one ‘Shidoi’, which literally means ‘teaching doctor’ in Japanese. One has to have been a board certified infectious diseases specialist for 5 years in order to become a Shidoi. Because of this JAID regulation, young, talented, and enthusiastic infectious diseases specialists are not able to become Shidoi, or to implement an infectious diseases fellowship program. I became an infectious diseases specialist certified by the American Board of Internal Medicine (ABIM) in 2003, but was certified by JAID in 2009. Therefore, I am not able to become a Shidoi as of this writing. As of January 2013, there were only 1140 board certified infectious diseases specialists in Japan (JAID data). Since the first graduates of the fellowship programs took the board examination in 2010, the majority of infectious diseases specialists in Japan became so without going through postgraduate training. A small number attended clinical training overseas, including in the USA. In terms of both regularity and practice, Japan is badly off with regard to infectious diseases specialists. Since the number of candidates taking the board examination was very low even after the accredited institutions were established, JAID created ‘collaborative institutions’ on top of
* Tel.: +81 78 382 6296; fax: +81 78 382 6298. E-mail addresses: [email protected], [email protected]
the existing accredited institutions to increase the fellowship programs. The collaborative institutions do not require the presence of a Shidoi, but an additional 1 year of training may be needed, with some exceptions, on top of the 3-year training required at the accredited institutions. This type of doublestandard regulation again holds back young attending physicians from teaching trainees in active form, since the 4-year curriculum at collaborative institutions would keep fellow candidates away. JAID requires no particular duty from a Shidoi. In fact, I have served as a program director for two different infectious diseases fellowship programs, including the current one. There was a Shidoi with me at both institutions, but neither had spent a minute actually teaching fellows, or doing administrative work for the development and maintenance of the fellowship program. They merely provided their presence so that the institution was certified as accredited. This ‘name-lending’ appears to be common in Japan. Masao Maruyama, a famous Japanese sociologist, called this ‘‘preference of being over doing’’.1 In contrast, the Accredited Council for Graduate Medical Education (ACGME) in the USA requires program directors to dedicate an average of 20 h per week of his/her professional effort to the fellowship, including time for administration of the program, with many additional duties.2 Since Shidois in Japan do not have such duties, there may not be any essential difference between the accredited and collaborative institutions, making an additional 1 year of training at the latter rather unfair. Currently, there are 195 accredited institutions and 99 collaborative institutions approved by JAID. However, most of them are not actively teaching infectious diseases fellows. According to our latest mail-in survey conducted during the
1201-9712/$36.00 – see front matter ß 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijid.2013.07.009
K. Iwata / International Journal of Infectious Diseases 17 (2013) e1098–e1099
period December 2012 to January 2013, only 34% and 37% of accredited and collaborative institutions had fellow(s) in action, respectively. There have been no fellowship activities ever at 45% and 51% of these institutions, respectively (collection rate 50% and 43%, respectively).3 In 2012, only 62 physicians took the infectious diseases board examination, and 57 of them passed (JAID data). Even though the number of training programs appears ample, only a small number of new infectious diseases specialists are certified annually. In the USA, there are 144 infectious diseases fellowship programs, which consist of a 2- to 3-year curriculum, much fewer than in Japan.4 However, there were 801 fellows in action as of December 31, 2011. So far, 8783 physicians have become infectious diseases specialists, 7881 of them have valid certificates, and 7509 of them reside in the USA.5 There are 2.4 infectious diseases specialists per 100 000 population in the USA, compared to 0.9 in Japan (and many of them without training).6 By both quantity and quality, Japan is far behind the USA. Disciplines of the infectious diseases specialty vary among countries and there is no global consensus on how these specialists should be trained.7,8 The US system may not be the only globally accepted standard for infectious diseases training. However, postgraduate training for healthcare professionals in Japan is still under development, despite the good health outcomes,9,10 and the difference between the USA and Japan in regards to infectious diseases fellowship should not be explained simply by cultural differences. Much more needs to be done to nurture better infectious diseases fellowship programs and specialists. Strict operational guidelines on curriculum development, including, but not limited to, the number of cases per fellow to experience, hours spent on didactic lectures, and duties of program directors, should be implemented for each program. At the same time, the rather irrelevant ‘5-year-rule’ of Shidoi can be abandoned so that programs run by talented young staff are encouraged. The
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integration of accredited and collaborative institutions and the closure of programs that are not active or up to standard, will concentrate fellow candidates in the good institutions and will eventually increase the number of high-quality infectious diseases specialists, who are desperately needed in Japan. Conflict of interest No conflict of interest to declare. References 1. Maruyama M. The Japanese thoughts. (In Japanese). Tokyo: Iwanami Publishers; 1961. 2. ACGME program requirements for graduate medical education in infectious diseases (internal medicine). Effective: July 1, 2012. Chicago, IL: Accreditation Council for Graduate Medical Education; 2012. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/ (accessed May 2, 2013). 3. Iwata K, Doi A. A survey on infectious diseases fellowship programs in Japan. 87th Annual Meeting of the Japanese Association for Infectious Diseases, Yokohama, Japan, June 2013. 4. Brotherton SE, Etzel SI. Graduate medical education, 2011–2012. JAMA 2012;308:2264–79. 5. American Board of Internal Medicine, 2013. Candidates certified—all candidates. Philadelphia, PA: ABIM; Available at: http://www.abim.org/pdf/datacandidates-certified/all-candidates.pdf (accessed May 2, 2013). 6. The World Bank. Total Population. Available at: http://data.worldbank.org/ indicator/SP.POP.TOTL (accessed May 2, 2013). 7. Ronald A, Memish Z. Infectious diseases: career preparation. J Chemother 2001;13(Suppl 1):50–3. 8. Cooke FJ, Choubina P, Holmes AH. Postgraduate training in infectious diseases: investigating the current status in the international community. Lancet Infect Dis 2005;5:440–9. 9. Koike S, Ide H, Yasunaga H, Kodama T, Matsumoto S, Imamura T. Postgraduate training and career choices: an analysis of the National Physicians Survey in Japan. Med Educ 2010;44:289–97. 10. Ban N, Fetters MD. Education for health professionals in Japan—time to change. Lancet 2011;378:1206–7.
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Perspective
Quantitative and qualitative problems of infectious diseases fellowship in Japan Kentaro Iwata * Kobe University, Kusunokicho 7-5-2, Chuoku, Kobe, Hyoto 650-0017, Japan
A R T I C L E I N F O
S U M M A R Y
Article history: Received 3 June 2013 Accepted 12 July 2013
Postgraduate clinical training in infectious diseases in Japan is still under-developed and needs further improvement. There are both quantitative and qualitative problems that need to be overcome. The system is unusual and two-layered, precluding young applicants from participating in many fellowship programs. To-date, less than half the programs actually have acting fellows involved in training. The system needs fundamental reform, with a better evaluation system for each program. ß 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Corresponding Editor: Eskild Petersen, Aarhus, Denmark Keywords: Infectious diseases Postgraduate training Japan
Board certification in infectious diseases in Japan is provided by the Japanese Association for Infectious Diseases (JAID). Since 2007, JAID has mandated 3 years of postgraduate training at an accredited institution for those who wish to become an infectious diseases specialist. To be certified as an accredited institution, there must be at least one ‘Shidoi’, which literally means ‘teaching doctor’ in Japanese. One has to have been a board certified infectious diseases specialist for 5 years in order to become a Shidoi. Because of this JAID regulation, young, talented, and enthusiastic infectious diseases specialists are not able to become Shidoi, or to implement an infectious diseases fellowship program. I became an infectious diseases specialist certified by the American Board of Internal Medicine (ABIM) in 2003, but was certified by JAID in 2009. Therefore, I am not able to become a Shidoi as of this writing. As of January 2013, there were only 1140 board certified infectious diseases specialists in Japan (JAID data). Since the first graduates of the fellowship programs took the board examination in 2010, the majority of infectious diseases specialists in Japan became so without going through postgraduate training. A small number attended clinical training overseas, including in the USA. In terms of both regularity and practice, Japan is badly off with regard to infectious diseases specialists. Since the number of candidates taking the board examination was very low even after the accredited institutions were established, JAID created ‘collaborative institutions’ on top of
* Tel.: +81 78 382 6296; fax: +81 78 382 6298. E-mail addresses: [email protected], [email protected]
the existing accredited institutions to increase the fellowship programs. The collaborative institutions do not require the presence of a Shidoi, but an additional 1 year of training may be needed, with some exceptions, on top of the 3-year training required at the accredited institutions. This type of doublestandard regulation again holds back young attending physicians from teaching trainees in active form, since the 4-year curriculum at collaborative institutions would keep fellow candidates away. JAID requires no particular duty from a Shidoi. In fact, I have served as a program director for two different infectious diseases fellowship programs, including the current one. There was a Shidoi with me at both institutions, but neither had spent a minute actually teaching fellows, or doing administrative work for the development and maintenance of the fellowship program. They merely provided their presence so that the institution was certified as accredited. This ‘name-lending’ appears to be common in Japan. Masao Maruyama, a famous Japanese sociologist, called this ‘‘preference of being over doing’’.1 In contrast, the Accredited Council for Graduate Medical Education (ACGME) in the USA requires program directors to dedicate an average of 20 h per week of his/her professional effort to the fellowship, including time for administration of the program, with many additional duties.2 Since Shidois in Japan do not have such duties, there may not be any essential difference between the accredited and collaborative institutions, making an additional 1 year of training at the latter rather unfair. Currently, there are 195 accredited institutions and 99 collaborative institutions approved by JAID. However, most of them are not actively teaching infectious diseases fellows. According to our latest mail-in survey conducted during the
1201-9712/$36.00 – see front matter ß 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijid.2013.07.009
K. Iwata / International Journal of Infectious Diseases 17 (2013) e1098–e1099
period December 2012 to January 2013, only 34% and 37% of accredited and collaborative institutions had fellow(s) in action, respectively. There have been no fellowship activities ever at 45% and 51% of these institutions, respectively (collection rate 50% and 43%, respectively).3 In 2012, only 62 physicians took the infectious diseases board examination, and 57 of them passed (JAID data). Even though the number of training programs appears ample, only a small number of new infectious diseases specialists are certified annually. In the USA, there are 144 infectious diseases fellowship programs, which consist of a 2- to 3-year curriculum, much fewer than in Japan.4 However, there were 801 fellows in action as of December 31, 2011. So far, 8783 physicians have become infectious diseases specialists, 7881 of them have valid certificates, and 7509 of them reside in the USA.5 There are 2.4 infectious diseases specialists per 100 000 population in the USA, compared to 0.9 in Japan (and many of them without training).6 By both quantity and quality, Japan is far behind the USA. Disciplines of the infectious diseases specialty vary among countries and there is no global consensus on how these specialists should be trained.7,8 The US system may not be the only globally accepted standard for infectious diseases training. However, postgraduate training for healthcare professionals in Japan is still under development, despite the good health outcomes,9,10 and the difference between the USA and Japan in regards to infectious diseases fellowship should not be explained simply by cultural differences. Much more needs to be done to nurture better infectious diseases fellowship programs and specialists. Strict operational guidelines on curriculum development, including, but not limited to, the number of cases per fellow to experience, hours spent on didactic lectures, and duties of program directors, should be implemented for each program. At the same time, the rather irrelevant ‘5-year-rule’ of Shidoi can be abandoned so that programs run by talented young staff are encouraged. The
e1099
integration of accredited and collaborative institutions and the closure of programs that are not active or up to standard, will concentrate fellow candidates in the good institutions and will eventually increase the number of high-quality infectious diseases specialists, who are desperately needed in Japan. Conflict of interest No conflict of interest to declare. References 1. Maruyama M. The Japanese thoughts. (In Japanese). Tokyo: Iwanami Publishers; 1961. 2. ACGME program requirements for graduate medical education in infectious diseases (internal medicine). Effective: July 1, 2012. Chicago, IL: Accreditation Council for Graduate Medical Education; 2012. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/ (accessed May 2, 2013). 3. Iwata K, Doi A. A survey on infectious diseases fellowship programs in Japan. 87th Annual Meeting of the Japanese Association for Infectious Diseases, Yokohama, Japan, June 2013. 4. Brotherton SE, Etzel SI. Graduate medical education, 2011–2012. JAMA 2012;308:2264–79. 5. American Board of Internal Medicine, 2013. Candidates certified—all candidates. Philadelphia, PA: ABIM; Available at: http://www.abim.org/pdf/datacandidates-certified/all-candidates.pdf (accessed May 2, 2013). 6. The World Bank. Total Population. Available at: http://data.worldbank.org/ indicator/SP.POP.TOTL (accessed May 2, 2013). 7. Ronald A, Memish Z. Infectious diseases: career preparation. J Chemother 2001;13(Suppl 1):50–3. 8. Cooke FJ, Choubina P, Holmes AH. Postgraduate training in infectious diseases: investigating the current status in the international community. Lancet Infect Dis 2005;5:440–9. 9. Koike S, Ide H, Yasunaga H, Kodama T, Matsumoto S, Imamura T. Postgraduate training and career choices: an analysis of the National Physicians Survey in Japan. Med Educ 2010;44:289–97. 10. Ban N, Fetters MD. Education for health professionals in Japan—time to change. Lancet 2011;378:1206–7.