Active learning such as problem based learning (PBL) and team based learning (TBL) has become increasingly popular in medical education among Asian countries including Japan.
HEATAPP has been provided to all of 4th year medical students since 2012. By the time HEATAPP was held, the students had been through all basic medicine curricula and they had completed a medical English course.
The participants were divided into teams of about 6 people. HEATAPP does not require readiness assurance activities as in conventional TBL, to focus more on clinical reasoning. We rather discussed the case without pre-notifying what the case is about, as in the PBL of Hawaii University, from which we adopted a lot.
After listening to a few sentences of the presenting illness of a case (patient’s age, sex and chief complaint), a group discussion on clinical reasoning, hypothesis generation and verification of the developed hypotheses was encouraged. The tutor (KI) provided further clinical information little by little (working forward), not revealing all information at once, to avoid thinking “backward”.
After these activities, the participants were asked to develop a Your Specific Question (YSQ) per team. YSQ was to investigate a topic regarding the case, mostly on diagnosis, treatment, epidemiology, or pathogenesis, which students chose to study.
After deciding YSQ, the session was adjourned and each group was asked to solve their YSQ. Group work on each YSQ was presented on the following morning, and the next new case was discussed afterward.
Students dealt with one case a day, dealing with a total of 5 cases. On the 4th and 5th day, cases were presented in English to encourage the use of English to the students.
After reviewing the group discussion, we found that many felt HEATAPP was effective in active learning, group discussion, and developing hypotheses and questions.
However, some students also expressed difficulty in active, participatory learning. For example, some preferred classical didactic lectures and memorization of things. In addition, some complained of not having much teaching about treatment, which we expected the students to learn through YSQ. Many also felt that asking questions was difficult. They often ended up with easy questions to answer, which might not be clinically important. They also found working in English very difficult.
We also found there were some less motivated students in teams. They merely relied on so-called “super-achievers”, copying and reading out the manuscripts these super-achievers prepared, and essentially did not participate in the activities at all.
They also found the difference between Japanese system and systems in other countries. The implication is that Japanese medical students are burnt due to the entrance exam (Juken) and need time to relax after entering medical schools.
We found several problems in HEATAPP after the group discussion. Even though active learning has gained popularity, it can be difficult to execute, particularly among students who are so used to learning things passively. This seems particularly true in Asian countries with the influence of Confucianism, where people are used to learning things through didactic lectures, spoon feeding knowledge and memorizing without any critique.
PBL-incompatible Asian cultural attitudes include fear of confrontation with authority, distaste for open criticism of authority, Confucian socialization requiring a person not to be outspoken, lack of passion for studies, lack of ability/motivation to ask questions, and low participation in class discussion.
Many medical students in Japan misunderstand PBL as problem solving, instead of learning.
To make things worse, some students are already burnt out after the rigor of entrance examinations. After years of training at school and knowledge-cramming schools, medical students seek happiness in extra-class activities and they float through their school years.
To overcome these problems underlying Japan’s medical schools, we probably need tactics to lead them to learn actively and lifelong. This means that just imitating western countries is not the answer (and imitation is ironically a kind of passive learning). For short-term improvement, one needs some gradual transition from passive to active learning. Teaching why active learning is important is another way to reconcile these two types of learning. For the long-term, Japanese students need to learn how to learn actively beginning in their childhood. This means we need fundamental reform in the educational system.
Lack of English skills, despite rigorous “Juken” study is another issue to overcome. The inability to search and read literature (most of which are written in English) is a drawback in active learning and information management, and physicians in the 21st century would not survive without these skills. In HEATAPP, we discuss cases in English for 2 days, but it is not enough in making students familiar with English. Long term practical use of English and making them read and write in English easily is an extremely important task.
We invented a novel educational activity called HEATAPP for active participatory learning for Japanese medical students. However, because of long term dependence on passive learning, implementing active learning might cause resistance among students. Some students are burnt out by the time they entered medical schools and group studies might be manipulated to allow them to be indolent. Lack of English skill is another impediment to search information actively.
We probably have to introduce active learning more carefully to make Japanese medical students more accustomed to this type of learning they are not familiar with. Introduction of active learning early in childhood would be a fundamental, long-term solution to this problem.
The authors truly appreciate Dr Daniel J Mosby for correcting English.
The authors declare that they have no conflict of interest.