An Interview with Shun Kohsaka, Project Lecturer: A New Wave of Education at Keio University School of Medicine

2015/12/15

The Keio University School of Medicine has many faculty members with world-class achievements in the fields of medical sciences and medical care, as well as many who are taking on the challenge of new medical education and care based on advanced ideas. Among them, we spoke with Project Lecturer Shun Kohsaka, an active young doctor and researcher.

As a junior faculty member at the Keio University School of Medicine, Dr. Kohsaka is involved in the daily instruction of students while also continuously proposing new approaches to medical education based on his experience in the United States.

What prompted you to go to the United States, Dr. Kohsaka?

"When I was in the School of Medicine, a senior student in my club told me about ashort-term study abroad program to the US within Keio. I applied in my sixth year and went to the US for a short period. Although it was like a trial course, it was very intensive and shocking to me at the time. I was in a state of lethargy for a while after returning to Japan. However, I felt that what I had gained from studying abroad had definitely become part of my abilities, so I chose the U.S. Naval Hospital in Yokosuka for my postgraduate training. Then, from my third year after graduation, I began my internal medicine residency in the United States."

What was it that was so shocking it left you in a state of lethargy?

"Every day was truly tough, right from the morning. For the first two days, I was just observing, taking notes on the rounds, just like in Japan. I was taking a step back, sort of like 'not treading on the master's shadow.' Then on the third day, I was yelled at: 'What did you come here for? This isn't what medical student clinical training is about. Training is about picking up and seeing patients.' They meant that even as a student, I should be properly in charge of patients, listen to them, and participate in their care. From that day on, my stomach started to hurt every day. After all, I was still an amateur, presenting to doctors who were like major league baseball players. It took a lot of time to prepare, and I was made to realize how comfortably I had been living until then."

So, they make you start with a dialogue with the patient?

"What the American doctors demanded first wasnot the answer, such as 'this patient has this disease,' but a logical explanation of the process to reach that conclusion.That was a major difference from the Japanese way of thinking, which emphasizes results. At the time of my study abroad, I was still wondering if this process-oriented approach was the right one, but when I returned to my clinical training in Japan, I found that this style was applicable not only in internal medicine but in any clinical department. I think the approach of identifying and thinking about the patient's problems was a useful method in any field. Also, constantly putting my own ideas forward and defending them was not something that fit well with Japanese culture, but this experience made me feel that I could become a full-fledged doctor faster by training in this way, so I decided to go to the United States."

What are the differences between medical education in the US and Japan?

"There's an analogy I heard recently. In a traditional sushi restaurant, it's normal for an apprentice to start with serving tea and not be allowed to make sushi until about their eighth year. However, I've heard that even a sushi chef can become a professional in about six months if they start with the core of the job, which is 'how to make sushi.'"

"The American approach to physician education is similar to that.They are thorough in deciding what the important core for a doctor is and then concentrating on mastering that crucial part during initial training.To use the previous example, it's the idea that if you're at a sushi restaurant, you should be making sushi, and other tasks like serving tea will be done by other specialists. I'm sure there are pros and cons, but that clear-cut environment suited me. Once I got there, every day was in English, and everyone was very assertive, so it was a huge trial, but I believe going to the US was the right decision."

Having been exposed to a medical education system different from Japan's, which aspects did you think of incorporating?

"I don't know which is more ideal, American or Japanese medical education. The American way is extremely pragmatic, which I think is driven by a strong societal demand for graduates of the School of Medicine to become useful specialists quickly. In Japan, society allows for a system where, even after graduating from the School of Medicine, you are expected to take your time to become a well-rounded and respectable 'doctor.'"

"So in the US, the thinking was that general practitioners are extremely broad but shallow, while specialists do only their narrow, specialized work. In Japan, there's a sense that specialists should be able to do their specialized work as well as other general things, so they are expected to do both."

"However, about 10 years after moving to the US, I thought it would be worthwhile to try this cutting-edge American style in Japan, so I returned. It was my first time working at my alma mater's university hospital after coming back, and the professor at the time told me, 'Try running the ward your way.' Taking advantage of being made the ward chief, I put the American methodology into practice there."

What was your educational policy, Dr. Kohsaka?

"I essentially put into practice, from the position of an attending physician, the very things I found difficult as a student and resident. First, in Japan, it's common for junior doctors to ask their attending physician, 'The patient has these symptoms, what should I do?'

In response, I kept asking them, 'First, tell me your plan.' I started this challenge half-convinced it wouldn't be a good fit, but I was surprised to find that many residents and senior residents in Japan were quite willing to meet the challenge."

What did you come to realize by continuing this approach?

"What I learned after about three years of this method is that it fosters independence. And that is the key to a long career as a clinician."

"The atmosphere probably emerged that if you don't go through the process of forming your own opinion, your superiors won't give you constructive feedback. You have to act on your own to figure out what the patient wants and how to respond. Furthermore, as the senior residents got used to it, they started to research things I didn't even know, saying things like, 'This is the case in the US, but it doesn't apply in Japan.' I felt they were leveling up at a faster pace than I had expected."

Please tell us what you are currently working on.

"Through my work on the wards, I realized that there are numerous gaps between cardiovascular care in Japan and the US. I found this culturally very interesting and thought it would be a good opportunity to think about what is truly important. I started writing about it in textbooks, but gradually I felt the need for proper scientific investigation, so I began to focus on creating databases for various cardiovascular diseases and procedures. For example, in the case of patients with coronary artery diseases like angina or myocardial infarction, the stance on whether to perform invasive procedures or surgery differs considerably between Japan and the US. After that, I expanded my research scope to heart failure and arrhythmia. I've done a lot of analysis myself, but in the future, I hope that young doctors struggling in the field of cardiology will use this data. I want them to get into the habit of properly verifying the data themselves and examining whether their own hypotheses are correct."

Will this become a new way of clinical practice?

"It has already been actively incorporated into physician education as evidence-based medicine (medical care based not only on experience but also on evidence). Furthermore, statistical verification can now be done very easily on a personal computer, so data analysis has become very accessible. Also, since the concept of big data is entering fields like business and engineering, I think there is less hesitation to use it as a tool to assist physicians' judgment. I think it's safe to say it's a field that can no longer be ignored."

From your perspective, what is Keio's medical education like?

"I think the strength of student education at Keio's School of Medicine is its 'formidable autonomy.' The school provides the learning materials, but how students learn from them is entirely up to them. This style, which could be described positively as fostering autonomy or negatively as a hands-off approach, is something I don't hear about at other schools. However, by taking advantage of this policy, students can delve deeply into research, learn about hierarchies and networks through extracurricular activities, and explore what career paths are available for a doctor beyond standard training. In a sense, the greatest feature and tradition of the Keio University School of Medicine is that it trusts its students to the fullest. This concept also connects to what I mentioned earlier about fostering a doctor's independence."

What did you gain from the Keio University School of Medicine?

"For both myself and for the current students, I believe the extracurricular activities we chose to do provided us with invaluable experiences. I realized after becoming a doctor thatit is impossible for a single super-doctor to handle modern medical care alone.No matter how great a doctor is, the quality of care, such as surgery, will never improve if the team is unstable, and I think it's better to acquire these important skills during one's undergraduate years. This is my personal opinion, but I feel that the Keio University School of Medicine is not a place for cultivating super-doctors, but rather is geared toward developing team players."

From the Keio University School of Medicine to the United States. And now, based on that experience, he has returned to Keio University to explore new ways of medical education and further research the digitization of clinical data. Dr. Kohsaka's challenging days may be a symbol of the ever-evolving Keio University School of Medicine.