The rate of implementation of palliative care lectures in universities was 44.0, 48.0, 94.0, and 98.5% in 1995, 1998, 2001, and 2015, respectively [4, 6]. In 2000, the draft of the “medical education model core curriculum,” (a guideline on the courses that should be taken by undergraduate medical students) was published in Japan. The curriculum was finalized in 2001, has been revised, and is presently positioned as a reference for the development of curriculums in universities (2007 and 2010 revised edition) [8, 9]. The model core curriculum’s establishment is one of the reasons for the increase in the implementation of palliative care lectures since 2001.
In 2005, 26.4, 16.7, and 25.0% of the schools included lectures entitled “palliative medicine,” palliative care,” and “terminal care,” respectively [10]. The usage of “terminal care” subsequently decreased, and “palliative medicine” and “palliative care” increased, presumably due to the development of the core curriculum.
Eight surveys examining the implementation of end-of-life (EOL) education at medical schools in the United States were conducted every five years from 1975; the rate of medical schools providing EOL training increased from 80% in 1975 to 100% in 2010 [11]. The mean time allocated for EOL training during the four-year school period was 17 h (2010); this ranged from 2 to 80 h depending on the school. Previous surveys indicate that all medical schools provide some palliative care teaching (mean duration: 20 h; range: 6–100 h), within their undergraduate curriculum; however, the contents of these programs vary [12]. The frequency of visits to hospices and discussion of clinical cases has increased [11]. It may be inappropriate to compare the present survey’s results; however, the mean number of class sessions per lecture was 6.6 and the mean session duration was 77.5 min; therefore, the mean time allocated to palliative care education in Japan was approximately 8.5 h. These results suggest that insufficient time is allocated to undergraduate palliative care education in Japan.
Regarding administrating teachers’ clinical departments, the largest proportion of teaching staff came from the Departments of Anesthesia, followed in order by the Departments of Palliative Care, Psychiatry, Internal Medicine, and Surgery. A survey conducted in 2001 found that teachers from the Departments of Surgery and Internal Medicine accounted for 35.8 and 20.9% of the total, respectively; the percentage of teachers from the Department of Internal Medicine and Surgery had decreased, while those in the Department of Palliative Care increased [6]. Historically, Japanese medical universities and colleges have conducted medical practice and education without a department of palliative medicine within their faculty of medicine. Palliative care physicians (who were formerly internists, surgeons, or anesthesiologists) therefore individually administered palliative care practice and education. Following the establishment of the department of palliative medicine, teaching staffs from the Department of Palliative Care typically administered lectures, with the teachers from the Department of Anesthesia administering them less frequently. No major difference existed in the curriculum itself; after the Department of Palliative Medicine was established, more problem-based learning curriculums were established. Only 13 medical faculties or colleges in Japan administer specialized courses in palliative medicine [5]. This is among the reasons for the observed differences in undergraduate palliative care education between universities. It is difficult to consider that pre-graduate education based on core curriculum is more commonly practiced at universities where specialized courses in palliative medicine are set up; however, our analysis does not show this. As shown in Table 3, lectures about hospice were widely delivered in universities with no established specialized courses in palliative medicine. Even in universities where there are no established courses, it indicates that a well-balanced pre-graduate education is provided. In addition to pre-graduate education, professional courses for palliative medicine are also required to train experts through post-graduate education of multi-disciplinary health professions and research for the development of academic disciplines. In this study, although there was no significant difference in the content of the postgraduate education depending on whether the Department of Palliative Medicine were established, there are still a few specialized courses that have been established in a small number of universities, and further studies to examine this will be necessary.
In September 2010, the United States Education Commission for Foreign Medical Graduates (ECFMG) advised that graduates other than those from internationally certified medical colleges or faculties would not be qualified for the ECFMG application from 2023 onwards [13]. In Japan, the Japan Accreditation Council for Medical Education (JACME) was established in February 2013. If the ECFMG recognizes the JACME as an organization for accreditation at an international quality, progress will be made in the accreditation of medical education curriculums adopted by Japanese universities and colleges at an international level. “Basic Medical Education: Japanese Specifications,” which complies with the World Federation for Medical Education global standards, recommends “palliative care” as a subject in “clinical medicine” that students should complete. In particular, bedside learning must be enriched, and an integrated curriculum should be developed [14]. The ECFMG’s recognition of the JACME as an internationally certified organization would promote these goals. Further, research has found that study time in clinical settings includes hours for clinical experience (based on a rotation system) and clinical clerkship, and that 43.9 and 25.8% of respondents underwent clinical training in palliative medicine as compulsory and selective subjects, respectively. In Japan, clinical clerkship courses that students may choose freely are termed selective subjects. This underlines the necessity of improving clinical training programs. Departments of palliative medicine should be established at Japanese medical universities and colleges in order to develop palliative care curriculums in Japan.
This study has the following limitations. First, not all contacting institutions responded and institutions without palliative care curriculums may have been particularly reluctant to respond. Nonetheless, the response rate was high. Second, many fields may have delivered lectures on palliative medicine under titles other than “palliative medicine” (e.g., practical lectures on terminal-care ethics in “Introduction to Medicine,” lectures on opioids in anesthesia, lectures on psycho-oncology in psychiatry). If so, the present results may not reflect the actual situation. Finally, the questionnaire did not examine a wide range of details of palliative care education at medical schools; therefore, some relevant data may not have been collected.