Student Clinical Skills Improvement

Clinical PBL Seminars

The basis of my clinical seminars is the application of the PBL thinking process to every clinical problem; PBL is the international method used in all medical universities in developed and many developing countries to teach the clinical narrative to medical students and other health providers.

Because Japanese medical universities are underutilizing PBL, I developed a research demonstration project with 3 universities, FukuiDai, OkayamaDai and TsukubaDai in a attempt to show the benefits of PBL. With the direct assistance of professors from these 3 universities(Dr. Terasawa-FukuiDai, Dr. Kataoka-OkayamaDai), Dr. Tokuda(TsukubaDai) secured a 3 year funded grant entitled "Webinar: a real time interactive medical student clinical seminar," or Webinar Project(WP for short)
[grant #23590870. URL:].

Link to the Webinar announcement:


A major component of the WP is the Internet pre and post test instrument, Sequential Question and Answer/SQA, a testing and teaching clinical thinking program to measure change after a clinical seminar.

This test is a clinical narrative( history, past history, medications, physical examination, laboratory and imaging studies) you write with questions for the student from the clinical narrative, the student writes the answers in Kanji using word processing, closes the window with the correct answers immediately appearing, plus more information as the narrative proceeds to the next question. Because the correct answers always appear after the student completed his answers, the student learns the order of the clinical narrative. The answers for the differential diagnosis teaches the use of the presented clinical data, a proxy for clinical thinking.

None of the SQA clinical team developers have any financial interest in the SQA. The SQA is owned by Imagine Labo Company [ ], contact Yamada San: [ ]Their fee is usually ~2 man yen. FuikuiDai ER staff Dr. Tokunaga may assist as webmaster if you like.

There are 2 problems with the current SQA program:1) the examinee does not make a Problem List ( a component of PBL) and 2) the computer scoring of key words failed. Adding a required Problem List should not be technically difficult. However, using a preexisting medical Kanji dictionary to score the answers represents a challenge, perhaps needing Ministry grant to automate the scoring with publishing business and academic coordination.

Japanese National Medical Licensure Examination

I propose the Japanese National Medical Licensure Examination committee consider the use of the SQA with these improvements to make the national examination more practical since the SQA assesses and teaches clinical reasoning to the examinee.

Also I propose the committee consolidate separate specialties' questions. For example, otorhinolaryngology sinusitis question can be combined with Infectious Diseases question; Abdominal pain can be combined question from gastroenterology and general surgery.

Skype Video Conference

Another concept from the WP is the use of Skype video conferences for improving communication between Hon-in and the affiliated hospitals and clinics. In addition I am available for Skype video-clinical conferences. For example Dr. Tokuda and I have used this free technology for several case based seminars with Dr. Tokuda and his Mito Kyodo Hospital residents in their conference room and me in my Florida home office.

Problem Lists

Most medical students have no experience making Problem Lists, an important component of learning PBL.

I propose an introduction to making problem lists of general topics for students grade 1-2, escalating into clinical topic problem lists for grade 3-5 students.

The entire problem list data for all 5 grades are designed to help the president and top administrative medical university leaders change from minimal practical clinical skills teaching to modest increase in clinical skill teaching for 5th grade students at JuntendoDai Hon-in.

Here is a proposed modest research project of teaching the Problem List to grade 5 students:

For 5th grade ID non-procedural specialty rotations, such as Infectious Disease, Rheumatology, Endocrinology/DM, nephrology, General Internal Medicine, Pediatrics and Emergency Medicine students on a one week 5 day rotation during 4 week intervals,
1. For weeks 1 & 3,
a. day 1 through day 5, students write daily supervised 2-3 clinical based problem lists with preliminary differential diagnosis from clinical narrative each of the 5 days,
b. comparing day 1 to day 5 problem list and preliminary diagnosis for the 1 week rotation.
2. For weeks 2 & 4, these students write a problem list and preliminary differential diagnosis on day 5 only,
3. Comparing these non-practicing writing problem list students to the problem list day 5 of the students practicing writing problem lists each day of their 5 day specialty rotation.

A simple quantity and quality-based scoring system needs to be developed for each student grade with increasing expected completion of their problem lists. Alternatively a pre and post brief SQA may be manually scored for small number of students entering and ending their rotation.

Please know that skilled clinicians are the best physicians to lead these clinical skills proposed changes at Japanese medical universities. Exact training in medical education may be a hinderance to improvements in clinical skill teaching.

I welcome your comments.

Jerry Stein