Number of Citations: 0

Submitted: 4 February 2023
Accepted: 19 April 2023
Published online: 3 October, TAPS 2023, 8(4), 53-56
https://doi.org/10.29060/TAPS.2023-8-4/CS3003

Maximilian Andreas Storz¹ & Rintaro Imafuku²

¹Department of Internal Medicine II, Center for Complementary Medicine, Faculty of Medicine, Freiburg University Hospital, University of Freiburg, Germany; ²Medical Education Development Center, Gifu University, Japan

I. INTRODUCTION

International medical electives are a central component of the academic curriculum in many medical schools and universities worldwide (Storz, 2022). As short-term clinical immersion experiences, abroad electives are essential in connecting medical faculties and academic hospitals around the globe. They foster cross-cultural exchange, medical skill training, as well as professional identity formation (Imafuku et al., 2021; Storz, 2022). From a global health perspective, abroad electives provide medical students with an opportunity to gain a better understanding of healthcare and medical education in an international context.

Historically, some countries cultivate close relationships in this regard. One example is the bilateral relation between Japan and Germany, which is characterised by a strong economic cooperation and close political dialogue (Hook et al., 2011). As pluralistic democracies, both share fundamental values and are closely tied in many socioeconomic aspects. Traditionally, there has also been a strong partnership in medical sciences between both countries (Horowski, 2018).

Japan is traditionally a popular destination for German-speaking medical students (Storz et al., 2021), and the most frequently reported elective destination in Asia. Nevertheless, little is known about student’s elective experiences in Japan. To address this gap, we reviewed four German open-access online-databases cataloguing elective testimonies and extrapolated key elective characteristics that may allow for a better understanding of abroad elective experience in Japan.

II. METHODS

The employed analysis method with its strengths and drawbacks has been described elsewhere (Storz et al., 2021). In brief, we analysed the 4 largest German open-access clinical elective reports databases called “Famulatur-Ranking” (www.famulaturranking.de), “PJ-Ranking” (www.pj-ranking.de), “ViaMedici” (https:// www.thieme. de/viamedici/medizin-im-ausland-ausland saufenthalt-allgemein-1627.htm), and “Medizinernach-wuchs” (www.medizinernachwuchs.de). Databases allow students to anonymously rate medical electives and to share their experience by uploading reports on a voluntary basis. Key information necessary to upload a report include the precise elective destination (e.g. country, city, hospital name), the elective year, the elective discipline and duration, a subjective elective rating (ranging from 1 to 6, whereby 1 is the best and 6 is the worst grade), and a short comment allowing a brief narrative summary of the elective experience. Generally, elective ratings refer exclusively to a subjective “overall elective experience”, and are not based on a clear rubric to guide students in their rating process. The databases’ search function was used to filter Japan-specific electives. For this particular analysis, all electives from 2005 onwards were considered. Databases were reviewed in September 2022 and data pertaining to any kind of clinical elective experience in Japan was then extrapolated to a Microsoft Excel-File.

III. RESULTS

We extrapolated n=36 Japan elective reports uploaded until 2020. Tokyo was the most frequently reported elective destination, accounting for 47% of reports (n=17), followed by Kyoto (11%, n=4). The remaining elective destinations are shown in Figure 1, which displays regions (coloured) and prefectures of Japan.

Figure 1. Elective destinations in Japan: An overview. Modified from TUBS (https://commons.wikimedia.org/wiki/File:Regions_and_Prefectures_of_Japan_no_labels.svg), based on a license under the Creative Commons Attribution-Share Alike 4.0 International license.

General surgery was the most frequently reported discipline (30.56%, n=11), followed by internal medicine (22.22%, n=8). Surgical disciplines accounted for 45% of reported electives (n=16), whereas internal medicine (including subspecialties) accounted for 1/3 of reports (n=12). The following disciplines accounted for n=3 reports each: Gastroenterology, Gynaecology, Neurology and Radiology.

Thirty-three students shared organisational details of their electives. More than 60% of electives were self-organised (n=20). Thirty-nine percent of electives (n=13) were organised through a bilateral international elective exchange program where a Japanese university partnered with a German university based on a signed memorandum of understanding.

Eight students possessed Japanese language skills to a varying degree (22.22%). Three students reported learning Japanese for one year, while one student learned Japanese for more than two years. The remaining four students did not share any information about their level of Japanese language skills. Despite the rather low percentage of students speaking Japanese, the vast majority of students rated their overall experience in Japan as excellent (grade: A, n=26). Of 28 students, two students rated their elective with the grade B.

Students reported a diverse set of gratifying elective experiences. The large majority of reports (n=33, 97.22%) highly appreciated the Japanese hospitality and the high level of social manners. More than half of students (n=19, 52.78%) reported the impression that students were generally highly respected in Japan. Frequent high-quality teaching and a thorough elective organisation were frequently mentioned (n=27 and n=29 mentions, respectively). Students also valued that they received clear instructions on the first elective day, often receiving in the form of a timetable or schedule, detailing their assignments, classes and teaching opportunities. Fourteen reports explicitly mentioned that a contact person at the international office was always available for questions, and reported their elective to be first-class in terms of organisation and structure.

Many students were surprised that students are denied hands-on experience in Japan by law prior to graduation, although this is usually explicitly mentioned on the elective program homepages. Almost 42% of students (n=15) valued that their hosting institution organised social and cultural events, including get-togethers and language courses. Eating-out after work with other hospital staff was considered an important and highly appreciated team-building strategy.

One third of students (n=12) stated that they received enough free time to explore the Japanese culture. Finally, n=5 students (13.89%) expressed their appreciation for the high technical standard in Japanese hospitals, particularly in terms of medical equipment and workflow.

IV. DISCUSSION

Our descriptive analysis allows for various helpful insights into German medical students’ destinations and experiences during their Japan elective. Students reported gratifying experiences and emphasised the very good organisation of electives in Japan.

Such information may be of paramount importance for host institutions because incoming students may be a double-edged sword. Hosting elective students is time-consuming and requires human resources. In some cases, international elective students may negatively impact the local community in terms of patient care and resource allocation (Storz et al., 2021), Then again, well-structured electives may also increase the reputation of hosting institutions and help foster bidirectional and transnational academic exchange.

As in most cases, benefits and downsides of electives are context-specific, and depend on local elective program structures. Here, students valued their electives and reported a substantial amount of gratifying experiences. Several students explicitly mentioned that their Japan elective was the “best elective during [their] entire time at medical school”. Understanding incoming students’ perspectives is vital for host institutions, and may benefit them in multiple dimensions, e.g. when tailoring elective programs. This may apply in particular to the post-COVID-19 era, where an increase in international student mobility is expected (Storz, 2022). In this context, it is worthy to mention that the majority of electives in our sample was self-organised. Host institutions should be prepared for receiving an increasing amount of elective applications in the post-pandemic years, where the elective landscape will likely be characterised by a more competitive seat-to-applicant ratio.

The reservation must be made that our analysis builds on a small convenience sample (n=36) that is not representative of German medical students in general (Storz et al., 2021). Additional interesting aspects, for example as to whether clinical experiences in Japan affected students’ career or future goals, were not ascertainable from our data. In addition, we were unable to measure whether Japan electives strengthened student’s clinical skills. Our data predominately suggested an increase in cultural competences but due to the cross-sectional nature of our data no reliable statementa can be made. For this, an interview-based approach utilising focused interviews with returnee students would have been more suitable. Regrettably, such an approach was hardly realisable during the past pandemic years.

V. CONCLUSION

Our results enable hosts to understand why foreign students seek electives at their institutions. Said information might be of paramount importance for elective organisers, since well-structured electives may increase the reputation of hosting institutions and help fostering transnational academic exchange.

Notes on Contributors

Maximilian Andreas Storz conceputalised the study, collected the data, performed the formal analysis, wrote the first draft of the manuscript, and approved the final version submitted.

Rintaro Imafuku contributed to the project administratition, supported the visualisation and criticially revised the manuscript for important intellectual content and approved the the final version submitted.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Interest

The authors declare that they have no competing interests.

References

Hook, G. D., Gilson, J., Hughes, C. W., & Dobson, H. (2011). Japan’s International Relations: Politics, economics and security (3rd ed.). Routledge. https://doi.org/10.4324/9780203804056

Horowski, R. (2018). Japanese medicine and Berlin: A very special and successful relationship. Journal of Neural Transmission, 125(1), 3–7. https://doi.org/10.1007/s00702-017-1800-1

Imafuku, R., Saiki, T., Hayakawa, K., Sakashita, K., & Suzuki, Y. (2021). Rewarding journeys: Exploring medical students’ learning experiences in international electives. Medical Education Online, 26(1), Article 1913784. https://doi.org/10.1080/10872981.2021.1913784

Storz, M. A., Lederer, A.-K., & Heymann, E. P. (2021). German-speaking medical students on international electives: An analysis of popular elective destinations and disciplines. Globalization and Health, 17(1), Article 90. https://doi.org/10.1186/s12992-021-00742-z

Storz, M. A. (2022). International medical electives during and after the COVID-19 pandemic – current state and future scenarios: A narrative review. Globalization and Health, 18(1), Article 44. https://doi.org/10.1186/s12992-022-00838-0

*Maximilian Andreas Storz
Hugstetter Str. 55
79106 Freiburg im Breisgau, Germany
+49 15754543852
Email: maximilian.storz@uniklinik-freiburg.de