As of earlier this year, the Japan Board of Surgery (JBS) now requires residents to earn 10 points in trauma surgery toward their completion of postgraduate training. These 10 points may be earned in a variety of ways, including functioning as the operating surgeon in a major trauma case (three points), attending a trauma seminar (one point), completion of the Japan Advanced Trauma Evaluation and Care course (four points), or completing the American College of Surgeons (ACS) Advanced Trauma Operative Management (ATOM) course (four points). The Surgery Board of Japan uses a point system to tally experience; the points do not represent credit hours. Hence, surgery trainees in Japan may now use the ATOM course as a credential toward board certification in surgery. The significance of this recent change is a tangible sign of the credibility that the ATOM course has earned in Japan as a result not only of the high quality of the ATOM course, but also of the continued efforts of a large group of highly dedicated individuals who coordinate the ATOM courses in Japan.
Differences in training
Achieving board certification in surgery in Japan is considerably different from the process used in the U.S., but obtaining a certain amount of clinical experience is requisite in both countries. In general, residency training in Japan is less structured than in the U.S., with more of the decisions about resident training made by each department rather than centralized requirements from an agency such as the Accreditation Council for Graduate Medical Education. Furthermore, the overall training period tends to be longer in Japan than in the U.S. Board certification in Japan is earned after passing a written examination, and criteria for board certification is determined by the Japan Surgical Society. A total of 10 trauma surgery procedures is required.
However, most of the cases used in the application for certification have involved suturing of skin lacerations. Each department cannot provide sufficient trauma cases for the residents. Thus, board-certified surgeons in Japan have limited experience in trauma surgery.
The causes of traumatic injury are different as well. Penetrating traumatic injuries are rare in Japan. Gun ownership is strictly prohibited, and compliance with this regulation is nearly 100 percent. The overall rate of assaults and attacks in Japan is extremely low, and except for suicide attempts, very few patients are seen for penetrating injuries. In 2010, just 19 murders with guns occurred in Japan (population 127 million), while in the same year there were 8,874 gun-related murders in the U.S. (population 310 million).* Taking these factors into account, as well as the fact that trauma patients are widely dispersed for initial care rather than sent to centralized trauma hospitals, it can be difficult for residents to obtain operative trauma experience.
ATOM in Japan
The ATOM course began in Japan in December 2008, and is now offered at six centers throughout the country including Jichi Medical University, Tochigi; Osaka City University; Teikyo University, Itabashi; Hokkaido University, Sapporo; Tohoku University, Sendai; and Kysuhu University, Fukuoka, covering a broad geographical area across the nation. Since its introduction in Japan, more than 40 ATOM courses have been presented, with more than 200 providers and 37 instructors certified.
The training has proven successful. In the last five years, four patients in Japan were treated for penetrating wounds to the heart, exactly the same as one of the standard injury scenarios in the ATOM course. For each of these four patients, their surgeon had taken the ATOM course and the surgeons directly credit the ATOM course with giving them the knowledge and skill to manage the injury. In each case, the surgeon had never before seen such an injury. Now that ATOM training is an accepted credential for JBS certification, we anticipate that even more Japanese surgeons and their patients will benefit from this training.
*Izawa Y, Suzukawa M, Lefor AK. Self-inflicted injuries are an important cause of penetrating traumatic injuries in Japan. Acute Med & Surg, 2016. Available at: http://dx.doi.org/10.1002/ams2.186. Accessed August 5, 2016.