Medical education in Germany has undergone significant reforms since the new law, “Regulation of the Licensing of Doctors,” was introduced in 2003. The major point of the reforms is the shift from theoretical education to practical clinical training. The national licensure examination consists of 2 parts: an examination for knowledge of basic medicine in the second year of medical school, and an examination for clinical knowledge and skills after clinical clerkships. These reforms should provide useful information for the reform of medical education in Japan.

　France’s sophisticated system of medical education achieves a seamless link between undergraduate education and postgraduate training and has eliminated the uneven distribution of physicians among disciplines and regions. The Épreuves Classantes Nationales （national ranking examination）, introduced in 2004, improved the uneven distribution of physicians among disciplines and regions. Although the medical board examination is not used in France, the unique medical education system, which develops both general practitioners and specialists, provides useful information for improving medical education in Japan.

・We visited the National Board of Medical Examiners and the Clinical Skills Evaluation Collaboration Center to discuss with the examiners the present state of the USMLE （United States Medical Licensing Examination）, to which clinical skills evaluation has been introduced.
・Evidence that the introduction of clinical skills evaluation to the USMLE has affected the reform of medical schools curricula in the United States supports the necessity of introducing clinical skills evaluation to the Medical Board Examination of Japan.

1) At Dundee University, which has an excellent history of medical education and where the objective structured clinical examination was developed, hematology and dermatology play integrated roles in the second semester of the first-year curriculum. 2) Integrated curriculums, exemplified by the study of hematology, are expected to be introduced to medical schools in Japan.

1) We report here the introduction of graduate entry programmes (GEP) of medical education curriculum in Ireland. Shortness of the doctors stimulated the introduction of GEP in Ireland.Two of the five medical schools introduced GEP and one is planning to introduce, while the other two do not have any idea to introduce it at present.
2) GEP can grow doctors of diverse abilities and is evaluated by Irish medical educators

1) Simulation-based learning is well organized in Universities of Dundee and Glasgow.Medical students use skills centre to brush up their clinical skills frequently.
2) University of Glasgow developed clinical final OSCE using 50 stations.In the United Kingdom, where national board examination is not necessary to be a doctor, OSCE using 50 stations is organized to foster good doctors.

1) We visited 4 universities in Germany, from where medical systems were once introduced to Japan as a model of modern medicine, and investigated the present conditions of medical education.2) The reform of curricula and methods of medical education has been actively performed in Germany, as it has been in Japan.

1) Simulation-based training is critical for medical students to acquire clinical skills. We sent questionnaires to all 80 medical schools in Japan asking about the status of clinical skills laboratories and received responses from 73 medical schools.2) Fifty-nine schools have skills laboratories. Forty-nine schools have curricula integrating simulation-based skills training. The 3 most common apparatuses are venopuncture trainers, basic life support mannequins, and skin-suturing trainers. Lung and heart sound auscultation trainers, advanced cardiac life support mannequins, and ophthalmoscopy trainers are used at more than 50 schools.3) Thirty-two of the 59 schools have simulation-based skills-training courses that are not included in the undergraduate medical curriculum. Medical staff and people in the community are participating. The four most common courses are, in descending order, basic life support, intermediate cardiac life support, advanced cardiac life support, and automated external defibrillation, which are held at more than 16 schools.

　Based on our experience of visiting the Medical Council of Canada and observing large-scale OSCE (objective structured clinical examination) in Canadian Qualifying Examination Part II , we report differences operation system, implementation status, and examination questions compared to Japan. This very important examination after the post-graduate residency program may provide several invaluable tips when we introduce nation-wide clinical performance examinations.

A 44-year-old man underwent implantation of a DDD pacemaker for third degree heart block at age 20. The cutaneous pocket for the pulse generator was situated in the left pectoral region. He visited our hospital because of skin ulcer over the pacemaker without any other complaint such as fever or pain. The patient received a new DDD pacemaker system in the right pectoral region and old pacing leads were translocated under the pectoral muscle. However, right pectoral skin ulcer appeared 1 month later. Patch tests revealed a positive reaction to silicon. Wrapping of the pacemaker with a polytetrafluoroethylene (PTFE) sheet proved to be effective.