CANAMED

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You will be placed in a Franco-Japanese room automatically - balanced by university, year and English level.

University Year of study English level (CEFR self-assessment)

CEFR levels: A2 elementary · B1 intermediate · B2 upper-intermediate (can discuss complex topics) · C1 advanced · C2 proficient. Pick the closest - it is only used to balance the rooms.

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Welcome to Session 3

Theme: Learning From Each Other — a student-led exchange session. Everything for today runs from this platform. You move through the session together; a facilitator advances your room from one block to the next.

Today's structure (approx. 2 hours)

Module A — Chronic Pain & the Clinical Case, worked through here on the platform.
Module B — Breaking Bad News, a cross-cultural roleplay.
Wrap-up — debrief and the end-of-session questionnaire.

Your facilitator will start your room when the session begins.

Name your team

Pick a fun team name together — it shows on the live leaderboard. Anyone in the room can set it.

Read the case below, then tap any button on the left (Ask the patient / Examine / Investigations) to start gathering info.

The patient in front of you

Mr Lefebvre, a 45-year-old office worker, comes to your clinic with 8 months of lower back pain. He is frustrated: a friend abroad was given oxycodone and "it fixed everything", and he wants the same. Your group must work up the case and agree a management plan.

Your shared chart for M. Lefebvre. Everything the team asks, examines, investigates or decides is recorded for everyone in the room and counts as the team's choice. Discuss first, then click together.

Opium is one of medicine's oldest drugs — used in ancient Sumer, praised by Galen, bottled as laudanum from the 17th century. The 19th century industrialised it: morphine was isolated around 1804, the hypodermic syringe arrived in the 1850s, and Bayer marketed heroin in 1898. Repeated waves of addiction made 20th-century Western physicians cautious — opioids were for cancer and acute pain only.

That caution collapsed in the United States. In 1995–96 pain was promoted as "the fifth vital sign" and OxyContin was launched with aggressive, misleading marketing; prescriptions tripled and hundreds of thousands of overdose deaths followed. Japan took a strikingly different path — tight narcotics regulation, restrictive insurance rules, conservative training and a deep cultural wariness of mayaku (narcotics) — and today prescribes opioids many times less than the US, with France and the UK in between. Low-back-pain care had its own reversal: until the 1990s bed rest and routine imaging were standard, until trials showed bed rest delays recovery and imaging rarely changes outcomes.

Did you know? Heroin was sold over the counter as a "non-addictive" cough remedy from 1898 — a marketing claim eerily echoed a century later for OxyContin.

Did you know? Japan prescribes opioids more than 20× less than the USA — not because Japanese patients feel less pain, but because of regulation, insurance and culture.

Jones MR et al. A Brief History of the Opioid Epidemic and Strategies for Pain Medicine. Pain and Therapy 2018;7(1):13–21. doi.org/10.1007/s40122-018-0097-6
Onishi E et al. Comparison of Opioid Prescribing Patterns in the United States and Japan. J Am Board Fam Med 2017;30(2):248–254. jabfm.org
Tompkins DA et al. Providing chronic pain management in the "Fifth Vital Sign" era. Drug Alcohol Depend 2017;173(Suppl 1):S11–S21. doi.org/10.1016/j.drugalcdep.2016.12.002
Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. Br J Gen Pract 1997;47(423):647–652. free full text
Foster NE et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet 2018;391(10137):2368–2383. doi.org/10.1016/S0140-6736(18)30489-6

Red flags — when to worry

Category	Ask / look for	If present
Cauda equina (emergency)	Saddle anaesthesia, urinary retention/incontinence, faecal incontinence, new sexual dysfunction, bilateral leg symptoms	Same-day emergency referral + urgent MRI
Malignancy	Age >50, cancer history, unexplained weight loss, rest/night pain, no improvement after 4–6 weeks	Bloods (FBC, ESR/CRP, calcium) + imaging; refer
Infection	Fever, night sweats, IV drug use, immunosuppression, recent spinal procedure, focal bony tenderness	ESR/CRP + urgent MRI; refer
Fracture	Significant trauma, or minor trauma with osteoporosis risk; focal midline bony tenderness	X-ray ± MRI
Inflammatory (axial spondyloarthritis)	Onset <45, morning stiffness >30 min, improves with exercise / worse with rest, second-half-of-night pain	ESR/CRP, consider HLA-B27, rheumatology referral

First-line management of chronic non-specific low-back pain

Education & reassurance — not dangerous, not "damage"; hurt ≠ harm; good prognosis.
Stay active — avoid bed rest; resume work, walking, gym.
Structured exercise / physiotherapy — the best-evidenced treatment; adherence matters more than the type.
Address yellow flags — fear of movement, catastrophising, low mood, poor sleep — treat these directly.
Non-opioid analgesia — NSAIDs at the lowest effective dose, shortest duration. Paracetamol alone is ineffective.
Do NOT — routine imaging, opioids, gabapentinoids / benzodiazepines, prolonged bed rest.

Opioids for chronic non-cancer pain

Small short-term pain benefit at best, no proven benefit on function, no good evidence beyond ~12 weeks; real harms (tolerance, dependence, hyperalgesia, falls, overdose). All four countries: not first-line.

France · Japan · UK · USA — at a glance

	Imaging	Opioids for chronic LBP	Prescribing-culture context
France	Not without red flags	Not routine; biopsychosocial care first	Moderate use — above Japan, well below USA
Japan	Restrict to indicated cases	Not first-line; cautious, harm–benefit weighted	Among the lowest opioid use of high-income countries
UK	Do not routinely image	Do not offer opioids for chronic LBP (NICE)	Risk-stratified, self-management–led NHS model
USA	Avoid routine imaging	Last resort only; maximise non-opioids first	Historically very high use; opioid crisis

Ready to write your working hypotheses?

Agree as a team: what do you suspect? List two or more differentials you want to rule in or rule out. Writing two unlocks the discussion prompts.

Write in any language — English, French or Japanese. You're not marked on your English; it's your clinical thinking that counts.

Pick your role below before starting the roleplay. The observer keeps time.

For most of Western medical history, concealing a grave diagnosis was considered good medicine. The 1847 AMA Code of Ethics told doctors to be "the minister of hope and comfort to the sick." As late as 1961, Donald Oken found that about 90% of US physicians preferred not to tell patients they had cancer.

The reversal was rapid. Driven by the 1960s–70s rights movements, the rise of bioethics, research scandals such as Tuskegee, and a new emphasis on autonomy and informed consent, a 1979 replication found roughly 97% of physicians now favoured disclosure. France formalised these patient rights later: the loi Kouchner of 4 March 2002 enshrined the right to information, consent and access to one's medical record. Japan's trajectory differed and is unusually well documented: into the early 1990s physicians routinely told only the family, not the patient, of a cancer diagnosis — disclosure then rose sharply through the 1990s, though Japan moved toward selective rather than universal truth-telling, still weighting family wishes heavily.

Did you know? In 1961, 9 out of 10 American doctors would not tell a patient they had cancer — within two decades, almost the same proportion said they would.

Did you know? Until the 1990s, Japanese physicians often told the family but not the patient — so the "please don't tell my parent" scenario in this roleplay was, until recently, simply standard practice.

Sisk B et al. The Truth about Truth-Telling in American Medicine: A Brief History. The Permanente Journal 2016;20(3):15–219. free full text
Oken D. What to tell cancer patients: a study of medical attitudes. JAMA 1961;175(13):1120–1128.
Novack DH et al. Changes in physicians' attitudes toward telling the cancer patient. JAMA 1979;241(9):897–900.
Elwyn TS et al. Cancer disclosure in Japan: historical comparisons, current practices. Soc Sci Med 1998;46(9):1151–1163. pubmed
Loi n° 2002-303 du 4 mars 2002 relative aux droits des malades. Journal Officiel 2002. legifrance.gouv.fr

SPIKES — the six steps

Step	What you do	One phrase
Setting	Sit down, privacy, no interruptions	"Is it alright if we talk now?"
Perception	Find out what they already understand	"What have you been told so far?"
Invitation	Ask how much they want to know	"All the details, or the headlines?"
Knowledge	Warning shot, then news in small plain pieces; pause	"I'm afraid the results are serious…"
Emotions	Name and acknowledge the feeling; allow silence	"I can see this is a shock."
Strategy	Agree the next concrete step; reaffirm you won't abandon them	"Here's what we do next — I'll be with you."

When the family asks you to withhold information

Step	Do	Don't
Pause	Thank them; the request comes from love/worry	Agree or refuse on the spot
Explore	"Help me understand what worries you most."	Dismiss the fear as irrational
Explain	Can't deceive a patient who wants to know; needn't force facts on one who doesn't	Lecture coldly about "the law"
Realign	Ask the patient what they want to know & who to involve	Keep a secret from the patient with the family

Disclosure norms & patient-information rights

	Who is told?	Right not to know?	Key instruments
France	Patient has a legal right to be informed	Yes — explicit in law	Loi Kouchner 2002; HAS guidance; Code de déontologie
Japan	Historically family-first; now patient disclosure is the norm	Respected in practice; supported by case law	JMA ethics guidelines; Cancer Control Act; SHARE model
UK	Patient-centred; shared decision-making is the standard	Yes — patient may decline information	GMC Good Medical Practice 2024; Montgomery 2015
USA	Patient-centred; withholding from the patient is ethically unacceptable	Yes — patient may ask not to be informed	ASCO communication guideline; AMA Opinion 2.1.3

Big point: both systems are negotiating the same tension — respecting the individual vs. protecting them through the family — and both are still changing.

Pick your role above (or tap “Randomly assign roles”) to see your part and a private brief here.

When the family asks you to withhold information — "Pause · Explore · Explain · Realign"

Pause — don't refuse or agree on the spot. Thank them; their worry is real and usually loving.
Explore the why — "Help me understand what worries you most about your parent knowing."
Explain your position — you cannot deceive a patient who wants to know, but you do not have to force information on someone who does not.
Realign — ask the patient how much they want to know and who they want involved (this is SPIKES' "Invitation"). The family's worry becomes part of the conversation, not a secret kept from the patient.

Playing the patient — make it real

Decide privately now — deep down, do you want to know everything, or would you rather not? Don't announce it; let the physician discover it through their questions.
React like a person, not a textbook. You can go quiet, ask "is it cancer?", well up, or freeze. There is no script.
Answer honestly if the physician asks how much you want to know — from the stance you chose.
It is okay to still be upset at the end. A good consultation does not always end calmly.

Playing the family member (adult child)

Partway through — not at the start — quietly take the physician aside and ask them not to tell your parent everything.
Your worry comes from love. Press gently if they hesitate: "It would crush them," "In our family we don't say the word."
You are not the villain — you hand the physician the real cross-cultural dilemma to navigate.
Let the physician explore your worry; don't back down the instant they push back.

Observer's SPIKES checklist — tick what you see, note one win + one hard moment

Just for you — tick a step when the physician does it, and jot the moments you'll raise in the debrief. Saved on this device only.

Setting — set up privately, sat down, no interruptions
Perception — asked what the patient already understands
Invitation — asked how much they want to know
Knowledge — gave a warning shot, then news in small plain pieces
Emotions — named and acknowledged the feeling, allowed silence
Strategy — agreed a next step; signalled they won't be abandoned

One thing the physician SAID that worked: One moment that was hard or could improve:

Before you start — two things.

This is a simulation. The feelings can still feel real. If anything hits too close to home, you can move into the observer role at any time, no explanation needed. When you debrief, talk about the physician's choices — never criticise the person.

English is everyone's second or third language here — that is part of the point. If you cannot find a word, slow down, use a simpler one, or pause. Silence is allowed in this conversation and often helps. Empathy is in your tone, your pace and your face, not in advanced vocabulary.

Module B — Breaking Bad News: A Cross-Cultural Roleplay

The situation (read once, together). Mr / Mrs Tanaka-Martin, 60 years old, came in for tiredness and weight loss. The tests are back: the diagnosis is a serious, chronic, life-changing illness — your group chooses one (for example: a newly diagnosed cancer, advanced heart failure, early Parkinson's disease, or kidney failure needing dialysis). It is treatable but not curable, and it will change how the patient lives. The patient does not yet know. Their adult child has come with them and is in the room — and at some point will quietly ask you something.

Pick your role for this roleplay. Everyone not in a named role is an observer (timekeeper + Phase 3 facilitator).

Picked the wrong role? Tap it again to clear your choice.

Everyone moves together — tap Next → when your group has finished this phase.

Phase 4 — Swap roles & replay

You've played it once and talked it through. Now swap: everyone rotates to the next role and replays the same scene from the other side — that's where the empathy really lands. Tap Swap; your role chip and your "Your role" tab update automatically.

Round 1 — first run

Phase 5 — Play it out (round 2)

Play the same scene again from your new role. Don't aim for a perfect run — notice what you do differently now that you've seen it from another side. Your role and a private brief are in the "Your role" tab.

Phase 3 — Talk it through & vote

Write in any language — your facilitator and teammates can read English, French and Japanese.

1. When the family asked you to withhold — what did you do, and would a doctor in France respond the same way as one in Japan?

2. One way disclosure practice differs between France and Japan — and one way it is converging

Phase 6 — What improved

You played it twice, from two sides. Reflect together on what changed — then each note one thing you'll take home.

Write in any language — your facilitator and teammates can read English, French and Japanese.

1. What did you do differently the second time — and what did playing the other side teach you?

2. One thing each of you will do differently, in your own country, because of this

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CaNaMED Session 3

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Welcome to Session 3

Before we start — quick questionnaire

Today's structure (approx. 2 hours)

Quick pre-session knowledge check

Name your team

The patient in front of you

Red flags — when to worry

First-line management of chronic non-specific low-back pain

Opioids for chronic non-cancer pain

France · Japan · UK · USA — at a glance

Group answers — Module A

SPIKES — the six steps

When the family asks you to withhold information

Disclosure norms & patient-information rights

Module B — Breaking Bad News: A Cross-Cultural Roleplay

Phase 4 — Swap roles & replay

Phase 5 — Play it out (round 2)

Phase 3 — Talk it through & vote

Phase 6 — What improved

Wrap-up & Next Steps

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Quick post-session knowledge check

Your feedback on today's session

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