Contrasting Residency Training in Japan and the United States From Perspectives of Japanese Physicians Trained in Both Systems

Abstract

Background

International medical graduates (IMGs) have significant exposure to clinical training in their home country, which provides opportunity for international comparison of training experiences. One relevant IMG population is Japanese physicians who have completed some training before entering residency programs in the United States and desire to improve medical education in Japan.

Objective

We examined Japanese IMGs' perceptions of the respective attributes of residency in the United States and Japan.

Methods

Individual semistructured interviews were conducted with 33 purposively sampled Japanese IMGs who had completed training. We used exploratory thematic analysis, iterative data collection, and thematic analyses with constant comparison.

Results

Comments were organized into 3 categories: (1) attributes of US residency preferable to Japanese residency; (2) attributes of residency training with no clear preference for the US or Japanese systems; and (3) attributes of Japanese residency preferable to US residency. Within each category, we matched themes to residency program requirements or culture of medical training. Main themes include high regard for Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements, with emphasis on efficient achievement of clinical competency through graded responsibility, contrasted with preference expressed for a Japanese training culture of increased professional commitment facilitated by a lack of work hour limits and development of broad clinician skills, including bedside procedures and radiology interpretation.

Conclusions

Japanese training culture contrasts with a US model that is increasingly focused on work-life balance and associated compartmentalization of patient care. These findings enhance our understanding of the global medical education landscape and challenges to international standardization of training.

What was known and gap

International comparisons of medical education could offer information about the efficacy of training, but opportunities are sparse.

What is new

Japanese physicians with exposure to US graduate medical education participated in a qualitative analysis of their training experience in both nations.

Limitations

Findings are not generalizable to other national contexts; majority participation by medical specialties may reduce generalizability to surgical and hospital-based training.

Bottom line

The findings highlight clinical and cultural differences that present potential challenges to the international standardization of training.

Introduction

Since the mid-20th century, international migration of physicians has received scholarly attention, with research often focused on patterns and impact.^1,2 Amid growing return migration due to evolving medical infrastructure in home nations³ and interest in international standardization of medical education,^4,5 examining the experience of international medical graduates (IMGs) has the potential to shed light on differences and similarities in educational methods across nations. This may deepen our understanding of medical education internationally and in the United States.

IMGs have significant exposure to clinical training in their home country, which often includes formal postgraduate training. Their experiences provide opportunities for international comparisons of clinical training. We focus on IMGs from Japan who commonly complete some residency training before graduate medical education (GME) in the United States. In addition, many Japanese IMGs choose US training in part to help improve medical education in their home nation.⁶

GME in Japan consists of 2 years of general residency with rotations in core clinical areas (internal medicine, surgery, pediatrics, emergency medicine), followed by clinical specialty training.⁷ The government directly oversees GME, including regulating the number of general residency slots for each geographic region and reviewing programs.^8,9 Residency program criteria are congruent with Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements,^8,10 but place more emphasis on clinical exposure and experiential learning than ACGME standards, potentially due to government compensation for training programs limited to less than $10,000 per trainee annually.¹¹ In addition, medical team roles are not clearly delineated, and expectations for didactics, assessment, and feedback are less rigorous than in the United States.^8,12,13 There is limited research on physician wellness in Japan and no discussion of work hour limits in residency requirements.^14,15 Instructional guidelines for residency training in Japan recommend aligning training with US residency attributes but are not legally binding.¹⁶ There is variation in the training experience across programs, and Japan's modest specialty certification criteria have prompted concern about physician competency.¹⁷

These observations suggest Japanese IMGs should view their US residency experience as superior. At the same time, perceptions also are strongly influenced by other factors, including the culture of clinical training and practice and interpersonal relationships.^18–20 In this study, we examine Japanese IMGs' perceptions of the respective attributes of residency training in the United States and Japan.

Methods

We chose a qualitative design, applying constructivist exploratory thematic analysis,²¹ to understand Japanese IMGs' perceptions of the attributes of US and Japanese training. Constructivism recognizes that researchers' knowledge of the subject matter and experiences influence data collection and interpretation.²²

Sample

We purposively sampled participants by (1) soliciting names of potential participants from training programs with a history of educating Japanese IMGs, and (2) asking participants to propose other potential participants, ideally with experiences contrasting their own. Inclusion criteria were graduation from a Japanese medical school and completion of clinical training in the United States within 1 to 15 years at time of interview. We purposively sampled physicians practicing in the United States and in Japan.

The study was approved by the Institutional Review Board at the University of Pittsburgh Medical Center. Participants provided informed consent.

Data Collection and Analysis

Thirty-three of 37 physicians contracted agreed to participate. We conducted individual semistructured interviews in English (in person, via telephone, or via Skype) between February 2013 and October 2015. Participants received an outline of the questions beforehand to enable reflection on the topics. We asked about attributes of their US residency versus training in Japan, followed by relevant probes (eg, the value of US training and differences between US and Japanese training). Interviews were transcribed verbatim.

We independently analyzed transcripts using open coding, discussed emerging themes, and combined them to create an initial codebook. Coding progressed in an iterative fashion; constant comparison of codes from current interviews with codes from prior interviews informed modification of questions and probing techniques in subsequent interviews. Disagreements were resolved through discussion. Interviews were conducted until themes were saturated. Coding was performed using Atlas.ti 7.0 (Scientific Software, Berlin, Germany).

To enhance the relevance of findings, where possible, we matched themes to the ACGME Common Program Requirements.¹⁰ As a validity check, we collected feedback on the themes from 4 participants representing different specialties. All corroborated the identified themes.

Results

Participant Characteristics

The 33 participants graduated from medical school in Japan, and 31 completed 2 or more years of Japanese residency (the remaining 2 had 1 year). Participants completed US residencies in 7 specialties at 13 US programs. All but 1 trained after the implementation of US work hour limits. Current job descriptions for 30 participants involve working with residents in the United States or Japan. Specialties with the largest number of participants were internal medicine (22) and family medicine (6). Added demographic details are provided as online supplemental material.

Qualitative Analysis

We organized participants' responses into 3 categories: (1) attributes of US GME preferable to Japanese residency; (2) attributes of training with no clear preference for either system; and (3) attributes of Japanese residency preferable to a US residency. Two themes emerged: (1) comments related to the ACGME Common Program Requirements, and (2) comments about the culture of medical training and practice. Across both themes, there was no difference in comments from participants practicing in the United States and those working in Japan. For quotations, participants in the United States are numbered 1 to 14, and those in Japan are numbered 15 to 33.

Attributes of US Residency Preferable to Japanese Residency

Participants described attributes in this category that are summarized below. Table 1 shows illustrative quotes. Attributes align with ACGME Common Program Requirements and with the culture of medical training and practice.

Table 1.

Attributes of US Residency Preferable to Residency in Japan

Themes	Subthemes	Representative Quotes
ACGME Common Program Requirements	Assurance of competency	[At any training] program you can expect yourself to become an effective physician to a certain level. Probably that's the biggest strength of US training. That [standardized] rigor of training is still lacking [in Japan]. (27)
	Clear goals, conditional independence	[In the United States] residents are given clear objectives, and after 3 years of residency, you're prepared in every aspect of general medicine. This doesn't happen in Japan. (23)
		[In the United States] conditional independence [enables you to become] a team leader as a second-year and third-year [resident]. (22)
	Didactic sessions, prioritization of education	[In the United States] I was pleasantly surprised that all attendings expected residents to learn rather than work and residents had to attend all the conferences. (3)
	Evidence-based medicine	. . . in the United States I not only learned the current evidence, [but also] how to read [research] papers, and apply the [literature] to clinical practice. People are always talking about that. (14)
	Research with faculty support	Japanese people don't know about mentorship. When I was a second-year resident I started a couple research projects [which helped my application for] fellowship. (3)
	Clinical decision-making	[In the United States] you must be able to clearly explain why you are doing everything that you're doing. Sometimes a Japanese doctor can't do that . . . You are held accountable, so you must follow the guidelines and be up to date on everything in standardized medicine. (4)
	Collaboration with patients	In the United States, they emphasize the importance of patient preferences . . . [In Japan] recently we have started to think about patients' [values] but [Japanese physicians often] don't know how to interview patients about this issue. I continue to struggle with how to educate physicians about [shared decision-making]. (32)
Culture of medical training and practice	Open discussion among care team members	[In the United States] whoever the teacher is, it can be a professor or even a junior resident, they ask questions to the medical students, and there's communication. And the medical students are never afraid to ask questions. (12)
	International exposure	American culture is heterogeneous . . . Diverse opinions are accepted. (16)

ACGME Common Program Requirements:

The predominant attribute of US residency training was the overarching design to assure residents' development of competency for independent clinical practice, including clear goals, graded and progressive responsibility, conditional independence, and summative evaluation. Participants admired the effectiveness and efficiency of progressive responsibility and senior trainees teaching junior trainees, contrasted with reliance on faculty to directly teach trainees in Japan. Other admired attributes of US residency were regular didactic sessions and protected time for participation, training in evidence-based medicine, research including formal mentoring by faculty, clinical role models in primary care fields currently underdeveloped in Japan, sharing decision-making with patients, and programs' efforts at continuous improvement.

Culture of Medical Training and Practice:

Participants highlighted benefits of a US training culture that encourages discussion, in contrast to Japan, where questioning senior team members may be perceived as disrespectful. There was recognition of support for phlebotomy and patient transport, which are common resident responsibilities in Japan. Participants also valued their exposure to different cultural backgrounds and associated ways of thinking in the more diverse US residency programs, contrasted with Japan's relatively homogeneous ethnic makeup.

Attributes of Residency Training Without Clear Preference for Either System

Participants described attributes of training where there was a lack of agreement about which system is preferable, with interviewees often describing positive features of both systems. Three attributes match to ACGME Common Program Requirements: work hours and transition of care, clinical documentation, and feedback. A fourth attribute was the attending-resident relationship. Table 2 contains illustrative quotes.

Table 2.

Attributes of Residency Training With No Clear Preference for US or Japanese Systems

Themes	Subthemes	Representative Quotes
ACGME Common Program Requirements	Work hours and transition of care	When I came [to the United States] people worked in shifts with a call schedule that was very established. I think when you are on, you are crazy busy. But when you are done, you are completely done . . . Work-life balance exists in the United States. (2)
		[Japanese residents have the attitude that] “this patient is my patient and I will be paged 24 hours [a day].” (21)
		In Japan you can experience continuity in patient care. For example, you start to build the doctor-patient relationship in the emergency room, you decide to hospitalize the patient, you are in charge of care during the hospitalization and then after discharge, if you want, you can do a home visit . . . [By contrast, training at my US residency] was so fragmented. (30)
		You don't get that same amount of training time in the United States because you have 80-hour rule, so there's no way of matching the amount of time that Japanese physicians spend [on patient care] in the first 3 years. (10)
	Clinical documentation	I have very mixed memories of [documentation during my US residency]. Sometimes [it seems] people write too much in the United States just to protect themselves . . . [At the same time] documenting explicit medical reasoning is good, of course. (15)
	Feedback	[In the United States there is] bidirectional evaluation between the attending and resident. At my Japanese residency we attempted to use the American system, but in the United States it's much more sophisticated. (8)
		[I received not only] positive feedback, but also negative feedback that improved me in many respects . . . [There was] very specific guidance. (17)
Culture of medical training and practice	Attending-resident relationship	I didn't think that I got a lot of personal teaching from attendings during US residency. In Japan if you meet nice attendings, I think they tend to teach you more . . . one-on-one. [Yet,] in the United States, as a system, we learn more. There's the noon conference, rounds, etc. (3)
		[In the United States] residents work with attendings only a couple hours a day, so I don't think they know their trainees. In Japanese training, attending physicians tend to stay [late] with their trainees . . . Sometimes we go out to eat dinner and go out for drinks, so Japanese trainers and trainees tend to have more personal relationships. (24)

Work Hours and Transition of Care:

Participants commented on the importance of work-life balance codified by the US GME system. Some complained that work hour limits and frequent handoffs fragmented patient care and learners' understanding of disease progression and recovery. By contrast, in Japan, individuals have continuous responsibility for their patients' care, and interviewees felt this instilled stronger ownership of patients and accelerated clinical experience.

Clinical Documentation:

Participants reported increased documentation of patient care in the United States. While recognizing the value of recording decision-making, they expressed concern for excessive detail motivated by billing and liability considerations.

Feedback:

Interviewees explained the explicit nature and increased sophistication of multi-directional feedback in US GME, but disagreed on the benefits of the feedback received. Several participants recalled helpful specific comments, but others reported affirmation of their work that failed to guide self-improvement.

Attending-Resident Relationship:

Descriptions of attending-resident relationships in the 2 systems paralleled those of resident work hours and transitions of care. In the United States, relationships appeared more compartmentalized within a system of regimented didactic experiences. By contrast, comments about Japanese faculty were characterized by on-the-fly teaching at all hours intertwined with efforts to know trainees on a personal level, including through social events.

Attributes of Japanese Residency Preferable to US Residency

Participants described attributes of Japanese residency, including (1) dedication to training; (2) bedside diagnostics and procedural skills; and (3) interpretation of radiology imaging. Table 3 contains representative quotes. Japanese residency guidelines list bedside procedures and radiology interpretation. However, their acquisition was observed in the context of a training culture that stresses self-reliance and self-directed learning.

Table 3.

Attributes of Japanese Residency Preferable to US Residency

Themes	Subthemes	Representative Quotes
Culture of medical training and practice	Dedication to training	Some Japanese residents are keen to learn, even, for example, attending conferences on their days off. (20)
		[Japanese residents] are hard workers . . . That's just [reflective of the culture of] Japan. (33)
	Safety	A patient's relative brought a gun to the ICU and demanded a specific physician. (9)
		While rotating at a hospital in Brooklyn, a patient collapsed in the ED after suffering a gunshot wound. Nobody performed ACLS out of fear the shooter may be following him . . . [Personal] safety is a clear advantage of training in Japan. (10)
Diagnostic and procedural skills and radiology study interpretation	Bedside procedures	After 3 years of training in Japan or in the United States, Japanese physicians are going to be better because more hands-on opportunity with more access to procedures. (10)
	Radiology study interpretation	[In Japan,] most residents are able to do echocardiograms and other ultrasounds. (33)
		Surgeons in Japan [perform] diagnostic studies, for example, ultrasounds, which are pretty limited to a radiologist's practice in the United States. (9)
		[In the United States] people rely on the report [from the radiologist], whereas in Japan people read [the image] themselves. (14)

Abbreviations: ICU, intensive care unit; ED, emergency department; ACLS, advanced cardiovascular life support.

Dedication to Training:

Participants reported that while there are individual exceptions, in general they found Japanese residents to be more intensely dedicated to training than their US counterparts. Time spent in patient care, personal study, and at academic conferences was noted. Participants consistently noted this reflected a difference between Japanese and US work ethics, rather than program design.

Bedside Procedural Skills:

Participants explained that residency in Japan (including non-surgical fields) fosters development of bedside procedural skills. This distinction was contextualized within the difference in inpatient practice care models where Japanese resident physicians must be able to perform all bedside patient care tasks while US residents increasingly rely on specialized services. Consistent with the attending-resident relationship in Japan, attending physicians were reported to be eager to teach procedural skills during routine clinical practice.

Radiology Imaging Interpretation:

Participants commented on confidence in interpreting radiology studies as a strength of Japanese residency training. This was explained as a skill learned out of necessity through self-study and on-the-fly teaching, due to more limited support from radiologists compared to the United States.

Discussion

To our knowledge this study represents the first comparison of residency in the United States with residency elsewhere through the lens of physicians trained in both systems.

Themes and ACGME Core Requirements

The main attributes of residency in the United States identified by participants can be summarized as the efficient achievement of clinical competency through graded responsibility within a system that prioritizes critical thinking, continuous learning, advancement of knowledge, and flexibility for improvement. Participant comments affirmed the essence of US clinical education rooted in the Flexner report and historical descriptions of GME.²³ By contrast, aspects of US residency where participants articulated mixed sentiments reflect more recent changes, including work hour limits and frequent transition of care, increased clinical documentation, reduced clinical time for faculty, and resulting attenuation of the attending-trainee relationship. These attributes are associated with the evolving clinical enterprise of US academic medical centers and societal expectations of trainee welfare and patient safety.^24,25 Participant comments around potential shiftwork mentality in US trainees are consistent with the literature on the effect of work hour limits and differences in perceptions by US trainees and faculty.^26–30

Themes and Culture of Medical Training and Practice

Our findings highlight a theme of participants' perception of increased professional dedication to training in Japanese residency, which may be an attribute of national culture.³¹ Although data are limited, Japanese resident physicians work approximately 80 hours per week on average³² and commonly take pride in their commitment. This contrasts with the views of US trainees, who value the improved work-life balance afforded by work hour limits,^33,34 though the comments of US faculty on work hour limits are more ambivalent.^27,30 The Japanese self-sacrifice that extends through one's medical career has been explained as a core quality of Bushido, the moral code that characterized samurai behavior; while Japanese society is changing, this heritage continues to influence physicians and patients' expectations of them.^35,36 Intertwined with this attitude is the Japanese tradition of after-hours socializing with bosses and coworkers.³⁷ This may partially explain the more intimate attending-resident relationship that participants described in Japan. The limited Japanese research on mental health during residency also focuses on the influence of trainee psychological qualities (ability to cope with stress) and interpersonal relationships.^15,38–41 The single Japanese study that trialed restriction of resident work hours identified no decrease in the prevalence of depression or burnout.¹⁵

The other main distinguishing theme of Japanese residency was the breadth of clinical skills acquired, including facility with bedside procedures and radiology image interpretation. Importantly, Japanese physicians train and practice with less fear of litigation than their US counterparts, with just 857 medical practice lawsuits filed in Japan in 2017.⁴² Participants commented on the widespread use of point-of-care ultrasound, including Japanese residency training in generalist specialties with expectation of proficiency to perform ultrasound examinations of the heart, abdomen, and neck vasculature without a standardized curriculum or assessment protocol.¹⁶ While point-of-care ultrasound is used routinely by US emergency medicine residents, assessment methods vary across residency programs and a reference standard for competency is lacking.^43–45

Our study has limitations. Findings are limited to the perceptions of GME in the United States and Japan, and are not generalizable to other nations. While we sought to include participants with contrasting experiences, the limited specialty representation with a majority of internal medicine and family medicine participants may have resulted in incomplete identification of themes for other specialties.

Conclusion

Japanese IMGs who trained in the United States describe a Japanese residency experience that echoes historical descriptions of US training and lacks core elements of current US training. Participants favored aspects of US training, including the focus on assuring competency for unsupervised practice. Conversely, they liked the greater clinical exposure and connectedness with faculty when training in Japan. Japan's organizational culture of training is intertwined with a national culture that takes pride in intense dedication to a career, contrasted with participants' views on the US medical education culture, including the emphasis on physician health and work-life balance, and the associated compartmentalization of patient care. Our findings contribute to the community's understanding of potential challenges to international standardization of training.