Table 2.

Summary of Main Findings

Main Category	Emerging Themes	n/24	Examples of Quotes From the Participants
Global impression of the training	Novel experience	15	“I have never experienced trainings such as how to deliver news to patients and what to be conscious about when communicating with them.” #1 (PGY7)
	Learning from other participants through observation	11	“Objectively watching other participants was different from just doing it myself.” #3(PGY3)
	Reflection on one’s own skills	9	“I was able to discover and recognize my own skills … and reflect on my communication techniques and my emotions in the moment …. Furthermore, I can take myself to the next step by developing concrete strategies to improve myself for the future.” #12(PGY32)
	Systematic training	5	“It was systematic, and the training taught me that communication is a learaable skill.” #1(PGY7)
	Efficient training	5	“The content was compact and straight to the point.” #21 (PGY14)
	Multipurposed training	2	“We can use these skills in many different clinical settings, not only in the palliative care setting.” #6(PGY11)
	The course was too long	1	“I am not sure if other learners will be interested in spending half a day just for the beginner’s course.” #17 (PGY14)
Main goals from participation	Improving general communication skills	14	“When I encounter difficult situations in the future, I think the communication process may go smoothly by using the skills that we learned.” #22(PGY24)
			“I was able to consider the patient’s emotions using the communication skills.” #23(PGY3)
			“I think the purpose of this course is to be able to consciously use the training tools, such as SPIKES and NURSE.” #24 (PGY19)
	Delivering bad news	3	“The goal is to help patients best understand the bad news, and we practiced this with the aid of the simulated patients.” #5 (PGY3)
	Building a relationship	4	“Communication skills—not only clinical competence —are very important, and I think they are crucial in building a rapport with patients and their families.” #3 (PGY3)
	Prevention from burnout	1	“I think I acquired skills to prevent myself from being burned out.” #13 (PGY4)
	Conceptualizing	1	“By implementing acronyms like NURSE into the lecture, the content and messages conveyed in the conversation with the patient can be conceptualized.” #19 (PGY14)
Appropriateness of didactics	SPIKES/NURSE mnemonics are acceptable in English	7	“English mnemonics are often used in Japan, so I don’t think acronyms like SPIKES would be an issue.” #5(PGY3)
	Adaption for SPIKES/NURSE mnemonics	5	“Acronyms made in Japanese are much easier to understand.” #2(PGY9)
	Discomfort with “Naming” the emotion	2	“The skill of naming the emotion was difficult to accept. I was concerned that this could influence the conversation in a negative way in Japanese culture. However, after using the skill myself, I have realized that it actually shows my willingness to acknowledge the patient’s emotions.” #12(PGY32)
			“Since we don’t understand if that emotional expression is correct, it’s difficult to assess whether showing our interpretation of patient’s entire emotion is the right thing to do.” #18(PGY7)
Role-play experiences	Realistic experience	15	The acting was so realistic, so I was able to get into my character naturally.” #14(PGY3)
			“The actor seemed like a real patient and even moved my emotions.” #22(PGY24)
	Learning from others through observation	6	“I felt like I got twice the learning experience, so that was great.” #10(PGY10):
	Effectiveness of timeouts	16	“It seemed as if the facilitator really knew the “best” timing to have the timeout to give the learners some advice when we were stuck and completely at a dead end.” #2(PGY9)
	Effectiveness of feedback	8	“I was able to receive feedback, which I rarely get in a clinical setting. At first, I was reluctant to do role-play, but in the end, I’m very glad that I was able to do it.” #14(PGY3)
	Japanese patients often would not show emotions	9	“In Japan, many people simply stay silent and accept whatever we (physicians) say without stating their opinions. So, I guess (expressive, emotionally simulated patients) would be helpful in that respect. #2(PGY9)
			“The simulated patient was emotionally expressive, but I think it’s rare to see Japanese people verbally express their feelings to someone who they meet for the first time. It may have been better to see variations like someone who fells silent or does nothing but cries. #7(PGY7)
			“Many patients in Japan don’t say ‘no’, and they often tell the nurses their true feelings later.” #13(PGY4)
	Recording will be helpful	3	“I think it is a good idea to record the role play so that we know exactly what was said.” #11 (PGY7)
Take away points from the training	Importance of demonstrating empathy	13	“Building trust is essential, and I really thought about how to build this with my patients …. I learned that I need to be conscious of my interactions with their families on a daily basis. #8 (PGY3)
			“In the past, when a patient expressed a certain emotion, a part of me had always tried to convince the patient by being logical. Instead, in response to these patients’ emotions, physicians must use proper techniques. That was the biggest takeaway.” #14(PGY3)
	Realistic role plays	7	“I was really amazed at how realistic the simulated patients were. That was the most surprising part.” #8 (PGY3)
	New teaching methods	5	“I learned new teaching skills which will be beneficials to share with my residents.” #21 (PGY14)
	Safe environment	4	“Watching other participants’ communication processes allowed us to exchange constructive feedback, and it was a safe environment to evaluate my own role play and how it looked like from other people.” #20(PGY17)
	Feedback is focused on words	4	“In the past workshops and communication courses that I have experienced, I often received feedback on the nonverbal parts of communication, but this time, I got feedback on what I said …. “ #15 (PGY6)
			“… the language and the wording … these are a set and do not change. The language, the vocabulary, and conjunctions used … these are universal and are the same to everyone, so I was amazed at how feedback was repetitively given, focusing on these points.” #20(PGY17)
Changes in communication practice after the training	Recommend participation to others	9	“I want everyone to take the course!” #8 (PGY 3)
	Realization of importance of communication skills training	5	“I again realized the importance of communication skills training. #1 (PGY 7)
	Importance of ongoing training	8	“I would like to take the course again or take a similar course.” #2 (PGY 9)
	Interest in becoming a future educator	2	“I hope I can help and support to promote VitalTalk in Japan, as this is such a compacted educational method.” #20 (PGY17)
	Strategies for physicians who are hesitant with role plays	2	“I think there are quite a few people who do not want to be critiqued in front of others. Depending on the situation, it may be necessary to create a course that allows participants to have the choice to observe.” #12 (PGY 32)