Kinoshita et al. BMC Medical Education (2015) 15:42
DOI 10.1186/s12909-015-0313-6

RESEARCH ARTICLE

Open Access

Challenging cases of professionalism in Japan:
improvement in understanding of professional
behaviors among Japanese residents between
2005 and 2013
Kensuke Kinoshita1*, Yusuke Tsugawa2, Peter B Barnett3 and Yasuharu Tokuda4

Abstract
Background: Professionalism is deemed as the basis of physicians’ contract with society in Japan. Our study in2005, using a questionnaire with scenarios to professionalism, suggested that many physicians at various levels of
training in Japan encounter challenges when responding to these common scenarios related to professionalism. It
is unclear how medical professionalism has changed among Japanese residents in over time.
Methods: We conducted a follow-up survey about challenges to professionalism for Japanese residents using thesame Barry Questionnaire after a seven-year interval from the prior survey. The survey uses six clinical scenarios withmultiple choice responses. The six cases include the following challenges: acceptance of gifts; conflict of interest;
confidentiality; physician impairment; sexual harassment; and honesty in documentation. Each scenario is followedby 4 or 5 possible responses, including the “best” and the “second best” responses. The survey was conducted as apart of nationwide general medicine in-training examination.
Results: We collected data from 1,049 participants (290 women, 28%; 431 PGY-1 and 618 PGY-2 residents). Overall,the current residents performed better than their colleagues in the earlier survey for five scenarios (gifts, conflict ofinterest, confidentiality, impairment, and honesty) but not for the harassment scenario. PGY-2 residents were more
likely to select either the best or 2nd best choices to gifts (p = 0.002) and harassment (p = 0.031) scenarios than
PGY-1 residents. Residents in the current study chose either the best or 2nd best choices to the gifts (p < 0.001) andhonesty (p < 0.001) scenarios than those of the previous study conducted seven years ago, but not for the harassment
scenario (p = 0.004).
Conclusions: Our study suggests that there is improvement of medical professionalism with respect to some ethicalchallenges among the Japanese residents in the current study compared to those in our previous study.

Background
Medical professionalism is defined as the ability to meetthe ethical expectations required to practice medicine
competently [1]. These expectations are based on theprinciples of patient welfare, autonomy and social justice. Professionalism should be manifested through acommitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to adiverse patient population [2]. In Japan, professionalism* Correspondence: kensuke.kinoshita@nifty.ne.jp
1
Department of Medicine, Mito Kyodo General Hospital, University ofTsukuba, Mito City, Ibaraki, Japan
Full list of author information is available at the end of the article

is seen as the basis of physicians’ contract with society,and public trust depends on the integrity of both individual professionals and the profession as an entity [3].
Sociocultural context is likely to have influence on theconceptual framework and practice of medical professionalism in different countries. Japanese physicians are
more likely to set professional altruism as a moral priority based on the bushido spirit from the Edo era [3-5].
There are several responsibilities among physicians, including competence, honesty, confidentiality, appropriate
relations with patients, improving quality of care, improving access to care, just distribution of finite resources,
commitment to scientific knowledge, maintaining trust by© 2015 Kinoshita et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Kinoshita et al. BMC Medical Education (2015) 15:42

managing conflicts of interest, and commitment to professional responsibilities [2,6]. As such, professionalism isviewed as one of the five core competencies as defined by
ACGME, and is expected to be part of a structured curriculum and assessment process in both undergraduate
and post-graduate medical education. On the other hand,
it is challenging to formally educate medical professionalism within the framework of the currently available professional development of practicing physicians, many ofwhom are the residents’ clinical faculty. Consequently, formal training in professionalism for both residents in training and their faculty may lag behind organizational
expectations, and residents therefore tend to learn about
medical professionalism through interaction with patients,
senior physicians, co-medicals and colleagues.
Previous studies reported that modern physicians encounter many challenges with regard to medical professionalism in their everyday practices [7-11]. Hodges BD
et al. suggested that there are different ways of thinking
about professionalism that can lead towards a multidimensional, multi-paradigmatic approach to assessing
professionalism [12]. In 2005, we conducted a study using
a questionnaire developed by Barry and colleagues [13]with challenging scenarios to professionalism, considered
to be one of the more commonly used tools based onpractical scenarios to measure professionalism, and foundthat many physicians at various levels of training in Japan
also encounter challenges when responding to thesecommon scenarios. Many Japanese physicians also report that they are concerned with their inadequate
training in this area [11]. However in the years surrounding our 2005 survey, Japan introduced a national
mandatory residency program and we noted thatteaching hospitals improved their educational environments, including appropriate behaviors related to professionalism [14], but little additional information is available
on the explicit evaluation of medical professionalism
among Japanese physicians.
In this context, it is important to investigate thecurrent state of professionalism in the Japanese medical
education environment, and to examine if the level of
medical professionalism among medical trainees has
improved in Japan between 2005 and 2013.

Methods
Design, setting and participants

We conducted a survey of resident physicians at multiple teaching hospitals in Japan, using the Barry Questionnaire [13]. Permission has been granted for the useof this instrument [2]. The questionnaire instrument
contains six challenging cases to professionalism: acceptance of gifts; conflict of interest; confidentiality; physician impairment; sexual harassment; and honesty indocumentation. Each scenario was followed by 4 or 5

Page 2 of 7

possible responses. After completing all six scenarios,
participants were asked about their demographics andinformation on their hospitals.
We used existing nationwide general medicine intraining examination (GM-ITE) for conducting the questionnaire in these hospitals [15]. This 100-item (total
score of 100) case-based examination was conducted by
the Japan Organization of Advancing Medical Education
Program (JAMEP, a non-profit organization) and washeld for three hours once in year 2013 in March, the lastmonth of Japanese academic year for Postgraduate Year
(PGY) 1 and 2 resident physicians. The invitation to participate in the study was announced on the JAMEP website, a monthly medical journal advertisement (Resident
Note, Yodosha, Tokyo, Japan) and was sent to program
directors of all teaching hospitals (n = 1,015) in Japancertified by Ministry of Health, Labour and Welfare,including 114 university hospitals and 901 community
teaching hospitals.
The program director at each hospital was required to assemble residents in a room at each hospital at a scheduled
time, and provide the GM-ITE for their residents. Each
program director then collected the completed examination
answer sheets, and returned them to JAMEP using anenvelope we had provided. All surveys were conductedin March, 2013.
Questionnaire

The Barry Questionnaire was developed and validated ina study conducted in Colorado, USA by Barry et al. [13].
They performed the following steps to develop andevaluate the instrument: the scenario review was conducted by a panel of people with experience in medical
ethics, clinical practice, or laws; the consensus on the“best response” and the “second best response” for eachscenario was derived. We present each scenario of theBarry Questionnaire with the best response and the second best response in the Appendix. In our previous pilot
study, we developed the Japanese version by translatingtexts and responses of the instrument into the Japanese
language [11]. Also in the previous study, content validityof this Japanese version was confirmed by an independent
panel comprised of physicians responsible for educational
programs in participating hospitals, based on the contents
of professionalism guideline of the Japanese Medical
Association [16].
Analysis

We analyzed the frequency of providing either the bestor the second best answers to each scenario as a main
outcome measure, and compared those frequencies between PGY-1 and PGY-2 resident physicians, between
men and women physicians, and also between residentsof university hospitals and those of community teachingKinoshita et al. BMC Medical Education (2015) 15:42

hospitals. We also compared the main outcome measures of the current study to those of our previous pilot
study [11] and also to US residents from the original
study by Barry and colleagues [13]. The Chi-Square Test
was used to analyze data for comparing proportions.
Student’s t-test was used to analyze data for comparing
mean scores. All statistical analysis was performed using
IBM SPSS Statistics 21.0 (IBM Japan, Tokyo, Japan), andtwo-tailed p-value of less than 0.05 was considered asstatistically significant.

Page 3 of 7

Table 1 The frequency of the best or 2nd best responses
for each scenario: PGY1 and PGY2

Gifts

PGY1 (N = 431)

PGY2 (N = 618)

n

%

n

%

331

76.8

522

84.5

p-Value
0.002

Conflict of Interest

317

73.5

479

77.5

0.14

Confidentiality

353

81.9

492

79.6

0.36

Impairment

409

94.9

582

94.2

0.62

Harassment

122

28.3

214

34.6

0.031

Honesty

403

93.5

588

95.1

0.25

Ethics statement

All participants, whose native language is Japanese, readand signed informed consent before the survey. Participants were assured of confidentiality and anonymity. They
had the option to decline participation or terminate participation during the course of the study. The study was
conducted in compliance with the Helsinki Declaration
and was approved by the Institutional Review Board of
Mito Kyodo General Hospital, Mito city, Ibaraki, Japan(reference No. 11–18).

Results
A total of 431 PGY-1 and 618 PGY-2 resident
physicians-in-training (290 women, 28%) participatedand completed the survey. Of the PGY-2 physicians, 159(26%) were women and 459 (74%) were men. Of the
PGY-1 physicians, 131 (30%) were women and 300(70%) were men. Among all participants, the mean scoreof the exam was 58.1 (standard deviation [SD], 7.5).
There were 114 teaching hospitals. Nine hospitals (7.9%)
were university hospitals, while 105 hospitals (95.6%)
were community hospitals.
Overall, residents performed better for five scenarios(gifts and honesty) but not for scenario of harassment
compared to the results of the survey conducted in
2005. The greater proportions of the best or 2nd best responses were identified in issues about gifts (n = 853,
81.3%) and honesty (n = 991, 94.5%). The proportion of
the best or 2nd best responses to the harassment was
lower (n = 336, 32.0%) in the 2013 survey than that of
the 2005 survey.
Table 1 compares the frequencies that the participants
provided the best or 2nd best responses between PGY-1
and PGY-2 residents. The frequency of either the best or
2nd best responses to the gifts (p = 0.002) and harassment (p = 0.031) scenarios were significantly greater in
PGY-2 residents than in PGY-1.
The results of comparing the frequencies of the best
or 2nd best responses between residents of university
hospitals and community hospitals are presented inTable 2. The frequency of either the best or 2nd best responses to the gifts (p = 0.006) and honesty (p = 0.001)

scenarios were significantly greater in residents of community hospitals than of university hospitals.
Table 3 shows the results comparing the frequenciesof the best or 2nd best responses between men andwomen residents. The frequency of either the best or
2nd best responses to the gifts (p = 0.005) scenario wassignificantly greater in men than women.
Table 4 compares the performance of residents of thecurrent survey in 2013 with that of our previous pilot
study in 2005. The frequency of either the best or 2nd
best responses to the gifts and honesty scenarios weresignificantly greater in the current residents than thosein previous study [11]. However, the frequency of either
the best or 2nd best responses to the harassment scenario was significantly greater in participants in theprevious study than those in the current study. Table 5shows the frequency of each response to harassment
scenario in total and by gender, since the frequency ofthe best or 2nd best responses to this scenario werelower than those of other scenarios. Many residents
choose the B response (Report the incident to the program director as an example of sexual harassment),
which was chosen more frequently in men than inwomen. Only two men and no women chose the response A (Do nothing, on the basis that the faculty
member was simply showing his appreciation for a job
well done).
Table 2 The frequency of the best or 2nd best responses
for each scenario: university hospitals and community
hospitals
University(N = 186)

Community(N = 855)

p-Value

n

%

n

%

Gifts

138

74.2

708

82.8

0.006

Conflict of Interest

135

72.6

653

76.4

0.27

Confidentiality

157

84.4

681

79.6

0.14

Impairment

172

92.5

812

95.0

0.18

Harassment

70

37.6

263

30.8

0.069

Honesty

167

89.8

818

95.7

0.001

Kinoshita et al. BMC Medical Education (2015) 15:42

Page 4 of 7

Table 3 The frequency of the best or 2nd best responses
for each scenario: men and women

Gifts

Men (N = 759)

Women (N = 290)

n

%

n

%

633

83.4

220

75.9

Table 5 The frequency of each response to harassment
scenario in total and by gender

p-Value

Men

Women

Total

n

%

n

%

n

%

2

0.2

0.005

A

2

0.3

0

0

Conflict of Interest

568

74.8

228

78.6

0.2

B

349

46

117

40.3

466

44.4

Confidentiality

607

80.0

238

82.1

0.44

C (Best)

117

15.4

61

21

178

17

Impairment

720

94.9

271

93.4

0.37

D

177

23.4

67

23.1

244

23.3

Harassment

230

30.3

106

36.6

0.052

E (2nd best)

113

14.9

290

15.5

158

15.1

Honesty

715

94.2

276

95.2

0.54

Discussion
Based on the results of the current study, many more
PGY-2 Japanese physicians were able to provide an “acceptable” response to challenges to professionalism on
several issues compared to PGY-1 physicians regarding
gifts and harassment issues. Residents in community
teaching hospitals provided the greater number of acceptable responses to professionalism issues than thosein university hospitals in terms of gifts and honesty issues. Moreover, residents in the current 2013 study
responded more appropriately to professional challenges
than those in our previous study in 2005, specifically
gifts and honesty issues with statistical significance.
There are numerous interesting aspects to this study.
First, the validation of the study by the Japan Medical Association is gratifying. It is important that medical leadership within the private, university and government sectors
explicitly support the teaching and assessment of professionalism (and the other core competencies as well) at alllevels. It would be extremely interesting to elicit the
responses of these and other medical leaders and teachers
to the professionalism scenarios of the study.
Gifts

A previous study [17] on the relationship between Japanesephysicians and the pharmaceutical industry showed thatmany physicians received gifts from pharmaceutical
Table 4 The frequency of the best or 2nd best responses
for each scenario: Our previous study in 2005 and thisstudy in 20132005
(N = 60)

2013(N = 1049)

p-Value for2005 vs 2013

n

%

n

%

Gifts

33

55.0

853

81.3

<0.001

Conflict of Interest

49

81.7

796

75.9

0.31

Confidentiality

54

90.0

845

80.6

0.07

Impairment

56

93.3

991

94.5

0.71

Harassment

30

50.0

336

32.0

0.004

Honesty

39

65.0

991

94.5

<0.001companies, indicating the close relationship between
Japanese physicians and pharmaceutical industries.
Recently, however, there has been active discussions
concerning the relationship between clinical physicians
and pharmaceutical companies in Japan. Several authors have emphasized receiving those gifts should be
regarded as inappropriate relationship between physicians and pharmaceutical companies [18,19]. Many
residency programs introduced faculty development
education recommending against receiving those gifts.
Therefore, recent residents may have learned more
ethically appropriate relationships with drug companies
than the earlier study group.

Harassment

In addition, Japanese society has recently supported policies and rules against several forms of harassment, including sexual, power, and academic issues. Many
industries, schools, and hospitals have introduced local
committees for preventing or managing these issues.
Thus, PGY-2 residents may have been introduced tomore appropriate behaviors about sexual harassment.
However, the proportions of acceptable response to theharassment scenario were lower than those of otherissues. The response B (Report the incident to the program director as an example of sexual harassment.) was
selected most frequently (44%) in the current study.
Based on the case scenario (Additional file 1), if the witnessed person (the person observing the incident and answering the questionnaire) is a resident, and the “suspect”
is a faculty member, many residents would answer the
response B because it seems difficult to confront orapproach someone in power position on this topic. Theremay be limitations on accurately evaluating this item: do
we recognize this behavior as inappropriate and unprofessional and how do we deal with it as individuals when
witness and suspect are in equal or different positions,same or different gender? Fortunately, no women and veryfew (2 men) chose the response A, which was more problematic because of under-recognition of the harassment
behavior. It is clear that the sexual harassment policy ofeach Japanese teaching hospital still needs to be widely

Kinoshita et al. BMC Medical Education (2015) 15:42

circulated and discussed, and they should provide reporting
procedures and counseling for victims and witnesses.
Gender differences

Gender differences were observed in this study. The
question of gender is of great interest in all societies.
The position of women within medicine occurs within
historic and cultural context, and has been changing inrecent years. Men performed significantly better in termsof gift scenario than women. One possible explanation
would be that women may tend to avoid the interpersonal conflicts by accepting gifts from someone evenrecognize that it is inappropriate. The other potential explanation may be that women are self-confident about
the independence between their financial relationshipwith pharmaceutical companies and their professional
decision-making with regard to medical care. A study on
Japanese medical students suggested that women weredifferent from men in terms of greater feelings of empathy in women students [20]. Regarding the sexual harassment scenario, there was no gender difference of the
responses in the current study, although this scenario
might reflect more greatly to gender difference. In Japan,
men and women may recognize this issue relatively
equally. There were no data about whether the proportionof women in the workforce may be related to attitudes
and further study is needed for exploring this point.
Professionalism curricula

On the different level, professionalism curricula itself isundergoing evolution in many countries. Like all educational change, the process is slow or even arduous, andsubject to many factors; not the least of which are themany competing priorities for faculty time and attention.
There is the paucity of data on “what works” in professionalism education and assessment. Since both “hard”
outcomes and process data are sparse, it is especiallychallenging to interpret the current study’s results as afunction of the specific curricula at participating medical
schools and residencies. Having said that, it is reassuring
to note the very helpful anecdotal references on corecompetency training on the ABIM website [21-23].
Hidden curricula

Of course, while many physicians, both in training and“after” training, perceive that professionalism educationis lacking, all professionals participate in what has beentermed the “hidden curriculum” [24,25]. Most professionals know what the “rules” are or ought to be, thehidden curriculum of hallways, call rooms, and elevators
teach the evolving physician how to deal with the “reality,”practically and safely if not purely “ethically.” The hidden
curriculum of expedience and survival cannot be ignoredor, by itself, dismissed or criticized. Only when “it” isPage 5 of 7

acknowledged, and subjected to a candid and “safe” discussion, including explicit inquiry into the challenges
faced especially by physicians in early training, can wehope to support professional behavior which is more consistent with formal guidelines for professional and ethicalbehavior [26]. In Japan, medical professionalism had been
considered as unwritten contract with society or a matterof course based on “noblesse oblige” [3,4]. However, as an
old fashioned code of personal conduct has lessened inrecent years, it is getting more important not to leave professionalism to each individual.
Community versus university hospitals

In terms of issues about gifts and honesty, many more residents in community teaching hospitals provided thegreater number of acceptable responses than those in university hospitals. After introduction national mandatory
residency program by Japanese Ministry of Health, Labourand Welfare, community teaching hospitals improved
their educational environments which were proved to bebetter than those of university hospitals [14]. The betterhospital educational environment included appropriate
behaviors related to professionalism.
Professional development

Lastly, the results here strongly support the development
over time of professional ethics, specifically from PGY-1
to PGY-2. It is clear that the evolution of all aspects
of professional “core competencies” has developmental
aspects. Clearly, there are no discrete “stages” in the evolution of professional beliefs or behavior, but we dochange with experience, exposure, repeated daily challenge, individual introspection and collegial consultationand discussion, both formal and informal. An important
opportunity for educators and trainees alike is to view
daily practice as a learning “laboratory.” Similar to theutility of problem-based learning approaches elsewherein medical education, the everyday challenges of hierarchy, temptation of all kinds, the myriad of ethical andcommunication dilemmas inherent in an imprecise,
uncertain, and often high stakes profession all provide
endless opportunities for explicit inquiry, exploration,reflection and discussion. In fact, it is an authors’ belief
that the process of honest and ongoing professionalism
dialogue is more important than the articulation of specific rules. In fact, it is only through such dialogue that
we have any hope of “playing by the rules”.
Limitations

There are several limitations in our study. The first limitation was low participant rate. Only 1,049 out of 15,800
residents (about 7%) participated in our survey. However, our sample size (over 1,000) was relatively large
given that there were about 15,800 PGY-1 and PGY-2

Kinoshita et al. BMC Medical Education (2015) 15:42

residents in Japan. The second limitation may be different
views by physicians in different cultures. Some scenarios
may not be encountered commonly and several responses
could be viewed as acceptable behaviors in Japanese practice settings. Third, given that only 1,049 of about 15,800
residents throughout Japan participated in this study, ourfindings may not be generalizable to all residents in Japan.
Program directors are responsible for decision to participate in this exam. However, no residents who received the
GM-ITE denied the participation for this survey and there
was little space for bias toward the participation of greatly
professional residents. Fourth, the current study differs insize and design from the 2005 study, which was small insample size and used a convenient sample with data collection involved not at the same time as an exam. A framing effect might have been operated in the current study
to lead respondent to more socially desirable responses
than at other times. Thus, the results might not havereflected the true change. Fifth, there has been no notablechange in the professionalism curricula over the last
8 years in the formal residency outcomes project initiatedby the Japanese Ministry of Health after the introductionof national mandatory residency programs. However, especially in community teaching hospitals, clinician educators
have been encouraged to take leading roles for resident
education partially motivated for recruiting the greaternumber of residents. This behavioral trend might havebeen a cause for better responses to some issues, including
gifts and honesty scenarios. Regarding gifts scenario, there
might not have been few practical changes (76% vs 83%)
despite its statistical significance.

Conclusions
Our results showed that residents in year 2013 weremore likely to provide acceptable responses than thosein year 2005, specifically gifts and honesty issues withstatistical significance, suggesting significant improvement of professional behaviors in Japanese residents forrecent several years. In addition, there was a learning
curve effects related to professionalism during first two
years of residency in Japan. Professionalism education in
university hospitals should be evaluated to improve educational environment for their residents.
Additional file
Additional file 1: Appendix: Barry Professionalism Questionnaire.

Competing interests
Y. Tsugawa and Y. Tokuda received honorarium from the JAMEP for
preparing study questions. The JAMEP funded the study grant andconducted the examination for resident physicians as explained in the text
and data collection, but had no role in the study design, data interpretationor preparation of the article.

Page 6 of 7

Authors’ contributions
KK conducted the analysis and wrote the manuscript. YT supported
designing the study and wrote the manuscript. YT conceived the idea, led
the data analysis, and wrote manuscript. PBB advised drafting of themanuscript and wrote the manuscript. All authors read and approved thefinal manuscript.
Authors’ information
K. K. works as a staff physician at Mito Kyodo General Hospital, University ofTsukuba.
Y. Tsugawa is a researcher at Harvard Interfaculty Initiative in Health Policy,
and a PhD candidate in Health Policy at Harvard University Graduate Schoolof Arts and Sciences, Cambridge, MA, USA.
Y. Tokuda is a General Medicine Chairperson of Japan Community
Healthcare organization and he has MPH degree of Clinical Effectivenessconcentration at the Harvard School of Public Health.
P. B. B. is a Clinical Assistant Professor of Medical Education in the Universityof Nevada School of Medicine.
Acknowledgements
We thank Nobuo Kikuhara (JAMEP) for their excellent assistance.
Author details
1
Department of Medicine, Mito Kyodo General Hospital, University ofTsukuba, Mito City, Ibaraki, Japan. 2Harvard Interfaculty Initiative in Health
Policy, Cambridge, MA, USA. 3Office of Medical Education, University of
Nevada School of Medicine, 1664N Virginia St, Reno NV 89557, USA. 4Japan
Community Healthcare Organization, Tokyo, Japan.
Received: 30 April 2014 Accepted: 18 February 2015

References
1. Lynch DC, Surdyk PM, Eiser AR. Assessing professionalism: a review of theliterature. Med Teach. 2004;26:366–73.
2. ACGME Outcome Project. Advancing education in medical professionalism.
2012. http://dconnect.acgme.org/outcome/implement/Profm_resource.pdf
Accessed 1 Oct 2014.
3. Ohbu S. What is professionalism? Rinsho Shinkeigaku. 2012;52:1024–6.
4. Nishigori H, Harrison R, Busari J, Dornan T. Bushido and medical
professionalism in Japan. Acad Med. 2014;89:560–3.
5. Tokuda Y. Re: When financial incentives do more good than harm: achecklist. BMJ. 2012;345:e5047.
6. Swick HM. Toward a normative definition of medical professionalism.
Acad Med. 2000;75:612–6.
7. McArthur JH, Moore FD. The two cultures and the health care revolution.
Commerce and professionalism in medical care. JAMA. 1997;277:985–9.
8. Hall M a, Berenson R a. Ethical practice in managed care: a dose of realism.
Ann Intern Med. 1998;128:395–402.
9. Fukumoto Y. Professionalism and medical education. Japanese J Gen Med.
2006;11:31–2.
10. Takeda Y. Professionalism in everyday practice. Japanese J Gen Med.
2006;11:38–9.
11. Tokuda Y, Barnett PB, Norisue Y, Konishi R, Kudo H, Miyagi S. Questionnaire
survey for challenging cases of medical professionalism in Japan. Med
Teach. 2009;31:502–7.
12. Hodges BD, Ginsburg S, Cruess R, Cruess S, Delport R, Hafferty F, et al.
Assessment of professionalism: recommendations from the Ottawa 2010
Conference. Med Teach. 2011;33:354–63.
13. Barry D, Cyran E, Anderson RJ. Common issues in medical professionalism:
room to grow. Am J Med. 2000;108:136–42.
14. Tokuda Y, Goto E, Otaki J, Jacobs J, Omata F, Shapiro M, et al. Educational
environment of university and non-university hospitals in Japan. Int J Med
Educ. 2010;1:10–4.
15. Shimizu T, Tsugawa Y, Tanoue Y, Konishi R, Nishizaki Y, Kishimoto M, et al.
The hospital educational environment and performance of residents in the
General Medicine In-Training Examination: a multicenter study in Japan. Int
J Gen Med. 2013;6:637–40.
16. Japan Medical Association Medical Ethics Committee. Guideline for medical
professionalism in Japan. Tokyo: Japanese Medical Association; 2008.

Kinoshita et al. BMC Medical Education (2015) 15:42

Page 7 of 7

17. Miyata Y. An internet survey of physicians’ attitude towards gifts from drug
companies. Med Educ. 2009;40:95–104.
18. Saito S, Mukohara K, Bito S. Japanese practicing physicians’ relationships
with pharmaceutical representatives: a national survey. PLoS One. 2010;5:e12193.
19. Miyata Y. Conflict of interest regarding clinical physicians’ relationship withpharmaceutical industry and medical education. Seishin Shinkeigaku Zasshi.
2010;112:1136–45.
20. Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS. Measurement of
empathy among Japanese medical students: psychometrics and score
differences by gender and level of medical education. Acad Med.
2009;84:1192–7.
21. The ACGME General Competencies: American Board of Internal Medicine
http://www.abim.org/program-directors-administrators/assessment-tools/
mini-cex.aspx#competencies Accessed 1 Oct 2014.
22. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation
system–rationale and benefits. N Engl J Med. 2012;366:1051–6.
23. Swing SR, Clyman SG, Holmboe ES, Williams RG. Advancing resident
assessment in graduate medical education. J Grad Med Educ.
2009;1:278–86.
24. Mossop L, Dennick R, Hammond R, Robbé I. Analysing the hidden
curriculum: use of a cultural web. Med Educ. 2013;47:134–43.
25. Browning DM, Meyer EC, Truog RD, Solomon MZ. Difficult conversations inhealth care: cultivating relational learning to address the hidden curriculum.
Acad Med. 2007;82:905–13.
26. Argyris C, Schön DA. Theory in Practice: Increasing Professional
Effectiveness. London: Jossey-Bass; 1974.

Submit your next manuscript to BioMed Central
and take full advantage of:• Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit