REVIEWPERSPECTIVES IN MEDICAL EDUCATION
7. Observations on Clinical Training at
a “US-style” Residency Program atTeine Keijinkai Hospital in Sapporo, Japan
R. Harsha Rao

School of Medicine, University of Pittsburgh, Pennsylvania, U.S.A.
(Received for publication on August 8, 2008)(Accepted for publication on December 18, 2008)

Abstract
The residency program at Teine Keijinkai Hospital in Sapporo has successfully implemented
a training philosophy that is focused on the development of clinical skills and critical thinking in Japanese residents. Several elements contribute to its success. The first and foremost
is visionary physician leadership, beginning with the pioneers who implemented the philosophy, and continuing through the current leadership, which has sustained the original vision.
A close second is the administrative and financial commitment to invest in producing moreclinically accomplished Japanese physicians, long before that need was officially recognized.
Third is the program’s explicit aim of adhering to international norms by requiring three
years of training, promulgating a benevolent, not paternalistic teaching philosophy and encouraging an interactive and interrogatory learning ethic. Fourth is the year-round presence of a US-trained Physician-in-Residence, to sustain the focus on clinical skills and international norms. Fifth is a long-term relationship with the Internal Medicine Training Program at the University of Pittsburgh, providing a conduit for ongoing academic exchange
and programmatic advice. Last, but not least, is its avowed intention of being viewed as an“American-style program” with a preference for English fluent applicants, which acts as amagnet for trainees motivated to acquire clinical skills and competencies, with an eye to future training in the US. All these elements contribute to the program’s unique focus onteaching clinical skills and critical thinking. Others who are striving with varying degrees
of success to implement a similar philosophy in Japan may benefit from studying its example. (Keio J Med 58 (2) : 84－ 94, June 2009)

Keywords: graduate medical education, internship and residency, training programs, Japan
Introduction

vations, conclusions and recommendations forchange.1-6 This paper, the seventh in this ongoing series
detailing my growing experience with Japanese medicine
in general, and Japanese medical education in particular,
expands on the earlier ones, and adds new understanding
to my insights. Readers interested in the body of literature in this area are directed to the earlier papers in theseries. This paper will focus on observations made by meduring two trips, in August 2007 and again in April 2008,
to the Residency Program at Teine Keijinkai HospitalOver the past five-plus years, it has been my privilege
to observe and critique the quality of medical education
at two of Japan’s premier institutions of medical training,
Keio University School of Medicine in Tokyo and the
Muribushi Project for Okinawa Residency Programs.
The deficiencies in the system and the progress of theongoing reform effort observed over a number of visits
are detailed in a series of reflective papers on my obser-

Reprint requests to: R. Harsha Rao, MD, FRCP, Room 580 Falk Medical Building, 3601, Fifth Avenue, Pittsburgh PA 15213, U.S.A., Tel: +1-412-586-9701,
Fax: +1-412-383-9586, E-mail: rhrao@pitt.edu
84

Keio J Med 2009; 58 (2):84－94(TKH) in Sapporo, Japan, as a Guest Professor. It draws
extensively from an evaluative report submitted by me to
the Program Director on the quality of clinical training
for residents at that institution.
On those twin visits, I had the opportunity to teach andto evaluate the residents in the TKH Program, much as I
have at the Muribushi Project and at Keio University
Hospital, in my ongoing role as a faculty member in the
Pittsburgh-Japan Program at the University of Pittsburgh,
School of Medicine. Also, just as I have at those othertwo institutions, I have waited to publish my findings
until I have had at least two opportunities to make those
assessments, so that my opinion is not skewed by a single experience, or by one set of residents. This paper details my observations over both those visits, and comprises an attempt to present what I see as the strengths
and weaknesses of the program. The sum of those is positive and is the reason that I am more optimistic now
about the eventual success of reform in Japanese medical
education than I was before.
Historical Background
1. The origins of the residency program at TKH
Even before my first visit, I was aware of the TKH
residency program’s unusual designation (for Japan) as a“US-style” program and of its one-of-a-kind relationshipwith the University of Pittsburgh Medical Center(UPMC) and School of Medicine (UPSOM). However,it was not until my second visit that I discovered the real
history behind those two unique features. It was duringthat visit that I sought out the opportunity to sit down fora one-on-one interview with Dr Keisuke Sakai, the first
Program Director of the TKH Residency Program, andone of its Founding Fathers (along with Drs Hiroshi
Maekubo, Hironori Murakami and Jun Yoshida). I leftthat interview with the amazed realization of having interacted with yet another astonishing medical visionary
in the mold of others I have met in Japan, like Professor
Amano at Keio, or Dr Miyagi at the Muribushi Project.
Dr Sakai, a cardiothoracic surgeon who is now retired
but still enjoys a quasi-emeritus status at TKH, is unusual in other ways, too. He is one of a select group of Japanese physicians of his generation who sought and completed clinical training as a resident in the US (in the early sixties, at Henry Ford Hospital in Detroit, MI).
During my interview with him, Dr Sakai described at
length the origins and founding of the residency program
at TKH in 1998. What was most helpful to me was his
willingness to elaborate on the motivation underlying theestablishment of a three-year training program in Japan,
at a time when there was no requirement in Japan for a
medical graduate to undergo any residency training, andthat too well before the mandatory two year residency

85

training was introduced in 2004 for all Japanese medical
graduates.
What I learned from him has placed my own observations of the residents’ performance over two visits intheir proper perspective. It has also helped me formulatea framework into which I could place my assessments ofthe program and my recommendations for change. Whatfollows is a summary of my interview with him, basedon notes taken by me at the time.
2. A new vision for clinical training at TKH
TKH opened in 1988 as the flagship hospital of the
Keijinkai Medical Corporation. According to Dr Sakai,from the very beginning, the hospital had little problem
staffing its Surgery department, thanks to the close cooperation Dr Sakai received from his surgical colleagues inthe two academic institutions based in Sapporo. However, the Medicine department was a different matter altogether, and the lack of cooperation in that area resulted
in an acute need for physicians to staff the non-surgical
specialties. Tired of struggling unsuccessfully to fill that
need, Dr Sakai, with the support of the TKH President,
Dr Maekubo, decided that the time had come to stop
waiting for outside help and to instead start training theinternists they needed themselves. Thus was born, in
1998, the TKH Residency Training Program in General
Internal Medicine (GIM).
The four objectives that the founders established forthe program at its outset, as articulated to me by Dr
Sakai, were:a. To establish a good clinical training system for
medical graduates;b. To increase the recruitment of good candidates
who, upon completion of residency, would stay in
Sapporo and form a nucleus upon which the program could build;c. To encourage the development of better teachers;
andd. To recruit an American Physician-in-residence
who would help achieve the first three objectives.
3. The early years
It is an understatement to say that the Residency Program in GIM at TKH went through some very difficult
times in the first few years. This is not surprising, if one
recognizes the obstacles in the way of success at thattime because of the state of medical education at the undergraduate and post-graduate level in Japan. In the firstplace, GIM departments either did not exist in medical
schools or were given no academic status and little respect even where they did.7, 8 Secondly, no residency
training was required of Japanese medical graduates at
the time, and they could start practice immediately upon

86

graduation even though they had no patient contact orhands-on clinical training in medical school. Thirdly, theonly form of post-graduate training available to an ambitious medical graduate who sought an academic future
was single specialty training, under the iron-fisted control exerted by departmental chairmen and within thefirmly entrenched feudal system of patronage that still
exists within academic medical departments in Japan(ikyoku koza).9 (Even with the advent of mandatory rotating residency training, many of the best and brightest
graduates from medical school still elect to remain in academic institutions and train as super-specialists, liketheir mentors,1 0 although a slim majority of graduates
now elects to train in community hospitals.)11
With this as background, it should come as no surprisethat there was little appreciation for the kind of ideals
and vision being offered at TKH ten years ago, at a time
when attitudes towards primary care and GIM were evenmore pernicious than they are now. It would not be toomuch of an exaggeration to say that it was tantamount tocareer suicide for ambitious graduates seeking an academic career to devote three years training in GIM in an
obscure hospital in remote Sapporo, instead of staying
on in their own medical schools. The only alternative
career route was to go into practice straight out of medical school and basically learn patient care “on the job”;
for these graduates, too, it would be a waste of time to
devote three years to pursue training that was not required of them.
For all the above reasons, recruitment was a real challenge in those early years. Dr Sakai freely admitted alsothat the caliber of the applicants was not high enough to
do justice to the ideals and vision of the founders. It is atribute to their will and determination, though, that they
were able to even get the program up and running, and tokeep their dream alive during those difficult early years.
That determination must be recognized and praised because it placed the TKH program in a uniquely advantageous position when the decision was taken nationally tomake residency training mandatory for all Japanese
medical graduates starting in April 2004. The unique advantage for TKH over many other Japanese institutions
lay in its hard-won experience in organizing and runninga program with a focus on clinical skills training and
GIM –even if one acknowledges its fitful success inachieving those goals to that point. So, when it cametime to implement the mandate, where most other programs were starting from scratch, TKH was already several years ahead of the curve.
4. The next phase: Making the American connection
In 2001, which was around the same time the decision
was taken nationally to implement compulsory residency
training for Japanese medical graduates starting from

Rao RH: Clinical Skills Training for Residents at TKH, Sapporo

2004, TKH made a crucial strategic move to sign a landmark collaborative agreement with UPMC/UPSOM. It
was a master-stroke, in hindsight, because the collaboration further enhanced the residency program’s ability to
exploit the opportunity and challenge presented by thenational mandate for universal residency training.
According to Dr Sakai, the move to seek this collaboration grew from a realization by the founders that theyneeded outside expertise and experience to turn their
dreams into reality. The selection of UPMC/UPSOM
was the brainchild of Dr Yoshida. He reached out to aclassmate of his from medical school, Dr Yoshio Arai,
who was a member of the faculty in the Department ofRadiology at UPMC/UPSOM. Together, they facilitatedthe dialogue between the two organizations which resulted in the collaborative agreement.
The official announcement of the collaboration in 2001
described it as a joint “educational voyage of discovery”
for both organizations, the purpose of which was “to establish and operate a US-style residency training program in internal medicine” in Sapporo.12 The document
went on to echo many of the same points in my own critique of Japanese medical education in the past as it articulates the background and motivation behind the collaboration. It stated, as an example, that “historically,
the Japanese philosophy of educating and training physicians has been based on students learning both from didactic experiences and from closely observing the words
and actions of a senior mentor and professor. This philosophy has extended into residency training, whichtends to follow an apprenticeship model through which
Japanese residents have relatively less direct patient careexperience than their counterparts in the United States.”
With this as the background, the objectives of the collaborative effort to set up a “US-style residency” at TKH
can be deduced through five explicit criticisms in the announcement of the prevailing system of post-graduate
training in Japan compared to the US.1 2 It can be reasonably concluded that the implicit purpose of describing the lacunae in residency training in Japan at the time
was to highlight the measures that would need to be introduced through the collaboration in order for TKH torightfully lay claim to the designation of a “US-style”
residency program. These are excerpted from the announcement, using the exact phraseology of the criticisms (highlighted in quotation marks), to read as the explicit goals of setting up a “US-style” residency training
program at TKH:(a) Students would “learn the clinical skills that directly will be passed on to their patients in theform of better care and treatment”(b) There would be “a greater expectation for direct
hands-on learning”(c) The program would encourage “progressive autonomy” and “increasing patient-care responsibility,

Keio J Med 2009; 58 (2):84－94

beginning in the first year of residency”.
(d) The program would incorporate “a formal curriculum that identifies specific skills and knowledge
areas that graduates must master”(e) It would also institute “a mandatory evaluation
process”
5. Establishing a “US-style” residency program at TKH
The contract between the two parties to establish a USstyle residency program at TKH was signed in 2001. To
cement the relationship, Asher Tulsky, M.D, Program
Director of the Internal Medicine Residency Program atthe UPMC affiliate Shadyside Hospital in Pittsburgh was
assigned to co-direct the TKH program along with theon-site Program Director at TKH at the time, Dr Hironori Murakami.
According to Dr Tulsky (personal communication),
there were several “expectations” in this collaborative
agreement. UPMC and the Department of Medicine at
UPSOM undertook to support the TKH program directly
and indirectly by providing program facilitators at Teine
Keijinkai Hospital, and offering advice regarding program goals, staffing and teaching materials, and the evaluation and development of residents, as well as guidanceand support to TKH residents who were US-bound. The
UPMC Shadyside Internal Medicine Residency Programagreed further to annually reserve two positions for qualified TKH graduates to obtain a further 3 years of training in internal medicine, with the hope was that somewould return to TKH with the skills to function as teaching faculty in GIM. The UPMC program also contracted
to help TKH recruit an American faculty member who
would stay in Sapporo as Physician-in-residence for aminimum of one year for on-site teaching advice andmentoring of residents. Finally, it undertook to ensurethat faculty members of the Department of Medicine
from the University of Pittsburgh would visit Sapporo ona regular basis to teach residents and help train the teachers.
On the other side of the equation, the TKH program
undertook to:a) develop a structured, three year curriculum of
training, evaluation and support for residents, following the US residency program paradigm ofprogressively increasing autonomyb) require that all applicants to the TKH program be
fluent in spoken Englishc) make English the language of instruction at allteaching conferences and teaching roundsd) encourage TKH residents to visit UPMC Shadyside to observe the system of medical educationand clinical training in the US, so they might better
appreciate what the program at TKH was trying toachieve87

6. Expanding the vision
In recent times, the TKH residency program has expanded beyond both the intent of its original founders aswell as its agreement with UPMC/UPSOM, to include
several specialties other than GIM, such as surgery, anesthesiology, pathology, pediatrics, radiology etc. The
unique nature and attraction of these specialized residencies in the Japanese context has led to a welcome increase in the strength of the applicant pool. Unfortunately, this has also led to an unwelcome dilution in thefocus on developing a cadre of physicians with interestand skills in GIM (one of the original objectives of thefounders). It remains to be seen whether this dilution
will lead to a decrease in the clinical commitment andfocus that constituted the foundation of the programfrom its very outset.
Evaluating the Residency Training Program at TKH
I was able to assess the content and quality of the training given to residents at TKH over the course of two visits to Sapporo separated by 8 months, each lasting for aweek. During both visits, I was provided unrestricted
access to the residents in a manner that was different
from the previous venues I have visited (Keio University
Hospital and the Muribushi Project) in two surprisingand unique ways. The first unique difference was thatmy access to the residents was truly unfettered, with nofaculty member from the program present at the bedsideteaching sessions. This was in contrast to my previous
experience at the other two locations, where a local faculty member was invariably present as observer/
moderator at all teaching sessions.
The other unique difference was that “bedside teaching” was truly direct and hands-on at the bedside, in both
the wards and in the outpatient setting, rather than in
conference room settings as at the Muribushi Project.
Thus, I had the unique opportunity to observe, evaluate
and critique the performance of the residents (a) in aclinical setting, (b) without any prior preparation, and (c)without any outside pressure on the residents.
My initial reaction to the unfettered access was surprise because it appeared to denote a degree of confidence on the part of the current Program Director, Dr
Akihiro Kishida, in the performance of the residents, thatthey would be able to hold their own without the watchful scrutiny of their own teachers. However, upon reflection, I realized that the confidence at TKH and thereluctance to do the same at the other venues may, in all
fairness, be a product of the undeniably greater English
fluency of the residents at TKH. Nonetheless, the willingness to let them “sink or swim” without supervision
was quite admirable, in my opinion.
In the same vein, the bedside teaching sessions in88which I engaged were not carefully choreographed, as
they were at the Muribushi Project, with prepared presentations. They were off-the-cuff, unrehearsed presentations of patients encountered by me at random on walkrounds with whichever team was available to accommodate me, or in the outpatient department on any patient
who happened to walk in while I was there. Thus, I wasable to evaluate the TKH residents’ clinical and criticalthinking skills in the most realistic, natural and spontaneous manner possible.
My evaluations of the residents and the residency program itself are based on these interactions, and on multiple free and frank discussions with Drs Tulsky andKishida. I will place my observations at TKH in thecontext of the terms of the collaborative agreement andthe intent and philosophy enunciated in the announcement, much as I have done previously with the Muribushi Program, which I evaluated using its own “Charter ofAims”.6, 1 3 In so doing, I will not dwell on the UPMC/UPSOM end of the collaboration. Suffice it to say that
UPMC has lived up to the contracted offer of support,with (a) Dr Tulsky’s active involvement in the TKH program through repeated visits over the years, (b) the successful recruitment of highly qualified American faculty
to fill terms of 1 to 3 years as Physicians-in-residence,(c) multiple visits of other ad hoc faculty, such as myself,and (d) recurrent opportunities provided to TKH residents to complete electives as observers at UPMC Shadyside Hospital, and the recruitment of several TKH residents to the UPMC Shadyside Residency Program inInternal Medicine.
The role of UPMC/UPSOM and any contributions theymight have made to the success of the TKH program are
not the focus of this paper. Nor was it the purpose of myvisit. The issue here is the progress that the TKH program has made towards achieving not just the items listed in the collaborative agreement, but also towards fulfilling the philosophy of “US-style” clinical residency
training, described in the announcement. To this end, it
is my intention to provide a quantifiable estimate of thedegree of success that the TKH program has achieved byusing two yardsticks for success that are immediately
available for this purpose:
A. The first yardstick is the degree to which the Program has implemented a Training Philosophy
based on Teaching Clinical skills as described in
the official announcement of the UPMC-TKH collaboration
B. The second measure is the degree to which the
TKH Program has fulfilled the Programmatic Details of a “US-style residency”, as required in thecollaborative agreement with UPMC/UPSOM

Rao RH: Clinical Skills Training for Residents at TKH, Sapporo

A. Is the Training Philosophy at TKH Focused on
Teaching Clinical Skills?
The announcement of the collaboration between
UPMC/UPSOM and TKH provides the necessary tools
for measuring what has been achieved by the program in
the context of implementing a philosophy of clinicaltraining at TKH. The individual components of that philosophy (which, as noted above, appear in the document
as criticisms of the prevailing system of Japanese residency training) also provide a framework into which I
can place my own experiences over two visits to TKH.
As enumerated earlier, the five components described inthat announcement that can be modified into objectives
were:1) To inculcate clinical skills that promote better patient care2) To promote direct hands-on learning for residents
3) To encourage progressive autonomy and increasing patient-care responsibility4) To develop a formal curriculum5) To implement a mandatory evaluation process
1. Does the TKH program inculcate clinical skills that
promote better patient care?
This is, of course, the centerpiece of the collaborative
effort, just as it is of the entire effort to reform and upgrade Japanese medical education as a whole and Japanese residency training specifically, ever since the Ministry of Health made a two year period of internship/
residency mandatory for all Japanese medical graduates.
As I have observed before at some length in previous
publications, the single greatest problem in Japanese
medical education (and, by extension, the Japanese
health care system itself) is its failure to develop eventhe most fundamental clinical skills in its physicians-tobe, like the ability to take a comprehensive history and to
perform a complete, systematic physical examination.3, 4The extent of this failure in clinical skills instruction in
Japan is glaringly evident even in a place with anavowed interest in clinical training like the Muribushi
Project.6 Moreover, the failure is widespread, not justrestricted to the two institutions I had visited previously
nor isolated to a minority of trainees, as I have described
elsewhere.6
Correcting this failing represents the single biggest
challenge facing would-be reformers, because a cultureof interactive learning and inspirational teaching is nonexistent in Japan, where didactic instruction and a longstanding feudal tradition of prolonged apprenticeshipused to be the norm. Moreover, a single-minded focus on
specialty skills training, coupled with a lack of GIM departments in most medical schools further exacerbates
the problem,3 since these are the traditional bastions of

Keio J Med 2009; 58 (2):84－94

clinical skills training in most other systems and countries.
Only by understanding this crucial fact can one appreciate what is being achieved at TKH. This is not to denigrate the achievements being made elsewhere, like the
Muribushi Project, which is ahead of the curve in recognizing a need for clinical training. It is to extol the progress that has been made at TKH in translating the recognition into action and action into success. The residents’performance and the dedication of their teachers are atestament to the success of the TKH program in inculcating clinical skills that promote better patient care.
Assessing the residents’ clinical skills:
My experience on the very first day of my first visit isan excellent example of the clinical skills that TKH residents possess. The case was one of severe hyponatremia
and the presentation was of exceptional quality, reminiscent of the best case presentations I heard in Okinawa.6
I was mindful, however, that those very presentations in
Okinawa, as excellent as they were on the surface, actually hid a very shallow understanding of clinical medicine and did not stand up to careful scrutiny. So, I
probed the presenter and the audience to see if they truly
understood the significance of the different elements in
the history and physical. To my amazement, all present
seemed to recognize the purpose of the various elements.
For instance, they knew the reason for asking questions
regarding thirst and fluid intake (SIADH vs primarypolydipsia) and postural symptomatology (volume status
and adrenal insufficiency), as they were aware of the importance of recording orthostatic blood pressures (euvolemic vs hypovolemic hyponatremia) and performing
a neurological examination, including a mini-mental
exam for subtle neuropsychiatric changes associatedwith hyponatremia. The discussion that followed waslively and purposeful, and even though there were somemembers of the audience who were afflicted by the Japanese student’s ever-present bug of passivity, for the mostpart they displayed a self-confidence that was quite remarkable and highly unusual, in my experience.
The foregoing was typical of the case discussions that
occurred at the Morning Report conference every day
that I was there. On each occasion, the case was presented with appropriate attention to clinical detail, the development of a line of reasoning leading to a focused differential diagnosis, and a coherent resolution of the majorclinical issues in the case.
Nor was this pattern isolated to the formal, preparedcase presentations. On multiple occasions, during ward
rounds, and in the outpatient department, when the discussion took an unexpected turn, a number of the residents displayed the necessary critical thinking skills topivot and follow a different line of thought. For instance, in the outpatient department, in a case of a patient89

with a long-standing, but suddenly expanding goiter, theresident was able with minimal help to make the connection between Hashimoto’s thyroiditis and thyroid lymphoma. In another case, the finding of a large ulcer on
the anterior shin of a patient with diarrhea opened thedoor to a discussion of the relationship between pyoderma gangrenosum and inflammatory bowel disease. Theseare examples of the more exhilarating aspects of my interactions with these residents.
In fairness, it must be noted that the presentations I
have recounted above were by the more senior (second
and third year) residents. My interactions with the interns were less encouraging. In particular, my second
visit, in April of 2008, when the new set of interns had
just arrived, revealed that the new entrants were as unskilled and unfamiliar with clinical practice as any others
I have encountered in Japan. In fact, at a mock “OSCE”-type session conducted while I was there, all four interns failed to fulfill even the most basic requirement ofeven a limited history and physical examination. By
contrast, several of the “freshly-minted” second year residents (just 2 weeks removed from their first year) displayed a considerably greater clinical maturity in fulfilling their roles as senior members of the ward team, compared to their own performance as first year residents
during my first visit just 8 months earlier.
This actually proves an important point: that the second year residents could only have achieved this degreeof clinical maturity from a progressive increase in clinical skills through the training in the first year, and thatthe same could be expected of the incoming first year
residents. And much of the credit for this must go to thequality of the clinical instruction they receive at TKH.
Assessing the teachers at TKH:
Obviously, none of this would be possible without
dedicated teachers, and the TKH program has been
blessed in this area to this point. Dr Kishida remains oneof that rare breed of visionaries in Japan with whom I
have had the privilege to interact, who fight against all
odds to implement a vision of clinical excellence as a focus of training for Japanese medical graduates. He is theface of the Program in much the same way as Dr Miyagi
is at Muribushi. I find his commitment to teaching andclinical training particularly noteworthy, because he is asurgeon! Notwithstanding his busy schedule, he attends
all Morning Report conferences, and it is his presence
that ensures a consistently impressive turnout for that
conference.
The strong GIM department that I encountered at TKH
during my first visit was one of the most pleasant of all
the surprises I have received during my five year involvement in Japanese medical education. It gave considerable hope that teachers and teaching would become
highly valued components of the program. However, the90

Rao RH: Clinical Skills Training for Residents at TKH, Sapporo

recent exodus of several of these faculty members has
left the GIM department bereft of a sufficient quorum ofteachers in the past year (which was painfully obvious
on my second visit). If this loss of faculty were to continue, the success that TKH has achieved so far will be
unsustainable.
Finally, TKH, with the help of UPMC/UPSOM, hasbeen able to fill the position of American Physician-inresidence over the years, without a break, with a seriesof highly motivated teachers. The constant presence of ahighly committed teacher with few service responsibilities is a major reason for TKH’s success in maintaining aclinical focus in training. This may be placed in jeopardy
if this individual is required to shoulder the entire burdenof teaching with the recent decimation of the GIM department.
On balance, then, my assessment is that the TKH program has established a clear clinical focus for its training
philosophy up to this point. Unfortunately, my enthusiasm is tempered by the recent loss of GIM faculty, whichcalls into question the continued maintenance of this otherwise admirable focus.

excellent in my estimation, and certainly well ahead ofthose I had encountered earlier in Japan. Moreover, thefact that the clinical skills of the more senior residents
stood out in such clear contrast to those of the first year
residents was clear proof of the success of a hands-on
approach to clinical training during the residency at
TKH.
In one important regard, however, the residents at TKH
were no different from all the other residents and students I have had the privilege of teaching in Japan: their
enthusiasm and fascination for anything and everything
having to do with clinical medicine. This is so universal
in my multiple experiences in Japan that I am convincedeven more than I ever was that the passivity of the students can be overcome, if medical education is mademore interesting, interactive and clinically relevant, andprovided teaching attitudes can be changed and clinically
adept teachers can be found.

2. Does the TKH program promote direct, hands-on
learning for its residents?

TKH has attempted to institute a system of progressively increasing patient-care responsibility, with second
year residents given greater authority than the interns.
This was evident in the team approach on the wards,
with interns doing much of the basic work, and the second year residents providing the supervision and teaching. On several occasions, I got the very distinct sensethat the senior members of the team took their responsibility for teaching the first year residents very seriously.
The extent to which that attribute was manifest depended on the individual resident, but in some instances it
was very well developed, suggesting a high degree of interest in imparting clinical instruction to the juniors.
Moreover, the progressive increase in clinical skills fromthe first year to the next that I witnessed, as noted above,
confirms that increasing responsibility from the first to
the second year at TKH is a verifiable fact. However,cause and effect are hard to determine from cross-sectional observations, such as mine. In the final analysis,though, it matters little whether the progressive increasein patient-care responsibility is a consequence or thecause of the increasing clinical skill. After all, the factthat both should occur synchronously is a highly desirable goal in any good residency training program.
These observations are a clear example of the successthat TKH is having in encouraging progressively increasing patient-care responsibilities for its residents. Unfortunately, this goes only so far as I have described. WhereTKH has failed is in taking the next step, which is to
give third year residents a clinical teaching role in theresidency program that allows them true autonomy under
supervision. Instead, TKH chooses to use the third year

The two venues that make for the most direct, handson learning experience for residents are the outpatient(ambulatory care) clinic and the inpatient wards. During
my twin visits to TKH over this past year, I had the opportunity to interact with residents at all levels of the
program one-on-one at the bedside in both the inpatientand outpatient settings, as well in groups in conference
discussions. In all these interactions, I was impressed by
the knowledge and understanding that many of thempossessed, particularly in the areas of critical thinking
and analysis. While there were a few residents who wereclearly the clinical equals of any of the best I have encountered in my experience in the US, the majority werecertainly functioning at a more-than-acceptable level,
particularly in the context of the level I have seen at theother venues I have visited in Japan.
Specifically, I was able to ascertain that the second andthird year residents were able to construct a valid differential diagnosis based on clinical findings, establish areasonably acceptable sequential priority of investigative
procedures and tests, and even present a plan of treatment based on the available information. All of thesewere done, in several instances, unrehearsed and without
any preparation, showing me that these were skills that
had been acquired through a hands-on approach. Obviously, this was not universal, because there were also
some residents who performed at a marginal level at bestin these areas. In the majority of instances, however, theclinical skills of the more senior residents were fair-to-

3. Does the TKH program encourage progressive autonomy and increasing patient-care responsibility
for its residents?

Keio J Med 2009; 58 (2):84－94

resident to fulfill service needs in the Emergency Room.
While there may be nothing inherently wrong with sousing these residents, it defeats the purpose of having athird year of “training” if the senior-most residents, withthe greatest experience, are simply shifted to a service
role. This means, in effect, that their training is aborted
at a stage that is no different from any other program, sothat the value of that additional year of training is lost to
the residents. Just as disappointing is the loss to the program itself of their clinical experience and teachingskills. This is, in my opinion, a critical failing that needs
to be corrected if the true spirit of residency training in atiered three-year system is to be achieved at TKH.
4. Has TKH developed a formal curriculum for its
residency training program?
The second major failing in the residency program isthe lack of a formal curriculum. This is, of course, nodifferent from most other residency programs in Japan,
which consist of a series of subspecialty rotations strung
together to make up the two year mandatory training period, as described earlier by me, and also noted by Teo.11
However, it is surprising that the TKH program has
failed to develop a written curriculum, despite its sevenyear-old commitment to do so in its agreement with
UPMC/UPSOM, and its avowed intention of being
viewed as “American-style”. The fact that a formal curriculum is not required for Japanese residency training
may be responsible for this inertia, but it does not excuse
it. This is a failing that must be corrected if the programis to take the next step to achieving its avowed objective.
The failure to develop a curriculum to date takes aneven more concerning turn with the recent expansion of
the program, as noted earlier, to applicants for several
other specialties. With the increased demand to satisfy
multiple curricular needs, the ability to develop and implement an effective curriculum in even one of them isfurther compromised. A related problem is that the entire program continues to be directed by a single individual, the Program Director, Dr Akihiro Kishida (I will return to this later).
5. Has TKH implemented a formal evaluation process
for residents and teachers?
This is the third area of major concern. Suffice it to
say that TKH has not developed, let alone implemented,
any form of evaluation, either by the program of its residents or of the program by its residents.
I have described in an earlier paper the vital role that
feedback (in both directions) plays in helping to improvea teaching program.2 It seems redundant to reiterate yetagain the benefits of such evaluation, but what seems so
obvious to the eyes of this outsider may not be to those91

used to a system that neither requires nor appreciates it.
Clearly, there are cultural impediments to honest feedback in Japanese society as a whole, which translate into
an unwillingness to say or write anything negative about
a teacher in Japan.2 While these barriers may explain the
reluctance of other programs to institute feedback evaluation, they must be overcome if a program seeks to justify its claim to being “American-style”.
Accurate feedback forms the very backbone of an effective training regimen in any field of learning, which is
why it is difficult to overstate the value of an effective
two-way evaluative process. From the standpoint of theresidents, the most obvious benefit is that they get toknow where they need to focus their efforts to improve.
Its benefit to the Program Director is equally valuable:honest and constructive two-way evaluations can identify areas of strength or weakness in the program, as well
as recognize those residents who might need remedialtraining or extra help to improve performance. One major related issue, in this regard, is that the TKH program
has no mechanism to identify residents who are in distress from a personal standpoint or are having trouble
coping with the stresses of a busy residency. At present,a distressed resident has to be recognized and reported
by a fellow resident to the administrative staff, and thento the Program Director. This is both completely unreliable and highly unlikely, particularly in the Japanesecontext. Moreover, even in the remote likelihood that a
distressed resident were to be recognized, there is no formal mechanism, as would exist in an American residency
program, for anonymous remedial intervention. At TKH,
such help, if it were needed, would be provided on an ad
hoc basis, there being no clearly established way for the
resident to receive the necessary professional help to resolve either professional or personal distress.
The program’s failure to evaluate is inextricably linked
to its failure to develop a formal curriculum. After all, if
there is no formally outlined curriculum with clearly
identified goals and objectives in developing competencies, there can be no way of assessing either the trainees’
achievement of those competencies, or the program’sability to develop or deliver the requisite competencies.
In other words, evaluation can only be relevant if there isa formal curriculum to establish the parameters and domains of the evaluative process.
In summary, therefore, the TKH program certainly has
achieved considerable success in implementing andmaintaining a training philosophy that is focused on theacquisition of clinical skills. However, it has failed tofollow through in several areas of clinical training thatare crucial to enhancing the quality of the training it offers.

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B. Has TKH Implemented the Programmatic Detailsof a “US-style Residency”?
The collaborative agreement with UPMC/UPSOM, as
described to me by Dr Tulsky, provides the framework to
answer this question in a comprehensive manner. The individual elements can being viewed as “successes” and“failures” in the context of implementing the programmatic details of a US-style residency that TKH contracted to fulfill in the agreement.
i. My observations verify that the TKH program has
been very successful in inculcating clinical skills in its
residents. In fact several of them possessed clinical skills
that were superior to those of residents at comparable
levels at the Muribushi Project, the other venue in Japan
where I have had the opportunity to observe and critiqueresidency training in Japan.6 Using a different yardstick,several of the second and third year residents displayed aclinical maturity and understanding that would allow
them to function successfully in a US residency program.
ii. Much of this success has come from the fact thatfaculty members from the US have been successfully recruited as Physicians-in-residence for terms ranging
from one to three years, with the specific intent that theywould be full-time teachers, helping to guide and coordinate the teaching program. Their continuous presence
over the years, in my opinion, has been largely responsible for developing the American-style clinical focus of
the program.
iii. Another reason for the success is the fact that, until
recently, the TKH program remained true to the original
intent of its founders in focusing exclusively on GIM.
As a result, the GIM department was able to develop a
distinct identity and stature with the hiring of several
Japanese-trained internists and even a US-trained couple
with both general medicine and subspecialty certification(in Pulmonary Medicine and Rheumatology). These individuals formed the backbone of the GIM teaching faculty and were responsible for maintaining much of theclinical focus in the program to this point.
iv. Several graduates of the TKH program have successfully applied for and been accepted in not only the
UPMC Shadyside Internal Medicine Residency Program
over the years, but also in other programs around thecountry. This success reflects my own assessment that
the TKH program inculcates the appropriate skills in its
graduates to make them competitive in US residency
program. In point of fact, the very first graduate of the
program excelled to such a degree in the UPMC Shadyside program that she was sponsored and selected for thehighly competitive fellowship in GIM at the Universityof Pittsburgh.
v. Several of the residents were comfortable conversing and engaging in impromptu case discussions in English (the language of communication at most conferenc-

Rao RH: Clinical Skills Training for Residents at TKH, Sapporo

es, and the language of instruction at all morning reportand afternoon case discussions that I attended). This was
also true of teaching rounds at the bedside. The comfort
that many residents displayed in the use of English inthese situations demonstrates the program’s success inpromoting the use of English in its trainees. The requirement for fluency in English in applicants is a unique aspect of the training being given to residents and represents a courageous attempt to prepare residents and makethem competitive to apply for training outside Japan.
Counterbalancing these successes are three major failures by TKH to implement critical elements that define aUS-style program that have been covered in the previous
section.
i. One is the failure to develop a formal curriculum.
ii. The second is the failure to provide or obtain feedback through evaluation.
iii. The third is the failure to ensure true autonomy at
the senior resident level.
iv. A fourth concern is very specific to the TKH program, and thus belongs in a separate category, in addition
to the foregoing: the program has clearly failed to consistently apply the requirement for English fluency as aqualification in its applicants. While this is not a criticism in the more general sense of the quality of residency training, it is can be classified as a failure in this specific circumstance, because of the contracted commitment to require fluency in English in applicants. The
English-speaking skills of the residents I encountered
were highly variable. While several were fluent English
speakers, there was a minority that was unable to participate in the interrogatory learning atmosphere because ofa lack of even rudimentary English-speaking skills.
The failure by TKH to consistently abide by its commitment to hire only English-fluent applicants is troubling in the context of the emphasis that is placed onpresentation skills requiring English. I greatly suspectthat this might lead to a sense of exclusion or of inadequacy, or even of “second-class status”, in those residents who are not English-fluent, contributing significantly to performance stress in these individuals. Without a true evaluative process in place, it is difficult to determine whether or not this stress is undermining or affecting their performance in any way, but there is an undeniable potential for serious problems. For this reason,
I believe that the program should either apply the policy
uniformly and consistently or else abandon it altogether.
Recommendations for Improvement
TKH has been very successful over the years in attracting strong applicants from several of the best medical
schools from all over the country to their residency program. All criticisms apart, the program has attained aKeio J Med 2009; 58 (2):84－94

degree of prestige among prospective candidates, particularly among those with intentions of applying to a US
residency program for further training, as a program thatis an excellent preparation for such a future. TKH has,indeed, established a good clinical training system for its
graduates, particularly with regard to developing goodclinical skills. My assessment is that several of theirtrainees display a degree of competence that would becommensurate with that of most US medical graduates –which is very commendable, indeed. As commendable as
this achievement is, there are several areas that cry out
for attention, if the program is to be strengthened and its
quality improved even further.
I would make the following recommendations for improving both the quality of clinical training, and thequality of the teachers in the residency training program
at TKH.
i. It is critical, with the rapid expansion and diversification of the program, to hire a full-time Associate Program Director responsible for GIM training, in order tore-emphasize the pre-eminent role of GIM training at
TKH as originally envisioned by the founders of the
TKH program. If the program is to return to its roots
and fulfill the vision of clinically focused training, thismove is a must. The role of this individual would be tocomplement Dr Kishida’s role as overall Program Director, as the one with day-to-day oversight over the GIM
residents, while Dr Kishida would retain day-to-day responsibility for Surgery training.
ii. It is very important to delineate and assign specificroles and functions to interns (PGY-1) and residents(PGY-2) on the wards, so that each member of the resident team understands their patient care responsibilities;
at the present time, the roles are blurred, with interns andresidents having to interpret, understand and work out
their responsibilities for themselves and between themselves, in an ad hoc fashion.
iii. It is equally essential that TKH establish a true
three-tiered system of progressively increasing autonomy
over three years within the residency program, in which
PGY-3 residents are assigned as teachers and mentors totheir juniors, instead of service providers, as they are now.
iv. The Program must develop a written curriculumthat specifically describes the training objectives for the
residents, the core content they are expected to master,and the manner in which they are to acquire specificskills at various stages of their training. The concerns described under (ii) and (iii) above would be addressed to agreat extent though this.
v. The position of Chief Resident must be made supernumerary, i.e. the Chief must not be one among themany PGY-3 residents, but a fourth year resident whosesole responsibility is to teach and to organize the day-today functioning of the program. This gives the position
authority and meaning.

93

vi. Another vital area for improvement is the lack of ameaningful two-way evaluation process (of the programand preceptors by trainees, and of the trainees by the
program). To succeed in its goals, TKH must develop amechanism that is truly anonymous and capable of being
used for honest and constructive feedback. This may be
the hardest of all, given the cultural constraints that I
have discussed at length in an earlier paper.2 For thisreason, I hesitate to recommend the use of any tools developed in other countries. The constraints being
uniquely Japanese, the evaluation tools need to be developed indigenously to address the deeply ingrained cultural barriers to evaluation among both students andteachers. TKH could claim the mantle of a pioneer inthis area if it were to develop such a tool and prove its
efficacy and applicability in the Japanese context.
vii. GIM faculty must be supported and given status by
the hospital, if the goal is to retain them as teachers in
the Program. In particular, there must be a concerted effort to change the prevailing view that GIM is a “wastebasket” in which only those cases belong where a specialist has no role.
viii.The loss of GIM faculty places the success that
TKH has achieved so far in jeopardy. To counter this,TKH must develop an incentive package that attracts
graduates of the program to stay on as members of thefaculty after they complete their residency. TKH has recruited excellent candidates to the residency, including
some with strong regional ties to Hokkaido. So far,however, TKH has not been able to build on that
achievement by offering them any incentive to remain in
Sapporo –one of the original goals of the program. Thisremains a major disappointment, because developing andretaining graduates of their own program as faculty, in
my opinion, should be a major source of highly qualified
members of the GIM faculty at TKH.
ix. In particular, the creation of a 4th year Chief Resident position can become an incubator of teaching talent
in the program, and a stepping-stone to a future career in
GIM at TKH.
x. Finally, the program should make a decision one
way or another to either abide by its commitment to hire
only English-fluent applicants or abandon English as themedium of instruction altogether.
Conclusions
In summary, there is much to cheer and to commend,
because the program at TKH seems far ahead of othersof which I have direct or indirect (through other members of the Pitt-Japan Program) knowledge. A longstanding and visionary commitment to clinical training(years before it became “fashionable” to do so in Japan),the collaborative agreement with UPMC/UPSOM, andthe steadfast support of hospital and corporate leadership

94

are all vital components of the success of the program inattempting to incorporate US-style residency training
practices at TKH. These elements, each vital in its own
way to the overall success, constitute a model that others
may wish to emulate.
Despite these accolades for what has been achieved,
there is much to be cautious about. The success that
TKH has achieved in implementing a training philosophy that is focused on clinical skills training may beplaced in perspective if one reviews the original intent of
the founders of the residency program at TKH, as described to me by Dr Sakai. The four objectives were:i. To establish a good clinical training system for
medical graduates.
My Assessment: It has (with caveats, as described)
ii. To increase the recruitment of good candidates
who, upon completion of residency, would stay in
Sapporo and form a nucleus to build on.
My Assessment: It has not given graduates of its program an incentive to stay on as teachers and mentors.
iii. To encourage the development of better teachers.
My Assessment: It has been successful in attracting
good teachers of GIM until recently, but has failed toretain them.
iv. To recruit an American Physician in Residence
who would help achieve the first three objectives.
My Assessment: It has maintained an unbroken recordof keeping an American faculty member on site overthe past several years.
Based on these four points, the TKH program can besaid to have fulfilled some but not all of its founders’goals. The incomplete success in fulfilling both the
dream of its founders as well as its own contractual obligations in its agreement with UPMC/UPSOM should not
detract from what it has succeeded in achieving. TKH
has achieved more and gone further than I ever expected.
That proves to me how much can be achieved in the Japanese context with the will, commitment and support of

Rao RH: Clinical Skills Training for Residents at TKH, Sapporo

leadership. Obviously, much remains to be done. It willtake even greater will, commitment and support of leadership for the dreams of its founders to be fulfilled. Nevertheless, TKH’s successes to date do point the way forothers who are attempting to make residency training
and, ultimately, medical care itself more clinically focused within the Japanese medical system.
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