REVIEWPERSPECTIVES IN MEDICAL EDUCATION
6. Reflections on the State of Clinical Training for Residents in Japan
R. Harsha Rao

Professor of Medicine, University of Pittsburgh School of Medicine(Received for publication on May 4, 2007)(Accepted for publication on November 15, 2007)

Abstract: The Muribushi Project in Okinawa, Japan, is breaking new ground for residency
training in Japan by explicitly emphasizing clinical skills training and primary care. The
core philosophy of the Project is defined by seven “concepts” that commit to (i) establishing cooperation between several hospitals to educate good clinicians; (ii) providing the bestlearning environment at multiple training sites; (iii) following global standards of practice;(iv) focusing on primary and emergency care of common diseases; (v) emphasizing faculty
development through international exchange; (vi) providing residents with opportunities toobtain training abroad; and (vii) improving the quality of medical care through residents.
Observations by the author during two week-long visits, one year apart, reveal that the
Muribushi Project is fulfilling conceptual goals (iv), (v) and (vi) by emphasizing primary careand encouraging international exchange for faculty and students. The opportunity exists tofulfill goals (i) and (ii), but it is not being exploited because programs at member hospitals
are not integrated, so that residents spend the duration of their residency at one location,and there is no formal system of rotations that would broaden their clinical experience. The
Project is failing to meet a sixth goal of following global standards of care (goal #iii) and it
is too early to say if it’s pioneering approach to residency training is having an impact on
healthcare in Japan (goal #vii). On balance, the Project’s success in implementing elementsof its core philosophy for residency training in the tradition-bound environment of Japan isparticularly laudable. (Keio J Med 56 (4) : 111－ 123, December 2007)
Key words: Muribushi Project for Residents, residency training in Japan, clinical training in Japan,
primary care training in Japan

Introduction
In four earlier papers, I have presented my views on
what ails medical education in Japan,1 how to reform it,2
why it so important to reform it3 and how much progresshas been made to reform medical education at Keio University School of Medicine in Tokyo.4 Those views are
based on my observations over 3 consecutive annual visits(2003-2005) to Keio University Hospital, during which
my primary focus was on medical education, and mymain mission was to round with and assess the skills of
medical students at Keio. I did have contact with residents on the wards during those visits, but my exposure
to the residency training program at Keio University

Hospital occurred only in the context of case presentations on ward rounds. My very limited assessment of the
Keio residency program, based on this circumscribed interaction, has been recorded in an earlier paper.1 Thoseassessments came with the very important caveat that I
did not have unfettered access to the residents outside of
the ward setting and so was unable engage them in a free
discussion of the strengths and drawbacks of their training. Most importantly, I did not have the opportunity, on
any of my multiple visits to Keio, to meet one-on-one
with the individuals responsible for overseeing residency
training at Keio. Thus, I could not ascertain for myself
the goals or programmatic themes of the residency training provided there. In essence, therefore, my visits toCorresponding Author: R. Harsha Rao, MD, FRCP. Room 580, Falk Medical Building, 3601, Fifth Avenue, Pittsburgh, PA 15213 U.S.A., e-mail:rao@dom.pitt.edu Tel: 412-586-9701 Fax: 412-383-9586
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Keio left me with no little or no real insight into the next
step in the ladder of medical education after graduationfrom medical school in Japan.
I had the unique opportunity to address this large lacuna in my still developing understanding of medical training in Japan when I was invited in February 2006, andagain in February 2007, to visit the Muribushi Project for
Okinawa Residency Programs in Okinawa, Japan. The
visits took place in the context of my ongoing efforts toobserve and critique medical education and training inJapan on behalf of the Pittsburgh-Japan Program at the
University of Pittsburgh, School of Medicine. The purpose was to evaluate the nature and quality of the training given to residents at one of the foremost residency
programs among non-academic teaching institutions inJapan.
This paper combines the reports describing my experiences and observations during my trips that I submitted
to the Muribushi Project. In that sense, this paper ismuch like earlier papers in this series.1-4 However, it
combines the core subject matter of all four, in being observational and descriptive in its content, forthrightly
critical in its analysis, and reflective in its conclusions.
As such, most of the literature that forms the backgroundand basis for the arguments and proposals I have put forward in earlier papers remains valid for this paper, too,and I will not reiterate it here. Readers who are interested
in the basis for my conclusions regarding the state of
medical education and healthcare in Japan are referred tothose earlier papers for a full list of references in supportof those conclusions.1-4
My trips to Okinawa were unique experiences for me,even in the context of the utterly fascinating introduction
I have received to Japan, its people and its medical education system. Not only did I get an opportunity to observe and evaluate the clinical skills of medical residents
in Japan, first-hand and with no strings attached, my visits also allowed me to compare and contrast the qualityof teaching at non-academic teaching hospitals with what
I had already observed in an academic setting.
Notwithstanding the thematic and geographic differences between my experiences in Tokyo and Okinawa,
they were very similar in many respects. Nowhere wasthis similarity more apparent than in the treatment I received. I was welcomed to Okinawa with a fanfare andexcitement that left me humbled by its exuberance andnot a little embarrassed, just like the hospitality bestowed
upon me at Keio. And just like Keio, the enthusiasm on
display on the part of the trainees was as boundless as it
was gratifying. It validated, yet again, my core belief inthe hunger of Japanese medical graduates for clinicalteaching. It is a sad commentary on the state of medical
education in Japan that students and residents who hunger for it must look to foreign visitors to give them what
is rightfully theirs to expect from their own teachers-with

Rao RH: Muribushi Project for Residency Training in Okinawaa few rare exceptions!
The Muribushi Project
A Brief Introduction
The Muribushi Project for Okinawa Residency Programs is underwritten by a consortium of “non-academic
teaching hospitals” in Okinawa Prefecture in Japan. For
those (like me) who are not familiar with the nomenclature, the term refers to hospitals that have active residency programs and maintain a teaching faculty on theirstaffs, but are not affiliated to a medical school, setting
them apart from “University hospitals”, which are part ofa medical school.
There are seven hospitals that provide residency training in the Project. They are:
1. Urasoe General Hospital (24 residents)
2. Okinawa Kyoudou Hospital (20 residents)
3. Nakagami Hospital (16 residents)
4. Tomishiro Hospital (12 residents)
5. Nanbu Tokushukai Hospital (8 residents)
6. Chubu Tokushukai Hospital (8 residents)
7. Onaha Hospital (4 residents)
The vision that went into the foundation of the Projectis captured in the form of seven core “concepts” that are
published on the Project’s website,5 and read much like a
Charter of Aims. Translated from the original Japaneseversion, they read as follows:
1) Establish cooperation between several hospitals in
Okinawa to educate good clinicians for the futureof Okinawa and Japan;
2) Set up an outstanding training program that provides the best learning environment at a multiplicity of hospitals;
3) Follow global standards of medical practice;4) Focus on training in primary care and emergency
management of common diseases;5) Emphasize faculty development through clinicalexchange programs with institutions in the US;
6) Provide residents with opportunities to obtain training in the US and Europe;7) Improve the quality of medical care in Japanthrough residents.
These seven “concepts” reflect the pioneering visionand revolutionary intent (for Japan, that is) of the Project’s founders. It is evident that the original motivation
for setting up the Muribushi Project was to provide comprehensive training for residents across several hospitals
in a relatively narrow geographic area that were previously in competition with each other. The opportunity
existed to create a truly integrated program that allowed
the individual hospitals to play to each other’s strengths,
by combining resources not available at every member
hospital. If that were achieved, the Project could, in fact,provide its residents with a broad range of opportunities

Keio J Med 2007; 56 (4): 111－ 123

to gain truly comprehensive training. In practice, however, the residencies at the individual member hospitals do
not function as a united program in either the spirit or theletter of the term. They do share thematic goals, and the
Project is blessed with a unifying spirit and teaching philosophy, in the form of the Director (as will be described
below), but in all other respects they function as individual and separate programs. The fact that they belong to a“consortium” is somewhat diluted by the fact that its
only purpose seems to be to enhance trainee recruitment.
In other words, several hospitals in a relatively narrowgeographic area that were previously in competition witheach other, have come together simply to expand thepool of residents available to staff all the member programs.
In practice, therefore, the seven “concepts” underlying
the founding of the Muribushi Project have evolved into
the single goal of becoming a “magnet” for the best andbrightest graduates seeking clinical training after graduating from medical school in Japan. There can be no
doubt that the Project has been a resounding success inthis regard, based on its success in recruiting candidates
from many of the best and most competitive medical
schools in the country. At last count, there were over forty medical schools represented among the residents in
the Project.
Administrative Structure
Translating any vision into tangible success requires
the drive to implement the vision and the force of will toconvert intention into action. A good example of thisphenomenon is the gradual evolution of change that I
have witnessed over the course of three visits to Keio
University.4 There, the visionary leadership of Dean Kitajima and the motivation and dedication of Professor
Amano are the twin forces that are enabling the transformation in medical education at that institution.
The good news for all those interested in the durabilityof reform of Japanese medical education is that the same
evolution is already under way in the Muribushi Project,
except that it seems to have occurred spontaneously.
Here lie the seeds of a renaissance for Japanese medical
education and training that could blossom into something
well worth cultivating and cherishing.
The Muribushi Project is overseen by a Director who
has supervisory authority over both the training program
as a whole and the residents at the member hospitals in
the consortium. The Director’s office maintains oversightover the Project through an administrative staff whose
job it is to monitor program performance, ensure compliance with training standards, and oversee resident training at the member hospitals. At each member hospital,
there is, in addition, a Clinical Program Director and an
administrator in charge of running the residency training
program at that site.

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The Director of the Muribushi Project is Dr Seishirou
Miyagi, and he is the reason for the success of the Project. He is to the Project what the combined talents andpersonas of Dean Kitajima and Professor Amano are to
the reform of medical education at Keio, serving all themultiple roles that both of them share of inspirational
leader, motivational guide, and forceful executor of thevision for change. He is a man who is unique in my limited experience of Japanese medical education, truly unlike anyone else I know in Japan-and this is meant as nodisrespect towards the few incredibly dedicated teachers
I have met at Keio. I say that because Dr Miyagi has
dedicated his whole life to teaching, forsaking the moreassured path to glory and financial security that researchoffers to most Japanese physicians. He has followed his
chosen path with a single-minded dedication that would
be incredible to behold if it were shown by a researcher
seeking the glory of recognition. That it should be so in ateacher in Japan, where teaching not only goes unrecognized, but is treated with disdain by any self-respecting
academic, is nothing short of miraculous.
After a thirty year career as an academic who charted
his own course, Dr Miyagi took over the running of the
Muribushi Project in Okinawa, and promptly set about
re-fashioning it into a platform for his iconoclastic views(for Japan!) regarding teaching and patient care. Under
his dynamic leadership, the Project has been resuscitatedfrom its former moribund state and is not only thriving
now, but has undergone a major expansion in the numberof residents it accepts. His focus on clinical medicine
and patient care is beginning to reap dividends, and I
was able to see for myself the tangible progress that isbeing made in Okinawa towards improving residency
training.
Dr Miyagi attended every one of my teaching sessions,
not just to fulfill a pro forma role as my host, but as anactive and involved member of my audience. He functioned as a kind of “super-interpreter”, translating backand forth between Japanese and English, occasionallyadding his own editorial insights to the clinical subject
under discussion. I sensed that his clarifications andfootnotes of my comments in English clearly amplified
their weight and import for the audience. That was a reflection of his stature among the faculty and resident
bodies alike. On a personal level, too, I found his footnotes to be particularly helpful, because they provided
me with invaluable insights into local clinical practicethat would otherwise have been unavailable to me.
Here I must also make special mention of his ebullient,energetic and enthusiastic presence at each of my teaching sessions. I discovered in him a shared passion forteaching and clinical practice, and a shared philosophy
that these were interconnected and inseparable components of our respective academic lives. That evolved
quickly into a bond of friendship and mutual respect that

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Rao RH: Muribushi Project for Residency Training in Okinawa

allowed me to interact with him in front of the residents
and faculty in a relaxed and jocular manner that wascompletely alien to the normal tradition of deferential respect bordering on reverence that characterizes all public
interactions between teachers, and between teachers andresidents. This set a lighthearted and jovial tone for every teaching session, transforming the learning experience for the residents into an entertaining, non-threatening and enjoyable exercise. This last observation was notmine, but based on repeated endorsement, individuallyand collectively, by successive batches of residents on
both my trips.
My Target Audience
That brings me to the best part of my trip: the residents!
The enthusiasm of the residents I had the privilege ofteaching in Okinawa was boundless. The fact that it far
exceeded their clinical skills was a minor drawback, oflittle note in the face of their relentless thirst for acquiring those skills. For me, as their teacher, it was the mostgratifying aspect of introducing them to the wonders ofclinical discovery, regardless of their skills.
A close second to that was seeing them get hooked onit!
I also met each successive batch of residents outside
the ward setting the same evening over dinner. The relaxed, social atmosphere allowed them the freedom tovoice their opinions regarding their personal experienceswith teaching and learning in Japan. They were vocal in
expressing their appreciation of how much “fun” it had
been to learn without feeling afraid of asking a question
or of laughing out loud.
I must add a couple of editorial asides here, because
the residents’ comments have contextual relevance to myprevious experiences in Japan. My first editorial observation is that the individual statements of almost one
hundred and fifty residents I met over two trips to Okinawa are almost verbatim copies of those made to me by
medical students at Keio University Hospital. Coming as
they did from a group of residents who graduated frommedical schools extending to virtually every corner ofJapan, they have particular significance for me.
On my very first trip to Japan in 2003, my original observations regarding the abysmal state of medical education in Japan were based on a small group of Englishspeaking students at one institution, namely, Keio University School of Medicine.1 Subsequent trips reinforced
my original criticisms regarding the clinical training given to students (and, by extension, residents) at Keio.2, 3
In this regard, I must note here that I have been politely
but firmly told on multiple occasions during my many
trips to Japan that the experiences and examples quoted
in my papers to support my criticisms do not reflect theexcellent teaching and clinical training that Japanese
medical students (and residents) receive. Some of myinitial critics at Keio insisted with equal conviction thatthe examples were not typical of Keio and, in any event,the “isolated” examples quoted by me were not a reflection of the quality of the teaching or the teachers, but thestudents’ ability to learn!
My own experiences with Keio students, together withthe whole-hearted endorsement of my critiques by such
Keio luminaries as two successive Deans (Professors
Kitajima and Ikeda), two Vice-Deans (Professors Aiso
and Suematsu) , and the Head of Medical Education(Professor Amano) are proof enough that the dysfunction
was neither the students’ fault, nor isolated.
More telling was the criticism of many who were noton the faculty at Keio. They were emphatic in their conviction that the problems were isolated to Keio University, notwithstanding its stature as one of the premier institutions in Japan. Even though I took great care to warn
against generalizing my observations to medical education elsewhere in Japan, at the back of my mind there
still lurked a very strong suspicion that what I observed
at Keio was not unique to that august institution. The
reason for it was the knowledge that the greatest drawbacks and weaknesses in medical education I observed at
Keio were outgrowths of traditional behaviors and practices that are ubiquitous in Japanese society.1, 2 Thus, it
seemed reasonable to suspect that those same problems
were almost certain to exist in all medical schools in Japan. With no proof to verify my suspicion, however, it
would have been egregious for me to make such an extrapolation with certainty.
No longer! I can safely conclude after my visits to Okinawa that my observations with regard to the state of
medical education at Keio University are applicable tothe state of medical education in Japan as a whole. The
unanimous opinion of a hundred and fifty residents fromall over Japan resoundingly confirms that the situation I
described at Keio was no different from that in mostmedical schools in Japan. Taken with the endorsement I
received from Dr Miyagi, I can now state that the extrapolation I was careful not to make is warranted.
My second editorial comment with regard to the Japanese residents’ appreciation of my teaching is that I experience a bittersweet reaction every time I hear the laudatory comments of these exceptional young people. It
comes from the very poignant realization that the residents’ appreciation of my teaching (like that of the students I have taught at Keio) is not so much a validationof my teaching skill as it is a reflection of their own hunger for teaching of any kind. Even more than that, it is atruly damning indictment of the intellectual starvation
inflicted on them historically by their teachers in Japan,
starting from their school days. That realization is all I
need to dampen the euphoria that would otherwise over-Keio J Med 2007; 56 (4): 111－ 123

whelm me each time I visit Japan, Not only does it bringme back to earth with a thud, it also reinforces my determination to do whatever I can to support those who aretoiling against all odds to change that untenable situation.
Revisiting the Experience
My experiences in Okinawa only continue my love affair with Japan in general and Japanese medical education in particular. During my two visits, I visited six ofthe seven hospitals in the consortium that underwrites
the Muribushi Project for Okinawa Residency Programs.
The schedule called, in each instance, for a two hour session that was devoted to a single case presented in a formal, classroom setting. In each instance, the audience
consisted of a number of residents (ranging from as few
as 8 to as many as 24) and attending faculty (from a lowof 3 at one site to a high of 12 at another). I was given
the seat of honor at the front, facing the audience, withan interpreter/translator next to me (a resident in mostcases). Dr Miyagi, as mentioned earlier, was always
present to provide his own “spot translation” and clinicalinsights.
At each of the hospitals I visited, the Clinical Program
Director for that location was invariably present for thecase presentation and discussion. Moreover, each one
took great pains to ensure that the resident presentations
were prepared in advance, that a printed copy of the
H&P was available as a handout, and that the residents
were in full attendance for the entire duration of theteaching session. Of particular note, every teaching session, nominally scheduled for 2 hours, lasted longer thanits allotted time-in one instance for almost five hours!
That particular instance stands out in my memory, because not a single resident or faculty member left theroom as the session wore on. Despite my repeated offers
to end it, as the case discussion unfolded and its complexity became apparent to me, everyone, including Dr
Miyagi (whose lead I followed in all such instances), insisted that they would keep going if I was willing to keep
going! Later that same day I asked him to honestly tellme if the reason everyone stayed was out of politeness,but he was vehement in his denial of it. I know him wellenough that I believe he would have told me if it wasotherwise, notwithstanding the tradition in Japan of never insulting a guest with blunt honesty, no matter how
well deserved it might be. All I can say is that I havenever in my life been in a position where I got tired ofteaching before my audience got tired of listening to me!
That single example is all I will offer to support myclaim that the enthusiasm for learning was truly boundless.
A summary of the teaching activities during one of thetrips is presented here, to provide a glimpse of the kinds

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of cases that were presented and the free-wheeling discussion that followed. It is based on brief notes scribbled by
me at the end of each day and is as imperfect as mymemory. For any factual errors, I am to blame, as thememory does play tricks, and hindsight is never twentytwenty when recalling details! The intent is not to dissemble, so I readily apologize in advance for any disagreements with other observers regarding the accuracyof the clinical talking points. In the final analysis, every
session was videotaped as it occurred. Thus, anyone interested in proving me wrong is welcome to do so, butthat would miss the point. The summary is not meant torepresent either a comprehensive or an exact record ofwhat transpired. Rather, it is a recounting of the day’s
journey based on my perception of what constituted the
major signposts on the trail we explored that day. Perceptions being what they are, they will vary from observer to observer!
I must clarify too that it is impossible to recreate, orpresent a coherent reason for, the manner in which thediscussions developed, and why, for instance, one caseof dyspnea led to a discussion of the pathophysiology ofheart failure and the other did not, even though it was associated with CHF! I have learned not to explore too
deeply the dynamic that leads to such forks in the trail
when I teach. It is intrinsic to my enjoyment of clinicalteaching that I not know where the discussion will lead.
It is because I place such a premium on that spontaneitythat I insist that I not be told the diagnosis, and that theclinical discussion be completed without the benefit of
the results of any but the basic lab tests. It is a paradigm
for teaching at the bedside that allows me, most crucially, to be fallible-a trait that teachers all too often want tohide, to the detriment of their students. After all, clinicalmedicine is the ultimate exercise in being proven wrong!
By failing to communicate that, clinical teachers makethe process too intimidating for the learner. I believe tothe contrary that acknowledging the uncertainty of clinical medicine actually enhances the excitement that it
generates. And it allows me to learn as I teach.
Nowhere are those components of my teaching paradigm better illustrated than in the case discussions that
occurred during my visits to the Muribushi Project, as
the sample schedule that follows will attest.
A Week of Discovery
Day 1
Location: Nakagami Hospital.
Approximate number of residents: Total of 10, combined from two smaller programs
Clinical Scenario: Progressive exertional dyspnea in apatient with hypertensive heart disease.
Clinical Diagnosis: Decompensation of CHF fromprofound macrocytic anemia.

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Clinical talking points:(i) Evaluation of dyspnea by history(ii) Relevance of physical signs in the heart(iii) Cardiac physiology in relation to physicalsigns.
Duration of session: Approximately 2.5 hours
Day 2
Location: Nanbu Tokushukai Hospital.
Approximate number of residents: Total of 12, combined from two smaller programs
Clinical Scenario: Acute dyspnea and chest pain in apatient with hypertension.
Clinical Diagnosis: Acute myocardial infarction
Clinical talking points:(i) Differential diagnosis of chest pain(ii) Pathophysiology of heart failure(iii) Management of acute pulmonary edema.
Duration of session: Approximately 2.5 hours
Day 3
Location: Okinawa Kyoudou Hospital.
Approximate number of residents: 16
Clinical Scenario/Diagnoses: Acute chest pain syndrome in a patient with a past history of MI, Type 2
DM and hypertension. During the hospital stay, he developed a short-lived neurological deficit, followed bysevere polyuria (treated as DI) and hyponatremia;
eventually developed serratia septicemia.
Clinical talking points:(i) Evaluation of pain as a general symptom(ii) Evaluation of the EKG in a patient with LVH
and MI(iii) Coronary artery risk reduction in the patient athigh risk for MI(iv) Preventing the Complications of Diabetes Mellitus; the UKPDS Results(v) Evaluation of polyuria and hyponatremia(vi) Pathophysiology of Diabetes Insipidus(vii) Differential diagnosis of SIADH(viii) Diagnosis and management of nosocomial septicemia
Duration of session: Approximately 4.5 hours
Day 4
Location: Tomishiro Hospital.
Approximate number of residents: 20
Clinical Scenario: Subacute onset of dyspnea and dry
cough in a diabetic patient with hyperlipidemia and apast history of 3-vessel coronary artery disease and astroke.
Clinical Diagnosis: Congestive Heart Failure with
Ischemic Heart Disease and Diabetes Mellitus
Clinical talking points:(i) Clinical evaluation of dyspnea and coughRao RH: Muribushi Project for Residency Training in Okinawa(ii) Signs and symptoms of CHF(iii) Differential diagnosis of CHF
Duration of session: Approximately 3.0 hours
Day 5
Location: Urasoe General Hospital.
Approximate number of residents: 24
Clinical Scenario: Sudden onset of right upper quadrant pain with vomiting, high fever, chills and rigors,
associated with jaundice and exquisitely tender hepatomegaly.
Clinical Diagnosis: Ascending Cholangitis
Clinical talking points:(i) Evaluation of abdominal pain as a symptom(ii) Differential diagnosis of jaundice(iii) Metabolic physiology of bilirubin (synthesis,
and excretion)(iv) Investigative approach to the patient with jaundice(v) Evaluation and management of acute ascending cholangitis
Duration of session: Approximately 3.0 hours
A Few Subjective Insights
The Residents’ Case Presentation and Physical Diagnosis Skills:
Positive Aspects: The first pleasant surprise that I received during my visit was that the residents’ case presentations were generally acceptable, and a couple ofthem were even very good. That assessment is based on
an absolute standard, not one based on a comparison
with what I initially encountered on the wards at Keio
University Hospital.1
The history and the physical examination in each casewere reasonably comprehensive, when taken in the context of the level of training of the residents. I have commented elsewhere that medical graduates in Japan enter
residency training with virtually no clinical skills, having
experienced nothing that is even remotely comparable tothe clinical exposure of the average third year student in
the US.1 Thus, a Japanese medical graduate’s first real
foray into hands-on clinical training occurs in the firstyear of residency. That means the average Japanese resident is really akin to the third year medical student in the
US in terms of clinical experience. Viewed in that light,
and in comparison with most residents at Keio on myinitial trip, there is no question in my mind that what isbeing achieved in Okinawa is nothing short of amazing.
Without exception, the case presentations from Japanese
medical graduates were the first ones that were up to mystandards in six visits to Japan, except for a handful of
students at Keio who had prior experience outside Japan.
For this achievement, the Muribushi project must takegreat credit. It is truly remarkable to see this happening

Keio J Med 2007; 56 (4): 111－ 123

in Japan.
Another pleasant surprise on my first visit was that theresidents seemed to be familiar with at least the basic
components of the physical examination. It was particularly gratifying for me to observe this, given their lack of
exposure in medical school to clinical or bedside problem solving. Physical diagnosis is not a valued skill inJapanese health care, so it comes as no surprise that theteaching of physical diagnosis is a lost art in Japan. Norshould it be unexpected, therefore, that the very conceptof bedside learning is alien to Japanese students. Instruction in basic clinical skills is non-existent at Keio University Hospital, as I have affirmed elsewhere.1, 2 However, Keio is not alone in that regard; the same dismaying state of affairs has been confirmed to exist in medical
schools across the country by other Japanese students,
residents and attendings to whom I have spoken.
Knowing this, it was with some trepidation that I
asked, at the first case presentation on my first visit, if I
could examine the patient myself so that I might elicit
and demonstrate physical signs. Much as I anticipated,
the request generated some unease among the residents
and in the presenting resident in particular. However, theenthusiastic endorsement of Dr Miyagi ― who else!―
turned the mood from unease to cautious acceptance.
At all subsequent sessions on that visit, and the second,with each of the remaining hospitals (and residents) forewarned, bedside learning and physical diagnosis became
the norm on teaching rounds. In fact, after that first spurtof unease, those forays came to be a much anticipatedand much appreciated adjunct to the learning process.
Only on two of the twelve sessions, spread over both
visits, did I fail to examine the patient myself: one, because the patient was discharged before the case waspresented to me, and the other, because I myself declined
to subject a patient who was obviously critically ill to therigors of bedside physical diagnosis rounds with a groupof twenty four eager trainees (the patient on Day 3 in theschedule above).
My own physical examination in each case confirmedthat the residents’ recorded physical exams were reasonably complete, if not always accurate. Most of the residents were not sure how exactly to elicit some of the abnormal physical signs that actually existed in the patient.
Despite this drawback, I was quite astonished by the familiarity of the residents with all the elements that comprise a comprehensive physical exam. Most impressiveof all was the fact that, in the last case on Day 5, the resident had actually performed a rectal exam. In contrast,
on my first trip to Keio University Hospital, I was
stunned to note that the students and residents were unable to perform even the most basic elements of a physical examination, and even on the GI unit, no resident or
student had ever considered performing a rectal exam.1
Negative Aspects: The positive achievements noted

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above with regard to the clinical skills of the residents
must not mask another reality. The residents know how
to take a history, and perform a physical, it is true. But
they seem to have little idea regarding the purpose of
performing an H&P.
From the very first case presentation itself it became
clear to me, upon closer questioning, that the presenter
had no sense of how to analyze the salient features of thecase, and to put those together in a manner that might
help elucidate the potential causes of the presenting illness. In other words, the concept of “clinical discovery”
was completely lost on the residents.
Thus, it soon became obvious that the residents’ history
was really a “by rote” recitation of positive and negative
answers given by a patient in response to pro forma
questions that were most likely taken verbatim from atextbook on clinical methods. That is why, after that firstcase, I forced myself to look past the apparent “completeness” of the recorded history and focus instead on
eliciting and placing into clinical context the residents’
textbook knowledge as it applied to the discussion at
hand.
When I began to delve deeper into this aspect (on mysecond visit), it became apparent to me that the residents
were really not convinced of the need to elicit a detailed
history. After all, the diagnosis was clearly identified either by the attending who admitted the patient or was
obvious after the first battery of tests had been performed; thus, the value of the history was never apparent. So, I began to ask each successive group if any
among them had had ever witnessed one of their attendings taking a complete history or performing a comprehensive physical, either in Okinawa or during their timein medical school. They were unanimous in their denialof it, with the one-time exception of the experience during the physical diagnosis course in medical school! No
wonder, then, they were utterly convinced that there wasno utility in taking a history or performing a complete
physical examination. Some were even frank enough toadmit, in a social setting, that they only performed a full
H&P because Dr Miyagi insisted on it. Much of my second visit, therefore, was devoted to explaining the concept of clinical discovery through interviewing and examining the patient.
Dr Miyagi, who attended and participated in eachteaching session, was himself astonished by the fact thatthe residents were unable to appreciate the significanceof the H&P. However, he explained the phenomenon
perfectly when he said that the Japanese student is nevertaught to either ask or answer the question “Why?”
This simple analysis came as a revelation to me, particularly when he went on to explain that everything inJapan is learned as a matter of rote, and the reason forlearning it is never explicitly stated. Thus, he said, themedical student or the resident is never compelled to ask

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himself or herself, “Why do I need to take a history?”, or“Why is it important to examine the patient?” That
seemed to be a revelation to Dr Miyagi, too, because he
immediately chastised himself for never having thoughtof that himself! He drew the inevitable conclusion thatthe residents who were “learning” to do a history andphysical in the Muribushi Project would promptly stop
doing it the moment they left the program, and thus all
the clinical training they had received would promptly
come to naught. The outcome was that he set himself thetask of correcting that deficiency from that point on.
It is truly commendable that the Muribushi Project ismaking such a determined effort to focus on developing
clinical skills in its residents. It gives me great hope thatthe lost art of teaching bedside diagnosis can be resurrected in Japan. All it takes is a similar commitment inother residency programs to teaching clinical skills, andthe grooming of teachers in the art of clinical instruction.
Herein lie the seeds of the renaissance in Japanese
health care. And here again, I see the hand of Dr Miyagi,
who the residents uniformly revere as the only teacher
who teaches them clinical skills. But he is one man, andhe admitted to me that he can, at the most, come to eachof the seven hospitals to teach no more than once amonth. More teachers are needed to follow the lead of
Dr Miyagi, who seems to have the sole prerogative of
being a real teacher in the Project. Even more broadly
speaking, his is an example that more teachers in Japanneed to follow if the seeds of the renaissance are to growand bear fruit.
The Residents’ Knowledge Base:
Positive aspects: The knowledge base of most of the residents was about what I would expect from the average
fourth year medical student in Pittsburgh. That is not a
criticism, given the fact that these residents, for the mostpart, have had no clinical exposure in medical school. In
a pleasant revelation, residents at a couple of the hospitals (Okinawa Kyoudou and Urasoe General Hospitals)
displayed an above average to excellent level of knowledge. In particular, the atmosphere at these two hospitals
tended to be more relaxed and the residents seemed to be
more confident of expressing themselves. I am not surewhat set those two hospitals apart in that regard, but I
wonder if it has to do with the attitudes of the faculty to
the residents. It is a point for Dr Miyagi to ponder, andinvestigate more deeply. If he can find the reason that
underlies the greater confidence of the residents at those
two hospitals, he might be able to transplant it to the other programs.
Negative aspects: Unfortunately, that knowledge seemed
to exist in a vacuum, with no real understanding thatbook knowledge is subservient to a clinical purpose.
That, to a large extent, stemmed from the lack of clinicaltraining, so I am hopeful that it is correctable with a

Rao RH: Muribushi Project for Residency Training in Okinawa

greater emphasis on developing clinical skills.
More troubling (and intractable), however, was a complete lack of understanding of the fundamentals of Evidence Based Medicine (EBM). I was shocked to discover, for example, that even the attending faculty had notheard of the UKPDS study in relation to glycemic control in type 2 diabetes (or the Kumamoto trial for thatmatter!) Even more dismaying was their complete unfamiliarity with the evidence regarding the use of beta
blockers post MI for prevention of sudden death.
Then there was the not-so-small matter of appropriate
antibiotic selection in a patient with ascending cholangitis. The knee jerk reaction was the same as the one that I
encountered in Keio, which is to immediately reach forthe most powerful antibiotic available and treat blindly(using carbipenem). Even after antibiotic sensitivities
became available, showing that the organisms (E coli)
isolated from the blood were sensitive to everything, noeffort was made to tailor the therapy!
The above could be dismissed as being nothing morethan “following usual practice” in Japan (the answer that
I was given when I asked why). That fact actually exemplifies my point that there is a widespread lack of clinicalreasoning or clinical judgment in medical decision making in Japan.3 With clinical judgment and reasoning suspended, it comes as no surprise that the use of EBM is
far removed from practice!
The Residents’ Learning Skills:
Positive Aspects: These are not difficult to identify: their
enthusiasm and eagerness for learning, their obvious intelligence, their desperate desire to learn clinical medicine. In that sense, the residents in the Muribushi Project
were no different from the students I have interactedwith at Keio University. I was delighted to discover yet
again that Japanese medical trainee, regardless of level,is avidly interested in learning physical diagnosis. Therein lies a message of tremendous hope for Japanese medical education and Japanese health care, and one thatmust be taken to heart by all teachers in Japan. If theytake the trouble to teach, the students will learn with an
enthusiasm that will stun them. I know that it has
stunned me, time and again, each time I visit Japan!
Negative Aspects: The single biggest weakness in theseotherwise stellar young individuals is their passivity. I
have commented on this at length in an earlier paper,1
but it is necessary for me to repeat my comments here,
even though it may seem redundant. Since those weremade with regard to medical students, they might be dismissed as being irrelevant once they achieve a greater
degree of intellectual and clinical maturity as residents.
That is not so. A verbatim quote taken from the first paper in this series,1 regarding medical students at Keio
University, will convey how I feel about the causes andeffects of this monumental waste of intellectual capitalKeio J Med 2007; 56 (4): 111－ 123

in Japan.
“It constantly drove me crazy to see these incredibly
brilliant and knowledgeable young minds go into limbo
because they were taught not to ask ANY questions. I
came to realize that it was the Japanese way when I wastold by them, in fact, that to ask a question was a sign ofdisrespect for their teacher! So much so that a couple ofstudents even implied that they were afraid to ask because they would be ridiculed for being too dumb to figure it out for themselves!”“What a travesty of the whole concept of teacher andstudent interaction! Even for me, as someone originallyfrom another Asian culture with a similar tradition ofreverential respect for the teacher, this was hard to swallow!
“This passivity of Japanese students is a failing that
may be much harder to correct than their lack of clinicalskills, because it appears to be culturally ingrained. It is
inextricably linked to an extremely formal and didactic
educational system, which is, from the very beginning(in grade school), one-way and passive, rather than twoway and interactive, and discourages non-conformity.
Changing that, in a society that prides itself (and justifiably so) on its incredible record of achievement using its
own traditional, home-grown approach, is a formidable
undertaking. But if ever there was a society where suchfundamental change might be possible, it is Japan, because the very desire to conform can be a powerful sustaining force for change, once reform is given institutional approval. That is my hope.”
The quote above regarding Keio students is exactly applicable to the residents I met in Okinawa. There were,
however, two additional nuances that are critical: theresidents I met from the Muribushi Project displayed (a)a greater readiness to emerge from their cocoons underinducement, and (b) a greater willingness to engage in a
two-way dialogue once brought out from those cocoons.
These differences might, of course, be attributable totheir greater maturity, compared to medical students, but
I do not think so, since my limited contact with Keio residents, who would be of an equal maturity, did not reveal
either of these two distinctions. The distinctions between
the member hospitals themselves with regard to the levelof confidence displayed by the residents (see above) further reinforces my belief that the reason has to do with
their teachers!
The Teachers
Positive Aspects: One name stands out: Seishirou Miyagi. He has received the honor of being named the “Best
Teacher in Japan”, and I can see why. His commitment
to clinical instruction is said to be legendary, and someof that has clearly rubbed off on the residents. The very
fact that they know how to do a comprehensive H&P isevidence of that. His genial manner is also just the right119

touch for encouraging a two-way dialogue, if he shouldmake that a priority. While it is clear that this has not occurred thus far, the resident body seems to be ready for
it! All that is required is for Dr Miyagi to adopt the “interactive” approach, and I am convinced that this will
happen. He has the ability to do so, and if he does, others
will quickly follow his lead, such is his stature.
Negative Aspects: There is no doubt in my mind, after
four trips to Japan, that the passivity of Japanese students
has two sources. One is the deeply ingrained cultural imperative to never question a teacher. That is a message
that is hammered into the Japanese student starting from
grade school. But there is another cause for that passivity: the investiture of the teacher with a god-like infallibility that is intimidating and overwhelming to the student. It is equally the product of Japanese culture. It is nowonder the student is afraid to ask a question! Breaking
a habit that is so deeply ingrained is no easy task.
The teachers I encountered in Okinawa were, almost
without exception, well-intentioned and eager to follow
in the footsteps of Dr Miyagi. However, they clearlyknew that they lacked the skills to be like him, admitting
as much, in different ways. One said that he did not havethe patience to deal with residents who were “not willing
to read themselves”, another that he did not like “students
who asked too many questions”, a third that he felt Japanese residents were not willing to participate in theirlearning, which he found very irritating!
Those attitudes are not the exclusive purview of theteachers I met in the Muribushi Project. They are exact
replicas of the attitudes I have witnessed among teachersat Keio. Except that the comments in Okinawa were always framed as part of a request for advice on how that
could be changed! Thus, each of the three faculty members quoted above was highly receptive to the message
that it was their duty to respectively (a) stimulate the students’ interest so that they will want to read, (b) encourage questions from students as a way to teach and learn,and (c) invite participation through interaction rather
than intimidation.
That willingness to change among the faculty is a major distinction, and it identifies the Muribushi Project asa beacon for hope for Japanese medical education. The
recognition of a need for improvement is the greatest
single step that any program can take to improve. And
the Muribushi Project has shown me that it takes onerole model―one Miyagi!―for that need to be recognized. Japan needs many more such role models.
Evaluating the Performance of the Muribushi Project
The deficiencies and problems associated with residency training in Japan are not unknown to me, even fromthe relatively brief contact I have had with the programat Keio University Hospital. However, this was my first

120

opportunity to spend a concentrated and dedicated periodof time observing the operation of a residency training
program in Japan. There is no doubt that some of the
problems I have detailed at great length elsewhere regarding student and resident training in Keio extend to
the Muribushi Project as well. These can be easily identified under the “negative aspects” I have highlighted
above. However, the “positive aspects” far outweigh thenegative, reflecting the success of the Muribushi Projectin pioneering a more comprehensive and clinically focused training program for its residents.
The philosophy of the Muribushi Project, reflected in
the “seven concepts” in its Charter, is revolutionary for
medical training in Japan.5 First and most striking is the
Project’s stated focus on primary care in the training ofresidents (concept #iv). It is a remarkable departure fromthe traditional focus on specialization and tertiary carethat is so widely prevalent in residency training programs and healthcare practice in Japan.6, 7 The absenceof general internists on the faculty of medical schools inJapan ensures that primary care training gets short shrift
in the education of most medical graduates in the firstplace.7, 8 On top of that, all hope of exposure to primarycare practice is lost for those who then elect to train at a
University hospital for residency, as is the norm in Japan.
The Muribushi Project, in making such an explicit commitment to primary care training, has changed the dynamic for recruitment of outstanding graduates seeking
truly comprehensive residency training. In prior years,
those graduates would have gravitated as a matter ofcourse to training in their own medical schools upon
graduation. Now, they are flocking to the Muribushi
Project in record numbers.
The second revolutionary concept that the Muribushi
Project is pioneering for residency training in Japan is its
explicit commitment to adopting “global standards” of
medical care in training (concept #iii). This concept isalmost heretical, given the otherwise universal belief inJapan that the Japanese “way” with regard to any and allpractices, whether in education or healthcare, is superior
to international practices in these areas. The grievous errors that underlie that assumption are too many to recapitulate here, and readers interested in the substantiationof those errors are referred to the third paper in this series3 and to three excellent papers on the subject by Japanese authors.9-11 In this regard, the Muribushi Project islight years ahead of its counterparts in other areas of thecountry in recognizing this important failing in medical
education in Japan.
Finally, the combined intent of the first and seventh
concepts is explicit. It is for the Project’s graduates to
evolve into good clinicians who will practice good medicine, not just for the benefit of the people of Okinawa,
but for all of Japan. This goal may seem naively idealistic to those who are familiar with my scathing criticism

Rao RH: Muribushi Project for Residency Training in Okinawaof Japanese healthcare practice. In actual fact, that criticism is the very reason I find it nothing short of amazingthat the Project’s founders should have recognized thatthe need of the hour was for clinicians if the future ofhealthcare in Japan was to be assured, and that the way
to achieve it was through training residents!
The seven concepts that make up the philosophy of the
Project provide an excellent tool to evaluate the extent towhich the Project is measuring up to the vision that went
into its foundation. My experiences during my weeklong visit provide some insight into how well the Muribushi Project is fulfilling the seven concepts listed in its
Charter:
1. Do the several hospitals in the Muribushi Project
cooperate to train good clinicians? My experiences at six separate hospitals in the program on two
separate visits demonstrated that there was excellent communication between the Project administration and the member hospitals. However, there
was no real coordination or cooperation between
them, with each hospital functioning independentlyof the others. To my mind, this is very unfortunate,because it wastes the talents and resources thatwould be collectively available if the training programs at the different hospitals were not isolated
from each other. An opportunity therefore exists togreatly expand the clinical base for training of residents and improve the quality of training by integrating the several sites into a single program.
2. Does the Muribushi Project provide the best learning environment at multiple hospitals? Yes, themultiplicity of hospitals provides residents with avariety of opportunities for learning in different environments. Thus, the three smaller hospitals I visited (Nanbu Tokushukai, Chubu Tokushukai, andNakagami Hospitals) are far more intimate andhave a “community hospital” atmosphere to them,and the focus on bread-and-butter medicine is evident in the cases presented there. In contrast, thelarger and more sophisticated nature of the otherthree (Okinawa Kyoudou, Tomoshiro and Urasoe
General Hospitals) comes through loud and clear in
the relatively greater complexity of the cases presented at each of those. That variety and thebreadth of the learning experience it provides
would be a priceless asset for any training program.
With such a tremendous opportunity available andwaiting to be exploited, it is particularly dismayingthat the Project should not organize a rotation
schedule that allows residents to rotate throughmore than one hospital. At the very least, the residents could be allowed to split the two years so thatthey get experience at one of the smaller, community-style hospitals as well as one of the larger hospitals. It would improve the quality of the trainingKeio J Med 2007; 56 (4): 111－ 123

immeasurably.
3. Does the Muribushi Project ensure that global
standards of medical care are practiced? As simple
and direct as this concept is in the stating, it is theone that gives the greatest cause for concern. Residents (and, even more disappointingly, the attending faculty, as well) exhibited a dismaying ignorance of evidence-based medicine. They were unaware of global standards of practice with regard todiagnostic and therapeutic interventions. Most of
their practice norms were based on empiric data
and, no doubt, had their origins in established practices in Japan, rather than internationally established norms.
4. Does the Muribushi Project focus on primary carefor common diseases? The bread-and-butter approach that is being followed is evident in each of
the cases presented to me. Although the residents
have developed neither the requisite clinical skills
nor the critical thinking that is integral to clinicalproblem solving, I believe that they can developthese twin abilities if they are instructed in theseimportant facets of training. There is no shortage ofcases, the focus is correct, and the desire is there.
The circle needs to be closed with the right kind ofteachers and the right form of instruction.
5. Does the Muribushi Project focus on faculty development through exchanges with programs in the
US? The Pittsburgh-Japan Program has sponsoreda number of visits by faculty members from the
Muribushi Project to its week-long Faculty Development Workshop conducted at the University ofPittsburgh. In addition, the Muribushi Project has
invited several visitors to Okinawa to participate inand help improve the quality of teaching in the residency training program. Most innovative is theongoing program with the University of Pittsburgh,whereby each year one Chief Medical resident, one
Fellow in General Internal Medicine and one ormore faculty members are hosted for a week at atime to participate in the education of residents on
the wards. It has provided the faculty in the Projectwith the unique opportunity to observe American
approaches to resident education at multiple levelsof training.
6. Does the Muribushi Project provide trainees with
opportunities to experience residency training
abroad? Each year, one or two residents from the
Muribushi Project are sponsored to attend theweek-long Student Workshop conducted by the
Pittsburgh-Japan program at the University ofPittsburgh. Space is limited, and the requirement ofsome degree of proficiency in English limits thenumber residents who can avail of this opportunity,
but that is no fault of the Project’s.

121

7. Is the Muribushi Project improving the quality andnature of healthcare practice in Japan? It is impossible to tell as yet if the pioneering approach to residency training that has been adopted in the Muribushi Project will pay off in terms of better healthcare practice in its graduating physicians. I havegone on record with my firmly held opinion withregard to the critical importance of changing
healthcare practice in Japan through clinically focused primary care training for Japanese medical
graduates.3 To the extent that the training in the
Muribushi Project is focused on clinical skills andprimary care, it can only mean that its graduates
will be much better suited than others to providing
clinically appropriate and fiscally responsible patient care. That is the hope. Only when the numberof graduates in practice reaches critical mass will it
be possible to measure the success of the Project inimpacting healthcare quality.
The Project appears to be on track to fulfill at least
some of the goals that are laid out in its founding concepts. It is too early to be sure if its pioneering attempt tofocus on clinical training for residents in Japan will succeed in full. At the present time, however, the performance can be said to be very encouraging, particularly
given the extreme difficulty in introducing such a revolutionary paradigm for residency training in Japan.
Conclusions
My trip to Okinawa was an eye opener for me in many
ways. First of all, I was able to observe and evaluate theworkings of the residency system in a non-academic
teaching hospital setting in Japan, something to which I
had very little exposure previously. This enabled me tocompare and contrast it with my previous experience of
medical student education and of residency training (aslimited as that was) in an academic setting in Japan. For
one thing, I was able to verify that there is a fearful symmetry between the problems in medical student education and in residency training in Japan. For another, I
was also able to verify that the enthusiasm of the Japanese medical trainee for active learning knows no boundaries of geography (Tokyo or Okinawa) or chronology(student or resident). However, I also verified that thesame passivity that holds them back from participatingin their learning as students also holds them back as residents, regardless of geography or chronology.
The second eye-opener for me was the success story
that is the Muribushi Project. I had the privilege of seeing for myself the progress that can be made when thewill and the resources are committed to reforming thesystem. In that sense, there is yet more symmetry-although the symmetry here is of the hopeful rather thanfearful variety-with my previous experience in Keio Uni-

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versity in the commitment of the authorities there to improving teaching for students.4
The tangible progress I have seen at the two institutions has not blinded me to the enormity of the task thatstill remains. Nor does the improvement remove the
doubts that linger regarding the commitment of the faculty to teaching or regarding the lack of recognition ofteaching as a worthwhile endeavor in the rest of Japan.
But the fact that it is happening, against all odds, does
give me great hope, because it means that it can be done,even in Japan.
The differences in geography, level of training, philosophy and type of training in the two programs are whatmake them so intriguing to contemplate together. This isbecause the two are complementary to each other, andtogether they form a complete solution to the problems
that bedevil Japanese healthcare as a whole.3
Inherent in the complementary nature of those characteristics is also the reason I temper my enthusiasm with anote of caution. Instead of occurring in concert, the reforms in each program appear to exist in a vacuum, withlittle hope of any cross-over. Thus, reform of student
teaching (as is occurring at Keio University) is foredoomed to failure if residency training remains mired ina super-specialty mindset. And reform of residency training (as is occurring in the Muribushi Project) is just as
certainly foredoomed to failure if graduating residents
are going to enter a healthcare marketplace that only rewards research and favors the development of super-specialists.
Notwithstanding this note of caution, I have hope thatthe progress being made in these two institutions will
spread. It is through the power of the marketplace thatthe battle will be won or lost. And the message from themarketplace is one of great promise. I have been toldthat the Okinawa residency is fast becoming a preferred
option for training in Internal Medicine amongst Japanese medical graduates. With time and the commitmentof resources, this could evolve into a trend that would
eventually transform the Japanese system into somethingthat is more akin to systems of medical education andtraining that are seen in most other parts of the world.
Together, the twin reforms, one academic and one nonacademic, one for students and one for residents, are acomprehensive recipe for renewal and hope in Japan.
Separated from each other, they constitute a deadly recipe for failure of all reform efforts in the long-term, if thegoal is to improve the quality of training in Japan andmake it compatible with global imperatives. That is theperspective (and goal) of no-less a person than Deanelect Ikeda of Keio University School of Medicine. It isalso the vision of Dean Kitajima and Professor Amano.4
It is a vision and perspective that is shared by Dr Miyagi.
Taken together, they constitute a beacon for hope fortransforming not just undergraduate and graduate medi-

Rao RH: Muribushi Project for Residency Training in Okinawa

cal education in Japan, but of the Japanese healthcare
system itself.3
I feel honored to witness what could be the beginningof far-reaching changes in Japanese medical education at
two levels, one for students at Keio University Hospital,and now for residents in the Muribushi Project. I am
acutely aware that it is a time of great uncertainty andanxiety. But it is also a time of great excitement andhope. It is that which fuels my desire to return again andagain, if those in charge will have me return! I am fully
aware of the blunt and sometimes hurtful home truths
that I am forced to tell. It makes me particularly uncomfortable to have to do that to a people and society as polite and courteous as Japan’s, but I consider myself a truefriend of the Japanese medical trainee, and I could notcall myself that if I shortchanged that friendship by sugar
coating the bitter pill of truth or, worse still, hiding it under a cover of dishonesty.
As always, the criticisms, the insights, and the conclusions are mine alone, and they are offered with all humility, in the hope that they will help the Muribushi Project
improve. I know that they will not be misunderstood, because I have learned from my visits to Keio University
Hospital that those truly interested in making things better in Japan are eager and anxious to learn what ails theirsystem, and how to fix it. The Muribushi Project is aheadof the curve in that regard. The vision that was responsible for the attempt to reinvent it as a facsimile of an
American-style residency program shows that Dr Miyagi“gets it”, as they say in the US. That it has not yet metthat goal is not the point. The point is that the vision exists and is being implemented, however imperfectly. In
particular, it is unfair to expect dramatic change whenboth teachers and trainees are still shackled by centuriesold tradition. It is the desire to change that sets the Muribushi Project apart, reinforced as it is by the indomitable
will of Dr Miyagi. Because of that, I am confident that
improvements are inevitable as experience is gained andmodifications are made to adapt the “American” style to
Japanese conditions.
Just as important as the will to implement the vision
for change, however, is Dr Miyagi’s willingness to not
only accept criticism, but to consider even deeper andbroader change. Those traits define him, in my eyes, as avisionary in the mold of Dean Kitajima, or Dean-electIkeda, or Professor Amano of Keio University ― exactly
the kind of individual who can revolutionize Japanese
medical education. He, like the authorities at Keio who I
have the privilege of advising, is of the mindset that values honest criticism even above the traditional Japanese
credo of courtesy at all costs. For that, the next generation of Japanese students and patients can be truly grateful.

Keio J Med 2007; 56 (4): 111－ 123

Acknowledgements
The author wishes to acknowledge and thank Dr Haruko Akatsu-Kuffner, Director of the Pittsburgh-Japan Program, for opening the doors that made my visit possible.
Her unflagging zeal and commitment to the cause of reforming Japanese medical education fuel my own determination to provide whatever insights I can to those inJapan who are genuinely interested in reform. I must also
make special mention of my indebtedness to MrTatsuya
Miyazato, Administrator-in-charge of the Muribushi
Project, for his help and diligent attention to detail in organizing my visits to Okinawa.
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