Asia Pacific Family Medicine 2009, 8:9 http://www.apfmj.com/content/8/1/9 "The only thing you must do to submit your reports is to make a copy of your textbooks." 6) Human relationships with colleagues and medical team members All together, 10 of the 25 medical students in the same year of training considered themselves to be more cooper- ative, unlike their UK counterparts who reported highly competitive characteristics. Some medical students also mentioned that relaxation of the atmosphere at the department is very important to promote them to study harder. They seem to put emphasis on harmony with other members in their group. "There are variations in how well skills are learnt, just as there are with individual drive and motivation, but as a group, we must do everything cooperatively." 7) First experience from the practical wards and their patients About one third of (9/25) medical students reported that their patients' support and encouragement enhanced their motivation for studying. As they were getting more and more empathetically connected with their patients, they felt more confident perceiving the patients as not only a disease but a living person with a disease. Additionally, they seemed to feel glad when patients encouraged them to say that students were on their way to becoming a doc- tor and they would depend on them in the future. "I gained deep insight into the aspects of my patients from not only a biomedical but also a psychosocial point of view. No doc- tor-patient relationship but an equal partnership exists here..." Discussion We found both similarities and differences when compar- ing our results to those of previous studies in the UK. In Japan, qualitative studies investigating this theme pub- lished in English are few and far between, probably mak- ing this the first piece of research qualitatively exploring educational practices in Japanese medical schools. The results indicate that at least some effects of the hidden curriculum in medical education likely exist in common in many so-called advanced countries. This is all the more intriguing when one considers that Japan adopted Confu- cian pedagogical principles from China, and a 19th cen- tury Western medical format from Germany [9], yet still exhibits the same effects from a hidden curriculum in medical education as the UK. Regarding the themes, "the perception of education as having a low priority" and "an overburdened medical knowledge," as Wear pointed out in her article, one usu- ally dominates the others when an institution has con- flicting goals [20]. As is usual in such a case, the values of education are subordinate to those of research or the clinic, and due to outcome will have not been identified promptly. In such an outcome-burdened environment, great importance is attached not to process but to out- come [21], so it is understandable that many people including students and faculty members believe the aph- orism: "knowledge is power," whereby medical education with information overload will be accepted. In addition, as the themes, "the persistence of hierarchy and exclusivity," "the prevalence of positive/negative role models," and "the existence of gender issues," Japanese cultural and ethnic background may make these problems more complicated. As Lempp & Seale indicated, "shy and quiet female Asian students were more likely to be humil- iated or ignored by consultants during ward rounds [22]." Besides, seniority carries a lot of weight in most Japanese medical schools, in which the sempai (senior)-kohai (jun- ior) relationships are strongly emphasized. These tradi- tional Japanese educational practices in medical schools may have had been responsible for problems related to hierarchical structure. Pertaining to the issue of persist- ence of hierarchy and exclusivity, for example, the teach- ers' behaviors, such as verbal abuse and vilification of other departments, seemed unlikely to give these instruc- tors an advantage over others, and resulted only in serving to generate harsh criticism of the professors from the stu- dents. Gender discrimination and career obstacles for women still exist in Japan as well, as Kaneto suggested [23]. That's also a common problem for both western industrialized countries [24] and Japan. Conversely, we discovered intriguing differences between the UK and Japan in two particular themes: "human rela- tionships with colleagues and medical team members," and "first experience from the practical wards and their patients." Japanese medical students tend to have less time in hospitals on a practical basis due to the structure of the medical curriculum in Japanese medical universi- ties [9-11]. According to the study of Lempp & Seale, com- petitive rather than cooperative characteristics were more common among clinical medical students [1], which does not necessarily apply to our Japanese cases. The Japanese approach towards education, which stresses didactic lec- tures and rote memorization -- that is to say, "teacher cen- tered, examination-driven and passive learning," symbolizing an educational philosophy that is much like that of many East Asian nations, which TEO & Song et al found [9,25], may also have an effect on Japanese medical students. In other words, the seemingly favorable results of Japanese medical students noted in our study might be a by-product of curricular differences. Page 5 of 7 (page number not for citation purposes)