Asia Pacific Family Medicine 2009, 8:9 http://www.apfmj.com/content/8/1/9 his interview published in Parade Magazine in 1994, C. Everett Koop, the former U.S. Surgeon General, cited "...What leads most young doctors away from such prac- tice [primary care] is not money but a medical school cul- ture that devalues the family doctor." [2,3] Most of what is acquired in medical school education con- tributes not to the manifested offerings called formal cur- riculum (defined by Hafferty as the stated, instead, and formally offered and endorsed curriculum [4,5]) but to the learning process called hidden curriculum (defined as a set of influences that function at the level of organiza- tional structure and culture [4,5]). The discordance between what formal curriculum intends to teach the medical students and what students perceive to be learned from hidden curriculum is difficult to deal with. It seems to be illustrated explicitly in the example of the white coat ceremony as a curricular event, which was originally expected to symbolize the students' sense of compassion and humility, but instead serves to impress care-giving hierarchies and the social privileges of physicians [6], though this might be one of its functions. If advocates for educational reforms have never been aware of solutions to the problem of reconciling the discordance between these curricula, "reform without change" may occur, as history repeats itself [7]. That is perhaps why it has only been over the past decades that researchers of medical education have come to focus on the concept of hidden curriculum [8]. Lempp & Searle presented a qualitative study of med- ical students' perceptions of teaching in light of under- graduate medical education in the UK, which conveyed critical problems about latent features of the effect of the hidden curriculum on the realm of medical education [1]. In the meantime, aspects of educational curriculum in Japanese medical schools have also undergone a major transformation over the past decades. Information about this, including problem-based learning and model core curriculum in Japanese medical education, was available elsewhere [9-11]. Such unprecedented curriculum change has never been experienced in Japan in the Postwar period. The prior study implemented by Lempp & Searle in the UK found these four themes about the perception of the hidden curriculum; "Personal encouragement," "haphaz- ard teaching," "important of hierarchy," and "getting ahead by being competitive." However, no similar quali- tative study concerning the perception of the hidden cur- riculum in Japanese medical schools has ever been conducted. Since many traditional Japanese medical schools adopted elements of the German style [12], which is quite distinct from the system in place in the UK, it is expected that many disparate themes may evolve from a similar survey in Japan. Accordingly, to explore themes pertaining to the students' perceptions of the hidden curriculum of undergraduate medical education in bedside learning in a Japanese med- ical school, and compare them with the prior study results from the UK, was the purpose of this study. It would be useful to utilize the results of our survey as feedback on teaching methods in faculty development workshops, which will contribute to the reform of medical education in Japan. Relating to the training for careers in family medicine in Japan, traditionally few institutions systematically foster primary care physicians and very few have truly embraced family medicine as their guiding discipline [13]. (Note: since Japan has few physicians trained in the delivery of primary care, and lacks recognition of the discipline of family medicine, here we use the term "primary care" to refer to the function as stated by the U.S. Institute of Med- icine; that is, primary care specialties include family med- icine by this definition [13].) Despite the shortage of primary care specialists, one of the authors [MMa] contin- ued to emphasize at length how important primary care physicians' roles as medical educators was, and the neces- sity of community-oriented medical education in Japan [14]. Methods We conducted qualitative methodology employing 1-to-1 semi-structured interviewsand thematic content analysis [15-17] to elicit and perceive in-depth thoughts and learn- ing experience. We used purposive sampling to identify a target population of undergraduate year-5 medical stu- dents in the initial stage of clinical training in a Japanese medical school. They were recruited as purposeful sam- pling to concentrate on the clinical stage (i.e. bedside training in clinical medicine). The interview agenda outlined in Figure 1 was conducted over an 8-month period in 2007, by the two researchers (MMu and HK) independently, with each interview last- ing 30 to 60 minutes in a private room, taking confidenti- ality into account. At the start of each interview, we used broad and open-ended questions and gradually asked per- sonal and in-depth questions, which had no threatening effect on students and gave the advantage of developing rapport with them. A preliminary interview guide was created, referring to the prior study [1] and initial 5 pilot interviews. The final interview guide was as follows, (1) Introduction/Ice- breaker: training atmosphere: 1. What do you think about your training, in general? 2. What do you enjoy most/least in your training? 3. Has the medical training met with your sat- isfaction? Why/Why not? (2) Knowledge and skills of med- ical practice: 4. What technical/diagnostic skills and Page 2 of 7 (page number not for citation purposes)