Perspectives in medical education 7. Observations on clinical training at a "US-style" residency program at Teine Keijinkai Hospital in Sapporo, Japan.

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 more clinically 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 a magnet 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 on teaching 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.