title: The cultural context of teaching and learning sexual health care examinations in Japan: a mixed methods case study assessing the use of standardized patient instructors among Japanese family physician trainees of the Shizuoka Family Medicine Program.
abstract: BACKGROUND
  In contrast to many western nations where family medicine is a cornerstone of the primary care workforce, in Japan the specialty is still developing. A number of services within the bailiwick of family medicine have yet to be fully incorporated into Japanese family medicine training programs, especially those associated with sexual health. This gap constitutes a lost opportunity for addressing sexual health-related conditions, including cancer prevention, diagnosis, and treatment. In this mixed methods case study we investigated the perceived acceptability and impact of a standardized patient instructor (SPI) program that trained Japanese family medicine residents in female breast, pelvic, male genital, and prostate examinations.
  
  
  METHODS
  Building on an existing partnership between the University of Michigan, USA, and the Shizuoka Family Medicine Program, Japan, Japanese family medicine residents received SPI-based training in female breast, pelvic, male genital, and prostate examinations at the University of Michigan. A mixed methods case study targeting residents, trainers, and staff was employed using post-training feedback, semi-structured interviews, and web-based questionnaire.
  
  
  RESULTS
  Residents' and SPIs' perceptions of the training were universally positive, with SPIs observing a positive effect on residents' knowledge, confidence, and skill. SPIs found specific instruction-related approaches to be particularly helpful, such as the positioning of the interpreter and the timing of interpreter use. SPIs provided an important opportunity for residents to learn about the patient's perspective and to practice newly learned skills. Respondents noted a general preference for gender concordance when providing gender-specific health care; also noted were too few opportunities to practice skills after returning to Japan. For cultural reasons, both residents and staff deemed it would be difficult to implement a similar SPI-based program within Japan.
  
  
  CONCLUSIONS
  While the SPI program was perceived favorably, without sufficient practice and supervision the skills acquired by residents during the training may not be fully retained. Deep-rooted taboos surrounding gender-specific health care appear to be a significant barrier preventing experimentation with SPI-based sexual health training in Japan. The feasibility of implementing a similar training program within Japan remains uncertain. More research is needed to understand challenges and how they can be overcome.
authors.affiliation: Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48104-1213 USA.
authors.forename: Cameron G
authors.initials: CG
authors.lastname: Shultz
authors.affiliation: University of Michigan Medical School, Ann Arbor, MI USA ; Virginia Mason Medical Center, Internal Medicine Residency, Seattle, Washington USA.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Chu
authors.affiliation: Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48104-1213 USA.
authors.forename: Ayaka
authors.initials: A
authors.lastname: Yajima
authors.affiliation: Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48104-1213 USA.
authors.forename: Eric P
authors.initials: EP
authors.lastname: Skye
authors.affiliation: Department of Family Medicine, Tokushukai Hospital Corporation, Haibara General Hospital, Makinohara, Shizuoka Japan.
authors.forename: Kiyoshi
authors.initials: K
authors.lastname: Sano
authors.affiliation: Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka Japan.
authors.forename: Machiko
authors.initials: M
authors.lastname: Inoue
authors.affiliation: Akatchi Family Medicine Center, Kikugawa, Shizuoka Japan.
authors.forename: Tsukasa
authors.initials: T
authors.lastname: Tsuda
authors.affiliation: Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48104-1213 USA.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Fetters
keywords: Family medicine; Japan; Sexual health; Standardized patient instructors