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

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 pre- vention, 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. Case description: 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. Discussion and evaluation: 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 *Correspondence: mfetters@med.umich.edu Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48104-1213, USA Full list of author information is available at the end of the article © 2015 Shultz et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 2 of 11 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. Keywords: Standardized patient instructors, Japan, Family medicine, Sexual health physicians can vary from clinic to clinic, and from physi- Background cian to physician [1–3, 16]. In contrast to many western nations where family medi- As measured by the number of doctor visits per year, cine is a cornerstone of the primary care workforce, in Japanese are among the top consumers of health care Japan the specialty is still developing [1–5]. A number of in the world (Table  1). An important driver of Japanese services within the bailiwick of family medicine have yet health care utilization stems from the absence of a gate- to be fully incorporated into Japanese family medicine keeping mechanism—any patient can essentially drop training programs, especially those associated with sex- in at any clinic at any time, and outpatient specialty and ual health [6]. This gap contributes to a lost opportunity hospital care do not generally require referrals [16]. In for identifying and treating sexual health-related condi- addition, Japan’s fee structure encourages more frequent, tions, as well as cancer prevention, early diagnosis, and shorter visits [18]. Despite excellent access in this system, treatment. health care is often fragmented, and many gender-spe- To address this gap, the Shizuoka Family Medicine Pro- cific services (e.g., female breast, pelvic, male genital, and gram, Japan, partnered with the University of Michigan prostate examinations) have yet to be fully incorporated Department of Family Medicine, United States of Amer- and accepted into Japanese family physicians’ scope of ica (USA), to implement a standardized patient instructor care [6]. (SPI) program to provide Japanese family medicine resi- In 2004, an obligatory 2-year postgraduate training dents with training in female breast, pelvic, male genital, program (shoki kenshū) was instituted for all new medical and prostate examinations at the University of Michigan. school graduates. The focus of this training is on general As part of a larger collaborative educational project—the medicine, with its curriculum centered on hospital-based Shizuoka-University of Michigan Advanced Residency general internal medicine, general surgery, emergency Training, Education and Research in Family Medicine medicine, anesthesiology, pediatrics, obstetrics and gyne- (SMARTER-FM) [7]—the SPI program was a key com- cology, psychiatry, and community medicine [19]. As part ponent of providing visiting residents with hands-on, real of the advanced training period (kōki kenshū), the Japa- life experience in performing these exams. nese family medicine residency lasts 3  years. Residency programs in family medicine remain inconsistent across Epidemiological background training sites [2, 3, 20], and qualified trainers remain in As shown in Table 1, incidence of prostate, breast (female short supply [3, 21, 22]. only), uterus, cervical, and ovarian cancers in Japan are markedly higher than the global average. Cervical and Sex, taboo, and gender‑specific health care mammography screening in Japan is much lower than Modesty and masculinity—central to gender identity in that of other developed nations [8]. While Japanese sur- many cultures—can have a large impact on how health veillance data on sexually transmitted infections (STIs) care is perceived and utilized [23, 24]. In Japanese cul- are incomplete [9], evidence suggests rates of some ture, Western-style medicine may at times be perceived STIs may be high [9–12]. Human papillomavirus (HPV) as invasive, especially for procedures requiring the infection, for example, may be common among some patient to undress [24]. Some Japanese believe that dis- segments of the population, particularly women of repro- cussions about genitalia and the gendered, sexualized ductive age [10, 13, 14]. body violate a “code of civilized morality” [25]. According to this code, sex-related behaviors outside of marriage Health care in Japan are thought to be indecent and require “silence or euphe- Like most developed nations, Japan provides its citizens mism” [25]. Hence, for those influenced by this code, the with universal health coverage. Implemented in 1961, act of seeking gender-specific health care may in and of Japan’s national insurance program combines employee- itself be intensely embarrassing. and community-based plans. Fees charged by hospitals and physicians are regulated, and most citizens have a co- Gender‑specific health care for women payment rate of 30 % [15]. The primary and specialty care Examination rooms for general and gynecological care disciplines in Japan are not wholly distinct [16, 17], and in Japan are typically not private, constructed with thin the training and services provided by primary health care Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 3 of 11 Table 1 Health indicators related to breast, pelvic, male genital, and prostate examinations, and the primary care work- force World Japan Age-standardized incidence rate for cancer per 100,000 population, 2010 [37] Prostate 37.9 56.0 Breast (female only) 60.8 78.4 Uterus 22.0 28.1 Cervix uteri 11.2 14.2 Corpus uteri 10.4 13.5 Ovary 9.0 11.3 Estimated number of new cancer cases attributable to HPV infection, 2008 [11] 610,000 11,000 Herpes simplex virus type 2, population aged 15–49 years, prevalence in millions [38] 535.5 4.8 Cervical cancer screening, percentage women screened aged 20–69 years, 2009 [8] 85.9 (United States) 24.5 78.7 (United Kingdom) 38.9 (Mexico) Mammography screening, percentage of women aged 50–69 years screened, 2009 [8] 81.1 (United States) 23.8 74.0 (United Kingdom) 16.6 (Mexico) Practicing medical doctors per 1000 population, 2009 [8] 2.4 (United States) 2.2 2.7 (United Kingdom) 2.0 (Mexico) c d,e General practitioners, as a share (%) of total medical doctors, 2009 12.3 (United States) [8] 16.7–34.4 [39] 27.1 (United Kingdom) [39] 36.7 (Mexico) [8] Doctor visits per year [18] 3.9 (United States) 13.2 5.9 (United Kingdom) 2.8 (Mexico) HPV human papillomavirus Based on Japan model population in 1985 Based on data from 2000 Based on data from 2009 Based on data from 2004 The primary care workforce in Japan includes many physician types, including internal medicine (41.8 %), ophthalmology (8.0 %), orthopedics (7.2 %), pediatrics (6.8 %), otolaryngology (5.6 %), surgery (5.5 %), obstetrics/gynecology (4.7 %), dermatology (4.7 %), and others (15.6 %) partitions (often open on one end), and may or may not to face barriers in securing modern contraception when have a curtain (in lieu of a door) [26]. With the intent of compared to women in the USA and France; moreover, preserving modesty, gynecological exam rooms may have Japanese women are less likely to understand the non- a curtain hiding the woman’s upper body and face [26, contraceptive benefits of oral contraceptives [31]. This 27]. For many Japanese women this clinical setting is not finding is supported by family planning indicators that acceptable, and can contribute to delaying or foregoing show Japanese women fall far behind women from other basic gynecological care. For example, female Japanese developed countries in terms of modern contraception university students reported fear and embarrassment as use: the proportion of married or in-union women aged principal reasons for avoiding gynecological care [28], 15–49  years using any modern method of contracep- and among Japanese women of reproductive age expe- tion in 2013 is 50  % for Japan, 70  % for the USA, 72  % riencing unusual menstrual symptoms, nearly one-fifth for France, and 81  % for the United Kingdom [32]. One cited “feeling resistance or aversion to gynecologists and explanation for the lackluster uptake may stem from lim- hospitals” as a contributing factor in their decision to not ited knowledge about oral contraceptives among both seek care [29]. patients and physicians [33]. Despite having more health care consultations per year when compared to most other countries, some Japanese Gender‑specific health care for men women report access-related problems for contraceptive Although Northeastern Asia has an extremely hetero- care. One consequence of the poor access is that abortion geneous culture, some cultural norms are shared across may at times become a default method of birth control geo-political borders and emerge as cultural themes. Like [30]. Evidence suggests Japanese women are more likely men from many cultural groups, Asian men may at times Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 4 of 11 act in ways to preserve a sense of masculinity. Identity- hands-on practice using models simulating physical related attributes endorsed by many Asian men include examination findings. On separate days, residents worked “having an active sex life,” “having success with women,” with a female SPI for female breast and pelvic exams, and “avoiding shameful situations.” Among men in Japan, and a male SPI for male genital and prostate exams. An the attributes of honor and control are also strongly experienced Japanese-English interpreter was present for endorsed [23]. When considering these attributes as part each resident throughout the training. Ample opportu- of a cultural schema or meme, they likely play a role in nity was provided for one-on-one practice and feedback. Japanese men’s hesitancy to seek (and physicians’ reluc- During the 2-week experience, residents worked closely tance to provide) the male genital exam, prostate exam, with University of Michigan family medicine faculty or other service that might threaten men’s sense of vital- at the Japanese Family Health Program in Ann Arbor, ity, honor, or control. MI (USA), where the SPI-based training was reinforced through focused instruction with consenting patients. The Shizuoka Family Medicine Program The Shizuoka Family Medicine Program, located in Design Shizuoka prefecture, Japan, has two main clinical sites This mixed methods case study was reviewed and classi - located approximately 32  km (20 miles) apart: Kiku- fied as exempt by the University of Michigan Institutional gawa (population: 47,000) and Mori-machi (population: Review Board. As illustrated in Fig. 1, data were collected 19,000). Since its establishment in 2010, the Shizuoka at three time periods. Years 1 (2010) and 2 (2011) indicate Family Medicine residency program has had class sizes the first and second wave of Shizuoka Family Medicine ranging from 1 to 6 residents per year. Residents alternate residents, respectively, receiving the SPI-based training between clinics for outpatient experiences and rotations at the University of Michigan. Year 3 (2012) indicates at three local hospitals (Kikugawa, Mori-Machi, and the follow-up data collection period in Japan (i.e., 2 years Iwata). While the Shizuoka Family Medicine residency post-training for wave 1 residents, and 1 year post-train- program trains residents to provide care across the life ing for wave 2 residents). span—from cradle to grave—the program has no on-site The study included four data collection arms: (1) post- or domestic SPI program to provide training in female training evaluations from Shizuoka Family Medicine resi- breast, pelvic, male genital, and prostate examinations. dents and SPI instructors (years 1 and 2); (2) follow-up Similar to other family medicine residency programs in semi-structured interviews with Shizuoka Family Medi- Japan, training for these exams is limited to practice with cine residents (year 3); (3) semi-structured interviews manikins or instruction with actual patients. with key informants (nurses and medical assistants) from Shizuoka Family Medicine (year 3); and (4) a web-based Case description questionnaire targeting Shizuoka Family Medicine resi- The purpose of this mixed methods case study was two - dents (year 3). fold: to investigate the SPIs’ and Japanese residents’ per- ceptions about the training experience in the USA, and Arm 1: post‑training evaluations to examine the perceived impact and acceptability of per- Written feedback about the training was solicited from forming the learned skills from residents and other key both Shizuoka Family Medicine residents and SPIs. informants after residents returned to Japan. Administered upon completion of the 2-week rotations at the University of Michigan (and for residents, before Standardized patient instructor‑based training at the returning to Japan), participants were asked to provide University of Michigan information about their overall experience and reflec - As part of the SMARTER-FM project, all Shizuoka Fam- tions on the SPI exercises. Resident and SPI evaluations ily Medicine residents had a 2-week rotation at the Uni- were completed in Japanese and English, respectively. versity of Michigan, usually in their first year (Fig.  1). In addition to other clinical teaching and experiences dur- Arm 2: follow‑up semi‑structured interviews with residents ing this rotation, residents received SPI-based training in The semi-structured interview guide was developed by female breast, pelvic, male genital, and prostate exami- the research team using an iterative, consensus-based nations. The SPI-based training started with residents process, wherein study investigators reviewed and reviewing in advance textual materials and online videos, revised the guide to ensure it was both easy to use and followed by didactic sessions—delivered by an attending adequately captured the topics of interest. The guide family medicine physician from the University of Michi- was designed to elicit residents’ perspectives on several gan (EPS)—focusing on anatomy and proper examina- domains: (1) the provision of gender-specific health care tion technique. Didactic sessions were augmented with in the Japanese family medicine setting; (2) physician and Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 5 of 11 Fig. 1 Overview of the standardized patient instructor experience for Japanese family medicine residents and the mixed methods case study procedures patient comfort in performing gender-specific exami - including administration by the same research assistant nations; (3) impact and utility of the SPI-based training (MSC). at the University of Michigan; and (4) the feasibility of implementing a similar training program in Japan. Arm 4: Web‑based questionnaire targeting Shizuoka Japanese residents who completed the University of Family Medicine residents Michigan SPI-based training were invited to participate The web-based questionnaire was developed by the by a research assistant (MSC) trained in qualitative inter- research team using an iterative, consensus-based pro- viewing. All interviews were conducted in-person and in cess to parallel and supplement the qualitative data Japanese. Individual interviews were scheduled at a time collection. The primary focus of the instrument was resi - agreeable to the resident, and conducted in a location dents’ self-perceived experience and proficiency for each offering privacy. Subjects provided verbal consent prior of the examinations. Questionnaires were completed at a to the interview. time and location of the residents’ choosing. Arm 3: semi‑structured interviews with Shizuoka Family Qualitative, quantitative, and mixed methods analyses Medicine nurses and medical assistant staff The qualitative feedback data from Arm 1 were organ - The interview guide developed for Arm 2 was modified ized into a matrix constituting 30 pages of single spaced for use with nurses and medical assistants to address text. This allowed parallel comparison of resident and parallel content. It sought information on resident per- SPI feedback. Two bilingual and experienced qualitative formance in providing gender-specific health care, and researchers (MSC and AY) immersed themselves in the the perceived impact of the SPI training. Using a pur- feedback data, and used an editing approach to reduce posive sampling strategy, nurses and medical assistants the data into salient themes (Table  2) [34]. Due to space who worked closely with Shizuoka Family Medicine resi- constraints and to simplify interpretation, example quo- dents were invited to participate. Interview procedures tations for each theme are not presented; rather, we pro- for these key informants mirrored that of the residents, vide summative descriptive statements [35]. Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 6 of 11 Table 2 Summary of the written qualitative feedback of family medicine residents and standardized patient instructors collected immediately after training sessions Stage Resident comments n = 8 SPI comments n = 2 Overall Wonderful experience Went extremely well Felt like I advanced more than any other teaching Enjoyed teaching, learned from experience with non-English Reviewing anatomy, having didactic, then performing speakers Learning directly from the patient, instead of books, videos, Met expectations for being polite, gracious and observing senior physicians Pleasantly surprised by curiosity, desire to clarify and ask Teaching systematic, better than during clinical care questions Discovered resident learning experiences in Japan mostly had been passive, observational Some learners initially tentative Agreed to being photographed after the teaching session Pre-SPI encounter Observing examinations in the clinic prior to SPI experience NA: SPI were not asked to provide made it more effective Helpful to review online written materials & videos on anatomy, and how to perform examinations Pre-SPI lecture/coaching Learning how to examine using manikin models NA: Provided by faculty member Learning the procedures for interacting with an SPI SPI session SPI comfortable with teaching Focused on “reading, watching, doing” SPI demonstrating how to do exam, then doing it Defined scope of session: e.g., procedures, role of SPI SPI knew own physical findings, and showed them Encouraged questions Understanding the patient’s perspective (e.g., anxiety, “Cheat sheet”—SPI prepared, helped learner discomfort, modesty) Inquiring about learners’ previous examination experiences Individualized teaching in detail, in person Taught examination techniques, communication skills, Learner repeating over and over until got it right sequence of the examination, putting the patient at ease, (e.g., finding cervix with speculum) when to use chaperone, accommodating family members, Pacing the teaching to the learner’s ability positioning (e.g., common patient preferences, and accom- Appreciation of teaching from the patient’s perspective modating co-morbidities) about modesty, protecting it Teaching how to protect patient modesty, how to incorpo- Learning different patterns of examination rate genitourinary exam routinely or focused into overall Feeling a real lump examination SPIs excited when learner palpated actual findings Enthusiasm of learners made session longer than SPI expected Using interpreter Having an interpreter present helpful to understand Using an interpreter was novel (pre-session) Reading in advance about how to use interpreter Very helpful for understanding and clarification Took nearly twice as long using interpreter (during SPI session) Interpreter used first person Tried speaking initially in phrases, but interpreter preferred full sentences Positioned interpreter facing away, toward wall during exami- nation, or caudad to exposed genitalia (male SPI on female interpreter) After getting used to interpreter, became easier, flowed better When learner practiced combining examination skills and communication to patient, opted to NOT use interpreter to facilitate the learner naturally integrating examination and communication skills (rather than disrupting flow by using interpreter) Improvements United States speculum different from Japan; not used to it Feel he/she needs to train many times after the session by oneself Video recording of the teaching session for reference for self-study would be helpful Want to confirm if performing examinations could be done by oneself Need manikin models with abnormal findings SPI standardized patient instructor Qualitative interviews from Arms 2 and 3 were digi- of an experienced researcher (MDF), interview data tally recorded, and the recordings transcribed verbatim were analyzed by the same team members (MSC and in Japanese. Interviews produced a total of 228 pages AY) who initially immersed themselves in the feedback of single-spaced, Japanese text. Under the supervision data. A coding scheme was developed using an iterative, Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 7 of 11 consensus-based process [36]. Data were further reduced challenges for the SPIs. Residents described that family into salient themes, and a matrix was developed to illus- medicine residency programs in Japan do not utilize SPIs trate comparison between resident and SPI feedback, for physical examinations or procedures. and resident and ancillary staff interviews. To show the One to two years after their return to Japan, residents breadth and relative frequency of comments, final cate - continued to highly value their SPI training experience. gories were transformed into quantitative data by count- Several explanations were provided for the sustained sat- ing the number of respondents who endorsed a given isfaction, including an appreciation of the training’s focus theme. This analysis was designed to understand how the to improve both interpersonal and clinical skill; specifi - qualitatively elicited opinions about specific topics were cally, it was noted that the training provided an oppor- distributed among the three groups. All text material was tunity to learn directly from the patient and about the analyzed qualitatively in the language of collection (Japa- patients’ perspective, and it helped residents learn how nese or English) as each analyst (MDF, MSC, and AY) is to perform the examinations while also maintaining fluent in both languages. Summary statistics were ana - the patient’s comfort and dignity. The training was also lyzed descriptively for the quantitative data produced by described as an excellent stepping-stone for obstetrics/ the web-based survey in Arm 4. By looking across quali- gynecology and urology rotations. Residents noted that tative and quantitative findings, we examined the extent the training made a positive difference in their ability to to which findings from each arm corroborated (or con - practice medicine more generally, as it provided skills in tradicted) each other. how to be more sensitive to patients’ needs. Nurses and medical assistants noted improved patient care by resi- Discussion and evaluation dents after the SPI-based training, though they did not Three Shizuoka Family Medicine residents participated necessarily consider the uptick in performance to be in the SPI-based training in year 1, and 6 participated in directly related to the training. year 2. Eight residents provided post-training feedback. Despite participants’ positive experience with the SPI Male (n = 1) and female (n = 1) SPI instructors provided training, there was little optimism about the potential for feedback from the perspective of the teacher. In Japan, such training to take hold within Japan (Table 3). Numer- all 9 residents participated in the follow-up interview ous cultural and social barriers were reported, the most and completed the web-based questionnaire. In addi- significant of which were perceived challenges to recruit - tion, seven key informants—5 nurses and 2 medical assis- ing Japanese SPIs. Study participants indicated the poten- tants—participated in interviews. tial for volunteers to be stigmatized if their identity were Four overarching themes were identified: (1) experience leaked to the community. Japanese identity was also men- with the SPI training program; (2) perceived proficiency tioned as a barrier, noting that Japanese are easily embar- in performing female breast, pelvic, male genital, and rassed and care a great deal about how they are perceived prostate examinations; (3) gender concordance between by peers. Before use of SPIs could become widespread in patients and residents; and (4) women’s and men’s health Japan, it was suggested that the general public would first issues. have to recognize and understand the value of SPIs to medical education. It was also noted that explicit support Experience with the SPI training program from a credible social institution (e.g., the government) A summary of the comments expressed by residents and would likely be necessary before an SPI-based training SPIs following the SPI training experience is presented in program could be sustained. Table  2. Corroborative information and salient themes from semi-structured interviews (arms 2 and 3) are out- Perceived proficiency in performing female breast, pelvic, lined in Table 3. male genital, and prostate examinations Resident and SPI feedback about the SPI-based train- As indicated in Table  4, findings from the web-based ing was universally positive, with both residents and questionnaire show that residents’ experience in per- SPIs praising all aspects of the training including the forming female breast, pelvic, male genital, and prostate pre-session studies, didactics with hands on teaching, examinations varied widely. With the exception of the pel- and the SPI teaching encounters. Resident and SPIs alike vic examination, residents’ experience with performing identified several components of the training as criti - the examinations was very limited. The count for female cally essential, including learning about communication breast and male genital examinations was particularly low, skills, practicing of psychomotor skills, identifying actual with some residents having never performed them. These findings during the examination, and receiving feedback. data corroborate the residents’ reports about the difficulty Residents and SPIs noted the utility of the interpreter for of continuing these exams in Japan and the limited oppor- mutual understanding, though this did raise some new tunity to practice their newly acquired skills. Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 8 of 11 Table 3 Resident, nurse, and medical assistant reports during semistructured interviews regarding skill proficiency, rel- evance of gender, sexual health discussions, and potential for SPIs in Japan Topic Residents in year 1 Residents in year 2 Nurses and medical (n = 6) (n = 3) assistants (n = 7) Examination proficiency Have performed pelvic exams many times 3 1 – Unsure if able to find abnormalities/diagnose in pelvic 4 1 – exams Does not get to perform breast exams often 5 2 – Does not get to perform male genital exams often 6 3 – Patient(s) seemed uncomfortable during male genital 2 1 – exam Can properly feel the prostate during digital rectal exam 4 3 – Gender concordance/discordance No issues with gender concordance 4 2 7 No issues with gender discordance 1 1 2 Prefers gender match 2 1 3 Female patients tend to request female physicians 1 1 5 Difficult to talk about sexual health when gender 4 1 3 discordant Able to ask appropriate questions regardless of concord- 1 – 3 ance Women’s and men’s health Discusses sexual health and vaccinations with female 3 1 3 patients Recommends contraception for female patients 3 – 2 Recommends pap smears for female patients 3 2 – Recommends smoking cessation outpatient services for – 2 3 male patients Cannot think of any issues specific to men’s health 1 – 3 Should improve on screening male patients for erectile 2 2 – dysfunction SPI training It was a great experience 3 2 – Allows for learning that would not otherwise be possible 2 2 – in Japan Would prefer more practice either at University of Michi- 4 1 – gan or in Japan Would be difficult to have in Japan 2 – 4 Would be difficult to find people willing to become SPIs 2 1 1 Would like to have an SPI program in Japan 5 3 3 SPI standardized patient instructor Several residents noted that some male patients have had little impact on care, more than one-third described had a negative response to the male genital exam. More that exams went more smoothly when pairs were gender than half of residents expressed that although they knew concordant; moreover, nearly half noted having difficulty how to perform a pelvic exam, they were uncertain if they in discussing topics related to sexual health in gender dis- could properly identify abnormalities or make diagnoses cordant pairs (Table  3). Improved communication and on their own (Table 3). decreased embarrassment were reported as the prin- ciple benefits of concordance, particularly for younger Gender concordance between patients and residents female patients who some participants described as more Despite the majority of interview participants indicating likely to request a female physician. It was noted that that gender concordance between patients and physicians the Shizuoka Family Medicine program’s administration Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 9 of 11 Table 4 Self-reported estimates of  the number of  exami- examinations would have been almost entirely limited to nations performed by Shizuoka family medicine residents, core obstetrics/gynecology and urology rotations in affili - from resident questionnaires (n = 9) ated settings. While the use of SPIs to assist with train- ing has many potential benefits, their use within Japan Examination Range Mean Median Standard deviation challenges long-standing and strongly-held sociocultural Women’s health beliefs about gender, identity, and sex. To overcome such Breast exam 0–20 6 5 6 deeply engrained beliefs will likely require considerable Pelvic exam 15–600 198 100 218 effort, and may necessitate securing support from the Men’s health local community and respected institutions (e.g., medical Genital exam 0–40 8 1 15 schools, professional organizations, government). Cul- Prostate exam 4–30 14 7 11 tural taboos notwithstanding, findings from this evalu - ation demonstrate the feasibility of implementing an SPI-based training program, that the skills learned were preferred gender concordance during encounters where transferable to the practice of family medicine in Japan, sexual health was the primary reason for the health care and that such a program is both acceptable and viewed visit. Participants also described that reception staff and favorably by key stakeholders. nurses commonly assigned specific residents to spe - There is a bit of a chicken and egg phenomenon rela - cific patients based on gender and the patient’s chief tive to the incorporation of sexual health into the practice complaint. of family medicine in Japan. While health indices in rel- evant diseases (e.g., sexually transmitted infections, can- Women’s health issues cer) need interventions, there are few faculty trained in The majority of participants stated that residents do an how to provide this care. Since there is little comfort pro- adequate job of discussing sexual health when working viding the care, few examinations are actually performed with female patients (e.g., contraception, screening, and and the care is not routine. Consequently, the care does menstrual cycles/menopause), even if the patient’s chief not seem routine to patients, and the services are not complaint was unrelated to sexual health. Areas noted as sought by patients. Our hope was that the SPI training needing improvement included taking steps to preserve would help to break this cycle within the Shizuoka Fam- patients’ comfort (e.g., not leaving patients in an exposed ily Medicine program in Japan, but our efforts achieved or uncomfortable position while the resident is seeking only limited success. This experience illustrates what we help from an attending), being sensitive to patients who believe is a common problem when family medicine is lack comfort in discussing sexual health (e.g., being care- adopted in cultures with very little history of address- ful to not overwhelm the patient with questions related ing women’s and men’s health as part of routine primary to sexual health, especially if the patient is sick), and care. As for how to further break the cycle, one possibil- increasing vaccination rates (e.g., for HPV). ity is much stronger self-promotion by trained family physicians themselves during individual patient consulta- Men’s health issues tions, such as raising sexual health and cancer prevention Participants’ recognition of men’s health issues was care during routine visits. A second possibility is for the almost exclusively limited to prostate and/or urinary practice to more strongly educate the patient population problems. Participants rarely raised the topics of erec- about sexual health services that are available. Doing so tile dysfunction and sexually transmitted infections. For will necessitate accommodating (and in some cases over- erectile dysfunction, it was noted that the topic was gen- coming) very strong traditions and taboos. And as articu- erally not discussed with patients unless the patient first lated by study participants, sustained change may require raised the issue on their own. Other men’s health issues explicit sanction from institutions already possessing the described as needing to be better addressed included public’s trust. education on contraceptive methods and discussing sex- This research has several limitations. First, the SPI train - ual health. ing occurred in a single training site (the University of Michigan), and follow-up was confined to a single, relatively Conclusions new family medicine residency program located in two To our knowledge, the University of Michigan SPI-based geographic areas (Kikugawa and Mori-Machi). Findings training program for Japanese family medicine residents should be interpreted cautiously, as they may not be gen- is the only one of its kind. In the absence of this training, eralizable to all Japanese medical training environments. practical experience for Shizuoka Family Medicine resi- Second, the number of residents participating in the SPI- dents in female breast, pelvic, male genital, and prostate based training was small. While all participants described Shultz et al. Asia Pac Fam Med (2015) 14:8 Page 10 of 11 Tokushukai Hospital Corporation, Haibara General Hospital, Makinohara, Shi- the training favorably, it is possible that others could have zuoka, Japan. Department of Family and Community Medicine, Hamamatsu a less positive experience. Follow-up studies using a more University School of Medicine, Hamamatsu, Shizuoka, Japan. Akatchi Family diverse resident population are needed. Third, the duration Medicine Center, Kikugawa, Shizuoka, Japan. between training and follow-up interviews ranged from 1 Acknowledgements to 2  years; this difference accounts for some of the varia - This project was conducted as part of the grant, “The Shizuoka-University of tion in the number of examinations performed. Fourth, Michigan Advanced Residency Training, Education and Research in Family Medicine,” (SMARTER-FM) generously funded by the Shizuoka Prefectural evaluation methods relied on respondents’ self-reported Government. The authors also gratefully acknowledge the physicians and staff perceptions and experiences. It is possible that participants at the clinic sites in Mori-machi and Kikugawa, Japan, for their hospitality and may have underreported or overreported the impact of the assistance in helping to coordinate data collection at each site. The authors also thank the standardized patient instructors at the University of Michigan training on their performance and skill. To combat this lim- who generously and patiently taught resident learners from Japan. itation, future research could measure the impact of SPI- based training on objectively-derived measures, such as Compliance with ethical guidelines correct diagnoses or correct adherence to an examinations’ Competing interests ordered steps. And last, given deep-rooted taboos sur- The authors declare that they have no competing interests. rounding gender-specific health care (e.g., code of civilized Received: 16 January 2015 Accepted: 28 September 2015 morality), study participants may have been influenced (knowingly or unknowingly) by their own cultural biases. Given the study’s mixed methods design and the applica- tion of multiple data collection procedures—using post training feedback forms, semi-structured interviews, and a References 1. Tsuda T, Aoyama H, Froom J. 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