Who comes to mind when you think of a "teacher?" In East Asian cultures, which have a strong Confucian culture, many people might envision a teacher to be an elderly and experienced individual. If you have seen the popular documentary about a Japanese sushi chef, you might think of someone like Jiro, who continues to hone his skills even into his 80s. These individuals do not teach their apprentices with meticulous instructions but rather through demonstrating their own practices. To illustrate, consider the relationship between Obi-Wan and Luke Skywalker in Star Wars. George Lucas was influenced by Japanese Kurosawa films.
Let me share my story. When I think of a teacher, I remember a second-year resident who was just one year ahead of me during my first year of my residency. We were on the same internal medicine team for three months, and he was not an exceptionally outstanding resident at that time. In fact, he often consulted me, a junior, when he did not know something, making me see him as more of a peer. Our attending physician was one of the most renowned doctors in our hospital, and I felt incredibly lucky to be under his instruction. However, he was extremely busy. If we managed to spend a few hours together each week, it was fortunate.
Once, I made a significant error in clinical judgment which negatively impacted my sense of self as a clinician. I reported the mistake to the attending doctor, who did not reprimand me but instead gave me appropriate feedback. It was a textbook example of excellent feedback. Despite that, I still felt down. The second-year resident noticed my state and took the time to talk with me. He shared some of his own past mistakes, and for the first time, I felt relieved. From that moment, I stopped seeing him as just a colleague and started seeing him as one of my teachers.
It is not uncommon for people to consider those close to them as their most memorable teachers. According to surveys, many learners choose someone just a few years their senior as their most impactful teacher. There is evidence supporting the importance of near-peer teachers, explained by theories like near peer teaching and concepts such as residents as teachers.
In Japan, all residents undergo a two-year program during which they rotate through all medical departments. Additionally, a certification for "attending doctors" is issued by the government, and without this certification, one cannot officially teach residents. To obtain this, more than seven years of clinical experience is required, and one must complete a government certified teaching training program. This reflects the Japanese value that a teacher should be a seasoned individual with significant life experience such as Obi-Wan.
I had strong doubts about this traditional view. I wondered if, even in Japan, residents, fellows, and young doctors without the teaching certification who spend the most time together with younger doctors or medical students also need teaching skills. However, there were no opportunities in Japan for them to hone these skills. Thus, a few colleagues and I started a nationwide Residents-as-Teachers fellowship program in 2018 targeting residents and young attending doctors with less than seven years of clinical experience who were not yet eligible to attend the certified supervising physician training issued by the government necessary for credentialing as an attending doctor. Initially held in person until the COVID-19 pandemic, the program transitioned online and, fortunately, continues today. Every year, 40 residents participate, and we now have over 150 graduates in Japan.
The foundation of this fellowship program is the teaching competency list for residents-as-teachers. As the field of medical education is vast, we needed to determine what was essential for resident teachers. While there is a resident-as-teachers competency list, there were no published articles which determined these competencies in a scientific manner. Using the modified Delphi method, my colleague and I identified 27 competencies that were truly necessary for residents to master prior to becoming attendings.
The central idea in our paper relates to the educational distance between learners and teachers. Educational distance encompasses cognitive, social, and temporal-spatial distances. Being cognitively close allows teachers to understand what learners do not know. Social proximity enables teachers to act as realistically attainable role models. Sharing time and space more extensively helps teachers notice more changes in learners. This concept significantly impacted me, as it was this close educational distance that provided me the support I needed.
Japanese craftsmanship culture has a rigid hierarchy between master and apprentice. In contrast, European craftsmanship culture includes a level known as the "journeyman." A journeyman is an intermediary between the master and the apprentice. Journeymen would often work for daily wages, moving from one master craftsman to another. They were not tied to a single craftsman or employer, allowing them to gain diverse experience and further develop their skills.
In Japan, the value that one must be fully-fledged before teaching others is strong. Through continuing our activity, I hope to spread new values. I shared this project with the Harvard Macy Institute Assessment and Evaluation: Systems Thinking in Health Professions Education course and the Transforming Your Teaching Using Technology course. I received various excellent feedback from my Harvard Macy colleagues. I would like to take this opportunity to thank my team, especially Dr. Alan Leichtner and Dr. Samara Ginzburg, who led our group. Our journey continues.
Tadayuki Hashimoto
