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Education in Cultural Competency in Japan
Educational Perspective
Education in Cultural Competency in Japan Richard Gunderman, MD, PhD, Charles N.C. Hua, MS Cultural competency can help radiologists and other radiology personnel provide better care to patients. This article illustrates this point with reference to Japanese culture. Key Words: Culture; cultural competency; Japan; Japanese; education. ªAUR, 2014
C
ultural competency is an important facet of professional education. Health professionals can be highly knowledgeable and skilled in technical senses, yet fail to care effectively for patients because of a failure to understand cultural differences. The same thing can happen in interprofessional domains, as when a physician interacts with nurses and technologists or with representatives from industry. Although the time available to devote to cultural competency in an educational program is small, merely making professionals aware of the importance of this dimension and providing examples of the differences it can make can be very important. Consider the differences between the US and Japanese culture. Radiologists come into contact with Japanese for a variety of reasons, although many are unfamiliar with Japan’s cultures and traditions, which can lead to avoidable misunderstandings. Japan has the world’s third largest economy, $5.9 trillion. It is also the world’s 10th most populous nation, with 128 million people (1,2). Japan plays a major role in the world’s electronic industry, including companies with substantial presences in radiologic imaging, such as Toshiba, Hitachi, and Fuji. Japan is the fourth largest trading partner of the United States, and there are many US residents and visitors from Japan, particularly in the western United States (3). Japan is often referred to as the ‘‘land of the rising sun.’’ Geographically, the nation is an archipelago, consisting of nearly 6900 islands, the four largest of which constitute nearly all of Japan’s land mass. It has over 100 active volcanoes, and powerful earthquakes, which are sometimes associated with
Acad Radiol 2014; 21:691–693 Indiana University, 702 North Barnhill, 1053, Indianapolis, IN 46202 (R.G.) and John A. Burns School of Medicine, University of Hawai’i, 651 Ilalo St., Honolulu, HI 96813 (C.N.C.H.). Received September 4, 2013; accepted September 9, 2013. Address correspondence to: R.G. e-mail: rbgunder@ iupui.edu ªAUR, 2014 http://dx.doi.org/10.1016/j.acra.2013.09.027
tsunamis that occur several times a century. More than 30 million people live in the vicinity of Japan’s largest city, Tokyo (2). Buddhism and Shinto are the largest religions; however, 70% of Japanese say they are not religious (4). In terms of public health, Japan has the highest life expectancy at birth and the lowest homicide rate in the world (5). Japan is a remarkable country demographically. For example, its birth rate has plummeted since the post-World War II baby boom (6). As a result, it is projected that by 2050 the population will fall to 108 million, and 40% of the population will be aged >65 years (7). This will pose an important economic challenge in the form of a worker shortage. Japan is also a much more genetically, culturally, and linguistically homogenous nation than the United States. For example, foreign-born, non-naturalized workers make up <2% of the population, and >99% of its people speak Japanese as their first language (8). By contrast, only about 80% of Americans are native English speakers (9). In terms of healthcare, Japanese culture differs from that of the United States in a number of important respects. Patients are accustomed to being seen on a first-come first-served basis, and not by appointment, and those who arrive by ambulance usually have priority (10). Otherwise, a patient would need to be in extremis to move up the priority list. Another major difference concerns the nondisclosure of lifethreatening diagnoses. It is much more common in Japan not to tell patients that they have a disease such as cancer, and in some surveys less than one-third of physicians say they would inform a patient of such a diagnosis (11,12). It is believed that disclosure of such a diagnosis may cause stress and precipitate psychiatric problems, or even suicide (12,13). Japanese typically view death differently from their western counterparts, usually in less scientific terms. For example, brain death is a concept that has not been embraced by the Japanese public. The ‘‘self ’’ is not seen as centered in the head, but rather in the heart or the abdomen. As a result, organ transplantation surgery is much less common in Japan than in the United States (11). Japanese tend to esteem family 691
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and corporate identity more highly than in the United States, and such relationships often trump the decision making of the individual (13). Moreover, advanced directives concerning end of life are not legally recognized, and physicians often defer to families regarding what course of care is most appropriate (11,14). There are many differences in business and professional interactions. Japanese corporate culture tolerates and even expects longer pauses between the posing and answering of a question, and often, the language barrier further heightens this tendency. Someone who answers questions immediately may appear glib or even rash. Furthermore, Americans tend to rely far more on the verbal aspects of communication, wanting to state everything explicitly, whereas Japanese rely on context, shared experiences, and nonverbal clues to convey meaning. A popular Japanese saying holds that you say one thing but understand 10 things (15,16). Japanese are also less likely to appraise people based on their position in a formal organizational hierarchy. To an American, a person’s job title tends to count for more. This can be explained in part by the fact that Japan is a much more patriarchal society than the United States, and promotions and raises are more likely to be based on seniority, age, and marital status. Gender is also an important factor, and women are less likely to move up the corporate ladder. In Japan, people are likely to be paid based on their loyalty to the corporation, whereas in the United States switching employers often produces faster income growth. In addition, Japanese firms place a higher priority on team orientation (14). Gender relations remain a big difference between the two countries. In Japan, the idea of treating women and men as equals is less common (14). This has led to some legal problems for Japanese corporations, which have been sued in the US courts for gender discrimination (17). Yet despite the fact that Japanese culture is generally more maledominated than the United States, there are respects in which the US women may enjoy an advantage over their male counterparts. For example, because Japanese communication is often less verbal than in the United States, American women who rely more on nonverbal and emotional dimensions of communication may actually adapt to the Japanese culture more naturally (18). When conducting business, Japanese tend to esteem personal relationships highly. Americans often evaluate deals in terms of fairness, price, and quality. In Japan, it is important to regard business as a means of building interpersonal ties. Gift giving plays an important role, and is not seen as a conflict of interest. Going to restaurants and bars is encouraged, and drinking together can be an important bonding experience. What to Americans might appear as intoxication to the Japanese might help to create a lifelong bond. In such contexts, Americans should be aware that talking loudly is not frowned upon, and slurping food is one way of showing that you are enjoying your meal (18). Corporations play a much larger role in general in Japan. In contrast to the United States, where most people change 692
Academic Radiology, Vol 21, No 5, May 2014
employers numerous times over their lifetime, approximately 80% of Japanese work for the same employer for life (18). The corporation is more than an employer; it plays an important cultural role. For instance, Japanese firms provide housing and social activities for many of their workers (14). Employees work together for much longer periods of time and form deeper bonds. Confrontation as a means of decision making is frowned upon and avoided at almost any cost. Instead Japanese prefer to reach decisions by building consensus (14). The team comes first. Generally speaking, Japanese business people, physicians, and scientists are more likely to have studied American culture than Americans are to have studied Japanese culture, and such cultural differences can lead to avoidable misunderstandings, especially on the American side. For example, American workers may be highly competent but fail to move up Japanese corporate ladders because of their aggressive communication styles (15). In addition, Americans may grow impatient with Japanese business partners over the apparent slowness with which they make decisions, failing to realize that Japanese place a high premium on thinking things through thoroughly and building consensus (16,18). Sometimes such cultural differences make national news. For example, when Akio Toyoda came to the United States to testify before Congress regarding the recall of many Toyota vehicles in 2009 and 2010, his approach seemed foreign to many US observers. For one thing, instead of offering an elaborate defense, he kept saying, ‘‘I’m sorry.’’ In addition, he looked down when he did this, which might lead an American to think the apology was insincere. In Japan, however, it would be inappropriate to look someone in the eye when apologizing. In reporting the event, the US press frequently alluded to the fact that Toyoda responded in a very ‘‘Japanese fashion’’ (16). Japanese business leaders tend to feel a stronger sense of responsibility to preserve and promote the identity of their corporation. They are responsible not just for the quarterly or annual financial report and share price, but for its identity, integrity, and even honor. To engage in practices that might bring dishonor or disgrace on the corporation would be almost unthinkable. By contrast, US leaders are often highly touted and rewarded for ‘‘shaking up’’ an organization’s culture. Press coverage of business in the United States tends to focus on individual leaders, as though they are the principal causes of a corporation’s performance, whereas Japanese put more stock in corporate identity (18). The differences in culture between Japan and the United States comprise just one example of the importance of cultural competency. Similar differences obtain in other cultures, such as China, India, and Russia. No health professional can be an expert in all such cultures, but it is vital that we introduce all learners to the existence of such differences and encourage them to develop some degree of familiarity with them, especially with respect to cultures with which they come into frequent contact. Doing so is an essential aspect of fostering
Academic Radiology, Vol 21, No 5, May 2014
respect and understanding for others, including not only patients but also other health professionals and business people. REFERENCES 1. Statistical Research and Training Institute. The statistical handbook of Japan 2012. Tokyo, Japan: Statistics Bureau, 2012. 2. Stockwin JAA. Governing Japan: divided politics in a resurgent economy. Malden, MA and Oxford: Wiley-Blackwell, 2008. 3. U.S.-Japan Economic Harmonization Initiative. Available at: http://www.ustr. gov/countries-regions/japan-korea-apec/japan. Accessed August 25, 2013. 4. International religious freedom report 2006. Available at: http://www.state. gov/j/drl/rls/irf/2006/71342.htm. Accessed August 25, 2013. 5. The world factbook. Available at: https://www.cia.gov/library/publications/ the-world-factbook/rankorder/2102rank.html. Accessed August 25, 2013. 6. Matsumoto Y, Yamabe S. Family size preference and factors affecting the fertility rate in Hyogo, Japan. Reprod Health 2013; 10:6. 7. National Institute of Population and Social Security Research. Population projections for Japan: 2001-2050 (with long-range population projections: 2051-2100). Uchisaiwaicyo, Chiyoda-ku, Tokyo, Japan: National Institute of Population and Social Security Research, 2002. 8. Lie J. Multiethnic Japan. Social Science Japan Journal 2002; 5:297–300.
EDUCATION IN CULTURAL COMPETENCY
9. Language use in the United States: 2007. U.S. Census Bureau. Available at: http://www.census.gov/hhes/socdemo/language/data/acs/ACS-12. pdf. Accessed August 23, 2013. 10. Fetters M. Cultural clashes: Japanese patients and U.S. maternity care. Journal of the International Institute 1997;4. 11. Berger J. Culture and ethnicity in clinical care. Arch Intern Med 1998; 158: 2085–2090. 12. Powell T. Cultural context in medical ethics: lessons from Japan. Philos Ethics Humanit Med 2006; 1:E4. 13. Hosaka T, Awazu H, Fukunishi I, et al. Disclosure of true diagnosis in Japanese cancer patients. Gen Hosp Psychiatry 1999; 21:209–213. 14. The U.S./Japanese HR culture clash. Available at: http://vcampus.uom.ac. mu/upload/public/2003311131933.htm. Accessed August 26, 2013. 15. How Americans can pierce Japan’s ‘rice-paper ceiling’;. Available at: http://www.bizjournals.com/atlanta/stories/1997/12/15/newscolumn5.html. Accessed August 26, 2013. 16. Toyoda in Washington: A clash of cultures? Available at: http://www. cnn.com/2010/BUSINESS/02/24/money.toyoda.culture.clash/index.html. Accessed August 26, 2013. 17. Managing; Japanese-American cultural clash. Available at: http:// www.nytimes.com/1990/09/09/business/managing-japanese-americancultural-clash.html. Accessed August 25, 2013. 18. Kopp R. The rice-paper ceiling: breaking through Japanese corporate culture. Berkeley, California: Stone Bridge Press, 2000.
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Education in Cultural Competency in Japan Richard Gunderman, MD, PhD, Charles N.C. Hua, MS Cultural competency can help radiologists and other radiology personnel provide better care to patients. This article illustrates this point with reference to Japanese culture. Key Words: Culture; cultural competency; Japan; Japanese; education. ªAUR, 2014
C
ultural competency is an important facet of professional education. Health professionals can be highly knowledgeable and skilled in technical senses, yet fail to care effectively for patients because of a failure to understand cultural differences. The same thing can happen in interprofessional domains, as when a physician interacts with nurses and technologists or with representatives from industry. Although the time available to devote to cultural competency in an educational program is small, merely making professionals aware of the importance of this dimension and providing examples of the differences it can make can be very important. Consider the differences between the US and Japanese culture. Radiologists come into contact with Japanese for a variety of reasons, although many are unfamiliar with Japan’s cultures and traditions, which can lead to avoidable misunderstandings. Japan has the world’s third largest economy, $5.9 trillion. It is also the world’s 10th most populous nation, with 128 million people (1,2). Japan plays a major role in the world’s electronic industry, including companies with substantial presences in radiologic imaging, such as Toshiba, Hitachi, and Fuji. Japan is the fourth largest trading partner of the United States, and there are many US residents and visitors from Japan, particularly in the western United States (3). Japan is often referred to as the ‘‘land of the rising sun.’’ Geographically, the nation is an archipelago, consisting of nearly 6900 islands, the four largest of which constitute nearly all of Japan’s land mass. It has over 100 active volcanoes, and powerful earthquakes, which are sometimes associated with
Acad Radiol 2014; 21:691–693 Indiana University, 702 North Barnhill, 1053, Indianapolis, IN 46202 (R.G.) and John A. Burns School of Medicine, University of Hawai’i, 651 Ilalo St., Honolulu, HI 96813 (C.N.C.H.). Received September 4, 2013; accepted September 9, 2013. Address correspondence to: R.G. e-mail: rbgunder@ iupui.edu ªAUR, 2014 http://dx.doi.org/10.1016/j.acra.2013.09.027
tsunamis that occur several times a century. More than 30 million people live in the vicinity of Japan’s largest city, Tokyo (2). Buddhism and Shinto are the largest religions; however, 70% of Japanese say they are not religious (4). In terms of public health, Japan has the highest life expectancy at birth and the lowest homicide rate in the world (5). Japan is a remarkable country demographically. For example, its birth rate has plummeted since the post-World War II baby boom (6). As a result, it is projected that by 2050 the population will fall to 108 million, and 40% of the population will be aged >65 years (7). This will pose an important economic challenge in the form of a worker shortage. Japan is also a much more genetically, culturally, and linguistically homogenous nation than the United States. For example, foreign-born, non-naturalized workers make up <2% of the population, and >99% of its people speak Japanese as their first language (8). By contrast, only about 80% of Americans are native English speakers (9). In terms of healthcare, Japanese culture differs from that of the United States in a number of important respects. Patients are accustomed to being seen on a first-come first-served basis, and not by appointment, and those who arrive by ambulance usually have priority (10). Otherwise, a patient would need to be in extremis to move up the priority list. Another major difference concerns the nondisclosure of lifethreatening diagnoses. It is much more common in Japan not to tell patients that they have a disease such as cancer, and in some surveys less than one-third of physicians say they would inform a patient of such a diagnosis (11,12). It is believed that disclosure of such a diagnosis may cause stress and precipitate psychiatric problems, or even suicide (12,13). Japanese typically view death differently from their western counterparts, usually in less scientific terms. For example, brain death is a concept that has not been embraced by the Japanese public. The ‘‘self ’’ is not seen as centered in the head, but rather in the heart or the abdomen. As a result, organ transplantation surgery is much less common in Japan than in the United States (11). Japanese tend to esteem family 691
GUNDERMAN AND HUA
and corporate identity more highly than in the United States, and such relationships often trump the decision making of the individual (13). Moreover, advanced directives concerning end of life are not legally recognized, and physicians often defer to families regarding what course of care is most appropriate (11,14). There are many differences in business and professional interactions. Japanese corporate culture tolerates and even expects longer pauses between the posing and answering of a question, and often, the language barrier further heightens this tendency. Someone who answers questions immediately may appear glib or even rash. Furthermore, Americans tend to rely far more on the verbal aspects of communication, wanting to state everything explicitly, whereas Japanese rely on context, shared experiences, and nonverbal clues to convey meaning. A popular Japanese saying holds that you say one thing but understand 10 things (15,16). Japanese are also less likely to appraise people based on their position in a formal organizational hierarchy. To an American, a person’s job title tends to count for more. This can be explained in part by the fact that Japan is a much more patriarchal society than the United States, and promotions and raises are more likely to be based on seniority, age, and marital status. Gender is also an important factor, and women are less likely to move up the corporate ladder. In Japan, people are likely to be paid based on their loyalty to the corporation, whereas in the United States switching employers often produces faster income growth. In addition, Japanese firms place a higher priority on team orientation (14). Gender relations remain a big difference between the two countries. In Japan, the idea of treating women and men as equals is less common (14). This has led to some legal problems for Japanese corporations, which have been sued in the US courts for gender discrimination (17). Yet despite the fact that Japanese culture is generally more maledominated than the United States, there are respects in which the US women may enjoy an advantage over their male counterparts. For example, because Japanese communication is often less verbal than in the United States, American women who rely more on nonverbal and emotional dimensions of communication may actually adapt to the Japanese culture more naturally (18). When conducting business, Japanese tend to esteem personal relationships highly. Americans often evaluate deals in terms of fairness, price, and quality. In Japan, it is important to regard business as a means of building interpersonal ties. Gift giving plays an important role, and is not seen as a conflict of interest. Going to restaurants and bars is encouraged, and drinking together can be an important bonding experience. What to Americans might appear as intoxication to the Japanese might help to create a lifelong bond. In such contexts, Americans should be aware that talking loudly is not frowned upon, and slurping food is one way of showing that you are enjoying your meal (18). Corporations play a much larger role in general in Japan. In contrast to the United States, where most people change 692
Academic Radiology, Vol 21, No 5, May 2014
employers numerous times over their lifetime, approximately 80% of Japanese work for the same employer for life (18). The corporation is more than an employer; it plays an important cultural role. For instance, Japanese firms provide housing and social activities for many of their workers (14). Employees work together for much longer periods of time and form deeper bonds. Confrontation as a means of decision making is frowned upon and avoided at almost any cost. Instead Japanese prefer to reach decisions by building consensus (14). The team comes first. Generally speaking, Japanese business people, physicians, and scientists are more likely to have studied American culture than Americans are to have studied Japanese culture, and such cultural differences can lead to avoidable misunderstandings, especially on the American side. For example, American workers may be highly competent but fail to move up Japanese corporate ladders because of their aggressive communication styles (15). In addition, Americans may grow impatient with Japanese business partners over the apparent slowness with which they make decisions, failing to realize that Japanese place a high premium on thinking things through thoroughly and building consensus (16,18). Sometimes such cultural differences make national news. For example, when Akio Toyoda came to the United States to testify before Congress regarding the recall of many Toyota vehicles in 2009 and 2010, his approach seemed foreign to many US observers. For one thing, instead of offering an elaborate defense, he kept saying, ‘‘I’m sorry.’’ In addition, he looked down when he did this, which might lead an American to think the apology was insincere. In Japan, however, it would be inappropriate to look someone in the eye when apologizing. In reporting the event, the US press frequently alluded to the fact that Toyoda responded in a very ‘‘Japanese fashion’’ (16). Japanese business leaders tend to feel a stronger sense of responsibility to preserve and promote the identity of their corporation. They are responsible not just for the quarterly or annual financial report and share price, but for its identity, integrity, and even honor. To engage in practices that might bring dishonor or disgrace on the corporation would be almost unthinkable. By contrast, US leaders are often highly touted and rewarded for ‘‘shaking up’’ an organization’s culture. Press coverage of business in the United States tends to focus on individual leaders, as though they are the principal causes of a corporation’s performance, whereas Japanese put more stock in corporate identity (18). The differences in culture between Japan and the United States comprise just one example of the importance of cultural competency. Similar differences obtain in other cultures, such as China, India, and Russia. No health professional can be an expert in all such cultures, but it is vital that we introduce all learners to the existence of such differences and encourage them to develop some degree of familiarity with them, especially with respect to cultures with which they come into frequent contact. Doing so is an essential aspect of fostering
Academic Radiology, Vol 21, No 5, May 2014
respect and understanding for others, including not only patients but also other health professionals and business people. REFERENCES 1. Statistical Research and Training Institute. The statistical handbook of Japan 2012. Tokyo, Japan: Statistics Bureau, 2012. 2. Stockwin JAA. Governing Japan: divided politics in a resurgent economy. Malden, MA and Oxford: Wiley-Blackwell, 2008. 3. U.S.-Japan Economic Harmonization Initiative. Available at: http://www.ustr. gov/countries-regions/japan-korea-apec/japan. Accessed August 25, 2013. 4. International religious freedom report 2006. Available at: http://www.state. gov/j/drl/rls/irf/2006/71342.htm. Accessed August 25, 2013. 5. The world factbook. Available at: https://www.cia.gov/library/publications/ the-world-factbook/rankorder/2102rank.html. Accessed August 25, 2013. 6. Matsumoto Y, Yamabe S. Family size preference and factors affecting the fertility rate in Hyogo, Japan. Reprod Health 2013; 10:6. 7. National Institute of Population and Social Security Research. Population projections for Japan: 2001-2050 (with long-range population projections: 2051-2100). Uchisaiwaicyo, Chiyoda-ku, Tokyo, Japan: National Institute of Population and Social Security Research, 2002. 8. Lie J. Multiethnic Japan. Social Science Japan Journal 2002; 5:297–300.
EDUCATION IN CULTURAL COMPETENCY
9. Language use in the United States: 2007. U.S. Census Bureau. Available at: http://www.census.gov/hhes/socdemo/language/data/acs/ACS-12. pdf. Accessed August 23, 2013. 10. Fetters M. Cultural clashes: Japanese patients and U.S. maternity care. Journal of the International Institute 1997;4. 11. Berger J. Culture and ethnicity in clinical care. Arch Intern Med 1998; 158: 2085–2090. 12. Powell T. Cultural context in medical ethics: lessons from Japan. Philos Ethics Humanit Med 2006; 1:E4. 13. Hosaka T, Awazu H, Fukunishi I, et al. Disclosure of true diagnosis in Japanese cancer patients. Gen Hosp Psychiatry 1999; 21:209–213. 14. The U.S./Japanese HR culture clash. Available at: http://vcampus.uom.ac. mu/upload/public/2003311131933.htm. Accessed August 26, 2013. 15. How Americans can pierce Japan’s ‘rice-paper ceiling’;. Available at: http://www.bizjournals.com/atlanta/stories/1997/12/15/newscolumn5.html. Accessed August 26, 2013. 16. Toyoda in Washington: A clash of cultures? Available at: http://www. cnn.com/2010/BUSINESS/02/24/money.toyoda.culture.clash/index.html. Accessed August 26, 2013. 17. Managing; Japanese-American cultural clash. Available at: http:// www.nytimes.com/1990/09/09/business/managing-japanese-americancultural-clash.html. Accessed August 25, 2013. 18. Kopp R. The rice-paper ceiling: breaking through Japanese corporate culture. Berkeley, California: Stone Bridge Press, 2000.
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