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A cross-cultural survey of residents’ perceived barriers in questioning/challenging authority
  1. H Kobayashi1,
  2. M Pian-Smith2,
  3. M Sato3,
  4. R Sawa4,
  5. T Takeshita4,
  6. D Raemer5
  1. 1Harvard School of Public Health, Boston, MA, USA, and Nippon Medical School Graduate School of Medicine, Tokyo, Japan
  2. 2Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
  3. 3University of Maryland, School of Pharmacy, Baltimore, MD, USA
  4. 4Nippon Medical School, Tokyo, Japan
  5. 5Massachusetts General Hospital, Harvard Medical School, and Center for Medical Simulation, Boston, MA, USA
  1. Correspondence to:
 Dr H Kobayashi
 Harvard School of Public Health, Boston, MA, USA; hajime2004{at}


Objectives: To identify perceived barriers to residents’ questioning or challenging their seniors, to determine how these barriers affect decisions, and to assess how these barriers differ across cultures.

Method: A written questionnaire was administered to residents in teaching hospitals in the US and Japan to assess factors affecting residents’ willingness to question or challenge their superiors. The responses were analyzed for statistical significance of differences between the two cultures and to determine the importance of issues affecting decisions.

Results: Questionnaires were completed by 175 US and 65 Japanese residents, with an overall response rate of 71%. Trainees from both countries believe that questioning and challenging contribute to safety. The perceived importance of specific beliefs about the workplace differed across cultures in seven out of 22 questions. Residents’ decisions to make a challenge were related to the relationships and perceived response of the superiors. There was no statistical difference between the US and Japanese residents in terms of the threshold for challenging their seniors.

Conclusion: We have identified attributes of residents’ beliefs of communication, including several cross-cultural differences in the importance of values and issues affecting one’s decision to question or challenge. In contrast, there was no difference in the threshold for challenging seniors by the Japanese and US residents studied. Changes in organizational and professional culture may be as important, if not more so, than national culture to encourage “speaking up”. Residents should be encouraged to overcome barriers to challenging, and training programs should foster improved relationships and communication between trainers and trainees.

  • trainer-trainee communication
  • patient safety
  • cross-cultural survey

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  • Dr Kobayashi is grateful to the Risk Management Foundation of Harvard Medical Institutions for the opportunity to perform this study. The study was supported in part by a Research in Education Grant (REG) of the Foundation for Anesthesia Education and Research (FAER) awarded to Dr Pian-Smith.

  • Competing interests: none declared.