Perceived factors in high-quality residency training programs in Japan: a thematic analysis of perspectives from directors of high-performing programs

Clinical training programs in Japan vary in performance, but the features perceived as important in high-performing programs remain insufficiently understood. This qualitative study explored the perspectives of program directors from high-performing hospital-based initial residency training programs in Japan, focusing on performance in the Clinical Simulation Video-Innovative Examination (CSV-IE), a component of the General Medicine In-Training Examination. Semi-structured interviews were conducted with nine program directors from programs ranked in the top 25% by CSV-IE accuracy rate, and the data were analyzed using thematic analysis. Program directors indicated seven interrelated training features as important: resident autonomy and progressive responsibility; broad and diverse clinical exposure; accessible, locally tailored learning resources; collaborative reflection and cascading peer-assisted learning; supervisory safety nets and supportive feedback culture; deliberate clinical reasoning practice; and professionalism development. Rather than identifying isolated factors, the findings suggest that high-performing programs were perceived as coherent educational systems in which these features mutually reinforced one another. These findings reflect program directors' perspectives and do not establish causal effects, but they may offer practical, adaptable insights for improving residency training programs in Japan, particularly in settings with variable local constraints.