Educational environment and the improvement in the General Medicine In-training Examination score

Association between regional quota program in medical schools and practical clinical competency based on General Medicine In-Training Examination score: a nationwide cross-sectional study of resident physicians in Japan

PURPOSE

A regional quota program (RQP) was introduced in Japan to ameliorate the urban-rural imbalance of physicians. Despite concerns about the low learning abilities of RQP graduates, the relationship between the RQP and practical clinical competency after initiating clinical residency has not been evaluated.

METHODS

We conducted a nationwide cross-sectional study to assess the association between the RQP and practical clinical competency based on General Medicine In-Training Examination (GM-ITE) scores. We compared the overall and category GM-ITE results between RQP graduates and other resident physicians. The relationship between the RQP and scores was examined using multilevel linear regression analysis.

RESULTS

There were 4978 other resident physicians and 1119 RQP graduates out of 6097 participants from 593 training hospitals. Being younger; preferring internal, general, or emergency medicine; managing fewer inpatients; and having fewer ER shifts were all characteristics of RQP graduates. In multilevel multivariable linear regression analysis, there was no significant association between RQP graduates and total GM-ITE scores (coefficient: 0.26; 95% confidence interval: -0.09, 0.61; P = .15). The associations of RQP graduates with GM-ITE scores in each category and specialty were not clinically relevant. However, in the same multivariable model, the analysis did reveal that total GM-ITE scores demonstrated strong positive associations with younger age and GM preference, both of which were significantly common in RQP graduates.

CONCLUSION

Practical clinical competency evaluated based on the GM-ITE score showed no clinically relevant differences between RQP graduates and other resident physicians. Key messages What is already known on this topic Many countries offer unique admission processes to medical schools and special undergraduate programs to increase the supply of physicians in rural areas. Concerns have been raised about the motivation, learning capabilities, and academic performance of the program graduates. What this study adds This nationwide cross-sectional study in Japan revealed clinical competency based on the scores from the General Medicine In-Training Examination showed no clinically relevant differences between graduates of regional quota programs and other resident physicians. How this study might affect research, practice, or policy The study provides evidence to support the Japanese regional quota program from the perspective of clinical competency after initiating clinical practice.

Impact of the resident duty hours on in-training examination score: A nationwide study in Japan

PURPOSE

The relationship between duty hours (DH) and the performance of postgraduate residents is needed to establish appropriate DH limits. This study explores their relationship using the General Medicine In-training Examination (GM-ITE).

MATERIALS AND METHODS

In this cross-sectional study, GM-ITE examinees of 2019 had participated. We analyzed data from the examination and questionnaire, including DH per week (eight categories). We examined the association between DH and GM-ITE score, using random-intercept linear models with and without adjustments.

RESULTS

Five thousand five hundred and ninety-three participants (50.7% PGY-1, 31.6% female, 10.0% university hospitals) were included. Mean GM-ITE scores were lower among residents in Category 2 (45-50 h; mean score difference, -1.05; p < 0.001) and Category 4 (55-60 h; -0.63; p = 0.008) compared with residents in Category 5 (60-65 h; Reference). PGY-2 residents in Categories 2-4 had lower GM-ITE scores compared to those in Category 5. University residents in Category 1 and Category 5 showed a large mean difference (-3.43; p = 0.01).

CONCLUSIONS

DH <60-65 h per week was independently associated with lower resident performance, but more DH did not improve performance. DH of 60-65 h per week may be the optimal balance for a resident's education and well-being.

The impact of autopsy participation on clinical residency

Background

Autopsy has had an essential role in ensuring the quality of education and medical care. However, its role in clinical residency has not been clarified. This study assessed actual autopsy circumstances during clinical residency and evaluated the association between autopsy and clinical knowledge.

Methods

We conducted a cross‐sectional study involving postgraduate second year residents in Japan who took the General Medicine In‐Training Examination in 2019. We modeled the General Medicine In‐Training Examination scores of the residents to examine their association with autopsy experiences and the number of autopsy experiences to assess its predictors.

Results

Of 2715 postgraduate second year residents, 353 (13.8%) had no autopsy participation, and 1015 (39.7%) had only one experience. Although autopsy participation was not related to the mean General Medicine In‐Training Examination score, the residents' clinicopathological conference participation, self‐study for more than 60 min per day, and wish to be pathologists were significantly associated with autopsy experiences. They experienced more autopsies when they belonged to small‐sized hospitals in rural areas performing many autopsies.

Conclusion

We reported the current status of autopsy in clinical residency and showed that more than half of the residents experienced no or only one autopsy. General Medicine In‐Training Examination scores were not correlated with the number of autopsy experiences.

Comprehensive Care through Family Medicine: Improving the Sustainability of Aging Societies

Comprehensive care through family medicine can enhance the approach to multimorbidity, interprofessional collaboration, and community care, and make medical care more sustainable for older people. This study investigated the effect of implementing family medicine and the comprehensiveness of medical care in one of the most rural communities. This implementation research used medical care data from April 2015 to March 2020. Patients' diagnoses were categorized according to the 10th revision of the International Statistical Classification of Disease and Related Health Problems (ICD-10). In 2016, family medicine was implemented in only one general hospital in Unnan. The comprehensiveness rate improved in all ICD-10 disease categories during the study period, especially in the following categories-infections; neoplasms; endocrine, nutritional, and metabolic diseases; mental disorders; nervous system; circulatory system; respiratory system; digestive system; skin and subcutaneous tissue; musculoskeletal system and connective tissue; and the genitourinary system. Implementing family medicine in rural Japanese communities can improve the comprehensiveness of medical care and resolve the issue of fragmentation of care by improving interprofessional collaboration and community care. It can be a solution for the aging of both patient and healthcare professionals. Future research can investigate the relationship between family medicine and patient health outcomes for improved healthcare sustainability.

Difference in the general medicine in-training examination score between community-based hospitals and university hospitals: a cross-sectional study based on 15,188 Japanese resident physicians

BACKGROUND

The general medicine in-training examination (GM-ITE) is designed to objectively evaluate the postgraduate clinical competencies (PGY) 1 and 2 residents in Japan. Although the total GM-ITE scores tended to be lower in PGY-1 and PGY-2 residents in university hospitals than those in community-based hospitals, the most divergent areas of essential clinical competencies have not yet been revealed.

METHODS

We conducted a nationwide, multicenter, cross-sectional study in Japan, using the GM-ITE to compare university and community-based hospitals in the four areas of basic clinical knowledge". Specifically, "medical interview and professionalism," "symptomatology and clinical reasoning," "physical examination and clinical procedures," and "disease knowledge" were assessed.

RESULTS

We found no significant difference in "medical interview and professionalism" scores between the community-based and university hospital residents. However, significant differences were found in the remaining three areas. A 1.28-point difference (95% confidence interval: 0.96-1.59) in "physical examination and clinical procedures" in PGY-1 residents was found; this area alone accounts for approximately half of the difference in total score.

CONCLUSIONS

The standardization of junior residency programs and the general clinical education programs in Japan should be promoted and will improve the overall training that our residents receive. This is especially needed in categories where university hospitals have low scores, such as "physical examination and clinical procedures."

Impact of general medicine rotation training on the in-training examination scores of 11, 244 Japanese resident physicians: a Nationwide multi-center cross-sectional study

BACKGROUND

Although general medicine (GM) faculty in Japanese medical schools have an important role in educating medical students, the importance of residents' rotation training in GM in postgraduate education has not been sufficiently recognized in Japan. To evaluate the relationship between the rotation of resident physicians in the GM department and their In-Training Examination score.

METHODS

This study is a nationwide multi-center cross-sectional study in Japan. Participants of this study are Japanese junior resident physicians [postgraduate year (PGY)-1 and PGY-2] who took the General Medicine In-Training Examination (GM-ITE) in fiscal years 2016 to 2018 at least once (n = 11,244). The numbers of participating hospitals in the GM-ITE were 381, 459, and 503 in 2016, 2017, and 2018.The GM-ITE score consisted of four categories (medical interview/professionalism, symptomatology/clinical reasoning, physical examination/procedure, and disease knowledge). We evaluated relationship between educational environment (including hospital information) and the GM-ITE score.

RESULTS

A total of 4464 (39.7%) residents experienced GM department rotation training. Residents who rotated had higher total scores than residents who did not rotate (38.1 ± 12.1, 36.8 ± 11.7, and 36.5 ± 11.5 for residents who experienced GM rotation training, those who did not experience this training in hospitals with a GM department, and those who did not experience GM rotation training in hospitals without a GM department, p = 0.0038). The association between GM rotation and competency remained after multivariable adjustment in the multilevel model: the score difference between GM rotation training residents and non-GM rotation residents in hospitals without a GM department was estimated as 1.18 (standard error, 0.30, p = 0.0001), which was approximately half of the standard deviation of random effects due to hospital variation (estimated as 2.00).

CONCLUSIONS

GM rotation training improved the GM-ITE score of residents and should be considered mandatory for junior residents in Japan.

Correlations Between the USMLE Step Examinations, American College of Physicians In-Training Examination, and ABIM Internal Medicine Certification Examination

PURPOSE

To assess the correlations between United States Medical Licensing Examination (USMLE) performance, American College of Physicians Internal Medicine In-Training Examination (IM-ITE) performance, American Board of Internal Medicine Internal Medicine Certification Exam (IM-CE) performance, and other medical knowledge and demographic variables.

METHOD

The study included 9,676 postgraduate year (PGY)-1, 11,424 PGY-2, and 10,239 PGY-3 internal medicine (IM) residents from any Accreditation Council for Graduate Medical Education-accredited IM residency program who took the IM-ITE (2014 or 2015) and the IM-CE (2015-2018). USMLE scores, IM-ITE percent correct scores, and IM-CE scores were analyzed using multiple linear regression, and IM-CE pass/fail status was analyzed using multiple logistic regression, controlling for USMLE Step 1, Step 2 Clinical Knowledge, and Step 3 scores; averaged medical knowledge milestones; age at IM-ITE; gender; and medical school location (United States or Canada vs international).

RESULTS

All variables were significant predictors of passing the IM-CE with IM-ITE scores having the strongest association and USMLE Step scores being the next strongest predictors. Prediction curves for the probability of passing the IM-CE based solely on IM-ITE score for each PGY show that residents must score higher on the IM-ITE with each subsequent administration to maintain the same estimated probability of passing the IM-CE.

CONCLUSIONS

The findings from this study should support residents and program directors in their efforts to more precisely identify and evaluate knowledge gaps for both personal learning and program improvement. While no individual USMLE Step score was as strongly predictive of IM-CE score as IM-ITE score, the combined relative contribution of all 3 USMLE Step scores was of a magnitude similar to that of IM-ITE score.