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

Hospital Use of a Web-Based Clinical Knowledge Support System and In-Training Examination Performance Among Postgraduate Resident Physicians in Japan: Nationwide Observational Study

Background

The relationship between educational outcomes and the use of web-based clinical knowledge support systems in teaching hospitals remains unknown in Japan. A previous study on this topic could have been affected by recall bias because of the use of a self-reported questionnaire.

Objective

We aimed to explore the relationship between the use of the Wolters Kluwer UpToDate clinical knowledge support system in teaching hospitals and residents' General Medicine In-Training Examination (GM-ITE) scores. In this study, we objectively evaluated the relationship between the total number of UpToDate hospital use logs and the GM-ITE scores.

Methods

This nationwide cross-sectional study included postgraduate year-1 and -2 residents who had taken the examination in the 2020 academic year. Hospital-level information was obtained from published web pages, and UpToDate hospital use logs were provided by Wolters Kluwer. We evaluated the relationship between the total number of UpToDate hospital use logs and residents' GM-ITE scores. We analyzed 215 teaching hospitals with at least 5 GM-ITE examinees and hospital use logs from 2017 to 2019.

Results

The study population consisted of 3013 residents from 215 teaching hospitals with at least 5 GM-ITE examinees and web-based resource use log data from 2017 to 2019. High-use hospital residents had significantly higher GM-ITE scores than low-use hospital residents (mean 26.9, SD 2.0 vs mean 26.2, SD 2.3; P=.009; Cohen d=0.35, 95% CI 0.08-0.62). The GM-ITE scores were significantly correlated with the total number of hospital use logs (Pearson r=0.28; P<.001). The multilevel analysis revealed a positive association between the total number of logs divided by the number of hospital physicians and the GM-ITE scores (estimated coefficient=0.36, 95% CI 0.14-0.59; P=.001).

Conclusions

The findings suggest that the development of residents' clinical reasoning abilities through UpToDate is associated with high GM-ITE scores. Thus, higher use of UpToDate may lead physicians and residents in high-use hospitals to increase the implementation of evidence-based medicine, leading to high educational outcomes.

Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study

BACKGROUND

In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training's quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach-whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience-and explored potential consequences for their clinical education.

METHODS

This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation.

RESULTS

Approximately half of the participants chose IM rotation periods of 32-40 weeks. A significant proportion of participants rotated in 5-7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices.

CONCLUSIONS

Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences.

How Do We Establish the Utility and Evidence of General Medicine in Japan?

Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.

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.

Safety culture survey among medical residents in Japan: a nationwide cross-sectional study

PURPOSE

This study aimed to examine safety culture among Japanese medical residents through a comparative analysis of university and community hospitals and an investigation of the factors related to safety culture.

METHOD

This nationwide cross-sectional study used a survey to assess first and second-year medical residents' perception of safety culture. We adapted nine key items from the Safety Awareness Questionnaire to the Japanese training environment and healthcare system. Additionally, we explored specific factors relevant to safety culture, such as gender, year of graduation, age, number of emergency room duties per month, average number of admissions per day, incident experience, incident reporting experience, barriers to incident reporting and safety culture. We analysed the data using descriptive statistics and multivariate logistic regression analysis.

RESULTS

We included 5289 residents (88.6%) from community training hospitals and 679 residents (11.4%) from university hospitals. A comparative analysis of safety culture between the two groups on nine representative questions revealed that the percentage of residents who reported a positive atmosphere at their institution was significantly lower at university hospitals (81.7%) than at community hospitals (87.8%) (p<0.001). The other items were also significantly lower for university hospital residents. After adjusting for multivariate logistic analysis, university hospital training remained significantly and negatively associated with all nine safety culture items. Furthermore, we also found that university hospital residents perceived a significantly lower level of safety culture than community hospital residents.

IMPLICATIONS

Further research and discussion on medical professionals' perception of safety culture in their institutions as well as other healthcare professionals' experiences are necessary to identify possible explanations for our findings and develop strategies for improvement.

Association between prolonged weekly duty hours and self-study time among residents: a cross-sectional study

PURPOSE

In 2024, the Japanese government will enforce a maximum 80-hour weekly duty hours (DHs) regulation for medical residents. Although this reduction in weekly DHs could increase the self-study time (SST) of these residents, the relationship between these two variables remains unclear. The aim of the study was to investigate the relationship between the SST and DHs of residents in Japan.

METHODS

In this nationwide cross-sectional study, the subjects were candidates of the General Medicine In-Training Examination in the 2020 academic year. We administered questionnaires and categorically asked questions regarding daily SST and weekly DHs during the training period. To account for hospital variability, proportional odds regression models with generalized estimating equations were used to analyse the association between SST and DHs.

RESULTS

Of the surveyed 6117 residents, 32.0% were female, 49.1% were postgraduate year-1 residents, 83.8% were affiliated with community hospitals, and 19.9% worked for ≥80 hours/week. Multivariable analysis revealed that residents working ≥80 hours/week spent more time on self-study than those working 60-70 hours/week. Conversely, residents who worked <50 hours/week spent less time on self-study than those who worked 60-70 hours/week. The factors associated with longer SST were sex, postgraduate year, career aspiration for internal medicine, affiliation with community hospitals, academic involvement, and well-being.

CONCLUSION

Residents with long DHs had longer SSTs than residents with short DHs. Future DH restrictions may not increase but rather decrease resident SST. Effective measures to encourage self-study are required, as DH restrictions may shorten SST.

Medical resident's pursuing specialty and differences in clinical proficiency among medical residents in Japan: a nationwide cross-sectional study

IMPORTANCE

Standardized examinations assess both learners and training programs within the medical training system in Japan. However, it is unknown if there is an association between clinical proficiency as assessed by the General Medicine In-Training Examination (GM-ITE) and pursuing specialty.

OBJECTIVE

To determine the relative achievement of fundamental skills as assessed by the standardized GM-ITE based on pursuing career specialty among residents in the Japanese training system.

DESIGN

Nationwide cross-sectional study.

SETTING

Medical residents in Japan who attempted the GM-ITE in their first or second year were surveyed.

PARTICIPANTS

A total of 4,363 postgraduate years 1 and 2 residents who completed the GM-ITE were surveyed between January 18 and March 31, 2021.

MAIN MEASURES

GM-ITE total scores and individual scores in each of four domains assessing clinical knowledge: 1) medical interview and professionalism, 2) symptomatology and clinical reasoning, 3) physical examination and treatment, and 4) detailed disease knowledge.

RESULTS

When compared to the most pursued specialty, internal medicine, only those residents who chose general medicine achieved higher GM-ITE scores (coefficient 1.38, 95% CI 0.08 to 2.68, p = 0.038). Conversely, the nine specialties and "Other/Not decided" groups scored significantly lower. Higher scores were noted among residents entering general medicine, emergency medicine, and internal medicine and among those who trained in community hospitals with higher numbers of beds, were more advanced in their training, spent more time working and studying, and cared for a moderate but not an extreme number of patients at a time.

CONCLUSIONS

Levels of basic skill achievement differed depending on respective chosen future specialties among residents in Japan. Scores were higher among those pursuing careers in general medical fields and lower among those pursuing highly specialized careers. Residents in training programs devoid of specialty-specific competition may not possess the same motivations as those in competitive systems.

Characteristics of University Hospitals Implementing the Postgraduate Clinical Training "Tasukigake Method" and Their Correlation with Program Popularity: A Cross-Sectional Study

PURPOSE

In 2004, the postgraduate clinical training system in Japan was radically revised by introducing a super-rotation matching system. Although postgraduate clinical training became a mandatory 2 years of training, the program and operation were left to each facility's discretion, leading to training-program popularity differences. The Japanese Tasukigake method provides clinical training in which "hospitals where junior residents work" and "external hospitals/clinics that provide clinical training" conduct clinical training alternately on a 1-year basis. The study aimed to identify the characteristics of university hospitals that implement the Tasukigake method to help educators and medical institutions create more attractive and effective programs.

METHODS

All 81 university main hospitals were included in this cross-sectional study. The information regarding Tasukigake method implementation was collected from the facilities' websites. The training program's matching rate (popularity) was calculated from the Japan Residency Matching Program's interim report data (academic 2020). We used multiple linear regression analysis to evaluate the association between Tasukigake method implementation, program popularity, and university hospital characteristics.

RESULTS

The Tasukigake method was implemented by 55 (67.9%) university hospitals, significantly more by public university hospitals (44/55, 80%) than by private (11/55, 20%) (P < 0.01) and by hospitals without branches (38/55, 69.1%) than with branches (17/55, 30.9%) (P < 0.001). The maximum hiring capacity of junior residents (P = 0.015) and number of branches (P < 0.001) were negatively correlated, and the population of the hospital's city (P = 0.003) and salary/month (P = 0.011) were positively correlated with the Tasukigake method implementation. Multiple linear regression analysis results showed no significant association between the matching rate (popularity) and Tasukigake method implementation.

CONCLUSION

The results show no association between Tasukigake method and program popularity; also, highly specialized university hospitals in cities with fewer branch hospitals were more likely to implement the Tasukigake method.

Impact of duty hours on competency-related knowledge acquisition among community hospital residents

Background

The effect of duty hour (DH) restrictions on postgraduate residents' acquisition of clinical competencies is unclear. We evaluated the relationship between DHs and competency-related knowledge acquisition using the General Medicine In-training Examination (GM-ITE).

Methods

We conducted a multicenter, cross-sectional study of community hospital residents among 2019 GM-ITE examinees. Self-reported average DHs per week were classified into five DH categories and the competency domains were classified into four areas: symptomatology and clinical reasoning (CR), physical examination and clinical procedure (PP), medical interview and professionalism (MP), and disease knowledge (DK). The association between these scores and DHs was examined using random-intercept linear models with and without adjustment for confounding factors.

Results

We included 4753 participants in the analyses. Of these, 31% were women, and 49.1% were in the postgraduate year (PGY) 2. Mean CR and MP scores were lower among residents in Category 1 (<50 h) than in residents in Category 3 (≥60 and <70 h; reference group). Mean DK scores were lower among residents in Categories 1 and 2 (≥50 and <60 h) than in the reference group. PGY-2 residents in Categories 1 and 2 had lower CR scores than those in Category 3; however, PGY-1 residents in Category 5 showed higher scores.

Conclusions

The relationship between DHs and each competency area is not strictly linear. The acquisition of knowledge of physical examination and clinical procedures skills in particular may not be related to DHs.

Clinical Clerkships in General Medicine Enable Students to Acquire Basic Medical Competencies and Experience in Community-Based Integrated Care: A Descriptive Questionnaire-Based Study

Background No previous research has targeted educators regarding educational practice and the achievements of students in terms of the learning objectives of clinical clerkships in university general medicine departments of Japan. We aimed to clarify the characteristics of clinical clerkships in Japanese general medicine departments using a questionnaire administered to chairpersons of university general medicine departments. Methods This was a descriptive questionnaire-based study using Google Forms (Google, Inc., Mountain View, CA, USA). We asked the chairpersons of general medicine departments in Japanese universities the following questions, with responses given on a 5-point Likert scale: Question 1: How well are primary symptoms in the national model core curriculum for undergraduate medical education taught in clinical clerkships in university general medicine departments? Question 2: How successfully can students achieve the learning objectives of the national model core curriculum for undergraduate medical education through clinical clerkships in general medicine departments of university hospitals? Question 3: How successfully can students achieve the learning objectives of the national model core curriculum for undergraduate medical education through clinical clerkships in other community clinics or hospitals? The results of the questionnaire responses are described as mean±standard deviation. Results Of the 71 Japanese universities with general medicine departments, 43 were included in the analysis. For Question 1, the symptoms and pathophysiologies with a mean score of 4 points or higher were fever, general malaise, anorexia, weight loss or gain, edema, abdominal pain, lymphadenopathy, and headache. All those symptoms require basic medical competencies. For Questions 2 and 3, the intramural clinical clerkship of general medicine departments had a higher mean score than the extramural clinical clerkship for diagnostic reasoning that emphasizes medical history and physical examination and a comprehensive approach to patients with multiple health problems. In contrast, the extramural clinical clerkship, in which medical students can build experience with community-integrated care, had a mean score of 3 points or higher for all items. Conclusions The clinical clerkship in general medicine departments of Japanese universities provides students with chances to acquire clinical competencies regarding primary symptoms and pathophysiologies. Additionally, the extramural clinical clerkship provides experience in community-based integrated care, including home medical care, collaboration, health and welfare, and long-term care.

Relationship between COVID-19 care and burnout among postgraduate clinical residents in Japan: a nationwide cross-sectional study

OBJECTIVE

The relationship between the care of patients with COVID-19 and mental health among resident physicians in Japan is imperative for ensuring appropriate care of patients with COVID-19 and should be clarified. We herein assessed the relationship between the care of patients with COVID-19 and mental health among postgraduate year 1 (PGY-1) and PGY-2 resident physicians and factors associated with mental health.

DESIGN

This nationwide cross-sectional study analysed data obtained using the clinical training environment self-reported questionnaire.

SETTING

An observational study across Japan among resident physicians (PGY-1 and PGY-2) from 583 teaching hospitals.

PARTICIPANTS

Examinees who took the general medicine in-training examination of academic year 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Patient Health Questionnaire and Mini-Z 2.0 were used to assess mental health, and experience of caring for patients with COVID-19 was divided into three groups (none, 1-10 and ≥11). The prevalence of mental conditions in the three groups was compared using the 'modified' Poisson generalised estimating equations by adjusting for prefecture-level, hospital-level and resident-level variables.

RESULTS

Of the 5976 participants analysed, 50.9% were PGY-1. The prevalence of burnout was 21.4%. Moreover, 47.0% of all resident physicians had no experience in the care of patients with COVID-19. The well-experienced group accounted for only 7.9% of the total participants. A positive association was found between the number of caring patients with COVID-19 and burnout (prevalence ratio 1.25; 95% CI 1.02 to 1.53). Moreover, the shortage of personal protective equipment was identified as a major contributor to burnout (prevalence ratio 1.60; 95% CI 1.36 to 1.88).

CONCLUSIONS

Resident physicians who experienced more care of patients with COVID-19 had slightly greater burnout prevalence than those who did not. Approximately half of resident physicians did not participate in the care of patients with COVID-19, which posed a challenge from an educational perspective.

Hands-on Clinical Clerkship at the Department of General Medicine in a University Hospital Improves Medical Students' Self-Evaluation of Skills of Performing Physical Examinations and Informed Consent: A Questionnaire-Based Prospective Study

Introduction

The educational effects of a hands-on clinical clerkship on medical students at the Department of General medicine of Japanese university hospitals remain to be clarified. This study aimed to determine how such education affects medical students' self-evaluation of their clinical skills.

Methods

We enrolled 5th-year-grade students at the Department of General Medicine, Saga University Hospital, Japan in 2017. The students were divided into those who were going to have Japanese traditional-style observation-based training mainly in the outpatient clinic (Group O) and those in the 2018, new-style, hands-on clinical clerkship as one of the group practice members in outpatient and inpatient clinics (Group H). A questionnaire survey using the 4-point Likert scale for self-evaluation of the students' clinical skills at the beginning and the end of their training was conducted in both groups. The pre- and post-training scores of each item in both groups were compared and analyzed using the Mann-Whitney test.

Results

All 99 students in Group O and 121 of 123 students in Group H answered the questionnaires. The response rate was 99%. Two items regarding the abilities of "can perform a systemic physical examination quickly and efficiently" and "can clearly explain the current medical condition, therapeutic options, or risks associated with treatment, and discuss the process for obtaining informed consent" showed higher scores in the post-training survey in Group H than in Group O. There were no differences in these scores in the pre-training survey between the two groups.

Conclusion

A hands-on clinical clerkship at the Department of General medicine in a university hospital in Japan provided medical students with higher self-confidence in their skills of performing a physical examination and better understanding of patients' treatment options and the process of informed consent than observation-based training.

Factors associated with delayed diagnosis of appendicitis in adults: A single-center, retrospective, observational study

Appendicitis is one of the most common causes of acute abdominal pain; yet the risk of delayed diagnosis remains despite recent advances in abdominal imaging. Understanding the factors associated with delayed diagnosis can lower the risk of diagnostic errors for acute appendicitis. These factors, including physicians’ specialty as a generalist or non-generalist, were evaluated through a retrospective, observational study of adult acute appendicitis cases at a single center, between April 1, 2014, and March 31, 2021. The main outcome was timely diagnosis, defined as "diagnosis at the first visit if the facility had computed tomography (CT) capability" or "referral to an appropriate medical institution promptly after the first visit for a facility without CT capability," with all other cases defined as delayed diagnosis. The frequency of delayed diagnosis was calculated and associated factors evaluated through multivariate and exploratory analyses. The overall rate of delayed diagnosis was 26.2% (200/763 cases). Multivariate analysis showed that tenderness in the right lower abdominal region, absence of diarrhea, a consultation of ≤6 h after symptom onset, and consultation with a generalist were associated with a decreased risk of delayed diagnosis of acute appendicitis. Exploratory analysis found that generalists performed more physical findings related to acute appendicitis, suggesting that this diagnostic approach may be associated with timely diagnosis. Future studies should adjust for other potential confounding factors, including patient complexity, consultation environment, number of physicians, diagnostic modality, and physician specialties.

Increasing the Status of Hospital General Medicine Departments with Emphasis on Outpatient Care in Japan

Demand is increasing for general medicine services in Japan, a super-aged society. The new medical specialty system introduced in 2019 obligates physicians to obtain a qualified specialty from among 19 basic specialty fields, including general medicine, before obtaining more advanced qualified subspecialties. The role of the department of general medicine in Japan varies in each hospital. Remuneration for medical services obtained by general medicine departments that mainly provide outpatient care is relatively low, making it difficult to fill positions in this department within a hospital. We conducted a narrative review and discussed ways to increase the status of hospital general medicine departments that mainly provide outpatient care. We consider the following four points to be important: improvement of diagnostic capabilities in the outpatient setting; playing a central role in education for medical students and residents; active involvement with patients who have diagnostic difficulties or social problems; and branding and promotion of the general medicine department. We envision that adopting an active approach to these points will increase the status of general medicine departments that mainly provide outpatient care within the hospital, allowing such newly established departments to start easily in Japanese hospitals in the future.

Association between mental health and duty hours of postgraduate residents in Japan: a nationwide cross-sectional study

The new duty hour (DH) limit for doctors in Japan will begin in 2024, setting the maximum DHs for postgraduate residents at approximately 80 h weekly. To set appropriate limits, understanding the association between DHs and psychological health is necessary. Thus, we assessed the relationship between residents' psychological health and DHs. We conducted a cross-sectional study involving examinees of the General Medicine In-training Examination 2020. Mental health outcomes were measured dichotomously using the Patient Health Questionnaire-2 for depression and Mini-Z 2.0, for burnout, stress, and satisfaction. Weekly DHs were measured in seven categories at 10-h intervals. The prevalence ratios (PRs) between the DH categories were estimated for each outcome. Of the 6045 residents who provided data on DHs and psychological outcomes, 37.3% showed signs of depression, 21.6% experienced burn out, and 39.2% were highly stressed. In contrast, 62.3% were highly satisfied with their training. Proportions of burnout were higher among residents in Category 6 (≥ 90 and < 100 h; PR 1.36; 95% CI 1.11-1.66) and Category 7 (≥ 100 h; PR 1.36; 95% CI 1.10-1.68) compared with residents in Category 3 (≥ 60 and < 70 h; reference). The results partially support the weekly 80-h DH limit in terms of resident well-being.

Factors Associated with Motivation for General Medicine among Rural Medical Students: A Cross-Sectional Study

General medicine, as the Japanese version of primary care or family medicine, is critical for healthcare in aging societies. Medical students’ perceptions of general medicine and education might be associated with changes in the number of general physicians. This study aimed to clarify the association between these perceptions and students’ preferences for general medicine. A cross-sectional survey was conducted among Japanese medical students using a questionnaire on their perceptions regarding general medicine, background, and preferences for general medicine (knowledge, interest, motivation, and intention). The response rate was 70.3% (490/697). There was a large percentage gap between interest and motivation; therefore, a logistic regression analysis was performed to investigate the cause of this difference. The perceptions that general medicine meets the needs of society and the lack of general medicine educators were positively associated with motivation to become a general physician. In contrast, perceptions of lack of exposure to general medicine beyond the curriculum and inaccessibility were negatively associated with motivation. Medical students’ motivation to pursue general medicine may increase with improvements in flexible general medicine education and accessibility. Future research should investigate the relationship between students’ perceptions of general medicine and their motivation to become general physicians through longitudinal studies.

Factors Associated With the Acceleration of Patient Enrollment in Clinical Studies: A Cross-Sectional Study

Under-recruitment in clinical trials is an issue worldwide. If the number of patients enrolled is lower than expected, based on the required sample size, then the reliability of the study results and their validation tend to be impaired. The current study therefore evaluated factors associated with accelerating patient enrollment using data from an ongoing multicenter prospective cohort study. The researchers encouraged research institutions to accelerate patient enrollment via e-mail, newsletters, telephone calls, and site visits. We analyzed the relationship between several potential factors associated with acceleration of patient enrollment including site visits and patient enrollment in a real clinical study. Data were collected from 106 research institutions that participated in a multicenter prospective cohort study. Results showed that the following parameters differed in terms of patient enrollment and non-enrollment: urban area (47.2 vs. 67.6%, p = 0.04), clinical research coordinator (CRC) participation in data input to electronic data capture (EDC) (41.7 vs. 11.8%, p < 0.01), and site visit (38.9 vs. 11.8%, p < 0.01). A multivariate analysis revealed that patient enrollment was significantly associated with urban area (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.12–0.86, p = 0.02), CRC participation in data input to EDC (OR 5.02; 95% CI 1.49–16.8; p < 0.01), and site visit (OR 4.54, 95% CI 1.31–15.7, p = 0.01). In conclusion, site visits and CRC participation in data input to EDC had a significant effect on patient enrollment promotion. Moreover, hospitals in rural areas were more effective in promoting patient enrollment than those in urban areas.

Validation of the General Medicine in-Training Examination Using the Professional and Linguistic Assessments Board Examination Among Postgraduate Residents in Japan

Purpose

In Japan, the General Medicine In-training Examination (GM-ITE) was developed by a non-profit organization in 2012. The GM-ITE aimed to assess the general clinical knowledge among residents and to improve the training programs; however, it has not been sufficiently validated and is not used for high-stake decision-making. This study examined the association between GM-ITE and another test measure, the Professional and Linguistic Assessments Board (PLAB) 1 examination.

Methods

Ninety-seven residents who completed the GM-ITE in fiscal year 2019 were recruited and took the PLAB 1 examination in Japanese. The association between two tests was assessed using the Pearson product-moment statistics. The discrimination indexes were also assessed for each question.

Results

A total of 91 residents at 17 teaching hospitals were finally included in the analysis, of whom 69 (75.8%) were women and 59 (64.8%) were postgraduate second year residents. All the participants were affiliated with community hospitals. Positive correlations were demonstrated between the GM-ITE and the PLAB scores (r = 0.58, p < 0.001). The correlations between the PLAB score and the scores in GM-ITE categories were as follows: symptomatology/clinical reasoning (r = 0.54, p < 0.001), physical examination/procedure (r = 0.38, p < 0.001), medical interview/professionalism (r = 0.25, p < 0.001), and disease knowledge (r = 0.36, p < 0.001). The mean discrimination index of each question of the GM-ITE (mean ± SD; 0.23 ± 0.15) was higher than that of the PLAB (0.16 ± 0.16; p = 0.004).

Conclusion

This study demonstrates incremental validity evidence of the GM-ITE to assess the clinical knowledge acquisition. The results indicate that GM-ITE can be widely used to improve resident education in Japan.

The Perception of Rural Medical Students Regarding the Future of General Medicine: A Thematic Analysis

Although the demand for general physicians has increased in Japan because of its aging population, medical universities primarily provide organ-based education; thus, medical students do not receive sufficient general medical education. The number of residents focusing on general medicine remains low; therefore, to understand the present situation regarding general medicine education, we attempted to clarify the views of medical students and the factors influencing them. In this qualitative study, semi-structured interviews were conducted in 12 medical students at Shimane University, and the results were analyzed through thematic analysis. The results indicated the emergence of three themes and 14 concepts. The three overarching themes were as follows: hopes for the field of general medicine, gaps between ideal and reality of general medicine, and factors affecting students’ motivation for specialization in general medicine. Medical students had a positive impression of general medicine and believed that it has potential for further development; however, they felt a gap between their ideals and reality (i.e., unclear expertise). Factors creating this gap included poorly developed education and medical policies. We need to restructure general medicine education based on the participants’ perceptions by establishing collaborative curricula between universities and community hospitals and by increasing students’ exposure to general medicine.

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.

Differences in clinical knowledge levels between residents in two post-graduate rotation programmes in Japan

BACKGROUND

In Japan, between 2010 and 2020, there were two post-graduate training curricula for post-graduate medical education, as follows: comprehensive rotation programmes (CRPs), which require rotation in at least seven clinical departments; and limited rotation programmes (LRPs), which require rotation in fewer clinical departments. The curriculum that should be used for standardized Japanese post-graduate training has long been debated. Multiple studies show that post-graduate trainees who trained with CRPs were more satisfied and confident and gained more clinical experience than those who trained with LRPs. However, a comparison of objective measurements of the clinical knowledge of Japanese post-graduate trainees has not been reported. The aim of this study is to objectively measure and compare the clinical knowledge of trainees in CRPs and LRPs using a component of the Professional and Linguistic Assessment Board test (PLAB test).

METHODS

A nationwide cross-sectional study was conducted in February and March 2020. Post-graduate trainees who graduated from medical school were voluntarily recruited from general hospitals in Japan. To objectively measure the trainees' basic clinical knowledge, the PLAB test was adapted from the UK. The cut-off point was set at 63%, as recommended by the UK General Medical Council. A statistical analysis was conducted to determine whether post-graduate programme differences contributed to the trainees' test scores.

RESULTS

Twenty-two facilities volunteered to participate after recruitment, and 97 trainees from 19 facilities participated in the study. Thirty-one participants (32%) were in a CRP, and 66 participants (68%) were in an LRP. According to multiple logistic regression, the adjusted odds ratio of CRP trainees being in the high-scoring group was 5.16 (95% CI: 1.28-20.73, p<0.05). Mean differences in the scores in paediatrics, mental health and neurology were statistically higher among CRP trainees than LRP trainees.

CONCLUSION

Post-graduate trainees who were in a CRP had better basic clinical competence knowledge (PLAB test) scores and performed better when tested in a wider range of subspecialties. Not only exam performance but also clinical performance and the longitudinal trend of trainees' competency in post-graduate medical training should be evaluated in future studies.

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."