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Kataoka K, Nishizaki Y, Shimizu T, Yamamoto Y, Shikino K, Nojima M, Nagasaki K, Fukui S, Nishiguchi S, Katayama K, Kurihara M, Ueda R, Kobayashi H, Tokuda Y. Hospital Use of a Web-Based Clinical Knowledge Support System and In-Training Examination Performance Among Postgraduate Resident Physicians in Japan: Nationwide Observational Study. JMIR MEDICAL EDUCATION 2024; 10:e52207. [PMID: 38825848 PMCID: PMC11154652 DOI: 10.2196/52207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 06/04/2024]
Abstract
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.
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Affiliation(s)
- Koshi Kataoka
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuji Nishizaki
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan
| | - Yu Yamamoto
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Kiyoshi Shikino
- Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masanori Nojima
- Center for Translational Research, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Kazuya Nagasaki
- Department of Internal Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan
| | - Sho Fukui
- Department of Emergency and General Medicine, Kyorin University, Tokyo, Japan
| | - Sho Nishiguchi
- Department of General Internal Medicine, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Kohta Katayama
- Division of General Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Masaru Kurihara
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Japan
| | - Rieko Ueda
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Hiroyuki Kobayashi
- Department of Internal Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan
| | - Yasuharu Tokuda
- Muribushi Okinawa Center for Teaching Hospitals, Okinawa, Japan
- Tokyo Foundation for Policy Research, Tokyo, Japan
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Shikino K, Nishizaki Y, Fukui S, Yokokawa D, Yamamoto Y, Kobayashi H, Shimizu T, Tokuda Y. Development of a Clinical Simulation Video to Evaluate Multiple Domains of Clinical Competence: Cross-Sectional Study. JMIR MEDICAL EDUCATION 2024; 10:e54401. [PMID: 38421691 PMCID: PMC10940988 DOI: 10.2196/54401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/14/2023] [Accepted: 01/28/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Medical students in Japan undergo a 2-year postgraduate residency program to acquire clinical knowledge and general medical skills. The General Medicine In-Training Examination (GM-ITE) assesses postgraduate residents' clinical knowledge. A clinical simulation video (CSV) may assess learners' interpersonal abilities. OBJECTIVE This study aimed to evaluate the relationship between GM-ITE scores and resident physicians' diagnostic skills by having them watch a CSV and to explore resident physicians' perceptions of the CSV's realism, educational value, and impact on their motivation to learn. METHODS The participants included 56 postgraduate medical residents who took the GM-ITE between January 21 and January 28, 2021; watched the CSV; and then provided a diagnosis. The CSV and GM-ITE scores were compared, and the validity of the simulations was examined using discrimination indices, wherein ≥0.20 indicated high discriminatory power and >0.40 indicated a very good measure of the subject's qualifications. Additionally, we administered an anonymous questionnaire to ascertain participants' views on the realism and educational value of the CSV and its impact on their motivation to learn. RESULTS Of the 56 participants, 6 (11%) provided the correct diagnosis, and all were from the second postgraduate year. All domains indicated high discriminatory power. The (anonymous) follow-up responses indicated that the CSV format was more suitable than the conventional GM-ITE for assessing clinical competence. The anonymous survey revealed that 12 (52%) participants found the CSV format more suitable than the GM-ITE for assessing clinical competence, 18 (78%) affirmed the realism of the video simulation, and 17 (74%) indicated that the experience increased their motivation to learn. CONCLUSIONS The findings indicated that CSV modules simulating real-world clinical examinations were successful in assessing examinees' clinical competence across multiple domains. The study demonstrated that the CSV not only augmented the assessment of diagnostic skills but also positively impacted learners' motivation, suggesting a multifaceted role for simulation in medical education.
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Affiliation(s)
- Kiyoshi Shikino
- Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Yuji Nishizaki
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Sho Fukui
- Department of Emergency and General Medicine, Kyorin University, Tokyo, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Yu Yamamoto
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Hiroyuki Kobayashi
- Department of Internal Medicine, Mito Kyodo General Hospital, Tsukuba, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan
| | - Yasuharu Tokuda
- Muribushi Okinawa Center for Teaching Hospitals, Okinawa, Japan
- Tokyo Foundation for Policy Research, Tokyo, Japan
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Watari T, Nishizaki Y, Houchens N, Kataoka K, Sakaguchi K, Shiraishi Y, Shimizu T, Yamamoto Y, Tokuda Y. Medical resident's pursuing specialty and differences in clinical proficiency among medical residents in Japan: a nationwide cross-sectional study. BMC MEDICAL EDUCATION 2023; 23:464. [PMID: 37349724 DOI: 10.1186/s12909-023-04429-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/06/2023] [Indexed: 06/24/2023]
Abstract
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.
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Affiliation(s)
- Takashi Watari
- General Medicine Center, Shimane University Hospital, 89-1, Enya-Cho, Izumo Shi, Shimane, 693-8501, Japan.
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Yuji Nishizaki
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Nathan Houchens
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Koshi Kataoka
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Kota Sakaguchi
- General Medicine Center, Shimane University Hospital, 89-1, Enya-Cho, Izumo Shi, Shimane, 693-8501, Japan
| | - Yoshihiko Shiraishi
- General Medicine Center, Shimane University Hospital, 89-1, Enya-Cho, Izumo Shi, Shimane, 693-8501, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan
| | - Yu Yamamoto
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Yasuharu Tokuda
- Muribushi Okinawa Project for Teaching Hospitals, Okinawa, Japan
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Nishizaki Y, Nozawa K, Shinozaki T, Shimizu T, Okubo T, Yamamoto Y, Konishi R, Tokuda Y. 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. BMC MEDICAL EDUCATION 2021; 21:214. [PMID: 33858403 PMCID: PMC8050907 DOI: 10.1186/s12909-021-02649-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/05/2021] [Indexed: 06/12/2023]
Abstract
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."
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Affiliation(s)
- Yuji Nishizaki
- Medical Technology Innovation Center, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
- Department of Medical Education, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Keigo Nozawa
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, 6-3-1 Niijuku, Katsushika-ku, Tokyo, 125-8585, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, 6-3-1 Niijuku, Katsushika-ku, Tokyo, 125-8585, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, 880 Kitakobayashi, Mibumachi, Shimotuga-gun, Tochigi, 321-0293, Japan
| | - Tomoya Okubo
- Research Division, National Center for University Entrance Examinations, 2-19-23 Komaba, Meguro-ku, Tokyo, 153-8501, Japan
| | - Yu Yamamoto
- Division of General Medicine, Center for Community Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Ryota Konishi
- Education Adviser Japan Organization of Occupational Health and Safety, 1-1 Kiduki Sumiyoshi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa, 211-0021, Japan
| | - Yasuharu Tokuda
- General Internal Medicine, Muribushi Okinawa for Teaching Hospitals, 3-42-8 Iso, Urasoe-shi, Okinawa, 901-2132, Japan
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Harada T, Miyagami T, Watari T, Hiyoshi T, Kunitomo K, Tsuji T, Shimizu T. Analysis of diagnostic error cases among Japanese residents using diagnosis error evaluation and research taxonomy. J Gen Fam Med 2021; 22:96-99. [PMID: 33717785 PMCID: PMC7921344 DOI: 10.1002/jgf2.388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/08/2020] [Accepted: 09/15/2020] [Indexed: 11/09/2022] Open
Abstract
The process of diagnostic errors among Japanese residents has not been previously studied. This descriptive study was conducted in June 2019 on junior residents at a single-center educational hospital in Japan. Diagnosis Error Evaluation and Research taxonomy was used to measure the process of diagnostic error in the most memorable error cases. High frequency of diagnostic errors resulted from inaccurate/misinterpretation of history, failure/delay in eliciting physical examination findings, inaccurate/misinterpretation of physical examination, failure in weighting of physical examination, and failure/delay in considering the diagnosis. Residents made diagnostic errors mainly during history taking, physical examination, and assessment.
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Affiliation(s)
- Taku Harada
- Division of General MedicineShowa University Koto Toyosu HospitalTokyoJapan
- Diagnostic and Generalist MedicineDokkyo Medical University HospitalTochigiJapan
| | - Taiju Miyagami
- Department of General MedicineJuntendo University Faculty of MedicineTokyoJapan
| | - Takashi Watari
- Postgraduate Clinical Training CentreShimane University HospitalShimaneJapan
| | - Tetsuya Hiyoshi
- Department of General medicineFukuoka University HospitalFukuokaJapan
| | - Kotaro Kunitomo
- Department of Internal MedicineKumamoto Medical CenterKumamotoJapan
| | - Takahiro Tsuji
- Department of Internal MedicineKumamoto Medical CenterKumamotoJapan
| | - Taro Shimizu
- Diagnostic and Generalist MedicineDokkyo Medical University HospitalTochigiJapan
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Nagasaki K, Nishizaki Y, Shinozaki T, Kobayashi H, Tokuda Y. Association Between Resident Duty Hours and Self-study Time Among Postgraduate Medical Residents in Japan. JAMA Netw Open 2021; 4:e210782. [PMID: 33666659 PMCID: PMC7936256 DOI: 10.1001/jamanetworkopen.2021.0782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This cross-sectional study uses information from the General Medicine In-Training Examination survey in Japan to assess the association between resident duty hours and self-study time.
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Affiliation(s)
- Kazuya Nagasaki
- Department of Internal Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan
| | - Yuji Nishizaki
- Department of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Hiroyuki Kobayashi
- Department of Internal Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan
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Nishizaki Y, Shimizu T, Shinozaki T, Okubo T, Yamamoto Y, Konishi R, Tokuda Y. 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. BMC MEDICAL EDUCATION 2020; 20:426. [PMID: 33187497 PMCID: PMC7666491 DOI: 10.1186/s12909-020-02334-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 10/28/2020] [Indexed: 05/09/2023]
Abstract
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.
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Affiliation(s)
- Yuji Nishizaki
- Medical Technology Innovation Center, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, 880 Kitakobayashi, Shimotuga-gun, Mibumachi, Tochigi, 321-0293, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, 6-3-1 Niijuku, Katsushika-ku, Tokyo, 125-8585, Japan
| | - Tomoya Okubo
- Research Division, National Center for University Entrance Examinations, 2-19-23 Komaba, Meguro-ku, Tokyo, 153-8501, Japan
| | - Yu Yamamoto
- Division of General Medicine, Center for Community Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Ryota Konishi
- Education Adviser Japan Organization of Occupational Health and Safety, 1-1 KidukiSumiyoshi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa, 211-0021, Japan
| | - Yasuharu Tokuda
- General Internal Medicine, Muribushi Okinawa for Teaching Hospitals, 3-42-8 Iso, Urasoe-shi, Okinawa, 901-2132, Japan
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Balogun JA, Adekanmbi A, Balogun FM. Recognition and Disclosure of Medical Errors Among Residents in Surgical Specialties in a Tertiary Hospital in Ibadan. World J Surg 2018; 43:717-722. [DOI: 10.1007/s00268-018-4836-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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9
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Tokuda Y, Soshi M, Okubo T, Nishizaki Y. Postgraduate medical education in Japan: Missed opportunity for learning clinical reasoning. J Gen Fam Med 2018; 19:152-153. [PMID: 30186726 PMCID: PMC6119786 DOI: 10.1002/jgf2.202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | | | - Tomoya Okubo
- Research Division The National Center for University Entrance Examinations Tokyo Japan
| | - Yuji Nishizaki
- Medical Technology Innovation Center Juntendo University Tokyo Japan.,Clinical Research and Trial Center Juntendo University Hospital Tokyo Japan
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Kuriyama A. Capsule Commentary on Nishizaki et al., Awareness of Diagnostic Error Among Japanese Residents: A Nationwide Study. J Gen Intern Med 2018; 33:494. [PMID: 29299812 PMCID: PMC5880767 DOI: 10.1007/s11606-017-4270-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Akira Kuriyama
- Department of General Medicine, Kurashiki Central Hospital, Okayama, Japan. .,Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan.
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