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

Integrating psychiatry into basic clinical skills: A three-year nationwide quantitative assessment of postgraduate training programs

Aim

The aim of this study was to develop quantitative outcome indicators for psychiatric training programs integrated into the General Medicine In-Training Examination (GM-ITE) and to investigate which characteristics correlate with high scores in psychiatry.

Methods

A nationwide cross-sectional study was conducted over 3 fiscal years (2021-2023). An anonymous online questionnaire was distributed to postgraduate year 1 and 2 residents who completed the GM-ITE. The primary outcome was GM-ITE score, with a particular focus on psychiatry. Multiple-choice questions for the psychiatry field were created by board-certified psychiatrists with various subspecialties, then reviewed and piloted. Multiple regression analysis examined correlations between GM-ITE score and various resident and facility characteristics.

Results

A total of 18,226 residents participated over the 3 years, of whom 5%-6% aspired to specialize in psychiatry. Quantitative scores were effective in the psychiatry field across all 3 years. Psychiatry aspirants had lower scores in internal medicine, emergency, and total scores but higher scores in psychiatry. Residents from university hospitals had lower psychiatry scores, while the number of psychiatry beds and supervising psychiatrists did not correlate with higher psychiatry scores. These findings indicate the need for psychiatric training programs distinct from general internal medicine and emergency training.

Conclusion

Based on these quantitative psychiatry scores, this study highlights the necessity of improving physical assessment skills during residency for psychiatry aspirants, who score higher in psychiatry. Future research should identify effective training programs and facility practices that lead to higher psychiatry scores among residents, and thereby better integrate psychiatry into basic clinical skills.

Association between physicians' maldistribution and core clinical competency of resident physicians: a nationwide cross-sectional study

OBJECTIVES

With physician maldistribution recognised as a global issue, Japan implemented the physician uneven distribution (PUD) index as a strategic measure. Currently, there is a lack of objective assessment of core clinical competencies in regions influenced by varying levels of physician distribution. In this study, we objectively assess the core clinical competencies in regions affected by physician maldistribution and explore the relationship between the PUD index and the clinical competencies of resident physicians.

DESIGN, SETTING AND PARTICIPANTS

In this cross-sectional study, we gathered data from the January 2023 General Medicine In-Training Examination (GM-ITE) survey. Participants included postgraduate year 1 and 2 resident physicians in Japanese hospitals mandating the GM-ITE or those who voluntarily took it. The GM-ITE scores of the resident physicians were assessed. The PUD index, a Japanese policy indicator, reflects regional physician disparities. A low PUD index signals a medical supply shortage compared with local demand. The trial registration number is 23-7.

RESULTS

The high and low PUD index groups included 2143 and 1580 participants, respectively. After adjusting for relevant confounders, multivariate linear regression analyses revealed that the low PUD index group had significantly higher GM-ITE scores than the high PUD index group (adjusted coefficient: 1.14; 95% CI 0.62 to 1.65; p<0.001).

CONCLUSIONS

The study revealed no clinically differences in GM-ITE scores between residents in regions with disparate physician distributions, suggesting that factors beyond PUD may influence clinical competency. This finding prompts a re-evaluation of whether current assessment methodologies or educational frameworks fully support learning across varied community settings.

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.

Association between mentorship and mental health among junior residents: A nationwide cross-sectional study in Japan

Background

Mentorship is a dynamic, reciprocal relationship in which an advanced careerist (mentor) encourages the growth of a novice (mentee). Mentorship may protect the mental health of residents at risk for depression and burnout, yet despite its frequent use and known benefits, limited reports exist regarding the prevalence and mental effects of mentorship on residents in Japan.

Methods

We conducted a cross-sectional study involving postgraduate year 1 and 2 (PGY-1 and PGY-2) residents in Japan who took the General Medicine In-Training Examination (GM-ITE) at the end of the 2021 academic year. Data on mentorship were collected using surveys administered immediately following GM-ITE completion. The primary outcome was the Patient Health Questionaire-2 (PHQ-2), which consisted depressed mood and loss of interest. A positive response for either item indicated PHQ-2 positive. We examined associations between self-reported mentorship and PHQ-2 by multi-level analysis.

Results

Of 4929 residents, 3266 (66.3%) residents reported having at least one mentor. Compared to residents without any mentor, those with a mentor were associated with a lower likelihood of a positive PHQ-2 response (adjusted odds ratio [aOR] 0.75; 95% confidence interval [95% CI] 0.65-0.86). Mentor characteristic significantly associated with negative PHQ-2 response was a formal mentor (aOR; 0.68; 95% CI 0.55-0.84).

Conclusions

A mentor-based support system was positively associated with residents' mental health. Further research is needed to determine the quality of mentorship during clinical residency in Japan.

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.

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.

Empathy competence and future specialty among medical residents in Japan: a nationwide cross-sectional study

Empathy is essential for physicians to provide patient-centered care. Nevertheless, the degree to which empathy varies among medical residents based on their desired future specialty remains undetermined. This nationwide cross-sectional study compared empathy levels (Jefferson Scale of Empathy, JSE) of 824 year one and two postgraduate residents in Japan by intended medical specialty, individual characteristics, and training and working environment characteristics. Empathy levels were compared with applicants for general medicine, which emphasizes patient-centeredness. The highest mean JSE and the highest percentage of women residents were observed in general medicine (M = 109.74; SD = 14.04), followed by dermatology (M = 106.64; SD = 16.90), obstetrics and gynecology (M = 106.48; SD = 14.31), and pediatrics (106.02; SD 12.18). Residents interested in procedure-centered departments (e.g. ophthalmology, orthopedics) garnered lower JSE scores. Multivariate regression revealed that future general medicine candidates achieved the highest JSE scores ([Formula: see text] = 6.68, 95% CI 2.39-10.9, p = 0.002). Women achieved significantly higher JSE scores than men ([Formula: see text] = 2.42, 95% CI 0.11-4.73, p = 0.041). The results have implications for empathy training and postgraduate education strategy in different clinical specialties.

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.

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.