山本 祐

PURPOSE: Patient care ownership (PCO) is a critical component of medical professionalism. Despite the mounting global recognition of its importance, there is little knowledge regarding what kind of learning environment is associated with greater PCO among medical residents. Therefore, the aim of the study was to examine the association between hospital type and PCO among residents throughout Japan. METHODS: This cross-sectional study was conducted from 17 January to 31 March 2024, as part of PCO research projects. Participants were residents who took the General Medicine In-Training Examination. We used the Japanese version of the PCO Scale, comprising the four subscales of assertiveness, sense of ownership, diligence and being the 'go-to' person, and treated hospital type (community hospital [reference category], university hospital or university branch hospital) as an explanatory variable. RESULTS: Data were analysed for 1836 residents. After adjustment for possible confounders, university hospitals were associated with lower PCO than community hospitals (adjusted mean difference -0.19, 95% confidence intervals -0.36 to -0.03). Among PCO subscales, university hospitals were significantly associated with lower assertiveness and diligence. Conversely, there were no statistically significant differences between residents in university branch hospitals and community hospitals, either in overall PCO or subscale scores. CONCLUSIONS: This study identified differences in residents' PCO between university and community hospitals. Resident autonomy support and/or collaborative educational strategies between these hospitals would aid in cultivating PCO. Given recent reports advocating the importance of PCO, these findings may provide international medical educators and policymakers with in-depth insights into PCO education strategies.

BACKGROUND: Traditional assessments of clinical competence using multiple-choice questions (MCQs) have limitations in the evaluation of real-world diagnostic abilities. As such, recognizing non-verbal cues, like tachypnea, is crucial for accurate diagnosis and effective patient care. OBJECTIVE: This study aimed to evaluate how detecting such cues impacts the clinical competence of resident physicians by using a clinical simulation video integrated into the General Medicine In-Training Examination (GM-ITE). METHODS: This multicenter cross-sectional study enrolled first- and second-year resident physicians who participated in the GM-ITE 2022. Participants watched a 5-minute clinical simulation video depicting a patient with acute pulmonary thromboembolism, and subsequently answered diagnostic questions. Propensity score matching was applied to create balanced groups of resident physicians who detected tachypnea (ie, the detection group) and those who did not (ie, the non-detection group). After matching, we compared the GM-ITE scores and the proportion of correct clinical simulation video answers between the two groups. Subgroup analyses assessed the consistency between results. RESULTS: In total, 5105 resident physicians were included, from which 959 pairs were identified after the clinical simulation video. Covariates were well balanced between the detection and non-detection groups (standardized mean difference <0.1 for all variables). Post-matching, the detection group achieved significantly higher GM-ITE scores (mean [SD], 47.6 [8.4]) than the non-detection group (mean [SD], 45.7 [8.1]; mean difference, 1.9; 95% CI, 1.1-2.6; P=.041). The proportion of correct clinical simulation video answers was also significantly higher in the detection group (39.2% vs 3.0%; mean difference, 36.2%; 95% CI, 32.8-39.4). Subgroup analyses confirmed consistent results across sex, postgraduate years, and age groups. CONCLUSIONS: Overall, this study revealed that detecting non-verbal cues like tachypnea significantly affects clinical competence, as evidenced by higher GM-ITE scores among resident physicians. Integrating video-based simulations into traditional MCQ examinations enhances the assessment of diagnostic skills by providing a more comprehensive evaluation of clinical abilities. Thus, recognizing non-verbal cues is crucial for clinical competence. Video-based simulations offer a valuable addition to traditional knowledge assessments by improving the diagnostic skills and preparedness of clinicians.

BACKGROUND: General medicine (GM) was formally recognized as a specialty in Japan in 2018 to address the need for primary care. Understanding factors influencing GM career choices is critical for recruitment. However, the reform's impact on career decision-making remains unclear. This study examined factors influencing GM career choices following the introduction of the new specialty certification and identified challenges in this field. METHODS: A secondary analysis of national survey data from the Ministry of Health, Labour and Welfare's questionnaire (2018-2020) for clinical training graduates examined post-training career intentions of specializing in GM, focusing on factors influencing choices such as demographics, education, and training contexts. Multivariable logistic regression was conducted with post-training GM preference as the dependent variable. The results are expressed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS: Among 16,674 complete responses, 59% of the 229 individuals initially interested in GM actually pursued it post-training. Positive factors included regional quotas (aOR 3.10, 95% CI 1.12-8.56), ≤ 1 month GM rotation (aOR 3.39, 95% CI 1.03-11.14), > 2 months community medicine (CM) rotations (aOR 13.35, 95% CI 2.40-76.58), desire for primary care skills (aOR 4.85, 95% CI 2.01-11.73), and community contribution aspirations (aOR 6.88, 95% CI 2.75-17.21). The most influential negative factor was perceived ease of specialization maintenance (aOR 0.01, 95% CI 0.00-0.12). Among 16,445 individuals who preferred other specialties, 86 switched to GM. Extended GM rotations (1<-≤2 months: aOR 3.54, 95% CI 2.06-6.09; >2 months: aOR 7.41, 95% CI 4.56-12.04) increased the likelihood of switching. Academic interest (aOR 0.36, 95% CI 0.23-0.58) and perceived ease of maintaining specialization (aOR 0.13, 95% CI 0.03-0.54) were negative factors. CONCLUSIONS: GM rotations may positively influence career choices, with longer CM rotations potentially increasing interest. Establishing clear career paths and educating resident physicians about the academic characteristics of GM remain challenging despite its recognition as a specialty.

Japan's workplace reforms, including a 60-hour weekly work limit for medical residents, that has been in effect from April 2024, have raised concerns about compliance and its impact on training quality. This study analyzed data from 17,967 residents who participated in the General Medicine In-Training Examination from 2019 to 2022, focusing on weekly duty hours, clinical responsibilities, and training environments. Duty hours increased from 2019 to 2021, before declining in 2022. The proportion of residents working over 60 h per week decreased from 57 to 49%, while those working under 50 h increased from 12 to 19%. Concurrently, the percentage of residents managing zero to four inpatients rose from 18 to 39%. University hospital residents reported shorter duty hours but fewer patient encounters and diminished clinical exposure compared to community hospital residents. These findings underscore the educational consequences of duty-hour restrictions, particularly in university hospitals, where reduced clinical responsibilities may compromise competency-based training. The results highlight the need for balanced policies that ensure compliance while maintaining sufficient clinical exposure. Future reforms should prioritize equitable workload distribution, increased clinical opportunities, and targeted interventions to address disparities between hospital types, thereby ensuring the dual goals of resident well-being and high-quality medical education.