山本 祐

PURPOSE: Both clinical knowledge and patient care ownership (PCO) are crucial to the provision of quality patient care and should be acquired during training. However, the association between these two concepts is under-examined. Here, we conducted a nationwide cross-sectional study to investigate the association between clinical knowledge and PCO among resident physicians in Japan. METHODS: From January 17 to March 31, 2024, we conducted an anonymous, online, self-administered survey for a series of PCO research projects. The survey targeted medical residents who took the General Medicine In-Training Examination (GM-ITE). The mean of the Japanese version of the PCO Scale was used as outcome variable. The primary explanatory variable was total GM-ITE score, while the secondary explanatory variables were GM-ITE category scores in medical knowledge. We conducted multivariable linear regression analysis, controlling for postgraduate years, sex, number of assigned inpatients, weekly working hours, type of hospital, and size of hospital. RESULTS: We included 1836 participants in our statistical analysis. Multivariable linear regression analysis revealed that after adjustment for possible confounders, GM-ITE total scores showed a significantly negative association with PCO in the highest score quartile (adjusted mean difference - 0.20, 95% confidence interval (CI) -0.33 to -0.07, compared with the lowest score quartile). Additionally, after controlling for possible confounding factors, scores for symptomatology and clinical reasoning showed a dose-dependent negative association with PCO (adjusted mean difference - 0.17, 95% CI -0.30 to -0.03 for the highest score quartile compared with the lowest score quartile). No significant dose-dependent associations were found for the other categories. CONCLUSIONS: These findings suggest the presence of potential challenges in the simultaneous fostering of clinical knowledge and PCO during residency training. This underscores the need for educators to actively engage in the reconsideration of current postgraduate training strategies, with the aim of effectively cultivating both clinical knowledge and PCO among medical residents.

BACKGROUND: Outpatient training for resident physicians has been attracting attention in recent years. However, to our knowledge, there have only been a few surveys on outpatient training, particularly in Japan. This study evaluates outpatient care among Japanese resident physicians by determining how the volume of outpatient encounters and length of outpatient training correlate with residents' clinical competence. METHODS: This study utilised the results of the General Medicine In-Training Examination (GM-ITE; resident clinical competency assessment) for 2,554 post-graduate year 2 (PGY 2) resident physicians in Japan, as well as a self-reported questionnaire regarding their educational training environments conducted after the examination. We investigated whether GM-ITE scores correlated with daily outpatient volume and duration of outpatient training. RESULTS: Regarding outpatient volume, having 1-5 new patient encounters per day was significantly associated with higher GM-ITE scores by multilevel analysis [0 patients: average score 43.7, 1-5 patients: adjusted estimated coefficient (aEC) 1.99, 95% confidence interval (CI) 0.44 to 3.55, P = 0.01]. Regarding the duration of outpatient training, residents trained for one month had the highest GM-ITE scores (one month: average score 46.9; two months: aEC -1.44, 95% CI -2.29 to -0.60, P < 0.001; three months: aEC -1.44, 95% CI -2.22 to -0.65, P < 0.001). CONCLUSION: Minimal daily new outpatient visits and one month of outpatient training effectively correlated with residents' basic clinical competence. TRIAL REGISTRATION: This study was approved by the Ethics Committee of the Japan Institute for Advancement of Medical Education Program (JAMEP; No. 22-30) and retrospectively registered.

BACKGROUND: Time-at-bedside plays a central role in clinical medicine. However, the amount of time Japanese clinical residents spend at patients' bedsides remains unexplored. OBJECTIVE: To quantify time-at-bedside and examine its association with in-training examination scores during clinical residency in Japan. DESIGN: Nationwide multicenter cross-sectional study. PARTICIPANTS: First- and second-year postgraduate residents who took the General Medicine In-Training Examination at the end of the 2022 academic year. INTERVENTIONS: Time-at-bedside was defined as the average time per day the residents spend providing care at patients' bedsides during their residency. Time-at-bedside was classified into six categories: C1 (10-20 min per day), C2 (30-50 min per day), C3 (60-80 min per day), C4 (90-110 min per day), C5 (120-140 min per day), and C6 (150 min or more per day). Data on time-at-bedside were collected through an electronic survey conducted immediately after the General Medicine In-Training Examination. MAIN MEASURES: The primary outcome was the General Medicine In-Training Examination score. A multi-level analysis examined the association between self-reported time-at-bedside and the General Medicine In-Training Examination score. KEY RESULTS: A total of 5344 residents were included in this study. Of these, 2760 were first-year residents, and 2584 were second-year residents. Of the 5334 residents, 66.9% reported spending less than 60 min at a patient's bedside. Compared to the C1, C2 (adjusted score difference [aSD] = 1.1, 95% confidence interval [95% CI] 0.48 to 1.79), C3 (aSD = 1.5, 95% CI 0.75 to 2.20), and C5 (aSD = 2.0, 95 CI 0.62 to 3.38) were positively associated with the General Medicine In-Training Examination score. However, C4 (aSD = 1.1, 95% CI - 0.15 to 2.26) and C6 (aSD = 0, 95% CI - 1.79 to 1.87) were not associated with the General Medicine In-Training Examination score. CONCLUSION: Self-reported time-at-bedside positively correlates with in-training examination scores among Japanese resident physicians.

BACKGROUND: The general medicine in-training examination (GM-ITE) assesses physicians' clinical knowledge. This study expanded on findings from a previous pilot study to assess the relationship between general medicine in-training examination (GM-ITE) scores and the diagnostic skills of resident physicians in Japan by employing an innovative clinical simulation video (CSV-IE). METHODS: This multicenter cross-sectional study included 4,677 resident physicians who took the GMITE between January 17 and 30, 2023. Participants watched the CSV-IE, depicting an emergency room scenario, and provided a diagnosis. The CSV-IE depicts an emergency case and provides a diagnosis. Discrimination indices were used to assess the CSV-IE's effectiveness across clinical competence domains, and multilevel logistic regression was used to analyze physician- and hospital-level factors associated with correct diagnoses. RESULTS: Correct diagnoses were provided by 470 participants (10.0%). The CSV-IE demonstrated high discriminatory power across all assessed domains, including basic clinical knowledge (DI = 0.44), symptomatology and clinical reasoning (DI = 0.31), physical examination and clinical procedure (DI = 0.35), and knowledge about the disease (DI = 0.25), supporting its utility as an effective assessment tool. In the multivariable analysis, factors associated with a higher likelihood of providing a correct CSV-IE diagnosis included a higher annual number of emergency outpatients (adjusted odds ratio: 1.025; 95% confidence interval [CI]: 1.003-1.047; P = .0230) and being in a higher postgraduate year (adjusted odds ratio: 1.387; 95% CI: 1.104-1.742; P = .005). Conversely, resident physicians at university hospitals were less likely to provide a correct CSV-IE response (adjusted odds ratio: 0.624; 95% CI: 0.435-0.896; P = .0107). CONCLUSIONS: CSV-IE modules may provide an integrative and realistic evaluation of clinical competence, addressing limitations of traditional MCQ-based assessments by offering contextualized, real-world scenarios that require dynamic decision-making and diagnostic reasoning.