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

In this nationwide, cross-sectional study, we examined associations among clinical proficiency and skill as assessed by the GM-ITE, training program characteristics, individual resident factors, and pursuing career specialty among resident physicians in Japan. We found that scores on the standardized GM-ITE assessment were higher for residents who planned careers in general medicine, emergency medicine, and internal medicine and lower for residents who planned for highly specialized departments that do not offer general practice. We also discovered distinctive trends based on hospital and resident attributes. GM-ITE scores were higher for those who trained in community hospitals with higher numbers of beds, who were more advanced in their training (i.e., PGY-2), and who spent more time working and studying. Higher scores were noted for residents who cared for a moderate but not extreme number of patients at a time.

In Japan, general medicine is a new specialty certification, established recently in 2018 [23, 25]. General medicine training includes care in the outpatient clinic, inpatient ward, and emergency department settings. Moreover, a resident may thereafter choose a career pathway among family medicine, hospital medicine, or general internal medicine [25]. One potential explanation of our data is that Japanese general medicine physicians cover a wide range of settings and contexts; this breadth of experience facilitates the acquisition of basic clinical skills (knowledge, skills, and attitudes) needed for success on the GM-ITE. This is supported by the fact that previous GM-ITE studies have shown higher scores among those who have completed a general medicine rotation [4, 23, 24]. It is not surprising that those residents with more clinical experience (in the form of time spent in practice and exposure to those clinical conditions most likely to be tested on the GM-ITE) fare better on the examination. In other countries also, postgraduate training examinations have shown that extensive comprehensive training results in higher examination scores [3]. It has been noted that learners in Japan who are passionate about lifelong comprehensive and extensive learning tend to go on to become general medicine physicians [6, 17, 23].

Nearly all physicians in Japan choose their specialty in the second postgraduate year. As a comparative example, trainees in the USA often select a residency program in the specialty of their coice before graduating from medical school. This decision may be based partly on USMLE performance, although the transition to pass/fail assessment for USMLE Step 1 has changed this dynamic. Unlike in Japan, considerable examination competition exists in the USA [7, 9, 26]. Competitive fields such as dermatology, otolaryngology, plastic surgery, and ophthalmology generally require high USMLE Step 2 score scores to be considered [9]. In the USA, annual incomes vary by specialty, with significant differences noted [26]. This pay discrepancy may be an external motivating factor in future career, in that departments with high income may attract residents with good performance in consideration of repayment of large student loans [26]. In Japan, however, there is no competition for nor restrictions on pursuing specific medical specialties. Additionally, physician income in Japan does not vary significantly between departments, further lowering competition compared with the system in the USA [7, 9, 18, 26, 27]. In a large-scale survey in Japan, high remuneration was not a contributing factor in matching training hospitals [18]. Instead, junior career Japanese physicians often decide their career pathways based on their medical interests and curiosity, the scope of their practice, ease of work, expected duties, and alignment of work and abilities [11, 18, 27].

Does the training environment influence residents’ future pursuing specialty, or do they choose the training environment based on their defined future career pathway? We cannot explain any potential or real causal relationships. However, the differences in examination scores according to the chosen future specialty may be due to differences in motivation and the actual amount of active learning during the two years of mandatory rotational training although this was not measured in this study [16, 21]. In addition, university hospitals in Japan tend to focus on experimental research achievement [28, 29] and do not provide the same levels of training in primary and general health care as community hospitals [6, 23]. In our study, a large proportion of residents who seek careers in highly specialized fields like ophthalmology and dermatology are trained at university hospitals, where the number of work shifts, amount of time worked, and amount of clinical experience tend to be smaller. Furthermore, it has been shown that residents who work fewer hours have significantly less time for actual independent study, despite having relatively more time overall, [21] in which case less studying correlates with lower GM-ITE scores [16, 21]. Considering all of the above, it is possible that in Japan, highly specialized departments, such as ophthalmology, dermatology, and plastic surgery, are not expected to have a wide range of clinical skills or knowledge related to systemic conditions. Thus, those who wish to pursue these careers may not have the motivation and study time to devote to skills assessed by the GM-ITE.

Our findings must be interpreted in the context of several limitations. First, this is a cross-sectional study, and it is unknown whether PGY-1 residents accurately predict their actual future specialties. In fact, the commencement of the GM-ITE coincides with the culmination of the academic year, suggesting a greater probability that PGY-2 residents would have delineated their career trajectory by this juncture compared to PGY-1. Furthermore, the GM-ITE scores even before the initiation of the PGY-1 residency are unknown, and the contemplation of future assessments to ascertain this before mandatory clinical training commences is currently under investigation. Second, the presence of selection bias is inevitable. Despite the test being taken by more than a half of residents nationwide, we exclude data from respondents who indicated more than one division from this cohort. Inclusion of such data might engender alterations in the results. Third, the history of the general medicine specialty in Japan is young, and there is mutual overlap among the fields of general internal medicine, hospital medicine, and family medicine, all of which are often also responsible for general internal medicine ward and outpatient services [25]. On the other hand, there may be residents in internal medicine who wish to choose hospital medicine or general internal medicine after their residency program. This overlap can be a major misclassification bias [25, 29, 30]. Subsequently, our GM-ITE data exclusively displays the four categories of examination questions and the total score, as articulated above. This may be because certain questions may appraise the attitude towards physical examination and interview, even when the disease is distinctly categorized under obstetrics and gynecology in the medical department classification. Consequently, it was not feasible to demonstrate a correlation between which medical department applicants are more likely to encounter questions in specific medical department categories. Nonetheless, this is congruent with the MHLW’s objective of training ‘physicians who can provide comprehensive and wide-ranging medical care. Finally, the results of this examination may serve as either intrinsic or extrinsic motivation for resident aspirants. Even though this examination does not exert a direct influence on career progression or retention, the results are communicated to the program director. Consequently, there exists a potential bias, such as residents who harbor future intentions to apply to a broader array of departments, inclusive of general practice or emergency medicine, may approach the examination with heightened diligence and engage in more rigorous preparation.