Trends in Sleep-Related Questions
on Japanese National Medical Examinations, 2006-2020
Norimi Takata1, 2, Ayuko Nii2, Rie Katsuta3, Junko Moriyama3, Yasunori Oka1,3*
1

Division of International Nursing, Department of Nursing, Matsuyama School of Nursing,
University of Human Environments

2

Division of Maternal Health and Midwifery, Department of Nursing, Shikoku University

3

Center for Sleep Medicine, Ehime University Hospital*Corresponding author

Abstract
Sleep is an essential element supporting human health.

indicate that sleep-related education varies among
medical fields; thus, education about sleep problems mayneed to be adapted for the demands of each medical field.

Sleep medicine is an emerging field, and awareness of it
is increasing gradually. National medical examinations
reflect the relative importance of topics covered. TheBackgroundexamination of sleep-related questions on different

Sleep physiology has been of scientific interest sincenational examinations may reveal how much knowledge

the beginning of the 1900s. In the mid-1900s, sleep-wakeof sleep and sleep disorders students in various fields ofmechanisms and REM sleep were identified. Progress inmedicine are required to have. The aim of this study wasbasic sleep science, including the identification of sleep

to identify changes in sleep-related questions on nationalsubstances, has facilitated the diagnosis and treatment ofexaminations for doctors, dentists, nurses, public healthsleep disorders (Jones BE, 2018).

nurses, midwives, physical therapists and occupational

Sleep occupies nearly one-third of human life, as antherapists. Percentage of sleep-related questions on

essential period of rest for the body and mind. Due to theexaminations were 1.49% for doctors, 0.27% for dentists,variation and complexity in modern life, sleep problems

2.39% for nurses, 1.67% for midwives, 1.18% for public

are becoming a social issue, as they may lead to accidents

health nurses, 1.40% for physical therapists, 2.00% forand impaired work and study performance. The influence

occupational therapists. On examinations for doctorsof disturbed sleep on society has attracted attention

and dentists, the number of sleep-related questions

in various fields, such as sleep sociology and sleep

increased in 2012 and 2014, and decreased in 2019 andeconomics, and intervention to ameliorate this problem is2020. For nurses, midwives, and public health nurses,

needed (Dinges DF, 2014).

this number increased in 2014 and 2015. Insomnia related

Medical and healthcare providers’education in sleep

questions were the most frequent on examinations for

medicine is important, as these professionals need todoctors; questions about other sleep disorders, sleep

educate patients and provide quality care. The leveltesting, treatment, and patient education also appeared

and amount of sleep education vary among schools foron these examinations. Questions on examinations for

medical and health care professionals; relevant content

dentists were limited to sleep apnea syndrome and sleep-on national examinations for these professionals may give

related bruxism. Examinations for nurses mainly included

us an important clue about the level of interest in sleep

questions about insomnia complaints; those for midwives

medicine (Blunden SL, 2012).

included questions about insomnia, as well children’sleep.

The model core curriculum for doctors includes

Examinations for physical therapists and occupational

the following sleep-related topics; rest, mental health,therapists contained many sleep-related questions

sleep quality and insomnia [B-1-5) - (4)] and sleep apnea

already 15 years ago, despite the lack of mention ofsyndrome [D-6-4) - (6)-2] (Committee for Model Core

sleep problems in the examination criteria. Our findings

Curriculum, 2016a). That for dentists includes causes,

大学教育実践ジャーナル 第19号 2021

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Norimi Takata, Ayuko Nii, Rie Katsuta, Junko Moriyama, Yasunori Oka

diagnosis and treatment of sleep apnea syndrome [E-Health, Labor and Welfare Website and included in the2-4) - (11) -6] and sleep disorders [E-6-1] (Committee foranalysis. The authors reviewed all medical examination

Model Core Curriculum, 2016b). The national examinationquestions, and extracted those pertaining to sleep

criteria for nurses include the major topics “sleep”,

problems and sleep-related issues, as well as those whose“sleep apnea”, and “sleep disorders”; those for midwives

response options contained sleep-related terms. The

include “sleep”, and those for public health nurses include

designation of an extracted question as sleep related was“sleep apnea syndrome”(Nursing Department of MHLW,based on discussion and agreement among the authors.

2018). National examination criteria for occupational

Sleep-related terms appearing in question and response

therapists and physical therapists include no sleep-text were also collected. The number of sleep-relatedrelated topic (Examination Department of MHLW, 2016).

questions per year and the frequency of appearance ofThese curricula do not provide a clear indication of how

sleep-related terms were determined for each type ofsleep-related issues are included in national medicalmedical examination.

examinations.

Results

Objectives

Percentage of sleep-related questions on national

The aims of this study were to analyze the amount andmedical examinations

content of sleep-related questions on different national

Examinations for doctors dating to the study period

medical examinations, and to elucidate how sleep-related

contained 1.49% sleep-related questions, of which 11.1%

problems are handled in various medical and healthcare

were clinical case questions (Table 1). Examinations forfields.

dentists contained 0.27%, of which 33.3% were clinicalcase questions. In the field of nursing, examinations fornurses contained 2.39% sleep-related questions, thoseMethods

for public health nurses contained 1.18% questions, andJapanese national medical examinations for doctors,examinations for midwives contained 1.67%. Examinations

dentists, nurses, public health nurses, midwifes, andfor physical therapists and occupational therapists

occupational and physical therapists from the past 15

contained 1.40% and 2.00% sleep-related questions,years (2006-2020) were downloaded from the Ministry ofrespectively.

Table 1. Percentage of sleep-related questions on national medical examinations4Year

Doctors

Dentists

NursesPublicHealthNursesMidwifes

PhysicalTherapists

Occupational
Therapists

2006

0.75

00.83

00.95

1.50

3.00

2007

1.20

01.25

00

2.50

2.50

2008

1.00

0

1.25

0

1.90

2.50

3.50

2009

0.40

0.27

3.33

1.90

0.95

4.00

2.00

2010

1.80

02.08

0

0.95

0.50

1.00

2011

1.40

01.67

00

1.50

0.50

2012

1.60

0

1.25

1.90

00.00

0.50

2013

1.80

0.27

1.67

0.91

1.82

0.50

1.50

2014

2.00

1.10

2.50

1.82

3.64

0.50

1.50

2015

2.80

0.82

4.17

1.82

0

1.50

1.50

2016

0.80

1.10

2.50

2.73

3.64

1.00

2.00

2017

2.20

0.27

3.33

0

4.55

1.00

2.50

2018

2.00

0.28

2.92

0.91

0.91

1.50

2.50

2019

1.25

0

4.58

3.64

3.64

1.50

3.00

2020

1.50

0

2.50

1.82

1.82

1.00

2.50

Total (%)

1.49

0.27

2.39

1.18

1.67

1.40

2.00

大学教育実践ジャーナル 第19号 2021

Trends in Sleep-Related Questions on Japanese National Medical Examinations, 2006-2020

Trends in sleep-related questions on medicalexaminations

Trends for nursing examinations are shown inFigures 3-5. Years in which the numbers of sleep-related

Trends in the numbers of sleep-related questions

questions on examinations were above the mean wereon examinations for doctors and dentists are shown in2009 and 2014-2019 for nurses and 2014, 2016, 2017, 2019,

Figure 1 and 2, respectively. On examinations for doctors,and 2020 for midwives. The 2019 examination for public

the number of sleep-related questions was greatest in

health nurses contained the maximum of four sleep-

2015 and least in 2009. Years with more than the mean

related questions.

number of sleep-related questions were 2012-2015, 2017,

Trends for physical therapists and occupationaland 2018; the 2019 and 2020 examinations contained about

therapist examinations are shown in Figures 6-7. The

one-third of the 2015 peak number of such questions. No

percentage of sleep-related questions peaked in 2009

sleep-related question appeared on dentists’examinations

for physical therapists. The percentage of sleep-related

in 8 years (including 2019 and 2020), and one question

questions was above the mean in 2006-2008 and 2017-

on the examinations in 4 years. Three or four questions

2020 for occupational therapists. This percentage peaked

were on these examinations in 2014-2016.

before 2008 and in recent years.

（％）

Figure 1. Trends in percentage of sleep-related questions on examinations for doctors（％）

Figure 2. Trends in percentage of sleep-related questions on examinations for dentists

大学教育実践ジャーナル 第19号 2021

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Norimi Takata, Ayuko Nii, Rie Katsuta, Junko Moriyama, Yasunori Oka（％）

Figure 3. Trends in percentage of sleep-related questions on examinations for nurses（％）

Figure 4. Trends in percentage of sleep-related questions on examinations for public health nurses（％）

Figure 5. Trends in percentage of sleep-related questions on examinations for midwifes

Sleep-related terms appearing on national medical

examinations were related to insomnia. The examinations

examinations

also contained terms related to sleep disorders. TheIn total, the examinations contained 646 sleep-related

most frequently appearing term related to sleep testingterms (Table 2). These terms appeared most frequently

was“polysomnography”. Terms related to sleep-on examinations for doctors (254 terms), followed bydisorder treatment devices included“continuous positivethose for nurses (n = 167), occupational therapists (n = 92),

airway pressure”and“oral appliance”, and related tophysical therapists (n = 47), midwives (n = 38), dentists (nmedications.

= 30), and public health nurses (n = 26).
The terms appearing most frequently on doctors’
6The terms that appeared most frequently on
examinations for dentists were“sleep apnea syndrome”
大学教育実践ジャーナル 第19号 2021

Trends in Sleep-Related Questions on Japanese National Medical Examinations, 2006-2020（％）

Figure 6. Trends in percentage of sleep-related questions on examinations for physical therapists（％）

Figure 7. Trends in percentage of sleep-related questions on examinations for occupational therapists

and“sleep bruxism”.

for physical therapists and occupational therapists wereThose that appeared most frequently on examinations

sleep disorders. Terms related to sleep disorders thatfor nurses referred to insomnia-related patient complaints.

appeared on these examinations were similar to those on

Terms related to sleep conditions, such as“sleep state”

the examinations for doctors.

and “sleep time”, also appeared on the examinations
for nurses, as did sleep terms used in clinical practice,such as “difficulty falling asleep”,“nocturnal arousals”,

Discussion“early morning awakenings”,“unrefreshed sleep”, andSleep management is an essential part of the careterms related to sleep intervention and treatment. The

provided by medical professionals, including medicine,

examinations for public health nurses contained general

nursing, and occupational therapy (Morgan, 2003). Sleep-sleep terms, such as “not sleeping well” and “sleeping”;

related questions appeared on the national examinations

the only medical term appearing on these examinations

for medical professionals in different manners, according

was “hypnotics”. Terms appearing on examinations forto specialty, as examined in this study. In mostmidwives referred to inability to sleep. Words related tospecialties, these differences reflect the curricula designed

sleep duration also appeared on these examinations, asfor the specialties (Nursing Department of MHLW,

did terms such as “newborn sleep” and “baby sleep”.

2018). However, examinations for physical therapists andThe terms appearing most frequently on examinations
大学教育実践ジャーナル 第19号 2021

occupational therapists contained many sleep-related
7

Norimi Takata, Ayuko Nii, Rie Katsuta, Junko Moriyama, Yasunori Oka
Table 2. Sleep-related terms on national medical examinations

Medical Dental
Doctors Doctors
Total
Sleep disorders (disease)
Sleep disorders (in general)
Insomnia (disorder)
Sleep apnea syndrome
Narcolepsy
Circadian rhythm sleep-wake disorers
Sleepwalking
Sleep terrors
Sleep related eating disorder
REM sleep bahavior disorderNightmare disorder
Restless legs syndrome
Bruxism
Sleep symptoms / complaints
Insomnia (in general as a symptom)
Sleeping well
Not sleeping well / inability to sleep
Difficulty falling asleep
Nocturnal arousals / awakenings
Early morning awakenings / wake up too early
Unrefreshed sleep / light sleep
Nocturnal behavior / movement
NightmareNocturnal delirium
Nocturnal attack
Long sleep duration
Short sleep duration / insufficient sleep
Disturbed sleep rhythm
Daytime sleepinessDozingDaytime fatigue
Dreaming
Sleep apnea / breathlessness
Snoring
Cataplexy
Sleep paralysis
Restlessness of the legs
Sleep anxiety / impatience
Hyperarousal
Increased muscle tone
Nocturnal sweatingPalpitation
Sleep related terms
Sleep (in general) / physiological sleep
Wake (in general)
Wakefulness
Sleep state / sleep cycle
Sleep desire
REM sleep
Non-REM sleep
Slow wave sleep / deep sleep
Sleep duration
Sleep in adultSleep in newborn / baby / children
Sleep in elderly
Sleep position
Sleep diaryNap
Bedtime / sleep onset / going to bed
During sleep / sleeping
Waketime
Dream
Hot drink before bedtime - bedtime routine
Melatonin
Circadian / sleep-wake rhythms /sleep cycle
82543733535151614105
2031162241112122113
75430
1111678173112323122112411869720
13664Public
OccuHealth Midwives Physical pational
Therapist
Nurses
Therapist
2638
47
920024328153261454231
1527232
15321

298

112

131
13
12

11511123
32Nurse122
73
1111211113111131121243282

1921321721151533213111927112624512341111110311121111421131131

大学教育実践ジャーナル 第19号 2021

Trends in Sleep-Related Questions on Japanese National Medical Examinations, 2006-2020

Sleep testings
Polysomnography
Electroencephalogram (EEG)Electromyogram (EMG)
Electrocardiogram (ECG) / heart rate
Eye movement
Sleep stage
REM sleep
Non-REM sleep
Slow wave sleep
Arousal index
Apnea hypopnea index
Oxygen saturation
Blood pressureTreatment
Continuous positive airway pressure (CPAP)Oral appliance
Medication
Hypnotics (in general)
Anxiolytic
Benzodiazepines
Phenobarbital
Pramipexole
Clonazepam
Diazepam
Dopamine blocker
Care / Guidance for sleep hygiene
Promote sleep
Improve sleep
Body position
Sleep knowledge
Sleep assessment
Sleep education / instruction (in general)
Proper use of hypnotics
Keep necessary sleep duration
Take breakfast
Get sunlight in the morning
Taking bath before bedtime
Early to bed and early to rise
Go to bed at proper time
Wake up at proper time
Control of nap duration
Leave bed when unable to fall asleep
Get out of bed in the morning
Avoid sleeping out of bed
Alcohol
CoffeeSmoking
Reduce body weight
Read a book in the bed
Watch television
Avoid catch-up sleep
Sleep position
Refreshed in the day with good sleep
Control of bedroom environment
Sleep environments

大学教育実践ジャーナル 第19号 2021

27
842
1121232
1
98
1
19
112
2
1
1
1
134

4
1

3

000

1
11
12

1
100

0

000

13
13

1
1333
154

11

100000

143
1

13
1
1221

11

122
125121141121
1111
100

121

10001

9Norimi Takata, Ayuko Nii, Rie Katsuta, Junko Moriyama, Yasunori Oka

questions already 15 years ago, despite the lack ofcore curriculum for medical education, 2016 Update

mention of sleep problems in the examination criteria.

edition” Ministry of Education, https://www.mext.go.jp/

The model core curricula and national examination
criteria for medical professionals indicate that national
examinations should contain questions on sleep-related
issues. We found that different percentages of sleeprelated questions were included in national medical
examinations for various fields. This percentage of suchquestions increased over the past 15 years in somemedical fields, but showed no clear trend in others,suggesting that national model core curricula andexamination criteria do not affect consistent percentage
of sleep-related questions. Year-to-year changes in
the percentage of sleep-related questions may reflect
the number of professionals for each year involved incomponent/b_menu/shingi/toushin/__icsFiles/afieldfi
le/2017/06/28/1383961_01.pdf(2020.10.15, Japanese)

Committee for Model Core Curriculum (2016b) “Modelcore curriculum for dental education, 2016 Updateedition” Ministry of Education, https://www.mext.go.jp/component/b_menu/shingi/toushin/__icsFiles/afieldfi
le/2017/12/26/1383961_02_3.pdf(2020.10.15, Japanese）

Dinges DF (2014) “The growth of sleep science and the role ofSLEEP” Sleep;37(1):7-8.
Examination Department of MHLW (2016) “Physical therapist
and occupational therapist national examination criteria, 2016
Version” Ministry of Health, Labor and Welfare, https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000058636.html(2020.10.15, Japanese）

question-posing who have some interest in sleep-related

Health Japan 21 Committee (2000) “National health promotion

issues. Whether the observed percentages are sufficient

movement in the 21st century” Ministry of Health, Labor

is difficult to judge, as increasing numbers of issues needand Welfare, https://www.mhlw.go.jp/file/06-Seisakujouhou-

to be covered on the national medical examinations.

10900000-Kenkoukyoku/0000047221.pdf

The National Health Promotion Movement in the 21stCentury (Health Japan 21), established by the Ministry ofHealth, Labor and Welfare, emphasizes the importanceof sleep habits and sleep disorders, with reference to“promoting physical and mental health by rest” (HealthJapan 21 Committee, 2000). Medical professionals arein positions to educate patients and recommend thatthey get sufficient sleep to meet this goal. Althoughmany questions need to be included in the nationalexaminations, sleep is a basic function supporting health.
More attention to sleep among medical professionals
would benefit patient management.

(2020.10.15,Japanese）
Jones BE (2018)“The mysteries of sleep and waking unveiledby Michel Jouvet.”Sleep Med 49:14-19
Ministry of Health, Labor and Welfare website, https://www.
mhlw.go.jp/index.html (2020.10.15, Japanese）
Morgan K (2003) “Sleep Management in Nursing Practice”
Tokyo：Brain Publishing (Japanese)
Nursing Department of MHLW (2018) “Public health nurse,
midwife and nurse national examination criteria, 2018
Version” Ministry of Health, Labor and Welfare, https://www.mhlw.go.jp/file/04-Houdouhappyou-10803000-IseikyokuIjika/0000158962.pdf(2020.10.15, Japanese）

Conclusion
The number of sleep-related questions on national
medical examinations tended to increase over the past
15 years, but varied among medical fields and years.
This study showed that clinically important sleep-related
topics were covered on all examinations for all medicalspecialists. Further enhancement of sleep education in
medical schools is expected.

References
Blunden SL, Chapman J, Rigney GA (2012) “Are sleep
education programs successful? The case for improved andconsistent research efforts” Sleep Med Rev;16(4):355-370
Committee for Model Core Curriculum (2016a) “Model10

大学教育実践ジャーナル 第19号 2021