Received: 13 June 2016

| Accepted: 20 September 2016

DOI: 10.1002/jgf2.57

LETTER TO THE EDITOR

Educational environment and the improvement in the General
Medicine In-­training Examination score
Dear Editor:

We analyzed GM-­ITE scores of 241 resident physicians affiliatedWe investigated the association between the educational environment

to 46 Japanese teaching hospitals (42 community and four univer-and performance in the General Medicine In-­training Examinationsity hospitals, age 26.8±3.0 years, 176 males and 65 females) under-(GM-­ITE) among postgraduate year (PGY)-­1 and -­2 resident physi-went GM-­ITE in 2013 and 2014. university hospitalswere collectedcians in Japanese teaching hospitals since 2012. GM-­ITE includes 100

using a self-­reporting questionnaire sheet, the Residency Electronicquestions designed by a committee comprised of experts organized

Information System website, and the Foundation for the Promotion

by the Japan Organization of Advancing Medical Education Program.1of Medical Training website. We examined the association between

1

According to our previous report , hospitals with a general medicine

the educational environment and changes in the GM-­ITE score (PGY-­2(GM) department or those located in a provincial community had sig-score minus PGY-­1 score) using hierarchical linear regression models.

nificantly higher GM-­ITE score compared with the other hospitals. DataThe covariates with P<.10 on the univariable analysis were included infrom the 2013 GM-­ITE showed that appropriate emergency depart-our multivariable model (Table 1).

ment (ED) workload, inpatient caseload, and online learning resource

Our results showed that age, the number of ED duty (3-­5 orwere associated with greater clinical knowledge.2 In addition, in 2014,≥6 per month), and the number of inpatients the resident was re-we found that factors affecting hospital volume, including the number

sponsible for (monthly average 5-­9) were associated with the im-of hospitalizations, had a positive impact on GM-­ITE scores.3 While ourprovement in GM-­ITE scores (Table 1). A previous study showed

team have been extensively studied factors related to the performancethat a heavy call rotation (every fourth or fifth night) was related toof the GM-­ITE, because previous studies were analyzing cross-­sectional

postcall performance impairment.4 Overnight calls were associateddata, we could not evaluate the improvement in GM-­ITE score overwith higher burnout and fatigue scores.5 Recently, there has been atime. In this context, we investigate how educational environment oftrend for limiting workloads for residents because there might have

hospitals is related to the improvement in GM-­ITE score using the lon-been relationship between an excessive workload and higher risk

gitudinal data obtained during two consecutive years.

at burnout.

TABLE 1

Association between educational environment and change in GM-­ITE scores (PGY-­2 minus PGY-­1)
Multivariable analysisa

Univariable analysis

Variable
Hospital-­level variables
Community hospital (vs. university hospital)
Number of hospital beds (per 100 increase)
Number of physicians (per 100 increase)
Located in urban area (vs provincial)
GIM/GM (vs no GIM/GM)
Salary (Japanese 10 000 yen)
Area of library (100 mm2)
Number of books in library (per 10 000 increase)
Doctor-­level variables
Age (year)
Male
ED duty per monthb
01-­2
3-­5

Estimate (theimprovement inGM-­ITE score)

95% CI
Lower
limit

Upperlimit

P-value

0.15
−0.47
−0.18
1.24
1.00
−0.160.01
0.01

−3.97
−1.35
−1.08
−1.70
−2.16
−0.35
−0.16
−0.18

4.28
0.42
0.73
4.18
4.15
0.03
0.19
0.20.94
.30
.70
.41
.53
.11.91
.92

0.47
−0.25

0.13
−2.45

0.81
1.96

.01**
.83

1
1.65
2.45

Reference
−2.31
5.62
0.41
4.50

.41
.02**

Estimate (theimprovement inGM-­ITE score)

95% CI
Lower
limit

Upper
limit

P-value

0.46

0.05

0.88

.03**

4.17
3.42

−0.37
1.46

8.71
5.37

.07*
<.01**(Continues)
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in anymedium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2017 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.
312|

wileyonlinelibrary.com/journal/jgf2	﻿

J Gen Fam Med. 2017;18:312–314.

| 313LETTER TO THE EDITORTABLE 1(Continued)
Multivariable analysisa

Univariable analysis

Variable
6 or greater
Unknown
Number of inpatients in chargeb
0-­45-­910-­14
15 or greater
Unknown
Study time (min)b0-­3031-­6061-­9091 or greater
Unknown

Estimate (theimprovement inGM-­ITE score)

95% CI
Lower
limit

Upperlimit

P-value

Estimate (theimprovement inGM-­ITE score)

2.15
8.34

−0.77
3.69

5.07
13.00

.15
<.01**

1
2.62
2.02
−0.58
1.89

Reference
0.24
5.00
−1.42
5.46
−4.42
3.26
−7.27
11.06

.03**
.25.76
.68

1
−0.99
0.65
−1.71
−0.59

Reference
−4.34
2.35
−2.69
3.98
−4.83
1.41
−11.8010.63.56.70.28.92

95% CILower
limit

Upper
limit

P-value

3.69
7.57

1.11
1.46

6.27
13.68.01**
.02**

3.17
2.15
−1.77
3.03

0.51
−1.65
−6.77
−2.11

5.82
5.95
3.22
8.17.02**.27.48.25

CI, confidence interval; NS, not significant; GIM, general internal medicine; GM, general medicine; ED, emergency department.
aEstimate of hospital random-­effects variance =6.42 (P=0.09).
bF-­test with 4 degrees of freedom for univariable analysis: P<.01 for ED duty per month, P=0.07 for the number of inpatients the resident was in charge of,and P=0.27 for study time.
*P<.1.
**P<.05.

Here hospitals with a GM department were not significantly re-Yusuke Tsugawa MD, PhD5

lated to the improvement in GM-­ITE scores. Therefore, we presume

Taro Shimizu MD, MPH, MBA6

that the resident physicians did not receive sufficient periods of GM

Ryota Konishi MD, MPH7
Yu Yamamoto MD8residency.
The main limitation of the present study was a small sample size.

Naotake Yanagisawa PhD9Although the total number of participants was 1049 and 2015 inToshiaki Shiojiri MD102013 and 2014, respectively, only 241 participants undertook GM-­

Yasuharu Tokuda MD, MPH11

ITE during the studied years. Another problem is the possibility ofceiling effect in participants achieving a high score in PGY-­1. The dif-1

Department of Cardiovascular Medicine, Juntendo University Graduate
School of Medicine, Tokyo, Japan

ference in scores (PGY-­2 minus PGY-­1) tended to be smaller when2

Department of Cardiology, St. Luke’s International Hospital,

participants achieved a high score in PGY-­1. Finally, the information
on ED duty, obtained from the self-­reporting questionnaire sheet,
was simply the number of overnight calls per month, and it could

Tokyo, Japan3

Department of Biostatistics, School of Public Health, The University ofTokyo, Tokyo, Japannot be used to assess the difference in the system of emergency de-4

Research Division, The National Center for University Entrance

partment of each hospital. Also, the number of inpatients in charge

Examinations, Tokyo, Japanobtained from the self-­reporting questionnaire sheet was simply the5Department of Health Policy and Management, Harvard T. H. Chan

average number of inpatients in charge, and it could not be used toassess the difference in the system of the specialties the residents
rotated on.

School of Public Health, Boston, MA, USA
6Department of Diagnostic and Generalist Medicine, Dokkyo Medical
University Hospital, Tochigi, Japan
7Department of General Internal Medicine, Kanto Rosai Hospital,

CO NFLI CT OF I NTERE S T

Kawasaki City, JapanThe authors have stated explicitly that there are no conflicts of inter-

8

Division of General Medicine, Center for Community Medicine, Jichi
Medical University School of Medicine, Tochigi, Japanest in connection with this article.
9Clinical Research Section, R&D Management Department, R&DYuji Nishizaki MD, MPH, PhD1
Atsushi Mizuno MD2Division, Morinaga Milk Industry Co., Ltd., Kanagawa, Japan10

Department of General Internal Medicine, Asahi General Hospital,Tomohiro Shinozaki MPH3Tomoya Okubo PhD

4Chiba, Japan
11

Japan Community Healthcare Organization, Tokyo, Japan

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1. Shimizu T, Tsugawa Y, Tanoue Y, et al. The hospital educational environment and performance of residents in the General Medicine In-­
Training Examination: a multicenter study in Japan. Int J Gen Med.
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2. Kinoshita K, Tsugawa Y, Shimizu T, et al. Impact of inpatient caseload,emergency department duties, and online learning resource on General
Medicine In-­Training Examination scores in Japan. Int J Gen Med.
2015;8:355–60.

LETTER TO THE EDITOR

3. Mizuno A, Tsugawa Y, Shimizu T, et al. The Impact of the hospital volume
on the performance of residents on the general medicine in-­training examination: a multicenter study in Japan. Intern Med. 2016;55:1553–8.
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performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005;294:1025–33.
5. Block L, Wu AW, Feldman L, Yeh HC, Desai SV. Residency schedule,
burnout and patient care among first-­year residents. Postgrad Med J.
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