Received: 22 December 2020

| Revised: 8 April 2021 | Accepted: 12 April 2021

DOI: 10.1002/jgf2.449

ORIGINAL ARTICLE

The impact of autopsy participation on clinical residency
Kohta Katayama MD1| Yuji Nishizaki MD, MPH, PhD2|
3
4Tomohiro Shinozaki MPH, PhD | Yuta Saitoh MD | Tetsuhiro Yano MD5 |Takuya Aoki MD, MMA6
| Masayuki Noguchi MD, PhD7 | Yasuharu Tokuda MD, MPH8
1Department of General Medicine,
Shirakawa Satellite for Teaching And
Research (STAR), Fukushima Medical
University, Fukushima, Japan2
Department of Medical Education,
Juntendo University School of Medicine,Tokyo, Japan3

Department of Information andComputer Technology, Faculty ofEngineering, Tokyo University of Science,
Tokyo, Japan
4
Department of Internal, Emergency,
and General Medicine, Saitama Citizens
Medical Center, Saitama, Japan
5

Department of Emergency Medicine,
Fukushima Medical University, Fukushima,Japan
6

Abstract
Background: Autopsy has had an essential role in ensuring the quality of educationand medical care. However, its role in clinical residency has not been clarified. This
study assessed actual autopsy circumstances during clinical residency and evaluatedthe association between autopsy and clinical knowledge.
Methods: We conducted a cross-­sectional study involving postgraduate second year
residents in Japan who took the General Medicine In-­Training Examination in 2019.
We modeled the General Medicine In-­Training Examination scores of the residents
to examine their association with autopsy experiences and the number of autopsy
experiences to assess its predictors.
Results: Of 2715 postgraduate second year residents, 353 (13.8%) had no autopsy
participation, and 1015 (39.7%) had only one experience. Although autopsy participa-

Division of Clinical Epidemiology, The
Jikei University School of Medicine,Tokyo, Japantion was not related to the mean General Medicine In-­Training Examination score,7

60 min per day, and wish to be pathologists were significantly associated with autopsy

Department of Pathology, Faculty of
Medicine, University of Tsukuba, Tsukuba
City, Japan
8

Muribushi Okinawa Center for Teaching
Hospitals, Urasoe City, Japan
Correspondence
Kohta Katayama, Departmentof General Medicine, Shirakawa Satellite
for Teaching And Research (STAR),
Fukushima Medical University, Fukushima,
Japan.
Email: pine77717@gmail.com

1|

the residents' clinicopathological conference participation, self-­study for more thanexperiences. They experienced more autopsies when they belonged to small-­sized
hospitals in rural areas performing many autopsies.
Conclusion: We reported the current status of autopsy in clinical residency andshowed that more than half of the residents experienced no or only one autopsy.
General Medicine In-­Training Examination scores were not correlated with the number of autopsy experiences.
KEYWORDS

autopsy, clinical residency, clinicopathological conference, JapanI NTRO D U C TI O N

In a retrospective review of 2 year records from an educational
hospital, 34% of autopsy cases had an unexpected pathological di-Historically, autopsy has made an invaluable contribution to medi-

agnosis leading to death, and 93% of the physicians who attended

cine, from understanding novel illnesses to answering patient man-the autopsies rated them as being a valuable educational experi-agement issues and maintaining quality of medicine. The value ofence.6 However, as a global trend, the autopsy rate has been con-autopsy in detecting diagnostic errors has been demonstrated.1–­5

tinuously decreasing.7 In Japan, it was 5.2% in 2012, and an autopsy

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,provided the original work is properly cited.
© 2021 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.
278

| 	﻿
wileyonlinelibrary.com/journal/jgf2

J Gen Fam Med. 2021;22:278–287.

| 279KATAYAMA et al.

was performed in approximately half of all in-­hospital deaths in the
1960s.

8

directors were required to assemble residents in a room at eachhospital at a scheduled time and administer the GM-­ITE to their

In Japan, residents were required to participate in autopsies andresidents. Then, each program director collected the completed ex-clinicopathological conferences (CPCs) since the new postgradu-

amination answer sheets and sent them back to us in an envelope we

ate medical education (PGME) program was introduced in 2004.9

provided. Since the academic calendar in Japan starts on April 1 andResidents must attend the autopsy explanation to the bereaved

ends on March 31 of the following year, the GM-­ITE was conductedfamilies, the autopsy itself, and CPCs to understand the pathophysi-

in February or March 2019. Immediately after the test, we provided

ology in detail during their 2 years of clinical residency training. The

a self-­reported questionnaire sheet regarding the residents' autopsy

purpose of PGME is training physicians with a holistic approach andexperiences (i.e., the number of autopsies experienced, autopsy par-acquiring primary care skills. This training, from the autopsy expla-

ticipants when they were in charge, and CPC participation). In addi-

nation to CPCs, is considered a part of this holistic approach. In ation, the sheet included the question whether residents wished tosurvey for each teaching hospital conducted jointly by the Japanese

be pathologists.

Society of Pathology and the Japanese Society of Internal Medicine,

We collected the number of autopsy cases and deaths at eachresidents learned autopsy explanation, including its permission, by

hospital from the Annual of the Pathological Autopsy Cases in Japanobserving their supervising physicians.10 In addition, the survey has

by the Japanese Society of Pathology. This database has registeredfound that autopsy education has become an on-­the-­job training.

all autopsies performed in Japan since 1960. We used the data fromHow many autopsies residents experience and how effective autop-

2017 (11,089 cases registered from 808 hospitals). In addition, wesies are in the PGME program are unclear.

obtained additional data, including whether it was a university hos-During these 16 years, we have verified the new PGME pro-pital, whether it was located in an urban area, how many beds it had,gram using the General Medicine In-­Training Examination (GM-­ITE),

and whether it had a general medicine department, from the website

which was developed using a similar methodology for developingof each hospital.

11

the Internal Medicine ITE (IM-­ITE) in the United States.

The pur-pose of the GM-­ITE (the same as that of the IM-­ITE) is providing

This study was approved by the Institutional Review Board of
Mito Kyodo General Hospital, Mito City, Ibaraki, Japan.

residents and program directors with an objective, reliable, and valid
assessment of each resident's clinical knowledge in a multiple-­choice
examination, and the mean scores of each program were compared

2.2 | General Medicine In-­Training Examination

with those of their peers.12,13 We have been examining the characteristics of residents regarding their clinical knowledge using a ques-

In Japan, since the new PGME program was introduced in 2004, thetionnaire survey conducted at the same time as the GM-­ITE. In ourmanagement and implementation of the training program were left

previous studies, we have reported the characteristics of residents

primarily to the discretion of each teaching hospital. Furthermore,with more excellent clinical knowledge, such as those with appropri-

objective outcome indicators in clinical training have not been es-

ate emergency department and inpatient caseloads and those work-

tablished, and the training contents during residency varied depend-

ing in provincial community hospitals with many beds.14–­17

ing on each hospital. In September 2005, the Japan Organization

We hypothesized that autopsy would be one of the factors as-of Advancing Medical Education Program (JAMEP), a nonprofit

sociated with clinical knowledge because autopsy has become aorganization, was established to resolve these issues. The JAMEP

compulsory part of PGME. Therefore, we used the GM-­ITE and adeveloped the GM-­ITE as an objective evaluation indicator of the

concurrent questionnaire survey to clarify the actual circumstances

resident's basic clinical knowledge. The GM-­
ITE, an “in-­trainingof autopsy among residents and evaluated the association between

examination” for residents, was introduced in 2012 (first edition),

their autopsy experiences and clinical knowledge.

and the number of participants has increased every year. In 2019(eighth edition), 6133 residents from 503 teaching hospitals took the2|

M E TH O D S

2.1 | Study design and study population

GM-­ITE.
The GM-­ITE included 60 questions testing a wide range of clinical knowledge, from clinical skills and practical medical knowledge
to patient psychosocial care. The examination was designed andwritten by a committee of experienced attending physicians orga-

We conducted a cross-­sectional study involving postgraduate sec-

nized by the JAMEP. Questionnaires presented at the GM-­ITE fo-

ond year (PGY-­2) residents of 441 teaching hospitals in Japan who

cused on residents' practical experience, not just questions on their

took the GM-­ITE in 2019. The participants were trainees of 2 year

knowledge. The maximum and minimum scores for the examination

postgraduate rotation training programs, including internal andwere 60 and 0, respectively, with higher scores indicating a better

emergency medicine, required for all residents regardless of theirperformance of the general medicine knowledge base. Before con-specialty before entering the specialty training programs (PGY-­3

ducting the examination, a question review was organized, and theor later). All participants provided informed consent, which wascontent validity was confirmed by the peer review of each commit-

obtained under the opt-­
out agreement. The residency program

tee member.

280

|

KATAYAMA et al.

2.3 | Statistical analyses

experiences of which the residents were in charge were 1307
(51.2%), 987 (36.7%), 195 (7.6%), 42 (1.7%), 13 (0.5%), four (0.2%),

We summarized the residents' (resident-­level variables) and work-

two (0.1%), and two (0.1%), respectively.

place (hospital-­level variables) characteristics using the self-­reported

The mixed-­effect model results showed that an increasing num-

number of autopsy participation during their clinical residency pro-ber of autopsy experiences were not associated with higher GM-­ITE

grams. The purposes of our analysis were as follows: (a) to assessscores (Table 2). Significant variables associated with a more excel-

the association between GM-­ITE scores and residents' autopsy ex-lent GM-­ITE score were internal medicine rotation for 11–­15 months

periences after adjusting the characteristics and (b) to investigate(score difference, 1.889; 95% confidence interval [CI], 0.726–­3.053;

the possible characteristics associated with the residents' autopsy

p = 0.001); handling an average of 0–­4 (score difference, 0.795; 95%

experiences. For the first purpose, we fitted the mixed-­effect mod-CI, 0.127–­1.463; p = 0.020) and more than 15 (score difference,els for the GM-­ITE scores by incorporating hospital variation as

2.013; 95% CI, 0.784–­3.241; p = 0.001) inpatients; and 30–­60 (scorenormally distributed random intercepts. The numbers of autopsies

difference, 1.143; 95% CI, 0.464–­1.821; p = 0.001) and 61–­90 (scoreand deaths at each hospital were adjusted separately in Model 1,

difference, 2.771; 95% CI, 1.643–­3.899; p < 0.001) min of study perwhereas the ratio of these numbers and resident-­and hospital-­levelday.

characteristics were adjusted in Model 2. For the second purpose,

The results of the log-­linear and linear models showed that thethe mean number of autopsy experiences was modeled using linear

more residents participated in CPCs, the more they experienced au-

and log-­linear models through the generalized estimating equations,

topsies (Table 3). The other resident-­level variables associated withtreating hospitals as clusters with the independence working cor-

autopsy experiences were study time of 61–­90 (mean ratio, 1.22;

relation. The linear and log-­linear models estimated the increase in

95% CI, 1.11–­1.34; p < 0.0001) and more than 91 (mean ratio, 1.20;

the average number of autopsy experiences by each variable on the

95% CI, 1.02–­1.42; p < 0.0001) min per day. Residents who wishedadditive and multiplicative scales, respectively.

to be pathologists experienced more autopsies (p = 0.005). Hospital-­

However, note that because the highest category of the num-level variables associated with autopsy experiences were number ofber of autopsy experiences was censored seven times (i.e., outcome

autopsies (mean ratio, 1.14; 95% CI, 1.09–­1.18; p < 0.0001), smaller

values range from 0 to 7), estimates may include the bias from thenumber of beds (mean ratio, 0.88; 95% CI, 0.85–­0.92; p < 0.0001),“ceiling effect.” Hence, we conducted sensitivity analyses. First, weand not working in hospitals in urban areas (95% CI, 0.78–­0.97;

excluded residents who participated in more than seven autopsies

p = 0.013).

(n = 36). Second, the number of autopsy participation was censoredusing the discrete-­time hazard model (with the robust varianceestimator clustering hospitals). The model was interpretable as a

4|

DISCUSSION

continuation-­ratio logit model for ordinal categories (i.e., the numbers of autopsy experiences) and provided estimates of common

To our knowledge, this is the first study that investigated the ac-odds ratios for the probability of taking several outcomes (autopsy

tual autopsy conditions during a 2 year clinical residency in Japan.

participation) among the residents with more than or equal to that

More than half of the study participants experienced no or only one

number. Tables S1 and S2 show the results of the sensitivity analyses.

autopsy per year.18 No correlation was observed between the num-

All analyses were conducted through SAS version 9.4 (SAS, Inc.).

ber of autopsy experiences and GM-­ITE score. Based on these twofacts, autopsy experience does not significantly affect residents'

3|

R E S U LT S

clinical competence. With the current low autopsy participation, autopsy is not beneficial for improving residents' clinical competence.
Hospital characteristics affecting whether residents' participa-

A summary of the baseline characteristics is shown in Table 1. Intion in many autopsies were those located in rural areas, with a small

total, 2715 PGY-­2 residents took the GM-­ITE in 2019. Among them,

number of beds, and performing a large number of autopsies. The

we retrospectively analyzed 2554 residents from 441 hospitals (re-former two characteristics, located in rural areas with a small num-sponse rate was 94.1%). Of these participants, 47 (1.7%) wished tober of beds, are also related to high GM-­ITE scores.14,17 Although we

be pathologists. We obtained all hospital-­level variables from the

could not verify the relationship between autopsies and the clinical

Annual of the Pathological Autopsy Cases in Japan by the Japaneseknowledge of residents, autopsy experience might be a factor ensur-

Society of Pathology and the websites of each hospital. The averageing the quality of clinical residency at rural hospitals.

GM-­ITE score was 31.6 ± 6.0. During the 2 year clinical residency,

Resident characteristics associated with participation in more

353 (13.8%) residents had no autopsy experience, 1015 (39.7%) had

autopsies were longer study time, more CPC experiences, and pa-

one autopsy experience, 608 (23.8%) had two autopsy experiences,thologist aspirants. In addition, longer study time is also related to337 (13.2%) had three autopsy experiences, 112 (4.4%) had fourhigh GM-­ITE scores in this study. CPCs are where autopsy cases can

autopsy experiences, 67 (2.62%) had five autopsy experiences, 26

be examined from pathological and clinical perspectives. Residents(1.0%) had six autopsy experiences, and 36 (1.4%) had more thanattending more CPCs must be highly motivated and manage their pa-

seven autopsy experiences. The corresponding number of autopsy

tients from a holistic view. This attitude toward patients is the same

585 (57.6)

0.03 [0.02, 0.05]

66 (18.7)

144 (40.8)

655.2 ± 258.0

238 (67.4)

Autopsy/death ratio

University Hospital

Urban area

Number of beds

31.5 ± 6.1

GM-­ITE score25 (2.5)
4 (0.4)77 (21.9)

13 (3.7)

2 (0.6)11–­15 months

16–­20 months

11 (1.1)

230 (65.2)

47 (13.3)

2 (0.6)

3–­5 per month>6 per month

Unknown

77 (21.8)

202 (57.2)

43 (12.2)

20 (5.7)

11 (3.1)

0–­4

5–­9

10–­14>15

Unknown

Average number of inpatients in charge

110 (10.8)

64 (18.1)

1–­2 per month

33 (3.3)

59 (5.8)

184 (18.2)

599 (59.1)

139 (13.7)

723 (71.2)

144 (14.2)

10 (2.8)0 per month

ED duty per month
27 (2.7)

234 (23.1)

233 (66.2)>21 months

710 (70.0)

27 (7.7)

0–­5 months

42 (4.1)

31.6 ± 5.8

353 (34.8)364 (35.9)

103 (10.2)

0.03 [0.02, 0.04]

6–­10 months

Internal medicine rotation

115 (32.6)

FemaleResident-­level variables

GM department

557.5 ± 215.5

473.4 ± 273.2

436.3 ± 242.5

17.8 ± 14.9

Number of deaths

15.4 ± 13.8

(n = 1015)(n = 353)

Number of autopsies

Hospital-­level variables

10

16 (2.6)

41 (6.8)111 (18.3)

348 (57.3)

91 (15.0)

9 (1.5)90 (14.8)423 (69.6)

75 (12.3)

11 (1.8)

3 (0.5)15 (2.5)

144 (23.7)

415 (68.4)

30 (4.9)

31.5 ± 5.9

188 (30.9)

341 (56.1)

519.9 ± 188.2

186 (30.6)

55 (9.1)

0.03 [0.02, 0.04]

396.6 ± 224.3

14.4 ± 14.0

(n = 608)

2

Number of autopsy participations during clinical residency

18 (5.4)

26 (7.8)

53 (15.8)

189 (56.4)

49 (14.6)

3 (0.9)40 (11.9)258 (76.6)

28 (8.3)

8 (2.4)2 (0.6)8 (2.4)92 (27.3)

223 (66.2)

12 (3.6)

32.6 ± 6.4

129 (38.3)

196 (58.2)

545.3 ± 199.1

101 (30.0)

35 (10.4)

0.03 [0.02, 0.05]

433.7 ± 221.9

18.2 ± 18.7

(n = 337)

3

3 (2.7)7 (6.3)15 (13.4)

67 (59.8)

20 (17.9)

1 (0.9)27 (24.1)

67 (59.8)

13 (11.6)

4 (3.6)0 (0)3 (2.7)27 (24.1)

78 (69.6)

4 (3.6)32.3 ± 5.9

38 (33.9)

65 (58.0)

546.9 ± 220.2

28 (25.0)

20 (17.9)

0.04 [0.02, 0.06]

424.9 ± 198.2

19.7 ± 19.4

(n = 112)

4

TA B L E 1 Factors related to GM-­ITE score compared with number of autopsy experiences during clinical residency

2 (3.0)1 (1.5)

11 (16.4)

44 (65.7)

9 (13.4)0 (0)10 (14.9)

48 (71.6)

7 (10.5)

2 (3.0)

0 (0)

0 (0)

15 (22.4)

50 (74.6)

2 (3.0)32.6 ± 5.7

8 (11.9)37 (55.2)

513.4 ± 210.2

13 (19.4)

10 (14.9)

0.04 [0.02, 0.07]

385.8 ± 223.8

20.3 ± 25.3

(n = 67)

50 (0)2 (7.7)6 (23.1)

15 (57.7)

3 (11.5)0 (0)3 (11.5)

16 (61.5)

6 (23.1)

1 (3.9)

0 (0)

0 (0)

7 (26.9)

17 (65.4)

2 (7.7)32.5 ± 6.0

12 (46.2)

20 (76.9)

479.8 ± 167.5

8 (30.8)

4 (15.4)

0.03 [0.01, 0.06]

380.4 ± 199.0

16.1 ± 18.8

(n = 26)

60 (0)1 (2.8)8 (22.2)(Continues)

20 (55.6)

7 (19.4)

0 (0)

0 (0)

9 (25.0)23 (63.9)

4 (11.1)0 (0)1 (2.8)7 (19.4)

26 (72.2)

2 (5.6)30.2 ± 5.5

9 (25.0)

13 (36.1)

463.6 ± 189.2

13 (36.1)

2 (5.6)0.03 [0.02, 0.05]

389.3 ± 200.6

14.6 ± 18.3

(n = 36)>7

KATAYAMA et al.

| 281

46 (13.0)

10 (2.8)

17 (4.8)

61–­90 min>91 min

None

0 (0)

1 (0.3)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

2 time3 time4 time5 time6 time6 (1.7)87 (24.7)

48 (13.6)

33 (9.4)

39 (11.1)

23 (6.5)

6 (1.7)84 (23.8)

1 time2 time3 time4 time5 time6 time>7286 (28.2)

28 (2.8)

72 (7.1)

80 (7.9)131 (12.9)

116 (11.4)

279 (27.5)

170 (28.0)

17 (2.8)

33 (5.4)

49 (8.1)

79 (13.0)

110 (18.1)

133 (21.9)

17 (2.8)

19 (3.1)

585 (96.2)

4 (0.7)

0 (0)

0 (0)

0 (0)

0 (0)

2 (0.3)93 (15.3)

268 (44.1)

245 (40.3)

26 (4.3)

31 (5.1)

115 (18.9)

244 (40.1)

192 (31.6)(n = 608)2

112 (33.3)

15 (4.5)

22 (6.6)

26 (7.7)

39 (11.6)

55 (16.4)

57 (17.0)

10 (3.0)

6 (1.8)329 (97.6)

2 (0.6)

0 (0)

0 (0)

0 (0)

0 (0)

25 (7.4)

59 (17.5)

133 (39.5)

120 (35.6)

20 (6.0)

11 (3.3)

53 (15.8)

152 (45.2)

100 (29.8)(n = 337)3

28 (25.0)

5 (4.5)13 (11.6)

18 (16.1)

11 (9.8)

17 (15.2)

17 (15.2)

3 (2.7)3 (2.7)107 (95.5)

2 (1.8)

0 (0)

0 (0)

0 (0)

7 (6.3)9 (8.0)17 (15.2)

39 (34.8)

40 (35.7)

5 (4.5)3 (2.7)32 (28.6)

31 (27.7)

41 (36.6)(n = 112)4

17 (25.4)

3 (4.5)10 (14.9)

14 (20.9)

10 (14.9)

4 (6.0)8 (11.9)

1 (1.5)3 (4.5)61 (91.0)

3 (4.5)

0 (0)

0 (0)

2 (3.0)3 (4.5)

1 (1.5)12 (17.9)

26 (38.8)

23 (34.3)

3 (4.5)3 (4.5)12 (17.9)

24 (35.8)

25 (37.3)(n = 67)5

6 (23.1)

1 (3.9)4 (15.4)

1 (3.9)6 (23.1)

4 (15.4)

4 (15.4)

0 (0)

0 (0)

23 (88.5)

3 (11.5)0 (0)2 (7.7)

1 (3.9)0 (0)1 (3.9)4 (15.4)

10 (38.5)

8 (30.8)

3 (11.5)

1 (3.9)8 (30.8)

12 (46.2)2 (7.7)(n = 26)6

18 (50.0)

1 (2.8)1 (2.8)3 (8.3)4 (11.1)

7 (19.4)

2 (5.6)0 (0)2 (5.6)28 (77.8)

6 (16.7)

2 (5.6)0 (0)1 (2.8)2 (5.6)

4 (11.1)

7 (19.4)

7 (19.4)

13 (36.1)

3 (8.3)8 (22.2)

7 (19.4)

10 (27.8)

8 (22.2)(n = 36)>7|

Note: Data are expressed as number (percentage), mean ± standard deviation, or median [25 percentile, 75 percentile].

33 (9.4)

0 time

CPC participations
22 (2.2)

23 (2.3)

331 (93.8)

Unknown

981 (96.7)

16 (4.5)No

11 (1.1)0 (0)1 (0.1)0 (0)2 (0.2)

Yes

Having wish to be a pathologist

>7

0 (0)

6 (1.7)

1 time498 (49.1)

344 (98.0)

514 (50.6)

63 (6.2)

48 (4.7)

149 (14.7)

417 (41.1)

0 timeAutopsy participants in which residents were in charge

135 (38.2)

31–­60 min

338 (33.3)(n = 1015)(n = 353)

145 (41.1)

10

Number of autopsy participations during clinical residency

0–­3 0 min

Study time per day

TA B L E 1 (Continued)

282
KATAYAMA et al.

1.8891.378−0.59316–­20 months>21 months−1.216

1.360

Unknown

Reference
0.011

0–­3 0 min

30–­60 min

Study time per day
0.535−1.901−0.521

10–­14>15

Unknown

0.784

0.668
2.013

5–­9
−0.178Reference
0.127

0.795

0–­4

Average number of inpatients in charge−0.197−0.162

1.312
1.481

3–­5 per month−0.4641.141

1–­2 per month>6 per month

Reference−4.037−0.3630.726−0.243

Reference−0.233−0.0860 per month

ED duty per month

0.847

6–­10 months

0.243

11–­15 months

0–­5 months

Internal medicine rotation

FemaleResident-­level variables−0.309−0.0490.563

Number of beds

GM department−2.863−1.068−1.291−0.387

University Hospital

Urban area—­

−0.158−0.388—­0.044−0.017

Autopsy/death ratio

Number of deaths (per 100)c

Number of autopsies (per 10)c

Hospital-­level variables

1.059

0.858

3.241

1.514

1.463

3.936

3.124

2.822

2.747

2.852

3.119

3.053

1.937

0.719

1.212

0.211

0.294

0.281

0.246

0.353

0.045

0.459

0.001

0.121

0.020

0.301

0.077

0.088

0.163

0.736

0.121

0.001

0.128

0.317

0.089

0.711

0.265

0.107

—­

0.671

0.928

0.518

−0.620

1.913

0.845

0.821

1.558

1.522

1.357

1.170

−0.347

1.804

2.002

1.082

0.337

0.597

−0.080−0.531−1.409

2.213

—­

—­

Estimatep

Estimate

95% CI

Model 2Model 1−0.025

Reference−2.1120.602−0.033

0.132

Reference−1.105−0.227−0.265−0.543

Reference−3.813−0.0250.750−0.096

Reference−0.155−0.069−0.267−1.242−3.060−13.710—­—­

95% CI

1.061

0.873

3.224

1.723

1.511

4.220

3.272

2.979

2.884

3.119

3.633

3.254

2.259

0.828

1.263

0.108

0.179

0.241

18.136—­—­(Continues)

0.061

0.416

0.004

0.059

0.020

0.251

0.088

0.101

0.180

0.844

0.053

0.002

0.072

0.180

0.079

0.404

0.143

0.094

0.785

p

TA B L E 2 Estimates of the mixed-­effect models for GM-­ITE score adjusting for the number of autopsies and deaths at each hospital (Model 1) or the ratio of these numbers (Model 2)a

KATAYAMA et al.

| 283

−5.088−2.904

0.128
0.994
0.726

3 or 45 or 6>6−0.659−0.483−1.246

Reference−1.900−0.573None

1 or 2

CPC participationseUnknown

Reference−2.470−0.761

Yes

No

Both models adjusted for hospital variation as normal random intercepts.

e

1.821

2.111

2.470

1.502

0.754

−0.7200.949−0.131

2.172

1.454

0.690

0.588

3.899

0.304

0.187

0.855

0.397

0.009

0.383

0.037

0.259

0.157

0.989

0.404

0.000

0.001

0.518

0.901

0.095

−0.713−3.308−0.950−2.286

0.736

0.466

−0.091−0.183

2.726

1.007

−0.931−0.638−1.345−2.109Reference−5.581−2.698Reference−4.332−0.660−0.407−0.819Reference−1.247

1.533

0.297

95% CI"CPC participation" variables were categorized in the same way as "Autopsy participations" variables.

"Autopsy participants in which residents were in charge" variables were removed due to a strong correlation with "Autopsy experiences" variables.

Hospital-­level continuous variables were categorized due to their high value.

dc−4.206−2.169

Having wish to be a pathologist>6−0.584

0.610
0.794

3 or 45 or 6−0.234

Reference−0.700−0.005None

1 or 2

Both models adjusted for hospital variation as normal random intercepts.

ba−1.457−0.435Autopsy participationsd

None

1.643

2.771

0.464

1.143

61–­90 min

Estimatep

Estimate

95% CI

Model 2Model 1>91 min

TA B L E 2 (Continued)

1.717

1.967

2.440

1.535

0.683

−1.0350.798−0.240

2.131

1.340

0.636

0.880

3.920

0.483

0.251

0.897

0.317

0.004

0.286

0.029

0.301

0.295

0.805

0.735

0.000

0.005

p

284

|
KATAYAMA et al.

| 285KATAYAMA et al.

TA B L E 3 Generalized estimating equations for linear and log-­linear models for mean number of autopsy participations among all
residents (the number of autopsy experiences was censored at 7)aLog-­linear modelLinear modelpMeandifferencec

95% CI

1.18<0.0001

0.22

0.13

0.31

<0.0001

0.97

1.03

0.873

−0.01

−0.05

0.04

0.742

0.88

0.85

0.92

<0.0001

−0.19

−0.25

−0.13

<0.0001

University Hospital

1.05

0.82

1.33

0.701

0.04

−0.37

0.46

0.841

Urban area

0.87

0.78

0.97

0.013

−0.24

−0.43

−0.06

0.009

GM department

0.95

0.86

1.06

0.382

−0.08

−0.27

0.11

0.397

0.99

0.93

1.06

0.750

−0.03

−0.14

0.09

0.654

6–­10 months

1.12

0.93

1.36

0.232

0.20

−0.11

0.52

0.198

11–­15 months

1.16

0.95

1.42

0.139

0.26

−0.07

0.59

0.120

16–­20 months

1.02

0.77

1.35

0.902

0.06

−0.38

0.50

0.786

>21 months

0.91

0.60

1.37

0.640

−0.13

−0.75

0.49

0.679

1.34

0.747

0.09

0.51

0.692

Mean
ratiob

95% CI

Number of autopsies(per 10)

1.14

1.09

Number of deaths (per
100)

1.00

Number of beds (per 100)p

Hospital-­level variables

Resident-­level variables
FemaleInternal medicine rotation
0–­5 months

Ref

Ref

ED duty per month0 per month1–­2 per month

Ref
1.04

0.81

Ref
−0.34

3–­5 per month

1.09

0.86

1.38

0.490

0.14

−0.26

0.55

0.483

>6 per month

1.23

0.93

1.62

0.144

0.37

−0.11

0.85

0.129

Unknown

0.92

0.69

1.23

0.574

−0.16

−0.65

0.33

0.523

1.16

0.355

0.08

−0.10

0.26

0.371

Average number of inpatients in charge
0–­4
5–­9

Ref
1.05

0.95

Ref

10–­14

1.02

0.90

1.16

0.762

0.04

−0.17

0.25

0.719

>15

0.99

0.86

1.13

0.857

−0.04

−0.26

0.19

0.742

Unknown

1.00

0.84

1.18

0.975

−0.02

−0.31

0.28

0.918

31–­60 min

1.04

0.96

1.12

0.329

0.06

−0.06

0.18

0.341

Study time per day
0–­3 0 min

Ref

Ref

61–­90 min

1.22

1.11

1.34

<0.0001

0.35

0.18

0.52

<0.0001>91 min

1.20

1.02

1.42

0.030

0.34

0.01

0.68

0.044

None

1.12

0.95

1.31

0.188

0.20

−0.08

0.48

0.169

Having wish to be a pathologist
Yes

Ref

Ref

No

0.68

0.52

0.89

0.005

−0.84

−1.50

−0.18

0.012

Unknown

0.81

0.58

1.12

0.206

−0.53

−1.28

0.21

0.162

1

1.17

0.95

1.45

0.141

0.24

−0.05

0.54

0.105

2

1.48

1.19

1.83

0.000

0.62

0.31

0.93

<0.0001

CPC participations
None

Ref

Ref

(Continues)

286

|

KATAYAMA et al.

TA B L E 3 (Continued)
Log-­linear model3

Meanratiob

95% CI

1.46

1.16

Linear model

1.85

p

Mean
differencec

95% CI

0.002

0.60

0.25

p
0.95

0.001

4

1.52

1.21

1.91

0.000

0.66

0.32

1.00

0.000

5

1.56

1.22

2.00

0.000

0.71

0.32

1.10

0.000

6

1.66

1.27

2.16

0.000

0.84

0.40

1.29

0.000

>6

1.49

1.19

1.87

0.001

0.65

0.32

0.97

0.000

a
Estimated by fitting the working generalized linear models with the canonical form (i.e., assuming Poisson distribution in log-­linear model and normal
distribution in linear model for outcome). Confidence intervals and p values were based on robust standard errors that treated hospitals as clusters,with the independence working correlation. Note that because the highest category of the number of autopsy participation was censored at 7
(outcome values range from 0 to 7), estimates may include the bias from the "ceiling effect."bcInterpretable as increase (>1) or decrease (<1) in average number of autopsy experiences on multiplicative scale.

Interpretable as increase (>0) or decrease (<0) in average number of autopsy experiences on additive scale.

as the position of the Association of Pathology Chairs, stating that

In conclusion, we reported the current status of autopsy in clin-

autopsy training in pathology residency should integrate anatomic

ical residency in Japan based on this questionnaire study involving

and clinical laboratory education.19 Moreover, this attitude leads to

PGY-­2 residents. We found that more than half of the residents

the ideal physicians setting out in the Japanese PGME.9

experienced no or only one autopsy. GM-­ITE scores were not cor-

The reported causes for the decrease in autopsy rate worldwide
are cause of death determined before death, no financial support

related with the number of autopsy experiences. Further study isrequired for improving autopsy training during clinical residency.

to the pathologist for autopsy procedures, fear of medical malpractice, and changes in public awareness toward autopsies. 2,3,7,20,21

AC K N OW L E D G E M E N T S

According to the questionnaire survey, 80% of attending physicians

We thank Norio Takayashiki for contributing research idea and con-in Japanese teaching hospitals were educating about autopsies.

structive pathological advice. We also thank Non-­Profit Organization

Some requested the redefinition of an autopsy.10 We found that

iHOPE International, Kyoto, Japan, for contributing study design.

several highly motivated residents, such as those with more CPC

Finally, we special thank the Japanese Society of Pathology for pro-participation, experienced more autopsies. The improvement of aviding us Annual of the Pathological Autopsy Cases of 2017.

CPC integrating clinical medicine and pathology does increase thenumber of autopsy participation.10 Moreover, an autopsy may sup-C O N FL I C T O F I N T E R E S T

port clinical competence if residents can actively participate in their

YN and YT participated on the General Medicine In-­training

patients' autopsies.

Examination project committee of the Japan Organization ofThis study has several limitations. First, this study involved aAdvancing Medical Education Program and received a reward.

small sample size. Only 2254 of the 8489 PGY-­2 residents in Japan
participated in this study. 22 Their program directors were responsible

ORCID

for the decision to participate in the GM-­ITE. PGY-­2 residents taking

Kohta Katayama

the GM-­ITE, who participated in this survey, were analyzed. There

Yuji Nishizaki

https://orcid.org/0000-0002-6964-6702

might have been a sampling bias in which the highly motivated teach-Takuya Aoki

https://orcid.org/0000-0002-8232-2155

ing hospitals might have involved more participants in the GM-­ITE.

Yasuharu Tokuda

https://orcid.org/0000-0001-8076-7188

https://orcid.org/0000-0002-9325-7934

However, the number of residents who took the GM-­ITE increased,
and only 341 residents (11%) who took the GM-­ITE were denied

REFERENCES

participation in this survey. Second, resident characteristics, such as

1. Thurnheer R, Hoess C, Doenecke C, Moll C, Muntwyler J, Krause
M. Diagnostic performance in a primary referral hospital assessedby autopsy: evolution over a ten-­year period. Eur J Intern Med.
2009;20(8):784–­7.
2. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg
M. The value of the autopsy in three medical eras. N Engl J Med.
1983;308(17):1000–­5.
3. Combes A, Mokhtari M, Couvelard A, Trouillet JL, Baudot J, Henin
D, et al. Clinical and autopsy diagnoses in the intensive care unit: aprospective study. Arch Intern Med. 2004;164(4):389–­92.

emergency room duty per month, number of inpatients handled, andnumber of autopsies experienced, could be influenced by recall or
cognitive bias, since it was a questionnaire study. We used the term“on average” in the questionnaire for these items over the 1 year before the test date or the 2 year clinical residency. Third, the numberof autopsies performed in each hospital used in this study was from2017. Although we could not use the 2018 data, we thought that the
number of autopsies at each hospital rarely changed.

| 287KATAYAMA et al.

4. Podbregar M, Voga G, Krivec B, Skale R, Pareznik R, Gabrscek L.
Should we confirm our clinical diagnostic certainty by autopsies?
Intensive Care Med. 2001;27(11):1750–­5.
5. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes inrates of autopsy-­detected diagnostic errors over time: a systematic
review. JAMA. 2003;289(21):2849–­56.
6. Durning S, Cation L. The educational value of autopsy in a residency training program. Arch Intern Med. 2000;160(7):997–­9.
7. Burton JL, Underwood J. Clinical, educational, and epidemiologicalvalue of autopsy. Lancet. 2007;369(9571):1471–­8 0.
8. Fukayama M. 110th Scientific Meeting of the Japanese Society ofInternal Medicine: Panel discussion: Development of a social system for the best medical quality and security: 1. Clinical autopsy:
need for countermeasures against its declining rates. Nihon Naika
Gakkai Zasshi. 2013;102(9):2320–­4.
9. Japanese Ministry of Health, Labor and Welfare. [The instruction
guidance for clinical residency in Japan]. 2020. [Japanese] Available
from: https://www.mhlw.go.jp/conte​nt/10800​0 00/00049​6242.
pdf. Accessed September 7, 2020.
10. Japanese Society of Pathology, Japanese Society of Internal
Medicine. Permission for pathological autopsy Autopsy Resultsof joint questionnaire survey. Nippon Naika Gakkai Zasshi.
2018;107:1394–­4 09.[Japanese].
11. Garibaldi RA, Subhiyah R, Moore ME, Waxman H. The in-­training
examination in internal medicine: an analysis of resident performance over time. Ann Intern Med. 2002;137(6):505–­10.
12. Kanna B, Gu Y, Akhuetie J, Dimitrov V. Predicting performanceusing background characteristics of international medical graduates in an inner-­city university-­affiliated internal medicine residency training program. BMC Med Educ. 2009;9:42.
13. Perez JA, Greer S. Correlation of United States medical licensing
examination and internal medicine in-­training examination performance. Adv Health Sci Educ Theor Pract. 2009;14(5):753–­8.
14. Shimizu T, Tsugawa Y, Tanoue Y, Konishi R, Nishizaki Y, Kishimoto
M, et al. The hospital educational environment and performance ofresidents in the General Medicine In-­Training Examination: a multicenter study in Japan. Int J Gen Med. 2013;6:637–­4 0.
15. Mizuno A, Tsugawa Y, Shimizu T, Nishizaki Y, Okubo T, Tanoue Y,
et al. The impact of the hospital volume on the performance ofresidents on the general medicine in-­training examination: a multicenter study in Japan. Intern Med. 2016;55(12):1553–­8.

16. Kinoshita K, Tsugawa Y, Shimizu T, Tanoue Y, Konishi R, Nishizaki
Y, 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.
17. Nishizaki Y, Mizuno A, Shinozaki T, Okubo T, Tsugawa Y, Shimizu
T, et al. Educational environment and the improvement in the
General Medicine In-­training Examination score. J Gen Fam Med.
2017;18(5):312–­4.
18. Fukui T, Takahashi O, Tokuda Y, Ohde S, Nomura K, Yano E,
et al. Effect of the new clinical training system. 1.Status of clinical training: results of a survey on university hospitals and hospitals participating in clinical training. Nippon Naika Gakkai Zasshi.
2007;96:2681–­94.
19. Hoffman RD, Kragel PJ, Kaul KL. Position paper from the Associationof Pathology Chairs: assessing autopsy competency in pathology
residency training. Acad Pathol. 2019;6:e2374289518824057.
20. Ornelas-­A guirre JM, Vázquez-­C amacho G, Gonzalez-­Lopez L,
Garcia-­Gonzalez A, Gamez-­Nava JI. Concordance between premortem and postmortem diagnosis in the autopsy: results of a 10-­year
study in a tertiary care center. Ann Diagn Pathol. 2003;7(4):223–­3 0.
21. De Vlieger GY, Mahieu EM, Meersseman W. Clinical review: Whatis the role for autopsy in the ICU? Crit Care. 2010;14(2):221.
22. Japanese Ministry of Health, Labor and Welfare. [The announceof adoption results of the resident physicians]. 2017. [Japanese]
Availablefrom:https://www.mhlw.go.jp/stf/houdo​u/00001​
71153.html. Accessed August 16 2020.

S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section.

How to cite this article: Katayama K, Nishizaki Y, Shinozaki T,
et al. The impact of autopsy participation on clinical residency.
J Gen Fam Med. 2021;22:278–287. https://doi.org/10.1002/
jgf2.449