DOI: 10.1002/jgf2.202

EDITORIAL

Postgraduate medical education in Japan: Missed opportunity
for learning clinical reasoning
Most Japanese physicians who graduated before 2004 received

to greater harmful events in the future of Japan. Second, sometraining in only single specialty during their residency and thus

residents in Japan have interests in acquiring procedural skills,

lacked attitudes, skills, and knowledge for basic primary and emer-

which can obviously show their competency to other members

gency care.1 Some of them revealed inadequate quality of primaryof their care team, including teaching faculty. However, compe-and emergency care and public pressure throughout Japan had

tent residents need not only procedural skills, but also basic skills

promoted the introduction of mandatory medical education for allof clinical reasoning based on good history taking and physicalnewly graduating physicians. 2examination.

Consequently, the current postgraduate medical education (PGME)

Therefore, we conducted a nationwide study comparing postgrad-was implemented in 2004 by the Japanese government as new 2-­year

uate year (PGY)-­1 and PGY-­2 residents for knowledge of basic clinicalsuper-­rotation program, including internal medicine, emergency med-care, including clinical reasoning, based on results of general medicine

icine, and community medicine as mandatory rotations and other spe-in-­training examination (GM-­ITE). The previous results of this exam-cialties as selective rotations.3 Objectives of this PGME are to educate

ination have been published elsewhere and elucidated important ed-residents to acquire attitudes, skills, and knowledge for providing basic

ucational factors related to the GM-­ITE scores.6–9 We analyzed theclinical care. A study showed that physicians who received the current

most recent (February 2017) GM-­ITE scores of resident physicians

PGME program were more likely to adhere to an appropriate standard

between postgraduate year (PGY)-­1 and PGY-­2 resident physicians inof care in emergency medicine and were more confident in caring for

459 Japanese teaching hospitals which participated in the GM-­ITE.

patients with acute illnesses, compared to those who graduated before
2004 and did not receive the current PGME.4

A total of 5593 resident physicians (2678 PGY-­1 and 2915
PGY-­2) participated in the examination. A total of 491 residents

Although the current PGME is better than the no-­rotation

were excluded from analyses, because we could not obtain theirtraining prior to 2004, there may be still some weaknesses of theconsent to the data use. Overall mean score among PGY-­1 andcurrent PGME. First, overtesting in diagnostic process is highly

PGY-­2 were 32.3 ± 5.1 and 32.5 ± 5.5, respectively, and theseprevalent in Japanese hospitals, 5 and thus, some residents, if not

were not significantly different. However, additional analysis wasall, may tend to order a long list of diagnostic tests, which mayconducted using scores of residents only in top 200 hospitals inmask lack of their diagnostic reasoning skills. Because overtest-

terms of the higher mean scores among participating residents.

ing can cause harm to patients through downstream tests includ-This subgroup analysis showed mean score 34.9 ± 5.0 of PGY-­2

ing invasive tests, the overtesting practice might potentially lead

was significantly higher than that 34.4 ± 4.7 of PGY-­1 (Table 1).
Based on our results, there are few improvements of the basic
clinical knowledge over the PGY-­1 to PGY-­2 years in low-­score hos-TA B L E 1PGY-­2

Comparison of GM-­ITE scores between PGY-­1 andPGY

pitals, but residents in high-­score hospitals have the significant improvement. In other words, good teaching hospitals may effectively

GM-­ITE scoreP-­value

Residents in top 200 hospitals (n = 2413)
PGY-­134.4 ± 4.7

PGY-­234.9 ± 5.00.03*

teach knowledge for clinical reasoning to residents, but other hospitals may not. Our result should be an alarm for teachers and residents in Japan, and further studies for assessing clinical reasoning
skills in each PGY year of Japanese residents should be considered.
Meanwhile, clinician educators in teaching hospitals should focus

All residents (n = 5102)

more on teaching clinical reasoning.

PGY-­132.3 ± 5.1

PGY-­232.5 ± 5.5>0.05

GM-­ITE, general medicine in-­training examination; PGY, postgraduate
year.
*Statistically significant.

AC K N OW L E D G E M E N T
We thank Mrs. Juhei Matsumoto and Yoshihiko Nakamura for their­excellent support for our work.

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.
© 2018 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.
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wileyonlinelibrary.com/journal/jgf2	﻿J Gen Fam Med. 2018;19:152–153.

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EDITORIALC O N FL I C T O F I N T E R E S T
The authors have stated explicitly that there are no conflicts of interests in connection with this article.
Yasuharu Tokuda MD, MPH1
Mano Soshi MD2Tomoya Okubo PhD3Yuji Nishizaki MD, MPH, PhD 4,5
1

Muribushi Okinawa for Teaching Hospitals, Okinawa, Japan
2

3

Minami Seikyo Hospital, Aichi, Japan

Research Division, The National Center for University Entrance
Examinations, Tokyo, Japan

4

Medical Technology Innovation Center, Juntendo University, Tokyo,Japan
5Clinical Research and Trial Center, Juntendo University Hospital,Tokyo, JapanEmail: yasuharu.tokuda@gmail.com

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