Shikino et al. BMC Medical Education(2024) 24:316
https://doi.org/10.1186/s12909-024-05314-4

BMC Medical Education

Open Access

RESEARCH

Distribution of internal medicine rotations
among resident physicians in Japan:
a nationwide, multicenter, cross-sectional
study
Kiyoshi Shikino1,2*, Miwa Sekine3, Yuji Nishizaki3, Yu Yamamoto4, Taro Shimizu5, Sho Fukui6, Kazuya Nagasaki7,8,
Daiki Yokokawa2, Takashi Watari9,10, Hiroyuki Kobayashi7,8 and Yasuharu Tokuda11,12
Abstract
Background In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least
24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise
the training’s quality and depth. For example, a resident might spend only a few weeks in cardiology before
moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This
study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It
scrutinized the piecemeal approach—whereby residents may engage in multiple short-term stints across various
subspecialties without an overarching, integrated experience—and explored potential consequences for their clinicaleducation.
Methods This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed
by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year
(PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation
duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation.
Results Approximately half of the participants chose IM rotation periods of 32–40 weeks. A significant proportion ofparticipants rotated in 5–7 internal medicine departments throughout the observation period. Notable variations in
the distribution of rotations were observed, characterized by a common pattern where resident physicians typicallyspend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated acrossdifferent subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did notundertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions andpatient care practices.
Conclusions Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggestthat short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical*Correspondence:
Kiyoshi Shikino
kshikino@chiba-u.jp
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in thisarticle are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not includedin the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you willneed to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.

Shikino et al. BMC Medical Education(2024) 24:316

Page 2 of 10

experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained andcomprehensive learning experiences.
Keywords Clinical rotation, GM-ITE, Internal medicine, Postgraduate clinical training, Residency program

BackgroundIn recent years, there has been a notable shift towards
community care over traditional hospital settings inJapan [1]. This may reflect a response to Japan’s demographic changes, such as its aging population. The evolving nature of patient preferences, alongside a national
agenda to enhance accessibility and personalized care incommunity settings, may also contribute to this trend.
These societal factors are critical in understanding thecurrent and future landscape of medical education, whichmust adapt to meet these changing healthcare needs.
Japan has 82 medical schools where the curriculum
spans 6 years, starting immediately after high school.
The initial phase of medical education covers a broad
range of general studies for the first 2 years, followed by
4 years of focused medical training. Upon graduation, thevast majority of students embark on residency programs
that begin with a required 2-year postgraduate residency
training [2, 3]. It is noteworthy that about one-third ofthese graduates opt to pursue a specialization in internal medicine or its related subspecialties. As part of their
postgraduate clinical training, which has been compulsory since April 2004, resident physicians undergo a comprehensive 96-week (2-year) residency rotation program[2, 3]. This program is structured to provide essential
foundational knowledge, with a minimum of 24 weeks
allocated to internal medicine (IM) or general internal medicine (GIM) subspecialties for the acquisition of
acute care skills. In addition to these, resident physicians
partake in rotations across six other medical domains(surgery, obstetrics and gynecology, pediatrics, psychiatry, emergency medicine, and community-based medicine), each for at least 4 weeks, ensuring a broad clinicalexposure. The program’s design also allows for 40 weeks
of flexible scheduling, permitting resident physicians totailor their training to either deepen their expertise in
specific areas such as family medicine or hospital medicine, or to further expand their proficiency within thewider field of general internal medicine, ultimately leading to specialty certification [4, 5].
IM is a multifaceted specialty requiring an extensive
knowledge base and a diverse set of skills. These competencies are traditionally developed through a series ofclinical rotations [5, 6]. The structure of these rotations,however, varies significantly across training programs,
potentially leading to varied experiences and skill sets
among graduates [7]. This variability underscores theimportance of a standardized framework to ensure a
uniformly comprehensive educational experience in IM.

However, there has been no recent analysis of the distribution of IM subspecialties or length of rotations within
Japanese residency programs [2]. Given the global trends
in medical education that prioritize adaptability and theswift integration of emerging medical knowledge, [8–10]
Japan has placed a particularly heightened emphasis on
training efficiency within its postgraduate medical education programs. This national focus is in response to thecountry’s unique healthcare needs, influenced by its aging
population and the necessity for rapid dissemination of
innovative treatments and technologies. The structure of
the IM residency program, which encompasses the entire
scope of training across various medical subspecialties,
requires a comprehensive review. There is a distinct lackof recent evaluations concerning how these subspecialties are distributed, the duration of each rotation, and theoverall coordination of these rotations within the broader
framework of the Japanese residency system [11, 12]. The
term “IM residency program” refers to the full curriculum designed to prepare physicians in internal medicine,whereas “dedicated IM rotations” pertain to the specificweeks within this curriculum that focus solely on internal
medicine [13–15].
This study aimed to comprehensively analyze the distribution and duration of IM rotations in Japan, provide
a descriptive overview of prevailing patterns and allocations within IM residency programs, and delve into thepotential relationship between the characteristics ofthese rotations and their performance on standardized
tests.

Methods
Study design

We conducted a nationwide, multicenter, cross-sectional
study to analyze the distribution and duration of IM rotations among Japanese resident physicians. By examining
the data from resident physicians who participated in the
General Medicine In-Training Examination (GM-ITE) atthe end of the 2022 academic year, we aimed to describe
the current patterns in IM residency training rotations.
Additionally, we explored the relationship between rotation characteristics and standardized test performance.
This study adhered to the Strengthening the Reportingof Observational Studies in Epidemiology (STROBE)
reporting guidelines for cross-sectional studies [16].
Participants and setting

The study included 9,011 resident physicians who worked
in 662 medical institutions nationwide and participatedShikino et al. BMC Medical Education(2024) 24:316

in the GM-ITE from January 17 to 30, 2023. Resident
physicians who did not agree to participate in the survey
or had missing data on the clinical training environment
were excluded.
GM-ITEThe GM-ITE was developed and introduced in 2011,
following the same format as the IM In-Training Examination [17, 18]. It has evolved into a nationwide examination in Japan, with over half of all resident physiciansparticipating. The GM-ITE is taken towards the end ofboth PGY-1 and PGY-2. The GM-ITE has been validated
by the Professional and Linguistic Assessments Board asa reliable measure to assess clinical competency [19, 20].
According to the objectives of clinical training, the GMITE is divided into four categories (medical interview/professionalism, clinical diagnosis, physical examination/procedure, and disease knowledge). Additionally,
the examination includes items regarding clinical fields
in which resident physicians have rotated, including IM,
surgery, obstetrics and gynecology, pediatrics, psychiatry,emergency medicine, and community-based medicine.
The GM-ITE is not simply a test of medical knowledge
but also evaluates resident physicians’ practical skills andmanagement abilities that have been developed in clinical settings. It is conducted via computer-based testing(CBT) and incorporates the advantages of CBT, including video-based questions that test resident physicians’
clinical experience. The primary objective of the GM-ITE
is to determine the relative ranking of clinical training
facilities in Japan and address their weaknesses in clinical practice. From the perspective of each resident physician, the purpose of taking the GM-ITE is not to passor fail but rather to establish their own grade ranking inJapan and help them overcome their weaknesses in clinical areas [21].
The 2022 GM-ITE included 80 multiple-choice questions regarding medical interviews and professionalism(eight questions), symptomatology and clinical reasoning(18 questions), physical examination and clinical procedures (18 questions), and disease knowledge (36 questions). Each question was worth one point, contributing
to a total score of 80. Although the primary language ofthe examination was Japanese, 12 out of the 80 questions
were presented in English, reflecting the importance ofbilingual medical competence.
Data collection

On completing the 2022 GM-ITE, the participants wereasked to complete a voluntary questionnaire designed by
the Japan Institute for Advancement of Medical Education Program (JAMEP) that included questions regarding postgraduate plans and IM rotation schedules within
their residency program. The questions included thosePage 3 of 10

about the duration of rotations in various IM departments, as defined by the Japanese Society of IM (GIM,
gastroenterology, cardiovascular medicine, endocrinology and metabolism, nephrology, respiratory, hematology, neurology, allergy rheumatology, infectious diseases,
and other IM). We surveyed resident physicians about
the duration of IM rotations in 4-week intervals. We
defined the resident physician popularity index as the
product of the number of weeks of IM rotations and thenumber of participating resident physicians.
The participants also provided their demographic
information, including hospital type (community oruniversity), sex, and postgraduate year (PGY; PGY-1 or
PGY-2), as well as information regarding their general
medicine and IM rotations. The participants were asked
about the number of night shifts per month, average
number of assigned inpatients, and self-study time perday. The association between the postgraduate clinicaltraining rotation style and 2022 GM-ITE scores was also
investigated.
Statistical analyses

Resident physicians were classified into three groups
according to their IM rotation duration: short-term (≤ 32
weeks), intermediate-term (36–48 weeks), and long-term(≥ 52 weeks) groups. The categorization was based on the
aim to create equal-sized cohorts for a balanced analysis. We had 11 categories for the rotation length: 24, 28,
32, 36, 40, 44, 48, 52, 56, 60, and 64 weeks. By grouping
these into three broader categories, we ensured that eachgroup had a comparable number of participants, thereby
facilitating a more uniform distribution for statisticalcomparison and interpretation. This approach allowed
for a more nuanced understanding of the potential
impact of rotation length on clinical training outcomes.
Data regarding the resident physicians’ IM rotation experience were gathered from a self-reporting questionnaireadministered to the resident physicians. In our classification of resident physicians into short-, intermediate-, andlong-term IM rotation groups, no categories for 33–35
weeks or 49–51 weeks existed because our institution
structures rotations in 4-week units, and as such, theduration of any given rotation will always be a multiple of
4 weeks. This systematic approach to scheduling ensuresconsistency across different programs and provides a
standardized framework for evaluating resident physicians’ experiences and performance in IM rotations.
We conducted multiple pair-wise comparisons of GMITE scores among the three IM rotation groups using
Tukey’s honestly significant difference test. Resident physicians with missing data for any variable were excluded
from the analyses. SPSS Statistics for Windows (version
29.0; IBM, Armonk, NY, USA) was used to conduct statistical analyses, following the STROBE guidelines.

Shikino et al. BMC Medical Education(2024) 24:316

Page 4 of 10

EthicsResults

Informed consent was obtained from all residents who
participated in the GM-ITE. The resident physicians were
provided the opportunity to opt out of this study. Before
the study, a comprehensive explanation of the research,
including details regarding data anonymization and voluntary participation, was provided to the participants.
This study was conducted according to the principles
outlined in the Declaration of Helsinki, and all methodologies adhered to the Ethical Guidelines for Medical and
Health Research Involving Human Subjects. The study
protocol was approved by the Ethics Review Board of the
JAMEP (approval number 23 − 2).

Demographics

Table 1 Baseline characteristics of resident physicians

GM-ITE score (Mean, SD)
Hospital typeCommunity
Hospital
University
Hospital
Gender
Women
MenNight shift per month
0
1–2
3–5
≥6
Unknown
Average number of assigned
inpatients
0–4
5–9
10–14
≥ 15
Unknown
Self-study time per day(minutes)
0
1–30
31–60
61–90
≥ 91
Duty-hour per week (hours)
Category 1(< 60)
Category 2(60–79)Category 3(≥ 80)Overall, 9,011 resident physicians participated in the
GM-ITE, including 1,393 from 449 hospitals who
consented and were included in the final analysis(response rate: 15.5%). Among these participants, 700(50.3%) were in PGY-1, and 413 (29.6%) were women(Table 1). Most participants worked in community
hospitals (76.7%), and 22.8% worked in university hospitals. The sex ratio was similar between the PGY-1
and PGY-2 groups. Most participants (73.4%) reported
three to five night shifts, 9.3% reported six or morenight shifts, and 2.2% reported no night shifts. Halfof the participants (50.2%) reported managing fiveto nine inpatients, whereas 37.5% reported managing zero to four inpatients. The mean daily self-study
time was 1–30 min in 44.3% of participants and 0 min
in 1.7% of participants. Nearly half of the participants(48.7%) reported working < 60 h/week, whereas 14.3%
reported working ≥ 80 h.

Totaln, (%)
1393 (100)46.0 ± 8.2

PGY1
n, (%)
700 (100)45.1 ± 7.8

PGY2n, (%)
693 (100)46.9 ± 8.5

1068 (76.7)

524 (74.9)544 (78.5)

318 (22.8)

173 (24.7)

145 (20.9)

413 (29.6)
980 (70.4)

208 (29.7)
492 (70.3)

205 (29.6)
488 (70.4)

31 (2.2)
192 (13.8)
1023 (73.4)
129 (9.3)
9 (0.6)19 (2.7)
89 (12.7)
518 (74.0)
66 (9.4)
3 (0.4)12 (1.7)
103 (14.9)505 (72.9)
63 (9.1)
6 (0.9)522 (37.5)
699 (50.2)
101 (7.3)
29 (2.1)
34 (2.4)

281 (40.1)
341 (48.7)
42 (6.0)
13 (1.9)
17 (2.4)

241 (34.8)
358 (51.7)
59 (8.5)
16 (2.3)
17 (2.5)

23 (1.7)
617 (44.3)
547 (39.3)
144 (10.3)
49 (3.5)

9 (1.3)338 (48.3)
264 (37.7)
64 (9.1)
18 (2.6)

14 (2)
279 (40.3)
283 (40.8)
80 (11.5)
31 (4.5)

679 (48.7)

347 (49.6)

332 (47.9)

501 (36.0)

265 (37.9)

236 (34.1)

Approximately half of the resident physicians chose
IM rotation periods of 32–40 weeks (Fig. 1). A significant proportion of participants rotated in five toseven departments throughout the observation period(Fig. 2). Fewer participants rotated in nine or more
departments. The top three IM subspecialties popularamong resident physicians were gastroenterology, cardiovascular medicine, and GIM. The resident physician popularity index for gastroenterology, calculated
as the product of the number of weeks of IM rotationand number of resident physicians who completed it,
was 9,728. A physician popularity index of 9,200 wasscored for cardiovascular medicine, while that for general medicine was 7,208 (Table 2 and Supplementary
file 1 and 2). It was observed that rotations in 4-week
blocks were the most common structure, followed by
8-week rotations, indicating a preference for modular
rotation lengths among residency programs.
Among PGY-1 and PGY-2 participants, there was anotable absence of rotations in several subspecialties.
Specifically, 59.3% of participants did not have a GIM
rotation, while 91.7% of participants lacked an infectious disease rotation. Similarly, there was an absenceof rotations in endocrinology metabolism (61.3% ofparticipants), nephrology (62.7% of participants), neurology (63.6% of participants), and respiratory medicine (53.7% of participants). Cardiovascular medicine
rotations were missing for 43.6% of participants.

199 (14.3)

81 (11.6)

118 (17)

GM-ITE score

GM-ITE: General Medicine In-Training Examination

IM rotation distribution

The 2022 GM-ITE comprised 80 multiple-choice questions, each valued at one point, yielding a total possible

Shikino et al. BMC Medical Education(2024) 24:316

Page 5 of 10

Fig. 1 Distribution of the internal medicine total rotation length. This histogram shows the preferred internal medicine rotation lengths on the x-axis
and the percentage of residents choosing each length on the y-axis. The most common duration is 32 to 40 weeks, selected by approximately 50% of
resident physicians

Fig. 2 Distribution of the number of internal medicine department rotations. This figure shows the distribution of rotations across internal medicine
departments. The x-axis shows the number of departments, and the y-axis shows the percentage of resident physicians. A notable number of resident
physicians rotated through five to seven departments

score of 80. The mean GM-ITE score was 45.3 ± 8.5(95% CI: 44.1–46.5) in the short-term group (n = 191),
47.4 ± 8.5 (95% CI: 46.4–48.3) in the intermediate-termgroup (n = 325), and 47.7 ± 8.6 (95% CI: 46.4–48.5) inthe long-term group (n = 177) (Fig. 3). The short-termgroup had significantly lower GM-ITE scores thanthose of the intermediate- (p =.004) and long-termgroups (p <.001). No significant difference existed in
GM-ITE scores between the intermediate- and longterm groups (p =.24).

Discussion
As healthcare continues to evolve rapidly, the current
structure of postgraduate clinical training in Japan, with
its fragmented rotations, is increasingly recognized as
insufficient for the development of essential clinical competencies. The evolution and structure of postgraduate
clinical training in Japan have been of paramount interest
to medical educators, healthcare policymakers, and residency program directors, particularly in their efforts toensure that resident physicians acquire a comprehensive
knowledge base and skill set [22, 23]. This study provides

*

2180
1304
876
9200
6640
2560
5360
3488
1872
9728
6912
2816
7208
4512
2696
3076
2124
952
1056
416
640
5172
3184
1988
5128
3248
1880
6836
4744
2092
1240
580
660

2354(84.5)
1149(74.4)1205(78.0)
1214(43.6)
302(19.6)912(59.1)
1709(61.3)
718(46.5)991(64.2)
1256(45.1)
346(22.4)910(58.9)1653(59.3)
751(48.6)902(58.4)2158(77.5)
975(63.1)
1183(76.6)2555(91.7)
1311(84.9)
1244(80.6)
1748(62.7)
772(50.0)976(63.2)
1771(63.6)
770(49.9)1001(64.8)1495(53.7)
538(34.8)957(62.0)2568(91.2)
1291(83.6)
1277(82.7)

339(12.2) *174(11.3) *165(10.7) *948(35.3) *583(37.8) *365(23.6) *842(30.2) *498(32.3) *344(22.3) *890(31.9) *547(35.4) *343(22.2) *696(25.0) *334(21.6) *362(23.4) *496(17.8) *314(20.3) *182(11.8) *203(7.3) *63(4.1) *140(9.1) *804(28.9) *459(29.7) *345(22.3) *770(27.6) *443(28.7) *327(21.2) *916(32.9) *551(35.7) *365(23.6) *144(5.2) *64(4.1) *80(5.2) *79(2.8)60(3.9)19(1.2)549(19.7)454(29.4)95(6.2)
213(7.6)
161(10.4)52(3.4)508(18.2)
413(26.7)95(6.2)
312(11.2)
215(13.9)97(6.3)125(4.5)97(6.3)28(1.8)25(0.9)17(1.1)8(0.5)
214(7.7)
150(9.7)64(4.1)225(8.1)
171(11.1)54(3.5)340(12.2)
280(18.1)60(3.9)62(2.2)34(2.2)28(1.8)12
weeks
9(0.3)
8(0.5)
1(0.1)
59(2.1)50(3.2)9(0.6)
16(0.6)12(0.8)4(0.3)
70(2.5)50(3.2)20(1.3)75(2.7)55(3.6)20(1.3)6(0.2)
6(0.4)0(0)1(0.1)
1(0.1)0(0)19(0.7)11(0.7)8(0.5)
18(0.6)9(0.6)
9(0.6)
31(1.1)23(1.5)8(0.5)
8(0.3)
3(0.2)
5(0.3)

16
weeks
4(0.1)
2(0.1)
2(0.1)
8(0.3)
2(0.1)
6(0.4)
6(0.2)
4(0.3)
2(0.1)
30(1.1)10(0.6)20(1.3)23(0.8)16(1)7(0.5)
0(0)
0(0)
0(0)
2(0.1)
1(0.1)
1(0.1)
1(0.1)
1(0.1)0(0)2(0.1)0(0)2(0.1)
2(0.1)0(0)2(0.1)
2(0.1)
1(0.1)
1(0.1)

20
weeks
1(0.1)0(0)1(0.1)
5(0.1)
1(0.1)
4(0.3)
0(0)
0(0)
0(0)
5(0.1)
3(0.2)
2(0.1)
7(0.3)
4(0.3)
3(0.2)
1(0.1)
1(0.1)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
2(0.1)0(0)2(0.1)

Rotation period with the largest number of people in each department (excluding no rotation) RPP index: Resident physician popularity index

Total
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd yearTotal
1st year
2nd year

Number of resident physicians Length of training in each department
× weeks (RPP index)(n, %)
Training period
NumberNo rotation 4 weeks
8 weeks
24
weeks
0(0)
0(0)
0(0)
2(0.1)
1(0.1)
1(0.1)
0(0)
0(0)
0(0)
20(0.7)19(1.2)1(0.1)
16(0.6)15(1)1(0.1)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
2(0.1)
1(0.1)
1(0.1)
0(0)
0(0)
0(0)

28
weeks
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
5(0.1)
4(0.3)
1(0.1)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)

32
weeks
0(0)
0(0)
0(0)
1(0.1)0(0)1(0.1)
0(0)
0(0)
0(0)
2(0.1)
1(0.1)
1(0.1)
2(0.1)
2(0.1)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)

36
weeks
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
2(0.1)
1(0.1)
1(0.1)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)

40
weeks
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)

44
weeks
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)

48
weeks
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)
0(0)

(2024) 24:316

Other Internal
Medicine

Respiratory

Neurology

Nephrology

Infectious Diseases

Hematology

General Internal
Medicine

Gastroenterology

Endocrinology
Metabolism

Cardiovascular
Medicine

Allergy
Rheumatology

Internal medicine
department
Total

Table 2 Internal medicine rotation distribution in the resident physicians’ clinical training program in Japan

Shikino et al. BMC Medical Education
Page 6 of 10

Shikino et al. BMC Medical Education(2024) 24:316

Page 7 of 10

need to prioritize the cultivation of professionals who
can play pivotal roles in enhancing the quality of residency education [26].
Furthermore, the increasing popularity of community
hospitals and decline in the appeal of university hospitals
necessitate the development of more attractive training
programs to retain and attract talent [27]. The current
study’s findings suggest that re-evaluation and restructuring of the rotation residency program may be beneficial.
Weaknesses in clinical training during IM rotations

Fig. 3 Relationship between the internal medicine rotation length and
GM-ITE scores in PGY-2 participants. This figure shows the mean GM-ITE
scores for PGY-2 residents across three rotation duration groups: shortterm (≤ 32 weeks), intermediate-term (36–48 weeks), and long-term (≥ 52
weeks). Scores increase with longer rotations, from 45.31 in the short-term
to 47.69 in the long-term groupan updated perspective on the current landscape of IM
rotations in Japanese residency programs, revealing
strengths and areas that require further attention.
One of the most significant findings of the current study
was the fragmented nature of IM rotations. Although thisstructure potentially offers resident physicians exposure
to a multitude of specialties, short-duration rotations
may hinder in-depth learning and skill acquisition. In thecontext of Japanese clinical training, the challenge lies
not in the 4-week rotation duration itself, which is standard practice, but in the limited availability and potential
undervaluation of rotations in GIM. This is compounded
by a rotation experience that is often passive and lessintensive, which may contribute significantly to the limited depth of clinical exposure and hands-on experience
for Japanese residents. It is plausible that the fragmented
structure of IM rotations is a significant factor limiting
the depth of clinical exposure and hands-on experience
for Japanese resident physicians.
A promising approach to mitigate these challenges is
integrating general medicine physicians, including primary care physicians and hospitalists, into the educational framework [24, 25] On the basis of their holistic
approach, these practitioners can provide comprehensive educational experiences, bridging gaps created byfragmented rotations. Thus, when general medicine physicians educate residents, they can provide them withcomprehensive and cross-sectional perspectives, which
can fill gaps in fragmented education and contributeto improvements in the learning quality. However, thescarcity of general medicine physicians in Japan poses achallenge in providing sufficient quality and quantity ofresident training in general medicine. There is an urgent

In the Japanese residency program, IM rotations are limited by their fragmented nature. Our nationwide surveys
regarding IM rotations are underway, among 1393 resident physicians. More than half (64.7%) of resident physicians in Japan rotate through specialized IM departments
every 4 weeks, focusing on specific areas of expertise.
When the rotation duration decreases, opportunities forthe supervising physician to allow the resident to makeindependent judgments are limited, leading to more
observational training. Resident physicians may havefewer opportunities to understand the pathophysiology of the disease and tend to spend most of their timeon tasks such as ordering laboratory tests, as directedby the supervising physician, and documenting the test
results in patients’ medical records. Therefore, Japanese
resident physicians may have a more passive attitude
toward their clinical training than resident physicians inother countries. Moreover, learning the entire field of IM
within the 2-year residency period is challenging, especially given that resident physicians may not have thechance to rotate in multiple IM subspecialties. Considering the aim of residency in Japan to instill fundamental
clinical skills irrespective of future specialization, dedicating sufficient time to rotations in general medicine,
known for its proficiency in handling common diseases,
could contribute to acquiring skill sets across various IM
areas. During the third wave of the coronavirus disease2019 (COVID-19) pandemic, a resident physician-based
survey was conducted to investigate the actual state of
COVID-19 patient care [27]. This previous survey indicated that 47% of resident physicians had no experiencein COVID-19 patient care [27]. Furthermore, IM is typically divided into 11 subspecialties, including cardiology,
respiratory medicine, gastroenterology, rheumatology,
nephrology, neurology, infectious diseases, oncology,
hematology, diabetes and endocrinology, and general
medicine. However, the most common number of medical specialties reported by participants in this study was
six. Thus, within the 2-year rotation framework, resident
physicians may not experience certain IM domains dueto the rotational structure, which could be compoundedby their pursuit of interests in other medical specialties.

Shikino et al. BMC Medical Education(2024) 24:316

In addition to the observational training style, involving watching the supervising physicians engage in actual
medical procedures, [28] the structure of short rotation
periods in internal medicine also has other limitations.
When the environment surrounding resident physicians,
including supervising physicians and nurses, undergoes substantial changes, establishing relationships andbuilding trust with supervising physicians requires time,leading to inefficient learning and reduced effectivenessduring fragmented rotations. A lower number of supervising physicians is associated with higher GM-ITE
scores [29].
Suggestions for overcoming weaknesses

To address limitations identified in our clinical training,a greater involvement of general medicine physicians isessential. These physicians, encompassing a holistic view
and managing broad spectrums of conditions, are crucial
in imparting comprehensive skill sets to resident physicians. Their expertise in core clinical competencies—
such as ethics, communication, examination techniques,
symptom analysis, clinical reasoning, and professionalism—is invaluable [30–32]. The United States model,
where over 50,000 hospitalists contribute significantly
to resident physician education, serves as an exemplar
of such an approach. However, Japan faces a shortage ofgeneral medicine practitioners, which hinders the promotion of this field among young doctors and resident
physicians [33, 34].
To enhance resident physicians’ education, it might bebeneficial to consider a more active integration of general medicine physicians into the teaching framework[35]. This integration could potentially be facilitatedby the establishment of formal mentorship programs,
an increase in the number of generalist-led teachingrounds, and offering residents longer rotations in general
medicine for a more immersive learning experience [7].
Moreover, Japan’s healthcare system may benefit fromincentivizing primary care and hospitalist roles throughthoughtful policy changes, examining options for more
substantial funding for these positions, and assessing
the development of clearer career pathways for resident
physicians in these areas [36]. Such exploratory measures
could play a role in supporting high-quality internal medicine education and contribute to the evolution of Japan’s
clinical training landscape.
Limitations

This study had several limitations. First, the data used inthis study were predominantly self-reported at the conclusion of the GM-ITE. While the data provide a comprehensive overview, there may be inherent biases or
inaccuracies in self-reporting, leading to potential discrepancies between reported and actual experiences.

Page 8 of 10

Second, the projected rotations are limited. PGY-1 participants reported scheduled rotations, which may change
throughout the year. Sudden changes, personal choices,
and institutional requirements may lead to deviations
from scheduled rotations. Third, the results cannot be
generalized easily as only Japan residents were included.
However, this study provides crucial insights into the Japanese medical education system. These insights may not
be directly applicable to other countries with different
training structures and healthcare systems. Fourth, theevolution of training programs cannot be ignored. The
current study provides a snapshot of the current state of
IM rotations. However, training programs are dynamic
and may undergo changes on the basis of feedback, institutional decisions, or policy changes. Fifth, the study
did not account for potential confounding variables that
could influence GM-IE scores and resident experience.
Sixth, the survey had a low response rate; out of 9,011
resident physicians who took the GM-ITE, 1,393 (15.5%)
provided responses. This could introduce response bias
and affect the representativeness of the results, limiting
the generalizability of the findings. Last, owing to thebroad study scope, specific subspecialties or nuanced
experiences within IM rotations were not thoroughly
analyzed. An analysis of these variables may offer further
insights regarding the duration and composition of IM
rotations in Japan.

Conclusions
This nationwide, multicenter study provides an exploratory overview of the current IM rotations of resident physicians in Japan, indicating potential areas for
improvement. These findings highlight the fragmented
structure of IM rotations, characterized by short, specialized periods that might affect the depth of clinicalexposure and experiential learning opportunities. Thispattern, which primarily consists of 4-week rotations,suggests an inclination toward observational learning,
possibly affecting training quality.
Abbreviations
ARCP	Annual Review of Competence Progression
CBT	Computer-based testing
COVID-19	Coronavirus disease 2019
GIM	General internal medicine
GM-ITE	General Medicine In-Training Examination
IM	Internal medicine
JAMEP	Japan Institute for Advancement of Medical Education Program
PGY	Postgraduate year

Supplementary Information

The online version contains supplementary material available at https://doi.
org/10.1186/s12909-024-05314-4.
Supplementary Material 1
Supplementary Material 2

Shikino et al. BMC Medical Education(2024) 24:316

Acknowledgements
The authors thank the JAMEP secretariat for their excellent support for ourwork.
Author contributions
Conception and design: Kiyoshi Shikino and Yuji Nishizaki. Drafting of thearticle: Kiyoshi Shikino. Critical revision of the article for important intellectual
content: Kiyoshi Shikino, Miwa Sekine, Yuji Nishizaki, Yu Yamamoto, Taro
Shimizu, Sho Fukui, Kazuya Nagasaki, Daiki Yokokawa, Takashi Watari, Hiroyuki
Kobayashi, and Yasuharu Tokuda. Final approval of the article: Kiyoshi Shikino,
Miwa Sekine, Yuji Nishizaki, Yu Yamamoto, Taro Shimizu, Sho Fukui, Kazuya
Nagasaki, Daiki Yokokawa, Takashi Watari, Hiroyuki Kobayashi, and Yasuharu
Tokuda. Provision of study materials or patients: Kiyoshi Shikino, Yuji Nishizaki,
Yu Yamamoto, Taro Shimizu, and Sho Fukui. Statistical expertise: Miwa Sekine.
Acquisition of funding: Yuji Nishizaki. Administrative, technical, or logistic
support: Yuji Nishizaki and Yasuharu Tokuda. Collection and assembly of data:
Kiyoshi Shikino, Miwa Sekine, and Yuji Nishizaki.
Funding
This work was supported by the Health, Labour, and Welfare Policy Grantsof Research on Region Medical (21IA2004) from the Ministry of Health,Labour, and Welfare. This work was supported by the MHLW Policy Grantsof Research on Region Medical (21IA2004) from the MHLW. The MHLW had
no involvement in the design and conduct of the study, data analysis andinterpretation, manuscript preparation, review, approval, or the decision tosubmit the manuscript for publication.
Data availability
The data sets will not be publicly available because informed consent
of participants in each hospital do not allow for such publication. The
corresponding author will respond to requests on data analyses.

Declarations
Ethics approval and consent to participate
This research was performed in accordance with the Declaration of Helsinki
and was approved by the ethics committee/institutional review board of theJapan Organization of Advancing Medical Education Program (Tokyo, Japan).
All participants read and signed the informed consent document before
participating.
Consent for publication
Informed consent was obtained from all participants for the publication ofidentifying information in an online open-access publication.
Competing interests
Dr. Shikino, Dr. Nishizaki, Dr. Fukui, Dr. Yamamoto, Dr. Kobayashi, Dr. Shimizu
and Dr. Tokuda participated on the JAMEP GM-ITE project committee andreceived a reward. The JAMEP was involved in collecting and managing dataas the GM‐ITE administrative organization. It did not participate in designingand conducting the study; data analysis and interpretation; preparation,
review, or approval of the manuscript; and the decision to submit themanuscript for publication. Dr. Nishizaki received an honorarium from the
JAMEP as the GM ITE project manager. Dr. Tokuda is the director of the JAMEP.
Dr. Kobayashi received an honorarium from the JAMEP as a speaker for the
JAMEP lecture. Dr. Shikino received an honorarium from the JAMEP as areviewer of the GM ITE. Dr. Shikino, Dr. Shimizu, and Dr. Yamamoto received
honoraria from the JAMEP as exam preparers of the GM ITE. All other authors
do not have any competing interest.
Author details
1
Department of Community-oriented Medical Education, Chiba
University Graduate School of Medicine, 1-8-1 Inohana Chu-ou-ku, Chiba,Japan
2
Department of General Medicine, Chiba University Hospital, Chiba, Japan
3
Division of Medical Education, Juntendo University School of Medicine,Tokyo, Japan
4
Division of General Medicine, Center for Community Medicine, Jichi
Medical University, Tochigi, Japan
5
Department of Diagnostic and Generalist Medicine, Dokkyo Medical
University Hospital, Tochigi, Japan

Page 9 of 10

6Emergency and general Medicine, Kyorin University School of Medicine,Tokyo, Japan
7
Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
8
Department of Internal Medicine, Mito Kyodo General Hospital, Tsukuba,Japan
9General Medicine Center, Shimane University Hospital, Izumo, Japan10
Department of Medicine, University of Michigan Medical School, Ann
Arbor, MI, USA
12
Muribushi Okinawa Center for Teaching Hospitals, Okinawa, Japan
11
Tokyo Foundation for Policy Research, Tokyo, Japan
Received: 29 January 2024 / Accepted: 14 March 2024

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