(2023) 23:464
Watari et al. BMC Medical Education
https://doi.org/10.1186/s12909-023-04429-4

BMC Medical Education

Open Access

RESEARCH

Medical resident’s pursuing specialty
and differences in clinical proficiency
among medical residents in Japan: a nationwide
cross‑sectional study
Takashi Watari1,2,3*, Yuji Nishizaki4, Nathan Houchens2,3, Koshi Kataoka4, Kota Sakaguchi1, Yoshihiko Shiraishi1,
Taro Shimizu5, Yu Yamamoto6 and Yasuharu Tokuda7

Abstract
Importance Standardized examinations assess both learners and training programs within the medical training system in Japan. However, it is unknown if there is an association between clinical proficiency as assessed by the General
Medicine In-Training Examination (GM-ITE) and pursuing specialty.
Objective To determine the relative achievement of fundamental skills as assessed by the standardized GM-ITE
based on pursuing career specialty among residents in the Japanese training system.
Design Nationwide cross-sectional study.
Setting Medical residents in Japan who attempted the GM-ITE in their first or second year were surveyed.
Participants A total of 4,363 postgraduate years 1 and 2 residents who completed the GM-ITE were surveyed
between January 18 and March 31, 2021.
Main measures GM-ITE total scores and individual scores in each of four domains assessing clinical knowledge: 1)
medical interview and professionalism, 2) symptomatology and clinical reasoning, 3) physical examination and treatment, and 4) detailed disease knowledge.
Results When compared to the most pursued specialty, internal medicine, only those residents who chose general
medicine achieved higher GM-ITE scores (coefficient 1.38, 95% CI 0.08 to 2.68, p = 0.038). Conversely, the nine specialties and “Other/Not decided” groups scored significantly lower. Higher scores were noted among residents entering
general medicine, emergency medicine, and internal medicine and among those who trained in community hospitals with higher numbers of beds, were more advanced in their training, spent more time working and studying, andcared for a moderate but not an extreme number of patients at a time.
Conclusions Levels of basic skill achievement differed depending on respective chosen future specialties among residents in Japan. Scores were higher among those pursuing careers in general medical fields and lower among thosepursuing highly specialized careers. Residents in training programs devoid of specialty-specific competition may notpossess the same motivations as those in competitive systems.

*Correspondence:
Takashi Watariwataritari@gmail.com
Full list of author information is available at the end of the article© The Author(s) 2023. 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 theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Watari et al. BMC Medical Education(2023) 23:464

Page 2 of 15

Keywords Postgraduate medical education, Essential clinical skills, General medicine, Cross-sectional study

Background
The quality of graduate medical education (GME) training received by resident physicians is challenging toassess [1–3]. It depends on a myriad of factors, including
the number and type of clinical experiences, patient population, and the country, geographic region, and hospital site of the training program [3–6]. It also depends on
individual residents’ intrinsic motivations, such as timespent acquiring medical knowledge and future career
pathway [7]. Standardized examinations assessing knowledge, skills, and attitudes are one of the methods evaluating the GME training programs’ effectiveness, including
their ability to equip residents with key clinical skills toprovide safe, effective patient care [2, 8]. For example, theUnited States Medical Licensing Examination (USMLE)
has historically been used to assess medical student
knowledge and, in some GME programs, determine candidacy for competitive residency positions within different specialties. Indeed, one study demonstrated an
association between residency specialty match and scoreson the USMLE examinations in the USA [3, 9].
Important differences exist between training systems
in different countries. In Japan, the current training program has only been in place since 2004 [10, 11]. Aftercompleting a six-year medical school, trainees in Japanare referred to as “residents” and spend the next two
post-graduate years acquiring essential clinical skills in
one of seven unique specialties (internal medicine, surgery, anesthesiology, pediatrics, psychiatry, obstetrics andgynecology, emergency medicine, and community medicine) and pursuing their future specialty [10, 11]. The
purpose of the compulsory post clinical training programas stipulated by the Japanese government is to foster thedevelopment of a physician’s character and to facilitate
the acquisition of fundamental medical skills necessary
for adequately addressing prevalent injuries and illnesses
encountered in general practice. This is undertaken while
acknowledging the social role that medicine and medical care ought to play, irrespective of the specific fieldthey may choose to specialize in the future (Article 16–2,
Sect. (1) of the Medical Practitioners Act). Thereafter,
three to five additional years are spent training within thechosen field. Unlike in the USA, residents in the Japanesetraining system may choose their career pathway without
specific external competition or need for a certain levelof achievement on standardized examinations [7, 10, 11].
In addition to defining individual trainee progress,
standardized examinations may provide critical feedback
to programs that are participating in nascent training

systems like the one in Japan, so that they may identify
issues within the education system or allow adjustmentof educational strategies [6, 12–14]. One such examination, the internationally validated General Medicine
In-Training Examination (GM-ITE), has been incorporated as an annual assessment into many Japanese training centers [8]. The GM-ITE is the Essential Clinical
Skills Assessment Test, aimed to facilitate an objective
appraisal of the residents’ comprehensive clinical competencies as mandated by the Japanese Ministry of Health,Labour and Welfare (MHLW), and is utilized with theintention of pinpointing focal areas and formulating
training programs to garner general clinical skills, as well
as for the assessment and enhancement of training programs at each medical institution. The Japan Association
for the Advancement of Medical Education (JAMEP), a
non-profit organization with experienced physicians andpeer reviewers, administers the examination.
Prior studies has shown that GM-ITE scores are higher
for residents training in rural settings, [6] those withmore rotations in general medicine departments, [4]and those with at least a moderate or higher number ofpatients at any given time [15–17]. Given that residents inJapan may choose their future specialty without external
competition (i.e., certain examination score attainment
for specific specialties), [10, 18] their intrinsic motivations and perhaps the pursuing specialty may influence
their respective levels of knowledge and skill acquisition
much more than residents in other countries. However,
it is unclear if there exists an association between clinicalproficiency (as assessed by the GM-ITE) and their pursuing specialty.
This study’s primary objective was to examine the relative achievement of fundamental skills assessed by the
GM-ITE based on pursuing career specialty among residents in the Japanese training system. The secondary
objective was to explore hospital and training program
characteristics as well as resident factors (e.g., work typeand amount, study habits) that may contribute to proficiency in the GM-ITE using the lens of future career
specialty.

Methods
ParticipantsThis is a nationwide cross-sectional study of medical
residents in Japan. First-year (PGY-1) and second-year(PGY-2) residents took the same GM-ITE exam, in whichstudy participants answered the surveys consecutively

Watari et al. BMC Medical Education(2023) 23:464

Page 3 of 15

immediately following the exam. The study was conducted between January 18, 2021 and March 31, 2021.
This study followed the STROBE guidelines. Residents
were included if they had just completed the GM-ITE,
provided informed consent, and completed the electronic survey (Fig. 1). Residents were excluded if they
did not respond to the survey (n = 1,514), did not provide
consent (n = 588), indicated more than one preferred specialty (n = 1,106), or did not respond to specific survey
questions, including the average number of hours worked(n = 74), the average number of patients (n = 10), emergency department shift amounts (n = 8), and time spent
studying (n = 18).

English are shown in Supplement 1) [8]. In line with theJapanese MHLW’s goals for residents, the 2021 GM-ITE
consisted of four domains of basic clinical knowledge: 1)
medical interview and professionalism, 2) symptomatology and clinical reasoning, 3) physical examination andtreatment, and 4) detailed disease knowledge. The examination assesses the most frequent skills in various fields
acquired during initial training. Upon completion of theexamination, residents receive feedback based on theirrelative scores and detailed explanations for each question. Our primary outcome was the total score and thescores in each domain described above.

Main measures

Immediately following the GM-ITE examination, resident participants provided consent and completed anelectronic survey that assessed their work and educational environment, future pursuing specialty, andsociodemographic details. We also surveyed durationof internal medicine rotation, number of emergency
department shifts per month which included both walkin patient settings and cases where patients were transported by ambulance, average daily number of inpatients

The GM-ITE assesses general clinical knowledge andits application according to the core curriculum of the
training programs of the Ministry of Health, Labour andWelfare (MHLW) [19]. It evaluates individual residents,
residency programs, and the clinical training system [8].
The GM-ITE comprises 80 multiple-choice questions andis completed by over 50% of all Japanese medical residents
every year (sample GM-ITE questions translated into

Data collection

Fig. 1 Flow chart of study participants. Note: First (PGY-1) and second (PGY-2) year residents who had completed the GM-ITE were surveyed
between January 18, 2021 and March 31, 2021. The residents were included if they provided informed consent and completed the electronic survey

Watari et al. BMC Medical Education(2023) 23:464

for whom they provided care, average resident duty
hours worked per week, and average time spent studying per week. Characteristic information on each hospital
was obtained from the Resident Electronic Information
System website [20] and the Foundation for the Advancement of Medical Training [7].
Statistical analysis

We used the above GM-ITE total score and scores onfour domains as the primary outcome (independent
variable). All analyses were performed using Stata statistical software (Stata Corp. 2015, Stata 17 Base Reference Manual). Standard descriptive statistics were used
to calculate each data set’s number, proportion, mean,
median, and interquartile range (IQR). The chi-square,
or Fisher’s exact test, was used to compare categorical data. Additionally, multivariate linear regression andmultivariate logistic regression analyses were performed
to examine factors associated with scores. Departmentspecific scores were adjusted based on clinical relevanceand prior studies [4, 6, 8, 15–18, 21–24]. Furthermore, we
assessed the multicollinearity of the multivariate model
employing Variance Inflation Factor (VIF) to scrutinize
the influence of the aforementioned variables on the GMITE score. Dunnett’s post hoc tests run after a significant
one-way analysis of variance (ANOVA), to determine
which differences are significant. Finally, a sensitivity
analysis was performed, incorporating several factors
into a multivariate regression analysis. All tests were twotailed, and the statistical significance was set at p < 0.05.

Results
A total of 4,363 residents were included in the analysis.
Table 1 shows hospital- and resident-level variables aswell as GM-ITE score details as they pertain to residents’pursuing future specialty. Internal medicine garnered
the most interest (n = 1,433, 32.8%), followed by surgery(n = 408, 9.4%), orthopedics (n = 305, 7.0%), pediatrics(n = 267, 6.1%), and obstetrics and gynecology (n = 214,4.9%). Community hospitals accounted for 81.3%, hospitals in rural cities accounted for 67.7%, and hospitals
overall contained an average of 559 beds. Among all
participants, 69.0% were male, and 58.7% were PGY-2
residents. The largest group of residents (71.0%) had 3–5
shifts per month in the emergency department, and 9.1%
had 6 or more. The most common number of patientsassigned to a resident was 5–9 (55.7%), followed by 0–4(29.6%) and 10–14 (9.2%). Residents worked an averageof fewer than 59 h per week (40.5%), 60–79 h (35.6%),
and more than 80 h (24.0%). Finally, 40.2% studied forless than 30 min per week, 39.7% for 31–60 min, 12.8%
for 61–90 min, and 3.6% for 91 min or more.

Page 4 of 15

Table 2 presents the mean of the total scores and standard deviations of GM-ITE pertaining to each hospitallevel, resident-level, and their pursuing future specialty
variables. The average score demonstrated an upward
trend proportional to the frequency of Emergency
Department duties per month, and a similar positive
correlation was observed with the average score as theweekly study hours escalated. Nevertheless, no substantial disparities were discernible in terms of gender, Postgraduate Year, or urban residency. Furthermore, Table 2
also shows the correlations between the GM-ITE total
scores and the multivariate linear analysis of the future
pursuing specialty and individual factors. The VIF estimations for all predictive variables were ascertained toreside within the permissible spectrum in our multivariate regression analysis (mean VIF = 1.42, all variables
were less than 10). Residents training in community hospitals scored higher than those in university hospitals(coefficient 2.44, 95% CI 1.08 to 3.81; p < 0.0001), andthere was a positive correlation for total scores as thenumber of beds increased. There was no difference inscores between residents training in urban hospitals andthose training in rural hospitals. There was no differencein scores between male and female residents, but PGY-2
residents scored higher than PGY-1 residents (coefficient
0.90, 95% CI 0.49 to 1.32; p < 0.0001). When compared to
the referent of zero shifts, there was no significant difference in scores between the number of emergency department (ED) shifts per month. When compared to thereferent of 0–4 patients, the average number of patientsassigned significantly correlated with higher scores for
those assigned 5–9 patients (coefficient 0.80, 95% CI 0.33
to 1.27; p < 0.001) and 10–14 patients (coefficient 0.86,
95% CI 0.04 to 1.68; p = 0.039), but not for 15 or morepatients or unknown. When compared to the referent of
59 or fewer hours, the average amount of resident duty
hours worked per week significantly correlated withhigher scores for those who worked 60–79 h (coefficient
1.18, 95% CI 0.73 to 1.64; p < 0.001) and 80 or more hours(coefficient 0.62, 95% CI 0.10 to 1.15; p = 0.020). When
compared to the referent of 0–30 min, those residents
who spent more than 30 min per week studying tended
to have significantly higher scores. Internal medicine waschosen as the referent since it was the most commonlychosen future specialty. When compared to internal
medicine, only those residents who chose general medicine achieved higher scores (coefficient 1.38, 95% CI
0.08 to 2.68, p = 0.038). Conversely, the nine specialties
and “Other/Not decided” groups had significantly lower
scores. Moreover, both the PGY-1 and the PGY-2 weresegregated into their respective categories, with the distinctive characteristics of each being elucidated utilizing
the identical methodology as depicted in Tables 1 and 2.

3549 (81.34)

2955 (67.73)

Rural

1354 (31.03)

2562 (58.72)

PGY-2

818 (57.08)

615 (42.92)

407 (28.40)

1026 (71.60)

564.87 (227.77)

918 (64.06)

688 (15.77)

3099 (71.03)

396 (9.08)

28 (0.64)

1–2

3–5

6 or more

Unknown

6 (0.42)115 (8.03)

1051 (73.34)

217 (15.14)

44 (3.07)2428 (55.65)

402 (9.21)

115 (2.64)

126 (2.89)

5–9

10–14

15 or more

Unknown

28 (1.95)

35 (2.44)

146 (10.19)

859 (59.94)

365 (25.47)

1552 (35.57)

1046 (23.97)

60–79

80 or more

364 (25.40)

515 (35.94)

554 (38.66)

1752 (40.16)1734 (39.74)

0–30 min

31–60 min583 (40.68)

513 (35.80)
164 (40.20)

152 (37.25)

124 (30.39)

142 (34.80)

142 (34.80)

12 (2.94)

12 (2.94)

48 (11.76)

225 (55.15)

111 (27.21)

2 (0.49)50 (12.25)

290 (71.08)

57 (13.97)

9 (2.21)259 (63.48)

149 (36.52)

101 (24.75)

307 (75.25)

570.67 (229.35)

273 (66.91)

135 (33.09)

346 (84.80)

31 (7.60)

31 (7.60)

408 (9.35)

Surgery

119 (44.57)

100 (37.45)

61 (22.85)

98 (36.7)

108 (40.45)

9 (3.37)

6 (2.25)

21 (7.87)

152 (56.93)

79 (29.59)

26 (9.74)

194 (72.66)

38 (14.23)

9 (3.37)

163 (61.05)

104 (38.95)

111 (41.57)

156 (58.43)

586.87 (232.57)

176 (65.92)

91 (34.08)

223 (83.52)

22 (8.24)

22 (8.24)

267 (6.12)

Pediatrics

101 (47.20)

87 (40.65)

54 (25.23)

83 (38.79)

77 (35.98)

6 (2.80)

4 (1.87)

13 (6.07)

123 (57.48)

68 (31.78)

3 (1.40)

12 (5.61)

157 (73.36)

34 (15.89)

8 (3.74)140 (65.42)

74 (34.58)

143 (66.82)

71 (33.18)

608.24 (226.2)

139 (64.95)

75 (35.05)

170 (79.44)

16 (7.48)

28 (13.08)

214 (4.90)

Obstetrics &Gynecology

55 (31.79)

90 (52.02)

13 (7.51)

62 (35.84)

98 (56.65)

4 (2.31)3 (1.73)

22 (12.72)

78 (45.09)

66 (38.15)

1 (0.58)

10 (5.78)

115 (66.47)

39 (22.54)

8 (4.62)122 (70.52)

51 (29.48)

41 (23.70)

132 (76.30)

529.53 (239.82)

126 (72.83)

47 (27.17)

131 (75.72)

8 (4.62)34 (19.65)

173 (3.97)

Psychiatry

34 (31.19)

55 (50.46)

26 (23.85)

31 (28.44)

52 (47.71)

3 (2.75)

12 (11.01)

60 (55.05)

34 (31.19)

2 (1.83)

7 (6.42)62 (56.88)

33 (30.28)

5 (4.59)

77 (70.64)

32 (29.36)

58 (53.21)

51 (46.79)

593.55 (254.93)

73 (66.97)

36 (33.03)

75 (68.81)

12 (11.01)

22 (20.18)

109 (2.50)

Dermatology

45 (38.14)

54 (45.76)

22 (18.64)

34 (28.81)

62 (52.54)

2 (1.69)

3 (2.54)

14 (11.86)

58 (49.15)

41 (34.75)

1 (0.85)

7 (5.93)

81 (68.64)

23 (19.49)

6 (5.08)74 (62.71)

44 (37.29)

49 (41.53)

69 (58.47)

549.13 (242.36)

78 (66.10)

40 (33.90)

82 (69.49)

15 (12.71)

21 (17.80)

118 (2.70)

Ophthalmology

45 (46.88)

38 (39.58)

22 (22.92)

37 (38.54)

37 (38.54)

1 (1.04)

3 (3.13)5 (5.21)44 (45.83)

43 (44.79)

1 (1.04)

6 (6.25)

68 (70.83)

15 (15.63)

6 (6.25)

67 (69.79)

29 (30.21)

38 (39.58)

58 (60.42)

549.6 (198.19)

71 (73.96)

25 (26.04)

79 (82.29)

10 (10.42)

7 (7.29)

96 (2.20)

Otorhinolaryngology

49 (40.5)

56 (46.28)

27 (22.31)

44 (36.36)

50 (41.32)

5 (4.13)

2 (1.65)

8 (6.61)62 (51.24)

44 (36.36)

1 (0.83)

14 (11.57)

87 (71.9)

19 (15.7)

84 (69.42)

37 (30.58)

17 (14.05)

104 (85.95)

548.4 (204.13)

86 (71.07)

35 (28.93)

107 (88.43)

6 (4.96)

8 (6.61)

121 (2.77)

Urology105 (34.43)

134 (43.93)

90 (29.51)

108 (35.41)

107 (35.08)

12 (3.93)

7 (2.30)

26 (8.52)

168 (55.08)

92 (30.16)

1 (0.33)40 (13.11)

222 (72.79)

33 (10.82)

9 (2.95)

190 (62.3)

115 (37.7)

28 (9.18)

277 (90.82)

537.65 (220.65)

213 (69.84)

92 (30.16)

255 (83.61)

22 (7.21)

28 (9.18)

305 (6.99)

Orthopedics(2023) 23:464

Average time spent studying per week

1765 (40.45)

59 or fewer

Average duty hours worked per week

1292 (29.61)

0–4

Average number of inpatients assigned

152 (3.48)

None

Emergency department shifts per month

1801 (41.28)

PGY-1

Post-graduate training level3009 (68.97)

Men

Women

Sex

Resident-level variables (%)

Number of beds 558.74 (228.99)

1408 (32.27)

Urban

Hospital location

515 (35.94)

1165 (81.3)

325 (7.45)

University
branchCommunity

115 (8.03)

489 (11.21)

University

Hospital type

153 (10.68)

1433 (32.84)

4363

Hospital-level variables (%)

Internal
Medicine

ALL

Table 1 Background factors and residents’ characteristics, among future specialty

Watari et al. BMC Medical Education
Page 5 of 15

41 (2.86)

159 (3.64)

45.86 (7.01)

6.34 (1.06)

11.39 (2.38)

9.68 (2.28)

44.62 (6.94)

6.26 (1.11)

10.92 (2.35)

9.42 (2.22)

18.02 (3.92)

Total; Max 80

Medicalinterview andprofessionalism;
Max 8

Symptomatology and clinicalreasoning;
Max 18

Physicalexaminationand procedure;
Max 18

Disease knowledge; Max 36

106 (90.60)

102 (87.18)

45 (54.22)

534.31 (235.37)

50 (60.24)

89 (70.63)

605.04 (251.44)

93 (73.81)

33 (26.19)

100 (79.37)

7 (5.56)

19 (15.08)

126 (2.89)

Emergency
Medicine

18.12 (3.78)

9.33 (2.09)

11.09 (2.19)

6.15 (1.11)

44.69 (6.44)

19.04

14 (3.43)

15 (3.68)

63 (15.44)

408 (9.35)

Surgery

18.35 (3.54)

9.76 (2.26)

11.01 (2.2)

6.27 (1.06)

45.39 (5.95)

5 (2.34)

3 (1.40)

18 (8.41)

214 (4.90)

Obstetrics &Gynecology

91 (55.15)

552.89 (219.34)

113 (68.48)

52 (31.52)

135 (81.82)

13 (7.88)

17 (10.3)

165 (3.78)

79 (84.95)

19 (61.29)

513.61 (283.45)

21 (67.74)

10 (32.26)

24 (77.42)

1 (3.23)

6 (19.35)

31 (0.71)

19 (70.37)

497.48 (198.3)

13 (48.15)

14 (51.85)

22 (81.50)

1 (3.70)

4 (14.81)

27 (0.62)

Pathology

17.16 (3.45)

8.77 (2.23)

9.94 (2.21)

6.19 (1.08)

42.06 (6.23)

56.88

7 (6.42)2 (1.83)

11 (10.09)

109 (2.50)

Dermatology

Rehabilitation
Medicine

17.58 (4.2)

8.97 (2)10.45 (2.17)

6.34 (1.14)

43.34 (6.79)

56.07

7 (4.05)

3 (1.73)

18 (10.40)

173 (3.97)

Psychiatry566.95 (212.39)

68 (73.12)

25 (26.88)

69 (74.19)

3 (3.23)

21 (22.58)

93 (2.13)

Anesthesiology Radiology

18.27 (3.85)

9.4 (2.09)

10.74 (2.17)

6.33 (1.15)

44.74 (6.37)

5 (1.87)

10 (3.75)

33 (12.36)

267 (6.12)

Pediatrics

2 (66.67)

523.33 (430.85)

2 (66.67)

1 (33.33)

2 (66.67)

1 (33.33)

3 (0.07)

ClinicalLaboratory

16.03 (3.98)

8.64 (2.06)

9.71 (2.05)

6.07 (1.17)

40.44 (5.91)

50

5 (4.24)

2 (1.69)

12 (10.17)

118 (2.70)

Ophthalmology

69 (68.32)

479.3 (231.05)

79 (78.22)

22 (21.78)

81 (80.20)

6 (5.94)

14 (13.86)

101 (2.31)

General
Medicine

17.2 (3.71)

9.09 (1.95)

10.2 (2.25)

6.23 (1.25)

42.72 (6.41)

3 (3.13)

2 (2.08)8 (8.33)

96 (2.20)

Otorhinolaryngology

54 (71.05)

526.91 (234.78)

51 (67.11)

25 (32.89)

67 (88.16)

3 (3.95)

6 (7.89)

76 (1.74)

Other

17.58 (4.01)

9.04 (2.05)

10.95 (2.29)

6.2 (1.12)

43.77 (6.79)

3 (2.48)

1 (0.83)

12 (9.92)

121 (2.77)

Urology

189 (63.64)

534.1 (220.61)

223 (75.08)

74 (24.92)

241 (81.14)

25 (8.42)

31 (10.44)297 (6.81)

Not decided

17.41 (3.57)

8.97 (2.09)

10.3 (2.24)

6.09 (1.14)

42.75 (6.3)

15 (4.92)

8 (2.62)43 (14.10)

305 (6.99)

Orthopedics(2023) 23:464

Men

Sex

Resident-level variables (%)

529.03 (216.92)

89 (76.07)

Rural

Number of beds

28 (23.93)

Urban

Hospital location

33 (39.76)

69 (83.13)

2 (1.71)

University
branchCommunity

7 (8.43)

9 (7.69)

University

Hospital type

7 (8.43)

83 (1.9)

117 (2.68)

Hospital-level variables (%)

Plastic Surgery

Neurosurgery

18.44 (3.95)

20.65

GM-ITE score
(SD)

None

71 (4.95)

158 (3.62)

225 (15.70)

560 (12.84)

91 min or
more

1433 (32.84)

4363

61–90 minInternal
Medicine

ALL

Table 1 (continued)

Watari et al. BMC Medical Education
Page 6 of 15

Women38 (45.78)

15 (12.82)

68 (58.12)

PGY-2

59 (71.08)

11 (9.40)

89 (76.07)

16 (13.68)

1–2

3–5

6 or more

8 (9.64)

60 (72.29)

13 (15.66)

2 (2.41)57 (48.72)

16 (13.68)

10 (8.55)

5 (4.27)

5–9

10–14

15 or more

Unknown

42 (35.9)42 (35.9)

60–79

80 or more

5 (6.02)18 (15.38)

10 (8.55)

3 (2.56)

61–90 min91 min or
more

42.31 (6.95)

6.22 (1.02)

23.93

45.74 (7.68)

6.22 (1.17)

Total; Max 80

Medicalinterview andprofessionalism;
Max 8

9 (10.84)

GM-ITE score
(SD)

None

1 (1.20)47 (40.17)

31 (37.35)

39 (33.33)

31–60 min37 (44.58)

13 (15.66)

40 (48.19)

30 (36.14)

2 (2.41)

8 (9.64)45 (54.22)

28 (33.73)

0–30 minAverage time spent studying per week

33 (28.21)

59 or fewer

Average duty hours worked per week

29 (24.79)

0–4

Average number of inpatients assigned

Unknown

1 (0.85)

None

Emergency department shifts per month

49 (41.88)

PGY-1

24 (28.92)

83 (1.9)

117 (2.68)

Post-graduate training level

Plastic Surgery

Neurosurgery

Table 1 (continued)

6.29 (1.05)

46.98 (7.56)

4 (3.17)6 (4.76)

15 (11.9)

52 (41.27)

49 (38.89)

27 (21.43)

45 (35.71)

54 (42.86)

5 (3.97)

11 (8.73)

76 (60.32)

34 (26.98)

1 (0.79)

13 (10.32)

86 (68.25)

21 (16.67)

5 (3.97)

88 (69.84)

38 (30.16)

37 (29.37)

126 (2.89)

Emergency
Medicine

6.18 (1.19)

44.75 (6.63)

5 (3.03)5 (3.03)11 (6.67)

75 (45.45)

69 (41.82)

33 (20)62 (37.58)

70 (42.42)

11 (6.67)

6 (3.64)

13 (7.88)

98 (59.39)

37 (22.42)

1 (0.61)

17 (10.30)

114 (69.09)

25 (15.15)

8 (4.85)

115 (69.7)

50 (30.3)

74 (44.85)

165 (3.78)

6.27 (1.19)

44.6 (6.84)

4 (4.3)7 (7.53)

6 (6.45)40 (43.01)

36 (38.71)

15 (16.13)

27 (29.03)

51 (54.84)

3 (3.23)

1 (1.08)

3 (3.23)42 (45.16)

44 (47.31)

2 (2.15)5 (5.38)

64 (68.82)

17 (18.28)

5 (5.38)

65 (69.89)

28 (30.11)

14 (15.05)

93 (2.13)

Anesthesiology Radiology

6.29 (1.22)

41.84 (6.89)

51.61

5 (16.13)

15 (48.39)

11 (35.48)

9 (29.03)

8 (25.81)

14 (45.16)

2 (6.45)

2 (6.45)

15 (48.39)

12 (38.71)

1 (3.23)

1 (3.23)

23 (74.19)

6 (19.35)

18 (58.06)

13 (41.94)

12 (38.71)

31 (0.71)

Rehabilitation
Medicine

6.63 (1.01)

44.59 (7.12)

1 (3.7)2 (7.41)

6 (22.22)

11 (40.74)

7 (25.93)

2 (7.41)

5 (18.52)

20 (74.07)

1 (3.70)

12 (44.44)

14 (51.85)

2 (7.41)

17 (62.96)

8 (29.63)

15 (55.56)

12 (44.44)

8 (29.63)

27 (0.62)

Pathology

7.67 (0.58)

45 (6.24)

1 (33.33)

1 (33.33)

1 (33.33)

1 (33.33)

2 (66.67)

2 (66.67)

1 (33.33)

2 (66.67)

1 (33.33)

3 (100)1 (33.33)

3 (0.07)

ClinicalLaboratory

6.51 (1.04)

47.66 (7.08)

24.75

2 (1.98)

5 (4.95)

20 (19.80)

42 (41.58)

32 (31.68)

18 (17.82)

45 (44.55)

38 (37.62)

3 (2.97)

5 (4.95)

9 (8.91)

53 (52.48)

31 (30.69)

1 (0.99)

8 (7.92)

71 (70.30)

18 (17.82)

3 (2.97)

68 (67.33)

33 (32.67)

32 (31.68)

101 (2.31)

General
Medicine

6.07 (1.39)

42.62 (7.42)

64.47

7 (9.21)

2 (2.63)

3 (3.95)

22 (28.95)

42 (55.26)

17 (22.37)

21 (27.63)

38 (50.00)

3 (3.95)

3 (3.95)

4 (5.26)

41 (53.95)

25 (32.89)

8 (10.53)

45 (59.21)

17 (22.37)

6 (7.89)

54 (71.05)

22 (28.95)

22 (28.95)

76 (1.74)

Other

6.21 (1.13)

43.05 (7.09)

56.57

18 (6.06)

3 (1.01)28 (9.43)

98 (33.0)

150 (50.51)

67 (22.56)

102 (34.34)

128 (43.1)

15 (5.05)

10 (3.37)

20 (6.73)

158 (53.2)

94 (31.65)

4 (1.35)

31 (10.44)

201 (67.68)

44 (14.81)

17 (5.72)

18 (6.06)

279 (93.94)

108 (36.36)

297 (6.81)

Not decided

Watari et al. BMC Medical Education(2023) 23:464
Page 7 of 15

83 (1.9)

10.19 (2.3)

9.29 (2.18)

117 (2.68)

11.28 (2.51)

9.67 (2.18)

18.57 (4.45)

Symptomatology and clinicalreasoning; Max
18

Physicalexaminationand procedure;
Max 18

Disease knowledge; Max 36

19.07 (3.78)

10 (2.4)

11.63 (2.43)

126 (2.89)

Emergency
Medicine

18.61 (3.54)

9.37 (2.28)

10.58 (2.2)

165 (3.78)

17.88 (3.73)

9.59 (2.02)

10.86 (2.32)

93 (2.13)

Anesthesiology Radiology

17 (4.35)

8.68 (1.97)

9.87 (2.09)

31 (0.71)

Rehabilitation
Medicine

17.85 (3.9)

9.41 (1.91)

10.7 (2.38)

27 (0.62)

Pathology

18.67 (3.06)

9 (4.58)

9.67 (2.89)

3 (0.07)

ClinicalLaboratory

19.34 (3.84)

9.98 (2.24)

11.83 (2.28)

101 (2.31)

General
Medicine

Abbreviations PGY-1 First year residents, PGY-2 Second year residents, ED Emergency Department, GM-ITE General Medicine In-Training Examination, SD Standard Deviation

16.61 (4.02)

Plastic Surgery

Neurosurgery

Table 1 (continued)

17.12 (4.1)

9.22 (2.18)

10.21 (2.43)

76 (1.74)

Other

17.19 (3.97)

9.16 (2.27)

10.48 (2.26)

297 (6.81)

Not decided

Watari et al. BMC Medical Education(2023) 23:464
Page 8 of 15

Watari et al. BMC Medical Education(2023) 23:464

Page 9 of 15

Table 2 The mean of the GM-ITE score among variables and the Multivariate Linear Regression Analysis
95% CI
Mean (SD)Co-efficient

Lower

Upper

p-value

Hospital-level variables
Hospital types
University

42.03 (6.56)

Reference---

University branch

41.91 (5.99)

-0.04

-1.91

1.84

0.969

Community

45.23 (6.93)

2.44

1.08

3.81

< .001

Hospital location
Urban

44.97 (7.20)

Reference

-

-

-

Rural

44.46 (6.80)

-0.36

-1.01

0.29

0.274

-

0.21

0.04

0.37

0.013

Number of beds (per 100 beds increase)
Resident-level variables
Sex
Men

44.67 (7.19)

Reference

-

-

-

Women

44.51 (6.33)

-0.01

-0.45

0.42

0.962

0.49

1.32

< .001

PGY
PGY-1

44.08 (6.76)

Reference

PGY-2

45.01 (7.03)

0.9

ED duty per monthNone

43.09 (6.55)

Reference

-

-

-

1–2

43.12 (6.63)

-0.58

-1.76

0.59

0.331

3–5

44.91 (6.85)

-0.07

-1.23

1.09

0.911

6 or more

45.71 (7.76)

0.37

-1

1.74

0.598

Unknown

42.29 (6.67)

-0.43

-3

2.15

0.745
-

Average number of inpatients in charge
0–4

43.87 (6.59)

Reference

-

-

5–9

45.05 (7.06)

0.8

0.33

1.27

< .001

10–14

44.69 (6.90)

0.86

0.04

1.68

0.039

15 or more

44.60 (7.96)

0.32

-1.03

1.68

0.638

Unknown

43.96 (6.37)

-0.11

-1.33

1.11

0.865
-

Resident duty hour per week
59 or less

43.68 (6.80)

Reference

-

-

60–79

45.42 (6.91)

1.18

0.73

1.64

< .00180 or more

45.03 (7.03)

0.62

0.1

1.15

0.02

Study hour per week
0–30 min43.82 (6.57)

Reference---

31–60 min44.90 (6.88)

0.52

0.09

0.95

0.018

61–90 min46.15 (7.24)

1.18

0.55

1.8

< .00191 min or more

46.81 (8.15)

1.26

0.18

2.33

0.022

None

42.79 (7.39)

-0.32

-1.36

0.72

0.548

Specialty
General Medicine (n = 101)

47.66 (7.08)

1.38

0.08

2.68

0.038

Emergency Medicine (n = 126)

46.98 (7.56)

1.02

-0.14

2.19

0.084

Clinical Laboratory (n = 3)

45.00 (6.24)

0.82

-6.38

8.03

0.823

Internal Medicine (n = 1433)

45.86 (7.01)

Reference---

Pathology (n = 27)

44.59 (7.12)

-0.42

-2.86

2.03

0.739

Radiology (n = 93)

44.6 (6.84)

-0.49

-1.84

0.85

0.47

Neurosurgery (n = 117)45.74 (7.68)

-0.57

-1.78

0.64

0.356

Obstetrics and Gynecology (n = 214)

45.39 (5.95)

-0.7

-1.63

0.23

0.141

Anesthesiology (n = 165)

44.75 (6.63)

-0.99

-2.02

0.04

0.06

Watari et al. BMC Medical Education(2023) 23:464

Page 10 of 15

Table 2 (continued)
95% CI
Mean (SD)Co-efficient

Lower

Upper

p-value

Surgery (n = 408)

44.69 (6.44)

-1.18

-1.88

-0.48

< .001

Pediatrics (n = 267)

44.74 (6.37)

-1.29

-2.12

-0.45

0.003

Psychiatry (n = 173)43.34 (6.79)

-1.76

-2.78

-0.74

< .001

Urology (n = 121)

43.77 (6.79)

-1.94

-3.13

-0.75

< .001
0.051

Rehabilitation Medicine (n = 31)

41.84 (6.89)

-2.29

-4.59

0.01

Dermatology (n = 109)42.06 (6.23)

-2.72

-3.97

-1.47

< .001

Otorhinolaryngology (n = 96)

42.72 (6.41)

-2.91

-4.23

-1.59

< .001

Orthopedics (n = 305)

42.75 (6.3)

-2.98

-3.78

-2.19

< .001

Plastic Surgery (n = 83)

42.31 (6.95)

-3.66

-5.09

-2.23

< .001

Ophthalmology (n = 118)

40.44 (5.91)

-4.37

-5.58

-3.17

< .001

Not decided (n = 297)

43.05 (7.09)

-1.81

-2.64

-0.98

< .001Other (n = 76)

42.62 (7.42)

-2.38

-3.86

-0.9

0.002

Abbreviations PGY-1 First year residents, PGY-2 Second year residents, GM-ITE General Medicine In-Training Examination, CI Confidence Interval, ED Emergency
Department
To adjust for potential confounders of clinically significant associated factors for the GM-ITE score, the following variables were incorporated in the multivariate
analysis: chosen specialty, hospital type, hospital location, sex, number of post-graduate years, number of emergency department shifts per month, average daily
number of inpatients for whom the resident provided care, average resident duty hours worked per week, and average time spent studying per week. When internal
medicine (the future specialty chosen by the highest number of residents) was set as the reference, residents planning on choosing general medicine were the only
ones who scored higher (coefficient 1.3792, 95% CI 0.07894–2.6796, p = 0.0376)

The outcomes exhibited a semblance to the comprehensive table, with scores for both General Medicine andEmergency Medicine exhibiting a propensity towards
higher values across both academic years. (Supplementary table 1–3.)
In addition, General Medicine scores in PGY-1 demonstrated a statistically significant escalation subsequent
to adjustment for Internal Medicine as a benchmark. The
residents of PGY-1 manifested a significantly superior
performance in General Medicine (coefficient 3.51, 95%
Confidence Interval 0.04 to 1.68; p = 0.039). Conversely,
the disparity between General Medicine and PGY-2 nolonger bore statistical significance in the aftermath of the
PGY-2 analysis. (Refer to Supplementary table 4 and 5 foradditional data). Figure 2 shows a heat map of the GMITE total score and scores for its four domains organized
by residents’ chosen future specialties. Total scores werehigher in general medicine, emergency medicine, andinternal medicine, with residents who chose general medicine having higher achievement in basic clinical skills
during the study period. Some areas of low performance
were also identified among certain future specialties. For
example, scores on the medical interview and professionalism tended to be lower in departments involving
procedures, such as ophthalmology (6.07/8), orthopedics (6.09/8), surgery (6.15/8), and anesthesia (6.18/8).
Scores in symptomatology and clinical reasoning tended
to be lower in the clinical laboratory (9.67/18), ophthalmology (9.71/18), and rehabilitation medicine (9.87/18).
Similarly, scores for physical examination/treatment

were lower among residents whose chosen specialty lacks
opportunities to examine the whole body, administer
medications, and perform procedures, such as ophthalmology (8.64/18), rehabilitation (8.68/18), and dermatology (8.77/18). Scores for detailed disease knowledge were
low in specialties lacking head-to-toe physical examinations, medication treatment, and procedures, such as
ophthalmology (16.03/36) and plastic surgery (16.61/36).
Next, interesting patterns emerged within individual specialties. In many specialties, all scores aligned (either allor most domain scores were high, as in general medicine, emergency medicine, and internal medicine; or allor most domain scores were low, as in ophthalmology,
rehabilitation, dermatology, and orthopedics). However,in other specialties, scores in some domains were higher
than in others. For instance, in surgery and anesthesiology, scores for medical interview/professionalism werelower, whereas those for detailed disease knowledge
were higher. In urology, symptomatology/clinical reasoning scores were higher, whereas all other domains werelower. Finally, we elucidate the outcomes of Dunnett’s
test as a post-hoc appraisal to authenticate the divergencein scores corresponding to each medical specialty (Fig. 3).
Within this illustration, upon scrutinizing the axis of
medical specialties in the leftmost column, it is observedthat general medicine, internal medicine, and emergency
medicine manifest significantly augmented scores. Conversely, the scores of residents nurturing aspirations todelve into highly specialized domains such as ophthalmology, dermatology, orthopedics, and plastic surgery inWatari et al. BMC Medical Education(2023) 23:464

Page 11 of 15

Fig. 2 Ranking heatmap of GM-ITE scores by chosen specialty. Note: A heat map of the GM-ITE total scores and scores in the four domains,organized according to the residents’ chosen specialties, is presented. The colors ranging from red to blue on the rightmost side serve as indicatorsof the rank order of the scores, which are classified into 21 levels. The left side provides a detailed breakdown of the scores, with the overall scoreequating to 80 points (1 point per clinical question). It is further divided into medical interview/professionalism (8 points), symptomatology/clinicalreasoning (18 points), physical examination/treatment (18 points), and detailed disease knowledge (36 points). Analysis of the data revealed thatthe attainment of basic clinical skills was generally higher in the specialties of general medicine, emergency medicine, and internal medicine.
However, certain specialties exhibited areas of underperformanceFig. 3 Univariate comparison of GM-ITE scores among medical resident’s pursuing specialty using ANOVA with Dunnett post hoc test. Note: For
the departments delineated in the left-hand column, the disparity between their scores relative to those departments listed in the corresponding
columns is indicated. Highlighted cells denote statistical significance, with an orange hue signifying a positive correlation and blue designating anegative one

Watari et al. BMC Medical Education(2023) 23:464

the impending future demonstrated a propensity towards
lower values in this examination, which gauges essential
clinical training proficiency.

Discussion
In this nationwide, cross-sectional study, we examined associations among clinical proficiency and skill as
assessed by the GM-ITE, training program characteristics, individual resident factors, and pursuing career
specialty among resident physicians in Japan. We foundthat scores on the standardized GM-ITE assessment
were higher for residents who planned careers in general
medicine, emergency medicine, and internal medicine
and lower for residents who planned for highly specialized departments that do not offer general practice. We
also discovered distinctive trends based on hospital andresident attributes. GM-ITE scores were higher for those
who trained in community hospitals with higher numbers of beds, who were more advanced in their training (i.e., PGY-2), and who spent more time working andstudying. Higher scores were noted for residents whocared for a moderate but not extreme number of patientsat a time.
In Japan, general medicine is a new specialty certification, established recently in 2018 [23, 25]. General
medicine training includes care in the outpatient clinic,
inpatient ward, and emergency department settings.
Moreover, a resident may thereafter choose a career
pathway among family medicine, hospital medicine, or
general internal medicine [25]. One potential explanation of our data is that Japanese general medicine physicians cover a wide range of settings and contexts; thisbreadth of experience facilitates the acquisition of basic
clinical skills (knowledge, skills, and attitudes) needed
for success on the GM-ITE. This is supported by the factthat previous GM-ITE studies have shown higher scoresamong those who have completed a general medicine
rotation [4, 23, 24]. It is not surprising that those residents with more clinical experience (in the form of timespent in practice and exposure to those clinical conditions most likely to be tested on the GM-ITE) fare betteron the examination. In other countries also, postgraduate training examinations have shown that extensive
comprehensive training results in higher examination
scores [3]. It has been noted that learners in Japan who
are passionate about lifelong comprehensive and extensive learning tend to go on to become general medicine
physicians [6, 17, 23].
Nearly all physicians in Japan choose their specialty inthe second postgraduate year. As a comparative example, trainees in the USA often select a residency program in the specialty of their coice before graduating

Page 12 of 15

from medical school. This decision may be based partly
on USMLE performance, although the transition topass/fail assessment for USMLE Step 1 has changed
this dynamic. Unlike in Japan, considerable examination competition exists in the USA [7, 9, 26]. Competitive fields such as dermatology, otolaryngology, plastic
surgery, and ophthalmology generally require high
USMLE Step 2 score scores to be considered [9]. In theUSA, annual incomes vary by specialty, with significant differences noted [26]. This pay discrepancy may
be an external motivating factor in future career, in thatdepartments with high income may attract residents
with good performance in consideration of repaymentof large student loans [26]. In Japan, however, there isno competition for nor restrictions on pursuing specificmedical specialties. Additionally, physician income inJapan does not vary significantly between departments,
further lowering competition compared with the system in the USA [7, 9, 18, 26, 27]. In a large-scale survey
in Japan, high remuneration was not a contributing factor in matching training hospitals [18]. Instead, juniorcareer Japanese physicians often decide their career
pathways based on their medical interests and curiosity, the scope of their practice, ease of work, expected
duties, and alignment of work and abilities [11, 18, 27].
Does the training environment influence residents’future pursuing specialty, or do they choose the training environment based on their defined future career
pathway? We cannot explain any potential or real causal
relationships. However, the differences in examination
scores according to the chosen future specialty may be
due to differences in motivation and the actual amountof active learning during the two years of mandatory
rotational training although this was not measured inthis study [16, 21]. In addition, university hospitals inJapan tend to focus on experimental research achievement [28, 29] and do not provide the same levels of
training in primary and general health care as community hospitals [6, 23]. In our study, a large proportion ofresidents who seek careers in highly specialized fields
like ophthalmology and dermatology are trained atuniversity hospitals, where the number of work shifts,
amount of time worked, and amount of clinical experience tend to be smaller. Furthermore, it has been shownthat residents who work fewer hours have significantly
less time for actual independent study, despite having
relatively more time overall, [21] in which case lessstudying correlates with lower GM-ITE scores [16, 21].
Considering all of the above, it is possible that in Japan,
highly specialized departments, such as ophthalmology,
dermatology, and plastic surgery, are not expected tohave a wide range of clinical skills or knowledge related
to systemic conditions. Thus, those who wish to pursue

Watari et al. BMC Medical Education(2023) 23:464

these careers may not have the motivation and study
time to devote to skills assessed by the GM-ITE.
Our findings must be interpreted in the context ofseveral limitations. First, this is a cross-sectional study,
and it is unknown whether PGY-1 residents accurately
predict their actual future specialties. In fact, the commencement of the GM-ITE coincides with the culmination of the academic year, suggesting a greater
probability that PGY-2 residents would have delineated their career trajectory by this juncture comparedto PGY-1. Furthermore, the GM-ITE scores even before
the initiation of the PGY-1 residency are unknown,
and the contemplation of future assessments to ascertain this before mandatory clinical training commences
is currently under investigation. Second, the presenceof selection bias is inevitable. Despite the test being
taken by more than a half of residents nationwide, we
exclude data from respondents who indicated morethan one division from this cohort. Inclusion of suchdata might engender alterations in the results. Third,
the history of the general medicine specialty in Japanis young, and there is mutual overlap among the fields
of general internal medicine, hospital medicine, andfamily medicine, all of which are often also responsible
for general internal medicine ward and outpatient services [25]. On the other hand, there may be residents
in internal medicine who wish to choose hospital medicine or general internal medicine after their residency
program. This overlap can be a major misclassification
bias [25, 29, 30]. Subsequently, our GM-ITE data exclusively displays the four categories of examination questions and the total score, as articulated above. This may
be because certain questions may appraise the attitude
towards physical examination and interview, even when
the disease is distinctly categorized under obstetrics
and gynecology in the medical department classification. Consequently, it was not feasible to demonstrate
a correlation between which medical department applicants are more likely to encounter questions in specificmedical department categories. Nonetheless, this iscongruent with the MHLW’s objective of training ’physicians who can provide comprehensive and wide-ranging medical care. Finally, the results of this examination
may serve as either intrinsic or extrinsic motivation forresident aspirants. Even though this examination does
not exert a direct influence on career progression or
retention, the results are communicated to the program
director. Consequently, there exists a potential bias,
such as residents who harbor future intentions to apply
to a broader array of departments, inclusive of generalpractice or emergency medicine, may approach theexamination with heightened diligence and engage inmore rigorous preparation.

Page 13 of 15

Conclusion
In conclusion, this nationwide study is the first of its kindto reveal differing levels of attainment of basic clinicalskills, as assessed by the GM-ITE, among residents inJapan according to their chosen specialty. In particular,
higher scores were noted among those pursuing careers
in general medicine and emergency medicine fields andlower scores among those pursuing highly subspecialized careers. Differences were also observed among
future departments with respect to the amount of timespent caring for patients and studying and the numberof assigned patients. Residents in medical training programs devoid of specialty-specific competition may notpossess the same motivations as competitive systems,
and countries may learn from these experiences. Further
research is needed to address potential causative factors for these disparate levels of achievement and associations, including perhaps intrinsic motivations to learn
within fields outside of the chosen career pathway during
the two years of required training. Future studies should
also seek to elucidate strategies to improve clinical skills
for residents with low achievement levels.
Abbreviations
GM-ITE	General Medicine In-Training Examination
GME	Graduate medical education
USMLE	United States Medical Licensing Examination
MHLW	Ministry of Health, Labour and Welfare
PGY-1	First year resident
PGY-2	Second year resident
JAMEP	Japan Association for the Advancement of Medical Education
IQR	Interquartile range

Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12909-​023-​04429-4.
Additional file 1. Background factors and PGY-1 residents’ characteristics,
among each pursuing specialty.
Additional file 2. Background factors and PGY-2 residents’ characteristics,
among each pursuing specialty.
Additional file 3. Mean scores with standard deviation of GM-ITE among
each pursuing specialty for PGY-1 and PGY2.
Additional file 4. The Multivariate Linear Regression Analysis of GM-ITE
score for PGY-1.
Additional file 5. The Multivariate Linear Regression Analysis of GM-ITE
score for PGY-2.
Additional file 6: Online-Only Supplements 1. Sample questions fromthe GM-ITE examination translated into the English language.
Acknowledgements
We thank Mr. Juhei Matsumoto for his careful support during this study. We
also thank our team members, Dr. Ichiro Kato, Dr. Seiji Odagawa, Dr. Takeshi
Endo, Dr. Nobuyuki Ueno, and Mrs. Kazumi Iwatani from Shimane University
Hospital, General Medicine Center, for sharing their wisdom with us during
this research. In addition, we also thank Dr. Sanjay Saint and Dr. Ashwin Gupta
for their remarkable guidance and advice on this research in Japan.

Watari et al. BMC Medical Education(2023) 23:464

Authors’ contributions
T.W. and Y.N designed the study, the main conceptual ideas, and the proof
outline. Y.N., T.S., Y.Y., Y.T collected the data via web survey on GM-ITE. T.W., K.S.,
Y.S., and K.K. analyzed and visualized the data. T.W., Y.N., N.H. K.K., K.S, Y.S., T.S.,
Y.Y., and Y.T. aided in interpreting the results and worked on the manuscript.
Y.T. and Y,N. supervised the project. T.W. wrote the whole manuscript withsupport from N.H and Y.N. All authors discussed the results and commented
on the manuscript.
Funding
This work was supported by the national academic research grant funds[JSPS KAKENHI: 20H03913]. The sponsor of the study had no role in the study
design, data collection, analysis, or preparation of the manuscript.
Availability of data and materials
The data that support the findings of this study are available from the corresponding author, T.W, the General Medicine Center, Shimane University
Hospital (E-mail. wataritari@gmail.com), upon reasonable request.

Declarations
Ethics approval and consent to participate
The authors obtained approval from the Ethical Review Committee of JAMEP(No. 20181017–1). All participants provided informed consent before engaging in the study following the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
Y.N. received an honorarium from the Japan Institute for Advancement ofMedical Education Program (JAMEP) as a GM-ITE project manager. Y.T. is the
director of JAMEP; he received an honorarium from JAMEP for delivering lectures for the JAMEP. Otherwise, the authors declare that they have no conflictof interest.
Author details
1
General Medicine Center, Shimane University Hospital, 89‑1, Enya‑Cho, Izumo
Shi, Shimane 693‑8501, Japan. 2 Medicine Service, VA Ann Arbor Healthcare
System, Ann Arbor, MI, USA. 3 Department of Internal Medicine, Universityof Michigan Medical School, Ann Arbor, MI, USA. 4 Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan. 5 Department
of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital,
Tochigi, Japan. 6 Division of General Medicine, Center for Community Medicine,
Jichi Medical University, Tochigi, Japan. 7 Muribushi Okinawa Project for Teaching Hospitals, Okinawa, Japan.
Received: 11 March 2023 Accepted: 6 June 2023

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