Nishizaki et al. BMC Medical Education(2020) 20:426
https://doi.org/10.1186/s12909-020-02334-8

RESEARCH ARTICLE

Open Access

Impact of general medicine rotation
training on the in-training examination
scores of 11, 244 Japanese resident
physicians: a Nationwide multi-center crosssectional study
Yuji Nishizaki1* , Taro Shimizu2, Tomohiro Shinozaki3, Tomoya Okubo4, Yu Yamamoto5, Ryota Konishi6 andYasuharu Tokuda7

Abstract
Background: Although general medicine (GM) faculty in Japanese medical schools have an important role ineducating medical students, the importance of residents’ rotation training in GM in postgraduate education has notbeen sufficiently recognized in Japan. To evaluate the relationship between the rotation of resident physicians in
the GM department and their In-Training Examination score.
Methods: This study is a nationwide multi-center cross-sectional study in Japan. Participants of this study are Japanese
junior resident physicians [postgraduate year (PGY)-1 and PGY-2] who took the General Medicine In-Training Examination(GM-ITE) in fiscal years 2016 to 2018 at least once (n = 11,244). The numbers of participating hospitals in the GM-ITE were381, 459, and 503 in 2016, 2017, and 2018.The GM-ITE score consisted of four categories (medical interview/professionalism, symptomatology/clinical reasoning, physical examination/procedure, and disease knowledge). We
evaluated relationship between educational environment (including hospital information) and the GM-ITE score.
Results: A total of 4464 (39.7%) residents experienced GM department rotation training. Residents who rotated had
higher total scores than residents who did not rotate (38.1 ± 12.1, 36.8 ± 11.7, and 36.5 ± 11.5 for residents who
experienced GM rotation training, those who did not experience this training in hospitals with a GM department, andthose who did not experience GM rotation training in hospitals without a GM department, p = 0.0038). The association
between GM rotation and competency remained after multivariable adjustment in the multilevel model: the score
difference between GM rotation training residents and non-GM rotation residents in hospitals without a GM department
was estimated as 1.18 (standard error, 0.30, p = 0.0001), which was approximately half of the standard deviation of(Continued on next page)* Correspondence: ynishiza@juntendo.ac.jp
1
Medical Technology Innovation Center, Juntendo University, 2-1-1 Hongo,
Bunkyo-ku, Tokyo 113-8421, Japan
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Nishizaki et al. BMC Medical Education(2020) 20:426

Page 2 of 10(Continued from previous page)

random effects due to hospital variation (estimated as 2.00).
Conclusions: GM rotation training improved the GM-ITE score of residents and should be considered mandatory forjunior residents in Japan.
Keywords: Basic clinical competency, General medicine, General medicine in-training examination (GM-ITE), Medical
education, Resident physician

Background
General medicine (GM) has an important role in healthcare systems of Western countries. In 1956, the Universityof Edinburgh opened a Department of GM for the firsttime in the world. GM physicians have been recognized as
specialists of primary care in many European countries
with universal health care coverage. The United States
health care system has developed a comprehensive GM
system, including family medicine for primary care, general internal medicine (GIM) for hospital outpatient care,and hospital medicine for inpatient hospital care [1, 2].
In Japan, a GM department was introduced at Tenri
Yorozu Soudan Sho Hospital, a community teaching
hospital, in 1976 for the first time [3]. Thereafter, GM departments have been increasing steadily among other community teaching and university hospitals. Physicians in GM
departments in Japanese hospitals provide outpatient and/or inpatient care for patients with complex problems andmultiple co-morbidities, and who cannot be cared for bysub-specialist physicians.
Although GM faculty members in many Japanese
medical schools have important roles as clinician educators for medical students, the importance of GM in a
postgraduate residency education has not been sufficiently recognized in Japan [4]. Thus, a 2-year training
program for postgraduate junior resident physicians has
become mandatory in Japan since 2004, but many juniorresidents are not required to have rotation training in
GM department and are required to have rotations ininternal medicine (mostly subspecialty internal medicine
divisions), emergency medicine, community medicine,surgery, psychiatry, pediatrics, and obstetrics/gynecology.
Learning objectives in the training program for postgraduate junior resident physicians include many areas
related to GM care settings. We believe that GM rotation training has a great effect on the educational
achievements of resident physicians. We previously reported a positive association between the presence of a
GM department at each teaching hospital and meanscores on the General Medicine In-Training Examination (GM-ITE) among junior residents [5]. Howeverthat study was based on an ecological design and did notevaluate the association between GM rotation training
and the test scores for individual residents. In thecurrent study, we evaluated the relationship between

GM rotation training for residents and their GM-ITE
score. We also evaluated the relationship between the
GM-ITE scores and factors associated with the educational environment, including time spent on Emergency
Department (ED) duties per month, average number of inpatients covered per day, availability and use of online
medical resources, and the amount of study time per day.
We have divided the students participating in a GM
rotation into three groups, including (1) those with noprevious GM experience (i.e., GM rotation) who weretrained in hospitals without a GM department (2) thosewith no previous GM experience who were trained in
hospitals that included a GM department, and (3) thosewith previous GM experience. Teaching hospitals inJapan, regardless of whether or not they have a GM
department, all have individual subspecialty divisions ofInternal Medicine, including Cardiology, Hematology,
Nephrology, and Respiratory Medicine.

Methods
Study design

We conducted a nationwide, multi-center, cross-sectional
study in Japan. We evaluated the association between the
educational environment and the GM-ITE score from thefiscal years 2016 to 2018 among resident physicians inJapanese teaching hospitals. This study was approved by
the institutional review board of the Mito Kyodo General
Hospital, Mito City, Ibaraki, Japan.
GM-ITEThe Japan Organization of Advancing Medical Education Program (JAMEP), a non-profit organization, hasbeen implementing the GM-ITE since 2011 as an objective evaluation of the basic clinical competency of juniorresident physicians (postgraduate years PGY-1 and PGY2) [5–9]. The GM-ITE is a multiple-choice knowledge
test. In 2016, it consisted of 100 questions. Following revisions in 2017 and 2018, the test has 60 questions.
In line with the early residency objectives of the Japanese
Ministry of Health, Labour and Welfare, the GM-ITE
covers four areas of basic clinical knowledge: medical interview and professionalism, symptomatology and clinical reasoning, physical examination and procedure, and diseaseknowledge. The test items relate to the fields of internal
medicine, surgery, emergency medicine, pediatrics,

Nishizaki et al. BMC Medical Education(2020) 20:426

obstetrics and gynecology, and psychiatry. Overall, the GMITE comprehensively covers all the relevant disciplines witha focus on primary care.
The test content and construct validity have been
proven. Upon completing the test, test-takers receive
feedback based on the relative scoring of the test participants and a detailed explanation about each question. A
sample English question from the GM-ITE is shown in
the Additional file 1: Appendix.
Data collection

We collected information about the educational environment from a self-reporting questionnaire sheet, which
included age, future desired specialty after residency,
GM rotation, period of internal medicine rotation, ED
duties per month, night duties per month, average number of inpatients in charge, use of medical online resources [including UpToDate (www.uptodate.com) [10]],
medical journals, medical manuals, medical information
websites, study time per day, number of participatingcase conferences per week, number of participating outside case conferences or lectures, and contribution by
the GM department. Hospital information was obtained
from the Residency Electronic Information System
website [11] and the Foundation for the Promotion of
Medical Training website [12]. Regarding the categories
of urban cities and local cities in the hospital characteristics, 20 cities designated by the Ministry of Internal
Affairs and Communications and in the 23 wards inTokyo were defined as urban cities and the rest as provincial cities.
Statistical analyses

Resident physicians were classified into three groups
according to their hospitals with or without a GM department and the experience of GM rotation from aself-reporting questionnaire sheet (hospitals without a
GM department did not offer GM rotation). We compared the GM-ITE total scores between the GM department/rotation groups by using linear multilevel regression
models adjusted for hospital-level information (hospital
location and hospital type) and resident-level information(sex, deviation value of graduating school in 2018, ED duties per month, average number of inpatients in charge,
UpToDate use, study time per day, and year of GM-ITE)
as well as hospitals as random normal intercepts. Residents with missing data for any variable were excluded
from the multivariate analysis. All analyses were performed by using SAS version 9.4 software (SAS InstituteInc., Cary, NC). We interpreted p-values as indicative ofcompatibility between the data and the “no-difference between that variable’s levels” hypothesis under the assumed
statistical model.

Page 3 of 10

Results
Throughout Japan, 381, 459, and 503 hospitals participated in the GM-ITE in 2016, 2017, and 2018, and thenumbers of GM-ITE participants were 4568, 5593, and6133, respectively, for each year. If consent for utilizing
the GM-ITE score could not be obtained, those data
were excluded from the analyses. If a resident physician
took the examination twice (in PGY-1 and PGY-2), we
excluded the data from PGY-1. Finally, the data of 11,
244 resident physicians were used for analyses.
Summarized hospital information, resident information, and GM-ITE scores are shown in Table 1. A totalof 11,244 residents (67.7% men) were retrospectively analyzed. Among the hospitals, 26.8% were urban and
88.8% were community hospitals. The average total GMITE scores were 37.3 ± 11.9 and 5.9 ± 5.4 for medical
interview and professionalism, 10.6 ± 2.5 for symptomatology and clinical reasoning, 10.3 ± 2.5 for physicalexamination and procedure, and 10.5 ± 4.2 for diseaseknowledge.
A total of 4464 (39.7%) residents experienced rotation
training in the GM department. Residents who rotatedin the GM department had higher total scores than residents who did not rotate. The results were 38.1 ± 12.1,
36.8 ± 11.7, and 36.5 ± 11.5 for residents who experienced GM rotation training, those who did not experience GM rotation in hospitals with a GM department,
and those who did not experience GM rotation in hospitals without a GM department (p = 0.0038).
The association between GM department/rotation
remained after multivariable adjustment in the multilevel
model (Table 2): the score difference between residents
who experienced GM rotation training and those who did
not in hospitals without a GM department was estimatedas 1.18, with a standard error of 0.30 (p = 0.0001), which
was about half of the standard deviation of random effects
due to hospital variation (estimated as 2.00). The analysis
also showed that community hospital, male sex, deviation
value, ED duties per month (three to five per month vs.
zero per month: estimated coefficient, 1.22; standard error,
0.40; p = 0.0022), average number of inpatients in charge(> 15 vs. zero to four: estimated coefficient, 1.18; standard
error, 0.40; p = 0.0036), UpToDate use (estimated coefficient, 1.48; standard error, 0.16; p < 0.0001), study time
(61–90 min vs. none: estimated coefficient, 1.65; standard
error, 0.39; p < 0.0001), test year, and GM rotation training were associated with the total GM-ITE score.
Table 3 includes the results of subgroup multilevel regression analyses that evaluate the relationship between
the GM rotation and the GM-ITE score (Table 3). Overall, we found no obvious difference in relationships between the GM rotation and the GM-ITE score withrespect to each subgroup except for hospital type (community hospitals vs. university hospitals).

Nishizaki et al. BMC Medical Education(2020) 20:426

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Table 1 Educational environment, characteristics of the residents, and GM-ITE scores
VariablesAll

GM department
yes

GM departmentno

GM rotationyes

GM rotationnoGM rotationnop-value*1

Hospital information
Location
Urban area, n (%)

3013 (26.8)

1197 (26.8)

1283 (26.1)

533 (28.7)

Rural area, n (%)

8231 (73.2)

3267 (73.2)

3641 (73.9)1323 (71.3)

0.9256

Hospital typeCommunity hospital (incl. University branch hospital), n (%)

9990 (88.8)4009 (89.8)

4150 (84.3)

1831 (98.7)

University hospital, n (%)

1254 (11.2)

455 (10.2)

774 (15.7)

25 (1.3)

0.0056

Male, n (%)

7611 (67.7)

3075 (68.9)

3294 (66.9)

1242 (66.9)

Female, n (%)

3633 (32.3)

1389 (31.1)

1630 (33.1)

614 (33.1)

Deviation value, mean ± SD

66.4 ± 2.2

66.3 ± 2.2

66.4 ± 2.2

66.6 ± 2.2

0.44480 per month, n (%)

347 (3.1)

127 (2.8)

180 (3.7)

40 (2.2)

0.0163 *2

1 to 2 per month, n (%)

1543 (13.7)

510 (11.4)

878 (17.9)

155 (8.4)

3 to 5 per month, n (%)

7779 (69.3)

3098 (69.5)

3235 (65.8)

1446 (78)More than 6 per month, n (%)

1473 (13.1)

693 (15.5)

575 (11.7)

205 (11.1)

Unknown

84 (0.7)30 (0.7)

47 (1)

7 (0.4)0 to 4, n (%)

1776 (15.9)

682 (15.3)

784 (16)310 (16.8)

5 to 9, n (%)

6650 (59.4)

2622 (59)2947 (60.1)

1081 (58.4)

10 to 14, n (%)

1812 (16.2)

725 (16.3)

770 (15.7)

317 (17.1)

Resident information
0.1981

ED duties per month

Average number of inpatients in charge

More than 15, n (%)

615 (5.5)

310 (7)245 (5)60 (3.2)

Unknown, n (%)

345 (3.1)

108 (2.4)

155 (3.2)

82 (4.4)

No, n (%)

5683 (72.4)

1948 (64.4)

2688 (76.7)

1047 (79.6)

Yes, n (%)

2162 (27.6)

1077 (35.6)

816 (23.3)

269 (20.4)

0.708 *2

UpToDate use<.0001

Study timeNone, n (%)

655 (5.9)

249 (5.6)

308 (6.3)

98 (5.3)

0 to 30 min, n (%)

4022 (36)1567 (35.2)

1864 (38.1)

591 (32)

0.053631 to 60 min, n (%)

4457 (39.8)

1762 (39.6)

1875 (38.3)

820 (44.4)

61 to 90 min, n (%)

1600 (14.3)

672 (15.1)

663 (13.6)

265 (14.3)

More than 91 min, n (%)

451 (4)198 (4.5)

180 (3.7)

73 (4)

2016, n (%)

2748 (24.4)

1089 (24.4)

1219 (24.8)

440 (23.7)

2017, n (%)

3251 (28.9)1380 (30.9)1395 (28.3)

476 (25.6)

2018, n (%)

5245 (46.6)

1995 (44.7)2310 (46.9)

940 (50.6)

Total, mean ± SD

37.3 ± 11.9

38.1 ± 12.1

36.8 ± 11.7

36.5 ± 11.5

0.0038

Medical interview and professionalism, mean ± SD

5.9 ± 5.4

6.1 ± 5.6

5.8 ± 5.3

5.7 ± 5.2

0.204

Symptomatology and clinical reasoning, mean ± SD

10.6 ± 2.5

10.8 ± 2.6

10.4 ± 2.5

10.4 ± 2.4

0.0002

Physical examination and procedure, mean ± SD

10.3 ± 2.5

10.5 ± 2.5

10.1 ± 2.5

10.1 ± 2.5

0.0006Subspecialties, mean ± SD

10.5 ± 4.2

10.8 ± 4.2

10.4 ± 4.2

10.2 ± 4.1

0.0069Year
0.1182

GM-ITE score

GM general medicine, GM-ITE general medicine in-training examination, SD standard deviation, ED emergency department*1= p-values from generalized estimating equations of univariable logistic (binary data), proportional odds (multicategory data), or linear (continuous data) models
with clustering hospitals. *2 = Excluding data in “Unknown” category

Nishizaki et al. BMC Medical Education(2020) 20:426

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Table 2 Factors related to GM-ITE score (multilevel analysis)
Estimated CoefficientStandard Error

p-value

Rural area (vs. Urban area)

0.30270.2795

0.279

University hospital [vs. Community hospital (incl. University branch hospital)]−1.7672

0.50520.0005

Variables
Hospital information

Resident information
Sex
Male

0

Female−0.33440.15110.0269Deviation value

0.29040.03638< 0.0001

ED duties per month0 per month0

1 to 2 per month

0.62830.42870.14283 to 5 per month1.22350.40030.0022More than 6 per month

1.14350.44990.0111

Unknown

0.12980.88690.8836

Average number of inpatients in charge
0 to 40

5 to 91.00890.2026< 0.0001

10 to 140.9146

0.26460.0006More than 15

1.18610.40680.0036

Unknown

0.32770.42270.4382

1.48420.1663< 0.0001

UpToDate use (vs. Not used)
Study time per day
None

0

0 to 30 min

0.56120.28730.050831 to 60 min

1.13790.29< 0.0001

61 to 90 min

1.71960.3308< 0.0001

More than 91 min

2.2147

0.4613< 0.0001

Year
2016

0

2017

−22.9810.1846< 0.0001

2018−24.2165

0.1651< 0.0001

Combination of resident and hospital information
GM department and rotation
Did not experience GM rotation in hospitals without GM department0

Did not experience GM rotation in hospitals with GM department

0.94230.30650.0021

Experienced GM rotation

1.18480.30450.0001

GM general medicine, GM-ITE general medicine in-training examination, ED emergency department

Discussion
We found a positive relationship between the experienceof GM rotation training and the total GM-ITE score.
The contribution for improving the GM-ITE score
ranged from highest to lowest as follows: experienced
GM rotation training > did not experience GM rotation
training in hospitals with a GM department > did notexperience GM rotation training in hospitals without a

GM department. These results suggest that educational
achievement in junior residents could be improved bytheir GM rotation training. We also found the several
significant factors associated with the educational environment that had an impact on the GM-ITE score, including ED duties (shifts per month), average number of
inpatients covered per day, availability and use of online
medical resources, and amount of study time per day.

Nishizaki et al. BMC Medical Education(2020) 20:426

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Table 3 Results of subgroup analysis
SEP-value

0.99970.656

0.12771197

1.34490.64580.03741323

0no/yes3641

0.90570.34480.0086

yes/yes

3267

1.10510.34350.0013Subgroup

GM rotation/GM department

N

Estimated Coefficient

Urban area

no/no

533

0

no/yes1283

yes/yesno/no

Rural area

Community hospital

University Hospital

Male

FemaleDeviation value <= 65.0

Deviation value > = 65.1

ED duty: 0 per month

ED duty: 1 to 2 per month

ED duty: 3 to 5 per month

ED duty: more than 6 per month

Average number of inpatients in charge: 0 to 4

Average number of inpatients in charge: 5 to 9

Average number of inpatients in charge: 10 to 14

no/no

1831

0

no/yes4150

0.93690.31210.00270.30980.0004yes/yes

4009

1.0941

no/no

25

0

no/yes774

2.98942.21380.1773yes/yes455

3.6334

2.19590.0984

no/no

1242

0

no/yes3294

0.78540.35330.02630.35130.001

yes/yes3075

1.1612

no/no

614

0

no/yes1630

0.92230.42610.0305yes/yes

1389

1.206

0.43080.0052

no/no

892

0

no/yes2570

0.79410.3787

0.036

0.37650.0045yes/yes2413

1.0696

no/no

964

0

no/yes2354

0.91230.41190.0269yes/yes

2051

1.2676

0.41370.0022

no/no

40

0

no/yes1800.93431.3604

0.4935yes/yes127−0.04607

1.38950.9736

no/no

155

0

no/yes878

1.26160.80980.1196

yes/yes

510

1.67890.83480.0446

no/no

1446

0

no/yes3235

0.8094

0.33880.0169yes/yes

3098

1.097

0.33710.0011

no/no

205

0

no/yes575

0.629

0.71020.376

yes/yes693

1.41920.7069

0.045

no/no

310

0

no/yes784

1.05230.59670.0781yes/yes682

0.82810.60930.1744

no/no

1081

0

no/yes2947

0.95040.36620.0095yes/yes2622

1.33870.36480.0002

0.6356

0.986

no/no

317

0

no/yes770

0.01113

Nishizaki et al. BMC Medical Education(2020) 20:426

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Table 3 Results of subgroup analysis (Continued)
Subgroup
Average number of inpatients in charge: more than 15

UpToDate non-user

UpToDate user

Study time: none

Study time: 0 to 30 min

Study time: 31 to 60 min

Study time: 61 to 90 min

Study time: more than 91 min

GM rotation/GM department

N

Estimated CoefficientSE

P-valueyes/yes725

0.85080.64020.1842

no/no

60

0

no/yes245−0.02175

1.18740.9854yes/yes310

0.1001

1.17930.9324

no/no

1047

0

no/yes2688

0.79960.312

0.0104yes/yes

1948

0.88330.3143

0.005

no/no

269

0

no/yes

816

1.048

0.576

0.069

yes/yes1077

1.9872

0.56350.0004

no/no

98

0

no/yes308

0.96090.97990.32771.00340.8936

yes/yes249−0.1344

no/no

591

0

no/yes

1864

1.15650.41120.0049yes/yes1567

1.54320.41610.0002

no/no

820

0

no/yes

1875

0.66620.40230.09790.40270.0005yes/yes1762

1.4065

no/no

265

0

no/yes663

0.21590.63850.7354yes/yes672

0.88120.64870.1748

no/no

73

0

no/yes1800.3576

1.3614

0.7935yes/yes198

0.9663

1.34990.4761

ED emergency department
Each multilevel regression analysis adjusted for variables indicated in Table 2

Although amount of study time and use of effective
learning materials are important factors with direct impact on test preparedness, we found no specific change
in relationships between the GM rotation and the GMITE score across subgroups of these factors.
We have previously reported that residents in teaching
hospitals with higher mean GM-ITE scores were associated with the presence of a GIM or GM department [5].
However, that study was an investigation with a small
sample size of 206 residents at 21 hospitals. Furthermore, because there was no questionnaire survey on the
educational environment, the association between GM
rotation and GM-ITE score was not verified. In thisstudy, we used a larger sample size and more directly
evaluated the effect of GM rotation training on educational achievements/competency by specifically investigating the relationship between GM rotation training
and the GM-ITE score for residents.
We believe bedside teaching by general physicians provides greater effectiveness of clinical education. The GM

department covers all areas of medicine with a broad
view to patient care and does not focus on a single organsystem, so training programs involving GM rotation
positively affect the GM-ITE score. Moreover, general
physicians are good at teaching essential elements forbasic clinical competency, such as clinical ethics, communication, physical examination, clinical reasoning,and professionalism [13–15].
Compared with Western countries, Japan has a shorter
history of developing GM departments in hospitals, sothese have not been recognized as a required department
for educational rotation of junior residents [16–18]. However, since there is a broad overlap of core competencies
between GM physicians and junior residents, rotation
training in this department is highly desirable. From 2018,
the designation of “general physician” has been newly acknowledged as a specialist in a basic area of the Japanese
medical specialty system [19, 20]. It is hoped that thischange will serve as an opportunity to introduce GM departments in all teaching hospitals throughout Japan.

Nishizaki et al. BMC Medical Education(2020) 20:426

The hospitalist plays a crucial role in improving thequality of resident physician education [21]. As in the
United States, Japanese hospitals should have a GM
department at the center of the medical ward, and itis necessary to build a system in which general physicians take care of the patient along with the resident
in the medical ward and have the option to immediately consult with sub-specialist physicians if necessary. Further, sub-specialist physicians should be able
to consult general physicians in order to facilitate asmooth diagnosis [2, 22].
We found that resident physicians with ED duty three
to five times per month were associated with the highest
GM-ITE scores relative to those with no ED duty permonth. Residents with three to five instances of ED duty
per month had higher GM-ITE scores than residents
with more than six instances per month. The results
revealed a trend similar to that of a previous study wereported in 2015 [6]. An appropriate workload in ED
duty may develop better competencies and lead to better
educational achievements among resident physicians.
On the other hand, an excessive workload may cause“burn out” or more medical errors [23–25]. Burnout is a
psychological syndrome that is experienced frequently
by medical residents. It consists of emotional exhaustion,
depersonalization and reduced feelings of personal accomplishment [26]. Trigger factors for burnout among
emergency physicians and emergency medicine residents
include non-patient-related problems (such as large administrative burdens) in addition to personal and interpersonal issues [27]. Shanafelt et al. reported differencesin burnout by specialty; the highest rates of burnout arereported among physicians on the front lines of medicalcare (i.e., family medicine, general internal medicine, andemergency medicine). This group also reported that,compared with a probability-based cohort sample of3442 working U. S. adults, physicians were more likely
to have symptoms of burnout (37.9% vs 27.8%) and to
be dissatisfied with their current level of work-life balance (40.2% vs 23.2%) [28]. Therefore, we should requirecontinual awareness of the optimized workload balancein ED duties to provide a safer educational environment
for resident physicians.
We showed that resident physicians in charge of > 15
inpatients had higher GM-ITE scores than residents incharge of 0 to 4 inpatients. We also demonstrated a relationship between appropriate study time and higher
GM-ITE score. The explanation for this observation liesin the following witty remark by William Osler: “Tostudy the phenomena of disease without books is to sailan uncharted sea, while to study books without patientsis not to go to sea at all” [29, 30].
UpToDate use was associated with higher GM-ITE
scores. The results coincided with those of our previous

Page 8 of 10

report [6]. Physicians need to effectively collect clinicalevidence for a short period in a clinical situation. Selfdirected reading of an electronic knowledge resource
have been found previously to have statistically and educationally significant independent associations with medical knowledge acquisition [31]. In addition, efficientcollection of clinical evidence by using UpToDate could
improve not only medical knowledge but also prognosesof patients [32, 33]. We expect resident physicians to appropriately use evidence-based electronic resources forbedside and clinical decision making.
Brint and Cantwell reported that more time spent focused on learning results in improved performance on
examinations [34]; reports from other groups revealed
that use of online resources resulted in improved student performance [35, 36]. Our findings are consistent
with the results of these earlier studies.
We found that the group of “no experience of GM
rotation in hospitals with GM department” tended toobtain the higher GM-ITE score than the group of“no experience of GM rotation in hospitals without
GM department”. Even if junior resident physicians
had no previous GM experience, GM departments
tend to have an overall profound educational impact
on resident physicians. GM departments typically include
faculty development programs that provide outreach to all
departments. GM physicians are also among the most
likely to provide resident physicians lectures and conferences that cover topics that are critical for clinical training
including ethics, communication skills, professionalism,and evidence-based medicine.
As shown in Table 3, there was no apparent difference
in relationship between having the experience of a GM
rotation and the GM-ITE score with respect to location(i.e., urban area vs. rural area). On the other hand, there
were significant differences in the relationship between
hospital type subgroups (community hospitals vs. university hospitals), with the university hospitals having agreater GM rotation and the GM-ITE score associations
than community hospitals. The estimated coefficient for“having experienced a GM rotation” was 1.1 in community hospitals and 3.6 in university hospitals. We
hypothesize that this result may reflect differences in theenvironment related to primary care education and thus
a higher educational impact of the GM rotation.
The present study revealed a positive association
between having participated in a GM rotation and GMITE score. In addition to the positive impact of a GM
rotation, we think that the potential negative impact oflimited training in specialized medical departments
should not be overlooked. In modern clinical practice,physicians are asked to care for patients with complex
medical problems and multiple co-morbidities. As such,physicians who are focused purely on one organ or

Nishizaki et al. BMC Medical Education(2020) 20:426

organ system may have a more narrow vision, and thus
may provide a limited educational view for junior resident physicians. Furthermore, learning objectives forpostgraduate junior resident physicians include aspects
such as ethics, communication skills, professionalism,and evidence-based medical practice, among other moregeneral topics. It is unlikely that a medical sub-specialist
will have the knowledge or interest in taking charge ofso wide a range of educational requirements. Given thissituation, we feel strongly that further enrichment of theeducation system with a strong focus on GM departments will ensure that the next generation of physicians
is fully equipped to deal with a wide range of problems.
However, there are other points that require some future consideration. Sub-specialists may need to put inmore effort towards identifying cross-disciplinary solutions for both social and medical problems, including
the doctor–patient relationship, problems associatedwith mental and psychological well-being as well as social welfare, and various approaches that feature input
from those knowledgeable in the behavioral sciences.
Furthermore, sub-specialists may need to contributetoward patient-centered health education regarding
smoking, drinking alcohol, and drug abuse. The subspecialists will need to foster and nurture sensitivity toward these problems; we recognize that this will be a
substantial paradigm-shift from the current diseaseoriented approach [3].
We were unable to identify any specific factors underlying the gender differences in the GM-ITE scores. This
result did not necessarily mean that female resident physicians possess less knowledge or fewer skills than dotheir male resident physicians. Additional analysis withrepresentative data will be needed to address this issue.
Our study had several limitations. First, we did notinclude all initial training participants belonging toteaching hospitals in Japan. The number of PGY-1 plus
PGY-2 resident physicians was approximately 18,000,
but about one-third of resident physicians participate in
the GM-ITE. Therefore, our findings might not be
generalizable to all residents throughout Japan.
Second, we did not evaluate the residents’ baseline
GM-ITE score. For a more precise measurement of the
impact of general medicine rotation training on the
GM-ITE score, the baseline GM-ITE score should be
adjusted.
Third, we did not take the participants’ medical school
experiences into consideration. The learning experiencesof GM training depend on one’s medical school education. This may have affected the study results.
The fourth limitation is the season of the GM rotation,that is, the GM-ITE scores are affected if the season of
the GM rotation is close to the time of testing. We were
not able to adjust this factor.

Page 9 of 10

Finally, the study variables did not include some thatmight have affected the results. For example, the numberof supervising physicians belonging to a GM department
and the years of clinical experience of the supervisingphysicians and contents of their educational programs
could affect the learned competencies and GM-ITE
scores of the residents. Future studies are needed to confirm the direct relationship between GM rotation training and GM-ITE scores after adjusting for the variables
mentioned above.

Conclusion
GM rotation training led to improvement in the GMITE score of residents. Therefore, mandatory GM rotation training should be considered for junior residents inJapan.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12909-020-02334-8.
Additional file 1. Appendix
Abbreviations
ED: Emergency department; GIM: General internal medicine; GM: General
medicine; GM-ITE: General Medicine In-Training Examination; JAMEP: Japan
Organization of Advancing Medical Education Program; PGY: Postgraduateyear
Acknowledgments
We thank the JAMEP secretariat for their excellent support for our work.
Authors’ contributions
YN and YT have designed this study in whole and drafted this manuscript.
TS 1, TO, YY, and RK have contributed to collect data. TS 2 has contributed
to statistical analyses in this study. All authors have contributed to provide
advice on interpretation of the results. YT has revised this manuscript
critically for important intellectual content and approved finally themanuscript submitted. All authors read and approved the final manuscript.
Funding
None.
Availability of data and materials
The data sets will not be publicly available because informed consent ofparticipants in each hospital do not allow for such publication. The
corresponding author will respond to requests on data analyses.
Ethics approval and consent to participate
This study was approved by the institutional review board of the Mito Kyodo
General Hospital, Mito City, Ibaraki, Japan. We obtained written consent fromall participants.
Consent for publication
Not applicable.
Competing interests
YN, TS 1, TO, YY, RK, and YT participated on the JAMEP GM-ITE projectcommittee and received a reward.
Author details
1
Medical Technology Innovation Center, Juntendo University, 2-1-1 Hongo,
Bunkyo-ku, Tokyo 113-8421, Japan. 2Department of Diagnostic and Generalist
Medicine, Dokkyo Medical University Hospital, 880 Kitakobayashi,

Nishizaki et al. BMC Medical Education(2020) 20:426

Shimotuga-gun, Mibumachi, Tochigi 321-0293, Japan. 3Department ofInformation and Computer Technology, Faculty of Engineering, Tokyo
University of Science, 6-3-1 Niijuku, Katsushika-ku, Tokyo 125-8585, Japan.
4
Research Division, National Center for University Entrance Examinations,
2-19-23 Komaba, Meguro-ku, Tokyo 153-8501, Japan. 5Division of General
Medicine, Center for Community Medicine, Jichi Medical University School of
Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan. 6Education
Adviser Japan Organization of Occupational Health and Safety, 1-1
KidukiSumiyoshi-cho, Nakahara-ku, Kawasaki-shi, Kanagawa 211-0021, Japan.
7
General Internal Medicine, Muribushi Okinawa for Teaching Hospitals, 3-42-8Iso, Urasoe-shi, Okinawa 901-2132, Japan.
Received: 13 December 2019 Accepted: 28 October 2020

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