Received: 30 August 2022

| Revised: 3 October 2022 | Accepted: 23 October 2022

DOI: 10.1002/jgf2.594

ORIGINAL ARTICLE

Impact of duty hours on competency-­related knowledge
acquisition among community hospital residents
Kazuya Nagasaki MD1| Yuji Nishizaki MD, MPH, PhD2
| Chisato Hachisuka BS3 |Tomohiro Shinozaki MPH, PhD3 | Taro Shimizu MD, PhD, MPH, MBA4|
5
6
Yu Yamamoto MD| Kiyoshi Shikino MD, PhD, MHPE
| Sho Fukui MD7 |Sho Nishiguchi MD, PhD8
| Kohta Katayama MD9| Masaru Kurihara MD10
|
1
11,12
Hiroyuki Kobayashi MD, PhD | Yasuharu Tokuda MD, MPH
1

Department of Internal Medicine, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan

2

Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan3

Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan

4

Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan

5

Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan

6

Department of General Medicine, Chiba University Hospital, Chiba, Japan

7

Department of Emergency and General Medicine, Kyorin University, Chiba, Japan

8

Department of General Internal Medicine, Shonan Kamakura General Hospital, Kamakura, Japan

9

Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan10

Department of Patient Safety, Nagoya University Hospital, Nagoya, Japan

11

Muribushi Okinawa for Teaching Hospitals, Okinawa, Japan

12

Tokyo Foundation for Policy Research, Tokyo, Japan

Correspondence
Yuji Nishizaki, MD, MPH, PhD, Division of
Medical Education, Juntendo University
School of Medicine, Tokyo, Japan, 2-­1-­1
Hongo Bunkyo-­ku, Tokyo 113-­8 421,
Japan.
Email: ynishiza@juntendo.ac.jp

Abstract
Background: The effect of duty hour (DH) restrictions on postgraduate residents' acquisition of clinical competencies is unclear. We evaluated the relationship between
DHs and competency-­related knowledge acquisition using the General Medicine In-­
training Examination (GM-­ITE).
Methods: We conducted a multicenter, cross-­sectional study of community hospital residents among 2019 GM-­ITE examinees. Self-­reported average DHs per week
were classified into five DH categories and the competency domains were classified
into four areas: symptomatology and clinical reasoning (CR), physical examinationand clinical procedure (PP), medical interview and professionalism (MP), and diseaseknowledge (DK). The association between these scores and DHs was examined using
random-­intercept linear models with and without adjustment for confounding factors.
Results: We included 4753 participants in the analyses. Of these, 31% were women,
and 49.1% were in the postgraduate year (PGY) 2. Mean CR and MP scores were lower
among residents in Category 1 (<50 h) than in residents in Category 3 (≥60 and <70 h;

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,provided the original work is properly cited.
© 2022 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.
J Gen Fam Med. 2023;24:87–93.	﻿

wileyonlinelibrary.com/journal/jgf2

| 87

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NAGASAKI et al.

reference group). Mean DK scores were lower among residents in Categories 1 and2 (≥50 and <60 h) than in the reference group. PGY-­2 residents in Categories 1 and 2
had lower CR scores than those in Category 3; however, PGY-­1 residents in Category
5 showed higher scores.
Conclusions: The relationship between DHs and each competency area is not strictly
linear. The acquisition of knowledge of physical examination and clinical procedures
skills in particular may not be related to DHs.
KEYWORDS

clinical competency, community hospital, duty hour restriction, General Medicine In-­training
Examination, Japan, postgraduate resident

1|

I NTRO D U C TI O N

In this study, we examined the relationship between DHs andscores in each competency area of the General Medicine In-­training

Since 2018, workstyle reforms in Japan have affected all workers,
1

including physicians and postgraduate residents. Among them,Examination (GM-­ITE), an in-­training examination in Japan amongresidents affiliated with community hospitals in Japan.

reducing long working hours is considered to be one of the mostimportant measures to improve the working environment. The
Ministry of Health, Labor, and Welfare (MHLW) decreed that theupper limit of duty hours (DH) for physicians should be 960 h peryear (equivalent to a 60-­h work week), starting in 2024, while the2|

M E TH O D S

2.1 | Study populations

limit for residents was set at 1860 h per year (equivalent to an 80-­hwork week), from an educational perspective. However, this deci-

In Japan, there is a 2-­year postgraduate clinical training system.

sion remains questionable because of concerns about residents'

We conducted a multicenter, cross-­sectional study of Japanese

health, as well as the lack of sufficient evidence on the relationshipresidents in postgraduate year 1 (PGY-­1) and postgraduate year 2

between DHs and educational outcomes.

(PGY-­2) of their training. Before conducting the survey, we obtained

There has been minimal research on the association between

written informed consent for study participation from all partici-

the number of DHs and resident competencies in Japan as wellpants. The research consent document stated that the questionnaire

as globally. One report analyzed the association between resi-

results would be anonymized. An appropriate research ethics com-dent DHs and in-­training examination scores in Japan. 2 The study

mittee approved the study. This study followed the Strengthening

demonstrated that fewer than 60–­65 DHs per week were inde-

the Reporting of Observational Studies in Epidemiology (STROBE)

pendently associated with lower performance; however, exceeding

guidelines.

65 DHs per week did not improve performance. 2 Another research

In Japan, teaching hospitals are divided into three categories:

further reported that Japanese residents with fewer than 60 DHs

independent hospitals, administrative hospitals, and cooperative hos-

per week tended to spend less time in self-­s tudy than did thosepitals.8,9 Independent hospitals provide training programs almost

with more than 65 DHs per week. 3 Surveys about the impact of

exclusively on their own, while administrative hospitals operate

DH restrictions on residents in the United States found that, while

programs in collaboration with cooperative hospitals. Many univer-resident health and burnout improved, there were negative effects

sity hospitals are administrative hospitals, and many of them haveon resident education and patient care.4–­6 These studies assessed

programs, so-­called tasukigake programs, where training at one co-the overall impact on resident education and suggested that DH re-

operative hospital lasts 1 year. Thus, the work styles of university

strictions had negative impacts on education. A systematic review

hospital residents are more diverse than those of community hospi-

researching the effect of DH restrictions on postgraduate medical

tal residents. Because this study used the average DHs of the entire

education found that the effect on education was assessed mostly

training program for analysis, university hospital residents, whoseby measuring access to educational opportunities, total in-­training

DHs would be difficult to interpret, were excluded from the study,

examination scores, and caseloads.7 In this context, we found no

and only community hospital residents were included in our study.

previous studies that directly examined the impact on DHs and res-

As part of a training environment questionnaire completed im-

idents' competency in various areas. Investigating the relationshipmediately after the examination, participants were asked about av-

between DHs and each resident's competency could prompt pro-erage DHs during their residency program. The questionnaire also

gram directors, training program developers, and policymakers toincluded the number of emergency department (ED) duties perconsider ways to mitigate the negative educational effects of DH

month, the mean number of assigned inpatients, and self-­study time

restrictions.

per day.

21897948, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jgf2.594 by Cochrane Japan, Wiley Online Library on [18/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License882.2 | Measurements

DH information, and also excluded another 840 university anduniversity-­affiliated hospital residents. Finally, the analysis included

The primary independent variable in this study was the average4753 participants. Among them, 31% were women and 50.9% wereself-­reported DHs per week. We defined DHs as the total hours of

PGY-­1. The mean (± standard deviation) of total GM-­ITE scores ofweekday work duty, night ED duty (including restrained time when

all the participants was 29.7 ± 5.3. The scores in the various compe-

not providing medical care), and weekend work duty. DHs weretency areas were as follows: CR, 9.9 ± 2.3; PP, 9.2 ± 2.3; MP, 2.9 ± 1.2;

answered in eight categories, which were reorganized into five cat-and DK, 8.2 ± 2.2. Table 1 summarizes resident characteristics cat-egories with 10-­h increments: Category 1 (<50 h), Category 2 (≥50

egorized by DHs, and Table S1 in Appendix S1 lists them stratified

and <60 h), Category 3 (≥60 and <70 h), Category 4 (≥70 and <80 h),

by PGY.
Figure 1 and Table S2 in Appendix S2 present the results of theCategory 5 (≥80 h). Category 5 exceeded the maximum DHs for residents set by the MHLW.1

analyses assessing the association between resident DHs and each

Knowledge acquisition of resident competencies was assessedcompetency area score. Compared with residents in Category 3,

using the scores of the GM-­ITE. The GM-­ITE is an in-­training exam-

mean CR scores were lower among residents in Category 1 (meanination conducted in Japan. It is administered each year by the Japanscore difference [MSD], −0.46; 95% CI, −0.70 to −0.23; p < 0.001)

Institute for Advancement of Medical Education Program (JAMEP,

and Category 2 (−0.19; −0.36 to −0.03; p = 0.02). Similarly, mean DK

a nonprofit organization in Tokyo, Japan), and training programs

scores were lower among residents in Category 1 (−0.33; −0.55 tovoluntarily participate in the examination. The GM-­ITE is designed−0.11; p = 0.004) and Category 2 (−0.22; −0.37 to −0.06; p = 0.01)

to provide objective and reliable clinical knowledge assessment ofthan in residents in Category 3. Compared with the Category 3

postgraduate residents, with results shared with the residents andgroup, Category 1 residents scored lower on PP (−0.26; −0.49 totheir residency programs.10,11−0.03; p = 0.03) and MP (−0.15; −0.28 to −0.03; p = 0.01).

The examination contains 60 multiple-­choice questions, which

After adjusting for possible confounding variables, mean DK

are grouped into four major competency areas: symptomatology andscores were lower among residents in Category 1 (−0.24; −0.47 toclinical reasoning (CR, 18 questions), physical examination and clin-−0.02; p = 0.03) and Category 2 (−0.19; −0.35 to −0.03; p = 0.02)

ical procedure (PP, 18 questions), medical interview and profession-

than among residents in Category 3. Compared with the Category

alism (MP, 6 questions), and disease knowledge (DK, 18 questions).

3 group, Category 1 residents scored lower on CR (−0.38; −0.62 to

Although both CR and DK areas contain case-­based questions on−0.15; p = 0.02) and MP (−0.15; −0.27 to −0.02; p = 0.02). Afterdiagnosis and management, CR mainly focuses on the diagnosis, andadjustment, there was little or no mean score difference among the

DK focuses on management. In the PP area, we applied audio and

DH Categories in the PP competency areas.

video questions. We excluded one question in the PP area after the

Figure 2 and Table S3 in Appendix S2 present the adjusted re-examination as an inappropriate question. Participants completed

sults of the association between resident DHs and each competency

the GM-­ITE from January 21 to 28, 2020.

area score stratified by PGY. PGY-­2 residents in Categories 1 and2 had lower CR scores than those in Category 3; however, PGY-­1

2.3 | Statistical analyses

residents in Category 5 had higher CR scores than those in Category
3. DK scores were lower for PGY-­1 Category 1 residents than for
the reference category residents, but there was no difference in DK

We examined the association between resident DHs and each com-scores between categories for PGY-­2 residents. MP scores werepetency area score (one point per question) using random-­intercept

lower for PGY-­2, but not for PGY-­1, Category 1 residents than for

linear models, accounting for hospital variability as normal random

the reference category residents. There was no difference in meanintercepts. Category 3 was set as the DH reference for the analyses,

scores between each DH Category for PGY-­2 and PGY-­1 residents inconsidering that 60 h per week was the basic upper limit of DHs for

the PP competency areas.

all doctors.1 We excluded residents who did not provide information
about DHs from the analyses. We repeated the analyses, stratified
by PGY. We adjusted for the following variables that could poten-

4|

DISCUSSION

tially be associated with the total GM-­ITE score: sex, PGY, ED duties,
number of assigned inpatients, and self-­study time. 2,12 All analyses

In this study of the effect of DHs on residents' competencies in dif-

were performed using SAS version 9.4 (SAS Inst.).

ferent areas, we found that, overall, community hospital residents
with <60 DHs per week had lower DK scores on the GM-­ITE than3|

R E S U LT S

those with 60–­70 DHs per week, whereas those with >70 DHs
per week did not have higher scores. Furthermore, <50 DHs wereassociated with lower CR and MP scores. When we stratified the

The GM-­ITE survey included 6869 postgraduate residents fromanalysis by PGY, CR scores decreased for residents in the ≤60 DHs

539 residency programs. The survey response rate was 89.7%

group for PGY-­2 and increased for those in the ≥80 DHs for PGY-­1.

(6164/6869). We excluded 571 residents who did not provide

In residents with <50 DHs, the DK scores decreased only for PGY-­121897948, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jgf2.594 by Cochrane Japan, Wiley Online Library on [18/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License| 89

NAGASAKI et al.

|

NAGASAKI et al.

C1: <50 h

C2: ≥50 and<60 h

C3: ≥60 and<70 h

C4: ≥70 and
<80 h

C5:
≥80 h

VariableN = 502N = 1393

N = 1542

N = 580

N = 736

Male sex (%)

65.1

69.6

69.5

66.7

70.9

PGY-­2 (%)

52.2

47.2

48.6

49.8

51.4

TA B L E 1 Characteristics. Baselinecharacteristics of residents categorized
by DHsED duties per month (%)
None

6.2

1.5

1

1.7

0.8

1–­2

24.8

13.7

7.6

7.2

4.6

3–­5

62.7

78.3

79.2

74.3

66.3

6 or more

6

6.1

11.6

16.6

27.6

Unknown

0.4

0.4

0.6

0.2

0.7

Assigned inpatients (%)
0–­4

30.3

21.4

16

13.3

9.9

5–­9

60.4

65.4

64.4

60.7

55

10–­14

6.6

9

13.7

17.8

18.4

15 or more

1.4

1.2

2.5

5.2

14

Unknown

1.4

3.1

3.3

3.1

2.7

Self-­study time per day (%)
None

3.4

3.4

3.4

4

6.2

0–­3 0 min

49.5

37.1

34.3

30.3

32.9

31–­60 min

36.5

43.6

44.3

43.8

38.5

61–­90 min

9.2

13.1

14.9

17.8

17.5

91 min or more

1.4

2.7

3.1

4.1

4.9

Note: Calculation of the average duty hours was based on the sum of weekday work duty, night
emergency department (ED) duties, and weekend work duty.
Abbreviations: C1–­C5, Category 1 to Category 5; DHs, duty hours; ED, emergency department;
PGY, postgraduate year.

residents, and the MP scores decreased only for PGY-­2 residents.

family medicine residents, and students on internal medicine clerk-

Thus, there were discrepancies in the association between DHs andships.17–­19 Future research should examine the relationship between

knowledge acquisition and its application in each competency area.

resident DHs and the number of clinical encounters, and the rela-

Knowledge acquisition for the competency areas of DK and CR

tionship between these and residents' clinical knowledge in Japan.

was found to be related to resident DHs, with a positive trend up to

The relationship between knowledge acquisition and work hours

60–­70 DHs per week, but no increase in the score when DHs ex-in the MP and PP competency areas showed a different relationshipceeded 70 h. For CR knowledge acquisition, working more during

than that in the CR and DK areas. MP scores appeared to be low for

PGY-­1 temporarily raised the score, but for those in PGY-­2, theresidents who worked less than 50 h per week, particularly in thescores of residents who worked more than 60 h per week eventually

PGY-­2. A 50-­h work week means almost no overtime work, which

seemed to reach a plateau. Nevertheless, reducing DHs of PGY-­1

implies that weekend work and nighttime ED duties are almost non-could be a barrier to CR skill acquisition. Although these adjusted

existent. This is quite different from the work style of a typical hos-score differences are about 2%–­4% in each category, the “cumula-pital doctor, and such a learning environment is unlikely to foster

tive” difference in scores by DHs was not negligible, as the resident

professionalism. On the contrary, DHs appeared to have no effectDH policies affect the working conditions of almost all residents.

on the PP scores. Clinical training in Japan may not provide sufficient

These two competency areas can be assessed by written exam-

education on these competency areas. In particular, previous studies

inations, and are generally the primary assessment items on the in-­have pointed out a lack of education on professionalism. 20 Anothertraining examination. There was no clear upward or downward trend

possible explanation is that DH variation may have both positivein the impact of work-­hour restrictions on the resident performanceand negative effects on these competencies, and the effects may

in in-­training examinations in the United States in the fields of in-

be offset. 21

ternal medicine, emergency medicine, and surgery.13–­16 The current

For scores in the PP area, there was no clear relationship be-variation in DHs in Japan may reflect the number of assigned inpa-

tween DHs and the acquisition of knowledge. There are two possible

tient cases. The number of patient encounters correlated with per-explanations for this observation. First, Japanese clinical residents

formance in in-­training examinations in internal medicine residents,

may have acquired sufficient knowledge of these competency areas

21897948, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jgf2.594 by Cochrane Japan, Wiley Online Library on [18/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

90

F I G U R E 1 Estimates of mean score differences for each subcategory score between residents' duty hour categories, with multivariableadjustments. Note: Non-­responders for Emergency Department duties and inpatients were included in “unknown.” Non-­responders for self-­
study time were excluded from the multivariable analysis. Error bars indicate 95% confidence interval. C1–­C5, Category 1 to Category 5.
during medical school training. Medical students in Japan mustfactors in determining DHs. Thus, further research will be needed

pass an Objective Structured Clinical Examination, which evaluatesin the future.

skills in physical examination, medical interviewing, and clinical pro-

There were several limitations in this study. First, the num-cedures. Second, postgraduate training may not adequately teachber of questions for each competency area is small and may notthese competencies, particularly physical examination skills. 22 Even

provide a reliable assessment. In general, in-­t raining examinations

if there is a large volume of case experience, teaching and feedback

are reportedly adequate, with a reliability coefficient of 0.80 at

may not be sufficient, possibly resulting in a lack of improved perfor-

around 100 questions; however, the GM-­ITE may not be as ac-

mance of residents.

curate, because it contains 60 questions in total and fewer ques-

In this study, we found that working more than 60–­70 h per week

tions for each competency area. 23 Additionally, there are some

did not increase scores in any competency area for PGY-­2 residents

concerns about the validity of the GM-­ITE itself. A previous study

nearing the end of their training, although the relationship between

showed that GM-­ITE scores correlated well with those of a foreignscores in each of the competency areas and DHs was different.

examination, but their relationship to actual clinical performance

McCoy et al. proposed four models for the relationship between

has not been investigated.11 Second, the GM-­ITE is a written test

patient encounter volume and knowledge acquisition: a linear rela-and, by its nature, can only assess knowledge and related cognitive

tionship, threshold, Yerkes–­Dodson curve (positive relationship up

abilities. Therefore, GM-­ITE scores are not necessarily a guarantee

19

to a certain point, negative relationship thereafter), and null.

Inof actual clinical competence. In this study, the areas of physicaltheir study, the patient encounter volume and in-­training examina-

examination, clinical skills, communication, and professionalism

tion scores were positively associated, but in our study, we foundwere assessed by evaluating the acquisition of knowledge aboutthat the relationship of DHs with CR and DK scores had a thresh-them and their application. However, we do not know whether

old. The in-­training examination score of residents may improve as

this reflects performance in real clinical practice. Third, DHs were

the patient encounter volume increases but increasing DHs further

self-­reported in the survey and may not have been reported accu-

will not improve scores. Therefore, it may be necessary to set an

rately. The trend of bias in self-­reported DHs may be different for

appropriate upper limit for DHs. Our recent study also found thateach group. In addition, residents who did not report their working

self-­study time was shorter in residents who worked less than 60–­

hours (571 excluded individuals) performed worse on the exam-

65 h per week.3 Taken together with the findings of this study, 60–­

ination than those who reported them (mean 29.7 [SD 5.3] vs. 28.9

70 h per week is a benchmark for an appropriate upper limit on DHs.

[SD 5.6]). The residents who performed worse in the examination

However, residents' health and patients' safety are also important

were more likely to refuse to participate in the study. Fourth, on

21897948, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jgf2.594 by Cochrane Japan, Wiley Online Library on [18/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License| 91

NAGASAKI et al.

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NAGASAKI et al.

F I G U R E 2 Estimates of mean score differences for each subcategory score between categories of residents' duty hours, withmultivariable adjustments stratified by postgraduate year. Note: Non-­responders for Emergency Department duties and inpatientswere included in “unknown.” Non-­responders for self-­study time were excluded from the multivariable analysis. Error bars indicate 95%
confidence interval. C1–­C5, Category 1 to Category 5.
average, only one-­t hird of all residents take the GM-­ITE, which

related to DHs. In addition, the limit of 80 DHs per week starting in

may introduce selection bias. Participation in GM-­ITE is voluntary2024 will have only a limited impact on the residents' acquisition ofin training hospitals, which may be more education-­oriented, andcompetency-­related knowledge. In the future, these competencies

residents in-­t raining hospitals may be more motivated to improveshould be evaluated using more suitable assessment methods, andtheir skills. In addition, we excluded university hospital residents

their relationships with DHs should be investigated in more detail.

from our analysis as they tend to have greatly variable working
patterns. To allow for a comparison of residents at university and

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

community hospitals, the baseline characteristics of the univer-This research received no specific grant from any funding agency insity hospital residents are shown in Table S4 in Appendix S3. A

the public, commercial, or not-­for-­profit sectors. The authors thanksummary of the examination scores is presented in Table S5 in

members of JAMEP and the question development committee andAppendix S4. University hospital residents appear to have lessthe peer-­review committee of the GM-­ITE for their assistance.

ED duty, fewer assigned inpatients, less time for self-­s tudy, andThe authors thank Enago (www.enago.jp) for the English language

lower scores than community hospital residents. Fifth, the study

review.

did not assess residents' baseline clinical knowledge. Therefore, tomeasure the impact of working hours on resident improvement di-

C O N FL I C T O F I N T E R E S T

rectly, adjusting for baseline GM-­ITE scores, national examination

The JAMEP was involved in collecting and managing data as the GM-­

scores, and performance during medical school is necessary. Sixth,

ITE administrative organization. It did not participate in designingsome community hospitals also have “tasukigake” programs. Thus,and conducting the study; data analysis and interpretation; prepa-

there are residents in community hospitals who work in a variety

ration, review, or approval of the manuscript; and the decision toof work locations similar to those in university hospitals. However,submit the manuscript for publication. Dr. Nishizaki received an hon-

this study did not examine the number of community hospital res-orarium from the JAMEP as the GM-­ITE project manager. Dr. Tokuda

idents who partook in “tasukigake” programs.

is one the JAMEP directors. Dr. Kobayashi received an honorarium

In conclusion, our results suggest that the knowledge acqui-from the JAMEP as a speaker for the JAMEP lecture. Dr. Shimizu

sition of CR, medical interviews, professionalism, and disease-­and Dr. Yamamoto received an honorarium from the JAMEP as exam

related topics requires a certain level of DHs, while the application

preparers of the GM-­ITE. Dr. Nishizaki, Dr. Tokuda, Dr. Kobayashi,

of knowledge of physical examination and procedures may not be

Dr. Shimizu, and Dr. Yamamoto were not involved in the analysis.

21897948, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jgf2.594 by Cochrane Japan, Wiley Online Library on [18/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

92

DATA AVA I L A B I L I T Y S TAT E M E N T
Due to the nature of this research, participants of this study did notagree for their data to be shared publicly, so supporting data are notavailable.

12.

E T H I C S A P P R OVA L S TAT E M E N T
The Ethics Review Board of Juntendo University School of Medicine
approved the study.
PAT I E N T C O N S E N T S TAT E M E N T

13.

14.

We obtained informed consent to participate in this study from allparticipants before the survey. The research consent document
stated that the questionnaire results would be anonymized.

15.

ORCID
Kazuya Nagasaki

https://orcid.org/0000-0002-8312-7802

Yuji Nishizaki

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

Taro Shimizu

https://orcid.org/0000-0002-3788-487X

Yu Yamamoto

https://orcid.org/0000-0003-2247-4963

Kiyoshi Shikino

https://orcid.org/0000-0002-3721-3443

Sho Nishiguchi

https://orcid.org/0000-0002-0060-0714

Kohta Katayama

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

Masaru Kurihara

https://orcid.org/0000-0001-9195-4202

Yasuharu Tokuda

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

16.

17.

18.

19.

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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information can be found online in the
Supporting Information section at the end of this article.

How to cite this article: Nagasaki K, Nishizaki Y, Hachisuka
C, Shinozaki T, Shimizu T, Yamamoto Y, et al. Impact of duty
hours on competency-­related knowledge acquisition amongcommunity hospital residents. J Gen Fam Med. 2023;24:87–
93. https://doi.org/10.1002/jgf2.594

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