Nishizaki et al. BMC Medical Education(2021) 21:214
https://doi.org/10.1186/s12909-021-02649-0

RESEARCH ARTICLE

Open Access

Difference in the general medicine intraining examination score between
community-based hospitals and university
hospitals: a cross-sectional study based on
15,188 Japanese resident physicians
Yuji Nishizaki1,2*, Keigo Nozawa3, Tomohiro Shinozaki3, Taro Shimizu4, Tomoya Okubo5, Yu Yamamoto6,
Ryota Konishi7 and Yasuharu Tokuda8

Abstract
Background: The general medicine in-training examination (GM-ITE) is designed to objectively evaluate thepostgraduate clinical competencies (PGY) 1 and 2 residents in Japan. Although the total GM-ITE scores tended to
be lower in PGY-1 and PGY-2 residents in university hospitals than those in community-based hospitals, the mostdivergent areas of essential clinical competencies have not yet been revealed.
Methods: We conducted a nationwide, multicenter, cross-sectional study in Japan, using the GM-ITE to compare
university and community-based hospitals in the four areas of basic clinical knowledge“. Specifically, “medical
interview and professionalism,” “symptomatology and clinical reasoning,” “physical examination and clinicalprocedures,” and “disease knowledge” were assessed.
Results: We found no significant difference in “medical interview and professionalism” scores between thecommunity-based and university hospital residents. However, significant differences were found in the remaining
three areas. A 1.28-point difference (95% confidence interval: 0.96–1.59) in “physical examination and clinicalprocedures” in PGY-1 residents was found; this area alone accounts for approximately half of the difference in total
score.
Conclusions: The standardization of junior residency programs and the general clinical education programs inJapan should be promoted and will improve the overall training that our residents receive. This is especially neededin categories where university hospitals have low scores, such as “physical examination and clinical procedures.”
Keywords: Community-based hospital, Generalist, General medicine in-training examination (GM-ITE), Juniorresident physician, University hospital* Correspondence: ynishiza@juntendo.ac.jp
1
Medical Technology Innovation Center, Juntendo University, 2-1-1 Hongo,
Bunkyo-ku, Tokyo 113-8421, Japan2
Department of Medical Education, Juntendo University School of Medicine,
2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
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which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
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Nishizaki et al. BMC Medical Education(2021) 21:214

BackgroundIn 1968, the ability to participate in training without
medical license after graduation from medical school
was abolished and replaced by the clinical training system in Japan, which required physicians to undergo afurther ≥2 years of clinical training, even after obtaining
their medical license. In 2004, a new residency system
was established, making it obligatory for physicians toundergo ≥2 years of residency with a super-rotation curriculum [1]. In Japan, physicians who are in postgraduate
clinical training years (PGY) 1 and 2 under this policy
are called junior residents.
Although junior residency has been made requiredsince April 2004, the design and operation of these training programs are largely left to the discretion of individual teaching hospitals. No objective outcome measuresof clinical training have been established, and the content of the education provided varies between institutions. This lack of standardization results in great
disparities in the competency of junior residents [2]. The
Japanese Institute for Advancement of Medical Education Program (JAMEP) has aimed to resolve these issues
and support residency education [3, 4].
The JAMEP is a non-profit organization established in2005 to enrich Japanese health care through the supportof resident education and thereby improve the quality of
medical care [2]. Its main activities are the following: (1)hosting continued professional development lecturesand inviting a wide range of physicians, including residents, supervising physicians, and practitioners; (2) providing Web-based platforms where physicians can share
their clinical skills, knowledge, and experiences; and (3)conducting the general medicine in-training examination(GM-ITE) for junior residents [3].
The GM-ITE is designed to evaluate the clinical competence of junior residents objectively. The examination
was developed by the JAMEP [5]. In line with the early
residency objectives of the Japanese Ministry of Health,Labour, and Welfare, the GM-ITE assesses the fourareas of basic clinical knowledge, including “medical
interview and professionalism,” “symptomatology andclinical reasoning” “physical examination and clinicalprocedures,” and “disease knowledge.” This comprehensive test covers all disciplines, with a focus on primarycare [6].
The purpose of this investigation was to compare GMITE score evaluations between the university andcommunity-based hospitals, which are characterized byvast differences in clinical training environments. University hospitals provide more advanced medicine inhighly specialized areas than community-based hospitals.
Analyzing how these differences impact GM-ITE scores
may help to elucidate the distinct training challenges
faced by each type of teaching hospital.

Page 2 of 9

We have previously demonstrated that the mean GMITE scores of junior residents in university hospitals
tend to be lower than those of community-based hospitals [7]. However, the difference in score was centeredonly on the total GM-ITE scores. As mentioned earlier,because the four distinct domains in the GM-ITE are
designed to measure different aspects of clinical competence, the trends in scores attributed to the training environment described could vary depending on theassessed area. In the present investigation, we assessed
the reasons underlying the differences in test scores between university hospitals and community-based
hospitals.

Methods
Study design

This was a nationwide, multicenter, cross-sectional study
performed in Japan. We used GM-ITE scores to compare university and community-based hospital residents.
This study followed STROBE guidelines.
Study population

The study population included 15,188 junior residents
working in 815 medical institutions nationwide who
took the GM-ITE for the first time in the three years
from 2016 to 2018. Residents with missing data from theclinical training environment survey questionnaire or
examinee characteristics were excluded from the analysis. Data regarding PGY-1 and PGY-2 were analyzed
separately because the differences in-training rotations
could significantly influence the results.
General medicine in-training examination

The GM-ITE was developed by the JAMEP in 2011 andserves as an objective evaluation of the essential clinicalcompetencies of junior resident physicians [8–10]. The
GM-ITE score consists of the following four categories:“medical interview and professionalism,” “symptomatology and clinical reasoning,” “physical examination andclinical procedures,” and “disease knowledge.” The GMITE is a multiple-choice knowledge test and used mainly
to assess the experience gained during clinical training.
The GM-ITE consisted of 100 multiple choice questionsin 2016 and was shortened to 60 questions in 2017 and2018. The test items cover the following fields: internal
medicine, surgery, emergency medicine, pediatrics, obstetrics and gynecology, and psychiatry. After completingthe test, resident physicians who took the GM-ITE receive feedback based on the relative scoring of all participants and an educational explanation about eachquestion. This examination is conducted at the end of
the year for PGY-1 and PGY-2 junior resident physicians. In line with the early residency objectives of theJapanese Ministry of Health, Labour, and Welfare, theNishizaki et al. BMC Medical Education(2021) 21:214

GM-ITE covers the four areas mentioned above of basic
clinical knowledge [6]. Thus, the test content and construct validity have been well-established.
The test questions are created through multiple processes over a year. First, all test questions are preparedby a question-creating committee consisting of 22 experienced physicians. Next, all prepared test questions arerevised by a peer review committee consisting of five instructors [11].
We also performed an analysis on all test questions
used in the previous year to improve the quality of the
GM-ITE. Figure 1 shows the test analysis results of theprevious test question in the field of “disease knowledge.” The test question’s passing rate was 44.5%, andthis test question was judged to be a good question as aresult of the test analysis because of the effect of a distractor. The correct answer of “4” exhibits a positive correlation with the overall examinee score, while thealternative “3” functions as a distractor (the alternative
more likely to be selected by lower scorers). The contents of the test question and detailed explanation of thetest analysis are shown in Additional file 1: Appendix 1.
The main purpose of the GM-ITE is to determine theranking of clinical training facilities’ own grade in Japanand to help overcome their weaknesses in clinical fields.
From the point of view of each resident physician, thepurpose of the GM-ITE is not to make a pass/fail judgment but to determine the ranking of the resident physician’s own grades in Japan and help overcome their
weaknesses in clinical fields. Participating resident physicians will receive detailed medical explanations about
the exam questions after the examination. They will also
receive feedback about their relative performance ineach category (“medical interview and professionalism,”

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“symptomatology and clinical reasoning,” “physicalexamination and clinical procedures,” and “diseaseknowledge”) and each clinical field (internal medicine,surgery, emergency medicine, pediatrics, obstetrics andgynecology, and psychiatry) and the proportion of correct responses. Residency program directors will be informed of the average total scores and proportion ofcorrect responses of the participating residents in theirprogram.
Data collection

We collected information regarding the clinical training
environment from a self-reported questionnaire administered just after the residents completed the GM-ITE. It
included GM rotation, emergency department duties permonth, the average number of inpatients in charge, useof online medical resources, and study time per day.
Hospital information (hospital type [university or community based] and location) was obtained from the Residency Electronic Information System website [12] andthe Foundation for the Promotion of Medical Training
website [13]. We classified university branch hospitals
into university hospitals. Regarding the categories of
hospital location, 20 cities designated by the Ministry ofInternal Affairs and Communications and the 23 wards
in Tokyo were defined as urban cities; and the rest as
provincial cities.
Statistical analyses

GM-ITE total scores were compared between the university and community-based hospitals. We estimatedthe two-level linear model, adjusting for the hospitaland resident-level variables listed in the Data Collection
section and each hospital as an average random

Passing rate

← Correct answer← Distractor, the alternative
more likely to be selected by lower scorers

High score

Low score

Quantiles of the total GM-ITE scoresFig. 1 The result of the test analysis for the previous GM-ITE in the field of “disease knowledge.” The vertical axis is the passing rate, and thehorizontal axis is the quintile of the total GM-ITE score. The numbers in the figure are the answer choices of the examinees, with “4” as thecorrect answer

Nishizaki et al. BMC Medical Education(2021) 21:214

intercept. The year of the GM-ITE was also adjusted toaccount for the difference in maximum scores (i.e., 100
in 2016 and 60 in 2017/2018). Each resident’s GM-ITE
total score was divided into four question fields (subcategories); hence, we also modeled the scores at distinct
subcategories (i.e., four observations per resident) using
the three-level linear model, including hospital- andresident-level random intercepts with subcategory-level
error terms. We adjusted for the same variables as thetwo-level linear model and the dummy variables for subcategories and their product terms with the university/community-based hospital type. All analyses were conducted in PGY-1 and PGY-2, using restricted (for the
two-level model) and unrestricted (the three-level
model) maximum likelihood methods using the Proc
Mixed assessment in SAS ver. 9.4 (Cary, NC).

Results
The total number of individuals who met the eligibility
criteria was 15,188, including 7552 PGY-1 and 7636
PGY-2 resident physicians. After excluding those withmissing data, we finally analyzed the data from 7111
PGY-1 and 7154 PGY-2 resident physicians. Table 1
shows that the residents from university hospitals had
less experience with emergency department duties, werein charge of fewer inpatients, spent less time studying,and had less experience with GM rotation despite having
GM departments.
Table 2 presents the average GM-ITE scores of the
PGY-1 and PGY-2 resident physicians and shows noareas in which junior residents working in university
hospitals scored better than those working incommunity-based hospitals. The slight fluctuation in
point rates (average scores divided by maximum score)
between the years suggested that the level of evaluationdifficulty is stable.
Table 3 shows the difference in total GM-ITE scores
between the university and community-based hospitals.
Additional file 1: Appendix Table 1 presents all the parameter estimates of two-level models. The mean total
GM-ITE scores of the PGY-1 and PGY-2 resident physicians were estimated to be 2.52 points (95% confidence
interval [CI]: 1.42–3.61) and 1.89 points higher (95% CI:
0.75–3.03) in the community-based hospitals than in theuniversity hospitals, respectively. The differences inmean scores (approximately 2 to 2.5) were similar withthe standard deviation of hospital-level variation as follows: the estimates of the standard deviations of
hospital-specific random effects were 2.1 = √4.46 (for
PGY-1) and 2.4 = √5.61 (for PGY-2; Additional file 1:
Appendix Table 1; likewise, the standard deviation of
the scores of the residents in each hospital was estimatedto range from 5.5 to 6 points from the residual estimates). The scores also positively correlated with study

Page 4 of 9time and GM rotation, as well as several emergency department duties and the average number of inpatients ofwhom PGY-2 resident physicians were primarily incharge (Additional file 1: Appendix Table 2).
Table 3 shows the differences in subcategoryspecific scores, which were calculated by combining
the parameter estimates of three-level models (Additional file 1: Appendix Table 2). No significant difference in “medical interview and professionalism”
scores were found between the community-based anduniversity hospital residents. However, significant differences were found for the three remaining areas. A
1.28-point difference (95% CI: 0.96–1.59) in “physicalexamination and clinical procedures” was found in
PGY-1; this area alone accounts for approximately
half of the difference in total scores. The difference inthis area was also found in the PGY-2 resident physicians. However, the estimated value for the difference
was halved to 0.51 points (95% CI: 0.19–0.83), reaching a similar magnitude as did “symptomatology andclinical reasoning” and “disease knowledge.”

Discussion
This investigation is the first to utilize JAMEP GM-ITE
data to formally evaluate the subcategory scores in
addition to the total score by using novel multilevel
models with statistical interactions. The present study
used a three-level model analysis to illustrate the differences in total GM-ITE scores and scores in four subcategories in junior resident physicians according tohospital type. University hospitals had lower scores in all
the subcategories when compared to community-based
hospitals. We found more significant gaps in the GMITE scores for “physical examination and clinical procedures” and negligible gaps in the GM-ITE scores for“medical interview and professionalism.”
As previously mentioned, the Japanese Ministry of
Health, Labour, and Welfare introduced a mandatory 2year postgraduate training program for graduating medical students with a super-rotation curriculum in 2004.
Simultaneously, a national matching system was established to determine the hospital residency programs best
suited for medical students [1]. Japan has approximately
1000 teaching hospitals and 1300 junior residency programs, including both community-based and university
hospitals. This matching system matches candidates withpostgraduate clinical training with teaching hospitals
that conduct junior residency programs. The matchingof a candidate to a hospital is determined by a computeraccording to an algorithm based on the preferences ofboth the candidate and the hospital [14, 15]. As a resultof the matching data analysis, community-based hospitals tend to be more popular than university hospitals
among medical students in the final (sixth) year [15].

Nishizaki et al. BMC Medical Education(2021) 21:214

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Table 1 Background characteristics of the residents
PGY-1 residents

PGY-2 residents

University hospital Community-based hospital University hospital Community-based hospitaln = 752n = 6359

n = 804n = 6350

112 (14.9)

1808 (28.4)

101 (12.6)

1851 (29.1)

Hospital-level variable
Hospital Location
Urban
Rural

585 (77.8)

4410 (69.4)

671 (83.5)

4382 (69.0)

Other (> 50 million)

55 (7.3)

141 (2.2)

32 (4.0)117 (1.8)

Male479 (63.7)

4316 (67.9)

516 (64.2)

4386 (69.1)

Female273 (36.3)

2043 (32.1)

288 (35.8)

1964 (30.9)

0105 (14.0)

163 (2.6)

58 (7.2)

120 (1.9)

1 to 2 h

348 (46.3)

698 (11.0)

289 (35.9)

624 (9.8)

3 to 5 h

206 (27.4)4716 (74.2)

393 (48.9)4582 (72.2)> 6 h per month

72 (9.6)

748 (11.8)

45 (5.6)

991 (15.6)

Unknown

21 (2.8)34 (0.5)

19 (2.4)

33 (0.5)

1078 (17.0)

189 (23.5)

868 (13.7)

Resident-level variable
Sex

Emergency department duty per month

Average number of inpatients each resident is in charged of
0 to 4158 (21.0)

5 to 9511 (68.0)

3816 (60.0)

519 (64.6)

3702 (58.3)

10 to 1469 (9.2)

961 (15.1)

63 (7.8)

1141 (18.0)> 15

7 (0.9)287 (4.5)

12 (1.5)430 (6.8)

Unknown

7 (0.9)217 (3.4)

21 (2.6)

209 (3.3)

0 to 30 min

361 (48.0)

2396 (37.7)

324 (40.3)

2088 (32.9)

31 to 60 min

245 (32.6)

2507 (39.4)

296 (36.8)

2614 (41.2)

61 to 90 min

54 (7.2)

866 (13.6)

108 (13.4)

994 (15.7)> 91 min12 (1.6)

242 (3.8)

26 (3.2)

301 (4.7)

None

80 (10.6)348 (5.5)

50 (6.2)

353 (5.6)

Yes

186 (24.7)

2119 (33.3)

319 (39.7)

2799 (44.1)

No (in hospitals with a GM
department)

552 (73.4)

2775 (43.6)

466 (58.0)

2180 (34.3)

No GM department

14 (1.9)1465 (23.0)

19 (2.4)

1371 (21.6)

Study time

General medicine department rotation

Use of medical online resources
Unknown/none

287 (38.2)

2736 (43.0)

362 (45.0)2649 (41.7)

Up-to-date

82 (10.9)1269 (20.0)

103 (12.8)

1373 (21.6)

Others383 (50.9)2354 (37.0)

339 (42.2)

2328 (36.7)

2016

287 (38.2)

1790 (28.1)

225 (28.0)

1884 (29.7)

2017

239 (31.8)2144 (33.7)

284 (35.3)

2214 (34.9)

2018

226 (30.1)

2425 (38.1)

295 (36.7)

2252 (35.5)

Year

Data are presented as n (%). PGY indicates postgraduate year(2021) 21:214

Nishizaki et al. BMC Medical Education

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Table 2 Mean (standard deviation) GM-ITE scores of the university and community-based hospital residents
Year Subcategory

PGY-1

PGY-2

University hospitals Community-based hospitals University hospitals Community-based hospitals
n = 287n = 1790

n = 225n = 1844

Medical interview andprofessionalism

10.20 (2.80)

11.77 (2.33)

11.23 (2.57)

11.77 (2.45)

Symptomatology and clinicalreasoning

13.57 (2.66)

14.72 (2.74)

14.15 (2.98)

15.30 (2.81)

Physical examination and clinical 10.33 (2.70)
procedures

12.03 (2.47)

11.46 (2.52)

12.19 (2.64)

2016

Disease knowledge

14.24 (3.20)

15.73 (3.04)

15.56 (3.49)

16.86 (3.24)

Total score (maximum score100)

48.34 (8.22)

54.26 (7.30)

52.40 (8.43)

56.13 (8.15)

n = 239n = 2144n = 284n = 2214

Medical interview andprofessionalism

2.98 (1.02)

3.07 (10.8)

2.87 (1.05)

2.98 (1.12)

Symptomatology and clinicalreasoning

9.01 (2.40)

10.01 (2.39)

9.53 (2.57)

10.43 (2.49)

Physical examination and clinical 9.46 (2.07)
procedures

10.43 (2.20)

9.73 (2.30)

10.52 (2.23)

Disease knowledge

8.44 (1.86)

9.11 (1.98)

8.18 (2.09)

9.02 (2.10)

Total score (maximum score60)

29.90 (4.67)

32.62 (5.09)

30.31 (5.43)

32.95 (5.43)

n = 226n = 2425n = 295n = 2252

Medical interview andprofessionalism

2.82 (1.01)

2.88 (2.30)

2.92 (1.17)

3.09 (1.10)

Symptomatology and clinicalreasoning

9.37 (2.16)

10.01 (2.12)

9.87 (2.08)

10.42 (2.19)

Physical examination and clinical 8.35 (2.40)
procedures

9.43 (2.27)

8.82 (2.26)

9.67 (2.42)

Disease knowledge

7.49 (2.40)

8.27 (2.30)

8.20 (2.32)

8.79 (2.52)

Total score (maximum score60)

28.00 (5.59)

30.59 (5.36)

29.81 (5.40)

31.97 (6.00)

2017

2018

GM-ITE indicates general medicine in-training examination; PGY, postgraduate year

In addition to providing advanced medical care, university hospitals also conduct medical research, including essential, translational, and clinical studies. In
comparison, community-based hospitals play a morecrucial role in treating neighborhoods afflicted withmany prevalent diseases. Thus, community-based hospitals are responsible for providing care to as many patients with common diseases as possible. This ispresumably why junior resident physicians working incommunity-based hospitals scored higher in the GM-

Table 3 Estimated differences in GM-ITE total score and scores in the 4 subcategories (university hospitals vs. community-based
hospitals)
PGY-1

PGY-2

Difference

95% CI

−2.52

−3.61

Medical interview and professionalism

0.00

−0.31

Symptomatology and clinical reasoning

−0.73

−1.04

Physical examination and clinical procedures−1.28− 1.59Disease knowledge

−0.52

−0.83

P

Difference

95% CI

P<.0001−1.89−3.03170.31

0.9843−0.08−0.4037

0.23730.6108−0.42<.0001−0.60−0.9252−0.28420.0002−0.96<.0001−0.51−0.8317−0.19070.0018−0.21

0.0011−0.69−1.0118−0.3708<.0001

Two-level model
Total score−1.42−0.74990.0012Three-level model

CI indicates confidence interval; GM-ITE, general medicine in-training examination; PGY, postgraduate year

Nishizaki et al. BMC Medical Education(2021) 21:214

ITE, which asks questions based on clinical case scenarios that simulate actual situations.
Issues have been raised in association with the education for junior resident physicians of the university anduniversity-affiliated hospitals in Japan. For advancing
medical care, advancing the differentiation of specialties
of each department was prioritized in university hospitals [16]. Subspecialization may be efficient in terms ofpromoting academic advances. However, from the perspective of a generalist who treats patients with a wide
range of common diseases, the inability to diagnose andtreat illnesses outside one’s specialty is highly disadvantageous. One of the main goals for junior residency islearning diagnostic and treatment skills through appropriate clinical reasoning processes that note common
symptoms and patients’ conditions in a primary care setting [1]. General physicians who acquire a broad
spectrum of essential clinical competencies such as clinical ethics, physical examination, clinical procedures,
clinical reasoning, and professionalism play a critical rolein the education of junior resident physicians [17, 18].
The three areas with differences in scores, namely,“symptomatology and clinical reasoning,” “physicalexamination and clinical procedures,” and “diseaseknowledge,” are all areas in which knowledge and experience can be mainly gained by examining patients atthe bedside. “Physical examination and clinical procedures,” in which the difference in scores was wide in
PGY-1, is a special area from the point of view of education for resident physicians. That is because it cannot be
acquired only by accumulating knowledge. To acquire
the sufficient basic clinical skills of physical examinationand clinical procedures, senior doctors need to provide
consistent education to resident physicians through bedside learning. We inferred that junior resident physiciansin university hospitals could have fewer opportunities
for systematic bedside learning by senior doctors thanthose in community-based hospitals.
The number of supervising physicians per junior resident physician is lower in community-based hospitals
than in university hospitals, which suggests that juniorresident physicians can care for many patients under thesame supervising physicians. Junior resident physiciansin community-based hospitals are therefore ensured
more opportunities for coherent bedside guidance whencompared to their colleagues at university hospitals. We
think these factors may cause the difference in “physicalexamination and clinical procedures” scores between the
junior resident physicians in university and communitybased hospitals.
Physical examinations are essential to the diagnostic approach of both resident physicians and physicians. However, a previous report has indicated that the physicalexamination skills of primary care physicians have a crucial

Page 7 of 9

drawback [19]. In addition, the physical examination skillsof resident physicians have been shown to be deteriorating[20]. Moreover, self-confidence in performing physical examinations does not necessarily increase at each stage oftraining [21]. To improve physical examination teachingskills, a systematic and innovative education program must
be developed to hone physical examination skills based on
the preceding pedagogy [22, 23].
Physical examination scores were especially low in university hospital programs, and the opportunity to teachthese skills could be enhanced by taking advantage of alarge number of supervising physicians. In addition, because university hospitals have several specialty departments, they can offer various educational programs inphysical examinations. Another alternative suggestion isto organize a comprehensive educational program on
physical examinations and procedures for junior residents in university hospital training programs in which
the involvement of all departments is mandatory and torequire junior residents to participate in the training
program. Consequently, we can expect that the performance of this GM-ITE section will improve among university hospital programs.
The results of our study showed that resident physicians in university hospitals spent a shorter amount oftime studying. From the perspective of clinical training
in junior residency, it is possible that less-motivated resident physicians may have chosen hospitals with shorter
duty hours [24]. The number of resident physicians inuniversity hospitals tends to be greater than incommunity-based hospitals, so the workload of eachresident physician in a university hospital could beshorter than that of a resident physician in acommunity-based hospital. Moreover, I previously revealed that the amount of study time significantly associated with the GM-ITE score [7]. Several previous studies
have also indicated the relationship between sufficient
self-study time and professional development [25, 26].
We believe that the generalizability of the whole results of this study is not guaranteed. This is because it isexpected that each country will have different medical
education systems and different roles between university
hospitals and community hospitals. However, we believethat the results of this study have provided medical educators around the world with some important insights.
First, the GM-ITE score of PGY-1 in the field of “physical examination and clinical procedures” in university
hospitals is extremely low. Attention should be paid tothe fact that university hospitals tend to adopt an organspecific educational system. Immediately after the startof junior residency, supervisors will need to see patientsat the bedside with the resident physicians and provide
consistent, thorough physical examination and education
on clinical procedure. Second, evaluating theNishizaki et al. BMC Medical Education(2021) 21:214

relationship between the in-training examination scoreand performance of resident physicians, the focus should
be on several aspects, such as the four domains we indicated, rather than focus on only the total score.
This study has several limitations. First, the rotation
order differs across departments and between individual
junior resident physicians. Thus, the scores in the four
categories measured may have been impacted by thecontent received by the residents immediately before
they completed the GM-ITE. Second, the overall number of participants in this investigation was limited.
More specifically, the total number of PGY-1 and PGY-2
junior resident physicians was approximately 18,000, but
not all the junior resident physicians participated in the
GM-ITE. In Japan, there were 1363 residency programs
among 1020 hospitals (907 community and 113 university hospitals, including affiliated hospitals) [15]. Our
study integrated and used three years of GM-ITE data,with data obtained from approximately 500 clinicaltraining facilities each year. In other words, about half ofthe clinical training facilities in Japan participated in
GM-ITE. It is also worth noting that the number of participants in university hospitals was smaller than that ofcommunity-based hospitals, which could have resulted
in a selection bias.
We did not assess the resident physicians’ baseline
clinical skills. Medical school experience differs between
participants, which could have impacted the study results. Finally, this investigation also did not evaluate thenumber of supervising physicians in each teaching hospital and the years of clinical experience of their residents. These factors could affect the GM-ITE scores.
Future prospective studies are needed to confirm the results of this investigation.

Conclusion
In conclusion, the present study focused on differences between community-based and university hospitals using four subcategories tested via the GMITE. The discrepancy in the GM-ITE score by subcategory was investigated to identify more significant
gaps between the GM-ITE scores for “physical examination and clinical procedures” and negligible gaps
in the GM-ITE scores for “medical interview andprofessionalism.” To standardize the quality of thejunior residency program in Japan, clinical educationin categories where university hospitals have lowscores, such as “physical examination and clinicalprocedures,”must be promoted.
Abbreviations
CI: confidence interval; GM-ITE: general medicine in-training examination;
JAMEP: Japan Institute for Advancement of Medical Education Program;
PGY: postgraduate year

Page 8 of 9

Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12909-021-02649-0.
Additional file 1 Appendix 1. An example of a good-quality question
and test analysis. Appendix Table 1. Parameter estimates of two-levellinear models for the GM-ITE total score. Appendix Table 2. Parameter
estimates of three-level linear models for the GM-ITE subcategory scores

Acknowledgments
We thank the JAMEP secretariat for their excellent support of our work and
Mr. Kento Isogaya and Mr. Yuji Tanaka for the supporting data analysis. The
authors thank Enago (www.enago.jp) for the English language review.
Authors’ contributions
YN and YT have designed this study as a whole and written this manuscript.
KN and TS 1 have contributed to statistical analyses. TS 2, TO, YY, and RK
have contributed to data collection. All authors have contributed, provide
advice on the interpretation of the results, and approved the final
manuscript.
Funding
This study did not receive any funding source.
Availability of data and materials
The corresponding author will respond to inquiries on the data analyses.

Declarations
Ethics approval and consent to participate
This study was approved by the institutional review board of Mito Kyodo
General Hospital, Mito City, Ibaraki, Japan. All the participants gave informed
consent under an opt-out agreement.
Consent for publication
Not applicable.
Competing interests
YN received an honorarium from the JAMEP as the GM-ITE project manager.
YT and TO were JAMEP directors. TS 2 and YY received an honorarium fromthe JAMEP as an exam developer for the GM-ITE. YN, YT, TO, TS 2, and YY
were not involved in the analysis.
Author details
1
Medical Technology Innovation Center, Juntendo University, 2-1-1 Hongo,
Bunkyo-ku, Tokyo 113-8421, Japan. 2Department of Medical Education,
Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo
113-8421, Japan. 3Department of Information and Computer Technology,
Faculty of Engineering, Tokyo University of Science, 6-3-1 Niijuku,
Katsushika-ku, Tokyo 125-8585, Japan. 4Department of Diagnostic andGeneralist Medicine, Dokkyo Medical University Hospital, 880 Kitakobayashi,
Mibumachi, Shimotuga-gun, Tochigi 321-0293, Japan. 5Research Division,
National Center for University Entrance Examinations, 2-19-23 Komaba,
Meguro-ku, Tokyo 153-8501, Japan. 6Division of General Medicine, Center forCommunity Medicine, Jichi Medical University School of Medicine, 3311-1
Yakushiji, Shimotsuke, Tochigi 329-0498, Japan. 7Education Adviser Japan
Organization of Occupational Health and Safety, 1-1 Kiduki Sumiyoshi-cho,Nakahara-ku, Kawasaki-shi, Kanagawa 211-0021, Japan. 8General Internal
Medicine, Muribushi Okinawa for Teaching Hospitals, 3-42-8 Iso, Urasoe-shi,
Okinawa 901-2132, Japan.
Received: 15 January 2021 Accepted: 5 April 2021

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