Nomura et al. BMC Medical Education(2021) 21:122
https://doi.org/10.1186/s12909-021-02515-z

RESEARCH ARTICLE

Open AccessPredictors of performance on the pediatricboard certification examination
Osamu Nomura1,2* , Hirotaka Onishi3, Yoon Soo Park4,5, Nobuaki Michihata6, Tohru Kobayashi7, Kazunari Kaneko8,
Tetsushi Yoshikawa9, Akira Ishiguro2 and Japan Pediatric Society Steering Committee of Board Examination10

Abstract
Background: Examining the predictors of summative assessment performance is important for improving
educational programs and structuring appropriate learning environments for trainees. However, predictors ofcertification examination performance in pediatric postgraduate education have not been comprehensively
investigated in Japan.
Methods: The Pediatric Board Examination database in Japan, which includes 1578 postgraduate trainees from2015 to 2016, was analyzed. The examinations included multiple-choice questions (MCQs), case summary reports,
and an interview, and the predictors for each of these components were investigated by multiple regression
analysis.
Results: The number of examination attempts and the training duration were significant negative predictors of thescores for the MCQ, case summary, and interview. Employment at a community hospital or private university
hospital were negative predictors of the MCQ and case summary score, respectively. Female sex and the number ofacademic presentations positively predicted the case summary and interview scores. The number of research
publications was a positive predictor of the MCQ score, and employment at a community hospital was a positive
predictor of the case summary score.
Conclusion: This study found that delayed and repeated examination taking were negative predictors, while thescholarly activity of trainees was a positive predictor, of pediatric board certification examination performance.
Keywords: Pediatrics, Predictors, Board certification, Performance, Resident

Background
Pediatrician competency is crucial for assuring an acceptable quality of pediatric care and improving patient
outcomes. Competency-based medical education(CBME), defined as “an outcomes-based approach to thedesign, implementation, assessment, and evaluation of
medical education programs, using an organizing framework of competencies” is a core concept in medical* Correspondence: osamunomura@hotmail.com
1
Department of Emergency and Disaster Medicine, Hirosaki University, 5
Zaifu, Hirosaki, Aomori 036-8216, Japan
2
Center for Postgraduate Education and Training, National Center for Child
Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
Full list of author information is available at the end of the article

education, and its framework reflects the social accountability regarding patient needs [1]. Evaluating the competency of medical trainees is therefore fundamental toensuring each trainee’s professional achievement andproviding effective feedback to trainees. In postgraduate
medical training, board certification examinations serve
as summative assessments of residents’ competency
which is expected to achieve when completing theirtraining. Examining the predictors of academic performance in pediatric board examinations is also a meaningful way of improving educational programs andconstructing appropriate learning environments forresidents.

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

Nomura et al. BMC Medical Education(2021) 21:122

Wakeford et al. investigated predictors of success inpostgraduate medical examinations among United Kingdom (UK) trainees, and identified ethnicity as a potential
predictor [2]. Scrimgeour et al. also suggested sex, ethnicity, and age as predictors of success in postgraduate
surgical examinations in the UK [3]. Furthermore,
Australian studies have found that Grade Point Averageat the completion of undergraduate studies predicted theworkplace performance of junior doctors [4, 5]. Whilesimilar studies have been conducted using board certification examinations in other specialties such as generalsurgery, anesthesiology, and emergency medicine in the
United States (US), studies examining these predictors
in pediatrics remain limited [6–9]. Performance on intraining examinations during pediatric residency is
known to offer a significant predictor of performance inboard examinations [10], but investigations into the relationship between trainee-related explanatory variables
such as characteristics of residency programs, scholarly
activities of residents, and test performance can provide
useful contextual indicators to improving learning andresidency curricula.
By identifying the predictors of academic performancein pediatric trainee physicians, the faculty of residency
programs can implement and promote a support system
to help trainees prepare for their board certification examinations. The aim of this study was, therefore, toidentify the predictors of postgraduate pediatric trainee
performance on board certification examinations.

Methods
Context

In Japan, the medical academic society in each specialty
has been responsible for the board certification oftrainees in accordance with the rules of the Japanese
Medical Specialty Board [11]. In pediatrics, the Japan
Pediatric Society (JPS) manages the board certification
examinations, and trainees who choose pediatrics as a
specialty enroll in a pediatric residency program approved by the JPS, which is supervised by a program director whose responsibility is to approve the trainees’
application for the board examination based on various
prerequisites, including completion of the residency logbook and a case summary report.
Assessment categories

The JPS board examination is designed to evaluate
trainees’ performance based on the CBME concept of
the JPS, which includes three components: (1) multiplechoice questions (MCQs), (2) case summary report, and(3) an interview regarding the submitted case summaries[12]. The written portion of the examination aims toevaluate the examinees’ knowledge of general pediatrics
and clinical reasoning skills in pediatric medicine.

Page 2 of 7

Examinees are administered 120 MCQs within 3 h in thefirst session of the board examination.
In case summary assessment, which measures integrative clinical understanding of patient care, child health,and pediatric advocacy, including injury prevention activities, each candidate is required to submit 30 casesummaries in designated disease categories, such as infectious, hematological, and endocrine diseases. Examinees submit summaries 3 months prior to theexamination date and members of the Steering Committee of Board Examination evaluate these summaries
based on the predetermined assessment rubric following
a double-blinded review protocol.
Interviews are designed to assess the candidates’ critical thinking skills and professionalism, and two examiners ask the candidates questions based on two casesummaries submitted by the candidates themselves. Interviews are held in the second session of the examination after the MCQ test, and the duration of theinterview for each examinee is 15 min. Evaluation is performed based on the predetermined assessment rubric.
All three test components are considered as completely separate elements using numeric scores (continuous data). Examinees are required to pass eachcomponent in a non-compensatory manner to pass theoverall board examination. Cut-off points for each component are determined by the Japan Pediatric Society
Steering Committee of Board Examination. This board
examination is administered once a year in September,and its annual pass rate is approximately 70 to 80%.
Failed examinees are eligible to take the examination ineach succeeding year as needed, with no limits imposedon the numbers of times a candidate may take the exam.
The pass or fail results were not available for this study
due to confidentiality issues.
Design and participants

We conducted a secondary analysis of the retrospective
examination data by utilizing the JPS board certification
database [13]. All pediatricians in Japan who took thepediatric board examination in 2015 and 2016 were recruited in this study, with 856 and 862 pediatricians taking the examination in 2015 and 2016, respectively. Of
all 1718 eligible participants, five declined participation,and 129 were excluded due to the omission of data.
Consequently, 1578 trainees were enrolled (Fig. 1).
Data collection

The database information included the trainees’ sex,
duration of training, types of training institutions, location of the institutions, number of times the board
examination was taken, numbers of research presentations and research publications, and the board examination results. Regarding number of examinations taken,

Nomura et al. BMC Medical Education(2021) 21:122

Page 3 of 7

Fig. 1 Flow chart of this study

the first attempt was indicated as 1, with pediatricians
who failed in their earlier attempt(s) showing 2 or ahigher number. These variables were selected for analysis based on evidence from the existing literature. For
example, studies from the US and UK have identified
the demographic characteristics of the trainees werepredictors of the test performance [2–10], and another
UK study found variation in exam performance according to the institution to which trainees belonged [14]. In
addition, US studies have suggested that number oftimes the board examination was taken and scholarly activity were associated with the academic performance ofthe trainees [15, 16].
The training institution categories included national or
public university hospitals, private university hospitals,
children’s hospitals, and community hospitals. We applied the definition of “urban areas” of the Japanese
Medical Specialty Board (i.e., Tokyo, Kanagawa, Aichi,
Osaka, and Fukuoka) to determine whether the institutions were located in an urban or non-urban area.
A research presentation was defined as a presentation
conducted at an academic conference held by an academic society; thus, conferences within the residents’ institutions, such as case conferences, grand rounds, andmorbidity and mortality conferences, were not included.
A research publication was defined as an article published in a peer-reviewed journal, including Japanesejournals published by Japanese academic societies as wellas PubMed-indexed international journals.

Statistical analysis

We employed descriptive statistics to characterize theparticipants by sex, number of examination attempts,
training duration, types of training institutions, locationof the institutions, number of presentations and publications, and the MCQ, case summary, and interview
scores. Multiple regression analyses were conducted forthe continuous scores of each of the three test components (i.e., separate models were created for each of the
MCQ, case summary, and interview tests) as outcomes,
and included demographic information from trainees as
independent variables, such as sex, number of examination attempts, training duration, type and location of
the institution, and scholarly activities. These variables
were chosen based on evidence from the literature andstatistical evidence such as improvement in model fit
and results from the bivariate analysis.

Nomura et al. BMC Medical Education(2021) 21:122

Page 4 of 7

Model fit and possible multicollinearity of predictors
were checked using standard diagnostic tools (F-statistic,
R2, and variance inflation factor statistics). Statisticalanalyses were conducted using SPSS version 23.0 (IBM
Corporation, 2018, Armonk, NY, USA).
Ethical aspects

This study was approved by the Ethics Committees of
The National Center for Child Health and Developmentin December 2014 (No. 74) and the JPS in March 2015.

Results
Descriptive statistics

The descriptive results are shown in Table 1.

Table 2 A simultaneous multiple regression for variables
predicting MCQ score
B

Constant

77.196

Female sex.44

We conducted simultaneous multiple regression analyses
to explore the predictors of test performance for each of
the three examination components: MCQ, case summaries, and the interview.

95% CI
75.76 to 78.63.002−.86 to .95

Training duration (years)−.651 −.205−.81 to −.49

Test attempts (times)−2.124 −.229−.2.59 to −1.66

Types of training institution–

Public university hospital (Reference)––

Private university hospital−.67−.032 −1.79 to .45

Children’s hospital

.751

.022

−.93 to .2.43

Community hospital−1.684 −.75

−2.98 to. -.38

Residency in urban area

Multiple regression analysis

βVariable−.667 −.035 −1.66 to .32

Number of academic presentations

.142

.047

−.010 to .294

Number of research publications

1.032

.075

.33 to 1.73

Note. R2= .141 (p < .05)

95%CI: − 2.98 to −.38) were negative predictors of
performance.

MCQ model (Table 2)

Case summary report model (Table 3)

A multiple regression model for the MCQ score indicated that predictors for sex, training duration, numberof examination attempts, type and location of the institution, and research experience explained 14% of thevariance in the MCQ score (F (9, 1568) = 28.56, p <.001). The number of research publications was found to
be a significant positive predictor of the MCQ score (β =.075, 95%CI: .33 to 1.73). On the other hand, the numberof examination attempts (β = −.229, 95%CI: − 2.59 to −1.66), training duration (β = −.205, 95%CI: −.81 to −.49)
and employment at a community hospital (β = −.75,

A multiple regression model for the case summary report score showed that the variables of sex, training duration, number of examination attempts, type andlocation of the institution, and research experience explained 10% of the variance in the case summary score(F (9, 1568) = 19.39, p < .001). Female trainees (β = .06,
95%CI: .19 to 1.36), employment at a community hospital (β = .06, 95%CI: .01 to 1.70), and the number ofacademic presentations (β = .06, 95%CI: .02 to .22) weresignificant positive predictors of their case summaryscore. However, training duration (β = −.21, 95%CI: −.53
to −.32), the number of examination attempts (β = −.14,

Table 1 Demographics of the participants (n=1578)
M (SD)
Female sex% (n)41.0 (647)

Training duration (years)

4.6 (3.0)

Test attempts (times)

1.5 (1.0)

Types of training institution
Public university hospital

34.5 (544)

Private University hospital

31.5 (497)Children’s hospital

9.1 (144)

Community hospital

24.9 (393)

Residency in urban area

47.6 (751)

Number of academic presentations

4.5 (3.2)

Number of research publications

0.3 (0.7)

MCQ score

71.0 (9.6)

Case summaries score86.5 (6.1)

Interview score88.6 (12.0)

Table 3 A simultaneous multiple regression for variables
predicting case summary scoresβVariableB

95% CI

Constant

89.66

Female sex

.77

.06

Training duration (years)

−4.2

−.21

−.53 to −.32

Test attempts (times)

−.80

−.14

−1.11 to −.50

–

–

–

Private University hospital

−.78

−.60

−1.51 to −.06

Children’s hospital

−.29

−.01

−1.38 to .80

88.74 to 90.59.19 to 1.36

Types of training institution
Public University hospital (Reference)

Community hospital

.085

.06

.01 to 1.70

Residency in urban area

−.12

−.01

−.76 to .52

Number of academic presentations

.12

.06

.02 to .22

Number of research publications

.16

.02

−.30 to .61

Note. R2=. 10 (p < .05)

(2021) 21:122

Nomura et al. BMC Medical Education

Page 5 of 7

95%CI: − 1.11 to −.50), and employment at a private university hospital (β = −.60, 95%CI: − 1.51 to −.06) were
negative predictors.
Interview Model (Table 4)

A multiple regression model for the interview score indicated that the variables of sex, training duration, examination attempts, types and location of institutions, andresearch experiences explained 5% of the variance in theinterview score, F (9, 1568) = 9.14, p < .001.
Female sex (β = .07, 95%CI: .42 to 2.79) and the number of academic presentations (β = .08, 95%CI: .09 to.48) were significant positive predictors of the interview
score. On the other hand, training duration (β = −.06,
95%CI: −.46 to −.04) and the number of examination attempts (β = −.15, 95%CI: − 2.36 to − 1.14) were negative
predictors.
Multicollinearity analysis (Additional file 1)

The correlation between variables and the variance inflation factor (VIF) were determined by multicollinearity
analysis. No strong correlation (i.e., > 0.9) was found between the variables and VIF exceeding the recommended cut-off (> 4), indicating that the assumptions for
multicollinearity were not violated.

Discussion
This nationwide study in Japan investigated predictors
contributing to performance of pediatric postgraduate
trainees on the board certification examination. We
found that a longer training duration and previous experiences of failure on the examination were independent
negative predictors. We also showed that scholarly activity, such as research presentations and publications represented a positive predictor.
Table 4 A simultaneous multiple regression for variables
predicting interview scoresβVariableB

95% CI

Constant

92.17

Female sex

1.60

.07

Training duration (years)

−.25

−.06

−.46 to −.04

Test attempts (times)

−1.75

−.15

−2.36 to − 1.14

–

–

–

90.30 to 94.04.42 to 2.79

Types of training institution
Public university hospital (Reference)
Private university hospital

.05

.002

−1.40 to 1.51

Children’s hospital

1.41

.03

−.78 to 3.60

Community hospital

−1.07

−.04

−2.76 to .63

Residency in urban area

.32

.01

−.97 to 1.61

Number of academic presentations

.29

.08

.09 to .48

Number of research publications

−.25

−.01

−1.16 to .67

Note. R2=.05 (p < .05)

Our study further suggested that trainees who neededa longer time to complete their training showed poor
performance. Similar results were obtained for the board
examination for pediatrics, emergency medicine, andsurgery in the United States and for surgery in the UK[6, 17–19]. These studies revealed that residents who delayed taking the qualifying examination were at high riskof failing to achieve board certification. Three possible
explanations of these observations have been adduced:
the inability to acquire the program director’s approval
to apply for an examination due to insufficient competency of the trainees, natural deterioration of the
trainees’ knowledge over time, and other determinants
affecting training completion, such as personal or family
health issues, anxiety about test performance, and procrastination. Among these potential causes of prolonged
training duration, the first explanation might be themost applicable to our setting. Candidates for thepediatric board certification examination are required
first to complete 30 case summaries then receive the attending physicians’ feedback [20]. The program director
finally approves the trainees’ application based on the revised case summaries. Thus, trainees’ exam-taking may
be delayed if they have difficulty completing the summaries and obtaining the approval of the program director. The natural deterioration in the candidates’
knowledge can also lead to a similar result. In Japan, it
had not been mandatory for postgraduate trainees totake the board certification examination after their residency until the new board certification system wasestablished across all medical disciplines in 2018 [11].
Therefore, a certain percentage of trainees did not taketheir board certification examination immediately after
completing their training; thus, it might have been difficult for pediatricians who postponed taking the examination to maintain and update their knowledge in general
pediatrics.
We also showed that candidates who had taken theexamination multiple times performed poorly on theirpediatric board certificating examination. Previous
Japanese studies indicated that medical students who
experienced at least one failure on the national medical
license examination tended to fail following examinations multiple times [21]. This finding was also observed
for the American Board of Physical Medicine and Rehabilitation certification examinations [15], suggestingthat repeated examination-taking is a negative predictorof test performance. In addition, a UK study showed thatfewer attempts at the mandatory Membership of theRoyal College of Surgeons examination predicted successat the Fellowship of the Royal College of Surgeons(FRCS) examination [19]. The issues of trainees who retake examinations multiple times have been debated in
the literature, but a report from the Membership of theNomura et al. BMC Medical Education(2021) 21:122

Royal Colleges of Physicians (MRCP) exam in the UK
found that candidates who took the exams multiple times
exhibited improved test performance across multiple attempts [22]. Thus, these results should not be used tolimit the number of attempts, but rather to identify thosetrainees who need special assistance to pass the exam.
While the two negative predictors discussed (delayed
and repeated examination-taking) might be correlated, themulticollinearity assumption was not violated, indicatingthat these two predictors were independent. In terms of
the implications of this finding, it is very important for thefaculty of pediatric residencies to provide special support
to trainees who are extending their training duration or
have failed previous examinations. In doing so, each residency program can utilize educational resources effectively and ensure the ability of graduating trainees tocompetently provide high-quality care to patients.
We also found that scholarly activity, either researchpresentations or publications, positively predicted performance on the examination. Studies suggests that theexperience of publishing studies did not disturb trainees’
academic activities during their residency but instead
predicted better performance on the certification examination [23, 24]. Another study reported that publication
experience among internal medicine residents significantly correlated with their clinical performance testscore [16]. Thus, more experience in research can provide excellent benchmarks for identifying academic
leaders in the trainee community, such as chief residents
who can help construct appropriate learning environments for other trainees to prepare for the examinations[8, 25]. This can provide opportunities to develop educational systems in each residency program or in board
systems that train and graduate competent pediatricians
to deliver excellent care to society. One systematic review suggested that educational interventions, such as
structured reading programs and a “boot camp” curriculum, were effective for improving the scores in in-training
examinations in surgery [26]. Thus, the faculty may beable to provide this peer learning opportunity for trainees
requiring special support by collaborating with potential
leaders with experience of scholarly activity [27].
Our results show that model fits for multiple regression
analyses were not particularly high, explaining 5–14% ofvariance. However, these models were all statistically significant (p < .001), and the current results are in line withthose of previous studies. Our findings can thus be considered reliable. Other potential variables may be clinicalworkplace performance in postgraduate training, such as
the Mini-Clinical Evaluation Exercise, Direct Observationof Procedural Skills, and Multiple Source Feedback, as discussed in previous reports [28, 29]. While these variables
were not included in the current analysis, the JPS has recently implemented such workplace-based assessment

Page 6 of 7

elements to the board training system. These assessment
results will thus be able to be incorporated into future
analyses of predictors.
There are some limitations to this study. First, this wasa nationwide study conducted in Japan, and several features, such as the national board system, are peculiar toour country. While the generalizability of the findings toother circumstances is unclear, our results were consistent with those of previous international studies, indicating possible applicability to other contexts. In addition,although we succeeded in identifying the predictors of
examination performance, the pass or fail results were
not available due to confidentiality issues, thus possibly
limiting the consequential validity of the board certificating examination system. This limitation is expected tobe addressed by the renewal of the national board
certification system, which aims to ensure the quality
and social accountability of each residency program to
the Japanese medical community in general. Finally, ouranalysis did not include pre-existing variables of trainees(such as academic performance in undergraduate medical education) that have been examined in previous
studies from other countries. This was because longitudinal cohort databases of medical trainees in Japan arelacking. However, the continuum concept of physician
competency has recently been implemented, andworkplace-based assessments have been stored in an eportfolio-type system in Japanese medical education. A
longitudinal cohort database may thus be able to be created in the near future.

Conclusions
This nationwide study in Japan showed that delayed andrepeated examination-taking were independent negative
predictors of performance on the pediatric board certification examination. These results should enable medical
educators to implement educational programs to improve the academic activities of trainees.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12909-021-02515-z.
Additional file 1: Appendix A. Pearson correlation analysis forvariables. Appendix B. Multicoliniality diagnostics.
Abbreviations
CBME: Competency-based medical education; MCQ: Multiple-choicequestion; CI: Confidence interval; VIF: Variance inflation factor
Acknowledgments
The authors wish to thank all those who participated in this survey and Mr.
James R. Valera for his editorial assistance.
Authors’ contributions
ON performed the statistical analyses and drafted the manuscript; HO andYSP supported the statistical analyses; NM and TK contributed to theNomura et al. BMC Medical Education(2021) 21:122

conception and design of this study; KK and TY critically reviewed themanuscript, and AI designed this study, made the database and supervised
the overall study process. All authors read and approved the final
manuscript.
Funding
This work was supported by a grant from the National Center for Child
Health and Development (grant number 26–15).
Availability of data and materials
Data are available from the authors upon reasonable request and withpermission of the Japan Pediatric Society.
Ethics approval and consent to participate
This study was approved by the Ethics Committees of the National Centerfor Child Health and Development in December 2014 (No. 74) and of theJapan Pediatric Society in March 2015. Written informed consent was
obtained from the participants.

Page 7 of 7

8.

9.

10.

11.
12.

13.

14.

Consent for publication
Not applicable.

15.

Competing interests
The Authors declare that there is no conflict of interest.

16.

Author details
1
Department of Emergency and Disaster Medicine, Hirosaki University, 5
Zaifu, Hirosaki, Aomori 036-8216, Japan. 2Center for Postgraduate Education
and Training, National Center for Child Health and Development, 2-10-1
Okura, Setagaya-ku, Tokyo, Japan. 3International Research Center for Medical
Education, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan.
4
Harvard Medical School, Harvard University, 25 Shattuck St, Boston, MA, USA.
5
Massachusetts General Hospital, 55 Fruit Street Bartlett (BAR-2R-202), Boston,
MA, USA. 6Department of Health Services Research, The University of Tokyo,
7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan. 7Department of Management andStrategy, Clinical Research Center, National Center for Child Health andDevelopment, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan. 8Department ofPediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, Japan.
9Department of Pediatrics, Fujita Health University, 1-98 Dengakugakubo,
Kutsukake-cho, Toyoake, Aichi, Japan. 10Japan Pediatric Society Steering
Committee of Board Examination, 1-1-5, Koraku, Bunkyo-ku, Tokyo, Japan.

17.

18.

19.

20.

21.
22.

Received: 11 June 2020 Accepted: 26 January 2021
23.
References
1. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al.
Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638–45.
2. Wakeford R, Denney M, Ludka-Stempien K, Dacre J, McManus IC. Crosscomparison of MRCGP & MRCP (UK) in a database linkage study of 2,284
candidates taking both examinations: assessment of validity and differential
performance by ethnicity. BMC Med Educ. 2015;15:1.
3. Scrimgeour DSG, Cleland J, Lee AJ, Brennan PA. Which factors predict
success in the mandatory UK postgraduate surgical exam: The
Intercollegiate Membership of the Royal College of Surgeons (MRCS)?
Surgeon. 2018;16(4):220–6.
4. Carr SE, Celenza A, Mercer AM, Lake F, Puddey IB. Predicting performance of
junior doctors: Association of workplace based assessment withdemographic characteristics, emotional intelligence, selection scores, andundergraduate academic performance. Med Teach. 2018;40(11):1175–82.
5. Sladek RM, Burdeniuk C, Jones A, Forsyth K, Bond MJ. Medical student
selection criteria and junior doctor workplace performance. BMC Med Educ.
2019;19(1):384.
6. Malangoni MA, Jones AT, Rubright J, Biester TW, Buyske J, Lewis FR. Delay intaking the American board of surgery qualifying examination affects
examination performance. Surgery. 2012;152(4):738–46.
7. Mcclintock JC, Gravlee GP. Predicting success on the certification examinationsof the American board of anesthesiology. Anesthesiology. 2010;112(1):212–9.

24.

25.

26.

27.

28.
29.

Mchenry MS, Abramson EL, Mckenna MP, Li S-TT. Research in pediatricresidency: National experience of pediatric chief residents. Acad Pediatr.
2017;17(2):144–8.
Welch TR, Olson BG, Nelsen E, Dallaghan GLB, Kennedy GA, Botash A.
United States medical licensing examination and American board ofpediatrics certification examination results: does the residency program
contribute to trainee achievement. J Pediatr. 2017;188:270–4.
Althouse LA, Mcguinness GA. The in-training examination: an analysis of its
predictive value on performance on the general pediatrics certification
examination. J Pediatr. 2008;153(3):425–8.
Onishi H. History of Japanese medical education. Korean J Med Educ. 2018;30(4):283–94.
Nishiya K, Sekiguchi S, Yoshimura H, Takamura A, Wada H, Konishi E, et al.
Good clinical teachers in pediatrics: The perspective of pediatricians inJapan. Pediatr Int. 2020;62(5):549–55.
Ishiguro A, Nomura O, Michihata N, Kobayashi T, Mori R, Nishiya K, et al.
Research during pediatric residency training: A nationwide study in Japan.
Japan Med Assoc J. 2019;2(1):28–34.
Devine OP, Harborne AC, McManus IC. Assessment at UK medical schools
varies substantially in volume, type and intensity and correlates withpostgraduate attainment. BMC Med Educ. 2015;15(1):146.
Robinson LR, Sabharwal S, Driscoll S, Raddatz M, Chiodo AE. How docandidates perform when repeating the American board of physicalmedicine and rehabilitation certification examinations? Am J Phys Med
Rehabil. 2016;95(10):718–24.
Seaburg LA, Wang AT, West CP, Reed DA, Halvorsen AJ, Engstler G, et al.
Associations between resident physicians’ publications and clinicalperformance during residency training. BMC Med Educ. 2016;16:1.
Du Y, Althouse LA, Tan RJB. Voluntarily postponing testing is associatedwith lower performance on the pediatric board certifying examinations. J
Pediatr. 2016;177:308–12.
Marco CA, Counselman FL, Korte RC, Purosky RG, Whitley CT, Reisdorff EJ.
Delaying the American board of emergency medicine qualifying examination
is associated with poorer performance. Acad Emerg Med. 2014;21(6):688–93.
Scrimgeour DSG, Cleland J, Lee AJ, Brennan PA. Prediction of success at UK
Specialty Board Examinations using the mandatory postgraduate UK
surgical examination. BJS Open. 2019;3(6):865–71.
Konishi E, Saiki T, Kamiyama H, Nishiya K, Tsunekawa K, Imafuku R, et al.
Improved cognitive apprenticeship clinical teaching after a faculty
development program. Pediatr Int. 2020;62(5):542–8.
Imawari M. The changes of national medical license examination and its
future movements. Nihon Naika Gakkai Zasshi. 2015;104(12):2527–32.
McManus IC, Ludka K. Resitting a high-stakes postgraduate medical
examination on multiple occasions: nonlinear multilevel modelling of
performance in the MRCP (UK) examinations. BMC Med. 2012;10(1):60.
Bhat R, Takenaka K, Levine B, Goyal N, Garg M, Visconti A, et al. Predictors of a top
performer during emergency medicine residency. J Emerg Med. 2015;49(4):505–12.
Zuckerman SL, Kelly PD, Dewan MC, Morone PJ, Yengo-Kahn AM, Magarik
JA, et al. Predicting resident performance from preresidency factors: A
systematic review and applicability to neurosurgical training. World
Neurosurg. 2018;110.
Nomura O, Kobayashi T, Nagata C, Kuriyama T, Sako M, Saito K, et al. Needs
assessment for supports to promote pediatric clinical research using an
online survey of the Japanese children' s hospitals association. Japan Med
Assoc J. 2020;3(2):131–7.
Kim RH, Tan T-W. Interventions that affect resident performance on theAmerican board of surgery in-training examination: a systematic review. J
Surg Educ. 2015;72(3):418–29.
Nomura O, Onishi H, Kato H. Medical students can teach communication
skills – a mixed methods study of cross-year peer tutoring. BMC Med Educ.
2017;17(1):103.
Kaneko K. The importance of clinical teacher development in cultivating
excellent pediatric residency programs. Pediatr Int. 2020;62(5):520.
Chang YC, Lee CH, Chen CK, Liao CH, Ng CJ, Chen JC, et al. Exploring theinfluence of gender, seniority and specialty on paper and computer-based
feedback provision during mini-CEX assessments in a busy emergency
department. Adv Health Sci Educ Theory Pract. 2017;22(1):57–67.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.