Improvement of residents' clinical competency after the introduction of new postgraduate medical education program in Japan

Figures & data

Table I.  Before and after the new postgraduate medical education in Japan

	April 2004	1969–March 2004
Law	The Revised Medical Practitioners Law	Medical Practitioners Law
Program style
	Mandatory rotation	The following options of training styles.
	First year: internal medicine (6 mo), surgery (3 mo), and emergency medicine (3 mo). Second year: pediatrics, OB & GYN, psychiatry, and community medicine/care (at least 1 mo each). Community medicine has various programs related to remote areas, small sized hospitals, health centers, social welfare facilities, nursing homes, red cross centers, and health checkup centers.	(1) Internal medicine, surgery-related subjects, pediatrics, and emergency medicine (at least 2 mo each). (2) Internal medicine and surgery-related subjects, or internal medicine, surgery-related subjects, and emergency medicine (at least 2 mo each). (3) Monospecialty
Matching scheme Facility requirements	Yes	No
Number of beds	No requirement	Over 300
On call	With senior physicians responding to requests for consultation by residents	None
Autopsy	No requirement, but clinical pathological conference required	Over 20 bodies per year and over 30% autopsy rate
Salary	Sufficient salary under which residents do not need to work at part-time jobs.	None
Education resource
	The availability of libraries, medical magazines, and the Internet	The availability of libraries, medical magazines, and the Internet
Eligibility for a program director
	• The number of residents must not exceed 20 per director	None
	• More than 7 years of clinical experience required, with effective clinical teaching ability and sufficient time contribution
Eligibility for teaching staff
	• The number of residents per teaching staff member must not exceed five.	More than 10 years of clinical experience required, with academic records in the recent 2 years
	• More than 7 years of clinical experience required, with effective clinical teaching ability and sufficient time contribution

Table

Practice points
•Mandatory rotation of various clinical departments incorporated in the new PGME program increased not only clinical experience but also confidence levels of medical residents.
•Clinical competency of residents increased in both university residents and nonuniversity residents.
•The trend of nonuniversity residents significantly obtaining more clinical experience than university resident decreased.

Table II.  Residents’ “no experience” of clinical skills and knowledge before (academic year 2003) and after the new PGME (academic year 2005)

		Teaching hospitals
		University hospital					Non-university hospital					Comparison between university hospitals and non-university hospitals
		Before (n = 1762)		After (n = 487)			Before (n = 712)		After (n = 679)			Before	After
		No experience	%	No experience	%	P*	No experience	%	No experience	%	P*	P*	P*
Specialty	Contents of clinical experience
Internal medicine
Nephrology	Edema, Hematuria, Renal Failure	222	13	2	0	<0.001	33	5	10	2	0.001	<0.001	0.137
Infection	Viral Infection, Bacterial Infection, Tuberculosis	764	45	84	18	<0.001	190	29	105	16	<0.001	<0.001	0.323
Neurology	Cerebrovascular Disease, Dementia	429	25	9	2	<0.001	58	9	6	1	<0.001	<0.001	0.139
Cardiology	Heart Failure, Myocardial Infarction, Acute Coronary Syndrome,	605	36	15	3	<0.001	91	14	11	2	<0.001	<0.001	0.087
	Arrhythmia, Hypertension, Arterial Diseases
Respiratology	Respiratory Failure, Respiratory Infection,	213	12	2	0	<0.001	26	4	1	0	<0.001	<0.001	0.571
	Chronic Obstructive Pulmonary Disease
Gastroenterology	Gastrointestinal Tract Bleeding, Esophagogastroduodenal Diseases	424	25	6	1	<0.001	49	7	3	0	<0.001	<0.001	0.172
Hematology	Anemia	195	11	2	0	<0.001	30	5	2	0	<0.001	<0.001	1.000
Hepatology	Acute,Chronic, Viral, Alcoholic, and Drug-induced Hepatitis	128	7	0	0	<0.001	10	2	2	0	0.021	<0.001	0.516
	Liver Cirrhosis, Hepatoma
Endocrinology and	Diabetes, Hyperlipidemia	121	7	1	0	<0.001	33	5	4	1	<0.001	0.074	0.654
metabolic diseases
Collagen disease and allergy	Rheumatoid Arthritis, Allergic Diseases	473	28	24	5	<0.001	100	15	42	6	<0.001	<0.001	0.424
Geriatrics	Geriatric Examination, Aspiratory Pneumonia, Decubitus, Malnutrition	351	21	5	1	<0.001	48	7	3	0	<0.001	<0.001	0.285
Psychiatry	Depression, Anxiety, Suicide Attempt, Schizophrenia	970	57	47	10	<0.001	260	41	56	9	<0.001	<0.001	0.336
Dermatology	Dermatologic Examination, Urticaria, Skin Infection	257	15	14	3	<0.001	54	8	17	3	<0.001	<0.001	0.646
Ophthalmology	Cataract, Glaucoma, Optic Examination	1129	67	111	24	<0.001	413	64	227	34	<0.001	0.156	0.000
Orthopedics	Fracture, Sprain, Dislocation, Lumbago, Osteoporosis	786	46	53	11	<0.001	167	25	56	8	<0.001	<0.001	0.093
Urology	Urinary Incontinence, Urolithiasis, Benign Prostate Hypertrophy	790	46	55	12	<0.001	196	30	70	11	<0.001	<0.001	0.496
Emergency medicine	Cardiopulmonary Arrest, Shock, Loss of Consciousness, Intoxication, Burn	752	44	60	13	<0.001	178	27	51	8	<0.001	<0.001	0.004
Surgery	Trauma, Peritonitis, Herniation	726	43	50	11	<0.001	165	25	54	8	<0.001	<0.001	0.140
Gynecology	Pregnancy, Menstruation Abnormality, Maternal Care	1120	65	4	1	<0.001	259	39	8	1	<0.001	<0.001	0.770
Otorhinolaryngology	Otitis, Allergic Rhinoritis	628	37	57	12	<0.001	152	23	67	10	<0.001	<0.001	0.240
Pediatrics	Convulsion, Bronchial Asthma, Viral Infection	996	59	59	13	<0.001	195	30	35	5	<0.001	<0.001	<0.001
Medical records
Death certificates		326	19	36	8	<0.001	93	14	41	6	<0.001	0.007	0.295
Clinical pathological conference reports		1152	68	37	8	<0.001	336	52	85	13	<0.001	<0.001	0.010
Referral forms		43	3	2	0	0.005	29	4	8	1	0.01	0.014	0.212

Note: *Fisher's exact test or Chi-square test

Table III.  Resident's confidence in clinical skills and knowledge before (academic year 2003) and after (academic year 2005) the new PGME

	Teaching hospitals
	University hospitals					Non-university hospitals					Comparison between university hospitals and non-university hospitals.
	Before (n = 1762)		After (n = 487)			Before (n = 712)		After (n = 679)			Before	After
	N	%	N	%	P*	N	%	N	%	P*	P*	P*
Question item
a. Basic area
Preparation and analysis of a Gram stain	529	30	266	56	<0.001	242	34	367	53	<0.001	0.042	0.259
Surgery complication management	895	51	346	74	<0.001	400	57	517	75	<0.001	0.008	0.827
Technical skill with the knowledge of infusion	1326	76	417	89	<0.001	586	83	600	87	0.080	<0.001	0.355
Technical performance of debridment	813	46	297	63	<0.001	375	53	504	73	<0.001	0.002	0.001
Case presentation skills	1525	87	428	91	0.012	611	87	623	90	0.067	0.917	0.457
Interpretation of the coagulation test	1485	85	439	93	<0.001	627	89	644	93	0.019	0.004	0.908
Medical chart record based  on POS (problem-oriented system)	1505	86	445	95	<0.001	617	88	650	94	0.000	0.196	0.590
Technical performance and analysis of ECG	1086	62	388	82	<0.001	523	74	568	82	0.001	<0.001	0.856
Interpretation of microscopic urinalysis	663	38	279	59	<0.001	212	30	316	46	<0.001	0.001	<0.001
Technical procedure of lumbar puncture	1123	64	352	75	<0.001	579	82	590	85	0.142	<0.001	<0.001
Technical skill with the knowledge of cross-matching	1032	59	377	80	<0.001	344	49	432	63	<0.001	<0.001	<0.001
Technical performance of artery puncture	1677	96	458	97	0.079	681	97	683	99	0.035	0.168	0.173
Technical performance of tracheal intubation	1291	74	403	86	<0.001	609	87	650	94	<0.001	<0.001	<0.001
Digital rectal exam for prostate diseases	498	28	216	46	<0.001	280	40	364	52	<0.001	<0.001	0.023
b. Allied area
Interpretation of high-resolution chest CT	989	56	381	81	<0.001	502	71	571	82	<0.001	<0.001	0.563
Interpretation of brain MRI	1030	59	377	80	<0.001	506	72	568	82	<0.001	<0.001	0.411
Differential diagnosis skills of a  sprain, fracture, and relocation	434	25	198	42	<0.001	295	42	358	52	0.001	<0.001	0.001
Pregnancy diagnosis skills	301	17	242	51	<0.001	188	27	342	49	<0.001	<0.001	0.551
Diagnostic skills for arteriosclerosis by fundscope	216	12	112	24	<0.001	66	9	129	19	<0.001	0.040	0.039
Diagnostic skills for tympanic membrane abnormality by otoscope	354	20	182	38	<0.001	208	20	291	42	<0.001	<0.001	0.227
c. Area related to the behavioral  sciences and social medicine
Knowledge of patient's interpret model	1615	93	454	96	0.016	654	94	669	97	0.007	0.573	0.533
Knowledge of psychological care of children	1045	60	388	83	<0.001	440	63	532	77	<0.001	0.182	0.019
Performance of patient education	1072	61	378	80	<0.001	452	64	543	78	<0.001	0.146	0.419
Knowledge of psychological  care of anxious patients prior to surgery	1299	74	415	89	<0.001	538	77	597	86	<0.001	0.226	0.214
Social worker collaboration in patient care	768	44	313	67	<0.001	393	56	457	66	0.001	<0.001	0.805
Knowledge of medical care reimbursement system	316	18	169	36	<0.001	126	18	203	29	<0.001	0.966	0.016
Knowledge of psychosocial care of patients	1224	70	377	81	<0.001	502	72	528	77	0.037	0.436	0.103
Knowledge of medical expenses and social welfare service	794	46	309	66	<0.001	348	50	409	59	0.001	0.063	0.025
Performance of psychological assistance  for family members of terminally ill patients	1052	60	357	76	<0.001	457	65	529	76	<0.001	0.019	0.949
Knowledge of social welfare facilities	588	34	275	59	<0.001	285	41	404	59	<0.001	0.001	0.977
Technical assistance for home care patients	535	31	275	59	<0.001	239	34	357	52	<0.001	0.094	0.016
Patient education for diabetes patients	804	46	376	80	<0.001	374	53	529	77	<0.001	0.001	0.145
d. Area related to clinical research
Interpretation of statistical analyses	433	25	194	41	<0.001	170	24	233	34	<0.001	0.776	0.009
Technical skills and interpretation of Medline searches	1384	79	382	81	0.287	559	80	536	77	0.323	0.822	0.101
Critical appraisal skills of scientific research	1025	59	315	67	0.001	412	59	455	66	0.007	0.963	0.653

Note: *Based on Chi-square test.