長崎 一哉

Knowledge on case sharing among healthcare professionals, its determinants, and its association with clinical competence and burnout among Japanese resident physicians remains limited. We compared background characteristics between resident physicians who did and who did not share voluntarily their own clinical cases and examined the associations between case sharing with burnout and clinical competence-based on the General Medicine In-Training Examination [GM-ITE®] score. The presence or absence of case sharing was assessed using a questionnaire item, asking, "Do you share your own clinical cases with resident colleagues for learning or educational purposes?" Participants responded YES or NO. Of the 6,063 resident physicians, 4,635 (76.4%) reported sharing their cases. The case-sharing group tended to be women and had more emergency department duties and longer daily study times. The overall burnout prevalence was 17.8% and was significantly lower in the case-sharing group; furthermore, GM-ITE® scores were slightly higher in the case-sharing group. Residents who engaged in case sharing also reported greater clinical and educational engagement. While causal relationships cannot be inferred, these findings highlight the potential relevance of informal peer-to-peer case sharing during residency training.

Although considerable bodies of literature have elucidated various determinants of burnout and job satisfaction among medical residents, one aspect that remains under-examined is the impact of patient care ownership (PCO). Therefore, we aimed to examine the associations between PCO, burnout, and job satisfaction among residents. This was a nationwide cross-sectional study, using online anonymous surveys from January 17 to March 31, 2024. The participants were residents who participated in the General Medicine In-Training Examination, a nationwide examination in Japan. The primary outcome was burnout, assessed using the Single-item Measure of Burnout Scale. The secondary outcome was job satisfaction, measured by the item included in the Mini-Z 2.0. The explanatory variable was PCO, as assessed by the Japanese version of the PCO Scale. 1816 participants were in the analysis. Multivariable logistic regression analyses revealed that, after adjustment for possible confounders, PCO showed a negative association with burnout, and that there was a positive association between PCO and job satisfaction. The findings suggest the importance of emphasizing PCO in the context of exploring burnout and job satisfaction among medical residents. This knowledge will inform educational interventions to help residents work with less burnout and greater job satisfaction, ultimately leading to better patient outcomes.

BACKGROUND: The optimal hospital size between adequate clinical training and resident well-being remains underexplored, particularly within Japan's unique medical training environment. This study examined the relationship between residents' nationwide General Medicine In-Training Examination (GM-ITE®) scores and their mental health to evaluate the validity of inpatient volume as a criterion for training hospital designation. METHOD: We conducted a nationwide cross-sectional study of 7,498 postgraduate year (PGY)-1 and PGY-2 residents from 608 community-based hospitals in Japan who participated in the GM-ITE® from January 17 to 30, 2024. The GM-ITE® is a highly reliable test for evaluating residents' basic clinical skills. The 2023 GM-ITE® included 80 multiple-choice questions with a maximum score of 80. In the Mini Z 2.0 survey, a score of 3 or more was defined as the presence of burnout symptoms. Training facilities were categorized into four groups by yearly inpatient volume: Very Low (< 3,000), Low (3,000-5,999), Moderate (6,000-9,999), and High (≥ 10,000). We explored the relationships using multivariable analysis between GM-ITE® score, burnout symptoms, and training environment. RESULT: The GM-ITE® scores in the Very Low-Volume group were significantly higher than those of the Low-Volume group (45.8 ± 7.3 vs. 44.3 ± 7.1; adjusted coefficient (AC): 2.007; p = 0.021), but did not differ significantly from those of the Moderate- (45.8 ± 7.3 vs. 44.9 ± 6.7; AC: 1.637; p = 0.060) or High-Volume (45.8 ± 7.3 vs. 46.2 ± 6.9; AC: 1.638; p = 0.082) groups. The prevalence of burnout symptoms among residents in the Very Low-Volume group, did not differ significantly from that of residents in the Low- (13.5% vs. 13.1%; adjusted odds ratio (aOR): 0.974; p = 0.940), Moderate- (13.5% vs. 12.8%; aOR: 0.967; p = 0.923), and High-Volume groups (13.5% vs. 12.1%; aOR: 0.994; p = 0.986). CONCLUSION: Residents at Very Low-Volume hospitals achieve comparable GM-ITE® scores and mental health outcomes to those of residents at larger hospitals. Even Very Low-Volume hospitals are individually assessed, and if recognized as having an educational environment where residents can acquire basic clinical skills, it may be appropriate to certify them as core clinical training hospitals. The educational environment in Very Low-Volume hospitals could be enhanced by supporting residents' mental health and advancing international clinical training programs.

OBJECTIVES: Previous literature suggest that female physicians have better patient outcomes, following guidelines and evidence-based practices. This study explored the potential roles of workload and psychological burden in shaping the association between gender and patient safety incidents among early career resident physicians. This study aims to improve training environments during early medical careers. METHODS: We analyzed cross-sectional data from the 2022 General Medicine In-Training Examination (GM-ITE) in Japan, including 6063 resident physicians in their first or second postgraduation year. Serious patient safety incidents were collected via anonymous questionnaire, defined as deaths or serious adverse events resulting from medical errors made by the resident physicians themselves occurring during the past 12 months. Multilevel mixed-effects logistic regression accounted for hospital differences and additionally examined working conditions, including working hours, night shifts, burnout, and co-worker disruption. RESULTS: Female resident physicians had a lower risk of serious patient safety incidents (odds ratio (OR) 0.71, 95% CI: 0.59-0.85) after considering co-worker disruption as a mediator. Males had a U-shaped association between weekly working hours and patient safety incidents (<45 h: OR 2.07, 95% CI: 1.39-3.09, ≥80 h: OR 1.35, 95% CI: 1.05-1.74), while females showed a dose-response association, especially with ≥80 hours (OR 2.10, 95% CI: 1.43-3.09). There was no significant interaction of physician gender with burnout or night shift frequency. CONCLUSIONS: Female resident physicians experienced fewer serious patient safety incidents. Reducing working hours may benefit female resident physicians in preventing serious patient safety incidents.

PURPOSE: Japan introduced physician work-hour regulations in April 2024. Perceptions of such regulations appear to be influenced by history and culture, and thus vary among stakeholders and countries. Here, we aimed to investigate supervising physicians' perceptions of physician work-hour regulations in Japan. METHODS: A nationwide cross-sectional study was conducted from March to April, 2024. We distributed an online anonymous self-administered questionnaire, which included closed questions about expected influence of physician work-hour regulations on various factors and an open-ended question regarding expectations or concerns about the regulations. The data were analyzed using descriptive statistics for the closed questions and inductive content analysis for the open-ended question. To explore whether various factors (sex, postgraduate years, specialty, hospital location, hospital type, and hospital size) were associated with the perceptions of the pariticpants on the implementation of physician work-hour regulations (overall, patient care, resident physician well-being, resident physician education, or supervising physician well-being), we also performed multivariable linear regression analysis. RESULTS: We included 144 participants in the analysis. Many of the participants raised concerns about the negative impact of the regulations, particularly on the training of medical residents. About one-fifth of the respondents described their thoughts about the gap between the real medical field and the system. Some participants used the Japanese term jikokensan, which literally means self-improvement but is used to refer to study or research conducted by a physician with the aim of acquiring knowledge or enhancing skills apart from their primary duties, in the context of physician work-hour regulations. In multivariable analyses, several organizational factors showed statistically significant associations with supervisors' perceptions of physician work-hour regulations. Nevertheless, effect sizes were small, there was no clear dose-dependent relationships, and findings were inconsistent across the five outcome domains; thus, no strong or consistent predictors were identified. CONCLUSIONS: These results highlight the need to more fully explore supervisor perspectives, which could lead to more discourse in policy-making and an improved system of physician work-hour regulations.

BACKGROUND: Traditional assessments of clinical competence using multiple-choice questions (MCQs) have limitations in the evaluation of real-world diagnostic abilities. As such, recognizing non-verbal cues, like tachypnea, is crucial for accurate diagnosis and effective patient care. OBJECTIVE: This study aimed to evaluate how detecting such cues impacts the clinical competence of resident physicians by using a clinical simulation video integrated into the General Medicine In-Training Examination (GM-ITE). METHODS: This multicenter cross-sectional study enrolled first- and second-year resident physicians who participated in the GM-ITE 2022. Participants watched a 5-minute clinical simulation video depicting a patient with acute pulmonary thromboembolism, and subsequently answered diagnostic questions. Propensity score matching was applied to create balanced groups of resident physicians who detected tachypnea (ie, the detection group) and those who did not (ie, the non-detection group). After matching, we compared the GM-ITE scores and the proportion of correct clinical simulation video answers between the two groups. Subgroup analyses assessed the consistency between results. RESULTS: In total, 5105 resident physicians were included, from which 959 pairs were identified after the clinical simulation video. Covariates were well balanced between the detection and non-detection groups (standardized mean difference <0.1 for all variables). Post-matching, the detection group achieved significantly higher GM-ITE scores (mean [SD], 47.6 [8.4]) than the non-detection group (mean [SD], 45.7 [8.1]; mean difference, 1.9; 95% CI, 1.1-2.6; P=.041). The proportion of correct clinical simulation video answers was also significantly higher in the detection group (39.2% vs 3.0%; mean difference, 36.2%; 95% CI, 32.8-39.4). Subgroup analyses confirmed consistent results across sex, postgraduate years, and age groups. CONCLUSIONS: Overall, this study revealed that detecting non-verbal cues like tachypnea significantly affects clinical competence, as evidenced by higher GM-ITE scores among resident physicians. Integrating video-based simulations into traditional MCQ examinations enhances the assessment of diagnostic skills by providing a more comprehensive evaluation of clinical abilities. Thus, recognizing non-verbal cues is crucial for clinical competence. Video-based simulations offer a valuable addition to traditional knowledge assessments by improving the diagnostic skills and preparedness of clinicians.

Drugs are a rare cause of acute pancreatitis. Mesalazine, a medication used to treat inflammatory bowel disease (IBD), has been reported to cause drug-induced pancreatitis. Here, we report a case strongly suggestive of mesalazine-induced pancreatitis. A 20-year-old man presented with left upper abdominal pain after eating. He was diagnosed with acute pancreatitis based on clinical symptoms, elevated amylase levels, and findings from contrast-enhanced computed tomography. Notably, he had been diagnosed with ulcerative colitis (UC) and had started mesalazine therapy six months earlier. Mesalazine was strongly suspected as the causative agent and was subsequently discontinued. Other potential causes of pancreatitis, such as alcohol use and gallstones, were ruled out. The patient's condition steadily improved after discontinuing mesalazine, along with general supportive treatment for pancreatitis. No recurrence has been observed over several years since discontinuation. Although re-administration has not been attempted, the clinical course strongly supports mesalazine as the likely cause. When evaluating pancreatitis in patients receiving mesalazine, drug-induced pancreatitis should be considered a potential etiology.

Japan's workplace reforms, including a 60-hour weekly work limit for medical residents, that has been in effect from April 2024, have raised concerns about compliance and its impact on training quality. This study analyzed data from 17,967 residents who participated in the General Medicine In-Training Examination from 2019 to 2022, focusing on weekly duty hours, clinical responsibilities, and training environments. Duty hours increased from 2019 to 2021, before declining in 2022. The proportion of residents working over 60 h per week decreased from 57 to 49%, while those working under 50 h increased from 12 to 19%. Concurrently, the percentage of residents managing zero to four inpatients rose from 18 to 39%. University hospital residents reported shorter duty hours but fewer patient encounters and diminished clinical exposure compared to community hospital residents. These findings underscore the educational consequences of duty-hour restrictions, particularly in university hospitals, where reduced clinical responsibilities may compromise competency-based training. The results highlight the need for balanced policies that ensure compliance while maintaining sufficient clinical exposure. Future reforms should prioritize equitable workload distribution, increased clinical opportunities, and targeted interventions to address disparities between hospital types, thereby ensuring the dual goals of resident well-being and high-quality medical education.

PURPOSE: In the current era of physician work-hour regulations, patient care ownership (PCO) has received considerable attention. The aim of the study was to investigate the association between working hours and PCO. METHODS: This was a nationwide cross-sectional study. The study recruited residents who completed the General Medicine In-Training Examination. The primary outcome was PCO, assessed using the Japanese version of the PCO Scale (J-PCOS). The secondary outcomes were the four dimensions of the J-PCOS (i.e., assertiveness, sense of ownership, diligence, and being the "go-to" person). The explanatory variable was weekly working hours. We examined the association using multivariable linear regression analysis. RESULTS: 1836 participants were included in the analysis. After adjustment for possible confounders, residents working ≥ 70 to < 90 h/week had greater PCO than those working ≥ 60 to < 70 h/week. Working ≥ 70 to < 90 h/week was also associated with assertiveness and being the "go-to" person. No clear trend was seen in the relationship between working hours and sense of ownership or diligence. CONCLUSION: While determining appropriate resident work hours requires comprehensive consideration of a number of factors, in terms of PCO training, the working hours of 80-90 h/week may be an option.

PURPOSE: The recently instituted Japan 2024 physician workstyle reform imposed upper limits on monthly overtime hours. However, the interpretation of these limits by different training hospitals for postgraduate medical trainees (PGY1-2) and their supervisors remains unclear. This study aimed to quantify program directors' perceptions of the "optimal" monthly overtime hours for: (1) achieving educational milestones (Q1), (2) maintaining trainees' well-being (Q2), and (3) complying with trainees' limits through supervisors' workload (Q3), and to compare urban and rural hospitals. PATIENTS AND METHODS: We conducted a cross-sectional, web-based survey of all accredited postgraduate training programs (N = 644) between March 1 and April 30, 2024. Program directors responded to three single-choice questions, selecting a monthly overtime band (none, 10, 20, …100 h/month). Hospitals were classified as urban or rural based on the Ministry of Health, Labor, and Welfare criteria. Linear trends across categories were tested using the Cochran-Armitage trend test. RESULTS: A total of 151 directors responded (response rate: 23%). Across Q1-Q3, 40 h/month was the most frequently selected time (21-23%). However, the proportion endorsing ≥ 60 h/month was significantly higher in urban than in rural hospitals (Q1: 43% vs 23%, p = 0.0347; Q2: 34% vs 23%, p = 0.0419; Q3: 40% vs 27%, p = 0.0405). Notably, urban programs were twice as likely to consider ≥ 80 h/month appropriate for both trainees' well-being (21% vs 6%, p = 0.0066) and supervisors (21% vs 7%, p = 0.0137). CONCLUSION: Although 40 h/month is the most frequent response by program directors, those from urban hospitals more commonly viewed extended hours acceptable, even exceeding the "A tier" limit of 45 h. Policy initiatives should tailor workload mitigation and task-shifting strategies to urban hospitals to safeguard the well-being of trainees and supervisors.

BACKGROUND: Time-at-bedside plays a central role in clinical medicine. However, the amount of time Japanese clinical residents spend at patients' bedsides remains unexplored. OBJECTIVE: To quantify time-at-bedside and examine its association with in-training examination scores during clinical residency in Japan. DESIGN: Nationwide multicenter cross-sectional study. PARTICIPANTS: First- and second-year postgraduate residents who took the General Medicine In-Training Examination at the end of the 2022 academic year. INTERVENTIONS: Time-at-bedside was defined as the average time per day the residents spend providing care at patients' bedsides during their residency. Time-at-bedside was classified into six categories: C1 (10-20 min per day), C2 (30-50 min per day), C3 (60-80 min per day), C4 (90-110 min per day), C5 (120-140 min per day), and C6 (150 min or more per day). Data on time-at-bedside were collected through an electronic survey conducted immediately after the General Medicine In-Training Examination. MAIN MEASURES: The primary outcome was the General Medicine In-Training Examination score. A multi-level analysis examined the association between self-reported time-at-bedside and the General Medicine In-Training Examination score. KEY RESULTS: A total of 5344 residents were included in this study. Of these, 2760 were first-year residents, and 2584 were second-year residents. Of the 5334 residents, 66.9% reported spending less than 60 min at a patient's bedside. Compared to the C1, C2 (adjusted score difference [aSD] = 1.1, 95% confidence interval [95% CI] 0.48 to 1.79), C3 (aSD = 1.5, 95% CI 0.75 to 2.20), and C5 (aSD = 2.0, 95 CI 0.62 to 3.38) were positively associated with the General Medicine In-Training Examination score. However, C4 (aSD = 1.1, 95% CI - 0.15 to 2.26) and C6 (aSD = 0, 95% CI - 1.79 to 1.87) were not associated with the General Medicine In-Training Examination score. CONCLUSION: Self-reported time-at-bedside positively correlates with in-training examination scores among Japanese resident physicians.

BACKGROUND: The general medicine in-training examination (GM-ITE) assesses physicians' clinical knowledge. This study expanded on findings from a previous pilot study to assess the relationship between general medicine in-training examination (GM-ITE) scores and the diagnostic skills of resident physicians in Japan by employing an innovative clinical simulation video (CSV-IE). METHODS: This multicenter cross-sectional study included 4,677 resident physicians who took the GMITE between January 17 and 30, 2023. Participants watched the CSV-IE, depicting an emergency room scenario, and provided a diagnosis. The CSV-IE depicts an emergency case and provides a diagnosis. Discrimination indices were used to assess the CSV-IE's effectiveness across clinical competence domains, and multilevel logistic regression was used to analyze physician- and hospital-level factors associated with correct diagnoses. RESULTS: Correct diagnoses were provided by 470 participants (10.0%). The CSV-IE demonstrated high discriminatory power across all assessed domains, including basic clinical knowledge (DI = 0.44), symptomatology and clinical reasoning (DI = 0.31), physical examination and clinical procedure (DI = 0.35), and knowledge about the disease (DI = 0.25), supporting its utility as an effective assessment tool. In the multivariable analysis, factors associated with a higher likelihood of providing a correct CSV-IE diagnosis included a higher annual number of emergency outpatients (adjusted odds ratio: 1.025; 95% confidence interval [CI]: 1.003-1.047; P = .0230) and being in a higher postgraduate year (adjusted odds ratio: 1.387; 95% CI: 1.104-1.742; P = .005). Conversely, resident physicians at university hospitals were less likely to provide a correct CSV-IE response (adjusted odds ratio: 0.624; 95% CI: 0.435-0.896; P = .0107). CONCLUSIONS: CSV-IE modules may provide an integrative and realistic evaluation of clinical competence, addressing limitations of traditional MCQ-based assessments by offering contextualized, real-world scenarios that require dynamic decision-making and diagnostic reasoning.

CASE PRESENTATION: An 86-year-old female presented to our emergency department with chest pain and orthopnea and was diagnosed with heart failure and ST-elevation myocardial infarction, prompting hospitalization. During hospitalization, she developed a fever. A chest and abdominal contrast-enhanced computed tomography (CT), conducted to investigate the cause of the fever, coincidentally revealed sedimentation of contrast agent in the descending aorta. To differentiate from aortic dissection, we conducted dynamic CT, and it was confirmed that the contrast agent within the aorta decreased over time. On the same day, an echocardiogram revealed a left ventricular ejection fraction of 36% with reduced contractile function, and a stagnant, hazy echo within the descending aorta. DISCUSSION: In aortic dissection, the retention of contrast agent in the false lumen of the aorta is a crucial finding for diagnosis. However, we experienced a case where contrast agent accumulated in the descending aorta, caused by low ejection fraction of the left ventricle. Differential diagnosis from aortic dissection may be possible due to the gradual decrease in contrast agent over time. This case is valuable to report given the limited number of previous reports on this phenomenon.

BACKGROUND: In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training's quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach-whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience-and explored potential consequences for their clinical education. METHODS: This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation. RESULTS: Approximately half of the participants chose IM rotation periods of 32-40 weeks. A significant proportion of participants rotated in 5-7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices. CONCLUSIONS: Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences.

Moyamoya syndrome, known as secondary moyamoya disease, is associated with various primary illnesses, such as brain tumor, meningitis, autoimmune disease, and thyrotoxicosis, and their relations are not clear. We report a rare case of moyamoya syndrome in a patient with Graves' disease. An 18-year-old woman was admitted to our hospital due to convulsions. She had symptoms of palpitations and fatiguability for half a year and transient numbness in her left upper extremity and dysarthria for a month. In physical findings, tachycardia and diffuse thyroid swelling were noted. A blood test revealed thyrotoxicosis and antithyroid antibody, and a diagnosis of Graves' disease was obtained. Brain magnetic resonance imaging (MRI) showed bilateral internal carotid artery occlusion. We finally diagnosed the patient with moyamoya syndrome caused by Graves' disease. Moyamoya disease or syndrome can cause symptoms like a stroke, sometimes requiring neurosurgical treatment. In our case, the therapy for Graves' disease resolved the symptoms. When diagnosing moyamoya disease, it is necessary to confirm whether there are any background diseases, such as Graves' disease.

Long duty hours (DH) impair sleep and negatively affect residents' health and medical safety. This cross-sectional study investigated the association among residents' DH, sleep duration, insomnia, sleep impairment, depressive symptoms, and self-reported medical errors among 5579 residents in Japan who completed the General Medicine In-Training Examination (2021) and participated in the training-environment survey. Weekly DH was classified under seven categories. Sleep duration and insomnia symptoms, from the Athens Insomnia Scale, were analysed to determine sleep impairment; depressive symptoms and medical errors were self-reported. Among 5095 residents, 15.5% slept < 5 h/day, and 26.7% had insomnia. In multivariable analysis, compared with ≥ 60 and < 70, DH ≥ 90 h/week associated with shorter sleep duration and worsen insomnia symptoms. Shorter durations of sleep and more intense symptoms of insomnia were associated with increased depressive symptoms. Medical errors increased only among residents with insomnia, but were not associated with sleep duration. DH > 90 h/week could lead to shorter sleep duration, worsen insomnia symptoms, and negatively impact well-being and medical safety. There was no significant association between sleep duration and medical errors; however, insomnia conferred an increased risk of medical errors. Limiting DH for residents to avoid excessive workload can help improve resident sleep, enhance resident well-being, and potentially reduce insomnia-associated medical errors.

PURPOSE: This study aimed to explore the perspectives of residency program directors in Japan regarding overtime duty hours and the balance between clinical training and self-improvement activities. This study explores the impact of work-hour regulations on resident well-being and training quality, contributing to global discourse on medical education reform. PARTICIPANTS AND METHODS: A cross-sectional survey was distributed to 701 residency training hospitals across Japan to investigate their readiness for new duty-hour limits under the Medical Care Act, which categorizes working hours into Level A (960 hours/year), Level B (1440 hours/year), and Level C-1 (1920 hours/year). The survey, conducted from October 18 to December 15, 2023, achieved a 36.2% response rate (n=254). Key questions included: "Considering the balance between clinical skills development and mental well-being, what do you think is the optimal number of overtime duty hours per month for resident physicians?" Statistical analysis included descriptive statistics and Chi-square tests to compare responses across hospital types. RESULTS: Most directors favored a conservative overtime limit of 40 hours per month (mean ± standard deviation: 40 ± 21 h), with 24.0% expressing this preference. These findings reveal a significant evidence-practice gap, suggesting that current practices often exceed recommended limits, highlighting a need for alignment between policy and implementation. CONCLUSION: This study provides insights into the complex interplay between resident training demands and well-being under Japan's new duty-hour reforms. It offers valuable insights for policymakers and educators aiming to optimize training environments and enhance resident well-being globally.

This article examines the impact of working-hour restrictions on the well-being, performance, and education of medical residents in Japan. Despite Japan's plan to introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the 80-hour-per-week regulation in the United States and the 48-h-per-week regulation in the European Union influencing other regions. The article also discusses the effectiveness of working-hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety and resident education are mixed, and further reduction in working hours must be carefully considered to avoid adverse effects. The planned changes to working-hour limits for residents in Japan offer a unique opportunity to gain new evidence on the impact of such regulations, which will be of interest to policymakers and researchers worldwide.

BACKGROUND: An increased focus on quality and patient safety has led to the evolution of hospitalists. The number of hospitalists covering ward and outpatient care is on the rise in Japan. However, it is unclear what roles hospital workers themselves consider important in their practice. Therefore, this study investigated what hospitalists and non-hospitalist generalists in Japan consider important for the practice of their specialty. METHODS: This was an observational study that included Japanese hospitalists (1) currently working in a general medicine (GM) or general internal medicine department and (2) working at a hospital. Using originally developed questionnaire items, we surveyed the items important to hospitalists and non-hospitalist generalists. RESULTS: There were 971 participants (733 hospitalists, 238 non-hospitalist) in the study. The response rate was 26.1%. Both hospitalists and non-hospitalists ranked evidence-based medicine as the most important for their practice. In addition, hospitalists ranked diagnostic reasoning and inpatient medical management as the second and third most important roles for their practice, while non-hospitalists ranked inpatient medical management and elderly care as second and third. CONCLUSIONS: This is the first study investigating the roles Japanese hospitalists consider important and comparing those to that of non-hospitalist generalists. Many of the items that hospitalists considered important were those that hospitalists in Japan are working on within and outside academic societies. We found that diagnostic medicine and quality and safety are areas that are likely to see further evolution as hospitalists specifically emphasized on them. In the future, we expect to see suggestions and research for further enhancing the items that hospital workers value and emphasise upon.

PURPOSE: In 2024, the Japanese government will enforce a maximum 80-hour weekly duty hours (DHs) regulation for medical residents. Although this reduction in weekly DHs could increase the self-study time (SST) of these residents, the relationship between these two variables remains unclear. The aim of the study was to investigate the relationship between the SST and DHs of residents in Japan. METHODS: In this nationwide cross-sectional study, the subjects were candidates of the General Medicine In-Training Examination in the 2020 academic year. We administered questionnaires and categorically asked questions regarding daily SST and weekly DHs during the training period. To account for hospital variability, proportional odds regression models with generalized estimating equations were used to analyse the association between SST and DHs. RESULTS: Of the surveyed 6117 residents, 32.0% were female, 49.1% were postgraduate year-1 residents, 83.8% were affiliated with community hospitals, and 19.9% worked for ≥80 hours/week. Multivariable analysis revealed that residents working ≥80 hours/week spent more time on self-study than those working 60-70 hours/week. Conversely, residents who worked <50 hours/week spent less time on self-study than those who worked 60-70 hours/week. The factors associated with longer SST were sex, postgraduate year, career aspiration for internal medicine, affiliation with community hospitals, academic involvement, and well-being. CONCLUSION: Residents with long DHs had longer SSTs than residents with short DHs. Future DH restrictions may not increase but rather decrease resident SST. Effective measures to encourage self-study are required, as DH restrictions may shorten SST.

OBJECTIVE: The relationship between the care of patients with COVID-19 and mental health among resident physicians in Japan is imperative for ensuring appropriate care of patients with COVID-19 and should be clarified. We herein assessed the relationship between the care of patients with COVID-19 and mental health among postgraduate year 1 (PGY-1) and PGY-2 resident physicians and factors associated with mental health. DESIGN: This nationwide cross-sectional study analysed data obtained using the clinical training environment self-reported questionnaire. SETTING: An observational study across Japan among resident physicians (PGY-1 and PGY-2) from 583 teaching hospitals. PARTICIPANTS: Examinees who took the general medicine in-training examination of academic year 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: The Patient Health Questionnaire and Mini-Z 2.0 were used to assess mental health, and experience of caring for patients with COVID-19 was divided into three groups (none, 1-10 and ≥11). The prevalence of mental conditions in the three groups was compared using the 'modified' Poisson generalised estimating equations by adjusting for prefecture-level, hospital-level and resident-level variables. RESULTS: Of the 5976 participants analysed, 50.9% were PGY-1. The prevalence of burnout was 21.4%. Moreover, 47.0% of all resident physicians had no experience in the care of patients with COVID-19. The well-experienced group accounted for only 7.9% of the total participants. A positive association was found between the number of caring patients with COVID-19 and burnout (prevalence ratio 1.25; 95% CI 1.02 to 1.53). Moreover, the shortage of personal protective equipment was identified as a major contributor to burnout (prevalence ratio 1.60; 95% CI 1.36 to 1.88). CONCLUSIONS: Resident physicians who experienced more care of patients with COVID-19 had slightly greater burnout prevalence than those who did not. Approximately half of resident physicians did not participate in the care of patients with COVID-19, which posed a challenge from an educational perspective.

OBJECTIVES: To examine the prevalence and the associated factors of burnout among both healthcare workers (HCWs) and the general working population, which has not yet been unknown, using large-scale, nationwide data. DESIGN: Cross-sectional internet-based study. SETTING: Nationwide internet survey conducted between 8 and 26 February 2021 in Japan. PARTICIPANTS: Workers aged 20-64 years. We classified the workers as HCWs and the general working population. EXPOSURES: Demographic characteristics (age, sex and marital status), socioeconomic status (education, employment and income), health-related, work-related and industry-related factors (smoking, alcohol use, physical and psychiatric comorbidities, working hours, types of healthcare professionals, experience on the COVID-19 frontline and working industries). MAIN OUTCOME MEASURES: Burnout defined as a score of ≥3 points on the Mini-Z Single-Item Burnout Scale. RESULTS: Of the included 12 650 workers, 1087 were HCWs. After inverse probability weighting on data from the 2016 Comprehensive Survey of Living Conditions, burnout in HCWs and the general working population was 33.5% (95% CI 29.2% to 38.0%) and 31.0% (95% CI 29.7% to 32.4%), respectively. In the weighted multivariable modified Poisson regression models, working 60 hours or more was associated with burnout in all workers (HCWs: prevalence ratio (PR) 2.52, 95% CI 1.68 to 3.76; general population: PR 1.26, 95% CI 1.07 to 1.48). Widowed/separated compared with married was associated with burnout only among HCWs (PR 1.69, 95% CI 1.16 to 2.47), whereas presence of physical or psychiatric comorbidities was associated with burnout among the general working population (PR 1.14, 95% CI 1.03 to 1.28; and PR 1.65, 95% CI 1.45 to 1.87, respectively). CONCLUSIONS: Burnout was prevalent in both HCWs and the general working population in Japan. Both common and specific risk factors were observed. Our findings highlight the need for the general workplace policy and targeted interventions for burnout prevention.

Purulent pericarditis is an infection of the pericardial cavity that produces purulent fluid and is commonly caused by Streptococcus pneumoniae. We herein report an autopsy case that is unique in two respects: the patient had pneumococcal bacteremia from a skin and soft tissue infection associated with acupuncture as well as purulent pericarditis from pneumococcal bacteremia. This case suggests that bloodstream infection should be included in the differential diagnosis on observing pneumococcal pericarditis. Furthermore, it is necessary to recognize that S. pneumoniae may be the organism responsible for skin and soft tissue infections caused by trauma in immunosuppressed patients.

Background: Burnout is a psychological syndrome consisting of emotional exhaustion, cynicism, and decreased professional efficacy. The Maslach Burnout Inventory (MBI) is widely used as the standard measure. However, the MBI is lengthy and not free to use, which makes it a less than ideal tool for regularly assessing burnout. The single question burnout measure (SMB) is a novel and simple measure of burnout, which is associated well with emotional exhaustion and has sufficient diagnostic performance for burnout. This study aimed to evaluate the concurrent and convergent validity of the Japanese version of the single-item measure of burnout (SMB-J) compared with the MBI. Methods: Ninety-four medical residents volunteered to complete the MBI-General Survey (MBI-GS) and the SMB-J. We assessed the concurrent (sensitivity and specificity) and convergent validity of the SMB-J compared with the MBI-GS. Results: The sensitivity for identifying burnout using the SMB-J was 53.8%, and the specificity was 88.2%. The area under the receiver operating characteristic curve (AUC) was 0.71. MBI-GS scores on the subscales of Emotional Exhaustion (r = 0.509, p < 0.0001) and Cynicism (r = 0.57, p < 0.0001) strongly correlated with the SMB-J scores. Conclusions: We concluded that for identifying burnout among Japanese medical residents, the psychometric properties of the SMB-J are comparable to those of the original version of the SMB. Although the SMB-J has low sensitivity to detect burnout, it is more convenient to use than the MBI.

The new duty hour (DH) limit for doctors in Japan will begin in 2024, setting the maximum DHs for postgraduate residents at approximately 80 h weekly. To set appropriate limits, understanding the association between DHs and psychological health is necessary. Thus, we assessed the relationship between residents' psychological health and DHs. We conducted a cross-sectional study involving examinees of the General Medicine In-training Examination 2020. Mental health outcomes were measured dichotomously using the Patient Health Questionnaire-2 for depression and Mini-Z 2.0, for burnout, stress, and satisfaction. Weekly DHs were measured in seven categories at 10-h intervals. The prevalence ratios (PRs) between the DH categories were estimated for each outcome. Of the 6045 residents who provided data on DHs and psychological outcomes, 37.3% showed signs of depression, 21.6% experienced burn out, and 39.2% were highly stressed. In contrast, 62.3% were highly satisfied with their training. Proportions of burnout were higher among residents in Category 6 (≥ 90 and < 100 h; PR 1.36; 95% CI 1.11-1.66) and Category 7 (≥ 100 h; PR 1.36; 95% CI 1.10-1.68) compared with residents in Category 3 (≥ 60 and < 70 h; reference). The results partially support the weekly 80-h DH limit in terms of resident well-being.