Author reply to "Being a family medicine resident in the United States".

This is a reply to a Letter to the Editor regarding our recent publications. We feel that the letter's content largely aligns with the content of our work.

Japanese International Medical Graduates and entrance into US clinical training: Challenges and methods to overcome them.

INTRODUCTION: Entering US clinical training requires completing requirements and navigating an application process differing from the Japanese system. Additionally, increases to the number of US medical school graduates have increased competition for US residency positions. We examined profiles of Japanese International Medical Graduates (IMGs) who completed US clinical training, the timelines to securing US clinical positions, and the greatest challenges during this process and methods to overcome them. METHODS: Individual semistructured interviews were conducted with 35 purposively sampled Japanese IMGs. We performed exploratory thematic analysis using iterative data collection and constant comparison. RESULTS: Twenty percent of participants lived in a native English-speaking country during childhood. The United States Medical Licensing Examinations were completed at ages 25-40 years. Challenges were categorized as: (1) English communication, (2) understanding the application process, (3) motivation to persevere through the process, (4) time management to complete Educational Commission for Foreign Medical Graduates requirements, (5) receiving letters of recommendation and overcoming competition for US residency positions, (6) financial cost of the process. Pragmatic generally self-dependent methods helped overcome challenges 1-4 and 6. Participants detailed personal or, more commonly, institutional connections to US training programs required to overcome challenge 5. CONCLUSIONS: Japanese IMGs pursue US clinical training from diverse backgrounds commonly without the advantage of prior English fluency. Amidst increased competition internationally to enter US residency coupled with cultural and linguistic differences making this challenge often greater for Japanese IMGs, the competition to participate in institutionalized connections to US training programs is anticipated to increase.

Japanese International Medical Graduates and the United States clinical training experience: Challenges abroad and methods to overcome them.

INTRODUCTION: Due to the large language and cultural distances between Japan and the US compared to many countries, Japanese International Medical Graduates (IMGs) may have a different US training experience, including more stress, than many IMGs. We examined the US clinical training experience for Japanese IMGs, including the challenges encountered, how those challenges are overcome, and the benefits of US training. METHODS: We performed individual semistructured interviews with 35 purposively sampled Japanese IMGs who had completed US clinical training. Exploratory thematic analysis was conducted using iterative data collection and constant comparison. RESULTS: All participants reported high personal growth and that US clinical training was worth the sacrifices. Commonly fatigue was lower than during Japanese residency. Participants explained medical practice and local culture associated challenges that aligned with literature on US graduates and other IMGs. By contrast, nearly all participants reported that English communication was very challenging, and described specific language related struggles and methods to help overcome them. Communication struggles were contextualized within an American training culture that values verbal assertiveness. Self-esteem varied among participants and, for some participants, improved with confidence in communication. Several participants reported depression and other mental illness. The training environment varied among residency programs. CONCLUSIONS: Japanese IMGs who completed US training report that it was worth it, but describe significant language and culture related struggles and effects on mental health. Further research should address which Japanese IMGs are most likely to struggle, how this will transpire, and how to optimize the US clinical training experience.

Contrasting Residency Training in Japan and the United States From Perspectives of Japanese Physicians Trained in Both Systems.

BACKGROUND: International medical graduates (IMGs) have significant exposure to clinical training in their home country, which provides opportunity for international comparison of training experiences. One relevant IMG population is Japanese physicians who have completed some training before entering residency programs in the United States and desire to improve medical education in Japan. OBJECTIVE: We examined Japanese IMGs' perceptions of the respective attributes of residency in the United States and Japan. METHODS: Individual semistructured interviews were conducted with 33 purposively sampled Japanese IMGs who had completed training. We used exploratory thematic analysis, iterative data collection, and thematic analyses with constant comparison. RESULTS: Comments were organized into 3 categories: (1) attributes of US residency preferable to Japanese residency; (2) attributes of residency training with no clear preference for the US or Japanese systems; and (3) attributes of Japanese residency preferable to US residency. Within each category, we matched themes to residency program requirements or culture of medical training. Main themes include high regard for Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements, with emphasis on efficient achievement of clinical competency through graded responsibility, contrasted with preference expressed for a Japanese training culture of increased professional commitment facilitated by a lack of work hour limits and development of broad clinician skills, including bedside procedures and radiology interpretation. CONCLUSIONS: Japanese training culture contrasts with a US model that is increasingly focused on work-life balance and associated compartmentalization of patient care. These findings enhance our understanding of the global medical education landscape and challenges to international standardization of training.

Working to Change Systems: Repatriated U.S. Trained Japanese Physicians and the Reform of Generalist Fields in Japan.

Phenomenon: Internationally, efforts to produce an adequate supply of effective generalist physicians commonly encounter resistance. Achieving reform requires changes in educational and clinical practice cultures, and clinician educators play a central role in championing change. In Japan, training in generalist fields has historically been lacking, but for decades the government has advocated alignment with Western models. Meanwhile, some Japanese physicians have pursued U.S. training in generalist fields with intention to help change the clinical education and practice systems back in Japan. This study examines the endeavors of repatriated Japanese International Medical Graduates and provides a lens to understanding national challenges with reform and insights into strategizing next steps. Approach: Individual, semi-structured interviews were conducted with 19 purposively sampled Japanese IMGs who had repatriated across Japan after completing U.S. clinical residency in generalist fields. Iterative data collection and thematic analyses were performed using constant comparison. Findings: Participants identified Japanese medical universities and public sectors as steeped in traditions with systemic inertia. In turn, participants described well-informed career decision making involving connections and teammates, which commonly resulted in employment at new or smaller hospitals. Education-related efforts prioritized direct clinical work with physician trainees in the hope of building expansive lineages of educators. Main challenges were Japanese structural and cultural incongruences with Western generalist-based clinical practice. Participants described a competitive relationship with the long-standing ikyoku-based postgraduate education model and associated organ-based organization of clinical practice. Insights: Japanese IMG championing of clinical education and practice in generalist fields is largely marginalized within Japan's clinical education and practice landscape. National-level reform will require transforming or displacing the structurally and culturally rooted traditional infrastructure. Specific measures must be culturally nuanced but likely include those proven effective for similar reforms elsewhere. Based on Japan's national cultural characteristics, sustained leadership is anticipated to be particularly important.

Medical migration: A qualitative exploration of the atypical path of Japanese international medical graduates.

BACKGROUND: International Medical Graduates (IMGs) are commonly understood to move from low to high resource countries with motivations including improved financial situations and cultures of emigration. A presumable exception to the above themes would be the Japanese IMG population. The aim of this study was to develop an understanding of the Japanese IMG experience. METHODS: Using a grounded theory approach, we interviewed 19 Japanese IMGs working in the US and 16 Japanese IMGs working in Japan who had completed US clinical training. Questions addressed decision-making to pursue US clinical training, goals for the training, and career decision-making upon completing the training. Data collection and constant comparative analysis were conducted iteratively to identify emerging themes. RESULTS: The emerging model of the Japanese IMG experience is focused around pivotal experiences that often include dissatisfaction with the quality of Japanese clinical training and personal exposures to US clinical education. Further decision-making in the pursuit of US residency is influenced by educator training quality, and clinical training and career opportunities. The desire to improve Japanese clinical training commonly influences career decision-making after US training. CONCLUSIONS: The Japanese IMG experience contrasts numerous perceptions of international physician migration and, in turn, enhances understanding of this paradigm.

Antimicrobial stewardship for carbapenem use at a Japanese tertiary care center: An interrupted time series analysis on the impact of infectious disease consultation, prospective audit, and feedback.

Given the concerns surrounding the overuse of carbapenem antibiotics in Japan, we evaluated the impact of infectious disease consultation and a prospective carbapenem audit at a tertiary care center in Tokyo, Japan. Overall, carbapenem use was safely and effectively reduced after implementation of these interventions. The leadership of the infectious diseases physicians also proved critically important to implementing effective stewardship.

Virtual patients to explore and develop clinical case summary statement skills amongst Japanese resident physicians: a mixed methods study.

BACKGROUND: In Western clinical training, formulation of a summary statement (SS) is a core exercise for articulation, evaluation, and improvement of clinical reasoning (CR). In Japanese clinical training, structured guidance in developing CR, including opportunity for SS practice, is uncommon, and the present status of case summarization skills is unclear. We used Virtual Patients (VPs) to explore Japanese junior residents' SS styles and the effectiveness of VPs on improving SS quality. METHODS: All first-year junior resident physicians at 4 residency programs (n = 54) were assigned randomized sequences of 5 VP modules, rolled out at 6 day intervals. During each module, participants free-texted a case summary and then reviewed a model summary. Thematic analysis was used to identify SS styles and each SS was categorized accordingly. Frequency of SS styles, and SS CR quality determined by 1) an internally developed Key Feature rubric and 2) demonstration of semantic qualification, were compared across modules. RESULTS: Four SS styles were identified: numbered features matched to differential diagnoses, differential diagnoses with supportive comments, feature listing, and narrative summarization. From module #1 to #5, significant increases in the narrative summarization SS style (p = 0.016), SS CR quality score (p = 0.021) and percentage of semantically driven SS (p = 0.003) were observed. CONCLUSIONS: Our study of Japanese junior residents identified distinct clinical case summary statement styles, and observed adoption of the narrative summarization style and improvement in the CR quality of summary statements during a series of VP cases.

Content and timing of feedback and reflection: a multi-center qualitative study of experienced bedside teachers.

BACKGROUND: Competency-based medical education increasingly recognizes the importance of observation, feedback, and reflection for trainee development. Although bedside rounds provide opportunities for authentic workplace-based implementation of feedback and team-based reflection strategies, this relationship has not been well described. The authors sought to understand the content and timing of feedback and team-based reflection provided by bedside teachers in the context of patient-centered bedside rounds. METHODS: The authors conducted a thematic analysis qualitative study using transcripts from audio-recorded, semi-structured telephone interviews with internal medicine attending physicians (n= 34) identified as respected bedside teachers from 10 academic US institutions (2010-2011). RESULTS: Half of the respondents (50%) were associate/full professors, with an average of 14 years of academic experience. In the context of bedside encounters, bedside teachers reported providing feedback on history-taking, physical-examination, and case-presentation skills, patient-centered communication, clinical decision-making, leadership, teaching skills, and professionalism. Positive feedback about physical-exam skills or clinical decision-making occurred during encounters, positive or constructive team-based feedback occurred immediately following encounters, and individualized constructive feedback occurred in one-on-one settings following rounding sessions. Compared to less frequent, emotionally-charged events, bedside teachers initiated team-based reflection on commonplace "teachable moments" related to patient characteristics or emotions, trainee actions and emotions, and attending physician role modeling. CONCLUSIONS: Bedside teachers use bedside rounds as a workplace-based method to provide assessment, feedback, and reflection, which are aligned with the goals of competency-based medical education. Embedded in patient-centered activities, clinical teachers should be encouraged to incorporate these content- and timing-related feedback and reflection strategies into their bedside teaching.

Identifying and overcoming the barriers to bedside rounds: a multicenter qualitative study.

PURPOSE: The use of bedside rounds in teaching hospitals has declined, despite recommendations from educational leaders to promote this effective teaching strategy. The authors sought to identify reasons for the decrease in bedside rounds, actual barriers to bedside rounds, methods to overcome trainee apprehensions, and proposed strategies to educate faculty. METHOD: A qualitative inductive thematic analysis using transcripts from audio-recorded, semistructured telephone interviews with a purposive sampling of 34 inpatient attending physicians from 10 academic U.S. institutions who met specific inclusion criteria for "bedside rounds" was performed in 2010. Main outcomes were themes pertaining to barriers, methods to overcome trainee apprehensions, and strategies to educate faculty. Quotations highlighting themes are reported. RESULTS: Half of respondents (50%) were associate or full professors, averaging 14 years in academic medicine. Primary reasons for the perceived decline in bedside rounds were physician- and systems related, although actual barriers encountered related to systems, time, and physician-specific issues. To address resident apprehensions, six themes were identified: build partnerships, create safe learning environments, overcome with experience, make bedside rounds educationally worthwhile, respect trainee time, and highlight positive impact on patient care. Potential strategies for educating faculty were identified, most commonly faculty development initiatives, divisional/departmental culture change, and one-on-one shadowing opportunities. CONCLUSIONS: Bedside teachers encountered primarily systems- and time-related barriers and overcame resident apprehensions by creating a learner-oriented environment. Strategies used by experienced bedside teachers can be used for faculty development aimed at promoting bedside rounds.

The value of bedside rounds: a multicenter qualitative study.

BACKGROUND: Bedside rounds have decreased on teaching services, raising concern about trainees' clinical skills and patient-physician relationships. PURPOSE: We sought to identify recognized bedside teachers' perceived value of bedside rounds to assist in the promotion of bedside rounds on teaching services. METHODS: Authors used a grounded theory, qualitative study design of telephone semistructured interviews with bedside teachers (n = 34) from 10 U.S. institutions (2010-2011). Main outcomes were characteristics of participants, themes pertaining to the perceived value of bedside rounds, and quotations highlighting each respective theme. RESULTS: The mean years in academic medicine was 13.7, and 51% were associate or full professors. Six main themes emerged: (a) skill development for learners (e.g., physical examination, communication, and clinical decision-making skills); (b) observation and feedback; (c) role-modeling; (d) team building among trainees, attending, and patient; (e) improved patient care delivery through combined clinical decision-making and team consensus; and (f) the culture of medicine as patient-centered care, which was embodied in all themes. CONCLUSIONS: Bedside teachers identify potential benefits of bedside rounds, many of which align with national calls to change our approach to medical education. The practice of bedside rounds enables activities essential to high-quality patient care and education.

The art of bedside rounds: a multi-center qualitative study of strategies used by experienced bedside teachers.

BACKGROUND: Medical educators believe bedside rounds are effective for the delivery of patient-centered care, and are necessary in helping trainees acquire competence in clinical care. Although recommendations for bedside rounds have been reported, a recent, systematic assessment of strategies used by current-day bedside teachers was needed to advance knowledge of this teaching method. OBJECTIVE: To identify and understand bedside teachers' 1) preparatory steps, 2) patient selection, and 3) role allocation during the process of bedside rounds. DESIGN: A qualitative inductive thematic analysis using transcripts from audio-recorded, semi-structured telephone interviews. PARTICIPANTS: Internal medicine physicians (n = 34) who perform bedside rounds from ten academic US institutions (2010-2011). APPROACH: A purposive sampling strategy was utilized to identify physicians who were active inpatient attending physicians and met specific inclusion criteria for "bedside rounds." A total of 34 interviews were completed, and each was recorded and transcribed verbatim. A thematic analysis extracted key themes pertaining to the three objectives. KEY RESULTS: Most respondents (51 %) were associate or full professors, with an average of 14 years of academic experience. Attending physicians prepared using trainee-specific, patient-specific and disease-specific information, while also mentally preparing for bedside rounds. They sought trainee buy-in and learning objectives, reviewed expectations and methods to ensure patient comfort, and provided early guidance with bedside encounters. Patients were selected if they required immediate care, were new to the service, or had a high educational value, while patients were deferred if unavailable, unwilling, or unable to communicate. The team members' roles during bedside rounds varied, with trainees being given graduated autonomy with increased experience. CONCLUSIONS: Bedside teachers' methods for preparation, patient selection, and role allocation during bedside rounds enhance trainees' education within the workplace. Strategies used by experienced bedside teachers can be used for faculty development efforts aimed at promoting this activity.

A global template for reforming residency without work-hours restrictions: decrease caseloads, increase education. Findings of the Japan Resident Workload Study Group.

BACKGROUND: Japanese physician training programs are currently not subject to rigorous national standardization. Despite residency restructuring in 2004, little is known about the current work allocation of residents in Japan. AIMS: We quantified the amount of time that Japanese junior residents spend in service versus education in the context of caseload, fatigue, and low-value administrative work. METHODS: In this prospective, time-and-motion study, the activity of 1st- and 2nd-year residents at three Japanese community hospitals was observed at 5-min intervals over 1 week, and categorized as patient care, academic, non-patient care, and personal. Self-reported sleep data and caseload information were simultaneously collected. Data were subanalyzed by gender, training level, hospital, and shift. RESULTS: A total of 64 participating residents spent substantially more time in patient care activities than education (59.5% vs. 6.8%), and little time on low-value, non-patient work (5.1%). Residents reported a median 5 h of sleep before shifts and excessive sleepiness (median Epworth score, 12). Large variations in caseload were reported (median 10 patients, range 0-60). CONCLUSIONS: New physicians in Japan deliver a large volume of high-value patient care, while receiving little structured education and enduring substantial sleep deprivation. In programs without work-hour restrictions, caseload limits may improve safety and quality.

Introducing the Professionalism Mini-Evaluation Exercise (P-MEX) in Japan: results from a multicenter, cross-sectional study.

PURPOSE: Despite the growing importance of and interest in medical professionalism, there is no standardized tool for its measurement. The authors sought to verify the validity, reliability, and generalizability of the Professionalism Mini-Evaluation Exercise (P-MEX), a previously developed and tested tool, in the context of Japanese hospitals. METHOD: A multicenter, cross-sectional evaluation study was performed to investigate the validity, reliability, and generalizability of the P-MEX in seven Japanese hospitals. In 2009-2010, 378 evaluators (attending physicians, nurses, peers, and junior residents) completed 360-degree assessments of 165 residents and fellows using the P-MEX. The content validity and criterion-related validity were examined, and the construct validity of the P-MEX was investigated by performing confirmatory factor analysis through a structural equation model. The reliability was tested using generalizability analysis. RESULTS: The contents of the P-MEX achieved good acceptance in a preliminary working group, and the poststudy survey revealed that 302 (79.9%) evaluators rated the P-MEX items as appropriate, indicating good content validity. The correlation coefficient between P-MEX scores and external criteria was 0.78 (P < .001), demonstrating good criterion-related validity. Confirmatory factor analysis verified high path coefficient (0.60-0.99) and adequate goodness of fit of the model. The generalizability analysis yielded a high dependability coefficient, suggesting good reliability, except when evaluators were peers or junior residents. CONCLUSIONS: Findings show evidence of adequate validity, reliability, and generalizability of the P-MEX in Japanese hospital settings. The P-MEX is the only evaluation tool for medical professionalism verified in both a Western and East Asian cultural context.