Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine.
BACKGROUND
The extent of clinical exposure needed to ensure quality care has not been well determined during internal medicine training. We aimed to determine the association between clinical exposure (number of cases seen), self- reports of clinical competence, and type of institution (predictor variables) and quality of care (outcome variable) as measured by clinical vignettes.


METHODS
Cross-sectional study using univariate and multivariate linear analyses in 11 teaching hospitals in Japan. Participants were physicians-in-training in internal medicine departments. Main outcome measure was standardized t-scores (quality of care) derived from responses to five clinical vignettes.


RESULTS
Of the 375 eligible participants, 263 (70.1%) completed the vignettes. Most were in their first (57.8%) and second year (28.5%) of training; on average, the participants were 1.8 years (range = 1-8) after graduation. Two thirds of the participants (68.8%) worked in university-affiliated teaching hospitals. The median number of cases seen was 210 (range = 10-11400). Greater exposure to cases (p = 0.0005), higher self-reports of clinical competence (p = 0.0095), and type of institution (p < 0.0001) were significantly associated with higher quality of care, using a multivariate linear model and adjusting for the remaining factors. Quality of care rapidly increased for the first 100 to 200 cases seen and tapered thereafter.


CONCLUSIONS
The amount of clinical exposure and levels of self-reports of clinical competence, not years after graduation, were positively associated with quality of care, adjusting for the remaining factors. The learning curve tapered after about 200 cases.
Hayashino
Yasuaki
Y
Kyoto University Graduate School of Medicine, Kyoto, Japan. hayasino-y@umin.net
Fukuhara
Shunich
S
Matsui
Kunihiko
K
Noguchi
Yoshinori
Y
Minami
Taro
T
Bertenthal
Dan
D
Peabody
John W
JW
Mutoh
Yoshitomo
Y
Hirao
Yoshihiko
Y
Kikawa
Kazuhiko
K
Fukumoto
Yohei
Y
Hayano
Junichiro
J
Ino
Teruo
T
Sawada
Umihiko
U
Seino
Jin
J
Higuma
Norio
N
Ishimaru
Hiroyasu
H
D002983:Clinical Competence / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D006784:Hospitals, Teaching / Q000592:standards; D006801:Humans; D007325:Institutional Practice / Q000592:standards; D007388:Internal Medicine / Q000193:education* / Q000592:standards; D007396:Internship and Residency / Q000592:standards*; D007564:Japan; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012655:Self-Evaluation Programs; D013997:Time Factors; D000078329:Workforce; D016526:Workload / Q000706:statistics & numerical data