title: Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine.
abstract: 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.
authors.affiliation: Kyoto University Graduate School of Medicine, Kyoto, Japan. hayasino-y@umin.net
authors.forename: Yasuaki
authors.initials: Y
authors.lastname: Hayashino
authors.forename: Shunich
authors.initials: S
authors.lastname: Fukuhara
authors.forename: Kunihiko
authors.initials: K
authors.lastname: Matsui
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Noguchi
authors.forename: Taro
authors.initials: T
authors.lastname: Minami
authors.forename: Dan
authors.initials: D
authors.lastname: Bertenthal
authors.forename: John W
authors.initials: JW
authors.lastname: Peabody
authors.forename: Yoshitomo
authors.initials: Y
authors.lastname: Mutoh
authors.forename: Yoshihiko
authors.initials: Y
authors.lastname: Hirao
authors.forename: Kazuhiko
authors.initials: K
authors.lastname: Kikawa
authors.forename: Yohei
authors.initials: Y
authors.lastname: Fukumoto
authors.forename: Junichiro
authors.initials: J
authors.lastname: Hayano
authors.forename: Teruo
authors.initials: T
authors.lastname: Ino
authors.forename: Umihiko
authors.initials: U
authors.lastname: Sawada
authors.forename: Jin
authors.initials: J
authors.lastname: Seino
authors.forename: Norio
authors.initials: N
authors.lastname: Higuma
authors.forename: Hiroyasu
authors.initials: H
authors.lastname: Ishimaru
mesh_terms: 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