title: Virtual patients to explore and develop clinical case summary statement skills amongst Japanese resident physicians: a mixed methods study.
abstract: 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.
authors.affiliation: University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. heistb@upmc.edu.|Adjunct Teaching Faculty, Teine Keijinkai Hospital, Sapporo, Japan. heistb@upmc.edu.|University of Pittsburgh School of Medicine, Division of General Internal Medicine, UPMC Shadyside Hospital - North Tower #306, Pittsburgh, PA, 15232, USA. heistb@upmc.edu.
authors.forename: Brian S
authors.initials: BS
authors.lastname: Heist
authors.affiliation: Department of General Internal Medicine and Infectious Diseases at Teine Keijinkai Hospital, Sapporo, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Kishida
authors.affiliation: St. Luke's International Hospital, Tokyo, Japan.|Department of Internal Medicine, University of Hawaii, Honolulu, HI, USA.
authors.forename: Gautam
authors.initials: G
authors.lastname: Deshpande
authors.affiliation: Hokkaido General Internal Medicine Education Center, Ebetsu, Japan.
authors.forename: Sugihiro
authors.initials: S
authors.lastname: Hamaguchi
authors.affiliation: Mito Medical Center, Tsukuba University Hospital, Mito, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Kobayashi
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D006801:Humans; D007396:Internship and Residency / Q000379:methods / Q000458:organization & administration*; D007564:Japan; D008505:Medical Staff, Hospital / Q000193:education*; D008606:Mental Processes; D017145:Models, Educational; D010865:Pilot Projects; D015397:Program Evaluation; D011446:Prospective Studies; D000066908:Simulation Training / Q000379:methods*
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