The current study showed that only 17% of our responding newly graduated physicians from all medical schools in Japan felt prepared by their schools in general clinical skills for their first postgraduate clinical training. Perceived preparedness for other clinical areas was similarly unsatisfactory. These results are in line with those of our recent pilot report indicating that Japanese medical graduates perceive that they are not well prepared clinically to start working as physicians-in-training, and that self-reported preparedness is significantly lower in Japanese graduates than in their US counterparts . However, because of a limited ability to accurately self-assess among professionals , external assessment is needed for evaluating a real difference in preparedness between Japan and US.
The Model Core Curriculum has been introduced in undergraduate medical education throughout Japan. But medical schools in Japan vary greatly in the extent to which they have adopted the Model Core Curriculum, and there are still considerable differences in the duration and contents of clinical clerkships among medical schools [20, 21]. In many schools, students have limited opportunities to examine and interact with patients and little direct responsibility for patient care . In this study, we found substantial differences among Japanese medical schools in self-perceived preparedness of their graduates, with significant positive correlations between self-assessed preparedness for all clinical areas and a better educational environment. These findings suggest that differences in educational environments among medical schools may be partly responsible for the differences in perceived preparedness of graduates for postgraduate clinical training. The implications of this finding and the need for improvement of the educational environment for medical students should be of concern to medical educators.
Engagement is a crucial step in learning that depends not only on the motivation and learning style of students, but also on the environment or "climate" in which the learning is taking place [23, 24]. Genn and Harden suggested that the educational environment is the soul and spirit of the medical curriculum and that establishing an effective environment is the most important single task of medical educators [10, 25]. Components of the educational environment related to the curriculum include the style (e.g., PBL vs. a traditional approach) and quality of teaching, signposting and clarity of the process, outcomes, assessment, and support mechanisms for students. Components of the educational environment related to individual teachers include teaching style, enthusiasm, physical environment, and role modeling . Thus, our finding of significant positive correlations between perceived preparedness for all clinical areas and a better educational environment in medical schools reflects the importance of this environment in affecting the extent of engagement of medical students. Further research is needed to determine the components in an educational environment that are most strongly related to preparedness.
We found no significant association between the pass rate on the NMLE and perceived preparedness for any of the six clinical areas addressed in our survey. Traditionally in Japan, medical students have been required to attend lectures that were aimed at equipping the students to pass the NMLE (a paper-only test with a major emphasis on cognitive domains), even in the last two years of clinical training in a six-year medical school program. Some schools still emphasize this traditional curriculum, with little emphasis on the new Model Core Curriculum [20, 21]. However, the result of our study showing lack of association between the pass rate on the NMLE and perceived preparedness may indicate poor predictive validity of students' perceived preparedness for their first postgraduate clinical training against the NLME outcomes. This may also reflect relative insensitivity for identifying any association between the NMLE and perceived preparedness when using data about the pass rate. Thus, this result should be cautiously interpreted and there would be a need for further investigations such as a study using actual scores of the exam rather than pas-fail rates.
If our results would be confirmed using actual scores of the NMLE, a change of the contents and assessment method of the NMLE, such as introduction of clinical skills assessment or an OSCE-type test, could be considered for improving preparedness by helping schools to focus their training on this aspect. Another possibility for a change of the exam would be to administer the cognitive domain tests of the exam prior to entry into the clinical clerkship period in the last two years of medical school, similar to the United States Medical Licensing Exam (USMLE) Step 1.
There are several limitations in this study. First, our results might have been influenced by sampling bias, since the response rate was relatively low and many residents may have been too busy to respond to the survey. As we have conducted a cross-sectional survey for 1st-year resident physicians at teaching hospitals with five or more 1st-year resident physicians, we did not obtained data from teaching hospitals with four or less 1st-year resident physicians. Thus, we did not know the range of response rates across schools and gender ratio in all PGY-1 population. However, our sample size was large and we were able to examine a nationwide sample. Although Japanese Ministry of Health, Welfare and Labor does not open data related to individual residents, based on data about 46,800 medical students in 2006, 33% were women . So our sample (38% were women) seemed not much different from the total population.
Second, our survey only investigated each resident's perception of their preparedness, rather than using clinical or objective assessment of preparedness. Thus, we cannot determine the differences in outcomes between universities objectively. Finally, because of the cross-sectional observational nature of the survey, we are unable to determine a causal link between the educational environment and preparedness, since confounding factors such as personal characteristics of students that may be related to both environment and preparedness may have influenced the results.