Educational environment and the improvement in the General Medicine In‐training Examination score

Dear Editor: We investigated the association between the educational environment and performance in the General Medicine Intraining Examination (GMITE) among postgraduate year (PGY)1 and 2 resident physicians in Japanese teaching hospitals since 2012. GMITE includes 100 questions designed by a committee comprised of experts organized by the Japan Organization of Advancing Medical Education Program.1 According to our previous report1, hospitals with a general medicine (GM) department or those located in a provincial community had significantly higher GMITE score compared with the other hospitals. Data from the 2013 GMITE showed that appropriate emergency department (ED) workload, inpatient caseload, and online learning resource were associated with greater clinical knowledge.2 In addition, in 2014, we found that factors affecting hospital volume, including the number of hospitalizations, had a positive impact on GMITE scores.3 While our team have been extensively studied factors related to the performance of the GMITE, because previous studies were analyzing crosssectional data, we could not evaluate the improvement in GMITE score over time. In this context, we investigate how educational environment of hospitals is related to the improvement in GMITE score using the longitudinal data obtained during two consecutive years. We analyzed GMITE scores of 241 resident physicians affiliated to 46 Japanese teaching hospitals (42 community and four university hospitals, age 26.8±3.0 years, 176 males and 65 females) underwent GMITE in 2013 and 2014. university hospitalswere collected using a selfreporting questionnaire sheet, the Residency Electronic Information System website, and the Foundation for the Promotion of Medical Training website. We examined the association between the educational environment and changes in the GMITE score (PGY2 score minus PGY1 score) using hierarchical linear regression models. The covariates with P<.10 on the univariable analysis were included in our multivariable model (Table 1). Our results showed that age, the number of ED duty (35 or ≥6 per month), and the number of inpatients the resident was responsible for (monthly average 59) were associated with the improvement in GMITE scores (Table 1). A previous study showed that a heavy call rotation (every fourth or fifth night) was related to postcall performance impairment.4 Overnight calls were associated with higher burnout and fatigue scores.5 Recently, there has been a trend for limiting workloads for residents because there might have been relationship between an excessive workload and higher risk at burnout.