Empathy Among Physicians and Nurses in Japan: A Nationwide Cross-sectional Study.

BACKGROUND: Empathy with patients improves clinical outcomes. Although previous studies have shown no significant differences in empathy levels between physicians and nurses, investigations have not considered differences in cultural backgrounds and related factors of healthcare providers at the individual level. OBJECTIVE: This study compares empathy between physicians and nurses in Japan and identifies relevant factors that contribute to these differences. DESIGN: A cross-sectional survey design was used in the study. The online survey was conducted using the Nikkei Medical Online website. PARTICIPANTS: A total of 5441 physicians and 965 nurses in Japan who were registered as members of Nikkei Medical Online were included. MAIN MEASURES: Empathy was measured by the Jefferson Scale of Empathy (JSE). KEY RESULTS: Cronbach's α was 0.89. The mean JSE score for Japanese physicians was significantly lower at 100.05 (SD = 15.75) than the mean score of 110.63 (SD = 12.25) for nurses (p<0.001). In related factors, higher age (increasing by one year) (+0.29; 95% CI 0.25 to 0.32; p<0.001), self-identified female gender (+5.45; 95% CI 4.40 to 6.49; p<0.001), having children (+1.20; 95% CI 0.30 to 2.10; p=0.009), and working at a hospital with 20-99 beds (+1.73; 95% CI 0.03 to 3.43; p=0.046) were significantly associated with higher scores, whereas those whose mother is a physician (-6.65; 95% CI -8.82 to -4.47; p<0.001) and father is a nurse (-9.53; 95% CI -16.54 to -2.52; p=0.008) or co-medical professional (-3.85; 95% CI -5.49 to -2.21; p<0.001) were significantly associated with lower scores. CONCLUSIONS: Physicians had significantly lower scores on the JSE than nurses in Japan. Higher age, self-identified female gender, having children, working at a small hospital, having a mother who is a physician, and having a father who is a nurse or co-medical professional were factors associated with the level of empathy.

Differences in the resident encounter of disruptive behavior by gender.

This study aimed to investigate the prevalence of gender-based differences in disruptive behaviors (DBs) among trainee physicians to shed light on the extent and nature of the problem. Using a national cross-sectional design, data were collected through a web-based, self-administered questionnaire administered to post-graduate first-year (PGY1) and second-year (PGY2) residents participating in the General Medicine Intermittent Examination (GM-ITE). A total of 5,403 participants, representing a response rate of 71.9%, were included in the study. Of these, approximately 35% of residents reported encounters with DBs in the past year. A gender-based comparison revealed that 38.4% of male residents faced DBs from physicians, compared to 27.6% of their female counterparts (p < 0.001). Conversely, a higher proportion of male residents (35.8%) experienced DBs from nurses than did female residents (32.9%; p = 0.037). After adjusting for factors such as hospital size, hospital type, urban location, age, and PGY, male residents exhibited an increased likelihood of experiencing DB from both physicians (adjusted OR 1.59, 95% CI 1.40-1.81) and nurses (adjusted OR 1.17, 95% CI 1.03-1.32) relative to women. Moreover, the study provides valuable insight into the prevalence of various types of DBs experienced by trainee physicians, including disrespectful behavior, exclusion from patient discussions, and reprimands. Understanding and addressing the gender-based differences in DBs among trainee physicians is crucial for improving the educational environment and promoting respectful behavior in healthcare settings. These findings highlight the need for targeted interventions based on gender to mitigate the negative impact of DBs on patient care and the well-being of medical residents.

Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study.

BACKGROUND: In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training's quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach-whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience-and explored potential consequences for their clinical education. METHODS: This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation. RESULTS: Approximately half of the participants chose IM rotation periods of 32-40 weeks. A significant proportion of participants rotated in 5-7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices. CONCLUSIONS: Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences.

Differences in empathy levels among physicians based on specialty: a nationwide cross-sectional study.

PURPOSE OF STUDY: A physician's ability to empathize is crucial for patient health outcomes, and this differs according to speciality, personal characteristics, and environmental factors. This study aimed to examine the empathy levels among physicians based on their specialities and to identify the influencing factors. STUDY DESIGN: A nationwide, online, cross-sectional survey was conducted using the Nikkei Business Publication online physician member homepage. Participants were 5441 physicians in Japan registered as members of Nikkei Medical Online across 20 specialities. We used the Jefferson Scale of Empathy (JSE) to measure the physicians' empathy levels. Cronbach's alpha was 0.84. RESULTS: The mean JSE score was 100.05, SD = 15.75. Multivariate analyses showed that the highest JSE scores were for general medicine [+5.58, 95% confidence interval (CI) 2.60-8.56], general surgery (+3.63, 95% CI 0.97-6.28), psychiatry (+3.47, 95% CI 1.76-5.17), and paediatrics (+1.92, 95% CI 0.11-3.73). Factors associated with higher JSE scores were being female (+5.86, 95% CI 4.68-7.04), managers (+1.11, 95% CI 0.16-2.07), working in a small hospital (+2.19, 95% CI 0.23-4.15), and with children (+3.32, 95% CI 2.29-4.36). CONCLUSIONS: A significant decrease in the empathy levels was found when the parent of the participant was also a medical provider. Being a general medicine physician or a female physician in a high position who has children was positively and significantly correlated with high empathy levels.

The impact and prevention of systemic and diagnostic errors in surgical malpractice claims in Japan: a retrospective cohort study.

The Surgical Patient Safety System (SURPASS) has been proven to improve patient outcomes. However, few studies have evaluated the details of litigation and its prevention in terms of systemic and diagnostic errors as potentially preventable problems. The present study explored factors associated with accepted claims (surgeon-loss). We retrospectively searched the national Japanese malpractice claims database between 1961 and 2017. Using multivariable logistic regression models, we assessed the association between medical malpractice variables (systemic and diagnostic errors, facility size, time, place, and clinical outcomes) and litigation outcomes (acceptance). We evaluated whether or not the factors associated with litigation could have been prevented with the SURPASS checklist. We identified 339 malpractice claims made against general surgeons. There were 159 (56.3%) accepted claims, and the median compensation paid was 164,381 USD. In multivariable analyses, system (odds ratio, 27.2 95% confidence interval 13.8-53.5) and diagnostic errors (odds ratio 5.3, 95% confidence interval 2.7-10.5) had a significant statistical association with accepted claims. The SURPASS checklist may have prevented 7% and 10% of the accepted claims and systemic errors, respectively. It is unclear what proportion of accepted claims indicated that general surgeon loses should be prevented from performing surgery if the SURPASS checklist were used. In conclusion, systemic and diagnostic errors were associated with accepted claims. Surgical teams should adhere to the SURPASS checklist to enhance patient safety and reduce surgeon risk.

Medical resident's pursuing specialty and differences in clinical proficiency among medical residents in Japan: a nationwide cross-sectional study.

IMPORTANCE: Standardized examinations assess both learners and training programs within the medical training system in Japan. However, it is unknown if there is an association between clinical proficiency as assessed by the General Medicine In-Training Examination (GM-ITE) and pursuing specialty. OBJECTIVE: To determine the relative achievement of fundamental skills as assessed by the standardized GM-ITE based on pursuing career specialty among residents in the Japanese training system. DESIGN: Nationwide cross-sectional study. SETTING: Medical residents in Japan who attempted the GM-ITE in their first or second year were surveyed. PARTICIPANTS: A total of 4,363 postgraduate years 1 and 2 residents who completed the GM-ITE were surveyed between January 18 and March 31, 2021. MAIN MEASURES: GM-ITE total scores and individual scores in each of four domains assessing clinical knowledge: 1) medical interview and professionalism, 2) symptomatology and clinical reasoning, 3) physical examination and treatment, and 4) detailed disease knowledge. RESULTS: When compared to the most pursued specialty, internal medicine, only those residents who chose general medicine achieved higher GM-ITE scores (coefficient 1.38, 95% CI 0.08 to 2.68, p = 0.038). Conversely, the nine specialties and "Other/Not decided" groups scored significantly lower. Higher scores were noted among residents entering general medicine, emergency medicine, and internal medicine and among those who trained in community hospitals with higher numbers of beds, were more advanced in their training, spent more time working and studying, and cared for a moderate but not an extreme number of patients at a time. CONCLUSIONS: Levels of basic skill achievement differed depending on respective chosen future specialties among residents in Japan. Scores were higher among those pursuing careers in general medical fields and lower among those pursuing highly specialized careers. Residents in training programs devoid of specialty-specific competition may not possess the same motivations as those in competitive systems.

The impact of system and diagnostic errors for medical litigation outcomes in orthopedic surgery.

BACKGROUND: Medical litigation resulting from medical errors has a negative impact on health economics for both patients and medical practitioners. In medical litigation involving orthopedic surgeons, we aimed to identify factors contributing to plaintiff victory (orthopedic surgeon loss) through a comprehensive assessment. METHODS: This retrospective study included 166 litigation claims against orthopedic surgeons using a litigation database in Japan. We evaluated the sex and age of the patient (plaintiff), initial diagnosis, diagnostic error, system error, the time and place of each claim that led to malpractice litigation, the institution's size, and clinical outcomes. The main outcome was the litigation outcome (acceptance or rejection) in the final judgment. Acceptance meant that the orthopedic surgeon lost the malpractice lawsuit. We conducted multivariable logistic regression analyses to examine the association of factors with an accepted claim. RESULTS: The median age of the patients was 42 years, and 65.7% were male. The litigation outcome of 85 (51.2%) claims was acceptance. The adjusted median indemnity paid was $151,818. The multivariable analysis showed that diagnostic error, system error, sequelae, inadequate medical procedure, and follow-up observation were significantly associated with the orthopedic surgeon losing the lawsuit. In particular, claims involving diagnostic errors were more likely to be acceptance claims, in which the orthopedic surgeon lost (adjusted odds ratio 16.7, 95% confidence intervals: 4.7 to 58.0, p < 0.001). All of the claims in which the orthopedic surgeon lost were associated with a diagnostic or system error, with the most common one being system error. CONCLUSIONS: System errors and diagnostic errors were significantly associated with acceptance claims (orthopedic surgeon losses). Since these are modifiable factors, it is necessary to take measures not only for individual physicians but also for the overall medical management system to enhance patient safety and reduce the litigation risk of orthopedic surgeons.

Cognitive biases encountered by physicians in the emergency room.

BACKGROUND: Diagnostic errors constitute an important medical safety problem that needs improvement, and their frequency and severity are high in emergency room settings. Previous studies have suggested that diagnostic errors occur in 0.6-12% of first-time patients in the emergency room and that one or more cognitive factors are involved in 96% of these cases. This study aimed to identify the types of cognitive biases experienced by physicians in emergency rooms in Japan. METHODS: We conducted a questionnaire survey using Nikkei Medical Online (Internet) from January 21 to January 31, 2019. Of the 159,519 physicians registered with Nikkei Medical Online when the survey was administered, those who volunteered their most memorable diagnostic error cases in the emergency room participated in the study. EZR was used for the statistical analyses. RESULTS: A total of 387 physicians were included. The most common cognitive biases were overconfidence (22.5%), confirmation (21.2%), availability (12.4%), and anchoring (11.4%). Of the error cases, the top five most common initial diagnoses were upper gastrointestinal disease (22.7%), trauma (14.7%), cardiovascular disease (10.9%), respiratory disease (7.5%), and primary headache (6.5%). The corresponding final diagnoses for these errors were intestinal obstruction or peritonitis (27.3%), overlooked traumas (47.4%), other cardiovascular diseases (66.7%), cardiovascular disease (41.4%), and stroke (80%), respectively. CONCLUSIONS: A comparison of the initial and final diagnoses of cases with diagnostic errors shows that there were more cases with diagnostic errors caused by overlooking another disease in the same organ or a disease in a closely related organ.

Idiopathic segmental anhidrosis in an older patient presenting with recurrent dizziness.

Dizziness is one of the most common complaints encountered in the outpatient clinic, which is difficult to diagnose, especially in older patients because of the multifactorial nature of the disease. Although not commonly recognised, anhidrosis can also cause dizziness.We report a case of a woman in her 70s who presented with long-term recurrent dizziness. She had a history of frequent hospitalisations for heatstroke. Physical examination revealed markedly less sweating in the left axilla and soles than in the right. Minol test revealed that most of the left side of her body, including the face, was anhidrotic. She was diagnosed with idiopathic segmental anhidrosis. We administered steroid pulse therapy without observing any significant effects.Although anhidrosis is a rare disorder, a careful interview and physical examination should be conducted to confirm a history of heatstroke and the absence of sweating to avoid missing the disease.

Japanese Internists' Most Memorable Diagnostic Error Cases: A Self-reflection Survey.

Objective The etiologies of diagnostic errors among internal medicine physicians are unclear. To understand the causes and characteristics of diagnostic errors through reflection by those involved in them. Methods We conducted a cross-sectional study using a web-based questionnaire in Japan in January 2019. Over a 10-day period, a total of 2,220 participants agreed to participate in the study, of whom 687 internists were included in the final analysis. Participants were asked about their most memorable diagnostic error cases, in which the time course, situational factors, and psychosocial context could be most vividly recalled and where the participant provided care. We categorized diagnostic errors and identified contributing factors (i.e., situational factors, data collection/interpretation factors, and cognitive biases). Results Two-thirds of the identified diagnostic errors occurred in the clinic or emergency department. Errors were most frequently categorized as wrong diagnoses, followed by delayed and missed diagnoses. Errors most often involved diagnoses related to malignancy, circulatory system disorders, or infectious diseases. Situational factors were the most cited error cause, followed by data collection factors and cognitive bias. Common situational factors included limited consultation during office hours and weekends and barriers that prevented consultation with a supervisor or another department. Conclusion Internists reported situational factors as a significant cause of diagnostic errors. Other factors, such as cognitive biases, were also evident, although the difference in clinical settings may have influenced the proportions of the etiologies of the errors that were observed. Furthermore, wrong, delayed, and missed diagnoses may have distinctive associated cognitive biases.

The Big Three diagnostic errors through reflections of Japanese internists.

OBJECTIVES: To analyze the Big Three diagnostic errors (malignant neoplasms, cardiovascular diseases, and infectious diseases) through internists' self-reflection on their most memorable diagnostic errors. METHODS: This secondary analysis study, based on a web-based cross-sectional survey, recruited participants from January 21 to 31, 2019. The participants were asked to recall the most memorable diagnostic error cases in which they were primarily involved. We gathered data on internists' demographics, time to error recognition, and error location. Factors causing diagnostic errors included environmental conditions, information processing, and cognitive bias. Participants scored the significance of each contributing factor on a Likert scale (0, unimportant; 10, extremely important). RESULTS: The Big Three comprised 54.1 % (n=372) of the 687 cases reviewed. The median physician age was 51.5 years (interquartile range, 42-58 years); 65.6 % of physicians worked in hospital settings. Delayed diagnoses were the most common among malignancies (n=64, 46 %). Diagnostic errors related to malignancy were frequent in general outpatient settings on weekdays and in the mornings and were not identified for several months following the event. Environmental factors often contributed to cardiovascular disease-related errors, which were typically identified within days in emergency departments, during night shifts, and on holidays. Information gathering and interpretation significantly impacted infectious disease diagnoses. CONCLUSIONS: The Big Three accounted for the majority of cases recalled by Japanese internists. The most relevant contributing factors were different for each of the three categories. Addressing these errors may require a unique approach based on the disease associations.

Educational strategies related to information science and technology for medical students: General medicine physicians' perspective.

The Model Core Curriculum for Medical Education in Japan was revised in 2022. It aimed to reflect changes in the nature of medical care, including the advancement of medical technology through the use of information science and technology and artificial intelligence in the Society 5.0 era. We summarize recommendations for good practice regarding learning strategies from the perspective of general medicine.

Gender Inequality Improvement in Medical School Admissions in Japan.

Purpose: To investigate the effects of gender discrimination in Japan's medical school admission process and to assess whether the situation has improved since the disclosure of such discrimination in 2018. Materials and Methods: A cross-sectional study was conducted using secondary data from the Ministry of Education, Culture, Sports, Science, and Technology. The proportions of male and female applicants vis-à-vis all successful candidates admitted from 2016 to 2021 were analyzed; four medical schools were found to be systematically guilty of discriminatory admission practices. Acceptance rate ratios (ARRs) were estimated, and difference-in-differences (DID) analysis was used to examine the differences in ARRs between the two groups-the 4 and 75 medical schools that were and were not reported, respectively-in the predisclosure (2016-2018) and postdisclosure (2019-2021) periods. Results: Female applicants were subjected to discriminatory admission practices at the four reported medical schools in the predisclosure period. However, postdisclosure, those four medical schools had higher female than male acceptance rates in all 3 years. DID analysis revealed a statistically significant estimated average treatment effect on the treated of 0.25148 (95% confidence interval [0.00455-0.49840]), indicating a 0.25-point increase in ARRs relative to the other 75 medical schools. Conclusions: Discriminatory practices against female applicants have decreased since the disclosure in 2018, with the acceptance rate of female students exceeding that of male students for the first time in 2021. In response to these findings, we propose recommendations to further promote gender equality in medicine.

Association between mentorship and mental health among junior residents: A nationwide cross-sectional study in Japan.

Background: Mentorship is a dynamic, reciprocal relationship in which an advanced careerist (mentor) encourages the growth of a novice (mentee). Mentorship may protect the mental health of residents at risk for depression and burnout, yet despite its frequent use and known benefits, limited reports exist regarding the prevalence and mental effects of mentorship on residents in Japan. Methods: We conducted a cross-sectional study involving postgraduate year 1 and 2 (PGY-1 and PGY-2) residents in Japan who took the General Medicine In-Training Examination (GM-ITE) at the end of the 2021 academic year. Data on mentorship were collected using surveys administered immediately following GM-ITE completion. The primary outcome was the Patient Health Questionaire-2 (PHQ-2), which consisted depressed mood and loss of interest. A positive response for either item indicated PHQ-2 positive. We examined associations between self-reported mentorship and PHQ-2 by multi-level analysis. Results: Of 4929 residents, 3266 (66.3%) residents reported having at least one mentor. Compared to residents without any mentor, those with a mentor were associated with a lower likelihood of a positive PHQ-2 response (adjusted odds ratio [aOR] 0.75; 95% confidence interval [95% CI] 0.65-0.86). Mentor characteristic significantly associated with negative PHQ-2 response was a formal mentor (aOR; 0.68; 95% CI 0.55-0.84). Conclusions: A mentor-based support system was positively associated with residents' mental health. Further research is needed to determine the quality of mentorship during clinical residency in Japan.