Key factors for high-quality residency training programs: Insights from program directors through thematic analysis

Key factors for high-quality residency training programs: Insights from program directors through thematic analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Key factors for high-quality residency training programs: Insights from program directors through thematic analysis Kiyoshi Shikino, Yuji Nishizaki, Sho Fukui, Yu Yamamoto, Taro Shimizu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7030199/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: Clinical training programs in Japan play a crucial role in shaping future healthcare professionals by providing resident physicians with comprehensive education and hands-on experience. Despite a structured framework, variability in the outcomes of residency programs indicates that certain factors may significantly enhance residents' competencies. This study aims to identify key factors contributing to the success of high-performing residency programs in Japan, as measured by their performance on the General Medicine In-Training Examination (GM-ITE), particularly the Clinical Simulation Video-Innovative Examination (CSV-IE). Methods Semi-structured interviews were conducted with nine program directors from the top 25% ranking residency programs based on the CSV-IE accuracy rates. The interviews explored factors contributing to effective clinical training and were analyzed using thematic analysis. Key themes were identified and consolidated to provide a comprehensive understanding of high-performing programs' characteristics. Results Seven key themes emerged as contributors to the effectiveness of residency programs: (1) Active engagement and autonomy in clinical practice: Residents were given substantial responsibility, fostering confidence and critical decision-making skills. (2) Diverse patient exposure: Broad medical conditions and patient demographics enhanced clinical competence. (3) Enhanced learning resources: Access to clinical decision support tools and customized educational materials facilitated evidence-based learning. (4) Peer-assisted learning: Collaborative learning environments promoted knowledge sharing and mentorship. (5) Supportive educational framework: Structured feedback, balanced with autonomy, created a positive learning atmosphere. (6) Clinical reasoning education: Emphasis on case-based learning and routine exercises developed robust diagnostic skills. (7) Professionalism development: Focus on communication and teamwork prepared residents for real-world clinical interactions. Conclusion High-performing residency programs in Japan integrate diverse clinical experiences, advanced resources, peer learning, and structured feedback to enhance residents' competencies. These findings offer valuable insights into optimizing clinical training programs under resource constraints, potentially leading to improvements in medical education frameworks across Japan. Health sciences/Health care Health sciences/Medical research deductive effective factor program director residency program thematic analysis Figures Figure 1 BACKGROUND In Japan, clinical training programs for resident physicians are crucial for shaping the future of the healthcare workforce, as they provide comprehensive education and practical experiences to ensure that resident physicians develop the skills and confidence necessary to deliver high-quality patient care [ 1 – 3 ]. Despite the structured framework of clinical training, there is considerable variability in the performance outcomes of different residency programs [ 4 ]. This suggests that certain factors within programs may significantly enhance residents’ competencies. Identifying these factors is crucial to improve medical education and ensure that all resident physicians receive the best possible training. The General Medicine In-Training Examination (GM-ITE) is a key benchmark assessment in Japan and is administered annually to approximately half of all resident physicians [ 1 , 5 , 6 ]. This examination evaluates the competencies acquired during residency training and measures the overall quality of the training programs. High performance on GM-ITE indicates effective training practices and superior educational outcomes [ 1 , 5 , 6 , 7 ]. In addition to traditional multiple-choice questions, the GM-ITE now includes an innovative component known as the Clinical Simulation Video-Innovative Examination (CSV-IE) [ 7 ]. This component, which assesses specific competencies in clinical reasoning, communication, and decision-making, presents simulated patient scenarios in emergency settings to evaluate how residents apply their medical knowledge in real-world contexts. The previous study showed remarkable correlations between the GM-ITE scores and CSV-IE performance, indicating the potential value of this innovative assessment tool. While many elements that contribute to effective clinical training have been widely studied and are embedded in international standards like those set by the ACGME in the United States—such as autonomy, feedback, and diverse patient exposure [ 8 – 11 ]—the unique context of residency programs in Japan, particularly in relation to success on the CSV-IE, remains underexplored. Furthermore, residency programs in Japan often operate with limited resources, making it essential to identify efficient and targeted training practices that can optimize clinical competencies within these constraints. This study focuses specifically on uncovering the characteristics of high-performing residency programs in Japan, with an emphasis on how they prepare residents for success in the CSV-IE. These insights can inform both the improvement of medical education frameworks in Japan and the development of strategies to efficiently train resident physicians under resource constraints. In this study, we conducted semi-structured interviews with program directors from the top 25% of residency programs, based on their performance in the CSV-IE component of the GM-ITE. By using thematic analysis, we aimed to identify the specific factors that contribute to high performance in residency training, offering valuable insights that can guide program improvements and policy development. The findings will help to clarify how residency programs can better prepare their physicians for practical, real-world challenges and ultimately enhance the quality of healthcare in Japan. METHODS Study Design This study aimed to identify the key factors contributing to the effectiveness of residency training programs in Japan, with a specific focus on performance in the CSV-IE. The CSV-IE is a component of the General Medicine In-Training Examination (GM-ITE), which evaluates competencies such as clinical reasoning, communication, and decision-making by presenting real-world clinical scenarios in video format. We conducted semi-structured interviews with program directors from high-performing residency programs, defined by their residents’ performance on the CSV-IE. The accuracy rate, defined as the percentage of correct responses to the CSV-IE scenarios, was used to rank the residency programs. Of the 701 programs that participated in the GM-ITE, 73 programs achieved an accuracy rate of at least 25% on the CSV-IE. These programs were considered high-performing for the purposes of this study (Table 1 ). Table 1 Characteristics of participants Interviewee information Hospital information ID Sex Position Hospital type Location Hospital beds (n) Number of physician (n) Numbers of resident physicians (n) Number of ambulance transports per year (n) Number of emergency department visits per year (n) CSV-IE accuracy rate (%) 1 Man Program director Community hospital Rural 486 110 25 1666 9061 41.7 2 Man Program director Community hospital Rural 384 120 21 1564 9452 38.9 3 Man Program director Community hospital Rural 460 159 34 2570 15262 30.8 4 Woman Program director Community hospital Rural 520 183 17 2408 1358 54.5 5 Man Program director Community hospital Urban 768 302 41 3559 11508 26.1 6 Man Program director Community hospital Urban 704 199 29 2726 16669 38.9 7 Man Program director Community hospital Urban 661 187 25 2174 10829 30.0 8 Man Program director Community hospital Urban 865 293 51 2060 7669 27.3 9 Man Program director Community hospital Rural 560 147 21 1833 7054 25.0 It is important to note that the CSV-IE is a relatively new and innovative tool designed to assess residents' ability to apply medical knowledge in clinical scenarios. The validity of the CSV-IE has been supported by prior research showing strong correlations between GM-ITE scores and CSV-IE performance [ 7 ]. However, further validation studies are ongoing to ensure its accuracy and applicability across different clinical settings. The scoring of the CSV-IE is based on predefined clinical decision-making criteria, and scores are assigned based on the appropriateness of the residents' responses to the simulated clinical situations. From the 73 high-performing institutions, we selected 14 that had more than 10 examinees in the CSV-IE for further study (Fig. 1 ). Of these, nine program directors agreed to participate in interviews. Theoretical saturation was reached after these nine interviews, as no new themes or insights emerged during the last interviews, indicating that additional interviews were unlikely to generate new information. Data source Semi-structured interviews, averaging 45 minutes in length, were conducted with nine program directors from the selected high-performing residency programs. The interviews were conducted by KS, YN, SF, YY, and TS. All interviews were recorded and transcribed verbatim for analysis. An interview guide was developed based on the research objectives, focusing on factors contributing to high performance in the CSV-IE. The guide included open-ended questions designed to explore specific competencies evaluated by the CSV-IE, such as clinical reasoning, decision-making, and communication skills. While the guide was deductively constructed, we also incorporated inductive questions to capture any additional factors that may contribute to program success (Supplementary File 1). The questions were aligned with both the literature on residency training and the competencies targeted by the CSV-IE, ensuring relevance to the study’s focus. Reflexivity We conducted this qualitative study using thematic analysis to determine program components that are effective in the training of resident physicians. In qualitative research, the background and potential biases of the researchers can influence data interpretation, making reflexivity crucial to ensure credibility. In this study, none of the researchers had formal relationships with the program directors interviewed. Additionally, the research team consisted of clinical educators with experience in residency training, which helped ensure a balanced understanding of both educational theory and practical clinical training. Analysis Thematic analysis was used to analyze the interview transcripts [ 12 , 13 ]. Coding was conducted by KS and SF, and a codebook was developed based on both deductive and inductive themes. The initial code template was refined through discussion, and consensus was reached on the final themes. To enhance the validity of the results, we plan to confirm the identified themes with several of the participating program directors and compare them with characteristics of lower-performing programs. This additional step will help ensure that the themes identified in high-performing programs are not universally applicable and can serve as specific benchmarks for program improvement. RESULTS Selection Bias and Resident Baseline Characteristics One concern in this study is whether superior performance on the CSV-IE is attributable to the residency programs themselves or to the baseline quality of the residents entering those programs. To address potential selection bias, baseline data on residents entering the high-performing programs were collected, including academic background, prior clinical experience, and entrance exam scores. The data suggest some variation in academic performance, but most residents had similar levels of clinical experience upon entering residency. Notably, no significant differences in pre-residency academic metrics were observed between residents in high-performing programs and those from average programs. This indicates that the residency programs themselves likely play a substantial role in preparing residents for success on the CSV-IE. However, further research with larger sample sizes is necessary to control for individual resident quality and better isolate program-related factors. Key Themes and Consolidation of Sub-Themes Through thematic analysis of the interviews with program directors, we identified seven primary themes and a set of consolidated sub-themes that represent the key factors contributing to the effectiveness of high-performing residency programs. Redundant sub-themes within and between primary themes were consolidated to improve clarity and avoid overlap. A detailed breakdown of these themes is provided below, and Table 2 offers a concise summary. Table 2 The results of thematic analysis Theme Subtheme Quote ID Active engagement and autonomy in clinical practice Active engagement in clinical practice "Emergency outpatient care plays a significant role in the training, where resident physicians feel they can take a proactive role in patient care. In other medical departments, the extent to which resident physicians can engage depends on how much they express a desire to participate. If a resident physician indicates they do not want to do much, they are likely to end up observing next to a supervising physician." 5 Autonomous patient care by resident physician "Resident physicians are likely the main force handling first contact in the emergency department. The anesthesiology department also operates as an incredibly valuable force. As for other departments, it depends on the specific department. General internal medicine sees patients with resident physicians acting as attending physicians, but to speak frankly, they might not be in trouble even without resident physicians. I believe other departments likely share this stance." 5 Autonomous patient care experience with responsibility "For routine matters, everything is done by the residents. Depending on the disease, when nurses ask "Who gets the first call?" the senior doctors will say "Please give the first call to the residents," so that the residents are the ones who receive the first call." 1 Autonomous patient care with sufficient support "In the emergency department, the on-call supervisors include one emergency physician, one internal medicine physician, one surgeon, who all provide backup for resident physicians. Additionally, there's always one cardiologist on-call to handle relevant diseases. The majority of supervising physicians in the emergency department are around their 10th to 15th year. Resident physicians receive support from their second-year colleagues up until around summer, after which they generally become capable of working independently." 5 High decision-making responsibility in patient care "Many of our on-call physicians have completed their clinical training at our facility, so younger physicians, who have recently finished their training, tend to work closely with the resident physicians during emergency on-call duties. However, in the case of older instructors, there's a tendency to leave the resident physicians to manage on their own to a large extent." 9 High responsibility in patient care with patient ownership "We've been implementing the resident physician primary care system for quite some time now. When patients are admitted, depending on the rotation department, resident physicians primarily take charge of the patients as their main physicians, with supervising physicians assigned to guide them. This structure emphasizes the autonomy of the resident physicians, allowing them a degree of responsibility as part of the program." 7 High responsibility in patient care with sufficient support "Emergency medicine rotations are mandatory for both first-year and second-year resident physicians, lasting one month each, where they genuinely handle patient assessments from the first touch. For such instances, mid-level physicians or, if during daytime hours, emergency medicine physicians, supervise and provide guidance in this structured format." 4 Training with autonomous patient care "In our facility, the annual number of emergency transports is about 4,200. Almost all cases are first touched by trainee doctors. We have about 120 cases of cardiac arrest, and although these are considered level 3 emergencies, almost all cases are first touched by trainee doctors as well." 1 Abundant opportunity to experience diverse patients Comprehensive medical specialties exposure "When there are few doctors, people often ask, 'What about the educational system?' But, having fewer doctors means there are more opportunities. Whether it's for initial training or specialized training, we manage with this number of full-time staff, covering most medical disciplines." 1 Diverse patient population exposure "Both patients with a primary care physician and those without one, of course, visit the emergency department, including a significant number of first-time patients. This aspect differs from university hospitals, characterizing a community hospital. I think this provides a valuable learning experience." 2 Opportunities for experiencing many clinical cases "The cases experienced by resident physicians vary from walk-ins, severe and complex referrals. The medical service area serves 500,000 people, with about 30,000 emergency outpatient visits and approximately 10,000 ambulance calls per year." 6 Opportunities for experiencing many clinical cases in ER "The average number of annual emergency department visits at facilities taking the GM-ITE was about 8,000, but in our case, we probably saw about twice to three times that amount." 1 Enhanced learning resources Access to clinical decision support tool "The clinical decision support tool "Today's Clinical Support" is integrated into the electronic health record system. Resident physicians frequently use it to confirm their clinical decisions, finding it useful for patient care in the emergency department." 8 Access to online leaning resources "For online resources, including UpToDate, the environment is set up so that resident physicians can search for information on their smartphones." 9 Customized educational resources "The attending physician in general internal medicine has compiled various literatures into a single booklet, creating an ER manual that aids in physical examination and clinical reasoning. This manual is used as a textbook, serving as an original resource for resident physicians at our facility, specifically designed for their training." 9 Peer-assisted learning Case reflection practices and problem-based learning approach in conferences "In the emergency department, there's a reflection session held after the day shift where resident physicians review the cases they encountered. It's unclear if every single case is discussed, but the session typically focuses on representative cases experienced by the resident physicians during the day, with a senior physician leading the review conference." 5 Peer teaching and learning "In the emergency department, there's a structure where first-year and second-year resident physicians train together, with the second-year teaching the first-year. Alternatively, second-year resident physicians and fellows work together, with the fellows teaching. This forms what's referred to as a tiered, or cascading, mentorship system." 5 Peer-to-peer learning and mentorship "In the emergency department training, I believe the cascading mentorship system is functioning well. Second-year resident physicians advise first-year resident physicians on various matters, such as how to handle orders or whom to consult for specific issues and offer strategies for dealing with different supervisors. Similarly, fellows provide guidance to second-year resident physicians, ensuring a layered learning environment is in place." 3 Understanding the problems in residency training and education improvement "I've been a bit concerned lately because there seem to be many resident physicians who may not be sufficiently trained in conducting physical examinations. Moving forward, I want to focus on strengthening this area." 9 Supportive educational framework Autonomous patient care experience with minimal support by attending physicians "Resident physicians are conducting examinations in the emergency department from the beginning. If a trainee seems particularly inexperienced, I might join the examination partway through or give them some advice, but in most cases, trainees are conducting the examinations and ordering tests on their own." 9 Autonomous patient care experience with necessary support by senior physicians "Resident physicians are encouraged to do as much as they can on their own, but beyond that point, consultations are always checked by an attending physician." 2 Feedback and case review system "Resident physicians sometimes overlook things, so while giving advice on potential findings that might be hidden, the final decision on whether to discharge the patient or admit them to the hospital is always made by a senior physician." 9 Feedback culture free of criticism "Of course, resident physicians can't handle emergency responses right from the start, so they often seek advice from attending physicians. When resident physicians consult with their attending physicians, the guidance is always provided with a positive attitude, never with annoyance or disdain, and there is absolutely no criticism or belittlement involved." 2 Clinical reasoning education Case-based practical education "In the past, residents simply presented cases they had experienced themselves. They would present something like, 'There was this case, and this is what happened.' However, just presenting from the start wasn't very interesting, so we decided to release clinical information bit by bit, encouraging those around to make differential diagnoses, essentially turning it into a conference in the style of problem-based learning." 9 Off-the-job opportunity to learn clinical reasoning "Once a week, the attending physicians in general internal medicine read from the New England Journal of Medicine's Clinical Problem Solving Collection and engage in studies on diagnostics with the resident physicians. This activity continues throughout the six months of rotation in internal medicine, and resident physicians are called upon in turn to participate. Even those resident physicians who do not specialize in internal medicine are encouraged to engage in these diagnostic studies." 9 Routine clinical reasoning exercises "We have a conference every day at noon. It's conducted on the spot without prior preparation, where all gathered members participate, but a resident physician is always the presenter. They present patients they've encountered in the emergency department or internal medicine ward, starting with the chief complaint and a brief history. The attending audience then collaborates to discuss what kind of questioning would be appropriate for such chief complaints." 3 Professionalism development Education on professional communication "We put a lot of emphasis on communication for various reasons, including preventing troubles. Every summer, we hold a study session that lasts an entire day, focusing on communication training. We invite volunteers, known as SPs, to participate in scenarios that involve explaining complex cases to patients or role-playing such interactions." 3 Theme 1: Active engagement and autonomy in clinical practice Residents in high-performing programs were given substantial responsibility in patient care, fostering autonomy and active engagement in their roles. Active engagement in clinical practice Encouraging resident physicians to take initiative and make autonomous clinical decisions considerably enhanced their confidence and competence. This was particularly evident in emergency outpatient care where residents were often the first point of contact. Autonomous patient care by resident physician Resident physicians are frequently the primary handlers in patient care, especially in emergency departments. They are expected to manage routine matters independently, which prepares them for their future responsibilities. Autonomous patient care experience with responsibility Emphasizing the importance of critical thinking and decision-making in emergency care. Autonomous patient care with sufficient support A structured support system with senior oversight ensures safe learning, while allowing residents to gradually take on more responsibility. This approach fosters a sense of independence and confidence in one’s own clinical abilities. High responsibility in decision-making in patient care The level of supervision and teaching varies depending on the on-call physician, highlighting the need for adaptability. This structure ensures that residents are not left without adequate support, thereby promoting a balanced learning environment. High responsibility in patient care with patient ownership A system where residents act as primary physicians and make decisions regarding consultations fosters a sense of responsibility and independence. This direct involvement in patient care, including critical care, helps develop critical decision-making skills and ensures that residents feel ownership and accountability for their patients. High responsibility in patient care with sufficient support A balanced approach, in which residents have high responsibility but also sufficient support, ensures optimal learning and patient safety. Training with autonomous patient care The importance of structured rotations in emergency departments and other specialties for a comprehensive training experience has been emphasized. These rotations provide residents with the necessary skills and confidence to handle patient care autonomously. Theme 2: Abundant opportunity to experience diverse patients Exposure to a broad spectrum of medical conditions and patient populations significantly enhanced clinical competence. Comprehensive medical specialties exposure Trainees at these institutions covered a wide range of medical specialties, ensuring well-rounded clinical education. Exposure to various fields of medicine was crucial for developing a broad understanding of different medical conditions and treatments. Diverse patient population exposure Exposing trainees to a wide range of patient demographics and conditions provided them with a well-rounded clinical understanding. Resident physicians encountered a variety of patients, enhancing their ability to effectively handle different medical scenarios. Opportunities for experiencing many clinical cases Resident physicians encountered a wide range of cases, from walk-ins to complex referrals, which facilitate a deeper understanding of various medical conditions. Extensive exposure was instrumental for building clinical expertise. Opportunities for experiencing many clinical cases in ER Emphasizing hands-on experience in emergency settings was deemed crucial for developing practical skills. The volume and variety of cases in the emergency department provided resident physicians with essential real-world experience. Theme 3: Enhanced learning resources High-performing programs provided residents with advanced learning resources that facilitated evidence-based clinical decision-making. Access to clinical decision support tool Access to diagnostic and clinical support resources facilitated evidence-based learning. Resident physicians frequently utilized these tools to confirm their clinical decisions and enhance their ability to provide quality patient care. Access to online learning resources Access to online learning resources involves the strategic use of digital platforms and collaborative decision-making in resource acquisition to meet trainees' dynamic needs. This access allows residents to efficiently find and use information relevant to their clinical practice. Providing comprehensive learning materials and online resources, such as UpToDate, supports self-directed learning, enabling residents to independently seek and study information pertinent to their clinical training." Customized educational resources The development of tailored educational materials such as ER manuals supported specific learning needs. These customized resources were designed to address the unique requirements of resident physicians and enhance their learning experiences. Theme 4: Peer-assisted learning Collaborative learning, particularly peer-assisted learning, was a cornerstone of resident education in these programs. Case reflection practices and problem-based learning approach in conferences Reflective and problem-based learning approaches stimulated clinical reasoning and diagnostic skills. These sessions were integral to helping residents learn from real-world cases and improve their clinical competencies. Peer teaching and learning Adaptable teaching approaches and cross-disciplinary education have enriched the learning experiences. Senior residents and colleagues played a remarkable role in teaching junior colleagues and creating a dynamic and collaborative learning environment. Peer-to-peer learning and mentorship Learning and mentorship in emergency settings, including tips and strategies for peers, were crucial for building a supportive and effective learning environment. This cascading mentorship system ensured that knowledge and skills were passed down through different levels of experience. Understanding the problems in residency training and education improvement Recognizing the need for flexible learning strategies to address gaps and enhance skills was a critical component of these programs. Continuous evaluation and adaptation of training processes were emphasized to ensure that all residents received comprehensive training. Theme 5: Supportive educational framework A structured yet flexible educational framework that balanced trainee autonomy with constructive feedback was key to the development of clinical competence. Autonomous patient care experience with minimal support by attending physicians The trainees gradually assumed more responsibilities and transitioned from observation to active participation. This approach allowed residents to build confidence and competence in patient care while knowing that they could seek support when needed. Autonomous patient care experience with necessary support by senior physicians Balancing trainee autonomy with access to consultative support was crucial to ensure learning while maintaining patient safety. Residents were encouraged to manage patient care independently, but senior physicians were available for guidance and final decisions. Feedback and case review system Structured feedback mechanisms were in place where senior physicians and trainees discussed the findings and reviewed the cases. This systematic feedback approach helped trainees learn from their experiences and improve their clinical skills. Feedback culture free of criticism Maintaining a supportive environment in which trainees could learn from feedback without fear of criticism was emphasized. The feedback culture was designed to be positive and constructive, ensuring that the residents felt comfortable seeking advice and learning from their experiences. Theme 6: Clinical reasoning education Training programs placed a strong emphasis on developing clinical reasoning skills, which were crucial for success on the CSV-IE. Case-based practical education Training emphasized active participation rather than mere observation, fostering a sense of responsibility among trainees. The case-based education was designed to engage residents in real-world problem-solving and diagnostic exercises. Off-the-job opportunity to learn clinical reasoning The trainees were encouraged to use clinical resources such as the New England Journal of Medicine (NEJM) and UpToDate for self-directed learning. These resources provide valuable opportunities for residents to study and enhance their diagnostic skills outside direct patient care. Routine clinical reasoning exercises Incorporating daily exercises into clinical reasoning and case discussions was a common practice to reinforce diagnostic and problem-solving skills. These routine exercises ensured that residents consistently applied their clinical knowledge in practical settings. Theme 7: Professionalism development Professionalism, particularly in communication and teamwork, was a focus of resident development in these programs. Education on professional communication Strategically emphasizing the improvement of trainees’ communication skills was a key component of training programs. This focus was aimed at ensuring that residents could effectively interact with patients and colleagues, thereby enhancing the quality of care and preventing misunderstandings. DISCUSSION An analysis of interviews with program directors from high-performing institutions in GM-ITE revealed seven key themes that contributed to the effective training of resident physicians. These findings offer valuable insights into the factors that enhance clinical competence and the quality of education in the context of initial clinical training in Japan. In order to validate the relevance and applicability of these themes, we compared our findings with existing literature on high-performing residency programs. For instance, one study emphasizes the importance of a supportive learning environment and feedback mechanisms, which aligns with our identified themes of a supportive educational framework and structured feedback culture [ 14 ]. Furthermore, the emphasis on diverse clinical exposure and autonomy in clinical practice found in our study is corroborated by some research [ 15 ], which highlights the significance of experiential learning and autonomy in medical education. By comparing our themes with these established studies, we can affirm that our findings are consistent with recognized effective practices in residency training. Theme 1: Active engagement and autonomy in clinical practice The importance of active engagement and autonomy in clinical practice cannot be overemphasized. The opportunity for resident physicians to take the lead in patient care, especially in emergency settings, fosters a sense of responsibility and confidence [ 16 , 17 ]. Encouraging autonomous decision-making while providing the necessary support ensures that residents develop critical thinking skills and clinical competence. This balance between independence and supervision aligns with the broader educational goal of preparing residents for real-world medical practice. Theme 2: Abundant opportunity to experience diverse patients Exposure to diverse patient populations across various medical specialties enriches the training experience [ 18 ]. High-performing institutions offer residents the opportunity to manage a wide range of clinical cases, from routine checkups to complex emergencies. This diversity not only broadens their clinical knowledge but also enhances their adaptability and problem-solving abilities. Such comprehensive exposure is essential for developing well-rounded physicians capable of addressing a wide spectrum of medical conditions [ 19 ]. Theme 3: Enhanced learning resources Access to advanced learning resources extensively boosts educational experience [ 20 , 21 ]. Tools, such as clinical decision support systems and online databases, provide residents with immediate access to evidence-based information and facilitate informed clinical decisions [ 21 , 22 ]. Customized educational materials tailored to residents’ specific needs further support their learning, ensuring that they have the necessary resources to excel in their training. Theme 4: Peer-assisted learning Peer-assisted learning creates a collaborative and supportive learning environment through mechanisms such as case-reflection practices and cascading mentorship systems [ 23 ]. Residents benefit from the guidance of more experienced peers and fellows, which helps them navigate complex clinical situations [ 24 ]. This approach not only enhances clinical skills but also fosters a culture of teamwork and mutual support, which is critical in medical practice. Theme 5: Supportive educational framework A supportive educational framework that balances autonomy with structured feedback is crucial for effective learning [ 25 ]. Providing residents with increasing levels of responsibility and constructive feedback from senior physicians ensures continuous skill development [ 26 , 27 ]. A feedback culture that is free of criticism encourages residents to seek advice and learn from their experiences without fear of judgment, thereby promoting a positive learning environment. Theme 6: Clinical reasoning education Focusing on clinical reasoning education through case-based practical education and routine exercises helps residents develop robust diagnostic skills [ 28 , 29 ]. Institutions that emphasize active participation in clinical problem solving and provide opportunities for self-directed learning enable residents to build strong analytical and decision-making capabilities. These skills are essential for an accurate diagnosis and effective patient care. Theme 7: Professionalism development Developing professional communication skills is essential for effective patient interaction and overall clinical practice [ 11 , 30 ]. Institutions that prioritize communication training ensure that residents are well-equipped to handle complex patient interactions and collaborate effectively with colleagues. This focus on professionalism not only enhances the quality of care but also helps prevent misunderstandings and conflicts in the clinical setting. Implications for initial clinical training in Japan The findings of this study have remarkable implications for the design and implementation of clinical training programs in Japan. By integrating these themes into training curricula, educational institutions can enhance the clinical competence and professional development of resident physicians. This comprehensive approach ensures that residents are well-prepared to meet the demands of modern medical practice and deliver high-quality patient care (Table 3 ). Table 3 Recommendation lists for residency training program 1 Enhance Autonomy with Supervision: Encourage resident physicians to take on more responsibilities while providing necessary support to ensure patient safety and effective learning. 2 Diversify Clinical Exposure: Ensure that residents have access to a broad range of clinical cases and patient demographics to develop well-rounded clinical skills. 3 Utilize Advanced Learning Resources: Integrate clinical decision support tools and online learning platforms into the training program to facilitate evidence-based practice. 4 Promote Peer-Assisted Learning: Foster a collaborative learning environment through peer teaching and mentorship systems. 5 Implement Structured Feedback Mechanisms: Establish a feedback culture that is constructive and free of criticism to encourage continuous learning. 6 Focus on Clinical Reasoning Education: Incorporate case-based learning and routine clinical reasoning exercises into the curriculum to strengthen diagnostic skills. 7 Develop Professional Communication Skills: Conduct regular communication training sessions to improve residents' ability to effectively interact with patients and colleagues. Limitations This study has some limitations that should be considered when interpreting the findings. First, while providing in-depth insights, the sample size of the nine program directors was relatively small and may not fully represent the diversity of clinical training programs across Japan. Future studies with larger and more diverse samples would help validate and generalize the findings. Second, the study relied on self-reported data from program directors, which may have been subject to bias. Directors might present their programs in a more favorable light, potentially overlooking challenges or areas requiring improvement. Triangulating these findings with other data sources such as direct observations or resident feedback could enhance the reliability of the results. Third, the cross-sectional nature of the study captures a snapshot of time and may not account for changes or developments in the programs over time. Longitudinal studies that track the evolution of training programs and their impact on resident performance would provide a more comprehensive understanding. Fourth, the study focused on high-performing institutions, as determined by CSV-IE accuracy rates. This focus may limit the applicability of the findings to programs with lower performance levels that may face different challenges and require distinct strategies for improvement. Finally, the integration and impact of the CSV-IE within the GM-ITE framework is still relatively new. Therefore, the long-term effects and potential benefits of this innovative assessment tool for resident training and competency development require further exploration through extended studies and continuous evaluation. Despite these limitations, this study provides valuable insights into the factors that contribute to the effectiveness of clinical training programs in Japan, offering a foundation for future research and improvements in medical education. In conclusion, this study highlights critical elements that contribute to the effective training of resident physicians in Japan. By focusing on active engagement, diverse clinical exposure, enhanced learning resources, peer-assisted learning, supportive educational frameworks, clinical reasoning education, and professionalism development, training programs can extensively improve future physicians’ competencies and readiness. These insights provide a valuable framework for optimizing the initial clinical training and ultimately enhancing the quality of healthcare delivery in Japan. Declarations Ethics approval and consent to participate This study was approved by the Ethical Review Committee of the Japan Organization for Advancing Medical Education (approval no. 24–1). All the participants provided informed consent before participating in the study. The study was conducted in accordance with the ethical standards and principles of the Declaration of Helsinki. Consent for Publication Informed consent was obtained from all participants for the publication of identifying information in an online open-access publication. All participants read and signed an informed consent form before participating in the study. To ensure confidentiality, all participants’ data were anonymized prior to analysis. No compensation was provided to participants for their involvement in the study. Data Availability Statement The data underlying this article will be shared on reasonable request to the corresponding author. Disclosure of Interest JAMEP was involved in collecting and managing data as a GM-ITE administrative organization. It did not participate in designing and conducting the study, data analysis and interpretation, preparation, review, approval of the manuscript, or the decision to submit the manuscript for publication. Dr. Nishizaki received an honorarium from JAMEP as GM‑ITE project manager. Dr. Tokuda is the director of JAMEP. Dr. Kobayashi received an honorarium from JAMEP as a speaker of JAMEP lecture. Dr. Shikino received an honorarium from JAMEP as a reviewer for the GM‑ITE. Dr. Shikino, Dr. Shimizu, and Dr. Yamamoto received honoraria from JAMEP as exam preparers for the GM‑ITE. The authors declare no competing interests. Funding This work was supported by the Health, Labour, and Welfare Policy Grants of Research on Region Medical (21IA2004) from Japan’s Ministry of Health, Labour, and Welfare. The funder had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. Authors’ Contributions KS had full access to all the study data and took responsibility for the integrity and accuracy of the data analysis; KS, YN, SF, and YT: study concept and design; HK, KN, TS, and YY: data acquisition, analysis, and interpretation; KS: manuscript drafting; YN: critical content revision; KS: statistical analysis; YN and YT: administrative, technical, and material support; YN, SF, YY, KN, HK, TS, and YT: supervision. YN contributed equally to this work and should be considered a co-corresponding author. Acknowledgments We thank the residency program directors who participated in our research: Dr. Satoshi Fujimi, Dr. Takeshi Fujimoto, Dr. Sawako Fujiwara, Dr. Kenko Maeda, Dr. Taizo Nakanishi, Dr. Hiroaki Nishioka, Dr. Naoya Takeda, Dr. Takao Tsuzuki, and Dr. Tomokiyo Yamamoto. References Shikino K, Sekine M, Nishizaki Y, Yamamoto Y, Shimizu T, Fukui S, Nagasaki K, Yokokawa D, Watari T, Kobayashi H, Tokuda Y. Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study. BMC Med Educ. 2024;24:316. Watanabe S, Kataoka K, Sekine M, Aune D, Shikino K, Nishizaki Y. Characteristics of University Hospitals Implementing the Postgraduate Clinical Training "Tasukigake Method" and Their Correlation with Program Popularity: A Cross-Sectional Study. Adv Med Educ Pract. 2023:14:323–332. Nagasaki K, Kobayashi H. The effects of resident work hours on well-being, performance, and education: A review from a Japanese perspective. J Gen Fam Med. 2023;24:323–331. Heist BS, Torok HM. Contrasting Residency Training in Japan and the United States From Perspectives of Japanese Physicians Trained in Both Systems. J Grad Med Educ. 2019;11:125–133. Fukui S, Shikino K, Nishizaki Y, Shimizu, T., Yamamoto, Y., Kobayashi, H, et al. Association between regional quota program in medical schools and practical clinical competency based on general medicine in-training examination score: A nationwide cross-sectional study of resident physicians in Japan. Postgrad Med J. 2023;99:1197–204. Nagasaki K, Nishizaki Y, Nojima M, Shimizu T, Konishi R, Okubo T, et al. Validation of the general medicine in-training examination using the Professional and Linguistic Assessments Board examination among postgraduate residents in Japan. Int J Gen Med. 2021;14:6487–95. Shikino K, Nishizaki Y, Fukui S, Yokokawa D, Yamamoto Y, Kobayashi H, et al. Development of a clinical simulation video to evaluate multiple domains of clinical competence: cross-sectional study. JMIR Med Educ. 2024;10: e54401. Crites K, Johnson J, Scott N, Shanks A.Increasing Diversity in Residency Training Programs. Cureus. 2022;14(6):e25962. Ercan-Fang NG, Mahmoud MA, Cottrell C, Campbell JP, MacDonald DM, Arayssi T, Rockey DC. Best Practices in Resident Research- A National Survey of High Functioning Internal Medicine Residency Programs in Resident Research in USA. Am J Med Sci. 2021;361(1):23–29. Yang A, Gilani C, Saadat S, Murphy L, Toohey S, Boysen-Osborn M. Which Applicant Factors Predict Success in Emergency Medicine Training Programs? A Scoping Review. AEM Educ Train. 2020;4:191–201. Hartman ND, Lefebvre CW, Manthey DE. A Narrative Review of the Evidence Supporting Factors Used by Residency Program Directors to Select Applicants for Interviews. J Grad Med Educ. 2019;11:268–273. Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Med Teach. 2020;42:846–854. King N. Using templates in the thematic analysis of text. In: Cassel C, Symon G, editors. Essential guide to qualitative methods in organizational research. London: Sage; 2004. p. 256–70. Niu W, Cheng L, Duan D, Zhang Q. Impact of Perceived Supportive Learning Environment on Mathematical Achievement: The Mediating Roles of Autonomous Self-Regulation and Creative Thinking. Front Psychol. 2022;12:781594. Silén C, Manninen K, Fredholm A. Designing for student autonomy combining theory and clinical practice - a qualitative study with a faculty perspective. BMC Med Educ. 2024;24(1):532. Crockett C, Joshi C, Rosenbaum M, Suneja M. Learning to drive: resident physicians' perceptions of how attending physicians promote and undermine autonomy. BMC Med Educ. 2019;19:293. Naveh E, Katz-Navon T, Stern Z. Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature. Adv Health Sci Educ Theory Pract. 2015;20:59–71. Haggins A, Clery M, Ahn J, Hogikyan E, Heron S, Johnson R, Hopson LR. Untold stories: Emergency medicine residents' experiences caring for diverse patient populations. AEM Educ Train. 2021;5:S19-S27. O'Malley AS, Rich EC, Shang L, Rose T, Ghosh A, Poznyak D, Peikes D. New approaches to measuring the comprehensiveness of primary care physicians. Health Serv Res. 2019;54:356–366. Abdulrahaman MD, Faruk N, Oloyede AA, Surajudeen-Bakinde NT, Olawoyin LA, Mejabi OV, Imam-Fulani YO, Fahm AO, Azeez AL. Multimedia tools in the teaching and learning processes: A systematic review. Heliyon. 2020;6:e05312. Nzabonimana E, Isyagi MM, Njunwa KJ, Hackley DM, Razzaque MS. Use of an online medical database for clinical decision-making processes: assessment of knowledge, attitude, and practice of oral health care providers. Adv Med Educ Pract. 2019;10:461–467. Muhiyaddin R, Abd-Alrazaq AA, Househ M, Alam T, Shah Z. The Impact of Clinical Decision Support Systems (CDSS) on Physicians: A Scoping Review. Stud Health Technol Inform. 2020;272:470–473. Bennett D, O'Flynn S, Kelly M. Peer assisted learning in the clinical setting: an activity systems analysis. Adv Health Sci Educ Theory Pract. 2015;20:595–610. Pethrick H, Nowell L, Paolucci EO, Lorenzetti L, Jacobsen M, Clancy T, Lorenzetti DL. Peer mentoring in medical residency education: A systematic review. Can Med Educ J. 2020;11:e128-e137. Telio S, Ajjawi R, Regehr G. The "educational alliance" as a framework for reconceptualizing feedback in medical education. Acad Med. 2015;90:609–14. Shafian S, Ilaghi M, Shahsavani Y, Okhovati M, Soltanizadeh A, Aflatoonian S, Karamoozian A. The feedback dilemma in medical education: insights from medical residents' perspectives. BMC Med Educ. 2024;24:424. de la Cruz MS, Kopec MT, Wimsatt LA. Resident Perceptions of Giving and Receiving Peer-to-Peer Feedback. J Grad Med Educ. 2015;7:208–13. Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85:1118–24. Abdul Rahman NF, Davies N, Suhaimi J, Idris F, Syed Mohamad SN, Park S. Transformative learning in clinical reasoning: a meta-synthesis in undergraduate primary care medical education. Educ Prim Care. 2023;34:211–219. Borhani-Haghighi A. How Can Clinical Communication Skills Improve Patient-Physician Relationship Building? Galen Med J. 2022:11:e2480. Additional Declarations Competing interest reported. JAMEP was involved in collecting and managing data as a GM-ITE administrative organization. It did not participate in designing and conducting the study, data analysis and interpretation, preparation, review, approval of the manuscript, or the decision to submit the manuscript for publication. Dr. Nishizaki received an honorarium from JAMEP as GM ITE project manager. Dr. Tokuda is the director of JAMEP. Dr. Kobayashi received an honorarium from JAMEP as a speaker of JAMEP lecture. Dr. Shikino received an honorarium from JAMEP as a reviewer for the GM ITE. Dr. Shikino, Dr. Shimizu, and Dr. Yamamoto received honoraria from JAMEP as exam preparers for the GM ITE. The authors declare no competing interests. Supplementary Files Supplementaryfile1Shikino.docx Supplementary file 1. Interview guide Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Apr, 2026 Reviews received at journal 09 Apr, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviews received at journal 23 Nov, 2025 Reviewers agreed at journal 09 Nov, 2025 Reviewers invited by journal 23 Oct, 2025 Editor invited by journal 07 Jul, 2025 Editor assigned by journal 04 Jul, 2025 Submission checks completed at journal 03 Jul, 2025 First submitted to journal 02 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7030199","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":538655923,"identity":"7d166265-3c92-4803-bdf7-9b1d3b19c693","order_by":0,"name":"Kiyoshi 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JAMEP was involved in collecting and managing data as a GM-ITE administrative organization. It did not participate in designing and conducting the study, data analysis and interpretation, preparation, review, approval of the manuscript, or the decision to submit the manuscript for publication. Dr. Nishizaki received an honorarium from JAMEP as GM ITE project manager. Dr. Tokuda is the director of JAMEP. Dr. Kobayashi received an honorarium from JAMEP as a speaker of JAMEP lecture. Dr. Shikino received an honorarium from JAMEP as a reviewer for the GM ITE. Dr. Shikino, Dr. Shimizu, and Dr. Yamamoto received honoraria from JAMEP as exam preparers for the GM ITE. The authors declare no competing interests.","formattedTitle":"Key factors for high-quality residency training programs: Insights from program directors through thematic analysis","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eIn Japan, clinical training programs for resident physicians are crucial for shaping the future of the healthcare workforce, as they provide comprehensive education and practical experiences to ensure that resident physicians develop the skills and confidence necessary to deliver high-quality patient care [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite the structured framework of clinical training, there is considerable variability in the performance outcomes of different residency programs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This suggests that certain factors within programs may significantly enhance residents\u0026rsquo; competencies. Identifying these factors is crucial to improve medical education and ensure that all resident physicians receive the best possible training.\u003c/p\u003e\u003cp\u003eThe General Medicine In-Training Examination (GM-ITE) is a key benchmark assessment in Japan and is administered annually to approximately half of all resident physicians [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This examination evaluates the competencies acquired during residency training and measures the overall quality of the training programs. High performance on GM-ITE indicates effective training practices and superior educational outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In addition to traditional multiple-choice questions, the GM-ITE now includes an innovative component known as the Clinical Simulation Video-Innovative Examination (CSV-IE) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This component, which assesses specific competencies in clinical reasoning, communication, and decision-making, presents simulated patient scenarios in emergency settings to evaluate how residents apply their medical knowledge in real-world contexts. The previous study showed remarkable correlations between the GM-ITE scores and CSV-IE performance, indicating the potential value of this innovative assessment tool.\u003c/p\u003e\u003cp\u003eWhile many elements that contribute to effective clinical training have been widely studied and are embedded in international standards like those set by the ACGME in the United States\u0026mdash;such as autonomy, feedback, and diverse patient exposure [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u0026mdash;the unique context of residency programs in Japan, particularly in relation to success on the CSV-IE, remains underexplored. Furthermore, residency programs in Japan often operate with limited resources, making it essential to identify efficient and targeted training practices that can optimize clinical competencies within these constraints. This study focuses specifically on uncovering the characteristics of high-performing residency programs in Japan, with an emphasis on how they prepare residents for success in the CSV-IE. These insights can inform both the improvement of medical education frameworks in Japan and the development of strategies to efficiently train resident physicians under resource constraints.\u003c/p\u003e\u003cp\u003eIn this study, we conducted semi-structured interviews with program directors from the top 25% of residency programs, based on their performance in the CSV-IE component of the GM-ITE. By using thematic analysis, we aimed to identify the specific factors that contribute to high performance in residency training, offering valuable insights that can guide program improvements and policy development. The findings will help to clarify how residency programs can better prepare their physicians for practical, real-world challenges and ultimately enhance the quality of healthcare in Japan.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study aimed to identify the key factors contributing to the effectiveness of residency training programs in Japan, with a specific focus on performance in the CSV-IE. The CSV-IE is a component of the General Medicine In-Training Examination (GM-ITE), which evaluates competencies such as clinical reasoning, communication, and decision-making by presenting real-world clinical scenarios in video format. We conducted semi-structured interviews with program directors from high-performing residency programs, defined by their residents\u0026rsquo; performance on the CSV-IE. The accuracy rate, defined as the percentage of correct responses to the CSV-IE scenarios, was used to rank the residency programs. Of the 701 programs that participated in the GM-ITE, 73 programs achieved an accuracy rate of at least 25% on the CSV-IE. These programs were considered high-performing for the purposes of this study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterviewee information\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHospital information\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePosition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHospital type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHospital beds (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNumber of physician (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNumbers of resident physicians (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNumber of ambulance transports per year (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNumber of emergency department visits per year (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eCSV-IE accuracy rate (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e486\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1666\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e9061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e41.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e384\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1564\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e9452\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e38.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e460\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e159\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2570\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e15262\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e30.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e520\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2408\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1358\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e54.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e768\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e3559\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e11508\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e26.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e704\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2726\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e16669\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e38.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e661\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e10829\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e30.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e865\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e293\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2060\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e7669\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e27.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProgram director\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCommunity hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e560\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1833\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e7054\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e25.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIt is important to note that the CSV-IE is a relatively new and innovative tool designed to assess residents' ability to apply medical knowledge in clinical scenarios. The validity of the CSV-IE has been supported by prior research showing strong correlations between GM-ITE scores and CSV-IE performance [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, further validation studies are ongoing to ensure its accuracy and applicability across different clinical settings. The scoring of the CSV-IE is based on predefined clinical decision-making criteria, and scores are assigned based on the appropriateness of the residents' responses to the simulated clinical situations.\u003c/p\u003e\u003cp\u003eFrom the 73 high-performing institutions, we selected 14 that had more than 10 examinees in the CSV-IE for further study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of these, nine program directors agreed to participate in interviews. Theoretical saturation was reached after these nine interviews, as no new themes or insights emerged during the last interviews, indicating that additional interviews were unlikely to generate new information.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eData source\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSemi-structured interviews, averaging 45 minutes in length, were conducted with nine program directors from the selected high-performing residency programs. The interviews were conducted by KS, YN, SF, YY, and TS. All interviews were recorded and transcribed verbatim for analysis. An interview guide was developed based on the research objectives, focusing on factors contributing to high performance in the CSV-IE. The guide included open-ended questions designed to explore specific competencies evaluated by the CSV-IE, such as clinical reasoning, decision-making, and communication skills. While the guide was deductively constructed, we also incorporated inductive questions to capture any additional factors that may contribute to program success (Supplementary File 1). The questions were aligned with both the literature on residency training and the competencies targeted by the CSV-IE, ensuring relevance to the study\u0026rsquo;s focus.\u003c/p\u003e\u003cp\u003e\u003cb\u003eReflexivity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted this qualitative study using thematic analysis to determine program components that are effective in the training of resident physicians. In qualitative research, the background and potential biases of the researchers can influence data interpretation, making reflexivity crucial to ensure credibility. In this study, none of the researchers had formal relationships with the program directors interviewed. Additionally, the research team consisted of clinical educators with experience in residency training, which helped ensure a balanced understanding of both educational theory and practical clinical training.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnalysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThematic analysis was used to analyze the interview transcripts [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Coding was conducted by KS and SF, and a codebook was developed based on both deductive and inductive themes. The initial code template was refined through discussion, and consensus was reached on the final themes. To enhance the validity of the results, we plan to confirm the identified themes with several of the participating program directors and compare them with characteristics of lower-performing programs. This additional step will help ensure that the themes identified in high-performing programs are not universally applicable and can serve as specific benchmarks for program improvement.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cb\u003eSelection Bias and Resident Baseline Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne concern in this study is whether superior performance on the CSV-IE is attributable to the residency programs themselves or to the baseline quality of the residents entering those programs. To address potential selection bias, baseline data on residents entering the high-performing programs were collected, including academic background, prior clinical experience, and entrance exam scores. The data suggest some variation in academic performance, but most residents had similar levels of clinical experience upon entering residency. Notably, no significant differences in pre-residency academic metrics were observed between residents in high-performing programs and those from average programs. This indicates that the residency programs themselves likely play a substantial role in preparing residents for success on the CSV-IE. However, further research with larger sample sizes is necessary to control for individual resident quality and better isolate program-related factors.\u003c/p\u003e\u003cp\u003e\u003cb\u003eKey Themes and Consolidation of Sub-Themes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThrough thematic analysis of the interviews with program directors, we identified seven primary themes and a set of consolidated sub-themes that represent the key factors contributing to the effectiveness of high-performing residency programs. Redundant sub-themes within and between primary themes were consolidated to improve clarity and avoid overlap. A detailed breakdown of these themes is provided below, and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e offers a concise summary.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe results of thematic analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuote\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003eActive engagement and autonomy in clinical practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eActive engagement in clinical practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Emergency outpatient care plays a significant role in the training, where resident physicians feel they can take a proactive role in patient care. In other medical departments, the extent to which resident physicians can engage depends on how much they express a desire to participate. If a resident physician indicates they do not want to do much, they are likely to end up observing next to a supervising physician.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAutonomous patient care by resident physician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Resident physicians are likely the main force handling first contact in the emergency department. The anesthesiology department also operates as an incredibly valuable force. As for other departments, it depends on the specific department. General internal medicine sees patients with resident physicians acting as attending physicians, but to speak frankly, they might not be in trouble even without resident physicians. I believe other departments likely share this stance.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAutonomous patient care experience with responsibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"For routine matters, everything is done by the residents. Depending on the disease, when nurses ask \"Who gets the first call?\" the senior doctors will say \"Please give the first call to the residents,\" so that the residents are the ones who receive the first call.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAutonomous patient care with sufficient support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"In the emergency department, the on-call supervisors include one emergency physician, one internal medicine physician, one surgeon, who all provide backup for resident physicians. Additionally, there's always one cardiologist on-call to handle relevant diseases. The majority of supervising physicians in the emergency department are around their 10th to 15th year. Resident physicians receive support from their second-year colleagues up until around summer, after which they generally become capable of working independently.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh decision-making responsibility in patient care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Many of our on-call physicians have completed their clinical training at our facility, so younger physicians, who have recently finished their training, tend to work closely with the resident physicians during emergency on-call duties. However, in the case of older instructors, there's a tendency to leave the resident physicians to manage on their own to a large extent.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh responsibility in patient care with patient ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"We've been implementing the resident physician primary care system for quite some time now. When patients are admitted, depending on the rotation department, resident physicians primarily take charge of the patients as their main physicians, with supervising physicians assigned to guide them. This structure emphasizes the autonomy of the resident physicians, allowing them a degree of responsibility as part of the program.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh responsibility in patient care with sufficient support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Emergency medicine rotations are mandatory for both first-year and second-year resident physicians, lasting one month each, where they genuinely handle patient assessments from the first touch. For such instances, mid-level physicians or, if during daytime hours, emergency medicine physicians, supervise and provide guidance in this structured format.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTraining with autonomous patient care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"In our facility, the annual number of emergency transports is about 4,200. Almost all cases are first touched by trainee doctors. We have about 120 cases of cardiac arrest, and although these are considered level 3 emergencies, almost all cases are first touched by trainee doctors as well.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eAbundant opportunity to experience diverse patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComprehensive medical specialties exposure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"When there are few doctors, people often ask, 'What about the educational system?' But, having fewer doctors means there are more opportunities. Whether it's for initial training or specialized training, we manage with this number of full-time staff, covering most medical disciplines.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiverse patient population exposure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\"Both patients with a primary care physician and those without one, of course, visit the emergency department, including a significant number of first-time patients. This aspect differs from university hospitals, characterizing a community hospital. I think this provides a valuable learning experience.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOpportunities for experiencing many clinical cases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"The cases experienced by resident physicians vary from walk-ins, severe and complex referrals. The medical service area serves 500,000 people, with about 30,000 emergency outpatient visits and approximately 10,000 ambulance calls per year.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOpportunities for experiencing many clinical cases in ER\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"The average number of annual emergency department visits at facilities taking the GM-ITE was about 8,000, but in our case, we probably saw about twice to three times that amount.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnhanced learning resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAccess to clinical decision support tool\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\"The clinical decision support tool \"Today's Clinical Support\" is integrated into the electronic health record system. Resident physicians frequently use it to confirm their clinical decisions, finding it useful for patient care in the emergency department.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAccess to online leaning resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"For online resources, including UpToDate, the environment is set up so that resident physicians can search for information on their smartphones.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCustomized educational resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"The attending physician in general internal medicine has compiled various literatures into a single booklet, creating an ER manual that aids in physical examination and clinical reasoning. This manual is used as a textbook, serving as an original resource for resident physicians at our facility, specifically designed for their training.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePeer-assisted learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase reflection practices and problem-based learning approach in conferences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\"In the emergency department, there's a reflection session held after the day shift where resident physicians review the cases they encountered. It's unclear if every single case is discussed, but the session typically focuses on representative cases experienced by the resident physicians during the day, with a senior physician leading the review conference.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeer teaching and learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"In the emergency department, there's a structure where first-year and second-year resident physicians train together, with the second-year teaching the first-year. Alternatively, second-year resident physicians and fellows work together, with the fellows teaching. This forms what's referred to as a tiered, or cascading, mentorship system.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeer-to-peer learning and mentorship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"In the emergency department training, I believe the cascading mentorship system is functioning well. Second-year resident physicians advise first-year resident physicians on various matters, such as how to handle orders or whom to consult for specific issues and offer strategies for dealing with different supervisors. Similarly, fellows provide guidance to second-year resident physicians, ensuring a layered learning environment is in place.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstanding the problems in residency training and education improvement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"I've been a bit concerned lately because there seem to be many resident physicians who may not be sufficiently trained in conducting physical examinations. Moving forward, I want to focus on strengthening this area.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eSupportive educational framework\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAutonomous patient care experience with minimal support by attending physicians\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Resident physicians are conducting examinations in the emergency department from the beginning. If a trainee seems particularly inexperienced, I might join the examination partway through or give them some advice, but in most cases, trainees are conducting the examinations and ordering tests on their own.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAutonomous patient care experience with necessary support by senior physicians\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Resident physicians are encouraged to do as much as they can on their own, but beyond that point, consultations are always checked by an attending physician.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e Feedback and case review system\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Resident physicians sometimes overlook things, so while giving advice on potential findings that might be hidden, the final decision on whether to discharge the patient or admit them to the hospital is always made by a senior physician.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFeedback culture free of criticism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Of course, resident physicians can't handle emergency responses right from the start, so they often seek advice from attending physicians. When resident physicians consult with their attending physicians, the guidance is always provided with a positive attitude, never with annoyance or disdain, and there is absolutely no criticism or belittlement involved.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eClinical reasoning education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase-based practical education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"In the past, residents simply presented cases they had experienced themselves. They would present something like, 'There was this case, and this is what happened.' However, just presenting from the start wasn't very interesting, so we decided to release clinical information bit by bit, encouraging those around to make differential diagnoses, essentially turning it into a conference in the style of problem-based learning.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOff-the-job opportunity to learn clinical reasoning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"Once a week, the attending physicians in general internal medicine read from the New England Journal of Medicine's Clinical Problem Solving Collection and engage in studies on diagnostics with the resident physicians. This activity continues throughout the six months of rotation in internal medicine, and resident physicians are called upon in turn to participate. Even those resident physicians who do not specialize in internal medicine are encouraged to engage in these diagnostic studies.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoutine clinical reasoning exercises\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"We have a conference every day at noon. It's conducted on the spot without prior preparation, where all gathered members participate, but a resident physician is always the presenter. They present patients they've encountered in the emergency department or internal medicine ward, starting with the chief complaint and a brief history. The attending audience then collaborates to discuss what kind of questioning would be appropriate for such chief complaints.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessionalism development\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation on professional communication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e\"We put a lot of emphasis on communication for various reasons, including preventing troubles. Every summer, we hold a study session that lasts an entire day, focusing on communication training. We invite volunteers, known as SPs, to participate in scenarios that involve explaining complex cases to patients or role-playing such interactions.\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: Active engagement and autonomy in clinical practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eResidents in high-performing programs were given substantial responsibility in patient care, fostering autonomy and active engagement in their roles.\u003c/p\u003e\u003cp\u003e\u003cb\u003eActive engagement in clinical practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEncouraging resident physicians to take initiative and make autonomous clinical decisions considerably enhanced their confidence and competence. This was particularly evident in emergency outpatient care where residents were often the first point of contact.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAutonomous patient care by resident physician\u003c/b\u003e\u003c/p\u003e\u003cp\u003eResident physicians are frequently the primary handlers in patient care, especially in emergency departments. They are expected to manage routine matters independently, which prepares them for their future responsibilities.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAutonomous patient care experience with responsibility\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEmphasizing the importance of critical thinking and decision-making in emergency care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAutonomous patient care with sufficient support\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA structured support system with senior oversight ensures safe learning, while allowing residents to gradually take on more responsibility. This approach fosters a sense of independence and confidence in one\u0026rsquo;s own clinical abilities.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHigh responsibility in decision-making in patient care\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe level of supervision and teaching varies depending on the on-call physician, highlighting the need for adaptability. This structure ensures that residents are not left without adequate support, thereby promoting a balanced learning environment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHigh responsibility in patient care with patient ownership\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA system where residents act as primary physicians and make decisions regarding consultations fosters a sense of responsibility and independence. This direct involvement in patient care, including critical care, helps develop critical decision-making skills and ensures that residents feel ownership and accountability for their patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHigh responsibility in patient care with sufficient support\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA balanced approach, in which residents have high responsibility but also sufficient support, ensures optimal learning and patient safety.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTraining with autonomous patient care\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe importance of structured rotations in emergency departments and other specialties for a comprehensive training experience has been emphasized. These rotations provide residents with the necessary skills and confidence to handle patient care autonomously.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Abundant opportunity to experience diverse patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003eExposure to a broad spectrum of medical conditions and patient populations significantly enhanced clinical competence.\u003c/p\u003e\u003cp\u003e\u003cb\u003eComprehensive medical specialties exposure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTrainees at these institutions covered a wide range of medical specialties, ensuring well-rounded clinical education. Exposure to various fields of medicine was crucial for developing a broad understanding of different medical conditions and treatments.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDiverse patient population exposure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eExposing trainees to a wide range of patient demographics and conditions provided them with a well-rounded clinical understanding. Resident physicians encountered a variety of patients, enhancing their ability to effectively handle different medical scenarios.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOpportunities for experiencing many clinical cases\u003c/b\u003e\u003c/p\u003e\u003cp\u003eResident physicians encountered a wide range of cases, from walk-ins to complex referrals, which facilitate a deeper understanding of various medical conditions. Extensive exposure was instrumental for building clinical expertise.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOpportunities for experiencing many clinical cases in ER\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEmphasizing hands-on experience in emergency settings was deemed crucial for developing practical skills. The volume and variety of cases in the emergency department provided resident physicians with essential real-world experience.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3: Enhanced learning resources\u003c/b\u003e\u003c/p\u003e\u003cp\u003e High-performing programs provided residents with advanced learning resources that facilitated evidence-based clinical decision-making.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAccess to clinical decision support tool\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAccess to diagnostic and clinical support resources facilitated evidence-based learning. Resident physicians frequently utilized these tools to confirm their clinical decisions and enhance their ability to provide quality patient care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAccess to online learning resources\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAccess to online learning resources involves the strategic use of digital platforms and collaborative decision-making in resource acquisition to meet trainees' dynamic needs. This access allows residents to efficiently find and use information relevant to their clinical practice. Providing comprehensive learning materials and online resources, such as UpToDate, supports self-directed learning, enabling residents to independently seek and study information pertinent to their clinical training.\"\u003c/p\u003e\u003cp\u003e\u003cb\u003eCustomized educational resources\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe development of tailored educational materials such as ER manuals supported specific learning needs. These customized resources were designed to address the unique requirements of resident physicians and enhance their learning experiences.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 4: Peer-assisted learning\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCollaborative learning, particularly peer-assisted learning, was a cornerstone of resident education in these programs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase reflection practices and problem-based learning approach in conferences\u003c/b\u003e\u003c/p\u003e\u003cp\u003eReflective and problem-based learning approaches stimulated clinical reasoning and diagnostic skills. These sessions were integral to helping residents learn from real-world cases and improve their clinical competencies.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePeer teaching and learning\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAdaptable teaching approaches and cross-disciplinary education have enriched the learning experiences. Senior residents and colleagues played a remarkable role in teaching junior colleagues and creating a dynamic and collaborative learning environment.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePeer-to-peer learning and mentorship\u003c/b\u003e\u003c/p\u003e\u003cp\u003eLearning and mentorship in emergency settings, including tips and strategies for peers, were crucial for building a supportive and effective learning environment. This cascading mentorship system ensured that knowledge and skills were passed down through different levels of experience.\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnderstanding the problems in residency training and education improvement\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRecognizing the need for flexible learning strategies to address gaps and enhance skills was a critical component of these programs. Continuous evaluation and adaptation of training processes were emphasized to ensure that all residents received comprehensive training.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 5: Supportive educational framework\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA structured yet flexible educational framework that balanced trainee autonomy with constructive feedback was key to the development of clinical competence.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAutonomous patient care experience with minimal support by attending physicians\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe trainees gradually assumed more responsibilities and transitioned from observation to active participation. This approach allowed residents to build confidence and competence in patient care while knowing that they could seek support when needed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAutonomous patient care experience with necessary support by senior physicians\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBalancing trainee autonomy with access to consultative support was crucial to ensure learning while maintaining patient safety. Residents were encouraged to manage patient care independently, but senior physicians were available for guidance and final decisions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFeedback and case review system\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStructured feedback mechanisms were in place where senior physicians and trainees discussed the findings and reviewed the cases. This systematic feedback approach helped trainees learn from their experiences and improve their clinical skills.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFeedback culture free of criticism\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMaintaining a supportive environment in which trainees could learn from feedback without fear of criticism was emphasized. The feedback culture was designed to be positive and constructive, ensuring that the residents felt comfortable seeking advice and learning from their experiences.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 6: Clinical reasoning education\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTraining programs placed a strong emphasis on developing clinical reasoning skills, which were crucial for success on the CSV-IE.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase-based practical education\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTraining emphasized active participation rather than mere observation, fostering a sense of responsibility among trainees. The case-based education was designed to engage residents in real-world problem-solving and diagnostic exercises.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOff-the-job opportunity to learn clinical reasoning\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe trainees were encouraged to use clinical resources such as the New England Journal of Medicine (NEJM) and UpToDate for self-directed learning. These resources provide valuable opportunities for residents to study and enhance their diagnostic skills outside direct patient care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRoutine clinical reasoning exercises\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIncorporating daily exercises into clinical reasoning and case discussions was a common practice to reinforce diagnostic and problem-solving skills. These routine exercises ensured that residents consistently applied their clinical knowledge in practical settings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 7: Professionalism development\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProfessionalism, particularly in communication and teamwork, was a focus of resident development in these programs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEducation on professional communication\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStrategically emphasizing the improvement of trainees\u0026rsquo; communication skills was a key component of training programs. This focus was aimed at ensuring that residents could effectively interact with patients and colleagues, thereby enhancing the quality of care and preventing misunderstandings.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAn analysis of interviews with program directors from high-performing institutions in GM-ITE revealed seven key themes that contributed to the effective training of resident physicians. These findings offer valuable insights into the factors that enhance clinical competence and the quality of education in the context of initial clinical training in Japan. In order to validate the relevance and applicability of these themes, we compared our findings with existing literature on high-performing residency programs. For instance, one study emphasizes the importance of a supportive learning environment and feedback mechanisms, which aligns with our identified themes of a supportive educational framework and structured feedback culture [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, the emphasis on diverse clinical exposure and autonomy in clinical practice found in our study is corroborated by some research [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which highlights the significance of experiential learning and autonomy in medical education. By comparing our themes with these established studies, we can affirm that our findings are consistent with recognized effective practices in residency training.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: Active engagement and autonomy in clinical practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe importance of active engagement and autonomy in clinical practice cannot be overemphasized. The opportunity for resident physicians to take the lead in patient care, especially in emergency settings, fosters a sense of responsibility and confidence [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Encouraging autonomous decision-making while providing the necessary support ensures that residents develop critical thinking skills and clinical competence. This balance between independence and supervision aligns with the broader educational goal of preparing residents for real-world medical practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Abundant opportunity to experience diverse patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003eExposure to diverse patient populations across various medical specialties enriches the training experience [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. High-performing institutions offer residents the opportunity to manage a wide range of clinical cases, from routine checkups to complex emergencies. This diversity not only broadens their clinical knowledge but also enhances their adaptability and problem-solving abilities. Such comprehensive exposure is essential for developing well-rounded physicians capable of addressing a wide spectrum of medical conditions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3: Enhanced learning resources\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAccess to advanced learning resources extensively boosts educational experience [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Tools, such as clinical decision support systems and online databases, provide residents with immediate access to evidence-based information and facilitate informed clinical decisions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Customized educational materials tailored to residents\u0026rsquo; specific needs further support their learning, ensuring that they have the necessary resources to excel in their training.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 4: Peer-assisted learning\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePeer-assisted learning creates a collaborative and supportive learning environment through mechanisms such as case-reflection practices and cascading mentorship systems [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Residents benefit from the guidance of more experienced peers and fellows, which helps them navigate complex clinical situations [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This approach not only enhances clinical skills but also fosters a culture of teamwork and mutual support, which is critical in medical practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 5: Supportive educational framework\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA supportive educational framework that balances autonomy with structured feedback is crucial for effective learning [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Providing residents with increasing levels of responsibility and constructive feedback from senior physicians ensures continuous skill development [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. A feedback culture that is free of criticism encourages residents to seek advice and learn from their experiences without fear of judgment, thereby promoting a positive learning environment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 6: Clinical reasoning education\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFocusing on clinical reasoning education through case-based practical education and routine exercises helps residents develop robust diagnostic skills [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Institutions that emphasize active participation in clinical problem solving and provide opportunities for self-directed learning enable residents to build strong analytical and decision-making capabilities. These skills are essential for an accurate diagnosis and effective patient care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 7: Professionalism development\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDeveloping professional communication skills is essential for effective patient interaction and overall clinical practice [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Institutions that prioritize communication training ensure that residents are well-equipped to handle complex patient interactions and collaborate effectively with colleagues. This focus on professionalism not only enhances the quality of care but also helps prevent misunderstandings and conflicts in the clinical setting.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for initial clinical training in Japan\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe findings of this study have remarkable implications for the design and implementation of clinical training programs in Japan. By integrating these themes into training curricula, educational institutions can enhance the clinical competence and professional development of resident physicians. This comprehensive approach ensures that residents are well-prepared to meet the demands of modern medical practice and deliver high-quality patient care (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRecommendation lists for residency training program\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnhance Autonomy with Supervision: Encourage resident physicians to take on more responsibilities while providing necessary support to ensure patient safety and effective learning.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiversify Clinical Exposure: Ensure that residents have access to a broad range of clinical cases and patient demographics to develop well-rounded clinical skills.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUtilize Advanced Learning Resources: Integrate clinical decision support tools and online learning platforms into the training program to facilitate evidence-based practice.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePromote Peer-Assisted Learning: Foster a collaborative learning environment through peer teaching and mentorship systems.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImplement Structured Feedback Mechanisms: Establish a feedback culture that is constructive and free of criticism to encourage continuous learning.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFocus on Clinical Reasoning Education: Incorporate case-based learning and routine clinical reasoning exercises into the curriculum to strengthen diagnostic skills.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDevelop Professional Communication Skills: Conduct regular communication training sessions to improve residents' ability to effectively interact with patients and colleagues.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study has some limitations that should be considered when interpreting the findings. First, while providing in-depth insights, the sample size of the nine program directors was relatively small and may not fully represent the diversity of clinical training programs across Japan. Future studies with larger and more diverse samples would help validate and generalize the findings. Second, the study relied on self-reported data from program directors, which may have been subject to bias. Directors might present their programs in a more favorable light, potentially overlooking challenges or areas requiring improvement. Triangulating these findings with other data sources such as direct observations or resident feedback could enhance the reliability of the results. Third, the cross-sectional nature of the study captures a snapshot of time and may not account for changes or developments in the programs over time. Longitudinal studies that track the evolution of training programs and their impact on resident performance would provide a more comprehensive understanding. Fourth, the study focused on high-performing institutions, as determined by CSV-IE accuracy rates. This focus may limit the applicability of the findings to programs with lower performance levels that may face different challenges and require distinct strategies for improvement. Finally, the integration and impact of the CSV-IE within the GM-ITE framework is still relatively new. Therefore, the long-term effects and potential benefits of this innovative assessment tool for resident training and competency development require further exploration through extended studies and continuous evaluation. Despite these limitations, this study provides valuable insights into the factors that contribute to the effectiveness of clinical training programs in Japan, offering a foundation for future research and improvements in medical education.\u003c/p\u003e\u003cp\u003eIn conclusion, this study highlights critical elements that contribute to the effective training of resident physicians in Japan. By focusing on active engagement, diverse clinical exposure, enhanced learning resources, peer-assisted learning, supportive educational frameworks, clinical reasoning education, and professionalism development, training programs can extensively improve future physicians\u0026rsquo; competencies and readiness. These insights provide a valuable framework for optimizing the initial clinical training and ultimately enhancing the quality of healthcare delivery in Japan.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethical Review Committee of the Japan Organization for Advancing Medical Education (approval no. 24\u0026ndash;1). All the participants provided informed consent before participating in the study. The study was conducted in accordance with the ethical standards and principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePublication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained\u0026nbsp;from all participants for the publication of identifying information\u0026nbsp;in an online open-access publication.\u0026nbsp;All participants read and signed an informed consent form before participating in the study. To ensure confidentiality, all participants\u0026rsquo; data were anonymized prior to analysis. No compensation was provided to participants for their involvement in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data underlying this article will be shared on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJAMEP was involved in collecting and managing data as a GM-ITE administrative organization. It did not participate in designing and conducting the study, data analysis and interpretation, preparation, review, approval of the manuscript, or\u0026nbsp;the decision to submit the manuscript for publication. Dr. Nishizaki received an honorarium from JAMEP as GM‑ITE project manager. Dr. Tokuda is the director of JAMEP. Dr. Kobayashi received an honorarium from JAMEP as a speaker of JAMEP lecture. Dr. Shikino received an honorarium from JAMEP as a reviewer for\u0026nbsp;the GM‑ITE. Dr. Shikino, Dr. Shimizu, and Dr. Yamamoto received honoraria from JAMEP as exam preparers for\u0026nbsp;the GM‑ITE. The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Health, Labour, and Welfare Policy Grants of Research on Region Medical (21IA2004) from Japan\u0026rsquo;s Ministry of Health, Labour, and Welfare. The funder had no role in the design and conduct of the study;\u0026nbsp;the\u0026nbsp;collection, management, analysis, and interpretation of the data;\u0026nbsp;the\u0026nbsp;preparation, review, or approval of the manuscript; or\u0026nbsp;the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKS had full access to all the study data and took responsibility for the integrity and accuracy of the data analysis; KS, YN, SF, and YT: study concept and design; HK, KN, TS, and YY: data acquisition, analysis, and interpretation; KS: manuscript drafting; YN: critical content revision; KS: statistical analysis; YN and YT: administrative, technical, and material support; YN, SF, YY, KN, HK, TS, and YT: supervision. YN contributed equally to this work and should be considered a co-corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the residency program directors who participated in our research: Dr. Satoshi Fujimi, Dr. Takeshi Fujimoto, Dr. Sawako Fujiwara, Dr. Kenko Maeda, Dr. Taizo Nakanishi, Dr. Hiroaki Nishioka, Dr. Naoya Takeda, Dr. Takao Tsuzuki, and Dr. Tomokiyo Yamamoto.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShikino K, Sekine M, Nishizaki Y, Yamamoto Y, Shimizu T, Fukui S, Nagasaki K, Yokokawa D, Watari T, Kobayashi H, Tokuda Y. Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study. BMC Med Educ. 2024;24:316.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatanabe S, Kataoka K, Sekine M, Aune D, Shikino K, Nishizaki Y. Characteristics of University Hospitals Implementing the Postgraduate Clinical Training \"Tasukigake Method\" and Their Correlation with Program Popularity: A Cross-Sectional Study. Adv Med Educ Pract. 2023:14:323\u0026ndash;332.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNagasaki K, Kobayashi H. The effects of resident work hours on well-being, performance, and education: A review from a Japanese perspective. J Gen Fam Med. 2023;24:323\u0026ndash;331.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeist BS, Torok HM. Contrasting Residency Training in Japan and the United States From Perspectives of Japanese Physicians Trained in Both Systems. J Grad Med Educ. 2019;11:125\u0026ndash;133.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFukui S, Shikino K, Nishizaki Y, Shimizu, T., Yamamoto, Y., Kobayashi, H, et al. Association between regional quota program in medical schools and practical clinical competency based on general medicine in-training examination score: A nationwide cross-sectional study of resident physicians in Japan. Postgrad Med J. 2023;99:1197\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNagasaki K, Nishizaki Y, Nojima M, Shimizu T, Konishi R, Okubo T, et al. Validation of the general medicine in-training examination using the Professional and Linguistic Assessments Board examination among postgraduate residents in Japan. Int J Gen Med. 2021;14:6487\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShikino K, Nishizaki Y, Fukui S, Yokokawa D, Yamamoto Y, Kobayashi H, et al. Development of a clinical simulation video to evaluate multiple domains of clinical competence: cross-sectional study. JMIR Med Educ. 2024;10: e54401.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCrites K, Johnson J, Scott N, Shanks A.Increasing Diversity in Residency Training Programs. Cureus. 2022;14(6):e25962.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eErcan-Fang NG, Mahmoud MA, Cottrell C, Campbell JP, MacDonald DM, Arayssi T, Rockey DC. Best Practices in Resident Research- A National Survey of High Functioning Internal Medicine Residency Programs in Resident Research in USA. Am J Med Sci. 2021;361(1):23\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang A, Gilani C, Saadat S, Murphy L, Toohey S, Boysen-Osborn M. Which Applicant Factors Predict Success in Emergency Medicine Training Programs? A Scoping Review. AEM Educ Train. 2020;4:191\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHartman ND, Lefebvre CW, Manthey DE. A Narrative Review of the Evidence Supporting Factors Used by Residency Program Directors to Select Applicants for Interviews. J Grad Med Educ. 2019;11:268\u0026ndash;273.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Med Teach. 2020;42:846\u0026ndash;854.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKing N. Using templates in the thematic analysis of text. In: Cassel C, Symon G, editors. Essential guide to qualitative methods in organizational research. London: Sage; 2004. p. 256\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNiu W, Cheng L, Duan D, Zhang Q. Impact of Perceived Supportive Learning Environment on Mathematical Achievement: The Mediating Roles of Autonomous Self-Regulation and Creative Thinking. Front Psychol. 2022;12:781594.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSil\u0026eacute;n C, Manninen K, Fredholm A. Designing for student autonomy combining theory and clinical practice - a qualitative study with a faculty perspective. BMC Med Educ. 2024;24(1):532.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCrockett C, Joshi C, Rosenbaum M, Suneja M. Learning to drive: resident physicians' perceptions of how attending physicians promote and undermine autonomy. BMC Med Educ. 2019;19:293.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNaveh E, Katz-Navon T, Stern Z. Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature. Adv Health Sci Educ Theory Pract. 2015;20:59\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaggins A, Clery M, Ahn J, Hogikyan E, Heron S, Johnson R, Hopson LR. Untold stories: Emergency medicine residents' experiences caring for diverse patient populations. AEM Educ Train. 2021;5:S19-S27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO'Malley AS, Rich EC, Shang L, Rose T, Ghosh A, Poznyak D, Peikes D. New approaches to measuring the comprehensiveness of primary care physicians. Health Serv Res. 2019;54:356\u0026ndash;366.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdulrahaman MD, Faruk N, Oloyede AA, Surajudeen-Bakinde NT, Olawoyin LA, Mejabi OV, Imam-Fulani YO, Fahm AO, Azeez AL. Multimedia tools in the teaching and learning processes: A systematic review. Heliyon. 2020;6:e05312.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNzabonimana E, Isyagi MM, Njunwa KJ, Hackley DM, Razzaque MS. Use of an online medical database for clinical decision-making processes: assessment of knowledge, attitude, and practice of oral health care providers. Adv Med Educ Pract. 2019;10:461\u0026ndash;467.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuhiyaddin R, Abd-Alrazaq AA, Househ M, Alam T, Shah Z. The Impact of Clinical Decision Support Systems (CDSS) on Physicians: A Scoping Review. Stud Health Technol Inform. 2020;272:470\u0026ndash;473.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBennett D, O'Flynn S, Kelly M. Peer assisted learning in the clinical setting: an activity systems analysis. Adv Health Sci Educ Theory Pract. 2015;20:595\u0026ndash;610.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePethrick H, Nowell L, Paolucci EO, Lorenzetti L, Jacobsen M, Clancy T, Lorenzetti DL. Peer mentoring in medical residency education: A systematic review. Can Med Educ J. 2020;11:e128-e137.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTelio S, Ajjawi R, Regehr G. The \"educational alliance\" as a framework for reconceptualizing feedback in medical education. Acad Med. 2015;90:609\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShafian S, Ilaghi M, Shahsavani Y, Okhovati M, Soltanizadeh A, Aflatoonian S, Karamoozian A. The feedback dilemma in medical education: insights from medical residents' perspectives. BMC Med Educ. 2024;24:424.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede la Cruz MS, Kopec MT, Wimsatt LA. Resident Perceptions of Giving and Receiving Peer-to-Peer Feedback. J Grad Med Educ. 2015;7:208\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010;85:1118\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdul Rahman NF, Davies N, Suhaimi J, Idris F, Syed Mohamad SN, Park S. Transformative learning in clinical reasoning: a meta-synthesis in undergraduate primary care medical education. Educ Prim Care. 2023;34:211\u0026ndash;219.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorhani-Haghighi A. How Can Clinical Communication Skills Improve Patient-Physician Relationship Building? Galen Med J. 2022:11:e2480.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"deductive, effective factor, program director, residency program, thematic analysis","lastPublishedDoi":"10.21203/rs.3.rs-7030199/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7030199/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eClinical training programs in Japan play a crucial role in shaping future healthcare professionals by providing resident physicians with comprehensive education and hands-on experience. Despite a structured framework, variability in the outcomes of residency programs indicates that certain factors may significantly enhance residents' competencies. This study aims to identify key factors contributing to the success of high-performing residency programs in Japan, as measured by their performance on the General Medicine In-Training Examination (GM-ITE), particularly the Clinical Simulation Video-Innovative Examination (CSV-IE).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eSemi-structured interviews were conducted with nine program directors from the top 25% ranking residency programs based on the CSV-IE accuracy rates. The interviews explored factors contributing to effective clinical training and were analyzed using thematic analysis. Key themes were identified and consolidated to provide a comprehensive understanding of high-performing programs' characteristics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSeven key themes emerged as contributors to the effectiveness of residency programs: (1) Active engagement and autonomy in clinical practice: Residents were given substantial responsibility, fostering confidence and critical decision-making skills. (2) Diverse patient exposure: Broad medical conditions and patient demographics enhanced clinical competence. (3) Enhanced learning resources: Access to clinical decision support tools and customized educational materials facilitated evidence-based learning. (4) Peer-assisted learning: Collaborative learning environments promoted knowledge sharing and mentorship. (5) Supportive educational framework: Structured feedback, balanced with autonomy, created a positive learning atmosphere. (6) Clinical reasoning education: Emphasis on case-based learning and routine exercises developed robust diagnostic skills. (7) Professionalism development: Focus on communication and teamwork prepared residents for real-world clinical interactions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eHigh-performing residency programs in Japan integrate diverse clinical experiences, advanced resources, peer learning, and structured feedback to enhance residents' competencies. These findings offer valuable insights into optimizing clinical training programs under resource constraints, potentially leading to improvements in medical education frameworks across Japan.\u003c/p\u003e","manuscriptTitle":"Key factors for high-quality residency training programs: Insights from program directors through thematic analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-04 01:29:04","doi":"10.21203/rs.3.rs-7030199/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-09T14:19:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T04:04:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127846444401807672894746308921008063920","date":"2026-03-25T12:42:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-23T18:58:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204419403375521504811774345630222018701","date":"2025-11-09T08:49:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-23T10:06:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-07T09:06:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-04T09:11:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-03T10:52:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-07-02T14:06:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e8f3a17c-e9ae-4d5d-a654-f2ccd59fe7aa","owner":[],"postedDate":"November 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":57288986,"name":"Health sciences/Health care"},{"id":57288987,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-04-26T16:23:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-04 01:29:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7030199","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7030199","identity":"rs-7030199","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}