Impact of third-party accreditation and General Medicine In-training Examination participation on residency program popularity: A nationwide matching data analysis in Japan

Impact of third-party accreditation and General Medicine In-training Examination participation on residency program popularity: A nationwide matching data analysis in Japan | 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 Research Article Impact of third-party accreditation and General Medicine In-training Examination participation on residency program popularity: A nationwide matching data analysis in Japan Kosuke Ishizuka, Yuji Nishizaki, Koshi Kataoka, Kohta Katayama, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8093417/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Third-party accreditation and the visibility of educational outcomes may influence medical students’ choice of training sites; however, national evidence of their effect in Japan is limited. This study examined whether hospital characteristics—especially Japan Council for Evaluation of Postgraduate Clinical Training (JCEP) certification and General Medicine In-Training Examination (GM-ITE®) participation—are associated with residency program choice in Japan’s Physician Clinical Training Matching Program. METHODS We conducted a nationwide cross-sectional study of 1,029 clinical training hospitals participating in the 2023 matching cycle. The outcome was a popularity index defined as the number of first-choice applicants per number of positions available. Predictors included JCEP certification, GM-ITE® participation, location (urban/rural), hospital type (community, university, university branch), and facility/service metrics (number of permitted beds, average daily number of inpatients, annual number of ambulance transports, annual number of outpatients, length of stay (general beds), number of doctors, number of nurses, annual number of computed tomography and magnetic resonance imaging scans). Continuous variables were analyzed using multiple linear regression of natural log-transformed data and exponentiated regression coefficients were reported. RESULTS Of the hospitals, 32.1% were JCEP-certified and 67.1% participated in GM-ITE®. In the multivariable analysis, the popularity index was higher for hospitals with JCEP certification (1.12, p = 0.022) and GM-ITE® participation (1.14, p = 0.011), urban locations (p < 0.001), and higher annual number of ambulance transports (per log-unit, 1.15, p = 0.006), and lower with longer hospital stay (per log-unit, 0.73, p = 0.005) and at university (0.48; p < 0.001) and university branch (0.59; p < 0.001) hospitals than at community hospitals. CONCLUSION Program popularity in Japan is positively associated with JCEP certification, GM-ITE® participation, urban location, and higher emergency caseload, and negatively associated with longer hospital stay and university affiliation. These findings suggest that assurance of educational quality and opportunities for diverse, practical clinical exposure are important drivers of medical students’ program selection. Clinical training GM-ITE JCEP Third-party accreditation Figures Figure 1 Figure 2 Introduction External, third-party accreditation has become a key mechanism for assuring the quality and transparency of postgraduate clinical training. In the United States, specialty residency programs are accredited by the Accreditation Council for Graduate Medical Education (ACGME), which has been associated with improvements in resident satisfaction, educational environments, and post-graduation outcomes. 1 , 2 Additionally, the international expansion of ACGME-International (ACGME-I) has demonstrated improvements in resident performance and alignment with competency milestones. 2 These accreditation systems enhance accountability and facilitate global comparability of medical education quality. 3 , 4 In contrast to U.S. specialty-based residencies, Japan employs a two-year broad-rotation internship system following graduation from its 6-year undergraduate medical curriculum, during which residents rotate through all major clinical specialties. 5 – 9 This postgraduate clinical training, mandated since 2004, is supervised by the Ministry of Health, Labour and Welfare (MHLW) to ensure competency in core clinical skills, professionalism, and communication. 8 , 9 A nationwide matching system allows medical students to apply to clinical-training hospitals across Japan. 10 In 2023, 1,029 hospitals provided such training. 10 Previous studies have shown that hospital characteristics—such as income, training content, and opportunities for clinical skill acquisition—affect medical students’ choice of clinical-training hospital. 11 , 12 However, with the widespread use of smartphones and social media, students increasingly gather real-time information about hospitals, shifting selection priorities. 13 A nationwide study reported that the popularity of training hospitals is more strongly associated with a higher annual number of ambulance transports, Urban location, and Community Hospital status, than with salary or bonuses, suggesting that applicants prioritize settings offering diverse and practical clinical experience. 13 In addition, hospitals with larger numbers of available positions may be preferred due to their psychological and workload advantages. 13 As a system of external quality assurance, the Japan Council for Evaluation of Postgraduate Clinical Training (JCEP) conducts third-party evaluations of clinical-training hospitals. 14 , 15 Some medical students may consider JCEP Certification when selecting hospitals. 14 , 15 Meanwhile, the General Medicine In-Training Examination (GM-ITE®), a validated nationwide competency-based assessment, is widely used as an objective indicator of residents’ clinical abilities in Japan. 16 , 17 GM-ITE® Participation may therefore reflect a hospital’s emphasis on educational quality. 16 , 17 However, whether JCEP Certification and GM-ITE® Participation are associated with hospital popularity in Japan’s matching system has not been evaluated at the national level. Therefore, this study aimed to investigate the association between hospital characteristics and popularity in Japan’s nationwide clinical-training matching system, particularly focusing on (i) JCEP Certification and (ii) GM-ITE® Participation. As an exploratory aim, we also examined (iii) other institutional characteristics including hospital location, type, emergency activity, and training capacity. We hypothesized that hospitals with third-party accreditation and active competency assessment systems would be more popular among applicants. Methods Study design A nationwide cross-sectional study was conducted using matching data to analyze hospital characteristics, including JCEP certification status and GM-ITE® participation, in clinical-training hospitals in Japan, and their association with popularity in physician clinical-training matching. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting cross-sectional studies. 18 Resident matching system in Japan The Physician Clinical Training Matching Program, operated by the Japan Residency Matching Program (JRMP), is a computerized system that matches medical students seeking postgraduate clinical training with clinical-training hospitals offering such programs. Matching is conducted based on the rank-order lists submitted by both applicants and hospitals, using a predetermined algorithm to determine the optimal pairings. Under the guidance of the MHLW, information such as the number of available positions at each hospital and the number of applicants is publicly disclosed. Final-year medical students can apply to clinical-training hospitals nationwide through this system, thereby ensuring fairness and transparency of placements. 19 JRMP The JRMP oversees operations related to the Physician Clinical Training Matching Program. It is composed of four entities: the Japan Medical Association, 20 the Medical Training Promotion Foundation, 21 the National Conference of Medical School Deans and Hospital Directors, 22 and the Clinical Training Council. 23 The flow of the physician clinical-training matching process is shown in Fig. 1 . The JRMP is responsible for the smooth operation of the Physician Clinical Training Matching Program and maintains an official website that provides information for applicants and clinical-training hospitals regarding the matching process. 19 This site publishes information provided by the MHLW, such as the number of available positions and applicant numbers at each hospital. It also operates a helpline to address inquiries from participants and clinical-training hospitals, maintaining a system to release relevant information as needed. The JRMP manages the matching schedule, discloses the algorithms used, and provides interim progress reports. Furthermore, after the matching process concludes, JRMP conducts surveys to improve the system, thereby contributing to the operation and development of the clinical-training system in Japan. 19 JCEP JCEP was established in 2007 to conduct third-party evaluations and improve the quality of the educational system and training environment of clinical-training hospitals in Japan. 14 Third-party evaluations began in 2006, with the initial evaluation conducted by its predecessor study group. Periodic JCEP certification renewals support the maintenance and improvement of training quality. 14 The primary responsibilities of JCEP include setting training program philosophy, establishing feedback systems for residents, defining educational processes, ensuring safety management, assuring case volume, and verifying each hospital’s implementation through on-site surveys. 14 The number of clinical-training hospitals nationwide undergoing JCEP third-party evaluations has progressively increased, with 327 facilities accredited by 2025. 14 This system encourages clinical-training hospitals to improve their educational systems and supervisory environments and is increasingly used as a quality-assurance indicator when medical students select clinical-training hospitals. 14 GM-ITE ® In the United States, the Internal Medicine In-Training Examination (IM-ITE) is administered to assess clinical knowledge during residency training. 24 – 26 In 2011, the GM-ITE® was developed and introduced in Japan, modeled on the IM-ITE. In Japan, the GM-ITE® has evolved into a nationwide exam, with over half of all residents participating. The GM-ITE® is taken at the end of Postgraduate Year (PGY)-1 and PGY-2. The GM-ITE® has been validated by the Specialized Language Assessment Committee as a reliable measure for evaluating basic clinical competencies. 16 , 17 Aligned with the objectives of clinical training, the GM-ITE® is divided into four categories: “Medical Interview and Professionalism,” “Symptomatology and Clinical Reasoning,” “Physical Examination and Clinical Skills,” and “Disease-specific Topics.” Furthermore, it comprehensively covers items related to the clinical fields through which residents rotate, such as internal medicine, surgery, obstetrics and gynecology, pediatrics, psychiatry, emergency medicine, and community medicine. The GM-ITE® is not merely a test of medical knowledge; but also evaluates residents’ practical skills and management abilities developed in clinical settings. The test is administered as a computer-based test (CBT), incorporating the advantages of CBT, such as video-based questions that assess residents’ clinical skills. The primary purpose of the GM-ITE® is to promote improvement of clinical-training programs by providing residents and program directors with an objective and reliable assessment of residents’ basic clinical competencies. 27 From each resident’s perspective, the purpose of taking the GM-ITE® is not simply to pass or fail, but to assess their level of attainment of basic clinical competencies and to identify and overcome weaknesses in specific clinical areas. 28 The 2023 GM-ITE® included 80 multiple-choice questions: “Medical Interview and Professionalism” (8 questions), “Symptomatology and Clinical Reasoning” (18 questions), “Physical Examination and Clinical Skills” (18 questions), and “Disease-specific Topics” (36 questions). Each question was worth one point, for a maximum total score of 80. Although the primary language of the GM-ITE® is Japanese, 10 of the 80 questions were presented in English to assess clinical competence in English. Data collection A popularity index of clinical-training hospitals in the Physician Clinical Training Matching Program was calculated from publicly available JRMP data for fiscal year 2023 as the number of first-choice applicants divided by the number of available positions for each clinical-training hospital. 19 When multiple clinical-training programs were available within the same hospital, the program with the largest number of available positions was used. Characteristics of clinical-training hospitals were obtained from the Healthcare Market Analysis Platform 29 database and included the following items: number of permitted beds, average daily number of inpatients, annual number of ambulance transports, annual number of outpatients, average length of hospital stay (general beds), number of doctors, number of nurses, annual number of computed tomography (CT) scans, annual number of magnetic resonance imaging (MRI) scans, hospital type (university hospital, university branch hospital, or community hospital), and location (urban or rural). For location, the 20 government-designated cities and 23 wards of Tokyo were defined as urban, and all other areas were defined as rural. JCEP certification was obtained from the 2023 accredited facility list published on the official JCEP website. 14 GM-ITE® participation was determined using the 2023 GM-ITE® examination facility list provided by the Japan Institute for Advancement of Medical Education Program (JAMEP). 30 Statistical analysis All statistical analyses were performed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC, USA), with statistical significance set at p < 0.05. Continuous variables were reported as the mean ± standard deviation (SD) unless otherwise specified. To examine the association of each clinical-training hospital and hospital characteristics with the popularity index, we fitted a multiple linear regression model with the popularity index as the dependent variable. Continuous variables, including the popularity index, were natural log-transformed to improve normality. The estimated coefficient (β) indicated the direction and magnitude of effect on the log-transformed popularity index, holding other covariates constant. On the original scale, a one-unit increase in the covariate corresponded to an approximate multiplicative change of e ^β in the popularity index. Exponentiated regression coefficients were reported for interpretability. In the multivariable model, we included the following covariates: number of permitted beds, average daily number of inpatients, annual number of ambulance transports, annual number of outpatients, average length of hospital stay, annual number of MRI scans, hospital type, location, JCEP certification, and GM-ITE® participation. Multicollinearity among covariates was assessed using the variance inflation factor (VIF), and highly correlated variables (VIF > 5) were excluded. For each variable, hospitals with missing data were excluded from the corresponding analysis. Ethics statement This study is based on analysis of aggregated publicly available data and did not contain any individual-level data on medical students or patients and therefore did not require ethics approval or informed consent. Results Hospital characteristics A total of 1,029 clinical-training hospitals participating in the 2023 Physician Clinical Training Matching Program and were included in the analysis (Table 1 ). Of the 1,029 hospitals, 321 (32.1%) held JCEP certification; 690 (67.1%) participated in the GM-ITE®; 736 (71.5%) were rural and 293 (28.5%) were urban; and 903 (87.8%) were community hospitals, 81 (7.9%) were university hospitals, and 45 (4.4%) were university branch hospitals. The mean popularity index for matching was 1.0 (SD: 0.8). Figure 2 shows the frequency distribution of the popularity index. Table 1 Background characteristics of the clinical-training hospitals Hospital-level information Total (N = 1029) JCEP certification Yes, n (%) 321 (31.2) No, n (%) 708 (68.8) GM-ITE ® participation Yes, n (%) 690 (67.1) No, n (%) 339 (32.9) Location Rural, n (%) 736 (71.5) Urban, n (%) 293 (28.5) Hospital type Community hospital, n (%) 903 (87.8) University hospital, n (%) 81 (7.9) University branch hospital, n (%) 45 (4.4) Number of permitted beds 445.1 ± 200.4 Annual number of ambulance transports 1331.6 ± 824.5 Annual number of outpatients 756.3 ± 467.5 Number of days in hospital 13.7 ± 6.4 Number of doctors 139.0 ± 139.9 Number of nurses 416.6 ± 229.7 Annual number of CT scans 18435.1 ± 11593.6 Annual number of MRI scans 6804.3 ± 6139.9 Number of first-choice applicants/Number of available positions 1.0 ± 0.8 Missing data: Number of permitted beds (n = 12), Annual number of ambulance transports (n = 12), Annual number of outpatients (n = 71), Number of days in hospital (n = 73), Number of days in hospital (n = 23), Number of nurses (n = 29), Annual number of CT scans (n = 126), Annual number of MRI scans (n = 127), Number of first-choice applicants/Number of available positions (n = 1) The histogram displays the distribution of the popularity index, calculated as the ratio of the number of applicants to the number of available residency positions at each hospital in the 2023 Physician Clinical Training Matching Program. The x-axis represents the odds (popularity index), and the y-axis represents the percentage of hospitals. The relationship between the popularity index for matching at each clinical-training hospital and hospital characteristics in the univariate analysis is shown in Supplemental 1. In the univariable analysis, statistically significant differences were observed for all variables (JCEP certification status, GM-ITE® participation, location, hospital type, number of permitted beds, average number of inpatients, annual number of ambulance transports, annual number of outpatients, average length of hospital stay, number of doctors, number of nurses, annual number of CT scans, and annual number of MRI scans). In the multivariable analysis, relationships among these factors were examined after excluding the number of doctors, number of nurses, and annual number of CT scans because these variables each had a VIF > 5. Table 2 shows the association between the popularity index and hospital characteristics based on the multivariable model. In the multivariable analysis, the popularity index was higher for hospitals with JCEP certification (1.12, p = 0.022) and GM-ITE® participation (1.14, p = 0.011), urban locations (p < 0.001), and higher annual number of ambulance transports (per log-unit, 1.15, p = 0.006), and lower with longer hospital stay (per log-unit, 0.73, p = 0.005) and at university (0.48; p < 0.001) and university branch (0.59; p < 0.001) hospitals than at community hospitals. Table 2 Relationship between residency program popularity and hospital-level information using multivariable analysis Factors Adjusted Exponentiated regression coefficient (95%CI) p-value JCEP certification No Reference Yes 1.12 (1.02 to 1.24) 0.022 GM-ITE® participation No Reference Yes 1.14 (1.03 to 1.26) 0.011 Location Rural Reference Urban 1.41 (1.27 to 1.56) < 0.001 Hospital type Community hospital Reference University hospital 0.48 (0.39 to 0.59) < 0.001 University branch hospital 0.59 (0.47 to 0.75) < 0.001 Log- number of permitted beds 0.92 (0.89 to 1.32) 0.430 Log- annual number of ambulance transports 1.15 (1.04 to 1.27) 0.006 Log- annual number of outpatients 1.10 (0.98 to 1.22) 0.098 Log- number of days in hospital 0.73 (0.59 to 0.91) 0.005 Log- number of MRI 1.07 (0.96 to 1.19) 0.248 Discussion This nationwide cross-sectional analysis of matching data from clinical-training hospitals in Japan showed that hospital characteristics, including JCEP certification, GM-ITE® participation, hospital type, location, annual number of ambulance transports, and length of hospital stay, were each independently associated with the popularity of the hospital as the first-choice training facility in the physician clinical-training matching process. These findings suggest that assuring the quality of education in clinical-training hospitals may meaningfully influence medical students’ selection of the hospital as their preferred training site. Previous studies have reported that structural factors such as location, emergency care systems, and hospital type are more strongly associated with popularity than salary or benefits. 13 Consistent with previous studies, we found that facilities located in urban areas, classified as community hospitals, and with a high annual number of ambulance transports were more popular. A higher annual number of ambulance transports reflects greater exposure to acute cases, aligning with medical students’ preference for practical clinical training. 13 The observed association between JCEP certification and popularity in clinical-training matching suggests that third-party accreditation may signal a well-organized educational framework and safety management, thereby shaping students’ choices. JCEP certification considers multiple criteria, including program philosophy, assurance of case volume, supervisory structure, and feedback mechanisms, and is a reliable indicator of educational quality. 14 Furthermore, the positive association between GM-ITE® participation and popularity suggests that the visibility of educational outcomes is a meaningful indicator for applicants. GM-ITE® is a reliable indicator that covers medical interviewing, physical examination, clinical reasoning, and disease-specific knowledge. 17 , 27 , 28 , 31 A previous study found that GM-ITE® scores correlated with the strength of the teaching system and the educational environment, supporting its role as an indicator of educational quality. 31 Notably, a shorter average length of hospital stay was significantly associated with popularity. Because length of hospital stay reflects patient turnover, hospitals with shorter average lengths of stay likely offer broader exposure to diverse conditions, which may attract students seeking varied case experience during their training. 32 By contrast, facility size indicators, such as number of permitted beds and the average number of inpatients, were significant in univariate analyses but not in multivariate analyses. This pattern suggests that medical students may prioritize factors such as educational quality, breadth of hands-on experience, and convenience of the living environment, over facility size alone. 14 Popularity may be shifting toward hospitals that demonstrate good educational outcomes and case diversity in preference to large size alone. These findings have several implications for educational policy and hospital management. First, maintaining and continuously operating the JCEP certification system may aid workforce recruitment by guaranteeing educational quality. Second, GM-ITE® participation and its active use can help quantify educational outcomes and provide an objective indicator to inform choice of training facility, in addition to supporting structural improvements in clinical-training programs. Finally, strengthening clinical service characteristics, such as robust emergency transport systems and shorter length of hospital stay, is important for providing varied practical clinical experience. These elements can also be understood within the World Federation for Medical Education (WFME) 2020 Quality Assurance Framework, in which JCEP certification functions as a structural indicator of educational governance and resources, GM-ITE® participation reflects an active process of assessment and feedback, and program popularity represents an externally validated outcome. 33 This structure–process–outcome alignment suggests that hospitals demonstrating both organized educational systems and ongoing competency-based evaluation are more likely to achieve favorable educational and social outcomes, including higher applicant preference. Moreover, these results may position JCEP as a Japan-specific counterpart to the ACGME-I system operating internationally. Previous studies have reported that ACGME and ACGME-I accreditation are associated with improved resident satisfaction, performance, and milestone attainment. 1 , 2 , 6 Given these findings, JCEP could similarly serve as a regional model for standardized postgraduate medical education in East Asia. Expanding JCEP’s visibility and alignment with international accreditation frameworks may facilitate cross-border recognition of training quality, enhance educational mobility, and contribute to global efforts to harmonize competency-based medical education. In practice, these strategies can be mutually reinforcing. Sustainable accreditation ensures baseline quality, while the use of standardized assessment tools, such as GM-ITE®, enables the identification of program strengths and weaknesses through data analysis. Hospitals that demonstrate both strong educational performance and efficient clinical operations may attract more applicants, thereby further improving the quality of training. Policymakers could also leverage aggregated GM-ITE® results to allocate funding or support to institutions that achieve measurable educational and clinical excellence. At the institutional level, integrating these metrics into management dashboards could help align hospital strategy with educational outcomes, creating a continuous feedback loop between education, service, and policy. Limitations This study has several limitations. First, as a cross-sectional analysis, it captured conditions at a single point in time and cannot establish causality. Whether popularity among medical students drives improvements in educational systems or, conversely, whether enhancements to educational systems increase popularity are unclear. Prospective studies are needed to clarify causation. Second, because the study focused exclusively on clinical-training hospitals in Japan, the findings may not be generalizable to hospitals in other countries, and external validation in other countries is warranted. Third, we did not directly measure factors or motivations governing individuals’ choice of clinical-training hospital and thus did not assess the psychological or social drivers of application behavior. Fourth, residual confounding by unmeasured factors that affect hospital choice may be present. Data were not available on applicant-related factors (e.g., academic performance, alma mater, intended specialty, local ties) and program-related factors (e.g., salary and working conditions, workload, presence of renowned supervising physicians, organizational culture, employee benefits), so the possibility of residual confounding due to unmeasured variables cannot be ruled out. Finally, for JCEP certification and GM-ITE® participation, we examined as dichotomous variables (present or absent) and detailed metrics such as JCEP evaluation or GM-ITE® scores were not considered. Future research should comprehensively assess both qualitative and quantitative aspects of these educational indicators. Conclusion This study examined found that hospital characteristics, including JCEP certification, GM-ITE® participation, hospital type, location, annual number of ambulance transports, and the average length of hospital stay, were associated with popularity in physician clinical-training matching. Being a community hospital, having a higher annual number of ambulance transports, a shorter length of hospital stay, an urban location, GM-ITE® participation, and JCEP certification were each independently associated with greater popularity as a clinical-training hospital. These findings suggest that medical students may consider multiple factors when selecting training sites, including assurance of educational quality, breadth of clinical experience, opportunities for hands-on training, and compatibility with living conditions. Declarations Acknowledgments: The authors thank the members of JCEP, JAMEP and the General Medicine In-Training Examination question development and peer-review committees for their assistance. Authors’ contributions Kosuke Ishizuka: conceptualization, methodology, formal analysis, writing—original draft. Yuji Nishizaki: conceptualization, methodology, writing—review and editing. All authors read and approved the manuscript. Koshi Kataoka: conceptualization, methodology, formal analysis, writing—review and editing. Kohta Katayama: writing—review and editing. Kiyoshi Shikino: writing—review and editing. Sho Fukui: writing—review and editing. Yu Yamamoto: writing—review and editing. Taro Shimizu: writing—review and editing. Mitsuyasu Ohta: writing—review and editing. Tsuguya Fukui: conceptualization, methodology, writing—review and editing. Yasuharu Tokuda: conceptualization, methodology, writing—review and editing. Funding: This work was supported by the Health, Labor, and Welfare Policy Grants of Research on Region Medical (21IA2004) by the Ministry of Health, Labor, and Welfare (MHLW). However, the MHLW was not involved in the study’s design and conduct, data analysis and interpretation, and the preparation, review, approval, and submission of the manuscript for publication. Availability of data materials The corresponding author will respond to inquiries on the data analyses in this study. Ethical approval and consent to participate The study was performed in accordance with the Declaration of Helsinki. All methods were conducted in accordance with relevant guidelines. This study is based on analysis of aggregated publicly available data and did not contain any individual-level data on medical students or patients and therefore did not require ethics approval or informed consent. Consent for publication: This study is based on analysis of aggregated publicly available data and did not contain any individual-level data on medical students or patients. Conflicts of Interest: YN received an honorarium from JAMEP as a GM-ITE project manager. YT is the JAMEP director, and he received an honorarium from JAMEP as a speaker of the JAMEP lecture. KS received an honorarium from JAMEP as speakers of the JAMEP lecture. TS, KS, YY and SF received an honorarium from JAMEP as exam preparers of GM-ITE. Notes on contributors Kosuke Ishizuka, MD, PhD, Clinical Lecturer, Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan. Yuji Nishizaki, MD, MPH, PhD, Professor, Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan. Koshi Kataoka, PhD, Assistant Professor, Center for Translational Research, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan. Kohta Katayama, MD, PhD, Assistant Professor, Department of General Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan. Kiyoshi Shikino, MD, PhD, MHPE, FACP, AFAMEE, Project Professor, Department of Community-Oriented Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan. Sho Fukui, MD, MPH, Assistant Professor, Department of Emergency and General Medicine, Kyorin University Hospital, Tokyo, Japan. Yu Yamamoto, MD, Assistant Professor, Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan. Taro Shimizu, MD, PhD, MPH, MBA, Professor, Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan. Mitsuyasu Ohta, MD, PhD, Professor, Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan. Tsuguya Fukui, MD, MPH, PhD, President, Nihon Pharmaceutical University, Saitama, Japan. 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Hum Resour Health 20:54 The Healthcare Market Analysis Platform Available at: http://caremap.jp/ [accessed July 27, 2025] JAMEP Available at: https://jamep.or.jp / [accessed July 27, 2025] Nishizaki Y, Nozawa K, Shinozaki T et al (2021) Difference in the general medicine in-training examination score between community-based hospitals and university hospitals: a cross-sectional study based on 15,188 Japanese resident physicians. BMC Med Educ 21:214 Kejela S, Tiruneh AG (2022) Determinants of satisfaction and self-perceived proficiency of trainees in surgical residency programs at a single institution. BMC Med Educ 22:473 Bórquez RL (2023) The WFME Basic Medical Education Standards on the Horizon 2030. Med Sci Educ 33(Suppl 1):15–18 Additional Declarations The authors declare potential competing interests as follows: Conflicts of Interest: YN received an honorarium from JAMEP as a GM-ITE project manager. YT is the JAMEP director, and he received an honorarium from JAMEP as a speaker of the JAMEP lecture. KS received an honorarium from JAMEP as speakers of the JAMEP lecture. TS, KS, YY and SF received an honorarium from JAMEP as exam preparers of GM-ITE. Supplementary Files Supplemental1.docx Cite Share Download PDF Status: Posted Version 1 posted 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8093417","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":543839191,"identity":"0da3fd25-bb69-46fb-b2f6-b5d553782789","order_by":0,"name":"Kosuke Ishizuka","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-4313-6592","institution":"Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan","correspondingAuthor":true,"prefix":"","firstName":"Kosuke","middleName":"","lastName":"Ishizuka","suffix":""},{"id":543850496,"identity":"c9572d30-dece-4f46-b63b-fffdb4d0a5c9","order_by":1,"name":"Yuji Nishizaki","email":"","orcid":"https://orcid.org/0000-0002-6964-6702","institution":"Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan","correspondingAuthor":false,"prefix":"","firstName":"Yuji","middleName":"","lastName":"Nishizaki","suffix":""},{"id":543850497,"identity":"eab0741d-9148-4128-9531-038b2f02dee1","order_by":2,"name":"Koshi Kataoka","email":"","orcid":"","institution":"Center for Translational Research, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan","correspondingAuthor":false,"prefix":"","firstName":"Koshi","middleName":"","lastName":"Kataoka","suffix":""},{"id":543850498,"identity":"6a4f1626-3345-4545-9850-2a102d93b154","order_by":3,"name":"Kohta Katayama","email":"","orcid":"https://orcid.org/0000-0001-8076-7188","institution":"Department of General Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan","correspondingAuthor":false,"prefix":"","firstName":"Kohta","middleName":"","lastName":"Katayama","suffix":""},{"id":543850499,"identity":"3632b2ce-d485-4fe2-880f-fdece9a4c33a","order_by":4,"name":"Kiyoshi Shikino","email":"","orcid":"https://orcid.org/0000-0002-3721-3443","institution":"Department of Community-Oriented Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan","correspondingAuthor":false,"prefix":"","firstName":"Kiyoshi","middleName":"","lastName":"Shikino","suffix":""},{"id":543850500,"identity":"1c105dff-4494-46ae-b7fe-ab7a46a643f7","order_by":5,"name":"Sho Fukui","email":"","orcid":"https://orcid.org/0000-0002-3082-1374","institution":"Department of Emergency and General Medicine, Kyorin University Hospital, Tokyo, Japan","correspondingAuthor":false,"prefix":"","firstName":"Sho","middleName":"","lastName":"Fukui","suffix":""},{"id":543850501,"identity":"f4361d9b-b1eb-4e14-8739-0f65e6c7665c","order_by":6,"name":"Yu Yamamoto","email":"","orcid":"https://orcid.org/0000-0003-2247-4963","institution":"Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Yamamoto","suffix":""},{"id":543850502,"identity":"54358dbe-7411-4139-9d1d-44cbd2eca90d","order_by":7,"name":"Taro Shimizu","email":"","orcid":"https://orcid.org/0000-0002-3788-487X","institution":"Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan","correspondingAuthor":false,"prefix":"","firstName":"Taro","middleName":"","lastName":"Shimizu","suffix":""},{"id":543850503,"identity":"30fac0e7-9fe2-4a6c-846e-d3cef7b33377","order_by":8,"name":"Mitsuyasu Ohta","email":"","orcid":"https://orcid.org/0000-0002-2386-3998","institution":"Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan","correspondingAuthor":false,"prefix":"","firstName":"Mitsuyasu","middleName":"","lastName":"Ohta","suffix":""},{"id":543850504,"identity":"cfc0cfd4-9f39-4c73-8ecd-641cff95dbe7","order_by":9,"name":"Tsuguya Fukui","email":"","orcid":"","institution":"President, Nihon Pharmaceutical University, Saitama, Japan","correspondingAuthor":false,"prefix":"","firstName":"Tsuguya","middleName":"","lastName":"Fukui","suffix":""},{"id":543850505,"identity":"e67af65e-6ff9-43bc-9fe2-9f2162c03bb3","order_by":10,"name":"Yasuharu Tokuda","email":"","orcid":"https://orcid.org/0000-0002-9325-7934","institution":"Muribushi Okinawa Center for Teaching Hospitals, Okinawa, Japan","correspondingAuthor":false,"prefix":"","firstName":"Yasuharu","middleName":"","lastName":"Tokuda","suffix":""}],"badges":[],"createdAt":"2025-11-12 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08:49:09","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14393,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8093417/v1/7781aca6c21d7ce4bf7ba581.png"},{"id":95807682,"identity":"181fad40-9c1c-47c4-8980-6061123b3c50","added_by":"auto","created_at":"2025-11-13 08:49:04","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101279,"visible":true,"origin":"","legend":"","description":"","filename":"rs80934170structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8093417/v1/38ed2e053b1d5f1ef1d76f42.xml"},{"id":95808042,"identity":"f80fa2f0-317c-4620-8e68-c3b25685181a","added_by":"auto","created_at":"2025-11-13 08:49:17","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":113271,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8093417/v1/cb9781fb3e4dd70aeb9cf1b6.html"},{"id":95808020,"identity":"797b85e2-d13c-4bd1-8445-8f0387f8f545","added_by":"auto","created_at":"2025-11-13 08:49:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":338003,"visible":true,"origin":"","legend":"\u003cp\u003eThe flow of Japan Residency Matching Program\u003c/p\u003e\n\u003cp\u003eClinical-training hospitals are first designated by the Ministry of Health, Labour and Welfare (MHLW) as approved sites for postgraduate physician training. Once authorized, hospitals register their programs and available training positions with the Japan Residency Matching Program (JRMP), which administers the nationwide computerized matching system. Final-year medical students then submit applications and rank-order lists through JRMP, and matching is completed based on preference lists from both applicants and hospitals.\u003c/p\u003e","description":"","filename":"Figure1Ishizuka.png","url":"https://assets-eu.researchsquare.com/files/rs-8093417/v1/e592508ec1750686c2069d44.png"},{"id":95807539,"identity":"11031cec-2ccd-4244-ac8f-9819c09ad815","added_by":"auto","created_at":"2025-11-13 08:48:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5836,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency distribution of the popularity index for all clinical-training hospitals\u003c/p\u003e\n\u003cp\u003eThe histogram displays the distribution of the popularity index, calculated as the ratio of the number of applicants to the number of available residency positions at each hospital in the 2023 Physician Clinical Training Matching Program. The x-axis represents the odds (popularity index), and the y-axis represents the percentage of hospitals.\u003c/p\u003e","description":"","filename":"Figure2Ishizuka.png","url":"https://assets-eu.researchsquare.com/files/rs-8093417/v1/a500acc3fce2ad768df081fe.png"},{"id":95810488,"identity":"01bfd713-753e-4260-99d5-a9da1b030f9a","added_by":"auto","created_at":"2025-11-13 08:52:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1212581,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8093417/v1/f77491b9-807f-49c9-8532-c4702fe4b990.pdf"},{"id":95808188,"identity":"05636841-591e-4c06-b61c-60c0e7c31f7c","added_by":"auto","created_at":"2025-11-13 08:49:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16674,"visible":true,"origin":"","legend":"","description":"","filename":"Supplemental1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8093417/v1/8bf0d9544d406dd9c2f007c9.docx"}],"financialInterests":"The authors declare potential competing interests as follows: Conflicts of Interest: YN received an honorarium from JAMEP as a GM-ITE project manager. YT is the JAMEP director, and he received an honorarium from JAMEP as a speaker of the JAMEP lecture. KS received an honorarium from JAMEP as speakers of the JAMEP lecture. TS, KS, YY and SF received an honorarium from JAMEP as exam preparers of GM-ITE.","formattedTitle":"\u003cp\u003eImpact of third-party accreditation and General Medicine In-training Examination participation on residency program popularity: A nationwide matching data analysis in Japan\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eExternal, third-party accreditation has become a key mechanism for assuring the quality and transparency of postgraduate clinical training. In the United States, specialty residency programs are accredited by the Accreditation Council for Graduate Medical Education (ACGME), which has been associated with improvements in resident satisfaction, educational environments, and post-graduation outcomes.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Additionally, the international expansion of ACGME-International (ACGME-I) has demonstrated improvements in resident performance and alignment with competency milestones.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e These accreditation systems enhance accountability and facilitate global comparability of medical education quality.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn contrast to U.S. specialty-based residencies, Japan employs a two-year broad-rotation internship system following graduation from its 6-year undergraduate medical curriculum, during which residents rotate through all major clinical specialties.\u003csup\u003e\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e This postgraduate clinical training, mandated since 2004, is supervised by the Ministry of Health, Labour and Welfare (MHLW) to ensure competency in core clinical skills, professionalism, and communication.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e A nationwide matching system allows medical students to apply to clinical-training hospitals across Japan.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In 2023, 1,029 hospitals provided such training.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePrevious studies have shown that hospital characteristics\u0026mdash;such as income, training content, and opportunities for clinical skill acquisition\u0026mdash;affect medical students\u0026rsquo; choice of clinical-training hospital.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e However, with the widespread use of smartphones and social media, students increasingly gather real-time information about hospitals, shifting selection priorities.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e A nationwide study reported that the popularity of training hospitals is more strongly associated with a higher annual number of ambulance transports, Urban location, and Community Hospital status, than with salary or bonuses, suggesting that applicants prioritize settings offering diverse and practical clinical experience.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In addition, hospitals with larger numbers of available positions may be preferred due to their psychological and workload advantages.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAs a system of external quality assurance, the Japan Council for Evaluation of Postgraduate Clinical Training (JCEP) conducts third-party evaluations of clinical-training hospitals.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Some medical students may consider JCEP Certification when selecting hospitals.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Meanwhile, the General Medicine In-Training Examination (GM-ITE\u0026reg;), a validated nationwide competency-based assessment, is widely used as an objective indicator of residents\u0026rsquo; clinical abilities in Japan.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e GM-ITE\u0026reg; Participation may therefore reflect a hospital\u0026rsquo;s emphasis on educational quality.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e However, whether JCEP Certification and GM-ITE\u0026reg; Participation are associated with hospital popularity in Japan\u0026rsquo;s matching system has not been evaluated at the national level.\u003c/p\u003e\u003cp\u003eTherefore, this study aimed to investigate the association between hospital characteristics and popularity in Japan\u0026rsquo;s nationwide clinical-training matching system, particularly focusing on (i) JCEP Certification and (ii) GM-ITE\u0026reg; Participation. As an exploratory aim, we also examined (iii) other institutional characteristics including hospital location, type, emergency activity, and training capacity. We hypothesized that hospitals with third-party accreditation and active competency assessment systems would be more popular among applicants.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003e A nationwide cross-sectional study was conducted using matching data to analyze hospital characteristics, including JCEP certification status and GM-ITE\u0026reg; participation, in clinical-training hospitals in Japan, and their association with popularity in physician clinical-training matching. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting cross-sectional studies.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eResident matching system in Japan\u003c/h3\u003e\n\u003cp\u003eThe Physician Clinical Training Matching Program, operated by the Japan Residency Matching Program (JRMP), is a computerized system that matches medical students seeking postgraduate clinical training with clinical-training hospitals offering such programs. Matching is conducted based on the rank-order lists submitted by both applicants and hospitals, using a predetermined algorithm to determine the optimal pairings. Under the guidance of the MHLW, information such as the number of available positions at each hospital and the number of applicants is publicly disclosed. Final-year medical students can apply to clinical-training hospitals nationwide through this system, thereby ensuring fairness and transparency of placements.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eJRMP\u003c/h3\u003e\n\u003cp\u003eThe JRMP oversees operations related to the Physician Clinical Training Matching Program. It is composed of four entities: the Japan Medical Association,\u003csup\u003e20\u003c/sup\u003e the Medical Training Promotion Foundation,\u003csup\u003e21\u003c/sup\u003e the National Conference of Medical School Deans and Hospital Directors,\u003csup\u003e22\u003c/sup\u003e and the Clinical Training Council.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e The flow of the physician clinical-training matching process is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The JRMP is responsible for the smooth operation of the Physician Clinical Training Matching Program and maintains an official website that provides information for applicants and clinical-training hospitals regarding the matching process.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This site publishes information provided by the MHLW, such as the number of available positions and applicant numbers at each hospital. It also operates a helpline to address inquiries from participants and clinical-training hospitals, maintaining a system to release relevant information as needed. The JRMP manages the matching schedule, discloses the algorithms used, and provides interim progress reports. Furthermore, after the matching process concludes, JRMP conducts surveys to improve the system, thereby contributing to the operation and development of the clinical-training system in Japan.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eJCEP\u003c/h3\u003e\n\u003cp\u003eJCEP was established in 2007 to conduct third-party evaluations and improve the quality of the educational system and training environment of clinical-training hospitals in Japan.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Third-party evaluations began in 2006, with the initial evaluation conducted by its predecessor study group. Periodic JCEP certification renewals support the maintenance and improvement of training quality.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The primary responsibilities of JCEP include setting training program philosophy, establishing feedback systems for residents, defining educational processes, ensuring safety management, assuring case volume, and verifying each hospital\u0026rsquo;s implementation through on-site surveys.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The number of clinical-training hospitals nationwide undergoing JCEP third-party evaluations has progressively increased, with 327 facilities accredited by 2025.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e This system encourages clinical-training hospitals to improve their educational systems and supervisory environments and is increasingly used as a quality-assurance indicator when medical students select clinical-training hospitals.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eGM-ITE\u003c/b\u003e\u0026reg;\u003c/p\u003e\u003cp\u003eIn the United States, the Internal Medicine In-Training Examination (IM-ITE) is administered to assess clinical knowledge during residency training.\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e In 2011, the GM-ITE\u0026reg; was developed and introduced in Japan, modeled on the IM-ITE. In Japan, the GM-ITE\u0026reg; has evolved into a nationwide exam, with over half of all residents participating. The GM-ITE\u0026reg; is taken at the end of Postgraduate Year (PGY)-1 and PGY-2. The GM-ITE\u0026reg; has been validated by the Specialized Language Assessment Committee as a reliable measure for evaluating basic clinical competencies.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Aligned with the objectives of clinical training, the GM-ITE\u0026reg; is divided into four categories: \u0026ldquo;Medical Interview and Professionalism,\u0026rdquo; \u0026ldquo;Symptomatology and Clinical Reasoning,\u0026rdquo; \u0026ldquo;Physical Examination and Clinical Skills,\u0026rdquo; and \u0026ldquo;Disease-specific Topics.\u0026rdquo; Furthermore, it comprehensively covers items related to the clinical fields through which residents rotate, such as internal medicine, surgery, obstetrics and gynecology, pediatrics, psychiatry, emergency medicine, and community medicine. The GM-ITE\u0026reg; is not merely a test of medical knowledge; but also evaluates residents\u0026rsquo; practical skills and management abilities developed in clinical settings. The test is administered as a computer-based test (CBT), incorporating the advantages of CBT, such as video-based questions that assess residents\u0026rsquo; clinical skills. The primary purpose of the GM-ITE\u0026reg; is to promote improvement of clinical-training programs by providing residents and program directors with an objective and reliable assessment of residents\u0026rsquo; basic clinical competencies.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e From each resident\u0026rsquo;s perspective, the purpose of taking the GM-ITE\u0026reg; is not simply to pass or fail, but to assess their level of attainment of basic clinical competencies and to identify and overcome weaknesses in specific clinical areas.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e The 2023 GM-ITE\u0026reg; included 80 multiple-choice questions: \u0026ldquo;Medical Interview and Professionalism\u0026rdquo; (8 questions), \u0026ldquo;Symptomatology and Clinical Reasoning\u0026rdquo; (18 questions), \u0026ldquo;Physical Examination and Clinical Skills\u0026rdquo; (18 questions), and \u0026ldquo;Disease-specific Topics\u0026rdquo; (36 questions). Each question was worth one point, for a maximum total score of 80. Although the primary language of the GM-ITE\u0026reg; is Japanese, 10 of the 80 questions were presented in English to assess clinical competence in English.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eA popularity index of clinical-training hospitals in the Physician Clinical Training Matching Program was calculated from publicly available JRMP data for fiscal year 2023 as the number of first-choice applicants divided by the number of available positions for each clinical-training hospital.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e When multiple clinical-training programs were available within the same hospital, the program with the largest number of available positions was used. Characteristics of clinical-training hospitals were obtained from the Healthcare Market Analysis Platform\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e database and included the following items: number of permitted beds, average daily number of inpatients, annual number of ambulance transports, annual number of outpatients, average length of hospital stay (general beds), number of doctors, number of nurses, annual number of computed tomography (CT) scans, annual number of magnetic resonance imaging (MRI) scans, hospital type (university hospital, university branch hospital, or community hospital), and location (urban or rural). For location, the 20 government-designated cities and 23 wards of Tokyo were defined as urban, and all other areas were defined as rural. JCEP certification was obtained from the 2023 accredited facility list published on the official JCEP website.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e GM-ITE\u0026reg; participation was determined using the 2023 GM-ITE\u0026reg; examination facility list provided by the Japan Institute for Advancement of Medical Education Program (JAMEP).\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were performed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC, USA), with statistical significance set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Continuous variables were reported as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) unless otherwise specified. To examine the association of each clinical-training hospital and hospital characteristics with the popularity index, we fitted a multiple linear regression model with the popularity index as the dependent variable. Continuous variables, including the popularity index, were natural log-transformed to improve normality. The estimated coefficient (β) indicated the direction and magnitude of effect on the log-transformed popularity index, holding other covariates constant. On the original scale, a one-unit increase in the covariate corresponded to an approximate multiplicative change of \u003cem\u003ee\u003c/em\u003e^β in the popularity index. Exponentiated regression coefficients were reported for interpretability. In the multivariable model, we included the following covariates: number of permitted beds, average daily number of inpatients, annual number of ambulance transports, annual number of outpatients, average length of hospital stay, annual number of MRI scans, hospital type, location, JCEP certification, and GM-ITE\u0026reg; participation. Multicollinearity among covariates was assessed using the variance inflation factor (VIF), and highly correlated variables (VIF\u0026thinsp;\u0026gt;\u0026thinsp;5) were excluded. For each variable, hospitals with missing data were excluded from the corresponding analysis.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthics statement\u003c/h3\u003e\n\u003cp\u003eThis study is based on analysis of aggregated publicly available data and did not contain any individual-level data on medical students or patients and therefore did not require ethics approval or informed consent.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eHospital characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 1,029 clinical-training hospitals participating in the 2023 Physician Clinical Training Matching Program and were included in the analysis (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the 1,029 hospitals, 321 (32.1%) held JCEP certification; 690 (67.1%) participated in the GM-ITE\u0026reg;; 736 (71.5%) were rural and 293 (28.5%) were urban; and 903 (87.8%) were community hospitals, 81 (7.9%) were university hospitals, and 45 (4.4%) were university branch hospitals. The mean popularity index for matching was 1.0 (SD: 0.8). Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the frequency distribution of the popularity index.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBackground characteristics of the clinical-training hospitals\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHospital-level information\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1029)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eJCEP certification\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e321 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e708 (68.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGM-ITE\u003c/strong\u003e\u0026reg; \u003cstrong\u003eparticipation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e690 (67.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e339 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e736 (71.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e293 (28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity hospital, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e903 (87.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity hospital, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity branch hospital, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of permitted beds\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e445.1\u0026thinsp;\u0026plusmn;\u0026thinsp;200.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual number of ambulance transports\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1331.6\u0026thinsp;\u0026plusmn;\u0026thinsp;824.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual number of outpatients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e756.3\u0026thinsp;\u0026plusmn;\u0026thinsp;467.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of days in hospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of doctors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e139.0\u0026thinsp;\u0026plusmn;\u0026thinsp;139.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of nurses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e416.6\u0026thinsp;\u0026plusmn;\u0026thinsp;229.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual number of CT scans\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18435.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11593.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual number of MRI scans\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6804.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6139.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of first-choice applicants/Number of available positions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eMissing data: Number of permitted beds (n\u0026thinsp;=\u0026thinsp;12), Annual number of ambulance transports (n\u0026thinsp;=\u0026thinsp;12), Annual number of outpatients (n\u0026thinsp;=\u0026thinsp;71), Number of days in hospital (n\u0026thinsp;=\u0026thinsp;73), Number of days in hospital (n\u0026thinsp;=\u0026thinsp;23), Number of nurses (n\u0026thinsp;=\u0026thinsp;29), Annual number of CT scans (n\u0026thinsp;=\u0026thinsp;126), Annual number of MRI scans (n\u0026thinsp;=\u0026thinsp;127), Number of first-choice applicants/Number of available positions (n\u0026thinsp;=\u0026thinsp;1)\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThe histogram displays the distribution of the popularity index, calculated as the ratio of the number of applicants to the number of available residency positions at each hospital in the 2023 Physician Clinical Training Matching Program. The x-axis represents the odds (popularity index), and the y-axis represents the percentage of hospitals.\u003c/p\u003e\n \u003cp\u003eThe relationship between the popularity index for matching at each clinical-training hospital and hospital characteristics in the univariate analysis is shown in Supplemental 1. In the univariable analysis, statistically significant differences were observed for all variables (JCEP certification status, GM-ITE\u0026reg; participation, location, hospital type, number of permitted beds, average number of inpatients, annual number of ambulance transports, annual number of outpatients, average length of hospital stay, number of doctors, number of nurses, annual number of CT scans, and annual number of MRI scans). In the multivariable analysis, relationships among these factors were examined after excluding the number of doctors, number of nurses, and annual number of CT scans because these variables each had a VIF\u0026thinsp;\u0026gt;\u0026thinsp;5. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the association between the popularity index and hospital characteristics based on the multivariable model. In the multivariable analysis, the popularity index was higher for hospitals with JCEP certification (1.12, p\u0026thinsp;=\u0026thinsp;0.022) and GM-ITE\u0026reg; participation (1.14, p\u0026thinsp;=\u0026thinsp;0.011), urban locations (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and higher annual number of ambulance transports (per log-unit, 1.15, p\u0026thinsp;=\u0026thinsp;0.006), and lower with longer hospital stay (per log-unit, 0.73, p\u0026thinsp;=\u0026thinsp;0.005) and at university (0.48; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and university branch (0.59; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) hospitals than at community hospitals.\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eRelationship between residency program popularity and hospital-level information using multivariable analysis\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdjusted Exponentiated regression coefficient (95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eJCEP certification\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.12 (1.02 to 1.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGM-ITE\u0026reg; participation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.14 (1.03 to 1.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41 (1.27 to 1.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48 (0.39 to 0.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity\u0026nbsp;branch\u0026nbsp;hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.59 (0.47 to 0.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLog- number of permitted beds\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92 (0.89 to 1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.430\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLog- annual number of ambulance transports\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15 (1.04 to 1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLog- annual number of outpatients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.10 (0.98 to 1.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLog- number of days in hospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73 (0.59 to 0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLog- number of MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.07 (0.96 to 1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis nationwide cross-sectional analysis of matching data from clinical-training hospitals in Japan showed that hospital characteristics, including JCEP certification, GM-ITE\u0026reg; participation, hospital type, location, annual number of ambulance transports, and length of hospital stay, were each independently associated with the popularity of the hospital as the first-choice training facility in the physician clinical-training matching process. These findings suggest that assuring the quality of education in clinical-training hospitals may meaningfully influence medical students\u0026rsquo; selection of the hospital as their preferred training site.\u003c/p\u003e\u003cp\u003ePrevious studies have reported that structural factors such as location, emergency care systems, and hospital type are more strongly associated with popularity than salary or benefits.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Consistent with previous studies, we found that facilities located in urban areas, classified as community hospitals, and with a high annual number of ambulance transports were more popular. A higher annual number of ambulance transports reflects greater exposure to acute cases, aligning with medical students\u0026rsquo; preference for practical clinical training.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe observed association between JCEP certification and popularity in clinical-training matching suggests that third-party accreditation may signal a well-organized educational framework and safety management, thereby shaping students\u0026rsquo; choices. JCEP certification considers multiple criteria, including program philosophy, assurance of case volume, supervisory structure, and feedback mechanisms, and is a reliable indicator of educational quality.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFurthermore, the positive association between GM-ITE\u0026reg; participation and popularity suggests that the visibility of educational outcomes is a meaningful indicator for applicants. GM-ITE\u0026reg; is a reliable indicator that covers medical interviewing, physical examination, clinical reasoning, and disease-specific knowledge.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e A previous study found that GM-ITE\u0026reg; scores correlated with the strength of the teaching system and the educational environment, supporting its role as an indicator of educational quality.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eNotably, a shorter average length of hospital stay was significantly associated with popularity. Because length of hospital stay reflects patient turnover, hospitals with shorter average lengths of stay likely offer broader exposure to diverse conditions, which may attract students seeking varied case experience during their training.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eBy contrast, facility size indicators, such as number of permitted beds and the average number of inpatients, were significant in univariate analyses but not in multivariate analyses. This pattern suggests that medical students may prioritize factors such as educational quality, breadth of hands-on experience, and convenience of the living environment, over facility size alone.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Popularity may be shifting toward hospitals that demonstrate good educational outcomes and case diversity in preference to large size alone.\u003c/p\u003e\u003cp\u003eThese findings have several implications for educational policy and hospital management. First, maintaining and continuously operating the JCEP certification system may aid workforce recruitment by guaranteeing educational quality. Second, GM-ITE\u0026reg; participation and its active use can help quantify educational outcomes and provide an objective indicator to inform choice of training facility, in addition to supporting structural improvements in clinical-training programs. Finally, strengthening clinical service characteristics, such as robust emergency transport systems and shorter length of hospital stay, is important for providing varied practical clinical experience. These elements can also be understood within the World Federation for Medical Education (WFME) 2020 Quality Assurance Framework, in which JCEP certification functions as a structural indicator of educational governance and resources, GM-ITE\u0026reg; participation reflects an active process of assessment and feedback, and program popularity represents an externally validated outcome.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e This structure\u0026ndash;process\u0026ndash;outcome alignment suggests that hospitals demonstrating both organized educational systems and ongoing competency-based evaluation are more likely to achieve favorable educational and social outcomes, including higher applicant preference.\u003c/p\u003e\u003cp\u003eMoreover, these results may position JCEP as a Japan-specific counterpart to the ACGME-I system operating internationally. Previous studies have reported that ACGME and ACGME-I accreditation are associated with improved resident satisfaction, performance, and milestone attainment.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Given these findings, JCEP could similarly serve as a regional model for standardized postgraduate medical education in East Asia. Expanding JCEP\u0026rsquo;s visibility and alignment with international accreditation frameworks may facilitate cross-border recognition of training quality, enhance educational mobility, and contribute to global efforts to harmonize competency-based medical education.\u003c/p\u003e\u003cp\u003eIn practice, these strategies can be mutually reinforcing. Sustainable accreditation ensures baseline quality, while the use of standardized assessment tools, such as GM-ITE\u0026reg;, enables the identification of program strengths and weaknesses through data analysis. Hospitals that demonstrate both strong educational performance and efficient clinical operations may attract more applicants, thereby further improving the quality of training. Policymakers could also leverage aggregated GM-ITE\u0026reg; results to allocate funding or support to institutions that achieve measurable educational and clinical excellence. At the institutional level, integrating these metrics into management dashboards could help align hospital strategy with educational outcomes, creating a continuous feedback loop between education, service, and policy.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, as a cross-sectional analysis, it captured conditions at a single point in time and cannot establish causality. Whether popularity among medical students drives improvements in educational systems or, conversely, whether enhancements to educational systems increase popularity are unclear. Prospective studies are needed to clarify causation. Second, because the study focused exclusively on clinical-training hospitals in Japan, the findings may not be generalizable to hospitals in other countries, and external validation in other countries is warranted. Third, we did not directly measure factors or motivations governing individuals\u0026rsquo; choice of clinical-training hospital and thus did not assess the psychological or social drivers of application behavior. Fourth, residual confounding by unmeasured factors that affect hospital choice may be present. Data were not available on applicant-related factors (e.g., academic performance, alma mater, intended specialty, local ties) and program-related factors (e.g., salary and working conditions, workload, presence of renowned supervising physicians, organizational culture, employee benefits), so the possibility of residual confounding due to unmeasured variables cannot be ruled out. Finally, for JCEP certification and GM-ITE\u0026reg; participation, we examined as dichotomous variables (present or absent) and detailed metrics such as JCEP evaluation or GM-ITE\u0026reg; scores were not considered. Future research should comprehensively assess both qualitative and quantitative aspects of these educational indicators.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study examined found that hospital characteristics, including JCEP certification, GM-ITE\u0026reg; participation, hospital type, location, annual number of ambulance transports, and the average length of hospital stay, were associated with popularity in physician clinical-training matching. Being a community hospital, having a higher annual number of ambulance transports, a shorter length of hospital stay, an urban location, GM-ITE\u0026reg; participation, and JCEP certification were each independently associated with greater popularity as a clinical-training hospital. These findings suggest that medical students may consider multiple factors when selecting training sites, including assurance of educational quality, breadth of clinical experience, opportunities for hands-on training, and compatibility with living conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The authors thank the members of JCEP, JAMEP and the General Medicine In-Training Examination question development and peer-review committees for their assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKosuke Ishizuka: conceptualization, methodology, formal analysis, writing\u0026mdash;original draft. Yuji Nishizaki: conceptualization, methodology, writing\u0026mdash;review and editing. All authors read and approved the manuscript. Koshi Kataoka: conceptualization, methodology, formal analysis, writing\u0026mdash;review and editing. Kohta Katayama: writing\u0026mdash;review and editing. Kiyoshi Shikino: writing\u0026mdash;review and editing. Sho Fukui: writing\u0026mdash;review and editing. Yu Yamamoto: writing\u0026mdash;review and editing. Taro Shimizu: writing\u0026mdash;review and editing. Mitsuyasu Ohta: writing\u0026mdash;review and editing. Tsuguya Fukui: conceptualization, methodology, writing\u0026mdash;review and editing. Yasuharu Tokuda: conceptualization, methodology, writing\u0026mdash;review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis work was supported by the Health, Labor, and Welfare Policy Grants of Research on Region Medical (21IA2004) by the Ministry of Health, Labor, and Welfare (MHLW). However, the MHLW was not involved in the study\u0026rsquo;s design and conduct, data analysis and interpretation, and the preparation, review, approval, and submission of the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe corresponding author will respond to inquiries on the data analyses in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was performed in accordance with the Declaration of Helsinki. All methods were conducted in accordance with relevant guidelines. This study is based on analysis of aggregated publicly available data and did not contain any individual-level data on medical students or patients and therefore did not require ethics approval or informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e This study is based on analysis of aggregated publicly available data and did not contain any individual-level data on medical students or patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003eYN received an honorarium from JAMEP as a GM-ITE project manager. YT is the JAMEP director, and he received an honorarium from JAMEP as a speaker of the JAMEP lecture. KS received an honorarium from JAMEP as speakers of the JAMEP lecture. TS, KS, YY and SF received an honorarium from JAMEP as exam preparers of GM-ITE.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNotes on contributors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKosuke Ishizuka, MD, PhD, Clinical Lecturer,\u0026nbsp;Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan.\u003c/p\u003e\n\u003cp\u003eYuji Nishizaki, MD,\u0026nbsp;MPH, PhD, Professor, Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan.\u003c/p\u003e\n\u003cp\u003eKoshi Kataoka, PhD, Assistant Professor, Center for Translational Research, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan.\u003c/p\u003e\n\u003cp\u003eKohta Katayama, MD, PhD, Assistant Professor, Department of General Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.\u003c/p\u003e\n\u003cp\u003eKiyoshi Shikino,\u0026nbsp;MD, PhD, MHPE, FACP, AFAMEE, Project Professor, Department of Community-Oriented Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan.\u003c/p\u003e\n\u003cp\u003eSho Fukui, MD, MPH, Assistant Professor, Department of Emergency and General Medicine, Kyorin University Hospital, Tokyo, Japan.\u003c/p\u003e\n\u003cp\u003eYu Yamamoto, MD, Assistant Professor, Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan.\u003c/p\u003e\n\u003cp\u003eTaro Shimizu, MD, PhD, MPH, MBA, Professor, Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan.\u003c/p\u003e\n\u003cp\u003eMitsuyasu Ohta, MD, PhD, Professor, Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan.\u003c/p\u003e\n\u003cp\u003eTsuguya Fukui, MD, MPH, PhD, President, Nihon Pharmaceutical University, Saitama, Japan.\u003c/p\u003e\n\u003cp\u003eYasuharu Tokuda, MD, MPH, Director, Muribushi Okinawa Center for Teaching Hospitals, Okinawa, Japan.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDas SU (2016) Impact of ACGME Accreditation Process on Quality of Program and Patient Care in the Community. 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Korean J Fam Med 44:215\u0026ndash;223\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatari T, Nishizaki Y, Houchens N et al (2023) Medical resident\u0026rsquo;s pursuing specialty and differences in clinical proficiency among medical residents in Japan: a nationwide cross-sectional study. BMC Med Educ 23:464\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShikino K, Sekine M, Nishizaki Y et al (2024) Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study. BMC Med Educ 24:316\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNishizaki Y, Nagasaki K, Shikino K et al (2023) Relationship between COVID-19 care and burnout among postgraduate clinical residents in Japan: a nationwide cross-sectional study. 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Hum Resour Health 20:54\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Healthcare Market Analysis Platform Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://caremap.jp/\u003c/span\u003e\u003cspan address=\"http://caremap.jp/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [accessed July 27, 2025]\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJAMEP Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://jamep.or.jp\u003c/span\u003e\u003cspan address=\"https://jamep.or.jp\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e/ [accessed July 27, 2025]\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNishizaki Y, Nozawa K, Shinozaki T et al (2021) Difference in the general medicine in-training examination score between community-based hospitals and university hospitals: a cross-sectional study based on 15,188 Japanese resident physicians. BMC Med Educ 21:214\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKejela S, Tiruneh AG (2022) Determinants of satisfaction and self-perceived proficiency of trainees in surgical residency programs at a single institution. BMC Med Educ 22:473\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eB\u0026oacute;rquez RL (2023) The WFME Basic Medical Education Standards on the Horizon 2030. Med Sci Educ 33(Suppl 1):15\u0026ndash;18\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"a955a4b5-88dc-42fe-8681-119bbc176638","identifier":"10.13039/501100003478","name":"Ministry of Health, Labour and Welfare","awardNumber":"21IA2004","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Japan Institute for Advancement of Medical Education Program","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Clinical training, GM-ITE, JCEP, Third-party accreditation","lastPublishedDoi":"10.21203/rs.3.rs-8093417/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8093417/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBACKGROUND\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThird-party accreditation and the visibility of educational outcomes may influence medical students\u0026rsquo; choice of training sites; however, national evidence of their effect in Japan is limited. This study examined whether hospital characteristics\u0026mdash;especially Japan Council for Evaluation of Postgraduate Clinical Training (JCEP) certification and General Medicine In-Training Examination (GM-ITE\u0026reg;) participation\u0026mdash;are associated with residency program choice in Japan\u0026rsquo;s Physician Clinical Training Matching Program.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMETHODS\u003c/b\u003e\u003c/p\u003e\u003cp\u003e We conducted a nationwide cross-sectional study of 1,029 clinical training hospitals participating in the 2023 matching cycle. The outcome was a popularity index defined as the number of first-choice applicants per number of positions available. Predictors included JCEP certification, GM-ITE\u0026reg; participation, location (urban/rural), hospital type (community, university, university branch), and facility/service metrics (number of permitted beds, average daily number of inpatients, annual number of ambulance transports, annual number of outpatients, length of stay (general beds), number of doctors, number of nurses, annual number of computed tomography and magnetic resonance imaging scans). Continuous variables were analyzed using multiple linear regression of natural log-transformed data and exponentiated regression coefficients were reported.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRESULTS\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOf the hospitals, 32.1% were JCEP-certified and 67.1% participated in GM-ITE\u0026reg;. In the multivariable analysis, the popularity index was higher for hospitals with JCEP certification (1.12, p\u0026thinsp;=\u0026thinsp;0.022) and GM-ITE\u0026reg; participation (1.14, p\u0026thinsp;=\u0026thinsp;0.011), urban locations (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and higher annual number of ambulance transports (per log-unit, 1.15, p\u0026thinsp;=\u0026thinsp;0.006), and lower with longer hospital stay (per log-unit, 0.73, p\u0026thinsp;=\u0026thinsp;0.005) and at university (0.48; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and university branch (0.59; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) hospitals than at community hospitals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCONCLUSION\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProgram popularity in Japan is positively associated with JCEP certification, GM-ITE\u0026reg; participation, urban location, and higher emergency caseload, and negatively associated with longer hospital stay and university affiliation. These findings suggest that assurance of educational quality and opportunities for diverse, practical clinical exposure are important drivers of medical students\u0026rsquo; program selection.\u003c/p\u003e","manuscriptTitle":"Impact of third-party accreditation and General Medicine In-training Examination participation on residency program popularity: A nationwide matching data analysis in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 08:20:42","doi":"10.21203/rs.3.rs-8093417/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72baa6dc-93c3-4a49-b5e7-132b430d1014","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-13T08:20:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-13 08:20:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8093417","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8093417","identity":"rs-8093417","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}