Open Access Research article

Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine

Yasuaki Hayashino1*, Shunich Fukuhara1, Kunihiko Matsui2, Yoshinori Noguchi3, Taro Minami4, Dan Bertenthal5, John W Peabody5, Yoshitomo Mutoh6, Yoshihiko Hirao7, Kazuhiko Kikawa2, Yohei Fukumoto8, Junichiro Hayano9, Teruo Ino3, Umihiko Sawada10, Jin Seino11, Norio Higuma12 and Hiroyasu Ishimaru13

Author Affiliations

1 Kyoto University Graduate School of Medicine, Kyoto, Japan

2 Kumamoto University Hospital, Kumamoto, Japan

3 Nagoya Second Red Cross Hospital, Aichi, Japan

4 Beth Israel Medical Center, NY, USA

5 University of California, San Francisco and Los Angeles, California, USA

6 Toranomon Hospital, Tokyo, Japan

7 Nara Medical University, Nara, Japan

8 Yamaguchi University Hospital, Yamaguchi, Japan

9 Nagoya City University Medical School, Aichi, Japan

10 Nihon University School of Medicine, Tokyo, Japan

11 National Hospital Organization Sendai Medical Center, Niigara, Japan

12 Niigata Municipal Hospital, Niigara, Japan

13 Tenri Hospital, Nara, Japan

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BMC Medical Education 2006, 6:33  doi:10.1186/1472-6920-6-33

Published: 13 June 2006



The extent of clinical exposure needed to ensure quality care has not been well determined during internal medicine training. We aimed to determine the association between clinical exposure (number of cases seen), self- reports of clinical competence, and type of institution (predictor variables) and quality of care (outcome variable) as measured by clinical vignettes.


Cross-sectional study using univariate and multivariate linear analyses in 11 teaching hospitals in Japan. Participants were physicians-in-training in internal medicine departments. Main outcome measure was standardized t-scores (quality of care) derived from responses to five clinical vignettes.


Of the 375 eligible participants, 263 (70.1%) completed the vignettes. Most were in their first (57.8%) and second year (28.5%) of training; on average, the participants were 1.8 years (range = 1–8) after graduation. Two thirds of the participants (68.8%) worked in university-affiliated teaching hospitals. The median number of cases seen was 210 (range = 10–11400). Greater exposure to cases (p = 0.0005), higher self-reports of clinical competence (p = 0.0095), and type of institution (p < 0.0001) were significantly associated with higher quality of care, using a multivariate linear model and adjusting for the remaining factors. Quality of care rapidly increased for the first 100 to 200 cases seen and tapered thereafter.


The amount of clinical exposure and levels of self-reports of clinical competence, not years after graduation, were positively associated with quality of care, adjusting for the remaining factors. The learning curve tapered after about 200 cases.