Journal of General Internal Medicine

, Volume 33, Issue 4, pp 445–448 | Cite as

Awareness of Diagnostic Error among Japanese Residents: a Nationwide Study

  • Yuji Nishizaki
  • Tomohiro Shinozaki
  • Kensuke Kinoshita
  • Taro Shimizu
  • Yasuharu Tokuda
Original Research



Residents’ understanding of diagnostic error may differ between countries. We sought to explore the relationship between diagnostic error knowledge and self-study, clinical knowledge, and experience.


Our nationwide study involved postgraduate year 1 and 2 (PGY-1 and -2) Japanese residents. The Diagnostic Error Knowledge Assessment Test (D-KAT) and General Medicine In-Training Examination (GM-ITE) were administered at the end of the 2014 academic year. D-KAT scores were compared with the benchmark scores of US residents. Associations between D-KAT score and gender, PGY, emergency department (ED) rotations per month, mean number of inpatients handled at any given time, and mean daily minutes of self-study were also analyzed, both with and without adjusting for GM-ITE scores. Student’s t test was used for comparisons with linear mixed models and structural equation models (SEM) to explore associations with D-KAT or GM-ITE scores.


The mean D-KAT score among Japanese PGY-2 residents was significantly lower than that of their US PGY-2 counterparts (6.2 vs. 8.3, p < 0.001). GM-ITE scores correlated with ED rotations (≥6 rotations: 2.14; 0.16–4.13; p = 0.03), inpatient caseloads (5–9 patients: 1.79; 0.82–2.76; p < 0.001), and average daily minutes of self-study (≥91 min: 2.05; 0.56–3.53; p = 0.01). SEM revealed that D-KAT scores were directly associated with GM-ITE scores (ß = 0.37, 95% CI: 0.34–0.41) and indirectly associated with ED rotations (ß = 0.06, 95% CI: 0.02–0.10), inpatient caseload (ß = 0.04, 95% CI: 0.003–0.08), and average daily minutes of study (ß = 0.13, 95% CI: 0.09–0.17).


Knowledge regarding diagnostic error among Japanese residents was poor compared with that among US residents. D-KAT scores correlated strongly with GM-ITE scores, and the latter scores were positively associated with a greater number of ED rotations, larger caseload (though only up to 15 patients), and more time spent studying.


Diagnostic Error Knowledge Assessment Test (D-KAT) General Medicine In-Training Examination (GM-ITE) postgraduate education 



The authors would like to thank Takeshi Asakura for help in translating this manuscript into English, and we thank all members of the GM-ITE production committee for their support. We would also like to thank Jeffrey Jackson, MD, MPH, for his editorial work and assistance with the SEM models.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


  1. 1.
    Kinoshita K, Tsugawa Y, Shimizu T, et al. Impact of inpatient caseload, emergency department duties, and online learning resource on General Medicine In-Training Examination scores in Japan. Int J Gen Med. 2015;8:355–60.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Reilly JB, Ogdie AR, Von Feldt JM, et al. Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents. BMJ Qual Saf. 2013;22:1044–50.CrossRefPubMedGoogle Scholar
  3. 3.
    McCoy CP, Stenerson MB, Halvorsen AJ, et al. Association of volume of patient encounters with residents’ in-training examination performance. J Gen Intern Med. 2013;28:1035–41.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Kanna B, Gu Y, Akhuetie J, et al. Predicting performance using background characteristics of international medical graduates in an inner-city university-affiliated Internal Medicine residency training program. BMC Med Educ. 2009;9:42.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Perez JA, Greer S. Correlation of United States Medical Licensing Examination and Internal Medicine In-Training Examination performance. Adv Health Sci Educ Theory Pract. 2009;14:753–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Shimizu T, Tsugawa Y, Tanoue Y, et al. The hospital educational environment and performance of residents in the General Medicine In-Training Examination: a multicenter study in Japan. Int J Gen Med. 2013;6:637–40.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Kline RB. Principles and practice of structural equation modeling. New York: Guilford Press; 1998.Google Scholar
  8. 8.
    Kay C, Jackson JL, Frank M. The relationship between Internal Medicine Residency Graduate performance on the ABIM certifying examination, yearly in-service examinations and attending evaluations. Acad Med. 2015;90(1):100–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Schmidt HG, Mamede S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ. 2015;49:961–73.CrossRefPubMedGoogle Scholar
  10. 10.
    Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21:535–57.CrossRefPubMedGoogle Scholar
  11. 11.
    Singh H, Schiff GD, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26:484–94.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Yuji Nishizaki
    • 1
  • Tomohiro Shinozaki
    • 2
  • Kensuke Kinoshita
    • 3
  • Taro Shimizu
    • 4
  • Yasuharu Tokuda
    • 5
  1. 1.Medical Technology Innovation CenterJuntendo UniversityTokyoJapan
  2. 2.Department of Biostatistics, Graduate School of MedicineUniversity of TokyoTokyoJapan
  3. 3.Department of Medicine, Mito Kyodo General HospitalUniversity of TsukubaTsukubaJapan
  4. 4.Diagnostic and Generalist MedicineDokkyo Medical UniversityMibuJapan
  5. 5.Muribushi Okinawa for Teaching HospitalsUrasoe CityJapan

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