Hands-on clinical clerkship | IJGM – Dove Medical Press


The standard 6-year medical educational program in Japanese universities consists of 4 years of pre-clinical training and 2 years of clinical training. 1 Clinical training in Japan is categorized into traditional observation-based training and a hands-on clinical clerkship, which has recently become more popular. 2 Until the 1990s, observation-based training had been the particular mainstay of training within Japan, one in which healthcare students acquired knowledge associated with clinical practice only through observing the practice of supervising clinicians. This style of coaching makes active learning an arduous goal and impairs students’ motivation. 2 In contrast, a hands-on clinical clerkship enables students to acquire a physician’s professional knowledge, mindset, skills, and attitude by sharing the medical work as one of the particular group exercise members. 3 Unlike observation-based teaching, this type of medical training provides medical college students with better opportunities to engage in energetic clinical practice, increasing their motivation to train themselves. 2 In 2010, the Educational Commission for Foreign Medical Graduates in the United States established the 2024 Healthcare School Accreditation Requirement. Starting in 2024, individuals applying for Educational Commission for Foreign Medical Graduates Certification must be a student or graduate of a medical school that is appropriately accredited. 4 , 5 Consequently, most Japanese Universities decided to acquire the international certification, which required them to change their scientific training system from observational-based training to a hands-on clinical clerkship. Therefore , in 2018, the Department of General Medicine (GM) of Saga University Hospital, Japan, also changed the particular clinical education system to some hands-on medical clerkship from observation-based instruction, which had been its main training program until 2017.

In Japan, the Model Core Curriculum for healthcare education was established within 2001 with three revisions by 2021, using the standard associated with clinical competencies (knowledge, abilities, and attitudes). The basic scientific competencies are (1) a problem-oriented system and clinical reasoning, (2) medical interviews, (3) medical records (chart), (4) medical judgment, (5) physical examinations, and (6) the basic scientific procedure, which usually medical learners must acquire. 6 Evidence-based medicine (EBM) has been added as one of the learning topics with regard to medical students in the particular revision in 2016. 6

To the best of our knowledge, there have been no reports on the educational effect of the particular hands-on clinical clerkship conducted at the Department associated with GM of an university hospital. The reason for this lack of reviews could partly be because the roles of generalists are variable and highly dependent on the background where they work. 7 One of the main working settings associated with generalists will be community medication. They are expected to play a major role within the comprehensive community healthcare system, focusing on not only the diseases that patients are suffering from, but also the particular lives of patients plus their families in connection with the community around them. 8 In such a situation, careful consideration and in-depth discussion on the influence of the background of their lives upon pathophysiological conditions are mandatory. However, the particular Department associated with GM at some university hospitals in The japanese, including Tale University Medical center, treat inpatients with severe medical conditions who require intensive general treatments in addition in order to newly visiting outpatients without a referral letter and patients returning to the clinic. 9 In these Departments of GM, generalists provide patients with healthcare care through a comprehensive plus holistic approach without limiting to specific organ disorders or refusing to treat patients owing to a lack of organ-specific expertise. Therefore, these types of departments could be ideal to educate students with a hands-on medical clerkship.

In this study, we investigated how a hands-on scientific clerkship in the Department associated with GM at an university hospital improved medical students’ self-confidence of their clinical competencies. We compared the results of the questionnaire survey between college students who underwent a hands-on clinical clerkship and those who had observation-based training.

Materials and Methods

Design and Participants

This was a questionnaire-based, prospective study. In 2017, all of us enrolled 99 5th-year-grade medical students who were going to have observation-based training mainly within the outpatient clinic (Group O). Within 2018, we all also enrolled 123 learners who have been going to participate in the new-style hands-on medical clerkship as one of the group exercise members (Group H). At the Faculty associated with Medicine, Fable University, all medical students were divided into groups with members of five to nine. They experienced clinical exercising in the Department of GM for 2 weeks between April from the 5th year and September of the particular 6th 12 months. Self-evaluation questionnaires were administered at the beginning plus the end of the clinical schooling to evaluate the particular students’ self-assessment regarding the achievement of scientific competencies.


Saga University Hospital is usually the just national college hospital within Saga Prefecture, which is definitely a regional city in the southern part of Japan. This hospital offers 602 beds and 29 departments. During the period of this study from 2017 to 2019, 13 physicians consisting associated with 7 faculty members (Assistant Professors and higher qualification) and six full-time doctors at the Division of GM were involved in the training of medical students through their own medical practices in outpatient and inpatient clinics. In the outpatient clinic, these physicians primarily treated newly visiting individuals without the referral letter or those who were referred directly to the department because associated with the difficulty in making a correct diagnosis at other hospitals. The GM division also has its own hospital beds, and it treats inpatients with infection, septic shock, fever of unknown origin, undiagnosed autoimmune disease, cancer of unknown primary source, and some other diagnostically challenging cases.

Changes in Medical Training Between 2017 plus 2018

Within 2017, healthcare students in Group O received observational-based training in a similar manner as that in the particular preceding years ( Supplementary Table 1 ). Every day, college students recorded the medical history of recently visiting sufferers in the outpatient clinic associated with the Section of GM in the particular morning and gave the presentation on their patients at a conference within the afternoon. The particular students then spent time taking classroom lectures generally on their particular practice at the outpatient clinic through faculty users of the departments or reviewing their practice within training by themselves. Consequently , they did not have the particular opportunity to see inpatients or even join the conferences on them.

In 2018, we changed the training method in the Department of GENERAL MOTORS to a hands-on clinical clerkship ( Supplementary Table 2 ). The learners in Group H went through the same outpatient clinic coaching with recording the medical history in the morning in the particular same way as the additional students did in 2017. In addition , they spent the larger amount of time working along with the attending physicians of inpatients that they were assigned to. Once a day, each student wrote a medical record around the inpatients under their own charge, plus the supervising physician provided them with some feedback on it. The students participated in the going to physician’s routine rounds associated with their inpatients every morning and evening, and each round took approximately 30 minutes. During the rounds, the patients’ current condition, any changes in their condition since the last round or during the course of the disease, or the plans of the treatment were discussed. Approximately 9. 5 hours were spent within the rounds in two weeks. Additionally , twice a week, the students participated in a round by a Professor or an Associate Professor of the section of almost all inpatients, and were offered a bedside lecture. They also joined case conferences on just about all inpatients once a week. Consequently, the length of classroom lectures from teachers members in the afternoon had been reduced in order to 12 hours from the particular previous 20 hours.

Questionnaire and Survey Strategies

Four from the faculty members carried out a narrative review of the essential expertise for common physicians that must be acquired in university private hospitals. They subsequently developed the questionnaire regarding self-assessment to measure students’ achievement via training within the Division of GM ( Table one ).

Table 1 Questionnaire Pre- and Post- Training

The particular questionnaire consisted of 23 questions. These questions covered all associated with the indispensable skills required for the practice of general physicians regarding medical understanding, clinical reasoning, clinical decision-making, clinical skills, attitude, and the ability of practicing EBM. 6 , 10–16 Questions #1 in order to 3 had been related to the assessment of healthcare interviews, 6 , 10–13 #4 in order to 7 to physical exams, 6 , 10 , 12 , 13 #8 to ten to medical reasoning, six , 12 , thirteen #11 to 12 to comprehension of necessary examinations intended for diagnosis, 6 , 13 #13 in order to judging the particular necessity associated with consultation, six #14 to 17 to planning of treatment, 6 #18 to 19 in order to judging the necessity of follow-up, 6 , 10–13 #20 to 21 to presentation skills, 6 , 14 and #22 to twenty three to the ability of practicing EBM. 6 , 15 , 16 We had college students complete the particular same self-assessment questionnaire twice, at the beginning as well as the end of the clinical teaching. The learners filled out the questionnaire themselves. The second survey was given without showing the students their responses to the particular first study. The college students responded to every question along with the 4-point Likert scale (3: very satisfied, 2: satisfied, one: dissatisfied, 0: very dissatisfied).

Statistical Analysis

Pre- and post-training scores of the set of questions provided to Group U and in order to Group H were tallied up, plus the mean and standard deviation were subsequently calculated. Initially, in each associated with the two groups, we compared the scores of questionnaire items between pre- and post-training using the Wilcoxon signed-rank test. We after that also compared each of the pre- and post-training quite a few questionnaire items among Group Um and Team H using the Mann–Whitney test. All of us defined an improvement in scientific competency due to the hands-on clinical clerkship when a score within the post-training set of questions of Group H was significantly higher than that within Group O, without any kind of significant difference in pre-training scores between the 2 groups. Analyses were performed using SPSS (version 25; IBM Corp., Armonk, NY, USA) The particular level associated with statistical significance ( p value) was set at 0. 05.


In Team O, 99 of 99 (men: n=60, 61%) learners responded, and 121 of 123 (men: n=69, 57%) responded within Group H, with an overall response rate of 99%. Table two shows the particular mean ± standard deviation score associated with each item of the questionnaire administered each year from pre- plus post-training. The post-training ratings for all items were significantly greater than pre-training scores in both organizations (all p < 0. 001).

Table 2 Questionnaire Scores Pre- and Post- Coaching

We in comparison the scores of the pre-training questionnaire between groups. Group H showed significantly higher scores to Question #8 (“Can understand the overall problems of a patient on the basis of selection interviews and physical examinations or even basic laboratory tests simply by describing them in a problem list”), Question #9 (“Can prioritize treatment for an emergency plus severe condition of the particular patient, regardless of whether a diagnosis is made”), Question #10 (“Can develop a diagnostic hypothesis on the basis of pathophysiological or clinical-epidemiological issues, and clarify essential information for verifying a hypothesis or excluding a diagnosis”), Question #13 (“Can assess the necessity of consultation and select the most appropriate specialty department in order to refer the particular patient”), Question #14 (“Can discuss the necessity to get hospitalization and choose the particular appropriate specialized department to refer the patient to”), Question #17 (“Can be familiar with characteristics of the patient’s life and relationship with family members leading in order to the development of illness, and discuss advice concerning lifestyle [e.g., diet, exercise, and sleep]”), Question #18 (“Can judge the need pertaining to follow-up plus the appropriate length associated with observation”), Query #19 (“Can accurately evaluate the medical course during follow-up and evaluate adherence of the particular patient to treatment from an interview, bodily examination, or even investigations”), Issue #21 (“Can select the required information in order to make the case demonstration according to the purpose of the presentation plus allotted time”) and Question #22 (“Can select suitable reference literature using databases such because PubMed”) than Group U ( Table a few ).

Table three or more Pre-Training Set of questions Ratings

We all also compared the scores of the particular post-training questionnaire between the groups. Team H demonstrated significantly increased scores to Question #5 (“Can perform a systemic physical examination quickly and efficiently”), Query #9, Issue #14, Question #16 (“Can clearly explain the present medical condition, therapeutic options, or risks associated with therapy, and talk about the process for obtaining informed consent”), and Query #17 compared to Group Um ( Table four ).

Table 4 Post-Training Questionnaire Scores

As a result, the enhanced clinical competencies by self-assessment utilizing the hands-on clinical clerkship were related to Issue #5 (“Can perform a systemic actual physical examination quickly and efficiently”) and Question #16 (“Can clearly clarify the current medical condition, restorative options, or even risks associated with treatment, plus discuss the process for acquiring informed consent”). The results of an additional analysis of covariance analysis to help interpret the outcomes associated with this study are shown in Supplementary Desk 3 .


This research showed that will students’ self-confidence in their particular ability to carry out a systemic physical exam and describe the patient’s medical options and understand the process of obtaining informed consent had been improved by the hands-on clinical clerkship. However, the particular post-training quite a few all products were considerably higher than the pre-training scores within both groupings. This finding suggests that even the traditional-style observation-based education had a good educational impact to some extent. In particular, products regarding healthcare interviews, case presentations, and EBM showed higher ratings after the learning both groups, irrespective of the particular change in training methods.

With regard in order to the ability associated with performing the systemic actual examination, the post-training score for Query #5 has been significantly higher in Group H than in Group O, with no difference within the pre-training score. Students in Team H were involved in the treatment of inpatients simply by performing a physical examination of them or recording relevant information in the medical chart daily, which were not required to be carried out by all those in Group O. Subsequently, the supervisory physician reviewed the medical records that will the students wrote plus provided some feedback, which could have supplied a beneficial educational effect on the particular students. Feedback from supervising physicians upon basic scientific competencies improves trainees’ abilities of healthcare interviews, physical examinations, and communication. seventeen In particular, general physicians are able to provide more learner-centered feedback compared to other specialists. 17 This much better feedback can be achieved by spending the longer period in engaging in discussions regarding the patients plus providing guidance or advice to learners. 18 Additionally , a study reported that residents supervised simply by general physicians received increased scores within the General Medicine In-Training Examination than individuals supervised by specialists. 19 This particular examination protected main four medical expertise of medical interviewing and professionalism, symptomatology and clinical reasoning, the physical evaluation and its procedures, and information of illnesses. Therefore, comments and medical instructions through general doctors could have been especially effective within the improvement of students’ self-confidence in their capability to execute a systemic physical examination in those who participated in the hands-on scientific clerkship in this study.

With regard to the ability of understanding patients’ treatment options and the process associated with obtaining knowledgeable consent (Question #16), the particular post-training score was also significantly higher within Group They would within Team O, with no difference in the pre-training rating. The college students in Group H had been assigned to inpatients, plus spent a larger period of time working on and communicating with actual inpatients. In addition , they took part in the particular attending physician’s routine models of their inpatients every early morning and night. The main purposes and benefits of medical center ward rounds were gathering information, a better understanding of the patients, reviewing the diagnosis, developing a treatment plan, and communicating with individuals. These factors might be extremely educational in order to medical learners. 20 The participation within the rounds could have allowed the students to deepen their knowing of sufferers. Additionally, this participation might have enabled college students to learn the supervisors’ thinking processes of making diagnoses and choosing treatments by means of their closer communication along with patients plus supervisors. Listening to the patient thoroughly and understanding their own social background in addition to their particular disease are important. This process is better than simply considering the patient as a person with a disease, especially patients of GENERAL MOTORS who tend to possess complicated plus multiple issues. 21 Engel proposed that understanding the aspects of the patient’s personality and relationship with family people, other people, or even surrounding community is necessary meant for the holistic understanding associated with the individuals, while biomedical aspects are usually also essential in health care. 22 These findings suggested that improved quality and an increased amount of communication along with inpatients or their supervisors via a hands-on clinical clerkship on the Section of GM enabled learners to better understand the sufferers. These college students were capable to focus on the psychological and social background from the patients, or even plan tests and therapy, which would have caused higher self-esteem in these students.

Finally, the particular post-training score of self-assurance in the capability to perform medical interviews, case presentations, and EBM were much higher than these of pre-training in both groups, with no significant difference involving the groups. This finding indicated that even observation-based training was effective for these types of items. The particular skill associated with performing the medical interview is important for healthcare workers, contributing to 76% of the process of producing a diagnosis. 13 To train for this skill, small-group workshops involving role-play and selection interviews with a simulated patient, virtual patient, or actual individual, followed by discussion and suggestions using a video review, have got become well-known as a good educational method. 23 Additionally , opinions from supervisors is especially efficient in improving skills of interviews plus communication. 17 At the Department of GENERAL MOTORS of Saga University Hospital, we have practiced an educational strategy of allowing medical college students to report the healthcare history and give presentations on the outpatients while receiving feedback from their supervisors since before 2017. This has been performed actually in the particular era associated with traditional-style observation-based training. This particular educational method enabled learners to experience the procedure repeatedly, that could possess improved their own self-confidence in their ability for medical interviews, even after observation-based instruction. Furthermore, students need to improve their oral presentation skills through trial and error by their own efforts. 14 Since before 2017, we have provided every college student with two for you to give presentations upon each affected person, immediately after their particular medical interview with the patient and at the outpatient conference later. College students might also have got improved their self-confidence within the ability of giving a presentation through such frequent opportunities of exercise. In inclusion, the revised Model Core Curriculum in 2016 added the capability of practicing EBM among the needed competencies. Therefore, medical learners were necessary to get the ability in order to generalize a good individual problem or clinical question gained from 1 patient to that of the entire population. 6 Since before 2017, all of us also have provided college students with instructions on how to identify clinical difficulties or questions about the patients these were allocated to, having a subsequent search and critical review associated with the books. This information furthermore might possess improved their own self-confidence within the skill of EBM.


This study has several limitations. First, the effectiveness and validity of the particular questionnaire making use of the 4-point Likert level that we all developed within this research have not been verified. This issue could have negatively affected the reliability from the results associated with this study, indicating an improvement in the students’ self-evaluation of their particular medical abilities. Further studies using confirmed indicators or even those aiming to verify our indicators are warranted because the particular present research used original indicators without validation. Second, 5th-grade medical students of two different years were included in the study, which might have affected the results because of differences in population backgrounds. Third, we defined an item associated with competency as improved using a hands-on clinical clerkship provided by the Department of GM when a score of the post-training questionnaire within Group H was significantly higher than that in Group O, with no significant difference in the pre-training score between the particular groups. However, there were 10 items that showed differences in the pre-training scores between the two groups, which we failed to analyze or discuss in this study.


Hands-on medical clerkships at the Division of GENERAL MOTORS of university hospitals could improve healthcare students’ self-confidence in performing a physical examination, and understanding patients’ treatment options and the process of informed consent compared with observation-based training.


EBM, evidence-based medicine; GM, general medicine.

Data Sharing Statement

The datasets generated during the current study are available from the corresponding author on reasonable request.

Ethics Declaration

The ethics committee associated with the Faculty of Medicine, Saga University waived the need for ethical approval for this particular study because no scientific information was being collected. All students were knowledgeable about the particular use of their educational data for research upon enrollment to our college after having provided comprehensive consent to participate in the study. Their personal information was anonymized within the analysis.


We thank Ellen Knapp, PhD, from Edanz ( https://jp.edanz.com/ac ) for editing the draft of this manuscript.

Author Contributions

All authors made a significant contribution to the original text, including the particular conception, research design, execution, acquisition of information, analysis plus interpretation, or all these areas; took part in drafting, revising or even critically reviewing the article; gave final authorization of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable with regard to all aspects of the work.


This study had no funding.


The authors report no conflicts of interest in this work.


1 . Kozu T. Medical education within Japan. Acad Med . 2006; 81(12): 1069–75. 2. doi: ten. 1097/01. ACM. 0000246682. 45610. dd

2 . Inada H, Mitsunami K, Motohara S, Fetters MD. Increasing motivation associated with medical students through a participatory style of learning: a case study demonstrating how to move away from “osmotic learning” Igakukyouiku 2010. Med Edu . the year 2010. 41(5): 347–351.

3. Yamawaki M, Okawa A, Tanaka Y. Continuum of learning objectives from undergraduate clinical clerkship to postgraduate residency. Igakukyouiku . 2009; 40(6): 399–410.

4. Saiki T, Imafuku R, Suzuki Con, Ban N. The truth lies somewhere in the middle: swinging between globalization and regionalization associated with medical education in Japan. Med Teach . 2017; 39(10): 1016–1022. doi: 10. 1080/0142159X. 2017. 1359407

5. Educational Commission regarding Foreign Healthcare Graduates. Medical school accreditation requirement; 2024. Available through: https://www.ecfmg.org/accreditation/ . Accessed July 12 , 2022 .

6. Medical Education Model Core Curriculum Coordination Committee. Model core curriculum for medical education within Japan. Available from: https://www.mext.go.jp/component/a_menu/education/detail/__icsFiles/afieldfile/2018/06/18/1325989_30.pdf . Accessed April 14 , 2022 .

7. Tago M, Watari T, Shikino K, et al. Five tips for becoming an ideal common hospitalist. Int J Gen Med . 2021; 29(14): 10417–10421. doi: 10. 2147/IJGM. S341050

8. Arai H, Ouchi Y, Toba K, ainsi que al. The japanese as the frontrunner of super-aged societies: perspectives from medication and healthcare care in Japan. Geriatr Gerontol Int . 2015; 15: 673–687. doi: ten. 1111/ggi. 12450

9. Takeoka H, Horibata K, Matui S. Trends within departments of general medicine in university or college hospital in Japan searched from websites. Med Bull Fukuoka Univ . 2017; 44(2): 81–86.

10. Feddock CA. The lost art associated with clinical skills. Am J Med . 2007; 120(4): 374–378. doi: 10. 1016/j. amjmed. 2007. 01. 023

11. Mukohara Nited kingdom, Kitamura E, Wakabayashi They would, et al. Evaluation of a communication abilities seminar intended for students in a Japanese medical school: a non-randomized controlled study. BMC Med Educ . 2004; 18(4): 24. doi: ten. 1186/1472-6920-4-24

12. Fred HL. Hyposkillia: deficiency of clinical skills. Tex Heart Inst M . 2005; 32(3): 255–257.

13. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Efforts from the history, physical examination, and laboratory investigation within making healthcare diagnoses. West J Med . 1992; 156(2): 163–165.

fourteen. Haber RJ, Lingard LA. Learning oral presentation abilities: a rhetorical analysis with pedagogical plus professional implications. J Style Intern Mediterranean sea . 2001; 16(5): 308–314. doi: 10. 1046/j. 1525-1497. 2001. 00233. x

15. Rengerink KO, Thangaratinam S, Barnfield G, ou al. How can we teach EBM in clinical practice? An evaluation of barriers to implementation of on-the-job EBM teaching and studying. Med Train . 2011; 33(3): e125–30. doi: ten. 3109/0142159X. last year. 542520

16. Matsui K, Ban N, Fukuhara S, et al. Poor English skills as the barrier to get Japanese health care professionals in understanding and practising evidence-based medication. Med Educ . 2005; 38(11): 1204. doi: 10. 1111/j. 1365-2929. 2004. 01973. x

17. Perron NJ, Louis-Simonet M, Cerutti B, ainsi que al. The particular quality associated with feedback during formative OSCEs depends on the tutors’ profile. BMC Med Educ . 2016; 16(1): 293. doi: ten. 1186/s12909-016-0815-x

18. Hauer KE, Wachter RM, Charles E, ou al. Effects of hospitalist attending physicians on trainee satisfaction along with teaching and with internal medicine rotations. Arch Intern Mediterranean . 2004; 164(17): 1866–1871. doi: 10. 1001/archinte. 164. 17. 1866

19. Nishizaki Y, Shimizu To, Shinozaki Capital t, et ing. Impact of general medication rotation coaching on the particular in-training exam scores of eleven, 244 Japanese resident doctors: a Nationwide multi-center crosssectional study. BMC Med Educ . 2020; 20(1): 426. doi: ten. 1186/s12909-020-02334-8

20. Perversi P. The purpose associated with ward rounds. Ir L Med Sci . 2019; 188(3): 1071–1073. doi: 10. 1007/s11845-018-1930-y

21. Hamada O, Tsutsumi T, Tsunemitsu A, et al. Impact of the hospitalist system within Japan upon the quality of care and healthcare economics. Intern Med . 2019; 58(23): 3385–3391. doi: 10. 2169/internalmedicine. 2872-19

22. Engel GL. The need for a new medical model: a challenge pertaining to biomedicine. Science . 1977; 196(4286): 129–136. doi: ten. 1126/science. 847460

23. Keifenheim KE, Teufel Meters, Julianne I, et ‘s. Teaching background taking in order to medical college students: a systematic review. BMC Med Educ . 2015; 15: 159. doi: 10. 1186/s12909-015-0443-x

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