Japanese medical school graduates who have just been licensed cannot properly conduct historytaking and physical examination because of inadequate undergraduate clinical practical training. We propose that each medical school should recruit senior physicians in its affiliated teaching hospitals as clinical professors who clinically train medical students in their own hospitals, evaluate the clinical competences of the students, and also participate in improving the undergraduate clinical curriculum of the medical school. The students poorly evaluated by clinical professors should not be allowed to graduate, while the clinical professors are evaluated by students and the medical school for renewal of the professorship.

We have attempted to train 1st-year medical residents who have just received their medical licenses in palpation of the thyroid gland. The residents were instructed to palpate goiters by an otolaryngologist responsible for the ultrasonography laboratory for thyroid disease, and palpation findings were compared with ultrasonography findings. Each resident examined an average of 6.0 patients with diffuse goiter and 4.6 patients with nodular goiter. One year later, 75% of the residents had confidence in palpation of the thyroid gland, and every resident had palpated the thyroid gland as a part of the physical examination for all inpatients, but not for outpatients. This training was useful for familiarizing medical residents with palpation of the thyroid gland in routine physical examination.

Among the 55 medical residents who had completed the 2-year postgraduate medical training course at Tenri Hospital in the past 5 years, the postgraduate medical education committee analysed 9 residents whose clinical performance was considered inappropriate. The committee, composed of eight instructors, found that residents with initially poor medical knowledge were able to improve their medical performance and skills during their 2 years of training; however, other residents who lacked responsibility towards patients, communication skills, and medical ethics during training had great difficulty improving or altering their attitude or performance in the 2 years.

All 11 1st-year medical trainees in 1999 participated in medical interview training in the outpatient department under the supervision of senior physicians. Interviews were to be done within 15 minutes. The training was completed when each trainee had interviewed an average of 10 patients. Approximately 70% of the chief complaints were common ones that the Japanese Society of Internal Medicine has recommended general internists master. Most trainees considered this training effective for learning to clarify the patient's reason for seeking care and for improving presentation skills. However, they considered the training ineffective for learning to judge the necessity of emergency care and for understanding the usefulness and limitations of laboratory data, electrocardiograms, and chest films.

We used a new cardiology simulator twice to train lst-year medical residents in physical examination with a specific behavioral objective shortly after they had received their medical licenses. The first training sessions were to teach residents to understand normal heart sounds and to perform physical examinations in the proper order; the second training sessions were to teach recognition of abnormal heart sounds and murmurs. After the first training sessions, all residents could perform physical examinations in the proper order with special attention to the jugular vein, differentiation of systole and diastole by palpating the carotid artery, splitting of S2, and the timing and transmission of heart murmurs. Just after the second training sessions, all residents thought that their physical examination skills and ability to recognize abnormal heart sounds and murmurs had improved. One year later, the residents were accustomed to performing physical examination in the proper order and could recognize gallop rhythms and murmurs of grade 3/6 or higher. Repeated training with specific behavioral objectives could motivate residents to understand both normal and abnormal heat sounds and murmurs.

With the development of sophisticated medical technologies, there has been a tendency to belittle the taking of the “history and physical, ” even in the field of cardiology. We have been holding cardiology case conferences for general medical residents, with the main focus on history taking and physical examination since 1992, so that all residents are able to provide a certain level of primary care for patients with cardiac diseases regardless of his or her future sub-speciality. We present our methods and the educational effect of these conferences.

To improve the ability of 1st-year medical residents to take histories from patients with chest pain we had residents re-interview patients in a senior cardiologist's outpatient department who had had chest pain of known origin. Three medical residents participated in this training program just after obtaining their licenses to practice medicine. Each resident took histories from approximately 25 consecutive patients during a 1-month period. Causes of chest pain included angina pectoris (38 cases), acute myocardial infarction (16 cases), pulmonary embolism (10 cases), and dissecting aortic aneurysm (4 cases).
Each of the three residents stated that they recognized the importance of taking histories from patients with ischemic heart disease and became confident doing so after having interviewed about 15 patients. What they learned in this training program was considered useful when they interviewed new patients in an emergency room who complained of chest pain. One resident wished that this training had started several months after receiving his license because they had little experience taking histories from patients while in medical school. Four months after this training, the senior cardiologist tested the three residents by having them interview new patients with chest pain and found their abilities to be satisfactory.
Twenty consecutive cases appears to be a satisfactory number for medical residents to become confident in taking histories from patients with ischemic heart disease. This training program should be started within 3 months after residents receive their medical licenses.

To evaluate the learning process in a general medicine training program for skills used in minor outpatient surgery, we introduced a new educational program for knot-tying technique. Eleven 1st year residents were enrolled in the program. The program consisted of initial instruction by senior surgeons through a video system, continuous training with a phantom at weekly surgical conferences, and practical application in the operating room. We objectively evaluated the effectiveness of this program with our unique scoring system for tying which includes speed, form, and securityof the knots. The scores after 4 months, especially the speed score, were significantly, better than those at the beginning of the program (P<0.05), and the scores for form and security tended to be higher than those of 2nd-year residents. We conclude that this unique program for knot tying is effective for teaching proper techniques for tying tight and secure knots and may be used as a part of general medicine training program.

Eleven 2nd-year medical residents were given the opportunity to take histories and give physical examinations for patients whose complaints included chest pain, palpitations, dyspnea on exertion, fainting, asymptomatic electrocardiographic abnormalities, and hypertension. Each resident took part in this program in an instructor's outpatient clinic twice a week for 2 consecutive months; each resident saw an average of 19 patients. The instructor discussed with the residents how to make diagnoses logically and the necessity of emergency treatment. The residents learned that taking histories accurately is an extremely important diagnostic tool, that a systematic approach is important, and that clinical decisions are often influenced by nonmedical factors. Medical residents need to have experience with such patients to improve their ability to take histories and perform physical examinations; however, proper supervision by an instructor in more important.