To evaluate whether general medicine training in our general ward has beneficial effects on postgraduate surgical training, questionnaires on general medicine training was sent to 30 doctors who had undergone initial training as residents in our hospital and were involved in surgical practice at the time of the survey. Twenty-two responses were obtained. Fifteen respondents had motivation for general practice at the beginning of their residency, and 20 attained their objectives during the 2-year training. Nineteen respondents appreciated their experiences in managing a variety of diseases encompassing the disciplines of internal medicine and surgery, although 12 complained of a shortage of teaching staff. From the viewpoint of its contribution to their present practice, their training in the general ward was evaluated by all respondents as having been beneficial. We conclude that general medicine training has beneficial effects on postgraduate surgical training that emphasizes comprehensive patient care.

In the past 2 years, all 1st-year medical trainees have been instructed in physical examination of patients with heart disease in the general ward of Tenri Hospital by two or three 2nd-year medical trainees who had received special training in physical examination for heart disease. After 1 year of training, all 1st-year medical trainees became confident in making a proper physical examination and in detecting an S3 gallop but were not confident in detecting other abnormal physical findings. On the other hand, the 2nd-year medical trainees thought that they were able to organize their own medical knowledge by teaching 1st-year medical trainees.

Objective: To investigate the role of postgraduate clinical training at the emergency department of Tenri Hospital in teaching the diagnostic process in the general outpatient department.
Method: Patients seen by 11 first-year residents at the emergency department were consecutively registered with summary sheets. Further information was added, and an analysis was performed of: 1) the distribution of chief complaints in the emergency and general outpatient departments and 2) initial diagnoses and the diagnostic process in the emergency department and the final diagnoses.
Results: The distributions of chief complaints in 89 cases in the emergency department and in 183 cases in the general outpatient department were closely correlated (p=0.0016). Diagnoses in the emergency department were correct in 58% of cases. Treatment was incorrect in 3% of cases.
Conclusion: The distributions of chief complaints in the emergency and general outpatient departments were similar. In our hospital the emergency department plays a major role in postgraduate clinical training by teaching the diagnostic process for the general outpatient department. Clinical management, including decision making for further tests and consultation, in the emergency department by first year residents did lead to any major adverse events.

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.

We have conducted weekly 40-minute training session of ECG diagnosis for lst-year postgraduate medical trainees for 6 months. Their abilities to read ECGs were tested before and after training sessions. Before training (just after graduation from medical school) they were able to diagnose typical ECGs if each tracing had only one abnormality and if enough time was given for interpretation. However, they frequently misdiagnosed even ECGs that they had correctly diagnosed on pre-tests if they were presented with many other ECGs and the time for interpretation was limited. Post-tests by students and teachers showed that our training of systematic and orderly reading of ECGs has enabled students to describe ECG findings fairly accurately but could not teach them to diagnose underlying cardiac disorders.

In the past 2 years, five 1st-year medical trainees with excellent knowledge and attitude trained with an instructor supervision in the physical examination of the heart with 4 to 5 patients a week. Despite their undergraduate medical education, these medical trainees could not detect abnormal physical findings of the heart. As much as 5 months of training was required before they could satisfactorily detect such abnormalities.

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.

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.

Based on 20 years of experience with an unique postgraduate clinical training program, consisting of “g eneral wards ” and “inninr-residents in general medicine” at Tenri Hospital (Nara, Japan), we have identified the following points for the successful evaluation of residents: 1) unlike undergraduate teaching, item-based evaluations do not fit teaching in the clinical setting, 2) evaluation of residents' attitudes should be emphasized, 3) comprehensive evaluation in regular meetings by the teaching staff is practical and useful, 4) mechanisms to reflect patients' opinions should be included in the evaluation process.