鋪野 紀好

PURPOSE: A regional quota program (RQP) was introduced in Japan to ameliorate the urban-rural imbalance of physicians. Despite concerns about the low learning abilities of RQP graduates, the relationship between the RQP and practical clinical competency after initiating clinical residency has not been evaluated. METHODS: We conducted a nationwide cross-sectional study to assess the association between the RQP and practical clinical competency based on General Medicine In-Training Examination (GM-ITE) scores. We compared the overall and category GM-ITE results between RQP graduates and other resident physicians. The relationship between the RQP and scores was examined using multilevel linear regression analysis. RESULTS: There were 4978 other resident physicians and 1119 RQP graduates out of 6097 participants from 593 training hospitals. Being younger; preferring internal, general, or emergency medicine; managing fewer inpatients; and having fewer ER shifts were all characteristics of RQP graduates. In multilevel multivariable linear regression analysis, there was no significant association between RQP graduates and total GM-ITE scores (coefficient: 0.26; 95% confidence interval: -0.09, 0.61; P = .15). The associations of RQP graduates with GM-ITE scores in each category and specialty were not clinically relevant. However, in the same multivariable model, the analysis did reveal that total GM-ITE scores demonstrated strong positive associations with younger age and GM preference, both of which were significantly common in RQP graduates. CONCLUSION: Practical clinical competency evaluated based on the GM-ITE score showed no clinically relevant differences between RQP graduates and other resident physicians.

BACKGROUND: A clinical diagnostic support system (CDSS) can support medical students and physicians in providing evidence-based care. In this study, we investigate diagnostic accuracy based on the history of present illness between groups of medical students using a CDSS, Google, and neither (control). Further, the degree of diagnostic accuracy of medical students using a CDSS is compared with that of residents using neither a CDSS nor Google. METHODS: This study is a randomized educational trial. The participants comprised 64 medical students and 13 residents who rotated in the Department of General Medicine at Chiba University Hospital from May to December 2020. The medical students were randomly divided into the CDSS group (n = 22), Google group (n = 22), and control group (n = 20). Participants were asked to provide the three most likely diagnoses for 20 cases, mainly a history of a present illness (10 common and 10 emergent diseases). Each correct diagnosis was awarded 1 point (maximum 20 points). The mean scores of the three medical student groups were compared using a one-way analysis of variance. Furthermore, the mean scores of the CDSS, Google, and residents' (without CDSS or Google) groups were compared. RESULTS: The mean scores of the CDSS (12.0 ± 1.3) and Google (11.9 ± 1.1) groups were significantly higher than those of the control group (9.5 ± 1.7; p = 0.02 and p = 0.03, respectively). The residents' group's mean score (14.7 ± 1.4) was higher than the mean scores of the CDSS and Google groups (p = 0.01). Regarding common disease cases, the mean scores were 7.4 ± 0.7, 7.1 ± 0.7, and 8.2 ± 0.7 for the CDSS, Google, and residents' groups, respectively. There were no significant differences in mean scores (p = 0.1). CONCLUSIONS: Medical students who used the CDSS and Google were able to list differential diagnoses more accurately than those using neither. Furthermore, they could make the same level of differential diagnoses as residents in the context of common diseases. TRIAL REGISTRATION: This study was retrospectively registered with the University Hospital Medical Information Network Clinical Trials Registry on 24/12/2020 (unique trial number: UMIN000042831).

BACKGROUND: Physicians frequently experience patients as difficult. Our study explores whether more empathetic physicians experience fewer patient encounters as difficult. OBJECTIVE: To investigate the association between physician empathy and difficult patient encounters (DPEs). DESIGN: Cross-sectional study. PARTICIPANTS: Participants were 18 generalist physicians with 3-8 years of experience. The investigation was conducted from August-September 2018 and April-May 2019 at six healthcare facilities. MAIN MEASURES: Based on the Jefferson Scale of Empathy (JSE) scores, we classified physicians into low and high empathy groups. The physicians completed the Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10) after each patient visit. Scores ≥ 31 on the DDPRQ-10 indicated DPEs. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians' empathy and DPE, adjusting for patient-level covariates (age, sex, history of mental disorders) and with physician-level clustering. KEY RESULTS: The median JSE score was 114 (range: 96-126), and physicians with JSE scores 96-113 and 114-126 were assigned to low and high empathy groups, respectively (n = 8 and 10 each); 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively. Among low empathy physicians, 23% of encounters were considered difficulty, compared to 11% among high empathy groups (OR: 0.37; 95% CI = 0.19-0.72, p = 0.004). JSE scores and DDPRQ-10 scores were negatively correlated (r = -0.22, p < 0.01). CONCLUSION: Empathetic physicians were less likely to experience encounters as difficult. Empathy appears to be an important component of physician perception of encounter difficulty.

Objective Difficult patient encounters (DPEs) are defined as encounters with patients causing strong negative feelings in physicians. In primary care settings, DPEs account for approximately 15% of visits among outpatients. To our knowledge, this is the first epidemiological study of DPEs in Japan. Methods We conducted a survey of 8 physicians (5.0±2 years of clinical experience) who examined first-visit patients ≥15 years old with clinical symptoms at the Department of General Medicine in Chiba University Hospital and 4 community hospitals over a 2-month period since December 2015. Materials We evaluated 10-Item Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10) scores (DPE ≥31 points; non-DPE ≤30 points) and patient age, sex, and presence of psychological or social problems. Results The valid response rate was 98.9% (94/95) and 98.4% (189/192) in the university and community hospitals, respectively. The percentage of DPEs was 39.8% (37/93) and 15.0% (26/173) in the university and community hospitals, respectively; the percentage of DPEs was significantly higher at the university hospital than at the community hospitals (p<0.001). The proportion of patients with psychosocial problems was significantly higher in the DPE group than in the non-DPE group (93.7% vs. 40.4%, p<0.001). Conclusion Our findings were similar to those reported in primary care settings in other countries in community hospital outpatient and general internal medicine departments, where patients are mostly non-referrals, although the values were higher in university hospital general medicine departments, where patients were mostly referrals. Patients involved in DPEs have a high rate of psychological and social problems.

Deep tendon reflexes (DTR) are a prerequisite skill in clinical clerkships. However, many medical students are not confident in their technique and need to be effectively trained. We evaluated the effectiveness of a flipped classroom for teaching DTR skills. We recruited 83 fifth-year medical students who participated in a clinical clerkship at the Department of General Medicine, Chiba University Hospital, from November 2018 to July 2019. They were allocated to the flipped classroom technique (intervention group, n = 39) or the traditional technique instruction group (control group, n = 44). Before procedural teaching, while the intervention group learned about DTR by e-learning, the control group did so face-to-face. A 5-point Likert scale was used to evaluate self-confidence in DTR examination before and after the procedural teaching (1 = no confidence, 5 = confidence). We evaluated the mastery of techniques after procedural teaching using the Direct Observation of Procedural Skills (DOPS). Unpaired t-test was used to analyze the difference between the two groups on the 5-point Likert scale and DOPS. We assessed self-confidence in DTR examination before and after procedural teaching using a free description questionnaire in the two groups. Additionally, in the intervention group, focus group interviews (FGI) (7 groups, n = 39) were conducted to assess the effectiveness of the flipped classroom after procedural teaching. Pre-test self-confidence in the DTR examination was significantly higher in the intervention group than in the control group (2.8 vs. 2.3, P = 0.005). Post-test self-confidence in the DTR examination was not significantly different between the two groups (3.9 vs. 4.1, P = 0.31), and so was mastery (4.3 vs. 4.1, P = 0.68). The questionnaires before the procedural teaching revealed themes common to the two groups, including "lack of knowledge" and "lack of self-confidence." Themes about prior learning, including "acquisition of knowledge" and "promoting understanding," were specific in the intervention group. The FGI revealed themes including "application of knowledge," "improvement in DTR technique," and "increased self-confidence." Based on these results, teaching DTR skills to medical students in flipped classrooms improves readiness for learning and increases self-confidence in performing the procedure at a point before procedural teaching.

BACKGROUND: Interprofessional collaborative practice competency (ICPC) is key to providing safe, high-quality, accessible, patient-centred care. Effective delirium management, particularly, requires a multi-component intervention, including the use of interprofessional teams at care point. This research aims to investigate the effectiveness of the flipped classroom approach for improving ICPC in simulation-based delirium case management. METHOD: An embedded mixed-methods study was designed to investigate the effects of the flipped classroom approach on health professionals' performance in delirium management. The study population comprised nine health professionals (three physicians, nurses, and pharmacists each). They used pre-class study materials about delirium management via a digital learning platform before a simulation case training session. A readiness assurance process test was conducted on key concepts, covered in the pre-class study material. Participants were randomly assigned to three teams, each of which included health professionals. Each team participated in a simulation case scenario. For the quantitative outcome measures, the Chiba Interprofessional Competency Scale (CICS29), a validated scale for measuring competencies of interprofessional practice, was used before, after, and three months after the educational intervention. The qualitative component consisted of a post-training questionnaire and semi-structured focused group interviews about the impact of the flipped classroom approach. RESULT: The CICS29 measured after the intervention and three months after was noted to be significantly higher than before the intervention. Three semi-structured focused group interviews were conducted (n=9), which, upon analysis revealed that the flipped classroom approach effected on four stages of Bloom's taxonomy level. A total of nine categories and 17 subcategories were identified corresponding to four levels of the revised Bloom's taxonomy: remember (1), understand (12), apply (23), and analyse (3). CONCLUSION: The simulation-based skill training using flipped classroom approach can be an effective method for improving ICPC for health professionals. In this approach, an elevated level of cognitive activity is practiced in the Bloom's taxonomy, and the participants worked on an application-based case simulation that promoted higher level learning and engagement in interprofessional collaborative practice. This approach also established a basic common language of delirium assessment and management, thus facilitating communication among health professionals and improving ICPC.

Background: The COVID-19 pandemic has affected the mental health of health care workers. This study aimed to investigate the stress factors that cause burnout in Japanese physicians and their coping methods during the COVID-19 pandemic. Methods: We conducted a sequential explanatory mixed-method study to investigate the psychological responses of physicians in the early stages of the pandemic. A cross-sectional, web-based, anonymous survey was conducted among members of the American College of Physicians Japan Chapter to quantitatively investigate the stress factors and prevalence of burnout. An open-ended questionnaire with questions about stress factors and coping methods was additionally administered. The qualitative data were analyzed using qualitative content analysis. Results: Among the 1173 physicians surveyed, 214 (18.2%) responded. Among the participants, 107 (50.0%) responded "yes" to the question "I feel or have felt very stressed at work during the COVID-19 pandemic," and 68 (31.8%) reported burnout symptoms. Those who reported feeling stress (117 respondents) were asked to select 12 items of the stress factors related to COVID-19. The most significant stress factor related to COVID-19 was "Perceived risk of spreading COVID-19 to family members" (n = 47). Content analysis identified 12 categories for the stress factors and 7 for stress-coping methods corresponding to COVID-19 (Cohen's kappa = 0.84 and 0.95, respectively). Conclusion: Several distinct stressors existed during the COVID-19 pandemic, which might be related to burnout among physicians. Practicing stress-coping strategies, as identified in the present study, may help reduce work-related stress and prevent burnout.

OBJECTIVE: To clarify the factors associated with prolonged hospital stays, focusing on the COMplexity PRediction Instrument (COMPRI) score's accuracy in predicting the length of stay of newly hospitalised patients in general internal medicine wards. DESIGN: A case-control study. SETTING: Three general internal medicine wards in Chiba Prefecture, Japan. PARTICIPANTS: Thirty-four newly hospitalised patients were recruited between November 2017 and December 2019, with a final analytic sample of 33 patients. We included hospitals in different cities with general medicine outpatient and ward facilities, who agreed to participate. We excluded any patients who were re-hospitalised within 2 weeks of a prior discharge. PRIMARY AND SECONDARY OUTCOME MEASURES: Patients' COMPRI scores and their consequent lengths of hospital stay. RESULTS: The 17 patients (52%) allocated to the long-term hospitalisation group (those hospitalised ≥14 days) had a significantly higher average age, COMPRI score and percentage of participants with comorbid chronic illnesses than the short-term hospitalisation group (<14 days). A logistic regression model (model A, comprising only the COMPRI score as the explanatory variable) and a multiple logistic regression model (model B, comprising variables other than the COMPRI score as explanatory variables) were created as prediction models for the long-term hospitalisation group. When age ≥75 years, a COMPRI score ≥6 and a physician with 10 years' experience were set as explanatory variables, model A showed better predictive accuracy compared with model B (fivefold cross-validation, area under curve of 0.87 vs 0.78). The OR of a patient with a COMPRI score of ≥6 joining the long-term hospitalisation group was 4.25 (95% CI=1.43 to 12.63). CONCLUSIONS: Clinicians can use the COMPRI score when screening for complexity assessment to identify hospitalised patients at high risk of prolonged hospitalisation. Providing such patients with multifaceted and intensive care may shorten hospital stays.

BACKGROUND: Training for the fundus examination using traditional teaching is challenging, resulting in low generalist physicians' confidence in performing the funduscopic examination. There is growing evidence suggesting a flexible e-learning video approach's value in teaching physical examination procedures. However, whether the flexible e-learning video approach is superior to the traditional, face-to-face (F2F) lecture-based teaching for the funduscopic exam and the cognitive processes supporting its effectiveness has not yet been determined. METHODS: We conducted a sequential explanatory mixed-method study to compare the flexible e-learning video approach's effectiveness versus the F2F lecture-based approach for teaching the funduscopic exam to medical students at Chiba University in Japan. Medical students were randomly assigned to either a flexible e-learning video approach group or a F2F lecture approach group. We then quantitatively measured the diagnostic accuracy of funduscopic findings before and after attending the specific classrooms. Next, we conducted student focus groups to explore the students' thinking processes in the flexible e-learning video approach vs. the F2F lecture-based teaching of fundus examination. The qualitative data were analyzed using the qualitative content analysis method. RESULTS: The mean diagnostic accuracy scores in the post-test significantly increased from pre-test in the intervention group (36.6 to 63.4%, p < 0.001). Post-post comparisons across the two groups revealed a significant difference (intervention group 63.4% vs. control group 34.6%, p < 0.001). Six semi-structured focused group interviews were conducted (n = 36). In the flexible e-learning video approach group, we identified ten categories corresponding to four levels of the revised Bloom's taxonomy: remember, understand, apply, analyze. Five categories were identified in the traditional F2F lecture approach group corresponding to three revised Bloom's taxonomy levels: understand, apply, analyze. Interrater reliability was substantial (Cohen's kappa = 0.81). CONCLUSIONS: Teaching medical students funduscopic examination using the flexible e-learning video approach leads to improved diagnostic accuracy of funduscopic examinations. The flexible e-learning video teaching method enabled higher cognitive activity levels than the traditional, lecture-based classroom, as assessed using the revised Bloom's taxonomy. TRIAL REGISTRATION: This study was registered with the University Hospital Medical Information Network Clinical Trials Registry on 08/02/2020 (Unique trial number: UMIN 000039434 ).

Objective The Mini-Z 2.0 is a new, simple, and nonproprietary tool for assessing physician well-being and burnout. To date, a non-English version of the Mini-Z 2.0 survey has not been validated. Therefore, we aimed to develop a Japanese version of the Mini-Z 2.0 and to evaluate its validity and reliability using survey data from physicians affiliated with an internal medicine academic society. Methods The Mini-Z 2.0 survey was translated into Japanese using a forward-backward translation method. The participants belonged to the American College of Physicians' Japan Chapter. The translated version of the Mini-Z 2.0 survey was distributed to participants using an electronic mailing list. Convergent validity was assessed between burnout and other items using Pearson's product-moment statistic. Structural validity was evaluated using an exploratory factor analysis and confirmatory factor analysis, and reliability was assessed using internal consistency. Results Of the 1,255 physicians and medical residents contacted, 283 responded (22.5%). Burnout was present in 34.6% of the participants, with 48.8% reporting high stress levels. Convergent validity was demonstrated, with satisfactory correlations between burnout and satisfaction, value alignment, work control, and stress. An exploratory factor analysis identified two factors (i.e., Well-Being and Relationships and Work-Related Stressors); however, the three models evaluated using the confirmatory factor analysis revealed a poor fit. Cronbach's alpha for the sample was 0.80. Conclusion The Japanese version of the Mini-Z 2.0 demonstrated good internal consistency and convergent validity. Despite its inadequate structural validity, it can be used to measure physician well-being and related workplace conditions in Japan.

During clinical reasoning case conferences, a learner-centered approach using teleconferencing can create a psychologically safe environment and help learners speak up. This study aims to measure the psychological safety of students who are supposed to self-explain their clinical reasoning to conference participants. This crossover study compared the effects of two clinical reasoning case conference methods on medical students' psychological safety. The study population comprised 4th-5th year medical students participating in a two-week general medicine clinical clerkship rotation, from September 2019 to February 2020. They participated in both a learner-centered approach teleconference and a traditional, live-style conference. Teleconferences were conducted in a separate room, with only a group of students and one facilitator. Participants in group 1 received a learner-centered teleconference in the first week and a traditional, live-style conference in the second week. Participants assigned to group 2 received a traditional, live-style conference in the first week and a learner-centered approach teleconference in the second week. After each conference, Edmondson's Psychological Safety Scale was used to assess the students' psychological safety. We also counted the number of students who self-explained their clinical reasoning processes during each conference. Of the 38 students, 34 completed the study. Six out of the seven psychological safety items were significantly higher in the learner-centered approach teleconferences (p<0.01). Twenty-nine (85.3%) students performed self-explanation in the teleconference compared to ten (29.4%) in the live conference (p<0.01). A learner-centered approach teleconference could improve psychological safety in novice learners and increase the frequency of their self-explanation, helping educators better assess their understanding. Based on these results, a learner-centered teleconference approach has the potential to be a method for teaching clinical reasoning to medical students.

Background: Few studies have focused on research practice in Japanese university general medicine (GM) departments. Methods: This is a questionnaire-based cross-sectional study to clarify the research achievement and associated factors of Japanese university GM department. Univariate analysis was performed to compare the number of English-language research publications and explanatory variables. Results: Forty-seven universities responded. Over a 3 years period, the median number of English-language research publications was 6. Perceived degree of research necessity, staff numbers, collaborative research, conference presentations, and obtaining research grants were significantly associated with a higher number of English-language research publications. Conclusions: While GM research output was found to be limited, numerous associated factors can potentially change Japanese GM departments' research environments.

Purpose: The training of generalist physicians in university hospitals needs to emphasize development of their research role in order to continue improving their research capacity and their standing in academic hospitals in Japan. This cross-sectional descriptive study aimed to survey departments of general medicine (GM) in university hospitals in Japan to identify the research areas and themes pursued by academic generalist physicians. Patients and Methods: The heads of the departments of GM from 71 university hospitals in Japan were enrolled. The main outcomes studied were the identification of the main research areas and themes in academic departments of GM, based on the classification of the National Grants-in-Aid for Scientific Research (KAKENHI): clinical research, public health, preventive medicine, medical education, basic science, health services and safety and quality. Results: We received 47 of 71 replies (66.2% response rate). Clinical research was the most common area of research (62%), followed by public health and preventive medicine (14%), medical education (11%), and basic sciences (9%). Only one department identified health services and safety and quality as a research area (2%). There was marked variability in research areas across the different departments, with 23% of the research targeting the highest specialties, particularly organ-specific research in the fields of gastroenterology, cardiology, immunology, neurology, metabolic endocrinology, and hematology-oncology. Conclusion: The training of generalist physicians in university hospitals needs to emphasize development of their research role in order to continue improving the research capacity and the standing generalist physicians in academic hospitals in Japan.

BACKGROUND: The COVID-19 pandemic has created a need for educational materials and methods that can replace clinical clerkships (CCs) for online simulated clinical practice (online-sCP). This study evaluates the impact of using simulated electronic health records (sEHR) for inpatients, and electronic problem-based learning (e-PBL) and online virtual medical interviews (online-VMI) for outpatients, for an online-sCP using a learning management system (LMS) and online meeting system facilitated by a supervising physician. METHODS: The sEHR was reviewed by medical students and subsequently discussed with a supervising physician using an online meeting system. In the e-PBL, medical students reviewed the simulated patients and discussed on the LMS. For the online-VMI, a faculty member acted as an outpatient and a student acted as the doctor. Small groups of students discussed the clinical reasoning process using the online meeting system. A mixed-method design was implemented. Medical students self-assessed their clinical competence before and after the online-sCP. They answered questionnaires and participated in semi-structured focus group interviews (FGIs) regarding the advantages and disadvantages of the practice. RESULTS: Forty-three students completed the online-sCP during May and June 2020. All students indicated significant improvement in all aspects of self-evaluation of clinical performance after the online-sCP. Students using sEHR reported significant improvement in writing daily medical records and medical summaries. Students using e-PBL and online-VMI reported significant improvement in medical interviews and counseling. Students also indicated CCs as more useful for learning associated with medical interviews, physical examinations, and humanistic qualities like professionalism than the online-sCP. Eight FGIs were conducted (n = 42). The advantages of online-sCP were segregated into five categories (learning environment, efficiency, accessibility, self-paced learning, and interactivity); meanwhile, the disadvantages of online-sCP were classified into seven categories (clinical practice experience, learning environment, interactivity, motivation, memory retention, accessibility, and extraneous cognitive load). CONCLUSIONS: Online-sCP with sEHR, e-PBL, and online-VMI could be useful in learning some of the clinical skills acquired through CC. These methods can be implemented with limited preparation and resources.

BACKGROUND: Patient awareness surveys on polypharmacy have been reported previously, but no previous study has examined the effects of sending feedback to health professionals on reducing medication use. Our study aimed to conduct a patient survey to examine factors contributing to polypharmacy, feedback the results to health professionals, and analyze the resulting changes in the number of polypharmacy patients and prescribed medications. METHODS: After conducting a questionnaire survey of patients in Study 1, we provided its results to the healthcare professionals, and then surveyed the number of polypharmacy patients and oral medications using a before-after comparative study design in Study 2. In Study 1, we examined polypharmacy and its contributing factors by performing logistic regression analysis. In Study 2, we performed a t-test and a chi-square test. RESULTS: In the questionnaire survey, significant differences were found in the following 3 items: age (odds ratio (OR) = 3.14; 95% confidence interval (CI) = 2.01-4.91), number of medical institutions (OR = 2.34; 95%CI = 1.50-3.64), and patients' difficulty with asking their doctors to deprescribe their medications (OR = 2.21; 95%CI = 1.25-3.90). After the feedback, the number of polypharmacy patients decreased from 175 to 159 individuals and the mean number of prescribed medications per patient decreased from 8.2 to 7.7 (p < 0.001, respectively). CONCLUSIONS: Providing feedback to health professionals on polypharmacy survey results may lead to a decrease in the number of polypharmacy patients. Factors contributing to polypharmacy included age (75 years or older), the number of medical institutions (2 or more institutions), and patients' difficulty with asking their physicians to deprescribe their medications. Feedback to health professionals reduced the percentage of polypharmacy patients and the number of prescribed medications. TRIAL REGISTRATION: UMIN. Registered 21 June 2020 - Retrospectively registered, https://www.umin.ac.jp/ctr/index-j.htm.

BACKGROUND: Objective structured clinical examinations (OSCEs) are important aspects of assessment in medical education. There is anecdotal evidence suggesting that students with non-native English accents (NNEA) may be subjected to unconscious bias. It is imperative to minimise the examiners' bias so that the difference in the scores reflects students' clinical competence. Research shows NNEAs can cause stereotyping, often leading to the speaker being negatively judged. However, no medical education study has looked at the influence of NNEAs in assessment. METHODS: This is a randomized, single-blinded controlled trial. Four videos of one mock OSCE station were produced. A professional actor played a medical student. Two near identical scripts were prepared. Two videos showed the actor speaking with an Indian accent and two videos showed the actor speaking without the accent in either script. Forty-two OSCE examiners in the United Kingdom (UK) were recruited and randomly assigned to two groups. They watched two videos online, each with either script, each with a different script. One video with a NNEA and one video was without. Checklist item scores were analysed with descriptive statistics and non-parametric independent samples median test. Global scores were analysed with descriptive statistics and Mann-Whitney test. RESULTS: Thirty-two examiners completed the study. The average scores for the checklist items (41.6 points) did not change when the accent variable was changed. Independent samples median test showed no statistically significant relationship between the accent and the scores (p = 0.787). For the global scores received by the videos with the NNEA, there were one less 'Good' grade and one more 'Fail' grade compared to those without the NNEA. Mann-Whitney test on global score showed lower scores for videos with NNEA (p = 0.661). CONCLUSIONS: Examiners were not biased either positively or negatively towards NNEAs when providing checklist or global scores. Further study is required to validate the findings of this study. More discussion is warranted to consider how the accent should be considered in current medical education assessment. REGISTRATION: Trial registration completed trial, ID: ISRCTN17360102, Retrospectively registered on 15/04/2020.

Objective This case series aimed to investigate the clinical and pathological characteristics of persistent postural perceptual dizziness (PPPD). Methods We retrospectively examined the medical records of patients with chronic dizziness in our department, and tracked the percentage of PPPD, the age and sex, disorder duration, exacerbating factors for dizziness, and duration of momentary worsening dizziness. We also examined the duration of momentary worsening dizziness in cases of depression, anxiety disorder, and somatic symptom disorder. Results Among 229 patients with chronic dizziness, 14.4% (33/229) met the diagnostic criteria for PPPD. PPPD was the second most common disorder of patients with chronic dizziness after depression. The median age of patients with PPPD was 75 (75.8% female) and the median duration of the disorder was 60 months (range: 3-360 months). The exacerbating factors were motion without regard to direction or position (90.9%), upright posture (66.7%), and exposure to moving visual stimuli or complex visual patterns (30.3%). While the duration of momentary worsening dizziness was less than 10 minutes in 93.9% of patients with PPPD, the duration in patients with depression, anxiety disorder, and somatic symptom disorder were 3.6 % (2/55), 16.1% (5/31), and 0% (0/11), respectively. When the duration was less than 10 minutes, the odds ratios of PPPD for depression and anxiety disorder were 46.5 (95% CI: 6.1-362.0) and 40.3 (95% CI: 7.4-219.3), respectively. Conclusion Short episodes of momentary worsening dizziness constitute a distinctive feature of PPPD that may be useful for differentiating PPPD from other types of psychogenic dizziness.