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With the growing volume of medical information, proficiency in utilizing clinical decision support systems (CDSSs) is increasingly important for physicians. Further, research has primarily focused on CDSSs' accuracy for specific symptoms, diseases, and treatments, but the extent to which CDSSs contribute to the clinical reasoning process and evaluation of their output remains unclear. While Google is not a traditional CDSS, previous studies have evaluated its role as a diagnostic support tool, demonstrating its ability to assist physicians in retrieving relevant medical information and influencing diagnostic decision-making. This study aimed to assess whether using Google search can enhance diagnostic accuracy and confidence among medical students, and to evaluate how the interpretation of search results influences their diagnostic confidence. Forty-eight fifth-year medical students in clinical clerkship at Chiba University Hospital were presented with ten clinical scenarios in text format. Initially, they provided the most likely diagnosis without assistance and recorded their confidence levels. Subsequently, they used Google search to revisit their diagnoses and confidence levels, using a 7-point Likert Scale. Focus group interviews were conducted to discuss changes in confidence, and the interviews were analyzed qualitatively using content analysis. A mixed-methods analysis compared the average number of correct diagnoses and confidence levels before and after using Google search. In total, 470 responses from 48 fifth-year medical students were evaluated after excluding 10 inappropriate responses. Correct diagnoses increased from an average of 63.6% without assistance to 76.2% using Google search (P < .001), and confidence levels rose from 4.9 to 5.9 (P < .001). Qualitative analysis of higher-confidence responses identified 108 codes within 17 subcategories related to diagnostic processes. This study underscores the value of using Google search in medical education to enhance diagnostic skills and confidence. The improvement in accuracy and confidence among students demonstrates the supportive role of Google search in clinical reasoning and education. This highlights the need for educators to teach discernment in information analysis to ensure optimal use of CDSS in medical training. Proper integration of these tools is crucial for developing future physicians capable of effectively navigating vast amounts of medical data.

A middle-aged woman presented with progressive pharyngeal symptoms and an enlarging neck mass, eventually diagnosed as human papillomavirus (HPV)-negative oropharyngeal squamous cell carcinoma (OPSCC). Due to impending airway obstruction, an emergency tracheostomy was performed. Histopathological examination confirmed squamous cell carcinoma, leading to a final diagnosis of non-HPV-associated OPSCC, a rarer and more aggressive subtype. Despite receiving palliative radiotherapy for symptom control, the disease progressed aggressively, and the patient was ultimately transitioned to best supportive care. OPSCC arises from the mucosal epithelium of the oropharynx. Early symptoms such as persistent throat discomfort, dysphagia, and cervical lymphadenopathy are relatively characteristic of oropharyngeal tumors. Tumor progression can cause critical airway obstruction depending on the lesion's size and location. In this report, we present a case of OPSCC that required emergency airway management due to the risk of airway obstruction. This case underscores the importance of early diagnosis and airway management in patients with progressive pharyngeal symptoms and high-risk features.

The contractions lead to the rapid opening and shutting of the Eustachian tube, which produces a clicking tinnitus that is usually audible to the examiner. Secondary or symptomatic palatal tremor is caused by lesions involving the connections between the ipsilateral red nucleus in the midbrain, the inferior olive in the medulla, and the contralateral dentate nucleus in the cerebellum—the three nuclei together being referred to as the Guillain–Mollaret triangle forming the dentato-rubro-olivary pathway (figure). In approximately 70% of cases the lesion is a vascular infarct; other causes include glial fibrillary acidic protein or mitochondrial DNA polymerase γ mutations, neuroferritinopathy, or progressive ataxia and palatal tremor.

Japan’s workplace reforms, including a 60-hour weekly work limit for medical residents, that has been in effect from April 2024, have raised concerns about compliance and its impact on training quality. This study analyzed data from 17,967 residents who participated in the General Medicine In-Training Examination from 2019 to 2022, focusing on weekly duty hours, clinical responsibilities, and training environments. Duty hours increased from 2019 to 2021, before declining in 2022. The proportion of residents working over 60 h per week decreased from 57 to 49%, while those working under 50 h increased from 12 to 19%. Concurrently, the percentage of residents managing zero to four inpatients rose from 18 to 39%. University hospital residents reported shorter duty hours but fewer patient encounters and diminished clinical exposure compared to community hospital residents. These findings underscore the educational consequences of duty-hour restrictions, particularly in university hospitals, where reduced clinical responsibilities may compromise competency-based training. The results highlight the need for balanced policies that ensure compliance while maintaining sufficient clinical exposure. Future reforms should prioritize equitable workload distribution, increased clinical opportunities, and targeted interventions to address disparities between hospital types, thereby ensuring the dual goals of resident well-being and high-quality medical education.

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.

Long duty hours (DH) impair sleep and negatively affect residents’ health and medical safety. This cross-sectional study investigated the association among residents’ DH, sleep duration, insomnia, sleep impairment, depressive symptoms, and self-reported medical errors among 5579 residents in Japan who completed the General Medicine In-Training Examination (2021) and participated in the training-environment survey. Weekly DH was classified under seven categories. Sleep duration and insomnia symptoms, from the Athens Insomnia Scale, were analysed to determine sleep impairment; depressive symptoms and medical errors were self-reported. Among 5095 residents, 15.5% slept < 5 h/day, and 26.7% had insomnia. In multivariable analysis, compared with ≥ 60 and < 70, DH ≥ 90 h/week associated with shorter sleep duration and worsen insomnia symptoms. Shorter durations of sleep and more intense symptoms of insomnia were associated with increased depressive symptoms. Medical errors increased only among residents with insomnia, but were not associated with sleep duration. DH > 90 h/week could lead to shorter sleep duration, worsen insomnia symptoms, and negatively impact well-being and medical safety. There was no significant association between sleep duration and medical errors; however, insomnia conferred an increased risk of medical errors. Limiting DH for residents to avoid excessive workload can help improve resident sleep, enhance resident well-being, and potentially reduce insomnia-associated medical errors.

Physical examination revealed body temperature of 37.0°C, pulse rate of 89 beats per minute, respiratory rate of 22 breaths per minute, blood pressure of 81/52 mm Hg and oxygen saturation of 91% on ambient air. Pylephlebitis, which is the septic thrombophlebitis of the portal vein and its tributaries, is a rare complication in an abdominal infection.1 Appendicitis and diverticulitis used to account for most of the causes,2 but in recent years, the proportion of pylephlebitis caused by liver abscesses and cholangitis has increased.3 4 Although there is no established treatment, clinicians should not overlook this disease because it is lethal, and long-term antimicrobial and anticoagulation therapy should be considered.1 The role of anticoagulation in the management of pylephlebitis is controversial, and data regarding its impact on outcomes is limited. [...]recently a large retrospective study showed that anticoagulation significantly improves the rate of portal vein thrombosis resolution, and significantly reduces the rate of chronic symptomatic portal hypertension without the increasing risk of major bleeding, among patients with pylephlebitis.5 A wedge-shaped enhancement effect of the portal vein occlusion area may be observed in the early arterial phase on CT.6 It is speculated that the effect is due to a compensatory increase in hepatic arterial blood flow caused by portal vein occlusion.6 If there is the effect of the liver in a patient with cholangitis, we should suspect a thrombus in the portal vein on the side that is being contrasted.