Context: As a contribution to this special issue of the journal featuring the computerization of the national medical licensing examination (NMLE), this paper seeks to explore the steps to shift the NMLE toward computer-based testing (CBT). Objectives: The purpose of this paper is to explore the movement of the NMLE toward CBT over the last 20 years and the merits and demerits of computerizing the NMLE. Methods: To explore the contents of committees' reports on the improvement of the NMLE, which have been held almost every five years. We also report the results of research we conducted on the computerization of NMLE. The research was supported by a grant from the Ministry of Health, Labor and Welfare (MHLW). Discussion: The former part of this paper explores the reports by the committees to improve the NMLE from 2011 onward. The latter half of this paper focuses on the result of our research from 2018 to 2020, favoring the computerization of NMLE based on the analysis of the merits and demerits of CBT.

　In this paper, from the standpoint of an expert in educational measurement, I clarified the problems of the current National Medical Licensing Examination and discussed the advantages and challenges of introducing computer-based testing (CBT) based on item response theory (IRT). The CBT is expected to contribute to improving the validity of the measurement in terms of construct representation by using a variety of question formats that are not available in the paper-based testing (PBT). In addition, by operating the test using an item pool, including equated items within the IRT framework, it is possible to continuously create tests that meet a certain quality by controlling difficulty and measurement accuracy and to compare scores on the common scale, even when the implementation schedule, implementation site, and examinee groups are different. On the other hand, the biggest challenges are doing detailed test planning in advance and building and maintaining an item pool.

　When introducing the computer-based test (CBT) to the National Medical Licensing Examination, it is desirable to introduce question items with video and audio to take advantage of the characteristics of computers and to fill in the gaps between the audiovisual information presented in the exam and in clinical practice. 　To this end, it is necessary to collect appropriate video and audio materials and to establish the know-how and human resource development for creating items that make use of these materials.　The authors have been engaged in the development of video/audio-assisted CBT for 12 years. In the Kawakita Group of the Health Labour Sciences Research Grant projects, video/audio-assisted question items were given in the CBT trials for the National Medical Licensing Examination. Also, a manual and workshops for video/audio-assisted CBT have been prepared. Based on these experiences, this paper discusses the merits and challenges of CBT for the National Medical Licensing Exam.

　In recent years, the Committee for the Improvement of the National Medical Licensing Examination has been discussing the possibility of replacing the National Medical Licensing Examination with CBT. The reasons for this include the diversification of the question format using multimedia and other methods and the need to respond to disasters and pandemics. Against this background, the authors are conducting research on CBT implementation for the National Medical Practitioners Examination. In FY2021, we conducted a CBT trial for the National Medical Licensing Examination using an open-source system. The trial was conducted at ten universities across the country, and most examinees were able to take the exam without any major problems. The future implementation of the CBT format for the national medical examinations will simplify the examination preparation system, develop a multiple examination system in preparation for contingencies, and evaluate examinees' abilities through more diverse question formats.

　We are conducting research funded by a grant from the Ministry of Health, Labor and Welfare of Japan to create standardized, high-quality medical education content that incorporates video, images, and sound files, to develop a system that can be widely used by everyone from medical students to clinicians, and to create CBT-enabled examination questions for the future CBT National Medical Licensing Examination. The research aims to conduct trial examinations, study issues and measures to deal with them, and make proposals for their implementation.　With regard to the CBT system for the National Medical Licensing Examination, questions incorporating video, images and sound files were prepared based on the scope of the current national examination, and a trial examination was conducted with the cooperation of 10 universities nationwide using the CBT examination system via the internet. The trial was generally conducted smoothly, with smooth playback of videos, etc., and no system problems.　In conducting this research, we believe that it should not be considered as an extension of the previous national examination initiatives for doctors, nor should it be regarded merely as a technological initiative. In addition, as advances in AI-based diagnostic technology and patients’ medical literacy are foreseen to change significantly in 2040, the competence of doctors to cope with these changes will be questioned.　For this reason, it is fundamental to consider medical education content and examination questions for the CBT National Medical Licensing Examination with a view to the ideal image of doctors of the future.

　In November 2014, a symposium was held by the Japan Society of Medical Education on the theme of the National Medical Licensing Examination. To improve the National Medical Licensing Examination, the post clinical clerkship OSCE was officially implemented from FY2020. Its introduction into the National Medical Licensing Examination will be discussed in the future based on the status of its implementation. The competencies to be assessed are clinical capabilities that can be performed on patients under the “guidance of a supervising physician,” and are suitable for evaluation in the clinical setting where the supervising physician directly observes and evaluates students’ medical practices. In comparison with the OSCE, which evaluates simulated clinical practice, the introduction of the post clinical clerkship OSCE into the National Medical Licensing Examination was discussed.

　Performance assessment is a generic term for assessment methods that require the use of knowledge and skills. When incorporating performance assessment, it is important to focus on the “complexity” and “authenticity” of the task. Rubrics as well as checklists are used as assessment criteria. The tasks used in many OSCEs are practical test items, which are suitable for looking at skills and processes elementally. However, to look at the ability to use multiple knowledge and skills comprehensively in realistic situations, complex and authentic performance tasks need to be used. Practical training in the field of practice is a set of performance tasks, and the use of portfolio assessment is effective for their assessment.

　Medical students are troubled by exams, relationships, and future choices, and some students are driven by psychological factors to stay or drop out of school, and in some cases, commit suicide. Especially during the COVID-19 pandemic since 2020, many students have been stressed and have complained of depressive symptoms. In recent years, self-care has been considered important in reducing stress and preventing burnout in healthcare professionals, and this article focuses on self-care education for medical students.　In the first paper, we introduce a practical example of self-care lectures that have been conducted at Showa University since 2015. In the second paper, we introduce the mindfulness practice that has been used at Kansai Medical University since 2018. Through self-care education, we hope that medical students will become physicians who can overcome stress and who have mastered professionalism.