Do programme coordinators contribute to the professional development of residents? an exploratory study.

BACKGROUND: With the development of training programmes for health professions, the role of programme coordinators has become increasingly important. However, their role in providing educational support for the professional development of resident trainees has not been investigated well. This study aimed to qualitatively analyse the involvement of programme coordinators in educational support for residents. METHODS: Semi-structured reflective writing on 'support for residents' was collected from programme coordinators in teaching hospitals in Japan in 2017-18 using a web-based questionnaire. Descriptions were qualitatively analysed thematically, using the professional identity formation (PIF) framework. RESULTS: A total of 39 cases of "support for residents" by 31 coordinators were analysed. We found that residents most commonly faced prior personal problems, including mental health issues and insufficient social skills/unprofessional behaviour. A thematic analysis revealed that coordinators played a variety of educational roles: 1) requesting supervisors to reconsider their teaching; 2) protecting residents from the negative influence of clinical experiences; 3) facilitating residents' self-assessment and confidence; 4) creating a safer learning environment; 5) providing support for prior personal problems through 5-1) fostering a better atmosphere for the mental health of residents, and 5-2) intervening for residents with insufficient social skills/unprofessional behaviour; 6) providing support for isolated residents; and 7) preventing problems with peers. CONCLUSIONS: This study identified seven educational roles of programme coordinators for residents from a standpoint of PIF of residents. Based on these findings, four valuable attributes for coordinators were established: non-hierarchical relationships with residents, parenting attitudes, sensitivity to residents' changes, and the perspective of the citizen and a member of the public. These attributes would underpin coordinators' educational roles and facilitate the professional development of residents. This study provides a basis for defining and revising the role profiles of programme coordinators, and for improving staff development.

Influence of national culture on mentoring relationship: a qualitative study of Japanese physician-scientists.

BACKGROUND: Nurturing of physician-scientists is an important mission of academic medical institutes. Although the importance of mentorship in developing future physician-scientists internationally is well established, not much information is available about how they are mentored and how national cultures influence the mentoring relationship. This study explores the cultural characteristics of mentoring relationships between senior mentors and junior mentees of Japanese physician-scientists. METHOD: A qualitative approach has been employed to explore mentoring relationships of Japanese physician-scientists from cultural viewpoints, through semi-structured interviews with 17 mentees who had the experience of working overseas as post-doctoral research fellow. The reflection of their experiences and the perception of mentoring relationships before going abroad were thematically analyzed by applying Hofstede's model of six cultural dimensions as a theoretical framework. RESULTS: Twelve characteristic themes for mentoring were observed, including trustworthy dependency on mentor, embracing paternalistic mentoring, mentee's initiative within expectations of mentor based on power distance, a sense of loyalty to mentor/organization/colleagues, family-like relationship with mentor based on collectivism, sense of security on being led by mentor through uncertainty avoidance, motivation by role modeling for the competitive academic world, and adaption of female mentee/mentor to a male-dominated academic structure based on masculinity, a long-term relationship between mentor and mentee, receiving advice for organizational continuity based on long-term orientation, putting work before leisure, and friendly relationship between mentor and mentee outside of work based on indulgence. CONCLUSIONS: This study identified the characteristic mentoring relationships of postgraduate mentees of Japanese physician-scientists. Considering the importance of mentoring for physician-scientists in a globalized society, understanding the characteristics of national cultures would help in ensuring culture-sensitive mentoring and would contribute to the development of academic medicine.

A global template for reforming residency without work-hours restrictions: decrease caseloads, increase education. Findings of the Japan Resident Workload Study Group.

BACKGROUND: Japanese physician training programs are currently not subject to rigorous national standardization. Despite residency restructuring in 2004, little is known about the current work allocation of residents in Japan. AIMS: We quantified the amount of time that Japanese junior residents spend in service versus education in the context of caseload, fatigue, and low-value administrative work. METHODS: In this prospective, time-and-motion study, the activity of 1st- and 2nd-year residents at three Japanese community hospitals was observed at 5-min intervals over 1 week, and categorized as patient care, academic, non-patient care, and personal. Self-reported sleep data and caseload information were simultaneously collected. Data were subanalyzed by gender, training level, hospital, and shift. RESULTS: A total of 64 participating residents spent substantially more time in patient care activities than education (59.5% vs. 6.8%), and little time on low-value, non-patient work (5.1%). Residents reported a median 5 h of sleep before shifts and excessive sleepiness (median Epworth score, 12). Large variations in caseload were reported (median 10 patients, range 0-60). CONCLUSIONS: New physicians in Japan deliver a large volume of high-value patient care, while receiving little structured education and enduring substantial sleep deprivation. In programs without work-hour restrictions, caseload limits may improve safety and quality.

Processes of increasing medical residents' intrinsic motivation: a qualitative study.

Objectives: This study aimed to determine qualitatively how medical residents develop intrinsic motivation to learn and work in clinical training settings. Methods: This study was a descriptive qualitative study, which is widely used in healthcare research. We conducted a semi-structured interview aimed to explore key participants' in-depth experiences and perspectives regarding intrinsic motivation. The authors interviewed seven postgraduate Japanese medical residents. The transcripts were analyzed using the sequential and thematic qualitative data analysis technique steps for coding and theorization, which entails coding steps from open to selective, writing a storyline using the final selective codes, and offering theories. Results: External stimulations (a self-handle environment and a near-peer role model) triggered the medical residents' cognitive process (gap recognition, awareness, and internalization) to intrinsic motivation. The residents' awareness of autonomy, responsibility, and independence played a vital role in this process. Furthermore, a psychological feeling of competence also reinforced their intrinsic motivation. Positive feedback and approval from attending physicians and patients' gratitude promoted residents' sense of competence. Conclusions: We illustrated a process for increasing medical residents' intrinsic motivation. The intrinsic motivation was triggered by external stimulations (a self-handle environment and a near-peer role model), which caused the cognitive process: gap recognition, awareness of important attitudes as a doctor (autonomy, responsibility, and independence), and internalization. Since the first step of this process was an external factor, there are potential benefits of designing an appropriate training environment for increasing medical residents' intrinsic motivation.

Undergraduate educational environment, perceived preparedness for postgraduate clinical training, and pass rate on the National Medical Licensure Examination in Japan.

BACKGROUND: We investigated the views of newly graduating physicians on their preparedness for postgraduate clinical training, and evaluated the relationship of preparedness with the educational environment and the pass rate on the National Medical Licensure Examination (NMLE). METHODS: Data were obtained from 2429 PGY-1 physicians-in-training (response rate, 36%) using a mailed cross-sectional survey. The Dundee Ready Education Environment Measure (DREEM) inventory was used to assess the learning environment at 80 Japanese medical schools. Preparedness was assessed based on 6 clinical areas related to the Association of American Medical Colleges Graduation Questionnaire. RESULTS: Only 17% of the physicians-in-training felt prepared in the area of general clinical skills, 29% in basic knowledge of diagnosis and management of common conditions, 48% in communication skills, 19% in skills associated with evidence-based medicine, 54% in professionalism, and 37% in basic skills required for a physical examination. There were substantial differences among the medical schools in the perceived preparedness of their graduates. Significant positive correlations were found between preparedness for all clinical areas and a better educational environment (all p < 0.01), but there were no significant associations between the pass rate on the NMLE and perceived preparedness for any clinical area, as well as pass rate and educational environment (all p > 0.05). CONCLUSION: Different educational environments among universities may be partly responsible for the differences in perceived preparedness of medical students for postgraduate clinical training. This study also highlights the poor correlation between self-assessed preparedness for practice and the NMLE.

A brief home-based palliative care learning experience for medical students and resident doctors in Okinawa, Japan.

BACKGROUND: The clinical component of medical education for students and resident doctors in Japan occurs almost entirely in the hospital setting. Because of this inpatient focus, graduate medical education clinical training often fails to expose physicians-in-training to the challenges that patients may face in the outpatient or home setting. This is a descriptive study in which we explore what participating students and resident doctors learned through our brief home-based teaching experience. METHODS: From June 2016 to December 2017, attending physicians on the internal medicine service had medical students and resident doctors accompany them on home care visits. Participants were selected by convenience sampling based on their rotation availability. After the home visit and the interactive discussion, the participants were expected to prepare a reflective journal on their experience and learning. Thematic analysis was applied, and key themes were developed based on Kolb's ELT (Experiential learning theory). Three months after completion of the experience, semi-structured interviews were individually conducted assessing participants' self-perceived changes. RESULTS: Thirty-two medical students(10) or residents(22)participated in a home visit. Thirty of these learners were able to complete a reflective journal. Using thematic analysis, we identified 2 domains and 6 key themes from the participants' perceptions. Participants recognized the importance of patient-centered care, inter-professional collaboration of the home care team, and reconceptualized the meaning of medical practice and their professional identity as a doctor. Three month post-experience interviews were completed on 12 of the original 30 participants who completed the reflective journal. 2 domains and 6 key themes from the residents' experiences and perceptions were generated. The participants reported an increased attention to the daily lives and social situations of their hospitalized patients, and an extension of their focus beyond the clinical medical treatment of the patient. CONCLUSION: The experience of a brief visit to a patient's home is a novel educational approach that may potentially provide medical students and resident doctors with opportunities to learn about out-of-hospital, patient-centered, home-based medical care.

Beyond work-hour restrictions: a qualitative study of residents' subjective workload.

INTRODUCTION: Following the introduction of work-hour restrictions, residents' workload has become an important theme in postgraduate training. The efficacy of restrictions on workload, however, remains controversial, as most research has only examined objective workload. The purpose of this study was to explore the less clearly understood component of subjective workload and, in particular, the factors that influenced residents' subjective workload. METHOD: This study was conducted in Japan at three community teaching hospitals. We recruited a convenience sample of 31 junior residents in seven focus groups at the three sites. Audio-recorded and transcribed data were read iteratively and analyzed thematically, identifying, analyzing and reporting themes within the data and developing an interpretive synthesis of the topic. RESULTS: Seven factors influenced residents' subjective workload: (1) interaction within the professional community, (2) feedback from patients, (3) being in control, (4) professional development, (5) private life, (6) interest and (7) protected free time. DISCUSSION AND CONCLUSION: Our findings indicate that residents who have good interaction with colleagues and patients, are competent enough to control their work, experience personal development through working, have greater interest in their work, and have fulfilling private lives will have the least subjective workload.

Pineal malignant B-cell lymphoma with lower cranial nerve involvement.

A 62-year-old man was admitted to our hospital complaining of dysphagia and hoarseness that had persisted for five days. A neurological examination indicated bulbar palsy. Brain magnetic resonance imaging showed thickening of cranial nerves IX, X and XI, in addition to pineal body enlargement with diffuse contrast enhancement. A tumor biopsy overriding the spinal root of the right XIth cranial nerve was performed. The histologic analysis confirmed a diagnosis of diffuse large B-cell lymphoma. Malignant lymphoma should be considered in the differential diagnosis of pineal region tumors. Furthermore, obtaining histological confirmation is crucial for making proper management decisions.

Intervals between symptom onset and clinical presentation in cancer patients.

OBJECTIVE: We aimed to investigate relative values of the intervals between symptom onset and clinical presentation in cancer patients and to correlate them with diagnosis of distant metastasis. METHODS: Cancer registry and medical records of all cancer patients for over a 10-year period in a medical center of Japan were reviewed. We examined the intervals of symptom onset to clinical presentation and the presence of metastasis at diagnosis. RESULTS: In 3,893 cancer patients, the mean interval of symptom onset to clinical presentation was 89 days (median, 30 days). The cancer group with a short interval of only days to weeks included hepatobiliary, ovary, brain, and acute leukemia. The group with a long interval of months to years included head and neck, thyroid, and skin cancers. Other types of cancer were included in the middle group with an interval of weeks to months. Among patients with head & neck, skin, and ovarian cancers, the longer interval was significantly associated with a lower likelihood of distant metastasis. A longer interval with an increment of each month was associated with a lower likelihood for distant metastasis with an odds ratio of 0.97 (95% CI, 0.96-0.99). CONCLUSION: Hepatobiliary, ovary, brain, and acute leukemia are among the cancer types with an interval of days to weeks, while head and neck, thyroid, and skin cancers are among the types with an interval of months to years. Among patients with solid tumors, those with metastasis are likely to present to a physician more promptly.

Acute care hospital mortality of schizophrenic patients.

BACKGROUND: Although schizophrenic patients have higher mortality than the general nonschizophrenic population, few studies have investigated acute care hospital mortality of schizophrenic patients. METHODS: To assess acute care hospital mortality of schizophrenic patients, we analyzed hospital mortality, the risk factors for hospital mortality, and the causes of death of schizophrenic patients admitted to an acute care hospital in Japan over an 18-year period. RESULTS: We identified 55 deaths among 1108 schizophrenic patients, for a mortality rate of 5.0%. The overall standardized mortality ratio was 1.29 (95% CI, 0.98-1.68) compared with nonschizophrenic hospitalized patients. Significant risk factors for mortality were malignant neoplasm, cardiovascular disease, and admission through the emergency department. The leading causes of death in acute care hospitalizations were suicide (14.5%), malignant lymphoma or leukemia (10.9%), stroke (9.0%), and sepsis (7.3%). CONCLUSIONS: There was a nearly significant trend toward increased mortality of schizophrenic patients receiving acute hospital care compared with that of nonschizophrenic patients. Because suicide was the most frequent cause of death, a focus on suicide prevention is needed in this population.

Irradiation of intense characteristic x-rays from weakly ionized linear molybdenum plasma.

In the plasma flash x-ray generator, a high-voltage main condenser of approximately 200 nF is charged up to 55 kV by a power supply, and electric charges in the condenser are discharged to an x-ray tube after triggering the cathode electrode. The flash x-rays are then produced. The x-ray tube is a demountable triode that is connected to a turbo molecular pump with a pressure of approximately 1 mPa. As electron flows from the cathode electrode are roughly converged to a rod molybdenum target of 2.0 mm in diameter by the electric field in the x-ray tube, weakly ionized linear plasma, which consists of molybdenum ions and electrons, forms by target evaporation. At a charging voltage of 55 kV, the maximum tube voltage was almost equal to the charging voltage of the main condenser, and the peak current was about 20 kA. When the charging voltage was increased, the linear plasma formed, and the K-series characteristic x-ray intensities increased. The K lines were quite sharp and intense, and hardly any bremsstrahlung rays were detected. The x-ray pulse widths were approximately 700 ns, and the time-integrated x-ray intensity had a value of approximately 35 micro C/kg at 1.0 m from the x-ray source with a charging voltage of 50 kV.

Monochromatic polycapillary imaging utilizing a computed radiography system.

A fundamental study on quasi-parallel radiography using a polycapillary plate and a copper-target x-ray tube is described. In the experiments, the tube voltage was regulated from 12 to 22 kV, and the tube current was regulated within 3.0 mA by the filament temperature. The exposure time was controlled in order to obtain optimum x-ray intensity, and the maximum focal spot dimensions were approximately 2.0 x 1.5 mm. The thickness and the inner capillary tube diameter of the polycapillary were 1.0 mm and 25 microm, respectively. Monochromatic x-rays were produced using a 10 microm-thick nickel filter with a tube voltage of 17 kV, and these rays were formed into quasi-parallel beams by the polycapillary. The radiogram was taken using a computed radiography system utilizing imaging plates. In the measurement of image resolution, the spatial resolution hardly varied according to increases in the distance between the resolution-test chart and imaging plate using a polycapillary. A 50 microm tungsten wire could be observed, and fine blood vessels of approximately 100 microm were visible in angiography.