Current States and Challenges of Clinical Training Systems from The Perspective of Trainers and Trainees / 医学教育

Introduction: We conducted a survey to examine the current state of objectives, evaluation, and issues related to the current clinical resident training system.Methods: We conducted focus group interviews using Skype software for qualitative analysis and classified the data using content analysis. The subjects were 20 experienced residents and/or attending physicians from the current and previous training systems.Results: The collective opinions were classified as positive, negative and neutral opinions with respect to ‘objectives', ‘evaluation' and ‘training program'.Discussion: The findings are expected to provide a basis for revising the current system.

Feasibility and Validity of a Computer-based Version of SEIQoL-DW Compared to Original Interview-based Versions in Healthy Medical Students / General Medicine

<b>Purpose:</b> The Schedule for the Evaluation of Individual Quality of Life - Direct Weighting (SEIQoL-DW) is designed to investigate an individual's perspective on their own quality of life (QOL) and has been used widely among various clinical populations, including cancer patients and those with chronic kidney disease, in addition to healthy participants. While the original SEIQoL-DW is a semi-structured interview, other formats have been developed; recently computer-based versions have yielded equivalent results comparable to paper-based versions. However, no previous study has examined differences between the computer-based version and its original interview-based design. The purpose of this study is to assess the feasibility and validity of a computer-based version of the SEIQoL-DW, compared with the original interview-based format.<br><b>Methods:</b> We conducted a non-randomized crossover study with 13 medical students from November 2008 to January 2009 at a municipal university in Yokohama, Japan. Both the computer-based and interview-based versions of SEIQoL-DW were administered to all study participants. Wilcoxon-signed rank test was used to compare differences in mean SEIQoL Index score between computer-based and interview-based results. The intra-class correlation coefficient and the Bland and Altman limits of agreement methods were used to compare formats.<br><b>Results:</b> No significant differences were found in the SEIQoL-DW Index between the computer-based and interview versions after analysis with Wilcoxon-signed rank test (p = 0.501). The intra-class correlation between formats was 0.94 (CI: 0.81–0.98). The limit of agreement analysis showed that 53.3% of the observations were within ±1–5 units of the average score, while 46.7% were within ±5–10 units. In total, 100% of observations were within ±1–10 units.<br><b>Conclusions:</b> The computer-administered version of SEIQoL-DW may be feasible and acceptable and provides a valid alternative, at least in healthy subjects, to the more cumbersome interview version. Use of the computer-based version will facilitate its application to larger patient populations in various clinical settings.

Characteristics of second-year residents intending to become a primary care physicians / 日本プライマリ・ケア連合学会誌

<b>Purpose</b> : To examine the characteristics of second-year residents intending to become primary care physicians.<br><b>Methods</b> : Using a self-administered questionnaire, we surveyed 7344 second-year residents in March, 2006. Of the 4167 responders (response rate 56.7%), the 3838 who answered that they intended to make a career choice of being clinical practitioners were taken as subjects for analysis. The odds ratios (OR) for the intention of being a primary care physician was calculated, together with the 95% confidence interval (95% CI), using logistic regression models (primary care physicians intended=1 vs. specialist intended=0) <br><b>Results</b> : In total, 56% of the residents affirmed an interest in becoming primary care physicians. Multiple stepwise logistic models showed that residents intending to become primary care physicians planned to open their own clinics in the future (OR 1.44, 95% CI : 1.20-1.73), did not wish to obtain doctor of medical science (DMSc) degrees (OR 1.29, 95% CI : 1.07-1.55), and were more likely to choose internal medicine (OR 1.44, 95% CI : 1.07-1.94).<br><b>Conclusion</b> : This study demonstrated that second-year residents who aimed to be primary care physicians were associated with more interest in opening private clinics for their future practice, preferably in the field of internal medicine, and with less interest in earning DMSc degrees.

Positive Association Between Sleeping Prone and Good Quality Sleep / General Medicine

<b>OBJECTIVE</b> : This study was conducted in a Japanese population to better understand the association between insomnia and sleeping prone.<br><b>METHODS</b> : A cross sectional questionnaire study was conducted with outpatients of St. Luke's International Hospital in August, 2007. Information on sleep position habits, symptoms, quality of life, and sleep quality was collected. The Athens Insomnia Scale (AIS) was used to measure sleep quality. Participants with an AIS score of 4 or higher were categorized as sub-threshold insomnia and as the insomnia group.<br><b>RESULTS</b> : Of the 784 subjects who returned completed questionnaires (response rate=65%) 30.4% were men. About 13% of the respondents slept in the prone position at least three times a week. Based on multivariate adjusted logistic regression analysis, there was a significant association between sleeping prone and having no problem with insomnia (odds ratio, 0.61 ; 95% CI, 0.38-0.99).<br><b>CONCLUSION</b> : These data suggest that sleeping in the prone position is associated with good quality sleep.

Medical Professionalism's themes from the viewpoint of general population: A qualitative study / 医学教育

Medical professionalism, which is of great interest in most countries, underpins the relationship between patients and doctors. The concepts of medical professionalism should be understandable not only by physicians but also by patients. However, there are few studies that evaluate the concept of medical professionalism from patients' perspective.a) We conducted two focus group interviews with 12 people who were not health care professionals. One interview was done with people who were living in Tokyo and one with people living in Osaka. Each interview was one hour long. During the interviews, we explored themes related to medical professionalism from patients' perspectives.b) We qualitatively analyzed response data from audio records of the interview and inductively extracted categories pertaining to medical professionalism. We compared our findings with the domains of the American Board of Internal Medicine's Charter on Professionalism (CP).c) We found 5 themes; 1) Primacy of patient welfare 2) Fairness 3) Social responsibility 4) Maintaining appropriate relations with industry 5) Maintaining appropriate relations with patients.d) Although our themes are almost equivalent to the principles cited in CP, there are some differences, such as the importance of maintaining appropriate relations with patients.e) Given the current findings, medical educators and trainers should continue to develop the Japanese concepts of medical professionalism in a manner that takes into consideration patients' perspectives.

Introducing a new medical school system into Japan

Entering into medical schools is the most difficult yet most prestigious among all of the undergraduate university departments. Most of the medical students in Japan come from the Mathematics/Physicochemical Science track, while a few are from the Humanities/Social Science track. However, to meet the needs of the Japanese society, medical students need to learn core competencies, such as professionalism, humanism, and ethics. Issues with regard to these competencies among medical students have recently become a widespread serious concern to medical educators and the general public in Japan. In this article, we suggest that the introduction of a new medical school system, by reforming the admission criteria, can be an effective measure for meeting the current needs of the Japanese society.

Graduate schools of medicine in Japan: The status and problems of researcher training / 医学教育

1) Common training for the introduction of research and the elective and individual guidance for research should be devised in a manner attractive to graduate students of medicine.<BR>2) To train researchers, a graduate school of clinical medicine should be established as a professional school, separate from an ordinary graduate school.<BR>3) To promote basic medical sciences, the capacity of graduate schools of basic medical sciences should be reduced despite the number of teachers and the bold plan for the financial support of students.

Management Matters: Why should medical education of Japanese doctors include management and leadership topics? / 医学教育

Worldwide societies are aging fast, demanding more and the rising burden of chronic and behavioural related disease increase pressure on healthcare systems.These healthcare challenges are alongside with the fact that formally Japanese doctors occupy a central role in the daily management of Japanese healthcare, as heads of departments, heads of hospitals in large urban settings or in the country side, and as responsible for thousands of clinics countrywide.This paper presents why we feel management education should be provided in medical education programs for Japanese doctors, how it could be structured and why it is relevant in today's Japanese healthcare.It further discusses some of the contents that ought to be taught, including the critical management area of leadership.We conclude that: i) Physician education in management is relevant as change management skills, leadership and motivation are increasingly called upon by new healthcare challenges;ii) The good aspects of Japanese healthcare need to be maintained and doctors'knowledge of management and leadership can prepare them to better defend and develop them with management and politicians; iii) Management education should be“spiral”, maybe starting with Japanese doctors who are heads of healthcare units possibly with a combination of workshops, residential and online courses.

Influence of Residents' Workload, Mental State and Job Satisfaction on Procedural Error: a prospective daily questionnaire-based study / General Medicine

<b>BACKGROUND</b> : Previous studies have suggested positive association between residents' workload and medical errors. However, few studies have investigated the possible associations between procedural errors, workload, and the individual characteristics of residents, including personality, mental state and job satisfaction.<br><b>OBJECTIVE</b> : To explore possible associations of workload and individual characteristics of residents with their procedural error rates.<br><b>DESIGN</b> : Prospective observational study based on a daily questionnaire.<br><b>PARTICIPANTS</b> : Residents of postgraduate year 1 and 2.<br><b>MEASUREMENTS</b> : Residents' workload (on-calls, work hours, sleep and napping hours), residents' physical and mental health state, personality inventory, and procedural error rate (defined as procedural error counts divided by overall procedural attempts).<br><b>RESULTS</b> : On average, the residents (N=49) were responsible for 9.8 inpatients per day (range, 1.9-23.1), worked for 16.0 hours per day (range, 12.6-19.8), slept for 4.4 hours per day (range, 2.8-5.7), napped for 0.2 hours per day (range, 0-0.7), and experienced 1 overnight work shift every 7.2 days. The procedural error rate was 2.2 per 10 procedures (range, 0.4-5.0). Using a multivariable adjusted regression model, significant factors associated with lower error rates included : longer napping ; reflective personality ; better mental state ; higher job satisfaction ; and, less on-call frequency.<br><b>CONCLUSIONS</b> : Procedural error of residents is positively associated with higher on-call frequency and inversely associated with napping, reflective personality, better mental state, and higher job satisfaction. For reducing procedural error among residents, improvement of modifiable factors, such as workload and mental health, is needed.

Autoimmune Hemolytic Anemia Associated with Primary Biliary Cirrhosis / General Medicine

<b>ABSTRACT</b> : Both primary biliary cirrhosis (PBC) and autoimmune hemolytic anemia (AIHA) are uncommon diseases. Immunological dysregulation is suggested as a causative factor for both diseases. We report a 77-year-old woman who suffered from warm type AIHA complicated by PBC. Her direct antiglobulin test was positive for IgG, and negative for C3. Both anti-mitochondrial antibody and its M2 component were detected. Both alkaline phosphatase (Alp) and IgM were elevated in the serum. She was initially treated with steroids for 8 months. Her steroids were discontinued when she underwent a laparoscopic splenectomy. Ursodeoxycholic acid was discontinued due to an allergic skin reaction. Her Alp improved with bezafibrate.

Physicians' Use of Local Dialects during Communication with Patients / General Medicine

OBJECTIVE: To investigate Japanese physicians' use of dialects related to geographic areas and to elucidate how physicians respond to dialect-using patients.<BR>METHODS: We conducted a web-based open survey, to which 170 anonymous physicians reported. We examined the following 1) whether dialects are used during communication with patients; 2) how to communicate with patients using dialects; and, 3) reasons for having difficulty in communicating with patients who regularly use dialects. Geographical areas were divided into the following 8 areas Hokkaido-Tohoku, Kanto, Koshinetsu-Hokuriku, Tokai, Kinki, Chugoku, Shikoku and Kyushu-Okinawa.<BR>RESULTS: Of 170 physicians, 61.2% (95% CI: 53.4-68.5%) reported using dialects. These proportions differed by geographic area (F= 8.141; p<0.001) . Physicians practicing in Shikoku and Chugoku used dialects most frequently, while those practicing in Kanto and Hokkaido-Tohoku used dialects least frequently. Many dialect-using physicians thought that physicians should use the same dialect as dialect-using patients. In addition, dialect-using physicians were more likely to think that a physician-related factor was responsible for having difficulty in garnering clinical information.<BR>CONCLUSIONS: Use of dialects by Japanese physicians during communication with patients seems common and may differ by geographic areas. Physicians' use of dialects could be a useful tool for effective clinical communication.

Sociodemographic Characteristics for Use of Complementary and Alternative Medicine in Japan / General Medicine

BACKGROUND: Use of complementary and alternative medicine (CAM) has become popular in Japan.<BR>OBJECTIVE: To investigate associations of symptom-related CAM use with sociodemographic factors in Japan.<BR>DESIGN AND SETTING: A prospective cohort study of a nationally representative sample of households in Japan.<BR>PARTICIPANTS: Community-dwelling adults who developed at least one symptom during a 31-day period.<BR>MAIN OUTCOME MEASURES: Self-reported, symptom-related use of CAM, either physical CAM or oral CAM.<BR>RESULTS: Of 2, 453 adults, 2, 103 participants (86%) developed at least one symptom. Of these symptomatic adults, 156 (7.4% ; 95% CI: 6.3-8.5%) used physical CAM therapy. The likelihood of using physical CAM was not significantly influenced by annual household income, employment, or education. Participants living in large cities had an increased likelihood of using physical CAM with an odds ratio (OR) of 2.6 (95% CI: 1.2-5.8), compared to those living in rural areas. Oral CAM therapy was used by 480 participants (22.8%; 95% CI: 21.0-24.6%) among the symptomatic adults. An age of 60 years old and older (OR 2.0; 95% CI: 1.2-3.3) and female gender (OR 1.8; 95% CI: 1.3-2.6) were significantly associated with an increased use of oral CAM. The unemployed participants had a lower likelihood of using oral CAM, with an OR of 0.6 (95% CI: 0.4-0.9), compared to the employed.<BR>CONCLUSIONS: Oral CAM use is common among Japanese patients and is associated with older age, female gender, and employed status, while physical CAM use is less common and is associated with living in a large city.

Current Situation of Medical Student Abuse / 医学教育

1) To our knowledge, medical student abuse has not previously been studied in Japan.<BR>2) In our survey, 68.5% of respondents experienced medical student abuse.<BR>3) Several students reported that they had been frequently neglected or ignored by teaching physicians during clinical clerkships and that such attitudes discouraged them and decreased their motivation.<BR>4) To improve the learning environment, medical educators must take action to resolve this serious issue.

Evaluation of Simulation Training During an Orientation Program for New Residents / 医学教育

In 2006 26 first-year residents at St.Luke's International Hospital underwent training with a highly sophisticated simulator to learn how to treat patients with cardiopulmonary arrest or anaphylactic shock.We evaluated the effects of simulation training for first-year residents.<BR>1) After training, we analyzed the residents' performance in the 2 scenarios and the residents' satisfaction with simulation training.<BR>2) According to the resident's performance dataduring simulation training, first-year residents have sufficient skill to treat patients in cardiopulmonary arrest but not patients with anaphylactic shock.<BR>3) Twenty-five of the 26 residents (96.2%) were highly satisfied with simulation training.

Medications Prescribed at Discharge for Patients with Acute Myocardial Infarction : Evidence-to-Practice Gap in Janan / General Medicine

BACKGROUND: The existence of a gap between research evidence and clinical practice has been described recently. Several drugs are effective in preventing secondary events after acute myocardial infarction (AMI), but it is not certain whether this evidence is employed in daily practice. We investigated the drugs currently employed for patients with a history of AMI in Japan.<BR>METHODS: Medical records of patients who developed AMI during the calendar year of 1999 were retrospectively identified at three teaching hospitals in Japan. We collected data on drugs prescribed at three time points (upon admission for AMI, at the time of discharge, and one year after discharge) for each patient.<BR>RESULTS: Data were available for 149 patients with AM!. Drugs prescribed at the time of discharge were aspirin (77.5%), nitrates (68.3%), and angiotensin converting enzyme inhibitors (52.8%) . β-blockers were prescribed for only 12.0% of patients. The drugs used one year after discharge were to a large extent similar to those at the time of discharge. There were no significant correlations between the use of these drugs and comorbidity.<BR>CONCLUSION: Despite established evidence that β-blockers offer benefits to patients with a history of AMI, they have not been prescribed frequently, for reasons that remain unclear. To improve the quality of clinical care, further systematic effort is needed to bridge this evidence to practice gap.

The Number of Lives Saved and Quality-adjusted Life Years Prolonged by Ticlopidine Hydrochloride over the Past 20 years in Japan / General Medicine

PURPOSE: Ticlopidine hydrochloride, an antiplatelet agent, is believed to have saved life years in many patients with ischemic cerebral vascular diseases in Japan. But severe adverse events have also been reported. The current investigation aimed to compare two hypothetical cohorts treated with and without ticlopidine in terms of risks and benefits of ticlopidine treatment using Markov model.<BR>METHODS: We conducted Markov decision analysis to estimate the number of lives saved and the increase in quality-adjusted life years (QALYs) over the past 20 years by ticlopidine in Japan. Two cohorts of 60-year-old male patients with previous histories of cerebral infarction, one of which treated with ticlopidine and the other not treated with ticlopidine, were compared with respect to the number of deaths and quality of life (QOL) . Data incorporated were the probabilities of the recurrence of cerebral infarction and the associated mortality, adverse events of the drug, and the utility of health status treated with ticlopidine.<BR>RESULTS: Approximately 1, 630, 000 patients were estimated to be on ticlopidine for variable periods of time during the past 20 years in Japan. With treatment, 17, 130 lives were saved, while 1, 338 patients died because of cerebral bleeding, agranulocytosis, severe hepatic dysfunction, or thrombotic thrombocytic purpura, resulting in a net benefit of 15, 792 lives saved by ticlopidine over the past 20 years. In terms of QOL, there was a total increase of 382, 191 QALYs. Sensitivity analyses showed that the older the patients when ticlopidine therapy was started, the smaller the benefits that were gained by treatment.<BR>CONCLUSIONS: Ticlopidine is considered to have made a great contribution in savingmany lives and improving QALYs in the past 20 years in Japan. This kind of analysis based on Markov model can be employed to demonstrate effectiveness of drugs and medical technologies in terms of population health outcomes.

Curriculum of Medical Schools in North America Offering Various Education Programs: A Report of the Inspection Tour Organized by Dr. Hinohara in July, 2005 / 医学教育

1) The study tour was organized by Dr. Hinohara to learn about the medical education in North America and its philosophy to support the method.<BR>2) The McMaster University, which started PBL curriculum in 1969, began COMPASS curriculum which focuses on conceptual thinking and e-learning in which tutorial groups still remain as the key to the learning process.<BR>3) The Duke University, which values the researcher promotion, began a new curriculum including at further integration of basic and clinical medicine and structural clinical training (Intersession).<BR>4) The Washington University, which constructed WWAMI Program that cooperated with the medical institutions in four states surrounding Washington, started College System to support the students and to strengthen their clinical competencies.<BR>5) Common aspects of the innovation of medical education in North America are (1) further integration of the basic and clinical medicine, (2) early exposure to the principle of clinical medicine and (3) promotion of professionalism by Clinical Preceptorship.

Japan's Contribution to Research in Medicine in 1991-2000 / General Medicine

We reviewed the literature regarding Japan's contribution to research in medicine in 1991-2000. Japan contributed 7.6% of all articles in English listed in the Medline database. The contribution ranged from 0.6 to 11.4% for various clinical science fields and 3.8 to 11.9% for basic science categories of reputable journals. The lowest contributions were in the categories “General and General Internal Medicine” and “Epidemiology”, where Japan contributed only 0.6% and 1.1% of the articles, respectively. The Japanese contribution to high quality clinical research (randomized controlled trials, case-control studies, cohort studies) was meager, while that to the basic sciences was more satisfactory than to the clinical science categories. Appropriate academic and social initiatives should be made to accelerate clinical research in Japan.

Teaching Ambulatory Care Medicine in Japan: A Nationwide Survey / 医学教育

Teaching ambulatory-care medicine is essential for primary-care education. However, few studies of ambulatory-care training have been done in the past decade. We performed a nationwide survey to examine whether and how ambulatory medicine is taught to medical students and residents. We sent questionnaires to all medical schools (n=80) and accredited teaching hospitals (n=389) in February 2001. The response rates were 83.3% and 79.2%, respectively. Fifty-one (78.5%) of the 65 medical schools provided ambulatory-care education, although the programs varied considerably from school to school. Only 104 teaching hospitals (26.7%) had an ambulatory-care training program.

Postgraduate Ambulatory Care Training at Government-accredited Teaching Hospitals: Results of a Nationwide Survey in Japan / 医学教育

Although postgraduate training in an ambulatory care setting is recognized as beneficial in Japan, such training has not been widely implemented. In April 2001 we surveyed all 389 accredited teaching hospitals in Japan about their ambulatory care training. We asked 1) whether they provide a postgraduate training program in ambulatory care, particularly for problems commonly encountered in primary care settings, 2) if such a program was provided, how it was organized, and 3) if such a program was not provided, what the reasons were. One hundred eighty physicians responsible for the residency programs of 120 hospitals replied (response rate, 87%). Most residents at these hospitals see patients in outpatient clinics regularly during their training. Many faculty members supervise their residents at the outpatient clinic and also see their own patients. Sixty-eight percent of the respondents did not set teaching objectives for ambulatory care training. Frequently mentioned barriers to providing ambulatory care training were limited space and tight outpatient schedules. To promote postgraduate ambulatory care training in accredited teaching hospitals, adequate resource allocation and a national policy are needed.