A Concept of "Transition of Care" in Japan -Focusing on Care Transition of Patients Who are Discharged from a Hospital and Treated at Another Clinic as an Outpatient- / 日本プライマリ・ケア連合学会誌

Recently in Japan, "transition of care" cases, in which patients are transferred from a medical institution that had once provided medical care to a new one and the medical care provider is therefore changed, are increasing. However, the concept of "transition of care" and "undesirable outcomes in patients accompanied by care transition" have been studied very little in Japan. The concept of "transition of care" consists of factors such as patient background (age, underlying disease, and family's caregiving ability), transfer of clinical information, and tools to transfer clinical information. In Europe and the USA, undesirable outcomes accompanied by care transition, such as "medicamentous adverse events", "clinical examination data taken during hospitalization are not confirmed", and "medical care planned for a patient is not implemented", are reported to have occurred for 19% to 50% of patients who had been discharged from hospitals and transferred to clinics. It is also necessary to understand the state of care transition in Japan and investigate countermeasures compatible with the Japanese medical care system.

An Investigation of the Relationship between Senior Doctor's Support and Resident's Depressive State / General Medicine

<b>Background:</b> A depressive state for residents during residency training is a serious problem. Enhancement of senior doctor's support is considered to be one preventive measure, but it is uncertain whether onset of a new depressive state during training is related to senior doctors' support.<br><b>Methods:</b> A dual questionnaire survey was conducted in 2003 on 608 first-year residents at 40 teaching hospitals in Japan. Residents who had not been in a depressive state at the time of the first survey-using the Center for Epidemiologic Studies-Depression (CES-D) Scale, but were in a depressive state at the time of the second survey were defined as “residents in a new-onset depressive state.” The degree of senior doctors' support was assessed with Senior Doctor's Support Scale (SDSS), then adjusted OR and 95% CI of the residents in a new-onset depressive state were computed with a multivariate logistic regression model.<br><b>Results:</b> 82 residents (24.4%) were determined to be “residents in the new-onset depressive state.” The mean CES-D Score of Low SDSS Score Group (n=24), Middle SDSS Score Group (n=100), and High SDSS Score Group (n=152) were 20.0 (SD=9.9), 13.8 (SD=8.7), and 11.0 (SD=8.0), respectively (p<0.001). With logistic regression, residents who could fall into a depressive state during residency training were considered to be those who achieve middle SDSS Score (OR: 3.04, 95% CI: 1.45-4.80) and low SDSS score (OR: 17.89, 95% CI: 4.83-66.30).<br><b>Conclusion:</b> Because onset of residents' depressive state is related to senior doctors' support, we should enhance support during residency training.

Status of Provision of Drug Information to Hypertensive Patients at Community-based Pharmacies / General Medicine

<b>Objective:</b> The present study examined the status of the provision of drug information to hypertensive patients at community-based pharmacies by evaluating patients' satisfaction, understanding, and wishes.<br><b>Design:</b> A cross-sectional study was conducted by surveying patients using a self-administered questionnaire.<br><b>Methods:</b> Three items were evaluated: 1) the level of patient satisfaction with provision of drug information; 2) the level of patient understanding of information provided on antihypertensive drugs; and, 3) patient wishes regarding provision of drug information.<br><b>Results:</b> The level of satisfaction with provision of drug information was high (86.6%). Although patients were found to understand the precautions for use of antihypertensive drugs, their understanding of drug efficacy was insufficient. Also, patients wished to receive more explanation from pharmacists regarding the efficacy of drugs in addition to explanations of associated adverse reactions or precautions for use of the drugs.<br><b>Conclusions:</b> Hypertensive patients were highly satisfied with the provision of drug information at community-based pharmacies, but did not show sufficient understanding of the efficacy of antihypertensive drugs, an issue to be addressed in the future by pharmacists in their instructions to patients on the use of drugs.

The International Trend in Continuing Medical Education / 医学教育

1)Continuing medical education (CME) systems were researched in 10 countries. In all countries but one CME is mandatory. Only Spain has voluntary CME, as does Japan.<br>2)The traditional CME systems in many countries were changed after 2000. We believe this change reflects a global revolution associated with a new wave of medical risk management.<br>3)To provide better medical services, we must keep improving Japan's CME system. Such improvement is an important responsibility to society.

Qualitative research for searching for the stressor of junior resident in Japan / 医学教育

In Europe and America, it is reported that residents develops burnout syndrome or depression by their stress, and these are connected with dropouts from their training program and undesirable outcomes of the patients such as unethical practice. Recently, though resident's poor working conditions and death from overwork, etc. become problems also in Japan.But, Japanese resident's stressor is uncertain.<BR>1) Focus group interview was executed for 25 junior residents in 10 facilities, and their stressor were explored.<BR>2) As a result, three cateogories ; physiological stressor as one human being, stressor as a new member of society, and stressor as a trainee doctor and beginner novice doctor was extracted.<BR>3) Three stressors were named the life gap, the society gap, and the profession gap respectively. The stressor of junior resident was described as the product what was born by the gap of medical student and becoming a doctor.<BR>4) Japanese residents have various stressors. Stressor as a trainee doctor was a stressor peculiar to Japanese junior residents.<BR>5) Stress management should be done considering such a stressor in the light of safety and effective clinical training.

What Motivates Community Physicians to Participate in Office-based Education? / 医学教育

Increased emphasis on community-based education in medicine requires close collaboration with and cooperation from general practitioners. This study examined what motivates community physicians to participate in office-based education, to explore the most appropriate method for recognizing physicians' efforts and keeping them motivated with their precepting role. A large majority of respondents to a questionnaire survey thought that the opportunity to learn from their own teaching was an important reward. When the preceptors were asked what support would be most appropriate, a teaching certification plaque, continuing medical education courses, and a title were ranked highest, while financial reward was listed as the least important. Considered most essential by community preceptors were constructive feedback from students, medical-school instructors' understanding of the importance of community-based medicine, and the instructors' enthusiastic promotion of primary-care education.

What does the General Public Think Residents can Do?: Exploratory Research on Layperson's Perceptions of Residents' Clinical Competence / 医学教育

This study explored the general public's perception of the clinical competence of residents. Methods: Individual interviews of laypersons, medical students, and residents and focus-group interviews of residents were conducted. Results: Individual interviews revealed the belief that residents acquired various clinical skills immediately after passing the national examination for medical practitioners. These skills included: assessment of the need for referrals, on-call jobs for after-hours and emergency services, interpreting X-ray films, performing cardiopulmonary resuscitation, performing surgery for appendicitis, and treating bone fractures and joint dislocations. Focus-group interviews revealed differences between residents and laypersons in the perception of residents' clinical skills. These skills included: general knowledge of diseases and medications, guidance about lifestyle after discharge, physical examinations, explanation of treatment, diagnostic imaging, and knowledge of or expertise in other medical professions. Conclusion: Laypersons and medical personnel have different perceptions about the clinical competence of residents.

Adapting the Physician Job Satisfaction Scale to Japan / General Medicine

<B>BACKGROUND</B>: Understanding the job satisfaction and dissatisfaction of physicians might help to improve health care in Japan. Nevertheless, no job-satisfaction scale for physicians has been validated in Japanese.<BR><B>OBJECTIVE</B>: To develop a Japanese version of the Physician Job Satisfaction Scale (JSS), a multi-dimensional questionnaire developed by the Society of General Internal Medicine (SGIM) Career Satisfaction Study Group (CSSG), and to evaluate its reliability and validity.<BR><B>METHODS</B>: A Japanese version of the JSS was developed according to the standard protocol of scale translation. A focus group of 7 Japanese physicians was established to identify “Japanese-specific” facets of job satisfaction. After revising the scale based on the discussions of the focus group, a cross-sectional sample of 87 Japanese physicians from hospitals in different regions completed the Japanese version of the Physician Job Satisfaction Scale (JSS-J) to assess its reliability and validity.<BR><B>RESULTS</B>: A focus group identified a Japanese-specific facet, “prestige”. Content validity was also established through the focus group. Internal consistency ranged from 0.53 to 0.83. Test-retest reliability, convergent and discriminant validity were good to excellent.<BR><B>CONCLUSIONS</B>: Although the overall results suggest that the JSS-J can be applied to assess the job satisfaction of Japanese physicians, further qualitative research is required to refine the JSS-J.

Evaluation of the Clinical Clerkship Program at the University of Tokyo (part 2): Course Evaluation and Faculty Evaluation by Students / 医学教育

The purpose of this study was to evaluate the clinical clerkship program at the University of Tokyo Hospital. We report results of course and faculty evaluations by students and of qualitative evaluations, such as students, free comments and group interviews. Methods: Each item of the course and faculty evaluations was related to the overall educational goals developed in advance. Students evaluated the course and faculty immediately after the course ended. Results: Students rated the clerkship program favorably overall, but the scores of thesecond month (3.38) were lower that those of the first month (3.63). Although learning basic clinical procedures is not the main educational goal of the clerkship, students varied widely in their opportunities to perform procedures. Scores of faculty evaluations ranged from 2.93 to 3.87 in the first month and were lower in the second month for all but two items. Interviews revealed that students had fewer learning experiences in the second month because new residents started their rotations at that time. Conclusion: The results suggest that the scheduling of clinical clerkships should be changed. The contents of clerkship need further consideration.

Evaluation of the Clinical Clerkship Program at the University of Tokyo (part 1): Student's Self-evaluation and Evaluation by Faculty / 医学教育

A clinical clerkship program was introduced at the University of Tokyo in 2002 to help students acquire clinical knowledge, skills, and attitudes by increasing their involvement in clinical activities. We assessed the learning effectiveness of clinical clerkships at the University of Tokyo Hospital by examining evaluations of student's clinical competence by themselves and by the faculty. Methods: We evaluated each clerkship with reference to overall educational goals developed in advance. We measured students' self-evaluations and evaluatio s by the faculty before and after the clerkship. Results: At the end of the 2-month clerkship, students' self-evaluation scores (3.18) were significantly higher than before the clerkship (2.71). In particular, scores for patient care were markedly higher. Evaluation scores by the faculty were also higher during (3.64) and after (3.57) clerkships than before (3.26) clerkships. Conclusion: We will use this data to make next year's clerkship programs more effective. We should also develop more-objective strategies for evaluation and establish relevant educational goals.

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.

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.

Introducing Evidence-Based Medicine Into Undergraduate Medical Curricula: Results of a Nationwide Survey in Japan / 医学教育

We conducted a nationwide survey in 2000 regarding undergraduate medical education in Evidence-based Medicine (EBM) in Japan. We asked faculty members responsible for medical education at each medical school 1) whether there are any barriers to teaching EBM, 2) what these barriers are, and 3) what educational resources are needed to overcome them. Responses were received from 64 schools (80%). More than half of the respondents reported barriers to teaching EBM. We identified two kinds of barriers: before EBM is introduced, skepticism toward the concept of EBM and the value of teaching EBM is encountered; later, problems of organizing a curriculum and shortages of staff and materials are encountered. To overcome these barriers, we need: 1) to establish organizations for coordinating educational programs among medical schools, 2) to hold seminars for faculty development, 3) to develop EBM curricula and teaching materials, and 4) to provide computer facilities and appropriate networks.

National Survey of Programs to Teach Evidence-based Medicine to Undergraduates in Japan / 医学教育

We conducted a national survey to examine the status of programs to teach evidence-based medicine (EBM) to undergraduates in Japan. Our survey specifically focused on four areas: 1) recognition of a need to teach EBM, 2) the present status of programs to teach EBM to undergraduates, 3) details of the timing of existing EBM teaching programs and of departments responsible for it. Sixty-four schools (80%) responded. Nearly all respondents agreed that EBM should be taught, and most agreed that it should be taught both before and after graduation. Most respondents stated that departments must collaborate when preparing to teach EBM. At the time of the survey, 22 medical schools (34%) had already started programs to teach EBM and 28 (42%) were planning to do so. Existing programs mainly targeted 4th-year students, but the department responsible for the programs varied among schools. Further evaluation of the effectiveness of existing programs is now needed.