Pitfalls in training simulated patients to respond appropriately to questions from medical students in family history-taking activities: the current situation surrounding the training of simulated patients for learning activities at Nippon Medical School.

Our goal was to train simulated patients (SPs) to respond appropriately to questions about family history from medical students in simulated medical interviews. To this end, we carried out a survey of 91 SPs and 76 4th-year medical students to investigate their notions of what constitutes a family. All of the SPs and students surveyed deemed parents and children living together to be members of a family. In a situation where one spouse's parents live together with the basic family unit, 93% of the SPs considered them to be members of the family, whereas only 79% of the students did. Married children living apart from their parents were considered members of the family by 18% of the SPs and 39% of the students. These results indicate clear differences between the SPs and students in their notions of the family. To verify the level of understanding of the definitions of family and blood relatives in particular scenarios used in simulated medical interviews, we administered a written test to 14 SPs who were training to assist in the nationwide common achievement test in medicine, the Objective Structured Clinical Examination (OSCE). The overall score of the SPs was 93.5%; the incorrect answers were "a sibling is not a blood relative" and "a spouse is a blood relative." We analyzed the performance of these 14 SPs in medical interviews carried out after training for the OSCE, in which they were asked questions that required them to reveal their understanding of blood relatives, cohabiting relatives, and the family. All of the SPs responded appropriately to the students' questions about family history. After the OSCE, we asked the SPs to assess themselves on how well they had given their family histories and to evaluate the usefulness of the SP training they had received. Their mean self-assessment score on providing a family history was 3.6 (scale: 1-4); on the usefulness of training, it was 3.4 (scale: 1-4). In conclusion, training SPs to respond appropriately to questions about family history in medical interviews is very important. Medical students have to learn how to take family histories accurately, so SP trainers should pay attention to training SPs in giving appropriate responses to students' questions, bearing in mind the differences between family history taking and everyday conversations about the family.

An effective training program for chest tube drainage for medical interns in a clinical simulation laboratory.

The Department of Respiratory Medicine of Nippon Medical School Hospital and the Working Committee of Clinical Simulation Laboratory have held training sessions for chest tube drainage since 2007. The training program consists of the preparation of a training manual, a small-group session, and a review of the process of chest tube drainage using a checklist of steps after the session. A total of 21 medical interns of Nippon Medical School Hospital participated in training sessions from April 2010 through February 2011. A questionnaire survey at the end of the session revealed that most participants rated highly both the explanations given by the instructors and the descriptions in the manual for comprehensibility. Only 3 interns felt that they had successfully acquired the clinical skill, and the other 18 interns felt that they had somewhat acquired the skill. Research after the interns had completed the program of the department showed that 80% of interns had performed chest tube drainage for patients during the rotation. The interns assessed the training program as useful, and some interns felt they could perform the skill with confidence or without anxiety. Other systematic programs of skill training for medical interns are recommended to ensure definite acquisition of basic skills.

Clinical clerkship course for medical students on lumbar puncture using simulators.

Lumbar puncture is a medical technique that physicians must learn and is, therefore, considered a basic medical procedure. The lumbar puncture simulators Lumbar-Kun (Lumbar Puncture Simulator) and Lumbar-Kun II (Lumbar Puncture Simulator II) (Kyoto Kagaku, Kyoto, Japan) are teaching aids designed for practicing spinal insertions. We describe and results of a lumbar puncture clerkship course, provided to 5th-year medical students during clinical clerkship activity. The aim of this study was to evaluate the effectiveness of the lumbar puncture clerkship course in the medical education program. Comprehension, technical achievement, and satisfaction were scored by students and instructors using a 6-point Likert scale. Scores for both comprehension and technical achievement were high, but technical achievement scores tended to be higher than comprehension scores. In addition, the scores students gave themselves were higher than the scores they were given by instructors. Student satisfaction was high. The lumbar puncture simulators, Lumbar-Kun and Lumbar-Kun II, achieved excellent overall impressions and represent useful tools for training in lumbar puncture procedures. In addition to the simulators, an appropriate preparatory text and a short lecture before training seemed to increase the educational effect of this lumbar puncture clerkship course for medical students.

A training session in a clinical simulation laboratory for the acquisition of clinical skills by newly recruited medical interns.

In organized orientation programs for newly recruited medical interns of the Nippon Medical School Hospital, the working committee of the clinical simulation laboratory introduced a laboratory training session that was designed to improve the clinical skills of the medical interns. The session consisted of 6 training courses, comprising internal examination, tracheal intubation, auscultation of heart sounds, bandaging and the collection of samples of venous and arterial blood. Medical interns rotated to a new course every 30 minutes and did practical trainings in each of the 6 skills. A total of 36 newly recruited medical interns participated in the training session. The majority of medical interns took part in the practical training actively and positively. The session was efficiently carried out from the standpoints of human resources and the teaching hours involved. A post training questionnaire survey, completed by the medical interns, revealed that many of them valued the sessions for comprehensibility of the instructions, the descriptions in the manual and the content of the training; however, only 21% thought that they had successfully acquired the clinical skills. Medical interns must continually engage in self-training to steadily acquire basic clinical skills. The convenience of a clinical simulation laboratory, together with the reinforcement of the education of clinical skills during internship, is necessary to strengthen the educational benefits of the training session.

Can interview prior to laparoscopic simulator training predict a trainee's skills?

BACKGROUND: Our institute started laparoscopic simulator training for medical students in 2006. During the training, we observed considerable interindividual differences in laparoscopic skills among those students. This study aimed to investigate the predictive factors that affect laparoscopic skill by assessing the students' training results data. METHODS: Forty-three, fifth-year medical students were asked several questions and were divided into 2 groups depending on their answers. The participants performed an object-positioning module on a ProMIS simulator (Haptica, Inc., Dublin, Ireland). Execution time, instrument path length, and economy of movement for each trial were recorded on ProMIS. Comparisons of mean performance measures between the 2 groups were made using a Mann-Whitney U test. RESULTS: Interest about laparoscopic surgery and accomplishment in playing piano did not affect the skillfulness significantly. The students who had an interest in television (TV) games completed the task in less time (p = 0.046) and had a shorter left instrument path length (p = 0.012). The students who thought themselves manually dexterous completed the task in less time (p = 0.008). The students who were confident about driving completed the task in less time (p = 0.0247). DISCUSSION: In our interview, the factors that had a relationship to laparoscopic skills were favorableness to TV games, manual dexterity, and confidence about driving. These results were expected because TV games and driving a car require the same abilities as laparoscopic surgery. Psychomotor, perceptual, or visuospatial ability are essential for good performance. In conclusion, our study suggests that the interview can be an effective measure to examine the aptitude of medical students without the use of a simulator.

Unique medical education programs at Nippon Medical School.

In an attempt to improve the content of the educational programs offered by Nippon Medical School and to better prepare our students to work in the rapidly changing world of medicine, the school has recently revamped its teaching methodology. Particular emphasis has been placed on 1) simulator-based education involving the evaluation of students and residents in a new clinical simulation laboratory; 2) improving communication skills with the extensive help of simulated patients; 3) improving medical English education; 4) providing early clinical exposure with a one-week clinical nursing program for the first year students to increase student motivation at an early stage in their studies; 5) a new program called Novel Medical Science, which aims to introduce first-year students to the schools fundamental educational philosophy and thereby increase their motivation to become ideal physicians. The programs have been designed in line with 2006 guidelines issued by the Ministry of Education, Culture, Sports, Science and Technology to allow flexibility for students to take part in education outside their own departments and year groups as part of the Ministry's program to encourage distinctive education at Japanese universities.

[Student evaluation of faculty teaching in molecular anatomy course at Nippon Medical School: results of a questionnaire survey].

For the purpose of improving education, the lecture and practices employed in the Molecular Anatomy Course were evaluated by students. The survey was performed with personal computer connected to a local area network and the results were readily exhibited on our website the following day. The total number of answers was 528 and the reply percentage was 31.2%. The average score (from 1: very bad to 5: very good) was 3.9, with a range of 3.2 to 4.8. Faculty teaching got better grades in the latter half of the period compared to those in the first half, particularly on "preparation" and "understanding". The correlation analysis showed a strong relationship between the understanding of the lecture and the orientation of practice. These findings suggest that constant evaluation by students during the whole period of the instruction is useful for improving the quality of education of our Anatomy Course.

Nutrition education in medical schools in Japan: results from a questionnaire survey.

Diet is known to play a critical role in the pathogenesis of major age-related chronic diseases, which are rapidly becoming more common in Japan and other industrialized countries. However, traditional medical education has not provided adequate knowledge of nutrition. To understand the current status of nutrition education in Japan, we sent a questionnaire to all Japanese medical schools to survey their nutrition curricula. The questionnaire was sent to 79 medical schools in Japan, which includes all medical schools except for that of the authors. We also used a questionnaire to survey second year medical students just after they received a short nutrition course at Nippon Medical School. Fifty-seven medical schools (72.2%) responded to the questionnaire: 12 (21.1% of the responding schools) offered a " nutrition" course and 3 (5.4%) offered a "clinical nutrition" course. Including "nutrition" and "clinical nutrition" courses, 14 of the responding medical schools (24. 6 %) offered stand-alone nutrition courses in their undergraduate education. Although a total of 48 of the responding medical schools (84.2%) offered some nutrition topics, only 8 of the responding schools (14.0%) may have offered substantial nutrition education. No special postgraduate course in medical or clinical nutrition was offered by any of the schools. Despite this, more than 80% of the students that appeared to be interested in a nutrition course recognized the importance of nutrition education in medical school. This survey showed that nutrition education in Japanese medical schools remains inadequate and changes are necessary.

Implementation of integrated medical curriculum in Japanese medical schools.

Recently, various integrated medical curricula, which can be defined as courses with subject matter classified by organ systems rather than according to departments such as surgery and internal medicine, are beginning to be introduced to bedside-learning in Japan. For example, in such an integrated medical curriculum, lectures in the course on neurological diseases would be given by a team that would include neurosurgeons, neurologists, and pathologists. Using medical education on neurological diseases as an example of an integrated medical curriculum, we analyzed the factors related to the neurological disease course as an example of an integrated medical curriculum in the clinical medicine course at our school. We also compared our course with those of all private medical schools in Japan, using the syllabuses of these private medical schools for the comparison, and considered elements that measured interdisciplinary participation in presenting the curriculum. For an integrated medical curriculum to gain interdisciplinary acceptance, the curriculum should be constituted using all medical disciplines related to the specific organ involved in the disease process under study, including both basic medicine and clinical medicine. In addition, teachers should be informed of the rationale for such a curriculum to promote their participation and a textbook on the integrated medical curriculum is needed. A curriculum committee should play an important role in promoting this type of medical education.

Intracranial osteosarcoma after radiosurgery--case report.

A 56-year-old woman presented with an intracranial osteosarcoma at the site of previous radiosurgery, manifesting as sudden onset of headache and left hemiparesis with aphasia. She had a previous history of stereotactic radiosurgery for an intracranial tumor under a diagnosis of falx meningioma. Computed tomography showed intratumoral and peritumoral hemorrhage at the right parietofrontal region. Gross total resection of the tumor with hematoma was performed. The histological diagnosis was osteosarcoma. Sarcomatous change is a rare complication of radiotherapy. This case illustrates that osteosarcoma may develop years after radiosurgery for benign brain neoplasm.

[A report of questionnaire survey asking teaching staff concerning evaluation of faculty teaching from the students in Nippon Medical School].

A questionnaire survey was conducted to ask teaching staffs about the present activities and opinions of evaluation of faculty teaching from the students (EFS). One hundred and eighty-eight among 336 members (56.1%) responded. Among them sixty-four (34%) replied that they had tried at least once EFS of their lectures and/or practices. Approximately 70% had a opinion that EFS would benefit them for improving their lectures and practices, and/or for improving course planning. Fifty-four per cent of members supported EFS to be introduced, 34% depended upon how to evaluate, and remaining 5% did not support it. These results indicate that the staff members are highly concerned with EFS which should be provided for introduction after a full discussion how to evaluate.

Central neurocytoma expressing characteristics of ependymal differentiation: electron microscopic findings of two cases.

We describe two cases of central neurocytoma in the lateral ventricle. Ultrastructural examination showed occasional cilia mixed in with sparse dense core vesicles and thin tumor cell processes containing parallel microtubules. These central neurocytomas revealed evidence of ependymal differentiation. We propose that central neurocytoma originates from multiple differentiation from the germinal matrix cell layer.

[BIS monitoring is useful for reliable intraoperative cortical mapping during brain tumor operations].

Poor detection of muscle motor evoked potential (m-MEP) by electrical cortical stimulation has often been encountered during neurosurgical operations, although widely known optimal factors for reliable detection have been put into practice. We hypothesized that the depth of anesthesia influenced the detection of m-MEP. Bispectral Index (BIS) monitoring was used to assess the depth of anesthesia for 16 patients during brain tumor operations. The doses of intravenous anesthetics, propofol, were titrated according to BIS indices during operations. When BIS indices were 40 or below, detection was difficult and higher intensities of electrical stimulation were necessary to evoke m-MEPs. Furthermore, risk of seizure was relatively high due to stronger electrical stimulation. Our results suggested that a BIS index above 50 and below 70 was optimal range. BIS monitoring is a useful method for setting the optimal dose of anesthetics for reliable intraoperative cortical mapping.

[An autopsy case with subacute spinal cord disease showing progressive paraplegia].

We report a 72-year-old woman who died of respitory failure. History included onset of diabetes mellitus at the age of 67 years and hypertension at the age of 72 years. The patient had been in good health otherwise until 2000, when she had onset of numbness or tingling of the bilateral lower limbs. On December 3, 2000, she was admitted to a hospital in the vicinity of her home because of the above-mentioned complaints. Neurological examinations revealed progressive paraplegia. Symptoms and signs suggested Guillain-Barré syndrome. Examinations of cerebrospinal fluids revealed cell count of 338/3 (mono 72%, poly 18%) and protein value of 100 mg/dl. Later the patient course deteriorated. On December 15, 2000, she was admitted to Hakujikai Memorial Hospital for the second time. Ten days later, MRI examination showed diffuse swelling of the spinal cord from the cervical (C 3/4) level to the thoracic level. Gd-enhanced T 1-weighted MRI performed 22 days later showed a partially enhanced lesion at the thoracic (Th 5/6) level of the spinal cord. The patient was treated with steroid therapy (methylprednisolone 500 mg/dl). She died of respiratory failure on January 6, 2001. The patient was presented in a neurological CPC. Neurological and imaging findings suggested a transverse myelopathy. However, there were several points in this case that were unusual for a typical transverse myelopathy, such as total sensory loss below spinal segments of thoracic level (Th 5) and motor weakness of the upper limbs of upper segment of the same level. A clinical neurologist concluded that the patient had subacute transverse myelopathy with fused multiple pathy pathologic lesions. We discussed whether this case was a transverse myelopathy or multiple sclerosis. Post mortem examination revealed acute necrotic myelopathy affecting the spinal cord from the second cervical to the tenth thoracic vertebrae, with conspicuous infiltration of CD 68-positive macrophages involving both gray and white matter, partially necrotic associated with scattered UCHL-1 dominants lymphocytic infiltration of T cells around vessels. There were relatively older lesions with demyelinating features in the spinal roots that were particularly dominant in the anterior roots. No demyelinated plaques in the optic chiasm, tracts and nerves, or in the cerebero-cerebellar white matter were found. Systemic pathological diagnosis was lung edema with fresh hemorrhage, pancreatic atrophy consistent with diabetes mellitus and choleductlithiasis.

[The relationship between the severity of a neurological condition and the blood coagulation/fibrinolytic system in patients with spontaneous subarachnoid hemorrhage].

In order to examine the relationship between the hemostatic systems and the severity of neurological changes, shortly after spontaneous subarachnoid hemorrhage (SAH) we reviewed 30 patients who had been admitted within 6 hours after the onset of SAH. Peripheral blood samples were obtained within 6 hours of the onset of SAH. There was a significant correlation between increased values of serum antithrombin III, thrombin-antithrombin III complexes, fibrinopeptide B beta 15-42, D-dimers, and the neurological severity of SAH. The data suggest that the activation of the blood coagulation system as well as the fibrinolytic system (especially the secondary fibrinolysis) occurs early in the course of SAH, particularly in patients with a severe neurological condition.