Healthcare use and RT-PCR testing during the first wave of the COVID-19 pandemic in Japan.

BACKGROUND: Rapid testing, tracing, and isolation among symptomatic patients are the standard for controlling the COVID-19. However, during spring 2020, Japan employed a RT-PCR test policy by using a guideline, which was used for the public to visit hospitals or clinics when they had mild symptoms for 4 days or longer ("4-day rule") among low-risk patients. It is unknown of patients' experience of healthcare use and testing during the period under the guideline. Thus, we investigated the healthcare visiting and testing among patients who developed cold-like symptoms during the period. METHODS: Our survey was conducted online in September 2020 to a nationally representative sample of adults throughout Japan. We investigated the public's understanding of the guideline. In addition, we asked their experience with healthcare use and testing if they had noticed new-onset cold-like symptoms. RESULTS: Of 2,137 people surveyed, 1,698 (79.5%) recognized the guidelines, but 422 people (19.7%) misunderstood. There were 144 (6.7% of 2,137 people) who developed cold-like symptoms, and many of them experienced difficulties in getting through telephone calls to a public health center, and 25 (17% of 144 people) visited healthcare institutions. Of these 25 symptomatic patients, 15 (60%) could not receive testing because of decisions by physicians (14 patients) or a local public health center (1 patient). CONCLUSION: There was a low use of healthcare and testing among symptomatic patients during the first wave of the pandemic in Japan. Testing capacity should be increased to provide effective care for patients with suspected COVID-19 in Japan.

Health-care-seeking behaviours of the Japanese lay public during the COVID-19 pandemic: a cross-sectional study.

INTRODUCTION Owing to a decrease in visits to health-care facilities due to the coronavirus disease 2019 (COVID-19) pandemic, the health-care-seeking behaviour of the Japanese lay public has yet to be adequately clarified. AIM To explore health-care-seeking behaviour of the Japanese lay public during the COVID-19 pandemic in 2020. METHODS We conducted a web-based questionnaire survey in September 2020 to enquire about visits to health-care facilities for disease treatment and preventive services (health check-ups or cancer screening tests) during two periods: mid-February to May 2020 and from June to September 2020. Survey respondents were selected from people who voluntarily registered with a Japanese consumer research company, excluding health-care workers. Respondents' residence and sex were adjusted to represent the Japanese population. Survey results were aggregated after anonymizing respondents' personal information. RESULTS In total, 2137 people responded to the survey. The proportion of respondents who avoided new and follow-up visits to health-care facilities were 31.1% and 25.0%, respectively, in the first period and 19.1% and 12.5%, respectively, in the second period. In both periods, dentistry and general medicine were the most avoided health-care sites. Trying to avoid infection was the main motivation for this behaviour. Nearly half of respondents stated that they would not visit health facilities after the COVID-19 infection became controlled. DISCUSSION During the COVID-19 pandemic, the Japanese lay public indicated that they would avoid new and follow-up visits to health-care facilities. The highlighted changes in health-care-seeking behaviour may be long-term, even after COVID-19 is under control.

Development of quality indicators for care of chronic kidney disease in the primary care setting using electronic health data: a RAND-modified Delphi method.

BACKGROUND: The prevalence of chronic kidney disease (CKD) has recently increased, and maintaining high quality of CKD care is a major factor in preventing end-stage renal disease. Here, we developed novel quality indicators for CKD care based on existing electronic health data. METHODS: We used a modified RAND appropriateness method to develop quality indicators for the care of non-dialysis CKD patients, by combining expert opinion and scientific evidence. A multidisciplinary expert panel comprising six nephrologists, two primary care physicians, one diabetes specialist, and one rheumatologist assessed the appropriateness of potential indicators extracted from evidence-based clinical guidelines, in accordance with predetermined criteria. We developed novel quality indicators through a four-step process: selection of potential indicators, first questionnaire round, face-to-face meeting, and second questionnaire round. RESULTS: Ten expert panel members evaluated 19 potential indicators in the first questionnaire round, of which 7 were modified, 12 deleted, and 4 newly added during subsequent face-to-face meetings, giving a final total of 11 indicators. Median rate of these 11 indicators in the final set was at least 7, and percentages of agreement exceeded 80 % for all but one indicator. All indicators in the final set can be measured using only existing electronic health data, without medical record review, and 9 of 11 are process indicators. CONCLUSION: We developed 11 quality indicators to assess quality of care for non-dialysis CKD patients. Strengths of the developed indicators are their applicability in a primary care setting, availability in daily practice, and emphasis on modifiable processes.

Improvement in medical students' communication and interpersonal skills as evaluated by patient satisfaction questionnaire after curriculum reform.

Fifteen years of undergraduate medical education curriculum reform at Saga Medical School was evaluated by measuring medical students' communication and interpersonal skills with a patient satisfaction questionnaire developed by the American Board of Internal Medicine. A multiphase cross-sectional study was conducted at the General Medicine Clinic of Saga Medical School Hospital in phase I (1998-1999), phase II (2001-2002), and phase III (2009-2010). A total of 1,963 patient ratings for 437 medical students' performance was analyzed. The average scores of phases II and III were significantly higher than for phase I. The average score of female students showed a significant difference between phases I and II, but no difference between phases II and III. The average score of male students showed no difference between phases I and II, but significant difference between phases II and III. The phase II curriculum introduced basic clinical skills and examination and improved female students' performance. The phase III curriculum was effective for male students because it emphasized the clinical skill program more and introduced problem-based learning. Curriculum reform at Saga Medical School is considered to have made good progress in improving students' clinical competence and patient-centered attitudes.

The characteristics of a good clinical teacher as perceived by resident physicians in Japan: a qualitative study.

BACKGROUND: It is not known whether the characteristics of a good clinical teacher as perceived by resident physicians are the same in Western countries as in non-Western countries including Japan. The objective of this study was to identify the characteristics of a good clinical teacher as perceived by resident physicians in Japan, a non-Western country, and to compare the results with those obtained in Western countries. METHODS: Data for this qualitative research were collected using semi-structured focus group interviews. Focus group transcripts were independently analyzed and coded by three authors. Residents were recruited by maximum variation sampling until thematic saturation was achieved. RESULTS: Twenty-three residents participated in five focus group interviews regarding the perceived characteristics of a good clinical teacher in Japan. The 197 descriptions of characteristics that were identified were grouped into 30 themes. The most commonly identified theme was "provided sufficient support", followed by "presented residents with chances to think", "provided feedback", and "provided specific indications of areas needing improvement". Using Sutkin's main categories (teacher, physician, and human characteristics), 24 of the 30 themes were categorized as teacher characteristics, 6 as physician characteristics, and none as human characteristics. CONCLUSIONS: "Medical knowledge" of teachers was not identified as a concern of residents, and "clinical competence of teachers" was not emphasized, whereas these were the two most commonly recorded themes in Sutkin's study. Our results suggest that Japanese and Western resident physicians place emphasis on different characteristics of their teachers. We speculate that such perceptions are influenced by educational systems, educational settings, and culture. Globalization of medical education is important, but it is also important to consider differences in educational systems, local settings, and culture when evaluating clinical teachers.

Arm span-height difference is correlated with gastroesophageal reflux symptoms in aged Japanese subjects.

Previous studies have indicated an association between the symptoms of gastroesophageal reflux disease (GERD) and aging plus height. In this study we investigated whether the arm span-height difference was related to GERD symptoms with a focus on aged subjects in the general population, since the arm span reflects the height in young adulthood before decreasing due to vertebral deformities from aging. A total of 285 elderly individuals (105 females) who visited nursing homes for the elderly in Japan were enrolled in this study. The GERD symptoms were evaluated by the Frequency Scale for the Symptoms of GERD (FSSG). The body weight, height and arm span were measured, and information regarding medications and complications were reviewed in each nursing record. 50.5% of women had more than 3 cm of arm span-height difference. In contrast, only 37.3% of men had more than 3 cm of arm span-height difference. The FSSG scores indicated more than 70% of subjects complained of any GERD symptoms. There was a significant correlation between the FSSG score and the arm span-height difference in the subjects with more than 3 cm of arm span-height difference (r = 0.236; p = 0.012). The correlation between the arm span-height difference and the FSSG score was significant only in women in females in the present study. In conclusion, our findings indicate that vertebral deformity evaluated by the arm span-height difference might have some positive relationship to the pathogenesis of GERD symptoms in elderly Japanese individuals.

Patient satisfaction questionnaire for medical students' performance in a hospital outpatient clinic: a cross-sectional study.

Medical education in Japan has undergone significant reforms. Patient perspective and outcome have been highly valued in curricular reforms. Therefore, we evaluated an undergraduate curriculum particularly on communication skills by comparing outpatient satisfaction before and after the reforms implemented at Saga Medical School. Cross-sectional study was conducted at the General Medicine Clinic of Saga University Hospital in 1999 and 2009. A total of 729 newcomer patients evaluated 159 students; namely, 287 patients evaluated sixth-year medical students (n = 82) in 1999, and in 2009, 442 patients evaluated fifth-year medical students (n = 77). Students interviewed newcomer patients prior to a faculty's clinical examination. After a student-patient encounter, the patient was asked to fill in six-item Patient Satisfaction Questionnaire (PSQ) developed by the American Board of Internal Medicine. Mixed model two-way analysis of variance (ANOVA) with covariant of students' gender was conducted. Effect sizes were calculated to evaluate the amplitude of influence. The average score in 2009 was significantly higher than that in 1999 (3.63 ± 0.62 versus 3.36 ± 0.66; p < 0.001). Since the "encouraging and answering questions" and "clear explanations" were lower than those of the other items (3.24 ± 0.98 and 3.46 ± 0.85), these two items showed the most significant improvements (Phi coefficient = 0.31 and 0.24, p < 0.001). Thus, students' performance has improved since 1999, which may represent the success of curricular reforms at Saga Medical School. We propose that "encouraging and answering questions" and "clear explanations" should be emphasized in interview training.

Japanese Resident Physicians' Attitudes, knowledge, and Perceived Barriers on the Practice of Evidence Based Medicine: a Survey.

BACKGROUND: Evidence based medicine plays a crucial role as a tool that helps integrate research evidence into clinical practice. However, few reports have yet to examine its application in daily practice among resident physicians in Japan. The aim of this study was to assess the attitudes towards and knowledge of EBM among resident physicians in Japanese and determine perceived barriers to its use. FINDINGS: A cross-sectional, self-administered anonymous questionnaire was distributed to 60 resident staffs at Saga University Hospital in Japan.Forty residents completed and returned the questionnaire. Fifty four percent of respondents understood the basic terminology of EBM, 3% could explain this to others, and 41% indicated they would like to understand the terminology more. Thirteen percent admitted having a good understanding of EBM basic skills. Fifty respondents indicated having read EBM sources, but only 3% indicated that they use these sources in clinical decision making. The most prominent barriers of EBM application revealed in this study were insufficient time to access the sources, a lack of native language references, and insufficient basic EBM skills, but not scepticism about the EBM concept. CONCLUSIONS: In general, respondents positively welcomed EBM, and moderately understood and knew basic EBM skill; however, barriers in its application were shown to exist.

The pathological role of visceral fat accumulation in steatosis, inflammation, and progression of nonalcoholic fatty liver disease.

BACKGROUND: Our previous studies have indicated a close association between visceral fat accumulation and hepatic steatosis in nonalcoholic fatty liver disease (NAFLD). This study investigated whether visceral fat accumulation was related to the pathogenesis and disease progression of nonalcoholic steatohepatitis (NASH)/NAFLD. METHODS: First, a total of 550 subjects who underwent a health checkup and measurement of visceral fat accumulation, done with a bioelectrical impedance analyzer (X-SCAN; Owa Medical, Fukuoka, Japan), were included. The relationship between visceral fat accumulation and biochemical parameters was examined. Second, a total of 74 patients with NASH/NAFLD who underwent liver biopsy were reviewed. Visceral fat accumulation was determined by abdominal computed tomography. The association between visceral fat accumulation and the histopathological grade/stage determined by the NAFLD activity score and Brunt's classification was evaluated. RESULTS: There was a significant relationship between visceral fat accumulation and glucose, triglyceride, and alanine aminotransferase (ALT; r = 0.423, P < 0.01). In stepwise regression analysis, visceral fat area (VFA), serum triglyceride level, and serum low-density lipoprotein (LDL)-cholesterol level were selected as predictor variables for serum ALT level, in a continuous manner (serum ALT level = -1.359 + 0.143 × VFA + 0.046 × triglyceride + 0.059 × LDL, R(2) = 0.217, P < 0.001). In patients with NASH, there was no correlation between histological grade and the visceral fat volume. Visceral fat accumulation in patients with stage 3/4 advanced NASH was greater than that in patients with stage 1/2 early NASH (P < 0.05). CONCLUSIONS: These results suggest that visceral fat accumulation plays a role in steatosis and fibrosis in the pathogenesis and prognosis of NAFLD.

Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment among closed claims in Japan.

BACKGROUND: Cognitive errors in the course of clinical decision-making are prevalent in many cases of medical injury. We used information on verdict's judgment from closed claims files to determine the important cognitive factors associated with cases of medical injury. METHODS: Data were collected from claims closed between 2001 to 2005 at district courts in Tokyo and Osaka, Japan. In each case, we recorded all the contributory cognitive, systemic, and patient-related factors judged in the verdicts to be causally related to the medical injury. We also analyzed the association between cognitive factors and cases involving paid compensation using a multivariable logistic regression model. RESULTS: Among 274 cases (mean age 49 years old; 45% women), there were 122 (45%) deaths and 67 (24%) major injuries (incomplete recovery within a year). In 103 cases (38%), the verdicts ordered hospitals to pay compensation (median; 8,000,000 Japanese Yen). An error in judgment (199/274, 73%) and failure of vigilance (177/274, 65%) were the most prevalent causative cognitive factors, and error in judgment was also significantly associated with paid compensation (odds ratio, 1.9; 95% confidence interval [CI], 1.0-3.4). Systemic causative factors including poor teamwork (11/274, 4%) and technology failure (5/274, 2%) were less common. CONCLUSIONS: The closed claims analysis based on verdict's judgment showed that cognitive errors were common in cases of medical injury, with an error in judgment being most prevalent and closely associated with compensation payment. Reduction of this type of error is required to produce safer healthcare.

Experiences of alcohol-related harassment among medical students.

OBJECTIVES: Although fatal accidents caused by alcohol-related harassment occur frequently among college students, this issue has not been adequately examined. This study set out to investigate the prevalence of alcohol-related harassment among medical students in Japan. METHODS: A multi-institutional, cross-sectional survey was carried out across seven medical schools in Japan. A self-report anonymous questionnaire was distributed to 1152 medical students; 951 respondents (82.6%) satisfactorily completed it. From the responses, we determined the reported prevalences of the following types of alcohol-related harassment among medical students by senior medical students or doctors: (i) being coerced into drinking alcohol; (ii) being compelled to drink an alcoholic beverage all at once (the ikki drinking game); (iii) being deliberately forced to drink until unconscious, and (iv) being subjected to verbal abuse, physical abuse or sexual harassment in relation to alcohol. The prevalence of becoming a harasser among medical students was also measured. Multivariate regressions were used to assess the associations between experiences of alcohol-related harassment and student characteristics. RESULTS: A total of 821 respondents (86.3%) had experienced alcohol-related harassment and 686 (72.1%) had harassed others. Experiences of the ikki drinking game were frequently reported by both victims (n=686, 72.1% of all respondents) and harassers (n=595, 62.6% of all respondents). In multivariate regression, having an experience of alcohol-related harassment correlated with both being harassed (odds ratio [OR] 14.22, 95% confidence interval [CI] 8.73-23.98) and being a harasser (OR 13.19, 95% CI 8.05-22.34). The presence of senior members of medical college clubs who were regular drinkers also correlated with both being harassed (OR 2.96, 95% CI 1.88-4.67) and being a harasser (OR 2.97, 95% CI 2.06-4.27). CONCLUSIONS: Alcohol-related harassment among medical students is common and tends to occur at drinking parties with senior college club members. Hence, one of the most important strategies for preventing alcohol-related harassment may be to disrupt this vicious cycle.

Development of a Japanese version of the care planning assessment tool.

AIM: To develop a Japanese version of the Care Planning Assessment Tool (J-CPAT), originally developed in Australia as a comprehensive assessment of people with dementia. METHODS: The process of adapting the CPAT into Japanese included translation into Japanese, assessment of item comprehension, and a validity and reliability study. The J-CPAT is composed of eight domains: Communication, physical problems, self-help skills, confusion, behaviour, social interaction, psychiatric observations and carer dependency. The participants were 199 aged care clients. Measures were the J-CPAT, Mini-Mental State Examination (MMSE) and Care Levels used in the Long-term Care Insurance scheme. RESULTS: Cronbach's alpha values in each J-CPAT domain were 0.74-0.95. The correlation coefficient between the score of Confusion and MMSE was -0.90, and those between physical problems, self-help skills, carer dependency in the J-CPAT, and care level were 0.70, 0.75 and 0.67. CONCLUSIONS: The J-CPAT appears to be a reliable and valid tool for care planning in Japan.

Moraxella catarrhalis bacteraemia associated with prosthetic vascular graft infection.

Moraxella catarrhalis, formerly called Branhamella catarrhalis, 'Neisseria catarrhalis' or 'Micrococcus catarrhalis', is a Gram-negative, aerobic diplococcus frequently found as a colonizer of the upper respiratory tract. Over the last 20-30 years, this bacterium has emerged as a genuine pathogen, and is now considered an important cause of otitis media in children and an aetiological agent in pneumonia in adults with chronic obstructive pulmonary disease. However, bacteraemia due to M. catarrhalis has rarely been reported. Presented here is a case of M. catarrhalis bacteraemia associated with prosthetic vascular graft infection along with a review of the relevant literature.

Interaction between cytochrome P450 1A2 genetic polymorphism and cigarette smoking on the risk of hepatocellular carcinoma in a Japanese population.

Limited epidemiological evidence suggests that genetic polymorphisms of drug-metabolizing enzymes such as cytochrome P450 (CYP), glutathione S-transferase (GST) and N-acetyltransferase (NAT) may be involved in tobacco-related hepatocarcinogenesis. We conducted a case-control study, including 209 incident cases with hepatocellular carcinoma (HCC) and two different control groups [275 hospital controls and 381 patients with chronic liver disease (CLD) without HCC], to investigate whether CYP1A1, CYP1A2, CYP2A6, CYP2E1, GSTM1 and NAT2 polymorphisms are related to the risk of HCC with any interaction with cigarette smoking. Overall, no significant associations with HCC were observed for any genotypes against either control group. However, we found a significant interaction (P = 0.0045) between CYP1A2 -3860G>A polymorphism and current smoking on HCC risk when we compared HCC cases with CLD patients; adjusted odds ratios [ORs; and 95% confidence intervals (CIs)] for G/A and A/A genotypes relative to G/G genotype were 0.28 (0.12-0.66) and 0.18 (0.04-0.94), respectively, among current smokers (P trend = 0.002), as compared with 1.28 (0.80-2.06) and 0.76 (0.34-1.71), respectively, among never/former smokers (P trend = 0.96). Similarly, in CYP1A2 G/G genotype, significant risk increase was observed for current smoking (OR = 4.08, 95% CI = 2.02-8.25) or more recent cigarette use (e.g. pack-years during last 5 years, P trend = 0.0003) but not in G/A and A/A genotypes combined (OR for current smoking = 1.39, 95% CI = 0.63-3.03; P trend for pack-years during last 5 years = 0.40). These results suggest that the CYP1A2 -3860G>A polymorphism modifies the smoking-related HCC risk among CLD patients.

The interrelationships between working conditions, job satisfaction, burnout and mental health among hospital physicians in Japan: a path analysis.

A growing number of physicians are leaving their hospitals because of painful working conditions in hospitals throughout Japan. We set out to analyze the interrelationships between working conditions, job satisfaction, burnout and mental health among Japanese physicians. A cross-sectional survey was conducted in 2007 for hospital physicians throughout Japan. A path analysis based on structural equation modeling was utilized for examining the interrelationships between work control, on-call duty volume, job satisfaction (the Japan Hospital Physicians Satisfaction Scale), burnout (the Japanese version of the Maslach Burnout Inventory) and mental health (the General Health Questionnaire). Of 336 physicians who received a solicitation E-mail, 236 participated in our study (response rate, 70%). Sixty physicians (25.4%) were women with a mean age of 41 yr. In the path analysis, burnout and poor mental health were related directly to job dissatisfaction and short sleeping time, while they were related indirectly to poor work control and heavy on-call duty. In the multi-group path analysis of both genders, sleeping time was related to job satisfaction more likely among female physicians but less among male physicians. Healthcare policy makers need to implement immediate, extensive and decisive measures to improve work condition and to reduce overwork among hospital physicians.

Interaction between interleukin-1beta -31T/C gene polymorphism and drinking and smoking habits on the risk of hepatocellular carcinoma among Japanese.

The risk of hepatocellular carcinoma (HCC) increases with the severity of hepatic inflammation. Interleukin (IL)-1beta and tumor necrosis factor (TNF)-alpha are proinflammatory cytokines with multiple biological effects and may play essential roles in inflammation-linked tumor development. We conducted a case-control study including 209 incident HCC cases and two control groups (275 hospital controls and 381 patients with chronic liver disease [CLD] without HCC) to investigate whether IL-1B and TNF-A gene polymorphisms influence HCC susceptibility with any interaction with alcohol and tobacco. By comparing HCC cases with CLD patients, we found that IL-1B -31T/C polymorphism was associated with HCC risk among never drinkers and current smokers; adjusted odds ratios (and 95% confidence intervals) for C/T and T/T genotypes compared with C/C genotype were 1.70 (0.76-3.77) and 2.46 (1.05-5.76) (P trend=0.03), respectively, among never drinkers, and 1.53 (0.60-3.99) and 2.54 (0.81-7.95) (P trend=0.11), respectively, among current smokers. Similarly, HCC risk associated with heavy alcohol intake and current smoking differed by this polymorphism among CLD patients. IL-1B -31T/C polymorphism may modify HCC risk in relation to alcohol intake or smoking.

[Development of the Japanese version Care Planning Assessment Tool (J-CPAT): reliability and validity studies].

AIM: To develop a Japanese version Care Planning Assessment Tool (CPAT) , a comprehensive geriatric assessment instrument for dementia care, originally developed in Australia. METHODS: The J-CPAT is composed of 61 items, and 8 domains: Communication, Physical problems, Self-help skills, Confusion, Behavior, Social interaction, Psychiatric observation, and Care dependency. The development of the J-CPAT included translation into Japanese, assessment of item comprehension, back translation, production of final version, and its validity and reliability analysis. Through this process, an item about family interaction was added in the J-CPAT. The participants were 199 clients in residential and day care. Raters were professional carers with 2.5 hours training about the J-CPAT. We assessed the validity of the J-CPAT, using correlation between the scores of the J-CPAT, MMSE, NM-scale, N-ADL, and levels of care needs (Kaigodo). Ten pairs of carers were included in the inter-rater reliability analysis. Fourteen carers participated in the intrarater reliability study. RESULTS: Cronbach's alpha values in each J-CPAT domain were 0.74-0.95. Mean difference of each domain between test and retest was 0.4-3.6%. Weighted kappa values for all items for 10 pairs of raters were over 0.6. The correlation coefficients between the domain score of 'Confusion' in the J-CPAT and MMSE was -0.90 (p<0.01). Those between the domain scores of 'Physical problems', 'Self-help skills', 'Dependency on care' in the J-CPAT, and Kaigodo were sufficient (>0.62), and those between the item scores of the J-CPAT, NM-scale, and N-ADL were relevant (>0.60). CONCLUSIONS: The J-CPAT is considered to be an appropriate assessment instrument for dementia care in Japan.

Status of medical education reform at Saga Medical School 5 years after introducing PBL.

In Japan, problem-based learning (PBL) is a relatively new method of educating medical students that is reforming the face of medical education throughout the world, including Asia. It shifts from teacher-centered learning strategies (for example, lectures in large auditoriums) to student-centered, self-directed learning methods (for example, active discussions and problem-solving by students in small groups under the guidance of faculty tutors). Upon a recommendation by the Japan Model Core Curriculum, Saga Medical School introduced a PBL curriculum 5 years ago. A full PBL curriculum was adopted from the McMaster model through Hawaii. A description of how PBL was implemented into the 3rd and 4th year (Phase III curriculum) is given. The overall result has been good. Students who experienced PBL had increased scores on the National Medical License Exam, and Saga increased its ranking from 56th to 19th of the 80 medical schools in Japan. A key step was introduction of the educational scaffolding in PBL Step 0. Students were allowed to see page one of the PBL case, containing the chief complaint, on the weekend before meeting in small groups. Despite a perceived overall benefit to student learning, symptoms of superficial discussions by students have been observed recently. How this may be caused by poor case design is discussed. Other problems, including "silent tutors" and increased faculty workload, are discussed. It is concluded that after 5 years, Saga's implementation of a PBL curriculum has been successful. However, many additional issues, including motivation of students and preparation for PBL in the first 2 years, must still be resolved in the future. This is the first description of the positive and negative outcomes associated with the reform of medical education and the introduction of PBL to a traditional medical school curriculum in Japan.