Utility of self-competency ratings during residency training in family medicine education-emerging countries: findings from Japan.

BACKGROUND: Family medicine education-emerging countries face challenges in demonstrating a new program's ability to train residents in womb-to-tomb care and resident ability to provide such care competently. We illustrate the experience of a new Japanese family medicine program with resident self-competency assessments. METHODS: In this longitudinal cross-sectional study, residents completed self-competency assessment surveys online during 2011-2015. Each year of training, residents self-ranked their competence using a 100-point visual analog scale for 142 conditions: acute (30 conditions), chronic (28 conditions) women's health (eight conditions), and geriatrics/home (12 conditions) care; procedures (38 types); health promotion (21 conditions). RESULTS: Twenty residents (11 women, 9 men) participated. Scores improved annually by training year from baseline to graduation; the mean composite score advanced from 31 to 65%. All subcategories showed improvement. Scores for care involving acute conditions rose from 49 to 75% (26% increase); emergency procedures, 46-65% (19% increase); chronic care, 33-73% (40% increase); women's health, 16-59% (43% increase); procedural care, 26-56% (30% increase); geriatrics care-procedures, 8-65% (57% increase); health promotion, 21-63% (42% increase). Acute care, chronic care, and health promotion achieved the highest levels. Women's health care, screenings, and geriatrics experienced the greatest increase. Health promotion gains occurred most dramatically in the final residency year. CONCLUSIONS: A resident self-competency assessment provides a simple and practical way to conduct an assessment of skills, to monitor skills over time, to use the data to inform residency program improvement, and to demonstrate the breadth of family medicine training to policymakers, and other stakeholders.

The cultural context of teaching and learning sexual health care examinations in Japan: a mixed methods case study assessing the use of standardized patient instructors among Japanese family physician trainees of the Shizuoka Family Medicine Program.

BACKGROUND: In contrast to many western nations where family medicine is a cornerstone of the primary care workforce, in Japan the specialty is still developing. A number of services within the bailiwick of family medicine have yet to be fully incorporated into Japanese family medicine training programs, especially those associated with sexual health. This gap constitutes a lost opportunity for addressing sexual health-related conditions, including cancer prevention, diagnosis, and treatment. In this mixed methods case study we investigated the perceived acceptability and impact of a standardized patient instructor (SPI) program that trained Japanese family medicine residents in female breast, pelvic, male genital, and prostate examinations. CASE DESCRIPTION: Building on an existing partnership between the University of Michigan, USA, and the Shizuoka Family Medicine Program, Japan, Japanese family medicine residents received SPI-based training in female breast, pelvic, male genital, and prostate examinations at the University of Michigan. A mixed methods case study targeting residents, trainers, and staff was employed using post-training feedback, semi-structured interviews, and web-based questionnaire. DISCUSSION AND EVALUATION: Residents' and SPIs' perceptions of the training were universally positive, with SPIs observing a positive effect on residents' knowledge, confidence, and skill. SPIs found specific instruction-related approaches to be particularly helpful, such as the positioning of the interpreter and the timing of interpreter use. SPIs provided an important opportunity for residents to learn about the patient's perspective and to practice newly learned skills. Respondents noted a general preference for gender concordance when providing gender-specific health care; also noted were too few opportunities to practice skills after returning to Japan. For cultural reasons, both residents and staff deemed it would be difficult to implement a similar SPI-based program within Japan. CONCLUSIONS: While the SPI program was perceived favorably, without sufficient practice and supervision the skills acquired by residents during the training may not be fully retained. Deep-rooted taboos surrounding gender-specific health care appear to be a significant barrier preventing experimentation with SPI-based sexual health training in Japan. The feasibility of implementing a similar training program within Japan remains uncertain. More research is needed to understand challenges and how they can be overcome.

Complementary and alternative medicine use by visitors to rural Japanese family medicine clinics: results from the international complementary and alternative medicine survey.

BACKGROUND: There is growing interest in the use of complementary and alternative medicine (CAM) throughout the world, however previous research done in Japan has focused primarily on CAM use in major cities. The purpose of this study was to develop and distribute a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q) to assess the use of CAM among people who visit rural Japanese family medicine clinics. METHODS: Using a Japanese version of the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q), a cross-sectional survey was conducted in three rural family medicine clinics. All patients and those accompanying patients who met inclusion criteria were eligible to participate. Data were entered into SPSS Statistics and analyzed for use by age, gender, and location. RESULTS: Of the 519 respondents who participated in the project, 415 participants reported CAM use in the past 12 months (80.0%). When prayer is excluded, the prevalence of CAM use drops to 77.3% in the past year, or 403 respondents. The most common forms of CAM used by respondents were pain relief pads (n = 170, 32.8%), herbal medicines/supplements (n = 167, 32.2%), and massage by self or family (n = 166, 32.0%). Female respondents, individuals with higher levels of education, and those with poorer overall health status were more likely to use CAM than respondents without these characteristics. Only 22.8% of CAM therapies used were reported to physicians by survey participants. CONCLUSIONS: These data indicate that CAM use in rural Japan is common. The results are consistent with previous studies that show that Japanese individuals are more interested in forms of CAM such as pain relief pads and massage, than in mind-body forms of CAM like relaxation and meditation. Due to the high utilization of certain CAM practices, and given that most CAM users do not disclose their CAM use to their doctors, we conclude that physicians in rural Japan would benefit by asking about CAM use during patient interviews, and by familiarizing themselves with the potential benefits and risks of commonly used CAM modalities.

Lifestyle changes of Japanese people on overseas assignment in Michigan, USA.

BACKGROUND: Temporary work assignments in the United States (US) are widely considered to have negative health outcomes on Asians mostly due to adverse changes in diet and exercise, though there is little research on this phenomenon. This study investigated the impact of lifestyle changes on the biological and psychological health and health behaviours of Japanese people on temporary assignments in the US. METHODS: In this cross sectional survey, we distributed a 38 item self-administered questionnaire addressing health habits, mental health function, lifestyle changes and dietary habits to adult Japanese patients presenting for general physicals at a family medicine clinic serving Japanese patients. We conducted simple statistics and regression analysis between length of stay and other health outcomes to determine whether length of residence in the US was predictive of negative lifestyle changes. RESULTS: Most participants reported increased caloric intake, weight gain, and less exercise. They also reported increased time with family. More women than men reported physical symptoms and anxiety related to stress. Smoking and alcohol intake were essentially unchanged. No associations were identified between length of residence in the US and health lifestyle habits or other health outcomes. CONCLUSION: Negative lifestyle changes occur in diet and exercise for overseas Japanese people, but a positive change in increased family time was found. Women appear to be at a greater risk for somatic disorders than men. As duration of stay does not appear predictive of adverse changes, clinicians should advise patients going abroad of these risks regardless of the term of the work assignment.

Japanese women's perspectives on pelvic examinations in the United States. Looking behind a cultural curtain.

OBJECTIVE: To elucidate overseas Japanese women's preferences on whether to use a curtain to separate themselves from the provider during pelvic examinations in the United States, as practiced in Japan. STUDY DESIGN: We qualitatively interviewed 19 overseas Japanese women who presented to a clinic serving Japanese people living in southeastern Michigan. We synthesized this interview data into a cohesive overview of the content and used illustrative quotes generated by the participants to provide a context. RESULTS: Most participants (n = 12) approved of the U.S. style of examination, including the use of private rooms and a sheet to cover the perineum. A minority of women (n = 4) said they were neutral to the approach, 2 preferred the Japanese examination style, and 1 did not like pelvic examinations. Some participants strongly disliked the use of the curtain and the structure of examination rooms in Japan. CONCLUSION: Most participating women did not support using a curtain during pelvic examinations in the U.S., as practiced in Japan, and some were critical of the Japanese practice. Clinicians may help place their Japanese patients at ease by acknowledging nonuse of a curtain in the U.S., and explaining the intentional use of a private room and sheet to protect patient privacy.

Calcium- and Cyclic AMP-independent, Labile Protein Kinase Appearing during Starfish Oocyte Maturation: its Extraction and Partial Characterization*: (oocyte maturation/protein kinase/histone H1/maturation-promoting factor/starfish).

A burst of protein phosphorylation and an appearance of maturation-promoting factor have been reported to occur shortly before germinal vesicle (nucleus) breakdown (GVBD) in 1-methyladenine-induced oocyte maturation of starfish. To detect if a protein kinase is activated before GVBD, protein kinase activity was compared in maturing oocytes which were just undergoing GVBD and immature oocytes of Asterina pectinifera. The oocytes were homogenized in a buffer modified from that used for extracting amphibian maturation-promoting factor. When the supernatant protein of homogenized immature oocytes was used as a substrate, protein kinase activity in the supernatant of the maturing oocytes was 7-fold higher than that of immature oocytes. The protein kinase in the supernatant of the maturing oocytes showed a high substrate specificity for histone H1 among the exogenous substrates examined, and the activity of the maturing oocytes for histone H1 was 6- to 7-fold higher than that of immature oocytes. The protein kinase detected in the maturing oocytes was very labile and was inhibited neither by ethylene glycol bis(ß-aminoethyl ether)N, N, N', N'-tetraacetic acid nor by the heat-stable inhibitor protein of cyclic AMP-dependent protein kinase. These results indicate that a calcium- and cyclic AMP-independent, labile "maturation-specific protein kinase" appeared before GVBD in maturing oocytes, and suggest its participation in the phosphorylation burst in vivo. The possible correlation of this kinase with maturation-promoting factor and chromosome condensation was discussed.

Concanavalin A-Induced Morphological Changes and Its Binding Sites in Starfish Follicle Cells as Revealed by Electron Microscopy.

Concanavalin A (Con A) stimulates the production in starfish follicle cells of 1-methyladenine, a hormone which induces oocyte maturation. We have therefore investigated Con A-induced morphological changes and Con A-binding sites in the follicle cell using native Con A and horseradish peroxidase- or ferritin-labeled Con A (HRP-Con A, Fer-Con A). After isolated follicle cells were incubated with Con A (1 mg/ml), vacuoles, the Golgi complex and multivesicular body-like organelles (MVBs) became prominent in most of the cells. After follicle cells were prefixed and then incubated with Fer-Con A for 60 min, tagged ferritin was diffusely and randomly distributed as single or small clustered particles on the cell surface. The incubation of isolated follicle cells with Fer-Con A for 10 min before fixation resulted in numerous ferritin particles localized along the internalized membrane, and also in vacuoles, MVBs and small lysosome-like structures. After 60 min incubation with Fer-Con A, ferritin was further located in large lysosome-like structures and in vesicles near and in the Golgi area as well as in the organelles described above. HRP-Con A binding sites were also observed in vacuoles and MVBs of the intact cells. These results suggest that Con A binds at first to the cell surface and causes rapid internalization and that membrane-bound Con A is easily endocytosed into vacuoles, MVBs and lysosome-like structures, and is later incorporated in some vesicles in the Golgi area.

MAGNESIUM ION-REQUIRING STEP IN FERTILIZATION OF SEA URCHINS.

The magnesium ion-requiring step in fertilization of sea urchins was investigated. When eggs were inseminated in Mg-free sea water, several spermatozoa were found to bind to each egg surface with their reacted acrosomes without elevation of fertilization membrane. The number of binding jelly-treated spermatozoa to an egg did not differ regardless of the presence or virtual absence of magnesium ions. Although fertilization did not occur in Ca, Mg-deficient sea water (CM-deficient SW) even when jelly-treated spermatozoa were employed, some eggs could be fertilized by the addition of magnesium to the CM-deficient SW 60 sec after insemination, when jelly-treated spermatozoa had completely lost their fertilizing capacity in the CM-deficient SW. The acrosomal process of jelly-treated spermatozoa appeared to penetrate the vitelline layer in the CM-deficient SW. DTT- or pancreatin-treated eggs could not be fertilized in the virtual absence of magnesium. Re-fertilization using the fertilized eggs deprived of fertilization membrane did not occur under conditions of magnesium deficiency. These results suggest that external magnesium ions are indispensable at least for the fertilization process following penetration of the vitelline layer by the spermatozoa, such as fusion of the plasma membrane between an egg and a reacted spermatozoon, or the subsequent step(s) such as sperm penetration into egg interior and egg activation which precedes the cortical reaction.

CHANGES IN CELL SURFACE MORPHOLOGY DURING DIFFERENTIATION OF MICROMERE- AND MESOMERE-DERIVED CELLS OF THE SEA URCHIN EMBRYO.

Micromeres and mesomeres isolated from 16-cell embryos of the sea urchin, Strongylocentrotus intermedius, were cultured in vitro, and changes in the cells surface architecture during the differentiation of the micromere- and mesomere-derived cells were observed using scanning electron microscopy. Two types of the distribution of the surface microvilli were observed in both blastomere-derived cell masses. One type showed a uniform distribution of the microvilli and the other type showed an uneven one. Though many microvilli were observed in most of both mesomere and micromere-derived cells at the 64-cell stage and the early blastula stage (16 hr after the 16-cell stage at 6°C) respectively, the microvilli decreased in number at the later stages in both blastomere-derived cell masses as compared with the 64-cell stage and the early blastula stage respectively. Rapid disappearance of the surface microvilli was observed in the micromere-derived cells in contrast with the mesomere-derived cells which still had many microvilli even at the midmesenchyme stage.

THE SURFACE EVENTS AT FERTILIZATION OF THE SEA URCHIN EGG I. EVENTS ON THE SURFACE OF THE VITELLINE COAT1.

Sperm-egg interaction during normal fertilization in the sea urchins, Strongylocentrotus intermedius and Hemicentrotus pulcherrimus, was studied by scanning and transmission electron microscopy. Several seconds after insemination, acrosome-reacted spermatozoa were found attached to the surface of the vitelline coat on each egg. Soon, several bulges of the vitelline coat appeared surrounding the fertilizing spermatozoon. These bulges then spread over the surface increasing in number, while they became fewer and disappeared around the sperm head. Thin sections of the bulging areas revealed discharging cortical granules. As the bulging vitelline coat was elevated, the sperm head was incorporated into the perivitelline space, passing through a small hole in the coat that resulted from penetration of the sperm acrosomal process immediately before fusion of the gametes. When the spermatozoon disappeared beneath the fertilization membrane, a hole was left in the membrane and the cortical reaction had finished on the other hemispheric surface. Mechanical removal of the membrane at that time exposed a spermatozoon protruding perpendicularly from the egg plasma membrane surface. The anterior tip of the sperm head was smoothly connected with the egg surface, and neither microvillous projections nor cytoplasmic covering of the egg cytoplasm could be found around the spermatozoon.

INHIBITION OF GERMINAL VESICLE BREAKDOWN AND POLAR BODY FORMATION BY NICOTINAMIDE IN STARFISH AND SURF CLAM OOCYTES.

Nicotinamide inhibited both germinal vesicle breakdown (GVBD) and polar body formation (PBF) in surf clam and starfish oocytes. In the surf clam nicotinamide at 0.3 mM completely blocked PBF in the fertilized oocytes. For blockage of GVBD higher concentration was required. In the starfish, nicotinamide (30 mM) prevented PBF but not GVBD, when added 7 min after the commencement of 1-methyladenine (1-MeAde) administration. These results suggest that PBF is blocked by nicotinamide independent of its effect on GVBD. In the case of starfish, NAD+ was more effective than nicotinamide in inhibiting oocyte maturation. Nicotinamide also blocked GVBD induced by microinjection of the cytoplasm containing maturation-promoting factor (MPF) obtained from 1-MeAde-treatcd oocytes. These results suggest that nicotinamide prevents the action of MPF rather than inhibiting the interaction of 1-McAde with cell membrane or the induction of MPF.

MAGNESIUM REQUIREMENT IN FERTILIZATION PROCESS OF SEA URCHINS.

The Mg2+ requirement in fertilization was investigated in sea urchins. It was found that when sea urchin eggs were inseminated in sea water free of Mg2+ , little fertilization took place. Even when spermatozoa pre-treated with dissolved egg-jelly to induce the acrosome reaction, which needs Ca2+ , were used, the fertilization rate remained quite low in the absence of Mg2+ . In Strongylo-centrotus intermedius, the lowest concentration of Mg2+ required for 50% fertilization was 0.05 mM in the presence of 10 mM Ca2+ , whereas that of calcium was 3 mM in the presence of 49 mM Mg2+ . These critical concentrations increased when the concentration of the other ion decreased. Removal of Mg2+ or Ca2+ or both from the suspending medium had little adverse effect on sperm motility. The elevation of the fertilization membrane was also induced by butyric acid independent of the presence or absence of Mg2+ and/or Ca2+ . These results indicate that Mg2+ are required at least in some process(es) between acrosome reaction and fertilization membrane elevation, such as sperm penetration or membrane fusion.