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<b>Background: </b>Although community-based training is included in medical undergraduate education in Japan, little assessment of the outcomes of community-based education programs has been performed. The aim of this study was to investigate the outcomes of a community-based education program using a mixed method.<br><b>Methods: </b>The study design utilized both qualitative and quantitative methods (mixed method). The subjects (n = 278) were fifth-grade medical students who were involved in the program from 2008 to 2010 inclusive. We collected two types of data: a six-item pre-and-post questionnaire (quantitative) and an open-ended questionnaire (qualitative) to evaluate the impressions this experience left on the students.<br><b>Results: </b>Pre-and-post questionnaires were completed by 263 (95%) of 278 subjects; on all items, the scores of the post- data were significantly higher than that of pre- data (P < 0.001). From the responses given by 139 respondents (total 181, 77%) in the open-ended questionnaire survey, 10 themes were extracted: 1. Inter-professional cooperation; 2. Role and cooperation among university hospitals, community hospitals, clinics, and welfare facilities; 3. Patient-centered medicine; 4. Trust-based relationships; 5. Competency in general medicine; 6. Professionalism; 7. Medical management; 8. Communication; 9. Common diseases; and 10. Long-term care.<br><b>Conclusions: </b>We found that medical students gained four major perspectives from their experiences: Inter-professional cooperation, trust based relationships, roles of community hospitals and clinics, and patient-centered medicine, respectively. Our findings suggest this program contributed significantly to their understanding of community medicine.
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In Horokanai town, Hokkaido, the policy of full subsidies for voluntary vaccinations against influenza, haemophilus influenzae type b (Hib), varicella, mumps, pneumococcal for children and human papillomavirus (HPV) was introduced between 2008 and 2010. A campaign for community education about vaccination was initiated.<br> Vaccination coverage improved after the subsidy as follows : influenza vaccination increased from 57.4% to 60.1%, Hib from 2.9% to 52.2%, varicella from 0% to 30.0%, mumps from 2.8% to 38.2%, pneumococcal for children from 1.3% to 50.6%, and HPV from 0% to 81.3%.
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This article summarizes the history of the modern Japanese healthcare system from the viewpoint of medical education, with emphasis on the role of general medicine and its core values as embraced by the members of the Japanese Society of General Medicine. The introduction of a German-based system, the role of universal national health care resulting in accessible healthcare, and the abolishment of American-type internships during Japan's period of student activism are among the topics covered. General medicine in Japan has been built upon the foundation of the Japan Society for Medical Education and the Japanese Society of General Medicine. The recent introduction of mandatory postgraduate clinical training for all medical graduates has alerted clinician-educators to the importance of competency-based approaches in medical professional education, especially in the areas of patient-centered care, team approaches, evidence-based medicine (EBM), and quality and safety. Generalist physicians should assume an active role as frontrunners in the current global trend toward healthcare reform, which requires healthcare providers be accountable and transparent in their professional activities.
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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.
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BACKGROUND: Prior research indicates that patients with medically unexplained symptoms and doctorshopping behavior are more likely to have psychological distress. In patients with somatic symptoms, we hypothesized that high scores on COOP/WONCA Functional Assessment Charts, in addition to the presence of medically unexplained symptoms and doctor-shopping behavior, might have an important role in diagnosing psychological distress.<BR>METHODS: Between November 2002 and March 2003, the patients who presented themselves to the hospital for the first time with somatic symptoms were enrolled in this study. In this study, we defined psychological distress as disease conditions, including Mood disorders, Anxiety disorders, Adjustment disorders, and Somatoform disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) . Symptoms that, in the doctor's judgment, could not be medically explained were regarded as medically unexplained symptoms. Doctor shopping was defined as those patients with a complaint of sustained and unsolved symptoms for more than one month who had visited two or more medical facilities prior to visiting our hospital and arrived without any physician's referral.<BR>RESULTS: One hundred and six patients out of 496 were diagnosed as having psychological distress. Among these 106 patients, 49 (46.2%) had doctorshopping behavior, 86 (81.1%) had medically unexplained symptoms, and 95 (89.6%) showed high scores on COOP/WONCA charts. Odds ratios and 95% confidence intervals of medically unexplained symptoms and doctor shopping were 24.12 (11.91-48.84) and 4.18 (2.16-8.07), respectively. High scores on COOP/WONCA charts 2, 3 and 6 were significantly associated with the presence of psychological distress, and the odds ratios (95% confidence intervals) of these three items were 1.41 (1.01-1.98), 1.41 (1.02-1.94), and 2.88 (1.68-4.95), respectively.<BR>Positive and negative likelihood ratios for 4 items (i.e., age of not less than 45 years; duration of symptoms of not less than 6 months, ; doctorshopping behavior; and, medically unexplained symptoms) were 1.16 and 0.85; 1.43 and 0.55; 3.16 and 0.63; and, 3.96 and 0.24, respectively. Positive and negative likelihood ratios for high scores on COOP/WONCA charts were 1.42 and 0.28. Under ROC curves for the diagnosis of psychological distress, the information of COOP/WONCA charts, in addition to that of clinical data, medically unexplained symptoms, and doctor shopping behavior, increased the accuracy in diagnosing psychological distress.<BR>CONCLUSIONS: In patients with somatic symptoms, COOP/WONCA charts increased diagnostic accuracy in predicting psychological distress when patients showed sustained symptoms for more than 6 month, doctor shopping, and medically unexplained symptoms.
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Influenced by a favorable environment, volunteer activities are integrated into medical education in the United States. Volunteer activities by medical students in hospitals are also becoming more common in Japan. With this background in mind, we performed a survey examining the nature of medical students' volunteer activities at the University of Hawaii in the United States and Saga University in Japan. By analyzing the percentages of students participating in volunteer activities and the location and content of the activities, we found that volunteer activities of medical students in Japan and the United States are strongly influenced by differences in the respective premedical education systems. We found that a premedical education that includes volunteer activities plays an important role in the United States. We suggest that further debate on premedical education that includes volunteer work is necessary for Japan to develop its own methods of medical education.
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A cross-sectional study was performed in the general medicine clinic of Saga Medical School Hospital to evaluate the humanistic quality of the clinical curriculum by assessing Patient satisfaction. The Patient Satisfaction Questionnaire (PSQ) developed by the American Board of Internal Medicine, was translated into Japanese, and 6 of 10 items were selected to evaluate the humanistic qualities of 123 fourth-year medical students who performed medical interviews of 442 patients. The patients rated each PSQ item with a 5-point scale from poor to excellent. The mean PSQ score was 3.38±0.66 (good to very good). The scores for “answering questions” and “giving clear explanations” were significantly lower than were scores for attitudinal aspects. The results suggest that the undergraduate curriculum at Saga Medical School for patient education skills requires further improvement.
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<B>OBJECTIVE</B>: To evaluate an undergraduate curriculum of communication skills by measuring satisfaction of outpatients whom final year students had examined.<BR><B>METHODS</B>: Cross-sectional surveys were conducted in General Medicine Clinic (GMC) of Saga Medical School (SMS) Hospital in 1999 and 2001. After the clinical clerkship in wards in fifth year, final year students experienced the two-week GMC clerkship, including seven hours of small group lecture in 1999, but partly converted into eight hours of small group discussion with a tutor in 2001. Six items in American Board of Internal Medicine Patient Satisfaction Questionnaire were selected as a validated instrument and incorporated into repeated measures ANOVA.<BR><B>RESULTS</B>: A total of 177 students were evaluated by 688 outpatients. Overall average score was 3.49+/-0.82. Average score in 2001 was significantly higher than that in 1999 (p<0.001; 3.58+ /-0.76vs 3.36+/-0.87) . The scores of“encouraging and answering questions”and“clear explanations”items were significantly lower than those of other items (3.21+/-0.98 and 3.37+/-0.92; Least Significant Difference) . The interaction between gender and years of curricula (1999 and 2001) was significant (p<0.001) ; female students showed remarkable improvement from 1999 to 2001 (Cohen's delta=0.67) .<BR><B>CONCLUSIONS</B>: Patient satisfaction scores indicated that undergraduate curriculum for communication skills in SMS improved from 1999 to 2001. Newly implemented small group discussion was a possible reason for the improvement, especially in female students. Further training for the skills of encouraging and answering questions and clear explanations will be the next step.
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Objective: To identify factors, such as embarrassment, contributing to the psychological resistance of female patients to physical examination.Methods: Female outpatients were given questionnaires asking about their degree of embarrassment in four areas of physical examination, their tolerance for disrobing during chest examination, and examples of actual episodes of embarrassment experienced during Physical examination. Answers were analyzed statistically. Results: Patients were more embarrassed when examiners were men or were students. When a male student examiner examined the chest and abdomen, the younger the female patients were, the greater their embarrassment was. Conclusions: Male student examiners should be most careful during Physical examination not to embarrass female patients. Gowning may reduce their embarrassment.
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PURPOSE: To determine whether faculty humanistic quality ratings for medical students in an Objective Structured Clinical Examination (OSCE) are associated with student OSCE scores and actual patient satisfaction in a university hospital outpatient (general internal medicine) clinic.<BR>METHODS: Our study was conducted on final-year (sixth grade) medical students in 1998. Forty medical students took the OSCE and were evaluated by faculty internists for humanistic qualities during OSCE sessions. Patient satisfaction ratings for students were also obtained in an outpatient clinic by using six items from the American Board of Internal Medicine Patient Satisfaction Questionnaire (PSQ) . A total of 40 students were evaluated by 117 patients. A multiple regression analysis was used for this study.<BR>RESULTS: In the OSCE, faculty humanistic quality ratings for students were associated with interview skills (p=0.004), but not with physical examination scores nor students' gender. However, patient satisfaction ratings were not statistically associated with faculty humanistic quality ratings for students, other OSCE scores nor with patients' demographic characteristics such as age, sex, occupation and education levels.<BR>CONCLUSIONS: Faculty humanistic quality ratings for medical students taking the OSCE were not significantly associated with patient satisfaction at the outpatient clinic in our study.
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OBJECTIVE: (1) To estimate the prevalence of cancer as an cause of abdominal pain, (2) to identify useful information of history and physical examination, (3) to assess performance of potential screening tests, and (4) to formulate an efficient algorithm for distinguishing patients with cancer.<BR>DESIGN: Prospective observational study.<BR>SETTING: General medical outpatient clinic in a university teaching hospital.<BR>PARTICIPANTS: 470 outpatients (men, 216; women, 254; mean age±standard deviation, 44.6±16.5; age range, 16 to 89) complaining of abdominal pain at their first visits.<BR>MEASUREMENTS AND MAIN RESULTS: A cancer causing abdominal pain was found in 18 patients (3.8%) . These 18 patients with cancer and the remaining 452 patients without cancer were compared regarding clinical findings. Findings significantly more common in patients with cancer were: age of 40 years or over; unexplained weight loss; insidious onset; and duration of pain longer than one preceding month without relief. Among recorded physical findings, countenance reflecting severe pain, fever, and abdominal tenderness were significantly associated with cancer. Elevation of LDH, WBC, CRP, ESR, and CEA were moderately useful discriminators for patients with and without cancer. The logistic regression analysis with complete clinical data set covering history, physical examination and laboratory tests showed that the only findings significantly associated with cancer were unexplained weight loss (odds ratio: 18.9, 95% CI 1.5-20.1), duration of pain over one month (odds ratio: 24.8, 95% CI 1.6-27.9), countenance of severe pain (odds ratio: 159.1, 95% CI 4.5-162.1), and WBC>10, 000 (odds ratio: 22.3, 95% CI 1.1-31.0) .<BR>CONCLUSIONS: Our data support the value of the combined use of history, physical and selected laboratory findings in detecting cancer among patients with abdominal pain. Application of such selected criteria holds the promise of more efficient care with judicious and effective use of endoscopy or sonography without lowering the quality of care.
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To examine ethical problems students may face during clinical clerkships and to help them to learn how to solve these ethical problems practically, we started a compulsory ethical case conference for medical students rotating through the department of general medicine. Actual cases were selected from among those students had encountered during their clinical clerkship. Groups of students were to analyze these cases and to discuss how to solve ethical problems. In this study, we evaluated this course on the basis of student's questionnaires and case sheets they submitted. Eighty students (92%) answered that they had encountered ethical problems. Each student encountered an average of 3.95±1.53 cases with ethical problems. Students noted 130 ethical issues (an average of 1.63±0.51 issues per case). Ethical issues included informed consent, treatment selection, refusal of treatment, medical distrust, and the doctor-patient relationship. In addition, such important subjects as economic burden, ability for self-determination, social rehabilitation, and patient-family relationships were mentioned, but only rarely. Eighty-five percent of students thought the conferences were valuable. Moreover, 87% of students thought such conferences would motivate them to think about ethical issues in the future. All students thought these compulsory ethical conferences should be continued. However, both the students' degree of participation and comprehensiveness of the conference contents could be improved.
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Objective: To investigate the role and validity of the objective structured clinical examination (OSCE) for neurological screening (Neuro-OSCE) performed by medical students and to analyze the association between Neuro-OSCE score and student behavior for acquiring skills. Method: A 31-item Neuro-OSCE was created for systematic and time-saving screening of neurological findings. At Saga Medical School, 44 final-year students took a screening neurological examination course and performed Neuro-OSCE from August through October 1998. A questionnaire asked about self-educational behaviors, such as self-evaluation, mental concentration, and self-learning (knowlege-based), and self-practicing time. The relationship between Neuro-OSCE score and self-educational behaviors were analyzed. statistically. Results: Cronbach's coefficient alpha was 0.731, which indicated fair internal validity. The mean Neuro-OSCE score was 51.2± 6.6 (SD). Neuro-OSCE score was correlated with self-practicing time and mental concentration but not with self-learning time or self-evaluation. Conclusion: Our Neuro-OSCE has construct validity in the psychomotor domain from a taxonomic viewpoint because the Neuro-OSCE score was correlated with self-practicing time rather than self-learning time. Mental concentration was better a self-assessment method than was self-evaluation. However, setting self-educational goals for neurological examination is probably too difficult at the undergraduate level. Objective assessment by Neuro-OSCE is expected to foster relevant learning behavior.
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To evaluate whether general medicine training in our general ward has beneficial effects on postgraduate surgical training, questionnaires on general medicine training was sent to 30 doctors who had undergone initial training as residents in our hospital and were involved in surgical practice at the time of the survey. Twenty-two responses were obtained. Fifteen respondents had motivation for general practice at the beginning of their residency, and 20 attained their objectives during the 2-year training. Nineteen respondents appreciated their experiences in managing a variety of diseases encompassing the disciplines of internal medicine and surgery, although 12 complained of a shortage of teaching staff. From the viewpoint of its contribution to their present practice, their training in the general ward was evaluated by all respondents as having been beneficial. We conclude that general medicine training has beneficial effects on postgraduate surgical training that emphasizes comprehensive patient care.
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Objective: To investigate the role of postgraduate clinical training at the emergency department of Tenri Hospital in teaching the diagnostic process in the general outpatient department.<BR>Method: Patients seen by 11 first-year residents at the emergency department were consecutively registered with summary sheets. Further information was added, and an analysis was performed of: 1) the distribution of chief complaints in the emergency and general outpatient departments and 2) initial diagnoses and the diagnostic process in the emergency department and the final diagnoses.<BR>Results: The distributions of chief complaints in 89 cases in the emergency department and in 183 cases in the general outpatient department were closely correlated (p=0.0016). Diagnoses in the emergency department were correct in 58% of cases. Treatment was incorrect in 3% of cases.<BR>Conclusion: The distributions of chief complaints in the emergency and general outpatient departments were similar. In our hospital the emergency department plays a major role in postgraduate clinical training by teaching the diagnostic process for the general outpatient department. Clinical management, including decision making for further tests and consultation, in the emergency department by first year residents did lead to any major adverse events.
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The clinical competence needed by every beginning resident and the present status of such competencewere examined in August 1998 through questionnaires distributed to clinical educators and the nursing staff of university hospitals and clinical training hospitals designated by the Ministry of Health and Welfare. Completed questionnaires were returned by 576 (65.9%) of clinical educators and nursing staff. With a cluster analysis of the necessity and the present status of clinical competence, 21 items for clinical competence were identified as those most requiring evaluation by the national examination. These 21 items included 11 items for clinical competence in the cognitive domain, 8 items in the psychomotor domain, and 2 in the affective domain. In about half of the direct answers obtained from clinical educators, evaluations were considered necessary for 15 items of clinical competence, of which 13 belonged to the cognitive domain. These results were consistent with the present status. However, practical examinations have also attracted increasing attention, as the results included strong demands that the national examination evaluate some basic clinical skills, such as physical examination and measurement of vital signs. However, about 30 % of authorities governing the national examination thought no changes are needed in the national examination.
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The working group on the education of general medicine, Japan Society for Medical Education, has defined general medicine as a discipline which includes following three areas; 1) basic clinical skills which incorporate humane health care, 2) comprehensive community and family medicine and 3) general internal medicine which provides integrated services to solve clinical problems at any level. It has also issued a proposal on undergraduate education of general medicine at university hospitals. The working group now propose a detailed sample curriculum which describes the instruction in three areas mentioned above. Overview, General Instructional Objective (GTO), Specific Behavioral Objectives (SBOs), Learning Strategies (LS) and Evaluation are included in this sequence.
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General Internal Medicine, as well as Family Medicine, plays an important role in the primary care of North America. General internists in Canada are virtually hospital-based physicians. However, most general internists in the United States are community-based primary care physicians. Although the system in both countries are different, the training of General Internal Medicine is very similar. General internists comprehensively manage patients with complex illnesses such as one with difficult diagnoses, multiproblem or chronic illness. In addition to basic clinical knowledge and skills, they teach students and residents clinical epidemiology, evidence based medicine and clinical decision making.
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Based on 20 years of experience with an unique postgraduate clinical training program, consisting of “g eneral wards ” and “inninr-residents in general medicine” at Tenri Hospital (Nara, Japan), we have identified the following points for the successful evaluation of residents: 1) unlike undergraduate teaching, item-based evaluations do not fit teaching in the clinical setting, 2) evaluation of residents' attitudes should be emphasized, 3) comprehensive evaluation in regular meetings by the teaching staff is practical and useful, 4) mechanisms to reflect patients' opinions should be included in the evaluation process.