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

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

A Qualitative Study on Career Conversion to a "General Practitioner" in Hospital Internal-medicine Physicians Specialized for Organs/Region / 日本プライマリ・ケア連合学会誌

Background: Internal medicine physicians are able to convert to "general practitioners" in the future.Objective: To examine factors related with "career conversion to a general practitioner" conceived by hospital internal-medicine physicians specializing in organs/regions.Materials and Method: A semi-structured interview was conducted for 20 internal-medicine physicians with their consent from November 2014 to November 2015. The verbatim records were analyzed with the modified grounded theory approach.Results: The facilitating factors for career conversion consisted of "a career plan where characteristics of a general practitioner can be utilized", "high-quality training that combines practical conditions", and "diverse ways of working and a specialist-licentiate who has opportunities for learning".On the other hand, the suppressive factors consisted of "a lack of understanding of general practitioners", "difficulties associated with re-training", and "a feeling of resistance toward comprehensiveness of general practitioners".Conclusions: Career conversion to general practitioner by qualified internal-medicine physicians was suggested to be promoted by enhancing the meaningfulness of the general practitioner license, the training circumstances, and ensuring the professionalism and financial aspects of physician life.

Families’ Sense of Discrepancy between the Explanations of Group Practice Doctors Providing Home Medical Care: A Cross-Sectional Study / General Medicine

<b>Background: </b>Group practices with multiple physicians are preferred for promoting home medical care, but the explanations to patients and families given by the visiting doctors may differ. That could sometimes lead to confusion in patients and families.<br><b>Methods: </b>We conducted a cross-sectional mail survey of families of Japanese patients who had previously received home medical care. Multivariable adjusted logistic regression for families’ sense of discrepancy between the explanations by doctors in a group practice was performed using eleven explanatory variables including: (1) number of doctors; (2) interval between the doctors’ visits; (3) duration of the doctor’s stay; (4) doctors’ frequent use of technical terminology; (5) doctors’ interruption of family’s talking, etc.<br><b>Results: </b>Among 271 families who were mailed surveys, 227 responded (83.8%). The final sample for the analyses was 139. Responses were divided into two groups: families who had experienced a sense of discrepancy about explanations by different doctors (“Experienced”, 30 families, 21.6%) and those who had not (“Non-experienced”, 109 families, 78.4%). Families’ sense of discrepancy between the explanations by doctors in group practice was significantly associated with a longer time interval between doctors’ visits (OR: 1.103, 95% CI: 1.008–1.208, p = 0.03) and doctors interrupting families while they were talking (OR: 2.559, 95% CI: 1.166–5.615, p = 0.02).<br><b>Conclusions: </b>Visiting doctors need to understand that families may have a sense of discrepancy about explanations given by different doctors. This sense of discrepancy was associated with less frequent doctors’ visits and doctors’ interrupting families while they are talking.

A qualitative study investigating desirable communication methods used during home medical care visits of patients with intractable neurological disorders who are unable to use any communication tools / 日本プライマリ・ケア連合学会誌

<b>Purpose</b> : To investigate the desirable communication methods, which can be used during home medical care visits of patients with intractable neurological disorders (INDs) who are unable to use any communication tools (hereinafter referred to as “communication methods”).<br><b>Methods</b> : Interview surveys were conducted with the spouses of the patients with INDs who were unable to use any communication tools, and among bereaved family members of patients with INDs to whom home medical care had previously been provided. At the interviews, both voice recording and dictation were utilized to prepare a verbatim record, with which qualitative analyses were later conducted.<br><b>Results</b> : In respect of communication methods, three concepts were apparent ; 1) family members who were present during home medical care visits “interpreted” and “inferred” what the patient wanted to convey to the medical care provider, 2) the family and the medical care provider conversed away from the patient in order to reduce patient anxiety and to provide reassurance, and 3) the medical care provider judged the correct timing for communication between himself/herself and the family, and exceptionally in the absence of the patient.<br><b>Conclusion</b> : A hypothesis was formulated, which is that “communication with the patient in the presence of the family” is the basic “communication method.”

Characteristics of second-year residents intending to become a primary care physicians / 日本プライマリ・ケア連合学会誌

<b>Purpose</b> : To examine the characteristics of second-year residents intending to become primary care physicians.<br><b>Methods</b> : Using a self-administered questionnaire, we surveyed 7344 second-year residents in March, 2006. Of the 4167 responders (response rate 56.7%), the 3838 who answered that they intended to make a career choice of being clinical practitioners were taken as subjects for analysis. The odds ratios (OR) for the intention of being a primary care physician was calculated, together with the 95% confidence interval (95% CI), using logistic regression models (primary care physicians intended=1 vs. specialist intended=0) <br><b>Results</b> : In total, 56% of the residents affirmed an interest in becoming primary care physicians. Multiple stepwise logistic models showed that residents intending to become primary care physicians planned to open their own clinics in the future (OR 1.44, 95% CI : 1.20-1.73), did not wish to obtain doctor of medical science (DMSc) degrees (OR 1.29, 95% CI : 1.07-1.55), and were more likely to choose internal medicine (OR 1.44, 95% CI : 1.07-1.94).<br><b>Conclusion</b> : This study demonstrated that second-year residents who aimed to be primary care physicians were associated with more interest in opening private clinics for their future practice, preferably in the field of internal medicine, and with less interest in earning DMSc degrees.

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

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

Resident stress in the new postgraduate clinical training system / 医学教育

Postgraduate residents face formidable stress. Unfortunately, many residents withdraw from training programs because of reactions to stress, such as depression. We performed a comprehensive study to examine the working conditions and stress of residents to improve the conditions of resident-training programs and reduce levels of stress.<BR>1) The study examined 548 first-year residents starting postgraduate clinical training at 41 hospitals in Japan. A selfadministered questionnaire, which included questions about working conditions, job stressors, buffer factors, and stress reactions, was answered before and 2 months after the start of training.<BR>2) A total of 318 subjects completed the survey.Of these subjects, 80 (25.2%) had depression after the start of training.<BR>3) Job stress patterns of residents were characterized by high workload and extremely low “reward from work” and “Job control.”<BR>4) Many residents had depression after the start of training.To improve residency programs, program directors should recognize the specific characteristics of residents' job stress and focus on buffer factors.

Qualitative research for studying stress reactions, stress-relieving factors, and constructing a theoretical model of stress for junior residents in Japan / 医学教育

In Europe and the United States, residents develop“burnout syndrome”or depression because of stress, and these conditions are associated with withdrawal from training programs and undesirable clinical outcomes, such as unethical practices.How stress affects Japanese medical residents and their practice is uncertain, as are factors that relieve stress.Furthermore, a theoretical model of stress in Japanese medical resident is uncertain.<BR>1) Focus group interviews were performed for 25 junior residents at 10 institutions to explore their stress reactions and stress-relieving factors.A theoretical model of stress was then constructed.<BR>2) Adverse effects in patient care and in training, in addition to events in daily life, were found to occur as stress reactions.<BR>3) Improvements in the support system and positive feedback from patients were found to be stress-relieving factors.<BR>4) A theoretical model of stress for trainee physicians was constructed and was similar to a general occupational stress model.<BR>5) Stressors should be reduced and stress-relieving factors should be improved to improve the working conditions of residents and the quality of medical care.

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

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

An Investigation of the Perception of Achievement and the Degree of Satisfaction of Junior Residents in Initial Clinical Training / 医学教育

We investigated factors related to the perception of achievement and to the degree of satisfaction of junior residents in initial clinical training. Questionnaires were given to second-year postgraduate students at 13 teaching hospitals in Japan. The response rate was 50%(n=89). The perception of achievement and the degree of satisfaction were converted to a 100-point scale. The mean±standard deviation of the two scores were 70±11 and 68±16, respectively. The average number of inpatients and whether the junior resident had taken care of patients were related to both scores. However, gender, the number of departments rotated through, and salary were not associated with either score.