A National Survey of Community-Based Medical Education in Japanese Medical Schools (second report) / 医学教育

Introduction: Recently, community-based medical education has become widespread in Japanese medical schools, but the current status is not clear on a national level. A second survey of community-based medical education at all Japanese medical schools was conducted. The first survey was done in 2011. Methods: Members of the Council made and distributed a questionnaire to medical schools in order to assess the situation of community-based medical education as of April 2014. Results: A total of eighty schools responded. The number of schools which had community medicine programs was seventy-eight. In the first survey, the number was seventy-three. Seventy-seven schools gave community-based clinical clerkships. Discussion: The number of medical schools that had curriculum about community medicine was more than indicated in the first survey. Further research about the contents or implementation system of community-based clerkships is needed.

Geographical distribution of primary care clinics for elderly ambulatory diabetic patients in Ibaraki Prefecture / 日本プライマリ・ケア連合学会誌

<b>Introduction</b> : The appropriate size of the regional coverage area for primary care in Japan has been unclear. The aim of this study was to determine the geographical distribution of primary care clinics for elderly ambulatory diabetic patients.<br><b>Methods</b> : Using an insurance claims database, we extracted data of patients aged 75 years and older requiring ambulatory diabetic care in May 2010 in Ibaraki prefecture. The geographical distance from each municipal office to the clinics was analyzed.<br><b>Results</b> : A total of 17,717 data points were extracted from the database. Data points that could not be mapped due to coding errors were eliminated, resulting in 17,144 (96.8%) data points that were ultimately analyzed. The median [25th-75th percentile] geographical distance was 5.5 [2.3-9.9] km. The distance was not related to municipal population, aging rate, or area size.<br><b>Conclusion</b> : The coverage area for diabetic care in this primary care setting was estimated. For most elderly ambulatory diabetic patients, clinics are distributed within a 10-km radius area. Further investigation is needed to clarify primary care coverage areas that result in the most efficient use of medical resources.

Fasting insulin and risk of cerebral infarction in a Japanese general population: The Jichi Medical School Cohort Study

Objective: We investigated the relation between fasting insulin (FI) and risk of cerebral infarction in a Japanese general population. Methods: The subjects were 2,610 men and women without past history of stroke or myocardial infarction and under treatment for diabetes, examined between 1992 and 1995 as part of the Jichi Medical School Cohort Study. The FI level was measured once at the baseline. Subjects were divided into quintiles by FI levels, and Cox’s proportional hazard model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for cerebral infarction. Results: During an average of 11.1 years of follow-up, 87 participants developed cerebral infarction. Crude incidence rates of FI quintiles 1-5 were 4.69, 2.35, 1.85, 2.77 and 3.30 per 1,000 person-years, respectively. The multivariate-adjusted HRs for cerebral infarction were 2.33 (95% CI, 1.10 – 4.96) in quintile 1 (Q1), 1.25 (95% CI, 0.55 – 2.84) in Q2, 1.68 (95% CI, 0.76 – 3.70) in Q4 and 2.06 (95% CI, 0.94 – 4.47) in Q5, using Q3 as the reference. Conclusions: The lowest FI level was associated with increased risk of cerebral infarction and the association between FI and risk of cerebral infarction appeared to be a U-shaped relationship.

Use of percutaneous endoscopic gastrostomy in long-term care facilities in Japan: analysis of published national statistics

<b>Aim</b>: To describe the current use of percutaneous endoscopic gastrostomy (PEG) in long-term care national health insurance facilities (special nursing homes for the elderly, health service facilities for the elderly, and long-term health care facilities), and assess whether its prevalence increased or not between 2007 and 2010. <b>Methods</b>: Based on data from the "Survey of Institutions and Establishments for Long-term Care" by the Ministry of Health, Labour and Welfare, we calculated the prevalence of residents with PEG in each type of long-term care facility in 2007 and 2010. <b>Results</b>: The prevalence of residents with PEG in 2007 versus 2010 was 5.8% versus 8.1% in special nursing homes for the elderly, 3.9% versus 5.9% in health service facilities for the elderly, and 18.4% versus 26.1% in long-term health care facilities. Among residents requiring level 3 or higher care, the prevalence of PEG increased in all three types of long-term care facility. <b>Conclusion</b>: From 2007 to 2010, the use of PEG increased among residents of long-term care facilities requiring level 3 or higher care.

Chlamydophila (Chlamydia) pneumoniae but not Helicobacter pylori infection, is associated with cerebral infarction in Japanese community-dwelling populations: The Jichi Medical School Cohort Study

Background: Chronic infections, such as Helicobacter pylori (H. pylori) and Chlamydophila pneumoniae (C. pneumoniae), are known to contribute to atherosclerosis. However, the relationship of the infections to cerebral infarction is still controversial. Methods: The Jichi Medical School (JMS) Cohort Study, a prospective population-based study, investigated the risk factors of cardiovascular disease in Japanese community-dwelling populations. In 1999, we measured serum H. pylori IgG, C. pneumoniae IgG and IgA levels in 2,632 subjects. Logistic regressions were used to analyze associations between H. pylori and C. pneumoniae seropositivities and cerebral infarction. Results: A total of 2,243 subjects were followed up and, during 10.7-years, 64 developed cerebral infarctions, whose prevalence of H. pylori IgG, C. pneumoniae IgG and IgA seropositivities were 51.6%, 71.9%, and 67.2%, respectively. Among seropositive subjects, adjusted odds ratios (ORs) for cerebral infarctions were 1.04 (95% confi dence interval (CI), 0.58-1.87, P=0.89), 2.02 (1.03-3.95, P=0.04), and 1.35 (0.73-2.49, P=0.34) respectively, after adjusting for sex, age, body mass index, total cholesterol, high-density lipoprotein cholesterol, fasting blood sugar, smoking, alcohol, and fi brinogen. C. pneumoniae IgG seropositivities in subjects aged > 65 years were associated with cerebral infarctions, whereas those in subjects aged < 65 years, were not. Conclusions: C. pneumoniae IgG was associated with cerebral infarction, C. pneumoniae IgA and H. pylori IgG were not.

The Analysis of questionares used in outpatient general practice clinics in Japan / 日本プライマリ・ケア連合学会誌

<b>Objective</b> : To analyze and reveal the contents of medical questionnaires distributed to nationwide general practice outpatients prior to their initial medical consultations.<br><b>Method</b> : An observational study was conducted, based on questionnaire format. Sample questionnaires were collected from 85 hospitals registered with the Japan Primary Care Association.<br><b>Results</b> : No standard format was found among the samples. A4 size forms (210 mm×297 mm) averaging 19.7 questions were in the majority, accounting for 68%. The distribution frequency of questionnaires reported by research cooperation centers listed 28 items (31.8%) concerning medical history, 19 items (21.6%) related to lifestyle, and 7 items (8.0%) referring to social and reproductive status.<br><b>Conclusion</b> : This research assessed the qualitative value of medical questionnaires used in General Practice Clinics in Japan. The results indicate the nature of the medical information required by physicians prior to medical consultation.

A retrospective study of 221 hospitalized patients with fever in the Department of General Practice at Jichi Medical University Hospital / 日本プライマリ・ケア連合学会誌

<b><i>Abstract</i></b><br><b>Objective</b> : To investigate the causes of fever of inpatients hospitalized in the Department of General Practice at Jichi Medical University Hospital.<br><b>Methods</b> : We reviewed all medical records of the patients hospitalized in the Department of General Practice at this hospital between April 2003 and March 2004. Patients were selected as the “febrile group” by following criteria, 1) body temperature exceeded 37.5°C on admission, 2) fever and fever of unknown origin (FUO) were included in the clinical problems, and the causes of fever were described.<br><b>Results</b> : A total of 464 patients were hospitalized and 221 patients (47.6%) were categorized as the “febrile group”. The most common cause of fever was infection (67.4%), followed by malignant disease (4.1%), collagen disease (3.2%), miscellaneous diseases (10.4%). 26 patients were classified as fever of unknown origin (FUO). Among FUO patients, collagen disease was the most common cause (34.6%), and undiagnosed cases was 26.9% that was similar to past reports. Although the rates of malignant disease and collagen disease were about sixteen percent in each generation from thirties to fifties as the cause of fever, only one patient met the criteria of classical FUO.<br><b>Conclusions</b> : The most common cause of fever was infection. Systematic survey including hospitalization is needed early in case an outpatient doesn't cure fever unexpectedly. Noninfectious inflammatory diseases emerge as an important category of the causative disease of FUO.

<i>Helicobacter pylori </i>Infection and High-density Lipoprotein Cholesterol in Japanese Women: the JMS Cohort Study / General Medicine

<b>Background:</b> <i>Helicobacter pylori</i> (<i>H. pylori</i>) infection has been reported to be associated with cardiovascular risk factors by inducing chronic low-grade inflammation and by influencing endocrine and metabolic systems, as well as the immunological response evoked by the host. This study investigated the association between <i>H. pylori</i> infection and high density lipoprotein cholesterol (HDL-C) in Japanese subjects.<br><b>Methods:</b> The study subjects were 2,632 (1,061 men and 1,571 women) living in rural areas in Japan. We checked <i>H. pylori</i> serum immunoglobulin G (IgG), HDL-C and other cardiovascular risk factors in 1999.<br><b>Results:</b> The overall prevalence of <i>H. pylori</i> seropositivity was 53.5% and increased with age. The prevalence was higher among men (58.3%) than women (50.3%). <i>H. pylori</i> seropositive women were more associated with decreased HDL-C than seronegative subjects (58.1±13.6 vs. 60.5±14.7, p<0.01). Multiple linear regression analysis with <i>H. pylori</i> seropositivity, age, body mass index (BMI), fibrinogen, blood glucose, and smoking and alcohol habits demonstrated that <i>H. pylori</i> seropositivity was a significant predictor of decreased HDL-C in women. In addition, there was a linear decrease in HDL-C with increments in the value of <i>H. pylori</i> antibody titer as a continuous variable in women. This association remained in <i>H. pylori</i> seropositive women aged ≥50 years. Moreover, <i>H. pylori</i> seropositive women with BMI <22 were associated with decreased HDL-C, whereas the association was not significant in women with BMI ≥22.<br><b>Conclusions:</b> We show that <i>H. pylori</i> seropositivity is associated with decreased HDL-C, especially in women with a lower BMI in rural areas of Japan.

Current Status of Kampo Medicine in Community Health Care / General Medicine

<b>Background:</b> Kampo medicine is the traditional form of medicine practiced in Japan, based on ancient Chinese medicine. Kampo medicine includes acupuncture and moxibustion, as well as herbal medicine. Physicians are allowed to prescribe ethical Kampo extract granules used in various formulae and practice acupuncture and moxibustion as acupuncturists and moxibustionists. However, medical schools do not offer many classes in traditional medicine. This study aims to analyze the use of Kampo formulae and practice of acupuncture and moxibustion in contemporary community health care.<br><b>Methods:</b> The subjects (1538 clinicians) were graduates of Jichi Medical University on or after 1978, affiliated with a clinic or hospital with 300 beds or less on July 2010, and surveyed by postal questionnaire in October 2010.<br><b>Results:</b> The effective response rate across Japan was 44% (n=679). Of these responders, 30%, 45%, and 22% were found to prescribe Kampo formulae regularly, occasionally, and rarely, respectively, in daily clinical care. Frequently prescribed formulae included shakuyakukanzoto, daikenchuto, kakkonto, rikkunshito, and hochuekkito. The reasons for using Kampo formulae given by 61% and 58% of the responders were, respectively, applicability for common diseases and ease of use for unidentified complaints and psychosomatic disease. Among the reasons for unlikely use, unclear applicability was chosen by 34% of the responders; difficulty stocking many formulations by 33%; and insufficient evidence of efficacy by 30%. Practitioners of acupuncture and moxibustion accounted for 4% of the responders. The main indications for acupuncture and moxibustion included low back pain and shoulder stiffness.<br><b>Conclusions:</b> A large number of primary care physicians use Kampo formulae, implying their usefulness. However, one out of three physicians complains of unclear applicability and insufficient evidence of efficacy for Kampo formulae. In the future, appropriate education and research will be needed to clarify these issues.

Analysis of the Reasons for Visits to a Clinic on an Isolated Island / General Medicine

<b>Background:</b> To date there had been no investigations using the International Classification of Primary Care, Second Edition (ICPC-2) at a clinic on an isolated island. In order to analyze health problems on the island, we investigated the reasons for visits, chronic illnesses, and the number of cases referred to other medical facilities using the ICPC-2.<br><b>Methods:</b> The study was conducted over a 12-month period, from April 1, 2006 to March 31, 2007. Patient complaints/symptoms were classified according to ICPC-2, and diseases of patients who regularly visited the clinic as of November 2006 were investigated.<br><b>Results:</b> Half of the patients that regularly visited the clinic had lifestyle-related or musculoskeletal diseases. On the first visit, several patients presented with cold, musculoskeletal, or skin symptoms. The specialist care to which the patients were most frequently referred was orthopedic surgery.<br><b>Conclusion:</b> Physicians working at a clinic on an isolated island need to be able to control lifestyle-related diseases and provide initial treatment for musculoskeletal or skin diseases.

A Study on Regional Disparities in Access to Inpatient Care, Using the Gini Coefficient / General Medicine

<b>Background:</b> When analyzing regional disparities in healthcare resources, hospital accessibility is given little consideration. We surveyed accessibility from residential districts to medical institutions using GIS (Geographic Information System) and estimated Gini coefficient for each hospital distribution.<br><b>Methods:</b> The subjects were 2,688 census mesh blocks ( “<i>Cho</i>-<i>cho</i>-<i>aza</i>” ) and 109 hospitals in Tochigi prefecture. The number of hospitals located within the road distances of 5 km, 10 km and 15 km from the geometrical center of each block was calculated using GIS. The Gini coefficient of each hospital per 100 residents was calculated among the regions located within 5 km, 10 km and 15 km from the geometrical center of the census mesh block.<br><b>Results:</b> The population of each block was 748±1,067 (mean±SD), and the road distance to the nearest hospital from the center of each block was 4.3±4.5 km. The number of census mesh blocks with distances from the center of each block to the nearest hospital within 5 km, 5-10 km, 10-15 km and more than 15 km were 1909 (71.0%), 561 (20.9%), 139 (5.2%) and 79 (2.9%) respectively. The number of hospitals located within 5 km, 10 km and 15 km were 3.3±4.7, 8.3±8.6 and 14.4±11.4. Gini coefficients were 0.65, 0.52 and 0.43.<br><b>Conclusion:</b> When analyzing regional disparities in healthcare resources, it is necessary to take into account not only the number of physicians and beds, but also accessibility. Gini coefficient is useful to estimate geographical distributions, and can be used as an indicator for improvement projects for hospitals.

Factors associated with residents' career plans in primary care / 医学教育

Owing to shortages of primary-care physicians, increasing their numbers has been recognized as an urgent issue in Japan and other countries. However, it is unclear which factors in medical education influence the decision of residents to go into primary care. We investigated the factors associated with residents' choosing to practice primary care.<br>Of 281 randomly selected medical facilities designated as residency training hospitals, 137 facilities answered. Self-administered questionnaires were completed by 724 residents in the third or fourth postgraduate year. Responses were compared between residents who intended to choose a career in primary care (n=175, 24.2%) and residents who intended to choose a career in other specialties (n=549, 75.8%).<br>In addition, for residents who had intended during their undergraduate years to enter a non-primary-care specialty (n=442, 61.1%), responses were compared between those who now intended to go into primary care (n=33, 7.5%) and those who did not (n=409, 92.5%).<br>Residents who had planned during their undergraduate years to choose a career in primary care (adjusted odds ratio [95% confidence interval]: 9.85 [6.24-15.5]), residents who were working as primary-care physicians at the time of the survey (7.58 [4.92-11.7]), and residents who wanted to enter rural practices in the future (2.24 [1.36-3.68]) were significantly more likely to plan to choose a career as a primary-care physician in the future.<br>Residents who had worked at a rural practice during residency training were significantly more likely to change their career plans from other specialties to primary care (crude odds ratio [95% confidence interval]: 2.18 [1.05-4.49]). Exposure to a rural practice during residency training may affect residents' career plans.<br>Integrating rural primary-care practice into residency training may help increase the number of primary-care physicians in the future.

Subjects of the training program related to the students' impressions and evaluations of community-based clinical training / 医学教育

Because of drastic changes in community health care in Japan, increasing emphasis has been placed on medical undergraduate education in community health care.The number of medical school introducing community-based clinical training is increasing.Therefore, effective clinical training in community health care should be developed. This study examined the effects of the location and subjects of training on students' evaluations and impressions of community-based clinical training.<BR>1) Self-administered questionnaires were completed by 499 fifth-year students taking part in community-based clinical training.The main items were the locations and subjects of training and the students' evaluations and impressi ons of training. The associations between these items were analyzed.<BR>2) A total of 96.8% of the questionnaires were analyzed. The students who trained only in clinics were slightly but not significantly more likely to have positive impressions of and to have given higher evaluation scores to training than were other students.<BR>3) Students who participated in health education for healthy persons or patients or both were significantly more likely to answer that“the training program was enjoyable, ”“the preceptors were enthusiastic, ”and“I spent more time with the preceptors.”On the other hand, the students who took part in inpatient care were significantly less likel y to answer that“the training program was enjoyable”or that“the training program is needed.”<BR>4) Students who studied 1 to 4 of the 11 subjects were significantly less likely than were students who studied 8 to 11 subjects to answer that“the preceptors were enthusiastic”and were less likely than were students who studied 5 to 7 subjects to answer that“the training was meaningful.”<BR>5) Students who studied few subjects during training might have negative feelings about community-based clinical training.The experience of health education might have a positive effect on students.On the other hand, the experience of inpatient care probably has a negative effect.

Undergraduate Medical Education in Narrative-Based Medicine by Small-Group Learning / 医学教育

Japanese primary-care physicians recognize that narrative-based medicine (NBM) is important in clinical practice, but there is no standard method for training physicians in NBM. We conducted small-group learning in NBM for medical students at Jichi Medical University in 2005.<BR>1) Our goals were to clarify what students learn and to investigate educational tools for teaching NBM.<BR>2) We qualitatively analyzed responses to a questionnaire composed of 3 questions that the students answered freely after small-group learning involving an actual scenario based on a patient's narrative of home-care service and including evidence-based medicine and medical communication skills.<BR>3) Students recognized that NBM is important in clinical practice. They also gained a deeper understanding of evidence-based medicine and medical communication skills, which are essential skills in primary care, and could integrate knowledge about primary care. Through discussion, they developed awareness of others and of themselves as doctors.<BR>4) Small-group learning with an actual scenario and NBM increased students' awareness and stimulated their imagination. We believe that small-group learning is useful as an educational method in NBM.

Education in Complementary and Alternative Medicine in Japanese Medical Schools: Follow-Up Study, 1999-2004 / 医学教育

This is a follow-up study to our 1999 telephone survey of education in complementary and alternative medicine (CAM) in Japanese medical schools. We surveyed the same workers in curriculum offices in all 80 Japanese medical schools in 2004. The number of medical schools that offer CAM education has increased significantly, from 16 schools (20%) in 1999 to 69 schools (86%) in 2004. Treatment with <I>kampo</I> is being taught in all 69 schools with CAM education. Fourteen (20%) of these 69 schools also teach a new framework of CAM and integrative medicine, and 7 schools teach evidence-based medicine in relation to CAM, although almost all schools (95%) taught <I>kampo</I> and acupuncture as types of traditional Asian medicine in 1999.

Opinions of Japanese Medical Students on the Necessity of Experience in Community-based Learning Programs / 医学教育

We conducted a questionnaire survey of all sixth-year students at 10 Japanese medical schools asking their opinions on the necessity of experience in community-based learning (CBL) programs. We developed a detailed questionnaire to examine students' experiences in CBL and their opinions of its necessity using the students' reports from CBL by Delphi process. After excluding data from 1 medical school because of a low response rate, we analyzed data from 659 students (response rate, 75%). The necessity of each item in the required programs, except “seeing labor in medical facilities, ” was more likely to be recognized by students who had experienced the item than by students who had not experienced it. The differences between experiencing and nonexperiencing students in recognizing necessity were greatest for “conversation with patients in their homes, ” “seeing physicians' consultation or referral to other medical institutions, ” “observing nurses work in the outpatient clinic, ” and “participation in conferences with various professional staff.” These results suggest that medical students can recognize the significance and meaning of CBL through experience.

Educational Effects of a Standardized Program for Community-based Clinical Clerkships / 医学教育

Education in community medicine has become increasingly important. At Jichi Medical School, community-based clinicalclerkships began in 1998. This study examined the effects of a standardized program for medical facilities and clerkshipcontents introduced in 2001. A self-administered visual analogue scale questionnaire was given to 308 fifth-yearmedical students to examine their opinions about this program, community medicine, and the future. Results from beforeand after the introduction of the standardized program were compared. After the program had been introduced, significantlymore students agreed that the clerkship program was “meaningful” and should be continued. Furthermore, significantly more students agreed that “physicians enjoy working in the community, ” “talking with people, patients, and public officials is not difficult, ” and “ I will become a general physician or a specialist in the future.” These resultsshow that the standardized program is effective for education in community medicine.

A Study of Support Systems for Women in Medicine: Dual Roles of Professional and Mother / 医学教育

We examined issues in balancing professional obligations with family needs, especially parenting, in female physicians. Questionnaires were given to all female physicians who had graduated from Jichi Medical School. Of the 196 graduates, 155 responded (79.1%), and younger graduates accounted for a greater proportion of subjects. Although many female physicians did not live with their parents, female physicians or their parents were usually responsible for caring for children when they become ill. Many respondents demanded better access to day care and greater flexibility in accepting sick children. Female physicians should contribute to society using the knowledge and skills they acquired in medical school; to do so they need support systems in their workplace and child-care services.

Nationwide Survey of Primary Care Curricula for Undergraduate Medical Students in Japan / 医学教育

We conducted a nationwide survey to examine the primary care (PC) curricula for undergraduates at Japanese medical schools. The present status of PC curricula and the degree of recognition of the need for improvement were examined. Seventy (88%) of the medical schools in Japan responded. PC education programs have been organized and are carried out by various departments in each school. Of the 69 medical schools, 42% have a PC education program with lectures to teach the role of PC physicians, 65% have a program to provide experience in community medical care, and 80% have programs to provide experience in health care institutions and welfare facilities. Although the number of schools with lectures and experience programs for PC has increased at least three-fold in the past decade, many medical school presidents (more than 60%) recognize PC education should be improved. By comparing medical schools with and without experience programs in clinic more presidents of schools without such programs recognized the need to improve PC education.

Undergraduate Medical Education in a Community: A Community-based Clinical Clerkship / 医学教育

In Japan, it is necessary to develop the community medicine (community health care) because of the current of the medical practice. Since 1998, the community-based clinical clerkship (the two weeks' program) has been introduced to the all 5-grade medical students in Jichi Medical School. The aim of this program is to learn not only the knowledge and skill for the community medical practice, but also the attitude included the pleasure, enjoyment and worth to do it. The program contains as many activities of the community medicine as possible other than the out-patient or the in-patient managements. The most of medical students give good evaluation to the program. After the program, many of the medical students became to have the motivation to work in the rural area. In the undergraduate medical education, a community-based clinical clerkship will be more necessary in terms of the development of the community medicine.