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.

Educating medical students in rural area through a rural medicine experience camp / 日本プライマリ・ケア連合学会誌

A rural medicine experience camp is held every year for medical students of Sapporo Medical University who are obligated to work in rural area after graduation. We organized two method in our camp : 1. the lecture about rural medicine by senior medical students, 2. setting up the learning content in camp by participant before camp. We investigated how these methods make an impact on the participant's motivation about rural medicine. The results suggested that a method 1 enhanced the understanding of rural medicine and method 2 raised an a warenss about rural medicine. We thought that it was important to try various education about rural medicine for increasing the motivation to rural medicine for medical student.

Examination of opinions of patients regarding physicians and medical care after withdrawal of community hospital internists / 日本プライマリ・ケア連合学会誌

Introduction <br>This study aims to clarify how patients and local residents regard physicians and medical care in light of the ongoing nationwide tendency of internists to unexpectedly abandon their posts in local community hospitals. <br>Methods <br>The subjects of this study were citizens who chose to continue visiting a community hospital in X City after some of its internists recently left their posts in order to return to their previous hospitals. A questionnaire survey was conducted by focus-group interviews of two patient groups. <br>Results <br>Three hundred and ninety-nine responses were judged valid. The causative factors cited by the respondents for the internists’ abandonment of their jobs were: the college or university system (81%), the national institutions (79%), and the nation’ s hospital system (72%). Eighty-eight percent of the respondents observed that internists had done the best they could, while 88% pointed out that internists could not avoid changing their workplaces, 96% wanted internists to exert their utmost efforts for their patients, and 85% found internists trustworthy. <br>Conclusions <br>Patients affected by internists' job changes were actually inconvenienced by these, and considered it a matter of course that the results should have meant some loss of freedom for themselves. Moreover, it was suggested that that the physicians had lost their trust in the medical organizations, and the patients were left with very mixed emotions about the physicians. Many patients considered that the practice of medicine is a vocation, and, even though they experienced the physicians' withdrawals from their posts, they still expected a humane attitude in the doctors and communication with them, and they trusted them. However, there were some patients who regarded medicine as a service industry, so that it was suggested that there may be a change in the nature of the trust that patients have in doctors.

Curriculum development of medical professionalism in undergraduate medical education at Sapporo Medical University / 医学教育

1) Since the 2006 academic year, we have developed a 13-hour course in professionalism for fifth-year medical students at Sapporo Medical University.<br>2) The course included lectures and small-group discussions on the concept of medical professionalism, the definition of medical professionalism, clinical ethics, legal understanding, and the crisis of community medicine. At the end of the course, the students created their own student physician charter and recited it at the student physician charter ceremony.<br>3) Seventy-four percent of students evaluated the course positively, 18% pointed out positive and negative aspects of the course, and 8% evaluated the course negatively.

Differences in perceptions about medical professionalism between Japanese and U.S. physicians / 医学教育

Recent changes in the relationship between physicians and society has affected the values and ethics of physicians, and a“Physician Charter”on medical professionalism has been drafted by the American Board of Internal Medicine Foundation, the American College of Physicians-American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine.We conducted this survey to determine whether the“Physician Charter”can be used to examine the medical professionalism of Japanese physicians.<BR>1) A questionnaire to examine the perceptions of physicians in Japan and the United States of the responsibilities of the “Physician Charter” was distributed.<BR>2) In both countries 30% of physicians understood the contents of the “Physician Charter, ”and 60% believed the charter should be used in every country.<BR>3) The physicians in the United States tended to consider most responsibilities more urgent than did Japanese physicians, and the perceptions of several responsibilities differed between physicians in the two countries.A generation gap among Japanese physicians was observed for some responsibilities.

Exploring students' impressions of community medicine clerkship experience by means of significant event analysis / 医学教育

Community medicine clerkships are said to be an important element of current undergraduate medical education. However, little is known about what medical students actually learn from them.Therefore, we performed a study by means of significant event analysis to examine what medical students had learned from 2-week community medicine clerkships.<BR>1) Students in 2006 took part in 2-week community medicine clerkships and then in sessions at the end of their clerkships to review their experiences.<BR>2) The review sessions were recorded, and the students'impressions were extracted and categorized.<BR>3) The depth of their impressions was categorized into 4 depth levels (describing, commenting, generalizing, and planning).<BR>4) Students gave their impressions of the medical system, the role of physicians, patient-centered care, role models, and clinical ethics, and the impressions of most students were at the levels of commenting and generalizing.<BR>5) Medical students learned system-based practice and medical professionalism during their community medicine clerkships, and significant event analysis was a valuable tool for understanding their experiences.

Student Perception of Feedback from Simulated Patients during Communication Training Sessions / 医学教育

Although simulated patients (SPs) has become indispensable for the development of medical students' communication skills, few studies have analyzed the effects of SPs on medical students. In particular, no studies have examined the effect of the feedback that medical students receive from SPs during communication training sessions.<BR>1) We invited students to complete a questionnaire and participate in a group interview; the responses and opinions obtained were then analyzed both quantitatively and qualitatively by two independent analysts.<BR>2) Sixty-four percent of students were satisfied with SPs' feedback, whereas 28% of students preferred toreceive negative feedback as a way to improve their skills.<BR>3) Some students criticized SPs' feedback and SPs themselves.<BR>4) The SPs' feedback should focus more on the negative aspects of students' performances, and faculty members should provide a safe and secure educational environment for both students and SPs.

Factors Influencing Primary Care Career Choice of Japanese Medical Students Graduating in 2004 / 医学教育

The selection of a primary care career by Japanese medical students is said to be increasing however there are no studies to support this belief.In order to fully understand the alleged increase in the number of medical students choosing primary care we believed that an examination of the factors influencing medical students' decision-making would be helpful.<BR>1) We distributed questionnaires to two hundred ninety eight medical students in 2004 who would graduate in four months from three Japanese medical universities.<BR>2) Questionnaires included demographic factors, career choice, important career choice factors, interest in community medicine, willingness to engage in community medicine, thinking community medicine is useful, and satisfaction with curricula.<BR>3) There were significant associations between a primary care choice and social experience, lifestyle preference, interest in community medicine, willingness to engage in community medicine, and contact with primary care faculty.<BR>4) Using a logistic regression model, lifestyle preference, male gender, social experience before entrance to a medical university and contact with primary care faculty were four significant factors.<BR>5) It might be important to consider those factors in addition to curriculum reform to increase primary care career choice among Japanese medical students.

Current Situation of Medical Student Abuse / 医学教育

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.

A Qualitative Study of First-year Medical Students : Why do students want to become physicians? What kind of physicians do they want to become? / General Medicine

This study used group interviews and questionnaires with first year medical students to determine: 1) their motivation for entering a medical school; 2) their self-image as future physicians; and, 3) the factors that have influenced these. Our study revealed that medical students' motivation for entering medical school and their self-image as future physicians were influenced by their personal medical experiences, family members who worked in medicine, and medical issues presented in the mass media. We believe that gaining an understanding of changes in students' self-image as future physicians and the factors influencing these changes can be important in the development of effective medical education curriculum, as we face change and upheaval in both medical knowledge and practice.

A Japanese Case of Episodic Fever Compatible with Familial Mediterranean Fever / General Medicine

A 31-year-old Japanese female came to our outpatient clinic because of a 15-year history of recurrent episodic chest pain accompanied by fever, each lasting for three days. The patient was diagnosed with familial Mediterranean fever (FMF) because of the following: 1) short attacks of fever recurring at varying intervals; 2) pleuritic chest pain accompanied by fever; 3) the patient's sisters had similar episodes of fever accompanied by abdominal or chest pain; and 4) absence of any other causative factors responsible for her symptoms or pathologic findings. Although FMF has been described primarily in several limited ethnic groups, only a few cases have been reported in Japan. No diagnostic tests are commercially available for FMF so identifying the characteristic clinical picture of FMF is important.

Predictive Factors for Cancer in Patients with Abdominal Pain / General Medicine

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.

Combining Data from Subjects' Histories for the Prediction of Imminent Atrial Fibrillation is Useful for the Elderly Male Population / General Medicine

OBJECTIVE: (1) To estimate the prevalence of atrial fibrillation (Af) in the general population of Saitama Prefecture, (2) to identify useful information obtained from subjects' history and laboratory findings for predicting imminent occurrence of Af.<BR>DESIGN: Cross sectional study and retrospective cohort study.<BR>SETTING: Annual health examination of the general population.<BR>PARTICIPANTS: Subjects were 5, 375 men and 8, 419 women with a mean age±standard deviation of 47.2±9.6 and an age range of 18 to 88 years old.<BR>MEASUREMENTS AND MAIN RESULTS: Among the 13, 794 participants who underwent conventional 12-lead electrocardiography (ECG) every year from 1994 to 1997, the prevalence of Af was 0.3%. The cross sectional data showed significant differences between male subjects with and without Af regarding age (P<0.0001), current treatment for hypertension (P<0.0001), arrhythmia (P<0.0001), angina pectoris (P<0.05), history of myocardial infarction (P<0.05), perception of palpitation (P<0.0001), perception of irregular pulse (P<0.0001), shortness of breath (P<0.0001), diastolic blood pressure (P<0.05), total cholesterol (P<0.0001), and casual glucose level (P<0.05) . Significant differences were also found between female subjects with and without Af with respect to creatinine (P<0.0001), current treatment of arrhythmia (P<0.0001), perception of palpitation (P<0.0001), perception of irregular pulse (P<0.0001), and HbAlc level (P<0.05) .<BR>The retrospective cohort data identified 22 subjects who had persistent Af during the study period, and 20 (0.15%) who had newly developed Af during this period on the basis of consecutive ECG recordings of the 13, 772 participants in 1994-1996. Logistic regression analysis revealed that there were significant differences in perception of irregular pulse (P=0.0004), history of myocardial infarction (P=0.0134), fatigability (P=0.0243), aging (P=0.0039) and total cholesterol level (P=0.025) for men, and in history of arrhythmia (P=0.0007) for women between the group with and without Af.<BR>The likelihood ratios and the respective 95% confidence intervals (C.I.) for ECG findings to identify the subjects who would develop Af were as follows: ST depression, 14.6 (C.I., 5.1-42) ; ventricular arrhythmia, 14.9 (3.9-56) ; incomplete RBBB, 9.2 (2.4-34) ; supraventricular arrhythmia, 8.9 (1.3-61) ; second-degree atrioventricular block, 342 (32-3624) ; abnormal Q wave, 16.3 (2.4-112) ; left atrial enlargement, 52.7 (7.2-383) .<BR>CONCLUSIONS: Combining data from subjects' histories for the prediction of imminent Af among subjects in the general population is likely to be useful, especially for the elderly male population. Aging in men, in particular, is an important factor when combined with abnormal findings on conventional 12-lead ECG.

What Aspects of Patient Affect Medical Students? A Qualitative Analysis of the Experiences of Medical Students at General Medical Ward and Clinic / 医学教育

<B>Objective:</B> To identify the usefulness of critical-incident reports for reflective learning and for classifying the types of experiences that medical students regarded most memorable during clinical clerkship at general medical ward and clinic.<BR><B>Design:</B> Descriptive qualitative study using the critical-incident technique.<BR><B>Setting:</B> General medical ward and clinic of a university hospital.<BR><B>Participants:</B> Fifth-year medical students that took part in the clinical care of patients during the clerkship from October 1, 1996 to September 31, 1997.<BR><B>Measurements and Main Results:</B> Ninety-five reports were collected over one year and subjected to the analysis. Reports were classified for seven major themes, with a mean of 1.85 themes per narrative. As for the distribution of themes, 68 reports (72%) dealt with biomedical topics, 45 (47%) with communication with patients and families, 26 (27%) with personal feelings, 19 (20%) with the physician's role, 11 (12%) with ethics, 7 (7%) with psychosocial subjects, and 1 (1%) with recognition of alternative medicine. Reports from men and women contained a similar mean number (men 1.82; women 2.09) and distribution of themes.<BR><B>Conclusions:</B> Medical students have divergent meaningful experiences on non-biomedical themes as well as biomedical issues during their general medicine rotation.

A Proposal on the Curriculum of Clinical Epidemiology / 医学教育

Clinical Epidemiology has been increasingly recognized as a basic science of clinical medicine as well as a prerequisite discipline necessary in practicing evidence-based medicine. However, no formal curriculum has been formulated for teaching clinical epidemiology to undergraduate medical students in Japan.<BR>We, as the Education on Clinical Epidemiology Working Group of Japan Society for Medical Education, here propose a curriculum of clinical epidemiology consisting of 15 sessions of 90 minute lectures, small group discussions, and practice. Learning such basic concepts as study design, bias, chance, and confounding factors is to be followed by case-based discussions and practicing on-line reference retrieval using MEDLINE. Our proposal awaits further refinement after its implementation at ambitious medical schools.