What primary care physician teachers need to sustain community based education in Japan.

BACKGROUND: Community based education (CBE), defined as "a means of achieving educational relevance to community needs and, consequently, of implementing a community oriented educational program," is reported to be useful for producing rural physicians in Western countries. However, why some physicians withdraw from their teaching roles is not well known, especially in Asian countries. The aim of this study was to clarify the requisites and obstacles for taking part in CBE. METHODS: WE COMBINED TWO STEPS: preliminary semi-structured interviews followed by workshop discussions. First of all, we interviewed four designated physicians (all male, mean age 48 years) working in one rural area of Japan, with less than 10,000 residents. Secondly, we held a workshop at the academic conference of the Japan Primary Care Association. Fourteen participants attending the workshop (seven male physicians, mean age 45 years, and seven medical students (one female and six male), mean age 24 years) were divided into two groups and their opinions were summarized. RESULTS: In the first stage, we extracted three common needs from interviewees; 1. Sustained significant human relationships; 2. Intrinsic motivation; and 3. Tangible rewards. In the second stage, we summarized three major problems from three different standpoints; A. Preceptors' issues: more educational knowledge or skills, B. Learner issues: role models in rural areas, and C. System issues: supportive educational system for raising rural physicians. CONCLUSIONS: Our research findings revealed that community physicians require non-monetary support or intrinsic motivation for their CBE activities, which is in accordance with previous Western studies. In addition, we found that system support, as well as personal support, is required. Complementary questionnaire surveys in other Asian countries will be needed to validate our results.

Frequency of neurotic symptoms shortly after the death of a pet.

Some individuals manifest psychosomatic symptoms after the death of their pets. A survey was conducted at four public and commercial animal cremation service centers in Japan. In each center, a questionnaire was distributed to 100 individuals (400 in total). The questionnaire consisted of the 28-item version of the General Health Questionnaire (GHQ28), the social readjustment rating scale (SRRS) and a series of questions regarding demographic information and the circumstances of their pet's death. In total, 82 returned questionnaires were available for analysis. GHQ28 proved the existence of neurotic symptoms in 46 responses (56.1%; 95% confidence interval: 44.7%-67.0%). Analysis of the responses using the GHQ28 subscales with a Likert scoring system demonstrated more somatic dysfunction in females (GHQ-A: P=0.04). Furthermore, significant correlations were identified among the following factors: owner's age (GHQ-A: ρ=-0.60, P=0.01; GHQ-B: ρ=-0.29, P=0.01; GHQ-C: ρ=-0.32, P<0.01; GHQ-D: ρ=-0.42, P<0.01), SRRS score (GHQ-A: ρ=0.32, P<0.01; GHQ-B: ρ=0.25, P=0.02; GHQ-D: ρ=0.30, P=0.01) and animal's age (GHQ-D: ρ=-0.26, P=0.02). The death of indoor pets caused deeper depression (GHQ-D: P=0.01) than that of outdoor or visiting pets. The results revealed neurotic symptoms in almost half of the pet owners shortly after their pet's death.

Analysis of needs of patients with idiopathic osteonecrosis of the femoral head: using focus group interviews.

AIM: The current needs of patients with idiopathic osteonecrosis of the femoral head were analyzed for the purpose of seeking effective support programs that would maintain and improve the quality of life of the patients. METHODS: A focus group interview method was used to collect data. Interviewees included eight patients. They were asked about their opinions and needs with respect to medicine, health care, and welfare. RESULTS: Overall, four needs were revealed as particularly significant: information needs, decision-making in the absence of pre-established treatment, psychological support, and sufficient medical healthcare institutions. CONCLUSION: These four needs are useful for the foundation of future support systems, whose main concerns will be: counseling support for patients with idiopathic osteonecrosis of the femoral head, currently adopted institutions, and resources that may be required in the future.

Perception of cervical cancer screening among Japanese university students who have never had a pap smear: a qualitative study.

This study aimed to explore attitudes towards cervical cancer screening among Japanese university students who had never had a Pap smear. Four focus-group discussions, each with 15 female university students, took place in November and December 2009. Discussions were recorded and transcripts were analyzed to extract attitudes of young women towards cervical cancer screening. The four themes that emerged were: i) a low sense of reality about cervical cancer; ii) a lack of knowledge about both cervical cancer and Pap smears; iii) a lack of motivation to get screened, and iv) a reluctance to visit the gynecologist. Participants who were interested in undergoing screening for cervical cancer cited the influence of conversations with friends and family, a diagnosis of cancer within their family, and relevant information from the media. The results indicate the importance of getting young women more interested in cervical cancer screening and overcoming their tendency to avoid visiting a gynecologist.

Care-seeking behavior of Japanese gynecological cancer survivors suffering from adverse effects.

BACKGROUND: Post-treatment follow-up visits for gynecological cancer survivors should provide opportunities for management of adverse physical/psychological effects of therapy and early recurrence detection. However, the adequacy of such visits in Japan is poorly documented. We qualitatively explored care-seeking experiences of Japanese gynecological cancer survivors and deduced factors influencing care-seeking behaviors and treatment access. METHODS: We conducted 4 semi-structured focus groups comprising altogether 28 Japanese gynecological cancer survivors to collect a variety of participants' post-treatment care-seeking behaviors through active interaction with participants. Factors influencing access to treatment for adverse effects were analyzed qualitatively. RESULTS: Survivors sought care through specialty clinic visits when regular post-treatment gynecological follow-ups were inadequate or when symptoms seemed to be non-treatment related. Information provided by hospital staff during initial treatment influenced patients' understanding and response to adverse effects. Lack of knowledge and inaccurate symptom interpretation delayed help-seeking, exacerbating symptoms. Gynecologists' attitudes during follow-ups frequently led survivors to cope with symptoms on their own. Information from mass media, Internet, and support groups helped patients understand symptoms and facilitated care seeking. CONCLUSIONS: Post-treatment adverse effects are often untreated during follow-up visits. Awareness of possible post-treatment adverse effects is important for gynecological cancer survivors in order to obtain appropriate care if the need arises. Consultation during the follow-up visit is essential for continuity in care.

Perception of inter-professional education (IPE) among laypersons in a Japanese rural area.

Many overseas healthcare researchers have advocated the importance of inter-professional education (IPE). However, to what extent laypersons, who reside in Japanese rural areas, understand IPE is not well known. To clarify this issue, we interviewed laypersons regarding their perception of IPE. We selected one rural area in Japan, where over 40% of the residents were more than 65 years old. Participants, who had an interest in their community healthcare system, were nominated. Semi-structured interviews of approximately 60 minutes were performed and topics focused on were: 1. laypersons' perception of IPE, 2. laypersons' views on educating future medical professions, and 3. what laypersons could contribute to the educating of future medical professionals. Nine participants (58 to 88 years, 1 female and 8 males, mean 76 years) took part. We found three common themes among the interviewees. These were: 1. little knowledge about IPE, 2. positive attitudes towards educating future medical professionals, 3. original ideas concerning how to educate medical professionals. We also found that laypersons in this rural region did not fully understand IPE. As one potential educational method, we should promote IPE involving laypersons. For future study, we plan to explore medical professionals' opinions, and compare them with those of laypersons'.

What rural physicians need to engage in community based education: a qualitative interview survey.

There is systematic evidence that community-based education is effective in the recruitment of rural physicians to remote communities. However, various obstacles may exist that prevent rural physicians from sustaining their mentoring activities. The aim of this study was to explore ways for rural physicians to overcome such adversities and continue their mentoring activities. We interviewed four nominated physicians (all male, mean age 48 years) based in Hokkaido, Japan, who practiced in an area with less than 10,000 inhabitants. Semi-structured interviews of approximately 60 minutes were performed and focused on topics rural physicians' found necessary for their teaching activities. All interviews were tape-recorded and transcribed, the verbatim transcripts were analyzed and repeated themes were identified. Three themes that emerged as needs were 1. sustained significant human relationship, including the formation of a network between students and university faculty, as well as developing partnerships with many community relationships, or other medical professions; 2. intrinsic motivations and satisfaction, including pleasure in mentoring the younger generations; and 3. rewards, including financial compensation. Rural physicians as preceptors require nonremunerative, intrinsic motivational factors, such as a sense of satisfaction regarding the education of medical students and being able to relate to residents and others health-care professions, when pursuing their educational activities. To support them, focusing only on monetary facets may be unsuccessful in encouraging them to continue their educational work.

Survey of patient and physician satisfaction regarding patient-centered outpatient consultations in Japan.

OBJECTIVE: The purpose of this study was to show the difference in consultation satisfaction between patient and physician in rural settings, and identify the variables affecting their satisfaction regarding these encounters. METHODS: We collected data by administering questionnaires that included questions regarding satisfaction for a patient-centered approach to patients and physicians, transcribing data from medical records, and observing consultations in person. We then modeled cumulative logits of patient and physician satisfaction scores by performing ordered logistic regression using the proportional odds model. PATIENTS: Seven physicians and 122 patients participated in the study. RESULTS: Both patients and physicians expressed high satisfaction with their consultation sessions. Patient satisfaction tended to be higher than physician satisfaction. Physicians were satisfied with longer consultations but patients were not. Moreover, the long waiting times dissatisfied patients. In cases of multiple healthcare episodes (courses of treatment for a different condition) during a single visit, patient satisfaction decreased, while physician satisfaction increased. Physician satisfaction for interactions in general was less when they checked the same patient who had previously visited them. CONCLUSION: Our findings suggest that if physicians feel satisfied with their consultation, patients also feel satisfied regardless of the physician's opinion. The variables that affect patient and physician satisfaction include prior visits with the same physician, consultation length, longer waiting times, and number of episodes. These findings from Japanese clinics are consistent with those previously reported for other countries.

Willingness to pay for municipality hospital services in rural Japan: a contingent valuation study.

BACKGROUND: The Japanese healthcare system has undergone reforms to address the struggles that municipality hospitals face. Reform guidelines clearly define criteria for administrative improvement. However, criteria to evaluate the demand for healthcare provisions in rural Japan, including the needs of rural residents for municipality hospitals in particular have not been specified. The purpose of this paper is to measure residents' willingness to pay (WTP) for municipality hospital services using the contingent valuation method, and to evaluate municipality hospital valuation on the basis of WTP. K town, located in the Hokkaido prefecture of Japan, was selected as the location for this study. Participants were recruited by a town hall healthcare administrator, hospital and clinic staff, and a local dentist. Participants were asked what amount they would be willing to pay as taxes to continue accessing the services of the municipality hospital for one year by using open-ended questions in face-to-face interviews. FINDINGS: Forty-eight residents were initially recruited, and 40 participants were selected for the study (response rate 83%). As compared to K town's population, this data slanted toward the elderly, although there was no significant difference in frequency among the characteristics. The median WTP was estimated at 39,484 yen ($438.71), with a 95% confidence interval 27,806-55,437 yen ($308.95-615.96). Logistic regression revealed no significant factors affecting WTP. CONCLUSIONS: If the total amount of residents' WTP for the municipality hospital were to be estimated by this result, it would calculate with 129,586,000 yen ($1,439,844). This is approximately equal to the amount of money to be transferred from the general account of the government of K town, more than one-half of the town tax of K town, and about two-fold in comparison to Japan as a whole. This showed that K town's residents placed a high valuation on the municipality hospital, which nearly equalled the amount that the K town government provided to the municipality hospital to cover its annual deficit. K town residents had come to expect not only general clinical practice, but also emergency medical services and night practice provided by their own town's municipality hospital. WTP can be used as a measure of hospital evaluation because it reflects the importance of the hospital to the residents in its region.

Psychiatric investigation of 18 bereaved pet owners.

This survey explores the grief associated with the loss of a pet, and was carried out using a self-administered questionnaire. The questionnaires were handed out to 50 bereaved pet owners attending a public animal cremation service, and we received 18 responses. Participants responded within 0 to 44 (median 4) days of the death of their pet. Although most mental health problems immediately following mourning are presumed to be normal grief reactions, on the basis of several psychiatric scales, 8 of the 16 valid responses indicated depression and/or neurosis. Statistical analyses showed that the following factors were significantly associated with grief reactions: age of owner, other stressful life events, family size, age of deceased animal, rearing place, and preliminary veterinary consultation.

Factors in the awareness of depression, focusing on perceptual dissimilarities between PCPs and patients: an exploratory and qualitative research.

Primary care physicians (PCPs) are said to play a leading role in the early diagnosis of depression. Sometimes however, symptoms can be overlooked or misdiagnoses may occur, and this may be due to differences in the way that PCPs and patients perceive depression. The aim of this study is to clarify factors that may contribute to suspicions, or awareness of depression, focusing especially on perceptual dissimilarities between PCPs and patients. We conducted our research using qualitative methodology, with individual interviews being conducted with five experienced primary care physicians working in a rural area, and five patients who had been in consultation with PCPs. The main interview topic of this study was the triggers for their, or their patients', depression. From our interviews we discerned five categories of factors: "mental manifestations," "physical manifestations," "events in the patient's private life," "social environment and conditions" and "others." Our findings suggest that a critical difference in the perception of depression may exist between PCPs and patients. PCPs should be more alert to uncommon conditions of depression, as well as the more prevalent symptoms. We found that PCP's latent abilities and attitudes, such as "intuition," "subjectivity," and "experience", are often cues in the diagnosis of depression. This is in accordance with existing research on the subject. On the patients' side, sometimes sufferers do not notice the symptoms of depression by themselves, which may also be a serious problem. In conclusion, we, as medical professionals, must take care to be aware of these distinctions in order to swiftly detect depression, and to better treat our patients.

Impact and characteristics of quality of life in Japanese patients with multiple sclerosis.

PURPOSE: To evaluate health-related quality of life (HRQOL) in Japanese patients with multiple sclerosis (MS) and investigate associations between the results of these QOL assessments and disease severity. METHODS: One-hundred sixty-three Japanese MS patients completed a questionnaire battery comprising the Functional Assessment of MS (FAMS), the Nottingham Adjustment Scale-Japanese version (NAS-J), and the European QOL scale (EQ-5D). Additional five factors affecting QOL as identified by MS patients in a focus group interview were also investigated: employment status, change of income, availability of disease information, communication with medical staff, and care received. Disease severity was determined using the Expanded Disability Status Scale (EDSS). RESULTS: There was a strong negative correlation of the subscale scores for mobility, symptoms, emotional well-being, thinking and fatigue, and additional concerns on the FAMS with EDSS score. For the NAS-J, only acceptance of the condition was correlated with disease severity. Among the five additional aspects of the condition identified by patients, employment status, income, and disease information were shown to be important for maintaining QOL in patients with MS. CONCLUSIONS: Support for finding employment and having increased or maintained household income and readily available information about the disease contribute to improving QOL in Japanese MS patients.

Incidence of Community-associated Methicillin-resistant Staphylococcus aureus Infections in a Regional Hospital.

BACKGROUND AND OBJECTIVE: Since the early 2000s, the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections among the community of people lacking known healthcare risk factors has increased. This MRSA infection is referred to as community-associated MRSA (CA-MRSA) infection and is distinct from hospital-associated MRSA (HA-MRSA) infection, which occurs among people with known healthcare risk factors. Understanding the epidemiology of CA-MRSA infections is critical; however, this has not been investigated in detail in Japan. Our objective was to investigate the incidence of CA-MRSA infections in a regional hospital. PATIENTS AND METHODS: We investigated CA-MRSA isolates and infections in a rural regional hospital by reviewing medical records of one year. Infections were classified as CA-MRSA if no established risk factors were identified. RESULTS: During 2008, 31 Staphylococcus aureus (S. aureus) isolates were detected in 29 unique patients, with 1 methicillin-sensitive S. aureus (MSSA) isolates obtained from 19 patients (66%) and MRSA obtained from 10 patients (34%). In the 10 patients with MRSA, the number of HA-MRSA and CA-MRSA cases were nine (32% of patients with S. aureus isolates) and one (3%), respectively. The patient with CA-MRSA was diagnosed with cellulitis due to CA-MRSA. All nine patients with HA-MRSA exhibited colonization. CONCLUSION: We observed a CA-MRSA case in a regional hospital in Japan, suggesting that incidence trends of CA-MRSA should be considered in future research and treatment.

Quantitative analysis of ontology research articles in the radiologic domain.

To investigate the most advanced ontology research in health care and its impact on the radiologic domain, we proposed a concept identification and abstraction technique called "Concept Step". This technique identifies a MeSH term, medical subject headings used in PubMed, in a sentence and climbs up through its hierarchy to reach an abstract concept. We developed original Java software to implement this technique. We tested it on 2,774 abstracts in health-care ontology research retrieved from MEDLINE on 23 October 2008. The total number of MeSH terms was 112,690. We counted a total of 33 MeSH terms (0.029%) in the radiologic domain. The most frequently occurring term was "radiology", which occurred 21 times in the article set. Other frequent terms were "magnetic resonance imaging" and "tomography", the counts of which were 4 and 3, respectively. A pair plot showed no correlation among the MeSH categories "Analytical Diagnostic and Therapeutic Techniques and Equipment", "Anatomy", "Biological Sciences", and "Chemicals and Drugs". We conclude that ontology research is well established in the biomedical domain, and that further study is required in the radiologic domain.

An interview survey on factors influencing the career choice of primary care physicians in rural areas.

BACKGROUND: The lack of primary care physicians working in rural areas is a major problem both in Japan and worldwide. Particularly in Japan, healthcare provision in the community is seriously deteriorating, due to the absence of a regulated instructional system for primary care physicians in rural areas. Understanding what influences the career choice of rural primary care physicians is vital, and this study aims to examine those factors. METHODS: Qualitative research methodology with semi-structured interviews and content analysis was used. All interviews were conducted in interviewees' rural clinics over three days in September 2007 and 2008; each interview lasted for 60 minutes. All interviews were recorded, transcribed verbatim, and analyzed thematically by two independent researchers, then the preliminary results were presented to the third and fourth authors. All authors were in agreement with the final results. RESULTS: Fourteen physicians (13 males and 1 female; mean age 43-years-old) agreed to participate in the interviews, and four themes emerged: "existence of role models for younger primary care physicians," "affinity with rural backgrounds and culture," "understanding the importance of a holistic approach," and "internal motivation for challenging and rewarding work as a doctor." DISCUSSION & CONCLUSIONS: Our research results were similar to those of previous overseas studies, regardless of differences in cultural background. We could explain our themes with the concept of the "rural pipeline into medical practice" by JP Geyman et al. according to the time frame described therein. Taking some potential limitations like generalizability and translation into account, we could utilize our research results to indicate how the number of rural primary care physicians may be increased.

A case of community-associated methicillin-resistant Staphylococcus aureus infections in a community hospital.

Infections caused by methicillin-resistant Staphylococcus Aureus (MRSA) have recently occurred in communities in people lacking known healthcare risk factors. This MRSA infection is referred to as community-associated MRSA (CA-MRSA) infection, and is distinct from hospital-associated MRSA infection, which occurs in people with risk factors. We experienced a patient diagnosed with CA-MRSA cellulitis, as culture of pus revealed MRSA and he had not been exposed to healthcare environments for the past year. The patient was a previously healthy 38-year-old man with suppurative cellulitis in his right index finger following injury to the finger at his worksite. The cellulitis was successfully managed with incision and drainage (I&D), followed by cefazolin during a 10-day clinical course, although the patient's MRSA strain was resistant to cefazolin. There are several reports that suggest that I&D followed by antibiotic treatment for CA-MRSA skin infection produces equivalent clinical outcomes, whether the antibiotic prescribed was effective or not. Given that MRSA emerged in an outpatient setting, CA-MRSA should be considered a possible etiology of skin infection in healthy individuals with no classical risk factors for acquisition of MRSA.

A Japanese case of familial Mediterranean fever with a MEFV gene mutation.

A 17-year-old Japanese male with a three-year history of recurrent episodic chest pain and fever, each lasting for one to three days, was diagnosed with familial Mediterranean fever (FMF) because of the following: 1) short attacks of chest pain and fever recurring at varying intervals; 2) no symptoms with a sense of well-being between attacks; and 3) identification of the Mediterranean fever gene (MEFV) mutation demonstrating M6941. Although FMF has been described primarily in several limited ethnic groups, a limited number of cases have been reported in Japan. No specific diagnostic tests are commercially available for FMF so identifying the characteristic clinical picture of FMF is important.

The perception of the hidden curriculum on medical education: an exploratory study.

BACKGROUND: Major curriculum reform of undergraduate medical education occurred during the past decades in the United Kingdom (UK); however, the effects of the hidden curriculum, which influence the choice of primary care as a career, have not been sufficiently recognized. While Japan, where traditionally few institutions systematically foster primary care physicians and very few have truly embraced family medicine as their guiding discipline, has also experienced meaningful curriculum reform, the effect of the hidden curriculum is not well known. The aim of this study is to identify themes pertaining to the students' perceptions of the hidden curriculum affecting undergraduate medical education in bedside learning in Japan. METHODS: Semi-structured interviews with thematic content analysis were implemented. Undergraduate year-5 students from a Japanese medical school at a Japanese teaching hospital were recruited. Interview were planned to last between 30 to 60 minutes each, over an 8-month period in 2007. The interviewees' perceptions concerning the quality of teaching in their bedside learning and related experiences were collected and analysed thematically. RESULTS: Twenty five medical students (18 males and 7 females, mean age 25 years old) consented to participate in the interviews, and seven main themes emerged: "the perception of education as having a low priority," "the prevalence of positive/negative role models," "the persistence of hierarchy and exclusivity," "the existence of gender issues," "an overburdened medical knowledge," "human relationships with colleagues and medical team members," and "first experience from the practical wards and their patients." CONCLUSIONS: Both similarities and differences were found when comparing the results to those of previous studies in the UK. Some effects of the hidden curriculum in medical education likely exist in common between the UK and Japan, despite the differences in their demographic backgrounds, cultures and philosophies.

Families' acceptance of near death: a qualitative study of the process for introducing end-of-life care.

AIM: Providing effective end-of-life (EOL) care for the elderly with severe brain damage is difficult because patients' families find it hard to accept the condition of their loved ones as "near death". In Japan, this has become an urgent social problem. Although health-care teams sometimes expect that the elderly with severe brain damage should be treated as terminal, many find that patients' families cannot accept the condition as near death. As a result, they are not able to appropriately introduce any EOL services. It was the aim of the present study to develop a comprehensive understanding of the process by which families accept the elderly with severe brain damage as near death. METHODS: Qualitative methodology with focus groups and semi-structured interviews were used. Twenty-three participants in two sets of male and female focus groups were interviewed in a semi-structured format. Ten participants (five men and five women) who made important medical decisions were then interviewed separately. RESULTS: Eleven categories emerged: (i) family affection with wishes for continued survival; (ii) vacillation of desire for death with dignity; (iii) family members' hierarchy; (iv) awareness that others may make different decisions; (v) family members' discussion overcoming discordance; (vi) satisfaction with physicians' explanations; (vii) impressions of life-sustaining measures; (viii) entrusting important decisions to hospital physicians; (ix) significance of family members' previous experiences; (x) patient's age; and (xi) duration of medical treatment. CONCLUSION: We developed a conceptual model that is useful for evaluating which stage of the process families are currently experiencing as well as introducing EOL care in a timely manner.