Article ID: 24-00040
Background:In 2020, 29 signs/symptoms as well as 26 diseases/disorders to be encountered during initial postgraduate training were defined in Japan. The purpose of this study was to determine the extent to which junior residents can encounter the signs/symptoms and diseases/disorders during general practice/family medicine training.
Methods:Junior residents who participated in general practice/family medicine training for four weeks between 2019 and 2022 were:enrolled in the study. They were each assigned to one of five medical institutions with full-time family doctors in Fukushima Prefecture. The rate of participants who encountered each sign/symptom and disease/disorder, as well as the number of signs/symptoms and diseases/disorders each participant encountered, were defined as outcomes and analyzed descriptively.
Results:Ninety junior residents participated in the study. More than half of the participants encountered 11 out of the 29 signs/symptoms, and each participant encountered an average of nine signs/symptoms. As for diseases/disorders, more than half of the participants encountered 11 out of the 26 diseases/disorders, with an average of 11 per participant.
Conclusion:General practice/family medicine training provided the junior residents with the opportunity to experience a wide range of signs/symptoms and diseases/disorders.
General practice/family medicine (GP/FM) is part of community medicine, and is a clinical field expected to contribute not only to the provision of high-quality primary care but also to medical education1). Internationally, postgraduate training reform efforts have been directed toward strengthening primary care education2). Therefore, experience in GP/FM during postgraduate training is considered beneficial to all junior residents, regardless of their future specialty choice3). Previous reviews have reported that GP/FM training has positive effects in terms of management of common diseases and chronic diseases, understanding of psychosocial factors of illness, communication skills, team medical care, and community care, as well as fostering better cooperation and understanding between primary and secondary care doctors4,5). The primary care described in these international studies is assumed to be provided by specialists trained in GP/FM2). In Japan, GP/FM specialist training has been developed and implemented. In 2020, the family medicine expert training program organized by the Japan Primary Care Association (JPCA) received international accreditation from the World Organization of Family Doctors6). With this accreditation, JPCA-certified family doctors are regarded as family medicine specialists trained to international standards. Fukushima Medical University has provided community medicine training supervised by JPCA-certified family doctors (known as GP/FM training) at five medical institutions in Fukushima Prefecture. In 2023, we reported the impact of GP/FM training using nationally standardized evaluation criteria7). Our findings in that study suggested that GP/FM training may greatly contribute to the acquisition of various clinical abilities required during postgraduate training.
In Japan, two years of initial postgraduate training is mandatory after graduating from medical school, and doctors undergoing this training are defined as junior residents8). The guidelines for initial postgraduate training in Japan were revised in 2020, specifying 29 signs/symptoms and 26 diseases/disorders to be encountered during the two years. However, it is not clear what signs/symptoms and diseases/disorders junior residents can encounter in GP/FM training, with limited international reports on this point. In Australia, it has been reported that more than half of junior residents during a 10-week GP/FM training period encountered 17 of the 22 signs/symptoms and 34 of the 65 diseases/disorders required in their initial postgraduate training9). However, this study was a pilot study involving eight junior residents in a single clinic, highlighting the need for multicenter studies, including comparisons between urban and rural areas.
The present study is a multicenter study aimed at determining to what extent junior residents in GP/FM training can encounter the signs/symptoms and diseases/disorders required during initial postgraduate training.
This study enrolled second-year junior residents who participated in four-week community medicine rotations between April 2019 and March 2022. They were assigned to one of the following five medical institutions with full-time family doctors in Fukushima Prefecture:Kashima Hospital, Asahi Clinic, Hoshi Yokozuka Clinic, Hobara Central Clinic, and Kitakata Centre for Community and Family Medicine. Kashima Hospital is a 193-bed facility located in Iwaki City that provides a range of medical services including respiratory medicine, gastroenterology, and nephrology, in addition to GP/FM. Asahi Clinic has inpatient beds and is the only medical institution in Tadami Town. Hoshi Yokozuka Clinic in Koriyama City and Hobara Central Clinic in Date City are both function-enhanced home care support clinics without inpatient beds, and they both have a high demand for home medical care10). Kitakata Centre for Community and Family Medicine is a clinic without inpatient beds located in Kitakata City and provides comprehensive medical services encompassing not only internal medicine but also specialties such as pediatrics and dermatology, which are scarce in the region.
Contents of GP/FM trainingThe initial postgraduate training period in Japan is two years, including one month of compulsory community medicine training in the second year8). Postgraduate community medicine training typically covers general ambulatory care, home medical care, specialized care in a chronic and/or recovery stage ward, and community-based care in a real-world setting8). General ambulatory care training provides opportunities to learn about comprehensive medical practice for new patients, without focusing on specific diseases or symptoms, as well as continuous care for patients with chronic conditions during follow-up visits. During home medical care training, junior residents visit patients’ homes together with family doctors and experience medical care tailored to each patient’s daily life and the characteristics of the community. Community-based care training provides opportunities to learn about collaboration with a variety of community health providers, such as medical and nursing care facilities, pharmacies, and welfare organizations. Junior residents are required to write a reflective report on the day’s events every evening and also receive daily feedback from their attending family doctors. Table 1 shows an example of the training schedule. In addition to the required training content, there is some optional content specific to each training site.
Data source and statistical analysisThe participants in the present study recorded the signs/symptoms and diseases/disorders they encountered each day on a reflection form. A previous study reported variations in the expressions used by junior residents in documenting signs/symptoms and diseases/disorders9). Therefore, we conducted a pilot study and standardized the terms used in the reflection forms (Appendix). The rate of participants who encountered each sign/symptom and disease/disorder and the number of signs/symptoms and diseases/disorders each participant encountered were defined as outcomes and analyzed descriptively.
Ethics approvalEthics approval was obtained from the Fukushima Medical University Research Ethics Committee (approval number #30250).
Training schedule example
Out of 95 junior residents who underwent the training, 90 participated in this study (participation rate:95%). Five participants were excluded because the coordinators at their medical institutions forgot to explain the study at the beginning or collect the reflection form at the end of the study. Their baseline characteristics are shown in Table 2. The rate of participants who encountered each sign/symptom is shown in Figure 1. More than half of the participants encountered 11 out of 29 signs/symptoms:abnormal bowel movement (83%), abnormal pain (76%), headache (71%), back pain (69%), fever (62%), vertigo (61%), burns and injuries (60%), urinary dysfunction (59%), nausea and vomiting (58%), skin rash (58%), and arthralgia (53%). Looking at the number of signs/symptoms encountered by more than half of the participants by training site, Asahi Clinic had the highest (12), followed by the Kitakata Centre for Community and Family Medicine (11), Hoshi Yokozuka Clinic (10), Hobara Central Clinic (9), and Kashima Hospital (7). Next, the rate of participants who encountered each disease/disorder is shown in Figure 2. More than half of the participants encountered 11 out of 26 diseases/disorders:hypertension (88%), diabetes mellitus (83%), dementia (83%), cerebrovascular disorders (80%), cardiac failure (79%), dyslipidemia (77%), chronic obstructive pulmonary disease (59%), high-energy trauma and fractures (56%), bronchial asthma (51%), renal failure (51%), and pneumonia (50%). By training site, Asahi Clinic and Hobara Central Clinic had the highest number of diseases/disorders encountered by more than half of the participants (12), followed by the Kitakata Centre for Community and Family Medicine (11), Hoshi Yokozuka Clinic (10) and Kashima Hospital (8). Finally, the numbers of signs/symptoms and diseases/disorders encountered by each participant are shown in Figure 3 and Figure 4, respectively. The average number of signs/symptoms encountered by each participant was nine, with Asahi Clinic having the highest average (12), followed by Hobara Central Clinic (11), Kitakata Centre for Community and Family Medicine (10), and both Kashima Hospital and Hoshi Yokotsuka Clinic (eight each). Regarding diseases/disorders, the average number of encounters per participant was 11, with Hobara Central Clinic having the highest average (14), followed by Asahi Clinic and Hoshi Yokotsuka Clinic (12), Kitakata Centre for Community and Family Medicine (10), and Kashima Hospital (nine).
Baseline characteristics of participants
The rate of participants who encountered each sign/symptom is shown. The total for the five training sites is shown on the far left.
The rate of participants who encountered each disease/disorder is shown. The total for the five training sites is shown on the far left.
The number of signs/symptoms each participant encountered is shown. For example, seven participants in total encountered nine signs/symptoms. Of the seven, one was from Kashima, two from Asahi, one from Hoshi, two from Hobara, and one from Kitakata.
The number of diseases/ disorders each participant encountered. For example, seven participants in total encountered eleven diseases/disorders. Of the seven, four were from Kashima, one from Hoshi, one from Hobara, and one from Kitakata.
Out of the 29 signs/symptoms, 11 were encountered by more than half of the participants. These 11 signs/symptoms spanned a variety of systems, such as the digestive system (nausea/vomiting, abdominal pain, abnormal bowel movement), nervous system (headache), musculoskeletal system (back pain), and urinary system (urinary dysfunction), and also included non-specific symptoms such as fever. Comparing by training site, Asahi Clinic had the highest number of signs/symptoms with a high encounter rate among participants. In particular, the encounters at that site with nausea/vomiting (90%), arthralgia (90%), back pain (100%), vertigo (90%), skin rash (100%), and burns and injuries (100%) were more frequent compared to other training sites. This is considered to be due to Asahi Clinic being the only medical facility in the area, accepting a wide range of patients, including those with gastrointestinal (nausea/vomiting), musculoskeletal (arthralgia), sensory (vertigo, skin rash), and surgical conditions (burns and injuries). A previous study in Australia reported that general practice/family medicine training in rural areas provides opportunities to encounter a range of signs/symptoms, including dermatology and surgical cases, which are not commonly encountered in urban training hospitals11).
Out of the 26 diseases/disorders, 11 were encountered by more than half of the participants. These diseases/disorders included a variety of systems, including cardiovascular (hypertension, cardiac failure), respiratory (pneumonia, bronchial asthma, COPD), metabolic/endocrine (diabetes mellitus, dyslipidemia), nervous (cerebrovascular disorders, dementia), and urinary (renal failure) systems, as well as surgical conditions (high-energy trauma and fractures). Comparing by training site, Hobara Central Clinic had the highest number of diseases/disorders with a high encounter rate among participants. In particular, the number of diseases/disorders with a 100% encounter rate (hypertension, cardiac failure, COPD, diabetes mellitus, dyslipidemia, cerebrovascular disorder, and dementia) was higher than at other training sites. This is considered to be because Hobara Central Clinic provided its participants with ample opportunities to learn about the continuous care of common chronic diseases/disorders. The purpose of general ambulatory care training is not only to learn about initial consultations with signs/symptoms, but also continuous care for patients with chronic diseases/disorders during follow-up visits8). Previous studies have also reported that general practice/family medicine training is a good opportunity to learn about the continuous care of chronic diseases/disorders compared to training in other specialties12-13).
The lower encounter rate of signs/symptoms and diseases/disorders at Kashima Hospital compared to other training sites may be primarily due to the fact that Kashima Hospital is the only hospital setting. Junior residents at Kashima Hospital were involved not only in general ambulatory care and home medical care but also in emergency care and multiple wards care. Therefore, their encounter rate was lower compared to junior residents at clinics who could conduct general ambulatory care every day. Additionally, such busyness might have indirectly led to insufficient time for completing reflection forms. In terms of training quality, a previous study conducted among the same participants as the present study found no difference in the effect size for the item related to signs/symptoms between Kashima Hospital and other clinics7). The self-evaluation in the previous study was conducted only on the first and last days of community medicine training, while the reflection forms in this study were completed daily. Thus, the reflection forms in this study were more susceptible to daily busyness, potentially leading to an underestimation of the encounter rate at Kashima Hospital. No distinctive trends were observed at Hoshi Yokozuka Clinic or the Kitakata Centre for Community and Family Medicine compared to the other training sites. Regarding the training period, it has been reported that in a 10-week GP/FM training program in Australia, more than half of junior residents encountered 17 out of 22 signs/symptoms and 34 out of 65 diseases/disorders9). Given the significant difference in training duration (4 weeks in Japan vs. 10 weeks in Australia), extending the training period in Japan may enable junior residents to encounter a greater number of signs/symptoms and diseases/disorders. In undergraduate medical education, longitudinal integrated clerkship has been reported to be effective in improving the clinical skills of medical students, and this approach has also started in Japan14-15).
There are several limitations to this study. Firstly, although this study focused on training at five medical institutions with full-time family doctors in Fukushima Prefecture, it lacks comparisons with other medical institutions, making it difficult to objectively evaluate its impact. Secondly, given that this study was conducted during the COVID-19 pandemic, there is a possibility that the number of cases encountered by the participants was lower than usual due to patients refraining from seeking medical care.
More than half of the participants encountered 11 out of 29 signs/symptoms, and each junior resident encountered an average of nine signs/symptoms. As for diseases/disorders, more than half of the residents experienced 11 out of 26, with an average of 11 encountered per resident. It was suggested that junior residents may be able to encounter more signs/symptoms in rural areas, and they may be able to encounter more diseases/disorders through continuous care of common chronic diseases/disorders.
We would like to thank Chisato Kubo of the Office for Diversity and Inclusion at Fukushima Medical University, for inputting the data.
We also wish to thank the Scientific English Editing Section of Fukushima Medical University.
The authors declare no conflicts of interest.
