Review
Division of General Practice at a University Hospital, Not a Fish out of Water: Unique Approaches at Shimane University
2021 年 38 巻 3 号 p. 85-88
詳細
2021 年 38 巻 3 号 p. 85-88
Societal needs for general physicians are increasing, and medical universities are responsible for meeting such demands by providing opportunities for medical students and clinical residents to experience the clinical practice of generalists, so that they become more aware of what it involves and might be inclined to become generalists in future. Our department runs a satellite campus at Oda City Hospital, called ‘Oda Training Center of General Practice’, where young trainees can experience general practice under the supervision of attending physicians. In addition, we are involved in several initiatives at Shimane University hospital, including collaboration with the Emergency Medical Center (EMC) and revamping of our clinical clerkship program, such as involving medical students in morning bedside-rounds, effective communication using a business chat-tool, and a joint conference with the EMC. We believe that these initiatives at Shimane University will contribute to fostering more general physicians in the years to come.
Currently, most university hospitals in Japan have a division of general practice, called ‘general medicine’, or a division of general internal medicine, where physicians called generalists, general practitioners, hospitalists, or primary-care physicians engage in clinical practice. When we checked the homepages of 82 university hospitals nationwide (excluding branch hospitals), as of 16th April 2021, 70 hospitals (85%) had a division of general practice or general internal medicine as one of the many clinical divisions at their hospital. There was no difference in the presence of such a division based on whether the hospital was a national, public, or private university hospital. However, the roles such departments play at each university hospital varies. While some of the divisions play an active role in clinical reasoning and education and attract many clinical residents from across Japan, some of them reportedly exist only to see first-time outpatients due to lack of manpower and the management policy of the university hospital they belong to.
In the late 1990s and 2000s, many university hospitals opened a division of general practice or general internal medicine. Reportedly, however, only few of them were successful and the departments were abolished at many hospitals, leading to the belief that "university hospitals and such divisions are incompatible in nature" [ 1]. It was thought that university hospitals, to which most patients are referred from primary-care physicians for a specific disease or particular symptoms, are a place for specialists, and not generalists.
However, many university hospitals are now re-establishing such divisions. Why? A major reason is undoubtedly the soaring social demand for generalists, who are thought to play a key role in providing comprehensive care for elderly patients in Japan’s rapidly aging society [ 2, 3]. In 2018, the Japanese Medical Specialty Board added ‘general practice’ as one of the 19 basic fields, along with internal medicine, surgery, etc., that trainees can choose to take up [ 4]. Will a current division of general medicine at a university hospital contribute to increasing the number of generalists? The success of such a system might vary depending on the situation at each university hospital [ 5]. In this manuscript, we introduce our unique approaches at the department of General Medicine at Shimane University and the division of General Practice at Shimane University Hospital.
Societal demands for fostering generalists are increasing. The current super-aging and multi-death society needs physicians who have the ability and the will to be in charge of patients with multiple comorbidities and complexities, especially at medically under-served areas that are increasing nationwide. The Ministry of Health, Labour and Welfare has recently started a project focusing on fostering generalists across Japan [ 2]. Currently, increasing their number has become a national policy.
Generally speaking, a university hospital in Japan has several disadvantages in fostering well-rounded generalists [ 1, 4]. First, the opportunities for exposure of young trainees to patients with common diseases, which is vitally important for becoming a well-rounded generalist, are expected to be less frequent compared to those for trainees working at a community hospital. Second, because of the fewer opportunities as mentioned above, a university hospital might not be the best place for generalists to show their utmost abilities. Their clinical abilities are best shown in a primary-care setting, such as a clinic or a medium-sized community hospital. Thus, it is sometimes difficult for them to inspire medical students and clinical residents to becoming generalists. Third, is the problem of manpower shortage. Although lack of human resources is a common problem for most clinical divisions at a university hospital, it is usually more evident in the division of general practice for several reasons, including its short history in Japan.
To address the disadvantages of a university hospital, in addition to our general practice department at Shimane University Hospital, our department runs a satellite campus at Oda City Hospital, called Oda Training Center of General Practice. The idea of running a satellite campus outside a university hospital setting was first introduced by the Department of General Medicine and Primary Care at the University of Tsukuba Hospital, which opened its satellite campus at Mito Kyodo Hospital. Influenced by their success in fostering many excellent generalists, our department has created a satellite campus at Oda City Hospital since its establishment in 2011. Currently, a total of seven attending physicians, including the authors of this report, are from our department, and six of them mainly engage in clinical practice and medical education at Oda Training Center of General Practice/Oda City Hospital.
Oda City Hospital is a medium-sized community hospital in Oda City. It has 225 beds and is a hub hospital in this area, catering to a population of 50,000. Like many community hospitals, Oda City Hospital is a suitable environment to foster well-rounded generalists. Young trainees are exposed to many patients with common diseases under the supervision of our staff members. They can also get feedback from specialists, such as gastroenterologists or neurosurgeons, because the emotional bond between physicians is stronger at community hospitals as compared to when working at a large hospital with many specialists. Furthermore, we started clinical practice at a small clinic, called Ikeda clinic, which is located in a relatively sparsely populated area of Oda City, as another satellite campus for the education of primary-care practice in April 2021.
In addition, taking advantage of the close relationship between the Oda City office and our department, we are planning to perform epidemiological research at Oda City. Currently, we are interested in building a model system for comprehensive community-based health care. By communicating and sharing information regularly with many stakeholders at Oda City, and exposing young trainees to such meetings, we try to foster excellent generalists with a wider perspective as community healthcare leaders.
Although our department has offered a fellowship program for generalists, there have been no applicants since the last two consecutive years, suggesting the need to publicize the attractiveness of our department to medical students and clinical residents at Shimane University. Since the author (T.M.) joined the department as a senior professor in July 2020, we have made several efforts to this end at Shimane University Hospital.
Until July 2020, our department had not engaged in clinical practice at Shimane University Hospital for the previous two years, because, after resignation of the former senior professor, all six staff physicians of our department during that period mainly worked at Oda Training Center of General Practice/Oda City Hospital. Their contributions at Shimane University Hospital were limited to simulation-based education for medical students at a clinical skills laboratory. In order to attract the attention of medical students and clinical residents, we thought it essential to showcase the real clinical practice of generalists at Shimane University Hospital. The author (T.M.) started an outpatient clinic of general practice at Shimane University hospital immediately after being appointed there, but the number of patients remained low for several months. The manpower shortage was evident, because the author was the only full-time physician at Shimane University Hospital. This made us assess the possibility of collaboration with the Emergency Medical Center (EMC) at Shimane University Hospital.
Unlike emergency medical centers at university hospitals in a big city where the focus tends to be on treating only severely ill patients, the EMC at Shimane University has been accepting many patients with common disorders, such as urinary tract infection or pneumonia, in addition to critically ill patients. Having heard that the EMC was also suffering from a manpower shortage, we proposed collaboration of clinical practice between the two divisions, and Dr. Yoshiaki Iwashita, the professor at the EMC accepted our proposal.
Since September 2020, in addition to running the outpatient clinic of general practice twice a week, the author (T.M.) has started working twice a week at the EMC. The author has also consistently been in charge of 5 to 10 inpatients thereafter. When the author is off duty, EMC physicians who are on duty at that time care for the inpatients of our division. In this way, the stage for showing the real clinical practice of generalists was set.
At entrance examination interviews at our university, many applicants answered “a generalist" in response to the question about the kind of doctor they wanted to be in future, although only few students have actually become generalists after graduation. Until fiscal year 2020, the opportunity for medical students at Shimane University to see the real clinical practice of generalists were limited to a few-week clinical clerkship at a community hospital in Shimane where they were assigned. If they do not have opportunities to see the clinical activities of generalists at the university hospital where they spend most of their time during their last two years before graduation, their motivation to become generalists is likely to diminish. Therefore, we asked the educational section of our university to extend the duration of clinical clerkship at our department, which used to be for one week, to two weeks from the 2021 fiscal year. Furthermore, we have started several initiatives, such as early morning bed-side teaching rounds, introduction of a business chat-tool, and a joint case conference with the EMC.
Participation in the early morning rounds that start at 7:30 am is not mandatory, but so far, all students have participated in it. As has been reported for bed-side teaching methods, they seem highly satisfied with these bed-side rounds [ 6]. They feel they get immediate feedback on how to communicate with patients and perform relevant physical examinations. We also use a business chat-tool (Slack®) for sharing information, reflection, and feedback. Again, participation is optional, but so far everyone has participated. Attempts to use chat-like communication tools are beginning to spread in many medical settings, such as education for medical students [ 7], as well as for communication with patients [ 8]. Since most medical students are digital native, communication and education using smartphone applications would be a perfect fit. It is also expected to work effectively for online-clinical clerkships during the COVID-19 pandemic, to prevent the spread of infections. Although it is too early to draw any firm conclusions, we have obtained favorable responses from medical students regarding our clinical clerkship program.
Japan’s rapidly aging society requires medical universities to increase the number of generalists, who are considered to be key players in providing comprehensive care for elderly patients with multiple comorbidities. Despite potential challenges, a division of general practice at a university hospital can be a fish in water by taking various initiatives to foster education and training in the field of general practice.
Acknowledgement
The authors would like to sincerely thank all the staff members for their great contributions to making our department better every day.
Conflict of Interest
Authors declares no conflict of interest.
