Evidence-based medicine (EBM) is the integration of best external evidence with clinical expertise and patient values. The full-blown practice of EBM comprises the following 5 steps; converting the need for information (e.g. diagnosis, prognosis, therapy, and prevention) into an answerable question (step 1), tracking down the best evidence with which to answer that question (step 2), critically appraising that evidence for its validity, impact, and applicability (step 3), integrating the critical appraisal with our clinical expertise and with the patient's unique biology, values and circumstances (step 4), and evaluating our effectiveness and efficiency in executing steps 1 to 4 and seeking ways to improve them both for next time (step 5). Concerning the step 1, it is often difficult to define "exposure" and "outcome" clearly in the field of psychosomatic medicine. For my clinical and research experience under Herbert Benson, M.D at Mind/Body Medicine, Harvard Medical School (1998-2001), definitions of stress and relaxation were quite elaborate tasks to assess the effects of stress management program in the treatment of patients with mind/body distress (Nakao M, Fricchione G, Benson H, et al. Psychother Psychosom 70: 50-57, 2001). He used the word of "relaxation response" instead of "relaxation", and defined it as follows; "the relaxation response is the psychological and physiological opposite of the arousal or stress response, characterized by decreased metabolism, blood pressure, rate of breathing and heart rate in association with feelings of calmness and control." Although general interest in relaxation therapies is on the rise, research in this area does not seem to be growing at the same pace. The working group of the Cochrane library has just begun their work to accumulate literature concerning relaxation therapies for the management of essential hypertension in adults (Nicolson DJ, et al. The Cochrane Database of Systematic Reviews, Volume 1, 2006 [Protocol]). According to this recent report, relaxation therapies include autogenic training, cognitive therapy, behavioral therapy, meditation, guided imagery, biofeedback, progressive muscle relaxation, breathing exercises, and yoga. They identified five systematic reviews, one of which was published by us (Nakao M, Yano E, Nomura S, et al. Hypertens Res 26: 37-46, 2003). In our systematic review, 388 articles were initially selected for review of biofeedback treatment for essential hypertension, but only 22 articles met inclusion criteria for further review and meta-analysis, meaning that the remaining 366 articles did not have enough information based on the standardized quality assessment. Although psychosomatic medicine is comprised of different approaches including internal medicine, psychiatry, psychology, sociology, and behavioral medicine, it should be recognized and applied in the mainstream of medicine, and many researchers and practitioners are needed to be involved in establishing the EBM of psychosomatic medicine.

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Evidence based medicine (EBM) requires the integration of the research evidence with our clinical practice. Many epidemiological data support correlation of psychosocial factors and health problem. These epidemiological data can change our cognition on medical problems therapeutically. Therefore, EBM is not conflict with psychosomatic medicine. Narrative based medicine (NBM) emphasizes importance to subjectivity of patient. Resent epidemiological data supports this principle. NBM is based on relativism. EBM also does not require faith in any single narrative. Thus, EBM and NBM are not opposed to each other. The practice of psychosomatic medicine is to listen to our patients' narrative told by their body as somatic symptom. EBM and NBM can help this challenging practice.

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Objectives: The purpose of this report is to show a key concept of Narrative-Based Medicine (NBM) through qualitative analysis of interactions between the patient, a doctor and a third person. We will now need to consider a plasticity of illness narratives more closely to understand this interactive relationship. Subjects and method: Illness narratives were collected from 20 outpatients at a clinic in Tokyo. From March 2000 to August 2000, we conducted non-structured interviews intensively to examine illness narratives. The subjects of this study were 5 patients who were placed in the 3rd stage of the Four-stage model (Table 1). This study adopted the qualitative research method from an anthropological point of view because it was necessary to mention the influence of researchers upon their subjects. Results: It has been recognized by our research that there is a process to refine illness narrative (Fig. 1). In the 3rd stage of the Four-stage model, patients become an expert of illness experience while medical doctors remain as a specialist of disease. Furthermore, we examined a key concept in NBM. We found that there are 3 aspects of witness in the 3rd stage (Fig. 2); (I) illness narratives of witness, (II) medical doctor as a witness person for their illness narratives, (III) researcher or family member as a second witness person for doctor-patient relationship. Conclusion: We found that each interaction among 3 aspects could be considered indispensable in order to conduct NBM effectively. It is sure that to witness a patient's daily life is one of the most important elements in NBM. Therefore, we named the interaction among 3 aspects Witness-Based Medicine.

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Despite rapid advances in recent years in the field of diabetology, current diabetic therapies still remain unsatisfactory and lead to poor outcomes. What is problematic presumably is that diabetic disorders are closely related to daily life style of the patient, and that the effective therapy requires good self-management of patient's daily life. In diabetes, the treatment significantly depends on the discretion of individual patients and profoundly involves the concept of values by which they live. Here biomedical models are quite limited in offering solutions to diabetic disorders. To cope with the difficulty of this nature in diabetic treatment, psychobehavioral study of diabetes has arisen as an alternative approach and made considerable achievements in intervention and support to change patient's behavior. However, there are encountered many cases that challenge the psychobehavioral approach. In these cases, we employ a narrative approach. Unlike the conventional approach based on objectivity and dualism (cause and effect) that characterize modern science, the narrative approach incorporates viewpoints from medical anthropology into diabetic treatment and heavily weighs patient's subjective attitude and interpretation of events. It is a nonlinear approach and complementary to those areas that are still beyond what biomedical models may address to. The narrative approach is expected to expand the possibility of diabetes practice.

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Communication between patient and physician has received special attention as a major component of medical encounters and a key to patient satisfaction and adherence. Various concepts and models developed in western countries have been introduced to Japan, including informed consent, decision-making, patient autonomy and patient-centered care. However, many aspects of social and cultural life relevant to patient-physician relationships differ between Western and Asian countries. Still, there have been few Japanese studies assessing the patient-physician communication quantitatively, although several qualitative studies focused on the interpretation of patient's narratives. Thus it is important to study the patient-physician communication using a standardized method in Japan. The purpose of this study is to describe characteristics of patient-physician communication in Japanese cancer consultations using the Roter Interaction Analysis System (RIAS), one of the most frequently used systems for the quantitative analysis of patient-physician communication, and to examine the relation of this communication with patient satisfaction. One hundred and forty cancer outpatients and twelve physicians were included. For our analysis, we combined the RIAS categories to make 12 clusters as follows; open-ended question, closed-ended question, information giving, direction, emotional expression (patient), emotional responsiveness (doctor), facilitation, positive talk, negative talk, orientation, requests for service, and social talk. Resultantly, a major part of the interaction concerned information-giving on both parts of physician and patient; this consisted of 35% and 34% of their communication, respectively. In contrast, some categories showed striking differences between physician and patient. The percentage of physicians' question-asking was almost double that of patients' for both open-ended and closed-ended questions, while patients made twice as many positive utterances as physicians. In summary, physicians made more utterances directing the interaction than patients did, and their discussion was largely focused on biomedical topics. The structure of the patient-physician interaction in our study was basically similar to those in previous western studies, although some differences were also found. The relation between patient-physician communication and patient satisfaction was generally consistent with previous studies. Patients were more satisfied with consultations in which the physician used more open-ended questions. On the other hand, physician direction and encouragement was negatively associated with patient satisfaction. Also, patients who asked more questions were less satisfied with the consultation. This study has suggested that the analysis using the RIAS might increase our understanding of the patient-physician interaction in Japan, though with a different perspective from the narrative approach, and provide a direction for future studies of patient-physician communication. In order to further explore the meaning and impact of the communication in the medical encounter and to find a way to improve it, qualitative and quantitative approaches should be used in combination based on study purposes.

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Objective: We have previously reported on how the participation of school health instructors can directly influence the effect and significance of integrated treatment for childhood onset anorexia nervosa. Recently, the prevention of eating disorders in schools has attracted attention. Beginning in 2000, after two-years of preparation, health instructors of junior high schools in the District A of Kobe City participated in a program of educational activities focused on the prevention of eating disorders. This study investigates the effect of these activities on the percentage of emaciated children. Methods: We investigated changes in the percentage of emaciated students (the proportion of students with weight equal to or less than 80% of standard weight) from District A, Kobe City, after school health instructors began conducting the above educational activities. This was compared with the percentage of emaciated students from District B which closely resembled the residential environment and emaciation percentage in District A, but where these activities had not been carried out. Results: 1. Before beginning the program of educational activities, an increased tendency in the percentage of emaciation had been seen, but the percentage significantly decreased after starting the activities. 2. In District B where activities were not performed, no significant changes in the percentage of emaciation were seen. Conclusions: The decrease in emaciation was directly due to the activities of school health instructors focused on the prevention of eating disorders in children. This indicates that prevention of childhood onset eating disorder is possible.

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