Journal of General and Family Medicine最新文献

Hepatocellular carcinoma (HCC) is the fifth leading cause of cancer worldwide and majority cases are diagnosed at an intermediate or advanced stage. Per our analysis, greater availability of primary care physicians correlates with lower HCC-related mortality. Our results underscore the need for efforts to expand access to primary care among all populations, especially African Americans, to improve overall HCC-related outcomes.

Since the end of the 20th century, patient safety has become a global issue.¹ Although many patient safety measures (such as changing the behavior of healthcare providers) have been taken, the role of patients in safety measures has also become more important in recent years. Patient engagement (PE) is defined as patients, families, their representatives, and health professionals working in active partnerships at various levels across the healthcare system to improve health and healthcare.² PE to address safety issues that cannot be resolved by healthcare providers alone is considered by policy makers and healthcare providers. However, in Japan, there are barriers to improving patient safety, and one of them is the emphasis on patient centeredness, including PE.¹ Translating patient-centered safety measures including PE from theory to implementation is challenging, making it a global issue; thus, it is important to create learning courses where PE can be taught. Therefore, to promote the PE implementation strategies in primary care, which have traditionally emphasized patient centeredness, we report a Japanese Patient Engagement Promotion Training (J-PEPT) course developed by the Committee on Quality and Patient Safety of the Japan Primary Care Association.

J-PEPT aims to provide participants with the necessary knowledge and skills to implement PE strategies in healthcare settings. It is held about twice a year and has been attended by more than 60 people from across the country to date. Participants include physicians, nurses, pharmacists, as well as patients. PE has been also emphasized when planning, involving not only healthcare professionals (including physicians), but also patients, families, and social scientists from various fields. This is designed such that participants can learn while incorporating diverse opinions, deepening their understanding of the importance of PE.

J-PEPT covers many topics regarding PE, including sessions on implementing PE in primary care using the “guide to improving patient safety in primary care settings by engaging patients and families”,³ utilizing patient experiences, and exploring PE in telemedicine. Several measures have been taken to enhance J-PEPT's implementation in healthcare settings: first, interactive opportunities are provided to offer participants a chance to learn how to promote implementation in their respective healthcare settings. Second, a mindset that can serve as an implementation champion within healthcare institutions is conveyed. Finally, opportunities for patient input are always provided to participants to spark insights, treating the course itself as an opportunity for PE.

In each session, learning objectives are set, and a survey using a 5-point Likert scale (1: “strongly disagree” to 5: “strongly agree”) is conducted to assess whether these objectives have been achi

We appreciate the opportunity to respond to the concerns raised in the letter¹ regarding our article, “Measurement of polydoctoring as a crucial component of fragmentation of care among patients with multimorbidity: Cross-sectional study in Japan.”²

First, we acknowledge the point that in Japan, organ-specific specialists often undertake primary care. This indeed contributes to the prevalence of polydoctoring as patients navigate through multiple healthcare providers. We agree that this unique aspect of Japanese healthcare necessitates a more nuanced understanding of polydoctoring, particularly how it impacts patients with multimorbidity. The propensity for patients to consult multiple healthcare providers is an important aspect of our study, and it is evident that this practice has deep roots in the structural makeup of Japanese healthcare.

Interestingly, our data indicated that approximately one-third of the participants were engaged in regular relationships with a single institution even though they have multimorbidity. This subset of the study population presents an important contrast to the polydoctoring narrative and suggests the presence of integrated care pathways for some patients. This variation in care-seeking behavior offers a unique perspective on patient autonomy and the choices made in managing their health within the existing healthcare framework.

The definition of high-risk polydoctoring is a critical area for further research. The delineation between necessary multidisciplinary care and potentially detrimental polydoctoring remains ambiguous and is subject to individual patient circumstances. Our study's threshold for high-risk polydoctoring may warrant reevaluation in future research to establish more precise criteria that can reliably predict adverse outcomes. Furthermore, it is important to note that fragmentation of care is influenced not only by the number of healthcare providers involved but also by the quality of coordination among them. However, objectively assessing the quality of coordination among various healthcare professionals remains a significant challenge in the current landscape.³ Future research efforts should be directed toward developing methodologies to measure the quality of coordination of care, an aspect crucial for understanding and improving patient care.

Regarding the concerns about selection bias, the letter accurately identifies a significant limitation of our study. Our focus on independently living elderly individuals excluded patients receiving home-based medical care. This omits a crucial subset of patients who may be receiving the most comprehensive care, potentially skewing our understanding of polydoctoring in the broader spectrum of care delivery. The homebound patients, often with diminished physical function, represent a contrasting group to the ambulatory patients who were the focus of our s

We read with great interest the article by T Ando et al, and appreciate the authors' efforts to assess the influence of the uncoordinated involvement of multiple healthcare providers: “polydoctoring.” The analysis highlights that the involvement of multiple healthcare facilities in patient care is correlated with a higher likelihood of polypharmacy and increased outpatient medical costs.¹ However, we would like to point out two concerns.

First, a significant issue in this study was that using the definition of “polydoctoring,” which refers only to having two or more regularly visited facilities, cannot appropriately evaluate the current situation in Japan. It might be unavoidable for today's elderly individuals in Japan to visit multiple medical institutions more than two. Historically, organ specialists played an important role in primary care settings in Japan, and we still have approximately 100,000 primary clinics run by organ specialists. The Japan Primary Care Association (JPCA) has started a training program to qualify doctors as General Practitioner/Family Physician specialists since 2017.² Although JPCA expects these doctors to address a wider variety of common problems such as eye problems and osteoporosis, as well as common medical conditions,³ it is inevitable to face a transient lack of genuine primary care physicians who have completed a proper program. Therefore, in Japan, visiting multiple clinics is necessary for elderly people with coexisting chronic conditions that are beyond the scope of the primary care physicians they see. While the primary care system in Japan is still in development, thanks to universal access under the national health insurance system, elderly individuals can visit multiple medical facilities and enjoy health equity. There is no doubt that the establishment of the universal health insurance scheme in 1961 supports freedom to access medical facilities and services in Japan.⁴ It might be effective to consider the medical specialties visited when renewing the definition of polydoctoring.

In addition, the sample selection was problematic. The authors enrolled individuals only from an independent-dwelling subset. Given the study result, if this survey were to include homebound elderly patients with multimorbidity, they would have fewer chances of receiving polypharmacy. Some elderly individuals, experiencing a decline in physical strength that makes it difficult to visit outpatient clinics, transition to home medical care, where their care should be consolidated. However, it was reported that the prevalence of inappropriate polypharmacy was 70% among older adults receiving home medical care.⁵ Inappropriate prescriptions do not always appear to be associated with care fragmentation.

Accordingly, we suggest that this study cannot accurately evaluate the impact of care fragm

To the Editor,

Burnout is a syndrome conceptualized by emotional exhaustion, depersonalization, and a diminished sense of personal achievement.^{1, 2} Physician burnout has several negative effects, including medical errors and mental ill health.^{2, 3} It is worth addressing that the prevalence of burnout among resident physicians in Japan is high at approximately 30%.⁴ Herein, we, the members of the American College of Physicians Japan Chapter Physicians' Well-being Committee, report factors contributing to burnout of Japanese resident physicians and propose specific countermeasures (Table 1). Our recommendations are the result of focus group discussions with individuals of broad expertise and recent evidence, ensuring that they are grounded and directly relevant to the current challenges faced by resident physicians in Japan.

Poor communication and stress in relationships with medical staff and patients may contribute to burnout among resident physicians.^{2, 3} Because most physicians in Japan start their careers without previous work experience, their communication skills with medical staff and patients may be underdeveloped. Mentoring, sharing plans within the medical team, and changing the teams may improve Communication with other medical staff. Resident physicians should also learn skills for coping with difficult patients who display strong negative feelings toward the physician.⁵ To cope with difficult patient encounters, metacognition of their own feelings, analysis on factors of difficult situations, and improvement in the capacity to empathize are important.⁵

Long working hours, increased workload, sleep deprivation owing to duty shifts, and increased burden of COVID-19 treatment are also risk factors for burnout.^{2, 3} Measures in line with the work reform of physicians in Japan, such as limiting or reducing work, introducing night flow, and mandatory rest after shifts, may be effective. Resilience can be improved by addressing “motivation” through coaching, setting incremental goals, building on successes to increase confidence, and setting new goals.¹

In Japan, factors contributing to burnout among resident physicians include rotations through multiple departments and affiliated hospitals and changes in the environment, including community medicine and “tasuki-gake” training (clinical training in which resident physicians work alternately between primary hospitals and external hospitals/clinics on a 1 year basis). It may be important to limit the number of patients to be assigned at the beginning of the rotation and to simultaneously assess the resident physician's performance. In addition, although changes in the environment increase the number of tasks to be acquired, it is important to modify one's mindset, for exam

I have read with interest the article by Fujimori et al.¹ This case involves a 40-year-old male patient who presented with an abdominal internal oblique muscle hematoma. The intriguing aspect of this case is that the hematoma occurred following a coughing episode, despite the absence of coagulation abnormalities.

Given this unique presentation, it is important to explore all possible underlying factors that could contribute to such an event. One potential cause is the presence of acquired hemophilia, specifically hemorrhagic acquired factor XIII deficiency.² While the patient's platelet count and routine coagulation parameters might appear normal, it is crucial to emphasize that the absence of overt platelet or coagulation abnormalities does not definitively rule out the possibility of acquired factor XIII deficiency.

Acquired factor XIII deficiency is a relatively common disease, but most cases are asymptomatic and do not lead to severe bleeding. However, symptomatic acquired factor XIII deficiency, presenting with hemorrhagic symptoms, is exceedingly rare. This condition can be classified into autoimmune, nonautoimmune, and idiopathic types. Autoimmune acquired factor XIII deficiency is infrequent, with the majority of hemorrhagic acquired factor XIII deficiency being nonautoimmune. Nonautoimmune hemorrhagic acquired factor XIII deficiency, typically presenting as a less severe bleeding disorder, is often attributed to overconsumption or reduced biosynthesis. This can be triggered by various conditions, including disseminated intravascular coagulation, major surgical procedures, liver diseases, and other related disorders. In cases where acquired factor XIII deficiency is suspected, referral to a hematologist is advised, accompanied by a thorough investigation for any underlying pathologies.²

Since neither prolonged clotting times nor decreased platelet counts are seen, many cases with unexplained intramuscular and subcutaneous bleeding might be overlooked. However, depending on the site and the amount of bleeding, the bleeding can be fatal, so prompt diagnosis and appropriate treatment are essential. Clinicians should be alert for acquired factor XIII deficiency when seeing such patients and consider measuring the factor XIII activity.

In conclusion, I recommend further investigation into the possibility of acquired factor XIII deficiency in cases similar to the one described. The absence of overt platelet or coagulation abnormalities should not discourage the pursuit of this diagnostic avenue, as this disorder can present with severe bleeding.

The author declares no conflicts of interest for this article.

This work has never been presented.