Journal of General and Family Medicine最新文献

Streptococcus agalactiae (GBS) is a rare cause of meningitis in healthy adults. We report the case of a healthy 33-year-old man with acute GBS meningitis who experienced relapsed high-grade fever and increased intracranial pressure following completing intravenous antibiotics. A short course of corticosteroids, along with additional antibiotics, improved the cerebrospinal fluid (CSF) profile, and no further complications occurred after the recurrent episodes. The study highlights the need to consider significant CSF inflammation and potential neurological complications in acute GBS meningitis patients, even in the absence of immunodeficiency or previous surgeries. One of the possible routes of infection in our case was suspected from a history of nasal mucosal damage. The importance of careful monitoring and treatment adjustments should be performed and correlated with clinical signs and symptoms.

Aspiration pneumonia (AP) is a major concern in aging populations. AP management requires a comprehensive, multimodal approach—notably including swallowing rehabilitation, oral care, and risk factor management. This scoping review evaluates evidence on swallowing rehabilitation for AP, which consists of compensatory strategies and exercise training. A systematic literature search identified 23 eligible studies from 522 articles; four directly investigated swallowing rehabilitation in AP, while 19 focused on patients with dysphagia due to stroke, neurological diseases, or aging. Two large-scale retrospective AP-specific studies demonstrated a correlation between rehabilitation and improved oral intake but did not evaluate AP prevention or specify effective components. In one study, water jelly ingestion reduced AP incidence. Another study demonstrated the benefits of texture-modified diets in reducing aspiration risk, although AP prevention was not assessed. While clinically compensatory strategies remain foundational, current evidence does not support routine exercise-based interventions for AP prevention. Further high-quality studies are needed.

Varicella pneumonia is a rare but severe complication of varicella-zoster infection in adults. We present what is, to our knowledge, the first documented case of a 24-year-old woman with trisomy 21 who developed disseminated varicella and varicella pneumonia, likely exacerbated by the absence of childhood varicella vaccination. Her social background, including single-parent upbringing and childhood relocation, contributed to her incomplete immunization history. This case highlights the convergence of immunological and social vulnerability and underscores the need for comprehensive vaccination assessments in adults with complex medical and social histories to prevent severe infectious diseases.

“What do generalists do in clinical practice?” Students and specialists often ask this question. Although the identity of generalists in Japan is steadily forming, their specific roles in clinical practice remain unclear.

This ambiguity stems largely from the diverse nature of generalist practice in Japan. Generalists engage in a wide range of activities, including clinical practice, medical education, research, and management; in a range of settings including hospitals, clinics, and home care; in both urban and rural areas.¹ Although this diversity is a strength, descriptions often emphasize differences rather than commonalities. Consequently, what generalists do in practice remains unclear.

This situation creates two important problems. For students, it can foster uncertainty about choosing a career as a generalist. For specialists, it can lead to confusion about when and how to collaborate with generalists, potentially hindering effective teamwork.

To address these challenges, we developed a model to clarify the common clinical roles of generalists (Figure 1). This editorial introduces the key aspects of the generalist's work in practice, focusing on the two fundamental processes of “problem setting” and “problem-solving”.²

Generalists fundamentally differ from specialists in their initial approach to patient care. Whereas specialists typically begin with a defined problem and apply evidence-based strategies to engage in “problem-solving,” generalists must first engage in “problem setting.” This is a complex process that involves identifying, prioritizing, and framing the patient's problems within their unique context before proceeding with problem-solving. Although specialists may appear to engage in problem setting during diagnosis, their main role is to assess whether managing the problem falls within the scope of their specialty; thus, their first step is problem-solving, not problem setting.

The process of problem setting starts with collecting a range of information extending beyond biomedical data from history taking, physical examination, and diagnostic tests, to include contextual factors such as daily life, the patient's health resources, biographical narratives, preferences, values, and life goals. The generalist then analyzes the interrelationships among these elements and works collaboratively with the patient to develop a shared understanding of the situation as a whole. Based on this holistic understanding, the healthcare team formulates a care strategy focusing on the most important health problem.

Problem-setting skills have become a focus of academic inquiry within the fields of generalism and diagnostic excellence. “Patient-centered medicine” stresses the importance of problem definition and proposes practical clinical methods.³ Furthermore, the “Craft of Generalism” highlights the role of interpretive

The effectiveness of Community-Based Clinical Training (CBCT) in increasing the number of general practice physicians remains uncertain. In Japan, where the population is rapidly aging and shrinking, the demand for general practice physicians has significantly escalated to ensure adequate health care for the public, particularly in rural and underserved areas. General practice physicians are expected to play a vital role in providing comprehensive and continuous care to the aging population. Therefore, finding an effective strategy to secure an adequate number of general practice physicians is a crucial social issue.

CBCT is considered a promising approach to addressing this issue. It provides students and residents opportunities to engage with various aspects of community healthcare, including outpatient care, home visiting care, nurse home care, preventive care, health education, and more, particularly in rural and underserved areas. First introduced in the United States, CBCT has been implemented in numerous countries. It has spread rapidly worldwide since the 1990s, and nearly all medical schools and teaching hospitals in Japan offer this clinical training program.

Several studies have examined the effects of CBCT. Trainees report that their experiences during CBCT profoundly influence their understanding of general practice. They acknowledge the importance of acquiring diverse perspectives, understanding the physician's role, recognizing the significance of community care, respecting individual lifestyles, addressing multimorbidity, navigating various healthcare settings, and collaborating with different professionals.¹ This training has a positive short-term impact on attitudes and awareness related to general practice and community healthcare. Participants' ratings of their attitudes and awareness significantly improved after the training, not only in rural areas,¹ but also in urban settings.²

However, the effect of CBCT is insufficient regarding career preferences for general practice physicians. The research conducted with graduates from a single medical university suggests that conventional CBCT might not be sufficient in Japan for effectively developing general practice physicians.³ Additionally, a study at one teaching hospital indicated no positive relationship between the amount of compulsory undergraduate education in community-based medicine and the subsequent rise in the number of residents choosing general practice majors in Japan.⁴

A Longitudinal Integrated Clerkship (LIC) is a novel model of CBCT where students participate in the comprehensive care of patients over time and maintain ongoing learning relationships with both patients and supervising clinicians across multiple disciplines. Although there is no definitive minimum duration for student placements in an LIC program, severa