Published papers

BACKGROUND: Family caregivers and care recipients do not always have the same usual source of care, which may create barriers to providing optimal care for caregivers. This study aimed to compare family caregivers' primary care experiences based on whether they used the same medical facility as their care recipient or a different facility. METHODS: We used cross-sectional data from a survey conducted in Japan in 2020. Participants were family caregivers aged 40-74 years who cared for community-dwelling adults with chronic conditions. Caregivers' primary care experiences were assessed using the Japanese version of the Primary Care Assessment Tool Short Form (JPCAT-SF). Multivariable linear regression analyses were conducted to evaluate differences in JPCAT-SF scores between caregivers who used the same medical facility as their care recipient and those who used a different facility. RESULTS: Of the 406 family caregivers analyzed, 216 (53.2%) used a different medical facility from their care recipient. After adjusting for possible confounders, JPCAT-SF total scores were significantly lower among family caregivers using a different facility compared with those using the same facility (adjusted mean difference -5.73, 95% confidence interval: -8.93 to -2.54). The JPCAT-SF subscale scores for longitudinality, comprehensiveness (services available), and community orientation were significantly lower in the different facility group than the same facility group. CONCLUSIONS: Family caregivers who used a different medical facility from their care recipient reported more negative primary care experiences than caregivers using the same facility. Greater efforts may be needed to provide patient-centered, family-oriented primary care for these caregivers.

PURPOSE: Many countries have introduced duty hour regulations for physicians. The perspectives of resident physicians and programme directors on working hour restrictions for physicians have been extensively studied. Conversely, the perspectives of medical students on this critical issue have been largely overlooked. Thus, we aimed to investigate perceptions of medical students regarding the scheduled implementation of physician work-hour regulation in Japan in April 2024. METHODS: We conducted a multicentre, cross-sectional study in February 2024, focused on medical students in Japan. The participants completed a questionnaire that consisted of closed questions regarding the anticipated impact of work-hour restrictions and an open-ended question regarding their expectations/concerns about the restrictions. We analysed the data using descriptive statistics for the closed-ended questions and inductive content analysis for the open-ended question. RESULTS: Three-hundred fifty-eight medical students responded to the survey. One hundred (27.9%) were not aware of the scheduled implementation of physician work-hour regulations. There was a discrepancy between responses to the closed-ended questions and that to the open-ended question; in the latter, more comments expressed concerns than expectations. A significant proportion of respondents were concerned about the increase in sabisu zangyo (unpaid work). Additionally, a considerable number were concerned about physicians' professional development and the system of limiting physicians' work hour. CONCLUSION: This study elucidated the perspectives of future physicians, a hitherto overlooked category of stakeholders. The findings will contribute to evidence-based policy-making regarding the restrictions and inform the development of concrete support measures to assist physicians in adapting to these changes.

To assess the relationship between polydoctoring and patient outcomes, we conducted a retrospective cohort study using a Japanese population-based dataset from April 2014 to December 2022. Overall, 2,338,965 patients aged 75-89 years with at least two chronic conditions were included. Polydoctoring was assessed by the number of regularly visited facilities (RVFs). The primary outcome was all-cause mortality, with secondary outcomes being all-cause hospitalizations, hospitalizations for ambulatory care-sensitive conditions (ACSCs), and outpatient costs. During the study period, 14.5% of participants died, 52.2% were hospitalized, and 12.5% experienced ACSC-related hospitalizations. Patients without RVFs had the highest mortality risk (HR: 3.23, 95% CI: 3.14-3.33), while those with ≥ 5 RVFs had the lowest (HR: 0.67, 95% CI: 0.62-0.73). ACSC-related hospitalizations were U-shaped, with increased risk at ≥ 5 RVFs (HR: 1.13, 95% CI: 1.06-1.22). Outpatient costs increased 3.21 times for ≥ 5 RVFs compared to 1 RVF. Polydoctoring was associated with reduced mortality but higher hospitalization rates and costs, with an optimal RVF range of 2-3 which minimized ACSC-related admissions. These findings emphasize the need for strategies that balance the benefits and costs of polydoctoring to support sustainable healthcare through improved care coordination and resource management for aging populations.

Background: The aim of this study was to explore what experiences certified primary care physicians (PCPs) in Japan found meaningful in their work. Method: Between October 2021 and February 2022, semi-structured interviews were conducted with Japan Primary Care Association (JPCA)-certified family physicians or JPCA Diplomates in primary care who were working at clinics or small hospitals in Japan regarding “work experiences that they felt were meaningful as physician’s work”. The interviews were conducted face-to-face or via video call. The data obtained were transcribed verbatim and data analysis was conducted using inductive thematic analysis. Results: Fourteen physicians participated in the interview survey. Six themes were identified regarding work experiences that PCPs found meaningful: 1) management of diverse health problems, 2) comprehensive approach to patients, their families, and their issues, 3) trust relationships with patients built by continuity, 4) experience supporting patients with complex problems through interprofessional collaboration, 5) contribution to healthcare provider and medical student education, and 6) contribution to the community and society. Conclusion: PCPs appear to find meaning in their work through two main pathways. First, they improve their own clinical abilities through practice. Second, they experience fulfillment by contributing to patients and the broader community. This clarification of the specific experiences of PCPs that are related to the meaning of work could potentially encourage PCPs working in various settings.

Video question answering (VideoQA) is a task to predict the correct answer to questions posed about a given video. The system must comprehend spatial and temporal relationships among objects extracted from videos to perform causal and temporal reasoning. While prior works have focused on modeling individual object movements using transformer-based methods, they falter when capturing complex scenarios involving multiple objects (e.g., "a boy is throwing a ball in a hoop"). We propose a contrastive language event graph representation learning method called CLanG to address this limitation. Aiming to capture event representations associated with multiple objects, our method employs a multi-layer GNN-cluster module for adversarial graph representation learning, enabling contrastive learning between the question text and its relevant multi-object event graph. Our method outperforms a strong baseline, achieving up to 2.2% higher accuracy on two challenging VideoQA datasets, NExT-QA and TGIF-QA-R. In particular, it is 2.8% better than baselines in handling causal and temporal questions, highlighting its strength in reasoning multiple object-based events.

BACKGROUND: Understanding social determinants of health is essential for medical education, particularly in complex urban settings. This study evaluated a fieldwork-based community diagnosis program designed to help medical students identify community health issues, appreciate diverse social contexts, and integrate theoretical frameworks into practical learning. METHODS: The program was integrated into a two-week general medicine clerkship at X Medical School in Tokyo in 2022-2023. It included an orientation on ecological systems theory and phenomenological reduction, followed by urban fieldwork, student presentations, peer and faculty feedback, and a final report. A realist approach using Context-Mechanism-Outcome (CMO) framework guided the evaluation, focusing on how contextual factors influenced learning mechanisms to produce specific outcomes. Data sources included students' reports, reflective writings, and feedback session transcripts. Qualitative analysis was conducted to identify patterns of learning and interaction. Students' understanding of community health and ability to apply theoretical models were assessed using structured rubrics. RESULTS: The program significantly improved students' ability to observe, analyze, and interpret complex urban community dynamics. Orientation sessions helped students overcome theory-laden biases and expand their observational skills. Fieldwork, coupled with iterative feedback, facilitated double-loop learning, enabling students to reassess assumptions and refine their perspectives. Positionality theory encouraged reflection on power dynamics, leading students to critically examine implicit biases and understand the perspectives of marginalized populations. Through phenomenological reduction, students recognized biases in their biomedical training and shifted toward a holistic understanding of community health, encompassing ecological and social determinants. Peer and faculty feedback promoted intersubjectivity, allowing students to develop a layered appreciation of urban diversity and social complexity. Students reported an increased ability to connect theoretical knowledge with real-world health disparities, proposing actionable, sustainable interventions for urban communities. CONCLUSIONS: This realist approach demonstrated that integrating fieldwork with reflective learning and theory-based frameworks can foster transformative educational experiences. The findings highlight the importance of incorporating community-based programs into medical curricula to prepare future physicians to address health disparities and complex social determinants effectively.

BACKGROUND: Although healthcare professionals pay attention to the drugs prescribed by physicians, few studies have assessed self-medication by family caregivers. Family caregivers' experience of interprofessional care in the care of patients can influence caregivers' health behaviors. OBJECTIVES: This study aimed to describe self-medication among family caregivers of community-dwelling adult patients, and to assess association between family caregivers' experience of interprofessional care and their self-medication, adjusting for possible confounding factors. METHODS: We conducted a cross-sectional survey from November to December 2020 in Ibaraki Prefecture, Japan. Family caregivers between 40 and 74 years old and caring for community-dwelling adult patients with chronic conditions were recruited. The use of any self-medication in the last 2 weeks by family caregivers was the outcome variable. The explanatory variable was family caregivers' experience of interprofessional care in the care of patients, using the Japanese version of the Caregivers' Experience Instrument (J-IEXPAC CAREGIVERS). Adjusted covariates were age, gender, educational attainment, annual household income, self-rated health, and caregiving time of family caregivers. RESULTS: Of 1091 recruited family caregivers, 750 were included in the analysis. A total of 258 (34.4%) family caregivers reported having used self-medication in the past 2 weeks. Logistic regression analysis showed that having a higher score on the J-IEXPAC CAREGIVERS (odds ratio 0.80 per 1 standard deviation increase) was associated with less use of self-medication by caregivers. CONCLUSIONS: This study revealed that about one-third of family caregivers self-medicate, and this practice is associated with a less positive experience of interprofessional care. These results suggest that it is important for healthcare professionals to be aware of the health condition of family caregivers and to provide appropriate advice regarding self-medication.

BACKGROUND: Polydoctoring is a crucial aspect of care fragmentation among patients with multimorbidity, but its impact on health outcomes remains unclear. AIM: To determine the effects of polydoctoring, as measured by the Regularly Visited Facility (RVF) indicator, on patient outcomes among older individuals with multimorbidity. DESIGN & SETTING: Data from the ongoing prospective cohort study, Kawasaki Aging and Wellbeing Project (KAWP), was utilized in this study. Among the 1,026 KAWP participants aged 85-89 years, those with two or more chronic conditions were enrolled in this study. METHOD: Care fragmentation or polydoctoring, was evaluated using the RVF, a new indicator that measures the number of medical facilities consistently involved in a patient's care. Based on RVF, mortality was analysed using the Cox-hazards model, with adjustments for age, sex, frailty, and number of comorbidities. RESULTS: A significant reduction in mortality rates was observed in participants with an RVF of ≥3 and 2-4 comorbidities (hazard ratio [HR] 0.46, 95% confidence interval [CI]: 0.18-0.99). However, no significant difference in mortality based on RVF was observed for those with ≥5 comorbidities. Notably, individuals with ≥5 comorbidities and an RVF of 0 had a significantly higher HR for death (HR 2.68, 95% CI 1.05-6.84). CONCLUSIONS: In older patients with multimorbidity, polydoctoring reduces mortality in patients with ≤4 coexisting conditions, but it does not significantly impact mortality in those with ≥5 conditions. These findings provide insights for healthcare decision-making in managing older patients with multimorbidity.

Abstract Purpose Ambiguity tolerance specific to the clinical context – in contrast to ambiguity tolerance as a personality trait – may vary with experience and has received considerable attention. Although this tolerance appears to be related to burnout and work engagement, few studies have examined this association among physicians. Thus, we aimed to examine the relationships between clinical context-specific ambiguity tolerance, burnout, and work engagement among physicians in Japan. Methods We conducted a nationwide cross-sectional study in Japan. We invited family physicians from 14 family medicine residency programs and physicians with specialties other than family medicine from monitors of an Internet survey company to participate in the study. We measured ambiguity tolerance in the clinical context using the Japanese version of the Tolerance of Ambiguity in Medical Students and Doctors (J-TAMSAD) scale, burnout using the Japanese version of the Burnout Assessment Scale (BAT-J), and work engagement using the Utrecht Work Engagement Scale (UWES). We performed a multivariable linear regression analysis to determine whether the J-TAMSAD scale score was associated with the BAT-J and UWES scores. Results 383 respondents were included in the analysis. After adjustment for possible confounders, clinical context-specific ambiguity tolerance showed a dose-dependent negative association with burnout (adjusted mean difference  -0.39, 95% confidence interval (CI) -0.56 to -0.22 for the highest J-TAMSAD score quartile compared with the lowest). Ambiguity tolerance in the clinical context also showed a dose-dependent positive association with work engagement (adjusted mean difference 0.83, 95% CI 0.49 to 1.16 for the highest J-TAMSAD score quartile compared with the lowest). Conclusions Our study showed that tolerance for ambiguity in the clinical context was negatively associated with burnout, and positively associated with work engagement. These findings will be useful in developing interventions aimed at preventing burnout and promoting work engagement among physicians.

The attributes of collaborative practice in health care vary across contexts, necessitating the adaptation of interprofessional education curricula to prepare students for the collaborative practice expected in their respective health care systems. Culture, when conceptualised through an organisational lens, allows an analysis of the shared assumptions, beliefs and values, without seeking to reduce to a uniform construct. This article explores the differences in interprofessional education competencies between Australia and Japan and considers the systems and patient expectations, which underpin each. While collaborative competence exhibits some similarities across contexts, competency frameworks differ in emphasis, language and key terminology, which highlight multiple points of difference in the expectations of interprofessional collaborative practice across contexts. There are education and practice consequences of these different perspectives of collaborative practice, in an increasingly mobile international workforce.

PURPOSE: In 2021, we introduced a new simulation-based learning program focusing on a roleplay conference before patient discharge. This study aimed to evaluate the program's effectiveness and highlight the significance of cross-training in interprofessional education (IPE). METHODS: In September 2023, the program included 346 students (98 medical, 110 nursing, and 138 pharmacy students). The students' reflective writing was analyzed using inductive content analysis to describe their learning and perspectives. The original items, subcategories, and main categories were extracted. The simulation involved the students role-playing various healthcare professionals during a discharge-planning conference for a stroke patient. This allowed them to experience the challenges and dynamics of interprofessional collaboration. RESULTS: Student feedback emphasized the importance of understanding what constitutes a good healthcare team. A total of 203 items were grouped into eight main categories and 17 subcategories, including patient-centered care (related to the importance of patient-centered care, supporting patient decision-making, communicating with patients during conferences, and facilitating decision-making processes), contrasts in patient and interprofessional communication, conference communication (challenge of building consensus, the way to proceed conferences, importance of conference preparation, and process of information aggregation and realization of outcomes), mutual recognition and role contribution, building relationships (importance of daily interprofessional communication), understanding one's profession (reflection on one's own profession, understanding the roles of different professions, and communication within one's own professional context), recursion into learning (motivation for continuous learning and improvement), and understanding other professions (understanding the role and perspectives of other professions and recognizing professional differences). Specific feedback highlighted improved empathy and communication skills. Students recognized the value of each profession's contribution to patient care. Moreover, students reported a deeper appreciation of patient-centered approaches and the complexities of coordinating care across different healthcare roles. CONCLUSION: Simulated interprofessional team conferences using cross-training effectively taught junior students to understand the essence of a good healthcare team and the importance of a patient-centered approach. Cross-training significantly enhanced students' interprofessional competencies, communication skills, and empathy toward other professions. This case underscores the necessity of incorporating cross-training into IPE to prepare healthcare professionals for collaborative practice and improve patient outcomes. Future research should consider expanding the scope to include more diverse scenarios and longitudinal assessments to measure long-term impacts on professional practice.

OBJECTIVES: Interventions to address psychosocial healthcare issues in older adults are increasing. Realist evaluation (RE) helps us understand how these interventions work for their issues. It is significant to obtain implications for further developing such research. We aimed to identify the characteristics of studies using RE to assess interventions that address psychosocial healthcare issues in older adults by mapping relevant literature. DESIGN: Scoping review. DATA SOURCES: MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science, Cochrane Library, ICHUSHI (a Japanese database) and Google Scholar were used for searches between 5 January 2022 and 4 January 2024. ELIGIBILITY CRITERIA: (1) Showing that most of the participants were older adults or their stakeholders; (2) stating in the research background or aim sections that the target interventions aimed at addressing older adults' psychosocial healthcare issues and (3) using RE to assess these interventions. DATA EXTRACTION: Data on country of origin, type of research, study design, qualitative data collection and analysis methods, desirable items for RE and intervention aims and purposes were extracted and summarised using descriptive statistics. RESULTS: Fifty-four studies were analysed. Most studies were conducted in the UK (54.5%). Mixed methods were used in 28 studies (51.9%), while only qualitative methods were used in 25 studies (46.2 %). Fourteen intervention aims and purposes were identified: improving dementia care, avoiding emergency admissions, preventing social isolation and promoting family involvement in the care of older adults. CONCLUSION: RE is useful for promoting an understanding of how interventions work for addressing psychosocial healthcare issues in older adults. RE also promotes the updating of plausible theories that lead to improving interventions. Our findings show the implications of managing time and resources to address the challenge of RE's time and resource intensiveness and carefully considering the data collection methods to reduce burdens on older adults.

INTRODUCTION: Medical education globally has evolved, with community-based medical education (CBME) and interprofessional education (IPE). This study aimed to explore the implementation of CBME, community comprehensive education, and IPE in Japan. METHODS: A cross-sectional study was conducted across all Japanese medical universities in 2021. Data on CBME clinical clerkships, community comprehensive care education, and IPE were collected from 82 medical universities using a self-administered questionnaire and analyzed using descriptive statistics. RESULTS: The study achieved a 100% response rate. 91.5% of universities offered CBME clinical clerkships, with 39.0% providing training periods up to 10 d. Outpatient practices were the primary CBME location in 90% of cases. 85.4% of institutions provided clinical care services, home medical care, and interprofessional collaboration. Direct observations were adopted 85.4% of the universities as an assessment method. Community comprehensive care education peaked in the fourth year (32.9%), while IPE was most prevalent in the first year (48.3%), followed by the fourth year (35.4%). CONCLUSION: This study, notable for its 100% response rate, highlights the significant incorporation of CBME. Future research should focus on the long-term effects, with recommendations for standardizing CBME curricula and enhancing staff development in a community to improve healthcare outcomes.

OBJECTIVE: To identify generalism-related competencies that medical students in Japan should acquire in order to provide comprehensive care for patients. METHODS: The team responsible for developing the new 'Generalism' section of the 2022 revision of the Model Core Curriculum for Medical Education in Japan (MCC) consisted of nine members from diverse medical backgrounds across Japan. We adopted pragmatism paradigm and analyzed to identify decision-making processes using a qualitative document analysis. RESULTS: The competency list was presented as a four-tier structure. The first tier of generalism was defined as 'take a multi-systemic view of the patient's problems and consider the patient's psychosocial background in order to provide comprehensive, flexible medical care that responds to the needs of the patient and is not limited to one's own specialty, supporting the achievement of individual and societal well-being.' The second tier was framed in terms of 'perspectives' and constructed of four different domains: 'holistic,' 'community,' 'life,' and 'social.' CONCLUSION: We identified and defined the competencies required by medical students in Japan to provide comprehensive care for patients. By including these competencies in the MCC, undergraduate medical education will be better placed to respond to anticipated changes in the demand for medical care in Japan. Success factors in our guideline development process include facilitating a collaborative and iterative development process, ensuring that diverse perspectives are integrated, and using practical examples and feedback to refine competencies based on a pragmatic approach.

BACKGROUND: Multimorbidity increases with age, leading to various adverse outcomes, including higher mortality, care dependency, hospitalizations, and healthcare costs. Polydoctoring, managing a patient with multimorbidity by multiple healthcare providers, can be a risk of fragmented care and increased healthcare expenditures. This study aims to identify patient-related factors contributing to polydoctoring in older adults with multimorbidity. METHODS: This study is a cross-sectional study using baseline data from the Kawasaki Aging and Wellbeing Project. Participants were residents of Kawasaki City aged 85-89 years, without disability in basic activities of daily living, and being able to visit study site. The regularly visited facilities (RVF) index was employed to quantify polydoctoring. Polydoctoring was defined as having two or more RVFs. Poisson regression analysis was conducted to assess the association between polydoctoring and patient demographics, including types of chronic conditions and socioeconomic factors. RESULTS: A total of, 968 participants with multimorbidity were analyzed. Increased RVF was significantly associated with eye diseases (rate ratio [RR] 1.27, 95% confidence interval [CI] 1.12-1.44), osteoporosis (RR 1.22, 95% CI 1.08-1.38), prostate diseases (RR 1.22, 95% CI 1.07-1.40), and osteoarthritis (RR 1.16, 95% CI 1.05-1.27). No significant correlation was found with educational status or financial hardship. CONCLUSION: The study indicated that certain chronic conditions are linked to increased polydoctoring among multimorbid older adults in Japan. However, most of those conditions are considered to be within a scope of family medicine/general practice. Training general practitioners to manage these conditions could reduce healthcare costs and the treatment burden, indicating a direction for future healthcare policy and medical education.

Community-engaged learning (CEL) has gained attention in health professions education, yet there remains limited explanatory understanding of how it generates learning processes in East Asian contexts characterized by hierarchical professional cultures. This study used realist evaluation to examine a two-week rural community diagnosis practicum involving Japanese medical, nursing, and pharmacy students. Data were collected through ethnographic fieldwork, students’ written reflective reports, and ten focus group interviews conducted in 2023 and 2024. Analysis identified five key context–mechanism–outcome (CMO) configurations explaining how learning unfolded under specific conditions. These included disruption of perceived “correctness” through lived community encounters, reframing deficit-oriented assumptions about resources through community storytelling, adaptive learning across institutional boundaries, reconsideration of urban-centric career values, and dialogic engagement enabled by students’ non-expert and outsider positioning. Across configurations, learning was generated when contextual conditions disrupted certainty and loosened institutional scripts, activating mechanisms of reflexive reappraisal, adaptive sense-making, and relational openness. These mechanisms contributed to outcomes such as increased epistemic humility, reorientation of professional assumptions, and heightened sensitivity to relational and contextual dimensions of care. Importantly, the uncertainty and ambiguity inherent in CEL functioned not as limitations but as conditions that enabled these learning processes to occur. By specifying how, why, and under what conditions CEL operated in this setting, the study offers a mechanism-focused explanation of learning in hierarchical and collectivist contexts. Findings from rural Japan highlight the theoretical transferability of these explanations and provide guidance for the design and evaluation of CEL initiatives in other sociocultural settings.