論文

我が国における医学部教育の歴史,現状,そして今後の展望について解説する.具体的には,江戸時代からの医学部の変遷をたどり,医学教育モデル・コア・カリキュラムを元にこの20～30年のカリキュラム改革を紐解いた上で,現在どのような入学者選抜,教養・基礎医学・臨床医学の教育が行われており,昨今話題のプロフェッショナリズム教育や共用試験の公的化に触れる.最後に,コロナ禍や国際化など変わりゆく社会での卒前医学教育の展望を述べる.(著者抄録)

保健医療福祉領域における多職種連携教育や複雑な課題を解決するためには,効果的な協働とそれを支える研究の知見が重要である。しかし,この分野の研究は複雑であるため,視座・視点・対象をより意識する必要がある。そのため,本論文では,視座としてのミクロ・メゾ・マクロへの影響,研究の視点の補助線となる学習理論や組織理論などを使用し,個人から地域まで幅広い対象の健康やQOLなどの指標を用いて評価する方法論を整理した俯瞰図を提案する。この俯瞰図に基づき,多職種連携コンピテンシーを理論的枠組みとした具体的な研究を例に,視座・視点・対象・研究デザイン・方法論について紹介する。また,医学・歯学・薬学教育のモデル・コア・カリキュラムにおいて,多職種連携能力が資質・能力に組み込まれたことを皮切りに,今後の多職種連携教育・協働の研究の種を共有する。(著者抄録)

＜文献概要＞Point　◎日本の多職種連携コンピテンシー(JASSIC)はコアにある「患者・利用者・家族・コミュニティ中心」と「職種間コミュニケーション」,それを支える「職種としての役割を全うする」「関係性に働きかける」「自職種を省みる」「多職種を理解する」の6つの領域からなる.◎多職種連携の能力(コンピテンシー),患者参加も含めたチームの協働の質,多職種協働学習の準備状態といった個人の協働能力について検証された自己評価票がある.◎多職種連携を円滑にするためのファシリテーションの評価,家族介護者からの多職種のケアの経験の質評価などもある.◎評価は多職種連携の質を向上させるために重要な役割を果たすため,現場のニーズに基づいて評価票を活用し,多職種連携の効果的な実践が推進されることを期待する.

＜文献概要＞Point　●2022(令和4)年度改訂版の医学・歯学・薬学のモデル・コア・カリキュラムに「総合的に患者・生活者をみる姿勢」が加わった●総合的な視点とアプローチを学ぶには,視点をずらす方法や視点の揺らぎをもたらす多職種連携教育が有用である●総合的な学習の指導には,学習理論の活用,信頼関係の構築,ファシリテーターの貢献が重要となる

保健医療福祉分野におけるエスノグラフィーは、対象者の思いや生活を深く理解するための重要な手法である。本分科会では、家庭医療と医学教育を専門とする医師が、医療現場や地域でのエスノグラフィーの実践を通じて得た知見を報告する。医療者と地域住民の相互作用を描き、数値では表せない現象を言葉で捉える喜びと驚きを得る一方、フィールドワークの難しさや、医師という立場性の影響も痛感した。これらの経験と知見を参加者と共有したい。

Background: General practitioners (GPs) are often faced with complex problems, including patients with socio-economic and medical problems. However, the methods they use to approach these complexities are still not understood. We speculated that elucidating these methods using complex adaptive systems (CAS) methodology to comprehensively assess GPs’ daily activities would contribute to improving the professional development of GPs. This study aimed to clarify how expert GPs handle complex problems and adapt to their community context through the ethnography of GPs and other healthcare professionals in terms of CAS. Methods: We adopted the interdisciplinary team-ethnographic research approach. Five hospitals and four clinics in Japan which were considered to employ expert GPs were selected by purposive sampling. 62 individuals of various backgrounds working in these nine facilities were interviewed. Using field notes and interview data, the researchers iteratively discussed the adequacy of our interpretations. The first author (JH) prepared a draft report, which was reviewed by the GPs at the participating facilities. Through critical and iterative consideration of the different insights obtained, the final findings emerged together with representative data. Results: We identified four approaches used by GPs to deal with complexities. First, GPs treat patients with complex problems as a whole being and address their problems multi-directionally. Second, GPs build horizontal, trusting relationships with other healthcare professionals and stakeholders, and thereby reduce the degree of complexity of problems. Third, GPs change the learning climate while committing to their own growth based on societal needs and by acting as role models for other professionals through daily interpersonal facilitation. Fourth, GPs share community vision with multi-professionals and thereby act as a driving force for organizational change. These various interactions among GPs, healthcare professionals, organizations and communities resulted in systematization of the healthcare and welfare network in their community. Conclusions: Expert GPs developed interconnected multidimensional systems in their community health and welfare networks to adapt to fluctuating social realities using four approaches. GPs’ work environment may be considered as a complex adaptive system (CAS) and the approach of GPs to complexities is CAS-based. Our findings are expected to have practical applications for GPs.

　筑波大学の取り組みを2つに分けて報告する. 第1部では, 筑波大学と茨城県立医療大学の大学間連携教育プログラムであるインタープロフェッショナル演習を紹介する. COVID-19パンデミック前は, この演習はTBL (Team-based learning) の方法を用いて大会議室で行っていた. パンデミック後はこれをオンライン (Zoom使用) で実施した. オンライン実施により変更した点は以下の5点 ; (1)教員会議のオンライン化, (2)資料の事前配布, (3)Googleフォームを用いたテスト, (4)ブレイクアウト機能を用いたグループワーク, (5)Googleドキュメントを用いた同時編集, であった. 今後は, オンラインの多職種連携教育プログラムだからこそできる新たな教育方法の可能性を検討していきたい.

　第2報第2部では, 筑波大学と東京理科大学の大学間連携プログラムであるケア・コロキウムを紹介する. ケア・コロキウムはPBL (Problem-based learning) 形式の多職種連携教育プログラムである. COVID-19パンデミックに対応し, このプログラムをMicrosoft Teamsを利用して, マニュアルの整備や通信テストなど事前準備を整えオンラインで実施し, 対面実施と同様の学びが抽出された. 卒前の多職種連携教育は大規模プログラムとなりやすく, 教員不足, 教室不足が障害となるが, オンライン教育ではこれらの障害を解決できる可能性がある. 対面とオンライン, 両者のメリットを生かしたハイブリッドプログラムの開発など今後の多職種連携教育の推進につながる可能性が考えられた.

Crush syndrome induced by skeletal muscle compression causes fatal rhabdomyolysis-induced acute kidney injury (RIAKI) that requires intensive care, including hemodialysis. However, access to crucial medical supplies is highly limited while treating earthquake victims trapped under fallen buildings, lowering their chances of survival. Developing a compact, portable, and simple treatment method for RIAKI remains an important challenge. Based on our previous finding that RIAKI depends on leukocyte extracellular traps (ETs), we aimed to develop a novel medium-molecular-weight peptide to provide clinical treatment of Crush syndrome. We conducted a structure-activity relationship study to develop a new therapeutic peptide. Using human peripheral polymorphonuclear neutrophils, we identified a 12-amino acid peptide sequence (FK-12) that strongly inhibited neutrophil extracellular trap (NET) release in vitro and further modified it by alanine scanning to construct multiple peptide analogs that were screened for their NET inhibition ability. The clinical applicability and renal-protective effects of these analogs were evaluated in vivo using the rhabdomyolysis-induced AKI mouse model. One candidate drug [M10Hse(Me)], wherein the sulfur of Met10 is substituted by oxygen, exhibited excellent renal-protective effects and completely inhibited fatality in the RIAKI mouse model. Furthermore, we observed that both therapeutic and prophylactic administration of M10Hse(Me) markedly protected the renal function during the acute and chronic phases of RIAKI. In conclusion, we developed a novel medium-molecular-weight peptide that could potentially treat patients with rhabdomyolysis and protect their renal function, thereby increasing the survival rate of victims affected by Crush syndrome.

Background: Care fragmentation, characterized by the uncoordinated involvement of multiple healthcare providers, leads to inefficient and ineffective healthcare, posing a significant challenge in managing patients with multimorbidity. In this context, “polydoctoring,” where patients see multiple specialists, emerges as a crucial aspect of care fragmentation. This study seeks to develop an indicator to assess polydoctoring, which can subsequently enhance the management of multimorbidity. Methods: Baseline survey data from the Kawasaki Aging and Wellbeing Project (KAWP) involving independent community-dwelling older adults aged 85–89 were utilized in this cross-sectional study. Polydoctoring measure was defined as the number of regularly visited facilities (RVFs). The association of RVF with the Fragmentation of Care Index (FCI) and the outcome measures of polypharmacy and ambulatory care costs were examined as indicators of care fragmentation. Results: The analysis comprised 968 participants, with an average of 4.70 comorbid chronic conditions; 65.3% of the participants had two or more RVFs, indicating polydoctoring. A significant correlation between RVF and FCI was observed. Modified Poisson regression analyses revealed associations between higher RVF and increased prevalence ratio of polypharmacy. Likewise, a higher RVF was associated with higher outpatient medical costs. Conclusions: RVF was significantly correlated with FCI, polypharmacy, and higher outpatient medical costs. Unlike complex indices, RVF is simple and intuitively comprehensible. Further research is needed to evaluate the impact of care fragmentation on patient outcomes, considering factors such as RVF thresholds, patient multimorbidity, and social support. Understanding the influence of polydoctoring can enhance care quality and efficiency for patients with multimorbidity.

In this study, we developed and validated the Clinical Student Version of the Japanese Interprofessional Competency Self-Assessment Scale (C-JASSIC) for healthcare students in their clinical practice phase. Data obtained from 331 students (medical, 98; nursing, 99; pharmacy, 134) during orientation for interprofessional education (pre-IPE) and from 319 students (medical, 94; nursing, 93; pharmacy, 132) within a week following IPE (post-IPE) were analyzed. Exploratory pre-IPE and Confirmatory post-IPE factor analyses revealed a consistent 6-factor structure aligning with the Japanese Interprofessional Competency domains. The scale exhibited strong internal consistency, with Cronbach’s α values exceeding 0.8 for all factors both pre- and post-IPE. Scores for overall competency and individual domains increased post-IPE in 234 matched cases. A notable significant pre vs post difference concerned “Understanding of Others,” indicating enhanced interprofessional comprehension after clinical practice. There was a weak but significant positive correlation between IPE satisfaction and difference in pre- and post-IPE scores. However, no significant differences were observed among medical, nursing, and pharmacy students. Despite its strengths, such as its competency-based design and cultural relevance to Japan, a limitation of the study may be potential self-reporting bias. Nonetheless, C-JASSIC represents a valuable tool for seamless competency evaluations from student to professional stages, with implications for broader Asian contexts.

In this short communication, we reconceptualize autonomy in medical education, particularly within the context of professional identity formation (PIF). Traditionally, autonomy has been framed as independence and achievement based on ‘fixed norms’. However, identity is also shaped through ‘relational responsiveness’, which emphasizes mutual engagement and co-construction. Drawing on Asian cultural understandings of selfhood, we propose viewing autonomy as integrity enacted within a network of mutual responsibility. We argue that both fixed norms and relational responsiveness are essential, and we introduce a preliminary framework that highlights their complementary roles. While responsiveness fosters adaptability and connectedness, it can lead to identity diffusion if not grounded in internal standards. A blended model of both modes offers a more inclusive, culturally sensitive, and resilient approach to PIF in today’s complex medical landscape.

The aim of the study was to examine laypeople's perspectives on the impending implementation of physician work-hour restrictions in Japan, which had received limited research attention. We conducted a nationwide cross-sectional study in January 2024. The participants were monitors of an internet survey company who responded to closed questions regarding the expected effect of work-hour regulations, along with an open-ended question regarding their expectations or concerns about these restrictions. The data were analyzed using descriptive statistics for closed questions and content analysis for the open-ended questions. The study included 484 laypeople. A significant portion (25.4%) was unaware of the scheduled start of work-hour restrictions. Approximately half of the participants had a neutral view of the overall impact of the restrictions. Content analysis of the open-ended responses identified 130 (60.2%) comments as “expectations” and 70 (32.4%) as expressing “concerns,” with a notable number of comments deemed to indicate that the respondents were “unsure” or found the changes “irrelevant” to them. This study indicates a substantial gap between the views of physicians and laypeople on this issue.

Crush syndrome, which frequently occurs in earthquake disasters, often leads to rhabdomyolysis induced acute kidney injury (RIAKI). Recent findings indicate that systemic inflammatory response syndrome (SIRS) exacerbates muscle collapse, contributing to RIAKI. The purpose of this study is to investigate the involvement of multiple site inflammation, including intraperitoneal, in crush syndrome. In a mouse model of RIAKI, elevated levels of inflammatory mediators such as TNFα, IL-6, myoglobin, and dsDNA were observed in serum and the peritoneal cavity, peaking earlier in the intraperitoneal cavity than in serum or urine. Our previously developed novel peptide inhibiting leukocyte extracellular traps was administered intraperitoneally and blocked all of these mediators in the intraperitoneal cavity and serum, ameliorating muscle damage and consequent RIAKI. Although further studies are needed to determine whether intraperitoneal inflammation associated with muscle collapse can lead to systemic inflammation, resulting in more severe and prolonged muscle damage and renal injury, early suppression of multiple site inflammation, including intraperitoneal, might be an effective therapeutic target.