Continuous epidural injection of opioid/local anesthetic drugs can be a useful tool to alleviate intractable pain in cancer patients. The use of an epidural catheter, however, always faces with contamination and infection. In order to avoid contamination, an injection port is often implanted in the subcutaneous space and intermittent or continuous injection is employed. The injection port requires an additional cost and a little more time for implantation. Both the cost and the time-requiring procedure may be of problem in the terminally ill cancer patients. We present 3 cases of cancer patients with high risk of catheter contamination treated with continuous epidural injection using catheters elongated through subcutaneous tunnel from the epidural puncture site to the front side of abdominal wall. The risk factors of the patients were; subcutaneous emphysema due to intestinal perforation in a 81 yr male with bladder cancer, local abscess and MRSA infection in a 45 yr female with uterine cancer, and cutaneous tissue disruption in a 51 yr female with lung cancer and multiple metastasis. The duration of epidural analgesia were 22, 26, and 21 days until the patient's death, respectively. Although the risk of epidural catheter contamination and infection was extremely high in all three patients, continuous epidural injection for more than 3 weeks was possible with favorable analgesic effects. Use of an epidural catheter elongated through subcutaneous route from the puncture site to the frontal abdominal wall offers a practical and inexpensive way in patients with intractable pain at least for a few weeks. Palliat Care Res 2011; 6(2): 350-357

We have reviewed the Recommendations on Undergraduate Medical Education published by the General Medical Council (GMC) of the United Kingdom in 1993, and have visited the University of Leicester to see how they have revised their medical course to take account of the GMC's recommendations. The aim of the GMC's recommendations is to promote a culture of self directed learning which will be of value to the future medical practitioners in their postgraduate careers. To achieve this the GMC recommends a reduction in the burden of factual information delivered to the student while promoting learning through curiosity and the exploration of knowledge. The students are given an integrated view of clinical and basic scientific disciplines. The University of Leicester has reorganised its medical teaching around modules relating to body function rather than the traditional disciplines, with contributions being made by clinicians and basic scientists in the same module. The new course places great emphasis on carefully guided and structured self directed study and a reduced number of lectures. Clinical skills are introduced early in the curriculum, while a deeper understanding of selected scientific disciplines are achieved by a series of special study modules where the students undertake supervised scientific research.

To clarify the experience in clinical practice of students at Osaka University Medical School, a questionnaire survey was performed according to the International Classification of Primary Care. More than half of the students had observed only 6 of the 23 reasons for seeking primary care such as headache and hypertension but had not experienced 17 of the 23 reasons, such as cough and abdominal pain. Most students had observed malignancy and chronic diseases, but more than half had only knowledge of 54 of 105 diseases such as appendicitis. In conclusion, medical students' experiences in clinical practice are not well balanced.

Approximately 80 % of medical students start medical training in a specific department at their medical school hospital after graduation and do not experience medical practices in other departments. Therefore, a questionnaire survey of conditions in and opinions about the present postgraduate clinical training was conducted among trainees at Osaka University Hospital. Questionnaires were returned by 136 of the 156 trainees (87.2 %). Their average income was ¥255, 000 per month. Approximately 85 % of trainees had less than 1 day's vacation each month. Forty percent of trainees were not satisfied with the present postgraduate clinical training course, because 75 % felt that their training life was too busy and did not allow them to observe a variety of diseases. These results suggest that the postgraduate medical training program in university hospitals should be changed to include various disciplines in several departments in cooperation with other hospitals and clinics for outpatients. To raise the quality of postgraduate medical training, an education system for trainees must be established and duties unrelated to medical examinations and treatment must be reduced.

Departments of general medicine in medical schools have a mission to innovate in clinical education. However, the kind of work departments should do to promote a newly developed method of clinical education is unclear. In our medical school, the department of general medicine was organized in 1997. In that year, the first task of this department was to strengthen a program of physical-diagnosis skills. Since 1999, this program has developed further and been reorganized. The basic clinical skills course has been organized to include communication, physical diagnosis, basic laboratory examination, and basic surgical skills. In this course students do not rotate through clinics in groups but learn together via a systematic program with simulators. The department of general medicine played a central role in establishing this course. This course led to the introduction of clinical clerkships at our medical school.