Background: Few studies have focused on the current state of referral and consultation practice between generalists and specialists at Japanese university hospitals.Methods: We retrospectively analyzed the electronic medical records of 513 outpatients (a cumulative total of 608 patients) who visited the Department of General Medicine of Toyama University Hospital between January and December 2016. All patients used our in-hospital consultation and referral service.Results: We referred 492 new patients to different specialists, with 40% referred to psychiatry, orthopedics, otolaryngology, and dermatology specialists. Our suspected diagnoses were correct for 285 of 395 patients (72%) who were referred to specialists to confirm the diagnosis. No abnormalities were observed in 86 patients (21%), and inappropriate referrals were made for 5 patients (1.2%). We also received 116 consultations from specialists, 66% of which were from orthopedics, psychiatry, gynecology, oral dental surgery, and neurosurgery specialists. Many of the referred patients had vague symptoms such as fever and general fatigue.Conclusion: Improving the practical skills of generalists regarding orthopedic and otolaryngologic problems may result in more appropriate referrals. Our department also served as a consultant for medical problems for specialists, especially orthopedic surgeons and psychiatrists.

A program for teaching basic clinical skills to fifth-year medical students was started at Toyama Medical and Pharmaceutical University in 1999. The five units of basic clinical skills included: 1) medical interviewing, 2) general physical examination, 3) chest examination, 4) abdominal examination, and 5) neurologic examination. The educational strategies and evaluations in each unit consisted of: 1) lectures, 2) videotape demonstrations, 3) role-playing in small groups, 4) practice on patients in small groups, 5) written examinations, and 6) objective structured clinical examinations. The students evaluated each session of the program with a five-grade rating scale and comments. Small-group sessions (role play and practice on patients) and objective structured clinical examinations received the highest scores, followed by videotape demonstrations. Lectures received significantly lower scores than did other parts of the program. In addition, most students recommended standardization of educational content, increased practice time, and fewer lectures. We conclude that evaluation by students is essential for improving programs for teaching basic clinical skills.

Abstract
Introduction : The purpose of this study was to identify the function of outpatients' explanatory models by qualitative research.
Methods : Medical records of ninety one patients from our department were investigated from 1st September 2011 to 28th February 2012 inclusive, and were analyzed by the modified grounded theory approach.
Results : The explanatory models were categorized into three groups according to their narrative, which included the following : Diagnostic model, Pathological model and Psycho-social model. Patients in the psycho-social model had no organic diseases except one pneumonia case. In the other two models, one half of the patients had organic diseases. However, the patients' self-diagnoses were frequently incorrect. We considered that their diagnostically incorrect narratives contained potential hidden messages. We therefore generated an hypothesis that patients projected their cognitive images onto the diseases they suspected.
Conclusion : We consider that a patient's self-diagnosis, such as cancer or cerebral infarction, appears to contain both medical information and a metaphorical message. Further investigation is needed to understand the meaning of such hidden messages.

Introduction: Primary care (PC) physicians often struggle with the local dialects of patients, especially when they work away from their hometowns.Method: We conducted a questionnaire survey of PC physicians in the Hokushinetsu region, the northcentral part of Honshu island of Japan, to understand how doctors recognize and deal with local dialects in their daily clinical practice.We also analyzed their comments qualitatively using the Steps for Coding and Theorization (SCAT) method.Results: Thirty-one physicians (21 men and 10 women) completed the questionnaire. Of the total, 71% of respondents worked away from their hometowns.Moreover, 81.8% of these respondents stated they had difficulties understanding the dialect spoken in the region of their workplaces and 36.3% misunderstood the meanings of the dialect spoken by their local patients as a result. Respondents often heard "ui" or "tekinai" as the chief complaints of local patients, and interpreted these words as physical symptoms such as fatigue, dyspnea, and abdominal distension. SCAT analysis suggested that these words can have different meanings depending on the context. PC physicians translate them into medical terms using paraphrasing techniques based on each patient's medical history. Furthermore, PC physicians use dialects according to their relationship with the patient.Conclusion: Understanding the characteristics of these dialects and using them appropriately may improve the doctor-patient relationship.

This study examined and improved the quality of inter-professional moral case deliberation (MCD) in a home-based medical care clinic by altering the MCD process and evaluating it using the REFLECT rubric. After altering the MCD process, four of the five main evaluation items in the questionnaire were shifted to a higher evaluation level employing a scaled evaluation. The free-entry field revealed future tasks. This report suggested that improving the quality and assessment of MCD using REFLECT promotes the reflection skills of clinical teams.

Background: Urosepsis is a potentially fatal syndrome that is sometimes difficult to diagnose. Thus, the aim of the present study was to clarify the clinical and laboratory characteristics and pitfalls in the diagnosis of urosepsis.
Methods: We enrolled the study participants based on clinical records of patients with urosepsis treated between January 2009 and April 2012 inclusive, in the Department of General Internal Medicine, Toyama University Hospital and retrospectively surveyed underlying diseases, clinical symptoms, physical findings, and laboratory data, respectively.
Results: Ten definitive patients were selected (nine females and one male; age, 55–86 years). Fever was the most frequent symptom followed by nausea. Lower back pain was the chief complaint in only two patients. One patient complained of dysuria, and on examination half of the patients lacked costovertebral angle (CVA) tenderness. Five patients showed elevated liver enzymes without evidence of hyperbilirubinemia.
Conclusions: There were no specific clinical characteristics of urosepsis, and symptoms in some patients resembled digestive diseases such as cholangitis. Our results demonstrate that use of dipstick urinalysis and microscopic urinalysis are essential for the diagnosis in patients with sepsis. Abdominal ultrasonography and/or computed tomography should also be considered to rule out false negative results of urinalysis related to urinary tract obstruction, and to detect other focal infections when appropriate.

Introduction : This study aimed to clarify the relationship between the presence of someone to care for and the subjective QOL (quality of life) of local elderly people.
Methods : Data for 7,728 residents aged 65 and above was obtained from the everyday life sphere needs survey implemented by the government of Nanto City, Toyama Prefecture, between May to July, 2014. Multiple logistic regression analysis was conducted to evaluate the relationship between two sets of variables : first, the presence (or absence) of “something to live for”, “sense of fulfillment”, and “self-esteem” as indicators of the respondents'subjective QOL ; and second, a set of explanatory variables (common to all models) including the presence of someone to care for, indicators of the personal attributes, health, and life style of the respondents.
Results : The presence of someone to care for was positively related to the presence of “something to live for,” “sense of fulfillment,” and “self-esteem,” which were indicators of subjective QOL, even after several indicators of personal attributes, health, and life style were accounted for.
Conclusion : Promoting mutual help in local areas has a positive significance for those elderly who take care of others, as well as for those who accept care. The results also suggest the social importance of being the recipient of care in the elderly.

Because the corona disaster made group medical training difficult, we conducted resuscitation training for new students and basic medical skills training for fourth-year students without face-to-face instruction using video learning, assessment, and ICT. In the resuscitation training, the students were allowed to take a mannequin home and film themselves performing the resuscitation while learning by video. Later, group and peer assessment were conducted via Zoom, and a significant increase in self-assessment was observed. In the basic medical skills training, the students filmed their own implementation at their own pace while learning by video, and the teachers later conducted video assessment and feedback. The lack of face-to-face instruction made it possible to implement the limb spine training, which had not been possible in previous years. It is necessary to adjust the timing of the video registration by the students and the video assessment by the teachers, and to make further improvements to the system.