General Internal Medicine, as well as Family Medicine, plays an important role in the primary care of North America. General internists in Canada are virtually hospital-based physicians. However, most general internists in the United States are community-based primary care physicians. Although the system in both countries are different, the training of General Internal Medicine is very similar. General internists comprehensively manage patients with complex illnesses such as one with difficult diagnoses, multiproblem or chronic illness. In addition to basic clinical knowledge and skills, they teach students and residents clinical epidemiology, evidence based medicine and clinical decision making.

Influenced by a favorable environment, volunteer activities are integrated into medical education in the United States. Volunteer activities by medical students in hospitals are also becoming more common in Japan. With this background in mind, we performed a survey examining the nature of medical students' volunteer activities at the University of Hawaii in the United States and Saga University in Japan. By analyzing the percentages of students participating in volunteer activities and the location and content of the activities, we found that volunteer activities of medical students in Japan and the United States are strongly influenced by differences in the respective premedical education systems. We found that a premedical education that includes volunteer activities plays an important role in the United States. We suggest that further debate on premedical education that includes volunteer work is necessary for Japan to develop its own methods of medical education.

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.

Objective: To investigate the role and validity of the objective structured clinical examination (OSCE) for neurological screening (Neuro-OSCE) performed by medical students and to analyze the association between Neuro-OSCE score and student behavior for acquiring skills. Method: A 31-item Neuro-OSCE was created for systematic and time-saving screening of neurological findings. At Saga Medical School, 44 final-year students took a screening neurological examination course and performed Neuro-OSCE from August through October 1998. A questionnaire asked about self-educational behaviors, such as self-evaluation, mental concentration, and self-learning (knowlege-based), and self-practicing time. The relationship between Neuro-OSCE score and self-educational behaviors were analyzed. statistically. Results: Cronbach's coefficient alpha was 0.731, which indicated fair internal validity. The mean Neuro-OSCE score was 51.2± 6.6 (SD). Neuro-OSCE score was correlated with self-practicing time and mental concentration but not with self-learning time or self-evaluation. Conclusion: Our Neuro-OSCE has construct validity in the psychomotor domain from a taxonomic viewpoint because the Neuro-OSCE score was correlated with self-practicing time rather than self-learning time. Mental concentration was better a self-assessment method than was self-evaluation. However, setting self-educational goals for neurological examination is probably too difficult at the undergraduate level. Objective assessment by Neuro-OSCE is expected to foster relevant learning behavior.

Objective: To identify factors, such as embarrassment, contributing to the psychological resistance of female patients to physical examination.Methods: Female outpatients were given questionnaires asking about their degree of embarrassment in four areas of physical examination, their tolerance for disrobing during chest examination, and examples of actual episodes of embarrassment experienced during Physical examination. Answers were analyzed statistically. Results: Patients were more embarrassed when examiners were men or were students. When a male student examiner examined the chest and abdomen, the younger the female patients were, the greater their embarrassment was. Conclusions: Male student examiners should be most careful during Physical examination not to embarrass female patients. Gowning may reduce their embarrassment.

OBJECTIVE: To evaluate an undergraduate curriculum of communication skills by measuring satisfaction of outpatients whom final year students had examined.
METHODS: Cross-sectional surveys were conducted in General Medicine Clinic (GMC) of Saga Medical School (SMS) Hospital in 1999 and 2001. After the clinical clerkship in wards in fifth year, final year students experienced the two-week GMC clerkship, including seven hours of small group lecture in 1999, but partly converted into eight hours of small group discussion with a tutor in 2001. Six items in American Board of Internal Medicine Patient Satisfaction Questionnaire were selected as a validated instrument and incorporated into repeated measures ANOVA.
RESULTS: A total of 177 students were evaluated by 688 outpatients. Overall average score was 3.49+/-0.82. Average score in 2001 was significantly higher than that in 1999 (p<0.001; 3.58+ /-0.76vs 3.36+/-0.87) . The scores of“encouraging and answering questions”and“clear explanations”items were significantly lower than those of other items (3.21+/-0.98 and 3.37+/-0.92; Least Significant Difference) . The interaction between gender and years of curricula (1999 and 2001) was significant (p<0.001) ; female students showed remarkable improvement from 1999 to 2001 (Cohen's delta=0.67) .
CONCLUSIONS: Patient satisfaction scores indicated that undergraduate curriculum for communication skills in SMS improved from 1999 to 2001. Newly implemented small group discussion was a possible reason for the improvement, especially in female students. Further training for the skills of encouraging and answering questions and clear explanations will be the next step.

A cross-sectional study was performed in the general medicine clinic of Saga Medical School Hospital to evaluate the humanistic quality of the clinical curriculum by assessing Patient satisfaction. The Patient Satisfaction Questionnaire (PSQ) developed by the American Board of Internal Medicine, was translated into Japanese, and 6 of 10 items were selected to evaluate the humanistic qualities of 123 fourth-year medical students who performed medical interviews of 442 patients. The patients rated each PSQ item with a 5-point scale from poor to excellent. The mean PSQ score was 3.38±0.66 (good to very good). The scores for “answering questions” and “giving clear explanations” were significantly lower than were scores for attitudinal aspects. The results suggest that the undergraduate curriculum at Saga Medical School for patient education skills requires further improvement.

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.

PURPOSE: To determine whether faculty humanistic quality ratings for medical students in an Objective Structured Clinical Examination (OSCE) are associated with student OSCE scores and actual patient satisfaction in a university hospital outpatient (general internal medicine) clinic.
METHODS: Our study was conducted on final-year (sixth grade) medical students in 1998. Forty medical students took the OSCE and were evaluated by faculty internists for humanistic qualities during OSCE sessions. Patient satisfaction ratings for students were also obtained in an outpatient clinic by using six items from the American Board of Internal Medicine Patient Satisfaction Questionnaire (PSQ) . A total of 40 students were evaluated by 117 patients. A multiple regression analysis was used for this study.
RESULTS: In the OSCE, faculty humanistic quality ratings for students were associated with interview skills (p=0.004), but not with physical examination scores nor students' gender. However, patient satisfaction ratings were not statistically associated with faculty humanistic quality ratings for students, other OSCE scores nor with patients' demographic characteristics such as age, sex, occupation and education levels.
CONCLUSIONS: Faculty humanistic quality ratings for medical students taking the OSCE were not significantly associated with patient satisfaction at the outpatient clinic in our study.