We held an interest group session at the 16th Annual Conference of the Japanese Primary Care Association to share best practices for diagnostic excellence in primary care. In addition to physicians, pharmacists and a medical clerk participated in the session. Participants provided examples of good practices for patient engagement and interprofessional collaboration during group discussion, which included themes such as "sharing diagnostic information," "safety netting to address diagnostic uncertainty," and "feedback about diagnostic errors."

We used a new cardiology simulator twice to train lst-year medical residents in physical examination with a specific behavioral objective shortly after they had received their medical licenses. The first training sessions were to teach residents to understand normal heart sounds and to perform physical examinations in the proper order; the second training sessions were to teach recognition of abnormal heart sounds and murmurs. After the first training sessions, all residents could perform physical examinations in the proper order with special attention to the jugular vein, differentiation of systole and diastole by palpating the carotid artery, splitting of S2, and the timing and transmission of heart murmurs. Just after the second training sessions, all residents thought that their physical examination skills and ability to recognize abnormal heart sounds and murmurs had improved. One year later, the residents were accustomed to performing physical examination in the proper order and could recognize gallop rhythms and murmurs of grade 3/6 or higher. Repeated training with specific behavioral objectives could motivate residents to understand both normal and abnormal heat sounds and murmurs.

To evaluate whether general medicine training in our general ward has beneficial effects on postgraduate surgical training, questionnaires on general medicine training was sent to 30 doctors who had undergone initial training as residents in our hospital and were involved in surgical practice at the time of the survey. Twenty-two responses were obtained. Fifteen respondents had motivation for general practice at the beginning of their residency, and 20 attained their objectives during the 2-year training. Nineteen respondents appreciated their experiences in managing a variety of diseases encompassing the disciplines of internal medicine and surgery, although 12 complained of a shortage of teaching staff. From the viewpoint of its contribution to their present practice, their training in the general ward was evaluated by all respondents as having been beneficial. We conclude that general medicine training has beneficial effects on postgraduate surgical training that emphasizes comprehensive patient care.

All 11 1st-year medical trainees in 1999 participated in medical interview training in the outpatient department under the supervision of senior physicians. Interviews were to be done within 15 minutes. The training was completed when each trainee had interviewed an average of 10 patients. Approximately 70% of the chief complaints were common ones that the Japanese Society of Internal Medicine has recommended general internists master. Most trainees considered this training effective for learning to clarify the patient's reason for seeking care and for improving presentation skills. However, they considered the training ineffective for learning to judge the necessity of emergency care and for understanding the usefulness and limitations of laboratory data, electrocardiograms, and chest films.

In the past 2 years, all 1st-year medical trainees have been instructed in physical examination of patients with heart disease in the general ward of Tenri Hospital by two or three 2nd-year medical trainees who had received special training in physical examination for heart disease. After 1 year of training, all 1st-year medical trainees became confident in making a proper physical examination and in detecting an S3 gallop but were not confident in detecting other abnormal physical findings. On the other hand, the 2nd-year medical trainees thought that they were able to organize their own medical knowledge by teaching 1st-year medical trainees.

Objective: To investigate the role of postgraduate clinical training at the emergency department of Tenri Hospital in teaching the diagnostic process in the general outpatient department.
Method: Patients seen by 11 first-year residents at the emergency department were consecutively registered with summary sheets. Further information was added, and an analysis was performed of: 1) the distribution of chief complaints in the emergency and general outpatient departments and 2) initial diagnoses and the diagnostic process in the emergency department and the final diagnoses.
Results: The distributions of chief complaints in 89 cases in the emergency department and in 183 cases in the general outpatient department were closely correlated (p=0.0016). Diagnoses in the emergency department were correct in 58% of cases. Treatment was incorrect in 3% of cases.
Conclusion: The distributions of chief complaints in the emergency and general outpatient departments were similar. In our hospital the emergency department plays a major role in postgraduate clinical training by teaching the diagnostic process for the general outpatient department. Clinical management, including decision making for further tests and consultation, in the emergency department by first year residents did lead to any major adverse events.

We have conducted weekly 40-minute training session of ECG diagnosis for lst-year postgraduate medical trainees for 6 months. Their abilities to read ECGs were tested before and after training sessions. Before training (just after graduation from medical school) they were able to diagnose typical ECGs if each tracing had only one abnormality and if enough time was given for interpretation. However, they frequently misdiagnosed even ECGs that they had correctly diagnosed on pre-tests if they were presented with many other ECGs and the time for interpretation was limited. Post-tests by students and teachers showed that our training of systematic and orderly reading of ECGs has enabled students to describe ECG findings fairly accurately but could not teach them to diagnose underlying cardiac disorders.

In the past 2 years, five 1st-year medical trainees with excellent knowledge and attitude trained with an instructor supervision in the physical examination of the heart with 4 to 5 patients a week. Despite their undergraduate medical education, these medical trainees could not detect abnormal physical findings of the heart. As much as 5 months of training was required before they could satisfactorily detect such abnormalities.