1. BACKGROUND: PROBLEMS IN JAPANESE MEDICINE Medicine in Japan has a lot of problems.
Even health care indicators of Japan are great(OECD,2006), self-reported health status of Japanese is lowest as 32.7% (Average 76%, The Conference Board of Canada, 2007).
HOW WE CAN IMPROVE PATIENT SATISFACTION AND PRACTICE EFFICIENCY • Another problem is doctors’ hard working environments. Average working hours per week is 63.3h/w (±20.2h/w, max 152.5h/w). • 67.7% doctors said work load has increased (2006, Ministry of Health, Labor and Welfare).
• Currently, the government is trying to increase doctors and reduce non-medical work of doctors by introducing medical assistants, but we also need to consider improving efficacy in medical practice.
2. PURPOSE This presentation picks up “Walk rounds” as an example of a changeable practice, and proposes alternative to improve quality of Japanese medicine. 3. METHODS • Internet research about Japanese Patients’ satisfaction towards medical service and walking round in the US and the UK • Estimate cost of Japanese walking rounds
4. FUNCTION OF ROUNDS 1. Patient Care and Safety 2. Practice management 3. Medical Education ■Type of the Rounds ■ 1. Team/Walk rounds: Common everyday clinical practice where a group of physicians visit and check their patients’ status in the ward 2. Pre-round : by only an intern 3. Attending rounds : with an attending 4. Teaching rounds : for medical students and interns 5. Chart rounds : by medical charts
5. JAPANESE “GRAND” ROUNDS • In many of so called “walk rounds” in Japanese medical schools, professors spend a few seconds to minutes with each patient. Their interaction to the patients is usually limited to a brief greeting. • There may be no oral presentation, physical examination, or patient centered discussion. • In most cases, the rounding team is so large that all physicians and medical students cannot watch rounding activities.
[ White Castle ~ SHIROI KYOTOU ~ ]
・Japanese one of the most popular medical novel (1963~1965, 1967~1968) ・Became TV drama and movie on 1968, 1978,1990, 2003. Author is Yamazaaki Toyoko (1924~)
PROFESSOR ROUND ≒ “DAIMYO-GYORETSU” ?? Daimyo Gyoretsu was one of the biggest events for Daimyo in the Edo-era (1600-1868, Edo is present Tokyo). The Daimyo procession is a symbol of authority, many Daimyos considered this procession as to display their wealth and status and became so “Grand” that as many as 1,320 men were in the retinue.
6. ANALYSIS : “DAIMYO” ROUNDS REALLY GOOD? (1)Patient satisfaction (2) Cost / Practice management (3) Medical Education
DATA1: PATIENT SATISFACTION
Questionnaire1: Factors needed for Patient-centered practice Doctors believe Doctors’ attitude is the most important, while Patients think Examination and consultation environment ■standardised partial regression coefficient■ Answerer Patients’ Commitment Pt’s Knowledge Patient (N=1131) - 0.17 Doctor (N= 1101) - 0.12 Doc Factor Examination Environment Answerer Thoughts Attitude Skills Patient (N=1131) 0.25 0.23 - 0.3
Doctor (N=1101) - 0.47 0.3 0.28
From Patient and doctor communication p65 , 2005, Tsukahara et al.
Q2 : CURRENT LEVEL OF ACHIEVEMENT OF PATIENT- CENTERED PRACTICE From Patient and doctor communication 10p , 2005, Tsukahara et al.
CURRENT LEVEL OF ACHIEVEMENT OF PATIENT- CENTERED PRACTICE (CONT.)
COST : 1 HOUR WALK ROUND 1. <Doctors’ payment by hour > 1 month ≒ 190 working hours
• Professor : 500000 Yen/month 2600yen/h • Associate & Assistant professor ：400000 Yen/month 2100yen/h • Faculty members : 300000Yen/ month 1600yen/h Total: (2600 + 2100x2 + 1600x15 ) x 1h = 30800 Yen/h
2. ＜opportunity cost＞ 4 patients/ 1 doctor / h x 18 doctor x 4000 Yen = 288000 Yen/h
1* ８hour / day X 24 days = 192h/Month ≒ 190 hour /month 2* Outpatient medical consultation fee : Average 4000Yen/ person/ 1visit /15min
EDUCATION : LONGER, LESS EFFECTIVE • Much time was spent on the first patient discussed, and time decreased until it reached a plateau at the 6th patient • 49.8% of the patients were discussed for < 2 min. each • The order of discussion did not appear to be planned around • specific teaching points or particularly interesting cases Patterns of interaction during rounds: implications for work-based learning MEDICAL EDUCATION 2010; 44: 550–558
7. PROPOSAL : NOT “DAIMYO” BUT “TEAM” ROUNDS (1) Small team Rounds Reduce the pressure to the patients Increase the interaction among the team member Increase visiting duration per each patient (2) Protect Patient privacy more Discussion before/after bedside Explanation about “Rounds” before visit (3) Consider Visiting Order Visit a patient who needs discussion first
REPORT1 : KAGOSHIMA UNIVERSITY Professor Mitsuhiro Osame, (Also Manager of KAGOSHIMA univ. hospital) One day I shocked to see a published diary of patient which strongly criticized Professor rounds. I decided to survey patient opinion towards professor rounds. Many patients preferred smaller rounds saying “Huge rounds scared me and made me hesitate to ask questions”
WE CAN DO “KAIZEN” IN OUR MEDICAL PRACTICE 8. Results Although some patients get reassured by “just being seen by doctors for a second", patient satisfaction may be much more increased if doctors spent more time in each patient with respecting their privacy. It is also suggested that smaller rounds has more educational effects. 9. Conclusion • We need KAIZEN of “Daimyo” rounds to improve quality of our medical service.
Definition : Self-Reported Health Status “In general how would you rate your health?” The percentage of the population, aged 15 years or older, who report their health to be “good” or “very good.”
• Patient and doctor communication 10p , 2005, Tsukahara et al. • www.jpma.or.jp/opir/research/paper-29.pdf • John A. Weigelt, Has Grand Rounds Lost Its Grandeur?
REFERENCE • Walk round in GIM at JICHI university Kuroki et. al • http://kyusyu-27.main.jp/page005.html • Journal of Surgical Education, Volume 66, Issue 3, May-June 2009, Pages 121-122 • Stefan Stieger, Andrea Praschinger, Kurt Kletter, Franz Kainberger • N. Agee, K.N. Foster, L.K. Komenaka, • The effectiveness of grand round lectures in a community-based teaching hospital, Journal of Surgical Education, Volume 66, Issue 2, March-April 2009, Page 67 • Weber, H (H); Stöckli, M (M); Nübling, M (M); Langewitz, W A (WA); Communication during ward rounds in internal medicine. An analysis of patient-nurse-physician interactions using RIAS.、Patient Educ Couns、: 2007-Aug; vol 67 (issue 3) : pp 343-8 ・Evans, H M (HM); Do patients have duties?、 J Med Ethics、2007-Dec; vol 33 (issue 12) : pp 689-94