上原 孝紀

BACKGROUND: This study aimed to clarify the influence of predicting a correct diagnosis from the history on physical examination by comparing the diagnostic accuracy of auscultation with and without clinical information. METHODS: The participants were 102 medical students from the 2013 clinical clerkship course. Auscultation was performed with a cardiology patient simulator. Participants were randomly assigned to two groups. Each group listened to a different simulated heart murmur and then made a diagnosis without clinical information. Next, a history suggesting a different murmur was provided to each group and they predicted the diagnosis. Finally, the students listened to a murmur corresponding to the history provided and again made a diagnosis. Correct and incorrect diagnosis rates of auscultation were compared between students with and without clinical information, between students predicting a correct or incorrect diagnosis from the history (correct and incorrect prediction groups, respectively), and between students without clinical information and those making an incorrect prediction. RESULTS: For auscultation with or without clinical information, the correct diagnosis rate was 62.7% (128/204 participants) versus 54.4% (111/204 participants), showing no significant difference (P=0.09). After receiving clinical information, a correct diagnosis was made by 102/117 students (87.2%) in the correct prediction group versus 26/87 students (29.9%) in the incorrect prediction group, showing a significant difference (P=0.006). The correct diagnosis rate was also significantly lower in the incorrect prediction group than when the students performed auscultation without clinical information (54.4% versus 29.9%, P<0.001). CONCLUSION: Obtaining a history alone does not improve the diagnostic accuracy of physical examination. However, accurately predicting the diagnosis from the history is associated with higher diagnostic accuracy of physical examination, while incorrect prediction is associated with lower diagnostic accuracy of examination.

Objective This study was performed to investigate the factors influencing the correlation between physician satisfaction and patient satisfaction in an outpatient setting.<br> Methods New patients attending the General Medicine Outpatient Clinic of Chiba University Hospital and their physicians were enrolled. After the initial consultation, both the patients and the physicians completed an anonymous questionnaire.<br> Results There were 875 patients (381 men and 494 women; mean age: 54 years) and 10 physicians (4 men and 6 women; mean experience: 6 years). The satisfaction of the patients and the physicians was not correlated (r=0.14, p<0.001). A logistic regression analysis revealed that the factors associated with greater physician satisfaction were "guidance/advice from senior colleagues" [odds ratio (OR)=2.03; 95% confidence interval (CI)=1.76-2.34] and "confidence in the diagnosis" (OR=1.52; 95%CI=1.37-1.69), while "a difficult patient" (OR=0.73; 95%CI=0.68-0.78) was associated with reduced satisfaction. The factors associated with greater patient satisfaction were "the doctor listened carefully" (OR=1.98; 95%CI=1.62-2.42) and "my diagnosis is correct" (OR=1.57; 95%CI=1.41-1.74). One item in the questionnaire for the physicians, "I diagnosed psychogenic illness" (OR=0.87; 95%CI=0.81-0.94), was associated with lower patient satisfaction.<br> Conclusion The satisfaction of the patients and the physicians was not correlated. If only the factors promoting the satisfaction of one party are targeted, the satisfaction of the other party will not increase. The satisfaction of the physicians may be increased by receiving advice from mentors and an improved diagnostic ability, while the patients wants a physician who listens carefully and makes the correct diagnosis.<br>

Background: There have been some studies of common primary care diseases in Japan, but no reports on which diseases it is difficult for general physicians to diagnose in daily practice. In this study, we identified diseases that provided a diagnostic challenge for Japanese general physicians in daily practice. Methods. The subjects were new undiagnosed patients referred to the General Outpatient Department of Chiba University Hospital during the one-year period from January 2008. We performed a retrospective chart review to identify the referring doctor, patient demographics, the duration of symptoms, the final diagnosis, and the outcome. Final diagnoses were classified according to the International Classification of Primary Care Second Edition (ICPC-2). In addition, the differences between referrals from general physicians and those from other physicians were assessed. Fisher's exact test and the Bonferroni-Holm correction were used for statistical analysis. Results: A total of 169 patients were referred by general physicians and 239 patients were referred by other physicians. The most common ICPC-2 diagnosis was "General & Unspecified" conditions (35 patients, 20.7%), followed by "Psychological" conditions (31 patients, 18.3%) and "Musculoskeletal" conditions (21 patients, 12.4%). No significant differences of the ICPC-2 category for the final diagnosis and each diagnosis were found between patients referred by general physicians and those referred by other physicians. The hospitalization rate was lower for patients referred by general physicians than for patients referred by other physicians (4 patients, 2.4% vs. 24 patients, 10.0%) (P = 0.002). Conclusions: Japanese general physicians found difficulty in diagnosing "Psychological" conditions, "Musculoskeletal" conditions, variations within the normal range, and viral infections that required diagnosis by exclusion. Because most of the patients referred by general physicians had mild conditions, further education at outpatient departments and clinics is required to improve diagnostic performance. Additionally, it is important to increase the gatekeeper role of general physicians and further development of the medical system by the government to distinguish the functions of clinics and hospitals is expected.

PURPOSE: To compare the diagnostic accuracy of diseases predicted from patient responses to a simple questionnaire completed prior to examination by doctors with different levels of ambulatory training in general medicine. PARTICIPANTS AND METHODS: Before patient examination, five trained physicians, four short-term-trained residents, and four untrained residents examined patient responses to a simple questionnaire and then indicated, in rank order according to their subjective confidence level, the diseases they predicted. Final diagnosis was subsequently determined from hospital records by mentor physicians 3 months after the first patient visit. Predicted diseases and final diagnoses were codified using the International Classification of Diseases version 10. A "correct" diagnosis was one where the predicted disease matched the final diagnosis code. RESULTS: A total of 148 patient questionnaires were evaluated. The Herfindahl index was 0.024, indicating a high degree of diversity in final diagnoses. The proportion of correct diagnoses was high in the trained group (96 of 148, 65%; residual analysis, 4.4) and low in the untrained group (56 of 148, 38%; residual analysis, -3.6) (χ (2)=22.27, P<0.001). In cases of correct diagnosis, the cumulative number of correct diagnoses showed almost no improvement, even when doctors in the three groups predicted ≥4 diseases. CONCLUSION: Doctors who completed ambulatory training in general medicine while treating a diverse range of diseases accurately predicted diagnosis in 65% of cases from limited written information provided by a simple patient questionnaire, which proved useful for diagnosis. The study also suggests that up to three differential diagnoses are appropriate for diagnostic prediction, while ≥4 differential diagnoses barely improved the diagnostic accuracy, regardless of doctors' competence in general medicine. If doctors can become able to predict the final diagnosis from limited information, the correct diagnostic outcome may improve and save further consultation hours.

RATIONALE, AIMS AND OBJECTIVES: To investigate the subsequent behaviour of doctor-shopping patients (defined as those attending multiple hospitals for the same complaint) who consulted our department and factors related to cessation of doctor shopping. METHODS: Patients who presented without referral to the Department of General Medicine at Chiba University Hospital in Japan (our department) completed a questionnaire at their first visit. A follow-up questionnaire was also sent to them in order to assess doctor shopping after 3 months. Then items in the questionnaires were investigated for significant differences between patients who continued or stopped doctor shopping. Logistic regression analysis was performed with items showing a significant difference between patients who stopped doctor shopping and those who continued it, in order to identify independent determinants of the cessation of shopping. RESULTS: A total of 978 patients who presented spontaneously to our department consented to this study, and 929 patients (95.0%) completed questionnaires correctly. Among them, 203 patients (21.9%) were identified as doctor shoppers. The follow-up survey was completed correctly by 138 patients (68.0%). Among them, 25 patients (18.1%) were found to have continued doctor shopping, which was a significantly lower rate than before (P < 0.001). Logistic regression analysis selected the following factors as independent determinants of the cessation of doctor shopping: 'confirmation of the diagnosis' (odds ratio: 8.12, 95% confidence interval: 1.46-45.26), and 'satisfaction with consultation' (odds ratio: 2.07, 95% confidence interval: 1.42-3.01). CONCLUSION: Doctor shopping decreased significantly after patients consulted our department, with 'confirmation of the diagnosis' and 'satisfaction with consultation' being identified as contributing factors.