AYAKO SHIBATA

MS6, ACP-Japan Chapter, Medical Student

Gunma University, Maebashi, Gunma

NO MORE “DAIMYO-GYORETSU”

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

■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

Questionnaire1: Factors needed for Patient-centered practice

Doctors believe Doctors’ attitude is the most important,

while Patients think Examination and consultation environment

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”

I proposed to stop Daimyo-rounds and

Changed it to smaller team rounds,

which works and accepted well by

Patients and Medical staff. (2004.2.18)

Igakukai shinbun 2007/10/15 and His HP: http://www5f.biglobe.ne.jp/~osame/omoukoto/9wa-kaishinn.htm

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.”

Reference ・Doctors’ payment at National university • http://www8.cao.go.jp/cstp/project/compe/haihu09/siryo3-1.pdf

• Outpatient medical consultation fee

• :http://sankei.jp.msn.com/photos/life/welfare/100219/wlf1002190732000-p1.htm

• 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