An "integration" of professional identity formation among rural physicians experiencing an interplay between their professional and personal identities

The present understanding of professional identity formation is problematic since it underrepresents minority physicians and potentially excludes their professional identity formation experiences. Rural physicians are expected to have similar underrepresented aspects as minority physicians because of their specific sociocultural contexts and consequent private-professional intersection, which lead to ethical complexities. Therefore, to bridge this research gap, we interviewed 12 early- to mid-career Japanese physicians working in rural areas and explored their experiences. Through a narrative analysis guided by Figured Worlds theory, we analysed the data by focusing on the vocabulary, expressions, and metaphors participants used to describe their experiences. A central theme emerged concerning how the rural physicians configurated their personal versus professional participation in their local communities. Further, their identity narratives varied regarding how they constructed their identities, rural communities, and relationships as well as their identity formation ideals and strategies to achieve them. Informed by 'Big Questions' concerning worldview framework, we delineated four identity narratives as prototypes to describe how they participated in their communities. These identity narratives provide a preliminary understanding of how diverse identity formation is for rural physicians. In addition, our findings exposed the current professional identity formation framework as potentially biased towards single forms of participation in monolithic communities, overlooking complicated forms of participation in multiple communities. We argue that applying frameworks and concepts to capture these multiple forms of participation as well as revisiting the 'discourse of integration' are necessary steps to overcome the limitation of the current understanding of professional identity formation.

Exploring yarigai: The meaning of working as a physician in teaching medical professionalism

INTRODUCTION

The shift in medical professionalism now considers the well-being of physicians, given the prevalence of burnout and the importance of work-life balance. To reconsider the question 'Why do doctors work for the patient?' and explore the meaning of working as a physician, this study adopts the concept of 'yarigai,' which represents fulfillment and motivation in meaningful work. The authors' research questions are: How do doctors recount experiences of yarigai in caring for patients? What kind of values are embodied in their stories about yarigai?

METHOD

They adopted narrative inquiry as the methodology for this study. They interviewed 15 doctors who were recognized by their colleagues for their commitment to patient-centered care or had demonstrated yarigai in caring for patients. The semi-structured interviews were conducted face-to-face with each participant by the Japanese researchers, yielding 51 cases of patient-doctor interactions. After grouping the interview data, they translated the cases into English and identified four representative cases to present based on the set criteria.

RESULTS

From the 51 case studies, they constructed four representative narratives about the yarigai as a physician. Each of them spoke of (1) finding positive meaning in difficult situations, (2) receiving gifts embodying ikigai, (3) witnessing strength in a seemingly powerless human being, and (4) cultivating relationships that transcend temporal boundaries, as being rewarding in working as a physician. The main results of the study, which are the narratives, are described in the main body of the paper.

CONCLUSION

The stories on yarigai gave intrinsic meanings to their occupational lives, which can be informative for students, residents, and young physicians when contemplating the meaning of their work as doctors. Rather than demanding selfless dedication from physicians towards patients, they believe it more important to foster yarigai, derived from the contribution to the well-being of others through patient care.

Deconstructing the masculinized assumption of the medical profession: narratives of Japanese physician fathers

BACKGROUND

Gender studies in the medical profession have revealed gender biases associated with being a doctor, a profession often regarded as more suitable for men. The path to gender equality inevitably involves deconstructing this masculinized assumption. Despite the decades-long expectation that ikumen-men who actively participate in childcare in Japan-would contribute to a change toward gender equality, Japanese society is still male dominated, and women suffer from a large gender gap. With the aim of exploring implicit gendered assumptions concerning being a caregiver and a doctor, the authors focused on the experience of individuals juggling the binary roles of a professional and a caregiver.

METHODS

The authors conducted subjectivist inductive research, recruited ten Japanese physician fathers through purposive sampling, and collected data through one-to-one semi-structured interviews between October 2017 and December 2018. The authors recorded and transcribed the narrative data, and extracted themes and representative narratives.

RESULTS

The study identified three themes about the reproduction and potential change of the gender gap: maintaining gendered assumptions of the medical profession without experiencing conflict, maintaining gendered assumptions of the medical profession while experiencing conflict, and deconstructing gendered assumptions of the medical profession through conflict. The authors found that these negotiations interplayed with the gendered division of labor between male doctors and their wives as well as the patriarchal family structure.

CONCLUSIONS

The study revealed how gendered assumptions of the medical profession, as well as gender stereotypes and gendered division of household labor, were reproduced in the course of male doctors' negotiations when they became fathers. For male doctors to question their unconscious gender bias, the authors emphasize the importance of men gaining knowledge about gender stereotypes, and propose that educators create such opportunities. Moreover, the authors assert that increasing doctors' awareness of how masculinized assumptions implicitly interact with ideas of being a doctor-an aspect rarely discussed among medical professionals-is crucial for deconstructing the gendered normativity in the medical field.

Reconstructing the concept of empathy: an analysis of Japanese doctors' narratives of their experiences with illness

The ability of doctors to empathise with patients is a crucial concern in establishing humanistic medicine. Therefore, the cultivation of this ability has been discussed extensively in medical education. One theory suggests that the experience of patienthood can increase empathy among doctors. This theory is supported by previous research that published doctors' illness narratives. However, the concept of empathy has been ambiguously defined in academic fields, including medicine; therefore, analysing how doctors experience 'empathy' in their interactions with patients is difficult. Our research question is how doctors who became patients describe the relationship between their illness experiences and the interactions with patients after their illness. To this end, this paper initially tracks the debates on 'empathy' in medicine and other disciplines, to develop a lens for analysing doctors' illness narratives. Next, we conduct a narrative analysis of illness stories from 18 Japanese medical doctors who became patients. Our analysis supports the traditional idea that an illness can enable a doctor to become more empathetic. However, this is overly simplistic; how doctors experience and subsequently process their illness is more complex. Moreover, this notion can disregard doctors' suffering in these circumstances, and fail to represent the often-lengthy process of mastering 'empathy' based on their experiences. Therefore, our analysis deconstructed the concept of 'empathy', showing that it can appear in various ways. Further research is required to elucidate how empathy is cultivated during the process of transformation of doctors' illnesses, focusing on their communities and practices.

Safety evaluation of the use of calcineurin inhibitor to prenatal and postpartum women in Japan from a health administrative database

BACKGROUND

To investigate the use of calcineurin inhibitors (CNIs) in pregnant Japanese women and to evaluate their safety in infants.

METHODS

Data were extracted from the claims database of the Japan Medical Data Center. The prevalence of CNIs was evaluated 180 days before pregnancy onset, during pregnancy, and within180-days post partum. We investigated the characteristics of the infants, including the presence of major malformations and their diagnoses, for 1 year after birth.

RESULTS

A total of 91,865 pregnancies in 80,049 women were included. Fifty-three women were prescribed CNIs between 180-day before pregnancy onset and 180-day postpartum; 35 of the 53 women were prescribed the drugs during pregnancy, and 10 of their infants were born preterm. Three were diagnosed with major congenital malformations, such as patent ductus arteriosus. Six preterm infants presented with infant respiratory distress syndrome.

CONCLUSIONS

No congenital anomalies were clearly attributable to the use of CNIs during pregnancy.

Locally adapting generic rubrics for the implementation of outcome-based medical education: a mixed-methods approach

BACKGROUND

Rubrics are frequently used to assess competencies in outcome-based medical education (OBE). The implementation of assessment systems using rubrics is usually realised through years of involvement in projects with various stakeholders. However, for countries or specialities new to OBE, faster and more simplified processes are required. In March 2019, Japan introduced nine competencies and generic rubrics of competencies for medical residents. We explored the local adaptation of these generic rubrics and its consequences for assessors.

METHODS

The study followed three steps. First, we locally adapted the generic rubrics. This was followed by conducting mixed-method research to explore the effect of the local adaptation. In step two, we examined the correlations between the scores in the locally adapted assessment sheets for supervising doctors and generic rubrics. In step three, we conducted interviews with supervising doctors. The study was conducted in the General Internal Medicine Department of Nagoya University, Japan. In the first step, doctors in the Medical Education Center and other medical departments, clerks, and residents participated. Supervising doctors in the General Internal Medicine Department participated in the second and third steps.

RESULTS

A locally adapted assessment system was developed and implemented in seven months. The scores of the generic rubrics and the adapted assessment tool completed by the supervising doctors showed good correlations in some items as opposed to others, assessed mainly with other tools. Participant interviews revealed that local adaptation decreased their cognitive load leading to consistent ratings, increased writing of comments, and promoting reflection on instruction.

CONCLUSIONS

This adaptation process is a feasible way to begin the implementation of OBE. Local adaptation has advantages over direct use of generic rubrics.

Cultivating cultural awareness among medical educators by integrating cultural anthropology in faculty development: an action research study

BACKGROUND

In faculty development, understanding each participant's cultural context is important. However, there is scarce evidence on how to improve cultural understanding in faculty development. Cultural anthropology is a discipline that focuses on developing cultural self-awareness by understanding different cultures. Professionals from this field can be crucial to the goal of cultivating cultural awareness among medical educators. The aims of this study are to 1) develop and modify cultural anthropology sessions in faculty development and 2) evaluate the effectiveness of these sessions, including their long-term impacts.

METHODS

The cultural anthropology sessions were organized as part of a longitudinal faculty development program-Foundation Course for Medical Education-at Kyoto University in Japan. The study included 47 medical educators participating in faculty development and three lecturers: two cultural anthropologists and a medical educator. We developed the cultural anthropology sessions and implemented them in the longitudinal faculty development program. In these sessions, cultural anthropologists used inquiry-guided reflection. An action research methodology was employed and repeated in four cycles from 2015 to 2018. Qualitative and quantitative data were collected during the action research cycles. The qualitative data were thematically analyzed.

RESULTS

The cultural anthropologists' inquiries fostered learning during the sessions, and three themes-cultural relativism, attention to context, and reframing-were synthesized. As a long-term impact of the sessions, the learners reported becoming more aware of the cultural contexts in their daily educational and clinical activities.

CONCLUSIONS

The cultural anthropology sessions in the faculty development program were shown to have enhanced the participants' awareness of cultural contexts. The concept and format of these sessions may be used more widely in faculty development programs.

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries

Purpose

The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data.

Methods

We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing.

Results

We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data.

Conclusions

Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

Advancing the science of health professions education through a shared understanding of terminology: a content analysis of terms for "faculty"

INTRODUCTION

Health professions educators risk misunderstandings where terms and concepts are not clearly defined, hampering the field's progress. This risk is especially pronounced with ambiguity in describing roles. This study explores the variety of terms used by researchers and educators to describe "faculty", with the aim to facilitate definitional clarity, and create a shared terminology and approach to describing this term.

METHODS

The authors analyzed journal article abstracts to identify the specific words and phrases used to describe individuals or groups of people referred to as faculty. To identify abstracts, PubMed articles indexed with the Medical Subject Heading "faculty" published between 2007 and 2017 were retrieved. Authors iteratively extracted data and used content analysis to identify patterns and themes.

RESULTS

A total of 5,436 citations were retrieved, of which 3,354 were deemed eligible. Based on a sample of 594 abstracts (17.7%), we found 279 unique terms. The most commonly used terms accounted for approximately one-third of the sample and included faculty or faculty member/s (n = 252; 26.4%); teacher/s (n = 59; 6.2%) and medical educator/s (n = 26; 2.7%) were also well represented. Content analysis highlighted that the different descriptors authors used referred to four role types: healthcare (e.g., doctor, physician), education (e.g., educator, teacher), academia (e.g., professor), and/or relationship to the learner (e.g., mentor).

DISCUSSION

Faculty are described using a wide variety of terms, which can be linked to four role descriptions. The authors propose a template for researchers and educators who want to refer to faculty in their papers. This is important to advance the field and increase readers' assessment of transferability.

A scoping review of clinical reasoning research with Asian healthcare professionals

Clinical reasoning is the thought process that guides practice. Although a plethora of clinical reasoning studies in healthcare professionals exists, the majority appear to originate from Western cultures. A scoping review was undertaken to examine clinical reasoning related research across Asian cultures. PubMed, SciVerse Scopus, Web of Science and Airiti Library databases were searched. Inclusion criteria included full-text articles published in Asian countries (2007 to 2019). Search terms included clinical reasoning, thinking process, differential diagnosis, decision making, problem-based learning, critical thinking, healthcare profession, institution, medical students and nursing students. After applying exclusion criteria, n = 240 were included in the review. The number of publications increased in 2012 (from 5%, n = 13 in 2011 to 9%, n = 22) with a steady increase onwards to 12% (n = 29) in 2016. South Korea published the most articles (19%, n = 46) followed by Iran (17%, n = 41). Nurse Education Today published 11% of the articles (n = 26), followed by BMC Medical Education (5%, n = 13). Nursing and Medical students account for the largest population groups studied. Analysis of the articles resulted in seven themes: Evaluation of existing courses (30%, n = 73) being the most frequently identified theme. Only seven comparative articles showed cultural implications, but none provided direct evidence of the impact of culture on clinical reasoning. We illuminate the potential necessity of further research in clinical reasoning, specifically with a focus on how clinical reasoning is affected by national culture. A better understanding of current clinical reasoning research in Asian cultures may assist curricula developers in establishing a culturally appropriate learning environment.

Problem-Based Learning in Child and Adolescent Psychiatry: A Perspective from Japan

PURPOSE

Japanese higher education institutions have long been striving for the globalization of medical education. Nagoya University (NU) adopted PBL as a means of enhancing intercultural awareness in globalizing medical education by working with the Norwegian University of Science and Technology (NTNU), Faculty of Medicine and Health Science, under the Trondheim NTNU-Nagoya (TroNa) partnership for mobility and internationalization of child and mental health studies. This study aims to assess students' attitudes towards PBL and to suggest future developments in this form of education by introducing common PBL scenarios experienced at NTNU and NU.

METHODS

Two 90-minute PBL sessions were conducted at NU. Ten groups of medical students were formed, each consisting of up to 10 students, and students were asked to fill in a questionnaire developed to assess their understanding of, attitudes to and satisfaction with the classes. We investigated three different groups of questions on: NU medical students' general impressions of PBL; their impressions of PBL in child and adolescent psychiatry (CAP); and their impressions of PBL in specific case scenarios. Correlations between each of the questions from the three groups were evaluated using multivariate analysis.

RESULTS

Overall, a majority of the NU medical students were satisfied with PBL, while a small number preferred traditional lecture-style learning (5%). More than half of the students agreed that PBL increased their understanding and interest in CAP (53%), although some male students felt that the amount of time spent was insufficient (20.3%). Correlations were seen for students who thought that PBL enhanced their understanding of and interest in CAP. Regarding case scenarios, most students (82.5%) agreed that PBL helped them to develop clinical problem-solving skills.

CONCLUSION

The study found an overall positive attitude towards PBL, PBL in CAP and the specific PBL case scenario presented.

A collaborative clinical case conference model for teaching social and behavioral science in medicine: an action research study

BACKGROUND

Effective social and behavioral sciences teaching in medical education requires integration with clinical experience, as well as collaboration between social and behavioral sciences experts and clinical faculty. However, teaching models for achieving this integration have not been adequately established, nor has the collaboration process been described. This study aims to propose a collaborative clinical case conference model to integrate social and behavioral sciences and clinical experience. Additionally, we describe how social and behavioral science experts and clinical faculty collaborate during the development of the teaching method.

METHODS

A team of medical teachers and medical anthropologists planned for the development of a case conference based on action research methodology. The initial model was planned for a 3-h session, similar to a Clinicopathological Conference (CPC) structure. We evaluated each session based on field notes taken by medical anthropologists and post-session questionnaires that surveyed participants' reactions and points of improvement. Based on the evaluation, a reflective meeting was held to discuss revisions for the next trial. We incorporated the development process into undergraduate medical curricula in clinical years and in a postgraduate and continuous professional development session for residents and certified family physicians in Japan. We repeated the plan-act-observe-reflection process more than 15 times between 2015 and 2018.

RESULTS

The development of the collaborative clinical case conference model is summarized in three phases: Quasi-CPC, Interactive, and Co-constructive with unique structures and underlying paradigms. The model successfully contributed to promoting the participants' recognition of the clinical significance of social and behavioral sciences. The case preparation entailed unique and significant learning of how social and behavioral sciences inform clinical practice. The model development process promoted the mutual understanding between clinical faculty and anthropologists, which might function as faculty development for teachers involved in social and behavioral sciences teaching in medical education.

CONCLUSIONS

The application of appropriate conference models and awareness of their underlying paradigms according to educational situations promotes the integration of social and behavioral sciences with clinical medicine education. Faculty development regarding social and behavioral sciences in medical education should focus on collaboration with scholars with different paradigmatic orientations.

Development of entrustable professional activities for residents rotating nephrology department in a Japanese university hospital: a Delphi study

OBJECTIVES

Training strategies regarding entrustable professional activities (EPAs) vary from country to country; one such strategy is for residents. However, there are no reports of EPAs developed for residents who rotate to the nephrology departments. We aimed to construct such EPAs, which could be generalised to other institutions.

DESIGN

Purposive design and a modified Delphi method to build consensus.

SETTING

The department of nephrology in a university hospital in Aichi Prefecture, Japan.

PARTICIPANTS

Based on the attainment goals used in our department, an initial list was developed within the research group. The expert panel included 25 nephrologists from our affiliate hospital. Responses were based on a 5-point method and agreement was reached if both (A) and (B) were met: (A) mean≥4 with a SD <1; (B) more than 75% of respondents rated the item 4 or more. With agreement, the item was left for the next round. This round was repeated.

RESULTS

An initial list of 11 items was developed; after three Delphi rounds and revisions, eight items remained that were then established as the final EPAs. These items can serve as a list of goals to be reached by residents who rotate to the department of nephrology. The results indicated that most of the experts believed residents should be able to perform tasks deemed necessary or urgent for all physicians, such as those that deal with hyperkalaemia and heart failure.

CONCLUSIONS

The concept of EPAs enabled us to develop goals and evaluation criteria for residents' training in nephrology. This study can serve as a springboard for future discussions and contribute to the development of resident education in nephrology.

Lists of potential diagnoses that final-year medical students need to consider: a modified Delphi study

BACKGROUND

Contrastive learning is known to be effective in teaching medical students how to generate diagnostic hypotheses in clinical reasoning. However, there is no international consensus on lists of diagnostic considerations across different medical disciplines regarding the common signs and symptoms that should be learned as part of the undergraduate medical curriculum. In Japan, the national model core curriculum for undergraduate medical education was revised in 2016, and lists of potential diagnoses for 37 common signs, symptoms, and pathophysiology were introduced into the curriculum. This study aimed to validate the list of items based on expert consensus.

METHODS

The authors used a modified Delphi method to develop consensus among a panel of 23 expert physician-teachers in clinical reasoning from across Japan. The panel evaluated the items on a 5-point Likert scale, based on whether a disease should be hypothesized by final-year medical students considering given signs, symptoms, or pathophysiology. They also added other diseases that should be hypothesized. A positive consensus was defined as both a 75% rate of panel agreement and a mean of 4 or higher with a standard deviation of less than 1 on the 5-point scale. The study was conducted between September 2017 and March 2018.

RESULTS

This modified Delphi study identified 275 basic and 67 essential other than basic items corresponding to the potential diagnoses for 37 common signs, symptoms, and pathophysiology that Japanese medical students should master before graduation.

CONCLUSIONS

The lists developed in the study can be useful for teaching and learning how to generate initial hypotheses by encouraging students' contrastive learning. Although they were focused on the Japanese educational context, the lists and process of validation are generalizable to other countries for building national consensus on the content of medical education curricula.

Continuing medical education during pandemic waves of COVID-19: Consensus from medical faculties in Asia, Australia and Europe

This article was migrated. The article was marked as recommended. Medical faculties have the responsibility to train tomorrow's doctors and in a crisis face the challenge of delivering students into the workforce promptly and safely. Worldwide, medical faculties have faced unprecedented disruptions from viral outbreaks and pandemics including SARS, Ebola, H1N1 and COVID-19 which bring unique challenges. Currently there is worldwide disruption to medical faculties and medical education due to COVID-19. Despite close links with clinical medicine and the known risks of pandemics, many medical faculties have been caught off guard without pandemic planning in place, to deal with an exponential rise in infections and deaths, overwhelmed health services and widespread community risk of transmission. Assessing transmission risk of COVID-19 in teaching, clinical and community attachments and continuing medical education is paramount as medical faculties face subsequent pandemics waves. Consensus statements based on best available evidence and international expertise from medical faculties in Asia, Australia and Europe were developed to help guide the protection of staff and students, priorities on teaching activities and further educational development. Infection prevention, infection control, contact tracing and medical surveillance are detailed to minimise transmission and to enhance safety. Recommendations on teaching activities planning can enhance responsiveness of medical faculties to tackle subsequent waves of COVID-19 infection. A global approach and dialogue are encouraged.

Correlation between the number of laparoscopy-qualified gynecologists and the proportion of laparoscopic surgeries for benign gynecological diseases in Japan: An ecological study

AIM

We aimed to evaluate regional disparities in the proportion of the three main laparoscopic surgeries for benign gynecological diseases among 47 prefectures in Japan and their correlation with the number of laparoscopy-qualified gynecologists per population.

METHODS

In this retrospective ecological study, we collected the data of patients from 47 prefectures in 2017 using "The National Database of Health Insurance Claims and Specific Health Checkups of Japan" Open Data from the Ministry of Health, Labor and Welfare in Japan. The primary outcome of the study was the proportion of laparoscopic surgeries conducted for benign gynecologic diseases (hysterectomy, myomectomy and surgery for the benign ovarian diseases). The main exposure was the number of laparoscopy-qualified gynecologists per 100 000 females.

RESULTS

The average proportion of laparoscopic hysterectomies, myomectomies and surgeries for the benign ovarian disease were 38% (standard deviation (SD) 16, range 12-74), 48% (SD 18, range 9-81) and 60% (SD 11, range 36-79), respectively. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists per 100 000 females and the proportion of the three main laparoscopic surgeries.

CONCLUSION

There are obvious regional disparities in the proportion of the three main laparoscopic procedures for benign gynecological diseases among 47 prefectures. The number of laparoscopy-qualified gynecologists correlated significantly with these regional disparities. The academic society should monitor these regional disparities and make an effort to reduce these regional disparities by increasing laparoscopy-qualified gynecologists in areas where the widespread use of laparoscopic techniques is lagging.

The number of overall hysterectomies per population with the perimenopausal status is increasing in Japan: A national representative cohort study

AIM

This study aimed to investigate the trends in overall hysterectomy and other alternative therapies for benign uterine diseases per population aged 40-54 years in Japan.

METHODS

We conducted a national representative cohort study in Japan. We obtained data from 'The National Database of Health Insurance Claims and Specific Health Checkups of Japan' Open Data. The primary outcome was the number of overall hysterectomies for benign gynecologic diseases per population aged 40-54 years, from 2014 to 2017 in Japan. The secondary outcome was the number of alternative surgical and drug therapies to hysterectomy per population. We also analyzed the correlation between the number of laparoscopy-qualified gynecologists and the number of overall hysterectomies per population among 47 prefectures in 2017.

RESULTS

The number of overall hysterectomies for benign gynecological diseases per 100 000 females aged 40-54 years gradually increased from 320 in 2014 to 344 in 2017 (7.5% increase overall). Moreover, there was a significant increase in the use of levonorgestrel intrauterine systems. We could not explain the reason for this increase in the rate of overall hysterectomies by summarizing the increase or decrease of alternative therapies to hysterectomy. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists and the number of overall hysterectomies among 47 prefectures.

CONCLUSION

Despite the spread of alternative therapies to hysterectomy, there was an increasing trend for overall hysterectomies in Japan. The reason was not clear but may be related to the spread of laparoscopic hysterectomy.

Admission policies and methods at crossroads: a review of medical school admission policies and methods in seven Asian countries

Selecting the right applicants is an important part of medical student admission. While one universally accepted selection criterion is academic capacity, there are other criteria such as communication skills and local criteria (e.g., socio-cultural values) that are no less important. This article reviews the policies and methods of selection to medical schools in seven countries with varying socio-economic conditions and healthcare systems. Senior academics involved in medical education in Indonesia, Japan, Malaysia, the Philippines, Singapore, Sri Lanka, and Taiwan completed a pre-agreed pro-forma per each country to describe the country's admission policies and methods. The details were then compared and contrasted. This review identifies tension between many of the policies and methods used in medical school admissions, such as between the need to assess non-cognitive abilities and widen access, and between the need for more medical professionals and the requirement to set high entry standards. Finding the right balance requires careful consideration of all variables, including the country's human resource needs; socio-economic status; graduates' expected competencies; and the school's vision, mission, and availability of resources.

Faculty development in medical education: an environmental scan in countries within the Asia pacific region

PURPOSE

In recent years, faculty development (FD) research is more noticeable within an inter-professional context and in allied health education. However, there is a paucity of published literature on FD medical education programs in Asia. With the formation of the Asia Pacific Medical Education Network (APME-Net) in 2015, a scoping review of an environmental scan of FD medical education programs in main institutions in South East Asia and Australia in 2018 was conducted.

METHODS

A survey was developed to collect data on FD in medical education after several rounds of discussion with APME-Net members. The representatives from nine countries in Asia and Australia were invited to partner in this research project. They sent the questionnaire to the Dean of all different medical schools after ethical clearance. The data collected was analyzed using descriptive statistics.

RESULTS

Only institutions in four countries responded to the questionnaire. The medical/health professions education center/department/unit has been established in most educational institutions in these countries. These centers/departments/units mostly carry out FD programs to improve the teaching and learning skills of trained participants, particularly clinical teachers via workshops and seminars. Staffing issues and participant buy-in are the current key priorities of the center/department/unit in terms of FD. Lastly, research related FD program has not been well-supported in these countries, hence, the lack of publication in this area.

CONCLUSION

Collaboration between countries to address key areas of interest and develop more standardized and productive FD medical education is required especially in research.

Current State and Future Opportunities for Continuing Medical Education in Japan

Globally, CPD systems vary widely. In Japan, the Japanese Medical Association (JMA) is responsible for identifying content and developing education for its speciality practice physicians. The JMA was concerned about persistent low levels of participation in its CME activities and wanted to better understand the root causes. The analysis would provide an opportunity to restructure its programme informed by the needs of its practising clinicians. The JMA engaged a global education provider to conduct an independent analysis of its CME programme. Using a mixed-methods approach, the education provider conducted an on-line survey (N = 338) and held two in-person focus groups (N = 24) to better understand the perspectives of physicians in speciality practice. The on-line survey was sent to over 7,000 practising physicians throughout Japan. Respondents reflected a variety of medical and surgical specialities and length in clinical practice. They described factors that influenced or were barriers to participation in JMA-sponsored education. Respondents also suggested changes to the current model of CME in Japan and expressed an ongoing commitment to life-long learning and achieving the goals set forth in Japan's vision for health care in 2035: Leading the World Through Health. Globally, medical associations are challenged with developing education that meets the needs of a diverse physician workforce. Improved understanding of the perspectives of its physician members and implementation of collaborations with speciality societies may be one strategy to improve quality and address healthcare population needs. Lessons learned from this analysis may help other medical associations with similar challenges.

Professional identity formation of female doctors in Japan - gap between the married and unmarried

BACKGROUND

During professional identity formation (PIF), medical students and young doctors enter the process of socialization in medicine with their preexisting personal identities. Here, the authors focused on how gender influences both the professional and personal identities of doctors. The authors' particular research question was how the professional and personal identities of female doctors are formed in Japan, a patriarchal and highly masculinized country, especially before and after marriage and childbirth.

METHODS

Narrative inquiry was used as the research methodology. The authors purposively sampled 10 unmarried and 15 married Japanese female physicians with varying lengths of full-time work experience and conducted individual semi-structured face-to-face interviews between July 2013 and February 2015. The authors recorded, transcribed and anonymized the narrative data and extracted themes and representative narratives related to the formation of professional and personal identities. Based on these, the authors developed the master narrative for the whole study.

RESULTS

The PIF process by which female physicians integrate personal and professional identities was profoundly affected by gender stereotypes. Further, participant narratives revealed the existence of conflict between married and unmarried female doctors, which created a considerable gap between them.

CONCLUSIONS

Female physicians lived with conflicting emotions in a chain of gender stereotype reinforcement. To overcome these issues, we propose that it is necessary to depart from a culture that determines merit based on a fixed sense of values, and instead develop a cultural system and work environment which allows the cultivation of a professional vision that accepts a wide variety of professional and personal identities, and a similarly wide variety of methods by which the two can be integrated.

National survey of international electives for global health in undergraduate medical education in Japan, 2011-2014

Interest in global health in medical education is increasing in Western countries, whereas data from non-Western countries is scarce. Here, we conducted a nationwide study of international clinical electives at Japanese medical schools from 2011 to 2013. We constructed a 28-item cross-sectional survey in Japanese to investigate the rate and characteristics of both Japanese students going abroad and international students coming on exchange to Japan. The surveys were sent to the administrative offices of all 80 Japanese medical schools in each of the three years, through the Japan Medical Education Foundation. All 80 medical schools responded to the questionnaire (response rate, 100%). An average of 70 of the 80 medical universities provided exchange programs across the three years to allow students to travel abroad as part of the school curriculum and obtain academic credit. The schools provided support in the form of in- and outside-class preparatory programs, tuition fee exemptions and housing. The most popular destinations for Japanese students going abroad were Europe and North America, which may reflect the desire of Japanese students to acquire medical knowledge or experience through exposure to the English language. In contrast, the most common countries of origin of international exchange students coming to Japan were Asian countries such as South Korea, Thailand and Taiwan, with pediatrics being the most popular elective. Foreign exchange programs are becoming increasingly incorporated into the Japanese medical education curriculum and can help to strengthen international partnerships and collaborations.

Translation and cultural adaptation of the Japanese version of the interprofessional facilitation scale

Effective interaction in interprofessional collaboration requires skills in interprofessional facilitation. The need for interprofessional learning and practice in Japan is highlighted by Japan's status as one of the most rapidly aging societies because good care for elderly people with complex needs requires effective collaboration between different professional groups. The development of interprofessional facilitation skills (including management of the additional complexities) among learners or professionals enhances interprofessional learning and consensus building and empowers them to make appropriate commitments when faced with difficult challenges. The 18-item interprofessional facilitation scale (IPFS) can be used to enhance interprofessional facilitation skills. Here, we aimed to develop a Japanese adapted version of the IPFS and to validate it for use with Japanese healthcare professionals. Consistent with guidelines for cross-cultural adaptation, three translators translated the original IPFS from English into Japanese, and an expert and all authors confirmed its face and content validity. The translated items were amended during backtranslation and expert reviews. Exploratory factor analysis was performed with 167 healthcare professionals to explore the underlying structure of the items. This analysis revealed two factors with good internal consistency (Cronbach's alpha > 0.8), which were labelled as: (1) encouraging interprofessional interaction and (2) respect for each professional. The original factor 'Encouraging interprofessional interaction' was divided into two factors in the study. One reason for this division might be related to the behaviour of Japanese health professionals, that is, most Japanese might understand that 'facilitation' encourages relationships as contextual belonging that are distinct from relationships based on respect for others. This mindset is likely based on the notion of 'relationalism', which is fundamental in Japanese culture. Further investigation of this Japanese version of the IPFS will strengthen factor construction and improve scrutiny of the relationships between factors.

Physical Examination and the Physician-patient Relationship: A Literature Review

This article was migrated. The article was not marked as recommended. BackgroundPhysical examinations in clinical settings are becoming relatively infrequent due to recent advances in diagnostic tests. However, for many physicians and patients, physical examinations remain a vital part of consultations. In addition, as a proportion of physicians consider these examinations to improve doctor-patient communication, they remain an important part of training for medical students.MethodsWe reviewed literature from medical and social sciences regarding the influence of physical examination on the doctor-patient relationship. Searching of 3 databases and 5 journals identified 1,447 studies, of which 57 are included in this review.ResultsAlthough historical studies have suggested that technological advancement increases the psychological and physical distance between doctors and patients, ethnographic studies have demonstrated a continued and close relationship between the two. A number of medical reports noted that close proximity during physical examination, particularly touch, strengthens doctor-patient relationships, reduces patient anxiety, and can have a healing effect on patients. In contrast, social scientific studies focused on patients, who considered this proximity invasive.ConclusionsIncreased collaboration between medical and social sciences, analysis of patient experiences, and research in non-Western countries might help characterize the benefits, or lack thereof, of physical examinations.

Beyond work-hour restrictions: a qualitative study of residents' subjective workload

INTRODUCTION

Following the introduction of work-hour restrictions, residents' workload has become an important theme in postgraduate training. The efficacy of restrictions on workload, however, remains controversial, as most research has only examined objective workload. The purpose of this study was to explore the less clearly understood component of subjective workload and, in particular, the factors that influenced residents' subjective workload.

METHOD

This study was conducted in Japan at three community teaching hospitals. We recruited a convenience sample of 31 junior residents in seven focus groups at the three sites. Audio-recorded and transcribed data were read iteratively and analyzed thematically, identifying, analyzing and reporting themes within the data and developing an interpretive synthesis of the topic.

RESULTS

Seven factors influenced residents' subjective workload: (1) interaction within the professional community, (2) feedback from patients, (3) being in control, (4) professional development, (5) private life, (6) interest and (7) protected free time.

DISCUSSION AND CONCLUSION

Our findings indicate that residents who have good interaction with colleagues and patients, are competent enough to control their work, experience personal development through working, have greater interest in their work, and have fulfilling private lives will have the least subjective workload.

Why do students participate in medical education?

BACKGROUND

Medical student involvement in curriculum development is important; however, little is known about why medical students become engaged in this activity. The aim of this study was to understand what motivates medical students at one university to participate in the process of curriculum development and gain a wider perspective on student engagement in medical education.

METHODS

Grounded theory methodology was the foundation of this study. We conducted semi-structured interviews with seven medical students from the University of Tokyo who developed and participated in a group whose aim was to actively contribute towards improving their medical education. The data from the interviews were analysed by thematic synthesis, with triangulation.

RESULTS

Three themes emerged as potential explanations for motivating student behaviour: (1) extracurricular interaction with faculty members; (2) engaging with highly motivated peers; and (3) student values for serving the public.

CONCLUSIONS

Students working to improve educational processes at their medical schools had the opportunity to communicate more with faculty members, enjoyed opportunities for networking with other highly motivated peers and enhanced aspects of their developing professionalism.

Bushido and medical professionalism in Japan

Medical professionalism has become a core topic in medical education. As it has been considered mostly from a Western perspective, there is a need to examine how the same or similar concepts are reflected in a wider range of cultural contexts. To gain insights into medical professionalism concepts in Japanese culture, the authors compare the tenets of a frequently referenced Western guide to professionalism (the physician charter proposed by the American Board of Internal Medicine Foundation, American College of Physicians Foundation, and the European Federation of Internal Medicine) with the concepts of Bushido, a Japanese code of personal conduct originating from the ancient samurai warriors. The authors also present survey evidence about how a group of present-day Japanese doctors view the values of Bushido.Cultural scholars have demonstrated Bushido's continuing influence on Japanese people today. The authors explain the seven main virtues of Bushido (e.g., rectitude), describe the similarities and differences between Bushido and the physician charter, and speculate on factors that may account for the differences, including the influence of religion, how much the group versus the individual is emphasized in a culture, and what emphasis is given to virtue-based versus duty-based ethics.The authors suggest that for those who are teaching and practicing in Japan today, Bushido's virtues are applicable when considering medical professionalism and merit further study. They urge that there be a richer discussion, from the viewpoints of different cultures, on the meaning of professionalism in today's health care practice.

Comparison of pregnancy outcomes between women with gestational diabetes and overt diabetes first diagnosed in pregnancy: a retrospective multi-institutional study in Japan

AIMS

To determine differences in pregnancy outcomes including diabetic complications, maternal and perinatal complications between gestational diabetes mellitus and overt diabetes in pregnancy in Japan.

METHODS

A multi-institutional retrospective study compared pregnancy outcomes between gestational diabetes mellitus and overt diabetes in pregnancy. We examined pregnant women who met the former criteria for gestational diabetes mellitus and received dietary intervention with self-monitoring of blood glucose with or without insulin. Overt diabetes in pregnancy was defined as ≥2 abnormal values on 75-g oral glucose tolerance test, fasting glucose ≥126 mg/dl (7.0 mmol/l) and 2-h postprandial glucose ≥200 mg/dl (11.1 mmol/l), or glycated hemoglobin levels ≥6.5% (48 mmol/mol).

RESULTS

Data were collected on 1267 women with gestational diabetes and 348 with overt diabetes in pregnancy. Pregestational body mass index was higher (26.2 ± 6.1 vs. 24.9 ± 5.7 kg, P<0.05) and gestational age at delivery was earlier (37.8 ± 2.5 weeks vs. 38.1 ± 2.1 weeks, P<0.05) in overt diabetes than in gestational diabetes. Glycated hemoglobin (6.8 ± 1.1% [51 mmol/mol] vs. 5.8 ± 0.5% [40 mmol/mol], P<0.05) and glucose on 75-g oral glucose tolerance test and prevalence of retinopathy (1.2% vs. 0%, P<0.05) and pregnancy-induced hypertension (10.1% vs. 6.1%, P<0.05) were higher in overt diabetes than in gestational diabetes. Pregnancy-induced hypertension was associated with pregestational body mass index, gestational weight gain, chronic hypertension, and nulliparity but not with 75-g oral glucose tolerance test.

CONCLUSIONS

Overt diabetes in pregnancy is significantly associated with maternal complications such as retinopathy and pregnancy-induced hypertension.

A global template for reforming residency without work-hours restrictions: decrease caseloads, increase education. Findings of the Japan Resident Workload Study Group

BACKGROUND

Japanese physician training programs are currently not subject to rigorous national standardization. Despite residency restructuring in 2004, little is known about the current work allocation of residents in Japan.

AIMS

We quantified the amount of time that Japanese junior residents spend in service versus education in the context of caseload, fatigue, and low-value administrative work.

METHODS

In this prospective, time-and-motion study, the activity of 1st- and 2nd-year residents at three Japanese community hospitals was observed at 5-min intervals over 1 week, and categorized as patient care, academic, non-patient care, and personal. Self-reported sleep data and caseload information were simultaneously collected. Data were subanalyzed by gender, training level, hospital, and shift.

RESULTS

A total of 64 participating residents spent substantially more time in patient care activities than education (59.5% vs. 6.8%), and little time on low-value, non-patient work (5.1%). Residents reported a median 5 h of sleep before shifts and excessive sleepiness (median Epworth score, 12). Large variations in caseload were reported (median 10 patients, range 0-60).

CONCLUSIONS

New physicians in Japan deliver a large volume of high-value patient care, while receiving little structured education and enduring substantial sleep deprivation. In programs without work-hour restrictions, caseload limits may improve safety and quality.

A national survey of international electives for medical students in Japan: 2009-2010

BACKGROUND AND OBJECTIVES

International electives can provide experiences for medical students to learn about health systems and foster critical self-reflection. So far, little is known about the status of Japanese students' engagement in international electives. We sought to provide information about the internationalization of Japanese medical education by clarifying the current situations of international electives.

METHOD

We undertook a cross-sectional national 17-item questionnaire survey of program officers in all medical schools in Japan in February 2010.

RESULTS

Sixty-five (81.3%) of 80 Japanese medical schools responded to the questionnaire. 462 Japanese medical students (3% of all students in their clinical years) travelled to North America (45.5%), Asia (25.0%), or Western Europe (24.4%) to study abroad. The number of students who participated in international electives was significantly increased when academic credit was available (median 6 vs. 1, p < 0.001) and institutional affiliations were present (median 7 vs. 2 students, p < 0.001). Most students were evaluated by means of written assignment on return.

DISCUSSION AND CONCLUSION

About 3% of Japanese medical students participate in international clinical exchanges. Academic credit and institutional affiliations appear to promote greater utilization of international exchange opportunities.

A model teaching session for the hypothesis-driven physical examination

INTRODUCTION

The physical examination is an essential clinical competence for all physicians. Most medical schools have students who learn the physical examination maneuvers using a head-to-toe approach. However, this promotes a rote approach to the physical exam, and it is not uncommon for students later on to fail to appreciate the meaning of abnormal findings and their contribution to the diagnostic reasoning process. The purpose of the project was to develop a model teaching session for the hypothesis-driven physical examination (HDPE) approach in which students could practice the physical examination in the context of diagnostic reasoning.

METHODS

We used an action research methodology to create this HDPE model by developing a teaching session, implementing it over 100 times with approximately 700 students, conducting internal reflection and external evaluations, and making adjustments as needed.

RESULTS

A model nine-step HDPE teaching session was developed, including: (1) orientation, (2) anticipation, (3) preparation, (4) role play, (5) discussion-1, (6) answers, (7) discussion-2, (8) demonstration and (9) reflection.

DISCUSSIONS AND CONCLUSIONS

A structured model HDPE teaching session and tutor guide were developed into a workable instructional intervention. Faculty members are invited to teach the physical examination using this model.

A hypothesis-driven physical examination learning and assessment procedure for medical students: initial validity evidence

CONTEXT

Diagnostic accuracy is maximised by having clinical signs and diagnostic hypotheses in mind during the physical examination (PE). This diagnostic reasoning approach contrasts with the rote, hypothesis-free screening PE learned by many medical students. A hypothesis-driven PE (HDPE) learning and assessment procedure was developed to provide targeted practice and assessment in anticipating, eliciting and interpreting critical aspects of the PE in the context of diagnostic challenges.

OBJECTIVES

This study was designed to obtain initial content validity evidence, performance and reliability estimates, and impact data for the HDPE procedure.

METHODS

Nineteen clinical scenarios were developed, covering 160 PE manoeuvres. A total of 66 Year 3 medical students prepared for and encountered three clinical scenarios during required formative assessments. For each case, students listed anticipated positive PE findings for two plausible diagnoses before examining the patient; examined a standardised patient (SP) simulating one of the diagnoses; received immediate feedback from the SP, and documented their findings and working diagnosis. The same students later encountered some of the scenarios during their Year 4 clinical skills examination.

RESULTS

On average, Year 3 students anticipated 65% of the positive findings, correctly performed 88% of the PE manoeuvres and documented 61% of the findings. Year 4 students anticipated and elicited fewer findings overall, but achieved proportionally more discriminating findings, thereby more efficiently achieving a diagnostic accuracy equivalent to that of students in Year 3. Year 4 students performed better on cases on which they had received feedback as Year 3 students. Twelve cases would provide a reliability of 0.80, based on discriminating checklist items only.

CONCLUSIONS

The HDPE provided medical students with a thoughtful, deliberate approach to learning and assessing PE skills in a valid and reliable manner.

I came, I saw, I reflected: a qualitative study into learning outcomes of international electives for Japanese and British medical students

BACKGROUND AND AIM

Although medical students have increasingly more opportunities to participate in international electives, their experiences are usually unstructured and the literature referring to their learning outcomes, educational environment, and assessment is scanty. This study was undertaken to clarify qualitatively what students learn from their international electives.

METHODS

We carried out semi-structured individual interviews with 15 Japanese students studying clinical medicine in British medical schools and six British students studying in Japanese medical schools. The thematic synthesis method was used in analysing the transcribed data and triangulation by multiple researchers was used to achieve higher reliability.

RESULTS

The main learning outcomes identified were skills in history taking and physical examination with clinical reasoning and in management of diseases rarely seen in the students' own countries; awareness of clinical ethics and merits and demerits of different systems of healthcare and medical education; sensitivity to issues in doctor-patient relationships and work ethics; enhancement of cultural competence; and personal development.

CONCLUSIONS

Most learning outcomes of international electives are culture- or system-dependent. Students achieved outcomes related closely to medical professionalism, mainly through reflection. International electives may give students opportunities to learn both professionalism and cultural competence.

Identification of protein phosphatase 2C and confirmation of other protein phosphatases in the ocular lenses

The reversible phosphorylation of proteins plays essential roles in regulating various cellular events, and is regulated by the opposing actions of protein kinases and protein phosphatases. Protein kinases in the lens system have been well studied, but very little is known about lens protein phosphatases. Protein phosphatases can be divided several families, such as protein phosphatase types 1, 2A, 2B and 2C (PP1, PP2A, PP2B and PP2C) and protein tyrosine phosphatases (PTP). In this study we evaluated what kinds of protein phosphatases are present in the lens by using various specific substrates and inhibitors. Samples were prepared from lenses of 17-day-old chick embryos, and fractionated by high-resolution gel permeation column chromatography, then the fractions were assayed for phosphatase activities. The results with 32P-labeled glycogen phosphorylase A, okadaic acid and inhibitor-1, which are a specific substrate and inhibitors of PP1 and/or PP2A, showed that PP1 activities were present in the 500-, 115- and 45-kDa fractions of the lens protein. The 115-kDa fraction also contained PP2A activity. By using a phosphothreonine-containing peptide as a substrate, three peaks of phosphatase activities were found at around 115, 55 and 35 kDa. Based on their response to various phosphatase inhibitors and their metal dependency, the fractions of 115 and 35 kDa were concluded to contain PP2A, while the 55-kDa fraction contained PP2C. Immunoblot using specific antibodies against PP1, PP2A and PP2C confirmed that each fraction above contained corresponding protein phosphatases as proteins. When a phosphotyrosine-containing peptide substrate was examined at pH 7.4, we observed a major peak at 500 kDa, which was presumed to contain receptor-like PTP(s). On the other hand, at pH 5.5, we observed a peak of 18 kDa, which was confirmed to contain a low-molecular-weight PTP. These protein phosphatases have recently been suggested to be involved in stress response and apoptosis. Their physiological roles in the lens are of much interest.

Identification of protein phosphatase 2C and confirmation of other protein phosphatases in the ocular lenses

The reversible phosphorylation of proteins plays essential roles in regulating various cellular events, and is regulated by the opposing actions of protein kinases and protein phosphatases. Protein kinases in the lens system have been well studied, but very little is known about lens protein phosphatases. Protein phosphatases can be divided several families, such as protein phosphatase types 1, 2A, 2B and 2C (PP1, PP2A, PP2B and PP2C) and protein tyrosine phosphatases (PTP). In this study we evaluated what kinds of protein phosphatases are present in the lens by using various specific substrates and inhibitors. Samples were prepared from lenses of 17-day-old chick embryos, and fractionated by high-resolution gel permeation column chromatography, then the fractions were assayed for phosphatase activities. The results with 32P-labeled glycogen phosphorylase A, okadaic acid and inhibitor-1, which are a specific substrate and inhibitors of PP1 and/or PP2A, showed that PP1activities were present in the 500-, 115- and 45-kDa fractions of the lens protein. The 115-kDa fraction also contained PP2A activity. By using a phosphothreonine-containing peptide as a substrate, three peaks of phosphatase activities were found at around 115, 55 and 35 kDa. Based on their response to various phosphatase inhibitors and their metal dependency, the fractions of 115 and 35 kDa were concluded to contain PP2A, while the 55-kDa fraction contained PP2C. Immunoblot using specific antibodies against PP1, PP2A and PP2C confirmed that each fraction above contained corresponding protein phosphatases as proteins. When a phosphotyrosine-containing peptide substrate was examined at pH 7.4, we observed a major peak at 500 kDa, which was presumed to contain receptor-like PTP(s). On the other hand, at pH 5.5, we observed a peak of 18 kDa, which was confirmed to contain a low-molecular-weight PTP. These protein phosphatases have recently been suggested to be involved in stress response and apoptosis. Their physiological roles in the lens are of much interest.

18 kDa protein tyrosine phosphatase in the ocular lens

Protein tyrosyl phosphorylation and dephosphorylation play essential roles in regulating cellular events such as proliferation and differentiation, and their involvement in the lens development and transparency is also suggested. The level of tyrosine phosphorylation in a given protein is regulated by the opposing actions of protein-tyrosine kinases (Tyr kinases) and protein-tyrosine phosphatases (TyrPases). Recent studies have revealed that some Tyr kinases, such as platelet-derived growth factor receptor and fibroblast growth factor receptor, are present in the lens, however, little is known about TyrPases in the lens. In this study, we found a 18 kDa protein tyrosine phosphatase (18 kDa TyrPase) predominantly present in the ocular lens of various animals. We purified the phosphatase from the lens of chick embryo and characterized its activity.Phosphatase activity was determined in chick embryo, mouse, rabbit and bovine lenses using p -nitrophenyl phosphate (p NPP) as substrate. All lenses examined dephosphorylated p NPP under acidic conditions, and a large portion of the activity resided in a low molecular weight protein, ca. 18 kDa, following high-resolution gel permeation column chromatography. The brain and liver showed high dephosphorylation activities, but most of their activity was present in high molecular weight fractions, unlike that in the lens. The 18 kDa phosphatase was purified from the lens of 17 day old chick embryos to near-homogeneity with two-step rapid chromatography. This phosphatase showed strict substrate specificity for phosphotyrosine and phosphotyrosyl peptides, suggesting that it was a kind of protein tyrosine phosphatases (TyrPases). Several known inhibitors of TyrPases, such as SH blockers, vanadate and phenylarsine oxide, strongly inhibited the enzyme activity. The molecular weight, substrate specificity, and responses to various inhibitors and activators coincide well with those reported for the low molecular weight protein tyrosine phosphatase (LMW-TyrPase), belonging to the TyrPase superfamily. These results suggest that the 18 kDa phosphatase found in the lens is a LMW-TyrPase. The 18 kDa TyrPase is the predominant phosphatase in the ocular lens. It may be involved in regulation of lens cell proliferation, differentiation and/or lens transparency.

Suppressive effects of thyroxine on glucocorticoid (gc)-induced metabolic changes and cataract formation on developing chick embryos

To prevent cataracts induced by glucocorticoids (GC) as a systemic disease, the suppression of oxidative stress caused by GC in the hepatic metabolism is of significant interest. In this study, to elucidate the formative mechanism of GC-induced cataracts, we examined the preventive effect and then analysed the mechanisms of thyroxine on GC-induced cataract formation. Fifteen day old chick embryos were administered with 0.25 micromol hydrocortisone succinate sodium (HC), and then 12-30 nmol of thyroxine 4 hr after HC administration. At the indicated time after HC treatment, we examined the incidence of cataract formation, the levels of serum glucose and lipids, lenticular and hepatic glutathione (GSH), and lipid peroxide (LPO) in the lens, blood and liver. Almost all lenses (96%) removed 48 hr after HC administration were opaque. Thyroxine prevented HC-induced cataract formation effectively, and suppressed the elevations of serum glucose and LPO in the lens, blood and liver. The treatment prevented the decreased lenticular GSH level at 48 hr, but the hepatic GSH level at 24 hr remained lowered in contrast to the results of previous studies using insulin. Moreover, thyroxine did not decrease the elevated serum lipid level (triglyceride and non-esterified fatty acid) caused by HC. Under thyroxine treatment, in constant to insulin, acceleration of GSH-GSSG cycle rather than GSH de novo synthesis keeps a certain level of hepatic GSH necessary for diminishing the elevation of LPO as a risk factor of GC-induced cataract formation. The regulation of metabolic changes ensured the maintenance of hepatic GSH level, which is necessary to reduce oxidative stress produced by GC and to protect the lens from oxidative stress leading to opacification.

Genetic variation in the hepatocyte nuclear factor (HNF)-3alpha gene does not contribute to maturity-onset diabetes of the young in Japanese

Heterozygous mutations in the genes encoding transcription factors in the hepatocyte nuclear factor (HNF) cascade are associated with maturity-onset diabetes of the young (MODY), a monogenic form of diabetes mellitus. However, these genes are responsible for only approximately 20% of the cases of MODY in Japanese patients. Searching for a novel MODY gene in this population, we investigated a candidate for encoding the forkhead transcription factor HNF-3alpha, which also belongs to the HNF-transcription cascade. The human HNF-3alpha gene, which was assigned to the segment near microsatellites D14S75 and AFM200ZH4 on chromosome 14 by radiation hybrid mapping, spans approximately 5 kb and consists of two exons. Ninety-five Japanese subjects with MODY/early-onset non-ketotic diabetes were screened for mutations in this gene. Direct sequencing of the exons and flanking regions identified one missense mutation (Ala-83-Thr) in exon 2 and three nucleotide alterations in the non-coding regions. However, their frequencies were not significantly different between MODY and control subjects, indicating that mutations in the HNF-3alpha gene are not a major cause of MODY in Japanese patients.

Establishment of a chick embryo shell-less culture system and its use to observe change in behavior caused by nicotine and substances from cigarette smoke

Early detection and removal of harmful factors are essential to the proper physical and psychological development of the fetus, presumably showing the effects during the prenatal period and after birth. As one procedure to aid in understanding such factors, we have established a shell-less culture system for video monitoring to observe change in behavior of 7-day-old chick embryos. Nicotine and aqueous cigarette smoke extract (ACSE) were selected for the present experiments, and the results showed a complete stoppage of swing-like movements by administrations of 10 microg nicotine and 1xACSE, possibly displaying paralytic symptoms. Quantitative analysis of nicotine in 1xACSE indicated that more than 10 microg of nicotine were contained in 100 microl of the extract. The present system, although in initial stage of development, may be a useful preliminary screening procedure for perhaps supervision and warning about the environment surrounding pregnant women.

Mutations in the small heterodimer partner gene are associated with mild obesity in Japanese subjects

Mutations in several genes encoding transcription factors of the hepatocyte nuclear factor (HNF) cascade are associated with maturity-onset diabetes of the young (MODY), a monogenic form of early-onset diabetes mellitus. The ability of the orphan nuclear receptor small heterodimer partner (SHP, NR0B2) to modulate the transcriptional activity of MODY1 protein, the nuclear receptor HNF-4alpha, suggested SHP as a candidate MODY gene. We screened 173 unrelated Japanese subjects with early-onset diabetes for mutations in this gene and found five different mutations (H53fsdel10, L98fsdel9insAC, R34X, A195S, and R213C) in 6 subjects as well as one apparent polymorphism (R216H), all present in the heterozygous state. Interestingly, all of the subjects with the mutations were mildly or moderately obese at onset of diabetes, and analysis of the lineages of these individuals indicated that the SHP mutations were associated with obesity rather than with diabetes. Therefore, an additional group of 101 unrelated nondiabetic subjects with early-onset obesity was screened for mutations in the SHP gene. Two of the previously observed mutations (R34X and A195S) and two additional mutations (R57W and G189E) were identified in 6 subjects, whereas no mutations were identified in 116 young nondiabetic lean controls (P = 0.0094). Functional studies of the mutant proteins show that the mutations result in the loss of SHP activity. These results suggest that genetic variation in the SHP gene contributes to increased body weight and reveal a pathway leading to this common metabolic disorder in Japanese.

Stimulation of melanogenesis in murine melanoma cells by 2-mercapto-1-(beta-4-pyridethyl) benzimidazole (MPB)

The effects of 2-mercapto-1-(beta-4-pyridethyl) benzimidazole (MPB), one of the benzimidazole derivatives designed for a nucleic acid analogue, on melanogenesis of murine B16-F10 melanoma cell lines were investigated. MPB (40 microM) induced a striking dendricity in B16 melanoma cells within 12 h and maximal dendricity between 48 and 72 h. The stimulation of melanin synthesis was observed after only 2 days of treatment together with a dose-dependent growth inhibition. Moreover, MPB increased the activity of tyrosinase through the expression of tyrosinase mRNA without increasing the intracellular cyclic AMP content. MPB-induced melanogenesis was inhibited by novel protein kinase A inhibitors, KT-5720 and H-85. These findings indicate that MPB stimulated B16 cells to terminally differentiate and may be a useful drug in studying the regulation of melanogenesis.