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Risa Hirata,1 Masaki Tago,1 Kiyoshi Shikino,2,3 Takashi Watari,4 Hiromizu Takahashi,5 Yosuke Sasaki,6 Taro Shimizu7 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Chiba University Hospital, Chiba, Japan; 3Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan; 4Integrated Clinical Education Center, Kyoto University Hospital, Kyoto, Japan; 5Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan; 6Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan; 7Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpPurpose: There has been growing interest in generalists in Japan in recent years. However, due to the diverse use of the term “generalist”, the specific roles of these physicians remain ambiguous. Consequently, the target population for research on generalists is unclear, making it challenging to conduct studies within the generalist practice framework. Therefore, a literature search was conducted to examine how generalists are defined and classified in research worldwide.Methods: We conducted a literature search that focused exclusively on articles written in English and used keywords related to generalists, general medicine (GM), primary care, and family medicine. Based on the results, six physicians working in GM reviewed the findings and discussed the identified issues and their potential solutions.Results: The definition of generalists in studies targeting GM, family medicine, and primary care conducted worldwide, including Japan, varies. Generalists exhibit diverse roles even within university hospitals in Japan. No studies provide a precise categorization or definition of generalists based on specific medical practices or roles, except for hospitalists, who are primarily involved in inpatient management in the United States.Conclusion: The definition of GM was unclear based on the results of the literature search, and the lack of uniformity in backgrounds has rendered the target population unclear. Consequently, in healthcare settings where medical systems vary by country or region, evidence from studies targeting generalists cannot readily apply to actual practice. Clarifying generalists through an explicit definition based on clinical practice will allow for a more precise target population for research on generalists and enable the accumulation of evidence related to well-defined groups of generalists, contributing to the advancement of GM. Therefore, future research is required to develop new indicators to precisely classify and define generalists.Keywords: generalist, general medicine, definition, hospitalist

Risa Hirata,1 Naoko E Katsuki,1 Hitomi Shimada,2 Eiji Nakatani,3 Kiyoshi Shikino,4,5 Chihiro Saito,6 Kaori Amari,7 Yoshimasa Oda,8 Midori Tokushima,1 Masaki Tago1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Shimada Hospital of Medical Corporation Chouseikai, Saga, Japan; 3Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan; 4Department of General Medicine, Chiba University Hospital, Chiba, Japan; 5Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan; 6Shizuoka General Hospital, Shizuoka, Japan; 7Department of Emergency Medicine, Saga-Ken Medical Centre Koseikan, Saga, Japan; 8Department of General Medicine, Yuai-Kai Foundation and Oda Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpPurpose: There has been no large-scale investigation into the association between the use of lemborexant, suvorexant, and ramelteon and falls in a large population. This study, serving as a pilot investigation, was aimed at examining the relationship between inpatient falls and various prescribed hypnotic medications at admission.Patients and Methods: This study was a sub-analysis of a multicenter retrospective observational study conducted over a period of 3 years. The target population comprised patients aged 20 years or above admitted to eight hospitals, including chronic care, acute care, and tertiary hospitals. We extracted data on the types of hypnotic medications prescribed at admission, including lemborexant, suvorexant, ramelteon, benzodiazepines, Z-drugs, and other hypnotics; the occurrence of inpatient falls during the hospital stay; and patients’ background information. To determine the outcome of inpatient falls, items with low collinearity were selected and included as covariates in a forced-entry binary logistic regression analysis.Results: Overall, 150,278 patients were included in the analysis, among whom 3,458 experienced falls. The median age of the entire cohort was 70 years, with men constituting 53.1%. Binary logistic regression analysis revealed that the prescription of lemborexant, suvorexant, and ramelteon at admission was not significantly associated with inpatient falls.Conclusion: The administration of lemborexant, suvorexant, and ramelteon at admission may not be associated with inpatient falls.Keywords: lemborexant, hypnotics, in-hospital falls, risk factor

Masaki Tago,1 Risa Hirata,1 Hiromizu Takahashi,2 Shun Yamashita,1,3 Masayuki Nogi,4,5 Kiyoshi Shikino,6 Yosuke Sasaki,7 Takashi Watari,8 Taro Shimizu9 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan; 3Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan; 4Hospitalist Division, The Queen’s Medical Center, Honolulu, HI, USA; 5Department of General Internal Medicine, Kameda Medical Center, Chiba, Japan; 6Department of General Medicine, Chiba University Hospital, Chiba, Japan; 7Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan; 8General Medicine Center, Shimane University Hospital, Shimane, Japan; 9Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpAbstract: Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.Keywords: classification, evidence, general medicine

Masaki Tago,1 Risa Hirata,1 Naoko E Katsuki,1 Eiji Nakatani,2 Midori Tokushima,1 Tomoyo Nishi,1 Hitomi Shimada,3 Shizuka Yaita,1 Chihiro Saito,4 Kaori Amari,5 Kazuya Kurogi,6 Yoshimasa Oda,7 Kiyoshi Shikino,8,9 Maiko Ono,10 Mariko Yoshimura,11 Shun Yamashita,1 Yoshinori Tokushima,1 Hidetoshi Aihara,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan; 3Shimada Hospital of Medical Corporation Chouseikai, Saga, Japan; 4Shizuoka General Hospital, Shizuoka, Japan; 5Department of Emergency Medicine, Saga-Ken Medical Centre Koseikan, Saga, Japan; 6Department of General Medicine, National Hospital Organization Ureshino Medical Center, Saga, Japan; 7Department of General Medicine, Yuai-Kai Foundation and Oda Hospital, Saga, Japan; 8Department of General Medicine, Chiba University Hospital, Chiba, Japan; 9Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan; 10Department of General Medicine, Karatsu Municipal Hospital, Saga, Japan; 11Safety Management Section, Saga University Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpPurpose: We conducted a pilot study in an acute care hospital and developed the Saga Fall Risk Model 2 (SFRM2), a fall prediction model comprising eight items: Bedriddenness rank, age, sex, emergency admission, admission to the neurosurgery department, history of falls, independence of eating, and use of hypnotics. The external validation results from the two hospitals showed that the area under the curve (AUC) of SFRM2 may be lower in other facilities. This study aimed to validate the accuracy of SFRM2 using data from eight hospitals, including chronic care hospitals, and adjust the coefficients to improve the accuracy of SFRM2 and validate it.Patients and Methods: This study included all patients aged ≥ 20 years admitted to eight hospitals, including chronic care, acute care, and tertiary hospitals, from April 1, 2018, to March 31, 2021. In-hospital falls were used as the outcome, and the AUC and shrinkage coefficient of SFRM2 were calculated. Additionally, SFRM2.1, which was modified from the coefficients of SFRM2 using logistic regression with the eight items comprising SFRM2, was developed using two-thirds of the data randomly selected from the entire population, and its accuracy was validated using the remaining one-third portion of the data.Results: Of the 124,521 inpatients analyzed, 2,986 (2.4%) experienced falls during hospitalization. The median age of all inpatients was 71 years, and 53.2% were men. The AUC of SFRM2 was 0.687 (95% confidence interval [CI]:0.678– 0.697), and the shrinkage coefficient was 0.996. SFRM2.1 was created using 81,790 patients, and its accuracy was validated using the remaining 42,731 patients. The AUC of SFRM2.1 was 0.745 (95% CI: 0.731– 0.758).Conclusion: SFRM2 showed good accuracy in predicting falls even on validating in diverse populations with significantly different backgrounds. Furthermore, the accuracy can be improved by adjusting the coefficients while keeping the model’s parameters fixed.Keywords: accidental falls, inpatients, validation study, accident prevention

Risa Hirata,1 Masaki Tago,1 Kiyoshi Shikino,2,3 Takashi Watari,4 Hiromizu Takahashi,5 Yosuke Sasaki,6 Taro Shimizu7 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Chiba University Hospital, Chiba, Japan; 3Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan; 4Integrated Clinical Education Center, Kyoto University Hospital, Kyoto, Japan; 5Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan; 6Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan; 7Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jp

Masaki Tago,1 Risa Hirata,1 Naoko E Katsuki,1 Yuki Otsuka,2 Taro Shimizu,3 Yosuke Sasaki,4 Kiyoshi Shikino,5 Takashi Watari,6 Hiromizu Takahashi,7 Kazunobu Une,8 Toshio Naito,7 Fumio Otsuka,2 Rachel Thompson,9 Susumu Tazuma8,10 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan; 3Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, Japan; 4Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan; 5Department of General Medicine, Chiba University Hospital, Chiba, Japan; 6General Medicine Center, Shimane University Hospital, Izumo, Japan; 7Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan; 8Department of Critical Care and General Medicine, Onomichi General Hospital, Hiroshima, Japan; 9Executive Team, Snoqualmie Valley Hospital, Snoqualmie, WA, USA; 10JR Hiroshima Hospital, Hiroshima, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpIntroduction: Hospitalists in Japan have been at the forefront of the COVID-19 pandemic. However, contributions of Japanese hospitalists during the COVID-19 pandemic and hospitalists’ awareness of crisis management education remain unclear.Material and Methods: We conducted a questionnaire survey to investigate the role of Japanese hospitalists during the COVID-19 pandemic. The questionnaire was conducted using email and Google Forms targeting the chairpersons of facilities certified by the Japanese Society of Hospital General Medicine (JSHGM). Members of the academic committee of the JSHGM and several hospitals conducted a narrative review and determined the questions for the survey in a discussion.Results: We conducted descriptive statistics based on the responses of 97 hospitals that agreed to participate in this survey. In total, 91.8% of general medicine departments in the included hospitals were involved in the medical care of COVID-19 patients. Furthermore, in 73.2% of hospitals, hospitalists were involved in infection control for COVID-19 inside or outside the hospital. Our survey revealed that Japanese hospitalists were responsible for COVID-19 treatment in over 60% of hospitals and contributed to hospital management, infection control, and vaccination. In total, 79.4% of hospitals answered that “training of personnel who can provide practical care for emerging infectious diseases is necessary”, 78.4% indicated that “the establishment of an infection control system in advance to prepare emerging infectious diseases in the hospital is necessary”, and 74.2% stated that “the establishment of an educational system for responding to emerging infectious diseases is necessary.”.Conclusion: In conclusion, during the pandemic, in addition to inpatient care, Japanese hospitalists provided outpatient care for COVID-19, which is the role of primary care physicians in other countries. Furthermore, Japanese hospitalists who experienced the COVID-19 pandemic expressed the need for personnel development and education to prepare for future emerging infectious disease pandemics.Keywords: COVID-19 pandemic, hospitalist, hospital management

Masaki Tago,1 Risa Hirata,1 Kiyoshi Shikino,2 Takashi Watari,3 Yosuke Sasaki,4 Hiromizu Takahashi,5 Taro Shimizu6 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Chiba University Hospital, Chiba, Japan; 3General Medicine Center, Shimane University Hospital, Shimane, Japan; 4Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan; 5Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan; 6Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpAbstract: Clinical physicians have the potential to contribute to the progress of medicine and healthcare through research based on their diagnostic and treatment practices and supported by their educational background. However, in the field of general medicine in Japan, publication of such research in international journals may be limited by challenges in English proficiency and the lack of opportunities to focus on specific research themes amidst the diverse range of diseases treated in clinical practice. Furthermore, novice researchers without prior research experience may lack a comprehensive understanding of the overall research process, including study design and article publication. To address these challenges, we developed a set of 22 milestones that highlight the necessary skills required to conduct and successfully publish clinical research. This guideline will enable novice researchers to identify and address individual barriers to undertaking a research project. These milestones are categorized into five parts: 1) preparing to undertake research; 2) conducting clinical research; 3) writing the article; 4) submitting and achieving acceptance for publication; and 5) advanced skills. For each part, we provide detailed recommendations on the specific steps and methods involved. By working through these 22 milestones, novice researchers can objectively assess their own level of achievement as researchers and continuously clarify the next step of each round of research. Through this set of milestones, we aim to increase the quality and quantity of research publications in general medicine in academic journals, ideally enhancing the overall research process and advancing the field of medicine and healthcare overall.Keywords: clinical research, original research, young physicians

Yoshinori Tokushima,1,2 Masaki Tago,1,2 Midori Tokushima,1,3 Shun Yamashita,1 Yuka Hirakawa,1 Hidetoshi Aihara,1 Naoko E Katsuki,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Community Medical Support Institute, Faculty of Medicine, Saga University, Saga, Japan; 3Saga Medical Career Support Center, Saga University Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpIntroduction: The educational effects of a hands-on clinical clerkship on medical students at the Department of General medicine of Japanese university hospitals remain to be clarified. This study aimed to determine how such education affects medical students’ self-evaluation of their clinical skills.Methods: We enrolled 5th-year-grade students at the Department of General Medicine, Saga University Hospital, Japan in 2017. The students were divided into those who were going to have Japanese traditional-style observation-based training mainly in the outpatient clinic (Group O) and those in the 2018, new-style, hands-on clinical clerkship as one of the group practice members in outpatient and inpatient clinics (Group H). A questionnaire survey using the 4-point Likert scale for self-evaluation of the students’ clinical skills at the beginning and the end of their training was conducted in both groups. The pre- and post-training scores of each item in both groups were compared and analyzed using the Mann–Whitney test.Results: All 99 students in Group O and 121 of 123 students in Group H answered the questionnaires. The response rate was 99%. Two items regarding the abilities of “can perform a systemic physical examination quickly and efficiently” and “can clearly explain the current medical condition, therapeutic options, or risks associated with treatment, and discuss the process for obtaining informed consent” showed higher scores in the post-training survey in Group H than in Group O. There were no differences in these scores in the pre-training survey between the two groups.Conclusion: A hands-on clinical clerkship at the Department of General medicine in a university hospital in Japan provided medical students with higher self-confidence in their skills of performing a physical examination and better understanding of patients’ treatment options and the process of informed consent than observation-based training.Keywords: general medicine, hands-on clinical clerkship, medical education, observation-based training

Risa Hirata,1 Masaki Tago,1 Naoko E Katsuki,1 Yoshimasa Oda,2 Midori Tokushima,1 Yoshinori Tokushima,1 Yuka Hirakawa,1 Shun Yamashita,1 Hidetoshi Aihara,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Yuai-Kai Foundation and Oda Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81-952-34-3238, Fax +81-952-34-2029, Email tagomas@cc.saga-u.ac.jpIntroduction: In our former study, we had validated the previously developed predictive model for in-hospital falls (Saga fall risk model) using eight simple factors (age, sex, emergency admission, department of admission, use of hypnotic medications, history of falls, independence of eating, and Bedriddenness ranks [BRs]), proving its high reliability. We found that only admission to the neurosurgery department, history of falls, and BRs had significant relationships with falls. In the present study, we aimed to clarify whether each of these three items had a significant relationship with falls in a different group of patients.Methods: This was a single-center based, retrospective study in an acute care hospital in a rural city of Japan. We enrolled all inpatients aged 20 years or older admitted from April 2015 to March 2018. We randomly selected patients to fulfill the required sample size. We performed multivariable logistic regression analysis using forced entry on the association between falls and each of the eight items in the Saga fall risk model 2.Results: A total of 2932 patients were randomly selected, of whom 95 (3.2%) fell. The median age was 79 years, and 49.9% were men. Multivariable analysis showed that female sex (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.39– 0.93, p = 0.022), having a history of falls (OR 1.9, 95% CI 1.16– 2.99, p = 0.010), requiring help with eating (OR 1.9, 95% CI 1.12– 3.35, p = 0.019), BR of A (OR 6.6, 95% CI 2.82– 15.30, p < 0.001), BR of B (OR 7.5, 95% CI 2.95– 19.06, p < 0.001), and BR of C (OR 4.1, 95% CI 1.53– 11.04, p = 0.005) were significantly associated with falls.Conclusion: History of falls and BRs were independently associated with in-hospital falls.Keywords: bedridden, Bedriddenness ranks, fall, predictive model, validation, Saga fall risk model 2

Shun Yamashita,1 Masaki Tago,1 Midori Tokushima,2 Sei Emura,2 Shu-Ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Saga Medical Career Support Center, Saga University Hospital, Saga, JapanCorrespondence: Shun Yamashita, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81952343238, Fax +81952342029, Email sy.hospitalist.japan@gmail.comPurpose: Many countries will be aged societies by 2060. As a super-aged society, Japan may offer a valuable reference point. The number of medical residents and doctors working at university hospitals in Japan has halved since 2004, resulting in serious shortages of doctors in rural areas. This study clarified factors influencing medical students to choose university hospitals as facilities for their initial training or to only choose community hospitals.Methods: This single-center cross-sectional study was conducted in a typical rural city in Japan from February to March 2021. Data were collected using a questionnaire developed from a narrative review and discussion among four researchers. The participants were divided into those who chose university hospitals and those chose only community hospitals for logistic regression analysis.Results: Of the 300 students who answered the questionnaire (46.4% response rate), 291 agreed to participate in the study. At the time, 93 students had not decided where to undertake initial training, and were excluded. Of the 198 analyzed students, 113 (57.1%) had chosen university hospitals. Significant factors affecting students’ choices were “good salary or fringe benefits” (odds ratio [OR] 2.6, 95% confidence interval [CI]: 1.3– 5.2) in the community hospital group, and “desire to have contact with doctors practicing in a medical setting before starting hospital training in the fifth and sixth grade” (OR 0.4, 95% CI: 0.2– 0.8) and “prefer Saga Prefecture for initial training” (OR 0.2, 95% CI: 0.1– 0.4) among the university hospital group.Conclusion: University hospitals could offer a good salary or fringe benefits to secure residents. Other useful measures include preferential admission of students who pledge to work in the prefecture of their medical school after graduation and facilitating contact between motivated students and senior doctors before starting hospital training.Keywords: medical student, initial clinical training, university hospital, community hospital, questionnaire, cross-sectional study

Masaki Tago,1 Risa Hirata,1 Takashi Watari,2 Kiyoshi Shikino,3 Yosuke Sasaki,4 Hiromizu Takahashi,5 Taro Shimizu6 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2General Medicine Center, Shimane University Hospital, Shimane, Japan; 3Department of General Medicine, Chiba University Hospital, Chiba, Japan; 4Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan; 5Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan; 6Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpAbstract: In Japan, general medicine is still relatively new as a specialty, having been established in 2018 as the 19th primary specialty. The relevant research field has therefore not been fully established yet, and the detailed research areas in this field have not been identified. We conducted a descriptive questionnaire-based web survey of members of the Japanese Society of Hospital General Medicine. Respondents were asked to highlight their research topics from the following categories: diagnostic excellence, design (problem-solving and thinking methodology), symptomatology, physical examination, clinical epidemiology, home and community medicine, general medicine education, organizational management, hospital administration, and “none of the above (add description of your work if desired)”. The respondents could choose multiple topics. There were 276 respondents (14% response rate), of whom 240 (86.9%) were male, 103 (37.3%) worked at universities, and 232 (84.1%) had previous research experience. Diagnostic excellence was the most common research topic category among generalists (n=87, 21.3%), followed by clinical epidemiology (n=83, 20.3%), symptomatology (n=41, 10.0%), home and community medicine (n=39, 9.6%), and general medicine education (n=36, 8.8%). Seventy-eight respondents (19.1%) chose “none of the above (add description of your work if desired)”. The main research topics were in areas fundamental to diagnostic excellence, ie, diagnostics, diagnostic error, clinical epidemiology, and symptomatology. Home and community medicine and general medicine education were also included as research topics because of their diverse roles. The research interests of generalists are therefore diverse, and new areas and frameworks are likely to be created in the future.Keywords: clinical research, diagnostic excellence, general medicine, medical education, research topic

Masaki Tago,1 Kiyoshi Shikino,2 Risa Hirata,1 Takashi Watari,3 Shun Yamashita,1 Yoshinori Tokushima,1 Midori Tokushima,1 Hidetoshi Aihara,1 Naoko E Katsuki,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Chiba University Hospital, Chiba, Japan; 3General Medicine Center, Shimane University Hospital, Shimane, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Email tagomas@cc.saga-u.ac.jpBackground: It is unclear how much effort Japanese university general medicine (GM) departments, which teach basic medical skills and have a high affinity for clinical practice, devote to medical education, particularly undergraduate education. This study aimed to clarify the contribution of GM departments of Japanese universities to medical education.Patients and Methods: This was a questionnaire-based descriptive study of GM departments of Japanese universities. We sent the questionnaire created using Google Forms by email, and the universities responded by Internet. The department chairperson of the universities’ main hospital was responsible for completing the questionnaire. It covered the number of staff, inpatients over the previous 3 years, affiliated hospitals, classroom lectures, and practical training sessions per year for each academic year in medical faculty and students accepted for clinical clerkship. Items also included the effort for clinical training, research, and education and the effort for undergraduate, initial clinical residency, and specialty program training.Results: In all, 46 of 71 universities responded, and we included 43 in our analysis. The median number of medical staff was 7; the median number of inpatients over the previous 3 years was 76. The median number of classroom lectures of the GM department was 1 for 1st-year, 5 for 3rd-year, 9 for 4th-year, and 0 for 2nd-, 5th-, and 6th-year students. The median total number of accepted students for clinical clerkship was 120. The median educational effort of the GM department was 30. With total educational effort set at 100, the median effort for undergraduate education was 45, for postgraduate residency 30, and for specialty program training 20.Conclusion: The undergraduate medical education by GM departments of Japanese universities was provided mainly in clinical settings for almost all medical students. A focus on exposing students to GM in early academic years would improve the educational environment.Keywords: clinical clerkship, general medicine, medical education, specialty program, university

Masaki Tago,1 Takashi Watari,2 Kiyoshi Shikino,3 Yosuke Sasaki,4 Hiromizu Takahashi,5 Taro Shimizu6 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2General Medicine Center, Shimane University Hospital, Shimane, Japan; 3Department of General Medicine, Chiba University Hospital, Chiba, Japan; 4Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan; 5Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan; 6Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, JapanCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, JapanTel +81 952 34 3238Fax +81 952 34 2029Email tagomas@cc.saga-u.ac.jpAbstract: Owing to the social structure issues caused by Japan’s super-aged society, health-care roles have become more complex, and the need for general physicians has increased. General hospitalists in Japan perform various roles. Thus, the ideal image of general hospitalists there has been unclear. We summarize the 10 key skills for Japanese hospitalists indicated in the specialty programs of the Japanese Society of Hospital General Medicine. We identified the following five crucial points for ideal general hospitalists: general mindset; leadership and management; community-based comprehensive care and cooperation with various professions; appropriate medical interviewing, physical examination, and diagnostic reasoning; and proactive education and academic activities. This paper presents five tips, which deal with why those items are necessary and how they should be learned.Keywords: academic activity, diagnostic reasoning, education, general hospitalist, general mindset, leadership and management

Shun Yamashita, Masaki Tago, So Motomura, Satsuki Oie, Hidetoshi Aihara, Naoko E Katsuki, Shu-ichi Yamashita Department of General Medicine, Saga University Hospital, Saga, JapanCorrespondence: Shun YamashitaDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, JapanTel +81952343238Fax +81952342029Email sy.hospitalist.japan@gmail.comPurpose: Infective endocarditis (IE) may be diagnosed as fever of unknown origin due to its delusively non-descriptive clinical features, especially in outpatient clinics. Our objective is to develop a prediction model to discriminate patients to be diagnosed as “definite” IE from “non-definite” by modified Duke criteria among patients with undiagnosed fever, using only history and results of physical examinations and common laboratory examinations.Patients and Methods: The study was a single-center case–control study. Inpatients at Saga University Hospital diagnosed with IE from 2007 to 2017 and patients with undiagnosed fever from 2015 to 2017 were enrolled. Patients diagnosed with definite IE according to the modified Duke criteria, except those definitely diagnosed with other disorders responsible for fever, were allocated to the IE group. Patients without IE among those defined as non-definite according to the modified Duke criteria were allocated to the undiagnosed fever group. We developed a prediction model to pick up patients who would be “definite” by modified Duke criteria, which was subsequently assessed by area under the curve (AUC).Results: A total of 144 adult patients were included. Of these, 59 patients comprised the IE group. We developed the prediction model using five indicators, including transfer by ambulance, cardiac murmur, pleural effusion, neutrophil count, and platelet count, with a sensitivity 84.7%, a specificity 84.7%, an AUC 0.893 (95% confidence interval 0.828– 0.959), a shrinkage coefficient 0.635, and a stratum-specific likelihood ratio 0.2– 50.4.Conclusion: Our prediction model, which uses only indicators easy to gain, facilitates prediction of patients with IE. These indicators can be acquired even at common hospitals and clinics, without requiring advanced medical equipment or invasive examinations.Trial Registration Number: UMIN000041344.Keywords: infective endocarditis, undiagnosed fever, case–control study, prediction model, area under the curve

Takashi Watari,1,2,* Masaki Tago,3,* Kiyoshi Shikino,4 Shun Yamashita,3 Naoko E Katsuki,3 Motoshi Fujiwara,3 Shu-ichi Yamashita3 1General Medicine Center, Shimane University Hospital, Shimane, Japan; 2Master of Healthcare Quality and Patient Safety, Harvard Medical School, Boston, MA, USA; 3Department of General Medicine, Saga University Hospital, Saga, Japan; 4Department of General Medicine, Chiba University Hospital, Chiba, Japan*These authors contributed equally to this workCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, JapanTel +81 952 34 3238Fax +81 952 34 2029Email tagomas@cc.saga-u.ac.jpPurpose: The training of generalist physicians in university hospitals needs to emphasize development of their research role in order to continue improving their research capacity and their standing in academic hospitals in Japan. This cross-sectional descriptive study aimed to survey departments of general medicine (GM) in university hospitals in Japan to identify the research areas and themes pursued by academic generalist physicians.Patients and Methods: The heads of the departments of GM from 71 university hospitals in Japan were enrolled. The main outcomes studied were the identification of the main research areas and themes in academic departments of GM, based on the classification of the National Grants-in-Aid for Scientific Research (KAKENHI): clinical research, public health, preventive medicine, medical education, basic science, health services and safety and quality.Results: We received 47 of 71 replies (66.2% response rate). Clinical research was the most common area of research (62%), followed by public health and preventive medicine (14%), medical education (11%), and basic sciences (9%). Only one department identified health services and safety and quality as a research area (2%). There was marked variability in research areas across the different departments, with 23% of the research targeting the highest specialties, particularly organ-specific research in the fields of gastroenterology, cardiology, immunology, neurology, metabolic endocrinology, and hematology-oncology.Conclusion: The training of generalist physicians in university hospitals needs to emphasize development of their research role in order to continue improving the research capacity and the standing generalist physicians in academic hospitals in Japan.Keywords: general medicine, research, academic activity

Masaki Tago,1 Keizo Anzai,2 Yuichiro Sakamoto,3 Yohei Hamada,4 Shinichiro Ishikawa,5 Shinya Kimura,6 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Division of Metabolism and Endocrinology, Faculty of Medicine, Saga University, Saga, Japan; 3Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga, Japan; 4Division of Infectious Disease and Hospital Epidemiology, Saga University Hospital, Saga, Japan; 5Department of Ophthalmology, Faculty of Medicine, Saga University, Saga, Japan; 6Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, JapanCorrespondence: Masaki Tago Department of General MedicineSaga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, JapanTel +81 952 34 3238Fax +81 952 34 2029Email tagomas@cc.saga-u.ac.jpAbstract: A worldwide shortage of personal protective equipment during the COVID-19 pandemic has led to the development of new alternatives. We introduce two new disposable box-like head-and-face shields constructed using Japanese origami-style folding. The design comprises a single sheet of thick paper and a shield made of a thin, transparent plastic sheet. The first design, Model 1, is a head-and-face shield designed to cover the wearer’s head and neck. Model 2 was designed to solve the problem of heat and moisture buildup inside the shield. This version can be used as face shields for patients, and it allows clinicians to collect swabs from the nasopharynx for virus detection via polymerase chain reaction through pre-cut incisions near the nasal orifices. These two new box-like face shields are excellent alternatives to traditional face shields because of the low cost, compatibility with mass production, lightweight, and disposability.Keywords: COVID-19 pandemic, head-and-face shield, personal protective equipment

Yoshinori Tokushima,1,* Masaki Tago,1,* Midori Tokushima,1 Naoko E Katsuki,1 Shinji Iwane,2 Yuichiro Eguchi,3 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Fujioka Hospital, Saga, Japan; 3Eguchi Hospital, Saga, Japan*These authors contributed equally to this workCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, JapanTel +81 952 34 3238Fax +81 952 34 2029Email tagomas@cc.saga-u.ac.jpObjective: To investigate effects of an altered medical environment between 2010 and 2015 on viral hepatitis treatment behaviors of doctors who were not hepatology specialists.Methods: Charts of patients who were identified as hepatitis B surface antigen (HBs-Ag)-positive or hepatitis C virus antibody (HCV-Ab)-positive by university hospital departments not specializing in hepatology from January to December 2015 were retrospectively reviewed. Patients were assigned to a “referred” group or a “non-referred” group based on whether they were subsequently referred to the Hepatology Department. Age, sex, type of department visited (one of various internal medicine departments, or a different department), and blood test results were compared in the two groups.Results: Among 7,824 patients screened for HBs-Ag, 82 were positive. Twenty-nine (35.4%) had subsequently been referred to the Hepatology Department, which was higher than the 2010 referral rate (20.6%). In multivariate analysis, patients in the referred group were significantly more likely to have visited one of various internal medicine departments, and they had higher levels of platelet count and γ-glutamyl transpeptidase. Among 7,778 patients screened for HCV-Ab, 279 were positive. Only 33 (11.8%) had subsequently been referred to the Hepatology Department, which was lower than the 2010 referral rate (18.7%). In multivariate analysis, patients in the referred group were significantly more likely to have visited an internal medicine department.Conclusion: HCV-antibody-positive patients screened by departments not specializing in hepatology were not managed adequately in 2015. This suggests a need for education of doctors not specializing in hepatology, particularly those not working in internal medicine departments.Keywords: hepatitis B virus, hepatitis C virus, hepatitis B, hepatitis C, referral, department

Shun Yamashita,1 Masaki Tago,1 Midori Tokushima,1 Tomotaro Nakashima,1 Naoko E Katsuki,1 Keizo Anzai,2 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Division of Metabolism and Endocrinology, Faculty of Medicine, Saga University, Saga, JapanCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, JapanTel +81952343238Fax +81952342029Email tagomas@cc.saga-u.ac.jpBackground: Our hospital’s department of general medicine is often involved in the diagnosis and treatment of diseases that are considered by other hospitals or other departments in our hospital to be difficult to diagnose correctly.Objective: The aim of this study was to clarify how patients with infective endocarditis (IE) being admitted to our hospital’s department of general medicine were examined and treated and to elucidate their prognosis compared with patients admitted to other departments.Materials and Methods: Inpatients of Saga University Hospital with definite IE from September 2007 to August 2017 were divided into 2 groups: those admitted to the general medicine department (the GM group) and those admitted to other departments (the non-GM group).Results: Seventy-four patients were included; 17 (23%) were admitted to the general medicine department. In the GM group, the percentage of patients diagnosed with definite or suspected IE was lower (0% vs 32%, p=0.008), as was the rate of patients with echocardiographic findings that fulfilled the major modified Duke’s criteria (71% vs 98%, p≤ 0.001), preadmission. The GM group had higher percentages of patients with back or joint pain (41% vs 9%, p=0.001) and complications, including pyogenic spondylitis (35% vs 2%, p≤ 0.001), deep-seated abscesses (24% vs 5%, p=0.024), pyogenic arthritis (18% vs 0%, p=0.001), and glomerulonephritis (77% vs 37%, p=0.004) than did the non-GM group. Mortality within 30 days of admission to our hospital (12% vs 14%, p=0.753) and overall in-hospital mortality (12% vs 18%, p=0.570) did not significantly differ.Conclusion: The general medicine department could have accurately diagnosed IE, given appropriate treatments, and obtained similar prognoses to those of IE patients treated by other departments, including cardiology and cardiovascular surgery, even in patients for whom diagnosing IE was more difficult or who had less typical echocardiographic findings preadmission.Keywords: infective endocarditis, echocardiographic findings of infective endocarditis, general medicine, cardiology, cardiovascular surgery

Tokushima Y, Tago M, Tokushima M, et al. Int J Gen Med. 2020;13:743—750. The authors have advised there are errors in Table 1 on page 746 in the Hbs-Ag positive patients’ data. The errors were introduced during the creation of the Table. The correct Table 1 is shown below: The errors were only in the patients’ background and do not affect the main results (consultation rate, comparison of RF and non-RF groups), discussion, or conclusion of the paper. The authors apologize for these errors. Read the original article

The freezing characteristics of an aqueous binary solution along a horizontal cooled tube are investigated. Experiments are conducted wherein a cylinder is dipped in an ethylene-glycol solution and subjected to both forced and free convection. The necessary measurements are obtained through a set of thermocouples placed around cooling tube. Results indicate that the characteristics of the frozen layer are considerably affected by the cooling conditions which are dependent on the temperature and concentration of the solution.

A study is conducted on the melting behavior of a horizontal ice cylinder submerged in quiescent saline water with a salinity level of 3.5 wt% for ambient room temperatures between 2.8 to 20.3 degrees Celcius. Results show there is laminar bidirectional flow at the lower part of the melting cylinder and a turbulent unidirectional flow at the upper portion. It was also observed that melting velocity increases with an increase in ambient fluid temperature.