Increasing the Status of Hospital General Medicine Departments with Emphasis on Outpatient Care in Japan.

Demand is increasing for general medicine services in Japan, a super-aged society. The new medical specialty system introduced in 2019 obligates physicians to obtain a qualified specialty from among 19 basic specialty fields, including general medicine, before obtaining more advanced qualified subspecialties. The role of the department of general medicine in Japan varies in each hospital. Remuneration for medical services obtained by general medicine departments that mainly provide outpatient care is relatively low, making it difficult to fill positions in this department within a hospital. We conducted a narrative review and discussed ways to increase the status of hospital general medicine departments that mainly provide outpatient care. We consider the following four points to be important: improvement of diagnostic capabilities in the outpatient setting; playing a central role in education for medical students and residents; active involvement with patients who have diagnostic difficulties or social problems; and branding and promotion of the general medicine department. We envision that adopting an active approach to these points will increase the status of general medicine departments that mainly provide outpatient care within the hospital, allowing such newly established departments to start easily in Japanese hospitals in the future.

In Japan, a super-aged society, there are 100,461 outpatient medical clinics and 8493 hospitals.1 Approximately 70% of all hospitals and 56% of all hospital beds are managed by private medical organizations.1 All Japanese citizens are covered by the universal health insurance coverage system.2 Under the system, patients usually pay only 10% to 30% of the total medical fees to medical institutions; the remaining 70% to 90% of the total fees are paid from an examination and payment agency to each medical institution.2 The Ministry of Health, Labour and Welfare in Japan reports that the system makes it possible for all citizens in Japan to easily visit any clinic or hospital, with unrestricted access, and to promptly receive high-quality medical services at any hour, at a low cost, resulting the world’s highest level of life expectancy and healthcare standards.2

In Japan, the new medical specialty system introduced in 2019 obligates physicians to obtain a qualified specialty, from among 19 basic specialty fields, before obtaining qualified subspecialties, which are more advanced fields than the 19 basic fields.3 General Medicine is included in one of the 19 basic fields.4 In Japan, the role of the department of general medicine varies in each hospital and in many hospitals, this includes outpatient care.5 Additionally, the demand for general medicine services is increasing in Japan,4 and it is possible that a department of general medicine will be newly established in many hospitals in the future. In such cases, it is likely that the initial setting will mainly be outpatient care owing to insufficient human resources. However, remuneration for medical services obtained by general medicine departments that mainly provide outpatient care is relatively low, making it difficult to fill positions in general medicine within a hospital. Therefore, our group of five academic generalists (median years since graduation: 11 years), including four board members of the Japanese Society of Hospital General Medicine - Junior Doctors Association, conducted a narrative review and discussed ways to increase the status within hospitals of general medicine departments that mainly provide outpatient care. On this basis, we propose the following four points of status: improvement of diagnostic capabilities in the outpatient setting; adopting a central role in education for medical students and residents; active involvement with patients who have diagnostic difficulties or social problems; and branding and promotion of the department of general medicine (Box 1).

Box 1

Ways to Increase the Status of General Medicine Departments that Mainly Provide Outpatient Care within the Hospital

1. Improvement of diagnostic capabilities in the outpatient settingThe final diagnoses of all patients should be confirmed. Misdiagnoses should be thoroughly investigated and the causes should be shared within the department.

2. Playing a central role in education for medical students and residentsTraining in general medicine is highly compatible with medical education. Involvement in education by the general medicine department can decrease the burden on other departments.

3. Active involvement with patients who have a difficult diagnosis, multimorbidity, common diseases, or social problemsIntervention in the treatment of complex patients by the department of general medicine may allow other departments to focus more on their specialized fields.

4. Branding and promotion of the department of general medicineHospital advertising can improve the reputation and financial performance of the hospital, which subsequently improves quality of care. Quantifying the economic benefit of advertising for the hospital is required.

Outpatients expect an accurate diagnosis in medical care.6 Additionally, diagnostic errors are the most common issue in medical lawsuits.7 This suggests that improvement of physicians’ diagnostic capabilities will lead to increased levels of satisfaction among both patients and physicians. To improve the diagnostic capabilities of physicians in the outpatient setting, it is essential to confirm the final diagnoses in all patients and thoroughly verify the causes of misdiagnosis, if identified. Because at an initial visit patients may have few symptoms, which may become more specific to the diagnosis over time such as with acute appendicitis,8 the initial diagnosis may be different from the final diagnosis. In cases where a patient only had an initial visit with no follow-up or was followed in another department or hospital, the physician who initially saw the patient cannot confirm whether the initial diagnosis was correct. Therefore, physicians who initially see a patient should confirm any subsequent change in symptoms with the final diagnosis via phone call or thoroughly following the clinical course in the medical records until a definitive diagnosis is made. If the initial diagnosis differs from the final diagnosis, the cause of the discrepancy should be investigated and actively shared with colleagues. This approach should be followed by all physicians. It is therefore important that physicians in a position with responsibility take the initiative to present their own misdiagnosed cases within the department to provide an environment that encourages their colleagues to present their own misdiagnosed cases. Summarizing misdiagnosed cases and holding case conferences may be useful methods to improve physicians’ diagnostic capabilities.

To improve status within the hospital, it is important to have a central role in the education of medical students and residents. Having few opportunities for contact with attending physicians decreases satisfaction levels among medical students and residents. However, having many opportunities to conduct physical examinations, contact with enthusiastic attending physicians, and participate in educational workshops may increase satisfaction levels and make hospitals more popular as training institutions.9–11 Thus, it is clear that the quality of supervision by attending physicians for medical students and residents is a main factor in determining their level of satisfaction. However, physicians who provide both inpatient and outpatient care may be unable to make sufficient effort toward educating medical students and residents owing to workloads that are heavier than those of physicians who only provide outpatient care. Because training in general medicine is highly compatible with medical education,12 practitioners of general medicine who mainly provide outpatient care adopting a central role in basic clinical skills training may increase satisfaction levels among medical students, residents, and even physicians belonging to other departments.

It is important for the department of general medicine to be actively involved with patients who have a difficult diagnosis; multimorbidity; common diseases such as pneumonia, heart failure, and urinary tract infection; or social problems such as complications of psychiatric illness or no family support. The universal health insurance coverage system makes it possible for such patients to visit hospitals easily.2 Therefore, doctors in specialty departments may have a large number of patients and must treat patients with comorbidities in non-specialty departments. The staff in general medicine departments in Japan have many opportunities to treat such complex patients.13 Interventions in treating such inpatients and outpatients conducted by the department of general medicine may permit professionals in other departments to focus more on their specialized fields. For complex patients who are admitted to other departments, the general medicine department can be involved in treatment alongside other departments. It is obvious that such involvement would increase satisfaction levels in other relevant departments and increase the status of the department of general medicine within the hospital.

In terms of remuneration for medical services, general medicine departments that only provide outpatient care make a smaller financial contribution to the hospital than departments providing inpatient care. To increase the status within the hospital, branding and promotion of the department of general medicine can be a useful strategy. Hospital advertising via social media can improve the reputation and financial performance of a hospital.14,15 Improvement in hospital financial performance can lead to a favorable feedback cycle owing to improved quality of care and further improved financial performance.16 It is important to promote the department of general medicine via media or social networking and quantify the economic benefits that advertising can bring to the hospital.

We envision that actively approaching these points will increase the status of general medicine departments that primarily provide outpatient care within the hospital, allowing such newly established departments to start easily in Japanese hospitals in the future.