学会誌

武田 裕子*

要旨：
医学生の卒業時の到達目標を示す「医学教育モデル・コア・カリキュラム」（平成28年度改訂版）では，初めて，「社会構造と健康・疾病との関係(健康の社会的決定要因:SDH)を概説できる」という学修目標が設定された．生活に困窮しているため外来受診を控える糖尿病患者，抑うつ・自殺企図のリスクを抱える性的マイノリティの方々など，社会の様々な状況・要素が「健康」に影響し健康格差の原因となっている． WHOはそれを「健康の社会的決定要因(Social determinants of health: SDH)」と呼び，医療者に取り組みを求めている．本稿では，格差が広がるなか，SDHを医療者教育で取り上げる意義を概説し，既存の講義や実習を活用して新たにSDH教育を導入する可能性について論じる．
キーワード：健康の社会的決定要因（SDH）, 貧困，健康格差，ヘルス・アドボケイト，カリキュラム開発

Yuko TAKEDA*

Abstract：
In the Model Core Curriculum for Medical Education revised in 2016, the aim to teach “social determinants of health (SDH)” appeared for the first time. In times of social disparity, socio-economic conditions, including unemployment and low income, sometimes discourage people from doing up visits to the clinic due to the copay. This happens despite the universal coverage of health insurance. The socio-cultural environment also affects individual health. For example, thee sexual minority suffers from depression and suicidal risk due to prejudice in our society. The WHO states that SDH are mostly responsible for health inequities and should be tackled by health professionals. In this article, we discuss why we should teach medical students SDH and how we could implement the program to an already overloaded curricula.
Key words: Social determinants of health (SDH), Poverty, Health inequity, Health advocate, Curriculum development

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*順天堂大学医学部医学教育研究室, Division of Medical Education Juntendo University Faculty of Medicine

小曽根 早知子*1　高屋敷 明由美*2

要旨：
筑波大学医学類では，「健康の社会的決定要因（SDH）」に関する教育について，3年次の医療概論での講義，および5-6年次の総合診療科・医療概論の臨床実習に組み込んだ教育プログラムを導入した．臨床実習では，初日にSDHに関するレクチャーと資料を提供した上で，実習中に出会った患者のSDHを考察する課題を課し，最終日にグループ発表とレポート作成を行った．多くの学生が生物モデルとは異なる視点で患者・家族を捉えることができていた一方，時間軸や社会背景を含めた考察ができた学生は一部に留まった．Faculty Developmentなどを通して地域の現場教育と発表会の振り返りの質を上げ，学生のSDHへの理解を深めることが今後の課題である．
キーワード：健康の社会的決定要因，地域医療実習，事例発表会，生物-心理-社会モデル

Sachiko OZONE*1　Ayumi TAKAYASHIKI*2

Abstract:
The University of Tsukuba School of Medicine introduced an education program on the social determinants of health (SDH). It consists of lectures during the 3rd year and a 4-week family practice and community medicine clerkship between 5th and 6th years. In the clinical clerkship, students receive lectures on the first day, are instructed to consider the SDH in the patient they met during the course, give group presentations and hand in written reports on the last day. Most students were able to analyze patients beyond the biomedical model, but only a few students were able to consider the social background and timeline of each patient. Our future challenge is to enhance students’ understanding of SDH through educational programs for faculty members.
Keywords: Social determinants of health, Community medicine clerkship, Case presentation, Bio-psycho-social model

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*1 筑波大学医学医療系地域総合診療医学，University of Tsukuba, Faculty of Medicine
*2 筑波大学医学医療系地域医療教育学／医学教育企画評価室，University of Tsukuba, Faculty of Medicine, Department of Primary Care and Medical Education

堀 浩樹*

要旨：
少子高齢化や医師の都市部偏在，地域医療の崩壊などの保健医療状況の変化に伴い，社会での健康格差が顕在化しており，新しい時代の保健医療人材には，「健康格差の社会的決定要因（SDH）」を理解することが求められている．三重大学医学部では，大学の特色ある教育として取り組んできたアジア・アフリカ諸国での「海外臨床実習」と三重県下全域で実施する「地域基盤型保健医療教育実習」，これら二つの要素を取り込んだ講義「国際保健と地域医療」において，”SDHの理解“を学修の到達目標としている．国際保健と地域医療には，多くの共通点があり，相互の学修課題を学ぶことからSDHの理解を深めることができると考えている．本稿では，三重大学医学部でのこれらの授業の取り組みを紹介する．
キーワード：海外臨床実習，地域基盤型保健医療実習，国際保健医療，健康の社会的格差

Hiroki HORI

Abstract:
Health disparity is an emerging issue in our society. It occurs in connection with an aging population, uneven distribution of health sectors or the collapse of medical care system in rural communities. Accordingly, future health professionals should learn more about social determinants of health (SDH). Mie University Faculty of Medicine has conducted international health electives in Asian and African countries and education about community-based health profession all over the Mie prefecture. Moreover, a lecture entitled “Global Health and Community Medicine” was launched based on the concept that both topics share common aspects of SDH.
In this article, I will report educational programs at Mie University, that provide medical students with opportunities to learn SDH.
Keywords: International health electives, Community-based health professions education, Global medicine, SDH

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*三重大学大学院医学系研究科医学医療教育学分野, Department of Medical Education, Mie University Graduate School of Medicine

武田 裕子*　建部 一夫*　岡田 隆夫*

要旨：
順天堂大学医学部では，3年次に5週間の選択実習を行っている．医学教育研究室では，「健康格差」をテーマにその社会的要因（Social determinants of Health: SDH）について体験を通して学ぶ実習となっており，路上生活者や簡易宿泊所に住む方々，「外国につながりのある子どもたち」など，生活に困窮したり貧困や社会的排除など厳しい環境にある方々とその支援者から直接にお話を伺ったり，支援活動に参加させていただいている．課題として出会った方々をアドボケイトする動画を，教材として作成している．本稿では，このプログラムがどのように始まり，発展しつつあるか，どのような教育理論の実践となっているかを紹介する．
キーワード：健康の社会的決定要因，地域基盤型医学教育, ヘルス・アドボカシー

Yuko TAKEDA*　Kazuo KEMPE*　Takao OKADA*

Abstract:
We provide “students selected components (SSCs)” for 3rd-year students at our school. They work with local NGOs and identify SDH that affect the underserved population including people in isolation, poverty and/or homelessness. Since most students are from privileged families, those encounters made strong impression on students who create a short video to advocate for people they have met. We describe the process of developing this program and explain the models and theories that underpin this education.
Keywords: Social determinants of health, Community-based medical education, Health advocacy

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*順天堂大学医学部医学教育研究室, Department of Medical Education, Juntendo University Faculty of Medicine

吉田 昂平*

Kohei YOSHIDA*

Abstract:
In recent years, health disparity has become more obvious and people from diverse backgrounds suffer from various kinds of problems. It is crucial to foster doctors who can respond to social needs. I participated in a five-week elective couse during his 3rd year of Juntendo University School of Medicine (2015). The course focused on health inequity and social determinants of health (SDH). As a student, I found it extremely important for medical students to learn about SDH. In this report, I will share my experiences as a junior doctor to reflect on what I learned then and how that affects my practice.
Keywords: Health disparity, Medical education, Social needs, Health advocate, Education curriculum

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*順天堂大学医学部附属静岡病院研修医1年，Juntendo university shizuoka hospital first year resident

松尾 沙緒理*　山本 一視*

要旨：
地域一般病院で2004年から取り組んできた地域診断フィールドワーク（FW）を振り返り，SDH教育としての可能性を検討した．新入職員6～8人で構成される多職種グループで数ヶ月間，援助担当者の支援を受けながら地域を調査し発表する．過去の調査の多くは結果的にSDHに関わるものであった．事後のアンケートは，学習者の多くは自分の成果として多職種協働の学びを挙げ，他方で援助担当者はSDHへの学びを多く挙げた．医師では，7割がこのFWの経験が自分の診療に「役に立っている」と感じ，中身では「多職種協働」，「地域を知ることの大切さ」が多く挙がった．「教えることは学ぶこと」はSDH教育でも重要である．
キーワード：地域診断，フィールドワーク，SDH，多職種教育

Saori MATSUO　Kazumi YAMAMOTO

Abstract:
We reviewed the Community Diagnosis Field Work (CDFW) that we have been working on since 2004 at the local general hospital, and examined the possibility of Social determinates of health (SDH) education. A multi-professional group consisting of 6-8 new employees, surveyed the community for several months with the help of support staff, and presented the results. Many of the previous surveys were eventually related to SDH. In the questionnaire after the presentation, many learners cited multidisciplinary learning as their own achievements, and support staff cited many studies on SDH. Among doctors, 70% felt that the experience of this CDFW was “helpful” for their medical care, and specifically mentioned that they learned “multi-professional collaboration” and “the importance of knowing the community”. “Teaching is learning” is also important in SDH education.
Keywords: Community diagnosis, Field work, SDH, Multi professional education

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*千鳥橋病院人事課， Chidoribashi Hospital Human Resources Department
*千鳥橋病院総合診療科， Chidoribashi Hospital General Practice

森屋 宏美*1　矢口 菜穂*1　横山 寛子*1　浦野 哲哉*2　和泉 俊一郎*2

要旨：
背景：看護教育の充実に向け，がん医療における遺伝/ゲノム看護実践能力の概念統合と妥当性の検証を目的とした.
方法：40文献のレビューにより概念を試案し（研究A），がん医療を担う看護師21名を対象とした遺伝/ゲノム看護実践のフォーカス・グループ・インタビュー結果を統合し（研究B），概念の経験的検証をした.
結果：7概念は「遺伝/ゲノム情報の利活用」「家系成員を含めたがん予防」「遺伝/ゲノム関連資源の調整」「個人の多様性に向き合う姿勢」「基本的責務の遂行」「遺伝/ゲノム医療知識の獲得」「遺伝/ゲノム医療への貢献意識」と命名した.
考察：本概念は一定の妥当性があり，がん医療における看護特有の知見を含んだ.
キーワード：遺伝/ゲノム看護，がん看護，実践能力，概念統合

Hiromi MORIYA*1　Naho YAGUCHI*1　Hiroko YOKOYAMA*1
Tetsuya URANO*2　Shun-ichiro IZUMI*2

Abstract：
Background: For enhancing nursing education, we conducted concept synthesis and empirical validation of the essential genetic/genomic nursing competencies on cancer medicine for all nurses.
Methods: First, 41 articles were reviewed to produce a prototype concept of the essential genetic/genomic nursing competencies on cancer medicine (Study A). Second, focus group interviews were conducted with 21 standard-level nurses in cancer care, genetic/genomic nursing practices were extracted, and these were synthesized into Study A results. Consequently, although two new nursing practices were generated, analysis was terminated because no new concepts were created (Study B). Lastly, two experts performed empirical validation for all subjects.
Results: The following seven concepts were identified: “Utilization of genetic/genomic information,” “Prevention of cancer including family members,” “Adjustment of genome-related resources,” “Attitude toward diversity in individuals,” “Fulfillment of basic responsibilities,” “Acquisition of specific medical knowledge,” and “Awareness of the contribution of genetic/genomic medicine.”
Discussion: Compared with the existing genetic nursing core competencies, cancer management systems and technological reforms have led to the addition of “administration management of molecularly targeted drugs” and “harmonization with organizational and regional policies.” Thus, the nursing practice behind the concept has shifted from the legally prescribed “medical treatment for injured and ill persons” to “assist in medical care” involving family members. Others concepts included core competences of general genetic/genomic nursing similar to cancer care.
Keywords: Genetic/Genomic nursing, Oncology nursing, Core competency, Concept synthesis

 

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*1 東海大学医学部看護学科，Faculty of Nursing, Tokai University School of Medicine
*2 東海大学医学部医学科，Faculty of Medicine, Tokai University School of Medicine

Yoshie SAWAYAMA*1　Daisuke SON*1　Eiji KANEKO*2　Masato ETO*1

Abstract:
Background: It is a major challenge to support training for simulated patients (SPs) and maintain a SP community. In order to promote the motivation of SPs, we conducted two sessions titled “clinical diagnostics lectures”. This study qualitatively explores the impact of the lectures for SPs.
Methods: Nine SPs who attended the clinical diagnostics lectures took part in focus group interviews. Transcripts were analyzed as per the Steps for Coding and Theorization (SCAT) method.
Results: Fifteen concepts and six categories were generated from the focus group interviews. The categories included <Medical information learning>, <Deepening understanding of scenarios>, <Effect on performance>, <Effect on feedback>, <Motivation for learning>, and <Concerns about biasing toward medical models>.
Discussion: “Clinical diagnostics lectures” provided to SPs offer a deeper understanding of scenarios and motivation for SPs to learn. However, there was concern about deviation from the patient’s perspective.
Keywords: Qualitative research, Simulated patients, Clinical diagnostics, Patient’s perspective

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*1 Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo
*2 Curricular Management Division, Institute of Education, Tokyo Medical and Dental University

須江 麻里子*1　廣井 直樹*2　高松 研*3

要旨：
日本の医学部入学試験では，独自の人材育成目標とアドミッションポリシーに適合する人材，すなわち卒業時に身につけておくべき様々な専門的実践力を修得出来る人材の確保を目指し，整合性の取れた入学者選抜を実施するために様々な取り組みを行っている．ドイツでの医学部入学者は，特定の分野に偏向せず系統的かつ継続的に学修できる学生を選抜するという国家の方針に基づき，国家規模で統制される第一次選抜と各大学で個別に行われる第二次選抜を経て選抜される．
本稿では医学部入学者選抜の改革が議論される中，ユニークな選抜方法であるTMSを中心にドイツの医学部入学試験の現状を報告することで議論の活性化を促すことを目的とする．
キーワード: 医学生選抜，ドイツ，TMS

Mariko SUE*1　Naoki HIROI*2　Ken TAKAMATSU*3

Abstract:
In Japan, medical schools are making various efforts for the purpose of establishing consistent admission selection process securing human resources, which are compatible with individual development goals as medical doctors and admission policies. In Germany, 40% of medical students are selected through the central office (Stiftung fuer Hochschulzulassung）for the allocation of places in higher education. The rest of the students are decided by Medical Universities. In addition to overall Abitur grade, the nationwide medical admission test　TMS (Test fuer Medizinische Studiengaenge) is used as one of the selection criteria by many universities in individual selection processes with the aim of choosing the students with better medical specialty aptitude. Similar attempts might be difficult in Japan where private and public universities are mixed. However, it is important to share the firm concept of 'what type of students should be selected as medical students'.
Here, we introduce the unique selection process of medical students in Germany, especially focusing on the re-introduction of TMS.
Keywords: Medical student selection, Germany, TMS

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*1 Uniklinikum Carl Gustav Carus an der Technischen Universitaet Dresden
*2 東邦大学医学部医学教育センター, Center for Medical Education, Faculty of Medicine, Toho University
*3 東邦大学，Toho University

里光 やよい*1　村上 礼子*2

要旨：
背景：2015年より定められた医行為を実施できる看護師の養成が開始された．
目的：特定行為看護師の行う気管カニューレ交換の成果を概観する．
方法：特定行為看護師に気管カニューレ交換の実践状況をインタビューした．
結果：抽出された成果は，【カニューレ閉塞の回避へ】【手に伝わる感覚を掴み確実なカニューレ交換】【呼吸状態のトータルな観察・判断】【観察に基づき継続される適切な看護ケア】【医師との連携強化】【看護師との連携強化】【患者・家族からの信頼獲得】であった．
考察：患者の呼吸状態を安全に維持し，観察力や判断力の向上により看護ケアにもよい影響が現れており，医師との連携により患者のQOL向上に寄与できる可能性がある．
キーワード：特定行為，看護師，気管カニューレ交換，成果

Yayoi SATOMITSU*1　Reiko MURAKAMI*2

Abstract:
Background: In 2015, training of nurses qualified to perform specified medical procedures began.
Method: Interviews with specified nurses regarding their practice of tracheostomy cannula replacement.
Results: The following seven outcomes were identified: [expectation of an increased number of cases with no occurrence of cannula obstruction], [thorough cannula replacement by developing an understanding of the feel on their hands], [comprehensive observation and judgment on breathing status], [appropriate continued nursing care based on observation], [improved cooperation with doctors], [improved cooperation with nurses], and [gaining of trust from patients and their family members].
Discussion: The study indicates that the breathing of patients can be maintained safely through procedures performed by the nurses and that the improved observation and judgment skills have a positive impact on nursing care as well. Further contribution to the improvement of patients’ QOL is possible through cooperation with doctors.
Keywords：Specified medical acts, Nurse, Tracheostomy cannula replacement, Outcome

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*1自治医科大学特定行為研修センター，Jichi Training Center for Nursing pertaining to Specified Medical Acts
*2自治医科大学看護学部，自治医科大学看護学研究科, 自治医科大学特定行為研修センター，Jichi Medical University School of Nursing, Jichi Medical University Graduate School of Nursing，Jichi Training Center for Nursing pertaining to Specified Medical Acts

八木（佐伯） 街子*1　松山 泰*2　淺田 義和*3　廣江 貴則*4　鈴木 義彦*5

要旨：
背景：本邦の多くの医学部でシミュレータが普及したが，医学生の自己学習での活用状況は不明である．
方法：同意した82校中29の医学部におけるシミュレータの使用状況を調査，分析した．
結果： 28校がシミュレータを所有し，自己学習での使用は24校が許可した．背景には「実技試験の準備」「自己学習の促進への期待」「学生の要望」があった．使用不許可の理由には「物品管理責任」や「指導者不在の学習成果への疑義」があった．使用時のルールは「予約制にする」など医学部間で共通した．
考察：自己学習でのシミュレータの使用について，適切な使用環境や自己学習に適したシミュレータが何かを探索することも重要である．
キーワード：シミュレータ，自己主導型学習

Machiko SAEKI YAGI*1　Yasushi MATSUYAMA*2　Yoshikazu ASADA*3
Takanori HIROE*4　Yoshihiko SUZUKI*5

Abstract:
While the number of medical schools with simulators is increasing, data pertaining to self-learning is scarce. We conducted a web survey, exploring the ownership and use of simulators at 82 medical schools in Japan; 29 medical schools responded. Twenty-eight of the medical schools owned one or more simulators. Twenty-four allowed undergraduates to engage in self-learning using simulators, and many imposed some restrictions on their use. The medical schools allowed the simulators to be used for a variety of reasons, including “examination preparation,” “improvement of clinical ability,” and “to meet strong demands from students.” Reasons for restriction on use were “equipment management” and “doubts regarding the outcome of self-learning without faculty.” The use of simulators in self-learning is widely supported at medical schools in Japan. In order to optimize self-learning with simulators, appropriate settings and optimal simulator choice should be explored.
Keywords: Simulator, Self-directed learning

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*1 自治医科大学看護学部/看護師特定行為研修センター, School of Nursing, Jichi Medical University/Jichi training center for nurse designated procedures
*2 自治医科大学医学教育センター, Medical Education Center, Jichi Medical University
*3 自治医科大学情報センター, Center for Information, Jichi Medical University
*4 京都大学大学院医学研究科 医療統計学, Department of Biostatistics, Kyoto University Graduate School of Medicine
*5 自治医科大学メディカルシミュレーションセンター, Medical Simulation Center, Jichi Medical University

小林 志津子*

　研究活動はここ数年間というもの休業状態で，リレーエッセイの執筆者にはふさわしくないと思い執筆を辞退しておりました．しかし，育児と研究を両立させていた時期のことをお伝えすることが一部の読者のお役に立つとの武田裕子編集委員長の命を受けましたので，当時の経験を振り返って育児中の研究者の方へ励ましのメッセージをお送りします．

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*京都博愛会病院, Kyoto-Hakuaikai Hospital

要旨：
医学教育における患者の語り（ナラティブ）の重要性が再認識されてきている．それは，プロフェッショナリズム教育においては，「利他性」や「共感」の教育に相当するものであるが，従来こうした教育機会やリソースは限られていた．約100年前に，ベッドサイド教育を重視したウィリアム・オスラー博士は“Just listen to your patient.”と患者の語りの重要性を強調していたことからも，医学教育の根幹には患者の語りへの傾聴がある．現在では，オンラインで視聴できる動画や，患者講師の登場などにより，患者ナラティブの教育の可能性が広がってきた．本稿では，患者ナラティブを活用した医学教育の実践例とその効果などについて検討してみたい．
キーワード：患者の語り，ナラティブ，共感，利他性，プロフェッショナリズム

Abstract:
The importance of patient narratives has been recognized in medical education. It is almost equivalent to concepts of “altruism” or “empathy” in medical professionalism. However, opportunities or resources on the matter have been limited. About 100 years ago, Sir William Osler said, “Just listen to your patient”, emphasizing the importance of patient narratives. Listening to the patient’s story has been situated at the core of medical education, and the value of patient narratives has been explored through an online database and activities of patient storytellers. In this article, examples from our empirical study on patient narratives are presented, and its effectiveness is then discussed.
Keywords: Patient narratives, Narrative, Empathy, Altruism, Professionalism

孫 大輔*

Daisuke SON*

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*1 東京大学大学院医学系研究科医学教育国際研究センター，Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo

香川 由美*

Yumi KAGAWA*

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*東京大学大学院医学系研究科社会医学専攻医療コミュニケーション学分野, Department of Health Communication, Graduate School of Medicine, the University of Tokyo

長尾 大志*

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*滋賀医科大学呼吸器内科, Division of Respiratory Medicine , Department of Medicine, Shiga University of Medical Science

向所 賢一*

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*滋賀医科大学病理学講座分子診断病理学部門, Division of Molecular and Diagnostic Pathology, Department of Pathology, Shiga University of Medical Science