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Investigation of diseases that cause diagnostic difficulty for Japanese general physicians

Investigation of diseases that cause diagnostic difficulty for Japanese general physicians Background: There have been some studies of common primary care diseases in Japan, but no reports on which diseases it is difficult for general physicians to diagnose in daily practice. In this study, we identified diseases that provided a diagnostic challenge for Japanese general physicians in daily practice. Methods: The subjects were new undiagnosed patients referred to the General Outpatient Department of Chiba University Hospital during the one-year period from January 2008. We performed a retrospective chart review to identify the referring doctor, patient demographics, the duration of symptoms, the final diagnosis, and the outcome. Final diagnoses were classified according to the International Classification of Primary Care Second Edition (ICPC-2). In addition, the differences between referrals from general physicians and those from other physicians were assessed. Fisher’s exact test and the Bonferroni-Holm correction were used for statistical analysis. Results: A total of 169 patients were referred by general physicians and 239 patients were referred by other physicians. The most common ICPC-2 diagnosis was “General & Unspecified” conditions (35 patients, 20.7%), followed by “Psychological” conditions (31 patients, 18.3%) and “Musculoskeletal” conditions (21 patients, 12.4%). No significant differences of the ICPC-2 category for the final diagnosis and each diagnosis were found between patients referred by general physicians and those referred by other physicians. The hospitalization rate was lower for patients referred by general physicians than for patients referred by other physicians (4 patients, 2.4% vs. 24 patients, 10.0%) (P = 0.002). Conclusions: Japanese general physicians found difficulty in diagnosing “Psychological” conditions, “Musculoskeletal” conditions, variations within the normal range, and viral infections that required diagnosis by exclusion. Because most of the patients referred by general physicians had mild conditions, further education at outpatient departments and clinics is required to improve diagnostic performance. Additionally, it is important to increase the gatekeeper role of general physicians and further development of the medical system by the government to distinguish the functions of clinics and hospitals is expected. Keywords: General physician, Referred patient, Final diagnosis, Diagnostic difficulty Background improve the primary care system and delivery of general All citizens in Japan are covered by a national health medicine being pointed out [2]. Primary care physicians insurance system in which there are no official “gate- are expected to perform a wide range of roles, such as keepers”. Patients can freely choose between attending a management and prevention of common diseases, and local physician’s office (clinic) or a hospital and Japanese one of their vital tasks is to detect patients with serious physicians can freely practice internal medicine [1]. But diseases among the many patients they encounter in recently, Japan has faced the problems of a rapidly aging daily practice [3,4]. Patients who present to general prac- population, financial constraints, and both a shortage titioners are often at an early stage in the natural history and unbalanced distribution of doctors, with the need to of their disease and have vague, atypical or confusing symptoms, resulting in a wide range of diagnostic possi- bilities [5]. In Japan, general physicians can refer their * Correspondence: toko@ra3.so-net.ne.jp patients to specialists at any medical institutions for Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba pref 260-8677, Japan © 2014 Tsukamoto et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 2 of 6 http://www.apfmj.com/content/13/1/9 diagnosis or treatment with a referral letter. When pa- and imaging as required. For psychiatric diseases, the tients visit an advanced treatment hospital without refer- diagnosis was made by consensus of two physicians from ral from a primary care physician, they have had to pay the General Medicine Department after careful investi- an additional charge since 1996 [6,7]. gation to detect any physical disease. If making a diagno- There have been some studies of common primary sis was difficult, we referred the patient to a psychiatrist. care diseases in Japan, but no investigations into which After checking the initial diagnosis and medical records diseases present diagnostic difficulty for general phy- over a 1-year follow-up period, the latest diagnosis was sicians working in community based primary care [8,9]. selected as the final one. If there was more than one Chiba University Hospital is located in the western part diagnosis, the principal diagnosis was defined as the final of Chiba Prefecture near Tokyo, and is a tertiary medical diagnosis. institution with 36 specialist departments that is desig- nated as an advanced treatment hospital. In the present Ethics study, we investigated the final diagnoses of patients re- Patient numbers were coded for information processing ferred to the General Medicine Department to deter- and were destroyed upon completion of the investigation. mine the diseases that are difficult for Japanese general Since the names were not attached to the information, physicians to diagnose in daily practice. We also assessed individual patients could not be identified. This study the differences between referrals from general physicians received approval from the Chiba University Graduate and those from other physicians. School of Medicine Ethics Board (number 1057). Methods Statistical analysis Subjects Differences of the ICPC-2 diagnostic classifications, the The subjects were new patients who were referred to the final diagnosis, and the presence/absence of specialist General Medicine Department of Chiba University Hospital treatment and hospitalization between patients referred for diagnosis during the one-year period from January by general physicians and by other physicians were 2008. Their medical records were retrospectively reviewed assessed for statistical significance using Fisher’s exact and information was stored in a database. The following test, and the level of significance was set at P < 0.05 for data were collected: the referring doctor, patient demo- each analysis. Because analysis of the ICPC-2 category graphics (age and sex), the duration of symptoms, the final (18 categories) and the final diagnosis (38 diseases) in- diagnosis, the final diagnostic category according to volved multiple comparisons, correction was done by a the International Classification of Primary Care Second post hoc Bonferroni test and the level of significance Edition (“ICPC-2”), and the presence/absence of specialist was set at P < 0.0028 and P < 0.0013, respectively. Com- treatment and hospitalization after diagnosis. The General pilation of data and calculation of descriptive statistics Medicine Department is part of the Internal Medicine De- were performed with SPSS for Windows (version 17.0). partment, and staff physicians provide initial treatment for patients who present during office hours after referral Results from other departments of the hospital or from other Referring doctor medical centers, including those of general physicians. In A total of 10,260 new patients presented to the internal Japan there is no official recognition of “family physicians” medicine departments of Chiba University Hospital du- or “general practitioners” by the government. Accordingly, ring the study period. Among these patients, 1,402 pre- we categorized physicians working at general internal sented to the General Medicine Department and 408 medicine clinics as “general physicians” and physicians (29.1%) of them were referred to us without diagnosis. working at specialist clinics or hospital physicians as Among these 408 patients, 169 (41.4%) were referred by “other physicians”. general physicians and 239 (58.6%) were referred by other physicians (Table 1). Diagnosis At our department, the diagnosis was made by a team of Demographics and duration of symptoms of the patients 3 staff physicians who assessed each new patient. If it referred for diagnosis was difficult to make a diagnosis, a medical board was The 169 patients who were referred by general physi- held at the department and we referred the patient to an cians included 60 men (35.5%) and 109 women (64.5%). appropriate specialist, if necessary. Diagnoses that were Their median age was 52 years (range: 16-86 years), and assigned to categories without specific findings, such as the median interval from the onset of symptoms until unspecified viral infections and adverse reactions to referral to our department was 60 days (range:1-3650 medications, were only made after taking a detailed his- days). These results were similar to those for the patients tory and performing physical examination, blood tests, referred by other physicians (Table 2). Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 3 of 6 http://www.apfmj.com/content/13/1/9 Table 1 Referring doctors for the 408 patients who were Table 3 International classification of primary care referred to the General Medicine Department for second edition (ICPC-2) category of the final diagnosis of diagnosis (n = 408) patients referred to the General Medicine Department (n = 408) General physicians 169 (41.4%) ICPC-2 organ Referred Referred Other physicians 239 (58.6%) system category by general by other Specialist departments at our hospital 119 (29.2%) physicians physicians Local/general hospitals 79 (19.4%) n (%) n (%) P value Specialist clinics 30 (7.4%) A. General & Unspecified 35 (20.7) 26 (10.9) 0.007 Other university hospitals 8 (2.0%) B. Blood, Blood Forming 11 (6.5) 11 (4.6) 0.505 Organs & Immune Mechanism More than one hospital 3 (0.7%) D. Digestive 20 (11.8) 20 (8.4) 0.311 General physicians: physicians working at general internal medicine clinics. Other physicians: physicians working at specialist clinics or hospital physicians. F. Eye 0 (0) 2 (0.8) 0.514 Our hospital: Chiba University Hospital. H. Ear 6 (3.6) 6 (2.5) 0.564 Final diagnosis K. Cardiovascular 6 (3.6) 14 (5.9) 0.356 When the final diagnosis was classified by organ system L. Musculoskeletal 21 (12.4) 29 (12.1) 1.000 according to ICPC-2, patients referred by general physi- N. Neurological 10 (5.9) 18 (7.5) 0.558 cians most commonly had “General & Unspecified” con- P. Psychological 31 (18.3) 69 (28.9) 0.019 ditions (35 patients, 20.7%), followed by “Psychological” R. Respiratory 11 (6.5) 10 (4.2) 0.364 conditions in 31 patients (18.3%), “Musculoskeletal” con- S. Skin 3 (1.8) 10 (4.2) 0.254 ditions in 21 patients (12.4%), and “Digestive” conditions in 20 patients (11.8%). When the patients were analyzed T. Endocrine/Metabolic & Nutritional 8 (4.7) 8 (3.3) 0.606 according to the referring physician, the three common U. Urological 2 (1.2) 6 (2.5) 0.478, categories were the same, and there was no significant W. Pregnancy, Childbearing, 0 (0) 0 (0) NA difference of each category between the two groups ac- Family Planning cording to Fisher’s exact test with a post hoc Bonferroni X. Female Genital (including breasts) 3 (1.4) 4 (1.7) 1.000 test (Table 3). Y. Male Genital 0 (0) 0 (0) NA Among final diagnoses in the category of “General & Z. Social Problems 0 (1.4) 3 (1.3) 0.270 Unspecified” conditions for patients referred by general Uncertain diagnosis 2 (1.4) 3 (1.3) 1.000 physicians, 9 patients had unspecified viral infections, 8 patients were found to be normal, and 8 patients had ad- Total 169 239 verse reactions to medications. Among the patients who Data were analyzed by Fisher’s exact test with a post hoc Bonferroni test and significance was accepted at P < 0.0028. NA: not available. were diagnosed as actually being normal, the main com- General physicians: physicians working at general internal medicine clinics. plaint was low-grade fever in 4 patients who were con- Other physicians: physicians working at specialist clinics or hospital physicians. cerned about serious diseases and had no abnormalities on testing. Their symptoms improved after they were reas- failed to return for further assessment and 1 patient im- sured that there were no abnormalities. “Psychological” proved spontaneously. Among the patients referred by conditions included anxiety disorder in 9 patients, mood other physicians, 19 patients had somatoform disorder, disorder in 6 patients, adjustment disorder in 5 patients, and there was no significant difference of each disease bet- and somatoform disorder in 4 patients. In two patients, a ween the two groups according to Fisher’s test with a post final diagnosis could not be made. Both were referred to hoc Bonferroni test (Table 4). our department with fever of unknown origin. One patient Specialist treatment and hospitalization after diagnosis While 107 patients (63.3%) completed treatment at the Table 2 Demographics and duration of symptoms for General Medicine Department, 44 patients (26.0%) were patients referred to the General Medicine Department for referred to specialist departments of our hospital for diagnosis (n = 408) further evaluation and treatment (Table 5). Among the Referred by general Referred by other physicians (n = 169) physicians (n = 239) patients referred by general physicians only four patients (2.4%) were admitted to hospital, which was a signifi- Sex-Male/Female 60/109 104/135 cantly lower rate than that for the patients referred by Median age (range) 52 years (16-86 years) 55 years (16-97 years) other physicians (P = 0.002) (Table 6). Their diagnoses Median duration of 60 days (1-3650 days) 60 days (1-10950 days) included microscopic polyangitis, relapsing polychondri- symptoms (range) tis, pneumonia, and purulent lymphadenitis in one pa- General physicians: physicians working at general internal medicine clinics. Other physicians: physicians working at specialist clinics or hospital physicians. tient each. Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 4 of 6 http://www.apfmj.com/content/13/1/9 Table 4 Final diagnoses of patients referred to the Table 4 Final diagnoses of patients referred to the General Medicine Department (n = 408) General Medicine Department (n = 408) (Continued) ICPC-2 Diagnosis Referred Referred R. Respiratory Cough variant 0 (0) 3 (1.3) 0.270 by general by other asthma physicians physicians Other 11 (6.5) 7 (2.9) 0.092 n (%) n (%) P value S. Skin Cellulitis 1 (0.6) 5 (2.1) 0.408 A. General & Unspecified viral 9 (5.3) 4 (1.7) 0.047 Unspecified infectious Stasis dermatitis 0 (0) 3 (1.3) 0.270 disease Other 2 (1.2) 2 (0.8) 1.000 Conditions 8 (4.7) 10 (4.2) 0.811 T. Endocrine/ Graves’ disease 3 (1.8) 2 (0.8) 0.653 within the Metabolic & normal range Other 5 (3.0) 6 (2.5) 0.767 Nutritional Adverse 8 (4.7) 3 (1.3) 0.058 U. Urological Pyelonephritis 0 (0) 4 (1.7) 0.145 reactions to medical Other 2 (1.2) 2 (0.8) 1.000 products X. Female Genital Other 3 (1.8) 4 (1.7) 1.000 Infectious 3 (1.8) 1 (0.4) 0.070 (including breasts) mononucleosis Z. Social Problems Other 0 (1.4) 3 (1.3) 0.270 Other 7 (4.1) 8 (3.3) 0.791 Other Uncertain 2 (1.2) 3 (1.3) 1.000 B. Blood, Blood Acute 4 (2.4) 4 (1.7) 0.498 diagnosis Forming Organs lymphadenitis (Diagnosis with more than three patients in any group are shown, and & Immune Adult Still’s 0 (0) 3 (1.3) 0.270 diagnosis with less than two are included as other in its category). Mechanism Date was analysed by the Fisher’s exact test and post hoc Bonferroni test, and disease the significant level was set at P < 0.0013. Other 7 (4.1) 4 (1.7) 0.213 General physicians: physicians working at general internal medicine clinics. Other physicians: physicians working at specialist clinics or hospital physicians. D. Digestive Reflux 3 (1.8) 3 (1.3) 0.695 esophagitis Acute 1 (0.6) 3 (1.3) 0.645 gastroenteritis Discussion Other 16 (9.5) 16 (6.7) 0.351 In the present study, patients who were referred to a H. Ear Benign 3 (1.8) 3 (1.3) 0.695 General Medicine Department because of difficulty in paroxysmal making a diagnosis had symptoms for 2 months on positional vertigo average. This suggests that a general outpatient de- partment is likely to attract patients who have Other 3 (1.8) 3 (1.3) 0.695 chronic diseases that do not require hospitalization K. Cardiovascular Cerebrovascular 0 (0) 4 (1.7) 0.145 disease but are difficult to diagnose and need to be investi- gated while considering a wide range of possibilities. Other 6 (3.6) 10 (4.2) 0.802 We will discuss the characteristics of the diseases in- L. Musculoskeletal Cervical 3 (1.8) 4 (1.7) 1.000 volved and the reasons for referral of these patients spondylosis deformans to the General Medicine Department by general Rheumatoid 1 (0.6) 3 (1.3) 0.645 physicians. arthritis Other 17 (10.1) 22 (9.2) 0.865 N. Neurological Other 10 (5.9) 18 (7.5) 0.558 Table 5 Specialist treatment after diagnosis (n = 408) P. Psychological Anxiety disorder 9 (5.3) 10 (4.2) 0.638 Treated by Referred Referred by P value by general physicians other physicians Mood disorder 6 (3.6) 14 (5.9) 0.356 n (%) n (%) Adjustment 5 (3.0) 6 (2.5) 0.767 disorder General Medicine 107 (63.3%) 120 (50.2%) 0.011 Department Somatoform 4 (2.4) 19 (7.9) 0.016 disorder Specialist 44 (26.0%) 82 (34.3%) 0.082 departments Delusional 1 (0.6) 4 (1.7) 0.409 disorder Other medical 18 (10.7%) 37 (15.5%) 0.186 institutions Hypochondria 0 (0 ) 6 (2.5) 0.044 Data were analyzed by Fisher’s exact test and significance was accepted Other 6 (3.6) 10 (4.2) 0.802 at P < 0.05. General physicians: physicians working at general internal medicine clinics. Other physicians: physicians working at specialist clinics or hospital physicians. Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 5 of 6 http://www.apfmj.com/content/13/1/9 Table 6 Hospitalization after diagnosis (n = 408) immunodeficiency virus), endocrine/metabolic diseases, Referred by Referred by P value cancer, and collagen diseases have a high frequency of general physicians other physicians mood disorder [14,15]. This adds another layer of diffi- n (%) n (%) culty to the diagnosis of psychological diseases because Hospitalized 4 (2.4%) 24 (10.0%) 0.002 physicians have to consider the possible coexistence of a wide range of organic diseases. Managed as an 165 (97.6%) 215 (90.0%) 0.002 outpatient Among “Musculoskeletal” conditions, which was the Data were analyzed by Fisher’s exact test and significance was accepted third major category, polymyalgia rheumatica and con- at P < 0.05. nective tissue diseases can be difficult to diagnose, but General physicians: physicians working at general internal medicine clinics. common diseases such as cervical spondylosis were also Other physicians: physicians working at specialist clinics or hospital physicians. missed. In Western countries, it is estimated that appro- ximately 20% of patients attending primary care clinics Classification of the final diagnoses of the patients complain of musculoskeletal symptoms. [16,17] In Japan, general physicians referred to the General Medicine De- Tanaka reviewed several nationwide studies of the symp- partment by organ system according to ICPC-2 revealed toms and diseases handled by primary care clinics, and re- that “General & Unspecified” conditions was the most ported that diseases related to pain and arthritis were frequent diagnostic category, among which the most fre- always frequent, indicating that primary care physicians quent diagnoses were normality, unspecified viral in- need to have sufficient knowledge and skill in the ortho- fections, and adverse reactions to medications. Patients pedic field [9]. who are actually normal and those with unspecified viral The types of patients under management and the spe- infections are unlikely to have any specific findings, so cialty fields differ between general physicians and other diagnosis often involves excluding a wide range of dis- physicians, suggesting that the diseases these doctors eases. According to a report from Australia, adverse re- find difficult to diagnose might also differ. A comparison actions to medications were detected in 10% of patients between referrals from general physicians and referrals consulting general practitioners over a 6-month period, from other physicians showed that the frequency of and the incidence was especially high among elderly “Psychological” conditions (especially somatoform dis- patients [10]. Physicians should keep this in mind order) were somewhat more frequent among patients re- when making a differential diagnosis, since adverse re- ferred by other physicians, suggesting that specialists actions can be improved by discontinuing/switching also have difficulty in diagnosing patients with various the causative drug. In general, patients with benign symptoms and no abnormalities related to their special- diseases such as viral infections have nonspecific ties, in whom it is necessary to exclude diseases from symptoms at an early stage, so that primary care phy- other fields. However, the categories of “Psychological,” sicians often need time to make a diagnosis. However, “General & Unspecified,” and “Musculoskeletal” condi- Japanese patients have a preference for attending large tions were common in both groups, and no significant hospital because of accessibility, so patients and/or differences were found. In Japan, there is no national family members might request referral to a university recognition of general practitioners, unlike the United hospital before their general physicians can make a Kingdom and many other countries. It seems that some diagnosis [11]. specialists who formerly worked in Japanese hospitals “Psychological” conditions was the second most fre- are now providing primary care as general physicians quent category. A possible reason for this high frequency without having received psychiatric and orthopedic of “Psychological” conditions may be that patients with training. This suggests that, even though the clinical set- psychological problems often consult general physicians ting differs somewhat between general physicians and other physicians, both group encounter difficulty with a or specialist departments other than the Department of Psychiatry while complaining of physical symptoms. It similar range of diagnoses. has been reported that patients with depression and anx- In the present study, very few of the patients referred by general physicians needed hospitalization and only 30% iety disorders diagnosed at primary care clinics often only complain of physical symptoms [12,13]. Thus, pa- needed specialist referral. Thus, Japanese general physicians tients with psychiatric diseases who present with phy- have difficulty in diagnosing mild conditions that require exclusion of a wide range of diseases. A questionnaire study sical symptoms may frequently be referred to a general outpatient department since their underlying diseases can- of Japanese and American residents revealed that Japanese not be identified by investigations for organic illnesses. In clinical training was predominantly focused on inpatients [18]. It was also reported that Japanese general physicians addition, it was reported that patients with neurological diseases (such as Parkinson’s disease, Alzheimer disease, want more outpatient training rather than inpatient trai- or cerebrovascular disease), infections (such as human ning in order to improve their clinical skills for primary Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 6 of 6 http://www.apfmj.com/content/13/1/9 care [19]. To improve the diagnostic performance of phy- 3. Ferrer RH, Hambidge SJ, Maly RC: The essential role of generalists in health systems. Ann Intern Med 2005, 142:691–699. sicians, further education at outpatient departments and 4. Green C, Holden J: Diagnostic uncertainty in general practice. A unique clinics is required. It is also possible that general physi- opportunity for research? Eur J Gen Pract 2003, 9:13–15. cians do not perform an adequate gatekeeper role in Japan 5. Knottnerus JA: Medical decision making by general practitioners and specialists. Fam Pract 1991, 8:305–307. and tend to refer patients who have mild diseases to large 6. Ikegami N, Campbell JC: Medical care in Japan. N Engl J Med 1995, hospitals because of the preference of Japanese patients 333:1295–1299. for these institutions and the free access provided by the 7. Ito M: Health insurance systems in Japan: a neurosurgeon’s view. Neurol Med Chir 2004, 44:617–628. national health system. The Japanese government has 8. Yamada T, Yoshimura M, Nagou N, Asai Y, Koga Y, Inoue Y, Hamasaki K, tried to address the issue of undifferentiated functions Mise J, Lamberts H, Okkes I: What are the common diseases and common among different tiers of health care facilities. Since 1996, health problems? The use of ICPC in the community-based project. Jap J Prim Care 2000, 23:80–89. patients who visit a large hospital without referral have 9. Tanaka K, Nomaguchi S, Matsumura S, Fukuhara S: Ranking the frequency had to pay an additional charge, but the fee (about 3000 of patient illness at primary care clinics. Jap J Prim Care 2007, 30:344–351. to 4000 yen) may not be high enough to deter patients 10. Miller GC, Britt HC, Valenti L: Adverse drug events in general practice patients in Australia. Med J Aust 2006, 184:321–324. from spontaneously presenting to large hospital [7,20]. 11. Sugisawa H, Nishi S: Factors related to choice of medical facilities by Further development of a system to distinguish the func- residents. Nihon Koshu Eisei Zasshi 1995, 42:463–471 (in Japanese). tion of clinics from those of hospitals by the government 12. Simon GE, Vonkorff M, Piccinelli M, Fullerton C, Ormel J: An international study of the relation between somatic symptoms and depression. N Eng may be needed. J Med 1999, 341:1329–1335. 13. Haug TT, Mykletun A, Dahl AA: The association between anxiety, depression, and somatic symptoms in a large population: the Hunt-II Limitations study. Psychosom Med 2004, 66:845–851. Because this study was conducted at a single outpatient 14. Evans DL, Charney DS, Lewis L, Golden RN, Gorman JM, Krishnan KR, department, it is unclear whether the findings are widely Nemeroff CB, Bremner JD, Carney RM, Coyne JC, Delong MR, Frasure-Smith N, Glassman AH, Gold PW, Grant I, Gwyther L, Ironson G, Johnson RL, Kanner AM, applicable to Japanese general physicians elsewhere. Katon WJ, Kaufmann PG, Keefe FJ, Ketter T, Laughren TP, Leserman J, Also, other factors that might influence referral, such as Lyketsos CG, McDonald WM, McEwen BS, Miller AH, Musselman D, et al: the patient’s preference, underlying mental condition, or Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry 2005, 58:175–189. relationship with the referring doctor need to be investi- 15. Chida Y: Depression and physical disease. Jpn J Clin Psychiatry 2006, gated in future studies. 35:927–933 (in Japanese). 16. Rekola KE, Keinänen-Kiukaanniemi S, Takala J: Use of primary health services in sparsely populated country districts by patients with Conclusion musculoskeletal symptoms: consultations with a physician. J Epidemiol This study demonstrated that Japanese general physicians Community Health 1993, 47:153–157. found it difficult to diagnose “Psychological” and “Musculo- 17. Busato A, Dönges A, Herren S, Widmer M, Marian F: Health status and health care utilization of patients in complementary and conventional skeletal” disorders in daily practice, as well as variations primary care in Switzerland-an observational study. Fam Pract 2005, within the normal range and viral infections. Since most of 23:116–124. these conditions referred by general physicians do not re- 18. Fetters M, Kitamura K, Mise J, Newton W, Gorenflo D, Tsuda T, Igarashi M: Japanese and United States family medicine resident physicians’ quire hospitalization, appropriate education at outpatient attitudes about training. Gen Med 2002, 3:9–16. departments and clinics will be required to improve diag- 19. Kiyota A, Kamegai M, Sugimori H, Ishii A, Hayashi J, Hamashima C, Sunaga T, nostic performance among general physicians in Japan. It is Ikusaka M, Yosida K, Nakamura T: Practice and education in the required clinical skills for primary care. Jap J Fam Pract 2002, 9:13–21. also important to enhance the gatekeeper role of Japanese 20. Ikegami N, Campbell JC: Japan’s health care system: containing costs and general physicians and to develop a healthcare system that attempting reform. Health Aff (Millwood) 2004, 23:26–36. more clearly demarcates the functions of clinics and doi:10.1186/s12930-014-0009-9 hospitals. Cite this article as: Tsukamoto et al.: Investigation of diseases that cause diagnostic difficulty for Japanese general physicians. Asia Pacific Family Competing interests Medicine 2014 13:9. The authors declare that they have no competing interests. Authors’ contributions TT carried out data collection, participated in the design of the study, and performed the statistical analysis. OY, KN, TT, and TU helped with data collection and statistical analysis. MI participated in study design and helped draft the manuscript. All authors read and approved the final manuscript. Received: 16 December 2013 Accepted: 18 July 2014 Published: 1 August 2014 References 1. Ikegami N, Campbell JC: Health care reform in Japan: the virtues of muddling through. Health Aff 1999, 18:56–75. 2. Koizumi S: The need of general internal medicine: its historical and social background. Nihon Naika Gakkai Zasshi 2003, 92:2319–2325. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Investigation of diseases that cause diagnostic difficulty for Japanese general physicians

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Copyright © 2014 by Tsukamoto et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: There have been some studies of common primary care diseases in Japan, but no reports on which diseases it is difficult for general physicians to diagnose in daily practice. In this study, we identified diseases that provided a diagnostic challenge for Japanese general physicians in daily practice. Methods: The subjects were new undiagnosed patients referred to the General Outpatient Department of Chiba University Hospital during the one-year period from January 2008. We performed a retrospective chart review to identify the referring doctor, patient demographics, the duration of symptoms, the final diagnosis, and the outcome. Final diagnoses were classified according to the International Classification of Primary Care Second Edition (ICPC-2). In addition, the differences between referrals from general physicians and those from other physicians were assessed. Fisher’s exact test and the Bonferroni-Holm correction were used for statistical analysis. Results: A total of 169 patients were referred by general physicians and 239 patients were referred by other physicians. The most common ICPC-2 diagnosis was “General & Unspecified” conditions (35 patients, 20.7%), followed by “Psychological” conditions (31 patients, 18.3%) and “Musculoskeletal” conditions (21 patients, 12.4%). No significant differences of the ICPC-2 category for the final diagnosis and each diagnosis were found between patients referred by general physicians and those referred by other physicians. The hospitalization rate was lower for patients referred by general physicians than for patients referred by other physicians (4 patients, 2.4% vs. 24 patients, 10.0%) (P = 0.002). Conclusions: Japanese general physicians found difficulty in diagnosing “Psychological” conditions, “Musculoskeletal” conditions, variations within the normal range, and viral infections that required diagnosis by exclusion. Because most of the patients referred by general physicians had mild conditions, further education at outpatient departments and clinics is required to improve diagnostic performance. Additionally, it is important to increase the gatekeeper role of general physicians and further development of the medical system by the government to distinguish the functions of clinics and hospitals is expected. Keywords: General physician, Referred patient, Final diagnosis, Diagnostic difficulty Background improve the primary care system and delivery of general All citizens in Japan are covered by a national health medicine being pointed out [2]. Primary care physicians insurance system in which there are no official “gate- are expected to perform a wide range of roles, such as keepers”. Patients can freely choose between attending a management and prevention of common diseases, and local physician’s office (clinic) or a hospital and Japanese one of their vital tasks is to detect patients with serious physicians can freely practice internal medicine [1]. But diseases among the many patients they encounter in recently, Japan has faced the problems of a rapidly aging daily practice [3,4]. Patients who present to general prac- population, financial constraints, and both a shortage titioners are often at an early stage in the natural history and unbalanced distribution of doctors, with the need to of their disease and have vague, atypical or confusing symptoms, resulting in a wide range of diagnostic possi- bilities [5]. In Japan, general physicians can refer their * Correspondence: toko@ra3.so-net.ne.jp patients to specialists at any medical institutions for Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba pref 260-8677, Japan © 2014 Tsukamoto et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 2 of 6 http://www.apfmj.com/content/13/1/9 diagnosis or treatment with a referral letter. When pa- and imaging as required. For psychiatric diseases, the tients visit an advanced treatment hospital without refer- diagnosis was made by consensus of two physicians from ral from a primary care physician, they have had to pay the General Medicine Department after careful investi- an additional charge since 1996 [6,7]. gation to detect any physical disease. If making a diagno- There have been some studies of common primary sis was difficult, we referred the patient to a psychiatrist. care diseases in Japan, but no investigations into which After checking the initial diagnosis and medical records diseases present diagnostic difficulty for general phy- over a 1-year follow-up period, the latest diagnosis was sicians working in community based primary care [8,9]. selected as the final one. If there was more than one Chiba University Hospital is located in the western part diagnosis, the principal diagnosis was defined as the final of Chiba Prefecture near Tokyo, and is a tertiary medical diagnosis. institution with 36 specialist departments that is desig- nated as an advanced treatment hospital. In the present Ethics study, we investigated the final diagnoses of patients re- Patient numbers were coded for information processing ferred to the General Medicine Department to deter- and were destroyed upon completion of the investigation. mine the diseases that are difficult for Japanese general Since the names were not attached to the information, physicians to diagnose in daily practice. We also assessed individual patients could not be identified. This study the differences between referrals from general physicians received approval from the Chiba University Graduate and those from other physicians. School of Medicine Ethics Board (number 1057). Methods Statistical analysis Subjects Differences of the ICPC-2 diagnostic classifications, the The subjects were new patients who were referred to the final diagnosis, and the presence/absence of specialist General Medicine Department of Chiba University Hospital treatment and hospitalization between patients referred for diagnosis during the one-year period from January by general physicians and by other physicians were 2008. Their medical records were retrospectively reviewed assessed for statistical significance using Fisher’s exact and information was stored in a database. The following test, and the level of significance was set at P < 0.05 for data were collected: the referring doctor, patient demo- each analysis. Because analysis of the ICPC-2 category graphics (age and sex), the duration of symptoms, the final (18 categories) and the final diagnosis (38 diseases) in- diagnosis, the final diagnostic category according to volved multiple comparisons, correction was done by a the International Classification of Primary Care Second post hoc Bonferroni test and the level of significance Edition (“ICPC-2”), and the presence/absence of specialist was set at P < 0.0028 and P < 0.0013, respectively. Com- treatment and hospitalization after diagnosis. The General pilation of data and calculation of descriptive statistics Medicine Department is part of the Internal Medicine De- were performed with SPSS for Windows (version 17.0). partment, and staff physicians provide initial treatment for patients who present during office hours after referral Results from other departments of the hospital or from other Referring doctor medical centers, including those of general physicians. In A total of 10,260 new patients presented to the internal Japan there is no official recognition of “family physicians” medicine departments of Chiba University Hospital du- or “general practitioners” by the government. Accordingly, ring the study period. Among these patients, 1,402 pre- we categorized physicians working at general internal sented to the General Medicine Department and 408 medicine clinics as “general physicians” and physicians (29.1%) of them were referred to us without diagnosis. working at specialist clinics or hospital physicians as Among these 408 patients, 169 (41.4%) were referred by “other physicians”. general physicians and 239 (58.6%) were referred by other physicians (Table 1). Diagnosis At our department, the diagnosis was made by a team of Demographics and duration of symptoms of the patients 3 staff physicians who assessed each new patient. If it referred for diagnosis was difficult to make a diagnosis, a medical board was The 169 patients who were referred by general physi- held at the department and we referred the patient to an cians included 60 men (35.5%) and 109 women (64.5%). appropriate specialist, if necessary. Diagnoses that were Their median age was 52 years (range: 16-86 years), and assigned to categories without specific findings, such as the median interval from the onset of symptoms until unspecified viral infections and adverse reactions to referral to our department was 60 days (range:1-3650 medications, were only made after taking a detailed his- days). These results were similar to those for the patients tory and performing physical examination, blood tests, referred by other physicians (Table 2). Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 3 of 6 http://www.apfmj.com/content/13/1/9 Table 1 Referring doctors for the 408 patients who were Table 3 International classification of primary care referred to the General Medicine Department for second edition (ICPC-2) category of the final diagnosis of diagnosis (n = 408) patients referred to the General Medicine Department (n = 408) General physicians 169 (41.4%) ICPC-2 organ Referred Referred Other physicians 239 (58.6%) system category by general by other Specialist departments at our hospital 119 (29.2%) physicians physicians Local/general hospitals 79 (19.4%) n (%) n (%) P value Specialist clinics 30 (7.4%) A. General & Unspecified 35 (20.7) 26 (10.9) 0.007 Other university hospitals 8 (2.0%) B. Blood, Blood Forming 11 (6.5) 11 (4.6) 0.505 Organs & Immune Mechanism More than one hospital 3 (0.7%) D. Digestive 20 (11.8) 20 (8.4) 0.311 General physicians: physicians working at general internal medicine clinics. Other physicians: physicians working at specialist clinics or hospital physicians. F. Eye 0 (0) 2 (0.8) 0.514 Our hospital: Chiba University Hospital. H. Ear 6 (3.6) 6 (2.5) 0.564 Final diagnosis K. Cardiovascular 6 (3.6) 14 (5.9) 0.356 When the final diagnosis was classified by organ system L. Musculoskeletal 21 (12.4) 29 (12.1) 1.000 according to ICPC-2, patients referred by general physi- N. Neurological 10 (5.9) 18 (7.5) 0.558 cians most commonly had “General & Unspecified” con- P. Psychological 31 (18.3) 69 (28.9) 0.019 ditions (35 patients, 20.7%), followed by “Psychological” R. Respiratory 11 (6.5) 10 (4.2) 0.364 conditions in 31 patients (18.3%), “Musculoskeletal” con- S. Skin 3 (1.8) 10 (4.2) 0.254 ditions in 21 patients (12.4%), and “Digestive” conditions in 20 patients (11.8%). When the patients were analyzed T. Endocrine/Metabolic & Nutritional 8 (4.7) 8 (3.3) 0.606 according to the referring physician, the three common U. Urological 2 (1.2) 6 (2.5) 0.478, categories were the same, and there was no significant W. Pregnancy, Childbearing, 0 (0) 0 (0) NA difference of each category between the two groups ac- Family Planning cording to Fisher’s exact test with a post hoc Bonferroni X. Female Genital (including breasts) 3 (1.4) 4 (1.7) 1.000 test (Table 3). Y. Male Genital 0 (0) 0 (0) NA Among final diagnoses in the category of “General & Z. Social Problems 0 (1.4) 3 (1.3) 0.270 Unspecified” conditions for patients referred by general Uncertain diagnosis 2 (1.4) 3 (1.3) 1.000 physicians, 9 patients had unspecified viral infections, 8 patients were found to be normal, and 8 patients had ad- Total 169 239 verse reactions to medications. Among the patients who Data were analyzed by Fisher’s exact test with a post hoc Bonferroni test and significance was accepted at P < 0.0028. NA: not available. were diagnosed as actually being normal, the main com- General physicians: physicians working at general internal medicine clinics. plaint was low-grade fever in 4 patients who were con- Other physicians: physicians working at specialist clinics or hospital physicians. cerned about serious diseases and had no abnormalities on testing. Their symptoms improved after they were reas- failed to return for further assessment and 1 patient im- sured that there were no abnormalities. “Psychological” proved spontaneously. Among the patients referred by conditions included anxiety disorder in 9 patients, mood other physicians, 19 patients had somatoform disorder, disorder in 6 patients, adjustment disorder in 5 patients, and there was no significant difference of each disease bet- and somatoform disorder in 4 patients. In two patients, a ween the two groups according to Fisher’s test with a post final diagnosis could not be made. Both were referred to hoc Bonferroni test (Table 4). our department with fever of unknown origin. One patient Specialist treatment and hospitalization after diagnosis While 107 patients (63.3%) completed treatment at the Table 2 Demographics and duration of symptoms for General Medicine Department, 44 patients (26.0%) were patients referred to the General Medicine Department for referred to specialist departments of our hospital for diagnosis (n = 408) further evaluation and treatment (Table 5). Among the Referred by general Referred by other physicians (n = 169) physicians (n = 239) patients referred by general physicians only four patients (2.4%) were admitted to hospital, which was a signifi- Sex-Male/Female 60/109 104/135 cantly lower rate than that for the patients referred by Median age (range) 52 years (16-86 years) 55 years (16-97 years) other physicians (P = 0.002) (Table 6). Their diagnoses Median duration of 60 days (1-3650 days) 60 days (1-10950 days) included microscopic polyangitis, relapsing polychondri- symptoms (range) tis, pneumonia, and purulent lymphadenitis in one pa- General physicians: physicians working at general internal medicine clinics. Other physicians: physicians working at specialist clinics or hospital physicians. tient each. Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 4 of 6 http://www.apfmj.com/content/13/1/9 Table 4 Final diagnoses of patients referred to the Table 4 Final diagnoses of patients referred to the General Medicine Department (n = 408) General Medicine Department (n = 408) (Continued) ICPC-2 Diagnosis Referred Referred R. Respiratory Cough variant 0 (0) 3 (1.3) 0.270 by general by other asthma physicians physicians Other 11 (6.5) 7 (2.9) 0.092 n (%) n (%) P value S. Skin Cellulitis 1 (0.6) 5 (2.1) 0.408 A. General & Unspecified viral 9 (5.3) 4 (1.7) 0.047 Unspecified infectious Stasis dermatitis 0 (0) 3 (1.3) 0.270 disease Other 2 (1.2) 2 (0.8) 1.000 Conditions 8 (4.7) 10 (4.2) 0.811 T. Endocrine/ Graves’ disease 3 (1.8) 2 (0.8) 0.653 within the Metabolic & normal range Other 5 (3.0) 6 (2.5) 0.767 Nutritional Adverse 8 (4.7) 3 (1.3) 0.058 U. Urological Pyelonephritis 0 (0) 4 (1.7) 0.145 reactions to medical Other 2 (1.2) 2 (0.8) 1.000 products X. Female Genital Other 3 (1.8) 4 (1.7) 1.000 Infectious 3 (1.8) 1 (0.4) 0.070 (including breasts) mononucleosis Z. Social Problems Other 0 (1.4) 3 (1.3) 0.270 Other 7 (4.1) 8 (3.3) 0.791 Other Uncertain 2 (1.2) 3 (1.3) 1.000 B. Blood, Blood Acute 4 (2.4) 4 (1.7) 0.498 diagnosis Forming Organs lymphadenitis (Diagnosis with more than three patients in any group are shown, and & Immune Adult Still’s 0 (0) 3 (1.3) 0.270 diagnosis with less than two are included as other in its category). Mechanism Date was analysed by the Fisher’s exact test and post hoc Bonferroni test, and disease the significant level was set at P < 0.0013. Other 7 (4.1) 4 (1.7) 0.213 General physicians: physicians working at general internal medicine clinics. Other physicians: physicians working at specialist clinics or hospital physicians. D. Digestive Reflux 3 (1.8) 3 (1.3) 0.695 esophagitis Acute 1 (0.6) 3 (1.3) 0.645 gastroenteritis Discussion Other 16 (9.5) 16 (6.7) 0.351 In the present study, patients who were referred to a H. Ear Benign 3 (1.8) 3 (1.3) 0.695 General Medicine Department because of difficulty in paroxysmal making a diagnosis had symptoms for 2 months on positional vertigo average. This suggests that a general outpatient de- partment is likely to attract patients who have Other 3 (1.8) 3 (1.3) 0.695 chronic diseases that do not require hospitalization K. Cardiovascular Cerebrovascular 0 (0) 4 (1.7) 0.145 disease but are difficult to diagnose and need to be investi- gated while considering a wide range of possibilities. Other 6 (3.6) 10 (4.2) 0.802 We will discuss the characteristics of the diseases in- L. Musculoskeletal Cervical 3 (1.8) 4 (1.7) 1.000 volved and the reasons for referral of these patients spondylosis deformans to the General Medicine Department by general Rheumatoid 1 (0.6) 3 (1.3) 0.645 physicians. arthritis Other 17 (10.1) 22 (9.2) 0.865 N. Neurological Other 10 (5.9) 18 (7.5) 0.558 Table 5 Specialist treatment after diagnosis (n = 408) P. Psychological Anxiety disorder 9 (5.3) 10 (4.2) 0.638 Treated by Referred Referred by P value by general physicians other physicians Mood disorder 6 (3.6) 14 (5.9) 0.356 n (%) n (%) Adjustment 5 (3.0) 6 (2.5) 0.767 disorder General Medicine 107 (63.3%) 120 (50.2%) 0.011 Department Somatoform 4 (2.4) 19 (7.9) 0.016 disorder Specialist 44 (26.0%) 82 (34.3%) 0.082 departments Delusional 1 (0.6) 4 (1.7) 0.409 disorder Other medical 18 (10.7%) 37 (15.5%) 0.186 institutions Hypochondria 0 (0 ) 6 (2.5) 0.044 Data were analyzed by Fisher’s exact test and significance was accepted Other 6 (3.6) 10 (4.2) 0.802 at P < 0.05. General physicians: physicians working at general internal medicine clinics. Other physicians: physicians working at specialist clinics or hospital physicians. Tsukamoto et al. Asia Pacific Family Medicine 2014, 13:9 Page 5 of 6 http://www.apfmj.com/content/13/1/9 Table 6 Hospitalization after diagnosis (n = 408) immunodeficiency virus), endocrine/metabolic diseases, Referred by Referred by P value cancer, and collagen diseases have a high frequency of general physicians other physicians mood disorder [14,15]. This adds another layer of diffi- n (%) n (%) culty to the diagnosis of psychological diseases because Hospitalized 4 (2.4%) 24 (10.0%) 0.002 physicians have to consider the possible coexistence of a wide range of organic diseases. Managed as an 165 (97.6%) 215 (90.0%) 0.002 outpatient Among “Musculoskeletal” conditions, which was the Data were analyzed by Fisher’s exact test and significance was accepted third major category, polymyalgia rheumatica and con- at P < 0.05. nective tissue diseases can be difficult to diagnose, but General physicians: physicians working at general internal medicine clinics. common diseases such as cervical spondylosis were also Other physicians: physicians working at specialist clinics or hospital physicians. missed. In Western countries, it is estimated that appro- ximately 20% of patients attending primary care clinics Classification of the final diagnoses of the patients complain of musculoskeletal symptoms. [16,17] In Japan, general physicians referred to the General Medicine De- Tanaka reviewed several nationwide studies of the symp- partment by organ system according to ICPC-2 revealed toms and diseases handled by primary care clinics, and re- that “General & Unspecified” conditions was the most ported that diseases related to pain and arthritis were frequent diagnostic category, among which the most fre- always frequent, indicating that primary care physicians quent diagnoses were normality, unspecified viral in- need to have sufficient knowledge and skill in the ortho- fections, and adverse reactions to medications. Patients pedic field [9]. who are actually normal and those with unspecified viral The types of patients under management and the spe- infections are unlikely to have any specific findings, so cialty fields differ between general physicians and other diagnosis often involves excluding a wide range of dis- physicians, suggesting that the diseases these doctors eases. According to a report from Australia, adverse re- find difficult to diagnose might also differ. A comparison actions to medications were detected in 10% of patients between referrals from general physicians and referrals consulting general practitioners over a 6-month period, from other physicians showed that the frequency of and the incidence was especially high among elderly “Psychological” conditions (especially somatoform dis- patients [10]. Physicians should keep this in mind order) were somewhat more frequent among patients re- when making a differential diagnosis, since adverse re- ferred by other physicians, suggesting that specialists actions can be improved by discontinuing/switching also have difficulty in diagnosing patients with various the causative drug. In general, patients with benign symptoms and no abnormalities related to their special- diseases such as viral infections have nonspecific ties, in whom it is necessary to exclude diseases from symptoms at an early stage, so that primary care phy- other fields. However, the categories of “Psychological,” sicians often need time to make a diagnosis. However, “General & Unspecified,” and “Musculoskeletal” condi- Japanese patients have a preference for attending large tions were common in both groups, and no significant hospital because of accessibility, so patients and/or differences were found. In Japan, there is no national family members might request referral to a university recognition of general practitioners, unlike the United hospital before their general physicians can make a Kingdom and many other countries. It seems that some diagnosis [11]. specialists who formerly worked in Japanese hospitals “Psychological” conditions was the second most fre- are now providing primary care as general physicians quent category. A possible reason for this high frequency without having received psychiatric and orthopedic of “Psychological” conditions may be that patients with training. This suggests that, even though the clinical set- psychological problems often consult general physicians ting differs somewhat between general physicians and other physicians, both group encounter difficulty with a or specialist departments other than the Department of Psychiatry while complaining of physical symptoms. It similar range of diagnoses. has been reported that patients with depression and anx- In the present study, very few of the patients referred by general physicians needed hospitalization and only 30% iety disorders diagnosed at primary care clinics often only complain of physical symptoms [12,13]. Thus, pa- needed specialist referral. Thus, Japanese general physicians tients with psychiatric diseases who present with phy- have difficulty in diagnosing mild conditions that require exclusion of a wide range of diseases. A questionnaire study sical symptoms may frequently be referred to a general outpatient department since their underlying diseases can- of Japanese and American residents revealed that Japanese not be identified by investigations for organic illnesses. In clinical training was predominantly focused on inpatients [18]. It was also reported that Japanese general physicians addition, it was reported that patients with neurological diseases (such as Parkinson’s disease, Alzheimer disease, want more outpatient training rather than inpatient trai- or cerebrovascular disease), infections (such as human ning in order to improve their clinical skills for primary Tsukamoto et al. 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Ito M: Health insurance systems in Japan: a neurosurgeon’s view. Neurol Med Chir 2004, 44:617–628. national health system. The Japanese government has 8. Yamada T, Yoshimura M, Nagou N, Asai Y, Koga Y, Inoue Y, Hamasaki K, tried to address the issue of undifferentiated functions Mise J, Lamberts H, Okkes I: What are the common diseases and common among different tiers of health care facilities. Since 1996, health problems? The use of ICPC in the community-based project. Jap J Prim Care 2000, 23:80–89. patients who visit a large hospital without referral have 9. Tanaka K, Nomaguchi S, Matsumura S, Fukuhara S: Ranking the frequency had to pay an additional charge, but the fee (about 3000 of patient illness at primary care clinics. Jap J Prim Care 2007, 30:344–351. to 4000 yen) may not be high enough to deter patients 10. Miller GC, Britt HC, Valenti L: Adverse drug events in general practice patients in Australia. 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Gen Med 2002, 3:9–16. departments and clinics will be required to improve diag- 19. Kiyota A, Kamegai M, Sugimori H, Ishii A, Hayashi J, Hamashima C, Sunaga T, nostic performance among general physicians in Japan. It is Ikusaka M, Yosida K, Nakamura T: Practice and education in the required clinical skills for primary care. Jap J Fam Pract 2002, 9:13–21. also important to enhance the gatekeeper role of Japanese 20. Ikegami N, Campbell JC: Japan’s health care system: containing costs and general physicians and to develop a healthcare system that attempting reform. Health Aff (Millwood) 2004, 23:26–36. more clearly demarcates the functions of clinics and doi:10.1186/s12930-014-0009-9 hospitals. Cite this article as: Tsukamoto et al.: Investigation of diseases that cause diagnostic difficulty for Japanese general physicians. Asia Pacific Family Competing interests Medicine 2014 13:9. The authors declare that they have no competing interests. Authors’ contributions TT carried out data collection, participated in the design of the study, and performed the statistical analysis. OY, KN, TT, and TU helped with data collection and statistical analysis. MI participated in study design and helped draft the manuscript. All authors read and approved the final manuscript. Received: 16 December 2013 Accepted: 18 July 2014 Published: 1 August 2014 References 1. Ikegami N, Campbell JC: Health care reform in Japan: the virtues of muddling through. Health Aff 1999, 18:56–75. 2. Koizumi S: The need of general internal medicine: its historical and social background. Nihon Naika Gakkai Zasshi 2003, 92:2319–2325.

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Asia Pacific Family MedicineSpringer Journals

Published: Aug 1, 2014

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