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Women’s impressions of their inpatient birth care as provided by family physicians in the Shizuoka Family Medicine Training Program in Japan

Women’s impressions of their inpatient birth care as provided by family physicians in the... Background: Even though Japan faces serious challenges in women’s health care such as a rapidly aging population, attrition of obstetrical providers, and a harsh legal climate, few family medicine residency training programs in Japan include training in obstetrics, and the literature lacks research on women’s views of intra-partum pregnancy care by family physicians. Findings: In this exploratory study, we conducted semi-structured qualitative interviews with five women who received their admission, intrapartum, delivery and discharge care from family medicine residents in the obstetrics ward of a community training hospital. Four women had vaginal births, andone hadaCesarean section.Three were primiparous, and two multiparous. Their ages ranged from 22–33. They found value in family physician medical knowledge and easy communication style, though despite explanation, some had trouble understanding the family physician’s scope of work. These women identified negative aspects of the hospital environment, and wanted more anticipatory guidance about what to expect physically after birth, but were enthusiastic about seeing a family doctor after discharge. Conclusions: These results demonstrate the feasibility of family medicine residents providing inpatient birth care in a community hospital, and that patients are receptive to family physicians providing that care as well after discharge. Women’s primary concerns relate mostly to hospital environment issues, and better understanding the care family physicians provide. This illustrates-areas for family physicians to work for improvements. Keywords: Family medicine, Family physicians, Residency training, Obstetrics, Women’s health, Qualitative research, Rural health care, Japan, Health care shortage, Community health Findings physicians to train in pregnancy care and provide it after Background going into practice in Japan. Women’s health care faces serious challenges in Japan The family physician’s ability to provide prenatal, due to the rapidly aging population and low birth rate pregnancy, post-partum and newborn care offers great [1] and physician trepidation with the legal climate [2]. potential for helping address these challenges [6]. This In addition, changes in the obstetrician workforce, both a is especially true in rural areas and small communities. decline in student interest in the specialty and a growing The low birth rate in low density population areas cannot proportion of female OB/GYN trainees [3], the decreasing support a critical mass of full-time obstetrician/gynecologists. number of facilities providing obstetrical care [4], the These areas face attrition from aging of current obstetricians trend to centralize obstetrical care into larger centers, and who retire, drop obstetrics or relocate to larger hospitals for an aging work force [5] contribute to the need for family benefits of higher obstetrics volume and lifestyle advantages of group practice. In addition, they face difficulty recruiting recently trained obstetricians as there are fewer of them, and * Correspondence: myokota-dky@umin.ac.jp female obstetricians tend to drop obstetrics practice due to Shizuoka Family Medicine Training Program, Kikugawa Family Medicine Center, 1055-1 Akatsuchi, Kikugawa, Shizuoka 437-1507, Japan exhausting work schedules that compromise their personal Department of Family Medicine, Kikugawa Municipal General Hospital, 1632 lives, or to locate in higher population density areas for per- Higashiyokoji, Kikugawa, Shizuoka 439-0022, Japan sonal and professional reasons. The inclusion of pregnancy Full list of author information is available at the end of the article © 2013 Yokota 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 cited. Yokota et al. Asia Pacific Family Medicine 2013, 12:1 Page 2 of 5 http://www.apfmj.com/content/12/1/1 care by family physicians in such settings has great potential to respond to questions posed by the interviewer for supporting the practice of obstetrics in rural and small and volunteer areas of importance to the subject. The communities. Kikugawa Municipal General Hospital Ethics Committee For family physicians to achieve their full potential in approved this research. the community [7], training experiences in OB/GYN and pediatrics are prerequisites. While the Japan Primary Care Setting Association [8] had certified 161 programs as of December The Shizuoka Family Medicine Residency Program, 18, 2012 to train family physicians, extraordinarily few Kikugawa City, Japan, an area situated about mid-way have actually incorporated training in pregnancy and between Tokyo and Kyoto, Japan served as the setting for newborn care. this research [9]. All five women in this project received The Shizuoka Family Medicine (SFM) Residency their prenatal care at the Kikugawa Municipal General Program was established in April, 2010 [9] with the Hospital from one of two OB/GYN doctors in the out- unprecedented support of a four-year grant from the patient clinic where family medicine residents also rotate. Ministry of Health, Labor and Welfare through a commu- All inpatient care for participants was provided by two nity rejuvenation application submitted by the Shizuoka family medicine residents in collaboration with the nurse Prefecture [10]. Developed in collaboration with the midwives in the hospital obstetrics ward. The residents University of Michigan Department of Family Medicine bear responsibility to admit patients, round daily, write [11], the SFM program trains family physicians in the medication orders and deliver patients with assistance full breadth of cradle to grave care. Training occurs in of the nurse midwives—usual practice in Japan—and two community hospitals, the Kikugawa Municipal under the supervision of an attending. All patients in- General Hospital and Morimachi Public Hospital each cluding study participants received a handout (available in with a separate family medicine clinic, and a tertiary Japanese upon request) describing family physicians and care hospital, Iwata Municipal General Hospital for in- family medicine resident participation on the hospital ob- patient pediatrics and obstetrics rotations. In one of the stetrics service. affiliated family medicine clinics, the Kikugawa Family Medicine Center, residents and select faculty provide pre- Participants natal care. Resident experiences in providing obstetrical We sought women participants in the hospital obstetrics care occur in Kikugawa Municipal General Hospital and ward of the community training hospital who received their Iwata Municipal General Hospital. Residents spend four admission, intrapartum, delivery and discharge care from a months during residency training in obstetrics and family medicine resident. Consecutive women admitted gynecology, two months each in years one and two. Resi- by a family medicine resident were eligible to participate dents experience a combination of a small number of con- and approached. All women agreed to participate. tinuity deliveries and deliveries of women from the hospital-based OB/GYN clinic that occur on the general Instrument obstetrics service. Senior family medicine electives in OB/ The interview instrument was designed for the interviewer GYN are possible. to first explain that the purpose of the research was to gain a broad understanding of the participants’ perspectives on Aim and objective their birth care from family medicine residents, and gain The purpose of this study was to elucidate from women insight into ways for family physicians to improve woman’s who received care at Kikugawa Municipal General birth experiences based on their views. The interviewer then Hospital their views about receiving their inpatient asked participants four interview questions, namely, “What birth care from family physician residents. The accept- went well?”, “What went poorly?”, “What are areas of im- ability of family physicians providing birth care is a very provement?”,and “Other general impressions?” timely and important topic in Japan since there are very Data collection procedures: Individuals gave verbal few residency programs or family physicians that provide consent to participate. The interviews were conducted birth care. Moreover, the Shizuoka Family Medicine during morning rounds by a family medicine resident Residency Training program has just started and there directly with the mothers in their hospital room one to is no precedent of family physician residents participating five days after delivery. The hospitalization duration for in birth care in the training hospital itself. normal delivery routinely lasts six days in this hospital. Participant comments were recorded by the interviewer. Methods Design Analysis We conducted an exploratory qualitative study using For the analysis, we employed a template approach [12], semi-structured interviews. This approach allows subjects i.e., the text was analyzed and edited by the four questions Yokota et al. Asia Pacific Family Medicine 2013, 12:1 Page 3 of 5 http://www.apfmj.com/content/12/1/1 that comprised the template. We organized the results They also expressed feeling some anxiety about not to develop a narrative of the participant’sviews. understanding a family physician’sroleand scopeofcare. Results Areas for improvement Participating women’sagesrangedfrom22to33, Areas for improvement focused on how to ameliorate three were primiparous, and two were multiparous. One the problems raised. Thus, participants wanted more delivered by Cesarean section while the rest delivered information about how long there would be incisional vaginally. As illustrated in Table 1, our results follow the pain, postpartum abdominal pain, breast engorgement, structure of the interview questions, namely, positive and and pain from the site of the intravenous catheter. negative experiences, areas for improvement, and other Measures to improve the environment could include general impressions. playing music, using lights with adjustable brightness, and eliminating odors in the ward. Also, to calm pa- Positive experiences tients, a verbal and written explanation during prenatal One positive experience highlighted the family medicine care or at the time of admission that describes the role resident’s functioning between that of a nurse midwife and expertise offered by family physicians would be and an obstetrician. While nurse midwives are usually helpful. available, they do not have the same degree of medical knowledge as a family physician about physiology and General impressions anatomy. Thus, the family medicine residents could provide Overall impressions about family physicians included: more complete answers to the women’squestions. wanting to be seen at follow-up by a family physician, While obstetricians are knowledgeable especially about wishing for a family physician to become the regular the physiological and surgically-relevant aspects of doctor, and feeling glad that a family physician was there birth, the women in this study could meet only briefly during birth care. with the obstetrician about once per day. In contrast, the family medicine residents participating in this research Conclusions were present throughout the day and could answer the Though this was an exploratory study, these findings women’s questions. Regarding their care, patients had demonstrate the feasibility of family physicians working various comments. For example, they described care as together with obstetricians and nurse midwives in rural feeling “safe” since family physicians provided repeated family medicine residency hospital settings. As illustrated, examinations and were present during the labor period, or patients feel there are benefits due to knowledge differ- they shared that it was easy to speak with a family ences between family medicine physicians versus other physician. types of physicians and due to the broad scope of family medicine training. While the concept of a family phys- Negative experiences ician was new to them, after the family physician’srole Women offered few comments about negative aspects and training were clarified, the participants could appreci- of their care. Specifically, they voiced the need for ate the value of family physicians’ contributions to more information about what to expect after the birth their birth care and anticipate benefits of continuity be- relative to pain and bleeding. One woman shared that tween the hospital and the outpatient setting. These data the environment of the delivery room made her nervous. illustrate that Japanese women find hospital-based birth Table 1 Responses about inpatient birth care by family physician residents Positive experiences Negative experiences Areas for improvement General impressions � Family physician’s role between � Lack of information provided � Need for information about � Wanting follow-up care by a family that of a midwife and obstetrician about what to expect after post-partum physical discomfort, doctor the birth i.e., pain from the surgical incision or � Feeling safe � Wanting the family doctors involved in intravenous catheter, postpartum � Lack of relaxing atmosphere their birth care to become their regular abdominal pain, and/or breast � Friendliness of family physicians in the delivery room doctors engorgement encouraged women to talk with them � Uncertainty about what a � Being glad that a family doctor was � Need to improve the delivery family physician does can there room environment with cause anxiety background music, adjustable lights and pleasant aroma � Need to provide an explanation about what family physicians do during prenatal care or at the time of admission Yokota et al. Asia Pacific Family Medicine 2013, 12:1 Page 4 of 5 http://www.apfmj.com/content/12/1/1 care by family physicians as acceptable, and should pro- demonstrate the feasibility of family physician residents vide encouragement for family medicine residents to train providing prenatal, intra-partum and post-partum care, in birth care in Japan. difficulties patients have distinguishing between hospital While this research was designed to assess women’sviews and family physician influences on their care, and positive about family physician involvement in their hospital-based contributions family physician residents can make in care, most negative comments referred to concerns and women’s hospital birth experiences. possible improvements in the hospital environment. To Abbreviations address these findings, the family physician’s view of JAFM: The Japanese academy of family medicine; MHLW: Ministry of health, patient-centered maternity care – when applied in this labour and welfare; OB/GYN: Obstetrics and gynecology; SFM: Shizuoka setting – could help improve the quality of care. Anticipatory family medicine; SMARTER FM: Shizuoka-University of Michigan advanced residency training, exchange and research in family medicine project. guidance, that is, anticipating the patient’sexperience and explaining what will happen beforehand, is a critical Competing interests communication skill strongly emphasized in family The authors declare they have no competing interests. medicine training that could address concerns about post-discharge care. Authors’ contributions MY conceptualized the design of the study, carried out the primary data Even though family medicine residents used a handout collection and worked on the preliminary write-up. ST contributed to the to explain in person what a family physicians does at the design and data collection support. KN helped conceived the study and led time of admission, and what they would be doing during the analysis. MF assisted in the data analysis and primary mentoring for writing the paper. All authors contributed to reading, editing, and approval the hospitalization, women still found it difficult to of the final manuscript. understand the family physician’s scope of work. As few patients have yet experienced the care of a family physician, Author’s information it will likely take time for patients to come to understand Mariko Yokoto currently is a family medicine resident post-graduate year five (including a two-year rotating internship), who began this study during her the breadth and depth of family medicine. Pamphlets, first year of family medicine training. Shinji Tsunawaki currently is a PGY6, use of social media such as Facebook, and community who supervised Dr. Yokota on the hospital ward and now serves as a fellow campaigns about family medicine might help. We are in the SFM family medicine training program. Keiichiro Narumoto serves as faculty member, SFM program and Kikugawa Municipal General Hospital, encouraged by the subjects who indicated their interest Department of Obstetrics and Gynecology, and as a local mentor to Drs. in seeing a family doctor after the hospitalization. If Yokota and Tsunawaki. Michael D. Fetters serves as Director of the Japanese experience from the US applies, patients who experience Family Health Program, and is Professor at the University of Michigan, Department of Family Medicine. Dr. Fetters also serves as the Principal the comprehensive scope of medical skills and care offered Investigator (PI) on the Shizuoka-University of Michigan Advanced Residency, by a family physician will communicate this knowledge to Training, Education and Research in Family Medicine (SMARTER FM) project their friends, and as a result, the popularity of family [9] that supports the University of Michigan’s collaboration in the launch of the SFM program. physicians will grow by word-of-mouth. As an exploratory study, this research had only a small Acknowledgements number of participants, though the encouraging nature This project was made possible through the generous support of the of these data are compelling. Further exploration can following grant: Shizuoka-University of Michigan Advanced Residency Training, Education and Research in Family Medicine (SMARTER FM). address many additional issues regarding roles of family physicians in the entire pregnancy experience including Author details prenatal and post-partum care. While it is plausible Shizuoka Family Medicine Training Program, Kikugawa Family Medicine Center, 1055-1 Akatsuchi, Kikugawa, Shizuoka 437-1507, Japan. Department participants had other concerns but were reluctant to of Family Medicine, Kikugawa Municipal General Hospital, 1632 Higashiyokoji, express them face-to-face with their doctors, we believe Kikugawa, Shizuoka 439-0022, Japan. Department of Obstetrics, Gynecology, most participants answered candidly as suggested by and Family Medicine, Hamamatsu University, School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka 431-3192, Japan. Department both their positive and negative comments. Future research of Obstetrics and Gynecology, Kikugawa Municipal General Hospital, 1632 also could include women’s perspectives regarding specific Higashiyokoji, Kikugawa, Shizuoka 439-0022, Japan. Department of Family ways to improve the training program for family medicine Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, Michigan 48104-1213, USA. residents as this was beyond the scope of this research. While most family medicine training programs in Japan Received: 27 June 2012 Accepted: 3 May 2013 have not embraced training in birth care, we believe that Published: 22 May 2013 even if a family medicine resident does not provide birth References care after completion of residency, the birth experience 1. Ministry of Internal Affairs and Communications: Population estimates by age during training will enable family physicians to understand (5-year age group) and sex-total population, Japanese population. [cited 2012 the nature of the birth process from the patient’s perspec- April 15]. Available from: http://www.stat.go.jp/data/jinsui/. 2. Leflar RB: The law of medical misadventure in Japan. Chicago-Kent Law tive, to grasp many issues that occur at the beginning Review 2012, 87(1):101–34. of life and to provide anticipatory guidance to their 3. Fujii S: Overcoming the crisis in obstetric and gynecologic practice. patients about birth issues [6]. These preliminary findings JMAJ 2005, 48(12):609–11. Yokota et al. Asia Pacific Family Medicine 2013, 12:1 Page 5 of 5 http://www.apfmj.com/content/12/1/1 4. Ministry of Health Labour and Welfare: Current status and issues of health care in our country. [cited 2012 April 15]; Chapter 2. Available from: http://wwwhakusyo.mhlw.go.jp/wpdocs/hpax200701/b0047.html. 5. Ministry of Health Labour and Welfare: Trends and characteristics of labor economics. [cited 2012 April 15]. Available from: http://www.mhlw.go.jp/wp/ hakusyo/roudou/11/dl/01-1-3.pdf. 6. Fetters MD, Fujioka Y: Why women’s health training is needed during family medicine residency training in Japan (なぜ、日本の家庭医学研 修に婦人医療研修が含まれるべきなのか?). Jpn J Fam Pract 2009, 15(1):44–51. 7. Fetters MD, Kiyota A, Sano K: The social role family practice plays in the community: Understanding the family physician as a specialist (地域にお ける家庭医療の社会的役割:家庭医を専門医として理解するために). Jpn J Prim Care 2004, 27(1):29–35. 8. Japan Primary Care Association: Overview of Advance Residency Training Programs. ; 2012. Available from: http://www.primary-care.or.jp/index.html. 9. Shizuoka Family Medicine (SFM): Shizuoka Family Medicine (SFM). Shizuoka Prefecture, Japan; [cited 2012 April 15]. Available from: http://www.shizuoka-fm.org/. 10. Terada M: Shizuoka Family Medicine Training Program. Journal of Japan Municipal Hospital Association 2011, 50(6):867–73. 11. Demsky I: U-M partnership will help revamp Japan’s approach to family medicine. Ann Arbor, Michigan: University of Michigan Health System; 2010. Available from: http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=1829. 12. Miller WL, Crabtree BF: The dance of interpretation. Doing qualitative research. Thousand Oaks, CA: Sage Publications; 1999:127–43. doi:10.1186/1447-056X-12-1 Cite this article as: Yokota et al.: Women’s impressions of their inpatient birth care as provided by family physicians in the Shizuoka Family Medicine Training Program in Japan. Asia Pacific Family Medicine 2013 12:1. 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Women’s impressions of their inpatient birth care as provided by family physicians in the Shizuoka Family Medicine Training Program in Japan

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Springer Journals
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Copyright © 2013 by Yokota et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
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Abstract

Background: Even though Japan faces serious challenges in women’s health care such as a rapidly aging population, attrition of obstetrical providers, and a harsh legal climate, few family medicine residency training programs in Japan include training in obstetrics, and the literature lacks research on women’s views of intra-partum pregnancy care by family physicians. Findings: In this exploratory study, we conducted semi-structured qualitative interviews with five women who received their admission, intrapartum, delivery and discharge care from family medicine residents in the obstetrics ward of a community training hospital. Four women had vaginal births, andone hadaCesarean section.Three were primiparous, and two multiparous. Their ages ranged from 22–33. They found value in family physician medical knowledge and easy communication style, though despite explanation, some had trouble understanding the family physician’s scope of work. These women identified negative aspects of the hospital environment, and wanted more anticipatory guidance about what to expect physically after birth, but were enthusiastic about seeing a family doctor after discharge. Conclusions: These results demonstrate the feasibility of family medicine residents providing inpatient birth care in a community hospital, and that patients are receptive to family physicians providing that care as well after discharge. Women’s primary concerns relate mostly to hospital environment issues, and better understanding the care family physicians provide. This illustrates-areas for family physicians to work for improvements. Keywords: Family medicine, Family physicians, Residency training, Obstetrics, Women’s health, Qualitative research, Rural health care, Japan, Health care shortage, Community health Findings physicians to train in pregnancy care and provide it after Background going into practice in Japan. Women’s health care faces serious challenges in Japan The family physician’s ability to provide prenatal, due to the rapidly aging population and low birth rate pregnancy, post-partum and newborn care offers great [1] and physician trepidation with the legal climate [2]. potential for helping address these challenges [6]. This In addition, changes in the obstetrician workforce, both a is especially true in rural areas and small communities. decline in student interest in the specialty and a growing The low birth rate in low density population areas cannot proportion of female OB/GYN trainees [3], the decreasing support a critical mass of full-time obstetrician/gynecologists. number of facilities providing obstetrical care [4], the These areas face attrition from aging of current obstetricians trend to centralize obstetrical care into larger centers, and who retire, drop obstetrics or relocate to larger hospitals for an aging work force [5] contribute to the need for family benefits of higher obstetrics volume and lifestyle advantages of group practice. In addition, they face difficulty recruiting recently trained obstetricians as there are fewer of them, and * Correspondence: myokota-dky@umin.ac.jp female obstetricians tend to drop obstetrics practice due to Shizuoka Family Medicine Training Program, Kikugawa Family Medicine Center, 1055-1 Akatsuchi, Kikugawa, Shizuoka 437-1507, Japan exhausting work schedules that compromise their personal Department of Family Medicine, Kikugawa Municipal General Hospital, 1632 lives, or to locate in higher population density areas for per- Higashiyokoji, Kikugawa, Shizuoka 439-0022, Japan sonal and professional reasons. The inclusion of pregnancy Full list of author information is available at the end of the article © 2013 Yokota 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 cited. Yokota et al. Asia Pacific Family Medicine 2013, 12:1 Page 2 of 5 http://www.apfmj.com/content/12/1/1 care by family physicians in such settings has great potential to respond to questions posed by the interviewer for supporting the practice of obstetrics in rural and small and volunteer areas of importance to the subject. The communities. Kikugawa Municipal General Hospital Ethics Committee For family physicians to achieve their full potential in approved this research. the community [7], training experiences in OB/GYN and pediatrics are prerequisites. While the Japan Primary Care Setting Association [8] had certified 161 programs as of December The Shizuoka Family Medicine Residency Program, 18, 2012 to train family physicians, extraordinarily few Kikugawa City, Japan, an area situated about mid-way have actually incorporated training in pregnancy and between Tokyo and Kyoto, Japan served as the setting for newborn care. this research [9]. All five women in this project received The Shizuoka Family Medicine (SFM) Residency their prenatal care at the Kikugawa Municipal General Program was established in April, 2010 [9] with the Hospital from one of two OB/GYN doctors in the out- unprecedented support of a four-year grant from the patient clinic where family medicine residents also rotate. Ministry of Health, Labor and Welfare through a commu- All inpatient care for participants was provided by two nity rejuvenation application submitted by the Shizuoka family medicine residents in collaboration with the nurse Prefecture [10]. Developed in collaboration with the midwives in the hospital obstetrics ward. The residents University of Michigan Department of Family Medicine bear responsibility to admit patients, round daily, write [11], the SFM program trains family physicians in the medication orders and deliver patients with assistance full breadth of cradle to grave care. Training occurs in of the nurse midwives—usual practice in Japan—and two community hospitals, the Kikugawa Municipal under the supervision of an attending. All patients in- General Hospital and Morimachi Public Hospital each cluding study participants received a handout (available in with a separate family medicine clinic, and a tertiary Japanese upon request) describing family physicians and care hospital, Iwata Municipal General Hospital for in- family medicine resident participation on the hospital ob- patient pediatrics and obstetrics rotations. In one of the stetrics service. affiliated family medicine clinics, the Kikugawa Family Medicine Center, residents and select faculty provide pre- Participants natal care. Resident experiences in providing obstetrical We sought women participants in the hospital obstetrics care occur in Kikugawa Municipal General Hospital and ward of the community training hospital who received their Iwata Municipal General Hospital. Residents spend four admission, intrapartum, delivery and discharge care from a months during residency training in obstetrics and family medicine resident. Consecutive women admitted gynecology, two months each in years one and two. Resi- by a family medicine resident were eligible to participate dents experience a combination of a small number of con- and approached. All women agreed to participate. tinuity deliveries and deliveries of women from the hospital-based OB/GYN clinic that occur on the general Instrument obstetrics service. Senior family medicine electives in OB/ The interview instrument was designed for the interviewer GYN are possible. to first explain that the purpose of the research was to gain a broad understanding of the participants’ perspectives on Aim and objective their birth care from family medicine residents, and gain The purpose of this study was to elucidate from women insight into ways for family physicians to improve woman’s who received care at Kikugawa Municipal General birth experiences based on their views. The interviewer then Hospital their views about receiving their inpatient asked participants four interview questions, namely, “What birth care from family physician residents. The accept- went well?”, “What went poorly?”, “What are areas of im- ability of family physicians providing birth care is a very provement?”,and “Other general impressions?” timely and important topic in Japan since there are very Data collection procedures: Individuals gave verbal few residency programs or family physicians that provide consent to participate. The interviews were conducted birth care. Moreover, the Shizuoka Family Medicine during morning rounds by a family medicine resident Residency Training program has just started and there directly with the mothers in their hospital room one to is no precedent of family physician residents participating five days after delivery. The hospitalization duration for in birth care in the training hospital itself. normal delivery routinely lasts six days in this hospital. Participant comments were recorded by the interviewer. Methods Design Analysis We conducted an exploratory qualitative study using For the analysis, we employed a template approach [12], semi-structured interviews. This approach allows subjects i.e., the text was analyzed and edited by the four questions Yokota et al. Asia Pacific Family Medicine 2013, 12:1 Page 3 of 5 http://www.apfmj.com/content/12/1/1 that comprised the template. We organized the results They also expressed feeling some anxiety about not to develop a narrative of the participant’sviews. understanding a family physician’sroleand scopeofcare. Results Areas for improvement Participating women’sagesrangedfrom22to33, Areas for improvement focused on how to ameliorate three were primiparous, and two were multiparous. One the problems raised. Thus, participants wanted more delivered by Cesarean section while the rest delivered information about how long there would be incisional vaginally. As illustrated in Table 1, our results follow the pain, postpartum abdominal pain, breast engorgement, structure of the interview questions, namely, positive and and pain from the site of the intravenous catheter. negative experiences, areas for improvement, and other Measures to improve the environment could include general impressions. playing music, using lights with adjustable brightness, and eliminating odors in the ward. Also, to calm pa- Positive experiences tients, a verbal and written explanation during prenatal One positive experience highlighted the family medicine care or at the time of admission that describes the role resident’s functioning between that of a nurse midwife and expertise offered by family physicians would be and an obstetrician. While nurse midwives are usually helpful. available, they do not have the same degree of medical knowledge as a family physician about physiology and General impressions anatomy. Thus, the family medicine residents could provide Overall impressions about family physicians included: more complete answers to the women’squestions. wanting to be seen at follow-up by a family physician, While obstetricians are knowledgeable especially about wishing for a family physician to become the regular the physiological and surgically-relevant aspects of doctor, and feeling glad that a family physician was there birth, the women in this study could meet only briefly during birth care. with the obstetrician about once per day. In contrast, the family medicine residents participating in this research Conclusions were present throughout the day and could answer the Though this was an exploratory study, these findings women’s questions. Regarding their care, patients had demonstrate the feasibility of family physicians working various comments. For example, they described care as together with obstetricians and nurse midwives in rural feeling “safe” since family physicians provided repeated family medicine residency hospital settings. As illustrated, examinations and were present during the labor period, or patients feel there are benefits due to knowledge differ- they shared that it was easy to speak with a family ences between family medicine physicians versus other physician. types of physicians and due to the broad scope of family medicine training. While the concept of a family phys- Negative experiences ician was new to them, after the family physician’srole Women offered few comments about negative aspects and training were clarified, the participants could appreci- of their care. Specifically, they voiced the need for ate the value of family physicians’ contributions to more information about what to expect after the birth their birth care and anticipate benefits of continuity be- relative to pain and bleeding. One woman shared that tween the hospital and the outpatient setting. These data the environment of the delivery room made her nervous. illustrate that Japanese women find hospital-based birth Table 1 Responses about inpatient birth care by family physician residents Positive experiences Negative experiences Areas for improvement General impressions � Family physician’s role between � Lack of information provided � Need for information about � Wanting follow-up care by a family that of a midwife and obstetrician about what to expect after post-partum physical discomfort, doctor the birth i.e., pain from the surgical incision or � Feeling safe � Wanting the family doctors involved in intravenous catheter, postpartum � Lack of relaxing atmosphere their birth care to become their regular abdominal pain, and/or breast � Friendliness of family physicians in the delivery room doctors engorgement encouraged women to talk with them � Uncertainty about what a � Being glad that a family doctor was � Need to improve the delivery family physician does can there room environment with cause anxiety background music, adjustable lights and pleasant aroma � Need to provide an explanation about what family physicians do during prenatal care or at the time of admission Yokota et al. Asia Pacific Family Medicine 2013, 12:1 Page 4 of 5 http://www.apfmj.com/content/12/1/1 care by family physicians as acceptable, and should pro- demonstrate the feasibility of family physician residents vide encouragement for family medicine residents to train providing prenatal, intra-partum and post-partum care, in birth care in Japan. difficulties patients have distinguishing between hospital While this research was designed to assess women’sviews and family physician influences on their care, and positive about family physician involvement in their hospital-based contributions family physician residents can make in care, most negative comments referred to concerns and women’s hospital birth experiences. possible improvements in the hospital environment. To Abbreviations address these findings, the family physician’s view of JAFM: The Japanese academy of family medicine; MHLW: Ministry of health, patient-centered maternity care – when applied in this labour and welfare; OB/GYN: Obstetrics and gynecology; SFM: Shizuoka setting – could help improve the quality of care. Anticipatory family medicine; SMARTER FM: Shizuoka-University of Michigan advanced residency training, exchange and research in family medicine project. guidance, that is, anticipating the patient’sexperience and explaining what will happen beforehand, is a critical Competing interests communication skill strongly emphasized in family The authors declare they have no competing interests. medicine training that could address concerns about post-discharge care. Authors’ contributions MY conceptualized the design of the study, carried out the primary data Even though family medicine residents used a handout collection and worked on the preliminary write-up. ST contributed to the to explain in person what a family physicians does at the design and data collection support. KN helped conceived the study and led time of admission, and what they would be doing during the analysis. MF assisted in the data analysis and primary mentoring for writing the paper. All authors contributed to reading, editing, and approval the hospitalization, women still found it difficult to of the final manuscript. understand the family physician’s scope of work. As few patients have yet experienced the care of a family physician, Author’s information it will likely take time for patients to come to understand Mariko Yokoto currently is a family medicine resident post-graduate year five (including a two-year rotating internship), who began this study during her the breadth and depth of family medicine. Pamphlets, first year of family medicine training. Shinji Tsunawaki currently is a PGY6, use of social media such as Facebook, and community who supervised Dr. Yokota on the hospital ward and now serves as a fellow campaigns about family medicine might help. We are in the SFM family medicine training program. Keiichiro Narumoto serves as faculty member, SFM program and Kikugawa Municipal General Hospital, encouraged by the subjects who indicated their interest Department of Obstetrics and Gynecology, and as a local mentor to Drs. in seeing a family doctor after the hospitalization. If Yokota and Tsunawaki. Michael D. Fetters serves as Director of the Japanese experience from the US applies, patients who experience Family Health Program, and is Professor at the University of Michigan, Department of Family Medicine. Dr. Fetters also serves as the Principal the comprehensive scope of medical skills and care offered Investigator (PI) on the Shizuoka-University of Michigan Advanced Residency, by a family physician will communicate this knowledge to Training, Education and Research in Family Medicine (SMARTER FM) project their friends, and as a result, the popularity of family [9] that supports the University of Michigan’s collaboration in the launch of the SFM program. physicians will grow by word-of-mouth. As an exploratory study, this research had only a small Acknowledgements number of participants, though the encouraging nature This project was made possible through the generous support of the of these data are compelling. Further exploration can following grant: Shizuoka-University of Michigan Advanced Residency Training, Education and Research in Family Medicine (SMARTER FM). address many additional issues regarding roles of family physicians in the entire pregnancy experience including Author details prenatal and post-partum care. While it is plausible Shizuoka Family Medicine Training Program, Kikugawa Family Medicine Center, 1055-1 Akatsuchi, Kikugawa, Shizuoka 437-1507, Japan. Department participants had other concerns but were reluctant to of Family Medicine, Kikugawa Municipal General Hospital, 1632 Higashiyokoji, express them face-to-face with their doctors, we believe Kikugawa, Shizuoka 439-0022, Japan. Department of Obstetrics, Gynecology, most participants answered candidly as suggested by and Family Medicine, Hamamatsu University, School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka 431-3192, Japan. Department both their positive and negative comments. Future research of Obstetrics and Gynecology, Kikugawa Municipal General Hospital, 1632 also could include women’s perspectives regarding specific Higashiyokoji, Kikugawa, Shizuoka 439-0022, Japan. Department of Family ways to improve the training program for family medicine Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, Michigan 48104-1213, USA. residents as this was beyond the scope of this research. While most family medicine training programs in Japan Received: 27 June 2012 Accepted: 3 May 2013 have not embraced training in birth care, we believe that Published: 22 May 2013 even if a family medicine resident does not provide birth References care after completion of residency, the birth experience 1. Ministry of Internal Affairs and Communications: Population estimates by age during training will enable family physicians to understand (5-year age group) and sex-total population, Japanese population. [cited 2012 the nature of the birth process from the patient’s perspec- April 15]. Available from: http://www.stat.go.jp/data/jinsui/. 2. Leflar RB: The law of medical misadventure in Japan. Chicago-Kent Law tive, to grasp many issues that occur at the beginning Review 2012, 87(1):101–34. of life and to provide anticipatory guidance to their 3. Fujii S: Overcoming the crisis in obstetric and gynecologic practice. patients about birth issues [6]. These preliminary findings JMAJ 2005, 48(12):609–11. Yokota et al. Asia Pacific Family Medicine 2013, 12:1 Page 5 of 5 http://www.apfmj.com/content/12/1/1 4. Ministry of Health Labour and Welfare: Current status and issues of health care in our country. [cited 2012 April 15]; Chapter 2. Available from: http://wwwhakusyo.mhlw.go.jp/wpdocs/hpax200701/b0047.html. 5. Ministry of Health Labour and Welfare: Trends and characteristics of labor economics. [cited 2012 April 15]. Available from: http://www.mhlw.go.jp/wp/ hakusyo/roudou/11/dl/01-1-3.pdf. 6. Fetters MD, Fujioka Y: Why women’s health training is needed during family medicine residency training in Japan (なぜ、日本の家庭医学研 修に婦人医療研修が含まれるべきなのか?). Jpn J Fam Pract 2009, 15(1):44–51. 7. Fetters MD, Kiyota A, Sano K: The social role family practice plays in the community: Understanding the family physician as a specialist (地域にお ける家庭医療の社会的役割:家庭医を専門医として理解するために). Jpn J Prim Care 2004, 27(1):29–35. 8. Japan Primary Care Association: Overview of Advance Residency Training Programs. ; 2012. Available from: http://www.primary-care.or.jp/index.html. 9. Shizuoka Family Medicine (SFM): Shizuoka Family Medicine (SFM). Shizuoka Prefecture, Japan; [cited 2012 April 15]. Available from: http://www.shizuoka-fm.org/. 10. Terada M: Shizuoka Family Medicine Training Program. Journal of Japan Municipal Hospital Association 2011, 50(6):867–73. 11. Demsky I: U-M partnership will help revamp Japan’s approach to family medicine. Ann Arbor, Michigan: University of Michigan Health System; 2010. Available from: http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=1829. 12. Miller WL, Crabtree BF: The dance of interpretation. Doing qualitative research. Thousand Oaks, CA: Sage Publications; 1999:127–43. doi:10.1186/1447-056X-12-1 Cite this article as: Yokota et al.: Women’s impressions of their inpatient birth care as provided by family physicians in the Shizuoka Family Medicine Training Program in Japan. Asia Pacific Family Medicine 2013 12:1. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

Journal

Asia Pacific Family Medicine – Springer Journals

Published: May 22, 2013

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