Tokyo Bay Urayasu Ichikawa Medical Center General Internal Medicine Resident
I am honored to report my experience in the externship at the Department of Hospital Medicine in Shands Hospital, UF Health, a program by the International Exchange Program Committee of ACP Japan Chapter.
I applied to this program because I would like to be a resident in the U.S., and to become a specialist in hospital medicine in the future. Since the field is not yet common in Japan, I thought that I would be able to gain a lot of experience that could not be obtained in my country. Consequently, my guess was correct.
I observed two branches of the division; the floor team and the consultation team. The floor team basically takes care of inpatients who have multiple health problems not limited to one organ. In my hospital, I usually work as a general internal medicine doctor, and I noticed that there is not such a big difference in terms of work content and treatment strategy between U.S. and Japan. I was pleased to know that the clinical skills that I have gained in my workplace are as good as the ones residents of one of the best teaching hospitals in the U.S. can learn.
The consultation team consists of a resident and an attending doctor. They accept consultations from other departments and procedures including thoracentesis, paracentesis, lumbar puncture, and so on. The main cases of referrals are co-management of patients in surgery divisions. For example, we get many patients from orthopedics with comorbidities such as hypertension, diabetes, and heart failure. The cooperation between each department to treat patients was quite impressive.
Since this unique consultation system is the biggest reason for me to become a hospitalist in the U.S., I was happy to have the chance to observe their work. Though the system is not prevalent in my country, I am convinced that it is beneficial to both patients and doctors in other departments because surgeons do not have to take care of those problems and can concentrate on their specialties, and patients are treated by specialists of internal medicine. In the future, I would like to learn about this culture and bring it back to my country to make the Japanese healthcare system better.
Not only was it an excellent chance to learn about medicine in America, but it was also such a great opportunity for me in terms of my future carrier as a resident. Doctor Kattan, the attending doctor, was so generous that he allowed me to see patients and make presentations on each round. Although it was a short externship, I felt that I made a significant improvement in my clinical skills through this experience. I believe that it was achieved by reflecting on the attending doctor’s evaluation and advice about my assessments, plans, and presentations every day. He also asked me a lot of clinical questions related to patients during rounds, which revealed that I need to be more familiar with a wide variety of diseases, treatments, etc. I also realized that it was vital for me to acquire his ability to educate residents and medical students in the future.
Through this externship, my determination of becoming a hospitalist has only gotten deeper. I strongly recommend this program to those who wish to work in the United States.
Finally, I would like to express my heartfelt gratitude to the attending doctors who gave us the chance to join the externship, doctors in IECP of ACP Japan Chapter including Dr. Maliishi, and Dr. Stein who kindly and wholly helped me before and during my stay in Gainesville, Florida.
このたび、アメリカ内科学会日本支部国際交流委員会のプログラムにより、University of Florida Department of Hospital Medicineに3週間のエクスターンシップの機会を頂きました。学んだことはあまりに多く、書ききれない事柄も多々ありますが、できるだけ詳細にご報告させていただきます。
はじめに、今回ローテーションさせていただきましたDepartment of Hospital Medicineとその志望理由について説明いたします。この診療科はいわゆるHospitalistが勤務している診療科であり、入院中の患者のうち複数科にわたるプロブレムを持つ患者を中心に担当を行っています。また、他科(主に整形外科、泌尿器科、産婦人科などの非内科系診療科)からの内科的コンサルトも引き受けています。私は将来米国にてHospital Medicineを専攻したいと考えており、今回のエクスターンシップは本場のHospital Medicineを学ぶまたとない好機と考えたため、応募をさせていただきました。
Hospitalistの勤務体系はseven days on, seven days offと呼ばれており、7日間の連続勤務ののちに7日間の休暇があります。休暇に入ってしまう関係上、単独の医師をShadowしつづけることができないため、7日間をFloorでshadowしたのち、次の7日間をConsultation serviceで過ごすという方法を採らせていただきました。正確には週の中盤でseven daysの交替が行われるため、バランスよくいずれも1週間半ずつ滞在することができました。
I am a PGY-16 board-certified nephrologist and have done my clinical and epidemiological research at University of California Irvine between 2014-2018. While studying there, I have become intrigued with the US clinical practice, which I was not able to get familiar with just reading articles or analyzing data. I do need to do clinical practice by myself for this purpose, and I started preparing to become a US-certified physician even though it may seem ridiculous to start over my career at the age of 40’s. Therefore, it was very fortunate for me to obtain an opportunity for the 3-week externship at Division of Nephrology, University of Florida (UF). I learned a lot there, but here I would like to briefly summarize some of the most impressive experience.
Figure 1. South tower view from North tower
UF Shands hospital is a huge hospital with more than 800 beds (Figure 1), and health care is provided across four buildings including its associated Veterans Affairs medical center. The nephrology team divides into several groups into those physicians who cover the general wards and ICU, those who cover ER and the chronic care hospital, and those who cover kidney transplantation. Nephrology fellows rotate these locations throughout their training period. At Shands hospital, the primary care providers for inpatients are hospitalists and/or surgeons, and the main role of the nephrology team is consultation where they suggest treatment advice and provide dialysis treatments. They take care mainly of dialysis patients admitted for complications and those inpatients suffering from acute kidney injury and/or electrolyte abnormalities. Fellows see patients early in the morning and then meet the attending physicians to discuss treatment options. They start ward round after electric medical record review, which is very similar to what I have done in Japan.
One of the biggest differences to Japan was the socioeconomic backgrounds of patients. There were quite a few young patients with alcoholic cirrhosis complicated by hepatorenal syndrome and those IV drug users with infectious endocarditis complicated by acute kidney injury. I often encountered hemodialysis patients coming into ER for fluid overload after skipping their last treatment session for a variety of reasons. Also, I recall meeting an undocumented and uninsured immigrant patient with ESRD who presented to the ER in the middle of the night after driving all the way from Orlando, where he had been receiving regular hemodialysis care for many years, in the hopes of receiving a kidney transplant. Shands hospital, like most hospitals in the US, face challenges of taking care of uninsured and undocumented patients with chronic comorbidities such as CKD and heart failure. Some states, such as California and Illinois, are able to offer kidney transplantation to select undocumented ESRD patients, mainly because it is less costly than continuing regular hemodialysis. Nevertheless, I was deeply impressed to see that the nephrology physicians always made every effort to listen to patients, feel for them, and respect their will regardless of their social backgrounds.
I had been just certified by ECFMG when I started this externship, and now I am preparing to start my career as a physician in the US. Therefore, it was a highly valuable opportunity for me to observe real clinical practice at UF Shands hospital before I work as a nephrology fellow. I greatly thank the nephrology attendings Dr. Tantravahi and Dr. Ali (Figure 2) who gave me flexible learning opportunities and taught me US medicine through discussions during their busy working time. I also thank Dr. Mark Segal, the Chief of Nephrology, and all the staff including Kayla; they welcomed me with warm hospitality although I was a total stranger to them. My special thanks go to Dr. Gerald Stein and ACP Japan Chapter for providing such a unique program. My experience at UF Shands hospital will definitely help me pursue my ambition to become a physician-scientist in the US, and I will strive to make my best effort to achieve my goal.
（Health and Public Policy Committee (HPPC) project）
Kichijoji Asahi Hospital, Internal Medicine
Yuhta Oyama, MD, FJSIM, FACP
On the second day of ACP Japan Branch Annual Meeting 2019, the afternoon of June 9, we held a session with the above title as a project of HPPC. There are 337 FACPs, 6 MACPs and 1 Honorary Fellow as of December 18, 2018 in the ACP Japan branch. By listening to the reason why they aimed at Fellow, how they changed their daily work by becoming Fellow, and how they would like to act as Fellow in the future, we hope more member aim to FACP.
We had conducted a similar session at the annual meeting last year, and in this project, we also conducted a preliminary questionnaire on acp-exchange etc. We ask FACP and MACP about the process of becoming FACP/MACP and the change after that, etc., we ask Members about the image of FACP and whether or not they are aiming, and how they think they would change by becoming a FACP.
In the session, after explaining the purpose first, we presented the results of the preliminary questionnaire. Based on the results, valuable comments were received from Dr. Kenji Maeda, the current Governor of the Japan Chapter, Dr. Fumiaki Ueno, the former Governor of the Japan Chapter, and Dr. Noriko Yamamoto, chair of the Women’s Committee. As a result, a more meaningful message was delivered to everyone who participated, as well as to HPPC members. We would like to deeply thanks to the three commentators for taking part in this session despite the busy period. There are various motives when becoming a Member or Fellow, but being a Fellow gives them a mental motivation such as pride, confidence, and a sense of responsibility that seems important to continue the profession of a doctor.
After that, participants, commentators, and HPPC members joined to form three small groups, and group discussion were conducted along the theme. Participants exchanged their opinions easily, and active conversations were held in all groups. Finally, we made a summary and ended this session.
Members who participated in the session could hear the story from Fellow in the group discussion, so they would have thought of becoming a Fellow. Thank you very much for all the participants who have been listening diligently. It is hoped that more people aim for Fellow with this project as opportunity, but eventually it is the hope of us that ACP Japan chapter members will be more by repeated such projects.
1, Become the best hospital many doctors would like to work at.
NPO Corporation Director Dr.Toshiko Takino, MD
2, How the maternity leave system works in the US and how to keep work-life Balance?
Sapporo Tokusyuukai Hospital Dr. Shadia Constantine, MD FACP
3, Diversity management of the Palliative care Division at Iizuka Hospital.
Iizuka Hospital Palliative care Division Director Dr. Hideyuki Kashiwagi MD
4, The approach at Tokyo Women’s Medical School, Now and then, in future. From medical education to re-training as physician after any leave.
Tokyo Women’s Medical School Center of the Adult Diseases. Professor Dr. Noako Iwasaki, MD
5, Career Support multiply Patients Safety equal Work style Reform to have approached For 12 years at Okayama University medical school.
Okayama University medical school Professor Dr. Hitomi Kataoka.MD
First speaker Dr. Takino has the corporation E-J net to measure the functions to work comfortably in the hospitals for female physicians. That is called HOPIRATE by Dr. Takino. She told why she has begun this program, she was a physician of gastroenterology and almost got burn-out when she was working the hospital by fulltime back in her days. She said recently young doctors has been changing to make much of work-life balance and female doctors make things of their personal life , they don’t take care of the patients around time of their return. Other male doctors compensate the patients care after female doctors left and they must work till late hour. The male doctors feel nuisance for that and think female doctors make trouble but are not useful. So HOPIRATE has changed the marks for measurement about working with high motivation not only the conditions of work place with childcare facilities, short time working. The hospital where female doctors are working cheerfully will gather good nurses and office workers and they get more fixed at the hospital, increase the number of patients, they will get more incomes and be happy.
Next speaker is Dr. Shadia Constantine. She was graduated from medical school of Panama and got her residency at US. She has come to Japan as the teaching stuff of the medical education and has three young kids. She told about the maternity leave system in the US. Most of all female physicians can take the maternity leave for about 8weeks. She is working as a teaching physician in Japan and learning at Oxford University.
Third speaker Dr. Hideyuki Kashiwagi has a certified MBA and qualification of social welfare. He affirmed not to admit the stereotype for previous winner. He declare the vision and mission of their division and he and his subordinates pursue to achieve them. He always try to get his subordinates engagement, stimulate their mindsets, share their Why thing. He gave the example the Mikoshi model, Mikoshi is portable shrine. 5 people keep to shoulder the Mikoshi and 2 people come to join, 7 people carry the Mikoshi comfortably but then they feel heavy strangely, 2 person hang the Mikoshi and load them. He told to start conducting easy issues he could do although they have many tough issues.
Fourth speaker Dr. Naoko Iwasaki is Professor of the Tokyo women’s medical school. Tokyo women’s medical school is very unique because the only female students study to become doctors and they perform to educate to become good female doctors and live their lives as doctors. They continue to educate their students why they want to become doctors, they must keep working as physicians. They have had some surveys for alumni association what you are doing. They especially told young female students must have the motivations to become good doctors. Also they perform the work-style reform to go back home at 18 o’clock.
Last speaker is Professor Dr. Hitomi Kataoka. She has a 2 years old baby. She has been working the MUSCAT career center at Okayama University medical school for 12 years. In rural area in Japan the numbers of doctors is running short, in city area especially Tokyo area the numbers of doctors is too much. She think the working doctors now in Okayama don’t quit and keep working with any personal conditions. Most of all doctors think they must work for their local patients because local medical care will collapse if they would quit to work. She told we have to balance between doctor’s well-being and local medical care continuity. They need the supports from their family, comprehension from co-workers. She told when female doctors is increasing in the hospital the female doctors got to have more motivation for upper titles of academic societies.
We held this long time symposium for about 130 minutes, but I didn’t feel too long. 5 doctors talked different issue from various viewpoints. I felt they all talked we need to change our perception for our well-being and social rules. Generation X and young generations have different wishes and lifestyles. But we will avoid to collapse the local medical care, Dr. Iwasaki and Dr. Kataoka have been working for medical education and making mediating center for re-job placement for long time. It would be most difficult and important that we must have been working for long time to change people’s mindset for equity in gender. But now we must take action for this issue with our colleagues and families.
I felt their each efforts are very venerable they have been working on their own identities. But I felt sorry the participants were very small this day. I think young doctors want to go to the educational sessions. They seem to think the work-life reform is not their issues, older peoples like directors and professors must think and perform that for young doctors. I don’t think young doctors don’t need to involve this issue I rather think they must involve this issue for themselves. And work-style reform is not only for female physicians. I think all the physicians must involve and think of this matter and take actions for it. The hospital that female physicians work comfortably and actively will gather good nurses and co-medical staffs and increase the numbers of patients and incomes. And I think the critical point about work-life reform is Patients First. I think we don’t forget we are working for the patients, not only to increase our medical knowledges and practices for ourselves. We must have the balance between personal life and work. But that will not always keep same balance. Sometimes doctors will make a thing of the work as physician but another time they will make a thing of the personal life. This seems long time challenges. But I think at this matter the important thing is physician’s Professionalism. I think we physicians must keep going upon the Professionalism. And we have to keep up with fast pace of daily life and receive the diversity, I think we have to change the mindset and stereotype about gender .That would be much more challenges.
Finally I would like to thank you for the 5 speakers. And I appreciate to Dr. Noriko Kawashima she designed this symposium and I admire her intelligence and networks. The members of our committee had meetings for respective charge and conducted their own ideas. I am very proud of them and appreciated.
米国内科学会日本支部年次総会におきまして、「”Is there a doctor on board?” 高度3万フィートのオンコールに自信を持って手を挙げられる医師になるために」というタイトルで講演を行いました。我々国際交流プログラム委員会では、国際交流にとって最も大切なツールの一つ、医学英語の教育を行うことを念頭に、今回の講演を企画しました。医学英語を使う状況を思い浮かべる中で、委員から、日本における航空機内救急に関する知識、教育の乏しさの指摘があり、ここに焦点を当てることになりました。
IATA（国際航空運送協会）によれば、世界の航空旅客数は2018年に40億人を突破し、さらに増加の一途をたどっています。常時5,000機以上の旅客機が高度30,000 フィートの上空を飛行し、1日あたり1,000万人が機内という閉鎖空間で数時間から十数時間を過ごします。そこで問題となるのが航空機内救急（In-flight medical emergencies; IME）です。過去の統計によればIMEは平均約600便に1件発生するとされ、毎日約1,000件のIMEが世界のどこかの上空で起こっている計算になります。このようなIMEに対して自信を持って対処できる術を身につけていただくことを目標に講演を行いました。
A report of the seminar; “Is there a doctor on board?” at the annual conference of American College of Physicians, Japan Chapter
GIM, Saitama Medical University Hospital
Yuji Yamada, M.D.
We held a seminar, the title of which was “Is there a doctor on board? -to be a physician who can confidently raise a hand to help in-flight medical emergencies” at the annual conference of American College of Physicians, Japan Chapter, Kyoto, Japan. Our initial plan was to create a seminar which can help participants improve their English communication skills. Through our discussion we found in-flight medical emergencies are not well recognized in Japan and decided to focus on this in our seminar.
The number of annual commercial airline passengers exceeded 4 billion for the first time in 2017 according to the report from International Air Transport Association (IATA) and it is expected to increase further. More than 5,000 aircrafts fly at an altitude of 30,000 feet at any given time and ten million people spend several hours daily on the plane. Here comes the problem: In-Flight Medical Emergencies (IMEs).
The estimated prevalence of IMEs is approximately 1 in 600 flights, meaning 1,000 IMEs occur somewhere in the sky every day. As a result, it is becoming inevitable to encounter some kind of IMEs when we take a flight. Therefore, learning and preparing for IMEs are essential for us physicians. The main purpose of this seminar was to provide basic knowledge and important skills to better cope with them.
On the day of this seminar more than 50 participants gathered early in the morning. After quick icebreaking activities, we started the session with a short play. Dr. Makiishi, who belonged to a drama club, played a role of a physician passenger. Dr. Tsutsumi became a passenger from Singapore, who developed syncope in the aircraft. Ms. Komazaki, who is a former cabin attendant, played a cabin attendant role very naturally. Their impressive performance instantly grabbed audience’s heart and greatly helped them understand the concept of IMEs. Lectures were also given in-between the performance, regarding 1) common presentations and proper management of IMEs based on up-to-date medical literatures, 2) tips of history taking in English, and 3) introduction of cabin attendants’ role in IMEs and emergency medical kits available on airplanes. I believe the lectures given not only by a physician but also by a cabin attendant made the understanding of audience even deeper.
It is essential to learn and prepare for IMEs in advance to care sick passengers efficiently since the condition in airplanes is quite unusual. However, in reality, there are not many workshops or seminars available in Japan. We hope this seminar was a great opportunity for audience to recognize the importance of preparation for IMEs and also a great start to expand this type of activities in the future.