Report my experience in the externship at the Department of Hospital Medicine in Shands Hospital, UF Health

Tokyo Bay Urayasu Ichikawa Medical Center General Internal Medicine Resident

Shuhei Uchiyama

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.

University of Florida Department of Hospital Medicineでのエクスターンシップ

東京ベイ・浦安市川医療センター 総合内科専攻医

内山 秀平

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。



入院患者の疾患は多岐にわたり、心不全、肺炎、COPD急性増悪、蜂窩織炎などの日本でも比較的よくみられる疾患から、cystic fibrosis、sickle cell diseaseによるacute chest syndrome、cocaine-induced ACSなどの米国ならでは(?)の症例まで見学をすることができました。日本でも見られる疾患の診療内容に関しては普段から私が総合内科医として行っているものと大きな差はないと感じられましたが、コストの意識が強い影響か退院のスピードは非常に早く、case managerが各患者のdispositionについて毎日確認を行っている場面が非常に印象的でした。

②Consultation service



もともと私がhospital medicineに興味を持ち始めたのは総合内科としての病棟担当もさることながら、このような他科からのcomanagementのシステムが素晴らしいと考えたことが契機でした。例としては、大腿骨頸部骨折で手術を控えている患者の併存疾患である高血圧、糖尿病、心不全のマネジメントを受け持つ、というような内容です。コンサルテーションのみを受け持つ部門は日本の病院には一般的でないと思われますが、非常にやりがいのある仕事だと感じられました。

さらに、attendingであるDr. Kattanは私がECFMG certificate holder(=USMLE STEP1/2 CK/2 CSをクリア済)であること、米国でresidencyを行おうと考えていることを汲んでくださり、患者のプレラウンドから回診におけるプレゼンテーション、さらには処置まで許可をいただくことができました。加えて短時間ではありますが新規のコンサルテーションがあると最初に通知が来るPager(ポケベル)も渡していただき、実に多くのことを経験させていただきました。これらの経験は私の将来のキャリアにおいてかけがえのないものになると確信しています。


最後に、このような貴重な機会を頂きました牧石先生をはじめ国際交流委員会の先生方、滞在前だけでなく現地にて多くのアドバイス、日常の手助けを頂きましたDr. Steinに心からの感謝を申し上げ、ご報告とさせていただきます。


小尾佳嗣, MD, PhD, FJIM, FASN小尾クリニック 顧問


写真1South towerから望むNorth tower


日本との大きな違いのひとつは、患者さんの社会的背景です。比較的若年でアルコール性肝硬変から肝腎症候群を発症している症例や、違法な静注麻薬の使用から感染性心内膜炎を来たし二次的にAKIを合併している症例が多く、また ERには金曜日の透析を種々の理由でスキップされ、溢水で運ばれて来る方も少なくありませんでした。また、長年オーランドの救急で定期的に透析を受けていた保険のない不法移民の方が、車を数時間運転して飛び込みでやってきて、ここで腎移植を受けさせてほしいと訴えてきたこともありました。確かにカリフォルニアやイリノイなどアメリカの一部の州では、こういった不法移民の患者にも腎移植を実施しているプログラムがあります(腎移植の方が透析よりコストが低いため)。しかし他の多くの病院と同様、Shands病院でもCKDや心不全など慢性疾患を抱えた保険のない不法移民患者へ十分なケアを提供するのは困難な状況でした。このように多様な社会的背景を持った患者さんを見ましたが、時に対応が難しい状況に対しても、Attendingはプロフェッショナリズムを保ちながら、常に患者さんに寄り添いつつ、個人として心から尊重して接していたのが非常に印象的でした。

写真2Dr. Tantravahi(上)とDr. Ali(下)

実は、このExternshipを始める直前にECFMG certificateを取得し、いよいよアメリカで臨床医と働く準備ができたばかりでした。そのような中、自分が実際にフェローとして働く前に実際の現場をフロリダ大学Shands病院で垣間見る機会を得ることができたのは大変貴重な経験でした。学習機会に対する私の求めに柔軟に対応しつつ、様々なDiscussionを通じてアメリカの医療を教えていただいたAttendingのDr. TantravahiとDr. Ali、見ず知らずの日本人を快く受け入れていただいた腎臓内科のチーフであるDr. Mark Segal、およびKaylaを含めたスタッフの皆様、このような特別な場を提供していただき、現地での生活をサポートしてくださったDr. Gerald Steinに心より感謝申し上げます。ACP日本支部の会員であったからこそ得ることが出来た今回の経験を糧に、今後もアメリカでPhysician-Scientistになるという目標へ向けて邁進してまいります。

My externship experience at Division of Nephrology, University of Florida

Yoshitsugu Obi, MD, PhD, FJIM, FASN

Advisor, Obi Clinic

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.

Dr. Tantravahi

Dr. Ali

Figure 2.  


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.

「”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」

米国内科学会日本支部年次総会 講演開催報告

埼玉医科大学病院 総合心療内科 山田悠史

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。

当日は、朝一番の企画にもかかわらず50名を超える聴講者が集まりました。講演は、短時間のアイスブレークのあと、元演劇部の牧石委員長扮する医師の乗客が、筒泉副委員長扮するシンガポール人の乗客リチャードの失神に対応するという寸劇で始まりました。元客室乗務員 の駒崎クララさんにもご協力いただき、本物の客室乗務員さながらの演技をしていただきました。寸劇での3名の迫真の演技は、すぐに聴講者の心を掴み、笑いも交えながら航空機内救急の理解にお役立ていただけたのではないかと思います。また、寸劇の合間にレクチャーを挟む形式で進め、山田より最新の文献に基づくIMEの基礎知識や対応方法についての講義、IMEで想定される英語表現の講義を行いました。また寸劇のあとには、元客室乗務員の星山芳実さんから、IMEにおける客室乗務員の役割、メディカルキットについて、航空機内の医療支援体制、医師登録制度についての解説が行われました。医師だけによる講演とせず、お二人の客室乗務員経験者にもご参加いただくことで、より深みのある内容になったのではないかと思います。


A report of the seminar; “Is there a doctor on board?”

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.




非常にcompetitive なプログラムですが、日本支部からは過去2名の先生がご参加されています。昨年度(2018-2019)は林幹雄先生(東京大学医学教育国際研究センター)がご応募され、見事選抜(ACP海外支部から約30名の応募があり、4名が選ばれました. 領域:医学教育、エクスターンシップ先:Thomas Jefferson University)されています。また2012-2013年年度には、池田裕美枝先生がご参加されています(領域 Menstruation disorder, Mayo Clinic)。

ACP’s International Fellowship Exchange Program (IFEP):
・参加者は、2020年4月にLos Angelesで開催されるACP年次総会で表彰されます。またその参加費用はACP本部から支給されます。



委員長 牧石徹也
副委員長 筒泉 貴彦

Annals of Internal Medicine へのレター投稿がアクセプト

Annals of Internal Medicine へのレター投稿がアクセプト
平成30年のACP日本支部総会で「レターの書き方ワークショップ(片岡 裕貴先生)」に一般参加者として参加しました。当日の課題であったAnnals of Internal Medicineへのレター投稿がアクセプトされ、2019年2月号(Annals of Internal Medicine • Vol. 170 No. 3 • 5 February 2019 218 )に掲載されました。課題となった論文に対して計4本のレターが日本から掲載されています。一つは片岡先生が共著者のもの、そしてもう一つは私が参加したグループによるものです。後の2つも当日のワークショップの課題として提出されたものである可能性が高いと考えます(未確認)。このことは、ACP日本支部総会のワークショップのレベルの高さを示す具体例の一つになるかと思いますし、またニュースバリューもあるかと思いご報告する次第です。

International Exchange Program Committee ACP Japan Chapter Interim Report

International Exchange Program Committee

ACP Japan Chapter Interim Report

Chair: Tetsuya Makiishi, MD, FACP

Saiseikai Shiga Hospital

  1. What We Accomplished
  2. INDIA PROJECT Two members of the IECP, Tetsuya Makiishi and Takahiko Tsutsumi participated in the ACP India Chapter annual congress held in Lucknow, India from August 31th to September 2nd, and provided lectures to enhance the interrelationship between the two chapters.
  3. HAWAII PROJECT The committee has received one applicant for the externship in Hawaii under the supervision of Dr. Jinichi Tokeshi, clinical professor of Family Medicine at the University of Hawaii, John A. Burns School of Medicine. The committee has supported the candidates’ CV and personal statement before submission. The externship is planned in January, 2019. One of the IECP members will be assigned as a mentor to support the candidate before, during, and after the externship.
  4. What We Were Already Working On
  5. FLORIDA PROJECT By the courtesy of Dr. Jerald Stein, well known for his dedication to medical education in Japan, a three-week externship program at the University of Florida was offered to two members of the ACP Japan chapter. The committee has been involved in a selection process for this program. Their externships are planned in early 2019.
  6. DOMESTIC PROJECT We are having a seminar focusing on how to get into a clinical training program overseas, mainly the US, at the end of November in Osaka.
  7. What We Initiated
  8. We started to interact with the ACP India Chapter as mentioned above to seek for the possibility to establish an exchange externship program between the two chapters in future years.
  9. We started to support the externship program at the University of Florida as mentioned above.
  10. What We Plan To Work On
  11. We plan to continue and further develop each PROJECT mentioned above.
  12. We plan to create a network among the members of the ACP to facilitate sharing information and know-how about working overseas as a physician.

Seminar Report from IEPC

A Seminar focusing on how to get into a clinical training program overseas

Department of Infectious Diseases, Kameda Medical Center   Emiri Muranaka

A Seminar focusing on how to get into a clinical training program overseas held at the Aijinkai Rehabilitation Hospital on November 25th was a great success. There were 11 motivated attendees including medical students and young doctors from all over Japan.

The seminar kicked off with opening remarks from IEPC chairman, Dr. Tetsuya Makiishi. He welcomed attendees to our seminar, introducing them on our latest activities, including externship programs in Hawaii and Florida.

After his remarks, Dr. Yuji Yamada, who had just completed residency, described the details of residency training in the US and how to study English effectively.

The next session was given by Dr. Takahiko Tsutsumi, which was on mentoring young doctors who want to get into clinical training in the US. He told them how to prepare to get into and survive US residency. ※Oral presentation and so on.

The last talk was given by Dr. Mitsuya Katayama, who gave a presentation about the process of fellowship application and what the infectious diseases fellowship in US is like. He described the typical daily workflow, yearly rotation schedule, and differences between Japan and US in infectious disease practice and fellowship programs.

There was mutual agreement among them with a positive message: “Getting into a clinical training program overseas is tough, but not impossible.” All the attendees were motivated and listened to the lecturer with their eyes shining.

The last session was a highly clinically relevant workshop about the problem representation, a one-sentence summary that highlights the defining features of a case. The “one-liner” statement is used to summarize the patient’s case on rounds in the US.

A post-event survey was administered to all participants. We posed the question, “Did this seminar meet your expectations?”  The overall consensus on this question was a resounding, “yes,” as 100% of attendees indicated that this seminar did meet their expectations.

Overall, the majority of attendees found the workshop to be of value, and met their expectations. We will work to not only meet, but exceed attendees’ expectations in the future.