Dr. Anuj Maheshwari, MD, FICP, FACE, FACP, FRCP (London, Edinburgh)
Professor & Head in General Medicine, BBD University, Lucknow, India
Organising Secretary, Annual Congress of ACP-India Chapter “Medicine 2018” at Lucknow
It has been my first visit to Japan. I had heard lot of good things about this country but found it much better than of my imagination. It has really been a wonderful experience for me and my family. It has been an excellent hospitality with flawless arrangements from beginning to the end. First of all, I shall like to pay my gratitude to our India Chapter Governor Dr Muruganathan who recommended and given me opportunity to represent India Chapter during annual conference of Japan Chapter. At the same time I can never forget to pay sincere thanks from core of my heart to Dr. Takahiko Tsutsumi and Dr. Tetsuya Makiishi who were our guest speakers in annual conference of ACP-India Chapter 2018 at Lucknow. Not only their deliberations were outstanding here in India but they must had praised us well there in Japan. After receiving a lovely invitation by Dr. Sugihiro Hamaguchi, chair Scientific program committee, ACP Japan Chapter, Dr. Yuka Kitano helped me in understanding the learning objectives of physicians in Japan regarding Diabetes. For me It was really seeming tough to keep audience attentive for one hour of my lecture. Yuka not only encouraged me but also helped me in deciding content to be included in my presentation which can create interest in Japanese audience. Evening before, I got an opportunity to see and pay my gratitude to Governor Japan chapter outgoing and incoming both together with Robert M. McLean, the President of the American College of Physicians (ACP) elected in 2019 with his wife.
As I have been given the topic to speak on treatment options, I tried to focus my talk on common factor between two populations, India & Japan. Although diabetes prevalence is increasing in both the countries, but faster is the progression in India for conspicuous reasons like carbohydrate rich diet, sudden affluence and luxury lifestyle with lack of physical activity. All this has happened in last 20-30 years which has changed typical Asian phenotype in India to overweight and obesity making Indians more prone to diabetes in lack of physical activity. In addition to these reasons our large population is also responsible for ten times more number of diabetic patients. In Japan 7.2 millions are suffering with diabetes while this number is 72 million in India second highest in the world next to China. Diabetes prevalence in Japan is 7.7 % while it is 8.8% in India.
If we really talk about common factors, typical Asian phenotype is actually a common characteristic between people of India and Japan. This typical Asian phenotype is characterised with accumulation of visceral fat with lean phenotype in extremities. Healthy Food habits and good amount of physical activities in Japan keeps away abdominal obesity and insulin resistance at large while in India same phenotype has progressed to abdominal obesity and Insulin resistance causing type 2 diabetes. What I noticed in ten days visit to Japan, plants & vegetables are used in good amount with food but with much less oil and fat contrary to India. Lot of lessons are there for Indians in Japanese life style.
Glucose control in diabetes deteriorates over time with the progressive nature of disease resulting in risk of developing various micro and macro vascular complications. Many classes of anti-diabetic drugs are available for treatment including metformin, sulfonylureas, glitazones, glinides, α glucosidase inhibitors and nearly a century old insulin. Newer drugs like gliptins (DPP-4 inhibitors), GLP1 agonist, flozins (SGLT-2 inhibitors) and insulin analogues have been added to the list during the last few years. These drugs effectively address various pathophysiological defects. However, given the need for multiple drug therapy, there is still a significant unmet need in the management of T2DM. Non-insulin antidiabetic agents have a potential to reduce HbA1c by an average of 1% and the simultaneous use of combination therapy can result in greater HbA1c reduction. Position statement on Standard of Care by ADA, recommends metformin as preferred initial pharmacological agent. Though we Asians do not match exactly with Americans, we need different recommendations to treat diabetes as we are not only different genetically but environmental factors, body habitus are also different.
A lot of questions had arisen out of these recommendations from audience citing Japanese are not usually obese or overweight then why is it necessary to begin treatment with metformin? It is true that Japanese may have many genes susceptible to diabetes including thrifty genes. Various environmental factors, added to these genetic factors, are considered responsible for the onset of disease, and the number of patients is increasing rapidly reflecting recent lifestyle changes. Impaired insulin secretion is characterized by lowered glucose responsiveness. In particular, the decrease in postprandial-phase secretion is an essential pathophysiological condition. Glucolipotoxicity, if left untreated, results in the decrease in the functional pancreatic cell mass. So it is not only an issue to improve insulin sensitivity. Metformin facilitates peripheral utilisation of glucose and equally beneficial in Insulin deficient type 2 diabetes mellitus. Although it may have some concerns for Indians as many of them are vegetarian having Vitamin B12 deficiency causing anaemia but not in Japanese. So it is appropriate selection of pharmaceutical agent which has immense importance. Now further recommendations should continue as follows:
If metformin monotherapy at highest tolerated dose does not achieve the optimum level, a second oral or injectable agent should be added.
Choice of the second pharmaceutical agent should be a based on environmental factors influencing therapeutic response.
Apart from this AACE suggests to start with dual drug therapy if HbA1c is 7.5 or more. If HbA1c is 9 or more at beginning, triple therapy is recommended to start with. If patient is symptomatic at 9 or more HbA1c, insulin should be a part of triple therapy.
Queries came from audiences regarding relevance of using pharmaceutical agents with weight loss potential in Japanese population like GLP1RA & SGLT-2 Inhibitors. A convincing explanation lies in visceral fat causing abdominal obesity giving rise a peculiar Asian phenotype. SGLT2 inhibitors act on the non-classical pathway and reduce hyperglycaemia by inhibiting renal reabsorption of glucose and thereby increasing urinary glucose excretion. They also lead mild reduction in blood pressure due to chronic osmotic diuresis and associated with lower risk of hypoglycemia.
SGLT-2 Inhibitors can only be justified if a person is having significant amount of visceral fat reducing insulin sensitivity. It also promotes usage of alternative fuels like fat for production of energy. As far as GLP-1RA is concerned, they increase insulin secretion in response to oral glucose ingestion, induce satiety by slowing gastric emptying, suppresses appetite, inhibit glucagon secretion and also have been proposed to cause ß cell regeneration. Endogenous GLP1 released from intestinal L cells has a short half-life of 4 – 11 min. To overcome this, GLP1 analogues resistant to degradation by DPP4 have been devised. Low dose usage can be safely done for Japanese population with central adiposity.
Later I got an opportunity to judge selected research papers for oral presentations by students, residents, Fellows & early career physicians. One of the most stimulating session with high class research had made it more challenging to decide the best. All research papers and presentations were so good that it was difficult to select one for “Kurokawa Prize”.
Then I got a chance to attend few plenary sessions which were in Japanese language but I am thankful of my interpreter Mr. Hideta Teshirogi who is pursuing his medical studies there. He has been so wonderfully translated all sessions on the spot sitting aside me. I appreciate his knowledge and translation power so fast. My medico daughter Shivangi who is also pursuing medical studies in India enjoyed all English sessions and Kurokawa Prize session.
Overall it has been a wonderful academic feast for me and my family at one of the most beautiful city of world Kyoto. We attended welcome dinner in evening with all attendees and faculties. Next day enjoyed sightseeing at Arashiyama before leaving back home India. It has been an unforgettable experience while being at Japan. I wish to thanks all members of organizing team and Governor Japan Chapter Dr. Kenji Maeda for great conference with wonderful hospitality. We shall surely try our best to reciprocate when Dr. Kenji Maeda comes India for our annual conference at Kolkata. We can plan many joint ventures together including Asia specific guidelines in future.
I was honored to have the opportunity to participate in the ACP Japan chapter meeting in early June. Chapter governor Dr. Kenji Maeda and the rest of his chapter leaders were wonderful hosts. It was very interesting to hear firsthand from many chapter members about the Japan healthcare system and especially the medical education and training system. I enjoyed the opportunity to speak on the topic and discuss how the current changes in the Japanese training and board certification processes will be very helpful to ensure that internal medicine specialists who choose to enter general primary care practice will have adequate training to deliver high-quality care to patients.
I also had the opportunity to give a brief update on activities of the American College of Physicians and review how Global Engagement and the role of international chapters continues to grow. The Japan Chapter was ACP’s first international chapter and remains a role model for how to grow and develop. I also gave a talk on the ACP’s guideline development process, using the Gout Clinical Practice Guidelines as an example. I explained how different guideline processes between various organizations lead to slightly different conclusions and recommendations. Some in the media tends to report these as controversies, when in reality they merely reflect different processes and the lack of definitive evidence to answer many of the clinical questions we face on a daily basis.
I greatly enjoyed the opportunity to tour the beautiful historic city of Kyoto and learn much about Japanese history and culture there. Following several days in Kyoto, I had the opportunity to travel to Tokyo and similarly tour and learn a great deal while spending several days there before returning home to Connecticut. After such a wonderful experience, I clearly intend to return to Japan! I thank all the Chapter members with whom I had the chance to interact.
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.
– 事前学習動画を見る（15 分） https://youtu.be/mQ8BXtw_cVI
– 課題論文（Graham KL, et al. Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine
Patients. Ann Intern Med. [Epub ahead of print 1 May 2018] doi: 10.7326/M17-1724 http://annals.org/aim/article-abstract/2680053/
「交絡」に着目したRisk of Biasの吟味とポイントの指摘を考えるhttps://drive.google.com/file/d/1NX3ejjD0pmlrxP1MWamnGHODcLO42
We planned and held the ACP Japan Chapter Annual Meeting 2018 at Kyoto University. We attracted almost 700 participants with approximately 40 sessions and 100 abstracts. We invited Dr. Jack Ende, the immediate past president of ACP, and has a constructive discussion with eager participants about “Mind & Arts as Essentials for Internists” in the plenary session. The new session, Kurokawa Award, a competition of clinical research presentations, gained a large amount of attention and gave an initial push for increasing academic atmosphere into the annual meeting.
What We Are Working On
We are preparing for the upcoming ACP Japan Chapter Annual Meeting 2019 at the same venues. The theme of the 2019 meeting is “Fostering Lifetime Fundamental Competences for Internists －Beyond Board Certification System－”. The board certification system has been recently revised in Japan and how to integrate mind and experience of general internal medicine into the system remains a great matter of debate in Japan where most medical residents strive to become a life-time specialist. We will have Dr. Robert M. McLean who is the president of ACP to discuss “the wider the general basis, the higher the special peak as a specialist” in plenary lecture before the plenary session with Japanese seasoned physicians.
In addition, we will offer many attractive sessions. The Lecture Marathon starting with Latest Paper reviews is a new session where a summary of the up-to-date papers will be introduced first followed by many short lectures on basic internal medicine will be provided. A special lecture concerning the nuclear plant disaster operation in Fukushima after the East Japan Earthquake will be presented by Dr. Kurokawa. We have also planned the same sessions that are popular in the previous meeting: Dr’s Dilemma (an inter-institutional Quiz tournament by teams of residents), MKSAP, and Kurokawa Award for poster session.
Many attendants will enjoy and learn a lot from English-speaking sessions as well.
We are sure that the increasing number of attendants will be expected to the 2019 meeting with plenty of attractive sessions.