Jack Ende, MD, MACP, Immediate Past-President, ACP
I was honored early in June to present a plenary talk on Professionalism and the College Update for the ACP Japan Chapter Annual Meeting 2018. The meeting was a great success. The topics presented ranged broadly across the practice of internal medicine, medical education, professional development, and, even, physical diagnosis. What left the greatest impression on me, however, was the theme of the meeting: “Mind and Arts as Essentials for Internists: Beyond Evidence and Technology.”
As Meeting Chair, Yugo Shibagaki, MD, FACP, so eloquently wrote in the program guide, “Patients’ needs are not only for medical treatment or cure, they’re also for relief and comfort, sincere attitude and sympathy, and for compassion of doctors and medical staff to listen to their mental as well as physical suffering.” Dr. Shibagaki continued, “Medical schools tend to teach only skills and knowledge, but not professional or affective attitude or mindfulness.”
What is mindfulness and how does mindfulness relate to practicing internal medicine?
Mindfulness can be defined as the psychological process of bringing one’s attention to experiences occurring in the present moment. It is a heightened sense of awareness of what is really happening. In our field, internal medicine, mindfulness is appreciating that a patient is sad or angry or confused – and doing something about these emotions, even if it is merely providing an empathetic comment. It is appreciating that a patient’s clinical situation is determined by their environment, their relationships, and their lived experiences – and then factoring those social determinants into the treatment plan. It is also the doctor recognizing within him or herself that, at least at that moment, the stress may be too intense, or the workload too great – and then taking steps to improve those unfavorable conditions.
I also appreciated the message of the program was intended to move us forward, not backward. This was clear from the subtitle: “Beyond Evidence and Technology,” calling attention to the word “beyond.” Mindfulness does not take us back, it moves us forward to a different level – I would say a higher level – of clinical expertise as internists.
The 2018 ACP Japan Chapter meeting was enormously successful, which is not at all surprising given the outstanding commitment and energy of the Chapter’s leadership, members and staff. The program demonstrated just how enriching medical practice can be, particularly when that practice goes beyond evidence and technology. I am grateful to have been part of the meeting.
Thank you for inviting me to attend the ACP Japan Chapter Annual Meeting 2018. I thank Governor ACP Japan Chapter Dr. Fumiaki Ueno and family for the nice welcome and hospitality. You have chosen the right theme “Mind & Arts as Essentials for Internists: Beyond Evidence & Technology”. The practicing medicine is both science and art. Science of uncertainty and art of probability.
The arrangements, the venue, the registration procedures were really good. The workshop on Statin was very innovative and involved everyone. The participants in the workshop were made to ask clinical questions and also were made to use the internet to search the latest guidelines and articles relevant to the topic. There were debates whether they can trust the answer
The participant clearly understood the 5 steps of evidence based medicine. With the above background applying and sharing the decisions with the patient was also highlighted. I understood in Japan they use only small dose of Statin to reduce cholesterol. On the whole the workshop was simple and
complete to cover all the points regarding Statin usage.
I could attend only one workshop. There were other useful interesting topics in other halls like How to evaluate jugular venous pulse at bedside – you can do it, from now on, Minds and arts for end of life discussions through case discussions of cancer patients at terminal stage, A workshop to write “letter to the editor” and etc.
We had a good lunch with the dignitaries who include Dr. Jack Ende Past President ACP, Governor Dr. Fumiaki Ueno, Dr. Kenji Maeda Governor Elect and others. Regarding the session on hypertension there was an initial discussion about how to develop guidelines. During my talk on “Recommended Treatment Protocol for Improving Management of Hypertension Globally” I recommended the following 2 protocols.
There were lot of questions on hypertension regarding the definition, the target especially for elderly population etc. I always used to promote home blood pressure monitoring in my country. I am very happy to know most of the patients in Japan are using the home blood pressure monitoring. Ambulatory Blood Pressure Monitoring (ABPM) is ideal but it is not practical. Sooner there may be some devices like wrist watch which can record ABPM very easily. There were lot of discussion about automated office BP monitors. There were lot of lively questions on various aspects of treatment from the audience and
the hall was full.
I was fortunate to be a referee for the “Kurokawa Prize” for poster presentation. Lot of innovative original research papers were presented by the junior doctors. The talk given by ACP past President Dr. Jack Ende on Professionalism was mind boggling. Overall I learnt lot of new points both in academics and organizing. The award function and reception were well organized. I could meet lot of new fellows during the reception and made friendship with them. This also helped me to initiate exchange programme and other joint activities between Japan and India ACP chapter.
The people in Japan are very nice, cordial, honest and helpful. The transport like bullet train, subway train and busses were amazing. I and my family thoroughly enjoyed every movement of our stay in Japan both at Tokyo and Kyoto. We are looking forward to the next best opportunity to visit Japan again. Congratulations to Dr. Fumiaki Ueno, Dr. Yugo Shibagaki, MD, FACP Chair, ACP Japan Chapter Annual Meeting 2018, Governor Elect Dr. Kenji Maeda and members of the organising committee for the wonderful conference.
Thank you once again.
A. Muruganathan, MD, FACP
Governor, ACP India Chapter
I performed my presentation titled“Cavitary Lung Lesions in a Patient with Positive IGRA and PR3-ANCA are not Always due to TB or GPA: a Case Report of Right-Sided Infective Endocarditis”. It was an honor to receive first place in theKurokawa prize competition, the best abstract award (medical student section) at the annual conference of the ACP Japan Chapter 2018.
I am interested in clinical reasoning, so I often attend case conferences and journal club sat the General Internal Medicine department to read and discuss cases from theNew England Journal of Medicine. A doctor suggested that I write an abstract. However, I was a fourth-year student at that time and had not started my clinical clerkship yet, so I started asking about cases for the abstract. Since I have a passion for studying infectious diseases and rheumatology diseases, I still remember how excited I was when I took this case.
In this case, it was saddening to learn that is under standing of laboratory data led to them is diagnosis of the patient which resulted in anatrogenic exacerbation of the patient’s condition. We must consider bacteremia and infective endocarditis from the history and vital signs, and send a blood culture for examination. If the culture is positive, then we need to perform an echocardiogram. There is no doubt that his quality of life would have been improved with those few non-invasive procedures. A famous Japanese doctor who I respect says that the essence of the physician is the differential diagnosis. You can’t take note of the patient’s history, conduct a physical examination, perform a laboratory examination, and conduct the treatment without a differential diagnosis. So in this case, if infective endocarditis was included in the differential diagnosis in the early stages, we could have avoided such a situation by conducting a blood culture and an ultrasonography. It is said that a lot of unneeded laboratory examinations are performed in Japan. Some people even say “clicking the order button is not the prescription for a doctor’s anxiety to misdiagnosis”, but the lesson I learned from this case is that laboratory examinations sometimes startle us, not knowing the character of the laboratory examination.
In closing, I would like to take this opportunity to express my appreciation to you all. It would be impossible to have this award without your help. I will go forward on my newly set goal, which is to do a presentation at theACP Internal Medicine Meeting 2019 in Philadelphia, PA, USA. Thank you for your time.
Department of General Medicine, Chiba University Hospital
I am honored to have received the Kurokawa Prize at the ACP Chapter Annual Meeting, 2018. The “Best Abstract Award” was named as the “Kurokawa Prize” beginning in 2018, I am especially honored to be the first person to be awarded this prize.
What triggered this research was that I felt that there were few physicians who could perform the fundus examination confidently. Even when I observed others, few doctors were using the ophthalmoscope with confidence in actual medical practice, except for my mentor, Professor Masatomi Ikusaka. Makoto Kikugawa (Department of Medical Education, Kyushu University), one of the co-researchers, reported that approximately 90% of junior residents, senior residents, and fellows in internal medicine performed the fundus examination less than once in a few months. He also reported that the reason for the problem was mostly that they were not proficient at the fundus examination.
When I taught residents the fundus examination, I discovered why observing the fundus was difficult for them. Funduscopy is inherently difficult to teach because there is no way to verify that the learners have obtained a proper view of the fundus. The teacher cannot give students feedback on whether what they are seeing or the teacher is seeing.Furthermore, it is extremely difficult for the teachers to point out why learners cannot observe the fundus. It was such a dilemma.
The turning point of our research was a visit to the Department of Internal Medicine, Stanford University Medical School in March 2017 where I met Dr. Errol Ozdalga and learned the educational method using the iExaminer system for fundus examination. I talked with him about implementing this educational method in Japan as well as to conduct research on its educational effect. He approved of it pleasantly.
Introduction to Clinical Clerkship at Chiba University School of Medicine
First, because of actual instruction in using this iExaminer system, student satisfaction was high, and I heard students saying that they wanted to use it actively even in future clinical training. Next, in order to confirm whether the skill really improved, I asked for the cooperation of the fundus examination simulator at the Chiba Clinical Skills Center. To evaluate the educational effects, we assessed fundus examination skills in a pre-test and a post-test. Discussions between co-researcherswere intense, raising questions such as what to make the subject matter, how many cases we must prepare, and so on. Since we were particularly interested in evaluating skills in “observing fundus,” I was keen to prevent the evaluation of skills in “interpreting fundus.” In addition,to minimize the influence of teachers’ educational skills, we developed an instructional design, led the faculty development, and randomly assigned the teachers.
In this study, the diagnostic accuracy of a fundus examination improved by using the iExaminer system and the time taken to identify funduscopic findingswas shortened. The iExaminer system can be implemented immediately because it can be used for free if you have the adapter and an iPhone. By spreading this teaching method, I hope that more internists can examine the fund us with confidence.
Last year, we held the ACP Japan Chapter Annual Meeting 2017 at the Kyoto University Clock Tower Centennial Hall and the Kyoto University International Innovation Center on June 10th and 11th, 2017. Since we expanded the venues (rooms) for the session, we could accommodate as many as 32 sessions (didactic sessions, workshops), 8 luncheon seminars, special sessions (Plenary session, Governor’s address, Dr’s Dilemma and ACP update), a poster session with almost 100 abstracts with best poster presentation on the following day, so we kept the number of the sessions which increased significantly every year since 2013. The Doctor’s Dilemma (Medical quiz session) attracted many contestants from hospitals all over Japan which ended with a much success and the some of the winners were selected as the members representing ACP Japan Chapter and just participated and did their best in the Doctor’s Dilemma held in Internal Medicine 2018 held in May, 2018 in New Orleans. The poster discussion was a very lively session with many participants with full of discussions. Three presenters with each representative of students, residents and young physicians were awarded and had a chance to give a presentation in the main hall the next day, applied to the Internal Medicine Meeting 2018 and seemed to get motivated by this wonderful experience. We had the immediate past president, Dr. Nitin Damle, who provided the educational talk at the plenary session and ACP update.
On June 2nd and 3rd, 2018, we will organize the Annual Meeting 2018 of the ACP JC in Kyoto. Beginning last year, Kyoto University International Innovation Center was added to the venue of the Meeting as well as Kyoto University Clock Tower Centennial Hall to accommodate more attractive sessions and lectures. In fact, this year we accommodate 45 sessions with special sessions
The theme of the Meeting this year is “Mind & Arts as Essentials for Internists: Beyond Evidence and Technology”. We will address this very important issue in the plenary session, following the keynote lecture from the immediate past president of ACP, Dr. Jack Ende, with experienced physicians who practice medicine with mindfulness as guest speakers, discussing how we can raise the mindful care as well as technical part of medicine in the era of super-aging society with the frail elderly. In addition, we will offer sessions like Dr’s Dilemma (an inter-institutional Quiz tournament by teams of residents), the poster-discussion session, as well as the special talk by Dr. Jack Ende. This time, we also invite Dr. Muruganathan from India chapter of ACP to enhance the partnership with Asian chapters.
– Organizing the Annual Meeting 2019 of the ACP Japan Chapter
We are planning to hold ACP JC 2019 on June 1st and 2nd in Kyoto with the same venue as this year.
In the Clinic Japanese Translation Project has been in progress which is one of the leading project of PRC (public relations committee). There have been more applicants than the actual slots for the translation teams. The first translated article of In the Clinic, which is HCV, has been posted on the ACP main chapter’s webpage this April. Through this project, our goal is to have the members of ACP Japan Chapter to be able to utilize the excellent ACP resources including In the Clinic.
At this year’s annual meeting, we have presented a practical workshop with the collaboration of ‘In the Clinic Translation Project’ and ‘Bedside 5-minute Teaching’ We prepared the 12 general rules = Bedside 5-munite Teaching, which are based on 6 articles of In the Clinic.
In this practical workshop, participants have output the Bedside 5-munites Teaching and at the end of the seminar, they appeared to find themselves be able to use the rules as part of their active knowledge in the clinical setting. We hope this workshop served as an eye-opener to get one out of a lifelong sense of insufficiency where one feel he/she is not acquiring active knowledge even with a lot of literature reading.