Yoshito Nishimura M.D., Ph.D. (Department of General Medicine, Okayama University Hospital)
I believe every one of you might have felt cardiology is difficult to learn. In the 5th Resident-Fellow Committee (RFC) Seminar on November 10, is a solution for those people.
The RFC Seminar is held up to twice a year. In the seminars, we invite internal medicine subspecialists as well as doing a brief “Dr’s Dilemma” like session to disseminate the high-tiered, essential internal medicine skills to medical students and residents. Through the seminars, we aim to get them together to strengthen the community of ACP as well. The 5th RFC Seminar was held in Nihonbashi, Tokyo. The guest lecturers were Dr. Akio Kawamura, Professor and Director of Department of Cardiology, International University of Health and Welfare, and Dr. Atsushi Mizuno from Cardiovascular Center of St. Luke’s International Hospital. Approximately 30 participants gathered Tokyo for the seminar.
In the lecture of Dr. Kawamura, he showed us his career path as a cardiologist as well as his view on medical education and treatment of patent foramen ovale (PFO). He also briefly summarized the clinical implication and rationale to treat PFO, which was meaningful to generalists as well.
Dr. Mizuno organized a session in a group-work style to let participants learn “how to manage heart failure and its complications”. Through the session, participants acquired skills of initial managements, differential diagnosis and clinical management. All the participants apparently enjoyed his session.
Lastly in the afternoon, the RFC committee presented a small Dr’s Dilemma-like session. Not only the participants solved the quizzes, Dr. Mizuno also added clinical implications and reality in the frontline clinical field to every question and answer. We are sure that this was the way to get the most from clinical quizzes.
RFC plan to continue seminars like this. Through the seminars, annual meetings and so on, we hope to contribute to the further development of ACP Japan Chapter as well as the field of Internal Medicine in Japan.
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.
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.
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.
（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.