My pride as a doctor was born from my experience in Hawaii

My pride as a doctor was born from my experience in Hawaii

Tokyo Women’s Medical University, Department of Nephrology

Yusuke Ushio, MD

In February 2018, I was trained at the Kuakini Medical Center and Queen’s Medical Center (QMC) in the state of Hawaii, U.S., through the ACP Japan International Exchange Program.

The main reason I applied to this program was that I wanted to learn more about medicine overseas and gain an objective view of medical practice in Japan. I had an opportunity to work with a physician who was trained in the U.S. during my residency and many colleagues were hoping to work abroad in the future. As a doctor, I wondered why they wanted to work abroad. At the time, my teacher said to me, “Not everything is always clear, at first,” and I decided to apply.

The first half of the training was held at Kuakini Medical Center. The institution was founded as Japan Charity Hospital for Japanese Immigrants. Following WWII, the name was changed to Kuakini Hospital and then its current name, Kuakini Medical Center.

I was trained in Family Medicine at Kuakini Medical Center. I shadowed the clinical professor of Family Medicine, Dr. Tokeshi, who was a student of the first graduating class of the John A. Burns School of Medicine at the University of Hawaii, established in 1973.

He said, “I like not only physiology but also surgery and all of the others, and I couldn’t decide on a department.”

In recent years, the concept of Family Medicine has been more acknowledged in Japan. The family physician is a doctor who provides wide-ranging, comprehensive medical care for the young and old, regardless of the affected organ. In U.K., there is a phrase “from the cradle to the grave.” The family physician is called a GP (General Practitioner) and provides primary care before patients see an organ specialist. Dr. Tokeshi has been providing this model of care for 40 years.

A wide range of medical students, residents, fellows, and even attending physicians from all over the world come to study under Dr. Tokeshi. The training provided by Dr. Tokeshi is called Tokeshi Dojo, and the doctors who study in Tokeshi Dojo are called Monkasei. A Monkasei’s day begins early in the morning; we attend a morning lecture at 6:30 and start working at 8:30. The most impressive aspect was the fact that Dr. Tokeshi asks us to take the details of patients’ social history. Questions include: “Where were you born? How did you grow up? How have you lived your life?” It is also important to remember his words, “It is not enough to only treat illnesses—doctors must be able to recognize all aspects of patients.” I took a look back on my own medical practice and reflected in my heart. “To always treat patients with respect is the most important thing of all” is a phrase I constantly repeated to myself. I learned from Tokeshi Dojo how to behave and live as a physician.

The second half of the training was held at QMC. At QMC, I shadowed Dr. Nogi, a hospitalist who is responsible for inpatient service at QMC. In recent years, the number of hospitalists has increased in the U.S. because of advantages such as a reduction in days of hospitalization. Because there is no outpatient duty, hospitalists can concentrate on inpatient care throughout the day. A shift system of seven days on duty and seven days off is common. Even in Japan, where voices calling for a revolution of work-life balance have become louder, there is a possibility that the number of hospitalists will increase if there is a major reform in the future and the need for hospitalists increases.

There are several small islands around Oahu Island where QMC is located, such as Hawaii Island and Maui Island. There was a case of consultation from a hospital in a small island via a video phone. Hospitalists at QMC provided appropriate instructions to the doctors at a hospital in Hawaii island, and the patient was taken to QMC by a medical helicopter on the next day. I think that such medical care can be applied to Japan, especially underpopulated areas, as a doctor on an isolated island can consult specialists in an urban area, using a video phone and can provide the best medical care.

I was also impressed by the medical education. I appreciated the idea of actively participating in a lecture rather than just listening to it. In resident conferences held twice a week, there was always an active discussion. In addition, I thought that this was a great opportunity to improve presentation skills. History and physical findings were considered more important to narrow down differential diagnoses than test results. I want to cultivate more this way of thinking.

Finally, since the time I studied in Hawaii until now, I have been reflecting on the days I spent there, wondering, “” When I look objectively at myself now, I think the days I spent were marvelous. I appreciate this wonderful experience and the support from all the committee members in ACP Japan, Dr. Tokeshi, and Dr. Nogi.

Thank you from my heart.

May 2018

Yusuke Ushio, MD

UshioHawaii1

Greetings from Dr. Muruganathan (Governor of ACP India Chapter)

 

Date: June 9th, 2018

Dear Brothers and Sisters, Greetings!

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

they found.

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.

HYPERTENSION PROTOCOL – SINGLE PILL COMBINATION AS FIRST-LINE TREATMENT

HYPERTENSION PROTOCOL – CALCIUM CHANNEL BLOCKER AS FIRST-LINE TREATMENT

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

Kurokawa Prize in Student

Toshiro Goto, senior medical student

Tokai University

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.

Kurokawa Prize in Early Career Physician

Section: Recipient’s Remarks

Kiyoshi Shikino, MD

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.

Research particulars

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.

Turning point

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.

Future expectations

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.

Poster_ACP Japan 2018_Shikino

 

Chapter Business Report 2017-2018: IEPC

International Exchange Program Committee

Chair: Harumi Gomi MD, MPH, FACP

Report:

What We Accomplished

  • Clinical observership at Olive View Medical Center, University of California, Los Angeles (UCLA) was initiated in 2012, and ended as of August 2017. Since 2012 until the end of the program, there had been a total of sixteen observers through this program.
  • Masayuki Nogi and Jinichi Tokeshi, and other supportive local physicians at Department of Medicine, University of Hawaii kindly offered clinical observership for our two members in November 2017 and February 2018, respectively.
  • The committee has created evaluation criteria (evaluation sheet) for the candidates’ CVs and personal statement.
  • Mentorship has been introduced for each observer before, during, and after the observership.
  • An Email list serve for the alumni members of this program, committee members, and the ACP council members has been launched for a weekly report from the Olive View Medical Center by observers.

What We Were Already Working On

  • Revision of credential evaluation/support for the candidates

 

What We Initiated

  • More strategic recruitment for the candidates of the observership.
  • New members who are still early in their career (such as Drs. Yuji Yamada, Emily Muranaka) joined this committee to support the members to obtain international medical experiences.
  • After the obsevership at Olive View Medical Center, University of California, Los Angeles ended, our committee tried to find any new programs for clinical observership and Dr. Takahiko Tsutsumi has significantly contributed to explore and support the clinical observership program at University of Hawaii.
  • The committee will organize a seminar to help early career physicians understand clinical and research experiences they could have in international settings for physicians in early career at the annual meeting of ACP Japan Chapter in June 2018.

Plan:

What We Plan To Work On

  • discussion on how this committee could explore or continue any exchange programs or international exchange activities after the UCLA program ended. This includes accepting students/residents/fellows from other countries.
  • How to disseminate the experience report to the younger ACP members and non-members, and those who are interested in the clinical observership in the United States.
  • More comprehensive recruitment and support systems for the program applicants.
  • Creating alumni members activities and leadership to share and sustain learning experiences after the observership.

Seminar Notice

International Exchange Program Committee

ACP Japan Chapter Annual Meeting

Luncheon seminar

Time: 11:40-12:40, Saturday, June 2, 2018

“Why not pursue a global career path?”

Held by International Exchange Program Committee

ACP日本支部2018年次総会 黒川賞(若手医師部門)を受賞して

千葉大学医学部附属病院 総合診療科の鋪野 紀好先生から、ACP日本支部2018年次総会 黒川賞(若手医師部門)受賞の報告を頂きましたので、PRC委員会から広報いたします。(PRC 宮内隆政)

・・・・・・・・・・・・・・・・・・・・・・・・・

ACP日本支部2018年次総会 黒川賞(若手医師部門)を受賞して

千葉大学医学部附属病院 総合診療科

鋪野 紀好

この度は、ACP日本支部2018年次総会で黒川賞を頂き、大変光栄です。2018年度から”Best Abstract”は「黒川賞」に変更となり、最初に黒川賞を受賞できたことを大変名誉に思います。

研究の経緯

今回研究を行うきっかけとなったのは、眼底鏡診察を、自信を持って実施できる内科医は少ないと感じたことである。自分の周りも見回しても、我が師匠である生坂先生を除いて、眼底鏡を実際の診療で積極的に活用している医師はほとんどいなかった。共同研究者である菊川誠先生(九州大学大学院医学研究院 医学教育学講座)が発表されているが、初期研修医、内科専攻医、内科指導医のいずれも、約90%は眼底鏡を利用していないまたは2、3ヵ月に1回の使用頻度とされる。その理由としては、眼底鏡診察が苦手というのがほとんどの理由であった。

自分が眼底診察を教えてみると、なぜ観察が難しいのかに気付いた。それは、学習者と指導者が同じ画面を共有できないことにある。学習者からすれば、今確認しているものが、本当に正しいのかについてフィードバックを受けられず、確証が得られない。また指導医も、なぜ確認できていないのかを指摘するのは至極難しい。そんなジレンマを感じていた。

研究の転機

研究の転機となったのは2017年3月のスタンフォード大学医学部内科への視察であった。そこで、エロル・オズダルガ医師と出会い、眼底鏡の教育にiExaminer systemを用いた教育手法について学んだ。彼とは、この教育手法を日本に持ち帰り実践したいこと、また教育効果についてリサーチしたいことを語りあい、快く承認してくれた。

千葉大学医学部クリニカル・クラークシップへの導入

まず、このiExaminer systemを用いて実際の教育を行ったところ、学生からの満足度は高く、今後の臨床実習でも積極的に使っていきたいという声が相次いだ。次に、本当にスキルが向上するかを確認するために、本学のシミュレーションセンターである、クリニカル・スキルズ・センターへ眼底鏡シミュレータの協力を仰いだ。教育の前後で評価することで、教育効果を明確にするためだ。題材は何にするか、問題数はいくつにするかなど、共同研究者とのやり取りは白熱した。特に今回の研究は「観察力」の評価だったので、そこに「解釈力」の評価が混入しないように腐心した。また、教員による教育効果は二重盲検化がデザイン的に困難であったため、最小限にするための工夫を行った。

今後の期待

今回の研究では、iExaminer systemを用いることで、眼底鏡診察の診断精度が向上し、かつ観察時間が短縮されることが示された。iExaminer systemは約8000円のアダプターと、今日だれもが携帯しているiPhoneさえあれば、フリーで利用できるため明日からでも実施可能である。この教育手法が広まることで、自信を持って眼底を診察できる医師が1人でも増えることを祈ってやまない。

Poster_ACP Japan 2018_Shikino

写真:黒川賞演題候補としてのプレゼンテーション

写真:スクリーンに自分の名前が映し出された時には心が震えた瞬間であった

写真:右からBA Muruganathan先生、Jack Ende先生、筆者、黒川 清先生

写真:応援に駆けつけてくださった千葉大学医学部附属病院 総合診療科 メンバーと

Chapter Business Report 2017-2018: CMC

Credentials/Membership committee

Chair: Eiji SHINYA

Vice-chair: Koichiro YUJI

Members: Katsuhisa BANNO, Hitoshi SAWAOKA, Shunji YAZAKI, Hideto WATABE, Jotaro OHNO, Yusaku KAJIWARA, Satoshi, JOSHITA、Tsunenori SAITOand Minako YAMAOKA-TOJO

Report:

  • Reviewed 14 application forms and the applicants’ qualifications for the FACP advancement.
  • Nine new fellows, including Three invited fellows, were elected from June 2017 to May 2018.
  • Revised the descriptions of each membership category in the home page to augment the recruitment of new members
  • Co-hosted the FACP session in the annual meeting of ACP Japan Chapter, to promote the understanding of FACP as well as the application for it

Plan:

  • Review application forms for FACP advancement and judge the applicants’ qualifications by online as quickly as possible.
  • Respond to queries from members and board of ACP Japan Chapter regarding membership in collaboration with secretary.
  • Co-host the FACP session in the annual meeting to promote the understanding of FACP to promote the applications for it

Chapter Business Report 2017-2018: ECPC

Early Career Physicians Committee

Chair: Akihito Kawashima, MD

What We Accomplished

  • 2017年度ACP日本支部総会において、若手医師および医学生を対象に国際学会会場でも積極的に討論へ参加できるような『英語力の身につけ方』についてのセッションを開催しました。
  • 日常の臨床現場で研修医のために役立つワンポイントレクチャーとして、『5分間ティーチング』と題してグループワークを開催しました。

What We are Working On

  • 若手医師に対して研修医への教育方法や自身のキャリアデベロップメントについての提案を行っています。
  • 委員内のディスカッションをよりタイムリーに、より活発にできるようにSNSを積極的に取り入れています。

What We Plan To Initiate

  • 2018年度ACP日本支部総会において、若手医師および医学生を対象に国際学会会場でも積極的に討論へ参加できるような『英語力の身につけ方』についてのワークショップを開催する予定です。
  • 2018年秋に関東でのワークショップも検討しています。
  • テクノロジーの目覚ましい進歩に着目しディープラーニングやAIの医療への応用について、積極的に検討していこうと考えています。

Chapter Business Report 2017-2018: HPPC

Health and Public Policy Committee

Yuhta Oyama MD, FJSIM, FACP

Report:

Planned and going to have a workshop at the 2018 chapter meeting titled “The road to an FACP – Why and how do we aim for it? -“

Plan:

  1. Continue to develop a model to resolve common challenges on medical professionalism
  2. Preparation of criteria for COI disclosure of roles at ACP Japan Chapter (ACP-JC) and COI disclosure at annual meeting of ACP-JC
  3. Attempt to publish Choosing Wisely lists as the ACP-JC based on questionnaire of ACP-JC members
  4. Examine and discuss “End of life care” that would more suitable for Japanese medical circumstances
  5. Analyze the attitude of ACP headquarters towards COI and report it to the ACP-JC members

Chapter Business Report 2017-2018: LNC

Local Nominations Committee

Nobuhito HIRAWA MD FACP

REPORT:

We recruited the candidate of new governor of ACP Japan Chapter. And we selected Dr. Kenji Maeda MD, FACP as the candidate of the next governor and reported it to ACP headquarter.

The following ACP members were selected to receive each award.

–  Laureate Award

Yuko Takeda MD, FACP (ACP Number 1009004)

–  Sakura Award of Excellence

Haruko Miyamoto (The former clerk of ACP Japan Chapter)

–  Volunteerism Award

There is not an applicable person this year.

–  ACP Japan Chapter Contribution Award

Yugo Shibagaki MD, FACP (ACP Number 1245920)

Soichiro Ando MD, FACP  (ACP Number 1290215)

Harumi Gomi Yano MD, FACP (ACP Number 1098937)

Eiji Shinya MD, FACP (ACP Number 1064281)

Nobuhito Hirawa MD, FACP  (ACP Number 1271684)

The shield or the commendation with a pin badge is conferred on the prize winner.

 

PLAN:

–  Start to accept recommendations for 2019 Laureate Award, Volunteerism Award, Sakura Award of Excellence and ACP Japan Chapter Contribution Award.

–  Start to search candidates for Mastership next year