ACP Japan Chapter communication server

July 10, 2019

ACP日本支部総会2019　黒川賞（学生部門）　受賞者のことば

ACP日本支部年次総会・講演会2019 黒川賞(医学生部門)受賞のご報告

順天堂大学医学部6年生

福本咲季

ACP(米国内科学会)日本支部年次総会・講演会2019において黒川賞をいただき、大変光栄に存じます。

この度、私は交通事故の一因である緑内障に対するクロックチャートを用いたスクリーニングの有用性について、「Unaware of glaucoma and traffic accidents: a proposal to detect visual field defects by CLOCK CHART」という演題名で発表を行いました。

私が所属する順天堂大学の公衆衛生学講座では、以前よりいわゆる健康起因事故に注目して研究しており、その原因疾患の例として睡眠時無呼吸症候群、花粉症、緑内障などが挙げられます。この中で緑内障は40歳以上の日本人の20人に1人が患っており、その9割が未治療・無自覚であると考えられています。多数の論文で緑内障と交通事故の関連が報告されており、多くの人が緑内障の適切な診断や治療を必要としています。

そこで、緑内障の視野欠損を簡単にスクリーニングできるクロックチャートを緑内障患者5名に用い、症例発表をさせていただきました。一般的に用いられているハンフリー視野検査の結果と高い一致率が認められ、全ての医師がクロックチャートで患者様の視野のスクリーニングを行うことで、緑内障の早期診断・早期治療、そして交通事故の防止を期待できると考えられました。

更に現在、タクシー・トラック運転手約2000名を対象としたクロックチャートによる検査結果、交通事故経験のデータを解析中です。

最後になりましたが、常日頃から熱心にご指導いただいた谷川教授、和田先生をはじめ本発表に際し大変お世話になりました皆様に心より御礼申し上げます。

July 10, 2019July 10, 2019

Dr. Yuichiro Matsuo, Winner of Kurokawa Prize in Early Career Physicians section

Yuichiro Matsuo

Tokyo Bay Urayasu Ichikawa Medical Center, Department of Internal Medicine

I am grateful that I could receive the Kurokawa Prize in the Annual Meeting of ACP Japan 2019. The basic idea of our study “Japanese people tend to overestimate their future cardiovascular risk” originated from the question, “aren’t people unnecessary worried about developing cardiovascular disease (CVD)?” In Japan, the risk of developing CVD in a patient with a slightly elevated LDL cholesterol is relatively low, in most cases, only a few percent in 10 years. Our impression was that people seem to be much more worried about developing CVD.

In our study, we could show that patients undergoing routine health check-up in our center significantly overestimated their risk of developing cardiovascular disease. Patients estimated their 10-year CVD risk as around 30%, compared with the calculated risk of 3%. From this result, we can make a hypothesis that CVD risk management in Japan may be conducted based on this misunderstanding.

We are planning for further research on this field. Will this misunderstanding affect the patient’s health seeking behavior, satisfaction, outcome, and will there be a positive effect of correcting this misunderstanding?

I would like to thank my boss, Dr. Eiji Hiraoka for supporting the whole work, and I would also like to thank all the people who were responsible for preparing this meeting.

July 10, 2019

ACP日本支部総会2019 黒川賞（若手医師部門）受賞者のことば　松尾裕一郎

ACP日本支部 2019年次総会黒川賞（若手医師部門）受賞によせて

東京ベイ・浦安市川医療センター総合内科松尾裕一郎

この度は、栄誉ある黒川賞をいただき、大変光栄に思います。今回の私達の研究「健康診断を受診する患者は、自身の心血管病リスクを過大評価する」は、私達が普段の外来診療で感じていた疑問、違和感を検証したものです。健康診断では、一般にLDLコレステロールが120mg/dLを超えると「軽度の異常」という判定になります。では実際に、それらの患者がその後10年でどのくらいの確率で心血管病を発症するかというと、問題が軽度の高LDL血症だけであれば数%以下程度です。しかしながら、患者自身はリスクがもっと高いと考えており、心血管病発症を必要以上に心配しているのではないか？というのが私達の疑問です。結果は私達の予想通り、Suita Scoreにより計算される患者の心血管病リスクは3%程度であるのに対し、患者自身が予測するリスクは30%程度である、というものでした。このことから、日本における脂質異常症などの生活習慣病診療が、患者の誤解のもとに行われている可能性、自身のリスクについて医療者と話をする機会の無い患者が、不必要な不安を抱えている可能性などを、間接的に示すことができたと考えています。

今後、このリスクのずれが患者の受療行動、意思決定、満足度、予後などの重要な指標とどのように関連するか、より臨床場面に直結する疑問に答えていけるよう、検証を進めていきたいと考えています。

改めましてこの場をお借りし、今回の研究の立案、計画、発表に至るまで多大なるご指導をいただいた当科部長の平岡栄治先生に御礼を申し上げ、私に発表の機会を与えていただいた米国内科学会日本支部総会の関係者の皆様に感謝の意を表したいと思います。

July 10, 2019July 10, 2019

Dr. Mai Okamoto, Winner of Kurokawa Prize in Resident/Fellow section

I am very honored to receive the Kurokawa Prize at the ACP Japan 2019. I greatly appreciate the support of attending doctors.

History of research

I have been interested in the appropriate antibiotics in my medical student days, but It was different from what I imagine in clinical settings. One of the reasons was that it needs several days to identify bacteria from specimens. Although the antimicrobial agent is determined on the assumption of the microbes, it does not always proceed as expected. In some cases, empirical treatment has failed to cover, on the other hand, I tended to use inappropriate broad-spectrum antibiotics.

The turning point of research

In July 2018, when I was the second year of residency, “FilmArray multiplex PCR” was introduced in our hospital. This machine can identify bacteria in the blood more rapidly than the conventional method. When the blood culture becomes positive, the FilmArray can detect in about one hour. This system has already been introduced abroad, and some studies have shown efficacy for antimicrobial stewardship. There are few experiences in our country and the microbiology laboratory setting is different from that high volume centers in prior reports. So, I decided to examine the change in the usage of antimicrobial agents before and after introducing FilmArray system.

Future expectations

This study showed that the time to start anti-MRSA drug for MRSA was shortened, and furthermore, 28-days overall survival was improved in the Gram-positive cocci baceteremia group by using FilmArray. The improvement of the survival rate is different from the prior studies, and it is considered that further study is necessary. However, our study suggested that the use of FilmArray may help the appropriate use of antibacterial agents. We hope further research will progress and would like to contribute to ASPs.

July 10, 2019July 10, 2019

2019年ACP日本支部総会　黒川賞（研修医部門）　受賞者のことば

ACP日本支部2019年次総会　黒川賞（研修医部門）を受賞して

岩国市立美和病院　内科　岡本麻衣

この度はACP日本支部2019年次総会において黒川賞を受賞することができ、大変光栄に存じます。全面的にサポートしてくださった方々に、この場を借りて心から感謝申し上げます。

研究の経緯

私は医学生時代から適切な抗菌薬使用について興味を持っていましたが、初期臨床研修医として臨床の現場に出てみると、理想通りにはいかない難しい場面にも遭遇しました。その理由の１つが、検体から起因菌を識別するのに数日かかることでした。起因菌を想定して抗菌薬を決定しても必ずしも想定どおりにいくとは限りません。経験的治療でも起因菌をカバーできていないこともあれば、必要以上に不適切な広域抗菌薬を使用してしまうこともしばしばありました。

研究の転機

研修医2年目の2018年7月、「FilmArray」という機械が当院で導入されることとなりました。これは従来の血液培養に比べ、迅速に起因菌を判別することのできる機械であり、FilmArrayを使用することで血液培養が陽性になった時点から約1時間で菌を同定することができます。。海外ではすでにこのFilmArrayが導入され、いくつかの研究では抗菌薬使用に対する有用性が示されていました。一方日本では使用経験がほとんどなく、また微生物検査の背景も海外と相違点があるため、これまでの異なる結果が出る可能性が考えられました。そこで今回、FilmArray使用による当院の抗菌薬使用の変化について研究しようと考えました。

今後の期待

今回の研究では、FilmArrayを用いることでMRSAに対する抗MRSA薬開始までの時間の短縮、さらにグラム陽性球菌菌血症群での28日生存期間改善を認めました。生存率改善については先行研究と異なる結果でありさらなる検討が必要と考えますが、今回の研究でFilmArray使用により日本でも抗菌薬の適正使用に役立つ可能性が示唆されました。さらなる研究が進み、ASPへの貢献につながることを願っています。

July 5, 2019

Memories of ACP Japan Chapter Meeting June 8-9, 2019’ Kyoto Japan

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.

July 5, 2019July 5, 2019

ACP Japan Chapter Meeting June 8-9 2019’ Kyoto Japan

President of the American College of Physicians

Robert McLean, MD, FACP

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.

June 30, 2019July 7, 2019

The road to an FACP – Why do we aim for it? –

（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.

June 30, 2019July 7, 2019

FACPへの道　- なぜ，それを目指すのか –

Health and Public Policy Committee（HPPC）企画

「FACPへの道　- なぜ，それを目指すのか – 」

吉祥寺あさひ病院　内科　小山雄太

ACP日本支部年次総会2019の2日目，6月9日の午後，HPPC企画として上記タイトルでセッションを開催した．ACP日本支部には2018年12月18日現在で337名のFACP，6名のMACP，1名のHonorary Fellowがおられるが，その方々はどのような思いでFellowを目指されたのか，Fellowになることでどのような違いが日常業務に生まれたのか，今後どのように活動していきたいか，といったことを聴くことで，より多くの方がFellowを目指しFACPになってもらいたいという意図があったからである．

同様のセッションを昨年度の年次総会でも行っているが，今回の企画でも，acp-exchangeなどで事前アンケートを行い，FellowやMasterの方々にはFellowになった経緯や昇格後の変化などについて，Memberの方々にはFellowのイメージや目指しているかどうか，Fellowになることで自身がどのように変化すると思うか，などについて回答を募っていた．

セッションでは，まず趣旨説明のあと，事前アンケートの集計結果をセッション中に発表した．結果をもとに，コメンテーターとして御登壇いただいた前田賢司・現支部長と上野文昭・前支部長，Women’s Committeeの山本典子委員長のお三方から貴重なコメントを頂戴した．これにより参加された皆さんにもHPPC委員にもより意義深いメッセージが伝えられることになった（3人の先生には会期中ご多忙にも関わらず本セッションにご登壇いただきありがとうございました．心より感謝申し上げます）．MemberやFellowになった時の動機は様々であるが，Fellowになることで誇りや自信，責任感など，医師という職業を継続するうえで重要だと思われる精神的な動機付けが付与されることが多い，ということが昨年同様に認識される結果であった．

このあと，参加者とコメンテーターの諸先生，HPPC委員が混ざり，スモールグループを作ってテーマに沿ったグループディスカッションを行った．広い会場では質問しにくい事も気楽に意見交換できる環境だったため，どのグループでも盛んな会話が交わされていた．最後にセッションのまとめを行って本セッションを終了した．特に後半のグループディスカッションでFellowである日本支部の同僚からいろいろ話を聞くことができたことで，参加したMemberの皆さんにとってもFellow取得に気持ちが傾いてくれたのではないかと期待している．熱心に聴講および意見交換してくださっていた参加者の皆さん，本当にありがとうございました．

本企画を契機にFellowを目指す方がより多くなることを願っているが，ひいてはこのような企画が繰り返されることによってACP日本支部会員がより多くなり，ACP日本支部がさらに発展することが委員一同の望みでもある．

June 27, 2019July 7, 2019

Contemplate the Healthcare Reform

Report from Women’s Committee 2019　June、2019

Chair; Noriko Yamamoto, MD FACP（President of Yamamoto Clinic）

Contemplate the Healthcare Reform. 9 June,2019 AM11:55-14:00

Women’s Committee；

Chair; Noriko Yamamoto, MD FACP

Co-Chair; Noriko Kawashima, MD FACP

Member; Keiko Arai, MD FACP, Yuko Morishima, MD FACP, Eri Matsumoto, MD Ayako Miki, MD

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.