Office of International Affairs Graduate School of Medcine Nagoya University

I spent my days in John’s Hopkins Hospital (JHH), Baltimore MD from March 27th to May 26th. Definitely, this is the biggest challenge I have ever made in my life and after finishing nine weeks of rotation I really think this is the precious experience. I cannot say thank enough for who concerned in my experience in Baltimore.

I rotated in GI and anesthesiology in JHH. GI has three groups and I was assigned in GI liver service and GI consultation team. In GI liver service, we did a conference about liver inpatients and hospital ward round in the morning. And afternoon, we went to the pre-rounds of patients who had LFTs problems in other wards of JHH based on the consults from other departments and attending doctor’s round. In GI consultation team, I participated in endoscopy procedures and pre-round for the consultations of other ward patients and attending doctor’s round in the afternoon same as liver service. In both GI teams, the consultation was very great opportunity to learn many thigs, like how to get information from patients, which points to take care in history taking and physical examination and so on. Writing medical records was what I tried hard during GI rotation. Medical records are the best places for me to present what I am thinking to other people. GI gave me many chances of learning clinical reasoning. Also I was impressed by GI Fellows who stored a lot of studies or guidelines which were related to the different types of patients’ diseases. Their effort of eagerness toward studying and updating is wonderful and should be a role model for me to be.

Anesthesiology has a lot of perspectives even about single operation case. Ventilation, drugs, circulation management, body positioning, depth of muscle relaxant were some of its perspectives and with my residents, the discussion about each topic was very exciting. In anesthesiology, the experiences of performing several skills like intubating, IVs, A-line and so on were very nice. Clinical reasoning was of course important but the time in anesthesiology gave me a lot of chances to practice skills. Every day I went to OR 6:30 and participated in many kinds of cases. Some cases were very rare in Japan so watching such fashionable cases itself was good opportunity.

What I learned most is the importance of outputting. Outputting what I am thinking or what idea I have is the most important skill. In other words, without outputting no one cares about me. No one will pay attention who does not say anything. Through this experience I realize that we have very great medical environment or medical education in Japan. Some points can be said better than U.S. But actually most of us take them granted and do not try hard well, me neither. I regretted that I had not taken such great advantages. It is recently said that Japanese lose other Asian people in terms of the presence in the world. I think it is because this great Japanese environment is too comfortable for us and we do not have to try hard. We should use the good points of Japanese medicine fully and should appeal its goodness to the world in various ways. This experience of JHH gave me a chance to reconsider what I have to do in my future and open new frontier in my life. By using this great experience which is very limited to few people in Nagoya University, I will make a lot of effort to output my ideas and make full advantages of Japan and to become a capable person who can play an active role not only Japan but also the whole over the world.

Finally, I want to say thank you to people who contributed to my JHH days.

I joined the clinical electives at Johns Hopkins Hospital in Baltimore from the end of March to May in 2017. The nine weeks became the most treasured memory in my life with various unforgettable experiences.

Before mentioning the rotation at JHH, let me briefly explain about the city and the hospital. Baltimore is a harbor city famous for crab cakes and the beautiful scenery at Inner Harbor. Although the city includes rough areas, Inner Harbor is a reasonably safe area with fabulous places to eat at. Another attraction in Baltimore is Mount Vernon. It has the George Peabody Library, which is a superbly beautiful library sometimes used as a wedding venue. In the middle of the city lies a prominent feature, Johns Hopkins Hospital. It is a huge hospital made up of dozens of buildings. It has long been ranked among the best hospitals in the U.S. Notably, ‘grand rounds’ is from this hospital.

I would like to move on to the main topic: my experience at JHH. I joined the electives of endocrinology and oncology for one month each, and both of them were educational, with invaluable learning experiences.

The first one month was in endocrinology, with the morning outpatient clinic and the afternoon consults. In the morning, I worked with the doctors seeing outpatients. Through this, I learned the efficient ways of history taking and concise ways of presenting cases. In addition, I saw patients with a variety of diseases: from major ones like diabetes to quite rare ones such as MODY, MPS, MEN, etc. All the attendings I worked with were so eager to educate students that they spared their time to teaching us about their specialty. Prof. Cooper was absolutely the most educational person I followed. He was a specialist of thyroid cancer, and taught me about it in a highly organized way. I am so impressed with his wide knowledge, efficient ways of explanation, and various techniques of physical exams.

In the afternoon, I worked with a fellow seeing the patients referred from other departments. Although, unlike at the outpatient section, I was able to give myself time to look through the chart and consult the guidelines, I first had difficulty associating my knowledge of the diseases with the latest medical practice; I sometimes focused too much on referring the guidelines and missed important points related to the reason of consult or to the primary disease. At such times, the fellow taught me to think systematically, showing the ideal presentation.

The elective in the following one month was that in oncology. I was assigned to the solid tumor team. It was quite different from the previous elective in that I was mainly in the oncology ward. I joined the round in the morning, and saw the patients on my own in the afternoon. I saw several patients every day, rounded on them at least twice a day, made presentations, and wrote notes from admission to discharge. The round consisted of all the medical staff: doctors, nurses, nurse practitioners, pharmacists, and social workers (and sometimes translators). The team had usually 10 to 15 patients, and the team had vivid discussions of each one of them, so the round often took three hours in total.

The most challenging work in the oncology elective was new admissions. I took advantage of the experiences in endocrinology elective to summarize the history, to talk with and examine the patients, to refer to the guidelines, and to structure the plans. The doctors gave feedbacks from other aspects than I had had in the past month, guiding me to improve the skills. Another precious learning was about the bedside manner. Compared to the patients with endocrine diseases, the patients were in more critical status. The doctors paid much attention to how they can make those patients more comfortable. I myself did talk with the patients and their family. At first, I could not perform well, wondering which expression was appropriate, when to approach patients’ bedside, how to bring out their status in their most difficult times. The doctors were so willing to teach those skills as to choose them as a topic for a lecture in the morning. Thanks to this, I gradually learned the techniques and managed to hear the patients’ hidden true feelings.

During the latter half of the oncology rotation, I managed to finish my work at the ward much earlier than in the former half. Thus, I asked the doctors to allow me to join their clinics, with kind acceptance from them. This experience absolutely taught me a lot: how doctors explain the current status to the patients, the words they choose when they talk about hospice, which is often seen as ‘the end of life with no hope.’

Along with these two rotations, I had opportunities of going to Prof. Goggins’ pancreatic cancer laboratory. Prof. Goggins, who is an old friend of Prof. Kasuya at Nagoya University, kindly accepted me to the laboratory. Drs. Tamura and Abe, from Kyushu University took much care of me, explaining their experiments. I had a great time participating in the research work such as polymerase chain reaction, electrophoresis, and next-generation sequencing.

Looking back on the 9 weeks at Johns Hopkins Hospital, every single moment is precious. I am deeply grateful for the opportunities of this hard-to-come-by experiences to my providers of support at Nagoya University including Prof. Kasuya, doctors at Johns Hopkins, and all the others that helped and advised me. Thank you very much.

This document is revised from the final report submitted to Children’s Hospital of Philadelphia as a conclusion of my coursework. I am a 6th grade student of Nagoya University Graduate School of Medicine. From February 27th to March 24th, I was on the observer ship at PICU for four weeks. I joined morning lectures dedicated to resident doctors, simulation based training, daily morning rounds, noon conferences, and ward observation.

The lectures for resident doctors took place three times a week. Simulation based training was conducted once a week. In the lectures, small review and tips on common emergent diseases and basic knowledge in servicing ICU were given. For example, in the lecture of asthma, I learned that intubation on children with asthma should be conducted with consideration because they might have developed bronchial responsiveness that leads increased airflow obstruction. I also learned that ketamine, which has an effect of bronchodilation by stimulating the release of catecholamine is useful when intubating the children with status asthmatics. I was not aware of the benefit of using ketamine, since it was not written on textbooks which many of medical students in my country uses. Actually ketamine is good not only because they can dilate the bronchus but also doesn’t reduce heart rate and contractility. In Japan, using ketamine as a sedative agent is not so much common as in the US, because some say its binding to NMDA receptor may have advent effect on children’s neurological development, which has not been supported by resources. I didn’t notice that there was a gap between countries using a certain agent. On a different day, the lectors brought adult, children and infants life-sized manikins, oral airway and nasopharyngeal airway. The participants were allowed to practice using airway devices. My biggest learning there was that I found that I gripped the wrong part of laryngoscope when using it. It is better holding the root of the handle to push the jaw 45 degrees upward than holding the distal end of the handle since it may hurt patient’s teeth. On another day, the lectors give us basic information about mechanical ventilation. And on another day, pharmacologists give us a lecture on pharmacokinetics especially on sedative agents.

All the lectures were scheduled to help resident doctors on service at ICU.

As far as I know in my country, all the resident doctors are given the same lectures despite which services they are on. It must be helpful to learn something related with daily work for resident doctors. Another difference I noticed from my country was that those lectures were not intended to give resident doctors a set of knowledge. Their main targets are to allow resident doctors to ask the questions by presenting a topic. Many questions were asked during the classes. The lectors seemed to expect answering many questions so didn’t go details on slideshow.

My learning goal for this observer ship was to learn the basic strategy of children with severe situation such as cardiac arrest. As soon as I began my observer ship, I learned that many children develop cardiac arrest by respiratory distress. I reviewed ARDS and asthma. During the observer ship on Thursdays, multidisciplinary MOCK code was conducted. Resident doctors, nurses, respiratory therapists tackled on a severe pediatric emergent situation which need life-supporting strategies. I didn’t join the participants, but was allowed to be with facilitators so that I didn’t affect the participants and was able to see what was going during simulation. It was very interesting to observe how team worked together and what kind of educational strategies for simulation-based learning were planned.

Firstly, I would like to mention participants. In the case which was less complicated, the team was calm and accomplished a stable status by giving bolus and adrenalin. However, in the cases which demanded the participants to more procedures for example, what they initially did was not enough to stable the patient, miscommunication was found. There were several types of miscommunication. Though some members in the team noticed something was wrong, they hesitated to speak up because the others seemed busy with their own business. Sometimes it was because though they tried to speak up, the other members unintentionally ignore them so that they gave up the second try. People who were not confident what they thought about the situation just kept silent. Lacking of knowledge would develop in the future, so it won’t be a big problem. However, I thought hesitation to speak up should often happen especially in a team consisted of unfamiliar members. I once had a chance to make a plan to an effective consultation for a patient in a team consisted of multidisciplinary medical students. I remember it took several time to be frank with each other since we had no idea what they had learned so that how they saw the situation. Much prompt and clear communication was needed in a situation like this MOCK code. The one who speaks out must certainly convey what they have in mind to others till the ones who listen to repeat it to show that they understood what they have been told. I strongly felt how closed loop communication works there.

The other problem often seen in MOCK code was that they often forgot to ask more people to help them. I saw some people were exhausted by chest compression but couldn’t ask for others take their part because the others were doing other things. On the other case, the leader had to take over other task too so that she didn’t have time to time-out and to summarize the situation. It was maybe because they unconsciously thought no one would actually come to help them. However, after I saw a real emergent situation on the ward on another day, I felt it was really important to have as many people as possible in such a situation. Also time-out is an important factor to share the information in a group. I was never told to do this in the past, but I found it works well especially there are many people working together working on different tasks. The lack of human resource seemed to cause both miscommunication and low efficiency. However, as the number of people in the team becomes larger, sharing information becomes more difficult when the strategies such as closed loop communication or time-out are absent.

I spent my most of the time in red team, where children who were unstable and post-cardiac arrest were. I encountered blue code several times during my observer ship there. There were more than 15 people in the room. One doctor took over a leader. Some worked to establish an intravenous and intra-arterial line. One nurse started to document the situation and another one became a timekeeper. Many people were in and out the room to ask for agents and apparatuses which were needed. They were well organized and calm. I was impressed to see them and felt that I would never be act like that without repeated practices.

While MOCK code, I was with the facilitators. There I learned the term “debriefing.” While I observed MOCK code several times, I noticed that the facilitators always put emphasis that they were not valued through the simulation. One of the facilitators told me that they followed a strategy for facilitator to accomplish a high yield education through simulation based training. I took a look at paper (The role of debriefing simulation-based learning, Simulation Healthcare 2007;2 : 1-1) on debriefing, and understood that they tried to make sure that their self-worth not be damaged through the session. Debriefing itself is reporting and sharing information after a specific event has taken place. There are a number of styles of debriefing. MOCK code was led by instructors, or expert debriefers. Facilitators help participants to get the whole picture of the situation and lead them to understand the facts and to accomplish the goal. As I mentioned some participants had noticed that they missed something they should have done before beginning debriefing. However technical points which could have been developed were not mainly asked in debriefing since it can be done by self-debriefing and could be a threat to self-worth by pointing out in front of the group. Participants were asked to dictate what they did and next they were asked what kind of emotion. Experience with emotion has a great impression and the memory lasts wrong. After they shared the situation they experienced, they discussed what the good points they did were and what could be better. Finally, the instructor gave some medical knowledge related the situation. When you did something wrong and feel down, it is difficult to view the situation rationally and might miss the point you actually had to learn. Description by own words and listen to others feeling mitigate one’s feeling and allow them to be rational again. I had several experiences of peer debriefing, but always felt that we tend to be generously rate ourselves especially in complicated cases, where people make many mistakes during the simulation because we don’t want to hurt other’s feelings. I got a feeling that as the situation becomes complicated, expert facilitator plays a greater role in debriefing.

Through this observer ship, I learned medical knowledge, gaps between the countries and differences in medical education. Patients in PICU had complex diseases so that too difficult to understand what was going on with them, but listening to their families in the morning conference and multidisciplinary medical stuffs discussing were very impressive. I would like to show my appreciation to all people in PICU. Thank you very much.

The following report was submitted to Children’s Hospital of Philadelphia (CHOP) as a final report for my coursework.

I participated in the observership at Pediatric Intensive Care Unit (PICU) from February 22nd to March 24th. During this four-week period, I was able to observe the service of three different teams in the PICU: two teams for one week each, and one team for two weeks. In each team, I observed the daily rounding and attended the resident lectures, the mock code, the PICU case conference, the PICU research conference, and the neurocritical care conference, and the professor rounds. Throughout this observership, I was able to learn and observe various aspects of pediatric intensive care; not only the clinical cares provided at PICU but also the educations for residents, process of medical decision making of physicians and families, collaboration of multidisciplinary professionals, and work-styles of physicians in the U.S.

In terms of clinical care, one of the most frequent and well-discussed topics was the respiratory management of children. Prior to the observation, I had learned that the respiratory management is the most critical factor in the pediatric intensive care; therefore, one of my learning objectives was to learn the logic of respiratory management in children. In PICU, different types of respiratory support were employed based on the condition of children. I learned the logic of different types of ventilation, non-invasive (BiPAP and CPAP) and invasive ventilation, and different modes of mechanical ventilation such as pressure support and volume support. The setting of the respiratory support was discussed everyday in the rounding, and weaning from the respiratory support was carefully managed along with the sedation management.

Having come from Japan, the most striking and novel for me was the rounding with active discussions by multidisciplinary team. In the daily rounding, residents or nurse practitioners present patients’ progress and the assessment and treatment plans for the day, and no day went without discussion. Furthermore, all people who engage in the child’s care participated, such as physicians from related specialties, nurses, case managers, pharmacists, social workers, respiratory therapists, and family. It seemed that the multidisciplinary team brought even more active discussion. Various professionals with different expertise are present to provide care for children, thus the discussion naturally arises as a mean of communication. This active discussion was especially beneficial throughout my observation because it enable me to learn the logic behind decisions made for patients. In addition, I find this active discussion is an effective way of avoiding errors because multiple individuals were present when any plans and decisions are made for patients.

Rounding also had the educational purposes; moreover, the PICU as a whole was filled with an educational atmosphere. In the rounding, attending physicians often provided mini-lectures related to children’s condition. The topics of lectures varied from going over the pathophysiology of the patient to the practical handling of defibrillators. As much as I found these lectures are helpful to understand the patient’s condition, I also found resident lectures and neurocritical care conference interesting and beneficial. The resident lectures covered frequently encountered topics in PICU such as mechanical ventilation, endocrine problems and ethical considerations. These lectures were good opportunity to review physiology and to relate it to the clinical practice. The neurocritical care conference was relevant for me because neurologists provided insights to the cases that I saw in the rounding. Other case conferences, professor rounds, fellow didactics were also educational. I was able to learn and observe the expectations for residents and fellows in PICU and continuing educational opportunities for physicians in general.

Educations provided at PICU seemed very different from Japan. In the clinical rotations in Japan, the emphasis in education is placed on learning the pathophysiology of patients rather than learning to make assessments and treatment plans. Therefore, learning the logic of decisions that are drawn from the pathophysiology and its application to the treatment through discussions were salient experience for me. Unfortunately, I did not meet medical students during my observation; however, I learned that medical students in the U.S. get trainings in coming up with assessments and treatment plans prior to their residency. In addition, when I asked questions, everyone nicely answered my questions with clear concise language, and this was consistent with physicians in any levels and other professionals. Every individual in PICU was trained and aware that they are providers of education. The observation of education here made me think that, although any medical professions are to use their knowledge for patients, they are to educate others as well. For the effective education, the verbal communication is essential. Verbal communication and the effective use of the language not only with the patients but also with students and other professionals were brought up to my attention during the observership, and it is something that I would like to be aware of throughout my career.

Research conferences were the great opportunity to learn about how physicians balance between research and clinical work. Although CHOP is an academic institution, and it may not be generalized to other hospitals, I learned that CHOP provides a great work environment for research-oriented physicians. Being able to divide the time in the year for clinical service and research was striking, and I was also surprised that there was a system to support researches financially and practically such as handling of samples and obtaining informed consent. As I engage in research in Japan and consider continuing getting myself involved in researches in future, the system at CHOP seemed idealistic for physicians to focus on their researches.

During my observation, I had opportunities to observe the events that are not common in Japan, for example, compassionate extubation, organ donation, and ethical consideration. I was surprised by how families actively make difficult decisions regarding the medical care of children. Societal and cultural differences can be attributed to these differences. In the PICU, physicians rotate weekly, monthly or daily, making it a large difference from Japanese hospitals where patients receive cares from the same physician throughout their hospitalization. In Japan, such system seems critical to help establishing the relationship between patients and a physician, which essentially contributes for patients and their families to make optimal medical decisions. In PICU, I learned that the difficult decisions could be made without the long lasting relationship with one physician, and despite the cultural differences, I could at least partially attribute it to the effective verbal communication skill of medical professionals.

The great deal of learning in PICU involved the psychological aspects of patients and their families. Of those, the involvement of social workers was notable. Social workers were to help facilitate various social issues and it seemed to serve the psychological wellness for people. Often times, aside from aiding families with insurance claims, they help families with meal vouchers, coordinating family housing and sleep rooms, and obtaining counseling service for family members. I think that supporting families in this way could reduce their psychological distress great deal. In addition, there were various services provided for patient and their families for their psychological wellness. For example, child life support provided toys and movies for children, and chaplains were there to provide religious support. I also learned about the psychological support for the medical provider side. Debriefing was held when a patient passed away in the team, and all the people who engaged in the deceased child participated and talked about their feelings and their views about the death of the child. I learned that PICU physicians have higher rates for burnouts and found that debriefing is one of the ways to improve the quality of life of physicians.

Overall my experience at PICU was filled with learning of various aspects of medical care, in other word, “the reality”, of medical care. The reality does not only consist with the knowledge from the book; rather, people make large part of the reality. My observation at PICU consisted of great deal of observation of people, and in this way, I learned many aspects of medical care in PICU that is not written in textbooks. As much as I learned the educational systems and the operation of PICU by multidisciplinary members, I also observed the disagreement in treatments between residents and attendings, or families complaining about the treatment plans to physicians. Being able to observe these realities of the systems and operations made this experience more invaluable. As a medical student, I am confident that I learned to my maximum ability during this observership, and what I saw and experienced in PICU will have a great impact on my values and beliefs in my career.

At the end, I would like to thank Dr. Nishisaki for supporting us throughout this observation, from the beginning to the end. I appreciate his time and effort for reading my daily report and giving me questions for further learning, which made this observation much more educational than it was already. I would like to appreciate Ms. Kathy Kennish for all the work she has done to make sure our visits to be comfortable. I also appreciate all members of PICU for nicely having us for observation and providing us with education.

I did clinical clerkship at Duke University in April and Lund University in May. Here I write about how I spent two months abroad.

【Duke University Consultative Cardiology】
I was in the cardiology consult team with an attending, a resident and two other students from Lebanon. Students’ duty was accepting consults. Once patients in other departments or ER are introduced to the resident, students touch patients first. Students can do interview, physical examination and viewing or writing notes. After seeing a patient, we make a presentation to an attending, see how he evaluates the patient and explains disease and treatment plan. Attending doctors want us to show our assessment and plan including which kind of medication and how much dose to prescribe. In total, I saw more than 20 patients in four weeks. The most frequent disease were atrial fibrillation and heart failure with reduced ejection fraction. Some patients had takotsubo-cardiomyopathy, so an attending told me to make a short presentation about this Japanese name disease.
What I felt “American” was, firstly, always asking patients whether they have health insurance. Doctors decides which medication to use depending on what kind of insurance the patient has or how much price is covered with it. Secondly, take patients’ opinion into consideration. I was surprised about that a doctor quitted an important test for diagnosis because the patient denied it and wanted to go home after explaining advantage and disadvantage of the test. Thirdly, preferring EBM such as the latest data or how much risk and benefit occurs with certain medication. Last, work is divide clearly to each co-medical staff. In cardiology department, doctors just order and evaluate results of ECG and echocardiogram done by nurses and technicians. It seemed like taking time to think and discuss is the major job of doctors.

【Life in Durham】
I stayed with Fred and Jenny, researcher at Duke, and their two dogs. They were so kind and took me to many delicious places like a BBQ restaurant which is famous in North Carolina. Durham was quiet, full of green and a little hot and humid town. I also enjoyed trip to Boston and New York with other students. Having Japanese dinner at former researcher at Nagoya University was also fun. On the last day of clerkship, he took us to a minor league baseball game. These weekend experiment made me refreshed a lot.

【People I met at Duke】
There were lots of foreign students and doctors at Duke who has great ambition. Two Lebanese students in our team were much better at using English and making presentation than me. Their aim was to achieve recommendation for applying residency in the U.S., so they did really good job in clerkship and studied for USMLE in free time. I was really depressed about how I could not do well like them, but I did my best to make me improved day by day. What I learned from this experience is I can learn much more with better English skill and more knowledge.
Patients and their family were very kind to me. Sometimes I was encouraged by talking with them even though I could not do anything helpful for them.
In the last week of April, I observed a surgery for a huge meningioma operated by Dr. Fukushima Takanori, one of the top neurosurgeon in the world. He told me lots of different points of American medical system compared with Japanese one. He was so energetic, confident and friendly. It was an amazing opportunity to have lunch with him and his patients on my departure day from the U.S.

【Diagnostic Radiology at Lund University】
I left Durham for the next clinical clerkship at Radiology department at Lund University. I rotated four sections for one month; thorax, abdomen, pediatric, musculoskeletal and neuro. A day starts with a morning round with other department followed by reading images and observing some tests. Although the name of elective was “diagnostic”, I could join treatment sections. Charts and conferences were all in Swedish, which was difficult for me to understand. However, some medical terms are similar to English ones, so I could grasp the picture by picking up some words. The most important thing is everyone in this country is fluent English speaker. I had few language problems during my stay because of the kindness of all medical staffs.
Swedish people like to take coffee break (=fika in Swedish) even when working in the hospital. And what I was surprised was how people are taking a balance between work and life. More than half of doctors are women in Sweden and it is common to continue working after having children. This is due to social welfare systems which support couples to bring up children. I found there is a big difference in both of social systems and people’s way of thinking between countries.

【Life in Lund】
The daytime became longer and longer during my stay in May. The city of Lund was beautiful and convenient. I was staying at one of the international dormitories with students from other countries. Most of them were in master course and it was interesting to listen to their plans such as finding job to stay in Sweden or going back to their own country. What is more, I was happy to meet the student who came to Nagoya University. I want to be nice to foreign students because I was so happy to have local student.

【People in Lund】
I met some doctors from other countries who graduated medical school in Sweden or started working after graduation of foreign medical schools. They chose to live in Sweden because social system and working style are better. I found some people are very interested in Japan. For example, one woman told me she visited Japan for an exchange a few years ago. I was surprised about Japanese culture and cuisine are popular among people far away from here.

【Overview】
Although my stay was one month each, it was so amazing and interesting experience for me. One of the reasons I applied this exchange was to challenge myself in unfamiliar environment. During these two months, I noticed my weak points that I did not know before. I want to keep these in my mind; to prepare well, to get involved with many people and ask anything without hesitation.
I would like to thank all the people who supported my exchange.

Introduction
I studied abroad for three and a half months. The schedule was like this, University of California Davis (2017/03/20-2017/03/30), Tulane University (2017/04/03-2017/04/28), and University of Western Australia (2017/05/01-2017/06/23). This is the precious opportunity I received thanks to Office of International affairs, Frontier members association, and many people who made this program and made it better.

Tulane Lakeside Hospital for women and children
My rotation was supposed to be only in pediatric GI, whose schedule covered just AM or PM every day. The first thing I had to do was to change my schedule. Otherwise, I was free half a day everyday even though I made every effort on preparing this program. I managed to make up the schedule by adding general pediatrics, well-baby nursery, where healthy babies come for a few days after birth, and preceptor, which is lectures done in small group. The doctor I met there was really nice and kind. She gave me a lot of chances to take histories and do physical examinations of the children. For students whose mother tongue is not English, having this kind of opportunity is not common. I really appreciate it. As I realized how great chance it was, I cannot forget the nervousness before knocking the door to the patient. In the preceptor, the students there answered the questions quickly, showed their opinions and discussed their cases. I was overwhelmed with this. I tried to join the discussion as much as I did, but I felt frustrated when I couldn't explain the morbidity of the disease in English though I could in Japanese. On the other hand, I felt brand new when I heard some students there said that studying medicine by two languages was absolutely impressive.

UC Davis Dermatology
I visited University of California Davis dermatology for ten days as well. Becoming a dermatologist in US is extraordinary competitive. I'm glad to experience the atmosphere of the highest level of the medicine as an observer. What I was surprised was there were many psoriasis and actinic keratosis. The insight for actinic keratosis and squamous cell carcinoma in US is completely different from that in Japan. It is not about medicine, but a doctor there is sociable, gentle and nice. He always cared about me. Residents and students there loves him. The way he speaks, communicates, and deals with the patients is worth learning. This must have a good influence on vision about my role model in the future.

Experience report University of Western Australia

Fiona Stanley Hospital acute surgery unit (ASU)
My clinical clerkship in Perth started soon after Tulane University’s. What amazed me initially was the difference of the pronunciations and the spells between American English and Australian English. OGJ and GORD stands for oesophageal gastric junction and gastro oesophageal reflux disease respectively. I have got used to them now. I rotated in ASU of Fiona Stanley Hospital. There are patients who suffer from diseases for which operations need to be done such as cholecystitis, appendicitis, small bowel obstruction, acute pancreatitis, and diverticulitis. The main role of students is helping ward round and operations. I sometimes joined lectures of Notre Dame University and University of Western Australia, took medical history, and did physical examination, but mainly students were free. The doctors always said, ‘It’s up to you.’ I couldn’t do anything at all if I hadn’t shown my positive attitude like, what can I do now, what can I learn, and what should I do. Indeed, even though you show your good attitude, it doesn’t go well. However, I tried to do every effort without caring about what others think as a foreign student. This experience have good effects on how I behave in Japan now.

Sir Charles Gairdner Hospital Vascular Surgery
I was always with Registrar and Fellow in this hospital. They did ward round, operations, catheter, and working on patients who come to the emergency department every day. I saw amputation (toe, below knee, above knee), endarterectomy, bypass, abscess drainage, angioplasty, atherectomy, EVAR, TEVAR, angiogram, and so on. What I remember the most is the patient who came to emergency department, had emergency femoral-popliteal bypass, had steel syndrome caused by bypass, was stented to shut off the shunt, had compartment syndrome, had fasciotomy, and finally recovered peripheral circular failure. I saw all the process of this patient from admission to discharge. The most important event for me was giving presentation of Moyamoya disease in the conference. They paid attentions kindly, but the nervousness when giving the presentation in front of doctors in Australia was amazing.

The purpose of studying abroad as a medical student
I was and am thinking about this, but it is really difficult to put it simply. To learn the difference of medicine between Japan and foreign countries? To improve language skills? To broaden my mind? It is not enough if you think one of them as the purpose. This opportunity is built on a lot of money, time, effort, and support of others. One of the purposes is in pursuing as many things as possible, isn’t it? After that, I have to digest, absorb, and use it. If I was asked whether I want to go abroad in the future, I’m absolutely sure that I answer, ‘I’d like to.’

In conclusion, thank you for giving me this opportunity. I’ll do my best without forgetting I’m blessed.

Hello. I am Kento Nakamura, Nagoya University School of Medicine, 6th grade. Thanks to the exchanging program, I got a chance to study in Tulane University School of Medicine, USA. Looking back when I made my mind to study abroad, I feel impressions for that.

Although my study plan was cancelled transiently because of Tulane side circumstances, doctors of office and international affairs negotiated again. Finally I got a permission to have a clinical rotation in one month. Given the short period, I had satisfactory days there.

Fortunately, I was rotating Pediatrics department, which I am really interested in. In America, there are so many subspeciality units not only general pediatrics, but also pediatrics nephrology, cardiology, genetics and so on. This is an intriguing difference from Japan. I was assigned to pediatrics hematology/oncology. Most of the patients are sickle cell disease because there are many African Americans in New Orleans. In contrast, Nagoya University Hospital has ALL and Neruoblastoma patients in the same department. This is another important difference. What is more, Tulane is the central hospital for the treatment of hemophilia in Louisiana states and my mentor was a specialist of hemophilia with inhibitor and bypass agent for that. Therefore I also experienced hemophilia patients.

I had difficulties overcoming Language Barrier, especially at the beginning of my rotation. Not only that but also I didn’t have a right to use electrically medical charts. As a result, what I could was totally limited and just shadowing of my mentor. Once she noticed that I was not good at English, time passed so rapidly without getting any significant tasks or assignments. I was like Air. Nobody needed my existence. I found it was meaningless to come to America if I didn’t change my circumstance. I strongly made my mind to appeal my enthusiasm to my mentor.

A Japanese doctor of Tulane said “most fail here in America because this is not your home country. However, it is important to express what you really want to do and sometimes it gets successful. Believe that and make an action anyway!” I was admired by his words and decided to work actively and positively for the rest of my stay, regretting my passive attitude in Japan.

I got medical chart copies of outpatient clinic to review on the previous day. I asked my mentor to give me assignments, and to get history and physical exams from patients. Because of these efforts, she gave me a permission to do that. It seemed I managed to appeal her. At first, I was not able to meet a patient alone, but finally, I got history and physical exams, made Assessment and Plan by myself, and, made presentation to her.

As I heard from doctors of office and international affairs, American educational system was severe to not a competent person. I felt inferiority complex. However, I struggled under that condition and became to work actively. It may change my mentor’s perspective to me. This is the best accomplishment for me than any medical knowledge I acquired through my entire stay. If I keep working actively, I can get more advantages than my expectation. I realized I need to continue this attitude toward studying even in my country Japan.

Finally, I want to say thank you to Mr. Kasuya, Mr. Hasegawa, Ms. Nishio, Tulane peds hem/onco team members and my family.

Clinical clerkship in University of Western Australia

Hello. I am Kento Nakamura, Nagoya University School of Medicine 6th grade. Thanks to the exchanging program, I got a chance to study in University of Western Australia (UWA), Perth, Australia for 2 months. I report what I learned there. Before my stay in Australia, I was in Tulane University, New Orleans, USA for another clinical clerkship. The experiencing medicine in 2 different countries is valuable for me.

I had a clinical training in Fiona Stanley Hospital and Sir Charles Gairdner Hospital for 1 month each.

In Fiona Stanley Hospital, I rotated in Cardiothoracic surgery. Ward Round and clinical meeting started at 7 am, then I participated in operations. There were 2 cases each in 2 operation rooms. Most of patients were for CABG. I also experienced AVR, MVR, lobectomy, and pleurodesis for pneumothorax. When I scrubbed in, surgeons often asked me some questions. Their English were so fast and I had difficulty understanding them, but they explained many times until I got them. Before operations, I got instructions from anesthesiologists. I performed tracheal intubation and urinary catheter. They also gave me lectures about TEE and anesthetic agents. Although my medical knowledge and English ability were poor, doctors were kind to me. On my final day, my boss said “First, an important thing, this is Kento’s last day!” I was really impressed by this.

On second month, I rotated Neurosurgery in Sir Charles Gairdner Hospital. Ward round stated at 7 am and I spent most time in an operation room. Fortunately, I scrubbed in many cases. This period was hard time for me, but it was the most satisfactory term in my stay. As an assistant, I sometimes performed ligation and suture. I was regarded as a team member, nurses prepared my gown and gloves. One surgeon said” No one is serious as much as you are”. This is the most memorable word I received. ※Grammatically, this sentence is wrong. However, this is my important memory. Therefore I described as it is.

Through my entire stay, I had hard time overcoming a language barrier. I was able to understand some lectures to medical students and plain explanations to patients on ward round because they are clear and not so fast English. However, I didn’t understand conversations between doctors as they contain abbreviation and slang. It was more difficult for me to follow chatting rather than medicine topics. I felt really lonely when all team members except me were laughing. I strongly recommend next year students to study not only clear and slowly English like TOEFL, but also fast and informal English in real conversations. There would be many times to spend time with local medical students or doctors. If you can understand what they say completely and tell your idea without any inconvenience, you can have more enjoyable time.

I can compare USA, Australia, and Japan. This experience is very precious for me. I am really lucky to spend much time in foreign countries while I am young. I have to apply this experience when I become a doctor.

Finally, I want to say thank you to Mr. Kasuya, Mr. Hasegawa, Ms. Nishio, team members of my rotation and my family.

Last spring, I got a precious opportunity to join clinical training programs as an exchange student in the U.S. and Australia. I would like to show differences which I felt between Japan, United States and Australia in medical procedures, health care systems, doctors’ career and medical students. I must say this is only my personal opinion and I do not mean to say which is better.

First, I'd like to point out differences in medical procedures. However, I could not find big differences between three countries. It is probably because people can share and get the latest information via the Internet these days. Also, I am just a medical student and I do not know much the details of treatments, so I cannot tell differences. I am ashamed of it, but this should be one of the main reasons.

Next, let’s take a look at health care systems. As you know, under Japan's universal health care system, all residents are required to join the public health insurance scheme. In Australia, the similar universal health care system is also introduced. However, U.S. does not have a uniform health system, has no universal health care coverage, and only recently enacted the Affordable Care Act (ACA) — commonly known as Obamacare — which mandates healthcare coverage for almost everyone. There are mainly two types of public programs; Medicare and Medicaid. Medicare is a federal social insurance program for seniors and certain disabled individuals; and Medicaid is funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families. When I was in New Orleans, I had several chances to observe outpatient clinic at University Medical Center New Orleans (UMC). UMC is operated by Louisiana State, therefore UMC accepts Medicaid and there were many Medicaid patients. I was shocked when an attending asked every patient the type of insurance in order to prescribe drugs which are covered by the insurance. I saw several times he was not able to prescribe drugs which he wanted to give patients at first and he had to change prescriptions. I talked about this story with local medical students who are rotating the same department and I asked how they feel about this problem. One of them said it is a pity that the market-based health insurance system in the U.S. has caused a human rights crisis that deprives a large number of people of the health care they need. Another student was afraid that a large healthcare system would cost an enormous amount of money and contribute to significantly higher taxes.

Third, I am going to describe differences in doctors’ career. In Japan, a doctor becomes a family doctor and has their own clinic after he or she becomes a specialist. However, in Australia and the U.S., when a medical student graduates from medical school and starts his or her career as a doctor, he or she should make a big choice whether he or she will be a family doctor (general practitioner in Australia) or a specialist in both countries. The family doctor and the general practitioner (GP) play a central role in the delivery of health care. People who are seeking medical care usually contact them first. When a patient develops a serious condition, they may refer him or her to a specialist. In addition, in Japan, a medical student can major in a specialty which he or she want to specialize in and he or she can become a specialist without competitions. However, in the other countries, he or she should win competitions at each stage to be a specialist. In the U.S., a medical student who wants to get into a neurosurgeon residency which is one of the most competitive departments must not only get excellent medical school grades and USMLE test scores but also need participation and publication of research, and strong letters of recommendation. Australia does not have the National Medical Practitioners Qualifying Examination, so a medical student can become a doctor just graduating from a medical school. However, he or she must pass exams at each stage to become a resident, registrar, fellow and consultant. The time required to become a consultant or an attending depends upon a number of factors, but principally the speciality they choose. They accept ultimate responsibility for the care of all the patients referred to them, so the job carries significant personal responsibility. And if someone becomes a consultant or an attending, he or can earn higher income and can work at his or her own direction with flexible schedule. Andrew is an anesthetist and he looks after us while we are in Perth. He has a Rolls-Royce and took 1-month vacation this summer and traveled all over the Europe.

Finally, I'd like to compare medical students among three countries. The biggest difference between Japan and two countries is that there are many students from all over the world such as China, Malaysia, Egypt and German. That is because the U.S. and Australia are multiracial nations and people in both countries speak English; the most pervasive language on the planet and the most universal language on Earth. English enables both countries to recruit top-class personnel from the world and I think that is a huge advantage. I talked with students from Malaysia and Egypt about Japanese medical education and they were surprised when I said almost all books on medicine are written in Japanese and we have to translate each word into English.

I've learned and experienced so much through this three-month exchange program. This kind of experience isn't really something everyone can have. This would not have been possible without everybody's contribution. I want to make use of this great experience for my life in the future.

This year, I had a precious opportunity to study both in United States and Hong Kong. I joined the clinical clerkship for four weeks at Tulane university of Medicine, which located in New Orleans, Louisiana and then another four weeks at Chinese University of Hong Kong (CUHK).

Tulane University
My rotation started at cardiology and I was assigned to CCU team. I really surprised that no one give me any tasks and I just followed and observed doctors at the first day. However, once I tried to ask questions and join discussions about treatments, they kindly taught me and started treating me as a member of the team. I realized how passive I was during clerkship in Japan and know the importance of learning initiatively.
The second rotation was endocrinology. It was so exciting because there were many rare cases that I couldn’t see in Japan; a girl with masculinization for ten years remain undiagnosed, a man with diabetes mellitus who has BMI 60, a woman with severe tetany seizure because she misunderstood the amount of medication for years after thyroidectomy. I took history and physical examination of patients and discussed diagnoses and treatments with doctors. My fellow was really kind to me and I learned from him not only medical knowledge but also the effective way to relieve anxiety from and fully satisfy patients. I never forget my last day, because he bought me a whole cake and said, “You are the most highly motivated student that I have ever met and I was really glad to work with you.”
Although I suffered from singles (It was really painful and I really had a trouble in getting antiviral drug. It gives me the chance to consider medical insurance system.), my stay at New Orleans was really fruitful.

CUHK
At CUHK, I rotated in cardiothoracic surgery department. I was a little anxious because I didn’t have sufficient knowledge about surgery and moreover I couldn’t speak Cantonese at all. However, these problems were immediately solved. Doctors were really favorable and educational. They were willing to teach me, translate what patients said to English, explain about each procedure during operation and let me take physical examinations. In this department, over 700 operations are performed every year. So I experienced almost all kind of cardiothoracic operations; CABG, valve replacement/repair, aorta replacement, lobectomy, thymectomy, pleurodesis and treatments for pneumothorax. They were all interesting. Furthermore, Hong Kong medical students are all good at English (It because they learn medicine all in English), diligent and eager to learn. So thanks to them, I got more motivation and acquire deeper knowledge during the rotation.

Summery
Due to studying both in U.S. and Hong Kong, I could compare their differences. I gained the opportunity to look at Japanese culture and medical system objectively. It is true that there were some difficulties during my stay, however, In addition to improving my command of English, I got confidence in myself and I could broaden my horizon.
I really would like to express my gratitude to Dr. Kasuya, Dr. Hasegawa and other staffs of International Affairs, doctors and staffs of Tulane University and CUHK and all the people who supported me. Thank you very much.

First of all, I would like to express my gratitude to all of you who support for the exchange program. I had been at Tulane University School of Medicine in April and The Chinese University of Hong Kong in May. I report what I did in each university.

Tulane University
I went to Tulane University in New Orleans, which is located in southern of the U.S. I was rotating on OBGYN with 3rd year medical students. In the first two weeks, I was a member of the UMC clinical team. Students took medical history of patients, and then did brief examinations and presented to senior doctors about the patients. What surprised me most was that how competent the medical students were. They had profound knowledge about diseases and did great at clinical exams as well. After finishing the clinical tasks, they went straight to the library and studied for hours every day. I wondered about this, so I asked one of the students why they were so diligent. He said that in the U.S. medical students could not choose the specialty they wanted unless they performed well in med school - there were fierce competitions! That's why they were so motivated and hard-working. I thought though med students might feel a very big stress, competitions would lead to improve the quality of national medical care.
In the next two weeks, I rotated in inpatients OBGYN team at Lake Side Hospital, where I observed various operations, for example, CS(cesarean section), delivery, TVH(total vaginal hysterectomy) and SO(salpingo-oophorectomy). There were some differences from what doctors did in Japan. When I saw a HIV patient had a vaginal delivery, I was astonished, since cesarean section is a standard care for HIV patients in Japan. I also found the difference in a medical insurance system. As you know, we Japanese take a universal healthcare system. Therefore, you can get the best medical care with very low cost. On the other hand, in the U.S. there is not such system, so they need to pay much money if they want to get the finest medical care. I saw some poor patients who were in trouble due to this system.
I rotated with 3rd year students. They were all kind and friendly, so I never felt lonely. Some of them invited me to their house and held a party for me. I liked the taste of beer I drunk with them. It was so much fun and I will never forget about those wonderful days.
Through the clinical clerkship, I learned a lesson – “everything is all up to you”. If you say nothing, nobody care about you in the U.S. In this circumstance, I needed to be more assertive to get what I wanted. I can say I became stronger through my stay in America.

The Chinese university of Hong Kong
I had a clinical clerkship at The Chinese University of Hong Kong (CUHK) in May. Let me introduce a little about CUHK. It is located in a residential area in Hong Kong and it placed 39th in the world universities rankings in 2013-2014. As for the connection between Nagoya University, unfortunately there are few - among our senior students, only one student had been there before. I was the second one. Now I have finished my journey. I wish more students choose CUHK - I spent a wonderful time there.
I rotated in Orthopedics Surgery at Prince of Wales Hospital, which is in CUHK. In the first two weeks, I was in the sport teams and in the next two weeks, I rotated in Hand team and Trauma team. I observed various operations – ACL reconstruction, fixation of bone for multiple bone fracture, total knee replacement, skin grafting for severe burns etc... Sometimes patients were so serious that it took 10hours to finish the operation. All of them were interesting to me.
Prof. Yung is a chief doctor. He is world recognized in the field of Orthopedic Sport Medicine and there were number of patients in his outpatient clinic to see him. There were not only Hong Kong people, but also foreign people and mainland Chinese people. What shocked me most was a case of an iatrogenic injury. Many people from mainland China had a severe damage due to previous bad medications they got. Prof. Yung, skilled surgeon, could fix them all, saying more and more people came to Hong Kong from China to get a better medical care. I had not known how high the medical level in Hong Kong until I came. I had considered Hong Kong was just a part of China, but actually it was not true - Hong Kong is one of leading developed countries and has a better-organized society than I had expected. Hong Kong people said that “Hong Kong was completely different from mainland China in a medical care, in social systems and even in language, so we were different countries.”
During this stay, I met several foreign doctors who worked as trainee or specialist. I tried to talk positively to them recalling a lesson I had got at the U.S. As a result, this effort turned out to be successful. We became good friends. Furthermore, I got an opportunity to take part in a research one of friends tackled. It was so exciting!!

Conclusion
I could spend the most challenging and exciting days in both the U.S. and Hong Kong. Many students and doctors kindly supported me. Thanks to them, I fully accomplish my clinical program. I would like to appreciate Dr. Kasuya and other staffs of Office of International Affairs, and all people who supported me. I will never forget this wonderful experience for the rest of my life.

“Are you a med student looking after that man in bed 18?”
“Yes...?”
“Okay, so what’s the medication, he is so nauseous. He need med.”
“Oh, sorry... I’m not sure. I’ll ask the doctor.”

This often happened me in a hospital in Australia. Nurses always asked me what to give patients or what plans were and even when to discharge because in Australia 6th-year medical students are meant to be able to work as the same as doctors. That was shocking to me, a Japanese medial student.

I did emergency department, general practice and pediatrics in the University of Adelaide, Australia. Especially, general practice is the most impressive among the three.

There is “rural health course”, which is quite unique program in the medical school of Adelaide Uni. 5th-year students can choose which they do clinical clerkship, in the city or in the country. The students who choose the country are divided to 15 small groups (each 4 to 6) and assigned to 15 rural regions, where they share one house, live together and do general practice for whole one year. I stayed Kadina, which is one of the rural town in the program. That was 3 hours away from Adelaide City by car and population is about 6,000, a really tiny town. What I had to do there first was dancing! On the 1st day at Kadina, I was put an old dress on and did pair dance with one of the medical students to celebrate the immigrants from England to Kadina. I’m not sure I did well or not, but joining the festival was very good chance to interact with med students and also people in Kadina. Later I saw many people who I met in the festival as a student doctor in the clinic. And the med student I did the dance with was the sweetest ever, so I really enjoyed the festival! Anyway, I should write about medical stuff now. There are one outpatient clinic and one hospital, which has 30 beds, in Kadina. Every day I saw patients in the outpatient clinic from 8 AM to 7PM, and then saw patients in the emergency department in the hospital. Moreover I went house visiting, nursing home visiting or vaccination travel when they called us. It was super busy, but the doctor who looked after me was very friendly and enthusiastic about medical education so I could enjoy that. He, Tim helped me got various medical experiences, like AMI, AAA and removing fishhook from the finger! I really appreciate to Tim, other doctors, patients, med students and nurses... everyone educated me. I would like to express my love to people in Kadina by using the “word” they often used.

Kadina was a bloody wonderful place, miss you guys, see you love!

I went to Adelaide University. Adelaide is a safe, small and livable city in South Australia. Living there was wonderful. Nice people, nice wines, nice cheese..., no other cities in Australia has more restaurants per person than Adelaide I hear. (I don't know it is because of many restaurants or small population.) Adelaide is also a music city. I could hear various kinds of music from traditional aboriginal didgeridoo to cool rap music in a mall at center of the city. I spent three months here sharing a room with two other students from Japan.

I visited Emergency Department, Haematology Department and Pediatrics Department in a low. The former two are in Royal Adelaide Hospital, and the latter one is in Women's and Children's Hospital.

First I went to Emergency Department. It is separated to 4 areas: area A, B, resuscitation and short stay. I went around these areas freely. At area A and B I went to meet new patients, took history and did physical examination. I wrote charts at the same time. After that I went back to talk to doctors and did presentation including history, findings, diagnosis and plan. At first I got confused as it was almost first time I took history from real new patients. At such situations, friendly medical students of Adelaide University were a great help for me. I learned a lot from them and had fun with them. As in a immigrant country, medical staffs are from various countries: UK, Korea, Malaysia, India, Vietnam et cetera.

Next month I visited Haematology Department. I went to laboratory, ward, clinics. Most memorable thing during Haematology months is PBL for medical students. It was completely different from I had done in Japan. Students there were much more aggressive and never hesitate to give their own opinions. At this PBL I most strongly felt my Japanese tendency to be shy. I had been amazed to see how fluently med students communicate with patients and senior doctors while I was at Emergency Department. I saw where their ability to communicate came from by joining their teaching. I think I came to be able to look more objectively at good and bad points of teaching style of Japan and other country. PBL was a stimulating opportunity for me.

Finally I went to Pediatrics Department. Pediatrics is separated into many divisions. I went to General, Pulmonary and Allergy and Immunology. I followed doctors and see what they do and take physical exam with them. Sometimes they asked me like, “Reiko, go to check whether he gives sign of meningeal irritation.” At such situation, I felt confident that the doctor believed me and also felt pressure because my fault must lead progression of the child's disease. Before I went to Adelaide I had been full of anxiety, but time flied while I was busy. Thanks to a lot of supportive people, I could successfully come back Japan with no problems. I really appreciate what they've done.

I was staying in Adelaide for 3 months. Adelaide is a small city in Australia, and it is very beautiful and safe. You can go to the beach or wineries if you drive or take a train and bus.

I rotated Psychiatry, Pediatrics, and Emergency department in the 3 months, and did my clerkship for 1 month each. I’d like to tell you what I did and what I felt.

In Psychiatry, I was usually attending the meeting for the patients and writing charts and records. I also did presentations about the patients at the ward round, and wrote discharge summaries of them. In addition, I was allowed to visit the community center and Emergency department to see how the psychotic patients are treated in the local community and Emergency Department. I found that there are so many social workers and meetings here compared to Japanese Psychiatry. The teaching system was a bit different from Japan, too. Students were assigned to registrar doctors, and spend all the time in the department with the fixed doctor as a partner. My registrar doctor was a young woman. I enjoyed the system very much because I could build a good relationship with her and could ask any kinds of questions to her.

In Pediatrics, I rotated Gastroenterology, and Respiratory department. Most of the work in Pediatrics was ward round and outpatient clinic. I wrote records and did physical examinations during the round. In the clinic, Consultant doctors taught me a lot and sometimes I did physical examinations instead of the doctors. I also attended the lecture for students. It was easy to understand even though it was done by English.

In the Emergency Department, I interviewed 3~5 patients every day and consulted to the senior doctor. The senior doctors helped me to order the test, but most of the tests were allowed to be done by students, so I did blood tests, sutures, and fluids. These were good experiences because thanks to this system, I was used to doing these skills. There were patients who were categorized as “psychosocial ”, too, so this department will be interesting to Japanese students who have a little chance to see such patients. In addition, most patients were very friendly and kind. One patients encouraged me by saying“Your suture was very good. Be more confident! ”Another patient told me that “You are very nice girl and doing really well. Thank you very much. ”These words made me so happy and feel confident.

Throughout my clerkship, I felt that staffs in the hospitals seemed to be enjoying their job and making good relations each other. There are many kinds of occupations like doctors, nurses, social workers, and office workers, but all of them are calling their first name each other, and it seemed really nice. They were trusting each other, and talking many things in frank. Such an atmosphere was so pleasant.

In Adelaide, all the people I met was so kind and treated me nicely. They always smiled at me and helped me a lot. Thanks to them, I could spend my 3 months in a wonderful environment and enjoyed all the clerkships without any hardships. I liked people here very much and I say with confidence that I was very glad to study in Adelaide.

I participated in the clinical clerkship at Medical University of Vienna. The reason why I decided to take part in this exchange program is that it would probably be the last chance for me to study abroad in my life, and that I wanted to broaden my perspectives by living overseas and meeting various kinds of people, such as doctors, students, and so on.

Firstly, I chose Pediatrics for four weeks. At first, I was told that I would be fixed at Pediatric Cardiology, but when I visited the secretary of Pediatrics, I found that I should rotate at Pediatrics Emergency Room. Since doctors and nurses were very busy and every patient’s information is written in German, I could do nothing and spent the first day just standing in the outpatient room. I considered what was the best way to learn Pediatrics for me, who could not understand German at all, and resulted that I should change to another department, like a ward to take time to see patients. Therefore, I asked The Professor of IMC (intermediate neonatal care unit) directly and she allowed me to study there. Although doctors and nurses speak only German at conferences, Professor translated the information to English for me. Because Babies were hospitalized for a long time and there is more time in this station, doctors took plenty time to demonstrate ultrasound of brain and heart, and physical examinations for students. During this two weeks, I realized that aggressiveness and self-directing are the most important things to learn in this environment.

I rotated at Pediatric Cardiology for the latter two weeks. Because AKH has Heart Center for children, many patients come to see doctors not only from Austria but also from East Europe. I learned a lot of diseases I have never learned even from textbooks. I rotated with 6th grade students of Medical University of Vienna. I was surprised that 6th grade students are treated as a staff in the department, and that they can do almost the same things with Japanese Residents, like taking blood from CV catheter and see new patients first in the ward. They also have much knowledge about the operation procedures and treatments, so I was overwhelmed about their skills and knowledge. However, I asked these students and doctors without hesitating so that I learn as much as possible.

Secondly, I rotated at OB/GYN for each two weeks. In obstetrics, I mainly observe the outpatient clinic and worked as an assistant of cesarean sections. At first, I was confused by the training style in this department because I had to decide what I want to do, and asked doctors every day. However, I could see some spontaneous delivery which was one of my objectives. One delivery was very impressive to me because the family is a refugee from Africa, which symbolizes the international affairs in Europe now. As the mother couldn’t understand either German or English, her husband translated what a doctor and a midwife told to her. The delivery took so long time, but I was moved to see the mother accomplish the difficult delivery and hold the baby; I felt a deep connection between the mother and the baby.

Gynecology is divided to three stations; oncology, gynecology and endocrinology. I was fixed in Oncology and mainly observed a lot of operations. As you know, AKH is the largest hospital in Austria. Therefore, many severe patients come here for further treatments. It was curious to see operations not only by gynecologists but also with urologists, general surgeons or plastic surgeons. The operations performed there were such rare cases that operation rooms were always crowded with a lot of doctors and students. I was also amazed by how wide range gynecologists can do, because Professor of Oncology performed liver resection in the ovary cancer operation.

Finally. I rotated at Emergency Room for the last 4 weeks. I mainly worked at walk-in outpatient clinic, where the students’ task is to take blood and perform ECG. At first, as I was not used to do, I made some patients shed blood and spread intravenous floods. However, doctors and students taught me how to improve the procedures patiently. When there was time, I took part in the lectures about respiratory care and automatic chest compression machines. Also, students and exchange students explained a lot for me there. I really acknowledge their favors. I was really stimulated by eminent students. They come to the clerkship even at night, on weekends and national holidays.

Aside from the clinical clerkship, I spend a productive time, such as playing volleyball, volunteering at Ronald McDonald’s House Wien, and going to see operas and concerts. I could study in the best season in Vienna and everything there was new to me, who had never lived apart from Nagoya.

When I entered Nagoya University, I didn’t believe that I could participate in clinical clerkship oversees. It is true that I made a lot of wonderful memories in Vienna, but the first thing to remember is a sense of alienation in the clerkship because of the language problem. A doctor compared me with a student there and said ” he is working, but you are observing.”. Although I was depressed several times, I could overcome them thanks to people’s help around me. Also, I could have my confidence by challenging new things every day and these experiences have made me more mature than before. I appreciate all the support I have received from everyone, especially Dr. Kasuya, Dr. Hasegawa and all staffs of international affairs. Thank you very much.

I finished the clinical clerkship in AKH.

AKH is the hospital of the Medical University of Vienna and it is the biggest one in Europe. The number of beds for patients is more than two thousand, which is more than twice compared to Nagoya University. As for the number of medical students, there are more than six hundred per grade. I studied in such a large university and I'd like to describe how the clinical clerkship was. I chose one section per month: Pediatrics tumor/epilepsy group, Ob/Gyn and Radiology.

First, I was assigned to the Pediatrics tumor/epilepsy group. It was unexpected because I had been registered as a student of Pediatrics cardiology. At first, I considered whether I would change the section, but I ended up deciding to do clinical clerkship in the tumor/epilepsy group. On the first day, doctors didn't care for me at all. They greeted me at first, but then, they went back to their own tasks. Moreover, all conversations were held in German and it was the same even during teaching students. So, I found that it was so hard to adapt to the circumstances on the first day. Although, if I didn't do anything, I couldn't get anything. Then I tried whatever I could do: translating patients' information from German to English, looking up some diseases on the internet or within thesis, asking doctors for what I didn't know, and asking doctors to teach me whatever they could. At first, they didn't care. Although, gradually doctors and students began to care for me. They let me see a patient and do physical examinations. Finally, the chief doctor communicated with some patients in English for me during the consultation. I was pleased to see how the circumstances changed. And I noticed that trying to do something would make a change.I was happy, but I also realized that I couldn't do any more there because the main event there was only the consultation and, after that, doctors and students did deskwork. So, I asked them to let me go to the Day-Clinic, where outpatients could take chemotherapy. Then, I went there everyday. There was a younger doctor and he usually took care of me. He was so kind that he explained everything in English, let me do physical examinations or neural examinations and gave me some thesis to study. I could spend a fruitful time there and I could study many brain tutors for children. Through rotating in the group, I learned that having the courage to try everything made the clinical clerkship better.

Second, I rotated to Ob/Gyn. Compared to Pediatrics, doctors were more kind and more enthusiastic to educate students. They sometimes let me scrub in and told me what the diagnosis was and what they were going to do. Because I couldn't see a lot of gynecology operations in Japan, all operations were interesting and I could learn lots of things from them. The most interesting thing for me was the operation for Endometriosis in urinary bladder with da Vinci.

The last section I rotated to was Radiology. In AKH, Radiology is one of the major sections and it occupies as many as three floors. In Japan, usually, Radiology isn't separated by groups. However, in AKH, there are so many groups in Radiology. For example, there are a CT group, MRI group, Mammo group, Angio group, Xray group, US group, and so on. Moreover, each group is also divided into small groups. For instance, as for the CT group, there are many groups: surgery CT, internal CT, CT for lung, CT for liver, and so on. Radiologists are divided into separate groups, so they work as specialized doctors. Of course, they can learn and get into a specialty in two or more groups if they want. In the clinical clerkship, there was no schedule for students, so they could go wherever they want everyday. they had to choose one section and asked a doctor whether they could follow them every morning. Because I wanted to study surgery CT, I went there everyday. A doctor I followed was so kind that he explained to me how to detect what was wrong in the image and taught me some basic knowledge, like anatomy, in English. It was so nice and I could ask him whatever I didn't know, so I could learn more than in Japan.

My clinical clerkship was like this. Surely, I had many difficult things there, but I overcame them and I gained confidence. I think this experience is precious and I couldn't have learned so many things and met such nice people if I had stayed in Japan. I am grateful to everyone. Without the support, I wouldn't have been able to finish my exchange study completely. Cordially, thank you very much.

I studied at the Medical University of Gdansk in Poland for three months. I am so grateful to all the people I’ve met there and thanks to my professors and friends, I had the most productive days of my life. There were three reasons why I chose this university.

First of all, this university has a special program “English division course.” Thanks to this course, I was able to interact with many students from a variety of countries, like Sweden, Saudi, Italy, Spain, Slovakia, Germany, the US, Canada, India and so on. I gained much information about their own countries and motivation for studying medicine through these interactions. I confirm that these experiences can contribute to my future.

In addition, I was interested in surgery, so I would like to have practiced surgical procedures. Therefore I preferentially selected surgery classes and my rotation was “Obstetrics and Gynecology (3w), Rehabilitation (2w), Neonatology (1w), General surgery (2w), Family medicine (3w). Although I could not learn more surgical procedures than I had expected, some professors taught me special procedures I had never experienced in Japan. For instance, Dr. Adamski, an obstetrician, was so kind to me that he politely taught me how to measure ‘Bishop Score’ with pelvic examination from the basics to the practical use.

Finally, I had the greatest concern for Eastern European countries like Poland. This is because I have believed that after I become a doctor in the future, while it would be likely that I could obtain chances to study in English-speaking countries like the United States of America, it would be so difficult to study in non-English-speaking countries. In fact, this experiences in Poland were definitely valuable opportunities, so I have a confidence that my choice was correct. To be sure, people in Poland were not so good at speaking English fluently (some people could not speak English completely), but this problem enabled me to try to understand actively what they wanted to say and to learn how to communicate with people who could not speak English.

In conclusion, I am so satisfied with these three months and would like to keep improving my skill which I gained in Poland. Thank you for all the people who supported me and the connection between Nagoya University and the Medical University of Gdansk.

I studied in Medical University of Gdansk for three months as an exchange program student. Medical University of Gdansk has two courses. One is Polish Division course, and the other is English Division course. The former is for students from Poland and they study medicine in Polish. The latter is for students from abroad and they study medicine in English. During my stay in Gdansk, I rotated Hypertension and Diabetology, Introduction to Gynaecology and Obstetrics, Pediatrics, Family Medicine, Surgery, and Pediatric Surgery with English Division students. They are from various countries like Sweden, Saudi Arabia, India, Kenya, America, Canada, Portugal and so on. Of course, we had different mother tongues, religions and skin colors, but we could communicate in English and took the same lecture. I realized the importance of English again. We talked about our religions, carrier pass and health systems. It was great experience for me. Most of the students are not native speakers, but they speak English fluently and they had more medical knowledge than me. I realized the lack of medical knowledges and English proficiency again and again. At the end of rotating, we had a written or oral test. I had a hard time preparing for the test. I barely caught up with them. I had a sense of inferiority against them. I had never felt such an emotion in Japan. I believe this experience made me grow.

In the department of surgery, I had clinical lectures and practice. Our group consisted of 20 members, but there were only a few operations we could join. They taught me the importance of asserting oneself. I luckily scrub in for the surgery of appendectomy. It was one of my goals during my stay in Gdansk. I want to be a surgeon in the future, so it was great experience for me. Although I experienced the same one in Japan, it was interesting and exciting. Last but not least, I would like to show my gratitude to all of the people who supported my exchange. Without the help from teachers, staffs of the international affairs office, friends and my family, my exchange couldn’t be such a meaningful one. The time I spent in Gdansk was amazing for me.