Office of International Affairs Graduate School of Medcine Nagoya University

I had the privilege of studying and rotating at the department of neurology in Ludwig Maximilians University of Munich (LMU) from March to mid-April 2024. The following is a brief account of my exchange: the internship itself, housing, private life, and a reflection on my experience overall.

At the LMU Clinic

Most of the clerkship took place in Großhadern clinic, one of the largest hospitals in Europe located in the outskirts of Munich. I participated in the Neurology Winter School (NWS) for the first half of my stay, and the remainder of the time I spent in the outpatient clinic for movement disorders.
A typical day in Winter School were as follows: ward in the morning, neuroradiology conference around noon, and a lecture/case discussion/tour in the afternoon.
My ward consisted of two attendings, two or three practical year (PJ) medical students, and a fellow LMU student also participating from the Winter School (“study-buddy”), all of whom were keen on teaching me unfamiliar topics. I was surprised to learn that German medical students start their hospital duties in early years of medical school, as this is not the case in Japan. Naturally, I felt the need to gain some hands-on experiences quickly so that I wouldn’t fall behind. Drawing blood, focused neurological examinations, and occasional history-taking were all part of our routine, and eventually I had somewhat gotten used to them with the help of my friend Michelle. Out of all the useful tips and tricks I was taught in the ward, the most practical one came from Yana, one of the PJs. She would often tell us to “Always protect your back” as she adjusted the patient’s bed; apparently, she’s had far too many instances of back pain after doing examinations in awkward positions, and I too would learn this the hard way.
Every day after lunch break, neurologists gathered around to discuss imaging studies at the neuroradiology conference. This was all done in German, of course, and the best I could do was to focus on the images themselves, or at the very least pay attention to see if there were any cases from my ward.
The afternoon session varied from day to day, and there was always something new to learn. Much of the time, professors of different subspecialties—and occasionally experts from different fields such as neurosurgery—would give afternoon lectures. Most of them would begin by asking us students to introduce ourselves, which would then lead them to ask innocuous follow-up questions such as why we picked this program, or which specialties we are interested in. Every now and then, we would also be asked somewhat tricky questions mid-lesson. Innocent-sounding questions such as “There is a large-scale research project related to this topic going on in Japan, correct?” or “How is the prevalence of this disease in your country, is it similar to Europe?” were not at all easy to answer, but it taught me to be more aware of Japan in comparison to foreign countries, and not just on its own. We would also occasionally have clinical case discussions, where a physician would walk us through real cases. Tours around the clinic and affiliated facilities were mesmerizing as well; aside from few research labs within the hospital premises, we also had opportunities to visit the inner-city campus several times and many more. One of the highlights was our one-day visit to a rehabilitation center in a rural area; there, I was able to feast my eyes on various equipment up close and even experience some of them firsthand.
The outpatient clinic was yet another aspect that I was looking forward to, and it was just as interesting as the first half. During my time there, I was given several chances to do a focused neurological examination on a few patients under the supervision of my attending, who was very knowledgeable and even offered me constructive feedback. As part of research, there were also several patients that required a thorough examination, questionnaires, and a battery of tests. At times my attending would inform me about any relevant ongoing clinical trials, many of which I hadn’t known about previously. The clinic usually ran until early afternoon, giving me plenty of time to enjoy what Southern Germany had to offer.

Life Outside of Hospital

Spending the bulk of my weekdays at the clinic doesn’t come without a need to unwind every now and then; social life and tourism are crucial parts of the exchange, after all. Fortunately, the non-medical aspects were more exciting than I had first anticipated.
NWS, alongside Oncology Winter School (OWS), came with a few pre-planned excursions around Southern Germany, which were major opportunities for participants from both programs to socialize. Apart from those, there were numerous occasions to get together in the evening and enjoy our social lives. One of the most memorable moments was during our third week, where I was invited to the annual strong beer fest (“Starkbierfest”) for an authentic German experience.
Of course, all of this is not to downplay the sheer beauty of the city; even a brief stroll from central station to the city center will give you a look into its rich culture and history. One of the most significant landmarks in Munich is Marienplatz; with the city hall (Rathaus) standing majestically, the city square also serves as a major transit and a booming local economy. I would always find something new and exciting: a busy marketplace, plenty of restaurants, various museums, beautiful churches and other religious sites.

Housing

Us non-LMU Winter School participants were lent a dorm room situated in the 1972 Olympic Village. As part of the massive student housing complex, there were several supermarkets, a handful of restaurants and bakeries, the titular Olympiapark, an inexpensive laundromat, and even a subway station (“Olympiazentrum”) nearby to suit our daily needs.
A smooth access to the city center with just one ride also meant easy commute to our hospital. The dorm room at the Olympic Village was only available throughout the Winter School program, and I was asked to leave at the end of March. Luckily, with the help of my friend Aurelia, I was allowed to stay at her friend Pia’s place for the remainder of my stay. This dorm, much like the previous one, was also situated by a park and was even more commute-friendly.

My Thoughts

Having completed a bulk of clinical rotations in Japan beforehand, this program was the perfect occasion to put my knowledge and skills to the test. Though there were certainly ups and downs throughout, I managed to put in my best effort and stayed on track for the entirety. In retrospect, I believe that the key component that kept me motivated, by far, was the hospital environment: everyone was always friendly and expressive. It was mentally stimulating to have people ask me about differences in culture, medical or non-medical, as this would often lead to a much more complex or abstract subject. I have also made friends with many of the local and international students, some of whom I still stay in touch with, that inspire me to become a better healthcare professional.
As my first time staying in Europe for a somewhat prolonged period, there were also minor challenges and troubles scattered throughout, chief among them being language barrier. While all the doctors had no trouble communicating in English, there were few moments outside of the hospital where I struggled. A bakery I stopped by every morning for a coffee didn’t have an English menu, and I would often try to Google whatever looked appetizing. At other times, I would blindly guess whatever was written in German or rely on pattern recognition to make the (seemingly) appropriate choice. The key lesson I learned was to study the basics of the local language before going abroad.

Acknowledgments

All of this would not have been possible if I weren’t blessed to meet so many wonderful people along the way. I would like to express my sincerest gratitude for the staff members at the Office of International Affairs and MISU for this wonderful opportunity; Professor Dimitriadis, for accepting me into the program and permitting my extended stay; my attendings at the ward and the outpatient clinic, for their superb mentoring; Aurelia and Pia, for their generous helping hand; all of my fellow Winter School participants, both international and local, for our cherished moments together; and lastly my family members, who showed great love and support all throughout.

From March to April 2024, I participated in a 4-week clinical elective in the Department of Medical Oncology at Duke University Hospital as part of Nagoya University's exchange program. As someone interested in the treatment and research of solid tumors, this elective at Duke University, a top academic institution, was an incredibly valuable experience.

Duke University and Durham

Duke University is located in Durham, North Carolina, and is one of the top universities all over the world. Durham was once known for its tobacco and textile industries, but since the establishment of Research Triangle Park (RTP) in the 1950s, it has become known as a university town with Duke University at its core. RTP is a vast research and development hub surrounded by the cities of Durham, Raleigh, and Chapel Hill, and is now one of the nation's leading centers for high-tech industries, biotechnology, and medical research. While Durham has developed as a hub of innovation, it remains a quiet town rich in nature. During my stay with a host family, I enjoyed the sight of squirrels and birds in their garden, making for a very comfortable and peaceful experience.

Hematology and Oncology at Duke University Hospital

Duke University is known as a pioneer in bone marrow transplantation for leukemia and has conducted clinical trials that have transformed treatments, such as Gleevec for CML and recent treatments for HER2-positive breast cancer. I was fortunate to have the opportunity to experience the elective in such a prestigious environment for four weeks.

About the Internship

I primarily assisted with ward duties and attended outpatient clinics with doctors of interest during my free time. A typical day focused solely on ward duties included:
• 5:30: Arrive at the ward and check on patients
• 7:00: Handover with night shift staff
• 8:00: Student rounds to assess and plan
• 10:00: Presentation and guidance from the attending physician during their free time
• 13:00: Shadowing a fellow
• 16:00: Fellows leave; complete homework and patient updates
• 17:00: End of the day
During the assessment and planning, I was required to practive evidence based medicine to each paeitnts. The ward I worked in specialized in medical treatment of cancer, and we needed to reference clinical studies behind the guidelines, assess whether patients met the study criteria, and predict progression-free survival, remission rates and overall survival from those studies. If no relevant studies were available, we had to infer from similar research and explain our rationale clearly to the attending physician. This process made me realize how current treatments are based on past research.

Notable Doctors

Outside of ward duties, I made appointments with doctors of interest to observe their outpatient clinics. One particularly memorable doctor was Dr. Carey Anders, a breast cancer medical oncologist. Her meticulous patient care, leadership in clinical trials, active participation in research, incredible mentorship, and role as the division chief of oncology, all while raising children, were inspiring. Patients trusted her deeply and often smiled and talked extensively upon seeing her. One patient, moved to tears when told there was few treatment available for her metastatic breast cancer, was given hope when Dr. Anders mentioned referring them to a physician leading a clinical trial at another facility. Although the patient did not participate in the trial, Dr. Anders' presence and the existence of clinical trials gave them hope. This experience reinforced my desire to become a doctor who, like Dr. Anders, gives patients hope through advanced medical care.

Family Conferences

I participated in family meeting on the ward and outpatient settings where hospice options were discussed with patients and their families who had limited prognosis. Not only the attending physicians but also resident doctors excelled at conveying bad news, likely due to their exposure to such situations since medical school. This was a precious experience for me, as I had not participated in such conferences during my training at Nagoya University. I believe that medical students are in a protected environment, and experiencing emotionally challenging situations during this period is meaningful for becoming a compassionate doctor.

Comparison Between Japan and Duke University

Comparing the oncology ward at Duke University with those in Japan:
1. Treatment Level: Apart from the abundance of clinical trials, the treatment levels appeared almost equal between Japan and Duke University.
2. Multidisciplinary Collaboration and Efficient Operations: In Japan, physicians perform various tasks, while at Duke University, physician assistants, nurse practitioners, and ward pharmacists specialize in their roles, complementing each other's knowledge and achieving high-level treatment and efficient operations. In fact, out of over 50 attending physicians in medical oncology, only one oversaw the ward.
3. Physicians' Work System: At Duke University, the workload for attending is minimized, allowing them more time for research and education. In terms of research, I felt the funding and collaborative environment were significantly better compared to Japan.
4. Educational Staff: Duke University's staff were educational, with every doctor taking time to provide explanations and lessons despite their busy schedules.

Activities During the Stay in Durham

During weekends, I enjoyed spending time with my host family and local friends. Every other week, I participated in volunteer activities with my host family, Fred and Jenny, spending time with kind-hearted people in a beautiful natural setting, which was refreshing. One weekend, I attended a Durham Bulls baseball game, experiencing the excitement of professional baseball. I was almost moved to tears by a friend's performance at a concert and had the opportunity to meet Prime Minister Kishida during his foreign visit, impressing many attendings when I mentioned, "I met the Prime Minister of Japan!! " Every experience, from local activities to being comforted daily by the host family's dog, Bagger, was also a cherished memory.

Conclusion

The significance of this elective

While similar training content might be available in Japan, two aspects made this elective at Duke University's Department of Medical Oncology invaluable:

1. Meeting Altruistic People: Previously, I was outcome-oriented and self-centered. However, through this internship, I met many kind-hearted people who helped me unexpectedly. This experience made me strongly desire to become someone who can extend a helping hand to those in need.

2. Time for Introspection: As an outsider in a new environment, I constantly needed to explain who I was, what I was there to learn, and what I wanted to achieve. This helped me listen to my true feelings. In Japan, my identity as a "Nagoya University medical student" both protected and defined me. However, in the elective environment, I was evaluated solely on my contributions and potential contribution. These four weeks helped me realize my future aspirations, and I am now determined to discover and develop my unique qualities.

My future goal is to become an "academic oncologist contributing to medical advancement and being needed by everyone around me." I will continue to strive, drawing on the incredible experiences I gained through this internship.

Lastly, I would like to express my heartfelt gratitude to Dr. Bustos for instilling the basics of medical education, Dr. Hasegawa and Dr. Kazuya for coordinating the study abroad until the end, the doctors of the Frontier Society for teaching the essentials of clinical training abroad, my host family Jenny and Fred in Durham, Dr. Harada, Dr. Anders, Dr. Matthew, and all the professors at Duke University, and all the doctors who supported me.

I studied abroad at the University of Munich, Germany, for one month in March 2024. Here I would like to introduce my practical training and my life there.

The University of Munich is officially known as Ludwig-Maximilians-Universität-München, or LMU. Every spring, LMU organizes a four-week program called Winter School in two departments, Neurology and Oncology, of which I participated in the Neurology Winter School (NWS). There, international students come from all over the world to study together. International students are paired with LMU students, and the pairs always work together and teach each other. My pair was a fourth-year male student who wanted to become a neurologist.

Every day, the mornings were spent on the ward training and the afternoons were spent in lectures. The first thing I did in the morning was to draw blood. After that, I accompanied the doctor on his rounds, conducted interviews with my partner, filled in medical records and discussed the necessary tests. Our pair was assigned to the general neurology department, where we were able to see a wide variety of diseases such as brain tumors, meningitis, and ALS. It was very exciting to be allowed to perform procedures alone, including blood sampling, which is not yet possible in Japan. As I repeated the procedures, I steadily improved and became more confident in my skills. The doctors in my department were very enthusiastic and gave me detailed information when I asked them about the disease and the treatment they were giving.

After lunch, we attended two lectures. They covered everything from neurodegenerative diseases to stroke and case discussions, and each day a specialist gave an interesting lecture on everything from basic to cutting-edge medicine. In addition to these ward practicals and lectures, I also had several opportunities to visit external institutions. For example, I took a two-hour trip to a rehabilitation facility in the suburbs, where I experienced state-of-the-art exercise equipment that I had never seen in Japan. I also visited a laboratory near the hospital and learned about basic research using mice.

The first and foremost difference between Germany and Japan was that the students from overseas were very proactive. During lectures, it was quite normal for them to interrupt the teacher and ask questions. I learned the importance of expressing one's intentions without being too reserved, and I try to put this into practice in Japan. I also felt that in Germany, students study harder than in Japan. In fact, many times I was taught by my pair student, which inspired me to study even harder.

This was my first time studying abroad and before I went, I was very anxious. But now that I have returned home safely, and I feel a great sense of achievement. I have had countless troubles, but I feel that I have grown a lot since could think for myself what to do in such situations and to take action. I also had friends who helped me at any time, and we worked together to find solutions to our problems. The friends I have met there are a great treasure for me.

I would like to express my deepest gratitude to the International Cooperation Office and LMU doctors for providing me with this wonderful opportunity. Not only that, I cannot thank all the students there, and my family and friends who supported me in Japan. Thank you very much.

Hello, my name is Mizuki Kaoru, and I studied abroad at the Medical University of Vienna for 10 weeks starting in February this year. I would like to share my experiences during my study abroad.

My clinical training began in the Department of Anesthesiology. In the first week, I was assigned to Group 4, one of the four operating room groups, which handled ophthalmology, orthopedics, and trauma. I mainly assisted with anesthesia for orthopedic and trauma surgeries. Mornings in Vienna start very early, with anesthesiology conferences beginning at 7:30 AM. I had to ask the doctors in charge of the operating rooms I was interested in to let me join them for the day. Before going to Vienna, I thought I could manage with just English, but once I arrived, I realized that all the operation schedules, room locations, and doctors' names were in German. Since I was the only student in the department at that time, it was incredibly challenging to get the hang of things. Fortunately, on the third day, I met a supportive anesthesiologist from the neurosurgery operating room who allowed me to participate in his surgeries. I had many opportunities to insert V-lines and A-lines and was even able to perform tracheal intubations without a video laryngoscope, which I heard even local students rarely get to do. I also practiced epidural anesthesia and learned a lot. In the second week, thanks to this doctor's arrangement, I did my training in the neurosurgery operating room. Unlike orthopedics, neurosurgical anesthesia requires more careful attention to patient positioning, medication doses, and vital signs. The most rewarding experience was when I was entrusted with managing the patient's vitals, monitoring the progress of the surgery, and administering anesthesia under the supervision of the doctor. This gave me a lot of confidence and valuable experience.

After the anesthesiology rotation, I started my obstetrics training within the Department of Obstetrics and Gynecology. For the first four days out of ten, I observed caesarean sections and natural deliveries, and for the remaining days, I observed outpatient and inpatient care. The first caesarean section started at 8:00 AM, and there were usually about five or six surgeries each day. I was surprised by how quickly the caesarean sections were performed, with different suturing methods and shorter anesthesia times compared to Japan. It was a whirlwind of activities, including attending natural deliveries between surgeries. Holding newborns who opened their gray eyes for the first time while their mothers were being treated was incredibly heartwarming. Additionally, I observed emergency treatments for severe postpartum hemorrhage in a couple of cases. The outpatient department of the Medical University of Vienna is one of the largest in Europe, attracting patients from all over the world. I observed various specialized clinics, including those for high-risk pregnancies (such as diabetes or advanced maternal age), patients at risk of chromosomal abnormalities, and those with fetal risks (such as suspected Down syndrome). One of the most memorable experiences was witnessing a termination of pregnancy procedure for a 25-week fetus. In Austria, abortion is permitted up to 12 weeks if both the mother and fetus are healthy, but can be performed at any time if there are health issues. This experience made me reconsider the ethical issues surrounding pro-life and pro-choice debates.

The next two weeks were spent in the Department of Radiology. The hospital has many wards and operating rooms, with CT, MRI, and X-ray rooms spread over three floors. I observed these rooms as well as esophagography and post-transplant ICU cases. This was the only rotation where I was assigned a supervising doctor, who taught me a lot and provided hands-on training with actual cases. The university is renowned for transplants, so I learned to interpret radiological images that differ from normal anatomy and observed post-transplant follow-up care. The radiology department has a viewing room adjacent to the imaging room, allowing radiologists to immediately check images and instruct technicians on patient positioning and imaging techniques. I found it interesting that radiologists could decide to stop imaging and send patients home if further treatment would not improve their prognosis.

Next, I returned to the Department of Obstetrics and Gynecology, this time in gynecology. Due to the Easter holiday, there were fewer doctors available, so I spent many days drawing blood from patients using my limited German and English skills. The gynecology department handles a large number of breast cancer cases, and I was able to examine several patients. Initially, I lacked confidence in my palpation skills, but the supervising doctor provided detailed explanations with images, which was very educational. I also got a glimpse into Austria's immigration issues. Sometimes patients couldn't speak German or English, and we couldn't even use Google Translate due to language barriers. Some had lived in Austria for decades but couldn't speak German, relying on acquaintances or children to communicate with doctors. This made me realize the importance of providing medical care to the growing number of immigrants in Japan as well.

The final two weeks were spent in the Department of Plastic Surgery. I chose this department because I wanted to experience a highly regarded and popular field abroad, and Germany is known for reconstructive surgery. However, many surgeries were body lifts for excess skin removal after weight loss or gynecomastia reduction surgery for thyroid disease, which are classified as cosmetic surgery in Japan. I was surprised to learn that these procedures are covered by insurance. Although these were not the surgeries I had expected, I still observed the management of severe burn patients and skin grafts, which were valuable experiences. The competitiveness of the department was evident, with doctors facing challenging job prospects, a somewhat severe atmosphere, and the presence of only German-speaking doctors.

Reflecting on my time abroad, I realize that my study abroad experience began with significant confusion and discomfort. Studying abroad had always been a dream, and I had prepared by studying medical English and practicing necessary skills. However, I was caught off guard by the language barrier and the lack of local student interaction due to overlapping holidays. I often felt lost, unsure if I was growing or gaining anything for my future. Now, looking back, I feel grateful for the experience. The challenging environment taught me the importance of taking initiative, persisting despite setbacks, and making the most of limited opportunities. My prior practice in suturing, venous access, and intubation in Japan allowed me to handle these procedures more confidently abroad. Additionally, the cultural experiences outside of my clinical rotations, such as visiting cafes, attending opera and theater, taking short trips, and encountering the "colorful" local drug addicts, enriched my three-month stay.

In conclusion, I would like to express my gratitude to Professor Hasegawa, Professor Itzel, and the teachers who provided pre-departure training. Most importantly, I am deeply thankful to my family for their unwavering support and financial assistance despite the rising yen exchange rate during my study abroad period. Thank you very much.

Study Abroad Experience

I completed a clinical clerkship at the University of Freiburg, located in southwestern Germany, from February to April. This was the longest of the overseas dispatch study programs, lasting three months, during which I experienced a great deal in the city known as "The sunniest city in Germany."

Introduction: The City of Freiburg and Its University

The official name of the city I visited is “Freiburg im Breisgau.” Interestingly, there are a few cities named Freiburg across Europe. Unlike the industrial image often associated with Germany, Freiburg is a charming city with cobblestone streets that retain a medieval atmosphere, enriched by the natural beauty of the Black Forest that surrounds it. The city has a population of 230,000, which is about one-tenth of Nagoya, Japan, with around 30,000 of these residents being students, making it a typical university town.
Founded in 1457, the University of Freiburg is the second oldest university in the Habsburg Empire after the Medical University of Vienna. It is also one of the oldest universities in Germany. The university hospital has 1,600 beds compared to Nagoya University Hospital's 1,080, making it one of the largest hospitals in Germany.

Departure to Europe

As I aspire to be a surgeon, the University of Freiburg was the perfect destination for me as it only accepts students in surgical departments. (In principle, there are language requirements for international students, but there are no such requirements for students from Nagoya University. For internal medicine clerkships, a B2 or B1 level of German is required.) I applied in late summer of my fifth year, hoping to do my clerkship in gastrointestinal surgery, urology, and orthopedics.
Although I received the acceptance notice quickly, it was not until December that I received confirmation of the departments I would be assigned to. Due to some misunderstandings on their part, my schedule turned out to be forensic medicine in February, infection control in March, and otolaryngology in April, which was quite different from my initial expectations. However, following the advice of Dr. Hasegawa from the International Affairs Office, I decided to negotiate directly with the desired departments once I arrived in Germany.
Upon arrival, I exchanged numerous emails with doctors and secretaries with my preferred departments. Despite battling homesickness and loneliness, I continued to negotiate. As a result, I succeeded in securing clerkships in my desired departments and had a very satisfying experience.

About the Clerkship

My clerkship schedule was as follows: February in forensic medicine, March in infection control (two weeks) and neurosurgery (three weeks), and April in general surgery. In forensic medicine, I observed and participated in autopsies. Towards the end of my clerkship, I was even entrusted with handling organs like kidneys and livers. It was a valuable opportunity to see firsthand what I had learned in forensic lectures, and I was particularly impressed by the experience of seeing burnt bodies and learning about police cooperation.
In the infection control department, I studied hospital hygiene, air and water quality management, and the identification and isolation of nosocomial infections. Unlike Nagoya University Hospital, the University Hospital of Freiburg has separate facilities for each department, so I learned the importance of understanding and addressing individual issues to ensure high-quality medical care. Knowing my interest in surgery, they also taught me about the hygiene of surgical instruments, and I toured the cleaning facilities. Forensic medicine and infection control were areas not covered in Japan's clinical clerkships, making these experiences all the more valuable.
During my neurosurgery rotation, I participated in rounds and conferences from 7 AM daily and observed surgeries throughout the day. The neurosurgeons also provided lectures on critical conditions not to be missed in the emergency department. I was involved in ward duties, making for a highly productive three weeks. In general surgery, I joined local sixth-year students from 7 AM, assisted in surgeries, and performed tasks such as drain removal, skin suturing, and blood collection. The local students, referred to as PJ (Praktisches Jahr: Practical Year), seemed similar to junior residents in Japan. I was impressed by their proficiency, which served as a motivation boost for me. Most importantly, I relished the joy of being able to participate in a surgical clerkship through my proactive negotiations with the departments and administration.

Life in Freiburg

The University of Freiburg did not provide dormitories, so I picked a suitable place through Airbnb and spent three months there. I stayed with a host family, who fortunately were very kind and supportive. The cost of living, except for dining out, was comparable to Japan, and the weather was pleasant, living up to the city's reputation as "the sunniest city in Germany." Outside of clerkship hours, I went out for drinks with local students at German restaurants and student pubs, or studied together at the library. I also traveled around Europe on weekends with friends I made locally and other Nagoya University students studying abroad in different cities. These experiences, which I could not have had in Japan, created many cherished memories.

Reflection on the Experience

Through this overseas dispatch study program, I realized the vastness of the world and my own smallness. I had been living in a comfortable environment surrounded by familiar faces, but I witnessed a change in my perspective by stepping out of my comfort zone with courage and proactiveness. I believe my determination to seize every opportunity led to my success. The growth I achieved in my studies and communication skills, along with the broadening of my horizons and increased proactiveness, made this an invaluable experience that allowed me to grow as a person.
Finally, I would like to express my gratitude towards everyone who supported me during this program.

From March to April 2024, I had the opportunity to study abroad at the Medical University of Vienna in Austria for two months. This experience, including the two years of preparation, was incredibly precious and unforgettable opportunity for me.

Neurology: The Neurology Department at the University of Vienna is divided into three floors: stroke, neurogenerative disorders, and movement disorders. I was assigned to the movement disorders group. In Vienna, final-year students are paid and play a role similar to resident doctors in Japan. They confidently communicate with patients, conduct interviews and physical exams, and present patients to senior doctors. This experience made me acutely aware of the differences in how well they are trained. At lunchtime lectures, they asked questions about specific drug dosages and selection, which were more practical than those I make.

I examined patients daily alongside the students, relying on physical findings because I was unable to read German medical records or conduct interviews. This inadvertently improved my skills in interpreting clinical signs to make a diagnosis. Additionally, I practiced procedures like blood sampling and IV insertion.

Thoracic Surgery: In the Thoracic Surgery Department, Japanese fellows Dr. Nakanishi and Dr. Saeki supported me a lot. Thanks to them, I learned about the differences in surgeries between Japan and Austria. There were many cases of advanced lung cancer, possibly due to insufficient preventive healthcare like regular checkups. Lung transplants were performed approximately every three days, and I had the chance to observe an organ explant from a donor, which involved a team of about 20 people. The experience of seeing a beating heart and lungs filled with perfusion fluid until it stops was unforgettable. Back in Vienna, it was impressing to see the lung implanted. Observing pre- and post-operative clinics showed me the positive impact of lung transplants, and I gained deeper insights into the ethical issues surrounding organ transplants well. Conversations with fellows from Italy, Spain, Portugal, and Turkey about their healthcare systems were also memorable.

Local Family Medicine Practice: Interested in family medicine and different healthcare systems, I visited local family doctors. I met four doctors who each had unique approaches: one spent an hour per patient for thorough care, another handled 100 patients a day in an immigrant-heavy, impoverished area, linking them to essential services. These experiences helped me shape my vision of the doctor I want to become. When I accompanied with the doctor at countryside, I received homemade wine-I experienced the joys of deep patient connections.

At the end of my practicum, I spent two days at the Cross Deep Surgery in London, observing General Practitioners (GPs). GPs in the UK handle a wide range of conditions across various specialties, from gynecology and mental health to dermatology and orthopedics. This system seemed highly beneficial to patients, though the system faces issues like long wait times for non-urgent conditions due to a shortage of doctors.

I also had the chance to meet many professionals, including those from WHO, MSF and Japanese doctors working as GPs in the UK. These encounters provided valuable perspectives on my future career as a doctor.

Vienna was a beautiful, green city, especially in early spring. I enjoyed visiting cafes, attending operas and orchestras, cycling along the river, and traveling to various countries on weekends. These two months were filled with new experiences and passed in the blink of an eye.

I am profoundly thankful to Dr. Kasuya, and the International Exchange Office, my colleagues who shared many experiences with me in Austria, and my family who always support me. I express my gratitude to all these people for making this precious experience possible.

Hello. It was the first time for me to go outside from Japan and I had a lot of completely new experience there. So, I would like to write about it. One of the most unforgettable memories I remember is one student who studies medicine in Germany. I studied neurosurgery for one month and I met her on the first day. The secretary told us that we would study together for that month. Actually, I had no experience to interact with someone from the other country so far for such a long time. It means that I found pretty many things in terms of culture and medicine.

Firstly, I realized the difference of medical educational system when I saw her acting in front of patients. She did perfectly taking blood from them but she was just 3 grade. It motivated me. (To be honest, I had a few chances but failed it….). When we discussed cases, I would always feel I had to study because she already had more knowledge than me… And I also found that there was a position named Physical Assistant (PE). They help doctors. For example, they do the daily stuff that Japanese doctors do like writing medical records from what doctors are saying and catheter removal, etc.

And I also interacted with many co-medical staff. Some of them were students but they studied and at the same time earned money. I think it is a really good system because it prevents the medical system from destroying because of the shortage of workers. Secondly, I was really surprised about the difference in characteristics. If the student doesn’t want to do it, she says No even if it’s to supervisors. In Japan, it is a bit rude to do that and we feel we have to say yes by reading the atmosphere. But in other words, it means that if she says Yes, it means truly Yes. It is smooth because we don’t have to spend time to read her feelings deeply.

I often asked her what the local people eat every day and I copy them. I eat pretzels every day with cutting them and putting some butter. It motivated me to study there.

Finally, I would like to talk about the severe situation. I was eager to do something like helping a bit or taking the table when operation. So, I asked the one doctor for me to participate in it, but I was rejected. At that moment, I was almost crying. But I never gave up. I asked the other doctors and then one of them said it was OK and finally I did it. I never forget the moment that I took the groove and table and irrigating.

I really enjoyed the days there. I would always try to make friends and try to talk. It was very hard but the last week, I had a few friends who study there, and we had something and had casual conversation. We hang out and eat many things. Every moment was precious for me and those give me the energy to keep my life going.
Thank you so much for everyone who helped me.

I did clinical clerkships as a medical elective in Glasgow for almost 2 months. I joined the geriatric department in Queen Elizabeth University Hospital (QEUH) in March, and then visited various GP clinics all over Scotland in April. Both experiences were very precious and meaningful to me.

Queen Elizabeth University Hospital (QEUH)

QEUH is a huge acute care hospital with over 1,600 beds located in the south-west of Glasgow. The geriatric department is largely divided into 3 sections, an acute receiving unit, acute rehab wards and outpatient clinics. In addition to doing clinical trainings in each section, I had opportunities to visit a rehab hospital and home care service. I also participated in bedside teaching classes with local university students.
Doctors at QEUH warmly welcomed me saying “Just tell me what you want to do and you can try anything!” Struggling with the new environment and strong Scottish accent, I tried taking history and performing physical examinations and asked for feedbacks. I felt my skills have improved day by day thanks to all the supports from QEUH staffs.
One of the things I learned at QEUH was the importance of understanding social backgrounds. One day in an outpatient clinic, I encountered a patient complaining of knee pain. As a doctor listened to her story carefully, she found that the main problem was not in her legs but in her family situation. She was unable to receive rehabilitation because there was a disagreement in her family, which resulted in a rapid decline in her ADL. I realized that focusing not only on symptoms but on social circumstances can lead to appropriate medical treatment.

GP training program

Primary care-based medicine is one of the characteristics in the UK healthcare system, and GPs (family doctors) play a main role in local communities. Dr. Alec Logan, a GP doctor in Wishaw provided me great chances to study at six different clinics with strong regional backgrounds. Those included a hospital in Glasgow working on drug addiction problems, a general surgery hospital at the foot of a mountain, and a GP clinic in a deprived rural area on a former coal mine site.
We often hear the word "Holistic Care" in primary care settings. I was impressed by how GPs let patients talk about themselves freely and grasp their physical, mental and social situations. They told me that “reassuring patients” is an important part of primary care. Conducting interviews by myself at those clinics was not easy but really worthwhile. One of the GP doctors I met advised me to acquire proper knowledge and skills in order to avoid saying worrying words unnecessarily even about trivial matters. I gained a new and important perspective through my experiences studying in this GP program.
I was also surprised by how doctors and healthcare professionals specialize in their work and cooperate as a team. GP clinics are run by several doctors, nurses and pharmacists, who all have their own consultation rooms and rights to prescribe drugs. There were many cases that a patient visits a nurse’s clinic or a pharmacist’s clinic, not a doctor’s one. For example, a patient coming for diabetes treatment or hormone replacing therapy is seen by pharmacists since they are skilled in serving long-term medications. At lunch time, everyone gathered together to assist each other with information sharing of each patient.
Moreover, all the GPs have great knowledge about local medical issues. They told me, for instance, how many years shorter life expectancy is, or how high the rate of certain diseases is in the particular region they work for. I was astonished to see how significantly the characteristics of GPs differed from region to region in order to tackle local issues.

Memories with wonderful people

I am so grateful to get to know with such a lot of wonderful people. There are many doctors and medical students in Scotland coming from different countries (Malta, Myanmar, Nigeria, etc.), and I enjoyed talking with them during my stay. They were interested in Japanese healthcare system and taught me about the one in their countries as well.
Many doctors, healthcare professionals and amazingly skillful students helped me a lot during these 2 months. I am especially thankful to Dr. Alec, who taught me about medical knowledge and how to enjoy Scotland throughout the entire period. In addition, he gave me lectures, took me to a GP event held at the University of Glasgow and to fabulous operas and concerts on holidays. I will never forget these memories.

Conclusion

It was a challenging experience for me to study abroad for such a long time. At first I felt nervous, but I spent really amazing time and now recognize progress in myself in these 2 points: I have gained the ability to try anything actively, and have started to think more seriously about what kind of doctor I want to be in the future.
Last but not least, I would like to express my gratitude to Prof. Kasuya, Prof. Hasegawa and all the teachers in the International Affairs Office, as well as to everyone who supported me in Scotland.

I studied abroad at Lund University in Sweden for two months starting in February 2024. I had never been to Europe before and was anxious about living in an unknown environment. However, thanks to the support of the lectures given by the professors of the International Relations Office, the study groups with my classmates, and my parents' assistance, I was able to spend a fulfilling two months. I would like to express my sincere gratitude to all these people.

Lund University is the second oldest university in the country, located in Lund, Skåne county, southern Sweden. Lund is a sophisticated, Scandinavian-like city, safe and comfortable to live in.

The first month, I was placed at the Surgery Clinic at Skåne University Hospital. There were three groups: the upper GI group, the HPB group, and the endocrine and sarcoma group, with more than 10 doctors in each group. I mainly observed surgeries in the HPB groups and assisted aspiration, ligation, and wound closure. I also observed cases of intraoperative ablation of metastatic liver cancer in collaboration with radiologists, and robot-assisted pancreaticoduodenectomy. Each doctor demonstrated their expertise and used cutting-edge technology to treat the patient.

For the next month, I spent my placement at the Hand Surgery Clinic at Skåne University Hospital in Malmö. In Sweden, hand surgery is a separate department from orthopedic and plastic surgery. The Hand Surgery Clinic at Malmö Hospital is one of the largest hand surgery clinics in Sweden, performing more than 10 operations a day. The outpatient clinic, wards, operating theatre, and rehabilitation unit were located in the same building and worked together seamlessly. The use of medical leeches for hand trauma was surprising.

This study abroad experience was extremely enriching. In addition to medicine, I learned valuable lessons about the Swedish healthcare system, education system, insurance and welfare system, and culture. The personal number system has long been used in Sweden, where patient ID, banking and work are all linked, making it easier to link them together. Moreover, I could learn about the local educational system for medical students and the requirements for job hunting. I interacted with students from Lund University and their knowledge and enthusiasm were amazing and motivated me. I would like to thank you again for this invaluable experience.

I had a two-month clinical clerkship at Lund University in Sweden. I am very pleased to have had the valuable experience through the study abroad program, which had been my long-cherished dream. I would like to share some of what I studied and experienced.

Lund University

Lund University is located in southern Sweden, and Lund is known as a student town. As one of the largest universities in Scandinavia, its campus is so large that I often found myself wandering into its grounds while walking around the town. Although it is in Sweden, it is located in the southern part of the country, so the temperature is not too cold even in winter, and it snowed only a few days during my stay from March to April. The official language is Swedish, but most people speak English fluently, so I had no language difficulties in daily life.

Emergency department

In March, I participated in the emergency department of the university hospital in Malmö for 4 weeks. The emergency department is quite large, with about 60 doctors, working in three shifts: Day (8 am–3 pm), Evening (3 pm–10 pm), and Night (10 pm–8 am). When I introduced myself in front of all the staff on the first day of training, I was very nervous. The rotation was in form of shadowing with a different doctor each day. Since all medical records and medical examinations were in Swedish, the doctors translated them into English for me. Since Sweden has a large immigrant population, some patients preferred to be examined in English, and in those cases, I was able to handle the entire process, including the interview, physical examination, and presentations, by myself. I was happy to be able to perform the physical examination in English that I had practiced before the exchange. Thanks to the doctors who taught me so diligently, I had rich learning experiences every day, such as thinking about differential diseases based on the medical interview and receiving feedback on my presentations.
 One of the significant differences between Japan and Sweden that I felt was the range of duties nurses perform. In Sweden, nurses provide the first contact with patients who come to the emergency department, and they can also conduct medical interviews, make triage decisions, and decide whether to send the patient home depending on the level of urgency. In addition, tests to be ordered and medications to be prescribed are predetermined for each symptom, so nurses can order specific tests and prescribe medications accordingly. In many cases, blood test results and X-rays were ready before the doctor saw the patient, which I found very efficient for determining treatment plans.
 One issue with the Swedish healthcare system is the long waiting time for access to medical care. Patients with minor cases sometimes waited 5-6 hours to see a doctor after arriving at the emergency department. To address this issue, the shortage of physicians was compensated by task shifting and the widespread use of a 24-hour public medical consultation line.

Pediatric department

In April, I participated in the pediatric department in Växjö, a city about 2.5 hours by train from Lund. There were about 20 pediatricians, all of whom were very kind and always concerned about whether I was in trouble during the training. Every week, I observed various aspects of pediatric care, including the general ward, outpatient clinic, emergency unit, and NICU. In the emergency department, I was impressed by the convenience of the medical record system linked to the national ID system. Swedish hospitals use a shared medical record for each region, making it easy to access a patient’s medical information, such as medical and medication history, when responding to referrals from primary care doctors.
 What struck me most was the difference in the NICU. In Japan, the NICU is generally a large room with a row of incubators for newborns so that doctors and nurses can monitor them in case of sudden changes. On the other hand, Sweden practices family-centered care, and each NICU bed in a private room equipped with adult beds for parents to stay overnight with their baby. I felt that this is the way a NICU should be, respecting the feelings of the baby and their families. Although it is difficult to immediately introduce such a system in Japan due to the number of medical staff, equipment, and space issues, I would like to think about what we can do to realize this model.

Equality

Sweden is known as a country with advanced gender equality, and women are making progress in society. I was impressed by the fact that women doctors can easily continue their careers because people do not consider housework, childbirth, and childcare to be solely women's responsibilities. I felt that the spirit of equality is not limited to men and women but is rooted in society as a whole. For example, in Sweden, doctors, nurses, and medical staff call each other by their first names without honorific titles. Even professors are called without titles such as "Dr." or "Prof.,"and I found this flat relationship very refreshing.

Conclusion

This exchange provided me with valuable insights into not only the medical field but also social systems, culture, and lifestyle differences. I will cherish the experiences I gained, stay highly motivated, and dedicate myself even more to my studies after graduation.
Finally, I would like to express my deepest gratitude to all those who supported me throughout this exchange program. Thank you very much.

Now that I have returned home after completing all my clinical training at the Medical University of Gdańsk, I deeply appreciate how invaluable those exciting days, filled with "destruction and creation," truly were.

1. Before Studying Abroad

As preparation for studying abroad, I participated in pre-dispatch training led by professors who had previously studied abroad, and I watched videos explaining medical concepts in English to study medical English. Additionally, I was concerned about my listening skills in English, so I watched English-language movies repeatedly and listened to podcasts to get accustomed to the sound of English. In terms of technical skills, I practiced laparoscopic suturing, thinking that I should not break the image of Japanese dexterity when given the opportunity to demonstrate my skills. Throughout this time, I constantly wrestled with the question, "Am I really the right person to go to Gdańsk?" and spent my days feeling more anxious than excited.

2. About the Clinical Training

When I arrived in Gdańsk, local students helped carry my luggage to the dormitory. In the evening, they showed me around the hospital grounds and took me to a famous café in the old town. I remember trying to mimic and incorporate the local students' English expressions every day since my English was still poor at that time.

The Medical University of Gdańsk has a Polish Division consisting of Polish students and an English Division consisting of international students. I joined the English Division for my clinical training. In the English Division, all lectures are conducted in English. The students come from various countries, including Norway, Switzerland, India, Spain, Kazakhstan, and so on, allowing me to experience a multicultural environment while in Poland.

During this study abroad period, I had the opportunity to train for one to two weeks each in neurosurgery, surgery, transplant surgery, urology, gastroenterology, cardiology, anesthesiology, and pediatric surgery. Being able to train in many departments is one of the attractions of the Medical University of Gdańsk. The training content mainly included lectures, ward training, outpatient observation, and surgical observation, like clinical training at Nagoya University.

The anesthesiology department left a particularly strong impression on me. Originally, I had no plans to rotate in anesthesiology, but I was so impressed by how the anesthesiologists worked in good communication with the surgeons and nurses during a surgery I observed that I directly negotiated with the anesthesiologist and got the opportunity to train there. During my training in the operating room, I gained experience in techniques like intubation and received logical and enthusiastic explanations about anesthesia maintenance. When an anesthesiologist told me, "As an anesthesiologist, I respect all staff," I felt the high humanity of the local anesthesiologists.

Additionally, there were written exams and oral tests at the end of each block. I managed to prepare by gathering information from students in the same group. The cardiology exam was difficult according to local students and involved interpreting electrocardiograms. During the ward training in cardiology, the doctor gave us several electrocardiograms to discuss within our group. Though I was nervous and sweating while describing my observations in unfamiliar English, it is now a good memory. By the final day, I could answer most of the doctor’s questions, and I felt a sense of growth.

One notable thing about the local students was their high level of autonomy. They freely made comments and asked questions even during lectures. The length of breaks between lectures could also be negotiated with the doctors. Witnessing this, I felt a strong impact as they maintained the ability to speak freely—a skill I had lost over the years. Initially, I hesitated, but gradually I began to regain this ability and became more proactive in expressing my opinions, feeling a sense of personal regeneration.

3. About Living in Gdańsk

I was greatly supported by Professor Woźniak, who has been accepting students from Nagoya University for many years. He provided me with a bag full of everyday items like frying pans and dishes left behind by previous students, which were very useful for daily life. He also regularly checked if I had any troubles and allowed me to participate in experiments with local students on weekends, providing support both academically and in everyday life. Additionally, he organized an event called "Nagoya Day" for local students, giving me a valuable opportunity to present about sushi and Japanese tea.

In the dormitory, I stayed in a double room with a shower and toilet, using it alone, so I did not feel any inconvenience. The dormitory staff were very kind, and chatting with them at the front desk gave me energy every day. Poland also has a low cost of living, and with the significant scholarship I received from Nagoya University, the financial burden was relatively light.

I looked back at the diary I kept at the time to reminisce about my life there. In the early pages, I wrote about feeling like an alien from another planet because I couldn’t adjust to European culture and realizing that the material wealth in Japan had nearly made me lose my own spiritual richness, which was a shock. Through various encounters, my long-held common sense formed by living in Japan was shattered, and every day I adopted the good aspects of European culture and created a new self. The exciting experience of feeling myself change, despite struggling with culture shock, was something I could only have had by studying abroad. When I looked at the page I wrote two weeks before returning home, it said, "If allowed, I would like to stay here longer. Above all, I don't want to lose the connections I have made here." Initially, I was filled with anxiety and honestly wanted to return to Japan quickly. However, I was blessed with wonderful encounters with the locals, allowing me to experience many new emotions. My study abroad life was not glamorous, but it was filled with a definite sense of living.

I am grateful to everyone who supported me greatly in Japan, and all the encounters in Gdańsk that helped me step out of my comfort zone and taught me courage. I hope the relationship between the Medical University of Gdańsk and Nagoya University continues for many years to come.

I had the opportunity to do a three-month clinical internship at the Norwegian University of Science and Technology (NTNU) in Trondheim, Norway. I am the third person from Nagoya University School of Medicine to be dispatched to NTNU. My desire to experience the healthcare system in Nordic countries which are vastly different from Japan, and in particular a nature-rich country like Norway, led me to choose this internship. First and foremost, I must say that this experience in Norway has become one of the most cherished memories for me. It undoubtedly ranks among the key moments of my life. I had a truly wonderful time and am extremely satisfied with the experience. Given the chance to share my experiences as “A message from an exchange student,” I would like to introduce as many of my experiences as I can think of during my time abroad.

Preparation for the Trip to Norway

For many Japanese people, Norway is a completely unfamiliar country. I was no exception, and I remember feeling incredibly anxious right before my flight, wondering, "Can I survive for three months in the unknown land of Norway?" I had traveled abroad with friends during holidays several times before, but I often experienced some kind of health issues during those trips. Naturally, my family and friends were quite worried about my health for this internship. As a result, I ended up packing more than enough medicines, winter clothing, food, heat packs, and even a portable electric massager, which filled my suitcase to the brim. After checking in my heavy suitcase, I bid farewell to my family, who had come to see me off at the airport, and went through the departure gate. Once I passed through the gate, there was no turning back, and all my negative feelings disappeared, replaced by growing excitement for my adventure overseas.
To reach Trondheim, I had to transit through Singapore and Copenhagen. It was physically demanding, but I managed to quickly visit two countries before heading to Norway. I felt especially fortunate to experience a "cold detox" in Singapore before heading for the frigid Norwegian climate.

Practical Training

During my clinical training, I was fortunate to spend one month each in the departments of cardiology, oncology, and pulmonology. Before introducing the specifics of my experience in each department, I’d like to share some of my observations and impressions about the hospital and the healthcare system.

All my training took place at St. Olav’s Hospital, an affiliate of NTNU. This hospital is organized with separate buildings for each department, all connected by walkways and underground passages. Unlike Nagoya University Hospital, where you often must wait a long time for an elevator to go up to the wards, this hospital's horizontal layout means there's no such wait, though it does mean longer distances to walk between wards. The hospital is so vast that scooters are used to travel between wards. I had the chance to use one myself, and although riding a scooter inside the hospital felt slightly rebellious, it was also quite comfortable and a refreshing experience. However, these scooters can go quite fast, making them potentially dangerous.
Additionally, not only doctors but also nurses, lab technicians, radiologists, and other medical staff provided guidance in English. Norway has one of the highest rates of English proficiency among non-native English-speaking countries, and most people, except the elderly, speak fluent English. This made the learning environment very siutable from a language perspective.
Lastly, I'd like to introduce the Norwegian healthcare system. In Norway, patients cannot visit major hospitals without a referral from their Fastlege (family doctor). The Fastlege decides whether a patient needs to see a specialist in a large hospital or not. This system helps prevent an excessive medical demand and allows for the efficient use of limited medical resources.

# 1. Cardiology
My first rotation was in cardiology. In Norway, sunrise is quite late during February, and it was still pitch dark when the conference began at 8 a.m. As I heard birds chirping during the conference and looked outside, I would see the sun just starting to rise. The sun also set early, around 4 p.m., so I would go to the hospital in the dark and leave in the dark, rarely seeing the sun. Navigating the snow and extreme cold to get to the hospital without slipping was a novel and exciting experience for me. The cardiology department is in the Acute and Heart-Lung Center, which also includes the pulmonology department. There is a heliport on the roof, frequently used to transport emergency patients from remote areas of Norway, more so than in Japan.
My mentor was Dr. Rune, a specialist in heart failure. Dr. Rune was very thorough in his guidance and had a great sense of humor, making him very popular among the local students. Every day, I spent time in Dr. Rune's office, enjoying the experience so much that I often couldn't tell whether I was there to study or just to chat with him. My training hours were from 8 a.m. to 5 p.m. In the mornings, I would visit patients in the ward with Dr. Rune. In the afternoons, he would schedule appointments for me to observe procedures in the echocardiography lab, angiography lab, and pacemaker operations. Everyone was very interested in me, coming from Japan, and would take the time to explain procedures and chat with me. They also answered my questions willingly. One memorable experience was observing coronary stent placement in the angiography lab. I watched the procedure up close, making sure to maintain a sterile environment, and afterward, the doctor explained how the catheter had moved inside the blood vessels of the patient using an actual catheter. This hands-on learning was far more enlightening than textbook studies. After the procedure, the patient noticed that I was not Norwegian and started talking to me. When they found out I was a medical student from Japan, they joked, "You're welcome to learn more with my body!" This patient's willingness to let Japanese medical student do procedures was a great encouragement to me, especially since I was still getting used to the practice at the time. I jokingly asked if I could try inserting the catheter next time, and they laughed and shook their head.
Every Friday, there was cake in the ward's break room, and after a day's work, the medical staff would gather to relax and chat. I would go to the break room every Friday with Dr. Rune to eat cake. Doctors and nurses would come and go, enjoying cake and coffee while discussing their weekend plans. Dr. Rune would always lighten the mood with his humorous remarks. The atmosphere in this ward was largely thanks to Dr. Rune. The local doctors and nurses seemed to work with a sense of ease and confidence. I realized the importance of creating a friendly workplace environment where all medical staff can work together effectively, and I aspire to be a doctor who values casual communication with the medical staff.

# 2. Oncology
After bidding farewell to Dr. Rune, I began my rotation in oncology in March. Winter was quite mild this year, and by March, the snow started to melt, signaling the arrival of spring. Norwegians seemed to need a certain amount of snowfall to enjoy winter fully, and many were disappointed that there wasn't more snow. The oncology department deals with cancers of various organs, and is divided into groups based on the organs. During the first week, I was in the endocrine and breast cancer group; the second week, in the gastrointestinal group; and the third week, in the urology group.
During the first week with the endocrine and breast cancer group, I shadowed a doctor during rounds and outpatient consultations. The most shocking moment was on the first day. The doctor was explaining the medical history and chemotherapy regimen of a patient and mentioned that they couldn't prescribe narcotics for painkillers yet. When I asked how long it takes for a doctor to be able to prescribe narcotics, the doctor replied, "I'm still a student." I was astounded. It turned out that she was a sixth-year student at NTNU, doing an internship in the oncology department. NTNU doesn't have something like a clinical clerkship phase 2 in our university; instead, students apply for internships individually. I was amazed at the proficiency of my peers and realized I needed to study harder. This marked the beginning of a stimulating week that constantly pushed me to improve. In this group, I performed daily neurological exams on a patient with breast cancer who was at risk of brain metastasis. Although I had studied neurology for OSCE and the national exam, I had forgotten some parts and had to review them quickly. Discussing abnormal neurological findings and predicting the location of brain lesions based on those findings was very educational.
During the second and third weeks, I saw many more patients. In the second week with the gastrointestinal group, in addition to rounds and outpatient consultations, I attended many conferences. These conferences were conducted in English for my better understanding. One memorable discussion involved a patient with liver cancer secondary to hepatitis C, which is rare in Norway. One doctor asked me about the prevalence of hepatitis B and C in Japan and Asia, but I could only provide vague answers, and they wanted specific numbers. I regretted not being able to provide precise data, which might have enhanced the discussion. This experience made me realize the importance of studying not just the pathology and treatment of diseases but also their epidemiology.
During the third week with the urology group, I performed rectal exams on patients with prostate cancer. Although I had practiced this on models during OSCE training, this was my first time doing it in a clinical setting. As I gained more experience, I became better at identifying the location and hardness of tumors, which was very gratifying. I am very grateful to the doctors and patients who cooperated with me.

# 3. Pulmonology
The final month of my training, after the Easter holidays, was spent in the pulmonology department. By April, the days had become much longer, and it was still light at 9 p.m. The skies were clear and spring-like, but the temperatures still fluctuated around freezing. The pulmonology department is divided into oncology and non-oncology groups, and I rotated between both.
The most memorable part of this month was the bronchoscopies. The pulmonology department at NTNU performs bronchoscopies daily, and I visited the bronchoscopy room every day. Unlike in Japan, no throat anesthesia was given before the procedure; sedation and local anesthesia were administered through the bronchoscope instead. I was impressed that nurses performed some of the anesthesia and bronchoscope operations. The bronchoscopes used there were from OLYMPUS, a Japanese brand, which was a pleasant surprise. By observing daily, I became able to identify the bronchoscope's location during the procedure. However, even after reviewing with photos, I still struggled with the finer details of bronchial anatomy, realizing I needed to study more. Thanks to my daily observations, I was allowed to practice handling the bronchoscope in the final week. It was my first time performing the procedure on actual patients, and although I was nervous, it was an invaluable experience.
Dr. Elena primarily supervised me in the ward. I joined her rounds and treatment discussions and was allowed to take initial consultations with English-speaking patients. I also had the chance to perform blood gas sampling. Although I struggled to get it right on the first try, patients encouraged me to keep trying until I succeeded, offering their arms willingly. This was excellent practice, allowing me to hone my skills before becoming a junior resident.
Every Thursday after work, Dr. Elena took me to classical concerts, which she highly recommended. Despite my lack of classical music knowledge, I found myself captivated by the music, including familiar pieces like Dvořák’s "From the New World." This unexpected exposure to classical music turned out to be a delightful experience.

Life in Norway

# First Day in Norway
My first day in Norway was quite eventful, mainly because I arrived on a Sunday. When I entered my room in the dormitory, I noticed that there was only a bed frame and no mattress. Having spent the night on a plane, I was longing for a soft mattress. Not only that, I had no food. When I tried to find a store using Google Maps, I discovered that all the stores were closed. It was only then that I remembered that many European stores do not open on Sundays. I felt like crying but ended up laughing at the absurdity of the situation. Thus, my first night in Norway was spent curled up on a bed frame. Looking back at it, it’s quite funny.

# 1. Dormitory
I lived in a student dormitory located about 20 minutes by bus from the hospital. The dormitory was managed by the Student Welfare Organization (Sit) and came in various forms and locations. I stayed in a nine-story dormitory in Moholt, housing 15 students per floor, the largest dormitory in Moholt (known among students as the "tower"). The kitchen and living room were shared, but each room had a private bathroom, making it a comfortable place to live. The most surprising feature of the building was its automatic doors. Most buildings in Norway had doors that operated with an IC chip, which automatically opened the door when scanned. This futuristic feature likely helps prevent doors from being blocked by snow.
In my dormitory floor, there were students from various countries including Norway, Germany, Turkey, Sri Lanka, and Mexico. This diversity allowed me to experience different cultures. The shared kitchen was a great place to have conversations while cooking or eating. It was fascinating to watch others prepare dishes that were unfamiliar to me. The dormitory was lively, and parties were held often, including a "tower party" involving the entire building. These gatherings were much more vibrant than any that I had experienced in Japan. The dormitory members even held a farewell party for me, leaving me with wonderful memories.
In the center of Moholt, there was a shared student space called Loftet. It was a popular place among students, offering a library, study areas, free drinks, billiards, musical instruments, and video games. I often went there after classes to study or research on my laptop. I made new friends there, whether through engaging in conversations or playing video games like Winning Eleven.

# 2. Food
The most challenging aspect of living in Norway was the food. As I lived alone in Nagoya, I thought I had decent cooking skills. And, I had brought food from Japan, so I didn’t expect any problems related to foods. However, I ended up cooking and eating bland pasta every day due to Norway's high cost of living, which made eating out impractical. While my dorm mates prepared delicious-smelling meals, I continued eating my unappetizing pasta.
Fortunately, my girlfriend sent me a small rice cooker and rice, greatly improving my meals. This brought immense joy and relief. Although Norwegian food wasn't as flavorful as Japanese food, I enjoyed local specialties like Norwegian salmon, brown cheese, fruits, juices, and chocolates.
In Norway, there is a weekly tradition of eating tacos for Friday dinner. I followed this tradition by eating tacos at the hospital and in the dormitory every Friday. Although the tradition is to have tacos for dinner, the hospital cafeteria served Norwegian-style tacos for lunch, so I joined the doctors in eating them then. They welcomed me, saying, "Once you start eating tacos on Fridays, you're one of us Norwegians." I found it amusing that the cafeteria's Friday menu never failed to include tacos.

In the dormitory, my Norwegian floormates occasionally prepared tacos for dinner. They would set up tortillas and various ingredients, allowing everyone to make their own tacos, which made for a very satisfying meal. When we ate tacos together, they would always show Viking movies in the living room. The history of the Vikings is quite deep and dark, making for some intense dinner conversations.

# 3. Social Connections
During my stay, I made many friends besides my dorm mates.
I belong to a club at Nagoya University School of Medicine called MDEC, which interacts with exchange students. Through this club, I had met some students from NTNU. One of the students, Mari, was the first one I reconnected with. Mari gave me a tour of the campus and introduced me to other medical students who had come to NTNU at the same time for their exchange programs. I became friends with two French medical students she introduced, and we deepened our friendship by eating ramen and going out for drinks. They invited me to join them on a cabin trip to a mountain lodge outside Trondheim one weekend. On the cabin trip, I experienced things I had never experienced before, such as walking in the forest and on a frozen, snow-covered lake, enjoying candlelit nights, and trying a Finnish-style sauna. The personal highlight of the cabin trip was cooling down by jumping into the snow or a lake with a hole cut in the ice after getting out of the Finnish-style steam sauna, heated by firewood. It was truly a wonderful memory. Mari has invited me to hang out several times in private. We had a taco party at her house, sang karaoke, and even took me to a sauna. When we went to the sauna with Mari and her friends, it was April and the snow had melted. So, we jumped into the sea in Trondheim instead of snow to cool down. It was cold, but it felt amazing.
In April, Sunniva, who I became friends with through MDEC, came back to Trondheim from Nagoya University. Sunniva also helped me with preparing for my return home, and we studied together in the library, and invited me to some parties. One of the most memorable experiences was eating Norwegian sushi together. Sushi is very popular in Norway, and I was excited to see what kinds of ingredients they had. Overseas sushi is often in the form of rolls, and there were strange combinations like strawberry and shrimp tempura, or tuna and fried seaweed. However, I was surprised that they all tasted good. While eating sushi, Sunniva's friend pointed out that I wasn't holding my chopsticks correctly, and I felt that as a Japanese person, I needed to correct my chopstick holding technique.

I am still in touch with the friends I made during my study abroad through social media, and we sometimes communicate. Although we are not close enough to meet easily, I hope to reunite with them someday.

Travel During Holidays

During long holidays and weekends, I traveled to various places. As I had never been to Europe or any Nordic countries before this study abroad program, traveling was one of the things I looked forward to the most. The aurora borealis and fjords I saw during my travels in Norway were simply breathtaking. I will never forget the night I saw the vivid and fantastical aurora dancing above me. During Easter and after my internships ended, I traveled to the UK, Portugal, Spain, the Netherlands, and Italy with friends who were also studying abroad from Nagoya University. Since I came to Norway alone and had little interaction with other Japanese people, traveling with familiar friends and sharing our study abroad experiences was a great way to refresh and enjoy our time together.

Reflecting on My Study Abroad Experience

Returning to Japan, the three months I spent in Norway which felt long at the time, now seem like a fleeting moment. I believe this is because I was so thoroughly engaged and enjoying each day. Every day during these three months felt like an adventure. Each new discovery made my heart race, and I gradually fell in love with the city of Trondheim and the country of Norway. What was once an unknown territory has now become a familiar and beloved place. The silver skies that snowed daily, the colorful buildings typical of Northern Europe, the majestic and beautiful nature exemplified by the fjords, and the robust Norwegians reminiscent of Vikings—I've come to love everything about Norway. I strongly wish to visit again, preferably in the summer next time.
The clinical internships in three different departments provided an intense and enriching experience that was unattainable through mere study or internships at Nagoya University. The interactions and learnings I had with the hospital staff and sometimes patients in English will be invaluable in my future career as a doctor. Experiencing the well-organized healthcare system of Norway up close was also a precious life experience.
When saying goodbye, Dr. Rune told me, "Masa, think long and deeply about why you work." He mentioned that Norwegians often see Japanese people as overworking and advised me not to be fixated solely on work but to spend time on various things to lead a fulfilling life. This perspective, which I felt was shared by Norwegians in general, made me realize the importance of prioritizing one's own life. As I strive to become a competent doctor starting next year, I intend to keep Dr. Rune's words, "Put first priority on your own life," and the Norwegian mentality in mind. Interacting with Norwegians helped me understand that this attitude is directly linked to their happiness.
I will cherish the lessons and Norwegian mindset I gained from my life in Norway. Whenever I hit a wall or feel overwhelmed, I will reflect on these three months, thinking of the distant land of Norway. These everlasting memories will surely provide me with strength.

Acknowledgments

I would like to take this opportunity to express my heartfelt gratitude to Professor Hasegawa, the staff members of the Office of International Affairs, the doctors who gave lectures during our pre-departure training, the seniors who provided me with advice, and my family and friends who supported me. Thank you very much for your immense support and assistance.

From Q1 to Q2 in 2024, I had the opportunity to undertake a four-week internship at National Taiwan University, spending two weeks each in the Emergency Department and the Psychiatry Department.
Firstly, as a prerequisite, in internal medicine departments, NTU's policy does not allow exchange students to write medical records or be involved in patient care, limiting them to observational roles. Exchange students are essentially integrated into local student groups, following their activities.
Furthermore, non-Chinese speakers are not accepted in the Emergency Department, while the Psychiatry Department is open to English speakers. However, without Chinese proficiency, the two-week period could feel isolating. Nevertheless, the language constraint in clinical departments allowed for a profoundly immersive experience, providing a deep learning opportunity at NTU.

Emergency Department

In the 14 days at the Emergency Department, the first two days were filled with lectures from morning to evening. For the remaining days, I was scheduled for night shifts. This included three day shifts (8 AM - 8 PM), two night shifts (8 PM - 8 AM), two evening shifts (12 PM - 8 PM), one pediatric emergency evening shift (12 PM - 10 PM), and one critical care area shift (8 AM - 8 PM). Although I was not directly involved in these shifts, I was permitted to observe by contacting the local student team, resulting in observing one day shift, one night shift, and one critical care shift.
During my rotation in Emergency Department, two main impressions stood out.
First, the level of autonomy granted to medical students was notable. While consultations with senior doctors were required, students independently managed emergency patients, including writing medical records and prescribing treatments. Graduating students were expected to perform procedures like inserting NG tubes and Folly catheters, and even suturing minor wounds. Though I was unable to perform procedures, I observed the students being integral to the medical team due to Taiwan's healthcare system pressures. Unlike Japan, Taiwan’s healthcare system does not emphasize a referral system, making university hospitals extremely busy as patients prefer them due to lower initial consultation fees.
The second significant experience was riding in an ambulance. Dr. Chong, my supervising doctor, is a medical counselor for the Zhongxiao Fire Department, which he visits monthly. I joined him and had the impactful experience of riding in an ambulance for the first time, including responding to an OHCA (Out-of-Hospital Cardiac Arrest) patient.

Psychiatry Department

Compared to the Emergency Department, the Psychiatry Department was more straightforward, focusing mainly on conferences and ward rounds, with occasional outpatient observations and lectures. Local students similarly spent most of their time on ward rounds and medical record documentation. Personally, I found NTU’s psychiatry internship less hands-on than at Nagoya University, where we had more opportunities to take patient histories.
Cultural differences seemed apparent as there were more patients with suicide histories and severe schizophrenia compared to Japan. The language barrier was also challenging as many patients spoke Taiwanese, making it difficult to follow ward rounds.
As part of the psychiatry internship, we visited Taipei City Hospital-Duties-Songde Branch, a specialized psychiatric hospital in Xinyi District. The visit included lectures and tours of the wards, seclusion rooms, and day service areas, which featured unique aspects such as cooking and craft classes, calligraphy workshops, and even a lively mahjong corner. We also saw the large gym with basketball and tennis courts and a dance studio.

Reflections

Reflecting on this exchange, four key points stood out. First, it reignited my passion for studying medicine. Despite not being diligent in my studies, the experience of working with NTU’s sixth-year students, who were about to graduate and become interns, highlighted my own lack of preparation and inspired me to study harder, including considering the USMLE.
Second, I made lasting friendships. I connected with fellow NTU students, teaching assistants, and senior doctors, broadening my network and receiving invitations for future internships at NTU.
Third, the experience made me think about digitalization in healthcare. Taiwan’s advanced medical information system, allowing access to patient records with a single health insurance card and remote access to medical records, is something worth emulating.
Fourth, it prompted me to consider internationalization in medicine. In Taiwan, medical records and drug names are predominantly in English. This was an eye-opener as I had assumed that medical documentation would be in the local language. Taiwan’s medical education has used English extensively since the 1950s, leading me to initially advocate for more English in Japanese medical education, including the physician licensing exams. However, I realized the potential downsides, such as the risk of doctors leaving Japan, highlighting the complexity of internationalization in medicine.

Acknowledgments

I owe a debt of gratitude to many individuals for making this invaluable experience possible. Special thanks to Dr. Kasuya, Dr. Hasegawa, and the staff at Nagoya University’s International Office, Ms. I-wen Chang, Dr. Kah-Meng Chong, Dr. Ming-Hsien Hsieh from NTU.

From March 18 to April 19, 2024, I participated in a five-week clinical training at Korea University in Seoul. It was unfortunate that I could not meet many residents and local students due to the residents' strike that started one month before my training. However, the doctors were very kind to me, so I was able to spend fulfilling days. I’ll write about my life in Korea.

Korea University

Korea University is one of the top three universities in Korea and has three affiliated hospitals in Korea. I trained at Anam Hospital, which is very advanced in robotic surgery. During my time there, I observed many robotic surgeries in Breast and Endocrine Surgery and Colorectal Surgery.

Department of Breast and Endocrine Surgery

In the first two weeks, I mainly observed surgeries in the Department of Breast and Endocrine Surgery. I was especially impressed by the Transoral Robotic Thyroidectomy (TORT) developed by Dr. Kim, a professor at Anam Hospital. In this innovative method, the thyroid gland is removed through three incisions made inside the lower lip, so there is no scar visible from the outside. This patient-centered approach, focusing on both medical and aesthetic outcomes, left a strong impression on me.
Furthermore, doctors in Breast Surgery contacted the Department of General Surgery and I could observe robotic surgeries of cholecystectomy for cholelithiasis and pancreatectomy. The use of robots in these surgeries is still relatively rare in Japan, so I realized that robotic surgery is being applied to more diseases in Korea. Notably, the da Vinci used for cholecystectomy was the Sp type, which has a single-port camera and forceps. This was a precious experience as this system is not yet commonly used in Japan. I am truly grateful to the doctors for contacting other departments flexibly.

Department of Colorectal Surgery

For the next three weeks, I studied in Colorectal Surgery and observed robot-assisted hernia surgery and laparoscopic colorectal cancer surgery, as well as outpatient observation. I also attended KSERS 2024, a symposium on robotic surgery held in Daejeon, and visited the Robotic Surgery Center with doctors of Colorectal Surgery. At KSERS, I learned about the features of robotic surgery in the gastrointestinal and breast and endocrine fields and had a good time interacting with doctors from Seoul National University and from Japan at the reception. At the robotic surgery center, I learned how to operate the da Vinci, including camera operation, arm clutch, and suturing, through a simulator. As I am interested in robotic surgery, it was a great experience for me to operate the da Vinci.

Extracurricular Activities

Outside of training, my teacher introduced me to other international students. I spent my free time with students from Singapore and Hungary. We visited many sightseeing spots, enjoyed local food, watched movies, and more. Although I was the only student from Nagoya University and could not meet many local medical students due to the strike, spending time with other international students made my experience enjoyable.

Personal Growth and Gratitude

This study abroad program not only expanded my knowledge of Korean medicine, especially robotic surgery, but also helped me grow personally. Being in an unfamiliar environment encouraged me to ask questions actively and talk to doctors, nurses, and fellow international students, without being afraid of mistakes. I feel more confident and energetic than before.
Finally, I would like to express my deepest gratitude to everyone who supported my study at Korea University.

Beijing (4th of March until 26th of April) – As part of an exchange program of Peking University with Nagoya University, I had the honorable opportunity of completing my medical clerkship at Peking University People’s Hospital, which is the second hospital, and the university has 10 affiliated hospitals. During my eight-week medical elective, I spent four weeks in the departments of Cardiac Surgery and four weeks in Cardiology.

In the cardiac surgery department, I primarily shadowed Supervisor Han, who is an associate chief surgeon. When he worked at another affiliated hospitals, I followed an attending doctor Zhang. The internship involved attending conferences on Monday to review the schedule and discuss upcoming surgical cases for the week. From Tuesday to Friday, I participated in morning handovers and ward rounds, followed by observing or assisting in surgeries. During downtime between surgeries, I learned postoperative management in the CCU. While conversations during conferences and ward rounds were conducted mainly in Chinese, several professors, including Dr. Han, provided translations when needed, allowing me to keep up. The number of surgeries was roughly twice as many as those at my university hospital, and there were many cases of concurrent cardiovascular diseases and malignant tumors, which was a refreshing experience. Dr. Han specializes in minimally invasive surgery, deepening my insight into cardiac surgery for cancer patients. Notably, I took part in surgeries on a patient with chronic myelogenous leukemia who had received transfusions to correct anemia the day before, and a lung cancer patient who underwent minimally invasive surgery, enabling early postoperative chemotherapy. These cases, considered high-risk in Japan, were unprecedented for me until this program. Initially, I only observed surgeries for about a week, but afterward, I was allowed to scrub in and participate actively, gaining experience in various surgical techniques. Although initial challenges were not fine, I improved through repeated practice, with guidance from Dr. Gau, a fellow, during lunch breaks, and assistance from Dr. Zhang, who lent me practice surgical instruments such as needle holders and forceps. Additionally, I was granted permission to observe and participate in surgeries during downtime throughout the Cardiology period, allowing me to witness and engage in surgical procedures daily for two months, contributing to significant growth in the operating room. This practical and intensive experience aligned perfectly with my aspirations.

In the Cardiology department, I primarily learned with an attending doctor Hou. I attended morning conferences and ward rounds and participated in catheterization procedures and treatments when applicable or discussed patient conditions and treatment plans while reviewing electronic medical records when not. Dr. Hou, who had experience of studying in the UK, provided instruction in fluent English, based on his overseas experience. During ward rounds, each patient's case was presented in English, followed by discussions on treatment plans and tests, allowing for active participation. He also recommended relevant articles (published in NEJM, for example) for discussion and answered questions after reading them. Additionally, during outpatient visits, he explained China's insurance system, prescription rules, and epidemiology. In the catheterization theater, where over five times more procedures were performed than at my university hospital, I was impressed by the volume of cases and the efficiency of the medical team. I also had the opportunity to meet Supervisor Professor Liu, who had conducted research on imaging tests (OCT and IVUS) in the United States and received advanced knowledge from him. Furthermore, after each catheterization procedure, I evaluated coronary angiography results with Dr. Hou, discussing the degree of stenosis for each segment, leading to significant improvement in my radiographic interpretation skills through one-on-one guidance. I also observed emergency catheter treatments. That was quite impressive for me since I did not have experiences of observing primary PCI (emergent PCI) at our university hospital. I was surprised at the dramatical change of patient’s condition before PCI (such as suffering chest pain) into after PCI within 15 minutes. In addition to this, I had the chance to give a presentation about heparin induced thrombocytopenia on the program's final day. I encountered a patient with the disease during this term, and it is an important risk factor not only for PCIs but also cardiac surgeries. My training achieved a balanced combination of learning and sharing experiences.
Outside of the internship, three volunteer students, including Mr. Shi, assisted me. Particularly during the first week, when communication with staff members outside of the hospital was necessary for tasks like facial recognition registration and dormitory payment, their help was invaluable, as I do not speak Chinese. We continued to bond over sightseeing, meals, discussions about our student lives, and future aspirations. Moreover, during daily lunches with Dr. Hou, I learned about Chinese culture, including classical Chinese poetry by Du Fu and Li Bai, minority costumes and lifestyles, and regional cuisine, strengthening my affinity for China. Despite differences in pronunciation, I discovered many cultural similarities between Japan and China, fostering a closer connection to China.

As I reflect on the past two months and write this report, every moment feels precious, and I deeply miss everyone I met in Beijing. When it comes to the support I received, I am sincerely grateful to Professor Xu for her support, from the pre-program preparation to the entire study period.

Finally, I extend my heartfelt gratitude to professors at Nagoya University Office of International Affairs, who gave this supreme chance and supported me. I will cherish this invaluable experience and the connections made. I hope for the continued success and growth of this program in the future.