Clinical Exchange in Japan

Ophthalmology 2017/10/02 - 2017/10/13

On my first day at the ophthalmology department my mentor, KANEKO-sensei, introduced himself and supplied me with the schedule for the following two weeks. I appreciated having such a plan, which enabled me to prepare in advance for the following days.

After I was shown around the hospital, ITO-sensei gave me a lecture on refractive errors. I was thankful that he held the presentation in English, even though Japanese students also participated. Later that week, a lecture on eye trauma was held.

On every Monday evening, there is a general meeting of all the department’s doctors, in order to discuss interesting and difficult cases, which would be treated in this department during the following week, and especially focusing upon the type of treatments, which the patients would receive.

As the university hospital’s ophthalmology department is specialised in the retina, I was taught a lot about pathogenesis, diagnosis and therapy of diseases occurring in this area of the eye.

Equal to many other hospitals, cataract surgery is one of the most often performed operations, and I was able to see and experience many of these procedures when I was present in the operating room. Being able to actually train upon cataract surgery techniques on a very modern simulator was a great opportunity for me to test my microsurgical abilities by working under a microscope and to get a real insight into this field of specialisation. Utilising this simulator, it was possible to perform a capsulotomy, with the cutting and removal of the old lens, with different levels of difficulty.

For me, it was very interesting to see and to experience the differences between European and Japanese patients, and the way in which a disease would present itself. For instance, normal pressure glaucoma is very common in Japan, but almost never occurs in Austria. Moreover, I was unaware beforehand that myopia is very common in Japan due to an elongation of the axial eye length. When the Japanese students’ and my bulbar axial length were measured by ITO-sensei, this issue became comprehensible, as the other Japanese students’ results were quite higher than both mine and the other European students.

Furthermore, I was shown different eye and vision examination techniques by several doctors, and I was then allowed to try and practise them together with some of the Japanese students. More complex examination methods, which involved special machines and computers, such as OCT, were shown and explained to us during these student teaching sessions by the responsible doctors.

At the end, I even had some contact with inward patients, who were mostly at the hospital for post-operation monitoring, and also outward patients, who had check-ups and eye examinations. It was very interesting to examine the patients’ eyes exhibiting pathologies, as I would normally not see this in the healthy eyes of other students.

During the second week I had the opportunity to improve my microsurgical suturing and knotting skills under a microscope. We used 6-0, 8-0 and even 10-0 threads, which I had not used before.

I was very thankful for the warm welcome at TERASAKI-sensei’s department, as she and also her team always tried to integrate me into their work, and to teach and answer my questions, and even translated into English for me.

Otorhinolaryngology 2017/10/16 - 2017/10/27

The second department, which I rotated to, was otorhinolaryngology. I was quite excited and interested about my time there, as I am planning to specialise in this field.

On the first day our supervising sensei introduced herself, and she asked me about my specific interests. As I wish to specialise in cancer surgery, being a part of the head and neck surgery team, and actually assisting with their operations was an especially great opportunity for me to extend and to optimise my knowledge in this field.

I was very impressed about the teaching in this department, especially because in Austria it is rare for a doctor to be patient enough to match the kind of teaching, which the resident doctors receive in Japan. NISHIO-sensei performed a glossectomy on a cancer patient, and allowed me to participate in his surgery. This was very interesting, especially because I was able to witness the reconstruction of the patient’s tongue from a skin-muscle-flap, as performed by plastic surgeons. I certainly increased my neck surgery knowledge, particularly the area of neck dissection surgery by watching and assisting with some of the operations performed.

Of course, this participation in a variety of operations and by assisting the surgeons has definitely improved my knowledge of anatomy and surgical techniques.

When I realised that the surgeons in Japan were using a different kind of suturing and knot technique, they asked me to demonstrate, and then I was taught the “Japanese style”.

In the outpatient clinic, I saw many cancer patients, mostly showing up for follow-up check-ups after operations, but also included patients with dysphagia or dysphonia. Therefore, the doctors performed diagnostic and therapeutic laryngoscopy. For training purposes, the other Austrian student allowed me to perform a laryngoscopy on her, which was a great opportunity for me to experience the handling of an endoscope, and also for Svenja to experience this examination from a patient’s point of view. Also, we both practised some neck and thyroid gland ultrasound together.

On one evening I accompanied some doctors to the Aichi cancer centre to attend a presentation by a researcher from the MD Anderson Cancer Center Houston, Texas, who was researching the effects of radiation in the head and neck region on osteonecrosis of the mandibular bone.

Additionally, I was requested to attend the weekly cancer board meetings on Monday, during which the head and neck team discussed new admissions to the hospital, and the best therapy for the patients, and also Tuesday evening meetings, when the department meetings were held together with the ear team.

During an outpatient clinic session, I was taught about the traditional Japanese medicine “Kanpo”, of which I knew nothing beforehand. So afterwards I made some research and opened my mind towards this alternative Japanese medicine.

Although I was part of the head and neck team, I was also able to watch one of the tympanoplasty operations, which was performed by the professor, who afterwards revised the most important facts about Menière’s disease with me and introduced me to his research.

I am very thankful for this translation into English, as my Japanese was almost nonexistent, and also for all the time and care which the doctors took to answer my questions, and finally for the opportunity to assist in surgeries.

Gynaecology and obstetrics 2017/10/30 - 2017/11/24

My visit to the department of gynaecology and obstetrics was split into three divisions: fertility, obstetrics and gynaecology. I spent six or seven days at each of these subdivisions.

At first, I was allocated to the fertility department and was supervised by MURASEsensei, who has put much effort into teaching and explained to me the different types of infertility treatment, such as AIH, IUI, ICSI or ART.

Furthermore, NAKAMURA-sensei, whose English is excellent, took me into the operating room to watch and to assist with some of her surgery, for instance the removal of endometrioma. It was very interesting for me to learn about the Japanese attitude towards oral contraception, and the effects resulting from the low usage rate, such as endometrioma with a consequential higher risk of developing a malignant tumour. In addition, NAKAMURA-sensei took me to the surgical training and simulation room, where she introduced me to laparoscopic surgery, and especially the suturing technique, which I was able to practise afterwards. In the outpatient clinic, I also saw a lot of patients with fertility disorders, who received fertility consultation or who had been undergoing various kinds of therapy. At this hospital the fertility treatment is subdivided into three steps: 1. Consultation by determining the optimal day of sexual intercourse by measuring hormone levels and a performing a transvaginal ultrasound examination, 2. Prescription of Clomifene (SERM) in order to induce ovulation or reverse anovulation or oligoovulation 3. Invasive methods for the artificial insemination. Later, I was taken to the fertility procedure room, where I was able to witness the oocyte harvesting and also an embryo transfer.

Furthermore, I learnt a lot about myoma and PCO syndrome and the effects, which it can have upon a woman’s fertility.

Next, I moved on to the obstetrics division, where I was supervised by USHIDA-sensei, who was simply amazing. He always answered my questions, and took time to explain different cases, and tried to involve me in his work. I was able to assist with several caesarean sections. As this hospital is specialised in risk pregnancies, it was very interesting for me to see a variety of patients exhibiting different indications before admission. Although it was a critical situation for the affected patient and doctors performing the caesarean section on a woman with a twin pregnancy, who developed a very strong bleeding after delivery, it was very interesting for me to see the approach to handle this common complication, taking place during such an operation. Furthermore, one evening I had the chance to witness my first natural delivery, which was a very moving moment, which I will probably never forget. In the ward, I went to the special care unit mostly with women experiencing premature contractions, and learnt how to treat women in this situation. USHIDA-sensei took the time to explain the CTG to me and showed me different pathologies, which he asked me to identify afterwards with his patients. Moreover, I was able to observe an amniocentesis in order to perform prenatal diagnostics.

During my time at the obstetric department, I was able to attend some lectures for the Japanese students on CTG, infertility, and MURASE-sensei introduced us into sewing and Japanese knotting techniques. One afternoon, USHIDA-sensei took us to the training and simulation room, where he explained the BISHOP-score, showed us how the bimanual palpation technique is conducted in Japan (whereby this technique differs from the European method, as the left hand is used instead of right hand, because usually the midwife will be using her right hand simultaneously), and asked me to perform an examination by myself. Finally, we simulated a normal natural delivery.

As a part of the mother and child identity card examinations, IMAI-sensei showed me how to perform a basic obstetric ultrasound and how to measure the foetus in order to determine the gestational age, and which I was allowed to practise on some patients afterwards at the outpatient clinic.

The third department was gynaecology, where I was supervised by YOSHIKAWA-sensei, who involved me in his work very nicely, for which I was thankful. He allowed me to perform transvaginal ultrasound and bimanual palpations. At the outpatient clinic he always introduced me into each patient’s medical history before they entered the room, enabling me to understand what they would be discussing. On Thursdays, colposcopy is performed, including the application of acetic acid to the portio and biopsy of suspect regions. Some patients may be informed about the histologic findings and the resulting therapeutic procedures, alternatively some of them have to undergo an additional biopsy in order to confirm the findings.

This hospital specialises on cancer in the minor pelvis (ovarian cancer, corpus carcinoma, cervical cancer), therefore there is no breast surgery performed by the gynaecologic oncologist surgeons. It was my pleasure to assist several operations in this department, especially because I was asked very often to do the final suturing. I have learnt a lot about the different types of cancers, and moreover the differing incidence ratios and differing treatments in comparison to Europe.

I really liked the idea of having a journal club twice a week on Monday and Thursday mornings, during which one or two of the researchers or resident doctors usually presented new important papers from their field of speciality. In this fashion, everybody was kept updated with the newest developments in every field of gynaecological specialisation. Then the subsequent discussions were always very interesting. On Friday afternoons a department meeting was held to introduce the new inward patients and to discuss the possible therapies and further handling of difficult cases. I am very thankful that most of the doctors and researchers tried to present their patients and hold their presentation in English, so I would be able to understand and participate in the discussions. Although not everybody was able to speak English during his or her presentation, I was still able to follow, as usually the doctors sitting next to me would translate the most important facts for me.

During my time at the OBGY department, I was invited to their annually onsen and ryokan trip in Minamichita. I cannot express my appreciation and thankfulness in words for the possibility to experience Japanese culture in this way and mostly the hospitality of all the people involved.

Neurology 2017/11/27 - 2017/12/22

I spent the final four weeks of my medical electives at the department of neurology. When compared to the other departments, most of the staff, researchers and doctors here were able to speak and to understand English very well.

The time there was very well organised by the department: on the first day I received a schedule with the program awaiting me during the next weeks.

I also had a meeting with the head of the department, Professor KATSUNO, at the beginning of the second week in order for him to evaluate my interests, and eventually to make some fine-tuning adjustments to the schedule, and to inform me about the organisation of the upcoming three weeks. He also asked my fellow student and myself to write a case report about a patient in whom we had interest, and also prepare some more patient cases to discuss during the second meeting on the final day of our rotation. Normally, in the morning there was a lecture given on a specific topic by a researcher. Usually, they presented the diseases in which they specialised, including the research and the project on which they were currently working. This was always very interesting, but in my opinion I found it sometimes a little too specific and difficult to understand. Nevertheless, I was very thankful for the translation of their presentations into English and the fact that everybody was eager to teach and to answer any questions precisely. The lectures covered a broad range, but were focussed upon neuro-degenerative topics, including ALS and TDP-43, MS, CIPD (which was very interesting, as there were quite a number of inward patients exhibiting such symptoms at this time), Parkinson’s disease and PD-like diseases, such as MSA, PSP, CBD and dementia with Lewy Bodies, SBMA and finally the different types of dementia.

In the afternoon, we usually met a doctor in the ward and after reading the patient’s medical history we were then introduced to the patient. Then the supervising doctor performed an examination in order to demonstrate the neurological signs typical for this disease. In some cases the patient presented in the afternoon, such as an ALS patient, matched the lecture on the following morning. On Tuesday afternoons there were ward rounds with all the responsible doctors, during which the treating doctors presented each of their current patients. Afterwards the patients’ therapy and the further procedure were discussed; subsequently, a ward round was performed and the professor himself or the associate professors examined the patients, which was quite impressive and interesting, as this does not happen often in Austria. As the actual presentation, discussion and the communication during the ward round was conducted mainly in Japanese, I was very thankful for the doctors and students, who translated the most important medical information into English, allowing me to participate and learn. The whole procedure in the afternoon takes approximately 3.5 hours; however, students are only asked to remain until 5 pm.

On two occasions, we had the opportunity to go to the EEG, EMG and nerve conduction examination room, and to gain some practical experience on these topics, which was supervised by NAKAMURA-sensei. I enjoyed this very much, since I did not have a lot of experience in this type of examination before I went to Nagoya.

In comparison to Japan, where the medical students do not have any contact with patients before the fifth year of medical school, in Austria students should be able to perform clinical examinations (both general and neurological status) by themselves. So even although I was allowed to practise some examination techniques on patients, I had the impression that in general I learned a lot more theoretical medicine than practical medicine in this department. Nevertheless, I am convinced that I now know at least as much about practical examination techniques, as the students who did the neurology rotation at my home university.

During my time at this department, a three-day medical clerkship at Nagoya Daiichi Red Cross Hospital in the western part of the city was organised for me. The other student, who rotated with me, was given a place at Toyota Memorial Hospital.

As this neurological department is very specialised, having mainly patients with neurodegenerative diseases in the ward, it was a great opportunity for me to go to another smaller and less specialised general hospital and to see more common diseases as well. On my first day, I was introduced to the team of eight doctors currently working at the neurology department, received lunch vouchers and a key access card. I was then shown around the hospital by MANO-sensei, who is the head of the department, and was a great – also German speaking – supervisor. Some of the doctors spoke English very well, so the communication was very easy for me. I believe that this was the most exciting part of my neurology rotation, as I got to see a patient with a stroke, who was treated by a catheter intervention, and I also witnessed two autopsies, which I have not experienced before. Furthermore, HONDA-sensei took some time and introduced me to several patients and asked me to examine them, also to do some anamnesis and tell him my further procedures in order to make a diagnosis. I am very thankful for this possibility as I learnt a lot about diagnosis based upon physical examinations.

Also, on my first day at this hospital, the internal medicine departments had their “bōnenkai“, a dinner party held at the end of the year, including friends or co-workers in order to forget troubles of the last year, and to look forward to the following year.

In my final week at Nagoya University Hospital I had the opportunity to participate in another bōnenkai. I am very thankful to have been invited to these events and not only to improve my medical knowledge, but also to learn about the Japanese culture as well.

On my last day, I had a second meeting with Professor Katsuno, in order to review my time spent at this department. I chose to present two cases from Nagoya Daiichi Red Cross Hospital, and I wrote my report about a very typical ALS patient, who was hospitalised due to an infection of the respiratory tract and was facing the typical progression of this disease leading to respiratory insufficiency. We discussed the presented cases and my report, and he gave me some helpful feedback.

I really enjoyed my time at this department, especially because it was so well organised, and in particular the secretary, SUZUKI-san, was a great help when there were any issues arising. Also, I enjoyed the three days at Nagoya Daiichi Red Cross Hospital very much and appreciated all the efforts, which were made to teach me and to make me feel welcome there. I would highly recommend a medical elective at this department to any other students who are interested in Neurology.

Before I arrived in Nagoya, I travelled through Japan for two weeks: I flew into Tokyo, climbed Mt. Fuji, and visited Kyoto, Nara, Koya-san, Osaka, Himeji, Kobe, Hiroshima and Miyajima. Also, I tried to make a lot of weekend trips and made use of the public holidays in order to see as much as possible of this fascinating country. There are some wonderful places, which are easily accessible by public transport around Nagoya and were certainly worth a visit, such as Magome and Tsumago, Nabana-no sato (excellent winter illuminations), Korankei (autumn leaves), Inuyama and the Mie prefecture.

Once again, I was very thankful for the hospitality and the friendliness exhibited by all those who made me feel so welcome at Nagoya University. I learned a lot at the hospital, more theoretical than practical, as discussed earlier, but additionally about Japan itself with its exceptional people and culture (unfortunately without a lot of Japanese language knowledge, which would have made some situations a little easier).

To all the medical students out there: I can recommend the medical electives at Nagoya Graduate School of Medicine to all of you who are interested in experiencing a high level of practiced medicine abroad, and wish to discover Japan from a another alternative side to that as regularly seen by tourists.