Clinical Exchange in Japan

Ophthalmology

On our first day we were kindly greeted by the International Office and given a quick tour of Tsurumai campus before we started with a rotation in Ophthalmology, where we were welcomed by Dr. Kaneko. He gave us a well-structured schedule for the course of the 2 following weeks, which was adapted by him over time to give us the best possible insight into ophthalmology. The staff made sure that we had several opportunities to attend surgeries including vitrectomies and cataract surgery, where we could follow the procedures on a wide HD screen in the operating theatre. On days without scheduled surgeries, we would have a lecture together with a small group of Japanese students before lunch that was thankfully held in English. We learned about the most important diseases such as wet/dry macular degeneration and diabetic retinopathies followed by emergencies like foreign bodies and acute glaucoma attack. The lectures further helped us to refresh our anatomical knowledge - thanks to high resolution new technologies like OCT we added the retinal layers to our list of terms to acquaint us with.
We were introduced to the technical aspect of modern ophthalmology in the outpatient clinic and in a room for surgical simulation training, where we could practice ophthalmic surgeries under guidance of MD/PhD students. We also had the chance to try our luck with microsurgical sutures in the research building with 6/0 and 10/0 threads, which made me appreciate the fine motor skills necessary for ophthalmic surgeries. An interesting ethnic difference we learned about was the higher incidence of axial myopia in Japanese people as a result of an increased bulbus length (>24mm), which we could observe in our own group when we measured both visual acuity and axial bulbus length on each other. Seeing our theoretical knowledge translated into a practical exercise helped consolidating the content of our lectures.

Otorhinolaryngology/Cognitive and Speech Medicine

I was given the opportunity to scrub in on a tongue cancer patient (SCC) with Dr. Nishio to assist on the first part, the neck dissection and tracheotomy. I would describe the experience of his operating skills and being taught the regional anatomy while he unfolded layer after layer as my personal highlight of this rotation! I noticed that I used a one-hand knotting technique in contrast to the residents who preferred two-handed knotting and they patiently showed me their way.
I was very impressed with the case load of the head and neck surgeons and the complex oncological procedures they performed.

We observed ultrasound guided biopsies of patients with neck tumors and afterwards practised neck sonography on each other. After the busy outpatient clinic slowed down a little, Christina, who already had an interest in ENT, performed a laryngoscopy with a flexible endoscope on me under supervision of a very patient doctor.

Obstetrics and Gynecology/Reproductive Oncology

We started our rotation in the Fertility and Reproduction group where we learned about the different steps for couples who suffer from difficulties in conceiving and observed oocyte retrievals and an IVF first hand – a unique opportunity for medical students. I also saw cystectomies in patients with PCOS and had the opportunity to practice my laparoscopic skills in the training room, which was incredibly fun!

This was followed by our rotation in obstetrics, where we first noticed the relaxed atmosphere and the empathy the doctors showed for the patients, who were often put in a stressful or even threatening position by their pregnancies. Since the department has a high level of care, most women had difficult pregnancies such as children with congenital malformations, or a cervical insufficiency due to a coniotomy. One of the most emotional moments for me was assisting in a caesarean section – I did not image the uterus to have such a strong vasculature, so the amniotic fluid and the bleeding made for a rather wet experience, but the first scream of the newborn and the reaction of the relieved mother made up for it.
We further witnessed an amniocentesis on a patient who we thought was around our age, so we asked if she had any risk factors to need this procedure. It turned out she was over 40 years old – Japanese women do not seem to age!

The oncology group offered a lot of opportunities to scrub in on complex surgeries, often involving meticulous lymphadenectomies, which gave me the chance to inspect abdominal/pelvic anatomy on a more detailed level. I saw a lot of young patients with cervical cancer and was surprised to learn how low the HPV vaccination rate in Japan is, but it motivated me to study the standard of care for different gynaecological malignancies.

We both agreed that one of the highlights of our stay was the department trip to an onsen in Minami-chita, where we saw a completely different side of the staff. I am very grateful for the invitation (!) and must say that both the hot baths and the traditional Japanese dinner and breakfast were a vacation on its own.

Neurology

Since I have focussed on neurosurgical research in my home institution, I was especially excited for the rotation in the department for neurology, where we were given a detailed schedule with lectures ever day before lunch time and had bed-side teaching on the ward in the afternoon. We often had a doctor completey to ourselves, who took his time even if it was stressful on the ward, which we really appreciated!

With the hospital being a tertiary care center, there were a lot of diagnostically challenging cases during our stay, which were discussed extensively in the grand rounds with Prof. Katsuno. I was encouraged to think about the steps of diagnostic approaches myself before being told about what the neurologists chose to be the most probable cause - which greatly improved my diagnostic approach. Clinical symptoms in neurology can be very impressive, such as the extreme muscle weakness of a therapy-resistant myasthenia gravis patient or the mixed upper and lower motor neuron symptoms of ALS patients throughout all stages of the disease. Back home we train the assessment of muscle tone on other students, where you sometimes ask yourself what you are doing there, but here I could observe a Jack-knife spasticity of the lower extremities in a NMO patient with an acute relapse first hand and the cogwheel rigidity of a patient with M. Parkinson, which gave me a better understanding of the reasons behind neurological examinations. I also learned about the differences in tremors by Dr. Tsuboi in one of the morning lectures – there is more to it than frequency, amplitude and intention/rest and from now on I will look more closely to get a routine in diagnosing them.

I was especially interested in the extensive research that is being conducted by the physicians and was happy to find that our lectures were held by experts of their field, who always found the time to discuss their methods and the outlook on future research. Their spectrum of studies involved both basic science and nationwide ongoing clinical trials and I will make sure to follow their results in the future! Due to their great work ethic, that sometimes means a limited private life, I expect the doctors of the neurology department to achieve great success in their projects.

To give us the chance to see a different spectrum of neurologic diseases, I was sent to Toyota Memorial hospital for three days, where I was warmly greeted by Dr. Ito – in fluent German! Due to my interest in neurosurgery, he incorporated a carotid endarterectomy into my stay at his hospital. He taught me in person over the whole three days and took me with him to see and examine patients in the outpatient clinic. I was also invited to dinner with the department, that had a family atmosphere and everyone made me feel at home in the team, which is not even standard in my home city. On my last day, Dr. Ito invited me to the christmas party of the Japanese-German society in Nagoya and to my biggest surprise we were served wine, that was imported from 50km away of my apartment in Vienna! We sang “Oh Tannenbaum”, a traditional christmas song from my childhood, which nobody wanted to believe back home. Thank you for the amount of time you and your staff invested in me – my stay in Toyota was incredible and gave me a new view on patient care and the love for the individual that sometimes gets lost in modern medicine.

Back in Nagoya, we ended the rotation with the department Bonenkai (忘年会) that showed how relaxed the atmosphere of the staff is outside of the hospital and it was a unique chance for European students to be involved with the staff in this fun tradition!
We were given the chance to reflect on our stay with Prof. Katsuno and get his input on our case reports - Even in the last moments at the departments we learned from such an experienced neurologist in person and received his advice for our future in the medical field!
The rotation in this department was very well structured and the teaching between the residents but also for us students was clearly seen as part of everyone’s responsibilities and seemed effortless for the doctors, although we know how much work it must have been over the whole month!

Here, I’d like to give my special thanks to Dr. Motomura from the Department of Neurosurgery. I contacted him in my first week in Nagoya to ask whether I could observe some of his operations during my stay, which was compatible with my regular schedule on a weekly basis. While I was only hoping to be allowed into the OR, he exceeded all my expectations by personally introducing me to each case with the help of imaging studies and his neuronavigational plans and by explaining the pitfalls and complications that need to be kept in mind during the procedure. He also stopped from time to time to lead me through the at times distorted anatomy and help me with the orientation in the surgical field.
I was further introduced to Dr. Takeuchi when he learned about my interest in neurosurgical endoscopy and I attended one of his transsphenoidal pituitary adenoma resections, where I had the chance to discuss the technical differences compared to Vienna. Back home I told my professor about the monostril approach and his dural sutures, which are quite rare to see in pituitary surgeries and technically most challenging!
I was also very impressed with the frequency of awake surgeries at Nagoya University Hospital and the use of intraoperative MRI in glioma surgery, which are going to serve both the patients and future research. He also invited me to the 76 th Meeting of the Japanese Neurosurgical Society that was held here in Nagoya and I benefitted a lot from the sessions I attended!

SUMMARY

The doctors went out of their way to share their knowledge and give us a great learning experience. The staff made a continuous effort to explain very complex topics to us in English, which we are very thankful for. They not only showed us their daily routines but also Japanese culture and I came to love the food and the country itself – I would very much like to come back one day and experience all the seasons and landscapes Japan has to offer!

I am very grateful for the time spent here and the three months went by too fast. We were integrated into the daily life in the hospital and received help for every problem we encountered.

Besides medicine, I was especially impressed by the politeness I encountered and the remarkable sense of ethics and the empathy for other people. My perspective on medicine and the role of the relationship between doctors and patients was shaken up and I hope to take some of this back home to become a better physician in the future.