Clinical Exchange in Japan

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Experience report

Name: Robert Kilzer
School: Technical University Munich, Germany
Study Period: 12/Nov/2018 - 08/Feb/2019
Departments: Otorhinolaryngology, Anesthesiology, Obstetrics&Gynecology, Neurology

Experience Report

I would very much like to start off my report by thanking the International Education & Exchange Center of Nagoya University for giving me the chance to take part in this quite unique format of NUPACE and for doing everything in their power to enable us participants to shape our stay in Nagoya according to our wishes. I am truly happy to have been a part of it.
As one of the few medical students of NUPACE I was from the very beginning confronted with the problem of not being able to take courses specifically offered by the NUPACE Program while, simultaneously, doing a Clinical Clerkship full time on another campus. For this reason I decided - with the kind support of the NUPACE office - to split my semester into roughly two months worth of studying in Japanese classes and visiting other NUPACE courses and into four months of completing my Clinical Clerkship in the Nagoya University Hospital. This allocation of my time will define the structure of my report.

NUPACE Courses and Japanese Classes

My academic term began with sitting a Japanese Language Placement test which was a prerequisite for those students wishing to enter a higher-leveled course than the beginner’s course, whereupon I was put into a level 2 course taking place every day of the week in the mornings. The daily rotation of teachers and the attempt to challenge us in different ways made this Japanese class quite worthwhile and I soon was able to notice improvements in my usage, even though the Japanese teaching methods required some getting-used-to in the beginning. Although, admittedly, the progress may very well be also be due to the high frequency in which we were to take small tests and presentations every week. In addition to the daily Japanese class I took up a weekly Kanji course which was in fact the only one I could carry on visiting throughout the whole semester as it was held in the early evening on Wednesdays (after the hospital shift).
With great pleasure I signed up for some other more culturally-oriented courses of the Liberal Arts and Science Department such as ‚Japanese visual culture‘, ‚Immigration, Law and Policy in Japan‘, ‚Biotechnology‘ - where we even were kindly invited to sightsee the pretty impressive ‚Asahi Beer Brewery‘-, ‚Gender issues in Japan‘ and, my favorite, ‚Multicultural approach to current issues in Japan‘ which included the sensei taking us out on various trips to experience Japanese culture first hand and get involved.
It still saddens me that I had to withdraw from nearly all of the courses for the sake of continuing my actual studies in medicine but I am happy to have gotten at least some taste of it. Overall I look back on that time fondly.

Otorhinolaryngology (ENT)

The first two weeks of my Clinical Clerkship I spent in the department of Otorhinolaryngology during which I interned one week in Group B with the focus on facial and throat-related surgery and the second week in Group A with cases concerning ears- and nose-related diseases. Within my first day I was already put at the operation table to observe and sometimes, depending on the leading surgeon, assist in surgical interventions. There I have spent most of my time doing long hours in the OR with a nice little lunch break with other surgeons. I was very taken aback by how kindly and willingly the doctors in charge - or sometimes even an additional doctor just for me - took their time to patiently explain the undergoing procedures in the best English they could summon.
One of the first operations I assisted with was a fairly rare intervention invented and introduced by a Japanese doctor called Makoto Kano one decade ago and also one of Nagoya University’s ENT department’s specialties where they really took pride in. In this procedure developed for bedridden patients with cerebrovascular or progressive neural disease, and therefore at the risk of suffering from recurring aspiration pneumonia, a glottic closure is attained by opening the larynx via midline thyrotomy, removing major cartilages, suturing the superior and inferior mucosal flaps of the vocal cord at the midline above and below and then inserting the sternohyoid muscle flap into the open space of the upper and lower closures. Thus, with this operation after Kano aspiration pneumonia can be effectively prevented.
Another little highlight for me was that I got the chance to try all the hearing ability and vertigo tests on myself with the assistance of a very welcoming nurse. In that afternoon I determined my hearing threshold, tested my directional hearing and did the famous revolving chair experiment to detect nystagmus. I was then sent home with the endearing health warning not to listen to extremely loud music too often. The most enjoyable procedures for me were the ear surgeries done microscopically, implanting hearing aids or removing tumerous tissue or containing life-threatening infections such as exacerbated mastoiditis. I believe to have learnt a lot from the doctors during those operations.
A special characteristic of the ENT department was also its long working hours as after the already extensive operation times the department often held conferences in the evenings to present the latest research or discuss current controversial cases. The free Bento box then came as the cherry on top.

Anesthesiology

I spent the following three weeks in the department of Anesthesiology which was split into two weeks of assisting in the OR and one week in the Surgical Intensive Care Unit (SICU). Since the anesthesiologists are the first doctors to fulfill duties in the OR, their working day starts respectively early at 7:30 am with a morning conference where all of the upcoming operations were reviewed. Fortunately, I was granted the liberty to freely choose what operations I wanted to visit which means I could very well satisfy my interests in any kind of surgical field imaginable. The teaching in anesthesiology was very hands-on, I got to do many i.v. lines and sometimes also i.a. lines with some assistance of the doctor if necessary. I gained insight into all of the preparative and working steps before and during an operation, was taught the principles of general anesthesia compared to pediatric or local anesthesia. For nearly every operation a nerve block was needed to pre-alleviate the pain during and after the operation and for reducing the usage of pain medication, and that was always pretty exciting to watch as depending on the location it proved to be fairly difficult from time to time and got some of the doctors sweating with tension. When I was assigned to a particular eager doctor they also entrusted me with intubating the patients before initiating general anesthesia - my great thanks to all the surgeons that were sometimes put to waiting because of my actions and the elaborate teachings by the anesthesiologists.
In the course of my rotating around the ORs, I twice visited ‚Awake Craniectomy‘ procedures where patients with brain tumors for instance have a part of their skull removed under general anesthesia and are then awoken with an open skull in order to answer questions in relation to the doctors manipulating specific areas of the surfacing brain simultaneously. That way the surgeons are able to determine more exact surgical margins. Logically this procedure took well about 10 hours to perform.
On the SICU I mostly accompanied the doctors doing follow-up postoperative check-ups or taking care of patients suffering from rather fatal conditions. The variety of different diseases I could witness there was quite fascinating although the severity inevitability of the cases were rather tragic. Therefore, unlike in the OR, a lot of the doctor’s work included dealing with the families of the patients and sometimes having to break dire news, especially when children as patients were concerned. Since in this setting the patients were more or less awake it was more of a challenge for me to perform small interventions like doing vessel lines or other procedures but once again the doctors in charge were very patient.
Overall I was very surprised by how many practical skills I got to improve and by how confident I felt with choosing upon which anesthetic or pain drug was required in specific situations.

Obstetrics & Gynecology

My third rotation at Nagoya University Hospital was 4 weeks in the department of Obstetrics and Gynecology (OBGY). As this department largely consists of three main subgroups, Reproductive Gynecology/ Obstetrics/Onco-Gynecology, I spent an equal amount of time working in each of them.
At first, I was assigned to the ‚Reproductive’ group where I got to witness different methods of assisted reproduction such as mostly In-vitro-Fertilization (IVF) and sometimes Intracytoplasmatic Sperm Injection (ICSI). Since it is quite essential for the patients to be relaxed in IVF, the whole atmosphere of this intervention was installed to be very soothing through playing some romantic Titanic music in the background and by having the whole room only dimly but warmly lit. It was a very surreal and to some extent even comical experience that was unlike I ever witnessed in a hospital. Apart from IVF and ICSI a lot of operational Cystectomies were performed on often young patients with Endometriosis-related chocolate cysts, dermoid cysts or other. During these operations I would always assist at the table, often being in charge of the uterus manipulator. Beyond that I accompanied one of the doctors twice to an afternoon outpatient clinic shift where many trans vaginal echography check-ups were performed to detect causes of menstruational disorders/bleeding, pain or infertility.
Secondly, I was assigned to the ‚Obstetrics‘ group, the main attraction of course being delivery. As Nagoya University Hospital is a highly specialized clinic to which mostly the extraordinarily complex or exotic cases are transferred, over half of the deliveries were done through Cesarian Section and not so many naturally. And as, furthermore, this clinic was specialized for doing assisted fertilization procedures many of the pregnancies were twin pregnancies involving its many delicate complications. Luckily I was allowed to assist multiple times at the operation table for C-sections which was easily the most frightening and fascinating couple of minutes I ever had in a medical context. I am very thankful for that unique experience. Apart from deliveries I participated in many ward rounds monitoring more challenging patients before or after their deliveries and doing regular trans abdominal echographies to determine fetal parameters or containing the risks of possible complications concerning placental growth pre-eclamptic problems.
Thirdly, I joined the ‚Onco-Gynecological‘ group whose main focus was on cancer therapy. Most of my time was therefore spent in the OR again where mainly extensive tumorectomies and ‚collateral damage‘- ectomies where performed. On top of all of the above I additionally took part in some student teachings with other Japanese medical students, either practicing echography and manual delivery techniques in the pretty fancy and high-tech simulation center or improving different suturing skills on models - as it turns out, we apparently use other suturing techniques in Europe than the Japanese do. All of these teachings I found quite helpful.
Similar to the ENT department, the whole OBGY department had a once-a-week gathering in the morning learning about latest results of current research and discussing its implications for their daily practice. I remember an interesting debate going on about how advanced parental age is associated with negative effects on both mothers and offspring as recent studies have suggested that epigenetic changes in the sperm of older men might affect placental and embryonic growth for worse.
If anything I will bear in mind to become a young father and spare the mother the higher chances premature births and gestational diabetes.

Neurology

My last rotation was another four weeks in the department of Neurology. Directly from the start I was pleasantly surprised by the level of organization of my clerkship there. Right on the spot I received a very detailed schedule of my month long stay including all doctors of reference and the to-be-covered topics, so I could prepare myself.
Since Neurology is evidently a rather non-surgical and more research inclined subject my typical days involved a private morning lecture run by alternating doctors presenting either a specific disease, its pathology, clinical implications and therapy or providing me insight into their field of research, often showing me their current point of research and their lab. The topics covered in those sessions were mostly concerning neurodegenerative disease such as Parkinson’s Disease and its various differential diagnoses, Amyotrophic Lateral Sclerosis (ALS), CIDP, Guillan Barre Syndrome, forms of Polyneuropathy, forms of dementia and - another Nagoya University specialty - Spinal and Bulbar Muscular Atrophy for which Nagoya is one of the world leading research centers. Beyond that, in some mornings I was also introduced to perform EEGs and Neural Conductive Studies (NCS).
In the afternoon I always accompanied a doctor(s) to the ward and worked with them on case studies of their own patients and subsequently examining the respective patients in order to get a more hands-on input. It was quite flattering how much time all of these doctors dedicated to me and how they struggled to teach me everything in English, keeping in mind how stressed and how much their daily workload was anyways. On Tuesdays all the neurologists came together for an extensive discussion of every single interned patient’s current state and therapy. After this many hours long session, we would all go on a long ward round seeing and examining all the patients of particular interest. That was also a pretty rewarding and insightful afternoon.
Aside from my daily schedule, I was required by the head of the neurological department Katsuno-sensei to fully work and a patient’s case myself and present a wrap-up including all my results to him in a small presentation. With the kind support of another Neurologists a learnt about ‚my‘ patient’s history, his current medical condition and performed a physical examination. It was a perfect avenue for me to deepen my knowledge about CIDP and the patient’s rather are form of ‚Neurofascin 155-IgG4-positive-antibody type‘ and brush up all the possible differential diagnoses and do a neurological examination. After presenting my case Katsunosensei took his time to further discuss this disease and to give me valuable feedback. I am very grateful for that.

Looking back on my semester here in Nagoya I can confidently say that it has effortlessly met if not exceeded my expectations. A great deal of thanks is to be owed to everybody included in organizing NUPACE and to all of the doctors and kind secretaries that were at any time more than eager to help with any problem I may have faced.

Thank you very much,
Robert Kilzer, Technical University Munich

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