Clinical Exchange in Japan

The experience at the Department of the Ophthalmology

The department where I began my internship at Nagoya University Hospital was the Clinical Oncology and Chemotherapy Department, where Mr. Yuchi Ando was a professor. I chose this department for the first part of my internship because I am very interested in the field of oncology; it is one of my future specializations.

A day on the ward began with a medical team meeting in the daytime chemotherapy room, where we reviewed the profiles of patients arriving for treatment that day. After the meeting, Professor Yuichi Ando or Professor Osamu Maeda, and I would proceed to the examination room, where I would be briefed on the medical history, including additional tests (primarily imaging) and diagnoses, of the patients who arrived for treatment that day. We would then conduct a brief medical interview and perform a basic physical examination, ensuring they were able to safely begin their next chemotherapy dose. Other daily activities depended on the specific day and the schedule.

Every Tuesday, an online meeting took place at Nagoya University Hospital, connecting with specialists from other locations in Nagoya and Japan. The meeting was held as part of a research study on targeted therapy in oncology. Patient characteristics were presented, along with the identified and, importantly, detailed mutations for specific therapies. As a medical student, I found this very interesting, as it introduced me to the importance of targeted therapy in oncology, the enormous investment required, and the broad scope of research and improvement of these therapies, ultimately leading to the adoption of standard treatment, which is my strength. On the other hand, it was very insightful for me to learn about dozens of mutations that can occur not only in the same type of cancer, but also within a single tumor mass in a specific patient. During these meetings, I was able to document many gene mutations, which I later explored further during my own studies and compared between cancers of the same type and also between cancers of different types and kinds. Thanks to Professor Ando's kindness, I was also able to actively participate in an experiment involving DNA purification from tissues using the QIAamp DNA Mini Kit. While it's supposed to be a simple and quick experiment, it was the first time I'd had the opportunity to perform something like this, so I consider it an important lesson, especially considering the emphasis on genetic research and targeted therapies in oncology.

During one of my days on the ward, after a morning meeting, I was also introduced to the therapeutic processes of rehabilitation and physiotherapy for oncology patients. I was shown the equipment loaned to patients, which, among other things, monitors and assesses their mobility parameters. I was introduced to the methods of patient activation used by the hospital staff to support their therapy and recovery. I also listened to a short but informative lecture on the value of rehabilitation and patient activation during and after cancer treatment, and how important it is as a component of patient care. This made me understand that as medical staff, we must approach patients holistically to achieve overall well-being, while also considering the effects of cancer treatment after full remission.

Another highlight of my internship at the Clinical Oncology and Chemotherapy Department was my introduction to a rare gynecological cancer: high-grade endometrial stromal sarcoma, a very rare and aggressive type of cancer. I was initially introduced to the medical history of this case by Professor Osamu Maeda. Importantly, I was informed that the patient had been enrolled in a clinical trial of a drug called BGB-43395, a selective cyclin-dependent kinase 4 (CDK4) inhibitor. This trial compares the efficacy of this drug as monotherapy or in combination with other drugs (fulvestrant, letrozole, elacestrant) in patients with HER2-/HR+ breast cancer and other advanced solid tumors. This is the basis for the patient's eligibility for the trial. After a brief introduction, we visited the patient for a brief medical interview and a basic physical examination. Afterward, we waited for the patient to be administered the drug being tested in the clinical trial. The drug was administered orally in tablet form. On the day of administration, we visited the patient several more times to check on her well-being after the drug administration and to measure her vital signs. Learning about this patient's case was the most valuable experience for me during my three-week stay at the Clinical Oncology and Chemotherapy Department. It was the first time I had been so closely involved in a clinical trial. I was able to see the rules governing such a study, the number of formalities and consents required during trial-related procedures, and finally, the degree to which we must intensify patient observation before, during, and after administration of the drug or preparation being tested. This will undoubtedly be an incredibly important lesson for me for the future, when I will be involved in clinical trials as a specialist in my future field.

Of course, thanks to the kindness of the team at the department, there were also plenty of experiences and impressions outside the department itself. At the end of my internship, I was invited to the Nagoya University Medical Museum, where I could learn about the history and development of medicine in general, by examining medical equipment used in earlier years, as well as about the history of Japanese medicine, presented through old textbooks and paintings depicting medical procedures. The history of Nagoya University Hospital itself and many important and colorful figures associated with Nagoya City were also explored. Also a restaurant near the hospital, next to Tsuruma Park, proved to be a crucial point for my continued stay in Nagoya. One of my colleagues introduced me to it one day during lunchtime. It was the restaurant where I ate delicious tsukemen, and I visited the place many times before my departure, deeming it one of the tastiest during my trip to Japan.

My three-week internship at the Clinical Oncology and Chemotherapy Department fully met my expectations. There was no shortage of patient meetings or interesting activities during the week, just like those described above. I also had the opportunity to work independently, which allowed me to reflect on and consolidate what I heard, saw, and experienced, and in many cases, expand my knowledge on the topic. My stay on the ward was perfectly balanced, giving me time to acclimate to a new country and my new workplace. We concluded our stay on the ward with a souvenir photo, and I also received a gift: a pen with a stamp with my name in katakana. The people were incredibly kind to me throughout the three weeks, so coming to the hospital was a truly enjoyable experience every day, for which I am very grateful.

The second department I visited during my internship in Nagoya was the Laboratory of Molecular Oncology, headed by Professor Hiroshi Suzuki, where I spent four weeks of my internship. I chose this laboratory as one of the departments I would like to visit during my internship at Nagoya University Hospital because of my interest in oncology, particularly its molecular aspects and tumor immunology. I combine my future career as a physician with laboratory work, and during medical studies in Poland, time for classes where we can familiarize ourselves with laboratory work, performing various experiments, and basic research is limited, which is why I was very keen to spend part of my internship in such a laboratory.

My planned laboratory schedule was carefully planned from the very beginning of my stay. It involved spending several days with a specialist who would present his research interests, introduce me to the topic he was currently working on in the laboratory, and demonstrate experiments and laboratory techniques that he applied daily in his professional practice. This allowed me to better immerse myself in the life and work of the department, and familiarize myself with and independently conduct many experiments in basic research.

In the first week, I had classes with Professor Koichi Ogami, who introduced me to various experiments related to working with DNA, including DNA amplification, PCR using the KOD-Plus-Neo kit, which is very efficient, DNA extraction, and techniques for joining DNA strands with bacterial plasmids.

In the second week, Dr. Watanabe Yu and I worked with kidney biopsy samples, first collecting glomeruli to compare the renal tubules and the glomeruli themselves. Later in the experiment, we amplified the DNA contained in our samples using qPCR. Finally, we examined the NPHS1, CD31, SLC22A8, VCAM-1, and GAPDH genes and analyzed them in our samples using various dilutions. The experiment was a success, confirming not only our assumptions regarding the presence of individual genes in the DNA of the tested samples, but also confirming that conducting a series of complex experiments, as in this case, is not doomed to failure when provided with good instructions and expert assistance. (Experiment results, in the form of sample analysis, are shown in the photo below.)

Another important series of experiments at the Laboratory of Molecular Oncology involved cell culture experiments. In this case, these were HEK293T cells, or human embryonic kidney 293 cells, which are characterized by very rapid growth and the ability to be transfected. Transfection was the next step in our experiments, ultimately allowing us to subject them to Flow Cytometry, where we measured the parameters of the cultured, modified cells. To my delight, this experiment was also successful. It was a valuable experience for me, arguably the most important one I was involved in during this part of my internship. The value of this experiment was so high for me because just before I left for Japan as part of the NUPACE program, at my home university, we had planned a study on cell cultures, including HT22 hippocampal cells. Thanks to a series of experiments on HEK293T cells at the Laboratory of Molecular Oncology, I was able to gain experience in working with cell cultures, I was able to observe the culture techniques, the equipment used by the workers and, most importantly, I was able to observe how much care and caution cell culture requires, and in particular, how much work needs to be put into ensuring sterile working conditions to avoid contamination of the cultured cells, which sometimes do not grow as fast as the aforementioned HEK293T cells.

During the next two weeks, experiments no longer required more than two days, so the people presenting the topics changed more frequently than during the first two weeks. Thus, in the following days, I performed many interesting basic research experiments under supervision and with assistance, including electrophoresis, Western Blot, detection of ecDNA using FISH analysis, protein purification, SDS-PAGE, and cDNA synthesis.

During my time at the Laboratory of Molecular Oncology, I also received a very warm welcome from my colleagues. During my first week there, we had a lunch together in the laboratory, where we ordered sushi, allowing me to try my first sushi in Japan. At the end of the four-week internship, after completing our experiments, we went to a nearby restaurant, where I tried a variety of Japanese delicacies that I had never had the opportunity to try before, or again during my time in Japan. This dinner was almost as interesting experiment as the ones we performed in the laboratory.

I won't deny that this part of the internship was probably the most demanding and intense of my entire stay at Nagoya University Hospital, mainly because many of the experiments I performed sometimes lasted hours, so the workday often ended late in the evening. This, combined with the weather, which was constantly changing to very hot, took its toll. However, I am grateful that I was able to complete the longest part of my internship at the Laboratory of Molecular Oncology. Although we primarily engaged in basic research, as in most laboratories, the simplest experiments, which allow us to obtain DNA, RNA, and purified proteins, are still essential for conducting many scientific studies in the laboratory. Therefore, the knowledge and experience, including practical experience, I gained will certainly be useful in the near future when I return to my university and pursue the aforementioned research. Reflecting for a moment on the value of this part of the internship, I come to the conclusion that it could have been the most important part, because I still have many hours of classes in clinical departments and many lectures and books to absorb, but I will no longer have the opportunity during my studies to learn about laboratory work in such details and to observe and perform as many experiments as I did in the Laboratory of Molecular Oncology at Nagoya University Hospital.

After seven weeks at Nagoya University Hospital, it was time for my penultimate department: the Neurology Department, headed by Professor Masahisa Katsuno. My third choice was this department, in part because I'm fascinated by the field of psychiatry. Unfortunately, due to the language barrier, I couldn't complete part of my internship in the psychiatric department, as medical staff-to-patient communication is crucial there, which would have been very difficult without my knowledge of Japanese. However, there are some common areas between psychiatry and neurology, such as dementia and neurodegenerative diseases, so I decided to choose the Neurology Department. Furthermore, I had just completed a neurology course at my university, so I thought it would be a great idea to refresh and consolidate my knowledge in this field, but also to compare department work, diagnostic procedures, and treatment methods between such distant places as Poland and Japan.

My internship at the Neurology Department consisted of daily classes, with morning and afternoon sessions, and self-study periods. The classes varied not only in topic but also in their delivery. It's worth noting that each class was taught by a different teacher, allowing me to explore a wide range of topics, sometimes from different perspectives. Lecture topics included molecular biology, ALS, Parkinson's disease, dementia with Lewy bodies, dementia, spinocerebellar ataxia, multiple system atrophy, and muscles. Ward rounds were also held every Tuesday. These involved a team meeting, including medical students, in the Neurology Department office to discuss all patients' profiles, diagnoses, additional tests and imaging, primary and secondary symptoms, and changes that had occurred over the past week in patients who had been in the department for a longer period. The entire team then proceeded to the ward, where they divided into two groups to visit patients, conduct brief interviews, and perform neurological examinations. Due to the large number of patients and beds in the Neurology Department Ward, the rounds were very long, but the second part, especially the one at the patients' beds, was particularly educational. I learned new things repeatedly and was able to observe pathological reflexes and characteristic symptoms specific to a given disease. Due to the highly specialized ward, the patient cases were truly interesting, and due to the differences in disease prevalence in Japan and Poland, I was able to observe symptoms and reflexes I had never observed before, even in neurology classes at my hospital.

One of the classes the clinic planned for me also included a session on electrographic examinations, specifically electroencephalography (EEG) and electromyography (EMG). Dr. Suzuki led the class, introducing me to EEG and EMG with a short lecture. Dr. Suzuki happened to have several EMG examinations scheduled for that day, so we saw patients together, with whom we briefly interviewed them before the examination, and then proceeded to the examination itself. I had learned about EMG during my previous years of study, but I had never had the opportunity to see a live examination performed with a patient. Furthermore, during the EMG, the doctor explained the results of the monitor recordings, the variables we needed to consider during the examination, and how to avoid potential artifacts.

During my second week of internship at the Neurology Department, one entire day of my classes was devoted to amyotrophic lateral sclerosis (ALS), a very difficult disease to diagnose and incurable. To my surprise, Nagoya University Hospital had a relatively large number of patients with or suspected of ALS, whereas in Poland I had only encountered one patient with suspected ALS. The morning ALS classes were led by Dr. Yokoi, who introduced me to the disease in detail and then immersed me in his research, which focused on the molecular aspects of ALS. These were very complex but fascinating topics. At the end of the lecture, the doctor showed me cell cultures that grow for about three months. Observing these cells was valuable for me because of the aforementioned planned study at my university in Gdańsk. While showing me these cultures, the doctor also emphasized the importance of extreme caution, as neuronal cultures are very difficult to maintain. This was a valuable lesson for me. Dr. Daisuke Ito then led my afternoon session, with whom we addressed the topic of ALS from a more clinical perspective. He introduced me to the complex diagnostics and treatment methods for this disease, and then we visited patients who had suspected or already had the disease. The entire day was well-planned, allowing me to gain a more holistic perspective on this difficult and interesting disease, as well as on the ALS patients I have seen and may see in the future.

My main task during this part of my internship was to write a case report based on the medical history of one of the patients. I selected the patient to describe during the first ward round. In the following days and weeks, I also had case study sessions, where I was able to expand my knowledge, including on this particular case. The case was very complex, meeting the criteria for several diseases, including ALS. Despite the difficulties, I managed to complete the case report by the end of the neurological portion of my internship. On the last day, I presented the described case to Professor Masahisa Katsuno, with whom we discussed and discussed further diagnostic and therapeutic steps for this patient. Although the patient hadn't received a final diagnosis by the time this part of my internship ended, the process of gathering information, reading the source materials, writing, and finally discussing the case was very educational. This wasn't the first patient case I'd described, but it's an element of a physician's work that should definitely be practiced.

The part of the internship that took place at the Neurology Department was well planned; I had time to learn new topics and study on my own. The system of dividing classes into mornings and afternoons was very convenient and allowed me to organize information and rest between classes. This made me feel more efficient in absorbing information and, thanks to this, I gained a lot of knowledge from this part of the internship, which I will certainly need both in the following years of my studies and in my future professional career.

The final department where I completed my internship at Nagoya University Hospital was the Hematology and Oncology Department. Professor Hitoshi Kiyoi heads this department, but my internship was led by Dr. Yoko Ushijima. I chose this department primarily because of my interest in oncology, as I had only encountered the hematology department in Poland during my pediatrics classes. However, my choice was also influenced by the fact that the elements of hematology covered in other courses during my studies never quite made sense to me, leaving me with many uncertainties. Therefore, wanting to delve deeper and expand my knowledge of hematology, I chose this department.

My internship schedule in this department was similar to that of the Neurology Department, with morning and afternoon sessions, but without predetermined topics. This was the department where I saw the most patients, as each session involved the doctor first providing a detailed medical history of the patient, explaining details or the mechanism of the disease if necessary. Then we went together to see the patient, with whom we conducted a brief interview and, in some cases, a basic physical examination.

One of my favorite classes, not only in the Hematology and Oncology Department but throughout my internship, were with Dr. Negishi. He discussed topics such as myelodysplastic syndromes, acute myeloid leukemia, and the double-hit theory of leukemia. He also talked to me about several other diseases, such as chronic myeloid leukemia, polycythemia vera, and essential thrombocythemia. There was nothing extraordinary about these lectures, as they dealt with clinical issues, like many other lectures presented to me during my internship, but Dr. Negishi had an unparalleled ability to impart knowledge, explaining concepts in a way that made complex concepts or mechanisms seem completely simple and easy to understand. This is what made these lectures and these classes so great.

In addition to lectures and clinical case studies at the Hematology and Oncology Department, I had the opportunity to observe several medical procedures that are frequently performed in hematology departments, but which I had not yet experienced. Among them was a lumbar puncture, which I had witnessed exclusively in the pediatric ward, but never in an adult ward. I was able to observe several differences between this procedure performed on adults and children. The most prominent difference was the use of analgesic sedation in pediatric patients and only local anesthesia in adults. It was also educational for me that the first lumbar puncture solely collected cerebrospinal fluid for further testing, whereas the lumbar puncture performed the following day primarily aimed to reduce the amount of cerebrospinal fluid through aspiration to allow for the administration of anticancer drugs to the patient.It seems rather mundane, but even though I hadn't previously encountered lumbar punctures, even these two different applications of this procedure truly changed my thinking about it. Another medical procedure I had the opportunity to witness, albeit very briefly, was the administration of genetically modified T lymphocytes to patients undergoing CAR-T therapy.

During the second week of my internship, a ward round took place with the department professor, attended by medical students from Nagoya University. Honestly, this event didn't teach me much about hematology, also because only a limited number of people can see hematology patients at a time, so it was usually the professor and two students from Nagoya University, who presented case reports on the patients they saw during the ward round.This was an interesting experience for me because I was able to observe a real-life part of the medical students' classes at Nagoya University. I could notice differences in the way the teachers conducted the classes, the students' behavior during the classes, and the teachers' approach to the students. In this respect, it was also a valuable lesson. The only drawback of this lesson was that it was conducted entirely in Japanese, but fortunately, one of the doctors was also present, helping me understand the course and explaining the most important points.

My additional task during the internship was to write a report. The topic of my thesis was "The Role of CAR-T Cell Therapy in Relapsed and Refractory DLBCL: Efficacy and Toxicity in Contemporary Clinical Trials." This therapy is one of the most advanced anticancer therapies used in hematology today. My task was to compare three clinical trials to assess the efficacy and safety of three leading CAR-T products: axicabtagene ciloleucel (axi-cel), lisocabtagene maraleucel (liso-cel), and tisagenlecleucal (tisa-cell) in patients with relapsed or refractory DLBCL. Dr. Furukawa supervised the writing of my thesis. During the first week of my internship in the Department of Hematology and Oncology, I discussed the topic and details of my report. During the second week, we discussed my progress, addressed any doubts, and answered any questions I had about the topic. We also went to talk with patients undergoing CAR-T therapy at Nagoya University Hospital at the time. It was interesting to observe many of the "textbook" side effects of CAR-T therapy in these patients. Finally, on the last day of the third week of my internship in the department, and indeed of the internship overall, I presented my completed thesis to Dr. Furukawa, after which we discussed and discussed it. Nothing develops a person like independent work, and because I had the space to explore the topic of CAR-T therapy, learning not only from the theoretical but also the clinical perspective, I know it will remain in my memory for a long time.

Another issue that stuck with me was the issue of single rooms in the hospital. During one of my days on the ward, Dr. Ushijima took me to a patient in the Hematology and Oncology Department to conduct a brief medical interview. This patient was in a completely different location from the rest of the ward. After speaking with the patient and leaving his room, Dr. Ushijima explained that if the patient so desired, if they wanted to increase their comfort level, they could pay extra to stay in a single hospital room. This was quite a surprise to me, as I had never before encountered such an option in Poland to pay extra for a single room in a public hospital. Noticing the differences between what happens in our university hospitals and the overall operating systems of these hospitals was very interesting for me, as it sparked ideas that could lead to future improvements to these systems if the new solution proved to work better than what we were currently familiar with.

To be honest, the Hematology and Oncology Department wasn't my first choice for the final department of my internship. I chose it, as I mentioned above, primarily because of my interest in oncology. However, I consider the time I spent there to be very valuable, not only in terms of gaining medical knowledge but also thanks to the other experiences I mentioned, including observing Japanese students' classes and attending Dr. Negishi's excellent lectures. I also greatly appreciated that my internship schedule was designed so that my internship period in the department was highly focused on the clinic, where I learned about a wide range of diseases and saw a significant number of patients daily. In previous departments during my internship, I also had contact with patients, but there was less of it than in this department.

Although I could only choose four departments for my internship, thanks to the kindness of Professor Hideki Kasuya, who favorably approved my request to pursue my interests in psychiatry, I had the opportunity to have a series of meetings with Professor Branko Aleksic, an excellent specialist in psychiatry. During our meetings, we discussed numerous topics in psychiatry, including those very specific to Japanese society, such as death from overwork and also the Kraepelinian dichotomy, schizophrenia, the pharmacology of selected diseases, as well as the possible academic path I could pursue, for example, at Nagoya University after completing my medical studies in Poland. During these meetings, we also analyzed various scientific studies, which I had developed into presentations, allowing us to discuss and discuss them more easily and in greater depth. These meetings truly taught me a great deal, not only about psychiatry itself but also about research analysis and preparing presentations based on research. I am incredibly grateful to Nagoya University, and especially to Professor Branko Aleksic, for allowing me to participate in such meetings.

Here, I'd like to highlight a few drawbacks, obstacles, and weaknesses of the internship as a whole, as not everything was perfect. One of the main drawbacks and, at the same time, the biggest barrier to absorbing knowledge from the specialists at Nagoya University Hospital was the language barrier. It was understandable to me that few patients were able to communicate with me in English, but often during classes or lectures with various doctors, physicians, or specialists in their fields, we found it extremely difficult to communicate, often requiring the use of speech translation applications to maintain conversation. I fully understand that not everyone needs to be able to communicate in English, but after completing all the blocks, I can say that when planning my internship, individual departments should take into account the fact that a member of staff doesn't speak English and not burden them with conducting a lecture in English for me, an English-speaking student. I met many doctors, physicians, and Nagoya University Hospital medical staff who were fluent in English, and conversation, teaching, or lecturing were no major problem for them.

Another major issue for me was sometimes excessively long breaks between classes. During the Clinical Oncology and Chemotherapy Department and Molecular Oncology portions of my internship, this wasn't a problem because I had more freedom, where I simply set the length of my lunch break myself, like other staff members, and then returned to the department, or the daily schedule was dictated by the experiments. However, despite the schedule in the Neurology Department and the Hematology and Oncology Department, which I really liked, it also posed a problem. There were days when either the planned break between classes was several hours long, or the morning classes ended earlier than planned, leaving a gap of several hours between the morning and afternoon classes. This gap was both too short for me to return to my dormitory and rest, but also too long for necessary activities like eating lunch or consolidating knowledge from the morning sessions. I believe these classes could be more condensed in time, as waiting several hours often leads to the opposite of the intended effect. Instead of resting and resetting, we start to tire and lose energy.

The last issue I considered a drawback was a more technical one. I believe there should be the option to choose a fifth department for the internship. I believe this option should exist because it wouldn't have to be mandatory, as some students prefer to spend longer in one department, being more determined about their future and specialization, while others, like myself, are still searching for their future path. After completing my internship, I believe that if I had shortened my time in two selected departments by a week, I wouldn't have lost much in relation to those departments, but I could have gained a great deal by learning about a new department and working there, a prime example of which was the Neurology Department. I wasn't sure I wanted to pursue neurology in my future, but now I'm reconsidering it as my future specialization, thanks to my internship at the department at Ngoya University Hospital.

Ultimately, summing up my entire internship at Nagoya University Hospital as part of the NUPACE program, I can say that despite some drawbacks, this adventure had countless positive aspects that definitely outweighed the less significant negatives. From the opportunity to learn about hospital operations in Japan, the work of doctors, the conditions of studying medicine, working in the laboratory, new diagnostic procedures, new therapies, and ways of treating various diseases, to being so close to clinical trials and scientific research, participating in such incredibly interesting meetings, and finally, simply to the very warm welcome in every department, full of wonderful and helpful people who crossed my path. It's also important to remember that being here allowed me to live, experience the culture, and explore such a beautiful country as Japan for such a long time. I know that for many people, this is an unattainable dream, but I achieved it, for which I am incredibly grateful. The trip cost me months of hard work beforehand, both to complete my fourth year of studies at my university and to logistically plan such a long trip to the other side of the world. However, I now know that despite the hard work both in Poland beforehand and in Japan during the trip, it was a wonderful time that taught me countless things, from which I learned countless lessons, and which I will fondly remember for the rest of my life.