Clinical Exchange in Japan

Introduction
 My name is Maja Nackenhorst and I am a 5th year student of the Medical University of Vienna. The Medical University of Vienna offers a large variety of possibilities to go abroad but for me it was crystal-clear that I wanted to spend the winter semester of 2016/17 in Nagoya. I have always wanted to visit Japan and have not managed to do so until this year, so my choice of destination was down to Tokyo or Nagoya, the two Japanese cities with partner programs for Viennese students. Several friends who had taken part in the NUPACE program in prior years highly recommended it and it is this that made me chose Nagoya over Tokyo. And I am very glad I did. Everything has been extremely well organized, all questions have been quickly answered and all arising problems were tackled and a convenient solution was searched for. Nagoya Daigaku is a great university and its hospital is a first-class teaching hospital. All the doctors were extremely capable, kind and happy to share their knowledge.

Neurology
 My first department was the department of Neurology which I entered together with Maximilian Mahrhofer, a fellow student from my university. On our first day, we were kindly greeted in the International office of the Tsurumai Campus and taken to the department by Dr. Hasegawa, who has been an immense help throughout all internships. The internship in Neurology was extremely well structured and we received a schedule for the four weeks to follow right in the beginning. The schedule was divided into a morning lecture every day and either ward rounds, lectures or study time in the afternoon and always said who the doctor that was in charge of us that day was. Therefore we never felt lost or had to look for someone to show us something. All doctors spoke English very well and communication was not problematic at all, even though my Japanese was limited to put it mildly. Probably the most exciting part of the Neurology internship was our three-day stay at Toyota Memorial Hospital from October 12th to October 14th. Under the care of Dr. Ito, who even spoke German, we got to see primary care neurology with a lot of stroke patients and two very interesting rare cases. One was a patient with recurrent ischemic strokes due to a papillary fibroelastoma and one was an unexpectedly fast growing aneurism that developed within days and eventually burst leading to an intense emergency operation. As the Neurology department in the Nagoya University Hospital is very specialized and has mainly neurodegenerative disease patients like Multiple Sclerosis patients, Sjögren’s syndrome neuropathy patients and even a case of Creuzfeld-Jacobs-Disease, it was nice to see the more common clinical presentations of typical neurological patients for a change. As far as the learning experience goes I feel that I have learned and seen new things and that I am not behind on knowledge compared to my fellow students in Austria. The morning lectures ranged from genetic topics like triplet repeat diseases to pathological ones like PNS pathology to more clinically relevant things like dementia. We also got to join Dr. Nakamura in the EEG room and watch the various tests performed on patients to determine muscle weakness and Parkinson’s disease. We even got to try out the smell test for Parkinson’s disease ourselves (luckily, we do not seem to have Parkinson’s). We had a review meeting with Professor Sone at the end of our stay where we discussed our stay with him as well as a case report that each of us was required to write. We both picked patients from Toyota Memorial hospital. Maximillian’s case report was about the before mentioned papillary fibroelastoma case and mine was about a patient on tPA (tissue plasminogen activator, it lyses thrombi responsible for ischemic strokes) therapy for ischemic stroke. All in all I really loved this internship because of its structure and the care everyone exhibited towards us. I would highly recommend it to other students.

Ophthalmology
 My next department was the ophthalmology department. Again, I received a schedule at the beginning which was immensely helpful. In this department I was under the great supervision of Dr. Kaneko who had spent some years in the states to acquire his PhD and therefore spoke English extremely well. He and the rest of the department went out of their way to make me feel comfortable and have a great learning experience. I was always taken out to lunch by someone and never had to eat alone, which was lovely. I got to see many interesting surgeries and even got to assist in a couple. Eye surgeries are different from “normal” surgeries in several aspects. The one most noticeable for me was the relaxed atmosphere in the operation room. As well as the fact that you every operation is performed while sitting, which takes away a lot of the physical strain an operation puts on the operator. All operations are very short and I have not witnessed one longer than one and a half hours which makes them fun to watch and easier to pay attention. By far the most common operation was the cataract procedure followed by vitrectomy. One very interesting case was a woman who had endophthalmitis following a cataract surgery which is extremely rare. I was absolutely delighted when a group of young doctors offered to take me to their training facility and practice cataract surgery on pig eyes. There are several companies that work together with the ophthalmology department and provide them with possibilities to train their surgical skill on pig’s eyes. So one evening we went to one of them and I got to practice my cataract operation skills. It was an amazing and fun experience and cataract surgery, which often takes no longer than ten minutes, is a lot harder than it looks. When I joined doctors for the outpatient clinic and watched them perform routine checks they would always explain in great detail and supervised me in the use of ophthalmic tools like the ophthalmoscope. On Monday nights the department had its weekly meeting and because of me it was held in English. I was even invited to tag along to a big conference in Kyoto on the weekend. In the end I couldn’t go because I had already made travel plans that weekend but I loved the invitation. The kindness and devotion of everyone made this internship the great experience that it was. I would absolutely recommend this internship to other students as well.

Otorhinolaryngology
 This department followed my two weeks in ophthalmology. It has two groups, A and B, where the A-group takes care of non-oncological cases and the B-team is responsible for everything involving oncology. On my first day I was kindly taken in and almost immediately taken to the operation room as there was a huge tumor operation taking place that involved the removal of the tumor itself as well as a neck dissection and plastic reconstruction of the area in a collaboration between otorhinolaryngology and plastic surgery. The operating doctors were very kind and explained everything that was going on in English to me. On my second day I was taken to the outpatient clinic and saw a lot of patients ranging from tumor patients to fistula patients. I later got to assist in the removal of a fistula as small procedures were also conducted during outpatient clinic time. I also watched and eventually got to perform the sonography of the head and neck region to detect cancer, cysts and other growths. Over all, I spend most of my time in the operation room, often getting to assist in the operation and only doing outpatients on Tuesdays. Every Monday and Tuesday night there were meetings in this department where cases would be discussed and presentations were held. Again, most of the time people took the effort of speaking English solely for my benefit. I really appreciated this, as it is in no way to be taken for granted and I should be the one to take greater effort in learning Japanese. The one downside to these meetings was that they started at six or seven p.m. and went on until eight or nine p.m. which makes for a very long day if you start at eight in the morning (which in itself isn’t that early but you have to take into account the 45 minutes it takes to get to the hospital from the Higashiyama campus site).

Gynecology
 The gynecology department is divided into three subsections, Gynecological Oncology, Reproduction and Fertility and Obstetrics. On our first day we could choose where we wanted to spend our time. I decided to spend two weeks in obstetrics and two in reproduction and fertility. The first day we were shown around the department and got a glimpse of the different sections. I was very excited to assist in my very first caesarian section on my second day. I must admit that gynecology was never one of my favorite subjects and that my knowledge is rather basic in this field. But the doctors explained everything in a very comprehensive manner.
 There are many reasons for the decision to deliver a baby through a caesarian like an unfortunate position of the placenta, a rotated position of the fetus, or certain conditions of the mother and many more. As Nagoya University Hospital is the biggest hospital in the area and also a teaching hospital it naturally has a large percentage of problematic pregnancies that often result in C-sections. In this procedure a cut is made into the abdomen (usually a transverse on but there are reasons for making it a vertical incision as well), the uterus is found and cut open and the baby is delivered through this hole. By far the longest time of the operation is spend stitching the uterus and abdominal wall back together after the delivery. Another interesting procedure I got to witness was Amniocentesis where a sample of the amniotic fluid surrounding the baby is taken for testing (for chromosomal abnormalities like trisomy 13, 18 and 21 for example). Once, they even performed the extraction of fetal pleural effusions through amniocentesis, which was quite interesting as it requires very exact sonography skills. After two weeks in obstetrics I switched to reproduction and fertility. This was another great experience as I got to see in vitro fertilization, which was something completely new to me.
 The doctors went out of their way to give us a great learning experience and not only showed us their daily routines but also went to the surgical practice room with us, where we could perform robotic surgery with the da Vinci surgical system.

Conclusion
 I greatly enjoyed my time at Nagoya University! Not only were the internships at the hospital extremely enjoyable but the NUPACE program enabled me to have an amazing experience on a personal level as well. Being housed in the Higashiyama International Residence, I had the chance to meet exciting and fun people in the same position as I was every day. Especially in the beginning this was great as one never felt lonely and could always discuss issues and possible solutions with the others. The NUPACE office offered massive help as well and without them we would have been completely lost. The one thing that I found disappointing was the fact that as a medical student I was unable to take any of the Japanese classes offered within the program (safe the class at Tsurumai campus once a week where not even all the hiragana were covered in a span of three month and business Japanese which is not only slightly useless for a medical students but also very advanced). I had taken Japanese classes before I came here and really wanted to continue my studies as knowing the language of a country where one lives is not only vastly helpful but also makes the experience so much more immersive. But none of the Intensive or regular courses were available in the evening and even though I looked thoroughly, I could not find a good and affordable class outside of the university. The other thing that could be improved is the fact that we often got very short notice of having to be somewhere and sign something until a certain deadline (at the NUPACE office or the international office etc) with the opening times being rather inconvenient if one is in the hospital from 8:00 am to 6:00 pm during some weeks on a different campus. If these notifications would be send further in advance it would be a lot less stressful for the medical students in this program to make it in time. But those are really my two points where I felt improvements could be made. I can only repeat myself and say that this has been an absolutely incredible experience that I will never forget. I also had a lot of fun at the organized trips in which I participated: the guided Mirin-Brewery tour and the trip to NIDEK, a company that produces ophthalmological equipment. They were fun and creative ideas and were very well executed. Another thing that I absolutely have to mention is the great tutor program. I had two tutors, Mirai Hozumi, a medical student from the fifth year like me and Hirokazu Yamada from the second year (I am not entirely sure why I had two but I assume one was officially designated by NUPACE and the other is from a volunteer program). Both of them have been so incredibly helpful and kind, taking me to parties, events and club activities that I would have never been able to experience without them. Hirokazu for example took me to Kendo class, which was something that I wanted to experience really badly. I am very glad I participated in the NUPACE program and I will take many things from it to hopefully become a good doctor and a cosmopolitan person.