Clinical Exchange in Japan

Neurology
 The first department I attended was neurology, where Professor Katsuno welcomed me very warmly. I was given a well-structured schedule of the following month in this department, which helped me very much in orienting myself in the first days of my clinical clerkship. The basic principle was that I had a lecture every morning, by one of the doctors of this department, followed by clinical rounds or another lecture in the afternoon. On Tuesdays there was a Grand-Round with Professor Katsuno together with most of the staff and a group of japanese medical students. On my first day I also received a tour through the hospital by one of the doctors, to help me orientate on my own in the University Hospital without getting lost.
 The staff of the neurology department was extremely courteous and they took a lot of time to make sure we students understand and learn a lot. Our lectures were held in English, which was very convenient for my due to the lack of Japanese vocabulary and they covered a broad range of topics. Usually the lecturing professor or doctor talked about his specialty or his current research project. This gave me the rare opportunity to learn a lot about ongoing trials and research, explained by the people who are conducting the studies. The topics ranged from basic research about Multiple Sclerosis, Neuropathies and Dementia to countrywide ongoing trials for new therapies in neurology. For most of the diseases covered in these lectures I had the chance to see actual patients on the ward suffering from them. Since Nagoya University Hospital is a tertiary clinic with a high specialization, I was able to see some rare diseases and this will definitely improve my skills as a future doctor. The time at the ward was depending on the number of new patients and their diseases. I got to see patients with Chronic Inflammatory Demyelinating Polyneuropathy, Myasthenia Gravis, Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Parkinson Disease, Guillain-Barrè-Syndrome and others. Especially watching the doctors perform the neurological testing helped my understand the complexity of the diseases. The staff was always trying to explain the details about the patient and answered my questions for therapies and symptoms. If possible I also got the chance to examine patients myself, check reflexes and rigidity or watch advanced tests like a lumbar puncture. I also had the possibility to see doctors perform an EEG, Nerve Conduction Study or Electromyography. Watching patients undergo an full EEG gave me an interesting insight on both the doctors and the patients side. One of the highlights of my rotation at the neurology department was the three-day stay at Toyota Memorial Hospital. Dr. Ito invited us to spend three days at his department and the amount of time he and his staff invested in us was incredible.
 Since the Toyota Memorial Hospital is different in his structure than Nagoya University Hospital, I got the chance to see a different spectrum of patients and diseases. Especially the possibility to see acute stroke patients made this a very valuable experience. The doctors treated me as part of their team and tried to give me a good overview of their work. I went to the OR, where I watched the neurosurgeons operate, saw patients at the Out-Patient Clinic, went on rounds and also received lectures by the staff. Toyota Memorial Hospital offers a high-level care, with the luxury of a very well equipped hospital and great staff. Since Dr. Ito took such good care of me, and even gave me the opportunity to go to dinner with the department, this was definitely one of my most favorite things during my stay. On certain days I had study-time at the library, which gave me the chance to read up on certain topics or do some research. Professor Katsuno also held review-sessions for us exchange students, where we could talk to him about problems or wishes that we have had and he tried to make our stay at his department interesting and educating, which he definitely achieved. To sum it up I have to say that the neurology department and its members enabled a great start into this program for me and I really enjoyed my time there.

Pediatrics
 My stay at the Department for Pediatrics was split in to two rotations, first starting with neonatology followed by general pediatrics each for two weeks.Since neonatology is not a very prominent subject in my home university I was very excited about this department. The staff was again very welcoming and from the first minute I felt treated very well. The neonatology consists of the Neonatal Intensive Care Unit (NICU) and the Growing Care Unit (GCU). At the NICU I was able to see lots of different cases and since most of them stayed for over a week I had the chance to get familiar with their problems and follow up on their development and treatment. The close connection to the Department of Pediatric Surgery made it possible for me to witness a number of surgical cases as well and see the close collaboration between these two specialties. Within these two weeks I attended two Cesarean Sections and had hands-on time in the immediate care of infants.
 The first case was a Placenta Praevia and the second one was a triplet-pregnancy. These events at the OR showed me a different side of this specialty and taught me much about neonatology.
 At the daily rounds I saw different post-operative patients (Omphalocele, Gastroschisis, Gastroesophageal Atresia) and infants with problems like low birth-weight or NEC. On Thursdays I was invited to attend the medical conference, which covered the new admissions of the last two weeks for the entire pediatrics department. After the conference where the chiefs explained about certain problems and solutions it went on with the rounds on the hematology ward, for which Nagoya University Hospital is famous. The cases there were mostly severe and pediatric hematology is in my opinion one of the emotionally most challenging specialties. Professor Takahashi explained a lot about the different treatments as well as the prognoses and he also made sure to have close contact with the parents to answer all their questions. The GCU is a concept that I have never seen before and that takes care of older children in need of consistent medical therapy, mostly ventilation. I got to see some patients there as well and was encouraged by my supervising doctors to perform examinations and check-ups. Since most patients stay there for a long time, up to years, the personal level of care in this unit, is very high. The time at the neonatology department was definitely very educational and helped me to gain a glimpse into this unique specialty and their tasks. The second part of my stay was at the general pediatrics, which mostly consists of the subspecialties cardiology, neurology and infectious diseases. Dr. Kato was my medical supervisor and he took very good care of me and I always had somebody who was responsible for me. My schedule consisted of lectures about special topics but also general things like the Japanese screening system or vaccinations, and rounds at the ward. The patients showed a broad range of diseases like Tetralogy of Fallot, Status post Transplantation, Coma or Cerebral Palsy. A big part of the pediatrician’s tasks was communicating with the parents, which I also got to witness. With the pediatric neurologists I saw EEG performances and was taught how to evaluate them. They also spend a lot of time with research and the multidisciplinary work in this field was very interesting. I learned from a number of doctors and was able to experience the important work they are doing first hand. In conclusion I have to say that the pediatrics department was treating me very kindly, I even got to attend two of their after work events, which showed me a side of Japanese working culture that I will surely miss back at home. The job these doctors are doing in the hospital is enormous and I will always appreciate the things they taught me.

Gynecology
 The last part of my clinical clerkship was at the Department for Obstetrics and Gynecology. On the first day as was warmly welcomed by the chief and the coordinator for international students and informed that this department has three faculties to choose from. In order to fulfill the most requirements of my logbook from Vienna, I chose to spend the first two weeks at the faculty for IVF and Fertility, followed by two more weeks of general gynecology and obstetrics. The staff was as always very welcoming and determined to make my stay special. From the beginning I got to attend various procedures of the fertility clinic, like blastocyst transfer or follicle puncture and follow up on the next steps in the lab. I learned a lot about the different histories of the patient, why they chose this way of conceiving and the underlying conditions. The doctors took a lot of time to discuss the differences in ethics and reproduction-laws in japan with me. I got to see how the work in the fertility lab is done and what the duties of the embryologist are, where I also got the chance to use the microscope on some cases myself. The other duty of this faculty was the minimal-invasive surgery, performed by laparoscopy. I got to watch a number of the operations first hand, mostly different kinds of Myoma (benigne tumors of the uterus’ muscle layer) that were interesting and educational. One of my highlights was definitely the opportunity to use the laparoscopy training room of the hospital. This state of the art training facility made it possible for me to try the techniques I saw in the operation room myself and to practice my skills with this method. My skills definitely improved in this field and I hope to be able to continue my education with this technique in the future. Thanks to the effort of the doctors I got to train there whenever I wanted and I cannot express how much I enjoyed this. One of my best experiences there was the chance to use the training-machine for the DaVinci robot. This was definitely a once in a lifetime opportunity and I really enjoyed doing this, since it is something that not even most doctors ever get to experience. During my second week at the Fertility-clinic I also got the chance to do an oozyte-retrieval myself under the instructions of a senior doctor, which was a great hands-on learning opportunity. For my last two week I switched to the group for general gynecology and obstetrics. The main focus here lay on pregnancy and since this is a very specialized hospital, most of the cases were high-risk pregnancies. The reasons for admission were manifold from complications like placenta praevia or placenta increta, to congenital malformations of the fetus. I got to see vaginal deliveries as well as a lot of cesarean sections. Especially the ones for placenta varieties were very interesting and highly professional procedures with a broad spectrum of surgeons at the table, from radiology to neonatology and it is always nice to see a team of doctors working together. On some occasions the doctors let me perform tasks like an ultrasound by myself and since this is something you can only learn by doing it, I was very happy to have this opportunity. The daily ward rounds in the morning where very short, but gave a good overview of the different reasons for admissions to this department. I was also able to learn a bit about the psychological problems and difficulties that can occur for women in these kind of situations.
 Twice a week there was a journal club where graduate- or PhD-students presented their own work or recent publications from renowned papers and some of the topics presented in English I found quite interesting. Overall the obstetrics and gynecology department offered an extraordinarily good experience to me and since I am a surgically interested student this was a very appealing specialty for me.

Summary
 The three months of my clerkship passed very rapidly and the amount of things I learn and saw are not possible to express in words. The Japanese culture is very different from mine and therefore nearly everything I experienced felt a bit different. I got a whole new perspective of some major points in medicine as well as general life. The difference in ethics, appreciation, contact, politeness and many others are remarkable, but they also have pros and cons on both sides. I am very glad and thankful that I had the opportunity to experience the time here and to grow on so many levels. The staff at every department was kind beyond words, help was offered where I needed it and I never felt lost or forgotten. The seemingly flat hierarchy in the hospital and the friendly way of interaction between doctors and colleagues as well as students and nursing staff is something I hopefully will be able to take home with me and implement in my future workplace. I really enjoyed the opportunities of trying Japanese food and beverages with the doctors who always showed a lot of interest in my culture and me. As always there are some things that could be better. The biggest problem was definitely the language barrier, which is mostly my own fault due to my lack of Japanese. Nevertheless was I surprised sometimes that doctors at a university hospital, who are doing research and following international literature, do speak so little English. Sometimes I would have wished to have someone in charge of the foreign students who speaks English on a high level, to explain me more of what is going on. I also think that this exchange is not only a great opportunity for me as a student, but for the Japanese doctors as well. Since nearly all doctors I spoke to complained that it is hard for them to practice their English, I personally think they should be more confident in seizing this opportunity of having international students around. One of the biggest differences to my medical education in Austria was the strictly theoretical approach for students, especially in the 5th year. I know that japan has a different style and curriculum, but since the best way to learn something is by doing it, I occasionally wished to have more opportunities to do something rather than watch. When I talked to Japanese students about this I always heard from them that they also wished to have more skill training and chances to do practical things. Nevertheless are these problems very small and mostly due to the cultural difference, which in most cases was a blessing and exactly why I came to japan in the first place. Overall my time here was great and my stay in japan will always be a big part of who I am, as a student and a person.
 Hopefully I will see some of the people I met here in the future and show my gratitude and repay their “Omotenashi”.