Clinical Exchange in Japan

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Experience Report

Felix Heilmeyer from Albert-Ludwigs-Universität-Freiburg, Germany
2016/06/30 – 2016/08/14
Departements: Brain Surgery, Emergency Medicine, Neurology

Compared to most students whose experience reports you will find on this webpage, my stay here at the NU was a little different. While most medical students come here to do a clinical clerkship of one or two months and then return to their home countries, I participated in the university-wide Nagoya University Program For Academic Exchange (NUPACE). This program enabled me to stay at NU for a whole year! While I was only doing clerkships for about 3 months like most other foreign medical students I also had the opportunity to take part in language and cultural classes together with foreign students from a wide range of majors.

I feel that taking part in these classes before starting my clerkships immensely enriched my experience by reducing the language barrier and therefore enabling me to communicate better with the hospital staff and understanding the contents of patient-doctor interaction. Furthermore, the time I spent in Japan before entering the hospital also gave me – although limited – some insight into the Japanese mind and consequently enabled me to grasp a little more of the inner workings of Japanese healthcare.

I am fully aware that, due to organisational and monetary barriers, taking a whole year to do this is rarely an option for medical students around the world. Taking this into consideration I am even more thankful to NU and the NU Hospital, the staff of the International Office and finally my home university for making this incredible experience possible. I urge everyone, who sees the slightest chance to do something similar, to consider this option as I am sure that what I learned as person and future doctor will accompany me for the rest of my life.

In the following I will describe my stay at the different departments. If you are interested in what I did for the rest of the year please have a look at the homepage of the NUPACE program. In the following I will try to honestly report on what I experienced during my clerkships. Some of it may seem encouraging to some while seeming discouraging to others. Therefore, I would like to stress that at no point of my clerkships I regretted coming to NU and while some days were better than others, overall I had a very rewarding stay at the hospital. As everyone’s expectations and goals for an exchange are different, I hope that my and other student’s reports will help future students to choose their departments according to theirs.

Brain surgery

My first department at Nagoya University Hospital was the brain surgery department. When I arrived at the office in the morning I was firstly introduced to Prof. Wakabayashi, the head of the department. We had a short very pleasant talk about me, my studies and the department – entirely in Japanese. He was very surprised about my ability to manage simple Japanese conversations and told all the other doctors about it when I introduced myself to them in the evening. In retrospect, if I compare my time in brain surgery with my experience in the other departments, this introduction made the doctors less reluctant to talk to me, because they knew they didn’t have to completely rely on English for communication. Thanks to this my relationship with the doctors in brain surgery was the best of all three departments. I would frequently get offered help and explanations or be invited to some event.

After our morning meeting Prof. Wakabayashi handed me a weekly schedule of the departments surgeries and case conferences. I was told that I should visit as many of the operations and attend all the conferences. On some days there were multiple operations on the list from which I had to choose one to attend. Each Monday morning, I would receive a new schedule. After, a doctor showed me the way to the operating theatre and I was left there to watch the surgery. When the surgery ended, I was sent back to the office, where the evening case conference had already begun. At the end of the conference I got the opportunity to introduce myself to the department.

The case conferences always followed the same scheme: Each doctor presented his patients and then asked the other members of the department for comment or advice. With my limited knowledge of Japanese, I had a superficial understanding what the case was about, but the interesting details surpassed my language ability. Combined with the fact that the conferences took place around 7pm to 10pm and after I attended an up to 10 hours long surgery made them a very tiring experience. I felt that there could’ve been more useful ways to spend my time in the clinic.

As for the surgeries: The brain surgery department is composed of several very specialised groups. Each group has a fixed reserved time in one of the two operating theatre. For example, Monday Morning the main operating theatre was reserved for the blood vessel group. So, each Monday Morning I would get to see a similar operation of one of the blood vessel brain surgeons. In some specialties like tumour surgery that was not an issue as the field is very broad and I got to see a bunch of different surgeries. In other specialties like the blood vessel surgery the cases each week were very similar. On some weekdays, I could choose between an operation in the main theatre and an operation in the secondary theatre or a catheter operation conducted in the radiology department. I very much appreciated the ability to choose on these days, because I had an alternative in case I already knew the procedure that was going on in the main operating theatre.

Watching the operations was mostly very interesting. Sometimes I wished I could have received more explanations, but I understand that when all attending surgeons are busy it’s sometimes just impossible to do so. On most days, I would just stand in the theatre and watch the operation while simultaneously studying the case with the help of the patient file and my textbooks. When other students or doctors were present we could also sometimes discuss the steps of the surgery that was being done. Rarely I was allowed to scrub in myself and watch directly on a free spot at the operation microscope. Once or twice I was even able use the instruments to hold a flap of tissue or do a similar uncomplicated task.

If there was free time between the surgeries and case conferences, I was mostly left to myself at the office. The department provided me with a desk at the office so I could study or prepare the cases of the next days. In those free times, I sometimes wished that they had prepared some little lecture for me or let me do training with the surgical microscope or training simulator like some of the other departments do. But mostly the surgeries were so exhausting, that I couldn’t have done more in one day, even though there was time left.

On Thursdays, I would come to the clinic even before the start of surgeries to attend the ward round of Prof. Wakabayashi held for the Japanese students in the department. We would go around the ward for about one to two hours and stop at each patient bed to get an explanation about the case from the professor and two assisting doctors. The ward round was of course conducted in Japanese, but in contrast to the conferences it was a more satisfying experience. The professor explained very detailed for the students so I could grasp most of what was going on with the patient. Additionally, the professor asked his assistants to provide more information in English for me. The information I got together with what I understood from the professor’s explanations made the ward round way more informative than the case conferences.

All in all, I was satisfied with the clerkship in the brain surgery department. I must admit that it was very exhausting to be in the clinic every day for 10-12 hours. On the other hand, I had the rare opportunity to see over 25 surgical interventions – an opportunity which not many students in my grade will have. Although there was certainly room for some improvement here and there – mainly more explanations of what I was observing – I really learned a lot in my five weeks in the brain surgery department. I even saw some diseases that don’t exist back home in Germany and of which I had never heard before. Everyone in the department treated me friendly and with respect, they even invited me to their half-annual department party. Overall I had a very pleasant stay and was happy that I chose the department for my first clerkship.

Emergency Department

My second clerkship was in the Emergency Department. The Emergency Department in Nagoya University is operated together with the Medical Intensive Care Unit. That means most of the staff is on rotating shifts between the ICU und the Emergency Room. As I will have another separate clerkship in an ICU in Germany I spent my two weeks mainly in the ER.

On my first day, I was introduced to Prof. Matsuda, the head of the department. He told me, that I could choose freely how to spend my clerkship. So I decided to do just as the other doctors and come in everyday for the hand-over from night to day shift in the ER. After the hand-over I would go to the ICU to also participate in the hand-over case conference for the stationary ICU patients. After that I sometimes would take a short look at a case in the ICU, if there something was of interest to me. Finally, I would go back to the ER and spent the rest of the day shift there.

How interesting the days in the ER were, was heavily dependent on how many and which patients would come in and what patients the Hospital did accept. Firstly, the University Hospital usually doesn’t accept any patients with heavy injuries, as there’s no specialised surgical staff to deal with them and there are plenty of other surgical emergency centres in Nagoya. Secondly, the acceptance of other emergency cases depends if there are free beds in the ICU as these are often occupied by or reserved for emergency patients from other departments of the Hospital or ER patients hospitalised on the days before. On days on which there are no free beds in the ICU the ER doesn’t accept any cases which have a chance that the patient might need a bed in Intensive Care. That basically means that on those days there are only patients with light fever, nausea, stomach pain or other less severe complaints. Or there might be very few to no patients at all.

So, my experiences in the ER vary from very exciting days with cardiac arrest and resuscitation on my very first hour in the ER to other days on which we had only 2-3 patients with a light fever in the whole day. The unpredictability of what will be treated on each day is of course the basic nature of emergency medicine, but there’s no doubt in saying that the ER of the NU Hospital is not a very exciting place to experience emergency medicine. It’s just the way of Nagoya that most of the emergency care is handled by other specialised hospitals. I wasn’t exactly aware of that before I interned in the emergency department so I was a little surprised at first and I wish somebody would have made me aware of that before I made my choices regarding the departments to stay at. On the other hand, at times when there were patients the staff of the department was very helpful and I learned a lot from them.

Everyone treated me friendly and with respect and all in all I had a very pleasant stay in the ER. Also, I learned a little bit about intensive care, even though that wasn’t exactly the purpose of this clerkship. In the end, I still wish I would have done more research before choosing the departments but the staff of the ICU did their best to accommodate my needs for this clerkship and the department staff was among the friendliest I encountered during my time at the Hospital. So, if you’re interested in Intensive Care, I definitely recommend you to consider this department.

Neurology

For my last department I choose the Department of Neurology. In this department the approach of how to deal with foreign students is fundamentally different than in the other departments. From what I heard from my Japanese friends I was much more treated like the Japanese student groups that rotate through all of the departments during their 5th year - with the only difference that I was alone.

That means when I first arrived at the department I received an introduction by a doctor who was designated as my advisor for the period of my clerkship. I then received a detailed schedule for the whole stay with one event for each morning and afternoon of the following four weeks. Each time I would either receive a one-to-one lecture with one of the departments members about research done at the department or be assigned to accompany one or multiple doctors when they performed treatments or diagnostic measures. Additionally, I was told to select one of the patients of the ward and write a case report to be submitted in the last week of the clerkship.

One special episode was my stay at the Toyota Memorial Hospital in Toyota City. I had the opportunity to accompany the neurological department’s head for some days and see a more general case mix than in Nagoya University which almost exclusively treats rarer and complicated cases. They also arranged for me to stay at the hospital overnight so I didn’t have to commute to the hospital. As I heard it’s quite common for Japanese students to take a look outside of the specialised world of Japanese University Hospital Medicine in an outside hospital for some days. I think it would have been fantastic if I could have had the chance to accompany one of the doctors to one of their shifts in outside hospitals in the other departments too. This was definitely one of the highlights of my whole stay at NU.

All in all, I think I learned the most in the Neurology department. Everyone was very eager to teach me about their work and the amount of time they spent on my education was so much more than in the other two departments. While the clerkship at the other two departments was good in every way, Neurology was just fantastic. Other students might not like the more school-like approach they took with me at Neurology, which also meant I had much less freedom to choose what I wanted to do, but it was just right for me.

The staff of the department treated me with the friendliness and respect I also experienced with the other departments. But not only the doctors and researchers took interested in me, also the administrative staff of the department took care of me and made sure I didn’t get lost in the busy daily routine of the hospital. If you have any interest in Neurology this is the place for your clerkship! And while I’m aware that they cannot send every foreign student to an external hospital there’s no harm in asking. Maybe you’re lucky.

Conclusions

As I explained in this report, the experiences I had with doing the clerkship at Nagoya University Hospital were very diverse. I had some really rewarding times and some less exciting times, but in the end, I’m very happy with my choice to come here. I think interning or working in a foreign country is something worthwhile to do for every medical student. Even though it might be chaotic at times and because of the language barrier you might not learn as much as if you would undergo the same training in your home country, I think it is worth it. Especially in a career in which for various reasons like language, cultural and legal barriers it’s very difficult to work abroad for some time later on. So I might have to study a little harder in the coming months to make up for what I missed compared to my fellow students who interned in Germany, but I would never exchange it for the things I’ve seen and learned here.

Regarding the organisation of the clerkship the International Relations Office of the hospital has my heartfelt gratitude. They did a wonderful job! From the time I started my application until the end of my stay here, whenever I had a problem, wanted to rearrange my schedule or for example tried to get access to the hospital patient database, they provided me with all the help I needed or arranged for someone to take care of me. They even gave me some advice on my vacation time plans. The secretary even called a vacation exchange organisation for me without me even asking for it! Also the student tutors of medical school were really committed to helping me – especially when I compare it to what I heard about other faculty tutoring from my exchange student friends. All things considered Nagoya University Hospital made me feel very welcome and I recommend any medical student who wants to go to Japan to consider Nagoya University.

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