Last update: 2009/12/18

Report from Duke University School of Medicine Daisuke Ito Exchange student 2008

Daisuke Ito

I had a chance to attend Clinical Clerkship in Duke University for 2 months in summer 2008. Here, Ifd like to report my experience that was accomplished with a lot of help.

1. Consultative Cardiology
At the first day of my rotation at Cardiology, I met Dr. Waugh, who was in charge of studentfs electives, and he gave me a brief orientation. And then I was introduced to Teaching Service Team, which was consist of 1 attending physician, 1 fellow, 2 residents, 2 interns, and 2 students including me. The team was divided into 2 groups, one was for inpatient service and the other was for consult service. Basically, I and Krishn, another student, were enrolled in consult service. Fortunately, I could ask another student a lot of question about the team, what students should do, where to go, so I had little difficulty in getting used to the team. Usually I took part in inpatient rounds in the morning and consult rounds. And on Tuesday, Wednesday and Thursday morning, we had lectures by Dr. Waugh.
In the first week, I understood that the work for students was consult, where students go to see patients and write the patients information and assessment and plan before our fellow and attending go there. However, in the first 2 weeks, I usually go to see consult with Krishn or my fellow because I did not get used to English itself. But in last 2 weeks, the fellow gave me some consults, so I could experience some complicated cases such as atrial fibrillation , AS, PE, heart failure and so on by myself. At first they were tough for me because I did not have enough time to prepare presentations compared with in Japan. But thanks to kind feedback by my fellow, I learnt to make a good presentation little by little. On the other hand, Cardiology Department was rich in conferences and lectures. In several lectures I could learn basic knowledge about HPI, physical exam, and laboratory test such as ECG. And in conferences I got familiar with resent researches, case presentations.
Though I didnft get used to the environment so much, the first 4 weeks were very effective for me not only to learn Cardiology but to know how to behave as a student in Duke University.

2. Pulmonary Medicine
In the last 4 weeks, I was in Pulmonary Medicine. Similar to Cardiology, I was enrolled in consult service. The fact I got used to English and consult system helped me get more consults there. So I could manage about 1 consult a day by myself. The cases I experienced were lung cancers, pneumonia, immuno-compromised hostc So many cases! Such plenty of experience made me notice attitude of American doctors toward medical education. I mean that I was treated as a member of the team and they paid much attention to my presentation and treated patients based on it. In this team, I got a lot of feedbacks that started from differential diagnosis or A/P to how to construct presentation and how to express what I thought. I was so inspired by the accuracy of their feedbacks. I thought that they put great emphasis on education and they thought it brought them much deeper understandings of their specialty. Such attitude was seen everywhere in Duke University Hospital, conferences, lectures, and even hallway. I felt sophisticated manner of education in the U.S. at that time, and I realized how important presentations are.
By the way, there were 1 Chinese doctor and Taiwanese medical student in my team. So my team was so international. I had a chance to discuss the differences of medical policy or ethics among in the U.S. , Japan, China and Taiwan. It was very precious time too because it gave me time to think about Japanese policy from the standing point of other countries. I believe it broaden my vision on medicine so much. In this aspect, my journey also brought me great benefit.

3. What I felt (Summery)
What was the most impressive through 2 months is MEDICAL EDUCATION as I stated above.
Of course I learnt the difference of medical policy such as insurance system, but the atmosphere that seniors teach juniors was so impressive. I could find hot discussions everywhere. They involved not only doctors but also nurse or pharmacist, whose topics varied from the patient issues to EBM or recent researches. And I felt so happy to join in the discussion. Thanks to this experience, I will be able to learn medicine more effectively when I become a doctor.
I could know various people and had a chance to ponder my future. This experience is priceless! I appreciate the people of the department of international affairs and the student office, who gave me a great chance to go to the US. And I also appreciate my friends, who wrestle with this Clinical Clerkship together. I believe I couldnft have accomplished it without them. I cannot appreciate them more. I hope this great system will last for the future and it will bring our juniors tremendous experience.

My Clinical Elective at Warwick Kazuto UEDA, Final Year Medical Student, Nagoya Medical School

Kazuto UEDA

Overseas education in medicine as clinical elective experience is becoming popular among Japanese students, usually within exchange programmes. About 10% of medical students at Nagoya normally have an overseas elective in UK, US, Germany and Poland. Its significance is not only to learn advanced knowledge and techniques but also to gain insight into broader aspects of medicine. My visit to Warwick Medical School gave me an opportunity to rethink my views about medicine. In particular it led me to realize that medicine is defined by culture and history. I would like to make some personal remarks by comparing British medicine to Japanese medical approaches.

Diagnosis Diagnostic approaches are very different. British medicine is said in Japan to be based on physical examination. The reality is beyond all expectation. Both British and Japanese doctors are very familiar with common symptoms and differential diagnoses. However British consultants take more time in history taking and physical exam and make efforts to achieve the diagnosis by the shortest way. As their style might be derived from NHS framework, it seems very smart and integrated. Detailed history and system-based examination would point the leading hypothesis and the appropriate investigation about patientsf problem. British style is based on logic and thinking processes in contrast to the Japanese style which is based on knowledge and investigation.

Medical student teaching Different styles are apparent in our respective educational systems. British medical students seem thoroughly trained in discussion. One of my unforgettable experiences was small group clinical teaching by a junior doctor. The patient was a middle-aged lady with ascites. The doctor advised us on advanced history taking and physical examination after we saw the patient. Withdrawing into another room, discussion focused on a summary of the history and physical findings, leading pathophysiological causes, classification of oedema, differential diagnoses, the leading hypothesis and most appropriate investigations. Another medical student answered them very fluently. In contrast, the Japanese teaching style still mainly involves passive lessons. As there is a shortage of teaching doctors in Japan, students have less
discussion time with doctors. The British educational system seems very good at developing doctors who can cope both with common and unusual problems from the pathophysiological point of view.

General Practice The British healthcare system is characterized by the NHS and the key role of the General Practitioner. Japan has a universal health insurance system like NHS but it also has a free access system. Patients can visit the surgery or hospital freely. Although the important role of the generalist is now being re-evaluated, the number of generalists is still very small in Japan. My main purpose in visiting a General Practice was to learn how the GP system works. Visiting a surgery in a village near Northampton, I was able to understand the diversity of a GP's work. They see patients from babies to the old and provide not only an out-patient service but also home medical care. The surgery is the base for doctors, nurses, health visitors, pharmacists and so forth. GPs are the true leader of healthcare at the village level. In my opinion, their spirit and practice is the same as those of the Japanese doctors keen on community healthcare. Thinking about the established healthcare system in UK, however, Japanese healthcare system would be improved by learning more about British health systems. In particular, I think that training courses in General Practice should be established in Japan.

Hospice Care Talking about the community healthcare, I was very impressed by my experience of hospice practice. Hospices are common in Japan but most of them are based on hospital wards. Many terminal patients in Japan would spend much time not at home but in hospital. Compared to that, British hospices seem very attractive. They mainly exist within the community and are strongly supported by charities. The cooperative framework between the hospice and the GP surgery achieves seamless community health between hospice and each home. Through this interaction, the policy of respite care is accomplished. I experienced an ideal healthcare approach focused on patients and organic linkage of community care.

Personal contacts My many encounters with health practitioners encouraged me to consider my next career destination. I found consultants, registrars and junior doctors very approachable and eager to give teaching. Through observing behaviour of consultants, I have learnt more about professionalism as a doctor. Advice from a community paediatrician made me realize more about the best policy as a paediatrician. Through discussion with medical students, I learned more about differences between the UK and Japan. These experiences encouraged me to reconsider my own policy.

Conclusions The British medical style is consistently characterized by two main aspects: the intelligent style of doctors and the strengths of community healthcare services. These aspects seem related to British history and culture. At the same time I was able to learn more about the third way for medical improvements, for example through evidence-based clinical guidelines such as those developed by NICE (National Institute for Health and Clinical Excellence), cost-effective practice according to evidence-based medicine, procedures for investigating and preventing clinical adverse events, and other governance approaches.

Acknowledgment I would like to express my gratitude to Prof.Sakamoto, Prof.Singer, Dr.Kasuya and every staffs at Nagoya University and Warwick Medical School.