Mr. Chengzhi Khor

Student Elective Report
Division of Gastrointestinal Surgery
Division of General Internal Medicine
Division of Radiology
13th June 2016 – 23rd July 2016
CHENGZHI KHOR
International Medical University (IMU), Malaysia
Introduction
There will come a time where every medical student has to undergo
elective program to seek exposure and observe practices different
from their respective training hospital. As for me personally, the
decision to conduct medical electives in Japan did not come easily as
there were several concerns such as language barriers, cultural
differences and financial issues. Nevertheless, Japan is one of the few
developed countries in Asia and the healthcare system is widely
regarded to be one of the forerunners in the entire world.
After careful consideration, I decided on Japan as my country of
electives and I truly glad I did. Kobe University Hospital was chosen for
my placement as it is one of the core hospitals in Kansai area and
affiliated with International Medical University (IMU) which I hailed from.
My elective was 6 weeks long in 3 different departments which
consisted of Division of Gastrointestinal Surgery, Division of General
Internal Medicine and Division of Radiology.
Division of Gastrointestinal Surgery
It is no surprise that Japan is ranked to be one of the most advanced
countries in gastrointestinal surgery. The country has adopted a more
aggressive screening for early gastric cancer since 1960 owing to
higher incidence and non-specific symptoms of such disease. Hence,
the prognosis of gastric cancer is better in Japan compared to other
countries.
In Kobe University Hospital, the gastrointestinal team and was
separated from hepatobiliary team approximately 10 years ago as due
to increasing complexity and focus in each field. The gastrointestinal
department is further divided into 4 different subdivisions focusing on
different parts of the gastrointestinal tract. My interest in gastric cancer
had particularly arranged me under the tutelage of A/Professor Shingo
Kanaji for the entire 2 weeks of rotation. The other subdivisions are
esophageal team lead by Nakamura-sensei and 2 colorectal teams
lead by Sumi-sensei and Matsuda-sensei respectively. The sensei are
really friendly and approachable, it did not take me long to acquaint
myself with the personnel from the entire department.
In Japan and other developed countries, all medical records are
stored digitally, known as Electronic Medical Record (EMR). Hence, the
ward rounds are conducted differently from Malaysia. It usually begin
by case presentation in a conference room where the patients’
progress and management are discussed by medical practitioners,
followed by the actual inpatients’ visit to address patients’ concerns
and physical examination.
On every Monday and Friday morning, the entire department gathers
around and discuss about new or existing cases, followed by grand
ward round to review patient's progress and management. On
Tuesday, case presentation is carried out alongside hepatobiliary team
where both teams present a case from each department. It was
intentionally conducted in English to suit the understanding of foreign
students which has proven to be quite a challenge to the medical
practitioners and students. Journal discussion is done on every Thursday
morning where articles are shared to keep everyone updated with the
latest development in medical field.
Kanaji-sensei's operations are usually scheduled on Monday, Tuesday
and Thursday. He leads the team of gastric surgery which consists of
Matsuda-sensei, Yamauchi-sensei and Yamamoto-sensei. Under his
guidance, I observed 4 gastric surgeries over the span of 2 weeks
which included 2 cases of laparoscopic total gastrectomy, open distal
gastrectomy and laparoscopic proximal gastrectomy. He also
explained to me about Endoscopic Mucosal Resection (EMR) and
Endoscopic Submucosal Dissection (ESD) which were pioneered in
Japan in the treatment of early gastric cancer. For the first few days, I
was astounded by the different approach to diseases in developed
countries with accessible cutting-edge technology. It was my first time
hearing the use of molecularly-targeted therapy such as Trastuzumab
in adenocarcinoma with overexpression of HER2 receptor which I
believe to be uncommon in Malaysia. Classification of gastric tumors
based on Japanese Gastric Cancer Adenocarcinoma (JGCA) is
different from Western classification with greater emphasis on
histopathology, metastasis and response to neo-adjuvant therapy.
Below is the typical schedule of my rotation in Gastrointestinal Surgery:
Time
Activities
0800 – 0900
Case/Journal Discussion
0900 – 0930
Morning Ward Round
0930 – 1200
Operation Theatre
1200 – 1300
Lunch Break
1300 – 1600
Operation Theatre
1600 – 1700
Afternoon Ward Round
As medical education in Japan is entirely conducted in Japanese,
there were times when explanation in English became too difficult as
medical terminology is a specialized jargon. The conversation between
me and sensei always ended up scrambling through our phones using
translator to get the conversation going which I found it both amusing
and challenging. I really appreciate that sensei took the effort to
explain the cases in English to me and I hope it did not cause much
inconvenience to them. The division of gastrointestinal surgery is rather
huge and 2 weeks of rotation were just barely enough to scratch the
surface and peek into the marvelous work of Japanese gastric
surgeons. With cutting-edge technology and refined surgical
techniques, even the most complicated surgeries were made to seem
like a walk in the park. It was truly phenomenal.
Kanaji-sensei’s team - (Left to right, back row) Kanaji-sensei, Amano-san
(Student), Me, Yamauchi-sensei, Matsuda-sensei and Yamamoto-sensei. We
were joined by two lovely nurses in the ward.
Division of General Internal Medicine
Adult medicine and inpatient care are always my interest and also the
reasons why I selected General Internal Medicine as one of my
rotation. Upon arrival to the office on the first day, I was greeted by my
supervisors, Mori-sensei and Tokunaga-sensei. The department is
comparatively smaller than gastrointestinal surgery as Internal Medicine
has already been separated into different subspecialties. It is
comprised of two teams, “Mikasa” led by Miyoshi-sensei and
Kasamatsu-sensei and “Tokunan” led by Tokunaga-sensei and
Minamiji-sensei. Each team is assigned with certain number of patients
so that the doctors have equal share of responsibilities and not
overwhelmed by the workload.
During my rotation, I met another foreign student from Philippine, Ms.
Aina who arrived in the department a week before I entered. For the
first few days, I was feeling a little intimidated as the transition did not
come easily and I am very grateful that Ms. Aina was there to help me
assimilate into the new environment. I also met a group of local
medical students who were conducting their 5th year rotation in the
same department.
Below is the typical schedule of my rotation in General Internal
Medicine:
Time
Activities
0800 – 0900
Case Discussion
0900 – 1000
Morning Ward Round
1030 – 1200
Lecture by Sensei
1200 – 1400
Lunch Break
1500 – 1600
Afternoon Ward Round
1630 – 1730
Mini Lecture by Medical Students
A normal day in the department begins with case discussion at 8.00am
every morning. The case discussion is very much similar to what I have
seen in gastrointestinal department except most of the cases in internal
medicine require multidisciplinary approach and referral. Case
discussion is followed by inpatient visit which I was assigned to “Mikasa”
group and followed Miyoshi-sensei, Kasamatsu-sensei and three local
medical students in their ward rounds. Every medical student including
foreign students is required to choose a patient as case study
throughout the length of rotation. I chose an elderly patient who was
admitted on the 2nd June 2016 due to infectious endocarditis
secondary to prosthetic valve with underlying multiple myeloma. As
Japan has strict policy to uphold patient confidentiality in hospital,
medical students are not allowed to approach patients without being
introduced by the physician-in-charge. Hence, I was only able to
engage with my patient by taking brief history with the help of local
medical students as translator and perform physical examination under
the supervision of physician.
The cases in the ward which I have seen were different from Malaysia
where infectious diseases are more prevalent than non-communicable
diseases. There were two interesting cases that I will definitely
remember:
(i)
32 years old lady with underlying bipolar mood disorder and
anorexia nervosa presented with left popliteal artery
thrombosis.
(ii)
72 years old woman with osteonecrosis of the jaw secondary
to bisphosphonate therapy.
Morning lectures were given by Mori-sensei or Otsui-sensei after the
ward round. Ms. Aina and I are very grateful for the effort from Morisensei trying to deliver the lecture bilingually to cater our understanding
as well as the local medical students. Otsui-sensei even went to great
lengths to recreate his slides in English and gave us a quick rerun of his
lecture after the original session in Japanese ended. I also joined one
of the simulated patient sessions with Japanese students. It was
facilitated by Kanazawa-sensei and conducted in a similar way to
what I have experienced in Malaysia. The session was a good refresher
class for me as I am preparing for my final year. Medical students were
also given English articles by Sakaguchi-sensei to read and discuss.
These articles contain cases to provide exercise for students to sharpen
their clinical problem-solving skills and reach a medical diagnosis. It is
immensely useful as we discussed about hypervitaminosis A and
haemophilia.
On every Wednesday afternoon, discharge conference is held with
participation of physiologists, nutritionists and nurses. The agenda of
such conference is to make early preparation and discuss about
patient discharge plans with exemplary showing of holistic medicine.
Lastly, medical students are also required to present a mini lecture in
the last week of the rotation. It is a 5 minutes short presentation where
students can present literally any learning outcomes from their
respective patient. As for me, I have chosen to present on the topic
“Infective Endocarditis – Importance on differentiating between
Prosthetic Valve Endocarditis (PVE) and Native Valve Endocarditis
(NVE)”. Japanese students are very considerate as to making separate
slides in English for Ms. Aina and I to suit our understanding. I am
thankful and guilty at the same time as my Japanese is too poor to
return their favor by doing the same.
On the first week, Ms. Aina and I were invited by sensei to dinner in a
nearby restaurant. It was intended to be a welcome party for us as well
as farewell party for Murakami-sensei, a resident in the department. The
atmosphere was really lively as we engaged in conversation which
revealed to me that these professionals are really humble despite their
accomplishment. There was no sense of awkwardness or seniority as
we conversed like peers throughout the meal and I really appreciate
the mutual respect that we have demonstrated for one another.
My time in General Internal Medicine was fruitful while it lasted. It
allowed me to learn about diseases of affluence which are more
predominant in developed countries and a chance to observe how
internal medicine is being practiced in Japan. I am also grateful to
have met all these sensei who are friendly, humble and passionate
about their job, they are definitely an inspiration to me.
Performing gram staining under the guidance of Minamiji-sensei.
Presenting mini lecture in the second week of rotation.
Dinner with the faculty. (Clockwise, nearer to the table) Otsui-sensei, Minamijisensei, Tokunaga-sensei, Ms. Aina (Student from Philippine), Me, Murakamisensei (Resident), Mori-sensei. (Left to right, further from the table) Miyoshisensei, Kasamatsu-sensei.
My supervisors in General Internal Medicine. (Left to right) Mori-sensei,
Yamamoto-san (Secretory), Ms. Aina, Me, Tokunaga-sensei
Division of Radiology
I believe the ability to interpret and extract information from images is
immensely helpful for medical students or even doctors in the clinical
settings and it was why I chose radiology as my third and final rotation. I
was greeted by Okada-sensei on the first day who is an interventional
radiologist and my supervisor during the rotation.
The department is separated into 3 subdivisions; diagnostic imaging,
interventional radiology and radiation oncology. It is huge as
compared to other department which I have been and it took Okadasensei an hour just to give me a tour around the department. If my
numbers are correct, Kobe University Hospital is equipped with 4 CTs, 4
MRIs, 1 PET-CT, 1 PET-MRI and not including the CT scan used in
angiography and hybrid operation theatre. I was astonished when I
found out that the hospital is performing CT scan for an average of 180
patients and MRI for approximately 60 patients in day, which is a huge
number of patients.
During the rotation, I alternated mainly between the subdivisions of
diagnostic imaging and interventional radiology. I also happened to
meet another foreign student from Bangladesh, Ms. Tashnova who was
in the same department. My time in subdivision of diagnostic imaging
was mostly spent sitting beside sensei and observed the interpretation
of CT or MRI images. Much to my surprise, I learned that some
radiologists in diagnostic imaging narrow their scope down to
anatomical locations, such as head, thorax, pelvis etc.; it enables them
to diagnose even the most uncommon diseases.
It was definitely my first time to observe interventional radiologist in
action. Interventional radiology is unlike diagnostic imaging whereas
the doctors are actively engage in the treatment of patients. Majority
of the cases in interventional radiotherapy are hepatocellular
carcinoma (HCC) which is treated by transcatheter arterial
chemoembolization (TACE), a minimally invasive procedure which the
tumor’s blood supply is embolized and treated with local
chemotherapy agents to reduce systemic side effects. I also managed
to observe other procedures such as:
(i)
CT drainage of paravertebral abscess.
(ii)
CT guided biopsy in lung malignancy to determine expression
tumor cells and subsequent targeted therapy.
(iii)
Adrenal vein sampling in primary aldosteronism.
On Thursday, Okada-sensei brought me to hybrid operating room
where surgery is done in conjunction with medical imaging devices
such as CT scan or MRI. I observed 2 cases of thoracic endovascular
aneurysm repair (TEVAR) done in aortic aneurysm and aortic dissection.
Vascular surgeons were involved to create a shunt from left common
carotid artery to left subclavian artery and followed by insertion of
expandable endograft which acts as artificial lumen for blood flow,
protecting the aneurysm. On the second week, I was fortunate to
observe the treatment of esophageal varices with trans-ileocolic vein
obliteration which is rather uncommonly done in the hospital.
I also spent a day in radiation oncology which Ishihara-sensei showed
me around and gave me a brief overview of the department. The
experience really opened my eyes as I have seen different types of
radiation therapy being done such as intensity modulated radiation
therapy (IMRT), image-guided radiation therapy (IGRT), brachytherapy
etc.
It has been a pleasure to learn from the sensei in Radiology. Everyone
was very kind to me. Hereby, I would like to extend my gratitude to
Katayama-sensei, Koide-sensei, Sofue-sensei and Maruyama-sensei for
their translation and tutelage. They made me realized that there is
much more to radiology than just interpreting medical images. The
advancement of radiology over the past few decades allows doctors
to treat some of the most unfavorable medical conditions without
surgical interventions. It was amazing to be here and witnessed that.
Team of interventional radiologists in the hybrid operating room. (Left to right)
Maruyama-sensei, Hiro-sensei, Yamaguchi-sensei, Ms. Tashnova (Student from
Bangladesh), Me, So-sensei (Resident), Sugimoto-sensei, Okada-sensei.
Picture taken in the interventional radiology room. (Left to right) Koide-sensei,
Me, Fujimoto-sensei (Registrar), Ms. Tashnova
Other Learning Activities
There is a debate class on every Friday evening organized by Kitamurasensei. It is similar to problem-based learning (PBL) where small group of
students share their knowledge and perspective to discuss about the
subject provided. It also serves as a platform for interaction and
bonding between foreign students and Japanese students.
The session was certainly multinational as I met other foreign students
from Taiwan, Singapore, Philippine, Indonesia and Bangladesh. It was
interesting to see how perspectives from different backgrounds and
cultures clashed and meshed so well together. I found it extremely
helpful as the scenarios provided by Kitamura-sensei were rather
controversial and ethically ambiguous, that teach us about the moral
principles and decision-making in the practice of medicine.
Leisure Activities
Life is definitely a little lackluster if everything is about studying.
Sightseeing is definitely a must do when travelling in foreign country. On
weekends, my host family would bring me to tour around the city of
Kobe. We even went to Naruto city in Tokushima Prefecture to see the
famous Naruto whirlpools.
Himeji Castle, a World Heritage Site and also the largest and most famous
castle in Japan.
Akashi Kaikyō Bridge, currently holding the world’s record of longest
suspension bridge.
Naruto whirlpools, created by tides moving between Seto Inland Sea and
Pacific Ocean.
The Japanese students including my student buddy, Ikagawa-san
would bring me and the other foreign students to nearby restaurants
and places after debate class on every Friday evening. I also had the
chance to meet Imamura-sensei, a dermatologist who offered to show
me around Osaka with Ms. Aina and her Philippine buddies. I also went
to Kyoto to participate in Gion Matsuri, one of three largest summer
festivals in Japan with Ikagawa-san and his friends. It is difficult to share
my experiences by words, so I will let the pictures speak of themselves!
My student buddy, Shota Ikagawa
and I having meal in a local
restaurant.
Multinational group picture with
students from Taiwan, Singapore
and Philippine after debate class.
(Left to right, back row) Kitamurasensei, Zerline Lee, Shinya Nagae,
Kun-Lin Cheng, Me, Angelo
Augusto Sumalde. (Left to right,
front row) Shota Ikagawa,
Shermaine Ng, Lingyi Chia, Arisa
Senda, Aina Fe Salem.
Karaoke session with fellow
Japanese and student from
Taiwan.
Farewell party for students from
Singapore.
Okonomiyaki for dinner during my
Osaka trip with Imamura-sensei (3rd
from left) and fellow students from
Philippine.
Casual night out after debate
class.
Acknowledgement
I have experienced one of the best hospitality in my life here in this
lovely country. Hereby, I would like to express my gratitude to each
and every one who made my stay an enjoyable and memorable one.
(i)
(ii)
(iii)
(iv)
First of all, personnel from Center of Education of Global
Medical and Health Science Leaders which include Kunosensei, Kato-san, Nakagawa-san and especially Sawada-san
who coordinated and helped me throughout my elective
program.
My student buddy, Shota Ikagawa-san who allocated most of
his time and accompanied with me throughout my elective.
Once again, every sensei that taught me during my rotations.
Thank you for your guidance and patience. It was a pleasure
to from all of you.
Imamura-sensei for his kindness by showing me and the other
foreign students not only around Kobe but also its nearby
cities.
(v)
(vi)
Kitamura-sensei for organizing debate class every Friday. Her
session definitely helped me in my clinical decision making
and future endeavor as a doctor.
Friends whom I have made throughout my stay in Japan.
Special shout-out to Aina and Tashnova for being my
unofficial partner during the rotation.
I received a farewell party as well. Feelings were mixed and memories were
made. Thank you so much for the memento!
Final Word
I am really grateful for the opportunity to conduct my elective program
here in Kobe University Hospital. Despite the language barrier and
cultural differences, it did not stop me from meeting new people,
experience new things and enjoying Japanese hospitality. 6 weeks
might seem a little long, but in retrospect, it did not feel like it. I guess it
is true that time flies when you are having fun. These memories are
invaluable and definitely those I will cherish in my life. Japan, it was fun
and nice knowing you. I will surely come back again, some day.