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HOME > 国際交流 > 留学体験記 > Report of Oversea Clerkship Program in Osaka City University


Clinical Training report

Yuko Sakamoto
International Exchange Prpgram(Bed Side Learning)
4th June to 30th June 2016
Elective period

Photo album

1. What new health problems were encountered which was not seen in Japan?

During four-week summer training in Gulf Medical University, I found three health problems which is not very popular in Japan but often seen in Gulf Medical University. I observed many cases in both General Surgery and Orthopedic department. I think there is almost no difference in basic diseases between United Arab Emirates and Japan, for example, appendicitis, gall stone and bone fracture is very familiar in both countries. However, there are three interesting findings. Three problems are Osteomalacia, trauma at construction site and circumcision.
While Osteoporosis is most common as bone disease in Japan, Osteomalacia is popular in United Arab Emirates because people tend to avoid being exposed the sunlight. This problem is more likely to be seen in women of various ages, and I surprised that one of my friends in GMC ladies hostel also suffers from Osteomalacia. The clinical feature of this disease is back pain, bone pain and muscle weakness. The main cause of Osteomalacia in United Arab Emirates is said to be the deficiency of Vitamin D, and the exposure of sunlight is highly related to this disease because it activates Vitamin D. United Arab Emirates is located in the desert with extremely strong sunlight, so it is natural for the citizen to avoid sunlight as much as possible. Moreover, Muslim lady always wear long-sleeved long dress which also protects her skin from sunlight. Even in Japan, young mothers who do not want their children to get sunburned protect them too much from sunlight, and some of their children suffer from Osteomalacia. It is one of the social topics in Japan these days. The sunbath from 10 am to 3 pm is said to be the best method to activate vitamin D, but too much exposure of sunlight during daytime is of course harmful because it may cause the heatstroke, skin problem, especially skin cancer, and so on. Accordingly, the doctor advises the patient to go outside in the early morning or the evening just before the sunset. Eating fish, which contains much Vitamin D, like Japanese people is also good way to prevent Osteomalacia, but it may be difficult here considering the location. In this connection I may add that Osteoporosis, which is led by aging, is very popular and one of the social problem in Japan. The more the society become mature, the longer people can live. Living longer is not bad thing, but the number of patients with Osteoporosis in Japan is now more than ten million. Japanese government recommends taking more calcium, for example drinking much milk, in order to prevent Osteoporosis. Both Osteomalacia and Osteoporosis are disease of bone, and the patients have pain in various parts. However, both diseases are avoidable with proper lifestyle and medication. I hope more and more patients understand what they need to prevent or improve bone disease, and the number of the patient will decrease in the future.
Second, I observed many trauma cases which occur at construction sites, for example cut fingers by machines, terrible burn with chemicals and fractures due to fall down from height. Of course I can see trauma occurred in construction site also in Japan, but the number of trauma case here seems to be larger than Japan. I know that more construction of new buildings take place in United Arab Emirates, and this is one of the great reason why the frequency of trauma is different in both countries. But I insist that the worker's carelessness during the job may lead terrible trauma, then the trauma case will increase. In Japan, both employee and employer pay attention to their safety as much as possible, and there are many posters saying "safety is most important" everywhere in construction site. I have never seen the working surroundings here, and perhaps it is same as Japan. Once the employee gets injured, he cannot work for certain period and the job operation will be delayed. I heard that most of construction workers are from abroad, and some patients have to be back to their home country for the surgery according to the insurance. So it is important to maintain working conditions in order to reduce injury, save money and promote working efficiency.
Circumcision is a kind of the religious ceremony and one of the procedure which is not seen in Japan, though it is not a health problem. Actually I have never seen or even heard about this procedure before coming to United Arab Emirates. When Muslim people who live in Japan ask the Japanese doctor to perform it, many hospitals refused to do especially for new born baby as I observed in minor operation theater. In Japan, circumcision for newborn baby is thought to be unnecessary, and it is only performed for abnormal case. But in near future, more and more Muslim people will live in Japan and circumcision for neonate may become popular. Adjusting social needs in the future, it is important to know, understand, and accept the different culture, and doctors should acquire the various medical technique.
I found this three health problem which is not seen in Japan at this time. If I observe another department, for example internal medicine, gynecology and obstetrics, or pediatrics, I would encounter another new health problem in each department. It was very good opportunity to think about not only diseases but also its social background which causes the difference between two countries. This is exactly the meaning of observing foreign hospital, and the experience in Gulf Medical University was fruitful in my career.

2. How healthcare is rendered in GMC Hospital? And how different is it from the practice in Japan?

Comparing to Japanese hospital, I found three differences about healthcare service in GMC Hospital, though it is almost equivalent in both United Arab Emirates and Japan. The flow from outpatient clinic to operation theater is same. When a patient come to the hospital, he or she starts at history taking, then physical examination, laboratory examination and/or X-ray, and the patient go back to the doctor for diagnosis, medication or procedure. The standard of procedure during major and minor surgery is as sterile as in Japan, and they use same equipment and medicine. Medical devices, for example X-ray, CT and MRI, are similar to Japan and I felt familiarness when I found some devices made by Japanese company. The positive attitude of doctors and nurses is also similar and they cooperate and respect each other. However, there seem to be the differences in the composition of surgery stuff, business hour of the hospital, languages using in the hospital and the number of caesarean sections.
In GMC Hospital, only one doctor performs surgery in most cases and one scrubbed nurse helps the operating surgeon. And the anesthetic technician sometimes takes the place of the anesthesiologist, then the number of doctors per one operation theater becomes only one. It is impossible in Japan. First of all, there are no profession of anesthetic technician and only anesthesiologist maintains patient's condition. This means at least one anesthesiologist stays in operation room from the beginning to the ending of surgery. Moreover, normally two or three doctors perform one operation. Second and third doctor helps the first doctor (operating doctor), and scrubbed nurse only deliver the instruments to them. Accordingly, it is natural in Japan that three or four doctors are in one operation theater at once. I don't think it is always good that many doctors perform one surgery together. Sometimes it is too much. If my university hospital follows GMC Hospital's example and reduce the number of doctor per one operation theater, they can spare their time for another job and reduce overtime work.
The business hour of GMC Hospital is much longer than Japanese hospital, and it offer more chance to a patient to come to the hospital. In Japan, opening hour is only from 9 am to 5 pm, both governmental and private hospital. After 5 pm, only one or two duty doctor in each department stays in the hospital and they just see emergency cases. I surprised that GMC Hospital has the evening shift and the hospital functions generally at night in all department as daytime. When I joined the evening shift, there are more patients than daytime because of the Ramadan. If it is not the season of Ramadan, there would be many patients in the evening, because evening is better to go out with avoiding hot weather. Long opening hour is difficult to realize in Japan, but it is suitable for the custom in United Arab Emirates.
Concerning language in the hospital is also not familiar in Japan. People from all over the world live together here, so sometimes the doctor need translator or acquiring second or third languages. In Japan, there are only Japanese doctor, Japanese student and Japanese patients. So we never care about the language to communicate with others, especially in the hospital. In outpatient clinic of GMC Hospital, language seems to be one of the important factors to distribute the patients to the doctors. The doctors who can speak Arabic (their home country is Egypt, Iraq and so on) are more likely to be in charge of Arabic-speaking patients, and the doctors from India are in charge of the patients from India, Bangladesh and Pakistan. While the specialty of each doctor is important factor when distributing the patients, it is big merit for both doctor and patient to communicate in their mother tongue. Now in Japan, we seldom see a foreign patient in the hospital, but it will be necessary to speak in English or other languages in near future.
The number of caesarean sections is obviously larger here than in Japan. Even the pregnant women without complications seem to choose caesarean section. When I did rotating training in my university hospital, only one caesarean section was performed per one week. Some student had no chance to observe it at all. Originally, it is because the number of birth is less in Japan. Moreover, Japanese women like vaginal delivery better than caesarean section, because there is the preconceived opinion that standing pain is a great virtue and only mothers who give birth with vaginal delivery can be a good mother. For that reason, caesarean section is thought to be only for the pregnant mother with some complication. I think this custom is bad because the woman should have a right to choose freely. Perhaps caesarean section will be more common in Japan in the future if Japanese people have broader mind to expected mothers.
Between United Arab Emirates and Japan, there are many common feature, but some different points exist in daily work. That is completely just a differences, and not the matter of superiority or inferiority. It is the best way for both countries to improve the quality of the hospital with reference to each other.

3. Did the Summer Training Program influence in making a decision about your future? If yes, how?

Yes, the summer training program encouraged me from two point of view, and this experience makes my dream clearer. One is the greater participation of female doctors, and another is international mind of GMC Hospital.
Many female doctors work in GMC Hospital, in various departments, and also in the college of medicine, there are more female medical students than male students. I would like to work as active as them in the future. In Japanese hospital, every department has more male doctors than female, even in obstetrics and gynecology department. Of course men are always majority in medical school. And what is worse, the way to surgeon seems to close for female doctors. Female surgeon is thought to give up her career with as a start of marriage or pregnancy, which may be because there is not enough social support for working women. In GMC Hospital, they have the split shift system and it enables mothers to both work as a doctor and care their baby at the same time. During training, I met one female resident doctor who had a baby in a few month and she just started working again at that day, maintaining her aspirations to be a surgeon. She chose to work on the split shift, and male colleagues were willing to accept her decision. I have no idea Japanese hospital can be helpful to female doctors as GMC Hospital someday, but I would like to do my best to cooperate with colleagues and make my desire choice without too much anxiety.
It was also very good stimulus for me that many doctors working in GMC Hospital are from abroad, because I took it for granted that the doctors are mainly or only local people. Observing their work, I would like to consider my future career in foreign countries after becoming a specialized doctor in Japan. Japanese doctors are educated all subjects only in Japanese language, so that it may be difficult for them to work abroad. Almost all Japanese doctors never want to work in other country than Japan, because they get plenty of salary and respect, they are used to live and there is no inconvenience as long as they stay in Japan. In other words, working in Japan is the easiest and the best way for them and there seem to be no merit to going out from Japan. But through the training in GMC Hospital, I felt that Japan is isolated in terms of both the location and medical world. Many doctors and students said to me that Japan is very good, sophisticated and high-tech country and Japanese medical level is really high in the world, but no one wants to go to Japan at the time of choosing their career. It may be because of the language problem. Many of them want to go to the United States of America or the West European countries, especially Great Britain. Japan can be one of the best countries in terms of clinical medicine, particularly surgical fields, but stands alone in this global world. This fact is a great pity. I would like to keep the experience in GMC Hospital in my mind talk about my experience to as many Japanese doctors and friends as possible. I am happy if some of them also have interest in visiting foreign country in their career. As for me, first of all, it is essential to acquire proper medical English as soon as possible. And I would like to grow up as the great doctor who can work all over the world. Finally, my dream career is to work somewhere in this broad world, not only in Japan.
These two stimuli were really meaningful for me, and I will never forget the experience here. Someday I would like to visit some country as a doctor. But before that, it is necessary to be a qualified Japanese doctor as Japanese medical service is still recognized to be high level.

4. Write a short note reflecting about your experience and new lessons learnt.

Most impressive lesson is about the insurance system related to the existence of the government and the private hospital. I encountered the problem of insurance many times in four weeks. This kind of matter is completely unfamiliar to Japanese citizen, so this is very good chance for me to study.
I learnt that there are government hospital and private hospital in United Arab Emirates, and this two kinds of hospitals are completely different in its services, mainly in its cost. I heard that the patients can decide which kind of hospital they choose according to the budget, waiting time, level of services and so on. One patient I observed in outpatient clinic came to GMC Hospital after diagnosed at one government hospital because it did not have enough equipment for his treatment. In another case, the patient who is diagnosed at GMC Hospital decided to go to a government hospital because of his budget. In Japan, I never see these problems. Some patients want to go to another hospital, but it is only for asking "second opinion". We have both government (public) hospital and private hospital in Japan, but these two kinds of hospitals are same in price and in service quality. All medical cost is decided by low according to the disease, the kind of surgery, the length of hospitalization and so on. And public hospital, mainly university hospital, often sends its doctors to private hospitals which have connection to university. This circulation contributes to keep the medical level of both hospitals high. So the price and the service of both kinds of hospitals are same everywhere in Japan, and we never consider government (public) or private.
I encountered the insurance problem many times in outpatient clinic. The doctor told me that there are many kinds of insurance in United Arab Emirates, and some of the citizen from abroad doesn't have enough insurance for the treatment of their disease or injury. One patient with fracture seemed to need to undergo CT for detail examination, but he did not want to do it because CT examination was not included in his limited insurance. Finally, he was treated on the basis of only plain X-ray but that is clearly not enough for the precise diagnosis. Another patient with back pain had to wait for the acceptance of MRI examination by insurance company. The doctor told me that he would wait for some days even he had severe pain on his back. Fortunately, his pain improved after a few days, but MRI was not accepted by insurance company. In another case, the patient from abroad was diagnosed in GMC Hospital, went back to his country for the surgery and came back in a few weeks. He didn't have insurance in United Arab Emirates so he could not pay medical fee in GMC Hospital. In this country, there are many citizens with various nationalities, so that the insurance system must be very complicated and it cannot spread to all citizens. But it must be most efficient to perform precise examination, give enough treatment and cure as soon as possible, wherever the patient is from. On the other hand, all Japanese citizen have same quality insurance, which enables them to pay basically 30 percent of total medical cost. As I mentioned before, the total medical cost is decided by low and the amount is always same in every hospital. Therefore, this system enables us to receive low-cost medical healthcare, though there are other problem of the debt of the government.
These two differences are obvious, and this fact influences the accessibility to the hospital. With the hospital system and the insurance system, all Japanese citizen can easily receive high-leveled and low-cost medical care at every hospital, which makes it difficult for us to understand the situation of United Arab Emirates. It may sound good but there is also inconvenient point. Almost all hospitals always look full, and it will take some months from outpatient clinic to Operation Theater especially in famous hospital, excepting emergency case. On the other hand, in GMC Hospital, once the doctor decides to perform surgery, it will soon be planed and be performed. The distinction between government or private hospital distributes the patients automatically and enables to receive medical treatment immediately with his or her intention. I think this is big strong point of the medical system in United Arab Emirates. There is no easy answer which is better and worse. The most important thing is that the people are satisfied with medical service in their living place.