Ms. Chanakan Chaidaroon(4th year Faculty of Medicine Siriraj

Clinical Elective Program Report
at
Kobe University Hospital
from Feb. 29th - Mar. 25th 2016
Ms. Chanakan Chaidaroon
4th year medical student
Faculty of medicine, Siriraj Hospital, Mahidol University, Thailand.
Introduction
I am Chanakan Chaidaroon, a 4th year medical student from Faculty of medicine, Siriraj hospital,
Mahidol University, Thailand. I have joined a 4-week clinical elective program at Kobe University
Hospital under the JASSO scholarship support. The duration for my program is from February 29th to
March 25th which includes a rotation of 2 departments, the Rehabilitation Department and the
Infectious Disease Department. There are 4 more medical students from Mahidol University that come
with me but we go to different departments.
Medical elective program
Rehabilitation department
duration : 29th Feb – 11th Mar Supervisor : Prof.Yoshitada Sakai
Rehabilitation is not a new field of medicine in Thailand, but the amount of the specialist and
the popularity for this subject is still a few. Only about 300 of registered rehabilitation physicians are
present throughout the country which has 67 million people right now. I think this number is not
enough. As for a medical student, the schedule for rehabilitation medicine is set to be only 10 days
during our 5th year, which is the next year for me. That's why I want to experience and learn about
concept and innovation for the rehabilitation, especially in a developed country with advanced
technology like Japan.
Activity
From the first day of my program, I met my contact person, Arissa Fukuoka, a 4th year medical
student. Even though it’s only a short meeting, but I feel that she is nice and helpful. I was guided to
Prof. Sakai’s room where I met the professor who greeted me and gave a brief introduction about the
Rehabilitation department. Since I haven’t learnt about this subject yet so I’m quite nervous but after a
small conversation, it really makes me feel relief. Then I was introduced to Dr.Nakayama who showed
me around and took me to the office where I can use a desk and locker. Then we went to the OPD
together and the work began. The schedule is slightly different every day, but the work mostly starts at
9.00 am unless there is a conference in the morning which starts around 8.30 am instead. I have been
assigned to follow Dr.Nakayama, a 3rd year resident and also other doctors including Prof.Sakai himself
and Dr.Harada who is also a pediatric orthopedist. During that time, there are 4 junior residents;
Dr.Miho, Dr.Mika,Dr.Agawa,and Dr.Sai. The activities that I have joined are as follows;
Routine patient visit; a daily activity starts at 9.00 am, when I go to the OPD. Normally I will
follow Dr.Nakayama and there will be 2 more junior residents. Because this department's main duty is
giving consultation, so we will read through the consultation letters and view additional information
from an electronic medical record by other doctors or staffs. After that, we will visit the patients at
different IPD to talk and perform a physical examination. After that, it's time for a medical record typing
and all of the consultation will be over around 11.00-12.00 am.
Conferences; Rehabilitation is teamwork, so we have many conferences including staffs from
different departments. For example; I have attended a rehabilitation case report in the morning with the
Physical therapist, occupational therapist and speech therapist. And there are also conferences with
other department such as palliative care or neurologist. And a case report at the inner patient
department with other doctors and the nurses.
Rehabilitation and physical therapy; in the afternoon, the schedule is not fixed so I have been to
different activities each day. I have a chance visiting a cardiovascular rehabilitation, pediatric
rehabilitation, cancer rehabilitation, occupational therapy, and sometimes a patient who had an
appointment at the orthopedic OPD.
Outside clinic; I have got a permission to observe my supervising doctor's work at other
hospitals; i.e. NikoNiko nursing house, Kanzaki hospital, and Ishikawa hospital. Therefore, I have seen
other clinical work such as a chronic care clinic, a nursing house for dependent patient like mental
retardation, and an orthopedic clinic.
Academic presentation; there is a meeting on Friday at the Professor’s office and also
sometimes a new drug presentation from the company representative. For example, I attended a
presentation about CO2 therapeutic effect research from Dr.Harada, a presentation about a new PPI
drug, etc.
Because all of the activities are mainly in Japanese which I hardly understand, but the junior
resident or other doctors will translate an important detail during the conference and summarize the
content for me in English later so I’m able to catch the main idea of that discussion. They also tell me
about a brief history and present illness of every patient before the patient visit and a bedside round.
Even though I haven't done any procedure or physical examination with the patient by myself, but I have
learnt many things from observing and asking. Moreover, other staffs like the physical therapist, the
occupational therapist, or even a PO technician, are also kind and helpful. They explain about their work,
show me so many instruments, and answer my question every time.
Learning outcome
First, the disease; I have learnt about signs and symptoms of diseases that are quite common
e.g. cerebral palsy, spinal cord injury, stroke and cardiovascular diseases, equinus foot, cancer, and
other neurological or muscular disorders. Besides, there are many patients with some rare disease that I
have never seen before e.g. Fukushima type muscular dystrophy, West syndrome, Monosomy 18
disorder, MELAS syndrome, etc. However, lots of the consultations are not only about the disease itself,
but also the problem from treatment, drug side effects, a long term hospitalization and the post-surgical
consequence.
Second, an orthotic and prosthetic technology; Most of the patients who visit an OPD are having
prostheses or orthoses. I have seen different kinds of these devices that are used in various purposes.
For example, a corset to protect the spine, a foot orthoses to stabilize an ankle and fixed a lower limb
deformity, a leg prostheses for a children who had a leg amputation due to osteosarcoma, or even an
electric wheelchair for Duchene muscular dystrophy boy who is going to high school next year. Most of
them are made-to-order so it’s specific to the user.
Third, an innovation for treatment; I have learnt about many methods of treatment such as a
transcutaneous CO2 therapy for Raynaud’s disease or a chronic ulcer which is non-invasive and doesn’t
need a complicated or expensive machine, a Botox injection for patients with muscle spasm that limit
their movement and cause abnormal position of finger or arm. Moreover, there is an interesting issue
about the way we treat an incurable disease such as Duchenne muscular dystrophy. In the past, doctor
will prolong the duration before using a wheelchair or other medical devices as much as possible. By
doing this, the patients can still use their muscle and walk by themselves. However, due to the disease,
they couldn’t move in a full speed or use their muscle in a full strength. But nowadays, many doctors are
having new method. They want the patients to be able to move around freely as much as possible, so a
wheelchair is provided earlier.
Finally, a concept of rehabilitation; the aim of rehabilitation is not the same because each
patient has different concern. In another word, the main purpose of rehabilitation is to make the patient
being able to live a normal life efficiently. Patients with same diseases and symptoms might need a
different rehabilitation because of their usual lifestyle and work is not the same. In order to find the best
conclusion, the doctor has to think about every aspect of the patient, for example, a housing style;
patients who live in a traditional Japanese house need a stronger proximal lower limb muscle i.e. leg
muscle because they sit on a mattress, using a toilet in a squad position, and sleep on a futon which
require changing position from sitting on the floor to standing. Compare to an apartment style, we have
to think about whether they have to walk up-stair or not, or do they use a bath tub that require an
ability to raise a leg high enough to get inside. Some tools for rehabilitation are very simple that the
patient cans effort or finds it easily after discharge from the hospital. So they can do some rehabilitation
at home like exercises that use only an elastic band or some weight or wooden stick. It’s important for
them to continue these exercises since rehabilitation require time and regularity to gain maximum
recovery. A patient’s preference is another thing to consider about. There are lots of orthoses designs
and materials to suit the patient’s need. A foot cast for a mountain-hiker, a slim cast for a stylist who has
to wear fashionable shoes, or a plastic cast that is light and easy to wear. It teaches me that our job is
not changing the patients’ lifestyle, but to find the best way to response to their demand.
There is also a ‘pre-treatment’ rehabilitation that amazed me. For example, a muscle exercise
and breathing exercise. It’s a program for a patient who is going to have a cancer treatment like
chemotherapy or surgery. The aim is to prepare the patient before starting treatment which will
definitely weaken their body and to reduce the following complication. It’s surprising because, for me,
rehabilitation is a process to support and promote a recovery after the disease is cured. But in Japan, a
concept of prevention is also mentioned. I think it’s essential to consider about this point too.
At this point, I have to admit that because of my knowledge and experience is not enough so I
couldn’t compare the difference between Thai and Japanese rehabilitation medicine. But so far, I feel
that the role of rehabilitation and the cooperation between medical staffs is very strong. They respect
each other and have a good collaboration among the team.
Prostatic Leg
Different Foot Orthoses
(sketch)
Staffs at Rehabilitation Department
Infectious disease
duration : 14th Mar – 25th Mar Supervisor : Prof.Kentaro Iwata
Infectious disease is ubiquitous for a tropical, developing country like Thailand. I have seen
numerous patients suffered from infection so it’s grasp my attention. Infectious is a complicated yet
straightforward medical field in my opinion. The main problem is to eradicate a harmful source of
infection. Once we know the causative microbes, prescribe antimicrobial drugs and wait for the result.
However, it’s only a theoretical speaking because when it comes to practice, we need to concern much
more detail to accurately and properly achieve that goal. Even more, prevention is another thing that
can’t be missed. Since the infectious disease department has a well-known reputation, so I want to see
and learn from this department in order that I can gain these skills and improve myself.
Activity
It’s my 3rd week of an elective program when I move to an Infectious disease department. I went
to the 6th floor where the conference room is. There were already some doctors checking the medical
record from the laptop and discussing about the patients. So I wait with Dr.Gina, a resident from
Portugal who is now doing a Ph.D. in infectious disease. Then I was welcomed by Prof.Ohji and after
introduced myself and a short greeting with everyone, I was assigned to join team A There are 3 fellowsDr.Nakata, Dr.Ebisawa, and Dr.Kudo, and 2 residents-Dr.Hongo and Dr.Nishihara. The other fellows and
residents are in team K. In the department, patients are divided into both teams and they will be
classified into 2 more groups. Every new patient will start in group 1 which needs more attention and a
closer observation. After starting a treatment and the disease is subsiding, the patient will be
transferred to group 2 so that the doctor will follow up by checking only a medical record.
A working schedule is almost the same every day; I go to the conference room around 7.30 am
and check the medical record of our team’s patients. After that we will go to the ward and visit the
patient, a history taking and physical examination is done, and sometimes a specimen collecting for an
immediate Gram’s stain is performed, and if necessary, we have to go to the laboratory to check a
culture and drug resistance result. A ward round usually finishes by 12.00 am unless there is new coming
patient or lots of patient is still left from the morning. In the afternoon, it’s time for a case report. Both
teams will present their patients’ past history, current illness, and updated situation. During the
presentation, everyone will discuss about the diagnosis and treatment plan. This is the best part, not
only because everyone is forced to speak English, but also everyone is sharing their own opinions. It’s
interesting to listen and re-think about the given explanation whether it’s reasonable or not. Once the
conference is over, sometimes we visit today’s new patient to talk and do the physical examination. In
addition, we used to pause the conference and visit the new patient right away if we find that this case
is interesting. The conference usually ends by 4.00 pm but it can be extended, for an hour or more, until
the discussion is finished.
Every morning, the team members will translate a medical record and tell me about every
patient’s information. There is also an updated list of patients with some details written in English;
name, age, gender, underlying disease, present illness, and current medication. Therefore, I find it’s not
too difficult to understand the case. During the patient visit, I have performed a physical examination
together with the residents and I have done the bedside Gram’s stain too. Even though I couldn’t
understand the conversation between patient and doctor, but the team members would translate the
important details afterward. In this department, English is used during the conference and everyone has
a good communication skill. Sometimes Prof. Ohji and Dr.Gina also tell me about some diseases that I
don’t know during the discussion. After the conference is over, if I still have question, I can stay a little
longer to ask the team members. So I can adapt myself and join the team after a few days. Then on the
3rd day, I received an assignment to do the presentation of some patients. It’s tough and challenging, but
with a help from other team members, I can make it.
Learning outcome
First, the diseases; because Kobe University Hospital is big, so I have a chance to encounter
many patients with various kinds of diseases, both intectious and non-infectious. For example,
pneumonia, secondary peritonitis, intra-abdominal abscess, cholangitis, infective endocarditis,
osteomyelitis, SSI, etc. Also there are uncommon ones like infective aortitis or Corynebaterium
bacteremia from LVAD. I learnt about signs and symptoms, a differential diagnosis, and a common
pathogen in each disease, and sometimes a drug-resistant organism infection. Besides, I have also learnt
about non-infectious disease too, because fever is not always a result of infection. There are many
patients who turn out to have other non-infectious disease such as a patient with lymphadenopathy and
fever has a Kikuchi disease, or a patient suspected of pneumonia has an UIP instead. Moreover, most of
the patients have an underlying disease and a past medical history. I have seen a real Noonan syndrome,
a MEN type1, or even an acute myocarditis with LVAD used patient.
Second, a treatment; the main treatment for an infectious disease is an antibiotics. Of course,
most of the patient needs the ATBs, but there is more detailed; which drug, when do we have to start
the ATBs, how long will it take, and whether the treatment is effective or not. Furthermore, there is
other reason of consultation like a surgery prophylaxis. This session is different from what I have studied
before, because the antibiotics usage in Japan is not the same in Thailand, for instance, the Thai first line
drug for MSSA is cloxacillin or dicloxacillin while it’s Ampicillin/Sulbactam in Japan. Some drugs is not
widely used in Thailand such as minocycline. Or even a vaccine like pertussis vaccine that Thai basic
health care still use a whole-cell type instead of acellular type.
Third, clinical skill; Because I have performed a physical examination so I have got a hands-on
experience with many signs and clinical findings, for example, a different between fine and coarse
crepitation, a Janeway lesion and subconjunctival hemorrhage, a heart murmur, or an abnormal muscle
tone. Besides, I have seen a technic when visiting patients like an order of physical examination that
disturbs the patient as little as possible, or warming the stethoscope between hands before touching
the patient. Another skill that I have practiced is a Gram’s stain which is slightly different from Thailand
in a matter of duration for each dyeing substance and the team members teach me a basic laboratory
interpretation. This kind of knowledge can’t be obtained unless I meet a real patient.
Finally, a learning method; A case conference teaches me a lot about how to approach the
patient and solve a problem. By having a case discussion, every team member has turn to speak out
their mind while the others are listening. As a result, not only the treatment was rechecked by other
doctors, but the knowledge and thinking process was also shared to everyone. In case there is a conflict
and the issue couldn’t be settled, it ends by finding a better reason to make a rationale conclusion. This
style of activity really improves our critical thinking skill and presentation skill. Furthermore, I think it
shows equality among team members and it proves that senior or superior doctors in this department
are open-minded and unprejudiced, especially Prof.Iwata. During the conference, he told us not only a
medical knowledge but also a logical thinking process and action, for instance, to make the best decision
which might not be a right decision, and there is always a risk in every decision making. Another
example is the fact that we don’t have to know everything in every detail but we must realize what we
don’t know, and the essential part which we need to truly understand is the principle of every subject.
He can give a concise yet thorough summary of these complicated matters. Thus, I have to admit that he
is a great teacher in my point of view and his attitude amazed me a lot. Comparing to my experience in
Mahidol University, it’s similar to a ‘morning round’ with attending doctor in an internal medicine,
pediatric, and gynecology department. The only difference is the place for discussion. Inspite of sitting in
the room and looking from the laptop, we do a presentation at the bedside and walking around the
inner patient ward.
Preparing for presentation
Performing Gram’s stain
Staffs at Infectious disease department
With Prof. Iwata and Prof. Ohji
Extracurricular activity
1. A Japanese class by Dr.Toshiaki Kato ; this class is scheduled once a week at 5.30 pm – 7.00
pm. There is also exchange student from other country joining this class, including Taiwan, and
Singapore. We learn about basic Japanese such as how to read and write a ‘kana’, Japanese letter. Then
after that, we have a lesson about a daily life conversation and useful vocabulary in medicine. Moreover,
we have special activities including a Karuta card game which a 3rd year medical student from Kobe
University has also joined us. I believe that in this generation, being able to speak only one language is
not enough. So it’s a good chance to practice both Japanese and English. At the same time, I get to know
new friends from other country as well.
2. A debate class by Dr.Aki Kitamura.; a private class is held in the last week around 5pm. We
have a sample case to discuss whether the surgical or conservative is better for this patient. Dr.Aki
divides us into 2 groups and let us discuss about this topic. It’s kind of a dilemma issue so the debate
began to heat up as the time goes by. In the end, neither the conservative nor surgical treatment is
wrong. It depends on the situation and other factors, so there is no definite answer for this question.
But I have learnt about an important of a good communication between doctor and patient’s relative.
Also a proper way to protect ourselves while doing our best as a doctor.
3. Japan and Japanese culture; I have been to many famous places around Kobe during my stay
such as Kobe port, Sannomiya, Chinatown, Kitano, Mt. Maya and Mt.Rokko, and Arima onsen. Plus a
nearby area like Himeji and Kanzaki while visiting outside hospitals. During my free time, I want to
explore Japan as much as possible thus I decide to travel around every weekend. So, I have already
visited Osaka, Kyoto, Uji, and Nara. It’s a joyful time travelling around both by myself and with my
friends. The scenery and architecture is unique. I prefer a cozy and peaceful atmosphere like Mt.Rokko
and Uji, but being able to slowly observe a rushing crowd in the middle of Kobe city and Osaka also give
a lively feeling of an urban life. Another thing that I really enjoy is Japanese food. There are numerous
meals, snacks, and desserts to try. The best meal that I have tried is the famous Kobe Beef and I agree
that it worth the price. Other thing that I like is a side dish. I have tried a pickle and a spice which can get
along with the main dish so well. Most of the food is delicious, maybe because the taste is not so strong.
However, my most favorite Japanese thing is people. The Japanese is welcomed and polite. They are
also generous, for example, the chairman of Kanzaki hospital gave me a rheumatic calculator as a gift,
and I have received so many snack and dessert from many staff and colleagues. At work, they are willing
to help and teach me even though it will slow down their task. In addition, I’m feeling lucky to meet
great supervisor and colleagues. They keep me company during lunch and sometimes they even treat
me a meal. In some occasion, we go for dinner together and have a fascinating time. I have lots of fun
talking with them about Japan and other topics. Lots of interesting conversations show me new aspect
of Japan and teach me other knowledge aside from medical content such as history, culture, social, and
lifestyle. I can feel a friendliness and kindness from everyone.
Debate class with Dr.Aki
Dr.Kato and exchange student classmate
Receiving Certificate from Dr.Kuno
With Japanese and Taiwanese friends
Accommodation and life
From the first day that I arrived, a taxi that Kobe University has booked picked us from the
airport and go straight to the accommodation. I stay at an apartment name ‘DAICHI GRAN HAIMU V’ it’s
about 20-minute walk from the hospital. I have to share the room with another girl, but it’s not a
problem since she’s my classmate who also joins the program. We have a small kitchen, a refrigerator, a
washing machine, and a heater. The previous room owner even left some necessary equipment like
cooking utensils and a plastic bag for us. The University also provided us a pocket Wifi, so we can use an
internet at our apartment and outside the hospital. At Kobe University Hospital, we can use a student
locker to keep our stuff.
Another thing I want to tell is about a language. In Japan, most of the Japanese isn’t used to
speaking English. I can hardly ask or talk with other neighbors or shopkeeper. But everyone is friendly
and willing to communicate. Students and staffs can use English but not all of them that can speak
fluently, so everything in hospital is still in Japanese. Moreover, all the medical term and drug name and
record are written in Japanese. During first week, I’m a little upset about this problem and keep
wondering why they don’t use more English. But come to think of it again and I realize that I also have to
adapt, not just them. So I change my role just a little bit, from a passive stranger who seeks for an
English speaking friend to an active foreigner who wants to get to know them, and the result is totally
awesome. I smile at them, try to start the conversation, learn some easy Japanese phrases from my
colleague. It’s true that they prefer Japanese than English, but they are also willing to help and talk with
a vivacious foreigner who shows an attempt to communicate.
Conclusion
Getting away from your hometown is always nervous and exciting at the same time, especially if
you’re going to spend one month at a renowned institution like Kobe University Hospital. There are
many thoughts bothering me before coming to Japan; the place, the people, the program, and so on.
Therefore, I prepare myself, not to avoid the problem, but to face whatever that is going to happen and
learn from it. When the program began, I found that every moment is educative and fun. Even if there is
a problem, but it’s one of the life lessons for me to grown up. After overcoming the hard time, I noticed
that part of the hardship is also because of my own thought and mind. It’s no use being over concerned
for an unpredictable matter. Moreover, I’m not struggling alone but I have friends and a team to get
through this difficulty together. So far, it seems like I have been surpassing myself a little more. I have
gained both academic and social skills, I have made new friends, and I have discovered many new
aspects of Japan. I think both Japanese and Thai medical system has its own good and weak point so it’s
not necessary to try to become like another country. But the important thing is to earn what we lack and
develop what we already have. I believe that by going abroad to encounter a different society is a way
to become mature and broaden my vision. This wonderful experience is a precious memory to me.
Eventually, I realized all over again how fast time flies. I still feel like yesterday was my first day in Kobe. I
appreciate every help and kindness from Prof. Takayoshi Kuno, Prof. Yoshitada Sakai, Prof.Kentaro
Iwata, Prof.Goh Ohji, Dr. Toshiaki Kato, Ms. Kimiko Nakagawa, Ms.Chieko Sawada, and other staffs. It’s
an honor for an ordinary medical student like to me to get this marvelous opportunity. This valuable
time fulfills one of my aims and also encourages me to continue reaching for my goal.