OJT

Today I attended on the job training in a hospital.

My attending doctor has high quality funduscope and otoscope. One of my friends also brought a good stethoscope. I tried to use them. This was my first time to watch fundus oculi so clear. Those equipments are expensive, but after using them and knowing the quality I want to buy them.
One of my mentors told young doctors that we should use funduscope and otoscope the beginning of training. When we used to check fundus and tympanic membrane from first, we always do that through our whole life-long work.

It is difficult for patients to change their life-style or action only from brief time of meeting with a doctor. We should approach more efficiently. For example, one of another mentors approach patients by handing in a paper which mentions about what he want them to do. I think it is good, because just only speaking people forget easily. But there is a paper, they can remind it.

Mock exam

Today, I didn't go out, just stayed home. I tried to do mock exam. The real exam is 8 blocks an hour each, and total an hour rest time. It was so tough for me to do that.

Previous exam was 7 blocks. I was used to long time test than first time. But the end of mock test, final block was difficult for me to concentrate.

We don't have enough time to think deeply to answer each question. We need to answer average 1 minute for each question. I should adjust this test style, and become "dog of Pavlov."

I hope these overwork experience will be available for me to be more mentally tough.

Tomorrow, suddenly I'll go to Mito to attend On the job training. I hope to become busy, and get a lot of clinical experience.

Conservative aspect

In this country, we sometime face to too conservative side.
I can partly understand to those aspect to maintain a system. From technological thinking, it is better to follow previous way until its function keep well. But sometime those conservative aspect effect bad, for example challenge new things.

We have to hide our private challenging for colleague. This is because some colleague don't think positive for these challenging. I think these phenomenon are not good for our mental health and society.

Our society should become tolerant to other thinking, other career, and other way of life.
Typical Japanese tend to prefer context rich environment.

Almost all Japanese know that this country slide down gradually when we keep same attitude as former. But they are hesitate to change, persist in closed mind, and stay domestic.

I'm sorry today's article to mention too abstract, but  I could not mention directly.
Today's experience is over all Japanese weak point in miniature.

World wide economic shrink especially in Japan

After World wide economic shrink, the economic condition in Japan is not good.
The beginning of the economic crisis was sub-prime loan.
After that, many countries try to recover their economy by increased export. On the other hands, Japan couldn't do that enough because of strong Yen.
Recently, Japan recover little, but not so much like other countries.

Many countries which has rich national resource like oil, coal, or rare metal, try to make good use of sustainable noninflationary growth. Japanese society failed to use the interest from high-growth period from postwar. It means Japan couldn't use our economic advantage well.

I'm really afraid of Japan becoming like Greece, where filed bankruptcy and suffered financial reverses.
What is a good way for Japan to survive in the world? We consider it and find the answer quickly. We don't have enough time to wait the answer. 

Anyway, today I got message from one of my English teachers on the Internet. It was really glad to me. Even if all technology develop, it is important for us to keep good relationship.
Even if I'm so busy, I don't want to loss my humor.

Merry Xmas

Today was Xmas. However, I spent my time as usual.

I got a phone call from one of my friends who is postgraduate student from Bangladesh. I was really glad to get his call. From his voice, he looked good.

When I visited Bangladesh, many Bengali people helped me. This is my turn to help exchange students.
My schedule is really tight. Three big exams remain before April 2011 when I start my junior residency program in Okinawa. But I want to make my time to visit Kyushu to see him.

philosophy

Wikipedia links about Michael Sandel is the following.
Japanese
English

I had a chance to talk with a post-graduate philosophy student. We told about Michael Sandel.
I explained that there is some boom for him, because he visited Japan to teach us the "Justice."
Of course, I tried to apply the lecture. Unfortunately I couldn't attend it, so watched in TV program.

We agreed that his lecture is attractive, because he tries to connect philosophy and real issue. For example, "Ichiro's salary is higher than President Odama, is it fair?"

"When you drove a train that brake is broken, you could only save passengers or mechanics on the track. Which do you choose?"
There is no simple answer for those complicated problems. Which you choose or whether agree or disagree depends on a individual sense of worth. We need to think deeply for complicated problems. It is because we don't have a time when we just face to these emergency situation.

Communication with people whose major is different is important for us to keep our mind broaden.

case10 -persistent cough-

I have to improve the following points.

• Asking more detail about suptum
• Asking more detail about sick contact
• When I suspect tuberculosis, I should ask last PPD
• Don't ask the detail of sexual activity which is not directly related to the situation in this time-limited situation
• advice her to do a standard protection to prevent around her

One expert of infectious diseases taught us that his big mistake was related to tuberculosis.
It is easy to say "suspect of Tb" retrospectively. But it is difficult to do that prospectively.

case7 -the patient's mother come to clinic-

Today, I practiced CS case. Today's case was little irregular one.
The setting was the child's mother came to the clinic. It means we can gather information from mother without physical exam.

I have to correct the following points.

• Asking the medication's effect (I'm satisfied to ask only medication)
• Asking last check-up (it is really important especially for child)
• Asking more detail about the brother who also had sick (we need to know more about sick contact)
• Suspecting of otitis media and UTI when you see a fever of child

Making a mistake is going shortest way to learn. However, I made same mistakes in different case.
It is difficult for us to select and concentrate on what we ask in time limitation.

Graduation exam finished

Today we finished our graduation exam. After all test over, a model answer is putted up a notice on a wall. According to self-scoring, I can graduate without accident.

It means I have to take three exams, Japanese medical board exam, Step2 CK, and CS.
Recently, I can connect Japanese medical studying and English one.

From a seminar for young doctors, I was inspired how to educate my juniors. When I have a next chance to teach junior students, I want to give them a message that it is important for young doctors to fall into a good habit to study.

It is important for medical staff not to make a big mistake.
It means we should do all things systematically, not to skip.
I have one idea to use some material to let them to read the results of follow-up tests systematically.

Multitask

Six years ago, I did multitask, writing paper, practicing tennis in formal club, and studying for transfer student's entrance of school of medicine.

According to twitter, US medical students can train their physical while they study in flashcards of their board exam.
Now, I have to study for Japanese medical board exam, Step2 CS, and CK.
I don't want to excuse myself for time limitation to prepare each exam.

When I start to work as a doctor, I have to manage my time more strictly. I'll not have enough time as now. Previous and recent hard work will be good experience for me.
When we don't give up, the trial become precious experience for us.

Today was first day of final graduation exam. Tomorrow is second day. I don't have confident to get enough score to pass, but I'll do my best as today.

This blog is visited just 1000 viewers. Thank you everyone!!

How to spend time systemically

From Sir William Osler, medical student should have form the habit of study. When we got into the habit of studying, it is better for us to spend our time systemically.

For example, the last one hour of a day, we study medical textbooks about today's cases on our desk.
Sir William Osler recommended students to put literal books on our bedside. It means before sleeping we should spend our time as reading books. It also means we should read not only medical textbooks, but also various kind of books, to keep our eyes open.

He was not only a great doctor and teacher, but also had a large stock of knowledge about the humanities and liberal arts. Therefore he had a lot friends of humanities scholars. He also registered humanities' congress.

I hope to keep my view broaden.

One of my mentors, Dr. Y.T. respects him so much. Therefore, he also registered one of humanities congress.

頭が毒入りリンゴになったわかものと王国の話

I read a picture book,　頭が毒入りリンゴになったわかものと王国の話 in a bookstore.
This book is written by a professor of Infectious disease.

This motif is swine flu in last year.
Poison apple means new unknown disease which has contagiousness.
The kingdom is a country which tries to protect their nationality by quarantine.

This book inspired me to think how difficult to make the decision for unknown disease.
Human always fight against many infectious diseases. We should remember that recent period is the first time the danger of infectious disease reduce.

One of my friends told that he want to show this book for children. I agree that. It is included too much black humor.

If you are interested in this book. Please try to see it in bookstore.

ECG Seminar for young doctors

Today I attended a seminar for young doctors which focused on ECG.
This seminar is so nice, because every doctor is famous and teaches well, and we can watch this in several branched places.


Today's topic of the seminar was ECG presented by Dr. K.
He taught us the limitation of  ECG. As experts of pulmonary finds the difficulty of chest X-ray, Cardiologist knows the difficulty and limitation of ECG.


Take Home message is the following.

• We should ask ourselves how useful to read ECG
• Don't recognize from patterns of ECG. Compare to previous ECG, and read systemically

For me, most impression his episode was that Evidenced-based medicine (EBM) is useful for non-experienced staffs. This is because EBM is made for them to become full-fledged except for experience. This is why EBM is friendly for young staffs.
Therefore, many young doctors can work and make clinical decision on the authority of evidence.

Statistic function of blogger

There is a new function in blogger, Statistic function.
We can check the trend of our blog by the function. We can know how many people visited this blog, what links were used to visit, and which country user visit it.

Recently, some friends told me to read this blog. I'm really surprised and appreciate to them.
This is because until recently, I believed this blog was read only few of my acquaintances.

It is funny to know what kind of viewers visit this blog.
Feedback encourages us to continue to do something. To know the trend of viewer in a blog is a kind of important feedback.

Japan was so cold today. I have to care for my health. Next Monday and Tuesday are our final graduation exam.

What are in your pocket ?

Some doctors call the pocket of their white coat "peripheral brain." It means that what bring in your pocket is important as your brain.

Stethoscope, Hammer
These are essential tools for physical exam.

Tongue depressor, Ruler, Pen light
These are useful when I measure the height of jugular vein distention.

Electronic dictionary, iphone
Of course, iphone can be used as dictionary. However, some doctors or patients don't want to use iphone in a hospital. In this situation, I use my electronic dictionary. When we just look for words, electronic dictionary is more quick.

MGH Pocket Medicine
There is MGH Pocket Medicine for iphone. When I buy new version, I'll choose that one.

The Sanford guide to antimicrobial therapy
Sanford always helps us to choose antibiotics. But there is pitfall for using this. We should think local factors. Don't believe it blindly, use it cleverly.

Small notebook

I plan to use a waist pouch for my residency.
I'll bring the following items: water, wallet, ophthalmofundoscope / otoscope, and tourniquet.

Symptomatology

When medical students learn medicine through textbooks, they approach from an index of diseases. It means that one disease makes us think of the symptoms, pathological mechanism, treatment, and prognosis.

On the other hand, in clinical situation, we have to think differential diagnosis from complain of patients.

Now I study mock medical interview. This preparation is good training of learning symptomatology as Dr.O told us last weekend.
In the training, I can find how my differential diagnosis is not enough.
Through this, I fail so much, and this experience are useful for me to see real patients.

Of course, there are Objective Structured Clinical Examination (OSCE) in Japanese school of medicine. However, in OSCE, we just learn how to get information systematically from a patient. There is no part to think differential diagnosis and plan. It looks like we can get subjective and objective information, but no assessment and plan in medical chart.

How to make your BSL well 1

When medical students become 4th or 5th year, they attend to bed-side learning (BSL).

This learning style was started by William Osler. We called him "a father who lead medical students to wards." Sometimes it is little difficult for medical students to learn clinical medicine only from textbooks. Bed-side learning is useful to learn more practical.

However, physicians are always busy, and all of them are not cooperative to educate medical students. Therefore, med students need to learn the ropes to adjust BSL.

The following tips are only from my experiences.

1. Try to act as semi-professional
When we get medical license, we have to behave as a professional doctor. We should practice to do so from med-student especially when students are on wards.

2. Find what students can do
All medical staffs are busy, so students should find what everyone can do, and do it. It will not only help for staffs, but also be useful for students to think subjectively.
Some doctors told me that when we become junior residents, the job looks like "assistant director."

3. Keep your own learning style

4. Try to manage your time efficiently

Maybe when I feel like writing this more, I'll continue to discuss about this.

Meet the Expert

Yesterday I attended one study group meeting. They invited two Infectious disease Experts.

Logic of Infectious diseases
A teacher of the first session was Dr. O.
I've attend his other teaching session previously. Yesterday's one was for medical students. It was first time for me to see his frankly talking. I could find new side for him.

In clinical medicine, there are two aspect, art and science. Sometimes we don't do our best to explain logically, just escape to use "experience", "sense", or "art".
We should try to explain those things logically to explain others.

He taught us to know "natural course" of diseases. It is difficult to study narrative story of diseases only from reading medical textbooks. Some experiences are useful to study more vividly.

Gram stain for medical students
The second session was Dr. H. He knows well for laboratory of microbiology.

He showed so many photos of gram stain. It was good training to learn morphology.

In my impression, he answered all questions from students in a polite way. I thought I would be like him to cope with every case and every clinical question carefully.

Yesterday, I could separate from multiple-choice style study. It was good refreshment for me.
Next week, I will study for our final graduation exam.

Meeting with a professor

Today, I and my friends met a professor who understands activities of medical students. We told career plan of doctor.

Medical students tend to choose program of municipal hospitals as junior residents. The professor also did so.

Clinical research is also useful for clinician to know how to use evidence-based medicine. The research is best training for clinician to study critical appraisal.

He also advised us that the career of doctors are long, and that there is no hospital which is perfect for learning every aspects of medicine. Therefore, we should fill in gaps.

He had a memo in which his clinical questions is written. I will follow his example. I admired his attitude that he tries to pick up clinical questions.

The most impression word for me in today's meeting was "My career after two years will be decided by me after two years."

How to associate with media

Recently, one of major Japanese newspapers, Asahi Shimbun reported a incidence of a clinical trial in the top page.
The newspaper claimed the delay of report the incidence to other institutions was blunder

Some doctors and association refused the claim, and insisted that the article was not scientific. There are some strain among those doctors and the newspaper.

Media tends to attack authority.
It is easy for media to report confrontation between patients and medical institutions.
It is partly because media can create root for the underdog. It means that viewer can support the patients' side.

Those sensational events tend to become articles.
However, I think media should report daily activities in medicine, How medical staffs do their best to help patients, How patients and medical staffs enhance collaboration with each other, and so.

We should make good relationship with media. We cannot make these good relationship quickly, but usual communication makes it build. I hope so.

Today's my schedule

1 Read Guyton medical physiology
2 study 2 blocks for CK
3 practice 1 case for CS
4 review last graduation exam
5 study gynecology for JP board exam

Yesterday, my performance of practice for mock medial interview was not good. It was partly because the case was surgical one. Today's case was internal medicine. So I did better than yesterday. It is ideal for me to practice CS every other day until CK.

It is difficult to keep a balance among preparing 3 exams. Sometimes I thought I was exhausted just arrange my schedule for study.

I'm little worried to my procedure of CS and CK. It's still pending.
Of course, in the mid-course, there was requirement of other documents, but it takes 2 months from I start the procedure.

Bad day

Today was not good day for me. I missed so much things.

I've not finished my assigned study.
In my jogging, I felt pain in my side. So I couldn't run enough.
I missed the time for my English lesson.
I couldn't perform well for practice for mock medical interview.

Until March 2011, I have to take many exams. The results of those exams are pass or fail. It means slight mistake affect the outcome.
Recently, I cannot get good achievement for all. I'm little nervous and in haste.

I fell deep regret for today. Life is long, so don't mind, and don't be so negative. Let's learn by mistake. Be refresh and do my best from tomorrow.

Struggling against difficulties for the sake of vengeance

Clinical training in Mito

I went to a hospital in Mito to attend clinical training. Actually I usually study for multiple-choice style exams. It means my clinical sense become blunt.

These training opportunities are precious for me to remind me enjoyment of clinical medicine.

Today was little tough, because all patient who I attended admitted.
There were some students who came from far area. One of the students came from Okinawa only attend this training. They use many time, money and elaboration for this. Their passion encouraged me so much.

I was not sure I taught them well. I was not afford to teach so much, because I don't have enough experience and time.

Anyway, when I have a time New Year, I want to attend this training finally. It's depend on how I can prepare for my board exams.

What "Sakano ueno kumo" teaches us

Recently, a drama "Sakano ueno kumo" is broadcasting.
The novel was written by Shiba Ryotaro, one of Japanese famous writers.
It was historical novel about Japanese-Russo War 1904.

Some people confuse that this novel admire Japanese win of the war.
He tried to find the cause why Japan won the war and lose next World-war 2.
Fundamentally Japanese had persisted the success until our critical failure in WW2. It is difficult for human to throw away their successful experiences and to face with miserable reality.

Nowadays, we are in a same situation.
After WW2, Japan was in remarkable high-growth period. Once Japanese high-growth system was made a lion of. However, now Japan cannot recover from economical shrink, while other countries tried to find new growth way.

Maybe it is a time to throw away our successful experiences in 1950's and to accept miserable reality that our country become shrink gradually.
We should learn our history more.

I like this novel, so I read twice. In my policy, I don't read a same book twice until I value the book more.

Announcement of Big project

This morning, there was so heavy rain. I was little hesitate to go to University, because of squall. Fortunately, when I went out, the squall just ended. Wind and heavy rain was so severe that according to news, there were some victims.

Today, we announced our "Big project" for our class-mates.
It was hard for me to gather money for inviting doctor. We had to negotiate many section or person. It was good social experience for me, however sometimes it was time-consumed thing for me. You know, now we have to study graduation exams and board exam. In addition, I have to study for US board exam. It means my time-limitation is more severe than other.
After this announcement, I hope everything to go smoothly.

I've just finished my semi-final graduation exam.
From tomorrow, I should study harder to pass all exams, but I'm glad to spend my time as my own pace.
Next three months will be last time for me to concentrate my study. From next April, I have to study on the job.

Pay attention & Time-lag

When I try to talk complicated things in English, My grammar of talking always become worse. This is because I can pay attention for grammar less, while pay attention for the content more.
I think I can improve this problem by learning more difficult or complicated words, and being used to grammar more.
In these situation, I feel speaking so much, but actually I don't speak so much. I have to use so much energy and attention for just seeking words. I need to be familiar to more words for various situation.


There is a time-lag to response in English conversation. This is because I cannot think English completely. Therefore, I have to translate some Japanese words to English.

It means there is time-lag . Of course, it is natural to speaking English more slowly than native Japanese. However, I do my best to reduce time-lag.

Today was a first day for semi-final graduation exam.

Staying Human During Residency

I found one blog which is written by Dr.H. He is a expert of pediatric infectious diseases.
Infectious diseases is not popular specialty in Japan. Pediatric ID is also.

Previously, I listened his lecture in Tokyo pediatric infectious diseases conference.

He also finished junior resident program in OCH. It was fun for me to read his article about legend of hard training in OCH.
For example...
The last time they ate meal was the day before yesterday.
Some resident bought a dozen of enteral feeding product for himself or herself.
They slept on the floor.
There was a rumor that one resident would be twins or double, because he is so tough.

It looks like real field hospital.
Maybe I have to read Staying Human During Residency Training: How to Survive and Thrive After Medical School
I hope I stay human even if I'm so busy.

Anyway, writing English in this blog is good training for me. This is because I can find my mistake for spell.
Tomorrow there is second final graduation exam. We take graduation exams half year. I hope to graduate without accident.