Practical Advice and Personal Experiences.
Medical Sciences International, LTD. Tokyo 1997
by
Jun Teruya, MD., D.Sc.
Introduction
In this chapter I present advantages and disadvantages for Japanese medical students, residents, and young physicians contemplating clinical training in America. In addition I answer frequently asked questions about some details of the entrance examinations and the application process. My observations and conclusions are based on my prior 20 year experience teaching and practicing general internal medicine in a large public American medical school as well as my current 4- year experience teaching basic clinical skills in a major Japanese community teaching hospital.
Advantages
for Clinical Training in America
The reasons for ranking American medical education the best in
the world are as follows: Logical thinking method is the best
way to understand comprehensively patient problems. Personal opinion
and learning by watching and observation, the traditional methods
of acquiring new skills, are less important in the American system.
Residents and medical students are actively taught and supervised
much more closely than in other developed countries. Teaching
physicians enjoy discussions with residents about their patients;
they bring current articles from the medical literature into the
daily rounds. This 'evidence based' clinical medicine method insures
that current information is applied to the patient's problems,
that personal opinion is less important than published data, that
senior physicians learn from junior physicians when such younger
physicians have better information. All these advantages are the
same for clinical training in Canada. This author has no information
about entry into the Canadian residency programs.
In many American hospitals, young physicians are urged to use and follow national consensus clinical guideline for patient diagnosis and management. Some hospitals use pre-printed physician's order forms for critical problems, such as acute myocardial infarction. Such use builds confidence and overcomes insecurities among physicians.
The group feelings are very different from those in Japan where the cultural emphasis is on the sempai kohai tradition The focus is exactly on the patient in American training. In American teaching hospitals, patients are managed by a team comprising a senior physician, senior resident, junior resident and medical students. Each resident solves the patient's clinical problems for himself, by his/her own independent analytical thinking. Then there is discussion about the best course to pursue for the patient. A consensus is reached to do whatever is best for the patient. Only in unusual circumstances does the senior resident make a decision based on seniority. In America all senior residents supervise junior residents. They do not have their 'own' patients as may occur in some Japanese hospitals. Medical students (equivalent to first and second year residents in Japan) are supervised by their senior and junior residents. Senior physicians supervise all members of the team. Note however, independent logical problem solving is encouraged at every level. No medical student or resident may advance to the next year's higher level without proof of satisfactory performance. There is no automatic promotion. Those medical students and residents deficient in clinical skills are required to repeat the year and may be removed from the program. Hence, as residents advance to the next higher level, they develop confidence in their clinical skills; they have passed practical tests; they have less insecurity and less need for arrogance. Also the practical aspect that senior physicians are regularly learning from junior physicians keeps the senior physicians from becoming arrogant while boosting the confidence that the junior physicians have meaningful contributions to make.
Another major difference between American and Japanese training programs is the pace of the workload. In America on a general internal medicine ward, junior residents admit about 4 patients each day; the senior resident who is supervising 2-3 junior residents is responsible for 8-12 daily admissions. The work place has a rapid pace of evaluation and treatment of inpatients; the average length of stay is about 6 days. Residents are 'on call' for emergency admissions every 4th evening, night and weekend; they spend the entire night in the hospital, at times without sleep. For the 3 other evenings and weekends, they may 'sign out' to the 'on call' team, leaving the hospital in the early evening. At Kameda Medical Center, Chiba, Japan, junior residents admit about 2 patients a week; senior residents about 4 patients a week. The length of stay is about 16 days. Some senior residents may not supervise junior residents. There is no standard admission day; all days are admission days. There is no formal 'sign out' system; residents informally make their own arrangements. Residents have not been required to stay in the hospital during the night. Most residents remain in the hospital until the late evening; even when they have no patient work, they stay late to talk to other physicians and nurses to convey the group's sense of togetherness.
The implications of these differences may not be apparent. In the American system the residents have many patients in a short period of time. Clinical skills are learned rapidly, generally by 2 years in non-procedural programs. There is much stress for residents working in teaching hospitals. In Japanese teaching hospitals, the pace is more relaxed; there is much less stress for residents. However it takes longer to develop competent clinical skills; it may take up to 2 extra years of post graduate training to equal the 2 years of American residency. Note that medical education in America requires 8 years of study for the M.D. Degree, then 3-4 or more years of residency. In Japan medical students study for 6 years at the university, are awarded a MB Degree, then most continue their residency training for an unspecified duration, perhaps from 1 to 10 years. An advanced medical science degree may be awarded during this interval. A small number go into practice directly after graduation. Hence the first two years of Japanese postgraduate medical education, that is, residency, should be considered equivalent to the last two years of American medical school.
The
patients' medical charts also reflect important
differences. All American physicians are required to have precise
collection of patient data; detailed admission histories and physical
examination, logical assessments and plans with at least daily
complete logical progress notes. All medical charts are reviewed.
Failure to comply results in penalties against the physician.
Chart work is extremely important because it documents the physicians
thinking processes and the exact patient course. In most Japanese
hospitals, chart work may be required; it is rarely reviewed except
for billing purposes. There are no penalties for incomplete chart
work.
On a related topic, American medical students attend all their
classes. The lectures and related laboratories are very practically
oriented. During the 1st and second year(year 5 and 6 in Japanese
system), the problem- based learning method is used. This means
students and the professor discuss clinical cases to integrate
the basic sciences with the clinical sciences. Lectures are less
frequently held. No one sleeps during lectures. Weekday evenings
are spent studying. Weekend parties are small with modest amounts
of alcohol consumption. Japanese medical students frequently do
not attend lectures which are predominantly related to the professor's
research. The lectures are considered boring; many sleep during
them. There are frequent parties with sometimes much alcohol
consumption.
Of course there are exceptions among students on both sides of
the Pacific.
Disadvantages for Clinical Training in America
The
Japanese medical educational system(including
residency) produces a physician competent to practice medicine
within the country. There is no extrinsic need to learn a 'foreign'
system such as that in America. The medical school system more
closely follows the German 'Herr Professor' authoritarian system
than the American 'transparent' model. Residents are comfortable
with minimal instructions and maximal observations in patient
management by senior physicians. Mistakes in medical practice
are forgiven; there are infrequent penalties for clinical errors.
Medical malpractice cases are rare. The patient -consumers are
satisfied with the level of care they receive. Physicians enjoy
very high prestige and comfortable salaries. Patients are accustomed
to brief encounters with their physicians; patients ask few questions.
Physician organizations and governmental agencies concerned with
medical practice are naturally content with their current status
and resistant to any major change. Medical practice is less regulated
than in America. One example is that physicians may admit patients
for hospitalization without requesting approval from insurance
agencies, a major daily annoyance for American physicians. In
summary, Japanese physicians have a near perfect situation for
the practice of medicine which makes them rather content and
comfortable.
A barrier for Japanese residents to train abroad is that their
English language proficiency must be very advanced. It requires
an exceptional person who is so highly fluent in English conversation
that he/she can solve problems, fully participate in rounds and
discussions, and converse with patients and their families about
life and death situations, all without the stress of processing
the two languages.
Another barrier is the general education in Japan. The generalizations include learning by attending lectures and observation, suppression of individual's ideas in the classroom, infrequent classroom discussions, obedience to the teacher and lack of formal teaching of problem solving analytical skills. The typical Japanese resident is not prepared for the rigors of the American teaching rounds system. The resident must defend all his actions, plans, and treatments in detail before the group. Quietness is presumed ignorance. Mistakes in patient management are openly discussed; residents may be criticized before the group; in extreme cases penalties for mistakes may be severe. Japanese residents who cannot tolerate the 'transparent' American system whereby all resident conduct is evaluated, where resident assertiveness is essential for communication, and where open criticism of residents is frequently dispensed, should consider this aspect seriously.
Japanese residents particularly enjoy performing procedures such as ECHO and cardiac catherization. A small number of training programs may permit 1st year residents to perform these studies. Learning the technology and techniques are considered adequate accomplishments. Japanese residents thinking about studying in America should know that American residents do not perform ECHO (done by technicians) and are prohibited from performing maximum invasive procedures until the fellowship year(see below). The goal is to have the foundations of the clinical skills completely mastered before learning procedures. Mastering clinical topics requires many years of patient exposure and experiences with full supervision. This insures that when problems arise either directly or indirectly from a procedure, the operator is competent to continue the patient's care. As a corollary, American residents are required to have 1-3 years of general internal medicine or general surgery residency before entering subspecialties. Japanese residents may enter subspecialty training directly from medical school.
Perhaps the greatest disadvantage to studying in America is the stress of living in a different culture. The interpersonal relationship, at work and at play, the degrees of permitted assertiveness, of passivity, are completely different. It is difficult to predict how well a person can adopt to a dissimilar environment.
A final but very important disadvantage for Japanese aspiring to study clinical medicine abroad is the competition with American medical school graduates for a shrinking number of residency positions. American residency positions are designed for American graduates. Significant reductions in residency positions are occurring in anticipation of a physician surplus. International medical graduates are targeted to bare the brunt of these reductions. Medical school graduates from developing Asian countries are favored over Japanese graduates because of their superior English language skills and medical curriculum which follows the American model.
Those Japanese medical students and residents contemplating the challenge of competing for clinical residency positions in America need to think long and hard about these realities. Dreams and fantasies may come true but testing of reality and expectations should take precedence in making this important decision. The input from family and professor is highly consequential and cannot be ignored. Serious thought about finding a position when returning from the several years of study abroad should be given consideration. Some returnees have made the re-entry smoothly; many others have been frustrated and depressed by the rejection of their American training by their Japanese colleagues.
In conclusion, I feel that the rewards of studying in America are great for those proficient in English and achieving high USMLE scores. However the rewards must be balanced by the uncertainties of acceptance of the returnees by his peers. Only you can make this important decision.
Frequently Asked Questions(FAQ)
1.
When is the best time to study abroad?
The younger you are the better you can accommodate the stresses
of the heavy work load and pace of American residency programs,
and in living in a foreign culture. For most Japanese physicians
the ideal time is about the 3rd-4th postgraduate year. There is
no reason to delay until completion of a doctor of science degree.
Such advanced degrees are of little importance for residency selection.
For those research oriented, another approach is to conduct some
research at an American medical school, get known by your American
professor and then request that professor's assistance in applying
for the residency at that school's hospital. No special examinations
or certificates are needed for a research position.
2. How can one prepare for the special examinations to enter American
residency programs?
Everyone(including American medical school graduates) must pass
the special examinations to enter any American residency program.
In addition international graduates are required to obtain a special
certificate documenting their skill level and training. I recommend
taking the United States Medical Licensing Examination (USMLE)
Step 1, at the end of the final medical school year or during
the 1st postgraduate year of residency. Step 2 should be taken
toward the end of the 2nd postgraduate year of residency. Each
candidate should expect to devote at least one month of intensive
review of all the 'basic sciences' for the Step 1 examination,
and an additional month for intensive review of the 'clinical
sciences' for the Step 2 examination. Preparation for the English
examination is not as clearly defined. Suggestions include speaking
English as much as possible, travel, work, or study English in
America, join English study groups and clubs, watch English language
movies and instructional video tapes.
Successful completion of these 3 tests results in the awarding of the certificate of the Educational Commission for Foreign Medical Graduates(ECFMG), the necessary document to enter American residency training. This certificate does not guarantee admission to a residency program. It documents your credentials and your skill levels for medical sciences and English language ability. The higher your score the more competitive are your chances of obtaining a residency position.
3. How
does one find a residency?
Japanese medical students and physicians may apply to each of
several national non- governmental organizations for advice and
assistance in obtaining a residency position. Noguchi Medical
Research Institute, Japan North American Medical Exchange Foundation,
and Tokio Marine Medical Service are three organizations offering
direct help and possible residency placement.
Also serious candidates should apply through the standard system used by all American medical students, called the 'match.' By enrolling with the National Residency Matching Program, those holders of the ECFMG certificate can apply to the several hundreds of American hospitals which offer residency training. The deadline to obtain this application is in the October before the usual anticipated starting date of July 1. The American Medical Association publishes annually a listing of all postgraduate training programs. Each training program must be contacted individually to request an application to their program. Certain training sites seldom admit international graduates; other programs have almost exclusively international graduates. In every case, acceptance is highly competitive. The higher your grades in medical school, the higher your class rank, the higher your USMLE scores, the more competitive you are to succeed. In finding a residency, of course contacts from friends, professors, returnees can be most useful.
There
are a limited number of scholarships
awarded by the national government, ministry of health and welfare,
for residencies abroad in primary care. The Japanese government
awards these grants to young physicians employed by national hospitals.
[Ed: please add addresses/phone# in appendix]
4. How does one write a CV and personal statement?
Each training program requires a competed application. Certain
parts of the application can be the same for each application.
The parts are the curriculum vitae(CV), personal statement and
letters of recommendation.
Your CV or resume should be written in outline format. It should
contain the following information: Name, local address and phone
number, permanent address and phone number, date of birth, marital
status, spouse's name if married( and name/ages of children),
place of birth, Medical school (and University degrees if any),
medical school/university student organization/club membership,
honors, research experience, publications/presentations, employment
experience.
Your personal statement should be written in prose format. Suggested
topics include a brief description of your background, explanation
of why you became interested in studying medicine and any particular
specialty, any unique features of your character, discussion of
your future plans, if decided, and other non -school activities
that make you different from other medical students/physicians.
5. From whom does one get letters of recommendations?
Names and addresses of 3 faculty who know you best and can write
a brief letter about your accomplishments, achievements and character
is usually required for each training program application. Clinical
faculty are preferred over basic science faculty. It is customary
for American medical students to have the dean of their medical
school write a special letter. This letter contain favorable comments
from the clinical rotations. Hence if a Japanese physician has
participated in a residency program, then the chairman of the
program may write a composite letter containing the comments from
the varied rotations.
6. Are
interviews required?
Yes, every hospital to which you apply requires a personal interview
before acceptance. The interviews are usually by invitation. This
means that after you complete the written application, the receiving
hospital reviews your application and then decides whether to
invite you for its interview. Most interviews are conducted from
November through January. An advantage to applying to one of the
Japanese organizations such as Noguchi Institute or Tokio Marine
programs is that each requires interviews in Tokyo, making it
convenient. In all other cases the applicant must plan for the
interviews at individual hospitals. An applicant can anticipate
about 2 separate interview sessions at each hospital, lasting
about 30 minutes each. Questions you might be asked include: Why
did you apply to this hospital?; Why did you select this specialty?;
What are your short term(3-5 year) and long term(final) career
goals?; What are your strong and weak attributes?; What hobbies
do you have? Why did you have a low grade in a medical school
course or low score in a part of the USMLE?; and what patient
problem was most interesting? Questions you might ask the interviewer
include: What percent of the residents are internationals?; What
percent of the residents pass the specialty board examinations?;
and which are the best parts of the residency and the worst parts?
7.
What about fellowships?
Fellowships are extensions of residency programs into more specialized
areas. For example all subspecialties of internal medicine, such
as cardiology, pulmonary medicine, nephrology, etc. require 3
years of general medicine residency before admission into the
special fellowship programs. In some surgical fields, a candidate
should plan to take a general surgical residency for one year
before applying to the specialty. In other surgical programs,
one year of general surgery may be included in the total program.
As in internal medicine, subspecialization may be offered via
fellowship programs. Most fellowships last 1-3 years. All require
American residency completion; all require ECFMG certification;
all are competitive.
8. Can I find a short term program?
Yes, there are several organized short term programs for both
medical students and residents. Most are about one month in duration.
Most require the payment of tuition to cover expenses while enrolled
in a program. They do not require the ECMFG certificate. I list
some of the popular programs in the appendix. In addition several
medical schools have made their own exchange programs permitting
medical students to spend 1-6 months at an American medical school.
Please check with your student affairs or international affairs
office of your medical school. Further, personal contacts through
your professors or friends or family may find willing sites for
you to experience clinical medicine abroad. I know of many medical
students and residents who have made their own private arrangements.
Lastly, in a similar fashion, many of your professors have professional
relationships with American medical researchers. Several weeks
or months can be arranged privately for you to have a research
experience in America. Please discuss this possibility with your
professors.
9. Can
you describe some of the special programs?
I will give a brief description of selected programs. The Noguchi
Medical Research Institute solicits medical student and resident
candidates for admission to Thomas Jefferson University Hospital(TJUH)
in Philadelphia. Interviews are conducted in Tokyo each December.
Successful candidates enter the 3 week training program at TJUH
the following summer. If TJUH staff evaluate their clinical skills
as superior and they have the ECFMG certificate, they may advance
to a 3-6 month subinternship. If their evaluations remain superior
they may be selected for the 'match' at TJUH. Tokio Marine Medical
Service recruits candidates with the ECFMG certificate for the
3 year general internal medicine residency at the Beth Israel
Medical Center in New York City. Interviews are conducted in Tokyo
during the fall for entering the residency the following summer.
Kameda Medical Center has an arrangement with the University of
Hawaii for selected 2nd year residents to have a one month rotation
on a general medicine ward at Kuakini Medical Center in Honolulu.
No ECFMG certificate is required for this short term program.
Excellent preparatory programs for serious candidates are the one year internships at the US. Naval Hospitals, either in Yokosuka or Okinawa. These sites offer training in the American method of problem solving as well as the opportunity of developing fluency in spoken English; all interns must speak English with all patient and staff contacts. No ECMFG certificate is required.
Appendix
I. Organizations accepting candidates for programs in America-Short
or long term
1. Noguchi Medical Research Institute
Koubu Toranomon Building 5th Floor
1-20-7 Toranomon, Minato-ku, Tokyo 105
Phone: 03 3501-0130
Fax: 03 3580 2490
2.
Tokio Marine Medical Service
Tokio Marine New Building 11th Floor
1-2-1 Marunouchi, Chiyoda-ku, Tokyo 101
Phone: 03 3214 1808
Fax: 03 3214 3806
3.
Japan-North American Medical Exchange
Foundation(JANAMEF)
3-5-6-560 Oyama, Shinagawa-ku, Tokyo 142
Phone: 03 3794 2811
Fax: 03 3794 2900
4. U.S.-Japan Training Institute in Geriatric Care
Univale Foundation
Sumitomo Higashi Sinbashi 5th Building 6th Floor
2-11-7 Higashi Shinbashi, Minato-ku, Tokyo 106
phone 03 3435 8031
Fax: 03 3435 8040
5.
Preceptorship in Clinical Cardiology
Jules Constant, M.D.
57 Tillinghast Place, Buffalo, New York 14216-3408 U.S.A.
Phone: 1 716 836 6503
Fax: 1 716 856 7003
6.
Kameda Medical Center Residency Program
929 Higashi-cho Kamogawa City, Chiba, 296
Phone: 0470 99 1166
Fax: 0470 99 1195
7.
United States Naval Hospital
Internship Program Secretary
1 Chome, Honmachi, Yokosuka-shi, Kanagawa 238
Phone: 0468 21 1911 extension 8748
8. United States Naval Hospital
Internship Program Secretary
Chatan Cho, Kuwae, Okinawa 904-01
Phone: 098 892 5111 extension 643 7714
Fax: 098 893 5754
II.
American organizations
1. USMLE Secretariat
3750 Market Street
Philadelphia PA 19104-3190 U.S.A.
Phone 1 215 590 9600
2. Educational Commission for Foreign Medical Graduates(ECFMG)
3624 Market Street 4th Floor
Philadelphia PA 19104-2685 U.S.A.
Phone 1 215 386 5900
3. National Resident Matching Program(NRMP)
2450 N Street N.W., Washington DC 20037-1141 U.S.A.
Phone 1 202 828 0566
[editor: please consider adding email addresses]
Acknowledgements:
My daughter, Lauren H. Stein, 4th year medical student, University
of Florida, Gainesville Florida, kindly provided data about the
'match' requirements. My wife, Sara Stein, gave capable editorial
assistance. Eiki Makino, Medical Director, Kameda Medical Center,
offered much appreciated manuscript review