Thursday, March 31, 2011
Sunday, March 20, 2011
Sunday, March 13, 2011
I had a very thoughtful and detailed schedule set up for me before I arrived to the hospital. I rotated in the pediatric department. I worked Mon-Fri, 9-5pm on average. It was divided into 10 half day blocks. Keio has 3 pediatrics wards: the NICU/step down unit, hem-onc and cardiology, and general pediatric floor. I would generally show up for morning rounds and then would have a discussion or see patients for the rest of the half-day block. Many days had special conferences or meetings that I would attend. The schedule was very flexible so that I could change it as I wanted. I requested more outpatient time and was given several days to see various outpatient pediatric clinics. I requested to see the ED and was able to spend a day in the ED. On my application, I made it known that I was interested in infectious disease and public health. I was included in the weekly infection control rounds and weekly HIV rounds. I sometimes attended the infectious disease outpatient clinic, also. Every day was different so it is hard to describe the “typical day.” Regular rounds I attended were morning NICU rounds 1x/week, daily review rounds in the pediatrics general ward, and the most educational rounds were probably the teaching rounds that happen twice a week. Once a week the chief and associate chief of pediatrics each take a half a day and have most of the pediatrics patients presented by a student or resident to them and the rest of the rotating medical students. The professor then critiques the presenting and asks questions about the patients while making educational points. Other attendings and specialists are present to answer questions as needed. When a very interesting teaching point or something that no one knows the answer to comes up, the topic is assigned to a resident to present to the department later. I feel that these rounds were very educational and could be quite useful in
Most visiting students are given living quarters a short walk from the campus. Since I brought a wife and child with me, we had to find our own living quarters. It was about a 30 minute walk from campus. The dress code is the same as most hospitals in
I was assigned a specific mentor during my time there. He was a pediatrics infectious disease specialist. He provided me with his home and cell number and went 110% to make sure I was comfortable 24 hours/day. He invited me to conferences that were in neighboring prefectures that he thought I might be interested in and paid for my train fare if we travelled together. He answered all my medical and Japanese medical policy questions, or referred me to someone else who could answer them. He created my whole schedule and adjusted it. Since I trained at the CDC, he even pulled some strings so that I could talk to people at the CDC equivalent at
At other times, there was usually someone there to help answer questions when I didn’t understand the language or just had something I wanted to know in each ward I rotated at.
Since I had studied Japanese for 10 years and lived there previously, my language made it possible for me to participate in rounds. I am not sure what adjustments are made for those with limited Japanese language skills. All physicians have English skills and there are a good proportion that have trained in
I did not get to see patients independently. You only can observe patient-physician interactions as far as I know.
My wife and I would love to live in
There are some aspects of working in
I am very interested and may be involved in public policy at one point so the following are things I learned about the Japanese health care system that may affect how I approach health care policy or possible practice in the future.
Japan’s healthcare program has become the standard for multi-payer national health insurance systems due to its consistently low costs, easy access to healthcare, and comprehensive benefits package. Ranked 10th for overall health system performance, 1st in level of health attainment, and 6th in level of responsiveness by the World Health Organization in 2000, Japan possesses among the longest life expectancies at birth at 82 years (2003) and highest per capita number of physician visits (WHO 2005). Moreover, Japan only devotes 7.9% of its Gross Domestic Product to health expenditures while simultaneously maintaining one of the highest computed tomography (CT) and magnetic resonance imaging (MRI) technology distribution rates per capita (WHO 2005; Yoshikawa and Bhattacharya 2002).
So how does a country with an aging population provide such great care and spend so little? I am not 100% certain of the answer, but I asked everyone I talked to. The government sets the rates of payment. Hospitals or insurance companies cannot change how much is charged for 1 hospital day or a medicine. These costs are extremely low compared to
There are many things I experienced that made me wonder how they managed to spend so little. They keep patients in the hospital for very long periods of time, especially for end-of-life care. I’m not sure of the laws of DNR orders and such, but it seems very hard to impossible for doctors to pull the plug on patients. I was told that even if there is a DNR order, they could still be sued. So there are patients in the hospital for 16+ years, some in comas the whole time. Even for less severe disease, people stay in the hospital longer. Women regularly stay in the hospital for over 1 week after giving birth. 1 week is common for influenza or any common pediatrics infection. CT scans and MRI scans seem pretty common and easy to order.
They also order lots of medicine for everything. Anyone who has a cough gets special cough medicine that decreases the amount of fluid secreted by the airway. Every patient with influenza gets anti-viral medication. I was told that patients strongly desire medicine so they have to give something to them.
-Adjust schedule to student’s preference
-Excellent attending supervision
-Lots of educational rounds, meetings
-Heavy student involvement in rounds and discussions
-Good food in area
-Might be hard with limited Japanese skills
-Little patient interaction (if you stress you want more, you can get more though)
-Expensive cost of living
Wednesday, March 9, 2011
July-November: Take all required courses to graduate. For Thanksgiving, 2 weeks in Baltimore/DC for interviews and hang out at Chris's place for the holiday.
December-January: Interview at pediatric residencies across the country. Spend Christmas in Seattle. Keiko and Taisei accompany me to southern California and Utah, but no place to stay in northern California.
End of January-February: Elective rotation at Keio University Hospital in Tokyo. Keiko and Taisei join me to live in a rental apartment in Shinjuku, one of the busiest places in Tokyo.
February: List of ranked pediatrics programs due
March: Spend first 3 weeks in Hiroshima with Keiko's family. Finish Master of Public Health paperwork and final essay. Study Spanish.
March 17th: Match day, the day I find out which program I will be training at for the next 3 years.
End of March: Return to Seattle for 1 week and prepare for trip to Bolivia.
April: A total of 6 weeks in Bolivia. Work at clinic and hospital and study Spanish.
May: Return to Seattle and meet Keiko and Taisei there.
End of May: Graduation, MPH presentation.
June: Move to pediatric residency location.
July: Start pediatrics residency.
August: Baby #2 is born.
Tuesday, March 8, 2011
Seattle Children's Hospital, University of Washington: This is a fairly famous program. It is the only non-military pediatrics program in Washington and covers 5 states: Washington, Wyoming, Alaska, Montana, and Idaho. In fact, you spend a few months living in a rural area on one of these states during the residency. This is possibly the only program in the country that has this unique program. I had mixed feelings about it, but the residents all say it is one of the best experiences of the 3 years. It has a special global health and community health training. Many of the residents are older because they have done things outside of medical school to enrich themselves. My parents and possibly older sister's family live in the area.
University of California, San Francisco: This is a famous academic center. UCSF itself has a highly specialized center for sick kids on it's main campus. It is building an independent children's hospital, but won't be available soon. You also rotate through some community hospitals, including the main county hospital. It has a special program called PLUS, Pediatric Leadership for the UnderServed. You learn special leadership and management skills and have dedicated time for doing projects dedicated to the underserved. They also have a global health program. My interviewer was Japanese and gave me some connections of people to visit in Japan. They give the biggest living expense stipend and probably have the highest living expenses.
Oakland Children's Hospital: Not associated with any university. It has the main emergency room and is the only children's hospital for the bay area. Like other children's hospitals, it has a combination of rare and common diseases. Although I didn't know it at the time, one of the people who interviewed me was part of the same drum/dance group I did in college, Boomshaka. I can't believe it never came up.
Univ of California, Davis: This was one of the smaller programs I interviewed at, in size of residents. You rotate in hospitals in the area, but they are all very close. It is an academic center. It is probably the most afordable of all the places I looked at, living expense wise, located in Sacramento. It also has an EIS-trained attending who interviewed me.
Univ of California, Los Angeles (UCLA): An Academic center, fairly famous residency.. It is similar to UCSF in some ways. It has a very specialized center at the UCLA campus, but you rotate at several community hospitals in the area. It has subsidized housing which is easier to get if you have kids. It has a special community health program (CHAT). One of my friends from medical school is an intern there this year (since I took a year off for the CDC). One of the community hospitals is where movie stars from Hollywood would take their kids.
UCLA / Harbor County Hospital: This was also a small program. It is exclusively at the county hospital. Keiko is a little afraid of a county hospital because of watching ER, the old TV show. I was interviewed by a CDC-trained pediatrician here, too. At a county hospital, you generally treat uninsured patients, focusing on the needy. I would definitely learn a lot of Spanish. You probably get more independence than at other programs.
Children's Hospital Los Angeles: This is the children's hospital of the LA area, including the main pediatric emergency department. Fairly famous residency. It seemed very resident focused. It has a dormitory/apartment for the residents that is next to the hospital and very affordable. They are proactive with public policy. Residents were very nice and social. Heard that they work very hard, but the resident's at the program say they think that is a thing of the past.
University of California, Irvine and Children's Hospital Orange County: This is a combination of a children's hospital and academic center. Since it has a children's hospital, there are no need for community hospitals. However, next year will be the first year the 2 have been combined. They have been trialling it over the last year with good success. The children's hospital is very close to Disney Land and has many connections with it, including themes and visitors. You can see the fireworks from the hospital. They had an emphasis on a good balance of work and enjoying life and were very creative on how they treated us on interview day (we had an ice breaker including saying what is your favorite drink at a coffee shop, then the drinks appeared later in the day). Very enthusiastic residency director. Known a little for working hard and playing hard.
University of California, San Diego: This is a program that has a few hospitals, including an academic center at UCSD, the naval medical center, and the children's hospital in San Diego. Everyone I have ever mentioned San Diego to says what a wonderful place it is to live and they would love to go back. The residency director was extremely nice and seemed willing to go the extra mile for the residents. They mentioned they have connections with the local health department, the AAP (public policy group), and even biotech companies.
Primary Children's Hospital, Salt Lake City, Utah. A Children's Hospital that is independent but associated with the University of Utah. You basically rotate at the hospital. The rent is fairly cheap in the area. They have good AAP/policy connections. The chief of the infectious disease service trained at the CDC and does great research. They allow 1/2 day a week for research. I have a lot of extended family in the area and it's the only place in the country with a Japanese LDS church or ward. I liked the residency director a lot.
Northwestern University, Children's Memorial Hospital: Famous residency in Chicago. I went to this medical school and know the hospital well. The program goes out of its way to make it pleasant and social. They have bbq's every Friday for the first while and make sure all first-year residents are free to attend, even if they are on-call. While having rare diseases, the residency has a focus on service to the community and education to the residents. I know I like the residents well, because I have worked with them. Will finish a new children's hospital during my first year of residency.
University of Chicago: They have a new children's hospital. Work with a largely underserved population in South Chicago. Have a focus on creating leaders in pediatrics, including research, public health, and public policy. The residency director is very enthusiastic and humorous. They also probably get the award for best gift, a 2gb flash drive. While the University of Chicago has a reputation for overserious hard workers, the pediatrics residents seemed extremely nice and pleasant.
National Children's Hospital in Washington DC. Being in Washington DC, it is close to capital hill and the center of policy. They have a fairly large program in community health that gives time to be involved in policy. It seems very resident-focused. They will have formal education for the residents working night shifts. Also, my brother and his family live nearby.
My final rankings were from this list. There were some programs I got interviews at but cancelled, and some programs I didn't get interviews at.
Monday, March 7, 2011
1. Geography: This is probably the most important thing that all medical students consider. In my case, I wanted to be in a place with family (Boston, Baltimore, Seattle, or Utah, recently New York) or at least near family. I also wanted there to be a decent Japanese community for Keiko. And as long as I can pick, I wanted it to be warm. Keiko definitely wanted a place to be warm. I'd get to use/learn more Spanish in southern California.
2. How famous is the program: There are some hospitals that are famous because everything is famous there and the programs are also good (Boston Children's with Harvard, Stanford, UCSF) and there are programs that are particuarly famous for children's programs (Univ. of Cincinatti, Children's Hospital of Philadelphia).
This matters to me because I want to do a fellowship. The more famous the residency, the more famous the fellowship for a pediatrics specialty you can get into.
3.Children's hospital: There are basically 3 types of programs I saw. Children's hospitals and academic centers/community hospitals.
At a program with a children's hospital, I generally only have to rotate at that hospital. If I live close, I can ride my bike or walk rather than buying an extra car. The hospital is clearly for children. Nearly all the doctors are specialized for children. The nurses and techs all know how to deal with children. There are Wii's and Xbox's, disney movies, murals on the walls, toys everywhere, ways to distract the kids to keep them from noticing needles, etc. The personalities generally fit with what you would expect. Also, they often have the main pediatrics emergency rooms so that you get good emergency training, which is something I value.
At an academic center, I usually rotate at 3-6 hospitals. One hospital is the academic center that has the rare diseases and very complicated diseases. Cancer, transplants, etc. But you also need to know how to take care of flu, asthma, upset stomach, so you visit other community hospitals that see less severe sicknesses. You learn several different hospital systems and patient populations so that you are prepared to have a job in any sort of environment. At a children't hospital, you learn how to work in a children's hospital.
4. The "fit": this is universally called the most important thing to look for. It is basically do you feel this program is fit to your personality or not. Will you get along with the residents? What is your gut feeling?
5. Things I personally look for: CDC-trained attendings, public health research, a connection to American Academy of Pediatricians including working on public policy, global health curriculum, are there enough guys in the program. Pediatrics is quite female-heavy. I prefer a program that is 1/3-1/2 guys as opposed to 1/20 guys. I'd also like to use some Spanish since I have been trying to learn it.
6. Other: insurance, salary, vacation, benefits. Some programs feed you every day so no sack lunches necessary. Keiko was a big fan of those programs.
How much does it focus on residents? Do they make sure residents treat patients that you learn from or do you treat the same disease over and over? Do residents control the treatment plan, or is done by fellows? Do fellows do the procedures or do residents?
Do they allow time for research or are you swamped with patient care you can't even study or read.
I didn't have this thought our in this amount of detail until I interviewed at a few programs. The next step is to rank the programs I interviewed at and upload them into the national system online.
Sunday, March 6, 2011
View them at your leisure. I put this off for too long and she has described them in youtube for the most part.
Taisei 7-8 months, last bit of time in Chicago:
And here come the videos.
Taisei enjoys playing games, like being chased.
He has developed some lungs, which makes for a cute big laugh among other loud voices and sounds...
Taisei and the daughter of a on missionary companion.
Taisei likes to act real cute before bed and try and extend his bedtime.
One of his favorite things to do is rearrange the furniture.
Enjoying some swing with the Milonas boys.
More games with mom
Taisei-zilla destroying a village of cars in Seattle
Taisei loves his Grandpa Roush, who is probably the best person I have ever seen at getting a kid to sleep.
And here you see the magic at work
Enjoying the jumper in Seattle. It's the same way he dances to TV shows and mp3's.
A little tickle from mom:
Hand-slap game with "Uncle Ward"
And there are plenty more to come from Keiko's Youtube account. I'll get to them later this week.
2. Emergency medicine
My first 3 rotations of my 4th year of medical school were those 3 specialties. I liked them all a lot. I found out during my year at the CDC that I might not need to see patients every day to be happy as I enjoyed that year a lot. This means that radiology might be a good specialty for me.
Radiology was a lot of fun. The attendings and the residents are all very nice and all laid back. They are all very smart and incredibly important in modern day medicine to the diagnosis and daily management of patients.
The emergency department is a lot of fun. You have the enjoyment of seeing patients for the first time. No one knows what the actual problem is. You work quickly to fix them or admit them to the hospital. In most cases, you know what the problem is by the time they are done with the ED. You get to do procedures which is fun. I really liked seeing a patient, hearing what there problem was, and trying to get it fixed quick. If my team couldn't fix it, we sent them to someone who could and on to the next patient. You really feel like you are helping.
Then there is pediatrics. The attendings and the residents are generally the nicest of them all. Pediatrics, or peds, is generally a specialty that pays as little as any. A pediatrics cardiologist gets paid less than an adult cardiologist and a pediatric dermatologist gets paid less than the adult counterpart, etc. But there are several things that I like about peds. These are generalizations, not black and white facts.
-Kids are so cute. If you have to be at the hospital every day, it is nice to see cute kids every day. Even if they are sick, some may cry, but there are a lot more happy cute kids than you might expect. I get a lot of energy from that compared to older patients.
-I could be wrong, but I felt like there were more acute and less chronic problems. At least in my experience, more kids come to the hospital looking and feeling really sick, you make them feel better, and then they go home. Adults more often had problems where you patched them up until they return to the hospital next time.
-When you prevent a child from dying or becoming disabled, you are making a large contribution to society. That child will likely become a working adult in the economy and contribute many productive years. This is a little different than prolonging patients lives near the end.
A point for pediatrics versus emergency: I can always do a pediatric emergency fellowship later. If I want to do something besides emergency, it is difficult to do after an emergency residency.
A point for pediatrics versus radiology: I am very interested in global health, in preventive medicine, and public health. Radiology has a lot of potential but not a lot of opportunities currently. There is a good chance I might end up returning to the CDC and pediatrics is much more suited for a global health career. If I end up at a public health department or agency, a more general field like pediatrics would be better suited for looking at patients overall status. Also pediatrics has a shorter residency and lower pay so switching to public health wouldn't be as big a sacrifice.
If you can't tell I have chosen pediatrics. I realize I am giving up future salary and possibly working harder hours, but I am quite sure I will live with more fulfillment and happiness.
I am quite sure I will do a fellowship and specialize. The main possibilities are
1. Public health/global health, returning to the CDC
2. Pediatrics infectious disease
3. Both 1 and 2
4. Pediatric emergency medicine
5. Pediatric cardiology
Now I just have to match to a residency program.