by Karl Zheng

For my exchange rotation, I spent one month in the department of cardiology at Tokyo Women's Medical University (TWMU). My time was primarily spent attending rounds and conferences in the CCU and observing procedures in the catheterization and electrophysiology (EP) labs.

I saw many bread-and-butter cases such as diagnostic catheterizations and stenting of coronary vessels as well as radio frequency ablation of various foci of atrial fibrillation and atrial and ventricular tachycardias. There were also many diagnoses of rare, complex congenital cardiac malformations such as single right ventricle with pulmonary stenosis and situs inversus with transposition of the great vessels. In the EP lab, several patients were evaluated for Brugada syndrome as well as ICD implants for patients with known Brugada diagnoses. I even learned about the obscure Taku Tsubo syndrome. In the CCU, I gained a lot of experience reading EKG's and echocardiograms and learned about the many modalities of information that can be garnered from a good echo exam. Because I never formally rotated through either the cardiology medicine service or the CCU at Columbia, all of these experiences were novel for me.

I also learned a great deal about the Japanese medical education and healthcare systems. Japan is similar to the rest of the world outside of the United States in that medical school is a 6-year program beginning after high school that incorporates university level education with core medicine courses in the first 4 years. The 5th and 6th years are considered clinical years when students rotate through different hospital departments every few weeks.

The application process to medical school in Japan is quite different from that of the US. There are roughly 100 medical schools in Japan, and TWMU's class size is 100 students per year, both of which are comparable to the US. The average applicant in Japan applies to only 2 or 3 programs whereas in the US the average is 13-15. There are no standardized examinations like the MCAT in Japan as applicants have to take an entrance exam specific to each medical school. TWMU interviews approximately 150 students for their 100 positions whereas Columbia typically interviews 1200 students for 150 positions.

The clinical curriculum at TWMU incorporates the equivalent of the American system of Problem Based Learning, meaning the majority of their clinical education is done in small groups that emphasize learning of concepts through case analysis rather than being lectured to. The majority of American medical schools still teach in the traditional lecture-based way, which is what Columbia practices.

The clinical years in Japan involve very short 1-2 week rotations through each department within the hospital. I believe this is superior to our system in the sense that Japanese students are exposed to literally every branch of medicine whereas certain specialties such as radiation oncology, interventional cardiology, radiology, and emergency medicine are not represented at all during our major clinical year. The downside to such short rotations is that medical students in Japan seem to have very little clinical responsibility in terms of following patients, writing notes, and reporting to residents or attendings. I only remember one 6th year student who ever presented a patient during rounds. Based on my rather limited experience in the CCU, it appears even the residents only present their patients to the attendings during rounds and do not appear to have much input into the further management of the patient.

Another major difference between the American and Japanese education systems is that any student can choose to go into any branch of medicine, no matter how specialized. For example, to become an interventional cardiologist in the US is an extremely challenging and arduous task whereas in Japan it appears to be primarily a decision of personal interest and not numerical limitations. Perhaps this is because of the way the Japanese health care system is set up in that interventional cardiologists earn the same salary as regular cardiologists, which is the same salary earned by any other type of physician.

The economics of the Japanese health care system are surprisingly different from that of the US. The majority of Japanese physicians work in hospitals as opposed to private practice in the US, and they are all salaried to an "above average" level. Over 99% of Japanese are insured, and the coverage is universal, meaning they can visit any doctor at any hospital in Japan with no limitations.

In fact, Japan was recently honored as having the most efficient health care system in the world; the US placed 14th. The cost of a first visit to a doctor is $15 in Japan, irrespective of the duration of the visit, and the second visit is only $6. The average patient pays only 1/3 of this cost. This system clearly provides incredible access to healthcare- so much in fact that the volume of patients at clinics has become so great that every cardiologist I met said they see at least 40-50 patients a day, spending an average of 5 minutes per patient. Oftentimes patients have to wait several hours prior to being seen! I feel that while the entire system runs well and pays for itself right now, the aging of the Japanese population combined with physicians starting to be stretched thin on a mediocre salary may lead to some inevitable changes.

During my time in Tokyo, I also had plenty of opportunities to experience all the sights and culture of the greatest city in the world. Exploring the plethora of ramen shops behind my residence in Ekoda; navigating the labyrinthine Sunshine City; savoring the freshest otoro at Tsukiji market; being caught in the stampede of two thousand people crossing the scramble intersection in Shibuya with every light change; the hidden peace of the shrine at Asakusa- for all of this and more, I am proud to have called Tokyo my home for even just a month.

Every facet of Tokyo is meticulously clean and organized. There is no trash on the ground or even on the subway tracks; every night, almost every floor is mopped and every handrail wiped down. Tokyo is home to a mammoth train and subway system that operates at maximum capacity every day, and yet each train is on time to the minute, even during rush hours. Station managers hand out late slips as proof to employers on the rare occasion that a train is actually late. The old and the new coexist in Tokyo- the peaceful temple in Asakusa is framed against a backdrop of the bustling Tokyo metropolis while citizens, some clad in kimonos, enjoy Hanami in Shinjuku gyoen and marvel at sakura, not far from the roar of pachinko parlors and blinding lights of electronics stores.

Along with the old ways of thinking are the principles of respect and personal responsibility that pervade Japanese society. Everyone greets you from the moment you enter their field of vision or the door of their shop- it is simply universal. Unlike most Americans, Japanese assume responsibility for tasks entrusted to them without objection or excuse. There is no violent crime in Tokyo… period. I felt completely at ease walking 7 kilometers from Ikebukuro to Shinjuku one night on a whim. Japanese television is devoid of sensationalism, instead reporting only positive stories, updates on Japanese players in American sports, and even game shows that teach English. Truly, my month in Tokyo can only be described as magical.