Looking back at 2007.

Time flies.

Oh boy, I wonder how many times I've said this phrase on this blog. But well, it's true. But it's also true that this year was full of meeting new friends and discovering my interests... and myself.

In spring, I participated in VIA's (a non-profit based in San Francisco and on the Stanford University campus) Exploring Health Care program to learn about health care in the USA and in the Bay Area in general. Along with medical students and undergraduates thinking of going that way, we hopped around the area to see hospitals, clinics (both private and free), homeless shelters, shadow doctors' rounds, participate in class to get a taste of what medical education is like there, and much much more over a period of 2 weeks.

The gay clinic called the Magnet, located in the heart of Castro, the gay mecca of the country, is what sparked me into community-based health care, or in other words health care that involves the entire community. What's amazing is that it's not merely a clinic but has the potential to act as a catalyst to bring a people together and empower them as a whole. I'll talk about this much more in detail another time...

And this summer, I found myself in a 11-day primary health care (PHC) training program at Mahidol University's ASEAN Institute for Health Development (AIHD) in Thailand. Along with nursing school students from that country, we followed a highly-concentrated course to see health care in the urban areas of Bangkok (including the slums), go up 4 hours by bus to the rural areas in Uthai Thani Province and stay in a village to do some epidemiology field work 'for beginners', and do a presentation at the end with our groups.

The rural area home-stay and the interviews and other interactions with the villagers totally changed how I think, and this is where PHC and community-based health care got on me. Again, I have to save another time to tell this in detail...

And last but not least, DOCS (acronym for Development of Clinical Skills), which we formed with the former participants of the Exploring Health Care program in our university to get a head start and practice clinical skills, played an important role in my life this year. We found energetic, passionate, student-caring doctors who were willing to teach us, in a university where we once felt finding those kind of mentors was devastating. Moreover, the activities led me to knowing general medicine, family medicine, and primary medical care, which then led me to Ukima Clinic, a community-based clinic up in northern Tokyo. (See post 2007/11/20.)

The more I look back at this year, the more the activities I was involved in get connected in one straight line. Compared to a year ago, I couldn't have imagined myself where I am now. This year helped me discover what my true interests are in (at least for now), and now I can much better describe the bigger picture of the doctor I have in mind for my future.

Wishing everyone a happy holiday season and another great year! :-)

Autumn leaves and climate change.

Autumn... trees are starting to change color, like a rendering of warm colors on a canvas. Temperatures have gone down, and I notice it's almost the end of November. Time flies.

Last Monday, I paid a visit to Kita-no-maru Park near the Imperial Palace in Tokyo. Spent maybe about an hour or two sitting on the bench, gazing at the picturesque scenery adorned with beautifully colored trees, while some little nursery children played with parents and other people sat on the lawn reading books or just taking a nap. Calm, quiet, and peaceful. Birds flew from a tree to another from time to time.

An oasis in bustling central Tokyo.

When you talk of autumn leaves in Japan, Kyoto is the first place that comes to mind. The former capital of Japan is just purely beautiful during this season. The scenery of numerous history-rich artistic temples with a balanced mix of red, orange, yellow, green, and sometimes pink and purple leaves is just simply magnificent.

However, peculiar things are starting to happen in Kyoto. The autumn period is becoming shorter and shorter year after year. Compared to half a century ago, leaves now start to change color two weeks late, and leaves fall off the trees a week late, shortening the "autumn leaves season". Why? It doesn't take a rocket scientist to guess... the temperatures at Kyoto have risen, widely thought to be the result of global warming. According to records, the average temperature of Kyoto is three to four degrees (Celsius) higher today than in the Meiji period, about a century ago.

Kyoto is where the international community agreed on a protocol to reduce greenhouse gases, and the host country promised to cut 6% by 2012 from the 1990 level. However, the reality is emission has increased by more than 8%. Experts note that the Japanese industries had already gone through a series of rigorous cost cutting measures in the 1980s through developing new technologies, thus cutting carbon emissions, so much of the current plans focus on taking advantage of the Kyoto Mechanism, such as emissions trading (ET) and joint implementation (JI), and also promoting and persuading offices and homes to save more energy.

We, as individuals, need to act now. For our future, not only to help our environment but also in order not to lose trust from the rest of the world. There are lots we can get done if we all do it. :-)

A visit to Ukima Clinic.

When I contacted Dr. Fujinuma to ask whether I could see Ukima Clinic, a community-based clinic operated by the Tokyo Hokuto Health Co-operative, he happily nodded. So, on November 6th, I had the chance to visit the clinic I had been wanting to visit since spring.

I invited three friends who also participated in the Exploring Health Care program this March at Stanford University and University of California San Francisco (UCSF) and now belonging to a clinical skills practice group called DOCS (acronym for Development of Clinical Skills), which we formed after knowing how much clinical experience the medical students on the other side of the 'big pond' are exposed to.

So that morning, the day there started out in the outpatient clinic. Of course, it was our first ever time shadowing a doctor, so there was so much to learn, both in terms of knowledge and the way the doctor interacts with the patient. However, what I felt here most strongly is that health care is truly patient-oriented, in other words, even if patient A and patient B have the same health issues, the medical treatment or the approach taken by the physician may not necessarily be identical.

For example, there's not much hope in persuading an alcoholic or a heavy smoker to quit or reduce the amount if he insists he earns money to drink or smoke, respectively, and if that is the ultimate joy for his life. However, a different approach may be taken towards a person who is more willing to care more for his own health. A woman who smokes five cigarettes a day to refresh herself during break at her work says she is aware that it's not good and she's thinking of cutting the amount, but just couldn't make the move. So, then the physician would actually show her some other ways of refreshing, for example drinking tea or coffee or having a light snack, and chatting with her fellow workers. Naturally, there are exceptions, but in general, the doctor does what makes the patient most happy.

In the afternoon, we participated in what is called an 'Oushin', which is a house call where a doctor goes and sees the patient at his or her home. This is a very interesting form of health care, since you really have the chance to see the environment the patient is in, including the lifestyle and the socio-economic background. There are households with various status, from seriously poor ones to rather wealthy ones. In this afternoon we visited seven.

There was a family where the only person in the house was a 90-year-old lady lying all day in the bed, having only one grandson living with her to look after her when he doesn't have work. Other members of the once big family have either died or are literally 'missing'. The house looked as if it's going to crumble with a couple more earthquakes (yes, common in Japan), and the physician, now used to visiting this home, told us the places in the room where the floor had become too weak to support us. There was also a relatively wealthy-looking family, living in a mansion. Nicely dressed ladies (apparently sisters) had gathered to look after their mother who had become ill. This was a first-time visit for this patient, so the doctor goes through the explaining and all the communication with the patient's family thoroughly and carefully with detail. After the visit, she added that it's essential to build a favorable first impression, since that leads to trust and will ultimately have a substantial effect on the future relationship with the family.

So the day ended roughly eight hours after we arrived at the clinic in the morning, though the physicians still had some paperwork left including reviewing the patients' medical records. It was a day where I had the chance to truly understand that there actually are various kinds of people with various backgrounds. I mean, I knew that by words, but this experience enabled me to put those words in my own context. It is often said that the socio-economic disparities have widened in Japan, but still not to the extent of those seen in the U.S., Europe, or developing nations, however, disparities do exist and those are not minute. It is all the more important to understand the true needs of the patient, considering the background and the environment of the patient, and think about what happiness means for each of the patients, and tailor health care to help them become happier.

At the end, Dr. Fujinuma summarized the day by giving us a small lecture about what primary health care (PHC) is, and what strategies the clinic is taking to make the community more happy as a whole. Through this talk, three key words got connected in one straight line in my mind: primary health care (PHC), public health, and community building and empowerment. There's a whole another story to this, so I'll stop here for now. :-)

Reshuffling the political industry.

When the leader of the main opposition party in Japan said he would resign, I first thought it was the beginning of a much-needed radical reshuffling of the "political industry" in Japan, contrary to what many critics and most media are saying.

He cited a couple of reasons for his decision to step down, but some notable points are him admitting that the Democratic Party (DPJ) still does not have enough strength to run a government, followed by presenting an idea of entering into positive talks with the ruling Liberal Democratic Party (LDP) about lawmaking, even hinting the possibility of a team-up. While DPJ's victory in the upper house (House of Councillors) elections that took place this summer represented a significant boost for the young party, effectively blocking the LDP from passing laws, ironically, the same could be said the other way around, as the LDP still controls the majority of seats in the lower house (House of Representatives), thus creating a political stalemate. Of course, the law says the lower house can pass laws even if the upper house vetoes it, but the LDP will not dare to do that, knowing how much criticism they would be receiving immediately afterwards.

In Japan, many speak of the advance the DPJ has made as the dawn of an era of a two-party system in Japan. However, if you look at the DPJ, it's just a cluster of former smaller opposition parties that joined together just because they weren't big enough to beat the dominant LDP in elections. So still, if you look at the members, some really have different views and ideas. Mr. Ozawa probably had this reality in mind that they at least aren't ready now to run a country. But then again, a similar comment could also be said with the LDP, since they are made up of nine factions that often compete against each other, though an increasing number of politicians do not belong to any. This said, I personally strongly believe that a radical reshuffling, or a reorganization in politics should be made. The resignation had the potential to spark this.

Many speak of DPJ's leader Ichiro Ozawa as a backroom dealer, but he has clear views and knows what he wants to do and what needs to get done. Politicians who have a clear picture should have their own parties with their own ideas with fellow politicians who share very similar views. However, the reality is, they just continue to cling to the LDP or DPJ, just for the sake of the support (including the financial part) they're eligible to receive when it comes to elections. But, we all have to remember that politics is for the benefit of the citizens and not the politicians themselves. Right?

Had Mr. Ozawa resigned and formed his own party with his colleagues who share similar views with him, independent from both the DPJ and LDP, it could have started a major reshuffling. After all, there are politicians in both parties who are likely to agree with him on a lot of terms. But well, he has somehow gone back to the chair. Now, he must be prepared for all the criticism he will be receiving especially through the media, in a country where the media has so much influence on the people. He might have changed his opportunity to instead be the beginning of an end of his career, at least in politics. But, I had hopes, yes, hopes... :-)

An evening in Shinjuku's good old backstreet.

A block still retaining post-war Showa era style, near bustling Shinjuku Station, houses over 30 "nomiya", or Japanese-style counter bars. It's called Omoide-Yokocho, which translates to something like "the backstreet of the good old days". The small community truly lives up to its name.

On October 28th, after we had the patient assessment workshop, I decided to go for a glass of beer and a light snack in Omoide-Yokocho with two of my friends who also participated in the activity. It's Sunday night, so not all of the nomiyas are open, and if you want to see how it is when it's busiest, Friday night would be best. So we walked down the small but lively alley and hopped into one named Asadachi. Many nomiyas call people walking by to come in, but this place didn't, so we just said why not.

This place had a very interesting, or to some maybe peculiar menu. They had raw pig and cow liver, testicles, penis, and uterus, while also boasting frogs, whale meat, fish, and many kinds of shellfish. Most of these could also be served cooked. A wide choice of rare alcohol was also offered, like "sake" made from aloe, snakes, lizards, etc... but with all of this, the two-hour talk with the owner of this place was so interesting that it made the menu irrelevant.

When he talked, he talked as though if he had met everyone from everywhere. And he closely looked into the other's eye when talking, and continued to look into it even after the other had shifted his eye somewhere else. Very observant he was... he really reads people's expressions. He's met all kinds of people, from TV superstars to politicians and company executives to front-line employees. They all come here to babble about what's up in the world they belong to, and that's why he knows a lot about them... And maybe because he has seen the eyes of so many that, he says he can read one's personality just by looking into the eye.

A 68-year-old actor came in while we were there, and says he has been a regular visitor for over a decade. The owner knows a lot about his life... that he was a playboy when he was young though having a wife, did ordinary desk work in his 40s and 50s at an insurance company, but decided to become an actor after he retired at 65.

The owner told us many things... but the one that seems to have been carved in my mind is "What's most important is your heart, but just that won't get you anywhere... you have to be clever, maybe sometimes even cunning or sly..." Hmm, maybe so. :-)

Patient assessment workshop by young doctors.

What would I do if a person walking in front of me suddenly collapses? He's holding his stomach and seems to be suffering from some kind of severe pain...

Much has been talked about basic life support (BLS), but that algorithm basically only applies to cases where the patient's heart has stopped. Well, then what do we do if a person's heart still seems to be working but he's unconscious and seems to be hurt in some way, is the question here. This is called advanced medical life support (AMLS) or international trauma life support (ITLS), and it's about assessing the condition of the patient in an emergency.

The algorithm consists of three major steps, and the first is called "Scene Size-Up", where the checklist assesses five points: body substance isolation (BSI), scene safety, number of patients, nature of the illness or the mechanism of the injury, and the resources that you have at that moment. The main purposes of this step is to provide safety not only for the patient but also for yourself, and collect information that can be gathered in a glance.

"Initial Assessment" is the second step, which is also the most important of the three. We assess five things here too: general impression of the patient, mental status, airway, breathing, and circulation. Does the patient seem severe? What's the level of consciousness? (AVPU - Alert, reacting to Verbal stimulation, reacting to Pain stimulation, or Unconscious?) Is there anything obstructing the airway? Is the patient breathing? What's the heart rate and condition of the peripheral circulation? Is the patient bleeding? Appropriate assessment in this step is vital, as the third step depends on the condition of the patient.

If the heart is not moving, we move on to BLS or advanced cardiac life support (ACLS). But if that's not the case, we first evaluate whether it's a trauma case or not. If it is, then we see if it's a single trauma or multiple. If it's single, we do a focused rapid examination of the injured area and ask the patient SAMPLE (Sign/symptom, Allergy, Medication, Past medical history, Event prior to the symptom) questions, while if it's multiple, we need to do a rapid thorough trauma survey of the entire body before asking the same set of questions. All of this is done before handing the patient over to the hospital.

Now, if the case is not a trauma, then we first see whether the patient is responsive or unresponsive. In the latter case, we must go through a rapid medical assessment of the entire body and check the vital signs (circulation and blood data). Gathering the medical history of the patient comes last, since one cannot speak at this moment. If the patient can respond to you, you gather this information first and then move on to rapid medical assessment and checking vital signs. Again, this is done outside or in the ambulance, before it reaches a hospital.

Of course, there's more detail and thinking to this, but the important thing about this type of learning right now is for us to do simulations with our fellow peers over and over to memorize the algorithm with your body, instead of the just the brain. Then we can move on to the details and the thinking of case-by-case scenarios. What's amazing about this workshop was that it was planned and carried out by a group of only first and second-year doctors and students. It really motivates you. :-)

AIHD 2007 reunites in October.

I really like these people.

And I think these people truly like each other. Almost three months have passed since the Primary Health Care (PHC) program at the ASEAN Institute for Health Development (AIHD) at Mahidol University, Thailand in August, but we're still close together. We're holding dinners and parties at least once a month, and the members just keep on coming. The October dinner was held on the 23rd, and one came from Nagoya by shinkansen, another came from Fukuoka, 900 km from Tokyo, just for the event. Two others dropped by at 10PM after finishing work and training, respectively, just to have a few moments to see who's here and what's up with them.

Just amazing. I wonder what got us so hooked up with each other... and no doubt I'm one of them. We had 37 Japanese in the flock in Thailand, and of course, not all of us come to join these events, but every time we get together, there's at least a dozen members, and what's both surprising and amazing, is that that number keeps on going up time after time.

And, we're all with different backgrounds. Not only are we comprised of medical or nursing students, but also people who already work, either in the medical field or somewhere else, or students from totally different areas of study (at one glance different, but actually connected). But there's some kind of intrinsic common factor that's keeping us together... :-)

International Health Co-operative Forum.

The International Health Co-operative Forum was held today in Shinjuku, Japan. It's the 3rd forum after Tokyo 1992 and Manchester 1995, and the theme of this occasion was to decide on the global objectives of the co-operatives' approach to health care, especially after the birth of regional health co-op organizations such as the International Health Co-operative Organisation (IHCO) and the Asia-Pacific Health Co-operative Health Organization (APHCO).

We first had a general assembly featuring some very interesting speeches, one of which I will discuss later, and then we divided into five sectional meetings: world's health co-ops, primary health care, poverty and international cooperation, coping with aging societies, and international exchange of people. I decided to participate in, you've guessed it, the primary health care meeting.

There I met Dr. Yasuki Fujinuma, one of four guest speakers for this sectional meeting. Actually, I've met him before, at a primary health care workshop which was held at the end of September. He's currently the director of Center for Family Medicine Development (CFMD), and also works at the Ukima Clinic, a community-based primary health care clinic located near Akabane in northern Tokyo, and is actively involved in both improving medical education and developing primary health care in Japan. Ukima Clinic is one of the clinics I have an eye on, as it is doing very interesting health care activities at a community-based level. I hope to visit the place sometime next month. Anyway, the part of his speech that caught my attention was when he talked about the near-term plans of primary health care in health co-ops. He talked about three.

One, he stated the need for clinical training in primary health care clinics. He showed us some numbers, and it was something we could nod at. If there were 1000 patients, 88 of them would be going to local clinics while only 0.3 would be paying visits to university hospitals, but the reality is, most of the young doctors train in university hospitals and others alike, the ones that provide specialized, so-called tertiary health care. Clearly, there is a definite need to do at least some training at the community-based, primary health care level.

Secondly, he mentioned that the health co-op should take part in more international activities, taking advantage of the fact that there are co-ops around the globe. In primary health care, you look at the patient as a whole, not just the disease, so it's all the more important to know and understand the socio-economic and cultural backgrounds of the patient. International staff exchanges and training sessions would surely provide an opportunity to see patients with various backgrounds and also have a look at what cross-cultural health care is like. The infrastructure already exists and works around the globe, so networking those is the key here, and I believe the recently-formed IHCO and APHCO can play a pivotal role in this.

And thirdly, he urged that more research be done on primary health care, and also stated that the quality of co-op's primary health care activities must be improved. After all, medicine is still a world where the more specialized skills you have, the higher your authority. In other words, areas like primary health care where you need more of a broad knowledge than specialized knowledge in a certain limited area are not so highly regarded, at least in Japan, so the people need to show with undeniable evidence that primary health care is something that plays an essential role in health care. The co-op's primary health care activities need to be improved too, since obviously you need trust from the people and the community, and quality is what builds it.

When I heard Dr. Fujinuma's talk, I just purely felt moved, and encouraged, as those were exactly what I had in mind. Primary health care, community-based health care, cross-cultural and international health care, education, networking of people and organizations... all of these words I've been thinking about suddenly got connected in one straight line. It's really exciting and encouraging when you meet these energetic people who share similar ideas with you, and especially if that person is already starting to get some things done.

Can't wait to visit Ukima Clinic... :-)