Report of MD Anderson Cancer Center
Japanese Medical Exchange Program JME Program 2018

Ryo InosePharmacist
Department of Pharmacy
Osaka City University Hospital

Personal Mission and Vision from JME Program 2018

●Mission:(Japanese)

医療ビッグデータ研究を用いて、二次発がんのリスクや発現時期を明らかにし、エビデンスを患者に還元する。
(English)

Clarify the risk of secondary cancer and the timing of incidence through the medical big data
research, and return evidences to the patient●Vision:(Japanese)

医療ビックデータ研究を用いて、化学療法による二次発がんを防ぐ(English)Prevent chemotherapy induced secondary cancer by using medical big data research.

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Purpose・MethodsPage． 1【Purpose】
1. Learn about team medicine practiced in MD Anderson Cancer Center (MDA)
2. Clarify my Vision, Mission, Goal
【Methods】
The training was conducted in MDA on following topics
・Observation about team medicine practiced in MDA and receive a lecture· Learn about leadership· Clarify my career development with mentors· Complete group project with multidisciplinary【Contents】
I. Purpose・Methods
II. Contents・Progress・Achievements
1. Team medical in MDA
A. Outpatient clinic (clinic)
B. Outpatient clinic (Ambulatory Treatment Center)
C. Inpatient clinic
2. Leadership
3. Career development
4. Mentorship
5. Team project
III. Future Prospects

ⅡContents・Progress・Achievements

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1. Team medical in MDA
The work of Mid-level Provider and patient attitude in MDA, which is very different
from Japan.
The Mid-level provider is Nurse practitioner (NP), Physician Assistant (PA), ClinicalPharmacist etc. They undertook the work that doctors would do in Japan.
When we observe inpatient clinics and outpatient clinics, the Mid-level provider has
always intervened. In Japan, the doctors are centers on medical practices, but in MDA,
doctors focus on decision making and there are many scenes where direct medical
practice is left to Mid-level provider and others.
They did not only examine and explain the treatment but also did the informed consent.
Furthermore, there are some clinics to be performed only with NP. The breadth ofMid-level provider's work was very impressive.
Regarding patient attitude, the number of patients learned about their own diseases
and treatment methods were overwhelmingly larger in MDA than in Japan. When I am
involved with patients in clinical, I feel that patients in Japan are not very interested intheir own diseases and treatments. Many patients have a posture to leave everything tothe doctor. Also, the patient does not positively ask questions to medical staff. To behonest, in Japan, we can sometimes find the patients who do not seize themselves as thecenter of the medical team. On the other hand, many patients who I met in MDA are
strongly aware that they are at the center of the team. They accept advice from medical
professionals, but clearly show the stance that they make the final decision on their own.
I thought many times during the training about why this difference in posture between
Japan and the US occurs. I think that the difference in national character is one factor,
but I think that the difference in patient education system is bigger than that. There areseveral libraries called “learning centers” in MDA, which are also present in adjacenthotels. Here, information on diseases, the kind of treatment, side effects can be obtained
from books and websites. Also, when parents suffered from cancer, books showing how totell the disease to children, and books for children were also abundantly available. In theLearning Center, a profession called Health Educator is stationed, listening to questions
and concerns of patients, and maintaining the website. In this way, there are so many
opportunities to learn about their own diseases and treatments and resolve their doubts.
Therefore, everyone can easily learn about their own diseases and treatments, I thinkthat they lead to a positive attitude of patients.

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3A. Outpatient clinic (clinic)
The outpatient clinical style was very different from that of Japan. In Japan, it iscommon that a patient goes to the examination room, but in MDA each medical
professional goes to the examination room which the patient waits, and medical care isperformed. Also, a waiting place for medical staff called Physician Room is provided foreach team, and many professionals such as doctors, nurses, pharmacists etc. aregathered together.
Specifically, first, a nursing assistant visits and makes a simple inquiry. Next, thenurse collects information such as vital signs. After that, NP / PA gathers more detailed
information, and finally the doctor goes to the examination room. All the information
gained by each job is shared by many professionals waiting at the Physician Room.
Although the pharmacist does not go to the patient every time, they interviews with thepatient directly at the beginning of a new medicine, at the onset of a side effect, when apatient has a question about a medicine, etc. As described above, waiting time of apatient decreases as each professionals change and visit the patient. Also noteworthy is
the scene of examination. There is an electronic medical record in the examination room,
but basically it is not used. Healthcare professionals have talked face to face withpatients and look at their eyes. At the end of the examination, be sure to receive aquestion and answer as being kind. Even though they are too busy they will never show
their figure to the patient. In the outpatient clinic, we were able to observe the somemultidisciplinary teams, but every team had the same policy. Every time I saw
outpatient clinic in MDA, I was able to witness a high degree of patient satisfaction. It isdifficult to introduce all these systems to Japan due to restrictions on medical resources.
However, I believe that increasing the work that each professional can do and sharing
the role will lead to enhancement of outpatient clinical practice.
As a very impressive service, there is a viewing of medical information from home andan inquiry system. The patients can browse their medical information through theirwebsite from their home. In addition, they can consult with questions such as clinicalexamination by e-mail. These are very useful systems for patients and their family, and I
would like to expect introduction in Japan.

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4B. Outpatient clinic (Ambulatory Treatment Center)
At Outpatient clinic (Ambulatory Treatment Center: ATC), administration ofanticancer agents is common in Japan. However, in MDA, not only anti-cancer drugs but
also central venous nutrition, antibiotics, infusion administration etc. are also conducted.
There are three ATCs in the MDA, one of which is fully operational 24 hours a day, 365
days a year. I was particularly interested in care for hematopoietic stem cell transplantpatients.
Prior to traveling to the United States, I heard that the hospitalization period is veryshort in the US, hematopoietic stem cell transplantation is no exception. I also heardthat patients will leave hospital soon if they engraft. However, After engraftment,
systemic management was necessary after hematopoietic stem cell transplantation, andwe thought that urgent discharge from the hospital was impossible. For that reason, I
had doubts about the story. The existence of ATC resolved the doubt. Indeed, in MDA,
patients after hematopoietic stem cell transplantation will be discharged promptly ifthey engraft. After discharge, the patient goes to the ATC every day and receives thenecessary treatment. The patient borrows an apartment nearby and lives at the hotel. At
the center of ATC was Mid-level Provider. They do the control of the immunosuppressive
drug, the monitoring of the viral load, the adjustment of the composition of the infusion
under the previously prepared protocols. These are works that doctors in Japan in chargeof inpatient do carefully every day, we were very surprised. Of course, a doctor intervenes
with cases with poor control. I was very impressed by the high level of expertise ofMid-level Providers and the importance of pre-defined protocols.
C. Inpatient clinic
In inpatient clinic in Japan, it is common that each professional goes to the patientindividually and provides medical care. While I work at hospital as a ward pharmacist inJapan, I frequently have discussions with each kind of professional. However, I
sometimes felt that there was a scene where it is difficult to share information of patientswith many kind of professionals because I do not always work together. In MDA'ssystem, such problems did not occur. In the MDA, multidisciplinary team discuss andshare information before they go to the patient room. Team members consist of doctors,
clinical pharmacists, NP/PA, ward nurses, etc. If necessary, doctors from otherdepartments and MSW will also participate. In this way, information on patients wasshared day by day. It was characteristic that many kind of professionals shared actions.
After the discussion, they go to the patient as multidisciplinary team, and they express
opinions. After leaving the room, they also gather at the conference room and discuss
about the next patient. They are confident in their own expertise and the sight that
positively expresses their opinions is very impressive.

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2. Leadership
We received training on Leadership several times in MDA. We have learned a lot ofthings the leader has to be conscious of. Among them, the word which “know the teammember's core value” was impressive. Even though I work in a team, I think that I often
do not often talk much about what each member puts weight on.
In fact, JME members had opportunities to talk about their core value, and we wereable to glimpse the surprising aspect of the members. Our project team was aware of thecore value of each member and discussed the presentation of the final issue. Because weknew their core value, I believe that they can think about what they value, and haveformed a stronger teamwork. It is an example that I felt very important to know the corevalue of each member when I accomplish things together. In Japan, there is little
opportunity to learn about the Leadership systematically. By increasing opportunities tolearn about Leadership, I believe that we can make better teams and lead to patient
benefits.

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63. Career development
Prior to training at MDA, I was asked to describe the Individual Development Plan(IDP) sheet. For IDP, it is necessary to describe own Vision, Mission, Goal. It is also
necessary to describe what goals I am working on and how to allocate time to education,
research, Patient care etc. It is my own experience. Since the fifth year of college, I
decided annual goal and monthly goal. I intended to be working toward those. Therefore,I meant to think a little about Career development. However, I found out that I do nothave any meaning in my goal management in the talk with Dr. Ueno and Mentors.
Although I have made small goals, it was a major problem that these small goals are notfacing the same direction. To solve this problem, I first started by clarifying Vision andMission. Initially, I had a prejudice that Vision had to be magnificent, and it became
content with poor feasibility. Upon receiving advice from Dr. Ueno, I was conscious ofbuilding Vision and Mission that can be realized within 10 years. Also, I learned that it isvery important to make one in career development. Even if I make Vision and Mission,others need to memorize. Therefore, it must be content including uniqueness. If I canbuild Vision and Mission including these, I can give the world the impression that "thisperson is in this theme". I created my own Vision and Mission with the above contents inmind. I could make multiple goals facing in the same direction by deciding clarify Visionand Mission. In the future, I will make daily efforts to achieve Vision, Mission and Goal.
4. Mentorship
In this program, 1 to 2 mentors were in charge of each member. Two mentors were in
charge of me and helped to create Vision, Mission and Goal over and over again. I amvery grateful to them for having the opportunity of discussion at least once a week. I hope
to continue to keep in touch and continue a good relationship with them even after
returning Japan. In the future, I felt strongly that I must become a mentor and be in aposition to nurture mentee. I am willing to make efforts to become a good mentor like thetwo mentors who took charge of me.

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75. Team project
We divided into two teams. Each team extracted clinical problems and devised a
project to solve it. In the final week, we made a presentation for mentors.
Our team was a medical oncologist, a nurse, a pharmacist. All of our members weremen. In addition, each member had experiences that were consulted about sexualdysfunction from male patients in clinical. Regarding male sexual dysfunction, medicine
and research have not progressed so much and in both cases it was very difficult toanswer properly. Therefore, we devised a project focusing on "Sexual Dysfunction in malewith cancer”. We create Vision and Mission. Vision was ”To create a society that relieves
the suffering of sexual dysfunction from male cancer survivors”. Mission was ”To offer
the educational and intervention program for male cancer survivors in order to reduce
the sexual dysfunction”. We discussed how to solve these from medical, education andresearch.
MDA is actively addressing male sexual dysfunction. Among them, I was able to talkdirectly to Dr. Wang who has a central role. We were able to hear specifically how to pickup patients with sexual dysfunction and what kind of algorithm to proceed withtreatment. Based on his story, we also created an assessment algorithm (Fig 1), andcompleted the medical part.

Fig. 1
Regarding education, we thought about two ways: education for patients andpartners, and education for medical professionals. In addition, we talked about
educational methods and devices.
Research is the most active part of the discussion. We talked about whether to conduct
research to grasp the actual circumstances of sexual dysfunction in Japan, not only tograsp the actual circumstances but also to conduct research involving intervention. We
also talked about whether to limit the kind of cancer or whether to consider broadly. The
discussion was very diverse. In addition, we got advice from Mentor and statisticians.

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While talking, there was a scene where conflict sometimes occurred, but it was able tosolve it well. Ultimately, we were able to create a project convinced by each member. I
was able to feel that their thoughts differ depending on job type and individual. I believethat each member demonstrated leadership and was able to unite it. I was able to have avery meaningful time.

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Future Prospects

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9I conducted training at MDA and found many problems. Although I want to challenge
various things, it is immediate task to achieve Goal set by myself.
I believe that I can reach even a little to Vision by achieving Goal one by one. For that
purpose, I made a lot of goals.
Over time, the situation and position where I am located changes. Therefore, in thefuture, there is always a need to create a new Goal and change its contents. In that case,make use of what I learned in MDA and make a Goal that matches my Vision andMission. Also consult with Mentor who met at JME and form a better career.
Acknowledgments
I would like to express my sincere gratitude to all people involved with JME 2018. In
particular, I thank Dr. Naoto Ueno, Dr. Jeff Bryan and Dr. Brandon Shank. I will makeevery effort to practice what you taught every day. I would like to express my gratitude toMr. Fueki who promptly made administrative procedures. I also thank to the sponsors.
Finally, I would like to thank everyone at JME 2018 who spent 5 weeks together.