MDAnderson Cancer Center
Japanese Medical Exchange Program2019

August 22, 2019 – September 27, 2019

Kie Nakamura, MSN
Keiyu hospitalMission and Vision created through JME2019●Mission:
Coordinating within the team as a nurse so that female cancer patients facing
life events (Marriage, pregnancy, childbirth, childcare) are able to makedecisions to live well with their own lives.
●Vision:Creating a society using the expertise of nurses where women cancer patientsfacing life events can live their own lives with happiness and highself-satisfaction.

Table of contents
Ⅰ．Purpose・Method ........................................................................................................ 1
1．Purpose ..............................................................................................................................1
2．Method ...............................................................................................................................1

Ⅱ．Contents and Progress ................................................................................................. 2
1．MD Anderson Cancer Center ...........................................................................................2
2．Multidisciplinary team at MD Anderson Cancer Center ..............................................3
3．Career Development .........................................................................................................6
4．Leadership .........................................................................................................................7
5．Final Presentation ............................................................................................................7
6．Utilization of electronic resources ...................................................................................8

Ⅲ．Results ......................................................................................................................... 9

Ⅳ．Future tasks .............................................................................................................. 10
Acknowledgment ..................................................................................................................10

Ⅰ．Contents・Progress

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1． Purpose
1） Learning about the skills necessary for team medical care by observing the team
medical care at the MD Anderson Cancer Center（MDACC）and connect it toJapanese team medical care

2） Creating my own mission and vision and clarify future career development plans

3） Learning about leadership and lead to practice in Japan

2． Method
1) Training period
August 22, 2019-September 27, 20192) Participants
2 doctors, 2 pharmacists, 2 nurses, 6 in total

3) Program contents
・ Understand the role of each occupation and team medical care by visiting team
medical care in each department of MDACC, participating in conferences, lectures,and engaging with staff.
・ Discussion between MDACC mentors and JME members about the roles of each
occupation learned at MDACC and discuss differences from Japan, issues in Japan,
and realization of team medical care in Japan.
・ Team consisting of doctors, nurses, and pharmacists from JME2019 conduct group
work and presentations to learn team building, and at the same time consider ways toachieve the mission and vision of the oncology team.
・ Through the relationship with MDACC mentors, deepen learning at MDACC andclarify my mission and vision.
・ Learning about career development, leadership, and medical ethics through lecturesand discussions, and rethink careers as a profession.

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1．MD Anderson Cancer Center
University of Texas MD Anderson Cancer Center (MDACC) is one of the largest cancer
centers in the world at a corner of the Texas Medical Center in Houston, Texas. MDACC
is the best cancer center in the care, research, prevention and education for cancer
patients, and the “Best Hospitals” which US News & World Reports covers about 5,000
hospitals for the past 16 years. It is a cancer center that continues to be selected as thetop.
In MDACC, about 141,600 patients are hospitalized and treated annually, and thenumber of outpatients is 1,500,000. The number of beds is about 700, which is less thanthat of Japanese university hospitals, but it may be sufficient in the United States where
the length of hospital stay is short. The number of employees is very large at 20,300, andstaff of various occupations are employed. In addition to employees, 7,000 trainees andabout 3,100 volunteer staff are also active. Many of the staff we meet at MDACC areproud of working at MDACC and can feel them from their conversation and attitude.
Among volunteers, there are survivors and local people who have been treated with
MDACC in the past, and it can be seen that MDACC is supported by the cooperation ofmany people, not just healthcare workers.
MDACC is built on a vast land and consists of several buildings. The shuttle bus andcart can be used to move between buildings, but the inside of the building is like a maze,and it may take about 30 minutes one way even if you use the shuttle bus or cart until
you get used to it is there. At MDACC, the following are stated in the mission and vision,and each staff was responsible for their professional expertise and felt that they
continued to grow to achieve the mission and vision.
MissionThe mission of The University of Texas MD Anderson Cancer Center is to eliminate cancer in
Texas, the nation, and the world through outstanding programs that integrate patient care,research and prevention, and through education for undergraduate and graduate students,
trainees, professionals, employees and the public.
VisionWe shall be the premier cancer center in the world, based on the excellence of our people, ourresearch-driven patient care and our science. We are Making Cancer History.

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2. Multidisciplinary team at MD Anderson Cancer Center(1) Outpatient Clinic
The outpatient practice at MDACC was very different from the Japanese outpatient
practice style. First, the first difference was that instead of the patient coming to see a
doctor or nurse in a waiting room, a health care worker visits the patient. Once thepatient has completed the reception, and after completing the vital signs and weightcheck by the Nursing Assistant or Registered Nurse (RN), they will be taken to the clinicroom. If you are waiting there, the health care workers will come to the clinic in turn.
The second is the number of professionals involved in the patient and the team's
collaboration. Although there are some differences depending on each department, in theoutpatient department, mainly Registered Nurse (RN), Nurse Practitioner (NP), or
Physician Assistant (PA), Clinical Pharmacist, and doctors have practiced as a team. In
addition, all the medical workers involved with the patients work in the same room
(Work room), and it is possible to share patient information in a timely manner after
completing medical treatment.The general medical procedure is that RN first visits thepatient's room, conducts an interview, takes the contents and assessment results back to
the work room, and shares them with NP or PA. Based on this content, NP or PA willconduct further assessments by conducting interviews, auscultation, and visualinspection. The results are shared with doctors and team members, and finally doctors
propose final treatment strategies. When starting chemotherapy, changing
chemotherapy drugs, or when providing nutritional information is necessary,
pharmacists and dietitians may give guidance to patients as needed. Furthermore, there
was a system for adding social workers and medical interpreters to the team whenmental care or interpreting was needed.Since all medical staff are staying in the sameroom, if there are points of concern about the patient or things that should be shared
immediately, the team can immediately share it and consider the treatment policy.
Communication between healthcare professionals is very active, and it was very
impressive that opinions were exchanged from a perspective that utilized their expertise.
What each team member is doing is partly overlapping, but the overlapping part has
been confirmed, and the roles have been subdivided to make use of their expertise.
Doctors were responsible for bringing the team members' information and assessments
together and delivering them to the patient, and this was possible because all teammembers respected the opinions of each profession. I felt that this was because there was

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a relationship of trust and there was a sense that each profession fulfilled their
responsibilities. The third is the time available for medical care. They correct
information from patient interviews to assess not only illness and symptoms but also
various aspects such as life, work, and spirituality from various perspectives. The
number of patients examined by the team per day was about 20 to 30. In order to provide
the medical care and nursing care that patients require, it is indispensable to understandpatients. In Japan, however, there are many situations that is not available to takeenough time to understand patients. It was very effective to be able to study how to
alleviate the patient's symptoms and to fulfill the patient's wishes from the viewpoint ofutilizing the expertise of each occupation
The fourth is the rights of prescriptions and orders for each professional. In Japan, only
doctors have the right to prescribe and order, but at MDACC, NP and pharmacists also
have the right to prescribe and prescribe at their own discretion. In some cases, narcotics
and anticancer drugs may require double signing with a doctor, but basically doctors do
the final confirmation, and pharmacists mainly calculate anticancer drugs.
Communication was indispensable when prescribing and ordering, and teams worked
together to ensure there were no omissions.
The fifth is patient power and patient participation. During the visit to the outpatient,
there was almost no situation where there was no question from the patient. In Japan,
there is a strong impression that doctors talk to patients unilaterally, but at MDACC,
patients seemed to be part of the team during all outpatient care. The patient's intention
was always incorporated when considering the treatment policy, and the healthprofessionals were honest with their feelings, wishes and questions.
The sixth is regional collaboration. Since MDACC treats patients on an outpatient basisand handles patients from all over the world, collaboration with the community is
indispensable. There are many cases where some patients receive actual medical care in
their own country or in their own area under the MDACC treatment policy, except thatthey come to MDACC once every few months for medical care. Information provision toother parts of the United States was easily done by email or text message. If it is a
hospital that uses Epic of the medical record used by MDACC, it is possible to view the
medical record description in MDACC from other hospitals, so it is not necessary to send
many by email or text message. Epic was used in 60% of hospitals across the UnitedStates and was a great tool for sharing patient information.There is no big difference inⅡ．Contents・Progress

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cooperation with other countries, and there are many cases that are exchanged by e-mail,and there was no form that must be prepared like a paper-based introduction letter ormedical information provision form.

(2)Inpatient ward
Every morning in the ward, there was a conference and round by a team (doctor, fellow,
NP, pharmacist). Share the status of inpatients and new patients with the entire teamand confirm treatment policies. First, all the teams gathered in the conference room of
the ward, the RN of the ward reported the patient's condition, and then the NP took thelead and reported the patient's blood collection data and symptoms to the team, and all
the teams will continue to work deciding about treatment of them. After that, everyone
rounded each patient's room, interviewed, inspected, and auscultated, and madeadditional suggestions and exchanged opinions. The team was led by a doctor, but the NP
gave prescriptions and instructions. After the team round, if there were patients who
were interested in the patients they were in charge of or patients who needed guidance,each job type was visited on their own.
In the ward, Assistant Nurse (AN), RN, and physical therapist work. RN was
responsible for 3-5 patients a day and the number of RNs for patients was substantial.
RN manages infusion and oral administration, and what RN does is not much different
from Japan. However, the role of the nurses is subdivided compared to the role ofJapanese nurses, such as checking vital signs and clean-up care by Assistant Nurses.
Compared to the daily routine of Japanese nurses, I was impressed with the slow
passage of time. If patients need discharge support or mental care, RN coordinate withthe team. It was the same as Japan in that it played a role. I felt that it was very efficientand effective for patients that RN had a place to communicate the patient's situation to
the team every morning.

(3) Survivorship clinic
I visited Brest Survivorship Clinic and stem cell transplantation survivorship Clinic. At
the Brest Survivorship Clinic, patients who had been for 5 years after treatment havebeen seen for follow-up once a year. At the Brest Survivorship Clinic, the NP was themain examiner, and no doctor was resident. While communicating, NP assessed patientsfrom a variety of perspectives, including physical and mental aspects, as well as physical.

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Instead of focusing only on the early detection of recurrence, consider the patient's lifeand examine whether they can spend what they like, and if necessary, in order to be able
to live better by coordinating with guidance and multiple occupations Adjustments werealso made.
Stem cell survivorship clinic is a clinic for following up patients after stem celltransplantation. It has been decided to stay in Houston for 100 days after stem celltransplantation, and then follow up the Survivorship Clinic before leaving Houston andreturning home. At the first time, NP mainly gave guidance on GVHD symptoms andcooperation with local doctors on how to stay at home, precautions in daily life, diet,
infection prevention, and vaccination. NP also listened to questions and anxiety ofpatients, resolved them one by one, and provided many pamphlets so that patients could
get information on their own when needed. The follow-up period is determined as 6months, 12 months, 18 months, 2 years, 3 years, and at the same time providing
necessary information for each period and also providing medical care for screening forrecurrence.

3. Career development
Through the once-weekly lecture by Dr.Ueno and the once-weekly mentor-mentee
meeting with MDACC mentor, I created my own mission and vision and created
Individual Development Plans (IDPs). Dr. Ueno gave basic lectures on what missions,visions, and smart goals are. Also we shared the creation process of IDPs every day andgave us polite advice. For me who was worried about my future career, each questionthat Dr. Ueno flew in was a valuable opportunity to look back and organize my thoughts.
I was able to learn about the process of developing a career through mentoring time andlectures with Dr. Ueno, but the questions “what you want to do” and “how to make it
happen” are always in my head. I will continue to ask myself. At the same time as the
career development, I received guidance on how to create CV. Though it was difficult to
express in CV thinking about how to market itself, I learned a lot.
At the mentor-mentee meeting, Nick gave feedback on what we learned at MDACC andat the same time carefully explained the questions. He listened to try to understand myEnglish and understand myself. He gave me advice and introduced me to the people I
could consult with according to the situation at that time. I also received advice andguidance on IDPs and CV, and sincerely thank Nick for the warm support.

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4. LeadershipI learned about leadership and team building by sharing lectures with Janis andmembers' thinking. The lecture contents were selected as core values, MBTI, and Wheelof life exercise. In order to demonstrate leadership, it was surprising that knowing
yourself first was important. I felt that my self-understanding deepened as I
reconsidered my confidence by using tools for self-recognition. Knowing what I value andliving, and how I tend to think, is fresh and a new discovery. I also learned about active
listening and dealing with difficult conversations as important skills for team building.
Janis' lecture was not unilateral and each member had the opportunity to present. By
listening to the stories and thoughts of the members, We felt that each other understoodand the team power increased, and it seemed to practice as well as gain knowledge
through lectures.
It is said that leadership is important in Japan, but it was a very valuable opportunity
because there was no opportunity to take leadership training. I would like to keep
learning.

5. Final presentation
Each JME2019 member doctor, nurse, and pharmacist belongs to each team and isdivided into two teams. Utilizing the learning at MDACC, team mission, vision andsmart goals are created and made final presentation. I belonged to Team A, but it took avery long time to narrow down the theme of the group.As we narrowed down the themes,
we shared what we learned and impressed in the two weeks at MDACC, but we weren't
able to narrow down to one even though everyone was facing the same direction. In thecourse of this, a situation was created in which it was not possible to convey the thoughtsof each of the gaps that occurred little by little, and a small team conflict occurred. I feelthat the team power has been strengthened by opening up opportunities to discuss what
each person thinks to rebuild the team, sharing their core values and MBTI, andunderstanding each other little by little. In the last two weeks, including the weekend, I
think that we were able to demonstrate the team power that enjoyed the course throughthe style of full discussion until all the team members were satisfied.
In this group work process, the team collaborates to create missions and visions
learned from Dr. Ueno, and the leadership and team building practices learned from
Janis were incorporated. Despite struggling with the team, we were able to complete theⅡ．Contents・Progress

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passionate mission and vision of each of the three, value the process with three smart
goals, and complete the final presentation with the team. I think it was a culmination.

6. Utilization of electronic resources
Many doctors and NPs were provided with mobile phones from MDACC, which
included a medical record (Epic). Work efficiency is improved because patient
information can be confirmed from anywhere. In collaboration with various occupations
and other hospitals, the computerization was progressing rather than paper-based, andthe work was smooth. Furthermore, even if patients and family members do not come tothe hospital, they can use the existing electronic tools to improve efficiency in various
situations, such as sending photos of wounds by photo-mail and writing medical records
by voice input. I witnessed these things and felt that if I could use resources in this way
in Japan, I would be able to improve the efficiency of my work.

Ⅲ. Results

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The following results were obtained through the JME2019 program.
First, I was able to learnabout effective team building and have opportunity toexperience about that. I observed the actual team medical practice and team building at
MDACC, and found out how effective team medical care should be. Furthermore, bylearning and practicing team building methods through lectures and group work, othermembers cover the weak parts of the members, and I can feel an effective team byproceeding while stretching the strong parts. In Japan, team collaboration continues tobe said to be important, but when in the clinical setting, it continued to question that itwas not. However, I think that through the entire JME2019 program, I was able to learn“what is a team”, “what is necessary for team building”, and “what can be achieved as ateam, not an individual”.
Secondly, I learned the career development planning process. I've been worried about
my career so far, but I haven't had the opportunity to learn how to sort out, plan andimplement it. Through Dr.Ueno's lectures, mentoring time with him, and mentoring timewith Nick, I learned how to make a career development plan, how to think, and how to
get support. It turned out that career development progressed further by acquiring thepresence of a mentor rather than vaguely worried alone. In addition, I felt theimportance of continuing to grow as a mentee.
The third is about leadership and team building. I thought that leadership wassomething that a person with a sense would take, but it turned out that it can be worn astechnology and knowledge. Although it was practiced through this learning, eventeammates with the same aspirations may find it difficult to work as a team. Rethinking
the importance of leadership, membership, and communication skills, and making fulluse of technology and knowledge I learned that building is necessary.

Ⅳ. Future tasks

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There are many challenges for me in the future, but first, I will continue to improve myskills learned at MDACC. Reading books introduced by Dr. Ueno and Janis, participatingin training and workshops on leadership and career development, and continuingself-development. Also,I try to meet many people, not just those in the same industry,and go outside to find mentors, so that I can always think about things from amultifaceted perspective. It is also an issue to cherish connections. At the same time, I
will keep in touch with mentors and friends we met at MDACC and continue to grow sothat we can become a win-win relationship. Furthermore, the career development
process learned at MDACC is followed, and after a certain period of time, missions,visions are evaluated and revised, and smart goals are continuously updated.
There was a lot of learning through the JME2019 program, but it was also true that I
felt regretful. That is my low level of English. It was regrettable and painful that I could
not fully understand the words of the people I respect. I'd like to learn listening andspeaking without forgetting this regret. I would like to make an effort to speak English
with myself at the workshop next year. Finally, electronic resources can be utilized. Until
now, electronic resources have been utilized only minimally, but it is clear that
efficiencies in work and private life can be achieved by using electronic resources in the
future. I would like to focus my attention on getting used to electronic resources so that I
can move as efficiently as possible.

Acknowledgment
I would like to thank all of you who have worked hard on the JME2019 program. Dr.
Naoto Ueno, Japan Team Oncology Program Founder, made time for us wherever he wasbusy, and gave us detailed words of guidance and warm encouragement. Dr. Joyce
Neumann, Chair of the JME2019 program, always cared and supported us. Mr. Nicholas
Szewczyk, MDACC mentor, listened to my career problems every week.
Japanese and American mentors, as well as Japan Team Oncology Program Secretariat
Mr.Hiroshi Fueki and JME2018 members who provided support and advice before
traveling to the United States, I feel that this wonderful opportunity has been received
with the support of many people. I would like to take this opportunity to thank all thepeople who supported JME2019. I would also like to thank all the companies that
donated the JME2019 program. Last, all the members of JME2019, supported when it
was difficult, and laughed together when we had fun. I sincerely thank you.