Report:
MD Anderson Cancer Center Japanese Medical Exchange ProgramJME Program 2018

Masami Tsuchiya, B.S. in Pharm
JSPHCS-Certified Oncology Pharmacist
Department of Pharmacy
Miyagi Cancer Center

Personal Mission and Vision from the JME Program, 2018

●Mission:（日本語）
薬剤疫学研究により、がん治療の副作用におけるリスク因子に関するエビデンスの不足を解消する（英語）
My mission is to fulfill the lack of evidence regarding the risk factors which may leadto side effects of cancer treatment using the pharmacoepidemiological approach.

●Vision:（日本語）
がん治療の副作用マネジメントに役立つような研究をすることによって、がん患者が、治療やその副作用に煩わされることなく、その人らしい人生を送れるような環境を提供する（英語）
My vision is to provide an environment in which cancer patients can have their own
lives without being bothered by cancer treatment and its side effects, using methods
developed through research, that can help to manage the toxicity of cancer treatment.

1.

PurposePersonal Purposes of the Japanese Medical Exchange 2018 (JME2018) Program:
1. To understand the multidisciplinary team approach and the role of the clinicalpharmacist in MD Anderson Cancer Center (MDACC).
2. To understand the concept of patient education implemented in MDACC anddetermine whether it can be applied to clinical settings in Japan.
3. To define my own mission and vision and develop my career plan as a pharmacist.

2.

Methods
JME2018 Contents of Training
Training was conducted in MDACC from August 30 to October 6, 2018 on the following
topics:1)

Observations/ Shadowing Clinical observations with Physicians, Physician Assistants (PA), Advance PracticeRegistered Nurses (APRN), Clinical Pharmacy Specialists (CPS), Registered
Pharmacists (RPh), Registered Nurses (RN), and other professions.
-Breast Medical Oncology: outpatient clinic (Dr. Ueno, Dr. Lim, Ms. Patel:
Pharm.D., APRN, RN)-

Breast Surgical Oncology: outpatient clinic (Dr. Teshome, PA, RN)-

Breast Surgical Oncology: surgery observation (Dr. Teshome)-

Gastrointestinal Oncology: outpatient clinic (Ms. Rogers: CPS)-

Thoracic Medical Oncology: outpatient clinic (Mr. Rivera: CPS)-

Stem Cell Transplantation unit inpatient round (Mr. Szewczyk, APRN, CPS,RN)-

Hematology unit inpatient round (Mr. Shank: Pharm.D., Physician, APRN)-Radiation Oncology: outpatient clinic (Dr. Liao, APRN, RN)-Radiology Clinic (Dr. Le-Petross)-

Breast Survivorship Clinic (APRN, RN)-

Infusion Clinic (APRN, RN)-

Patient Education (Ms Tanha: Certified Health Education Specialist)-

WOCN (Wound, Ostomy and Continence nursing) round (RN)-

NST (Nutrition Support Team) round (Ms. Mowatt-Larssen: CPS)-

Inpatient Pharmacy (Ms. Wu: RPh)-

Mays Ambulatory Treatment Clinic (ATC) (Ms. Tran: RPh)-

Main ATC (RN) Observation in MDACC in the Woodlands-

Breast Surgical Oncology (Dr. Reyna)

 Special observation-Houston Hospice-

Center for Advanced Biomedical Imaging (CABI) Participation in Nursing Ethics Round (Ms. Neumann)
2)

Lectures Lectures/workshop on leadership/career development-Difficult Conversations (Communications/Emotional Intelligence) (Dr. Baile)-Mentoring (Ms. Cameron)-

Leadership, Conflict Management (Ms. Yadiny) Lectures on Ethics (Dr. Theriault)
 Lectures on Nursing division (Ms. Johnson)-

Education, professions, research in nursing, Nursing Practice Congress, PrimaryTeam Nursing-

Safety control/quality control system Pharmacy Presentation
 Breast Surgical Oncology Lecture Service Excellence Modules
 Lecture on antimicrobial stewardship (Mr. Aitken: CPS) Statistics/ Design lecture (Dr. Shen) 22th Annual Interdisciplinary Conference on Supportive Care, Hospice andPalliative Care Medicine3)

Development of Mission and Vision Meetings with Mentor (Ms. Patel: CPS) Meetings with Dr. Ueno4)-

Individual Development Plan-

Curriculum Vitae-

Career Development-Leadership-

Mentoring, and other topics

Presentation of the JME2018 Team A project

3.

Results

3.1.

The multidisciplinary team approach in medical care in MDACC
One of the main purposes of this program was to study the multidisciplinary teamapproach implemented in MDACC. As I mentioned in the methods above, I havestudied the multidisciplinary team approach through observation in outpatient
clinics, inpatient rounds, NST or WOCN rounds, and other departments ordivisions. At MDACC, duties performed by a physician alone in Japan are
performed by the multidisciplinary team, consisting of a physician, an NP or PA,
and a CPS. Their tasks partially overlap; these professionals share the work
depending on their specialties. This style makes medical care more efficient andsafer.

3.1.1. The role of pharmacy staff in MDACC
Division of Pharmacy in MDACC consists of three professions: Operational
Pharmacists, Clinical Pharmacy Specialists (CPS), and Pharmacy Technicians. Thework related to pharmacy or pharmaceutical care has been divided and differs
according to their professions. For example, pharmacy technicians are in charge ofpreparation of oral medication, making chemo- and non chemo-drugs in the cleanroom, and supply medications to the pyxis system set up in the ward. Operational
pharmacists can verify prescriptions, make a final check of mixed chemo- or nonchemo-drugs in the central or satellite pharmacy, and check the medication history in
the ward. Clinical Pharmacy Specialists belong to the multidisciplinary medical team
based on their specialty. They can check the drug-drug interaction, do therapeutic
drug monitoring (TDM), adjust the dose in hepatic or renal failure, give the discharge
counseling in the inpatient unit, provide patients education, suggest the supportive
care medication of chemotherapy, and sign chemotherapy orders.
In Japan, pharmacists have to do almost all the duties mentioned above, regardlessof their specialty. Dividing the work depending on the specialty or profession as in
MDACC will allow each professional to focus on their work or specialized duties,
which will help to provide high-quality cancer care. Because the number of pharmacy
specialists is smaller than operational pharmacists generally, it would be needed todevelop the system which enables the multidisciplinary team to use the maximum
knowledge and skills which pharmacy specialists have efficiently in clinical settings
as in MDACC. On the other hands, in order to implement this system in clinicalsettings in Japan, it is needless to say that it is necessary to have enough humanresources and to build the consensus to introduce pharmacy technicians topharmaceutical services. In order to gain a shared understanding of pharmacy
specialists’ improving their expertise and play an important role in themultidisciplinary team, I think that pharmacy specialists should actively participate
in cancer treatment with their maximum use of their skills and knowledge.

3.1.2. The unique multidisciplinary team approach in MDACC
During the JME2018 Program, I observed the Breast Medical Oncology Clinic, theBreast Surgical Oncology Clinic, the GI Clinic, the Thoracic Medical Oncology Clinic,
and the Radiation Oncology Clinic.
In Japan, physicians, sometimes nurses and pharmacists, are usually fixed in one
examination room, and patients visit the room and take an interview or examination.
While in MDACC or some other hospitals in the United States, patients areindividually waiting for the medical staff in one of many examination rooms where an
examination chair and computer with electric medical chart system are set up. A
physician, an NP or PA, an RN, and a CPS visit the room and give an interview or anexamination. This multidisciplinary team approach is based on the unique conference
style. In MDACC, all the team staff are stationed in same work room and it makes
easier discuss something about patients who visit the clinic at that day. It seems to beinefficient way that all the team staff should stay in the same room at the same time.
But, they can get and share the latest patient information and discuss a treatment
plan in the multidisciplinary team without delay. This style can help them to workwith using their specialty in an effective way.
3.1.3. The role of the CPS in the outpatient clinic
In MDACC, clinical pharmacy specialists authorized by a supervising physician are
delegated to write or sign certain medication orders under the protocol. The CPS who
is in charge of the breast medical oncology clinic said that she did not have anopportunity to write a medication order so much because the member of the team in
the same room could have a discussion frequently and make medication suggestions
to the physicians easily. In the breast medical oncology clinic, CPSs are often in
charge of making one of dual signature required in ordering chemotherapy after
confirming patients’ lab data, medication or treatment history, and drug-druginteraction, etc.
During the observation in the clinic, CPSs suggested to the attending physiciansthat the dose should be adjusted depending on patients’ hepatic or renal function, andexplored research paper and showed evidences of second line treatment for patient
who had treatment failure. CPSs visited a patient as needed when the physician hadchanged the treatment or medications or when a patient had a medical issue about
the side effect of the treatment. They gave a medication instruction to a patient withleaflets with confirming patient understanding. CPSs also received many questions
from patients or their family about their treatment or side effects and made answers
appropriately. I have an impression that what CPSs do in MDACC is same as whatclinical pharmacists do at the outpatient clinic in Japan. What we should do forJapanese pharmacists’ building up the strong position in the multidisciplinary teamis to create and share evidences that shows pharmacist contribution to cancer care,and to develop pharmacists’ presence in the multidisciplinary team.
3.1.4. The role of the CPS in the inpatient unit
Same as in the outpatient clinic, the multidisciplinary team consisted of physicians,
NP or PA, and CPS decides the treatment plan and gives a treatment in the inpatient
unit. I observed the Hematology (Lymphoma/ Malignant Myeloma) unit and did
shadowing the CPS. Because the CPS as a member of the multidisciplinary team took
in charge of many patients, he went the rounds while moving ward to ward from 9 am
until noon. Duties of CPSs in the inpatient unit are almost same as in the outpatientclinic. In addition to duties performed in outpatient, CPSs in inpatient make aprescription order, do the TDM, and give the discharge counseling. They can alsocollaborate on checking patient medication history with CPSs in the outpatient clinic.
Outpatient CPSs check patient medication history or medical issues and send them
via email to inpatient CPSs. It would be helpful for both of them to share the patient
information and to provide seamless pharmaceutical care from outpatient toinpatient.
3.2.

Patient Education in MDACC
I was very impressed to see that patients in MDACC learn well about their disease,medications, and treatment. Not only patients but also their family and friends took
notes of the medical staff explanation in detail and asked a lot of questions aggressively.
Even though there will be a selection bias that they are patients who can choose
MDACC as a place for treatment from all over the United States or all over the worldand have high health awareness, as written in Dr. Ueno’s book, it seemed that patients
have autonomy and decide their own treatment plan by themselves without leaving it
all to the medical staff. Patients and their caregivers seemed to be satisfied after
receiving explanation from the medical staff and asking many questions. I think the
difference of patients’ attitude towards their treatment between in Japan and in theUnited States is influenced by the school education, medical insurance system, and thenational characters. When I participated in the Tea Party sponsored by theInflammatory Breast Cancer (IBC) patient advocacy group, I asked one of the IBC
survivors why patients in the United States knew about their disease so much. She told
me that she thought it was her own business and it was natural for her to understandand manage her condition by herself. She also said that she searched about her cancer
on the Internet before her first visit to medical examination.
In addition, there are three Learning Center (Patient Education Library) in MDACC
and they provide leaflets, books, CDs, DVDs, computers connected to the Internet, andonline materials. Patients and caregivers can use them anytime they want. The
Certified Health Education Specialists (CHES) and librarians are stationed there andhelp patients and caregivers to search information they need. The CHES said thatsome patients and caregivers search original research papers. I was certain thatpatients in MDACC received the cancer treatment with using these resources so muchto get correct information.
3.3.

Personal Mission and Vision Development/ Leadership
In the JME2018 program, we had an opportunity to consider future goals and careers
through lectures and workshops on leadership and career development, lectures on
medical ethics, and meetings with our mentor and Dr. Ueno. In the lecture, we could
learn about topics such as difficult conversations, mentoring, leadership, and conflict
management. It was a very valuable experience for us because there are hardly any
chances to receive such as this type of training in Japan.

3.3.1. Personal Mission and Vision, and Career Development
Dr. Ueno told us the meaning of having a mentor in our life, how to communicate witha mentor, and how to communicate with a mentee when we will have a mentee in thefuture. My mentor (Ms. Neelam K. Patel, Clinical Pharmacy Specialist) also gave me
valuable professional and personal suggestions through the discussion based on herown experiences and career development in the specialized field of clinical pharmacy.
In this training, I have developed the following Mission and Vision.
Mission:My mission is to fulfill the lack of evidence about risk factors for side effect of thecancer treatment by pharmacoepidemiologic research activities.
Vision:My vision is providing an environment in which cancer patients can carry on theirown lives without being bothered by cancer treatment and its side effects by research
activities that can help to manage the toxicity of cancer treatment.
We have been given a lot of valuable topics in the meeting with Dr. Ueno. One of theimpressive points in the Dr. Ueno’s lecture was that someone who had many chanceson business had a clear view of the world and had a life based on their own missionand vision. It is certain that the amount of work which one person can be done islimited. Because we all have only 24 hour a day and we cannot change it, it isimportant for me to know what I give priority to regarding to my work and life.
During the JME2018 program, I noticed that I had not have appealed what is
specialty or uniqueness of me on my work. It was very good opportunity for me tothink about my strength, my priority, and the core value which is the most importantfor me sincerely.

3.3.2. Leadership
Ms. Jadiny told us that it was important for team members to know each other when
we would like to develop a high-performance team. For example, to share what arecore values and something a little private will help to develop the deep relationship inthe team. She also told that the fundamental of team building was to create
psychological safety, which was the environment enabled us feel safety to talk and act
without hesitation to achieve high productivity. I thought we needed thispsychological safety in the meeting or conference in Japan more because someJapanese still tended to hesitate to speak in the conference with being afraid of socialpressure.
3.4.

Presentation of the JME2018 Team A Project
The JME2018 members were divided into two teams (Team A and Team B) and eachteam chose the subject based on the findings from the training in MDACC. I was amember of Team A and we decided to focus on the Patient Education, because all themember of Team A was very impressed to see that patients in MDACC had learned
about their disease, treatment, and medication intensely. We developed the projectthat we could implement into our clinical settings when we went back to Japan. In ourproject, we decided to have the mission "To develop an integrated educational program
for leaning about the illness and treatment for the older (above 75 years of age)patients who need oral anticancer medication, which helps to maintain their QOL.”
and the vision "To spread the patient education program throughout Japan, especiallyfor oral anticancer medication for older patients and caregivers." We worked on theprojects based on individual specialties and presented how to provide good patient
education program for patients, caregivers, and medical staff. It was a very valuable
experience that we could discuss about how we could make improvements in theJapanese medical environment based on the experiences in MDACC.

4.

Future Prospects

4.1.

Patient Education in Japan
In Japan, the concept of the Patient Education has not been spread enough. Some ofpatients in Japan do not know well what medications they take, or what treatment
they receive. I imagine that it is because there is still the paternalism in Japaneseculture especially at the medical situation. To know what medications patients havetaken and the purpose for the medication or treatment will help them to receive
their treatment independently and safely. Because cancer patients in Japan often
have some comorbidity and receive many medications from several hospitals orclinics, it will be more important for them to know their medication or treatment
history to avoid duplication of medications. I would like to learn more about thePatient Education overseas, and introduce them into Japanese medical situation.
4.2.

Personal Mission and Vision
I think that the part which I can contribute in the Team Oncology to is themanagement of side effects of cancer treatment. My vision is to provide an environment
in which cancer patients can carry on their own lives without being bothered by cancer
treatment and its side effects. For making my vision come true, what I should do is tosee cancer patients in the clinical settings and follow them up carefully. I think it isduty for me as an oncology pharmacist. In addition, considering what I can do forreducing or preventing side effects of cancer treatment, I think it is effective way tofind risk factors of side effects by pharmacoepidemiologic approach with using big data.
Fortunately, I have found the mentor specialized in the pharmacoepidemiology at thegraduate school, moreover, it is my advantage to have a specialty. I would like to do mybest in research and clinical to find evidences what I can create with the knowledge ofoncology, good clinical sense, and the epidemiological point of view.

5.

Acknowledgement
I would like to thank Oncology Education Project who supported the JME Program 2018
and all the staff of Team Oncology Program (J-TOP) for making JME Program 2018come true. In particular, I thank Dr. Naoto Ueno and Ms. Joyce Neumann of MDACC,
the ex-JME members, and Mr. Fueki who supported us administratively. I also thankChugai Pharmaceutical Co., Ltd., Novartis Pharma Co., Ltd., NPO Run for the Cure
Foundation and many other organizations and individuals for their support for JME
2018 Program. Finally, I am grateful to my mentor Ms. Neelam K. Patel for giving me
many good suggestions.