Report:
MD Anderson Cancer Center
Japanese Medical Exchange Program 2019

Keiko Miyagawa
Department of Pharmacy
Kameda Medical Center

Personal Mission and Vision from JME Program 2019

Mission:
To offer optimal supportive care to cancer outpatient, by thorough patient education andcontinuous side effect monitoring, so that patients can live their daily life without sufferingfrom side effects.

Vision:I would like to create person-centered care by providing the optimal and cost-conscious
pharmaceutical care based on the respect of each patient’s value and understanding their needs.

Table of contents
Ⅰ Purpose
Ⅱ Methods
Ⅱ Results
Multidisciplinary Cancer Care Approach in MDACC
1. Mid-level provider
2. Outpatient
3. Inpatient
4. Multidisciplinary support
5. Department of Pharmacy and the role of clinical pharmacists
6. Leadership
7. Career development

Ⅳ Achievement
Ⅴ Future prospects
Ⅵ Acknowledgements

ⅠPurpose

My purposes of JME Program 2019 are:
-To learn the role of clinical pharmacists in MD Anderson Cancer Center（MDACC）-To understand the multidisciplinary collaborative approach to cancer patients in MDACC-To develop personal mission and vision-To learn leadership and communication skill for team building

ⅡMethods

1

Training period
From August 26th to September 27th, 20192

Our team
Two surgeons, two nurses and two pharmacists from different institutions throughout
Japan participated in JME Program 2019. Each member has mentors who work in MDACC.

3

Visits- Rounds and Hospital tour in MDACC
Outpatient: Breast Medical Oncology outpatient / Breast Surgical OR and Breast SurgicalOncology / Breast Survivorship Clinic / Surgical Oncology outpatients /GVHD Clinic / Apheresis Clinic / Ambulatory Treatment Center (ATC) andATC Pharmacy MaysInpatient: Palliative care rounds / WOCN (Wound Ostomy Continence Nurse) rounds /Hematology Unit: Lymphoma/Leukemia/CAR T Cell/ Stem Cell
Transplantation Inpatient / Pharmacy Inpatient
Other: CABI (Center for Advanced Biomedical Imaging) / Pathology Tour / Radiology Tour- Institution outside MDACC: Houston Hospice, American Cancer Society

4Lectures and Conferences by multidisciplinary teamLectures: Role of Social Worker / Pathology Lecture / Nursing presentations (About Nurse
practitioner, Nurse Research) / Nursing Ethics Rounds / Statistical Tutorial /Ethics Meeting (Dr. Theriault)
Conferences: Breast cancer conference, Radiology conference

5Lectures about leadership and career development
Mission and Vision / Impact to play / SMART Goal / Mentorship / Curriculum Vitae
Leadership / Communication / Building self-awareness / Teamwork / Handlingdifficult conversations / Creating your own strategic plan for your career and life

6Mentor/Mentee meeting

7

Groupwork and final presentation: What we learned and how to bring it to our institution

ⅢResults

Multidisciplinary Cancer Care Approach in MDACC
As the top cancer center hospital, MDACC provides individual cancer treatment with highpatient satisfaction and practices seamless and comprehensive cancer treatment - prevention,
diagnosis, treatment, follow-up, life and psychological support and palliative care. It ismultidisciplinary approach that realize above. Mid-level providers who we don’t have in Japanand other variety of staffs play professional roles, trust and collaborate each other. All medical
staffs discuss as equals and every single person think about patient-centered care. While I
visited many departments in MDACC, staffs are proud of working at the No.1 cancer center,strives to achieve mission and vision of MDACC – eliminate cancer and making cancer history
as logo indicates, and practice daily medical care. Furthermore, patients themselves are alsoessential members and they actively collect information, send messages and join theirtreatment. Medical staffs respect patients’ participation and empower patients.
It was a priceless experience for me to join JME program and learn multidisciplinary cancer
care approach in MDACC with wonderful team members.
1. Mid-level provider
One of the biggest differences between the US and Japan is mid-level provider. We do
not have nurse practitioner (NP), physician assistant (PA) and clinical pharmacist (CPh)in Japan. It was surprising that mid-level providers can prescribe orders of medications,tests and blood transfusion with agreed contracts with individual physicians. NP provide
the medical care and through follow-up only by themselves in survivorship outpatient clinic
as well. I found that because of the specialized education in college and clinical practice,
mid-level providers are professional in their fields so that physicians and mid-levelproviders trust each other.
2. Outpatient
The system of outpatient is totally different from that in Japan. There are ‘teams’ in workroom, which consist of physicians, registered nurse (RN), NP, PA and CPh. Team members
share information about each patient and discuss their cancer treatment. When patientssee doctors in Japan, patients come into the physician’s room. On the other hand, in theUS, patients wait in the exam room and medical staffs go into the room in turns. First, RN
take vital signs and provide medical interview and share the information to the team. Then,
NP/PA give questionnaire and provide deeper medical interview or explain the cancer
treatment such as surgery, chemotherapy and radiotherapy. CPh check lab data, vital signs
and side effects from nurse’s interview and judge whether the patient can receive
chemotherapy on that day or not with the team. CPh also adjust medication dose based onliver/kidney function, propose supportive care and search resources about medication andprotocols. Also, if the patient receive chemotherapy at the first time, CPh educates thepatient about the chemotherapy. Lastly physicians go into the exam room and explain thefinal treatment plan.
Because the main medical care in the US is outpatient, there are variety of service foroutpatient. One of the services is My chart and message system. Patients can access totheir medical records and make medical reservation through My chart and send email tohealth care providers easily. Although we pharmacists in Japan sometimes follow side
effects by giving phone call to patients, the system in MDACC is very convenient and usefulfor patient.
3. Inpatient
The daily care, such as medication administration and measuring vital signs, are doneby RN. Based on RN records and lab data, ‘Team’ collect information. In similar way as
outpatient, Dr, NP, CPh and fellow make a team and go rounds in the morning. Normally
NP takes the leadership of discussion and share information what happened the day beforeand overnight. Then NP and CPh propose medications and additional exam tests according
to the treatment guideline which MDACC establish and revise annually, and put orders
with physician’s agreement. Normally physicians agree the recommendation of NP andCPh. NP and CPh do the most part which is done by physician in Japan. NP and CPhprovide the detail care instead of physician so that physicians can spend time to research.
They play bigger roles to create and develop cancer treatment worldwide.
I found that each staff’s role is not clearly separated, but they overlapped in some way
and by playing their own role, team works functionally. Each has professionalism andshares roles to some extent, which leads to sufficient and safe medical care to patients.
4. Multidisciplinary support
There are variety of professionals and assistants in MDACC. Among them, I would liketo report about social worker (SW), ethician and volunteer.
-Social worker
In MDACC, there are 100 social workers and they all got Master Degree of SW. SW

support all aspects about life outside being cancer patient, such as employment, financial
counseling and health insurance. They also provide advanced care planning, counselingabout stress, anxiety, communication among family and grief care. Since SW support
patient by playing these important roles which are mainly provided by nurses in Japan,
nurses can concentrate on nursing care and SW presence makes patients reassured.
-Ethic issue
We had ethics lecture by Dr. Theriault who is breast oncologist and was the Chair ofIRB in MDACC for many years. I learned that in MDACC when there is ethical problems
in clinical setting, ethicists go to bedside and resolve the conflict between patient andfamily or help patient for decision making. Also, in the ethical meeting of transplantation
unit, nurses and other medical staff discussed about ethical problems. They deal with theethical problems which do not have the right conclusion, set up the meeting to discuss andtry to find out the best way for patients. I could understand a piece of why MDACC ranked
as NO.1 in cancer care in the US.
-Volunteer
In MDACC, cancer survivors contribute to MDACC and cancer patients as volunteer.

For example, when a colon cancer patient has something wrong with stoma, he can ask
cancer survivor volunteers about how to manage stoma. A breast cancer patient who isgoing to have reconstruction operation can get to know how her breast will look like after
the surgery by being showed of cancer survivor’s breast. There might be differences ofcultures, but it was the most impressive thing for me that cancer survivors actively help
other cancer patients as volunteers.
5. Department of Pharmacy and the role of clinical pharmacist
There are approximately 600 pharmacists and pharmacy technicians in MDACC.
-Clinical pharmacist
After four-year Pharm.D course, they go to PGY1 and 2 to become clinical pharmacist.
CPh check lab data and side effects, prescribe orders of medication, adjust medication
doses and propose supportive care and protocols. Other role is selecting optimal
antibiotics, TDM (Therapeutic Drug Monitoring), discharge instructions, making new
protocols, searching resources and education of student and PGY1 and 2.

-Operational pharmacist
After getting four-year Pharm.D, they work as operational pharmacist. In MDACC,
they verify the orders, check mixtures in central pharmacy and satellite pharmacy andcheck Pyxis and emergency cart filled by technicians.

-Pharmacy technician
They get education in technical college for about one year. They pick up or mix
medications and fill medication to Pyxis and emergency cart. In MDACC, techniciansneed to have two-week special training for mixing chemo-medications.
The differences between the US and Japan are the presence of technicians, advanced

computerized medical system and pharmacists’ right to prescribe medication orders. The
most job of pharmacists in Japan is done by technicians in the US. By segmentation likethe US, pharmacists can take role in their specialty and provide high-quality
pharmaceutical care for patients. Also, 80% of medication is dispensed by Pyxis in MDACC,
which means pharmacists do not have to put medication in medication bag. Nurses pick up
medication from Pyxis through computerized controlled data. I found that automatedsystem ensures the medical safety and enhances work efficiency. I think that the role of
CPh in MDACC is not so different from that in Japan, except for the right of prescribing.
In MDACC, each CPh has contract, called DTM (Drug Therapy Management), with eachphysician. CPh can prescribe medication and exam test. In Japan, pharmacists cannot

prescribe, but we’ve expanded our role by PBPM (Protocol Based Pharmacotherapy
Management). To actively promote the optimal pharmacotherapy in team work, we need tosend powerful message to our society that we pharmacists have valuable role in medical
team for patients.
6. Leadership and team building
Through lectures by Janis from Faculty Department, I learned core value, leadership andskill for difficult conversation.
The most important thing in team work is self-awareness and insight. Self-awareness isto understand who we are, how others see us, and how we fit into the world around us. By
recognizing my core values and sharing core values each other, we can know ourselves andteam members. Not being a passenger, but with team-oriented mind and feedback fromothers, I would like to be a good team member.
When we have difficult conversation with colleagues, the key is self- awareness and theclose communication in daily life. Any small talk is essential, and speaking up and not
avoiding difficult conversation is important. I would like to keep active listening,understand that I am a member of our team, recognize what others cherish and try to havegood communication.
We did the Wheel of Life exercise, in which we quantified the distribution of life, such aswork, money, family, health and so on. It is one of the coaching tools for finding balance in
my life and taking actions for change. I could assess what matters by visualizing my lifeand could find what I can do for next step.
In the lecture, Janis introduced us some readable books. I would like keep learning byreading them and practicing in daily life.
7. Career development
Every week Dr. Ueno gave us lectures about mission/vision, career development andmentorship. I learned that when we clarify our own mission and vision, it is important tomake a list of what I really want to do, and which goal can affect strong and vast ‘impact’
to the world; why we should do that, whom we want to impact, what is my uniqueness. Itwas difficult for me to find out what is unique about me. I would like to continue revising
IDP (Individual Development Plans) sheet, which I made during this JME program andcontains my mission, vision, goals and how to achieve each goal.
Also, every week my mentors, Jeff and Brandon made time for me and we talked about
what I’ve learned and my mission/vision. They encouraged me and I could face myself. It
was meaningful time and I am appreciated their supports and useful advice. As Dr. Ueno
taught us that it is important to keep contact with mentors when we are in good situation
or bad situation to be a good mentee. I would like to keep in touch with my mentors.

ⅣAchievement

1. Mission and Vision
When I think of my own mission and vision, what is important for me is to provide thebest treatment to each patient. I work at the Chemotherapy Department of Pharmacy now,and the part of my job is to educate patients and monitor side effects. One of the differences
between MDACC and Japan is the patients’ attitude towards their own treatment. It might
be based on the differences of insurance system and it may be because this is MDACC.
Patients actively participate in their treatment and are the important part of team member,though patients normally just follow physician’s indication in Japan. So, I would like to‘empower’ patients to join their treatment and provide the best cancer treatment
individually.
2. Group work
We six members were divided into two groups and each group set up its own theme about
what we learned, felt, thought in MDACC and what we will be able to put our learning toour institution or Japan. In our Group A, it took about two weeks to set up our theme
because there were so many key words that we learned in this program, such as
multidisciplinary team work, specialty, patient empowerment, outpatient services andcareer development. In these keywords, we tried to find out what is unique and what weJapan can take leadership in the world. Finally, we made our mission and vision as follows.
Our Vision：
All cancer patients live with their value and their own right.
Our Mission：
To create an environment where cancer patients in Japan could die in dignity.
From when patients are diagnosed as cancer to complete their life, there are many
situations to make decisions. How can we support the decision-making and support thepatient to live their life in their own way? Japan is a leading country of aging society in theworld. If we can establish the system to support elderly people or people close to elderly, it
can be a model of decision making for cancer patients. Through this program, we abstracted
the essential factors to support decision making for cancer patients and we made one of ourgoals to achieve our mission and vision as follows.
Goal：
Guide patients through a shared-decision-making process by integrating interactive andcohesive multidisciplinary team.
Although our theme is very huge, it has potentially powerful meaning. During discussion,
we could step forward with advices from mentors in MDACC and social worker. We
discussed the theme with enthusiasm and learned many things from this discussion itself.

ⅤFuture prospects

Joining this program, I learned multidisciplinary team work, career development and teambuilding. ‘Team care’ which I had understood before coming to MDACC and which I saw in
MDACC was totally different and I could understand what is multidisciplinary care throughthis program. I found that staffs in MDACC trust each other, and it is because each of them isvery professional. So, to be trusted by other medical staffs, I would like to get oncology
certification in Japan and to become professional in pharmaceutical care for cancer patient. I
also found that multidisciplinary care can come true the real patient-centered care. I would
like to share what I learned in MDACC with my colleagues and other medical staffs to makeour team better collaborated for patient. In terms of teambuilding, I would like to enhance
daily communication with other staffs and try to practice team building.

ⅥAcknowledgements

I would like to thank Japan Team Oncology Program for giving this priceless experience forJME2019 members. I received generous support from Mr. Fueki, who helped us all aspects tojoin this JME program, and Ms. Sanchez Marcella, who supported the procedure of Discoverand during this training. Dr. Ueno gave us wide perspective about mission and vision,encouraging advices about my goals, CV and career development. Ms. Janis Yadiny gave us
insightful lectures about leadership, communication and team building. Our mentors gave
great opportunity to follow their work and taught us what they do and how to collaborate as ateam member and took us to fun activities on weekends and at night. Special thanks to mymentors, Jeff and Brandon, who spared time for me to talk about my mission, vision and careerdevelopment. Dr. Iwase and Dr. Sasaki helped us stay in Houston and gave us helpful advices
about training in MDACC. JME2018 members gave us great support before coming Houston.
And I would like to thank all of staffs in MDACC who took care of us. Also, I could not join thisprogram without support from my colleagues and department of pharmacy.
Above all, I would like to show my greatest appreciation to JME 2019 members. We stay inHouston as if we were family, talked openly and discussed enthusiastically. We could share
our core values and passion. I wish we can continue keeping this strong connection.