Natsuki Fukuwatari (6th grade)

I would like to report that I completed my clinical training at the University of Wurzburg in Germany for four weeks from April 3rd to 28th, 2023. While studying at the Faculty of School of Medicine, I learned that the content of clinical training differs between Japan and overseas, and I wanted to experience clinical training overseas. I also learned that the Japanese medical system was modeled after the German one, which made me interested in the German medical system and why I applied to this program. Here, I would like to talk about the differences between the medical systems and clinical training in Japan and Germany that I felt during my training.

Würzburg is a city in southern Germany, surrounded by vineyards and rich in nature, with a population of about 130,000. The University of Würzburg has a long history of over 600 years and is a comprehensive university with over 25,000 students. It is known as the university where Dr. Siebold graduated and where Dr. Roentgen worked as a teacher.

The first thing that surprised me about the hospital was the difference in the atmosphere of the wards. Not only were the rooms spacious, but they also had sunrooms, and the wards had drink and snack bars that patients could use freely. It seemed like they placed more importance on patient comfort than Japanese university hospitals. I was told that these facilities were related to the German medical insurance system. In Japan, medical insurance is only public, but in Germany, patients can currently choose between public and private insurance, and since the premiums for public insurance are higher depending on income, those who are financially well off often choose private insurance. There are also differences in the medical services available depending on the insurance, and the sunroom and drink bar are for private insurance patients, and when bone marrow puncture or biopsy is performed, patients with private insurance can be sedated to reduce fear and pain, and private insurance patients are given priority during professor rounds. I was surprised at the situation in which patients are differentiated based on their insurance.

As for clinical departments, I first did my internship in the Department of Hematology and the Stem Cell Transplant Center. Most of the departments at the University of Würzburg start their internships at 7:30 in the morning.

In these two departments, blood is drawn first after arriving at the hospital in the morning, in order to determine whether chemotherapy is possible that day or whether a blood transfusion is necessary depending on the results of the blood draw in the morning. In Germany, except for certain departments such as emergency department and anesthesiology, nurses cannot perform invasive procedures such as blood draws and peripheral venous routes; these are the duties of doctors, and at university hospitals, medical students perform them instead of doctors. Therefore, medical students practice procedures such as blood draws from their third year, and begin clinical training with the procedures mastered. In Japanese clinical training, students only practiced a few times with each other, so at first I was very nervous about suddenly performing procedures on patients. However, as I practiced every day with the help of German students, by the end of the training, I had enough time to chat with patients while drawing blood and taking routes. What I felt here was that patients' attitudes toward student training are very different from those in Japan. In Japan, medical students are just students, and many patients are uneasy about performing invasive procedures. However, in Germany, medical students are expected to become doctors in a few years, and there is a widespread understanding that practice is essential to mastering techniques. This is no different for international students with little experience like me, who were willing to accept me and say, "The more you practice, the better you'll improve, so if you can't do it in Japan, you should practice with me now!" Even if I failed, they would cheer me on by saying, "Don't worry, this thin needle doesn't hurt at all, so try again calmly," and if I succeeded, they would be happy and praise me, so it was a very warm environment. When I asked German students, they said that in the second half of their clinical training, they can perform more invasive procedures such as bone marrow puncture and cholecystectomy, which patients usually accept. They said they were very lucky to be able to experience these procedures while they were students, with constant supervision from doctors and support in case something happened. In Japan, there is a trend to increase what students can do during clinical training, but I felt that there are still many issues to be addressed, such as patients' understanding of the existence of students and a curriculum that allows students to practice procedures before their clinical training.

After taking blood samples, the students perform a physical examination of all the patients in charge of the team before the doctor's rounds, and record the results in the patient's chart. If they notice any abnormalities that were not there the day before, they report them to the supervising doctor. During the team's rounds that follow, the doctor's interview is the main focus, and the physical examination is only performed on areas that the doctor notices during the interview or that the student reports as abnormal. What surprised me here was the level of trust the doctor has in the students. If the student says there is nothing abnormal, the doctor will believe them and skip the physical examination. To live up to that trust, the students will carefully perform auscultation and palpation so as not to miss anything. This relationship of trust not only reduces the doctor's workload, but also gives the students a sense of responsibility, and I felt that the physical examination is not just a daily routine, but also provides high-quality training.

I also had the opportunity to do practical training at Department of Medicine, courtesy of Dr. Higuchi, who is researching nuclear medicine at the University of Wurzburg. In Department of Medicine, both internal radiation therapy for thyroid diseases such as Graves' disease and internal radiation therapy for prostate cancer are performed as part of clinical trials, and patients come from all over the world, including Japan, to receive treatment. Unlike surgery, internal radiation therapy can be expected to be effective on minute lesions throughout the body that cannot be confirmed by images, and it has the advantage of causing fewer side effects that worsen the overall condition than chemotherapy (patients who come from overseas for treatment can apparently fly back home a few days after treatment with so little physical damage). It was a very valuable experience to be able to come into contact with such cutting-edge medical technology, which will likely become more widely used in the future.

I have studied abroad before, so I was relatively familiar with life abroad and English, but this time I was worried about the clinical training, which required specialized conversation, and the fact that I would be studying in Germany, a non-English-speaking country. However, being able to actually experience the medical care and clinical training in Germany in an environment filled with the warmth of such teachers, students, and patients was an invaluable experience for me. Finally, I would like to express my gratitude to the teachers at Hyogo Medical University of Medicine, the teachers at the University of Wurzburg, the students at the University of Wurzburg, and all the other people who supported me and gave me this wonderful opportunity. Thank you very much.