Local Medical Practitioners Offer Students a View of the Larger World A look inside the 44th IMA Delegation During the COVID-19 Pandemic

2022/08/04

"Can I really become a doctor without expanding my horizons and being aware of medical conditions abroad?" In 1978, the International Medical Association (IMA) was born when a single medical student pondered such a question. Over the next 45 years, the IMA’s members would often visit South America in pursuit of international exchange, experiencing medicine and its education in the region. Yet the COVID-19 pandemic has prevented the IMA from traveling abroad for the last two years. Here, we sat down with Mr. Yujiro Yoshioka from Saiseikai Utsunomiya Hospital; Mr. Eiki Sato from the Ashikaga Red Cross Hospital; Mr. Konan Sakai from Tokyo Dental University Ichikawa Hospital; and the Keio University School of Medicine’s Prof. Hiroyuki Yamagishi, advisor to the IMA’s 44th delegation, to learn about their efforts during these unprecedented circumstances.

Could you start by giving us a quick overview of the IMA?

Yoshioka: 45 years ago, Keio University School of Medicine student Masahiro Ogami wondered whether he could truly become a doctor without understanding the world at large, leading him to found the student-led International Medical Association (IMA). The future doctor and his colleagues ventured to medically underdeveloped regions of South America to experience firsthand the “building blocks of medicine” and to focus on international exchange efforts in medical science and treatment. The IMA’s aspirations have continued ever since at the Keio University School of Medicine, where the association celebrates its 45th anniversary in 2022.

At the heart of the group’s activities is participation in international medical activities abroad—primarily in Central and South America—for about 40 days during the summer holidays. The group includes three sixth-year students who are supported by three fifth-year students. One thing that sets the IMA apart is the fact that members plan each trip themselves, determining their destinations and activities in addition to the necessary fundraising.

Why did you decide to join the IMA?

Sato: I was a loyal member of the School of Medicine baseball team in my Keio days, but I wanted to try something new during my last two years as a student. I happened to see a flier for the IMA posted in the training room and was inspired by its call to "see Brazil’s medical care for yourself.”

Yoshioka: I was on the baseball team with Mr. Sato and heard about the IMA through him. I didn't feel like I was good enough to join after reading about the great things the older students were doing. I wanted to be like them and thought the program would be a great opportunity for me to grow as a person.

Sakai: I'd grown up in the Keio system since kindergarten, so once I finished my career at the Keio Medicine Track & Field club, I decided to spend my last two years at Keio doing something unique that I could only do while a student. The IMA offered precisely that, and I thought it would be an excellent opportunity to test myself, so I looked into joining.

When you joined the IMA in 2020, the COVID-19 infection was already spreading.

Yoshioka: That’s right. During my fifth year, I was in charge of supporting the sixth-year members of the 43rd delegation. I saw firsthand how they had meticulously planned their expedition to Brazil and how they explored all options but were left with no choice but to abandon their trip.

Sakai: Even though the IMA had to cancel its overseas delegation for the first time in its history, we couldn't forget the dedication of the 43rd delegation, which served as the main driving force behind our activities as the 44th delegation.

In the midst of all this, the IMA founded the International Medical Student Meeting on COVID-19.

Sato: In July 2020, the senior members of the 43rd delegation organized the International Medical Student Meeting on COVID-19, an online conference bringing together medical students from eight countries around the world. At the time, there was no vaccine for COVID-19, and much remained unknown. This forum offered a meaningful opportunity to discuss different countries’ policies and how medical students best fit into the situation.

Following in their footsteps, we took the lead in organizing a second International Medical Student Meeting on COVID-19 in January 2021. Medical students from around the world brought their vitality and enthusiasm to numerous learning opportunities. For example, a student at Johns Hopkins University in the US recognized the spread of “fake news” about COVID-19 as a potential problem and immediately sought to rectify it by posting researched articles and other accurate information on Instagram. To see someone of my generation taking such initiative was inspiring. The International Medical Student Meeting on COVID-19 was started by the 43rd delegation of the IMA, but we are now committed to ensuring that this important event continues in the future.

Amid ongoing uncertainty, how did you decide on the path the 44th delegation would take?

Yoshioka: When the COVID-19 pandemic was just starting, I still assumed I'd be able to go abroad the next year and contribute to the legacy of the IMA. But it became clear that things weren’t going to come together, and I was forced to give up on that plan. To be honest, I felt conflicted, but I tried to stay positive and optimistic in order to achieve something unique with this delegation.

Sakai: We decided to focus our activities within Japan, guided by four goals of "gaining hands-on experience with early-stage medicine," "facilitating international exchange through medicinal science and care," "approaching medicine as a societal gamechanger," and "exploring infectious disease countermeasures through the lens of COVID-19." We intended to reconnect with the basics of medicine in remote islands and regions, consider what an ideal remote island medical system would look like, and understand the realities of care currently available to foreign residents of these areas as well as their future support needs. After much consideration, we chose to visit three locations during our delegation: Aguni Island in Okinawa, Tsushima in Nagasaki, and Hamamatsu in Shizuoka.

Professor Yamagishi, as the faculty advisor for the 44th delegation, what did you think of this undertaking?

Yamagishi: We left it to the members to decide for themselves whether they should go abroad or not. As their advisor, I simply did what I could to help them develop their ideas to the fullest by connecting them with the right people. With the assistance of myself and many other professors, the 44th delegation was able to craft and successfully carry out their own plan. I'm really proud of all that they accomplished.

Yoshioka: Having Prof. Yamagishi as our advisor was incredibly encouraging. As we shifted our focus inward, he was very flexible and accommodating of all the changes we made. It's a shame we couldn't travel to Brazil together, but thanks to Prof. Yamagishi, we were still afforded many rewarding opportunities. As a member of the 44th delegation, I am sincerely grateful for all that he contributed to our team.

Your 38-day tour of Japan started in Hamamatsu, Shizuoka.

Yoshioka: Well, we understood that with its declining birthrate and aging population, Japan now depends on the labor of international workers. We wanted to learn about what kind of medical assistance foreign nationals needed, and, in particular, we wanted to connect with people who have come to Japan from Brazil, a nation that has deep ties with the IMA. So from July 17 to 24, 2021, we visited Hamamatsu, Shizuoka, which is known for producing textiles, musical instruments, and transportation equipment and is home to Japan's largest Brazilian population.

Our first visit was to the Yamaguchi Heart International Clinic, established by director Dr. Takaji Yamaguchi to provide medical care to foreign nationals in the area. We were very impressed by how the hospital operates in order to accommodate international patients, such as having on-site Spanish and Portuguese interpreters and staying open on weekends to make it easier for factory workers to visit the hospital. Dr. Yamaguchi really knows how to communicate with his patients, cracking the occasional joke and creating genuine connections with them. We could tell that his patients trusted him, as more than 40 patients came to the clinic in the morning alone. It impressed upon me the tremendous impact physicians can have on the lives of their patients and their community as a whole.

We also visited Hamamatsu Catholic Church, the Consulate-General of the Federative Republic of Brazil in Hamamatsu, and the Shizuoka University of Art and Culture. Through these visits, we had the chance to experience aspects of the local Brazilians’ way of life and learn about the concerns of students who have roots in other countries.

Sato: At EAS Hamamatsu, a Brazilian international school, we lectured on infectious diseases in Portuguese and conducted a well-being survey with the students. The children were all cheerful and enthusiastic about learning, but there are still significant language and identity barriers for many of these international students, which seem to have an effect on their mental health.

It was also shocking to find that 63% of the children said “no” when asked if they would want to live in Japan in the future. Their responses included reasons such as “I can’t speak Japanese” and “I don't know what kind of job I would be able to get in the future.” Since they don’t interact much with Japanese people, they seem to have difficulty obtaining information about university admissions and career opportunities. While the term “multiculturalism” has taken on a life of its own, during our visit, I felt that, in reality, there are still many issues left to be addressed.

After Hamamatsu, you visited the city of Tsushima in Nagasaki Prefecture. What did you do during your week on the island?

Sakai: Tsushima is a large remote island city covering 708 square kilometers in Nagasaki Prefecture, and for many years, the city has developed its own remote island medical care system. On the island, we had the opportunity to engage in practical training at a remote core hospital and several remote clinics from July 25 to 31.

Tsushima Hospital, the island's core hospital, is so big I almost forgot how remote it is. With a rehabilitation facility and a home-visit nursing station located next to the hospital, residents can receive all of their medical care on the island, save cardiovascular and neurosurgical treatments. It was amazing to see the level of comprehensive care that these doctors provide, with surgical specialists performing things like dermatological treatments for their patients.

Yoshioka: I will never forget one patient who came to Tsushima Hospital complaining of a headache. When we first examined him, we thought the cause of the headache might be tight shoulders, but the doctor decided to do a CT scan just to be sure. The CT scan revealed that there was blood collecting on the surface of his brain, a condition known as chronic subdural hematoma (SDH), and the patient was rushed by helicopter to a hospital in Nagasaki. It was a testament to the importance of being able to provide thorough examinations and a sobering reminder of how lax my assessment of the patient had been.

Sato: In Tsushima, we learned the vital role core hospitals and clinics play in this kind of remote area. The city of Tsushima runs north to south with quite uneven terrain, making it time-consuming to travel by car. For this reason, the city has established several remote clinics staffed with doctors from Tsushima Hospital and other facilities to treat nearby residents suffering from chronic diseases. The system the city has established to allow seamless collaboration between Tsushima Hospital and other facilities was impressive.

Sakai: In Tsushima, I experienced how the government plays a critical role in properly allocating medical resources, including human resources and medical equipment, and shifting the overall direction of medical care on the island. I learned a lot by seeing this remote medical care system with my own eyes. I would not have been able to gain this perspective in the classroom or through practical training at the university alone. As I embark upon my career as a physician, I’m considering a career in government as one way to help steer the future of healthcare in Japan.

From Tsushima, you went to your final destination, Aguni Island. Could you tell us how you spent your 20 days there?

Sato: We visited the tiny island of Aguni Island in Shimajiri-gun, part of Okinawa Prefecture, from August 3 to 23. The island is only 12 km in circumference and has a population of less than 700. We visited the Aguni Clinic, the only medical facility on the island for outpatient treatment and home visits, and saw an intensive-care nursing home and elderly daycare center.

The Aguni Clinic is responsible for seeing all 700 islanders and is operated by a three-person team: a doctor, nurse, and office staff. We witnessed how dedicated the doctors were when they rushed to help when the phone rang in the middle of the night. We also saw the difficulty of making an accurate diagnosis with limited resources available. When transporting a patient to a hospital on the Okinawa mainland for an emergency, doctors must decide whether to wait for the once-a-day ferry or call for a medical transport helicopter or the Self-Defense Forces for help.

Yoshioka: You often hear people talk about “patient engagement,” but it wasn't until my 20-day stay on Aguni Island that I truly understood what the phrase meant. Patients can end up spending a long time at the clinic. It was impressive to see how attentively the doctor listened to their stories and gave detailed explanations of their diagnoses to put them at ease. During home visits, I was surprised how much there was for doctors to learn about other aspects of patients’ lives, like their daily diet, room temperature, and hygiene, which they could never have found out at the clinic. You only see one aspect of the patients’ lives at the clinic, so I felt that we need to make more of an effort to get to know them.

At the hospital where I work now, I hope to connect more deeply with patients by cooperating with nurses, physical therapists, and other healthcare professionals. I’m glad I encountered these flexible ways of thinking as a student before I become too set in my ways.

Prof. Yamagishi, you later joined the students on Aguni Island. How was it?

Prof. Yamagishi: First, let me say how grateful I am to Dr. Takamitsu Miyake of the Aguni Clinic and to the people of Aguni Island for welcoming us so graciously. In fact, I myself once spent several months on a remote island when I was young, so I thought I knew the realities of remote island medical care. But having experienced so many years of so-called “urban practice” at Keio University Hospital, I once again realized the differences between rural and urban care, which has helped me deepen my understanding of the issues.

Understanding the reality of such remote island medical care will be a great asset to students no matter where they end up in the future. Of course, Keio University Hospital and other hospitals provide exceptional medical care, but on remote islands, you have to rely more heavily on medical examination and diagnosis. Patients may have to be transported by boat or helicopter for a single test. Students need to know the weight of such decisions, and I believe this experience has been eye-opening in that respect.

Sakai: Among the 38 days of activities, the days I spent with Prof. Yamagishi on Aguni Island were extraordinary. He always had little nuggets of wisdom for us. One such insight was his take on what professionalism means as a physician. He taught me that true professionalism means becoming close to the patient without becoming emotionally involved and giving the best possible care as a physician while remaining neutral. That was something missing from my practice, and it has stuck with me ever since. There are many other little words of wisdom, but I will refrain from mentioning them since they may not be as appropriate. [laughs] Among the many experiences unique to the IMA, I think one of the most valuable was the opportunity to spend a lot of time with a beloved faculty member whom I both respect and admire.

Prof. Yamagishi: The lessons you learn in the classroom only really stick after you experience them in the field. As a professor, I am in a position to teach young people, but it isn’t always easy to talk with students in such intimate settings during lectures. As a physician and researcher, it was good for me to be able to share my life experiences, including my own reflections. It was certainly tiring [laughs], but I really enjoyed it.

What have you gained from the IMA, and is there anything you’d like to say to the next generations of the IMA?

Yoshioka: Never stop moving forward, even when things don't go your way. Take it one step at a time. It’s times like these when you can gain a whole new outlook on life. I am sure that I will face many difficulties in my career as a doctor, but I believe the lessons I've learned through the IMA will provide me with emotional support.

At the heart of the IMA is the pioneer spirit of building something out of nothing. While we weren’t able to go to South America like the delegations before us, we were able to pioneer our own activities elsewhere. I hope the students who come after us will take on new challenges and opportunities to expand the IMA. We’ll all be rooting for you.

Sakai: In retrospect, I wonder if we got lucky ending up with the first domestic IMA activity in Japan. No matter what career path I take in the future, I want to move forward with a positive attitude, cherishing the power of chance and always remembering to be grateful to those around me.

Despite this challenging situation and an uncertain future, the IMA will surely provide unique experiences. I want future members to be proud to be a part of the IMA.

Sato: Personally, having to balance my studies for the National Medical Examination and the IMA has sharpened my ability to multitask. I felt nervous seeing my other friends studying diligently for their examinations, but I realized that my own path, too, would open up as long as I kept working hard day in and day out.

The activities of the IMA are not just the work of us three. They have been made possible by the support of the professors at Keio University and the people and places we visited. I hope that future generations of the IMA will continue to boldly take on new challenges while always appreciating the help of those around them. We’re no longer students and have started our careers as doctors, but the three of us are going to make sure that we get to travel together to Brazil someday, no matter what!

Any final words of encouragement for the three members of the 44th delegation and the future of the IMA?

Prof. Yamagishi: One of the most important principles of Keio University is combining orthodoxy and heresy. This principle also seems to be an apt way to describe both the IMA and the 44th delegation. When I was a student, the IMA was a newly established "heretical" organization. But that was 45 years ago. The organization has since been passed down through generations of many now distinguished alumni, becoming a legitimate entity within the orthodoxy. The 44th delegation, however, was not able to go to Brazil, which was heresy in terms of the IMA. And in that case, why can’t they start over and create a whole new IMA? They have made the first strides in reforming the organization with a pioneering spirit. The 44th delegation was indeed a great generation of orthodoxy and heresy.

Earlier, each member of the last delegation shared their messages for future generations, but to me, it all sounded more like encouragement for themselves. I hope they will remember how they feel in this moment and stay the course, even when the going gets tough. I am confident that they will give it their all, and I look forward to watching them succeed in their careers.