by Wakana Inumaru
First of all, I’d like to thank FUTI for supporting my clinical electives abroad. I had the incredible opportunity to participate in a 4-week clinical elective at two institutions: Johns Hopkins University and Icahn School of Medicine at Mount Sinai. I was a part of the pediatric surgery department and transplant surgery department consecutively, at each university.
I. Pediatric Surgery at Johns Hopkins
i. Daily Schedule
5:00-5:30 check on assigned patients
5:30-6:15 sign out
6:15-7:15 rounds
7:30-10:00 surgery①
10:00-10:20 review surgery① / prepare for surgery②
10:20-13:00 surgery②
13:00-13:20 lunch
13:20-15:30 surgery③
15:30-17:00 consults, emergency cases
17:00-17:40 sign-out
ii. Sign-out
I presented assigned patients every day. During the first week, I was responsible for two patients, which increased to three in the second and third weeks, and four in the final week.
iii. Rounds
The pediatric surgery service typically had between 20 and 40 inpatients at any given time. Rounds usually began in the PICU, followed by the general pediatric ward and then the NICU. Since many patients (or their parents) were Spanish-speaking and many physicians were fluent in Spanish, communication was often conducted in Spanish.
iv. Surgery
Johns Hopkins has a very high surgical volume and a dedicated pediatric hospital building. One entire floor was reserved for pediatric surgeries, with 12 operating rooms exclusively for children. Pediatric surgeries were performed daily, averaging about three cases per day. Patients were referred from surrounding areas, with e a broad spectrum of symptoms.
Some of the most memorable cases I observed included ileal atresia, esophageal atresia, bowel necrosis caused by a lactobezoar, gastroschisis repair in neonates, ovarian tumors, pelvic Ewing sarcoma, emergency splenectomy, and robotic-assisted procedures using the Da Vinci system.Additionally, about half of the pediatric surgery attendings specialized in burn and trauma care, so I was able to observe laser therapy and skin grafting for extensive burns.
v. Consults
At Hopkins, the pediatric surgery team was typically the first to be consulted for children presenting to the ED with trauma or burns. Assisting with CT scans and X-rays for a child who had suffered multiple fractures in a traffic accident on a Saturday was an unforgettable experience. Besides trauma cases, we were also consulted by other pediatric departments. For example, we were asked to evaluate a swollen gastrostomy site, or to determine whether a lung abscess secondary to pneumonia required drainage. I accompanied the residents on these consults and participated in the assessments.
vi. Surgical Experience and Skills Development
My time in the OR allowed me to significantly improve my technical skills, including assisting techniques and suturing. Before each surgery, I waited for the patient’s arrival and helped transport the bed to the OR with the anesthesia team. I assisted with tasks such as transferring the patient to the operating table and positioning them, working closely with the anesthesiologists and nurses.
In the OR, I frequently served as the second assistant and helped with wound closure. I also volunteered to hold the camera during laparoscopic procedures, which attendings kindly allowed. Although I had prior exposure to some surgical techniques, this was my first opportunity to perform them repeatedly, and the hands-on experience I gained at Hopkins was invaluable—especially as a fifth-year medical student.
One particularly memorable case was assisting an attending one-on-one during a posterior neck mass excision. I was given the opportunity to use the electrocautery (bovie) and perform parts of the procedure as the primary operator. Being entrusted with this level of responsibility and receiving direct instruction was a rare and extremely rewarding experience.
II. Transplant Surgery at Mount Sinai
i. Summary
At Mount Sinai, the transplant surgery department primarily focused on liver and kidney transplants, with additional hepatobiliary procedures. When notified of available donor organs, the team would travel, often on short notice, across the East Coast, day or night, to procure them.
ii. Scheduled Surgeries
I had the chance to observe several scheduled procedures, including living donor kidney transplants, Whipple procedures for pancreatic cancer, liver resections for hepatocellular carcinoma, and robot-assisted cholecystectomies. Most of these were new to me, and I gained valuable exposure to both surgical and non-surgical treatment approaches for liver and pancreatic cancers.
iii. Organ Procurement and Recipient Surgery
When a donor became available at a nearby hospital and the team accepted the offer, we would travel by car or plane for organ procurement. This was one of the most exciting parts of the elective, with many opportunities for student involvement. I participated in three procurements and assisted in retrieving the liver and kidney, as well as closing the donor afterward.
v. Surgical Experience and Skills Development
Transplant surgery is a field with significant differences between the U.S. and Japan, particularly in terms of the number of available donors and frequency of recipient surgeries. Through this elective, I gained in-depth knowledge of transplant procedures, post-transplant patient care, and the use of immunosuppressive therapy. I also progressively improved my ability to assist in high-stakes, complex surgeries, contributing more confidently and effectively each day.
III. Simulation Training
Johns Hopkins and Mount Sinai both had a simulation center available for residents and students to practice surgical skills. I visited whenever I had time and trained on the Da Vinci robotic surgical system. The simulator was identical to the machines used in actual procedures. Given that the Da Vinci systems are extremely expensive and access to practice in Tokyo is limited, this was a rare and valuable opportunity to gain hands-on experience.
Acknowledgment
The opportunity to participate in surgeries at two distinctly different institutions in the U.S. has given me invaluable perspectives and insights that will have a lasting impact on my future career as a surgeon. I am deeply grateful to Friends of UTokyo for their generous support of my clinical electives. This experience was truly the highlight of my student life, and it would not have been possible without your help.
