Respiratory Center Training Program

Program Instructors: Motonari Fukui and Zhenglong Huang

• Through training at the Respiratory Center, students learn the basic attitude of a clinician, such as how to interact with patients and how to respond to their complaints. It is important to always maintain a sincere attitude toward patients, their families, society, and yourself. Furthermore, students strive to acquire the common knowledge and skills required of clinicians.
• In June 2007, the Department of Respiratory Medicine and the Department of Thoracic Surgery were merged to form the Respiratory Center. The aim is to provide seamless medical care without any barriers between internal medicine and surgery. Residents are also responsible for patients from both the internal medicine and surgical departments.
• However, for the sake of convenience, the training programs below will be described separately for internal medicine and surgery.

Internal Medicine

1. Program Objectives and Features

1. The main goal of training in our department is to acquire the ability to recognize the characteristics and specificities of the respiratory system, which consists of the upper and lower respiratory tracts, lungs, pleura, thoracic cavity, mediastinum, and diaphragm, to understand each respiratory disease, and to accurately perform differential diagnosis and initial treatment based on the symptoms, physical findings, and test results presented by the patient.We also aim to acquire the basic techniques and problem-solving skills necessary for medical treatment.
2. A distinctive feature of our department is that we see a large number of patients admitted with a wide variety of respiratory diseases, including lung cancer, pneumonia, chronic obstructive pulmonary disease, bronchial asthma, interstitial pneumonia, and vasculitis. Although you will be extremely busy during your training period, we hope you will cherish the opportunity to treat a variety of respiratory diseases. Furthermore, respiratory symptoms can appear not only as a symptom of respiratory diseases, but also as a symptom of other diseases. Another distinctive feature of our department is that we can learn about these diseases at the same time through good collaboration with other departments.

2. Guidance system

1. As a general rule, there are two to three attending physicians, including staff members who are certified specialists by the Japanese Respiratory Society, and one-on-one guidance is provided during daily medical care. Other staff also join in the guidance as needed.
2. Cases are presented at respiratory conferences and new patient conferences, and guidance is provided tailored to each individual case.
3. I have meetings with my department head on the weekend to resolve any questions or problems I have for the week.

3. Specific goals to achieve

1) Diagnosis method

• a) Medical history and current symptoms of outpatients and inpatients
  Accurately ask about and understand the patient's medical and family history of tuberculosis and atopic diseases, smoking history, occupational history, pet ownership and living conditions, and the progression of the illness that led to the patient's current condition.
  A differential diagnosis can be made by conducting a detailed medical interview about symptoms that are particularly common, such as fever, cough/sputum, difficulty breathing, wheezing, and chest pain.
• b) Physical findings
  It accurately captures findings such as nutritional disorders, cyanosis, respiratory abnormalities (including paradoxical breathing and apnea), the presence or absence of edema of the lower legs and dorsum of the feet, and abnormal respiratory sounds that are specific to patients with respiratory disease, and is useful for diagnosis.

2) Testing method

• a) Bacterial and cytological examination of sputum
• b) Various blood tests
• c) Arterial blood gas analysis
• d) SpO2 monitoring (overnight, all-day, and during exercise)
• e) Respiratory function tests: spirometry, DLCO
• f) Tuberculin reaction, intradermal reaction to various antigens
• g) Plain chest X-ray, chest CT scan, MRI scan, RI scan (bone scan, lung perfusion scan, Ga scan)
• h) thoracentesis
• i) Bronchoscopy
• j) CT-guided lung biopsy and ultrasound-guided lung biopsy

3) Respiratory Diseases

[Diseases and conditions requiring urgent attention]

• a) Acute respiratory infections (acute bronchitis, acute pneumonia, influenza, acute pleurisy, etc.)
• b) Bronchial asthma attack
• c) Acute exacerbation of chronic obstructive pulmonary disease or other acute respiratory failure
• d) Tension pneumothorax, massive pleural effusion
• e) Aspiration

[Diseases and pathological conditions requiring clinical experience]

• a) Lung cancer
• b) Respiratory infections (pneumonia, chronic bronchitis, bronchiectasis, nontuberculous mycobacterial infections, pulmonary mycosis, etc.)
• c) Bronchial asthma
• d) Chronic obstructive pulmonary disease
• e) Restrictive lung disease (interstitial pneumonia, collagen disease, etc.)
• f) Chronic respiratory failure
• g) Breathing disorders (sleep apnea syndrome, hyperventilation syndrome, etc.)
• h) Pulmonary circulatory disorders (pulmonary embolism, pulmonary infarction, right heart failure)
• i) Pleural, mediastinal, and diaphragmatic diseases (spontaneous pneumothorax, pleurisy, pleural effusion, etc.)
• j) Others (sarcoidosis, pulmonary vasculitis, eosinophilic pneumonia, hypersensitivity pneumonitis, etc.)

4. Curriculum

1) Weekly schedule and educational activities for residents

• Respiratory Joint Conference (Every Monday 5:30pm-6:30pm)
• Respiratory Medicine New Patient Conference (Every Tuesday 5:00 PM - 6:00 PM)
• Respiratory Medicine Journal Reading Group (Every Wednesday 8:20-9:00 AM)
• Internal Medicine Department Chief Rounds (Every Wednesday from 9:30 AM to 9:00 PM)
• Bronchoscopy (Mondays and Wednesdays, 1:30 PM - 4:00 PM)
• CT-guided biopsy (Every Wednesday and Friday, 3:00 PM - 5:00 PM)
• Internal Medicine Review Club (Every Thursday 6:00 PM - 6:30 PM)
• Internal Medicine Case Review Meeting, CPC (Every Thursday 6:30pm-7:30pm)
• Meeting with the Chief of Internal Medicine (Every Friday 6:00-7:00 PM)
• In addition, at the start of their training, a resident orientation is held, which is an opportunity for them to learn about the various systems within the hospital, hospitality, and infection control measures within the hospital, and participation is mandatory.

2) Activities that residents may find useful in participating

• NST (nutrition support team) study sessions and rounds (every Thursday from 5:00 PM to 6:00 PM)
• Kyoto University Respiratory Medicine Case Review Meeting (several times a year)
• Kinki Regional Meeting of the Japanese Society of Internal Medicine (twice a year)
• Japanese Respiratory Society Kinki Regional Meeting (twice a year)
• Community-Based Comprehensive Respiratory Care Meeting (twice a year)
• Osaka North Lung Disease Study Group (3 times a year)
• Respiratory disease club (twice a year)
• Hanshin Joint CPC (twice a year)

5. Evaluation Method

The final evaluation of the trainee's level of achievement is made by the head of the respiratory medicine department, who serves as the overall supervisor, taking into consideration the opinions of the training instructors and ward head nurses who supervised the trainee during their respiratory medicine training.
Evaluation items include (1) self-evaluation by trainees, (2) the writing and consideration of medical records and summaries for cases in their care, (3) clinical experience and acquisition of knowledge and skills related to respiratory diseases, (4) the clinical attitude and humanity expected of doctors, (5) the content of presentations and discussions at conferences, study groups, etc., and (6) the ability to search for literature.

6. Other

Surgical system

1. Program Objectives and Features

Through thoracic surgery, students will gain an understanding of the pathology and symptoms of the respiratory system, mediastinum, and thorax, as well as basic knowledge and skills as a clinician and how to respond to patients.

In particular, knowledge of the diagnosis and treatment of lung cancer, which is the leading cause of cancer deaths, is expected to be useful when moving on to other fields in the future, and students will be able to experience the cases essential for obtaining surgical specialist certification.

Under the guidance of senior doctors, students will become doctors in charge of patients admitted to the respiratory surgery department, and will experience various tests, surgeries, and postoperative care, as well as how to make a diagnosis, the process of deciding whether surgery is appropriate, and postoperative treatment, and will understand how to proceed with medical treatment.

Students attend various conferences to improve their diagnostic skills, learn about collaboration with other departments, and learn about the process of deciding on treatment plans.

2. Guidance system

In principle, daily instruction is provided by staff who are certified as instructors of the Japan Surgical Society, certified physicians of the Japanese Association for Thoracic Surgery, and specialists certified by the Japanese Association for Thoracic Surgery. Residents prepare case reports for the patients they are responsible for, and based on these, the department head meets with the residents once a month to discuss their progress and any issues.

3. Specific goals to achieve

Items to be learned based on typical diseases, pathologies, examination methods, and surgical methods

1) Common symptoms

• A) Chest pain
• B) difficulty breathing
• C) Cough, sputum
• D) Hoarseness
• E) Lymph node enlargement
    Directly experience and observe the symptoms listed above seen in various diseases and understand their pathology.

2) Symptoms and conditions requiring emergency treatment

• A) Cardiopulmonary arrest
• B) shock
• C) acute respiratory failure
    Each of the listed conditions requires immediate treatment, so participants will learn emergency procedures such as intubation and cardiac massage.

3) Diseases and pathologies that require experience

• A) Respiratory diseases
  • - Experience primary lung cancer, metastatic lung cancer, benign lung tumors, pneumothorax, etc. and strive to understand their symptoms and pathology.
  • ・Learn how to interpret chest X-rays and CT scans as diagnostic imaging, and how to make treatment decisions based on the results, including surgical indications.
  • ・Experience bronchoscopy, a basic respiratory examination, and learn how to identify findings and intubation techniques. At the same time, perform respiratory function tests yourself in the examination department to understand the difficulties involved and use this as a reference for how to treat patients.
  • - If the patient undergoes angiography, catheterization, CT-guided biopsy, ultrasound, etc., you will experience this together with the doctor performing the test.
    Students will gain experience in chest drainage, central venous catheter insertion, and pleurodesis with supervising physicians.
  • ・Acquire skills by assisting with tracheotomy, pericardial drainage, supraclavicular, cervical and axillary lymph node biopsy, and chest wall tumor biopsy.
    Mediastinoscopy, thoracoscopy, open heart surgery (partial lung resection, segmental lung resection, lobectomy, total pneumonectomy, lung cerclage, cyst
    Assist with procedures such as resection, tracheal and bronchial plastic surgery, pulmonary artery plasty, pleural pneumonectomy, and empyema surgery, and perform thoracotomy and thoracotomy.
• B) Mediastinal and thoracic diseases
  • - Experience with mediastinal tumors (including thymoma, neurogenic tumors, lymphoma, and various cystic diseases), myasthenia gravis, palmar hyperhidrosis, chest deformities, and chest wall masses, and strive to understand the pathology.
  • - Experience interpreting chest X-rays and CT scans and the process of deciding whether surgery is appropriate.
  • Assisting in chest wall surgery (surgery for chest deformities such as pectus excavatum, chest wall tumor resection, etc.), mediastinal surgery (mediastinal tumor resection, extended thymectomy, etc.), and thoracic sympathectomy
• C) Postoperative treatment

70% of the diseases we treat are malignant, so post-operative treatment is often required. In the case of lung cancer, we work in collaboration with the respiratory medicine department. You will gain experience in determining whether or not these cancer patients are suitable for chemotherapy and radiation therapy, and in carrying out these treatments.

4. Curriculum

1) Weekly schedule and educational activities for residents

• Bronchoscopy on Mondays at 1:30 PM or outpatient biopsy at 2 PM
• Pre-operative case review meeting will be held from 3:30pm on Monday, followed by a problem case review meeting.
• Joint respiratory conference with respiratory medicine and radiology departments from 5:30pm on Mondays
• Friday reading session at 4pm
• Ward rounds every morning other than the above

5. Evaluation Method

The trainees' level of achievement is evaluated by the chief of the Department of Thoracic Surgery, who serves as the overall supervisor, taking into consideration the opinions of the trainee instructors who supervised them during their thoracic surgery training.
The evaluation criteria are (1) self-evaluation by the trainee, (2) reports on cases in their care, and (3) an interview with the trainee's supervisor and the supervising supervisor, during which they are evaluated on not only their medical experience and knowledge, such as clinical experience, knowledge, and attitude, but also the personality traits desired of a thoracic surgeon.

6. Other

Characteristics of training in our department

We provide thoracic surgery and primarily treat lung cancer, which is currently the leading cancer in men and the third most common in women. We also perform volume reduction surgery for emphysema, and we have many cases of mediastinal tumors, including pneumothorax and myasthenia gravis, as well as palmar hyperhidrosis. Experience with these surgical treatments allows for a well-balanced training experience. During the rotation, we hope you will gain an understanding of the basic pathology and symptoms of each disease and gain experience in what thoracic surgery is all about.