Sushi for breakfast.

Reading the Air

2009-04-23T00:38:00.001-07:00

The Japanese are a very homogeneous culture - in physical appearance and attitude. This means that they do not share our discomfort with nudity, and they often dis-robe at drinking parties or bathe naked together at public onsens or hot springs. There isn't the same mystery to nudity as there is in the States because there isn't such variety.

But this homogeneity also breeds somewhat of a group-think mentality. On our outing on Sunday (over breakfast at Denny's), Dr. G asked the resident Eri to explain the idea of kukioyamu to me.

She sighed, "It's very childish. It's like, if a group of friends are all going to dinner, and three people want to go to Chinese, but one friend says no, he wants sushi. That person... people will stop talking to him."

"For how long?"

"Months," came the unexpected answer.

"Maybe even until he finishes his residency," Dr. G adds.

"He is shunned," Eri continues. "That's kukioyamu," which literally translates as reading the air. "It's very childish," she repeats.

It certainly is. It reminds me of my friends in the States who learned not to be know-it-alls in elementary school if you wanted friends. But that was when we were kids, not adults. Plus, in America, even if you went against the grain, you could still hang out with the fat kid, or the boy with glasses, or the minority child, or the girl who's too tall. There is a frightening lack of oddballs here to keep you company. Kukioyamu is a powerful concept.

It encourages students who are good English speakers to keep quiet during English lessons so as not to show off. Residents are unwilling to criticize another's idea or they change their minds at the first word of dissent from a superior, rather than defending their idea, building on it, making it stronger. I haven't been able to engage someone in a good, solid philosophical argument here. As a former debater, it can be frustrating.

Even more maddening is how it affects morning rounds, which can go on for hours, often taking a rambling course and never coming to a consensus on what is the final diagnosis and the plan of action. Because it is uncouth to take credit for the best idea or criticize a poor idea, so the discussion just sort of peters out to a quiet, unsatisfying end.

But it would be unfair to not recognize also what society gains from this mentality. For instance, there is art everywhere here. It is in the ceramic tiling on their houses, the well-manicured gardens in the yards, the precise wrapping of a gift. Art, music, an appreciation of beauty, is a natural part of life that all share. In America, society tends to encourage us to drop out of activities when we don't possess "special talent". Rather than recognizing that, despite your level of talent, sketching a scene or playing an instrument can be an ordinary, but enriching part of everyday life.

A Date with Rebecca

2009-04-23T00:28:00.000-07:00

Pouring tea at a real Japanese restaurant.

This Sunday, I had dinner again with the junior resients. A real Japanese place this time where you take off your shoes and everyone sits on the floor. We all sat at one table, and there is something about sitting on the floor together that brings a real sense of comfort and familiarity to a group.

One of the residents asked me if I had met all of the male residents, and wondered if I had a favorite? I told him that wasn't fair and this conversation somehow morphed into every male present having to introduce himself to me and tell me where he would take me on a date. Quite embarrassing, but also turned out to be fun.

Some male residents looking cool.

One resident said he would take me scuba diving, another to oyama sen maida (the 1000 rice fields). One would take me to a musical in Tokyo. One would drive me to his family's house on a private island. But my favorite was Tomo, who said he likes photography and would take me to a scenic spot for photos followed by dinner at his favorite chinese restaurant. The boys were surprised by my pick until one caught on that Tomo's was the only date that included food. Of course.

The obligatory food pic: tempura AND sushi-zen.

Princess Rebecca

2009-04-23T00:18:00.000-07:00

Every visiting student here gets a nickname. Dr. Gremillion was apparently dubbed Gre-chan, which is a shortening of his last name combined with chan, which translates as "silly, like a little girl." He asked Hitomi what my nickname was and she said she calls me hime, or "princess". "Princess Rebecca," she laughs. I was really touched.

Hitomi's nickname among the male reisdents is "snake" or "octopus". It is meant as a playful teasing taunt, but I can't seem to make sense of it. It has something to do with her walking like a snake or an octopus' tentacles. Today, Brian-sensai even gave her a note with a picture of an octopus on it. She glared at him and then laughed. She told me it was alright because at least it was a cute octopus. I don't know. Perhaps the joke is just beyond translation.

The octopus and the princess.

I had a similar boggling encounter with a student at the conference last weekend. After shaking my hand, he remarked that it was cold. A little embarrassed, I explained that I was just holding a cold bottle of water. "In Japan we have a saying," he said. "Cold hands, warm heart," then he laughed heartily. I smiled, trying to understand. He went on to say that in Japan, many women have cold hands. "What about women in America? Do they have cold hands?" I really had no idea how to answer that.

One thing that does seem to transcend countries and culture, however, is the reputation of our former president. Dr. G took Hitomi and I out to dinner on Friday night. Noticing the untouched broccoli on Hitomi's plate, he remarked that she must not like it very much, and she agreed.

"You know who else doesn't like broccoli?" Dr. G asked.

She shook her head.

"George W. Bush."

Hitomi grabbed that piece of broccoli with her chopsticks faster than I thought possible and ate it in one bite. Then she nodded her head decisively at that.

Turning Japanese

2009-04-22T16:04:00.000-07:00

So I keep getting compliments on my pronunciation. Almost every other day I will have someone new respond to me in Japanese after an ohiogazaimus or konichiwa and then apologize, but my pronunciation was so good that I sounded fluent. Apparently, my year of Japanese in sixth grade rubbed off somewhere. It's making me really regret switching to Spanish, which I continue to lack any skill or proficiency at. Of course, it could also just be that I have a five word vocabulary in Japanese, which isn't very hard to master. But truthfully, it's the first time in my life that I have really wanted to learn a language, not out of necessity, but for the shear thrill of being able to say the words.

Breakfast at the Bakery

2009-04-22T01:46:00.000-07:00

MikoMiko, the hospital bakery.

I have gotten into the bad habit of buying my breakfast from the hospital bakery. In my own defense, it is not just because fresh-baked cream and chocolate filled pastries are so enticing, it is also because the Japanese just don't do breakfast. The Japanese breakfast looks much like the Japanese lunch, which looks much like the Japanese dinner. Rice and miso and maybe even nato (mmm). Cereal was introduced to the country but never really caught on.

Mmm...pastries...

So if you don't eat a home-cooked breakfast at home (which I don't since I don't have a Japanese cook in my apartment), most residents just buy pre-packaged pastries from the mini-mart. I decided to go with the slightly healthier and much more delicious fresh-baked pastries.

My only mishap with the bakery was when I bought one pastry that appeared to be filled with a novel green and maroon fruit that turned out to be... beans. Yes, beans in a pastry. It didn't taste all that bad after I figured out what it was that I was actually eating. But it didn't taste that good either.

Japanese Flower

2009-04-22T00:16:00.000-07:00

"A Japanese woman only pours sake for men," Dr. G explains after we visited a local sake brewery. "But that's not what Mamiko here did," he continues. "We just saw Mamiko pour sake for herself."

Indeed, during the sake tasting, Mamiko had poured herself a tasting cup when the woman had accidently missed her, apparently a taboo in Japan where one never refills their own glass and women are expected to pour whenever they notice an empty cup. Mamiko, the senior nephrologist who had accompanied us on our tour and provided Japanese translation, laughed and answered, "Somtimes I forget."

From left to right: the owner of the sake brewery, myself, Sealy Harris, Dr. Harris, and Dr. Mamiko Ohara.

The role of Japanese women in society and medicine in particular seems to be a topic on everyone's lips these days - at least, when you are tagging along with Dr. G, the American who likes to stir things up. It was part of the discussion at our fancy dinner with the dignitaries, there was a scheduled "Women's luncheon - not just for women" at the ACP conference, and it was a very real concern for Eri, one of the junior residents here who toured the region with us this weekend.

The Women's luncheon was a formal meeting, discussing the various barriers to women practicing medicine in Japan. Their handout had a neat little chart, outlining the age of a woman during the stages of medical training and showing how it overlapped with the prime years of child bearing and rearing, a very serious task in Japan where children are highly revered.

The American female physician in attendance explained how, in the States, many women now job-share. This is when two women agree to work part-time in the same position. One of the Japanese women then asked if many females in America have paid housekeepers, and the American laughed and answered, "Yes, in fact, I have an au pair."

A yamato nadeshiko or "japanese flower" is the term here for an ideal housewife - a beautiful, quiet woman who knows how to keep old customs and a good house. In Japan, housekeeping is an integral part of the female role and seems to encompass much more than vacuuming and laundry. The society is complex and one of the mother's most important roles is to teach her children to navigate the various unspoken customs. This is one of the reasons that childcare is less successful here. Nonetheless, childcare is also less available and "part-time" is still a novel concept.

Myself as a yamato nadeshiko.

Part of the problem is the shortage of physicians, which also feeds the residents' long hours. The idea of someone working part-time is... not ideal. But the problem then becomes women quitting the profession altogether. In the group of 16 junior residents, there are only three females. I have only met one female attending here and two female senior residents. I have come to realize how lucky I am at UNC to practice with so many women - maybe still not enough, but enough to feel comfortable most of the time. As long as I'm not on urology.

Snacktime

2009-04-21T03:18:00.000-07:00

The hospital's 24-hour mini-mart.

Lawson's is the 24-hour mini-mart in the hospital, where all of the residents go for their off-hours snacks and caffeine fixes. Believe it or not, it is a Japanese chain, despite it's English-sounding name. The most interesting purchase I have seen a resident make is a packaged hot dog bun filled with strawberry jam and whipped cream, eaten for breakfast. Stores here also offer a boggling array of caffeinated drinks that I have never seen before, most some combo of coffee and milk or tea. They aren't that into soda.

The caffeine aisle.

My first Lawson's purchase turned out to be one of my bests. Two different flavors of o'nigiri. O'nigiri may be one of the best food inventions ever! At its most basic, it is a ball of rice wrapped in dried seaweed - a perfect utensils-free and filling lunch. But usually, the rice is filled with something (these fillings are often a bit of a surprise for me each time since I can't read the wrappers). I prefer my o'nirigi filled with pickled seaweed or fish roe. Not a fan of the ones filled with canned tuna and mayo.

My first Lawson's purchase.

A delicious bite of o'nigiri.

My first goal when I return home is to learn how to make sticky rice to create my own o'nigiri.

My other favorite Lawson's meal is make-it-yourself noodle salad:

Pre-packaged salad, unopened.

Opens into three compartments - noodles, toppings, and dressing (creamy ginger).

Composed salad - o-mai (translation: yummy yummy).

Karoshi in Action

2009-04-20T22:53:00.001-07:00

One of our patients died last night. So Hitomi and Koji have not slept. Even though they were not on call, they had to be here because hospital policy requires that you come in when one of your patient's dies. This means that Koji, who was on call two nights ago, has now not slept for over 58 hours.

I try to explain that in America, the doctos on call cover your patients, even when something bad happens, even when they die. I admit that this might be why patients don't like us much in the States - we are always leaving the hospital and sending in people they don't know to take care of them.

Koji laughs a little, then rubs his eyes. "The system here is very difficult on doctors," he says, "but it is much better for patients and their families."

American that I am, I have trouble giving up the argument. "But in this system, we now have a doctor who hasn't slept in over two days," I come back with. "We consider that dangerous. Dangerous for the patients. You can't make good decisions like this."

He nods and says nothing. It is an argument that doesn't seem to hold much weight in Japan. However, on my part, it is only later, upon talking with Dr. G, that I realize the meaning I had been missing in Koji's statement about their ways being better for patients...

In Japan, when a patient dies, the doctor is not present in order to make the call and do the necessary paper work, as they might in the States. Every person that has been involved in that patient's care is present - from the most senior physician to the most junior staff member. These people stand in a row before the family, and are present when the now deceased patient is rolled away to their next place.

"A moment straight out of National Geographic," Dr. G says. Unfortunately, I was not called in the middle of the night and did not witness the scene, but it sure sounds powerful. To be part of an experience like that would be something special. I am still not convinced that it is special enough to warrant 50 hours without sleep everytime a patient of mine passes away, but I think I now have a glimpse of what we might strive for within our own limitations.

Lunch

2009-04-20T22:34:00.000-07:00

The hospital cafeteria serves a set lunch every day from 11 AM until 1 PM. I usually eat with my team around 12:30, anticipating what the day's selection will be all morning. For only 350 yen ($3.50), there are two choices of main dish always served with a bowl of rice and miso soup. The two trays are laid out beside the cafeteria line with plastic wrap over them. You glance over them, make your choice, and then go through the line and pick up bowls to match the model tray.

The cafeteria line.

The main dishes range from tempura to curry noodles to fried chicken (which amazingly turned out to be my favorite), and I even had meatloaf yesterday. The miso soup always contains something different - the typical seaweed and tofu, cabbage and carrots, or perhaps something novel and pickled. After you get your food, there is a table with containers of pickles - purple ones, yellow ones, red ones, and green ones - and various creamy and soy-based sauces. A sample of my lunches:

Fried fish and vegies in broth, spinach salad, miso soup, rice with purple pickles and chili powder, and green tea.

Sauteed pork with onions and my favorite side of shredded cabbage that I load up with creamy ginger dressing, spinach and mung salad, miso soup, rice with sweet soy sauce and yellow pickles, and green tea.

Karoshi

2009-04-20T05:16:00.000-07:00

"He says you are beautiful," Hitomi translates with a smile. I blush and mutter an harigato-gazaimus to the elderly man in the hospital bed. "He likes you," she explains for another patient, a pleasant monk who touched hand to forehead the first time we met. "You see that, Rebecca?" Dr. G asks as the very old, very sick woman we had been examining tried to rise from the bed and bow her head. "That's a Japanese woman, sick in the hospital, but still trying to bow to show her respect."

I feel honored to meet the patients here at Kameda who are all smiles and respect. I am amazed as they allow themselves to be examined - poked, prodded, undressed and dressed again - each morning on rounds in front of a dozen residents with no sense of discomfort. I am equally surprised to learn that patient compliance is never an issue here - patients always take their medications as prescribed and never argue over why they need to be stuck again for blood.

I asked Koji one day, "Do you ever have difficult patients?" He looked confused, and it turned out to be a hard concept to relate. Patients here have deep respect for their physicians. But unfortunately, this trusting relationship comes at a price.

Doctors here feel bound to their patients. Like the nurses who used to not be allowed to marry in the States, or the old country doctor who makes house visits and is always on call. Doctors in Japan still hold to the view that a career in medicine is a dedication of your life to the caring of the ill. You are always on call for your own patients. Even on your days off, you must still come in to check on your patients.

This dedication is admirable, but exhausting. Residents here work at least 6 days a week, often from 6 AM until midnight. Some residents spend months where they never leave the hospital - crashing in a call room or a matress in the workroom for some of their few free hours each night. When they have overnight call, which can be as often as every other day, they are expected to work a full day the next day. And then again the day after that. That's 42 hours without sleep, maybe 4 or 5 hours of sleep-like-the-dead, then 18 more hours of work.

I recently learned that when a resident says that another resident "looks tired", they actually mean that he or she looks sad. Suicide is a very real risk in Japan as young doctors lose their hobbies, stop visiting their families, and are perpetually sleep deprived.

This attitude of working hard is not unique to the medical profession in Japan. The Japanese have a word for "the syndrome of dropping dead at work", called karoshi, as it is just so common here. But as much of Japan is modernizing their work hours and responsibilities, the idea of reasonable duty hours has not yet reached the Japanese medical system.

Celebrity Sushi Night

2009-04-20T04:55:00.000-07:00

On Sunday night, all of the first-year residents took me out for sushi. The first thing most Japanese seem to ask me is "Do you like Japanese food?" When I say"Yes, of course!" they smile and ask, "Do you like raw fish?" They seem a little surprised when I answer so emphatically with "I LOVE it!" and also surprised that it is eaten so frequently in the States (at least by my friends). However, the next question is always, "But do you like nato?"

Nato is a traditional Japanese food that one of the residents describes lovingly as "rotten soy beans". They insisted on ordering a sushi roll filled with nato, and I can now answer honestly, "I'm afraid not".

But the rest of the meal was fantastic. We started off with green tea, of course. This time, with green tea powder that you spoon into your mug and then cover with hot water from a spigot at your table.

Next came miso soup with an unexpected habitant....

The dishes came out quickly - maguro (tuna), onago (the cheaper version of eel here), and some other form of mashed up rare tuna with another name - and all were a surprise since the residents were ordering in Japanese. There were twelve of us all together, so halfway through dinner, they insisted on switching tables so that everyone had a chance to sit with the American. I felt like a celebrity.

Table 1

Table 2

Hitomi shows me how to pose Japanese-style.

Octopus Burn

2009-04-20T04:16:00.000-07:00

Me and Aki at the entrance to the temple in Asakusa.

Aki, one of the sixth-year students at the conference and a native of Tokyo, kindly offered to show me around the city on Sunday. We started the day in Asakusa, an older area of the city with a famous temple (the country abounds with temples). We ate kaminariokoshi or "thunder candy", which looks like miniature rice crispy treats but it's crunchier and has a mild sesame and honey flavor. The candy is named after the god of thunder who oversees the temple.

The temple at Asakusa.

Aki showed me how wave the smoke into my face and hair for good luck. Then we climbed the steps into the temple and he showed me how to toss a coin into the big wooden box, put my hands together and make my wish known to the gods. Inside the temple, he explained that, according to my year of birth, my god is Senju Kannon, or "God of 1000 hands", that really awesome god you sometimes see in Indian stories that has all those arms.

The smoke is good luck.

After the temple, Aki insisted that we eat Udon noodles, as this is the part of the city that is known for making traditional Udon.

Lucky for me, you are allowed to be messy when eating noodles in Japan.

The next stop was Harajuku, a street in Tokyo known for its weirdly dressed young people. Kind of like Haight St in San Fransisco, but Japanese. And weirder.

Harajuku St on a sunny, crowded weekend.

An example of the Harajuku style.

Apparently the style where girls dress like dolls with lacy knee socks, puffy dresses, and big bows in their hair, is known as Gothic Lolita.

Lastly, we went to Shibuya, where Aki says the young people more our age hang out. It is equally crowded, with lots of expensive European shops, a 10 story music store, and the world's largest traffic scramble. On the walk to Shibuya, we came across a funny-looking food stand, which turned out to serve Aki's favorite Japanese delicacy. Takoyaki, literally translates as "octopus burn", is deep fried octopus and comes with a variety of toppings. Aki selected mayo and scallions, and we enjoyed the treat on the street, watching the passers-by.

Aki and his Takoyaki stand.

What do Japanese really eat for breakfast?

2009-04-20T03:37:00.001-07:00

The Tokyo Forum, where the ACP meeting was held. If you can believe it, this is their convention center.

The Japan chapter of the American College of Physicians is the only chapter of the ACP outside of the Americas, but it is apparently more active and filled with enthusiasm that many of its counterparts in our own country. The medical students who attended the conference in Tokyo on Saturday were eager to practice their English and learn about Western style case discussions - your basic presentation of a patient followed by a group effort to create a differential diagnosis and diagnostic plan.

This format is somewhat foreign to Japanese students and residents because students are taught that there is only one correct answer rather than many valid possibilities. Students here prefer to be quiet rather than speak up, and it takes much encouragement to overcome this tendency.

For my part, I played the patient - a 50-year-old woman with fever and a headache. I dutifully sat on a table and allowed about 30 students to crowd around me, ask questions, and examine my old, aching joints. When one student asked me what I ate for breakfast before I got sick, I panicked and answered "Pizza." Dr. G pointed out that I was in Japan, so I changed my answer to "Rice" and got a good laugh. It was surprisingly fun :)

But the best part of the day was meeting all of the medical students.

The student leaders of the conference who also planned the after-party.

Saki, one of my new Japanese friends. She speaks English with a British accent and wants to be a pediatrician!

Medical training is a little different here. Students enter medical school straight out of high school and it lasts 6 years. The first two years are sort of undergrad-like and the last four are much like here. Except they get a lot less patient contact on the wards, their role being mainly to shadow. Hitomi said in her whole 15 months on the wards, she only saw about 15 patients.

At the end of the conference, I was invited to an after-party with the students. We ate communally at a Chinese restaurant and played get-to-know-you games such as Bingo with your first and last name. Despite having more letters than anyone else, I actually won a prize at that one. Some yummy sweet rice crackers.

The next morning, Dr. G and I ate an Easter brunch buffet at the ritzy Imperial hotel, and I had my first traditional Japanese breakfast.

Miso soup, rice gruel, a light broth with fish and various veggies, and in the far right corner, a poached egg in broth, which was delicious! The gray thing that looks like a stone in the main dish was my first mochi ball, a very, very condensed ball of congealed rice. I learned about them in the conference because apparently, they are a real hazard to the elderly here who don't chew them very well and end up getting them caught in their intestine or aspirating them into their lungs. Hmmm... I had to try one anyway, but I think I'll pass in the future.

At last...

2009-04-19T02:02:00.000-07:00

In Tsutsuki Fish Market, you eat sushi for breakfast. I woke up two hours early before the conference on Saturday to see the open air market in action. Fishers unpacking and displaying their wares alongside strange pickled items of all colors, fresh produce, and dried sardines.

And along the outskirts of the market, as well as hidden in mazes between the stalls, are tiny eateries where everyone is eating sushi for breakfast :) !!! It took me awhile to choose which stall I would eat at, but I finally made my decision and cautiously motioned to the woman behind the counter. I pointed to one of the pictures displayed on her sign. That one. She came around to see, nodded, and motioned for me to sit. I paid her my 800 yen and after a few minutes, she deposited this masterpiece in front of me:

Raw tuna on a bowl of rice. Miso on the side filled with fresh shellfish. It was glorious. It was spectacular. It was o-may (pronounced Oh my! and means yummy yummy).

The man sitting next to me noticed my delight and smiled in welcome. In halting English, he introduced himself and poured me a cup of green tea. He pointed to a small figurine of an animal sitting next to the tea and explained that it was a charm to bestow goodness over the food. During the meal, he noticed my failed attempts to extract the shellfish from their shells with my chopsticks and signalled that it was ok to use my hands. Having devoured my meal, I thanked him warmly for his kindness, and went on my way, a happy, happy girl.

My little food stand. I sat on the far end next to the man in the black jacket.

The place for people who cannot go home

2009-04-19T01:29:00.000-07:00

It turns out that the Emperor's garden is not open to the public. But American tourist that I am, I had no idea and purposely set out to find the oasis after checking into my hotel. I wandered around the green area on my map for about an hour. There were nice trees and a lot of signs I couldn't read, but not any sort of entrance to a garden, no trickling streams lined with exotic flowers. However, I did take a really awesome photograph:

Interestingly, one map had some English translations and called this park surrounding the palace the "Place for people who cannot go home". And there were some of Japan's only homeless people sleeping on the grass with their trash bags and worn packs. It sort of warmed me, reading that.

Tokyo at night is... exhilarating. There are flashing lights and sounds everywhere, hundreds of people cross at giant "scrambles" or crosswalks that don't just go across each street but also cross in an X in the middle, so at one turn, all the cars stop and all the people start scrambling in every direction. We were staying in Ginza, which is one of the ritzy shopping districts with Channel and Gucci that looks much like any city.

But beneath the elevated train that runs through the middle of downtown is a winding alley of hundreds of tiny restaurants. It is dark, smoky, and loud but filled with tantalizing smells of barbeque, fried dumplings, and steaming miso. The store fronts have their meals displayed in perfect plastic replica, so all you have to do is point. And inside are masses of black-suited businessmen, ending their workday with a meal after emerging from the subway.

Dr. G and I ate at one of these places last Friday night, a barbeque joint serving up meat on a stick like an assembly line. It looked and smelled delicious, but my heart yearned for the raw selections on the other side of menu. So I finally had my first meal of SUSHI!!!!

The chef's platter for only 1300 yen ($13), offering a selection of tuna, salmon, octopus, and an irresistable silvery fish that I have never tasted before. In that moment, Tokyo won me over.

Tokyo asks why not?

2009-04-18T05:24:00.000-07:00

Q: Where can you find Disneyland, the Golden Gate bridge, and the Eiffel Tower all in the same place?
A: (Bet you weren't gonna say) Tokyo!

The real question is, what can't you find in Tokyo? Last Friday, we drove into the world's most overcrowded city, with a population of 35 million (the fact that we drove in was an amazing thing to most Japanese who can take the train almost anywhere, and who in their right mind would want to drive in Tokyo anyway?). One route into the city passes by Disneyland, but we decided to take the Tokyo Bay Aqua-Line. This monstrous construction is a 2.7 mile bridge and a nearly 6 mile tunnel across and under the bay. In the middle is an "artificial island" designed to look like a large cruise ship.

Looking back on the bridge.

Looking over the tunnel toward Tokyo.

Our GPS quite sensibly points out that we are in the middle of a body of water.

Upon exiting the tunnel, we then drove over Tokyo's own Golden Gate bridge.

To be quite honest, Tokyo frightened me. Part of the problem was my fear of bridges (and this one was massive) but everything was also so metal-and-concrete and huge and sleek. I have probably read too many sci-fi novels, but the scene felt really alien. And the gimicky Eiffel tower and Golden Gate added to the feeling that this was a city and a very real progression of the human race that asked, if we can build it or create it, why shouldn't we?

Plus, the highways around Tokyo are elevated above the streets, so when you drive in, you feel "among" the skyrises and don't really see any people. I felt better when we were on ground level and I spotted a mote surrounding a large walled-off area of gorgeous green. It was the Emperor's garden, preserved and sitting in the middle of the city. I decided that if I had to live in Tokyo, I would want to live there, in the Emperor's garden, but in general, I preferred Kamogawa.

Food Art

2009-04-17T02:15:00.001-07:00

In honor of our American dignitaries - Dr. Harris, President of the American College of Physicians, and his wife Sealy - we concluded our whirlwind tour on Thursday with an amazing meal at La Mirador, a restaurant on the hilltop where I saw the sakura. The restaurant was filled with antiques and served up several courses of deliciousness that were also works of art on their own:

Scallops

More scallops, but this time, wrapped in bacon.

An unfamiliar but scrumptious meat with soaked and roasted bamboo.

A peach tart and something gelatin for desert, decorated with a sakura blossom.

Sadly, some of our dignitaries were not keen on sushi, so everything was cooked, but still wonderful. And during the meal, the wife of one of the Kameda physicians entertained on the koto, a traditional Japanese harp-like instrument, that is apparently a rare talent these days. It was delightful! I wish I had an audio recording.

One Thousand Rice Fields

2009-04-16T02:55:00.000-07:00

Oyama sen mayda or "1000 Rice Fields" is famed to be one of the most beautiful regions of Japan. The many, many levels of terracing or tanbo is not typically seen in Japan anymore because it is difficult to maneuver machinery on the terraces, so all of the planting must be done by hand here. It is somewhat of a cultural center with an educational building at the top of the hill where school children learn about traditional rice planting. We stopped here for a picnic lunch on our tour around the town of Kamogawa.

Lucky for me - April is planting season! So when I arrived, the rice fields had just been flooded and over the weekend, many farmers began the process of planting, so I am able to see the the full process. On our drive back from Tokyo, we came across a small family of three generations in the midst of planting a field.

A father sits atop a tractor with his son, teaching him how to plant the tiny seedlings stacked up on the back in perfect little rows as they move.

Grandmother follows behind, hoe in hand, smoothing out the ruts the tractor has made in the mud.

Dr. G again insisted that I pose for a picutre with the grandmother, and this time, I overcame my embarrassment. She showed me how to use the hoe, and I attempted to repeat her motions and smooth out a few ruts myself. My first stroke was shallow and clumsy. On my second stroke, I went too deep and the hoe got stuck - it was heavy! The woman laughed, but let me continue for a little while longer. After handing back over the hoe, she gracefully allowed us to photograph her and her family until the sun fully set behind the hills.

Newly planted rice seedlings I came across on my walk this afternoon.

Artist-in-Residence

2009-04-15T21:34:00.000-07:00

During our tour of the fabulous Kameda Medical Center, I couldn't keep my eyes off the art. There were these little detailed pieces of art mounted on the walls, hanging from the ceiling, and hidden in nooks and crannies:

A bookstand by the bathroom.

Teapots over telephone booths.

A hanging toy in the pediatrics clinic made from recycled kimono silk.

As it turns out, Kameda has its very own artist-in-residence, Kako Anagarasu. What an AWESOME concept! This is an idea I want to import to the US! It really wouldn't cost that much to add one more person on the UNC hospital pay-roll and honestly, I would much rather it be an artist than another medical specialist. A few more samples of her work:

City block scenes in the background made from actual wood blocks.

A fishbowl on the wall and then fish mobiles hanging from the ceiling.

A living room, of course.

After snapping photos of the walls in delight throughout our tour, can you believe that at the end, we ran into the artist, by chance, sitting in the lobby?! So of course, I got my picture with her and her assistant:

The Business of Patient Delight

2009-04-15T03:32:00.000-07:00

"Most Japanese are humble," says John Wocher, the American ex-patriot who is now one of the head administrators at Kameda. "Well, I'm the exception."

Picture a large Texan used-car salesman, add a degree in Health Care Administration, and you might get a glimpse of John Wocher. He was stationed here in the navy 20 years ago, married a local woman, and has since worked to put Kameda on the medical tourism map. Medical tourism, you ask? Yeah, my thoughts exactly.

Last Thursday, John Wocher gave a tour of the Kameda clinic and hospital to myself and the visiting dignitaries - Dr. Harris, president of the American College of Physicians, and his wife Sealy. "Every room has an ocean view," our guide informed us. And every room also has a computer - soon to be wide-screen plasma tvs - where you can, of course, watch tv, but you can also order room service, do some online shopping from the stores downstairs, or research medical information. If you pay for the super suite, you get a master-sized bathroom with a hot tub overlooking the ocean. There is even - no joke - a pet shop (not PET), where your dog or cat can be groomed and cared for during your stay. "We're not in the business of patient satisfaction," John Wocher delivered the line with a smile, "we're in the business of patient delight."

Of course, not every patient gets this treatment. You have to pay extra for these rooms. But they are apparently quite popular and often stay full. Can you believe - Medicare will even pay for these foreign beach-resort hospitals because it costs less, just like producing a t-shirt or a toy costs less in China or Thailand than in America. It's an interesting concept - patient care as a commodity.

Some things I really liked: The lobbies all have computer portals where patients can access their electronic medical record. In the clinics, rooms have two computer screens side by side so that the patient can see what the doctor is entering into their record. Cell phones are encouraged, and there are no limitations on visiting hours - "We're living in an age of communication."

Some things seem like a harmless way to generate some extra income for the hospital: in the NICU, for only $10, you can watch your baby on a webcam 24/7 from the comfort of your home and know that he/she is safe even if they cannot come home. And in labor and delivery, there is well-placed lighting and a camera installed in the ceiling to snap a professional photograph of the happy family after the birth.

Birthing suite

And then some things made me a little uneasy: for instance, Kameda (and much of Japan) offers elective PET scans (not pet). A very beautiful, but very expensive piece of technology. I wonder, at what point does the attempt to make medical information accessible and patient-oriented become a misuse of medical technology?

CORRECTION: There are no photos sold in the birthing suite. They will help a family set up a video camera if needed, and every mother receives a coupon for a champagne candlelight dinner on the 13th floor restaurant, redeemable within a year.

Sakura

2009-04-14T20:51:00.000-07:00

April in Japan is sakura season, or the blooming of the cherry blossoms. The Japanese take their sakura seriously. I hear that when the flowers first bloom, the major businesses in Tokyo send their lowliest interns to stake out a good spot beneath the trees. Then at night, everyone gathers together and drinks sake and beer until they are senselessly drunk. This festive tradition is known as yozakura or "night sakura". Sadly, I missed the yozakura, but I was still lucky enough to catch the end of the blooming season.

Dr. Gremillion drove me to a park at the top of the hill overlooking Kamogawa. I dutifully posed with my face beside a sakura branch, looking this way or that, while he took pictures and tried to capture a gust of wind and the falling of the sakura petals like snowflakes to the ground.

My attention was drawn to a group of mothers in the middle of the park, all sitting in a circle on yoga mats, stretching and meditating together as their young children wove in and out. (Dr. G tried to convince me to sit among them, as if I were on my own yoga mat, so he could take a picture, but I declined.)

There were several families and groups of elderly sitting on blankets and tarps with a full mid-day meal laid out in bento boxes. There were pairs of old woman lounging beneath the sakura sharing wine and sake. A tiny grandfather, hunched and weathered, tossed a soccar ball to his even tinier 3-year-old grandson. And a mother was walking beneath the sakura, infant daughter in her arms, hoisting the girl up and down, up and down, into the blossoming branches for her to appreciate their beauty. It was one of the most beautiful scenes I have ever witnessed.

Kameda Medical Center

2009-04-13T23:02:00.000-07:00

Every room at Kameda has a window overlooking either the sea or the mountains. The windows are large with clear glass panels and often open, allowing a light sea breeze to drift through the patients' rooms and down the corridors. The abundance of sunlight and natural air make Kameda feel very un-hospital-like. However, in many other ways, Kameda feels surprisingly much like UNC.

Every morning starts with rounds, an in-depth discussion of the new patients, followed by division of tasks and extensive electronic charting. Afternoons are filled with work - changing out foley catheters, drawing arterial blood gasses, reviewing lab results - scattered with lectures. The IV hook-ups here even beep at you in the same infuriating way whenever you so much as touch a patient. Really, very much like home. The big difference is that most of this is conducted in Japanese, and I am dependent on kind-hearted residents to translate for me along the way. Luckily, there is no shortage of kind-heartedness in Japan.

My team consists of:
Hitomi - a junior resident or JR1 (the equivalent of an intern)
Koji - a fellow, but one who recently transfered here from another hospital
Kazusa - the true leader of the team, a fellow with a sweet disposition but a quietly impressive will
And Dr. Sando - the attending physician

Dr. Gremillion, the sort of American-physician-in-residence here (going on 6 years in Japan) and my helpful American mentor, introduced me to Kazusa on my first night because she is so sweet and speaks fluent English. She was anxious about leaving her team, even for the short duration of dinner, but was still nice enough to teach me how to properly use chopsticks (or hashi) and how to introduce myself in Japanese:

Hajimimaste. Watashi-no nameo-wa Rebecca-desu.

Koji speaks good english as well and even gave Hitomi and I a lecture in English as a welcome on my first day - a review of gram staining and the most common pathogens in each category, complete with English acronyms. Hitomi is the most junior member of the team, so I naturally feel most in common with her, and she has such a contagious smile and laugh that it is wonderful to be on a team with her.

The Japanese calendar starts in April, with the blooming of the cherry blossoms (or sakura) . So all of the junior residents and transfering physicians started at Kameda the same week as me, and I don't have to feel so embarrassed when I get lost in the hospital.

Sadly, I didn't eat sushi at all during my first week, much less for breakfast. My apartment has a stove, refridgerator, microwave, and rice maker (of course), and I am unexpectedly expected to fend for myself on breakfasts and dinners, which has led to some interesting culinary combinations since I can't read any packaging in the grocery store. So my first few days I braved dehydrated miso soup packets (something I was familiar with from the States), apples, and something I thought was seaweed salad but turned out to be disgusting and ended up in the trash. Ah, well. The adventure continues!