Chapter 05: Medical Education in Japan and Internship and Residency in the United States
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Description
Dr. Komaki begins this chapter by adding to the Chapter 04 discussion of the features of medical education in Japan that led to the student strikes and her own decision to pursue an internship and residency in the United States. She explains that through her volunteer work at the Atomic Bomb Casualty Commission, she met and married her first husband and also made a connection with Walter Russell, MD, who helped her secure an internship at the Medical College (1972). (Her husband also secured a fellowship, but later returned to Japan to practice and the couple divorced.) She intended to focus on hematology and leukemia.
Dr. Komaki talks about the differences between medical education in the US and Japan.
Identifier
KomakiR_02_20181128_C05
Publication Date
11-28-2018
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - Educational Path; Professional Path; Evolution of Career; Overview; The History of Health Care, Patient Care; Understanding Cancer, the History of Science, Cancer Research; Cultural/Social Influences; Global Issues –Cancer, Health, Medicine
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
T.A. Rosolowski, PhD:
You had wanted to—we left off last time with the medical student strike and how you ended up coming to the U.S. for your further medical training. You were about to tell me about that nationwide, more about that nationwide strike, so please do continue.
R. Komaki, MD:
So, we have 47 [plus] university hospitals in Japan and of those hospitals, they do get financial support from [the Japanese] government. But because of the medical system, which has a hierarchy, one professor and then one associate professor and one assistant professor, and there are a couple fellows. In each department, they have only five or six employees [as faculty members], and when you enter to the department, you really have to stay there forever [if you would like to be promoted in the same department]. Most of the time, because [there is] one professor, they have to think about [joining or opening private practice, or you think about going to] other hospitals, based on prefecture or city hospital, [if you cannot get to the top in] university hospitals. The way we were taught during medical school, that was based on the professor’s opinion. We had a clinic, you know we had to go on rounds, and [questions to the professors or discussion with them during rounds]. Some of the professors were trained in Germany. Some of the professors, like the cardiology [department], they [received training in] the United States. Whenever we saw the patients, making rounds, we never ever asked any questions. Whatever the professor said, that was it. So that kind of training, we started to have some questions, and we said we have to change the system. That’s one. The other one was we requested payment for the internship. After you graduate from medical school, one year we had to work free at the university hospitals. We requested payment for internship; otherwise, we would have to go out to private clinic to do moonlighting to get the money. In the meantime, we really had to work very hard at the university hospital. We had to take on-calls and ignore the family. So usually, they don’t get married during internship or medical students. So those two things we requested –[payment for internship and a change in the university medical system]. We had to walk out from the university hospitals [when our requests were rejected]. I had experience at the RERF, Radiation Effects Research Foundation. It used to be ABCC, Atomic Bomb Casualty Commission in Hiroshima. That’s the place, they were checking all those people who were exposed to the atomic bomb. So during medical school, I went there as a volunteer, to check all those people who were exposed to the atomic bomb. I was checking the patients’ blood pressure, and I also volunteered to check the blood count and so on, but I was just fascinated [by] those people who were exposed to atomic bomb, so every summer, I volunteered to be there. I had the connection with the people who were working at the RERF, and they said, “Well now, [ ] your university hospital is closed and sure, you can come and do internship.” So I went [to ABCC/RERF for my internship].
T.A. Rosolowski, PhD:
Oh, so you started an internship at RERF.
R. Komaki, MD:
Yeah, an internship at the RERF, yes. Walter Russell came from Seattle. He was the chairman of Diagnostic Radiology. He said, “Yes, you can work at the RERF as an internship.” So I was doing a general internship at the RERF. That was in 1970. Right, because I graduated in 1969 from the medical school.
T.A. Rosolowski, PhD:
Yeah, and it says ’69 to ’70.
R. Komaki, MD:
Right. So I started to work there in April, 1969, and then I met Dr. Komaki and we got married. That’s why my maiden name was Ueda --that’s my [father’s] name, and my mother’s name was Obata. My father’s name was Ueda. So we got married [in 1970].
T.A. Rosolowski, PhD:
And what is Dr. Komaki’s first name?
R. Komaki, MD:
Senichiro, S-e-n-i-c-h-i-r-o, Senichiro. He came from Kagoshima, really the southern part of Kyushu, and he graduated from Kyushu University, which was a very, very good university. He was working as a fellow at the RERF, under Dr. Russell. After we got married, we came to the United States. Just before we came here to the United States, I worked at the Red Cross Hospital very briefly, about three months, but we came to Medical College of Wisconsin.
T.A. Rosolowski, PhD:
Now why did you decide to come to the U.S.?
R. Komaki, MD:
Oh, because Dr. Russell had a connection, his friend, Jim Youker [James Youker, MD]. He was the chairman of radiation, the Department of Radiology, at the Medical College of Wisconsin, so that’s the connection. I had to have postgraduate education somewhere [outside of Hiroshima University Hospital because of the medical students’ and interns’ strike in Japanese University Hospitals].
T.A. Rosolowski, PhD:
Was it a big decision, to come to the U.S.?
R. Komaki, MD:
That was a big decision, but Sen, my ex-husband, who died of lung cancer, he got a fellowship. I think he wanted to do his residency program at the Medical College of Wisconsin, so that’s the way we came.
T.A. Rosolowski, PhD:
When did your first husband die?
R. Komaki, MD:
That was after we divorced. After his finished his residency program, [he worked at the VA Hospital in Wood Milwaukee until 1977]. [Then he decided to go] back. His professor in Kyushu University wanted him to come back [to succeed the professor’s job in future. I was still doing my radiation oncology residency program. We divorced since I wanted to finish my program, which as completed in 1978.] He got remarried and then he passed away from adenocarcinoma of the lung. This must be like oh, almost 20 years ago. Yeah.
T.A. Rosolowski, PhD:
Okay. We can fill in the date later on.
R. Komaki, MD:
Yeah. He never smoked but he developed adenocarcinoma of the lung and the “bone mets” and the “lung mets,” and so he passed away, but that was after both of us, we got remarried. Basically, he wanted to go back home after he finished his residency program, but I was right in the middle of my residency program and I said no, I cannot go back home and I stayed.
T.A. Rosolowski, PhD:
So tell me a little bit about kind of that process of getting immersed into American education, American culture.
R. Komaki, MD:
Oh yeah, it’s so different.
T.A. Rosolowski, PhD:
Yeah, tell me about that.
R. Komaki, MD:
It is so different. I was just watching NHK, Channel 1221 [in Houston]: that’s all Japanese broadcast on the TV. They were talking about how [the medical system] never changed. We went on strike and tried to change the system of the medical system. The most difference between U.S. and Japan: [for example, in the US] medical students or interns or residents always ask questions to the professors, and that’s okay. When we see the patients [with medical students, interns or residents, anyone can ask] questions and [give] answers. And if I cannot answer to the medical student or resident, [I] always say well, let’s find out, we can do some trial to find out which is right. So that’s the difference. In Japan, the professor [ ] have been treated like gods and they have the most powerful positions even if they’re wrong. [In Japan, they] cannot say he or she is wrong, because they would like to keep their positions. So they never argue, they never question, even if he or she was wrong. That’s the kind of system that still exists [although the power of the professors is getting less, since the professors now are educated mostly in the modern medical system in the US].
T.A. Rosolowski, PhD:
What is the relationship between doctor and patient in Japan, you know in that kind of situation, and how was it different or similar in the U.S.?
R. Komaki, MD:
Okay. In the United States, the patient has so much power. If the physician is wrong or did something wrong, the patients are ready to sue them, but in Japan, they don’t sue doctors. These days, you know, I left Japan a long time ago, but these days some of the cases, the patients, they sued the physicians, but most of the time they don’t sue the physician, even if they did the wrong thing. What does it mean? [Is this] the wrong thing? They do not have pure --like a multidisciplinary approach. The surgeons, they [perform] biopsy to make a diagnosis of cancer. I’m talking about the [multi-disciplinary management of] cancer patients. [Surgeons] keep [the patients] under their control. They don’t give those patients to a radiation oncologist or medical oncologist. They always said the only one way to cure cancer is resection. They cut it. That’s the only one way. If it’s not operable or if [they] cannot resect the tumor. [The patients] are going to be dead, so chemo or radiation treatment, it doesn’t work.
T.A. Rosolowski, PhD:
Now I was reading, in some of the article and interviews that you’ve done previously, that you talked about how the attitudes about radiation therapy in Japan, versus the U.S., and there were substantial differences. In Japan, there were attitudes about radiation therapy that had been shaped by the dropping of the atomic bomb.
R. Komaki, MD:
Right.
T.A. Rosolowski, PhD:
So tell me more about that.
R. Komaki, MD:
Japanese people in general, they are so afraid of radiation. And radiation --they cannot see it, but after the atomic bomb in Hiroshima and atomic bomb in Nagasaki, they have seen the people who immediately died. Like in Hiroshima, seventy-five thousand people, immediately died. Then within six months, another seventy-five thousand people died due to the GI toxicity, bone marrow toxicity and so on [including malignancies]. They are still dying due to exposure to the atomic bomb. So they feel like radiation causes malignancy or death and just because they cannot see it, they have fear. This [fear of radiation exposure became so obvious in] 2011. The tsunami [hit the Fukushima area and] and the Daiichi Nuclear Power Plant was destroyed by tsunami and [resulting in radioactive contamination of the land and sea]. They were so afraid of cesium contamination, so they never bought [beef] or vegetables or the meat from that area. In Hiroshima, we were told actually nobody could live in that city for 25 years, but everybody moved back within six months. My father had to go in the day after and was exposed to black rain, which contained a very high dose of radiation, and my grandmother, she was dug out [from under the collapsed house]. She had total body exposure, but she was taken away from Hiroshima City but came back toward the [suburb] of the city and she lived there after six months of the atomic bomb. The one thing all the Japanese people have the words, radiation, you know they cannot separate out external radiation versus medically targeted radiation treatment, they cannot separate out. All the patients that get the radiation treatment in Japan basically, very few we call curative intent. It used to be only 25 percent of the cancer patients, they had like curative intent. The others, another 25 percent of the patients, they had chest palliation, bone mets or brain metastases, they were treated by radiation treatment very briefly. So terminal cases, they had radiation treatment to relieve the pain or to shrink the tumor. I have like five nephews and they were told, the radiation oncologist, they said your aunt is a very famous radiation oncologist in the United States, you should be a radiation oncology specialist. They all said well, whenever I saw the patient with radiation treatment, treated by radiation treatment, they were all palliative, like terminal, and they never thought about the radiation can be used for curative intent.
T.A. Rosolowski, PhD:
So that’s still the case.
R. Komaki, MD:
Yeah, it’s still the case. Also, they feel like when they get radiation treatment, like babies, young children, it might cause second malignancy, you know that’s the fear they always have.
T.A. Rosolowski, PhD:
Now when did you start questioning that?
R. Komaki, MD:
Well, when I came to the United States, I did both. Originally, I was thinking to go to hematology oncology, so for one year, I worked at the VA Hospital as a fellow of the Hematology Oncology.
T.A. Rosolowski, PhD:
This was ’73 to ’74.
R. Komaki, MD:
Right, right. So I thought maybe my interest was always leukemia, and checking blood counts. So I went to the VA Hospital and I was doing a fellowship in Hematology Oncology, but around that time, all the patients, except for some lymphoma or testicular cancer, the chemotherapy was very effective, but otherwise, not very good chemotherapy around the time and all those patients are there dying due to chemotherapy and it’s not worth it. And then I saw a patient who had cancer of the larynx, they were cured by radiation treatment, very limited and it doesn’t metastasize like lung cancer, so I started to be more interested in radiation treatment. Coming from Hiroshima, I was always thinking about this radiation effect to the human body, but also, if we can target at each stage of the cancer, maybe we can cure some of the patients. So I became more interested. There was a guy, when I was at the Saint Mary’s once, I was doing a general internship there, Saint Mary’s Hospital, I think that was in 1973 or ’72.
T.A. Rosolowski, PhD:
Yeah, ’72 to ’73 are the dates I have on your CV.
R. Komaki, MD:
Yeah. There was a Dr. Gueninger, Anthony Gueninger, who had internal medicine specialty board as well as radiation oncology specialty board, and he was trained at the Penrose Cancer Center of Radiation Oncology. Juan Del Regato, this guy, he had incredible knowledge about cancer itself and all the surgeons and the medical oncologists, they went to talk to him and ask him his opinion, how to treat the cancer patients. I was following the surgeon and I was following the medical oncologist while I was doing general internal internship there. I was fascinated about this guy who had so much knowledge about the behavior of the cancer, and so they treasured his opinion and they wanted him to cover their patients while they had to be on vacation or something. I thought wow, if you have knowledge about the cancer, you can be radiation oncologist and they will respect your opinion.
T.A. Rosolowski, PhD:
So you said he had internal medicine but also radiation therapy.
R. Komaki, MD:
Yeah.
T.A. Rosolowski, PhD:
Okay, I missed that.
R. Komaki, MD:
Originally, he was an internal medicine, board certified [physician], and then he decided to [specialize in] radiation oncology, so he took a radiation oncology residency program after internal medicine, so he had a double certificate and board. He was such a wonderful, wonderful person and everybody respected him. His office, I followed all those attendings to go to talk to him, and he was like one of the multidisciplinary conference authorities, and they did not have like we have, multidisciplinary conference. They did have a tumor board or that was my residency program. Anyhow, he died suddenly by [an automobile] accident, [with] his wife and two friends.
T.A. Rosolowski, PhD:
Oh dear.
R. Komaki, MD:
And then my husband, he had to cover Saint Mary’s Hospital, Deaconess Hospital, VA Hospital, and West Allis Hospital, as well as Medical College of Wisconsin, County General Hospital. All of a sudden, after Dr. Gueninger died, my husband, Jim Cox [oral history interview], came from Washington, D.C. He was chief at Georgetown, and he came and Dr. Youker, he created a separate department for Jim Cox to become chairman of Radiation Oncology [Department].
T.A. Rosolowski, PhD:
So this was right after Dr. Gueninger died.
R. Komaki, MD:
Yeah, that’s correct.
T.A. Rosolowski, PhD:
Jim Cox was kind of designed to start the department after he died, because he died?
R. Komaki, MD:
No, no, no. Jim Cox came as a chairman at the Medical College of Wisconsin, County General Hospital, so that’s the one place he was supposed to be the chair, but after he arrived as a chairman, this Dr. Gueninger died. Maybe there was like six months after he arrived. So he had to cover pediatric [oncology]—the Milwaukee Children’s Hospital, VA Hospital, Deaconess Hospital, Saint Mary’s Hospital, West Allis [Hospital].
T.A. Rosolowski, PhD:
So tell me, when did you decide to make the transition from hematology and a focus on leukemia, to radiation oncology, or to radiation?
R. Komaki, MD:
So, when I was doing a general internship at Saint Mary’s, I started to think about going to radiation oncology, and then Jim Cox came from Washington, D.C., and I was interviewed, and I was the first resident there. [Dr. J Frank Wilson, Dr. Don Eisert and Dr. Maurice Greenberg accepted me to be the first year resident after interview] and I started to be a resident in radiation oncology. [ ] When I did [my hematology/oncology fellowship at] the VA Hospital, that was before I started [my radiation oncology residency at the Medical College of Wisconsin]. Yeah, before I started my residency program.
T.A. Rosolowski, PhD:
So you were a fellow at the VA, from ’73 to ’74, and then I have your residency in radiation oncology from ’74 to ’77.
R. Komaki, MD:
Correct, that’s correct. So while I was doing a fellowship at the VA, I was so disappointed. Not so many patients [with malignancies] were cured. I felt so bad that those young people are dying, but when I saw some patients, they were cured by radiation treatment, I was so encouraged, you know? Maybe we can do something by radiation treatment [for cancer of the larynx and other early stage cancers].
T.A. Rosolowski, PhD:
Let me just ask you, was that kind of—you know conceptually, that’s a huge shift, I mean coming from Japan, with all of these attitudes. What was that like, because I’m thinking about talking to people about that sea change in cancer, when suddenly cancer was one disease, now it’s many diseases, I mean these big conceptual shifts, those are tough. What was that process like for you?
R. Komaki, MD:
When I saw those patients at the VA Hospital, there were many lung cancer patients, [also] cancer of the larynx, head and neck, testicular cancer, prostate cancer. I realized [that] all those patients, whenever they were found to have very early stage, they could have been cured. And you know, I was so interested in epidemiology, what’s the cause of cancer, because my father was a heavy, heavy smoker as a banker. So, I always had the fear that my father might develop lung cancer. Every year for his birthday, my sisters and I, we gave [him a book], “How to Quit Smoking.” But he never quit smoking because his diabetes became worse when he quit smoking. He gained weight that made his diabetes worse. [ ] He finally quit smoking [ ] because of this intermittent claudication. His peripheral blood circulation was so bad he couldn’t walk and finally he quit [smoking]. He was found to have bladder cancer and that was related to smoking and exposure to radiation [from the atomic bomb in Hiroshima]. I always thought that the effect of the radiation [was different for human beings. For example,] Sadako was an infant [when she was exposed], causing leukemia. My grandmother had total body radiation but never had any leukemia or cancer. My father smoked [as well as being exposed to radiation] and he developed this bladder cancer. But there were many, many, many smokers in Japan that never had any lung cancer, never had any bladder cancer. Why is it? I was always curious, the difference. Even we are surrounded by all those carcinogens. Some people, they develop cancer, some people they never develop cancer, why is it? I was always curious: the difference of the sensitivity [and occurrence of malignancies among people exposed to the atomic bomb] depending on their genetic background, or age when they were exposed to carcinogens. I was always very, very curious about the cause of cancer. Then I realized, early stage: if you can pick up cancer at an early stage, we can cure [most cancers]. That’s really what I learned while I was at the VA Hospital. I had seen enough [patients with] early cancer of the larynx and prostate cancer and also, some early cancer of the lung [who had been cured by radiation therapy or surgery]. The most important thing is early detection. That is what I started to think about. Also, if we can pick up early cancer, we can cure those patients. Very elderly patients, that cannot go through the surgery, maybe we can cure by radiation treatment. I have seen some of the veterans who developed cancer of the—breast cancer, some of the women, they were VA patients, had cancer of the cervix, and they were cured by radiation treatment. Many cancers of the cervix, some of the women who served were VA patients. So I started to really think about there is a way we can cure [cancer patients with radiation treatment]. Some of the patients that I saw at Saint Mary’s, they were cured by radiation treatment [under the direction of] Dr. Gueninger. Also [ ] certain types of cancer that doesn’t metastasize so quickly, we can cure those patients by radiation treatment [ ]. When I was working as an intern at Saint Mary’s, we [performed several cases of] intracavity application for cancer of the cervix: Dr. Gueninger showed me. When I was of course a medical student, we did have those cases, but mainly, I started to really think about [being a radiation oncologist due to] my background [and observation of] curative cases. [I thought we could cure most cancer based on] early detection, early stage of cancer, and with really targeted radiation treatment.
T.A. Rosolowski, PhD:
Mm-hmm.
R. Komaki, MD:
And then I started to think about our life expectancy, since it’s getting longer and longer. Eventually, some of the patients, like 85, 90 years old, they cannot go through the surgery because of their cardiac problems and poor pulmonary function. They cannot go through surgery, but those patients, eventually, we can cure if we can pick up cancer early enough.
Recommended Citation
Komaki, Ritsuko MD and Rosolowski, Tacey A. PhD, "Chapter 05: Medical Education in Japan and Internship and Residency in the United States" (2018). Interview Chapters. 1286.
https://openworks.mdanderson.org/mchv_interviewchapters/1286
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