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| Japanese Journal of Clinical Oncology | Pages |
Letter
Clinical Medicine and Culture: Impressions of the First Australian Exchange Clinician to the NCCH
To the Editor:
I have recently returned to Melbourne, Australia, after spending 4 months in the Gastric Surgery Division of the National Cancer Center Hospital in Tokyo as a visitor of the Foundation for the Promotion of Cancer Research. I write this letter to describe some of my reflections of my time spent there.
Two particular factors affected my experience at NCC. First, I lived in Japan for 12 months as a secondary school exchange student in 1977. I spent this time in the city of Oyabe, in Toyama prefecture, and have visited many times since. I therefore arrived in Tokyo with reasonable Japanese language skills, and an appreciation of the customs and culture of Japan. The second factor is that I had just spent 18 months working as a Fellow in the Department of Surgery at Memorial Sloan-Kettering Cancer Center, New York. There I had been exposed to the best of the ‘American Approach’ to the management of many cancers, including gastric cancer.
I believe that some differences between Melbourne, New York, and Tokyo are related to cultural differences. While stereotypes can be dangerous, and do not apply to all members of any given society, I think it is valuable to consider whether our cultural background affects our approach to our patients.
Australians generally do not like authority. Possibly because Australia was established as a prison colony of England, Australians have a distrust of rules, and do not like being told what to do. As a consequence, most surgeons have their own methods of doing things. It is considered that as long as the result is satisfactory, the precise method is unimportant; it would be unacceptable for surgeons to tell each other how they should be doing things. Thus during my training in general surgery, each of my teachers performed operations in a significantly different manner. This is not seen as a problem. A disadvantage of this is that standardization of techniques in a trial setting is very difficult. The advantage may be that surgeons are better able to adapt to new and unexpected circumstances that may arise during an operation.
Because Australians value independence very much, it has been difficult to standardize treatments. Personal experience, and experience of close colleagues have been more influential than the opinions of ‘experts’ writing in journals. This means that wide acceptance of developments in technique or management philosophy tends to be slow. Many people involved in cancer care have recognized this problem, and so recently there has been the publication of ‘guidelines’ for the standard treatment of conditions such as breast cancer and melanoma. The books are very useful, but we do not yet know if they will lead to improved patient care.
American culture values innovation and individual effort. At the Memorial Hospital in New York, Fellows were expected to think independently, and their opinions were sought and valued. There was great emphasis on the scientific approach to surgical oncology, and on improving present treatment methods. Much of this is due to the nature of the institution, but I believe there is a cultural component as well. Thus in breast cancer sentinel node mapping was being actively investigated, and new treatment methods in various diseases were continually being discussed and trialled. In major abdominal surgery, the role of perioperative nutrition has been established (1), and in gastric cancer, staging laparoscopy to identify patients who would not benefit from open surgery has been introduced (2). Before I arrived in New York, I thought that palliative gastrectomy was usually appropriate to prevent complications of bleeding and obstruction. This teaching seemed reasonable, and so I was surprised to find that analysis of results at Memorial suggested that patients generally did not benefit from such palliative surgery. Such developments were new to me, and I was amazed that current practices were constantly being discussed and challenged with enthusiasm.
In Tokyo, everything that was done was done perfectly. I was very impressed with the meticulous way that the appropriate extent of surgery has been established. Thus bursectomy and splenectomy have been abandoned in early gastric cancer, endoscopic resection has been introduced for small intramucosal cancers, and D4 dissection is under trial for some advanced cancers. I was even more impressed by the fact that all of the surgeons performed the same extent of surgery, and were almost always able to perform the planned operation. Pre- and post-operative care for all patients was carried out in the same manner, and I am sure that this contributes to the excellent results reported from many Japanese centers. Many observers of Japan have remarked on the perfectionism present in many facets of Japanese life - from the beauty of the lacquerware and calligraphy to the presentation of food to the extraordinary punctuality of the trains. Such traditions are not strong in Australia. Related to this, there is not much kengaku (‘watching study’) in Australia. When residents are not involved in an operation, they do not come to the operating theatre, as they do not believe that they would learn much from simply watching. I initially found it difficult to watch a large number of operations before I participated. Since I have come back to Australia, I have realized that I did learn much from this time. Observing many D2 lymphadenectomies performed precisely has provided me with a model to compare my work with.
The potential downside of this attention to detail is that it may become difficult to ask and address the question ‘are we doing the right thing?’. For example, the role of splenectomy as part of the surgery for advanced cancer is widely debated in the West. Much of the impetus for this debate derives from the association with higher morbidity and mortality in the Dutch and MRC trials. There remains the question of whether the spleen may play some immunological role. If it does, then removing the spleen in a patient with negative group 10 and 11 nodes may adversely effect the outcome. The Japanese approach of perfecting the technique to ensure that splenectomy is not associated with operative mortality does not lend itself to addressing such bigger questions.
My conclusion from my experiences is that our different cultural backgrounds may give us different strengths and weaknesses. When looking at each other’s approach, we should keep this in mind, and attempt to learn from each other, rather than attempt to justify or explain the differences. I had a wonderful experience in Tokyo, and am grateful to all the people at NCCH who helped make it so enjoyable. I would also like to thank the Foundation for the Promotion of Cancer Research for generously sponsoring my stay.
References
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G. Bruce Mann Senior Lecturer and Consultant Surgeon Royal Melbourne Hospital University of Melbourne Victoria, Australia |
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