Dr. Robert Yanagisawa is Associate Professor of Medicine, Endocrinology, Diabetes and Bone Disease at the Mount Sinai School of Medicine, and is director of the endocrinology fellowship program. Dr. Yanagisawa is a board member of the Japanese Medical Society of America, and VP for membership development. He has medical licenses in both the US and Japan, and recently established a Mt. Sinai-Tokyo Women’s Medical University (TWMU) exchange program, and has been appointed Visiting Professor by TWMU.

Undergrad:     Brown University
Med School:    Alpert Medical School of Brown University
Residency:      Miriam Hospital, Brown University
Fellowship:      University of Massachusetts Medical Center

Thank you for meeting with me today Dr. Yanagisawa. First, could you tell us how you grew up in both Japan and the US?

I was born in the US, but was raised in Japan from 2 to 12. Then I came back, went to the New York Japanese School for 7th and 8th grade, and did all of my schooling here thereafter. I went back to Japan for 6 months after my 1st year of residency in internal medicine, to take the Japanese medical board examination. I wanted to figure out if I wanted to, and could, practice in Japan.

What is the process of taking the Japanese board exam?

It’s very unusual for American grads to take the Japanese board. The opposite is more common, if anything. My residency program director, Dr. Fred Schiffman and Chairman, Dr. Charles Carpenter were so incredibly understanding to allow me to build my career in this direction.

First, you have to get an application from the Koseisho [Ministry of Health and Welfare]. You need documentation that you’ve graduated an accredited medical school, and they ask for official documentation of a lot of details, like the size of the school, how many cadavers were available in anatomy class, etc. Then you need to translate all the documents into Japanese, and have it certified that it’s an accurate translation.

The next step is to take the Japanese Language Proficiency Exam Level 1, which is administered by the Ministry of Education. (www.jlpt.jp/e/index.html)

Like a Japanese eiken [an English proficiency exam in Japan]?

Yes, a J-ken! You have to be able to read and understand Japanese.

Fluently?

I wouldn’t say fluently. It’s a multiple choice test, made up of 3 sections on vocabulary, listening, and reading/grammar. If you can read the Japanese newspaper, say about 70%, then you should be okay. Then there’s an interview / oral exam to qualify to sit for the Japanese medical board.

An interview before the actual board exam?

Yes. They only interview foreign graduates. They examine you in 4 disciplines: Medicine, surgery, pediatrics, and Ob/Gyn. There’s an interviewer for each discipline. It’s a very subjective screening process that does not seem standardized. They can ask impossible questions, or they can ask easy questions.

How did the interview go for you?

Each examiner was very different. For me, the pediatrician asked the toughest questions. You need to be humble, acknowledge that they knew more, and that you need to study more! On the other hand, the surgeon just wanted to know why I was interested in taking the board exam. Overall, I think they want to make sure you can actually practice medicine in Japan.

During the interview, they also asked me to write a sample patient referral letter.

There are a lot of steps before you can take the actual exam!

Yes, a lot of steps. So now, they finally approve that you can sit for the board exam, and you take it with all the other Japanese medical students.

And this is one exam, instead of the 3 steps that we have in the U.S.?

Yes, just one exam. It covers all disciplines, and it’s multiple choice.

Did you attend prep schools to prepare for the exam?

Yes. I originally wanted to take university courses at Keio, where Brown had an exchange program. But they told me they didn’t have review courses specifically for the board. They recommended attending prep schools instead - sort of like Kaplan classes.

Do most Japanese medical students attend prep schools like they do for college entrance exams?

They do offer courses to currently matriculated students, but there are also many students who previously failed the exam. This is really interesting: the board passing rate is very important for medical schools. So if they know certain students are struggling based on in-service exams, schools often give them the option of A) Not being able to graduate and having to repeat a year, or B) Being able to graduate, but not being allowed to sit for the board for one year. Once it’s over a year after graduation, their performance does not get reflected on the school’s statistics!

That’s sneaky! So compared to Steps 1 to 3 in the US, was it harder or easier, and how different were the contents?

After having taken the USMLEs, the studying itself was not that hard. The concepts were also similar in general. The big task for me was to learn the Japanese medical terminology. I remember the first day I attended the prep course. The professor wrote “gastric ulcer” on the board in Japanese, but I couldn’t recognize the characters! So I was often looking up my dictionary for simple things like “ulcer” (laugh!) All those characters with tsuki-hen.

Oh yes, all the body parts have tsuki-hen in their kanji.

The prep classes were really interesting for me because it was the first time for me to interact with Japanese college students. Everyone was really friendly and we had a good time. The main instructor, Dr. Higashida was interesting also. He had taken all three USMLEs, and was getting ready to come to the US before he started his faculty position. He felt it’s important for Japanese medical students to be able to understand English medical terminology, so he would start mixing English into his classes. A lot of students were not happy because there’s no English on the Japanese board exam, but it helped me a lot because I didn’t have to look up my dictionary as much (laugh)!

Would you like to practice in Japan at some point of your career?

Unlike the period when I was in Japan to take the board exam, the Kouseisho is now pushing for medical education reform. That’s something I’m interested in, so if an opportunity arises, I would be happy to consider it. This is one of the reasons why I became interested in exchange programs.

You recently launched an exchange program with Tokyo-Women’s Medical University. How did it all start?

When I felt I was finally ready to start inviting students from Japan and start contributing to Japanese medical education, I found that Tokyo-Women's had an exchange program with Dr. Homma at Columbia University. He kindly introduced me to the students and faculty, who were interested in expanding their US program.

Who needs to get involved on the administrative end?

I took the initiative to go present our institution to their head of international studies division, their Dean, and there was a whole committee of professors who approved the exchange locations and the curriculum (Photograph above, Dr. Yanagisawa's presentation; photograph below, with TWMU faculty and students). MSSM hosted TWMU's President this summer to formalize our exchange program.

How long did the process take from the conception until the students actually came?

One year of planning, TWMU committee then approved the program, selected their students, and the students came a year after that. Hiroko and Rie that you met were the first students on this program (Photograph below, Hiroko (right) and Rie (left)). Just prior to their 2nd year of student selection, I went and did a student work-shop on how to make rounds with help of Hiroko and Rie.

I think many of our readers including myself, are also interested in facilitating exchange programs with Japan as part of our careers. If there is one advice you would give us, what would it be?

One is to find a key faculty and the school that's interested, because the process requires a lot of motivation from both sides. Most universities like to set up exchange programs, because it’s a big attraction for applicants. Some schools just tell students to go on their own, while some are very involved, like Tokyo-Women’s, and they try to make sure that their students have quality educational experiences and guidance on both ends.  The other point is to have patience and perseverance when it comes to bridging two large institutions with different cultures.

In addition to working with Japanese universities, you’re vested in medical education as a whole. Where does that passion stem from?

Medical school is challenging, and residency is tough. If I didn’t have my supportive mentors, I would have dropped out many times (laugh)! A good mentor will motivate you when you are having tough times, so that you get back on your feet and try harder next time.

I was really blessed with great mentors at Brown’s combined undergraduate and medical school program called Program in Liberal Medical Education.  During my 8 years in PLME, Dr. Julie Ip, the Associate Dean of Medicine, not only looked over my entire curriculum, but she encouraged and became my senior thesis co-advisor on Sugita Genpaku, an 18th century Japanese physician who introduced autopsy based western medicine to Japan. With such an impact on my career, I promised myself that I would also make education a big part of my career. That’s one of the main reasons why I wanted to stay in academics.
How long have you been director of the fellowship?

Since 2004. I love seeing patients, but I feel most privileged to be able to help groom the future endocrinologists. I am very grateful for the honor and the opportunity and I want everyone in our program to have the best fellowship training possible.

Let’s change gears now and talk about your specialty. What drew you to endocrinology?

I had a number of great mentors during residency who encouraged me to pursue the specialty. During residency, I wasn’t sure if I wanted to specialize or not, but during an Endocrine rotation, Dr. Charles (Bud) Kahn said, “Robert, you’re going to do Endocrinology because you’re really good at it, you have what it takes to put your patients at ease.” He and his colleagues even helped me find a fellowship program most suitable for me.

What do you enjoy most about endocrinology?

Endocrine is fun because you establish long-term relationships with patients. For thyroid and diabetes it’s a lot of chronic disease management, so you end up working with the patients for a long time. In NYC, that last only as long as they like you (laugh)!

I feel that most people in academics have their niche or their ‘thing.’ So in addition to education, what’s your special interest?

My two areas of interest are the thyroid, especially thyroid cancer, and obesity. Both of these areas require truly a multidisciplinary approach and I enjoy working as a team. For thyroid cancer, I started a multidisciplinary conference to bring together the key people from Endocrine, ENT, Surgery, Pathology, Nuclear Medicine, and Radiation Oncology. We can do amazing things for our patients when we put our heads together and it's a great learning experience for our fellows.

Let’s talk about JMSA. Can you tell me what the benefits are of joining JMSA as a student, and as a resident?

One is networking. You’ll meet a variety of people in academics and private practice. It’s not a medical specialty organization where everyone is from the same field. Our members are from all the different specialties, and what brings us together is our Japanese heritage and/or interests in Japan. We’re also a good resource for career ideas. Many of us have practiced in both countries, or have worked with residents and fellows who have training in the US and Japan, so that’s also another unique experience that you might not see in your medical school.

As for residents, currently, the majority of resident members are those who are Japan-trained physicians. So they know the most about both education systems. For American grads, like me and yourself, it’s definitely a unique and fun experience to interact with these residents. For the Japanese residents and fellows here, it’s nice to expand their networks and experiences beyond their own medical centers.

We also organize many community projects, and it’s always fun to have more people involved. We do a lot of lectures and health screenings. In the end, it’s not just what you get from joining JMSA, but what you make of it as a member and a colleague.

We talked about US-Japan educational exchange. Can you tell me what JMSA’s role is, currently, and what it could be in the future in this arena?

JMSA’s current role is limited to individual programs, like Dr. Homma’s and mine. That’s something we can work on, to reach out to Japan and American schools to establish more programs. At the same time, I think JMSA can serve as an information hub for both ends. It’ll be good to compile a list of programs and opportunities.

We could have that information on the website also.

Students on exchange programs have a great advantage because the paper work is all pre-set and tuition and board are covered. Otherwise, it's costly to go on these programs, so hopefully JMSA can help expand some of these activities in the future.

We also started a mentoring program recently. Before, we were simply giving out scholarships to great students, but not much more was done besides the application process and the awards ceremony. The mentoring program teams up scholarship recipients with JMSA faculty, and it’s our effort to bring together and continue our relationship with students, residents, and fellows. Hopefully they become active JMSA members in the future, and become good mentors themselves. Several members on our board are actually former scholarship recipients also.

Dr. Yanagisawa, thank you for all the wonderful advice, stories, and inspiration. We’re very lucky to have great teachers like you.

Interview in person on September 18, 2009, by Yoshihiro Yonekawa (Weill Cornell Medical College, MSIV). Profile photograph courtesy of Nobutoshi Mizushima.