Impressions of being a doctor in Japan, the Japanese medical care system

https://picasaweb.google.com/jones.jefferson/NonTaiseiJune2010March2011#

The last 7 pictures are of Keio University hospital.

These are the responses to a form I had to submit to my school after finishing my time in Japan as a medical student. It is a little detailed but for those interested, feel free to peruse.

I had a very thoughtful and detailed schedule set up for me before I arrived to the hospital. I rotated in the pediatric department. I worked Mon-Fri, 9-5pm on average. It was divided into 10 half day blocks. Keio has 3 pediatrics wards: the NICU/step down unit, hem-onc and cardiology, and general pediatric floor. I would generally show up for morning rounds and then would have a discussion or see patients for the rest of the half-day block. Many days had special conferences or meetings that I would attend. The schedule was very flexible so that I could change it as I wanted. I requested more outpatient time and was given several days to see various outpatient pediatric clinics. I requested to see the ED and was able to spend a day in the ED. On my application, I made it known that I was interested in infectious disease and public health. I was included in the weekly infection control rounds and weekly HIV rounds. I sometimes attended the infectious disease outpatient clinic, also. Every day was different so it is hard to describe the “typical day.” Regular rounds I attended were morning NICU rounds 1x/week, daily review rounds in the pediatrics general ward, and the most educational rounds were probably the teaching rounds that happen twice a week. Once a week the chief and associate chief of pediatrics each take a half a day and have most of the pediatrics patients presented by a student or resident to them and the rest of the rotating medical students. The professor then critiques the presenting and asks questions about the patients while making educational points. Other attendings and specialists are present to answer questions as needed. When a very interesting teaching point or something that no one knows the answer to comes up, the topic is assigned to a resident to present to the department later. I feel that these rounds were very educational and could be quite useful in America. Once a week (on Tue evenings) there is pediatrics teaching conference, probably the equivalent of grand rounds. Here all the assigned topics during teaching rounds are presented along with grand round speakers and other topics that come up.

Most visiting students are given living quarters a short walk from the campus. Since I brought a wife and child with me, we had to find our own living quarters. It was about a 30 minute walk from campus. The dress code is the same as most hospitals in America. White coat, dress shirt, and tie.

I was assigned a specific mentor during my time there. He was a pediatrics infectious disease specialist. He provided me with his home and cell number and went 110% to make sure I was comfortable 24 hours/day. He invited me to conferences that were in neighboring prefectures that he thought I might be interested in and paid for my train fare if we travelled together. He answered all my medical and Japanese medical policy questions, or referred me to someone else who could answer them. He created my whole schedule and adjusted it. Since I trained at the CDC, he even pulled some strings so that I could talk to people at the CDC equivalent at Japan.

At other times, there was usually someone there to help answer questions when I didn’t understand the language or just had something I wanted to know in each ward I rotated at.

Since I had studied Japanese for 10 years and lived there previously, my language made it possible for me to participate in rounds. I am not sure what adjustments are made for those with limited Japanese language skills. All physicians have English skills and there are a good proportion that have trained in America.

I did not get to see patients independently. You only can observe patient-physician interactions as far as I know.

My wife and I would love to live in Japan at some point. I wanted to find out what kind of opportunities there would be to work in Japan if I wanted to work there. I found out that I would have to pass the Japanese national board examination for medicine but if I did, I could probably find a job there.

There are some aspects of working in Japan that make it less appealing. Japanese doctors work very long hours. During residency, they have no days that they don’t have to come to the hospital unless there are special circumstances. The pay is significantly less than salaries in America, often less than half.

I am very interested and may be involved in public policy at one point so the following are things I learned about the Japanese health care system that may affect how I approach health care policy or possible practice in the future.

Japan’s healthcare program has become the standard for multi-payer national health insurance systems due to its consistently low costs, easy access to healthcare, and comprehensive benefits package. Ranked 10th for overall health system performance, 1st in level of health attainment, and 6th in level of responsiveness by the World Health Organization in 2000, Japan possesses among the longest life expectancies at birth at 82 years (2003) and highest per capita number of physician visits (WHO 2005). Moreover, Japan only devotes 7.9% of its Gross Domestic Product to health expenditures while simultaneously maintaining one of the highest computed tomography (CT) and magnetic resonance imaging (MRI) technology distribution rates per capita (WHO 2005; Yoshikawa and Bhattacharya 2002).

So how does a country with an aging population provide such great care and spend so little? I am not 100% certain of the answer, but I asked everyone I talked to. The government sets the rates of payment. Hospitals or insurance companies cannot change how much is charged for 1 hospital day or a medicine. These costs are extremely low compared to America. Going to the ER will usually cost a Japanese person $100-300. Some possible answers I heard were that Japanese people go to the doctor a lot. They are not afraid to go because they think they might be sick. Perhaps they get treated before diseases turn serious. Some physicians thought it was because Japanese doctors work for little money and long hours. Some think it is because hospitals are usually 8+ patient beds/room, they often have older technology and avoid high spending. There are no IV access teams or several different nurse practitioner specialists added to the work force. Another reason might be that there is universal health care. Medical care and insurance is provided to all Japanese citizens, regardless of income. A big factor is probably that Japanese culture is healthier in general. There is less obesity, the diet contains more fish and vegetables, and people walk (to the train station) and ride their bikes rather than use cars.

There are many things I experienced that made me wonder how they managed to spend so little. They keep patients in the hospital for very long periods of time, especially for end-of-life care. I’m not sure of the laws of DNR orders and such, but it seems very hard to impossible for doctors to pull the plug on patients. I was told that even if there is a DNR order, they could still be sued. So there are patients in the hospital for 16+ years, some in comas the whole time. Even for less severe disease, people stay in the hospital longer. Women regularly stay in the hospital for over 1 week after giving birth. 1 week is common for influenza or any common pediatrics infection. CT scans and MRI scans seem pretty common and easy to order.

They also order lots of medicine for everything. Anyone who has a cough gets special cough medicine that decreases the amount of fluid secreted by the airway. Every patient with influenza gets anti-viral medication. I was told that patients strongly desire medicine so they have to give something to them.

Strengths:

-Adjust schedule to student’s preference

-Excellent attending supervision

-Lots of educational rounds, meetings

-Heavy student involvement in rounds and discussions

-Good food in area

Weaknesses:

-Might be hard with limited Japanese skills

-Little patient interaction (if you stress you want more, you can get more though)

-Expensive cost of living