Wednesday, December 28, 2011

Random Thoughts: Encounter With the Japanese Medical System (Part 1)

I'm going to take a very temporary break from my usual posting style on this blog to do a three-part long-form piece to detail my recent experiences with the Japanese medical system. At the end of the third part, I will further deviate from form and allow comments. I have only one request of people who read this post and choose to comment and that is to take it at face value for what it is; it is a record of a personal experience with a certain type of surgery (partial thyroid removal) at a particular hospital in Japan. Nothing more. Nothing less. 

Talking about this experience is in no way meant to imply all experiences with this surgery in Japan (or any treatment in this country) would be the same. Noting things of interest to me is also not meant to imply that things would be different in other countries. I have very limited experience with medical treatment of any kind and remark upon things I want to recall from my subjective viewpoint. This is essentially an exhaustive notebook of my experience for any people who would like to know what I went through, but it is mainly for my own records. It may be of value if you're having surgery in Japan, or having thyroid surgery, or of no use whatsoever. Take it for what it's worth rather than extrapolate further meaning or see my speaking of it as my attempt to speak for all medical experience in Japan before commenting. To be clear, because willful misunderstanding is a favored practice among many folks on the internet, I am not saying this is what all medical experiences in Japan will be or are like. This is specific, not representative.

I will return to usual form with short, notational pieces at the beginning of next year (from January 2, 2012). 

The hospital. Looks nice, doesn't it?

I've lived in Japan for 23 years, but I've tried my best to avoid the medical establishment as much as possible. In particular, I've tried to avoid any sort of non-essential treatment such as the free annual health check-ups that all people who are registered with the Japanese national health care system can take. This was, perhaps, rather foolish on my part as I strongly believe these routine exams in which many people receive chest X-rays, blood and urine tests, EKGs, and dreaded testing for stomach cancer (a bigger issue in Japan than many other countries so it is routinely screened for) are responsible in no small part for the long-lived nature of the Japanese people. Catching small issues early and often decreases health care costs on the whole and allows for early intervention. In fact, given what I have witnessed about lifestyles in Japan (little to no formal exercise, less than the imagined stellar dietary habits), I wonder if it is greatly responsible for longer lives here.

This past year, for the first time, I decided to subject myself to the routine health check. I am quite phobic about medical situations, as many people are, but at 47, I decided I should just be a grown-up and do it. This wasn't by any means my first experience with Japanese doctors, but it was the first voluntary one. In the past, I've had treatment for persistent headaches that lasted for 6 months, intense and persistent back pain, tetanus shots, and, biggest of all, gall bladder surgery. I only went to the hospital when something was wrong enough to warrant attention. To me, this was the natural situation as it is the mindset I grew up with back home. I still fully believe that people in Japan are too quick to run to the doctor for trivial issues and don't trust their bodies to recover from minor ailments, but I equally strongly believe that routine check-ups are very important. The fact that I didn't do them when I could reflected on my fears, not on their value.

My routine examinations included the aforementioned free tests with an added round of tests for problems specific to women (pap test, mammogram) for the added trivial cost of 1000 yen (about $13) per test. Women in Japan can take these types of routine tests for that low price once every two years, but only if they fill out a special postcard and request them (at least the first time, after that, the local government may send out reminders). Despite my neglect of such tests for so many years, all of my results came back in the pink. You are told of annual check test results by mail in a lengthy report (in Japanese) and then can discuss them or have them explained in a follow-up consultation with a doctor (which is not free, but cheap because of the insurance coverage). It was at this meeting that my road to surgery began.

Though my test results proclaimed me free of any diseases that those tests and a cursory exam could reveal, the doctor looked at me and asked, “have you ever had your thyroid checked”. He then felt my neck a bit, asked me to swallow and asked to look at my legs. This was followed by queries about sore throats, difficulty swallowing or breathing, and heart palpitations and though I replied in the negative to all of these questions, he said that I should have my thyroid checked. At this point in time, I was actively annoyed at the suggestion that something was wrong when I was asymptomatic. I could have ignored what he said, but he planted a seed of worry so I made an appointment for an ultrasound test.

Part of the annoyance of socialized medicine is that the way in which treatment is offered is idiosyncratic and bureaucratic. Expediency is often not a part of the program and it can be frustrating. While the doctor suggested I had a thyroid issue at the follow-up consult and recommended a test, he was not allowed to actually schedule the test during that visit because the government rules say doctors can only do certain things during the free annual health checks. So, I had to make a second appointment in which the only thing the doctor did was schedule another appointment for me with a technician. I kid you not. I walked in and he asked what he could do for me to which I replied that he said I needed an ultrasound for my thyroid so I came back. He typed into his computer to schedule it and then we were done. A trip to the hospital and a waste of his time and mine because of the way red tape is written. It wasn't his fault and I did not blame him at all, but it was annoying.

At the next appointment, as I lay on a table having my jelly-slathered throat tested by the technician, I still didn't believe they'd find anything. When I looked at my neck, I saw the same neck I'd seen all of my adult life and no enlargement or weirdness of any kind. I kept asking other people if they saw anything and no one did. I thought they were being extra cautious or covering their asses, but I was wrong. An hour after the test, the doctor reviewed the results with me and said I not only had an enlargement but a lesion (tumor). It was both too big and possibly cancerous. He said I was “lucky” because a surgeon was available to test it a few days hence. At this point, I was filled with fear at the prospect of cancer and this doctor, who spoke English well but had what I have experienced as the very typical stoic and impassive manner of a Japanese physician, was not the least bit helpful in allaying my fears or contextualizing my situation by answering my questions. He essentially shrugged his shoulders and said that women got enlarged thyroid glands for a lot of reasons and they wouldn't know anything until the test results were done. He also instructed a nurse to give me a pamphlet on cancer detection before I left. That didn't exactly fill me with confidence that my situation was trivial. It made me think he knew more than he was telling.

Two days later, I was in the office of another doctor who was also Japanese, but had been educated in the United States (Loma Linda, California). His English was smoother, his manner more approachable and his answers to questions much, much more helpful. He performed an aspiration in which a long, thin needle was inserted into my neck and cell samples were removed for testing. And, no, it didn't hurt that much, but I'm fairly tolerant of needles relative to some people. In fact, I try very hard not to flinch, complain or react to pain during medical procedures or tests because I know it can't be helped and the people doing them do their best not to hurt me. As I've had the opportunity to remark all too often as of late, “I try not to be a big baby.” He also had me take more blood tests to see if my thyroid function was being affected by the tumor. That is, they wanted to know if I was hypo-(under) or hyper-(over) thyroid.

The manner in which this particular doctor answered my husband's and my questions showed that he understood how to handle foreigners, who tend to be much more aggressive about seeking information than Japanese patients, and he gave us all the time we needed. In my experience, this is rare for Japanese doctors who tend to shuffle people out as rapidly as possible. It's also one of the reasons that I tried to be very calm when he was late for my appointments with him. I figured that he may be giving another patient time they need as he gave me the time I needed.

Unfortunately, the fast food shuffling of one patient in and the next out is consequence of the managed care in Japan. Price controls are in effect for medical treatment so the only way doctors can increase their income is by seeing as many people as many times as possible. The situation is such that some doctors have to see patients every 10 minutes to maintain a profitable practice. I've been told that it's very hard for doctors running private clinics to make a decent profit because of price controls. In fact, for some treatment, doctors certainly lose money. I guess my doctor, who is a surgeon, may not have quite the same pay scale or concerns and for that I was grateful.

What followed my aspiration test was the most agonizing 15 days of my life while we waited for test results to see if I had cancer. I believe, based on queries with students and other people in Japan, that this was atypically long and the wait was linked to my particular hospital, not Japanese medical treatment in general. While the wait for tests is still generally longer (about a week is what I have been told) in Japan, two weeks is beyond what most people are going to experience. Coincidentally, one of my students had a cancer scare two weeks before my testing. He coughed up blood and cancelled his lessons during the test and the wait for results. He told me he “only” waited 8 days.

During the wait, my husband had researched all sorts of permutations of thyroid problems and the doctor had said there were 4 types of cancer and only one was fatal and it was very rare, but the favorable statistics are of little reassurance under such circumstances. I know this all sounds very dramatic to people who have never faced a situation in which they might receive such news, but it one of the scariest things you will ever experience. Daily life takes on a weird unreality and you feel like you're going through meaningless motions as you wait for something truly important to happen.

In the end, as my readers of my blog already know, the results of the aspiration proclaimed it benign and the blood tests indicated my thyroid function was not being affected, but it still had to come out for two reasons. First of all, it was 4.45 cm. (1.75 in.) and doctors believe anything over 4 cm. should be removed to prevent future problems. Second, though the two successful samples indicated there was no cancer, they can't really know until they take it out and test the entire enlarged area. One of my students is a nurse who discussed this with me and she said several of her friends had had thyroid problems. She said only one of them had any cancer and that was only about 2% of the entire tissue removed. Thyroid cancer is generally slow-growing and remains contained, but that doesn't mean it's a good idea to wait for it to spread or possibly grow. Because of this, I decided to have the surgery as soon as possible and scheduled it for three weeks from receiving the good news about the test results.

The hospital I went to is the TokyoAdventist Hospital. This is a public Japanese hospital, not a private one specializing in treatment of members of the foreign community so anyone who uses the Japanese national health insurance can go there to receive treatment and there will be largely Japanese patients being taken care of. It is also the place in which I had my gall bladder removed 20 years ago. At that time, I had been in Japan for only two years and we chose that place because they had an English-speaking physician or two (or three, or ten). It is also relatively close to where we live so it isn't too much of a trek. When I had my gall bladder surgery, the doctor told me that Japan tended to lag behind America in medical techniques. Laparoscopic surgery was relatively common in U.S. hospitals at that time, but somewhat new to Japan. Fortunately for me, an American surgeon was at that hospital teaching the technique to the Japanese staff and I was one of the first patients at that institution to have it performed upon her. I don't know if what that doctor said about medicine in Japan lagging behind that in America by about 5 years was true, but it has stuck with me and has been one of the reasons I stick with doctors who trained in my home country. There is also the fact that, no matter how super you believe your Japanese is (and mine is not), when it comes to health, I personally want to be dealing in my native tongue with someone who has second language skills sufficient to see them through medical school in a native English-speaking country. It's not something I want there to be any risk of misunderstanding about.

My surgery was scheduled for December 20, but I had to have a repeat of some of my annual health check medical tests before going in because they need to check you within three weeks of the operation. I'm sure this is standard procedure and for my own safety, but the blood samples this time were removed by less skillful technicians who couldn't find a vein and I had several holes and a huge black and blue mark. I must say, to be fair, that this was not about them, but about me. Later, prior to surgery when the I.V. was put in, the nurse also had problems and commented that she felt American nurses would do better with my American arms. I reassured her that nurses who tried to put in a line when I was 12 years old and had my tonsils taken out also had problems, so it wasn't her fault. That didn't make it hurt any less when she poked me deeply three times with a big needle, but I did not blame her or her nationality for the problem.

A view of the ward. My area is in the back left, hidden behind a curtain. During my stay, the two units in front had a revolving door of patients or were vacant. 

Two days before the surgery, I had to come in for a pre-surgery consultation in which they explained a wide variety of things to me and were supposed to talk about the results of the recent battery of tests, but they never mentioned them. Part of this was telling me what I needed to bring, when to show up, and, of course, not to eat within 12 hours of admittance. They also explained what the Japanese health insurance did and did not pay for. Again, the bureaucratic guidelines are rather strange at times and the room cost was not to be covered by insurance. Procedures are covered, but not the room. I should note that medical coverage for everything other than the annual health check-up is not free in Japan. The patient pays 30%, but because prices are controlled, this rarely is an oppressive amount of money. We were given three options for rooms: private, semi-private (2 people) and ward (4 people). When I last had surgery there, I opted for the middle option, semi-private, which cost about 11,000 yen ($139) a day. Private rooms are a whopping 23,000 yen ($290) whereas the ward option was only 3150 yen ($40). I went for the cheapest option and I did not regret it. Based on what I saw of the more expensive accommodations and my experiences, I doubt there was any benefit in having one of them.

One of my students fell down earlier this year and broke his knee-cap and he told me that he stayed in a semi-private room for 49 days as a result. Given the expense, I wondered how he could manage it on a retiree's income. He told me that some people in Japan take on secondary private insurance which covers whatever expenses are not covered by the national health care plan. He said he pays about 15,000 yen a month ($190) for this. Personally, I'm not sure that it is worth it, but I'm not as old as he is and perhaps not capable of grasping the idea that I could be hospitalized for an extremely long time. That being said, I've been told that you can't remain in the same hospital in Japan for more than three months. After that, you have to be discharged and re-admitted at another hospital or placed in a care facility (or returned home). Again, there are some idiosyncratic rules which sometimes do not necessarily make a lot of sense, but I'm guessing that one was created to stop people from trying to pawn their elderly relatives and their care off on the medical system rather than look after them at home or place them in a nursing home if it is at all possible. I'd also wager that Japan hardly has the market cornered on such regulations, but I have no way of speaking to the case in other countries.  

(to be continued in parts 2 and 3)