Wednesday, April 10, 2013
Random Thoughts: Imperfect Among Equals
I audited (took, but didn't get credit for) a class on psychopharmacology at my husband's graduate school during the previous quarter. This is one of those things which I can do here that I couldn't imagine being able to do in Japan. I somehow doubt that spouses can take part in their partner's classes, let alone do so for free.
This experience was an interesting way of being immersed in a specific social setting and it gave me further experience with something I mentioned when I reviewed Baye McNeil's book. That is, I was faced with a bunch of people who had a lot of baseless preconceptions about Japan. Those experiences inspired "The Lost Horizon" post, though I didn't detail the contents of them there. I mainly focused on the thinking that formed the basis for what I was exposed to. For this post, I want to mention more specific assertions and what they said about the people who said them.
Part of the class I took part in included discussion of medical treatment, which is no surprise since the class was about medication for mental health disorders. During a "triad" (3-person) discussion involving my husband, me, and another man in the class who was around his mid-30's in age and had actually taken a short vacation in Japan, he mentioned not trusting doctors in America to properly medicate people.
When he said this, I replied that how drugs are prescribed is a problem in many countries, not just the U.S. I said that, and this is something that is discussed on blogs about Japan all over the place, that doctors in Japan are notorious for prescribing three different medications in three different forms nearly regardless of the problem at hand. The fact that it is relatively uniform that you get 3 drugs, usually a tablet/capsule, liquid, and a powder, can't be a coincidence and indicates a high likelihood of drugs being given according to a formula rather than according to need.
When I mentioned that drugs are over-prescribed or inappropriately offered in many countries, not just the U.S., he said that he still would "trust" a Japanese doctor more than an American one. He went on to say that he was sure that Japanese doctors would listen more carefully to problems and attend more to what was said. He said he was sure they "cared" more than American doctors about dealing with the patients' needs.
To this, I had to hold back on scoffing. Mind you, I'm not saying Japanese doctors are bad nor that American doctors are worse. The Japanese doctors are just as variable as those in other countries. There are great ones, decent ones, and terrible ones. However, all medical practice is influenced by the systems within which they operate and this fellow had no clue about how the system in Japan made what he said about time and care as a blanket statement absurd. If anything, the system, both cultural and politically-imposed, in Japan promotes less time with patients less attention, and an overall more cursory standard of care.
One aspect of socialized medicine which is a dual-edged sword is price control. The government sets the rate that a medical practitioner or entity can charge for each particular service when they accept the national health insurance. Only private practitioners can charge more, and most people don't have the cash to go to them. That means that the doctor can only make so much money per consultation. The only way for him to increase his salary is to see more people. This is an incentive to keep the amount of time spent with the patient to a minimum. In fact, some doctors schedule patients as little as 10 minutes apart, often as little as 15. This means they start running increasingly late, of course, but they'd rather bet on no-shows or cancellations than reduce the profitability of the day.
The notion that a doctor in Japan would spend more time with a patient is laughable. I found that they only way you got "more" time was to repeatedly return for future short visits. The doctors barely listened on the first visit because they wanted to solve the problem as simply and rapidly as possible. I read a blog once where a foreign woman went in due to a particular kind of pain (sore throat, perhaps) and lingering fatigue. The doctor gave her a gargling liquid, a powder to drink, and a pill to take and when she said that she was worried about the persistent tiredness, his response was, "we're all tired." He simply wanted to hustle her out of the office and get to the next patient.
My mentioning the general way in which doctors tend to handle things is not meant to say you won't get decent care. The truth is that many Japanese people run to a doctor at the drop of a hat and this quick diagnosis and treatment probably works most of the time. If you have a persistent problem, you can go back again and again and you will eventually be referred to a specialist or sent for testing if you don't get better from the first consult. It's imperfect with good and bad points, but it is one in which time and careful listening are not supported by the system as a whole.
The truth is that many doctors in Japan in private practice with their own little clinics struggle to be sufficiently profitable to make their career choice worthwhile. I don't believe they live in poverty, but they aren't making nearly as much as doctors in the U.S. can due to the price controls put in place by the government. General practitioners in particular have a lot of trouble covering costs and making a decent salary relative to their investment in education and time. They work very hard, and aren't exactly making money hand over fist.
Half of my former classmate's uninformed opinion about Japanese doctors was that they'd spend more time with patients. The other half was that they'd care more and listen more carefully. This imagined situation is less likely because of the manner in which status is handled in Japan. Those who are regarded as being in higher status like teachers, doctors, bosses, etc. expect to speak and be listened to. Patients give the symptoms and doctors then do the explaining and treating. The patients' role is generally to passively accept whatever is given by the doctor, not to ask a lot of questions. The patient is seen as possessing inferior knowledge and is generally not seen as being in a position to make informed conclusions or ask intelligent questions about the condition.
One of the side effects of this situation is that patients in Japan are far less proactive in their treatment. They tend to question the effectiveness less and have more implicit trust that the doctor is doing the best thing to treat them. Needless to say, this creates a culture in which malpractice is under-recognized and rarely dealt with in the legal system unless it is very clear cut and fairly egregious. Compared to the American system in which people seem to be far too eager to blame the doctor for death or medical difficulties that only an omniscient entity could have predicted with great accuracy, this may sound like a vast improvement. Unfortunately though, it's actually just the flip-side of a really unhappy coin. It's too far in the other direction and does not serve people well.
The interesting thing about this particular classmate was that he was a staunch supporter of the idea that people must advocate for themselves in their health treatment, both medical and physical. He asserted quite stridently that they should do research online and ask informed questions. In my experience, most Japanese people feel that the doctor is the one who knows best because he's the one who went to medical school and it is his duty and responsibility to treat you competently. It is not their job to manage their own care.
I wasn't stunned necessarily that an American who only had experience as a tourist in Japan would not know the deeper details of how a particular aspect of society works. What I am surprised by, however, is that someone would say that they'd "trust" a medical practitioner from another culture more based on not having had any experience with medicine in that culture and with not having researched the situation. What is informing that conclusion? Is it because they export good cars? Is it because they're Buddhist? Is it because we have an image of them as hard-working?
I can't know what it is that makes people think what they do about Japan, but I can say that I continue to experience the default assumption that whatever systems exist in America are worse than those in Japan. What is more, I frequently encounter the idea that they are ideal or far superior to others. While I do believe this is related to the type of thinking I discussed in my Lost Horizon post, that is, a need to believe that there is an ideal society of people who know and embrace their roles in peace, harmony, and contentment, I think there is something else in play. Just as there are jingoistic people in America who have a need to elevate the U.S. above other cultures despite the obvious problems we have, there are people who need to denigrate American culture to suit their pessimistic outlook. In order to validate that pessimism, they need to concurrently elevate another system so that they can believe that another culture has a more perfect system.
To see all cultures as equally possessing merits and demerits and simply choosing one set of good points over another and suffering the resulting bad points would mean that they would have to see America as imperfect among equals. If your perspective requires that you paint the U.S. as the mustache-twirling bad guy, then this sort of balanced view of societies in general upsets the apple cart on your worldview.
Since it's ascendance in the 80's, Japan has served as a comfortable blank canvas upon which people can project their notions of a superior society in accord with their need to believe such exists. This was part of my motivation in writing this blog. It doesn't have to do with bursting the bubbles of those who idealize it, though a lot of the vitriol I have gotten about my posts proves that it certainly has that effect. It has to do with humanizing the Japanese people and making people understand that there is bad and good everywhere in the world and it serves us all poorly to vilify any culture.