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.


  1. This goes back to the curious form of Orientalism that I have witnessed since returning to America after a few years in Asia. It seems there is often a visceral response to various groups of Asians that has more to do with the western fantasy of Asia than on Asia per se.

    China - Big, monstrous economic threat full of hard-working and intelligent savers.

    South Korea - Fast-growing third-world country producing a lot of technological innovations, but a place of low quality and standards with a creepy or unattractive culture. (This is changing--I expect South Korea-focused otakus to become more common in the next 10-20 years just as Japan otakus grew in the 2000s)

    Japan - Advanced economy and society where everyone and everything is better, with a glorious, dignified history and elegant culture. A place to learn from and be humbled by.

    Of course, all of these countries are much more complicated, but Americans see the world from the American perspective. Unsurprising, sure, but very frustrating for us expats and ex-expats who know better.

    1. The image of China certainly has changed. It seems they've gotten the reputation Japan had during their ascendance (when we were getting Saturday Night Live sketches in which a round table of Japanese were pronouncing all Americans lazy and stupid). I think China will remain a threat longer than Japan, not only because they are likely on a longer slower curve to economic ascendance, but because they will likely overtake America as having the #1 economy in the world (which I actually think would be a good thing).

      And absolutely they are more complicated. Even writing over 1000 posts, I feel I've only scratched the surface and I'm absolutely not fully versed. There are deep pockets of Japanese culture that I personally never explored and know nothing about since my experience was in one area. While I had the luxury and pleasure of conversing with those who worked high and low in government, business, art, fashion, education, etc., I never had experience with truly poor people or those who never migrated from rural areas to the city.

      Thanks for your comment.

  2. I went to a Japanese doctor recently, and I had very good service from a bi-lingual doctor in Shinjuku who was recommended.

    I went to see him at his clinic, explained my symptoms and my thoughts and how I felt it was best to ask a professional as I am not a doctor.

    He ummed and ahhed and did an examination and agreed. This was followed by a prescription for an appropriate course of medicine.

    I would do the same in the UK. Perhaps I am on the sensible side as I have medical staff in the family and we are quite well informed about medicine and illness.

    At no point did I blow the situation out of proportion and worry about my symptoms being evidence of a greater illness. I just took the time to explain carefully what was happening and how it related to my present and past health.

    It was comparable with NHS care from the UK, apart from the bill at the end of the consultation! I have read many, many horror stories of ex-pats *cough* Americans *cough* finding care and treatment from Japanese healthcare to be incredibly substandard.

    All I can attribute this to is an inappropriate level of expectation on the part of the patient, and a kind of cultural mismatch between both sides of the patient/doctor relationship.

    Maybe I am wrong as I can only speak from personal experience?

    1. Most of my information does not come from personal experience, but from two other sources. The primary source is people who either are medical care professionals (mainly doctors, but also nurses) and Japanese people. One of my best sources of information was a pharmacist who was married to a doctor who runs his own clinic. She really explained a lot about the inner workings of the system (and why it is cheaper to go to a doctor and have him give you an aspirin than to buy a box of it yourself at the drug store).

      My personal experience was highly variable, but, in general, the more proficient a doctor is in English, the better care I got. My feeling is that these doctors, who were trained abroad, were cognizant of how to handle foreign patients and even appreciated the variation. If you were specifically recommended a bilingual doctor in a major area of Tokyo, you were't getting an average experience. And, as I said before, there are great doctors in Japan. The one who gave me my thyroid surgery was one of them. He never rushed me, never failed to answer a question well, and in fact kept me in the hospital far longer than I would have liked. On the flip-side, the woman who shared the room I was in (a 4-person room) and the other occupants were booted out as fast as possible. The turnaround for them was insane, especially given that the woman I spoke to the most was in incredible distress and still walking around with an I.V. bag the day she was discharged. She told me that each doctor was different and some would hustle patients out ASAP and others would keep you.

      So, I believe your personal experience is a valid indicator of the fact that their are doctors who take their time, but, I also believe that systemically, that is not something that is always or often the case. And, again, I don't believe it is because of anything bad about the doctors (or the patients, I don't think they expect too much whether they expect their questions to be answered or are content to shut up and do as they're told), but just part of the way it works.

      Thanks for your comment.

  3. Brazilians also feel that American doctors are incompetent. I am Brazilian, living in the USA and most people I know will spend the ticket money to travel to Brazil just to get a checkup there. Any medical issues, including dentistry, is usually left uncared for until they travel to Brazil. Usually once a year. Only emergencies go through American doctors.

    The reasons they provide are the same: American doctors just don't listen. You go into a consultation, it takes 10 minutes, you can only present them with one or two health issues at a time, and they usually prescribe general medicine like an antibiotic.

    On the other hand, Brazilian doctors take more time with you. You can sit there and spell out 10 different issues you are having and they will try to treat every single one (of course, not a specialized doctor). Because of this, Brazilian doctors have more experience than American doctors (since they try to treat a greater number of issues per patient) and they are more trusted to deal with major diseases than American doctors.

    On the other hand, the US has better facilities to handle things like cancer patients, and labor.

    I've also heard that Brazilian doctors are far superior in doing cosmetic surgery.

    All the things I detailed above are how a Brazilian views American vs. Brazilian doctors. I am only 25 and very inexperienced with doctors, so I have no clue if it is all true, or not. But it's interesting to see it!

    On the other hand, my personal observation in having lived in 2 different cultures, is that Brazilians have horrible health issues after a certain age. Although I'm sure that the relative poverty of the area, which takes a toll on the people's health, is more than partly to blame.

    Just my 2 cents. Not about Japan, but I think it's interesting to know how it's not just Brazilians or Japanese who think American doctors are incompetent.

    1. Thanks for your comment, Rebecca.

      I can't speak to the experiences of other people in the U.S. I can say that I haven't seen an American doctor for a very long time and, when I did, I did not experience the problems you mention. In fact, in America, most of the doctors I saw as an adult were not born in the U.S.

      My last experiences in the U.S. were very good ones, a very good one with a gynecologist and another good one with a general practitioner giving me a general exam. However, this was over 25 years ago.

      One of my friends who has never left the U.S. has never had the experiences of which you speak (he's 30) when he goes to doctors here.

      I think one thing that is important to keep in mind is that anyone who is not of the cultural they are operating in will not have a typical experience. Just as I got specialized treatment in Japan because I was foreign (sometimes far better than average, sometimes far worse), your friends who came to the U.S. would receive different treatment than the average American. Language, accent, attitude, expectations, and the patience of the doctor with dealing with a patient with such differences factor heavily into it. While I can't say that I can agree that American doctors don't listen and are impatient as, anecdotally, that has not been the experience of me, my friends, or my family (and my sister has been battling cancer for the past 15 months and has had copious amount of experience in this area so I have a lot of second-hand knowledge here), I can say some things which may relate to the experiences of Brazilians coming to the U.S. for treatment.

      The main thing I think may be happening is a form of prejudice against South Americans. If they don't speak English perfectly, there's a high chance (depending on the area they go to, especially), that the doctor will regard them dismissively and have a poor attitude toward them. The treatment they receive may be especially bad due to impatience with understanding their speaking (as some ears are not well-tuned to varied accents and they get frustrated when they don't understand clearly) or simple prejudice.

      That's just an opinion and food for thought.

  4. I'm Australian, which also has "socialized" healthcare (what an odd word!). I've attended the doctor in Australia with a friend, and my friend unexpectedly had the same medical issue arise in Japan.

    In both Australia and Japan, my friend was asked the same questions, was listened to, the same treatment advice was given and the same medicine (when you look at the active chemical ingredient) was prescribed. Yes, we were obviously foreign-looking in Japan, if that affects the way we were treated, but we were happy with the Japanese doctor's work.

    I have also taken my children to doctors in Japan, and again received similar advice and basically the same medicine as I would in Australia. The only problem was that the Japanese medicine was in "dumpling" form (powder to be mixed with water into a paste or ball) which I found difficult to administer to the one year old. Children's medicine in Australia is usually liquid, which can be syringed into the mouth, if needs be.

    I don't think it's inevitable that doctors paid by the government seek to maximise income by rushing patients. Doctors in Australia operate under a fixed fee scheme, but I have always felt listened to here, with one exception. I later read about the exception (who seemed to rush and not really listen) in the newspaper: - he had been struck off for malpractice (i.e. was not allowed to work as a doctor anymore). Of course, the event of a doctor being struck off for malpractice is rare enough that it did make headlines in all the big newspapers ;)

    Due to having small children, and the standard requirement that you get a doctor's letter if you miss more than a day or 2 of school or work, I visit the doctor on average every 2-3 months in Australia.

    However, I do agree with you that doctors in any country will vary - some good, some bad. And I do agree patients always need to advocate for themselves, or bring a friend/family member to advocate for them.

    1. ginevra. Thank you for sharing your experience. Please keep in mind that I am not criticizing Japanese doctors or the medical system. I've said before that, warts and all, I'd take the Japanese system over the American one. The point of this post was that there are systemic issues that make asserting that the experience of a Japanese doctor is not necessarily going to be superior to that with an American doctor. It wasn't to say it would be inferior. This post questioned an assumption which made no sense, the assumption that by some magical default, a Japanese doctor would care more and take more time with a patient. Even your experiences support this as you are saying the experiences in Australia are the same. They are equal, not superior.

      In the U.S., there are a lot of problems and one is that the "haves" (people with good insurance) receive excellent care while the "have nots" (people without insurance or with poor coverage) get poor care (not due to their treatment type, but rather that it is too expensive and the government only pays if you have emergency needs). The high cost and private nature of the care means that the "haves" often get better treatment on the whole (more time, more and more advanced testing).

      This has been an immensely difficult situation for my family since my sister developed cancer. Because of the economic downturn due to the sub-prime mortgage crisis, she went from working full-time with insurance to working part-time at the same job without it. And then she was diagnosed with cancer and no way to pay for treatment. Now, she has horrible and life-threatening complications which are only treated when she's on the brink of collapse because it's the only way her government medical coverage works. She gets chemo, develops huge problems from all of the toxic chemicals, and is put in the ICU (intensive care unit) for 4-5 days then booted directly back home where she may have a further downturn and go right back to ICU. They won't put her in a normal room and give her a few days of rest there because government care only pays if you're in dire straights. It's a horrible system, but I can't say she has had anything, but good doctors and nurses who have treated her well. The overall level of care though, is very uneven and actually more costly since the trips to the ICU cost more than maintenance care. If she had insurance, they wouldn't hesitate to give her a $12,000 (yes, that's the price) injection to improve her white blood cell counts so she wouldn't get so sick she nearly dies, but because she's on government care, they won't give it.

      In Japan, in general, everyone gets a somewhat lower standard of care, but that care is relatively uniform. That means that they might be getting 75% of what we get in the U.S. if we have good insurance, but they all get 75%. In the U.S., it's 100% or 25% (or nothing at all). There is a price for everything in life and no perfect system. The socialized medical system has systemic problems which rounds off the top, but it also lifts the bottom. The private system in America raises the top, but at dire cost to the bottom.

  5. Thank you for the thoughtful and informative post. I've lived in Japan for over 40 years, although most of the first decade was in the US military or as a civilian US government worker. After '79 or so, however, the doctors and hospitals I've visited have all been Japanese. As one would, I think, expect, I've had both good and bad experiences. I have noted the (in)famous tendency to over-prescribe medicine, including what seems to be a common tendency for at least one of the drugs to be a palliative or remedy for the side-effects of one of the others.

    I have been told by Japanese doctor, dentist, and nurse friends that sometimes the apparent over-prescription is for financial reasons: although I'm told there is less of it going on these days, there is/was reputedly a tendency for some clinics with their own dispensaries to prescribe--and charge for--drugs that they had received as highly discounted or even free samples from pharmaceutical salespeople.

    On the other hand, I have also known several Japanese doctors who follow a very strict policy of prescribing the *smallest* effective dose/amount/selection of drugs that they believe will deal with the problem. Some of them will prescribe _kampoyaku_ rather than, say, antibiotics or other strong, quick-acting "Western" drugs, depending on the patient's condition, usually to reduce the risk of side-effects, even though such remedies tend to take longer to take effect, and are often considerably cheaper. These practitioners also tend to be the ones who devote as much time as necessary to each patient, and are more than willing to listen to and elicit as much information from, their patients as necessary, with no rush at all.

    The "informed consent" principle is still relatively new in Japan, although there were major hospitals operating on the principle in the very early '90s that I know of personally. To follow that principle faithfully of course requires considerable discussion time with the patient. There seems to be a (rather slow) trend toward that and away from the rather arrogant-seeming traditional "I'm the _sensei_, you're merely the patient, here's your prescription for a ton of patient!" attitude.

    I have known both types, and these days only visit the ones that I have found to exhibit more careful, thoughtful consultation and prescribing.

    Oddly enough, however, I know quite a few Japanese patients--especially older ones, it seems to me--who actually *strongly prefer* the type of doctors who appear to me to be impatient, overbearing, and arrogant. Evidently they are regarded as "confident" and "masterful", with a side helping of "the more medicine, the quicker the cure" thinking on the part of their patients.

    There are sufficient people who share my preferences, however, that the doctors I visit do not lack for patients. According to one of them (a fellow, BTW, who left his job as the head of neurosurgery at a major Tokyo hospital to run his own clinic as a GP in rural northern Saitama, *much* less lucrative but more rewarding, he says), his clinic has a good reputation based on his approach and results, and as an added bonus there are a lot fewer patients who go for minor complaints or mainly to socialize.

    Thoughtful, patient physicians tend, it seems, to attract thoughtful, patient patients.

    Finding the kind of care that you prefer can involve a fair bit of trial and error, but lately there seems to be a rapidly growing trend of people searching the 'net for opinions/recommendations from current or former patients, as a way of finding the doctors/clinics that are most likely fit one's preferences/expectations.

  6. I have heard and have had the same experiences as you, Balefire. The medication situation is definitely what I was told as well, that they sell samples or discounted medication to make more money and that's one reason that some doctors prescribe so much.

    It also does not surprise me at all that there are older people who prefer the overbearing and arrogant doctors or that they view them as more masterful or competent. We feel comfortable with what we are all used to and they are used to that sort of doctor. I think it really makes people uncomfortable when they have been treated one way in a particular situation and then are treated another way.

    Regarding kampoyaku, I talked to two different kinds of "doctors" - they both called themselves doctors, but I believe one would not be recognized by the other as being a true medical practitioner. One was the usual medical school attendee with all of the rights and privileges to be a doctor. The other was someone who was trained in traditional Chinese treatment practices and medicine (kampo). I don't know if the traditional doctors prescribed kampo (they never did for me) or if one tended to get it from doctors trained in it specifically. It was a question I never asked and wished that I had.

    Thanks so much for your input.


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