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)
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