A Week in Asia: Today, Japan; Tomorrow, Singapore

A couple of weeks ago, I had the chance to visit Tokyo and Singapore – the former to speak at a conference on “Training of the Generalist Physician,” and the latter as visiting professor at Singapore General Hospital. Today: some observations on the medical scene in Japan; tomorrow, the same viz Singapore.

The Tokyo conference was the brainchild of Dr. Shigeaki Hinohara, chairman of the board of St. Luke’s International Hospital, one of Japan’s finest. Dr. Hirohara gave the opening address, speaking thoughtfully for 15 minutes, rarely glancing at his notes. He walked slowly and was a bit stooped – I guessed he was in his early 80s. Not exactly – he’ll celebrate his 100th birthday in two years!

A brief aside about Dr. Hinohara… after meeting him, I came to learn that he may well be the most prominent physician in Japan – Dean Ornish, Mehmet Oz, and Zelig rolled into one. Take a minute to read this brief interview with him in the Japan Times, and this Time magazine profile. In the interview, he describes caring for victims of the Tokyo subway nerve gas attack, being on a plane that was hijacked by the Red Army in 1970 (he was handcuffed to his seat for 4 days in 100-degree heat), his daily diet (which includes coffee, cookies, and orange juice laced with olive oil), and his life’s philosophy. His book, “How to Live Well,” has sold 1.2 million copies. He penned it when he was 90. This is great news for us slackers – there’s still time!

Here are a few random observations from my visit to Japan:

1.    Business class is a wonderful thing, but I knew that already. Several years ago, I had to fly to Frankfurt, then Japan, and finally back to San Francisco on the same trip, and managed to upgrade all three legs. After returning, I said to a friend, “You know, when you circumnavigate the globe in three equal hops, the world seems like a very small place.” “Only from business class,” he said wryly. How true.

2.    So too are Japanese toilets: in my Tokyo hotel, the seat was heated and had about 6 different options for how you wanted warm water to be sprayed. I’ll spare you the details, but suffice it to say that with this kind of technology, Japan seems poised to emerge as the next superpower.

3.    At the conference, I spoke about the hospitalist model in the United States, something that seemed to be of great interest to the Japanese audience. As I understand it, hospitalized patients in Japan are usually cared for by subspecialists – the patient with abdominal pain goes to the gastroenterologist, chest pain to the cardiologist, etc., not unlike the system in the U.K. These subspecialty-based systems work well when patients are cooperative enough to only have a single organ out of whack, but tend to be ineffective and expensive when patients are more complex.

?Although there is substantial interest in moving toward a generalist-hospitalist system of hospital care, they lack a large base of general internists to assume these roles – virtually everyone subspecializes here. (This is true in Singapore as well, but Singapore – like Canada – is working on converting some of its family physicians into hospitalists.) Interestingly, in the U.S. it was the large cadre of general internists, many of whom found delivering hospital care more attractive than providing primary care, that fueled the hospitalist field’s meteoric growth.

4.    Japan’s national expenditures on healthcare are extraordinarily low – about 8% of their GDP, or roughly half those in the U.S. Despite this, both their infant mortality rates and life expectancies put ours to shame. I never quite figured out how they manage to do this. ??Most countries that contain their healthcare costs rely on a strong primary care system, channeling patients through primary care practices that address most of their patients’ problems while acting as “gatekeepers” to expensive specialists and all their wondrous toys. But in Japan, far as I can tell, patients have nearly unfettered access to any specialist they like, the primary care base is quite weak (most primary care doctors are semi-retired specialists who decide to leave the hospital to make more money churning through patients in private clinics – sometimes seeing over 100 patients a day), primary care for illness and chronic care is divorced from prevention (patients go to separate “prevention clinics”), and there is no public health enterprise to speak of (most of the Japanese docs with MPH’s seemed to have received them from abroad, often from Harvard or Hopkins).

??As I tried to get my arms around why Japan’s healthcare costs are so modest, I stumbled onto a few hints. First, physician wages are quite low, and generalists and specialists make similar salaries. There are no Jaguar-driving neurosurgeons here. In fact, everybody’s wages are low, including nurses and administrators. And there are far fewer specialized ancillary staff: it’s hard to find any respiratory therapists, physical therapists, or nurse’s aides, even in large hospitals. So, although hospital lengths of stay are nearly twice ours (8-10 days on average; women stay in the hospital for 5 days after childbirth), hospital costs are a fraction of ours, largely because labor costs are so low.??

Second, they are pretty loosey-goosey about specialties and competencies: there is no systematic process of board certification and certain fields that are prominent in the states barely exist here. This raises concerns about quality, but probably also tamps down costs. (The most jaw-dropping example: there are very few radiologists – the doctor who ordered the radiograph is also expected to interpret it, for no additional fee. Ergo, no MRI Centers.) ??

Finally, the social determinants of health must play a major role. In my three days in Tokyo, I didn’t see one obese person (the national rate is 3%, the U.S.’s is 30%). Everybody uses public transport and walks everywhere, and their diet is modest and fish-based (though there are more smokers here than I’m used to, at least in California). Although the 98-year-old Dr. Hinohara is an extreme example (he still works full-time, by the way), many of the folks I met looked “far younger than their stated age” (as we teach the med students to say), which must contribute to lower healthcare costs. ??

But Japan is quite worried about the future of its healthcare system – they are starting at a lower baseline, but are beginning to share our scary and unsustainable “cost curve”, particularly since the Japanese population, already the world’s oldest, is aging faster than any other. They’ll need to get a handle on generalism and a primary care infrastructure, and they know it.

5.    Finally, walk around town or ride the subway and the most striking thing is that about 1-in-10 people are wearing masks. According to my old friend Josh Jacobs, a Hawaiian family physician who spent two years at St. Luke’s and also spoke at the conference, Japanese folks who wear masks while going about their daily activities might be worried about catching flu or allergies; a few, but not the majority, might be sick themselves and interested in preventing the spread of their illness. The remarkable thing, Josh told me, is that “there is no stigma.” I remember when “Swine Flu” hit the U.S. this spring – I was flying a lot and packed a N-95 mask in my carry-on bag, vowing to don it if I felt at risk. And I never took the thing out, despite sniffles, coughs, and sneezes from people well within aerosolized sputum range. I would have gotten too many funny looks.

In ways small and big, ??it’s striking how cultures differ, particularly when the ease of both telecommunications and travel (at least in business class) threatens to homogenize our world.

Tomorrow, the remarkable city-state of Singapore.