Little and often

Being kindly hosted by Kae, a Japanese GP trainee in her first year of training, only a 5 minute walk from the medical centre has made for a swift and thorough entry into practice life in Tadami.

The Asahi Medical team currently consists of two GPs, a GP trainee and junior resident (the equivalent of a foundation year 2 doctor in the UK) and at this point I'll explain a little bit about what makes the primary care system in Japan so unique..

Firstly primary care, as we are familiar with the term in the UK, is a fairly new concept in Japan. First point of contact care has, for many years, been delivered by community-based practitioners but these practitioners were and still are predominantly 'organ focused specialists' such as cardiologists or respiratory physicians who have opened up their own outpatient clinic within a community. They offer expertise in their chosen field but are also required to provide primary care, seeing patients for all manner of conditions, due to the absence in many areas of a GP-type figure who might be more suited to take on this role. Patients are free to go wherever and see whomever they choose and require no referral as such.

Since 1961, Japanese people have been required to join the Medicare national insurance scheme which usually covers 70% of fees for consultations, examinations and treatments. The remainder is determined by income so routinely a patient will have to pay 10-30% of the cost themselves with a monthly cap or limit in place. In a similar way to the United States, doctors are paid per patient and per investigation and therefore treatment can be driven by financial incentive.

From a patient's point of view, the upside of this system is the direct access to specialists; many amongst us might see the attraction of being able to see a cardiologist with chest pain in the first instance, however the downside is the potential for large costs and delayed diagnoses when people are unsure of which specialist they need and end up making several visits and undergoing multiple investigations. With this is mind, increasing medical expenditure coupled with a rapidly ageing population has led to major reform in the Japanese health system over the last 10-15 years with the introduction of GPs at the forefront of the agenda.

It is, therefore, understandable that many of the population are not currently aware of General practice as an area of medicine and those that are, might be a little bit doubtful.

But now back to some pictures..lets take a tour around Asahi Medical centre: the practice serving Tadami and the surrounding area..

Wood paneling and sliding doors give the building a traditional feel alongside the modern and airy environment. My very first impression, however, as has often been the case in Japan was of utmost cleanliness. As is routine in the country, both patients and staff remove their shoes at the door and, as pictured, are provided with slippers to wear. I'm fairly fond of the concept now and chosen shade of green but will say that walking downstairs in them whilst negotiating expensive camera equipment is always a little unnerving.

As is often the case in the UK, clinic lists are divided into 'reserved' and 'walk-in' patients. Emergency clinics can be quiet and understanding why requires insight into how patients are managed here. Similar to what I'd observed in the United States, only a few sessions in I was noting that the majority of consultations are follow ups; usually a blood pressure check, a general 'look over' and a rationalisation of current medications where possible. Most patients are seen at least every two months (seeing a patient before giving a repeat prescription is mandatory here) and some even more frequently than that. From what I've deduced so far, there seems to be several reasons for this. Firstly Tadami is home to a large number of elderly people; 47% of the population is over the age of 65% (as a comparison, the UK national average is 17.8%) and therefore many of the patients attending Asahri will very likely have accrued a series of chronic conditions that require regular monitoring. However even in terms of chronic illness surveillance, their follow up rate is high compared to some other systems. It therefore perhaps speaks more of the general healthcare culture here; one in which much importance is put on investigations and frequent contact. This is illustrated, as it was in the States, in the disease screening programmes which are more comprehensive to those we are used to in the UK and the availability of annual health checks for all.

With every new place I've been to and every new doctor I've observed as the year has progressed, the impact of the type of presentation on what is required from the consultation has become more and more apparent. For example, I noted early on in Norway that the majority of appointments were acute presentations or 'new problems'. This was primarily due to the absence of fixed guidelines dictating disease follow up like we experience in the UK as well as perhaps the absence of a financial incentive I have seen in other places. Addressing new problems with patients can naturally require more time than reviewing an ongoing issue and it seemed therefore logical that in the Norwegian system, doctors are allotted 20 minutes per patient. If the same rule applies, in the Japanese system where most appointments are follow ups, they should be able to cope with shorter time..and indeed they have to.

Appointment times are on average 3-6 minutes per patient and I have to confess I've never seen anything quite like it. The amazing thing is that due to the efficiency of the operation, 5 minutes can in some cases begin to feel quite lengthy or at least ample. The clinic setup has a lot to do with it..

On arrival patients check in at the reception desk and have their observations taken so that these are available to the GP on review. When they are called in they are seen not in a room but a cubicle with a door to the waiting room and a curtain to the back. As pictured, every GP is supported by a clinic nurse who waits at the curtain and prepares tasks as the consultation progresses. Every step, that can be, is anticipated to ensure minimal delay. As I observed, injections would be produced without a pause and prescriptions printed and handed over mere seconds after a GP had suggested them. In watching this, it was difficult to not make comparisons with home and how a simple task such as giving an injection would likely take at least several minutes of finding the equipment, looking in the second store cupboard when the first yielded nothing and generally preparing the patient.

In the Japanese clinic this smooth system makes seeing patients at such a rate possible; doctors can tally up more than 35 in one morning session alone. However, regardless of the nature of the problem, be it 'old' or 'new', it begs the question of whether a patient's complete needs can really be met in such a short time? and what happens when the consultation is not so straight forward?

I pondered this last question only today along with a group of fantastic GPs and GP trainees as we met in Kitakata, a town two hours north of Tadami, for their monthly training day. One of the first cases up for discussion involved the scenario of breaking bad news to a patient. Being a part of the job that most doctors find difficult, the example prompted much conversation and in my small group we very quickly began to make comparisons between our two experiences of training from across the globe and as a result how well prepared we felt for such a task. I was interested to learn from the discussion that communication skill training, for scenarios such as the one in question, is not a big part of Japanese medical school curriculum and so, for some, today was their first exposure to some of the techniques used in breaking bad news taught elsewhere. When considering this, coupled with short appointment times and long patient lists, it is easy to imagine how such a scenario might bring with it a fair share of anxiety for both doctors and patients.

In my first week in Tadami I've observed probably one of the most efficient primary care services, certainly time-wise, in action. However, on reflection and on speaking to members of it's workforce, I wonder whether such a conveyor belt, as smooth as it is, is leaving it's patients in need and its doctors overwhelmed...

Please tune into the next blog where I'll explore further the views of the doctors I've met already as well as contemplate just how useful it would be to have one of these kicking around in the practice at home...

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