HEALTH CARE PROBLEMS IN JAPAN: DOCTOR SHORTAGES, LONG HOURS, MALPRACTICE, PEOPLE TURNED AWAY FROM HOSPITALS

HEALTH CARE PROBLEMS IN JAPAN

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ambulance responding
after an earthquake
In Japan, there are no clear guidelines in some cases of when to stop life-prolonging treatment. There was some discussion of bringing murder charges against a doctor for removing the respirator from a nearly-dead, 80-year-old patient at a hospital in Wakayama Prefecture in 2006. One survey found that 31 percent of hospitals let terminally ill patients die by withholding or withdrawing life-sustaining treatments such as artificial respirators.

In Japan it is relatively easy to borrow a friend’s health insurance card and use it as their own. Member of the Aum Spreme Truth cult that were on the run did this. Nonpaying patients cost hospitals $4.6 billion a year. Over 90 percent of those who don’t pay cite poverty as their reason for not paying.

Physical violence and verbal abuse directed at doctors, nurses and staff members is a problem in some hospitals. Longs waits and stress are often the trigger for incidents. A doctor who said much of his day is taken up by demanding parents screaming at nurses demanding that hospital hours be changed to fit their schedules told the Time of London, “People sense their rights are getting stronger and stronger but the expression of that is just becoming violent and radical.”

Books: The Japan Healthcare Debate by Mark A. Colby (Global Oriental, 2005); Negotiating the Gray Maze: The Business of Medicine in Japan by Mark A. Colby and Micheal P Birt; Good Websites and Sources: Photos of Health Care Workers japan-photo.de , Ambulance japan-photo.de ; and Neo-Natal Care at Japan-Photo Archive japan-photo.de ; Japan’s Health Care System nyu.edu/projects/rodwin ; 2009 Washington Post article About Japanese Health Care washingtonpost.com ; 2009 New York Times Blog Report prescriptions.blogs.nytimes.com ; NPR Report on Health Care in Japan npr.org/templates ; U.S. Versus Japan in Health Care livescience.com ; Public Health Insurance in Japan unpan1.un.org/intradoc ; Physician Job Satisfaction and Working Conditions in Japan pdf file joh.med.uoeh-u.ac.jp/pdf ; Japan Pharmaceutical Association nichiyaku.or.jp

Sites for Expats with Info on Health Care Japanable site for Expats japanable.com ; That’s Japan thats-japan.com ; Orient Expat Japan orientexpat.com/japan-expat ;Kimi Information Center kimiwillbe.com ;Foreign & Commonwealth Office Report on Japan fco.gov.uk/en/travel-and-living-abroad ; Student Guide to Japan www2.jasso.go.jp/study ; Japan in Your Palm japaninyourpalm.com

Links in this Website: HEALTH IN JAPAN Factsanddetails.com/Japan ;HEALTH CUSTOMS IN JAPAN Factsanddetails.com/Japan ; HEALTH CARE IN JAPAN Factsanddetails.com/Japan ; HEALTH CARE PROBLEMS IN JAPAN Factsanddetails.com/Japan ; ORGAN TRANSPLANTS IN JAPAN Factsanddetails.com/Japan ; HIGH TECH MEDICINE AND MEDICAL ADVANCES IN JAPAN Factsanddetails.com/Japan ; DISEASES AND HEALTH PROBLEMS IN JAPAN Factsanddetails.com/Japan ; HANDICAPPED PEOPLE IN JAPAN Factsanddetails.com/Japan

Good Websites and Sources on Health and Health Care: Statistical Handbook of Japan Health Care and Public Hygiene Section stat.go.jp/english/data/handbook ; 2010 Edition stat.go.jp/english/data/nenkan ; News stat.go.jp ; World Health Organization Japan who.int/countries/jpn ; Center for Disease Control in Atlanta CDC ; Medical Information for Foreigners pref.osaka.jp/iryo/medicalinfo ; Medical Resources by region compiled by U.S. Embassy /tokyo.usembassy.gov ; Japanese Government Organizations: Ministry of Health, Labour and Welfare mhlw.go.jp/english ; National Institute of Public Health niph.go.jp ; National Institute of Health Sciences nihs.go.jp ; National Institute of Health and Nutrition nih.go.jp/eiken

Japanese Health Care System Problems

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ambulance responding to a call
The health care system in Japan is expensive and contributes to the national debt and could bankrupt the country. By some estimates health care will eat up a forth of GDP in 2020. (See Elderly).

The Japanese health care system is very inefficient and wasteful. Japan has the longest hospital stays in the world. Patients often stay in the hospital much longer than they need to. People are prescribed a lot of medicines, and often get a lot of tests they don’t need simple because the know that heath insurance will pay for it. Thirty percent of health care budget goes to drugs, compared to 11 percent in the United States.

There have been some reforms. In the mid 1990s most people were required to pay 20 percent of their medical bill compared to 10 percent before. In the mid 2000s, payments to drug companies and doctors were cut.

Because not so many Japanese give blood and domestic blood is much more expensive than foreign blood, an increasing number of hospitals are switching to blood products made overseas, rasing concerns about the safety and reliability of medical treatments involving blood preparations.

In April 2008, a new health insurance system was introduced for people aged 75 or older. The new policy was widely unpopular not only because health care fees were raised for some elderly people but also because the rules were confusing and money was deducted directly from the pension payments paid to them.

The new health insurance system for people over 75 targeted about 13 million people, most of them not working. One of its goals is to cut health care costs paid to retired and nonworking people out of the insurance fees paid by working people. The new system met immediate criticism for the use of the phrase koki koreisha---literally “last-stage elderly people”---as part of its name.

Problems with Doctors in Japan

Many Japanese complain that doctors spend too little time with them during office or hospital visits. Some patients have blamed perfunctory examinations for misdiagnosis. One person who was misdiagnosed three times by three separate doctors and spent a month in bed wrote to the Daily Yomiuri, “All insisted it was a common cold, Mononucleosis has similar symptoms, but some are unique to the disease. All gave me a multitude of conflicting prescriptions not knowing or asking what previous doctors had prescribed. One of them caused a severe reaction. Nor did the doctors request any tests.”

Many women say they prefer women doctors and complain especially about male gynecologists because they are arrogant and condescending and some complain of harassment. One woman told the Asahi Shimbun one doctor lectured her for not having any children. Another said that she went to doctor for a pap smear and was shown photographs of woman’s genitals and told that her sex organs were darker than that of other women because she had a lot of sex.

Name lending---in which doctors accept money but don’t provide any treatment in return for allow their to names to be listed as staff members at hospitals---is a common practice. Doctors are not required to taken an supplemental education for maintaining their medical licence.

Threats of malpractice suits and tough working conditions resulted in 11 percent of maternity institutions shutting down between 2002 and 2005.

Doctor Shortage in Japan

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The number of doctors increased from about 241,000 in 1996 to 278,000 in 2006, about 15 percent over 10 years, yet there is a severe shortage of doctors in many places. In some places the shortage of surgeons is particularly serious. Some medical facilities have a single doctor, which makes it difficult for that doctor to take time off.

There is a severe shortage of doctors in many rural areas. In some remote villages patients have to be helicoptered to a hospital because they are more than an hour from the nearest medical facility.

Reasons for the doctor shortage include the fact that too many doctors choose the same place to work and specialize in the same fields. Many doctors seek work in the large city hospitals and choose ophthalmology or dermatology and avoid surgery because of its tough hours and stressful working condition. Japan has a huge number of hospitals and hospital beds but only a limited number of doctors to work at each hospital.

The government is making an effort to produce more doctors by increasing the enrollment at medical schools and providing financial assistance to medical students who will work in rural areas for 10 years after they become doctors. Japan plans to use more “doctor helicopters” to help people in remote areas get timely emergency medical care as well as provide quick emergency care in the case of accidents.

Shortage of Obstetricians in Japan

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In many places there is a shortage of obstetricians, especially outside large urban areas. The number of obstetricians declined seven percent over ten years to 10,594 in 2004. The number of medical institutions with obstetrics departments declined from 4,286 in 1993 to 3,056 in 2005. Many medical students steer clear of obstetrics because of the strenuous working conditions and threat of legal action.

Increasingly pregnant women have to go to large hospitals as the number of mid-size hospitals and clinics has declined. In some rural areas pregnant women sometimes have to travel over 100 kilometers for medical care.

The shortage has caused some hospitals to stop accepting new reservations for prenatal checks. An NTV television documentary on the problem talked to one woman who gave birth to a stillborn baby because no specialists were available to provide emergency treatment. She was told, “You shouldn’t have come to my hospital, as we don’t have enough obstetricians.”

One survey found that nearly half of general prenatal care center nationwide have only one obstetrician on duty at nights and on weekends, An official at one hospital told the Yomiuri Shimbun, “We have only eight ful-time obstetricans, and some of them have to work nights six or seven times a month. They often are unable to take a day off after the night shift.”

Long Hours for Obstetricians in Japan

Obstetricans and pediatricians are often dangerously overworked. Medical students don’t want to pediatricians as well because they are put off by the tough working conditions and the possibility of malpractice suits

There have been reports of obstetricians working 505 hours a month, which works out to an average of 16 hours day without any days off. One obstetricians interviewed by the Yomiuri Shimbun worked the night shift 15 times a month, often in a addition to the day shift, and worked an average of 17 hours a day without any days off.

A pediatrician in Hokkaido who put in more than 100 hours of overtime a month officially died of overwork. He died of heart disease in October 2003 at the age of 31. He worked long hours and often had to respond to emergency calls during the night.

In 1999, 44-year-old pediatrician Toshiro Nakahara committed suicide by jumping off the roof of the hospital where he worked. In his suicide note he wrote, “Working the night shift five or six times a month is too hard for me now I’m in my mid-40s...I don’t have physical or mental strength to keep working as a doctor.” Nakahara’s daughter filed a law suit over the death. In 2010 she was awarded ¥7 million in an out-of-court settlement.

Solutions for the Obstetrician Shortage

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Clearly more obstetricans are needed, but training medical students takes a lot of time. In the meantime the government has suggested using more female doctors and private medical practitioners, namely midwives, to perform routine chores, and leaving specialized work to the doctors.

Improvements can be made to accommodate women doctors better. Half of female obstetricians and gynecologist leave the field after 10 years of practice as the find impossible to hold down their career and raise children at the same time.

Some insist that the only solution is a systematic assigning of doctors to make sure enough doctors go onto pediatrics and obstetrics and make sure that pediatricians obstetricans are evenly distributed among hospitals so that these hospitals have enough doctors to meet the hospital’s scheduling needs.

Foreign Nurses and Aides in Japan

The Japanese are beginning to woo immigrants to take care of the elderly, something they desperately need to get on top of taking care of Japan’s aging population.

In August 2008, 205 Indonesian caregivers arrived in Japan, representing Japan’s first full-fledged effort to accept foreign workers in the medical and nursing care fields, which are facing serious labor shortages. The workers were required to pass a Japanese proficiency exam to gain entrance to the country and can be shipped back to Indonesia of they fail to pass the exam required of Japanese workers.

Filipina nurses have also come to Japan. In May 2009, 273 Filipino health care workers arrived in Japan. They are given six months language training are to come on two-year contracts and are required to return home after that time. They are paid ¥2.2 million a year, well below the ¥3.8 million that salaried workers receive

After three or four years Filipina and Indonesian nurses are expected to take the same test that Japanese nurses and caregivers have to take and often have difficulty passing. Indonesian nurses and other foreigners who have come to work in Japan and have to meet language requirements struggle with the written language, especially the kanji (Chinese characters).

Medical Mistakes in Japan

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According to a government report, 15,000 medical errors were committed in 82 major hospitals over a two year period in the mid 2000s. The mistakes included transfusing the wrong blood type and leaving gauze and other medical tools inside a patient’s body after surgery. Some of the mistakes led to death. Doctors have traditionally covered their mistakes and left patients and their families in the dark. Medical records are the property of doctors, hospital and medical staff and patients don’t have the right to see them.

In the late 1990s and early 2000s a number of cases of incompetence by doctors received widespread media exposure. In 1999, a year-old women who checked into a hospital for minor finger surgery died after a nurse mistakenly gave her an IV with disinfectant. Doctors first tried to cover up the mistake and the truth came out after members of the victim's family "pursued their suspicions." The family of the victim was awarded ¥60 million in 2004.

In another case surgeon mixed up two patients and removed part of lung from a heart patient and removed part of the heart of a lung patient. Both survived but the story made front pages of major newspapers.

In March 2001, a 12-year-old girl died after a mistake was made during a heart operation. In October 2002, a woman died in surgery after a doctor mistook her pancreases for the adrenalin gland.

The head surgeon at Tokyo Medical University lost three out of 20 patients he performed a heart valve operation on. The operation is regarded as fairly routine and the usual fatality rate is only 4 percent. Questions were raised about why he was doing valve surgery when his specialty was surgery and how he managed to keep his position as head surgeon after the deaths.

More Medical Mistakes in Japan

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In September 2003, a 60-year-old man died during prostrate surgery from loss of blood when young, inexperienced doctors tried a new less invasive technique. An operation that should have been routine and taken less than two hours instead lasted for 13 hours, and caused the patient to lose five liters of blood. What was worse is that the doctors didn’t realize the man was bleeding and failed to have blood ready for transfusions.

The doctors involved were in their 30s, inexperienced with the technique and had failed to get proper authorization for the surgery. At one point as things were going wrong the doctors read through a manual on the laser devise they were using. They were arrested by police for professional negligence.

A study found that some operations that weren’t needed were performed on patients on the orders of head doctors to give young doctors a chance to learn new techniques.

In July 2007, a girl died of acute heart failure after being given a general anesthetic for treatment for a dental cavity. The child of a friend of ours suffered severe brain damage as a result of oxygen deprivation during her birth because the doctor delayed doing a Cesarean.

In January 2009, an 87-year-old man died after his liquid meal was put into his UV drip rather than his feeding tube. A nurse admitted making the mistake and he did because she was busy,

In September 2008, a doctor accidently impregnated a woman in her 20s. with an in vitro-fertilized egg of another woman at a hospital in Takamatsu in Kagawa Prefecture. Later the doctor who made the mistake said he performed the procedure by himself and admitted not following the safety procedure used to prevent such mistakes from occurring. The doctor had petri dishes with fertilized eggs from two women on his desk and placed the egg of the other woman in the dish with their name on it. The impregnated woman terminated the pregnancy

See Hemophiliacs and Tainted Blood,

Unneeded Operations Done in Japan

In January 2011, the Yomiuri Shimbun reported, “A total of 140 people were subjected to unnecessary heart surgery at a Nara Prefecture hospital that was shut down in 2009 after revelations of fatal negligence and fraud, sources said Friday. The patients at Yamamoto Hospital underwent coronary artery stenting, a catheterization procedure that expands an artery in the heart to prevent heart attacks. Using an X-ray device to observe the artery, doctors insert a stent---a tube made of wire net---in the coronary artery.” [Source: Yomiuri Shimbun, January 8, 2011]

“The operations were mainly conducted by former hospital director Fumio Yamamoto, 53. Yamamoto is currently serving a prison term for falsely claiming to have performed catheterization surgeries on eight welfare recipients to obtain medical fees totaling about 8.3 million yen between January 2005 and May 2007. Yamamoto also was indicted in February 2011 for allegedly causing a male patient to bleed to death after damaging a vein in his liver during surgery for a vascular tumor in 2006.” [Ibid]

“Footage of the stenting procedures was recorded automatically by an X-ray photography device in the operating room of the hospital. Discs containing the footage were among materials seized by Nara prefectural police in the fraud case and were later returned to the Osaka municipal government. In the case of stenting operations, hospitals can only claim remuneration from the national health insurance system when 75 percent or more of the diameter of a coronary artery is blocked. The municipal government asked a university hospital to examine the discs, and a panel of seven doctors of cardiovascular internal medicine concluded that 98 of 116 patients did not need the stenting surgery.; [Ibid]

Malpractice in Japan

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There are relatively few malpractice suits in Japan. One average only around 800 such suits are filed in all of Japan in a year. By contrast about 1,500 suits are filed in the state of New York alone. Even so the number of cases is rising. There were only 370 suits in 1992.

Malpractice cases are a hard slog. On average they last 33 weeks and judges are often changed in the middle of the trial. Decisions are often based on the testimony of medical experts, who are supposed to be neutral but are often doctors who are reluctant to point the finger at other doctors.

Dr. Tsuneko Kunuo is a pediatrician who has worked for 30 years in Kyushu. In 1992, her 17-year-old daughter Akiko died after being misdiagnosed and forced to undergo dangerous brain surgery. When she sought hard answers about her daughter’s death she was given evasive answers and labeled as pushy. She decided to sue for malpractice and draw public attention to the issue. She spent more than a decade carrying on her battle in the courts. For that she was ostracized by the medical community and died of cancer before verdict was made. .

People Turned Away From Hospitals in Japan

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ambulance waiting outside a ferry
A record 16,381 people in serious condition were refused admission by hospitals three times or more during ambulance transport in 2010, up 3,217 from the previous year, the Fire and Disaster Management Agency said. The agency said the rise came as hospitals are yet to be prepared to receive an increasing number of elderly patients in aging Japan. Among the reported cases, 727 people were rejected 10 times or more, with a 60-year-old man in Tokyo rejected the most, 41 times. He had to wait more than three hours while ambulance crews kept searching for a hospital that could accept him, according to the agency. [Source: Kyodo, Mainichi Japan, July 23, 2011]

As reasons for rejection, 21 percent of hospitals responding to the agency’s survey said it was because they were engaged in operations or dealing with other patients, and another 21 percent cited lack of medical staff or equipment.About 19 percent of hospitals said their beds were fully occupied.The agency has been releasing related surveys since 2007. It was the fourth consecutive year that more than 10,000 people in serious condition were refused hospital admission three times or more. For young people aged under 15, including those mildly to moderately ill, there were 10,924 cases in which they were refused at least three times. There were 587 similar cases for pregnant women. [Ibid]

In 2006, a pregnant woman who fell unconscious during delivery at a public hospital and was placed into an ambulance and turned away by 19 hospitals and died eight days later with a brain hemorrhage. In September 2007, eleven Kobe hospitals refused to admit a woman in labor, citing either a lack of beds or obstetricians. The woman was admitted to a hospital after an hour and gave birth normally. The same month 16 hospitals in Chiba near Tokyo rejected a pregnant woman in her 30s in danger of having a miscarriage.

In August 2007,a 38-year-old woman in Nara Prefecture who was six months pregnant miscarried after being rejected by nine hospitals while being in an ambulance that collided with a minivan while on its way to the 10th hospital. In September 2007, a 63-year-old blind man was abandoned in a park by four employees of the Shin Kanaoka Toyokawa Hospital in Osaka. The employees, acting under orders from heir bosses, had taken the man to the house of woman to t leave him there but when she wouldn’t accept him the employees left the man, who been getting treated for diabetes, in the park, where someone anonymously called an ambulance.

In November 2007, a Sapporo woman in her 30s gave birth prematurely to 1.3 kilogram baby in her home. The baby was refused admittance to seven hospitals and later died.

In December 2007, an 89-year-old woman died after she was rejected by 30 hospitals in Tondabayashi, The woman went into cardiac arrest while an ambulance crew spent two hours contacting hospitals before finding one that would accept her. In January 2008, a 70-year-old man died after being rejected by 21 hospitals.

In October 2008, a 36-year-old pregnant woman with a brain hemorrhage died after being denied admission by seven Tokyo hospitals before finally being accepted at one of the hospitals that originally refused to take her. The hospital that accepted her initially rejected her because it had only two obstetricans working there. The other hospitals said they didn’t have enough beds or were understaffed and didn’t have enough doctors.

In February 2009, a 68-year-old man injured in traffic accident was rejected by 14 hospitals in the Kobe, Osaka area and eventually died of hemorrhagic shock three hours after the accident.

The rejections occurred mostly at urban hospitals, where there were other hospitals patients could be sent to. Rural hospitals generally accept everybody, even if it is temporary, because there is no other place to send them. One hospital official told the Yomiuri Shimbun, “In urban regions, many hospitals fear they won’t be able to treat a patient adequately after learning of his or her condition and often leave it up to other hospitals.”

In December 2008, new rules were put on the books that prevent hospitals from refusing patients.

Health and Medical Care Reform in Japan

Japan’s medical care system is at a major turning point. In order to create a health and medical care system that is sustainable over the long term, the government continues to study and implement wide-ranging reform measures. The cost of public health care has been rising sharply; as of 2009, the cost of health care for people over 65 rose to over half of total costs, or around 55 percent. The costs for people 75 years of age or older on average are about five times higher than those of adults under 65. Faced with this situation, the government introduced a Health Care System for the Very Old in April 2008, a new scheme designed specifically for the older segment of the elderly population that features a thorough administration of their medical benefits. A number of revisions were later made to the system, including a change in its name to Long Life Health Care System in response to opposition by older adults to the designation “very old.” Although the recent focus for medical system reforms has been on funding issues, it should not be forgotten that reform efforts are also being made in order to improve the quality of health care. [Source: Web-Japan, Ministry of Foreign Affairs, Japan]

“Private-sector initiatives have been introduced, including measures allowing the incorporation of service businesses (both profit and non-profit) that provide care for the elderly. In the past, public services have been predominant in this area. The official drug-pricing system has also been revised. Since 2000 private corporations have been able to operate childcare facilities whereas before only municipal governments and social welfare corporations were able to do so. [Source: Web-Japan, Ministry of Foreign Affairs, Japan]

“General pharmaceutical goods had once only been sold at licensed pharmacies staffed with a pharmacist, but starting in 1999 some goods once designated as prescription medicines, such as vitamins, were categorized as “quasidrugs” so that they could be sold at drugstores and other stores besides pharmacies. Starting in 2009, low-risk pharmaceuticals have been allowed to be sold by registered retailers, expanding the lineup of pharmaceuticals sold at supermarkets and convenience stores. The use of self-service pumps by gasoline stations was permitted in 1998. [Ibid]

Image Sources: Japan Photo japan-photo.de ; except Earthquake Image (Archives M. Yoshimine, Tokyo Metropolitan University) and ferry (Ray Kinnane)

Text Sources: New York Times, Washington Post, Los Angeles Times, Daily Yomiuri, Times of London, Japan National Tourist Organization (JNTO), National Geographic, The New Yorker, Time, Newsweek, Reuters, AP, Lonely Planet Guides, Compton’s Encyclopedia and various books and other publications.

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© 2009 Jeffrey Hays

Last updated October 2012

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