A need to move to patient centered: Why Japan needs 'family doctors'

Eighty percent of our health-care needs are related to everyday illnesses such as colds, high-blood pressure, diabetes or depression.

Most of us, though, don't have a local practitioner whom we can visit to discuss these problems. Japan needs to train "family doctors" capable of providing continuous medical support over a wide range of medical fields. These doctors can play a separate but complementary role alongside specialist physicians who deal with only a few particular diseases or body organs. This will reduce mismatches between doctors and illnesses while at the same time improving the efficiency of health care.

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Since the Great East Japan Earthquake, many elderly in the afflicted regions have had to live as evacuees in areas with no medical facilities within walking distance. Rather than advanced, specialist health care, these people need "primary care" facilities where they can discuss everyday health problems.

More specifically, they need doctors and medical teams who can treat colds and lifestyle-related illnesses, provide home medical care, and offer nutritional advice. Doctors from all over Japan flocked to the Tohoku region after the earthquake, but only a few of these were capable of providing continuous daily care. These regional health-care problems actually epitomize the challenges facing the entire Japanese health-care system.

LOCAL DOCTORS NEEDED FOR DAY-TO-DAY ADVICE

Until now, reforms of the health-care system have focused on hospitals. University hospitals and large-scale medical centers were established across each region to treat serious diseases such as cancer or heart disease, while ballooning medical costs were tackled by reducing the length of hospital stays and reforming the medical fees system.

Different fields sprung up to deal with each particular body organ or disease, with doctors highly regarded for their expertise in one specialty area or other. As a result, Japan now has the infrastructure and human resources necessary for the provision of specialist health care.

When it comes to everyday chronic illnesses, though, many people have no idea how to go about finding a local doctor to consult with. As a result, they end up dropping by a hospital when it suits them, just like they would a convenience store.

General hospitals treat anything from minor headaches to serious diseases. Doctors on duty at these establishments are worn out by working through shifts without sleep. This is reflected in increasing medical expenses. At the same time, doctor-patient communication is also quite formal and impersonal.

Merely increasing the number of physicians will do nothing to fundamentally solve this problem of doctor exhaustion. What we need is a system for assigning different roles to each health-care facility depending on the seriousness of the illness. We also need to train specialist family doctors who can watch over the day-to-day lives of patients or local residents and offer early-stage treatment for a number of ailments.

Family doctors are specialist physicians who are licensed to provide primary care over a wide range of medical fields following the completion of a postgraduate training course in "family medicine." In Japan, the phrase "family doctor" conjures up the erroneous image of an elderly practitioner providing second-class health care in his or her dotage after a successful career in the field of specialist medicine.

In actual fact, doctors specializing in family medicine account for around half of all practitioners in Europe, Australia and Canada. They are established as a medical group in their own right, one with highly developed specialist skills. These skills include the ability to communicate with patients, for example, or a level of knowledge and expertise comprehensive enough to treat several kinds of illnesses. Family doctors adopt a holistic approach to health care that even takes into account the lifestyles and family circumstances of their patients.

Also, when a patient is discharged from a hospital following a serious illness, the family doctor is there to give advice about nursing or recuperation at home. They attend to their patients and offer comfort to the relatives. If there were more family doctors, then specialist physicians at university hospitals and so on would be able to concentrate more on providing advanced specialty medical treatment.

JAPAN LAGGING BEHIND GLOBAL TRENDS

A long time ago, many regions in Japan had their own local doctor. However, from the 1960s-70s onwards, more people began to die from cancer or strokes, so doctors started to become more specialized. In countries such as Britain, however, family doctors have remained a common feature for around 60 years. Taiwan also introduced a systematic training program for family doctors after many victims were unable to receive primary care following a major earthquake in 1999. Systems of primary care have also been established in Canada, Australia, South Korea and Singapore.

Japan is unique in having no place for primary care in its educational or institutional systems. The baby boomer generation is now approaching retirement age, and in 10 years' time the country will have to deal with a huge number of chronically ill people and a booming demand for home health care. Before then, we need to train a generation of talented people with the special qualities it takes to become a family doctor. There has to be a framework for equipping doctors with primary care skills.

At the same time, there also needs to be a debate about the reward system for doctors. In Britain, family doctors are rewarded not for how many prescriptions they write or patients they see, but for how well they improve overall health-care management in the area where they practice.

According to a study by the Organization for Economic Co-operation and Development (OECD), Japan has 97 CT scanners for every 1 million people, as opposed to 34 in the United States, 37 in South Korea and 7 in Britain. It is said that Japan has 5-10 times more CT scanners and other high-price medical equipment than the global average. This is partly due to that fact that hospitals make their living from health checkups and drug prescriptions.

In order to improve this situation, the system needs to be reformed to focus less on the amount of prescriptions and checkups and more on reassuring patients through day-to-day contact with doctors. As a first step, physicians trained as family doctors should gather together to provide family medical care at local government clinics or hospitals. This would bring many benefits to the people living in those areas.

In countries with developed systems of family medical care, each family doctor has around 2,000 local residents under his or her care. These doctors are rewarded according to how well they respond to the medical needs of the entire local community. As such, the idea of bumping up the number of checkups or prescriptions to pay for running costs is an alien one to them. Japan needs to act now if it doesn't want to fall behind the rest of the world.

(This article was compiled from an interview by Yu Miyaji from Asahi Shimbun's GLOBE.)

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Masako Ii

Masako Ii was born in 1963. Ii is a health economist. She graduated from International Christian University and subsequently obtained a doctorate in economics at the University of Wisconsin-Madison. She then headed research into developed country health-care reform at the World Bank's Development Research Group. She assumed her current position in 2004 following a stint as associate professor at Yokohama National University. She also serves as visiting associate professor at the University of Tokyo's Graduate School of Public Policy.