ACP Japan Chapter IEP

Exchange period: 2017/10/31-2017/11/21

Through the ACP Japan Chapter International Exchange Program, I was privileged to observe Hospital Medicine and Family Medicine in Hawaii. I would like to thank Dr. Nogi, Dr. Tokeshi, and everyone else involved in the Program, for helping me to gain invaluable insight into the significant differences between the way health care systems are organized from country to country.

<Hospital Medicine>

I performed the observation of Hospital Medicine by shadowing a hospitalist Dr. Nogi at the Queen’s Medical Center (QMC) in Honolulu.

Firstly, I learned that Hawaii’s population is quite diverse. Almost 40% of the state’s 13.6 million residents have Asian roots, including 15% Japanese; a quarter of the population is White; Native Hawaiian and other Pacific Islanders account for 10%; and finally, African Americans about 2 %. Of the above, 10% also count themselves Hispanic, and 25% overall identify as two or more races. In view of the Compact of Free Association between the United States and the three Pacific island nations: the Federated States of Micronesia, the Marshall islands, and Palau, as the biggest hospital in the region, QMC accepts a variety of transferred patients reflecting a diversity of race, creed, and other characteristics. In this way, severely ill patients in the vast area will converge at QMC, and hospitalists at QMC, together with numerous consultants, must deal with a wide range of diseases. For example, I witnessed a hospitalist consulting oncologists for a chemotherapy regimen, a palliative care team for management of side effects, infectious doctors for febrile neutropenia, and specialists in the main land about the Car-T therapy to treat a patient diagnosed with B-cell lymphoma. Throughout the observation, I also learned that hospitalists are required to show leadership like an orchestral conductor to convey harmonic medical care with many specialists. Especially because of Hawaii’s great diversity, the local hospitalist’s competency as a team leader required both familiarity with the medical resources in the hospital and the skill to operate as a communication hub for directing the best multidisciplinary care.

More broadly, I learned that the number of “hospitalists” in the United States has grown from a few hundred to more than 50,000 over the last decade?larger than any other subspecialty in internal medicine. I also learned that hospitalists bring reductions in hospital costs, lengths of admissions, and rates of readmission. It is for these reasons that approximately 75% of U.S. hospitals now hire hospitalists. Some specialists predict that the number of hospitalists will further increase, although this new type of specialty has its disadvantages, such as discontinuity of care from outpatient to inpatient care or medical field overlap with other specialists.

Meanwhile, the number of hospitalists in Japan is as few and far between as they were a decade ago in the United States. Because of Japan’s rapidly growing aging population, the myriad diseases and intense need for acute hospital care common to this group will require new strategies. I anticipate the number of Japanese hospitalists who play a leadership role in those settings may increase over the next decade, following the footsteps of the United States.

<Family Medicine>

I performed Family Medicine observation by shadowing Dr. Tokeshi who is a clinical professor of Family Medicine at John A. Burns School of Medicine at the University of Hawaii. Dr. Tokeshi has been serving his male and female patients of all ages from the cradle to the grave for almost 40 years. As a matter of fact, he is the primary care physician for 5 generations of one family. Shadowing him was truly inspiring and I learned that the family doctors’ approach to health problems is through longitudinal continuity of the patient/doctor relationship?one seldom established in the relatively short-term clinical relationships within other specialties. Furthermore, personal life histories were meticulously taken. For example, I learned that Japanese descendants in Hawaii often have unique life histories influenced by migration or world war. Those factors proved indispensable in interpreting health problems in the physical, psychological, social, cultural, and spiritual dimensions. These problem-solving strategies appeared to be core elements to a professional primary care physician’s repertoire in Hawaii.

From a wider perspective, family doctors are the first gates in primary care and have important roles as coordinators and advocates for the health of the community. When it comes to the health care system in the United States, I learned that it is difficult for ill or poor people to purchase insurance contracts and gain easy access to primary care. I understand that in 2010 the Affordable Care Act (“Obamacare”) was made to improve the situation, and as a result, the number of people who have insurance is expected to increase by 2020 and bring more fairness in primary care.

Japan, by contrast, offers medical insurance for the whole nation and people there have ease of access to medical care. On the other hand, Japan does not yet have qualified training programs for primary care physicians; and although the Japanese Medical Specialty Board has been preparing for establishing a new training system in each medical field by April 2018, there remains a shortage of family doctors. Consequently, Japanese patients are rarely seen by their officially trained primary care doctors, but are seen instead by providers whose specialty is on the boundaries of medical fields divided by anatomical and physiological systems.

With the number of Japanese elderly, multi-morbid patients skyrocketing, I imagine the number of Japanese trained as primary care physicians like the family doctors in Hawaii?who approach and can manage any health problems from holistic perspective, will increase, once global standard primary care training programs are established here in Japan, in the near future.

Tomohiro Fujisaki, MD 2018 January