I would like to thank you for the generous grant I received to help towards accommodation fees during my recent medical elective to Japan (October-December 2015). As a result of your donation, I was able to secure a room in the staff dormitory. This was within walking distance of the hospital and thus saved me time, stress and unnecessary expense associated with the morning commute. Had I not received your donation, I would have had to stay hours away from the hospital to permit my modest budget and this would have detracted from both my time in the hospital and studying (a 3 hour-round commute in addition to a 9-6pm working day would be too much to handle, especially when faced with the prospect of travelling in a crowded subway carriage). As I was able to save time by avoiding a lengthy commute, I was able to spend more time studying both Dermatology and Japanese and this enabled me to build upon my knowledge of diseases which I had seen in the hospital. Furthermore, staying in the staff dormitory allowed me to meet other international students who were also studying at the university hospital. This was a really good way to make friends and something which enhanced my trip – staying away from home, in an unfamiliar environment where I could not fully understand the language was mentally and emotionally very demanding. Without the support from friends I may not have felt capable of engaging with my studies, or of taking advantage of the opportunities presented to me during the course of my stay (I will outline some of these later).
My 16 weeks of studying in Japan were very educational, both academically and personally. I spent 8 weeks studying Psychiatry in the University of Nagoya and 8 weeks studying Dermatology at the Jikei University in Tokyo. These are described below:
Part 1 – Nagoya
Nagoya is Japan’s third largest city and home to over 2 million people. As a result of this population density, I expected the hospitals to be crowded with people waiting for appointments. However, this was not the case. My tutor informed me that this was due to the way healthcare is funded in Japan. In comparison to the UK, where healthcare is free of charge at the point of use, healthcare in Japan requires a comparatively larger financial input from patients: 30% of all medical expenses must be paid by the patient with the remaining 70% paid by a state-owned insurance scheme (equivalent to the UK’s National Insurance). (For foreigners such as me, healthcare must be paid upfront or else charged to personal insurance.) Due to the financial implications of attending appointments, the Japanese are more hesitant when seeking healthcare advice and this may explain why the queues for the clinics were rather modest in spite of the significant population density. [More information on Japanese healthcare funding (kokuho) can be found in the attached document]
During my hospital attachment, I was fortunate enough to see Psychiatry practiced in a variety of settings: out-patient clinics, in-patient assessments and ward rounds. This variety allowed me to examine the nuances of psychiatry, and the healthcare system, in Japan.
Whilst I saw many consultations during my time at the university, a few cases still stand out in my mind. I saw a patient presenting for the first time with a suspected episode of mania. Despite my rudimentary Japanese, I was able to appreciate that the patient exhibited pressure of speech and restlessness (features of mania). Indeed in the presence of the patient I felt energetic myself. Whilst the patient clearly needed treatment, they refused to be admitted. Due to the patient’s mental capacity the doctor legally had to accept this decision despite the prospect of the patient’s mental state declining. However, due to input from family members, the patient changed their decision and was subsequently admitted. This reminded me of the importance of family in influencing healthcare needs and treatment decisions, as is often seen in the UK, and highlighted the importance of including the whole family when deciding upon the best treatment. Furthermore, this case highlighted the importance of having an ethical code of conduct to guide treatment policy – as is also the case in the UK. By observing this patient’s transition from initial assessment to inpatient stay, I was able to understand the patient experience of the Japanese healthcare system.
One of the main benefits of studying Psychiatry in Japan, for me, was the opportunity to hone my clinical observation skills. In bedside learning, we are taught to observe and make a brief assessment of the patient on approach and before talking to them. During my time in Japan I had to rely more heavily upon this skill as I could not fully understand the patient due to the language barrier. Indeed, I witnessed one patient fail to respond to a doctor’s line of questioning , and instead talked to the space around themselves. Conducting a mental state exam, it was clear that the patient was experiencing auditory hallucinations . Talking with the doctor afterwards confirmed this. I later saw many patients exhibiting different traits: poverty of speech, poor eye contact and lethargy ( depression);aggressive and uncontrollable (ADHD);abnormal social skills and repetitive movements (ASD). Indeed my time in clinics allowed me to develop my observation skills and mental state exam – key skills for any medical student or doctor. Whilst the language barrier was apparent, it did not reduce the usefulness of my experience and instead encouraged me to develop other skills, particularly observation. Furthermore, I was able to see the effect of culture on healthcare. For example, in the UK, plants are popular gifts to give in-patients. During hospital ward rounds, however, I saw that few patients had potted plants by their bedside. The reasoning for this, I was told, was because potted plants have roots – and giving this as a gift would result in the intended recipient growing roots and failing to recover. As a result of this belief, patients only received cut flowers.
My learning was not confined to clinical psychiatry as I was able to attend weekly group discussions regarding psychiatric research. In this way, I was able to keep abreast of developments in new treatments for psychiatric diseases and develop a better understanding of psychiatric diseases at a molecular level e.g. I learned of treatments being developed to overcome social difficulties in autistic patients. One drug being tested is oxytocin. I also learned about the risk factors for autism development such as the broader autism phenotype (BAP). Out-with the psychiatry department, I was given the opportunity to sit in with a clinical psychologist who was assessing palliative patients. In this way, multi-disciplinary team working could be observed.
Part 2 – Tokyo
Tokyo, with its towering skyscrapers and crowded streets was a complete contrast to my rural hometown of Dumfries.
Similar to my experience in Nagoya, I found the hospital to be relatively quiet compared to my expectations (for the aforementioned reason). Clinical Dermatology in Jikei was almost identical to practice I had seen in Edinburgh – new patients attended assessment clinics to receive their diagnoses and initial treatments. Returning patient would be seen at specialist clinics (e.g. for psoriasis, dermatitis). However, there were a few disparities that I noted:
- · Patient consultations were shorter, averaging around 5 minutes or even less on some mornings. As a result (or perhaps because of this) the doctors tended to focus only on the patients’ symptoms rather than the patient as a person – there was little discussion around patient concerns or acknowledgement of any psychosocial factors influencing their presentation e.g. job stress, social problems. From my time studying at University, I am well aware of the detrimental effect that stress can have on health and health-seeking behaviour: I have seen some patients attend hospital because their health worries had not been addressed in the past. I have also seen patients with curable diseases fail to achieve remission in spite of optimum medical therapy because of problems with their social circumstances. By only addressing the patients’ disease, I feel that the doctors may be missing the bigger picture and therefore any treatments offered may only offer a temporary solution. [However, there may be a cultural reason for this – I was told by one of the doctors that the Japanese do not like to show too much emotion or “weakness” and therefore the omission of a social history may be a nod towards this cultural belief rather than a failure to fully assess the patient.]
- · Clinics dealt with hundreds of patients in only an hour or two. This is because Japanese doctors are cheaper than nurses to employ and therefore 7 or 8 could be employed to conduct one clinic. Furthermore, doctors performed all treatments themselves – I saw many doctors applying steroid creams or bandaging limbs. This meant that patients did not have to wait for a referral to nursing staff and could quickly be discharged home.
- · Patients sought more aggressive treatment. In the UK, broadly speaking, medical treatment is allocated based on disease severity, treatment availability and response to previous treatments. In the UK, for example, a patient with eczema would normally be treated with creams prior to steroid use. In Japan, however, the same patient could potentially start on steroid therapy or even phototherapy. This is because patient lifestyle is busier than in the UK (6-day working week) and therefore patients do not comply well with treatments which must be taken regularly to have an effect e.g. skin cream for eczema. As a consequence, more drastic – and effective – treatments were sought, in spite of the risk of side-effects occurring.
- · The types of diseases that I saw in clinic were different compared to the UK. In the UK, psoriasis and head lice are relatively common. In Japan, however, these are rare. Conversely acral melanoma (skin cancer of affecting the soles of the feet/palms of the hand) are common in Japan, and virtually rare in the UK.
- · In spite of Japan’s reputation as a centre of technological development, much of the diagnoses I saw were made by doctors in clinic and not by machines. This is also the case in the UK.
Outside of Hospital
I was able to explore the city and get a glimpse of the Japanese lifestyle during my weekends. Some of the hospital staff kindly took me to local landmarks such as Tokyo Tower, Tsukiji fish market and Tokyo Palace, and further afield to Osaka, Japan’s second largest (and most congested) city. In this way, I was able to try many local delicacies including sushi, tempura and takoyaki – part of the diet which is believed to promote longevity. I was also able to observe some local practices. In terms of medically-related practices, I witnessed restaurant patrons smoking indoors – something which I do not recall seeing in the UK. Indeed, I am curious if the smoking rate is higher in Japan, and if cessation is as effective there due to the abundance of people smoking in public. This is something that has been addressed recently in the UK due to health public policy –the smoking ban.
Overall my time in Japan allowed me to expand on my knowledge of medical practice (particularly how it is influenced by culture) witness treatment of diseases which are not common in the UK, develop an understanding of the the challenges faced by overseas visitors in a foreign health service (and country) first-hand and appreciate the health benefits that are offered by public health policies. Thanks to the grant I received from the Holywood Trust, I was able to gain experience in two fields of medicine, one of which I hope to pursue in my future medical career. I am truly grateful for your help in making this experience happen.