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Wednesday, Dec. 19, 2001
NO HELP ON THE WAY
Pediatrics strained to breaking point
By TOMOKO OTAKE
It was just after midnight one recent weekend in the emergency room of Showa University Hospital in Tokyo's Shinagawa Ward. Pediatrician Katsura Sugihara was treating his 12th patient of the night, when the phone rang.
It was from a nurse in the pediatric ward, saying she needed him right away to give medicine to patients.
He scurried out of ER and into an adjacent building housing the pediatric ward. Swiftly moving from one bed to another, Sugihara uncapped drips on the arms of the sleeping children and started injecting drugs.
Then his pager went off. The ER nurse wanted him back, saying waiting patients were hassling her.
Sugihara shuttled between the ER and pediatric ward with little rest, meanwhile nursing his own cold.
"This is the time of day when you could make a mistake," he said in the dark, quiet pediatric ward. "You are dead tired, it's dark and you are all alone. You could mistakenly put the wrong drug into a patient. Or you could forget to put the rail of the bed back up, causing the patient to fall out later."
Sugihara, 29, has good reason to be worried. His tribulations only begin to illustrate the many ills afflicting the nation's pediatric health care.
As Japan grapples with a declining birthrate by supporting families with children, and while more parents are seeking expert advice on the health of their kids, hospital pediatric departments are too short-staffed and ill-prepared to provide satisfactory care for ailing children.
With relatively few young doctors entering the field, many pediatricians are overburdened, working shifts spanning more than 32 hours -- two full days of work before and after a night shift -- five or six times a month.
Stress takes its toll
Stories of hospital pediatricians quitting their jobs due to work-related stress are everywhere. The strain pushes some even further.
Toshiro Nakahara, a pediatrician at Kosei General Hospital in Nakano Ward, Tokyo, committed suicide two years ago due to what his family and former colleagues considered to be depression brought on by overwork.
His workload snowballed from around spring 1998, as the hospital, struggling with finances, started to cut the number of doctors and staff, according to his lawyers. One month he worked 24-hour shifts at least seven times, they said, adding that, on top of long work hours, the pressure from management to improve profits was enormous.
By June 1999, he was habitually taking sleeping pills and showing signs of depression. Two months later, Nakahara jumped off the top of the hospital building, leaving a note that decried the shortage of pediatricians and their heavy workload, the lawyers said.
Tetsuro Tanaka, director of the department of maternal and child health at the National Institute of Public Health, said pediatrics is unprofitable for reasons unique to the nation's medical system.
Under the current system, hospitals can claim a certain percentage of payments from health insurance unions for medication and tests they give to patients. The government subsidy system has been criticized for providing incentive for doctors to abuse the rule by giving unnecessary tests and writing excessive prescriptions.
For pediatricians, however, the system works against them, Tanaka said. They prescribe medicine according to the patients' weight, so they can claim only a fraction of fees per patient compared with adults.
Also, the system does not take into account the additional manpower and patience that handling children requires. Babies, for example, cannot go to the toilet and provide urine for testing by themselves. Nor can they explain to the doctors what is wrong with them.
"The distortion of the postwar medical system in this country is magnified in pediatric care," Tanaka said.
Pediatricians grow scarce
Many general hospitals see pediatrics as an unprofitable division and are closing shop.
The number of hospitals with pediatric departments has dropped 17 percent from 4,502 in 1993 to 3,720 in 1998, according to the Health, Labor and Welfare Ministry. This in turn has increased the workload for the remaining hospitals with pediatricians.
The number of pediatricians has actually edged up 7 percent from 33,832 in 1992 to 34,064 in 1998, but that rise is proportionally small compared with the growing number of doctors -- a 12 percent increase in the same period -- across the medical field. In any case, the numbers fall short of the growing demand for pediatric care.
Young doctors like Sugihara shoulder the heaviest burden also in terms of finances. Doctors fresh out of school usually go through a two-year residency, during which they work 30-hour shifts for almost nothing.
Sugihara, who is in his fourth year of practice, still receives only about 70,000 yen per month from the university, not even enough to support himself.
It is standard practice for young doctors to work part-time at other hospitals to make ends meet, further increasing their workload and responsibility.
On top of all this, the trying circumstances pediatricians face make becoming one ever less attractive, creating a vicious cycle where the shortage of doctors is both cause and effect.
A recent study compiled by Tanaka has found that, out of 1,316 medical students who responded, 74.3 percent ruled out pursuing pediatrics, with many citing the harsh working environment and low financial rewards.
Yoji Iikura, professor and director of the department of pediatrics at Showa University, lamented that students nowadays prefer dermatology, ophthalmology or ear, nose and throat because "they want to make money without the pressure of night duty."
Many hospital pediatricians quit clinical work halfway through their career and find research positions at universities. Or they choose to open their own clinics and write their own schedules.
Tadashi Kataoka is one of them. He worked for a number of general hospitals, lastly at Japanese Red Cross Medical Center in Tokyo's Shibuya Ward.
Kataoka, who now has his own clinic in Kawasaki, said he quit the Red Cross hospital partly because he could not put up with his 32-hour shifts, including night duty.
"I still found nighttime ER exciting when I was in my 30s, because you never know what case will come up and your skill really determines the fate of the children," he said. "But once you turn 40, you start wondering if your physical stamina can last. And I started to hate being unable to be nice to patients after working 24 hours straight."
Where subsidies go
The central and municipal governments, aware of the shortage of after-hours pediatricians, are doling out subsidies. The Tokyo Metropolitan Government, for example, is providing 800 million yen this year to 51 hospitals that offer after-hours emergency pediatric services.
But little of the money is actually spent for pediatricians on night duty, said one doctor in his 40s who works for a private university-affiliated hospital in Tokyo.
The pediatrician complained that his hospital raked in 15 million yen this year from the metro government for providing pediatric ER, but only 2.5 million yen came to his department. The rest went to the hospital's general account, he fumed, adding: "My pay for the 16-hour night duty is only 10,000 yen. On an hourly basis, that is probably less than what cashiers at McDonald's make."
Hospital pediatricians on night duty are also kept busy by many patients who are -- contrary to the image conjured up by ER -- not necessarily in a life-or-death situation.
Family pediatricians these days take few night patients, especially in cities, where new clinics are located in office buildings and open only during the daytime on weekdays.
As more mothers work full-time, demand for after-hours medical care is on the rise. Exacerbating the problem is that fewer families -- especially in cities -- live with in-laws, who traditionally help out and teach young parents how to care for their kids.
While experts agree that the problems are enormous, none can write a simple prescription for solving them.
Some doctors say the medical fee system should be revised to reward pediatricians more for their specialty. But amid a recent trend to review the nation's spiraling medical costs -- for which elderly care is mostly blamed -- government officials are unwilling to commit to a rise in the fees for pediatricians.
"We are aware of the claims" that the fees are too low, said Yutaka Takeda of the health ministry. "We will consider matters from a comprehensive point of view, but I don't think we will take an approach where we will drastically increase the fees pediatricians can claim while decreasing those for doctors in elderly care."
In some municipalities, efforts to enlist pediatricians in providing primary care at night and on weekends are under way. For example, in Nerima Ward, Tokyo, the ward opened an after-hours pediatric clinic within its office building in June, with the help of independent pediatricians.
The move was intended to help alleviate the heavy concentration of patients -- mostly not serious cases -- at Nihon University Nerima Hikarigaoka Hospital, which attracts some 14,000 after-hours outpatients per year.
But in the six months since the service was launched, the number of children who visit the hospital remains about the same, a doctor said.
Some doctors, including Kataoka, said parents should stop to think before going to hospitals, and should know some basic guidelines.
For example, a baby 1 month old or younger who has a fever is an emergency case, but babies aged 6 months or older can wait until the next day to see a doctor, Kataoka said, adding that in case of convulsions, while it is understandable for first-time parents to panic, they can wait five minutes before calling an ambulance -- in most cases the convulsions stop by the time the baby reaches the hospital.
Tanaka of the national institute meanwhile said that the long-term solution will hinge on whether there is a national consensus that more public money should be spent on pediatric care.
"All citizens should realize the need for pediatric care as an investment for the future," he said.