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Saturday, Nov. 15, 2008
A doctor in the house? Do you feel lucky?
With fewer opting for OB-GYN grind, even in big cities, good help — or even any help — can be hard to find
By ALEX MARTIN
After being turned away by eight Tokyo hospitals last month, a 36-year-old woman died of brain hemorrhage after giving premature birth by Caesarian section. A month before, a 32-year-old pregnant stroke victim was bounced among six hospitals before one finally accepted her for treatment. She is currently reported to be in a vegetative state.
A spate of incidents in which perinatal care centers — 24-hour emergency centers for infants and pregnant mothers — failed to help those in dire need of immediate medical attention has once again spotlighted a problem slowly corroding Japan's medical system: the lack of doctors and an apparent rigidity in the system that hampers remedial change.
"We need to create a system that allows healthy competition and sufficient rewards, both monetary and psychological, for doctors working in high-risk fields," said obstetrician Masakazu Tamura, stressing that working conditions for doctors like him are "exhausting."
Fed up with toiling long hours for relatively low pay, obstetricians, surgeons and pediatricians have been opting out for the past decade.
A study released Nov. 2 by the Japan Society of Obstetrics and Gynecology revealed that obstetricians spend more than 300 hours a month on average at hospitals — the equivalent of 10 hours a day without any days off.
Takafumi Shimizu, a 24-year-old medical student, said he knows doctors who work 36-hour shifts, and expects he will be doing the same. "The system shouldn't let this happen, but that's the reality," he said.
According to data compiled by the Organization for Economic Cooperation and Development in 2005, its member states had on average 290 doctors per 100,000 people, whereas Japan had only 200, despite the country's reputation for providing world-class medical care.
Besides the lack of doctors, a larger collapse of regional health care has been attracting media attention. A new clinical training system introduced in 2004 assured interns the freedom to choose where to be posted for their mandatory two-year training, which some say has accelerated the shortage of physicians in rural areas.
Mitsuyuki Fukuda, vice president of the Akita Medical Association, thinks otherwise. "The new system only acted as a catalyst in bringing to the surface an underlying problem the government has been ignoring for all these years," Fukuda said. "The imbalance of doctors in rural and urban areas is a result of a combination of several factors, primarily the discrepancy in regional economies," he explained.
According to Fukuda, prefectures that fail to provide adequate employment opportunities for the younger generation find that their populations and economies shrink. This lowers community morale and creates a general downward spiral.
"A combined lack of vitality in the regions and their economies obviously do not appeal to young doctors. Their eyes will naturally turn toward large cities," he said. "Although as we have seen with the recent incidents involving pregnant mothers, metropolitan areas, which are supposed to be better equipped than rural areas, also seem to be suffering from system failure."
To counter the problem, the government, led by health minister Yoichi Masuzoe, has decided to increase the enrollment capacity of medical schools in 2009 by 700 — a record high. Simultaneously, it's asking for a bigger budget for various projects intended to improve conditions.
"We're asking so-called magnet hospitals (popular hospitals that attract many physicians) to dispatch some of their doctors to hospitals that are understaffed," said a health ministry official, explaining some of the procedures the government is promoting to respond to the crisis.
"We also plan on investing in enhanced working conditions, as well as considering cutting back the training period to one year instead of two," he said.
However, Fukuda was critical of the government's response. "It's way too late, and their policy mistakes have resulted in deaths. I wonder which politician or government official is going to take responsibility," he said.
Shimizu, the medical student, was also skeptical of the government's policy reversal after years of indifference. "An increase in medical students means less training per student," he said. "I think the situation will worsen in the years to come."
Although criticism of the government is heated, some say medical experts also need to take matters into their own hands.
"Yes it's a fact that Japan lacks doctors, but we cannot just rely on the government," said Kiyoshi Kurokawa, chairman of the Health Policy Institute, Japan.
Kurokawa, who spent 15 years working at a U.S. university hospital, said doctors need to take the initiative in laying out a concrete vision for improving health care.
"Don't let the government decide what type of doctors we need and where we need them most," Kurokawa said. "Let the doctors and local governments decide. What we're lacking here is professionalism, a result of over five decades of one-party rule and a complete dependence on the government to decide everything for us."
Kurokawa suggested promoting the so-called open system, a method adopted in the United States whereby local private practitioners can use a hospital's facilities when treating their patients. In Japan, once a patient is taken to a hospital, medical responsibility is handed over to its doctors.
"Also, there are too many understaffed hospitals concentrated in one area," Kurokawa continued. He stressed the need to balance the population-hospital ratio so a well-staffed core hospital can sufficiently serve a population group, rather than having multiple dysfunctional hospitals bouncing patients around.
According to a recent health ministry survey of 75 perinatal care centers nationwide, 15 of the facilities had only six full-time doctors. At least 10 doctors are considered necessary to maintain a functioning center.
During a press conference in late October, the husband of the deceased mother made it clear he had no intention of blaming her death on the doctors involved. If anything changes in the medical system, "I'd like to tell our child, 'It was your mother who prompted that to happen.' "
Kurokawa, however, insisted that for any real change to occur, people need to understand that it's up to them to demand the policies they want.
"People need to decide for themselves what's best for society," he said.