Japanese health-care issues still building
Ah, socialized medicine. No one gets extravagant care, no one gets inadequate care–we all get good, solid, top-of-the-line care delivered as cost-effectively as possible.
Except when we don’t:
The deaths of four patients at Tokyo Medical University Hospital as a result of coronary artery bypass operations performed by one of its surgeons has highlighted the fact that the hospital failed to properly operate a system under which the surgeon’s skills could improve.
An external committee investigating the hospital on suspicion of malpractice pointed this out at a press conference on March 30 in Tokyo following its probe of the hospital’s second surgery department, to which the 45-year-old surgeon belonged.
The independent committee was established in December and comprises five heart surgeons from outside the hospital.
One of the committee members said at the press conference: “The surgeon was unskilled. He hadn’t acquired the basic knowledge required for heart surgery.”
Do be sure to click on the link and keep reading–it gets worse from there. Bear in mind that Tokyo Medical University Hospital is not some little backwater institution, either. And heart surgery, in a first-world population that is rapidly aging, is not an obscure little specialty. And screw-ups in the health-care system have been news for at least the near-decade I’ve been here.
Of course, Japan’s nationwide certification systems–not just those of the hospital–may need review:
Japan has about 260,000 doctors, but there are about 300,000 specialists as some doctors hold more than one specialization, an indication of how easy they are to get.
I don’t really know what to make of this–maybe the US is as bad. I’d have no trouble believing that it isn’t, though. The Japanese, in all fields, love certifying boards, but that doesn’t necessarily mean high standards are consistently maintained.
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In related news, a committee of the Japan Society of Intensive Care Medicine has proposed guidelines for treatment cessation–again, a very sticky issue in an aging society (English version, which differs in small points from my translation, here):
The committee proposed strict conditions as grounds for cessation of treatment: (1) multiple doctors have administered the highest-level of treatments currently available [for the patient’s illness], (2) the medical facility has informed the family that it has the option to seek a second medical opinion from a different hospital, (3) doctors with the fullest available experience and specialized knowledge have confirmed repeatedly that it is impossible to save the patient.
In addition, the proposal establishes four options that a medical facility must offer to the family [of a patient whose case meets the above conditions]: (1) intensifying of treatment, (2) maintenance of the current course of treatments, (3) decrease in amount of medication or treatment, or (4) cessation of treatment. However, in the case that cessation of treatment is chosen, it is forbidden to detach the patient from an artificial respirator, oxygen supply, or minimal supply of water and nutrients.
Mercy-killing is an issue that’s started to bubble through the Japanese medical system, erupting most recently in the conviction of a Kawasaki doctor for murder:
Suda has insisted that she removed the tube and instructed the nurse to give him muscle relaxant without attaching a respirator in a bid to help him die in a natural way at the request of his family in November 1998.
…
Presiding Judge Kenji Hirose denied her claims.
“There was a possibility of recovery. The court doesn’t find that she provided the best treatment,” the judge said.
As for Suda’s claims that the patent’s family approved of her actions to help him die naturally, Hirose said that the doctor misunderstood the family’s mindset.
As reasons for suspending the sentence, Hirose said that Suda tried to help the patient die naturally for the sake of his family although she misunderstood his family’s sentiment at that time.
In this case, the tragedy was pretty clearly a misunderstanding. The patient was comatose; the prosecution acknowledged that he was expected to live only a few weeks. The doctor claimed that she had given him not a lethal dose of muscle relaxant but just enough to try to keep his airway open after the tube was removed. I’ve seen no medical evidence to prove or disprove that; if it existed, I think it would have come out in the two or three years the case has been around.
However, health care costs are skyrocketing in Japan, for obvious reasons. For now, Social Insurance still makes it possible for the four options enumerated above to be equally feasible, I think, for most people. It’s not hard to imagine that triage-minded doctors, constrained by funding and resource shortages, will in the not-too-distant future gradually begin more frequently urging family members to approve cessation of drug and surgical treatments, with only nourishment provided.
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I know that American readers will be reminded of a recent, similar (thought not entirely parallel) case in our own country. I haven’t said a public word about that case in two years, and I’m not going to make it a topic here, because I’ve found that no one on either side of the debate has been able to do so without speculation about who really loves and understands whom, within a family most of us don’t know at all. So if anyone is inclined to comment, be it known that any comment mentioning that case explicitly will be deleted. I don’t care whom it’s from.
Well, oncology is one area where multiple specializations are required, because oncology really is not available as a discipline in Japanese medical schools. Most cancer was and is treated by organ-specific surgeons. That bothers me a bit, as surgeons in the US cut first and medicate afterward. Japanese docs are a little better, but there is something odd about getting chemo from a surgeon.
Neurologists or anesthesiologists who also treat in hospital-affiliated or in stand-alone pain clincs also might have two specialites listed. With just those two examples, I bet I covered a lot of the docs who list multiple specialties. The definition and distribution of specialites in Japan differ widely from the US. So, I’m not sure that the number of multiple specialites is really that much of an indicator of poor quality (although it is an indicator of an ossified academic establishment), but I do wholeheartedly agree that the standards are too lax.
John,
Since I can’t edit comments, I had to delete your last one and move it to this post–this was where you meant to put it, right?–and since I can’t post under your registered name, I had to post as a guest with some stuff after the “John.” Sorry about that.
As for the content…yeah, I really don’t know how to judge. I do know that in general, it’s never safe to bet in Japan that just because something has lots of official oversight it’s actually being strictly monitored.