Japan is renowned for having an ancient and elegant culture, steeped in tradition and history. It is also a wealthy and busy country with, to the Western eye, some unique quirks. With all of this comes a range of health problems. Philip Alexander finds out how medicine uses electronic gadgetry to care for the population
The land of the rising sun is not a popular destination for elective students despite a rich variety of opportunities for both learning and cultural experience. One reason may be the language barrier: Japanese students learn to read and write English but not to speak it, and very few of us can communicate in Japanese at all. In addition, people seeking electives at the cutting edge of modern medicine seem to look first to the United States or Australia.
Why Japan?
Japan is a wealthy modern country with an ancient history and a culture different from the West, and I wondered whether the ideals central to medicine in the United Kingdom were common to Japan also--for example, the nature of the doctor-patient relationship and the application of ethical principles.
Although I expected Japan to have a similar disease profile to other developed countries, I found some variants and diseases that I had not encountered before. Medicopolitically, it was interesting to consider whether Japan, in the middle of an economic crisis, faced the same delivery of care problems as in the United Kingdom--bed shortages, long waiting lists, and insufficient resources. Of course, I was also strongly motivated by the opportunity to travel around this fascinating country.
Getting a placement: the Kameda Medical Center
Few hospitals in Japan have established elective programmes, although a quick search on the internet quickly helped me find one. Kameda Medical Center is a 900 bed, privately owned teaching hospital on the eastern coast of the Chiba peninsula, about two hours' drive from Tokyo. It is one of the largest and most progressive private hospitals in Japan. To create the best combination of Japanese and American medicine it has been employing American doctors with a background in teaching for the past 9 years.
My elective was in cardiology, although there were seminars in general medicine and neurology on most days that I could attend if I wished. The average working week for the juniors in cardiology is Monday to Saturday, 8 am to 8 pm, but I slacked off and worked only five days each week. The doctors are keen to teach students on the rounds and during the seminars that occur during the week, but clinics are too busy for teaching.
Cardiovascular disease in Japan
Until recently, coronary artery disease was uncommon in Japan, mainly due to the abundance of vegetables and fish in the diet and the lack of oily or fatty food. The low levels of low density lipoprotein cholesterol more than offset the high prevalence of smoking and hypertension. Interestingly, some psychologists suggest that the traditional workplace is not rife with hostility and interpersonal competitiveness but is instead a long term emotional network with a significance similar to family. Recent increases in cardiovascular disease may be due to the adoption of a more sedentary lifestyle and Western diet. In addition, the uncertainty in the workplace since the beginning of the economic crisis may have played a role. Certainly rates of Karoshi--death through overwork--have increased.
Although the bulk of the workload of the cardiology service is due to ischaemic heart disease, there are some interesting variants of cardiovascular disease that are uncommon in the United Kingdom. For example, around two thirds of cases of angina in Japan are vasospastic (also known as Printzmetal's) angina. This condition is characterised by chest pain caused by spasm of the coronary arteries--the coronary angiogram in these patients is normal.
Takotsubo's cardiomyopathy is a rare disorder that has only ever been observed in Japan. It causes apical ballooning of the myocardium, often after myocardial infarction, and resolves spontaneously after about two weeks.
Although valvular disease is no more common in Japan than in Western countries, I saw two cases of mitral stenosis and several cases of mitral regurgitation and aortic regurgitation. This allowed me to practise cardiovascular examination and hone my murmur detecting skills.
The future of health care?
The use of technology at Kameda was evident everywhere. Electrocardiogram machines--attached to all patients--transmit information to monitors in the nurses' station. High risk patients--for example, elderly patients with dementia or in an acute confusional state--are placed in beds under the scrutiny of tiny video cameras that hang unobstrusively from the ceiling.
The bleeps for intrahospital communication in the United Kingdom have been superseded at Kameda by a local "personal handyphone system." The handsets--which look and work like mobile phones--can only be used within hospital premises and, unlike mobile phones, do not affect the functioning of medical equipment.
Perhaps one of Kameda's greatest triumphs is its electronic patient record. This custom built system incorporates both the medical and the nursing notes. Having a computer based system makes it possible to access and enter information about any patient from any location in the hospital: there are laptop computers throughout the building. Most of these computers are not connected to the network by wires, but have a wireless transmitter making it easier to move them around.
After entering a password, all aspects of a patient's record are accessible. Nursing observations such as temperature, blood pressure, heart rate, etc, are recorded every hour directly onto the computer system (there is a laptop in every patient's room on the ward). As for the medical side, investigations can be ordered and the results viewed, including x rays, echocardiogram reports, and electrocardiograms.
Patients are given a great deal of information about their hospital stay. A sheet of paper that contains photographs of every tablet that they have been prescribed, along with an explanation of what it is for, and its side effects, is particularly useful when patients see doctors at different hospitals.
The rest of Japan
It would be negligent not briefly to mention travelling around Japan. Tokyo is, in many ways, like any other capital city in the world. Kyoto, in contrast, is what many people probably imagine Japan to be like: a host of temples, statues, castles, and other historical and religious sights.
The Japan rail pass allows unlimited travel on almost any train in Japan: this can be used to full advantage on the famous Shinkansen bullet trains. Crime is almost unheard of, and Japanese people are incredibly courteous, friendly, and accommodating, as long as you are equally accepting of their culture.
If you wish to see some high tech medicine on your elective, and you like the taste of raw fish, you now know where to go.
