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Japan: Doctor shortage, the medical system in crisis

Together with the economic crisis the shortage of doctors (医師不足, ishi busoku in Japanese) is becoming more and more urgent in Japan. As a Fire and Disaster Management Agency survey pointed out in 2007, the causes are the uneven distribution of the doctors mainly settled in urban areas and the fact that the medical profession has lost its attractiveness, because of the work load and salaries which have lagged behind other professions. Also the increasing age of the Japanese population and the consequent rise in the patient numbers has contributed to an impending collapse of the medical system.

20090224_shinjuku_12

by flickr user pqw93ct, used with permission

Among the symptoms are the large number of cases, (the last one happened in February) which sees patients turned away by the hospitals because of the lack of beds or staff. Also the unduly long shifts for the few doctors left, with the attendant risk of accidents due to fatigue.

One patient, Seichiro Sonoda (園田 誠一郎), tells of his experience when he was startled by the large number of patients crowding the hospital waiting rooms.

大学病院に行ってきたのですが患者の多さにびっくりしました。
耳鼻科と採血の2ヶ所とも椅子にあふれんばかりの患者さんでごった返していて、今の医療業界の現状を垣間見たような気がしました。
医者不足だそうですね。

I have just been to a university hospital and I was astonished by the number of patients waiting.
In the otolaryngology ward and the blood donation ward there was great confusion and all the seats were full. I had the feeling that I was really witnessing the parlous condition of the medical system
They call it “doctor shortage”.

At Isha Ni Naru Hoho (医者になる方法 lit. how to become a doctor), a blogger explains the problem of the uneven distribution of doctors in the country.

厚生労働省の調査によると、医療 法の定める医師の配置基準の充足率は、全国で約83.5%(2004年度)。東京や大阪などの首都圏・近畿圏は概ね90%前後の充足率を達成していますが、田舎へ行くほど充足率は下がり、全国最低の青森県ではわずか43%に過ぎないと言う惨状です。

According to a Ministry of Health and Welfare's survey (2004), the desirable rate for standard distribution of doctors is set by the Law on Medical Treatment at about 85% overall nationally. The area of the capital Tokyo and that of Kinki, with Osaka, reach more or less 90% but the rate gets lower in the countryside and particularly in Aomori Prefecture where it only reaches about 43%, unfortunately.

これは、田舎や離島・へき地での勤務を希望(容認)する医学部生が極端に少ないことが原因です。へき地勤務を選ぶことで学費が免除される自治医科大学でも、卒業生の約6割が(学費返済を条件に)大都市圏での病院を選んでいるのが現実です。

The cause of this uneven distribution is the fact that very few medical graduates want to work in remote villages or islands. Even though the autonomous universities have a system which allows graduates, who choose to work in the isolated areas, to have school fees exempted some 60% of the graduates decide to work in hospitals in the area around Osaka even though school fees must be repaid.

また、特に産科医と小児科医の不足は深刻です。というのは、産科と小児科は、どの医者に聞いても「最も過酷な診療科だ」と答える位、激務な仕事だからです。

In particular, the shortage is worrying in the field of obstetrics and paediatrics. Ask any doctor and they will respond that “these are the most exhausting medical fields to work in”.

A Japanese girl who studies to work at the E.R. illustrates in detail the causes and the consequences of this shortage of doctors.

まずドクターの場合、

The problem of doctor shortage has several causes:

①2004年度より始まった厚労省の愚策のせいです。
(掲げる理想は間違っていなかったのですが、急すぎて厳しいものがあります。)
端的にいうと、実質的な教育期間がさらに2年延びました。
それにより、具体的な数字は忘れましたが、
約16000人の新しいドクターの供給がストップしたに等しいです。
それがevenになるまでに、かなりの時間を要します。

1. One of the cause is the stupid plan started by the Ministry of Health and Welfare in 2004. (The plan itself was not wrong in its purposes but it was too rushed and now we are experiencing the unintended consequences. )
They prolonged the training period by 2 years consequently, I forget the exact numbers, it's as if they had blocked the graduation of almost 16,000 new doctors.

しかしそれ以前に、日本の場合、根底として、

But perhaps the causes lie in the basics of Japanese demographics.

②他のどの国も経験していない未曾有の高齢化(スピードという意味で)により、過去10年で、患者数が激増しました。
これに追いつくだけの医療者を育てるのには時間とお金がかかりすぎます。

2. Because of the unparalleled increase in elderly people, which is greater than in any other country, the number of patients has risen enormously in the last 10 years. In order to deal with this fact there is urgent need for both time and money to train new doctors.

③とてもとても小さな理由でわざわざ大病院を訪れる人が多い。
[...] これは単に私の実感として常にあります。
私の祖母とか、「散歩を兼ねた趣味」として、月曜日はどこどこ、火曜日はどこどこ、と、病院通いをして友達を増やしていますから…。

3. There are many people who go to the hospital for even trivial reasons. [...] This is simply my feeling but I think that many like my granny attend hospital merely to make new friends here and there and on different days of the week, as if it was both a hobby and an excuse to go for a walk.

④日本のドクターは、国立大学の場合、税金で育てられる。
これがどこまでをカウントするかによりますが1人辺り5千万円を超えるといわれます。
(学生の負担は6年間で計330万円、貧しいと免除です)。

4. In case of public universities, the Japanese doctors are paid with people's taxes.
Now, it depends on what you consider when you calculate the total amount of money but it is estimated that for each doctor trained more than 50 million Yen is spent. (Students are charged 3,3 million Yen for 6 years but if they can't afford this it may be waived).

[…]

⑤税金で育てらた限りは、育ててもらった大学がある土地(主に田舎)で8年ぐらい(~永久)奉公をする義務、というのが以前はあったんだけど、
それが2004年に急になくなった結果、田舎で奉公をしない人が圧倒的に増えました。
(私も少ししかやってません。いずれやるつもりですが。)

5. In the past there was the obligation for those who had been educated with public money to render service in the area of the home-university, generally in the countryside for at least 8 years.
However in 2004 this condition was abolished and the number of doctors electing to work in the countryside drastically declined.
(Personally, I did it only for a short time but I have every intention to do it sooner or later)

[…]

そして、国立の場合、
⑥その税金への恩返しとして「noblesse oblige」という観念を叩き込まれます。[…]
そういう意味で、確かに、やれ給料の増加だの、休みの増加だのと、大声で主張してはいけないという文化が、根強くあり、これが結果的に職場環境の整備を遅らせてきた、という事実があると思います。

Lastly, in case of [doctors graduated from] the public universities:
6. They have drummed into them a sense of responsibility and gratitude for the public money received, a sort of ‘noblesse oblige’ if you will. [...]
In this sense and because of our culture where it is considered wrong to agitate loudly for a pay raise or more leave, truth is that improvement in the working environment still has far to go.

Lastly, blogger at labayame reflects on how the image of a doctor has changed over the years.

以前は、子供を医者にするのは親の夢
進学校から有名大学医学部へ進むのは
エリートコースとされていました
今は、どうなのでしょうか?

In the past many parents’ dream was to have a son become a doctor.
Entering the medical faculty of a famous university was considered a privilege.
But now?

相変わらず最高位の国家資格である
医者への希望者は、多いでしょうが
卒業後、医者になった人は
「志高く」仕事をしていますか?
もしくは、現実に驚愕ですか?

Certainly many still desire to become doctors and obtain one of the most prestigious national qualifications but, after the graduation, do those who have become doctors work with the same dedication or does harsh reality change them?

医者不足で公立病院が閉鎖しても
私立病院が増えている訳ではない
医師免許を持つ方は、何処へ?

As well as some public hospitals being closed by staff shortages, the number of private hospitals hasn't increased either. So where do those who have earned the license to practice medicine go?

今は、医療技術、医療機器の進化で
かなり危険度は予知できるのですが
人間の出産は、今だ謎に満ちていて
想定外の事も発生するのでしょう
一方、医療の発達が明らかになるほど
運が悪かったでは、済まされない事が
明らかになり、医療訴訟となるのです

Nowadays, with the evolution of both medical technology and the equipment for medical procedures, the risks in treatment are generally small. However, childbirth is still a mysterious event for some aspects and you can never know with certainty what may happen. The problem is that if for any reason, despite the advanced equipment, there are complications then [the patient] immediately threatens a lawsuit.

[…]

医者が、いくら勉強していても
医療現場では想定外だらけの
事態が発生するのでしょう
妥協点は何処なのか
今後は、何処まで処置できて
何処まで処置できないのかを
事前に明らかにして、同意後
医療を進めるという時代かも
そうなると、昔のように
先生に、おまかせします

A doctor, even though he studies widely, may always have to face situations that he couldn't expect.
So the problem is…where is the meeting point [of patient/doctor responsibility]? In future maybe there will come a day when the doctor and his patient will agree on a medical treatment and on what the treatment can and cannot solve.
If that moment arrives, we may have to say to our doctor “I leave everything in your hands”, just as once we used to do.

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