The medical reality in Japan seems stranger than fiction. We often hear horror stories of pregnant mothers not finding a hospital to deliver a child, dying in transit, delivering their babies in ambulances or at home unassisted by paramedics. Most of these stories belong to hospitals in Tokyo, a metropolis that is the hub of both political and medical activities in Japan. We can rightly guess the inhospitable conditions in suburban areas or remote islands. There are regions where there are no doctors. The emergency cases from such regions have to be taken to far-flung places for treatment. The dearth of obstetricians is so acute that in the three-year period, from 2004 to 2006, there have been 2939 cases of pregnant women who were refused admittance to one or more hospitals in Japan. 

Like all the other systems that have failed or are failing, beginning with the education system to the insurance system, the medical system too gives us a false impression of robust strength. It makes us believe that it is facing a temporary shortage of doctors and soon this will be overcome. Both the government and the JMA have functioned on this assumption but they have increasingly begun to realize that the problems will not just go away. The medical system has worked well with its diverse protectionist measures and narrow policies for nearly half a century, but with the decline in population, aging of society, costly medical education, antiquated teaching methods, strenuous job profile, urban-rural salary differences and disinterestedness amongst the young towards the medical profession, hospitals are losing doctors and nurses at a fast rate. The more experienced and skilled physicians are so stretched that some of them have left the medical profession and sought other careers or are on the verge of mental breakdown.

Last week the 350-bed Higashijujo Hospital in Kita Ward, Tokyo closed its doors to inpatients and outpatients citing shortage of doctors. It decided to suspend all medical services from October 31st 2007. Most of the doctors to the hospital were supplied by the Nihon University School of Medicine, which refused to send them to the hospital, as it needed them too. Of the thirty doctors working at the hospital a week ago only two remained. Obviously the hospital was in no position to treat even outpatients. Most hospitals like the Higashijujo depend on university medical schools for their quota of doctors. Now that the university hospitals are running short of doctors, regular hospitals find it increasingly difficult to treat patients. Undoubtedly the problem in other cities and outskirts is more acute. Local residents realize this problem and choose to go to a university-run hospital, as it would ensure reliable medical attention.

The Japanese medical system is sui generis. The medical practices here are quite different from those in other developed countries. In the west a general practitioner visits the homes of patients who cannot go to the hospital on their own. In Japan doctors never visit the homes of patients. Even if a patient needs immediate attention he is expected to follow the general assembly line system and wait for his turn unless he is in a critical condition. The assembly line system forces patients to use the hospital ambulance as a free taxi service, thereby preventing critically ill patients to avail of the hospital transport facility. Some hospitals are so frustrated by patients using ambulances as taxis that they are calling for a legislation to punish those who call an ambulance on flimsy grounds.

The singular nature of the medical system continues in the procedure of dispensing medicines, assigning hospital timings or creating weekly schedules. The medical prescriptions are valid for about three days after which the patient is expected to visit the hospital one more time to get a fresh diagnosis and medicine. This gives hospitals the much-needed revenue from both the patients and the government but it also increases the pressure of work. Furthermore, in Japan the regular services of most hospitals are suspended on Saturday and Sunday. Some of these hospitals are open partially on weekends and take turns to operate as emergency centers for a large area. Doctors are not available on hospital or mobile phones for consultation. Patients must travel all the distance to the hospital to avail of the skeletal medical service which hangs like a fig leaf making them somewhat embarrassed why they came. Most hospitals now encourage patients to call their emergency service prior to visiting them in order to filter out cases that may not be serviceable during 'off hours.' Unless a case is treated as an emergency it may not be given high priority treatment. Some hospitals even refuse admittance to serious cases citing shortage of staff and refer them to other hospitals. 

The medical profession is no longer seen as financially lucrative or emotionally satisfying. The JMA has recently reiterated the altruistic aspect of care giving as one of its objectives. The medical schools charge exorbitant sums as tuition fees and this deters most young people from choosing the medical profession as their calling. The young do not wish to spend enormous money, study hard to become doctors and then work equally hard at nominal salaries. The risks and liabilities are far greater than the gains. Many patients are now filing lawsuits against hospitals and doctors demanding large sums of money as compensation for a botched case. 

The preferences of medical students also play a large role in aggravating the shortage of medical doctors. Most students at medical schools are choosing to specialize in areas other than gynecology as there are fewer risks of malpractice lawsuits and the work schedule is not heavy. The recent horror stories have to do mostly with pregnant women who could not reach the hospital on time or were refused admission due to lack of obstetricians. Many medical students feel that as fewer women are giving birth to children, their chances of gaining experience on real-life cases are decreasing. As the opportunities to practice gynecology is becoming less, fewer students wish to specialize in the branch. The JMA also realizes the scarcity and uneven distribution of pediatricians and obstetricians in the medical industry and intends to set up a 'Female Doctor Bank' in cooperation with the Ministry of Health, Labour and Welfare, but this move may not completely address the problem. Unless the government subsidizes the specialization in gynecology and pediatrics the problem at private hospitals will not be removed. 

The intense competition and professionalization in medical schools has shifted the emphasis from student-based education to research-based work. Most medical schools are interested more in conducting advanced research and less in providing clinical clerkship or practical bedside training to their students. The overspecialized graduate medical education further adds to their lack of apprenticeship and practical experience in hospital care. Most Japanese medical students therefore lack a clear understanding of patho-physiology, clinical reasoning, differential diagnosis and direct patient management. To add to this drawback most medical students do not get a broad-based education in humanities, social sciences and the sciences before or during their study at medical schools. Most Japanese universities, based on the buddy system instead of the merit system do not employ qualified teachers to teach these subjects in a clear fashion. Furthermore many medical students complain that even at medical schools they do not find faculty members who can combine sound clinical expertise with effective teaching skills. The high profile professors are busy conducting nano-technology or advanced medical research, earning kudos from the medical industry and the government in the form of research subsidies or better job offers. 

The unique nature of the medical system and its protectionist policies do not, as a general rule, allow non-Japanese doctors or nurses to work in the country. Some international hospitals that are allowed to function are not supported by government subsidies or insurance. As such they charge exorbitant sums and can only be accessed by the super rich. The Tokyo Midtown Medical Center opened this year by Baltimore's John Hopkins Hospital charges 80,000 yen (about 689 USD) for a one-day appointment and 2 million yen (about 17,230 USD) for a three-day medical checkup. 

There have been experiments with Chinese doctors and Philippines nurses but they are rather few and far between. Even Japanese students studying for a medical profession in Australia or Europe are not allowed to return and join the Japanese medical system. Many conservative ideologues argue that unless doctors are familiar with the Japanese language, customs or medical practices they will not be able to offer effective treatment to Japanese patients. Most of the Japanese doctors prefer to stay in big cities and feel frustrated with long working hours and low wages. If this is the condition of the medical system in normal times, then what would happen in the event of a natural disaster such as earthquake, tsunami or an epidemic? We hear of the JMA drawing up a program of medical assistance during national disaster but a lot of it is based on just premises or untested conclusions.

Japan must evolve a new system that would be conducive to its needs. Just importing a European or American model would not do either. The medical system should be overhauled completely which will improve the working conditions of Japanese doctors and allow foreign doctors to enter the profession as equal partners. Unless these structural problems are taken care of immediately the Japanese medical system will not be able to provide effective treatment to all its citizens.