A Glimpse of Culture & Healthcare in Japan: Observations from an Oncology Experience

Published 11/02/2022 in Scholar Travel Stipend

Written by John Shen | 11/02/2022

The island country of Japan, located in East Asia, has long been a harbor of trade, technologic advance, and cultural importance. As home to over 120 million people, Japan ranks amongst the top ten most populous countries. The city of Tokyo is a bustling region of commerce and tourism. As the capital city of Japan, nearly 10 million inhabitants reside in Tokyo.

From a cultural standpoint, many historic elements remain deep rooted in the day-to-day behavior of its residents. Public gardens, temples, and shrines are dispersed throughout the country. Subways and trains are kept clean, quiet, and timely. Even at the fullest capacity, a slew of new riders can be expected to politely invade your personal space at the next overly congested stop. At certain peak hours, women have the luxury of additional “reserved” sections or cars of the train. On the streets, students can be easily identified by their standardized uniforms. In stores and restaurants, ordering and paying solely via technology or electronic interface is common. An atmosphere of respect, responsibility, efficiency, and service is pervasive.

From a healthcare standpoint, Asian countries have become determined to control health spending with various approaches to financing and delivery. Japan, in particular, is known for strict cost control and setting limitations on healthcare reimbursement. In contrast, the U.S. has one of the highest total healthcare expenditures per capita in the world. In terms of life expectancy, the Japanese population has historically outlived almost all other countries. In the most recent years, this amounts to an overall increase of about 5 years compared to the U.S. population.

There are similarities yet marked differences in both the delivery of medical care and the medical training process between these two countries. Access to healthcare in Japan is universal. Patients have their choice of medical facilities and resources, limited only by their ability and desire to travel. From a logistical standpoint, there is an overt difference in the extent of ancillary support for physicians. In the U.S. healthcare system, we have an abundance of support staff as part of healthcare teams. These include but are not limited to nurses, nurse supervisors, physical therapists, occupational therapists, social workers, case managers, and hospital management. They may even range to include patient relations personnel and transport staff. This level of detail for work responsibilities is simply not as prevalent in the Japanese healthcare delivery system, at least from an inpatient oncology ward perspective. Physicians are expected to do their own phlebotomy (blood draws) and administer their own chemotherapy. One may ponder if this level of direct participation in the actual delivery of healthcare requires a provider to be more judicious when ordering tests or deciding on therapy. These decisions may have downstream consequences with regard to cost and the overall economics of healthcare delivery. This scenario, multiplied by the sheer number of outpatient and inpatient healthcare settings can already offer a glimpse into the cost control element of healthcare delivery in Japan.

Similar to U.S. oncologic care, there is significant support in Japan for making treatment options available to patients on an outpatient basis. This saves hospital admissions, decreases length of stay, and prevents iatrogenic complications (which are due to medical intervention or treatment) such as nosocomial (or healthcare-associated) infections. At the National Cancer Center Hospital in Tokyo, newly constructed outpatient treatment spaces were some of the institutional highlights.

An interesting observation of clinical research differences in Japan compared to the U.S. is that a typical oncology ward in the U.S. would consist of all inpatients that needed any form of treatment, regardless of whether this treatment was considered standard of care or investigational. The ward would also usually consist of patients with different types of cancers. In Japan, for both the inpatient and outpatient settings, there are specifically designated areas for “experimental” or “phase one” research, commonly thought of as early investigational studies. This means that patients on research protocols may be housed in a completely different area than patients receiving already approved standard of care therapy. This opens the door for unique psychosocial considerations that are simply not seen in the U.S. system.

In terms of medical education and training in Japan, conversations with physicians at the National Cancer Center Hospital in Tokyo revealed that physicians-in-training are expected to specialize quite early on in their educational system. For example, in the U.S., a typical education timeline would consist of undergraduate studies (usually 4 years and may not necessarily be focused on medicine or science) followed by medical school (typically another 4 years) followed by post-graduate residency (can range 3-8 years) and then possibly additional fellowships if further subspecialty training is pursued. This easily represents over a decade of medical education and training prior to practicing independently. In Japan, medical school can be and usually is the first formal educational program after completing high school. In addition to this, after medical school, Japanese physicians-in-training are expected to directly pursue a certain scope of practice. In the U.S., a budding medical oncologist typically completes a general internal medicine residency (approximately 3 years) prior to their subspecialty fellowship (an additional 3 years) which provides training in both hematologic (e.g. leukemia, lymphoma) and solid malignancies (e.g. lung, prostate, breast, or colon cancers). Though there are many benefits to a broad and comprehensive medical training background, an earlier differentiation by a physician may offer several more years of making field-directed advances and contributing to meaningful scientific progress, especially earlier on in one’s career.

In terms of partnership in clinical practice, a similar “on-call” model is followed in the Japanese medical system. At the National Cancer Center Hospital, physicians are responsible for the routine care of their designated patients and are expected to follow them throughout the course of their treatment to ensure continuity. In addition to this, for cases of strict emergencies, there remains an in-house physician (both resident and attending physicians) to address unexpected complications. The scope of these responsibilities is relatively similar to the U.S. system and the frequency of these shifts is also comparable.

Japan is a country of tremendous culture, pride, and ingenuity. From an economic perspective, the U.S. healthcare system could definitely benefit from incorporating elements of cost control and limitations. Access to care is readily available in Japan and one major anticipated problem in the Japanese community is in fact managing the expected healthcare costs and utilization needs for a disproportionately aging population. Similar to the U.S., the percentage of older, non-working, and chronically ill adults continues to rise in Japan. This will inevitably pose both an economic dilemma and a healthcare resource shortage for both countries in the coming decades. As countries continue to focus on solving their own problems of priority, an effort to collaborate and learn from each other on mutual healthcare challenges will be imperative.

Originally written in 2016