Curzon on Japan’s Medical System

The New York Times blog has a Q&A series on the health care systems of the world, and their latest post concerns the health care regime in Japan. The supposed expert is Dr. John Creighton Campbell, professor emeritus of political science at the University of Michigan, apparently presently in Tokyo, and author of a book on Japan’s health care system.

Cards on the table: I have generally had pretty good health care coverage while living in the United States, although I have been burned with enormous bills at times, and generally support some government alternative that covers the uninsured. I have had some nightmarish experiences with Japan’s medical system with incompetent doctors, meaningless medicines, and endless hospital visits — and am infuriated when it is brought up as a wonderful alternative to the American system. In a nutshell, here are the inherent systematic flaws in Japan’s medical system that are in dire need of repair:

* The average US doctor sees 1,600 patients a year or so, while the average Japanese doctor sees 6,000 patients a year. That’s because there’s a maximum fee doctors can charge patients/the system per visit, so the incentive for doctors is to get you to come back as frequently as possible. My US doctor gives me 10 days of antibiotics and tells me to get back to him if I still feel ill; the Japanese doctor gives me 48 hours worth of a cocktail of multiple medicines and tells me to come back as soon as possible.

* There are hordes of incompetent doctors out there and few legal remedies to medical malpractices. I’ve had my own problems with poor care, such as one problem that was in danger of becoming chronic after three doctors incorrectly diagnosed the problem (the fourth got it right and solved it almost immediately; my family doctor in the US diagnosed it correctly over the phone with a mere description after the second doctor was giving me problems and I called overseas). AndI have numerous friends who have been permanently crippled by shoddy surgery — incorrectly setting broken bones, wrong setting of pins in knee surgery, botched eye surgery, all with no effective or meaningful legal remedy. Medical negligence is a serious problem that is only recently starting to be addressed. Basic rule: if you can afford to get a major medical procedure done in the US, do it.

* There is ancient and inferior technology, especially in smaller practices. I’ve been in medical clinics in Kyoto where doctors were wielding devices that looked like they belonged in museums. I shudder to think what the people out in Sadoshima or the wilds of Hokkaido have to face.

* Pharmacology is random and placebo-centric. Doctors give medicines in little paper bags with instructions on how to take them, but the type of medicine and amount is rarely included. Antibiotics are distributed in doses of only a few days, which runs the risk of doing more harm than good and spreading disease.

* Dental care is atrocious! I do not lie when I say that Lady Curzon goes to the same dentist as the Japanese Imperial Family. Her most recent trip earlier this year to repair a chipped tooth was, frankly, poorly done. During Golden Week, we spent a week in the US, and my hometown doctor in a small rural town, wielding technology that was cutting edge circa 2007, did a far superior job. We had US insurance covering our cost, but even if we didn’t, the total cost would have been roughly equivalent to the cost in Japan.

* Japan provides great care if you get typical Japanese old-age problem like cancer; you are in real trouble if you get a typical Westerner old-age problem like heart disease. According to the figures of the MacKenzie Consultants, which I don’t have in front of me now so these figures are only approximate, the survival rate for heart attacks in the US, UK and Germany is between at 60-80%; it’s 30% in Japan.

Which brings me to the article, with Curzon commentary embedded where the spirit moves me to agree with, or take issue with, Dr. Campbell’s assertions.

How does the Japanese system provide health care at lower cost than the American system?

Japan has about the lowest per capita health care costs among the advanced nations of the world, and its population is the healthiest. That is largely due to lifestyle factors, such as low rates of obesity and violence, but the widespread availability of high-quality health care is also important. Everyone in Japan is covered by insurance for medical and dental care and drugs. People pay premiums proportional to their income to join the insurance pool determined by their place of work or residence. Insurers do not compete, and they all cover the same services and drugs for the same price, so the paperwork is minimal. Patients freely choose their providers, and doctors freely choose the procedures, tests and medications for their patients, as for mental health, people also need help all the time and that’s why starting an hypnosis business can be great to help with this an you can learn stage hypnosis online just for this purpose.

[Basically correct. And yes, lifestyle is the most important factor.]

Reimbursement rates to doctors and hospitals are negotiated and set every two years. The fees are quite low, often one-third to one-half of prices in the United States. Relatively speaking, primary care is more profitable than highly specialized care, so Japanese doctors face different incentives than U.S. doctors. As a result, the Japanese are three times more likely than Americans to go to the doctor, but they receive many fewer surgical operations.

What does the Japanese health system do particularly well?

First, Japan is egalitarian and medical bankruptcy is unknown. [Nonsense. At my previous firm, one attorney had as part of his personal practice handling individual bankruptcy, and many of his cases involved families filing for bankruptcy to cope with a spouses long-term care. This was often also accompanied by a legal divorce so that the spouse receiving care would qualify for extra benefits/cheaper care.] An individual’s income influences the quantity and quality of medical care probably less than in any other country. Premiums and out-of-pocket costs are minor concerns for most, and low-income people and the elderly receive subsidies to afford care.

Second, the Japanese system is quite good for chronic care, particularly because it has so many older people. Along with appropriate medical care, Japan also provides long-term care to all older people who need it through a public insurance system that started in 2000.

What is your biggest criticism of it?

Financial stringency and organizational rigidities have led to inadequate hospital services in some areas, particularly in emergency care, where patients in ambulances are sometimes turned away. [Yup, how many stories have we seen in the last year of people dying in ambulances after being turned away from a dozen or so hospitals?] There also are doctor shortages in some regions and specialties. [As noted, I shudder to think of the medical technology available in the sticks — where most of the old people live.] Consultation times can be too short for complicated diagnoses and for psychotherapy. Specialized training and certification for physicians should be better, and cutting-edge surgical techniques should be more available.

Many of the problems are largely due to underinvestment, and the severity of the cost control has become an issue in the current election campaign.

What is the most important lesson Americans should learn from the Japanese system?

In the 1980s, health care spending was increasing as quickly in Japan as in America, but the Japanese government learned how to influence medical care provision without rationing by manipulating how it paid for services. Annual spending growth has thus been quite low despite a rapidly aging population. Including everyone in a controllable system was a prerequisite. Japan is not a single-payer system, but like France and Germany, it has been able to control costs by tightly regulating multiple insurers.

51 thoughts on “Curzon on Japan’s Medical System”

  1. “As noted, I shudder to think of the medical technology available in the sticks”

    Maybe not. Seems like a great place for pork. Give them a slick hospital ten times too big for them, and they’re happy little LDO voters.

    No idea what dental is like in the US, but when I last had a checkup at home – just a check, with X-rays and cleaning – it cost more than what my wife paid for a filling or two in Japan. Plus the work the dentist did on me fell out after less than a year.

    I’ve always had the doctors explain exactly what they are giving me. That is, they have explained without me needing to ask. But the frequent visits thing is true enough. Every time I go to a Japanese hospital I am reminded of the old joke:
    Three old woman are in the waiting room of the local clinic, gossiping. Suddenly one says, “Hey, where’s Mrs Higashiyotsuyanagi?” “Oh, she can’t come in today – she’s not feeling well.”

  2. You mentioned technology. I have heard this also. I think one of the reasons that medical costs are somewhat high on the United States is due to the fact that the United States has the highest level of medical technology in world and that stuff isn’t cheap. I think many people do not realize this when they question why medical costs are so high in the United States.

  3. I’ve mentioned these issues in various blog posts at various times and I always get shouted down by people who say America’s health care system is worse than Cuba’s and those who have children and feel greatly relieved to be able to run to the doctor so cheaply when their kids have runny noses or a cough.

    The main problem with the U.S. though is that the whole “pre-existing condition” situation which prevents people who most need insurance coverage from getting it and those who are uninsured are in serious trouble. More bankruptcies in the U.S. are medical than any other (or so I’ve been reading). I think such situations do occur in Japan, but they are relatively rare compared to the U.S. Essentially, the “haves” in the U.S. with insurance have it far better than the Japanese and the “have nots” have it far worse than the Japanese. The question is whether it’s better to make everyone a “have” and sacrifice some of the highest quality care, or to keep the status quo which leaves a lot of people stranded completely. I can tell you that this issue has me absolutely terrified about returning to the U.S. in the future (which I plan to do to attend grad. school).

    My experiences in Japan with dentists, btw, have been excellent for the most part. The fast food part of it is frustrating at times though, because you have to get things like teeth cleanings broken into two appointments when it easily can take only one. I think, like with doctors, it really is about finding the right one. I’ve always gone to the Tokyo Adventist Hospital’s (in Ogikubo) clinic where they have at least one American-trained dentist who speaks English around.

  4. My dentist is pretty good and seems more high-tech than my one back home.

    My only real issue is that I get handed antibiotics every time I have some ailment that is clearly viral, not bacterial. Maybe this is also done in the US, but I feel it’s pretty standard here.

  5. Yeah, my dentist is fine too. Whenever I read stories like this I am struck by how heavily they rely on anecdotes. Not to deny the validity of anyone’s personal experience, but “I saw a crappy doctor in Japan but my family doctor in the US is great” and untested hypotheses about health care in the sticks should not carry any weight in a debate about public policy. If you open that door, how are you going to close the one through which rich, healthy people will drag in their “Well, _I_ never had any problems getting insurance” stories?

  6. Blimey, Curzon, when I hear that you have “numerous friends who have been permanently crippled by shoddy surgery—incorrectly setting broken bones, wrong setting of pins in knee surgery, botched eye surgery, all with no effective or meaningful legal remedy”, I can’t help thinking that you have a lot of very unlucky friends to have picked up so many serious injuries that needed treatment in the first place.

    I’m sorry to hear you’ve had such poor experiences and I think you’ve made some good points about where the problems lie. One thing that helped the Japanese healthcare system was the overwhelming confidence the population had in it. As more malpractice stories abound and ambulances are turned away, this confidence erodes a little more. It can help a patient a great deal if they think they are getting the right treatment and it can hinder recovery if there is any anxiety.

  7. “I can’t help thinking that you have a lot of very unlucky friends” — no, I’ve just been here too long:
    * incorrectly setting broken bones: permanently crippled teacher at my high school.
    * wrong setting of pins in knee surgery: former professor at Kyoto University
    * botched eye surgery: friend of a colleague who was a victim of the infamous doctor in Ginza who did LASIC without sterilizing his equipment.

    Yes, of course this relies heavily on anecdotes. And Orchid has it right — this is all about how you see a socialist policy. America’s “haves” generally get better care than what is available in Japan; America’s “have nots” generally get worse care than what is available in Japan. Is that good or bad? The answer often depends on where you see yourself in the pecking order.

  8. My wife is a J-doc with her own clinic. She does have an astonishingly high patient load (120 patients per day is not uncommon), and she does seem wont to give out antibiotics a bit too freely, as well as “kampo” medicine (which I perceive as being essentially a placebo). Nonetheless, I’ve found her diagnoses are as accurate as those of US physicians when I’ve had the chance to make direct comparisons. J-docs don’t like to prescibe opiods like Oxycontin of Vicodin and seem to have a “gambatte” philosophy toward pain, unlike the US, where the number of people using opiods has been rapidly increasing.

    As for medical technology, the ready availability of CAT and MRI scans here has always astonished me. In the US, it’s always seemed difficult and extemely expensive to get one unless you succeed in getting a referral from your primary care doc.

    One thing that does concern me about the J-medical system are the number of doctors who’ve graduated from private medical universities and who are profoundly incompetent. Medicine, like politics, is a strongly hereditary occupation here, and there many doctors here who were too dumb to get into a national university, or one of the few good private ones, but whose doctor father was willing to pay the hundreds of thousands of dollars for a private university for junior. Private-university docs here should have a skull-and-crossbones sign on their office doors. It’s a subject my wife, a national-university grad, is loathe to talk about, buy she’s conceded that there’s a great deal of truth to it.

  9. My anecdotes would also be the opposite of Curzon’s. I ran into one Paleolithic clinic in Osaka back in high school, but my medical experiences in Tokyo have been just fine. In contrast, I have had some awful and expensive medical experiences in the US, *especially* with dental care — an orthodontist who tore up my mouth in high school, extensive (and probably unnecessary) surgeries to repair it, and then being told that I needed $10,000 porcelain veneers to fix the remaining cosmetic issues, when the dentist in the Fukoku Seimei Building next door was able to get me 90% of the way there for less than $100 over a couple of lunch breaks.

    Curzon’s last comment above is the most salient, I think. On a “micro” level, there is certainly reason to fear socialized medicine in the US if you would be getting better medicine from a private system. On a “macro” level, it’s a much tougher argument, because there are a lot of people who get literally nothing under the US system, except stabilization and release from the hospital if something catastrophic happens.

  10. I have a major issue with your comment on the prices between dental in the US and Japan. In America it costs $900 to get a root canal. Just the root canal. With the insurance I had from my company, I still had to pay $450. Then of course I had to get a filling. Which cost an additional hundreds. In Japan, although you were right about multiple unnecessary visits, I only paid 1300yen per visit, and 2600yen for my last visit. I think the total came to 7000yen. Thats roughly $70. That included the root canal and the filling. Granted, they have restrictions on the type of material covered (didn’t used to cover ceramic back when I got my teeth worked on, had to be metal fillings) and not sure if they cover braces…so those upgrades would cost extra. Don’t know where you’re getting your cost comparison…but dental is ridiculously cheap here. If its not something “cosmetic” as deemed by the government. And while I agree the level of dental care is much higher in the US, so are the prices. I was going to have major surgery done on one of my teeth in the US and with insurance the bill I was going to have to pay was $3500. The great thing about the US is “if” you can afford the “good” insurance, then life is great. If not, you might have to choose which fingers you can afford to reattach and which you can’t.

  11. I have had great care from dentists in Japan (Dr. Onozawa in the basement of the Nippon Press Center does excellent work); I see a doctor for a sinus condition who gives me a month’s worth of meds and tells me to come back in if I feel like I need to get looked at again. The post above isn’t very valuable since it’s mainly an invitation to whip out warring anecdotes.

    One strength of the Japanese system IMO is that if you do get crappy care from Dr. Tanaka, you’re perfectly welcome to go to Dr. Suzuki instead to see if that improves matters, without worrying whether he’s on your HMO’s list of approved MDs or whatever. You have options, and there are quality caregivers out there if you’re willing to find them.

    In around 1995 I considered having knee surgery here to replace a blown ACL, but the doctor who did my arthroscopy (in a hospital in the wilds of northern Tochigi, mind you) told me I should get it done in America if at all affordable, since the options were better there. He told me reconstruction in Japan would involve a month-long hospital stay with little in the way of physical rehab. Even my scoping had me there for three days. So there you have an example where US medical care was ahead of the Japanese version, although it certainly cost a hell of a lot more–but at the same time, I had a very open, communicative doctor who sat down with me and talked over my options at length, so I came away from it with another anecdote to counter the “doctors are hurried and don’t spend proper time examining patients” one.

    It’s a big country with a big medical system. Painting it all with one brush doesn’t make a lot of sense.

  12. My 2 – no 3 cents:

    First ambulances in Japan:

    It is my understanding that if you arrive in an ambulance you are already technically under professional care and can be turned away. However, if you arrive on your own (via taxi or whatever) the hospital is obligated to take and treat you.

    I have not verified this, but an old Japanese friend told me to always call a cab not an ambulance.

    Second, an anecdote:

    Having said that, a friend of mine had a severe herniated disk in his neck. He was diagnosed as such but it took a month to get him in the hospital for the operation. By the time he got to the hospital, he had lost feeling in his legs, lost bladder control, and could hardly walk (obviously).

    He finally got to the hospital by lying down on the floor, calling the ambulance, and saying he fell and he can’t get up. The doctor who performed the surgery the next day immediately ordered an MRI and found his spinal cord to smashed down to about 1/10th its normal diameter and said you should have had this operation a month ago.

    Third, US health care:

    The world’s highest quality of care is available in the US… if you can afford it.

    I became a graduate student in 2001. Our student insurance plan was about $700/year for 100% benefits and a choice of doctors. 2 years later is was over $1500/year for 80% benefits and required a referral from the student health center located at the other end of the next city over, 45 minutes away by highway. No referral, no benefits.

    At my next school where I did my dissertation, by the time I graduated, the cost for the university-sponsored insurance plan was unreasonable expensive compared to the university stipend for both research and teaching assistants. This fact was so obvious that the outgoing Dean of the Graduate School left as his legacy the still standing policy to pay 100% of the premium for every PhD student at the university.

    Basically he said, the US health care system is broken and if no one is going to fix, then I’ll take care of my own. And he did.

  13. I believe I heard somewhere that there are more dentists in Japan than convenience stores. The “I had to go back 20 times until they finally gave me a filling” stories one hears so often from foreigners could be the result of a lack of knowledge on how to choose the best of the 10 dentists offices within a 15 minute drive.

    I’ve never required major dental work in Japan, but the 3 or 4 times I went for cleaning/check-ups were not bad at all.

  14. One point I just remembered which illustrates the flip side of generous med-mal liability in the US:

    My mother and I were in a car accident in the US a couple of summers ago — a clueless kid made a left turn on a red light right in front of our car as we were going through an intersection around the intra-city speed limit. Fortunately our car had sturdy seat belts and air bags, so we both survived, albeit with the wind totally knocked out of us.

    The accident happened late at night, and the next morning we were both in pain all around our chest and back, so we went to the hospital to get checked. The doctor said it was probably our muscles’ reaction to the stress on our vital organs caused by decelerating so abruptly — the body naturally tightens up to keep the innards in place.

    Just to be sure, my mother wanted us to get X-rayed to check for broken ribs or other abnormalities. The doctor refused to do it. When we asked why, he explained that the hospital’s insurer would not allow the hospital to conduct chest or abdominal X-rays in situations it deemed non-essential, because of the risk for radiation damage to the vital organs.

    I was between insurance policies at the time, as I had just graduated school (thus no longer counted as a dependent on my parents’ corporate policy) and hadn’t started working yet. So I paid $400 out of pocket to have a doctor look at me for 5 minutes, refuse to X-ray me, and prescribe me some muscle relaxants and Voltaren. (Fortunately we were able to get reimbursed from the other kid’s auto insurance company, and I got miles from charging the hospital bill to my credit card.)

    By contrast, several friends of mine in Tokyo get chest X-rays as part of their routine annual checkup under their corporate health care plan.

  15. In my experience, Japanese doctors are all to willing to insist on chest x-rays – polar opposite to your description indeed.

  16. Curzon, I am sorry, but your third example about the person who got stung by that eye “doctor” should be thrown out. I mean seriously, that quack was offering LASIC surgery at a small fraction of the price basically every other clinic was offering it at. I don’t think we should even include him in a discussion of the general state of medical care in Japan. It would be like using Dr. Shipman as an example of the general state of socialized medicine and elderly care in the UK. Meaningless. His “clinic” was so far beyond the pale that, especially after footage from inside was shown on the news, my sympathy for his patients was greatly limited. Anyone who would visit that rathole he was operating out of and let him operate on their eyes just because he was the lowest bidder by a factor of 10 must not have thought much of their eyes to begin with.

  17. A nuanced account, but I think that you should drop the point about “the sticks” – as a sticks dweller, I have often been shocked at how good the local hospital gear is – massive hospitals are being built as part of the local pork network and the care may be better than in smaller clinics in the cities.

  18. My medical experiences in Japan (at a variety of hospitals and clinics) have generally been neutral-to-good, but with one glaring negative experience. Rather than happening out in the sticks with the country doc using Meiji-era equipment, it was at the Tokyo Medical Clinic (across from Tokyo Tower), which promotes itself as offering ‘American-style’ medical care.

    Two general practitioners there (on two separate visits) diagnosed a lump on my knee as a cyst caused by an injury and said it would go away by itself. I went back several more times over the course of a year and kept getting the same response. Only after I began to lose the feeling in my calf did I take my now-mikan-sized lump to an orthopedic specialist elsewhere. Within five minutes he said he would write me a reference letter for the National Cancer Center. It turned out the lump was liposarcoma (fat cancer) that had pinched off the main nerve in the back of my knee and was now pressing dangerously against the central vein.

    That was six years ago and I’m fine now (like Curzon said, cancer care here is quite good), but I’m still amazed at how badly the first doctors dropped the ball. One even ordered an MRI and said the results backed his diagnosis. According to the doctor at the NCC, however, a fluid cyst would be solid black on an MRI, while fat (or a fat tumor) would be solid white, which the MRI clearly was. I won’t name names, but one of them (the doc who ordered the MRI) is now at the Azabu Clinic (which also caters to foreign patients) and was recently quoted in the Japan Times voicing his opposition to requiring all foreigners to have national health insurance (neither Azabu nor Tokyo Medical take it).

  19. I’ve read a lot of complaints about both of those clinics on the GaijinPot forums. It’s enough to make me avoid “foreigner-oriented” doctors in Tokyo generally.

  20. “My medical experiences in Japan (at a variety of hospitals and clinics) have generally been neutral-to-good, but with one glaring negative experience.”

    I have pretty much the same words to say.

    One thing I will add is that the level of suspicion I have for the medical world here (from the lack of explanations to the prescriptions of antibiotics when they aren’t necessary — see Marxy’s comment above) has actually forced me to learn a lot on my own. Aside from preventive measures, asking tons of questions in the examination room is one of the best ways to regain control of the situation. Some doctors look at me like I’m questioning their authority, but others enjoy the opportunity to explain their diagnosis and prescription.

    Granted, this approach doesn’t apply to procedures like surgeries or emergencies. Nonetheless, I think information is the key to avoiding the negative experiences.

    Speaking of information, maybe Japan could use more NPOs like this:

  21. @sublight – glad to hear you’re OK now. But what the – Japanese hospitals that won’t accept the national health insurance? And a doctor opposed to having people follow the law and pay into the system?


  22. Japanese hospitals that won’t accept the national health insurance?

    Most of the “expat clinics” are like this. I believe it’s because they have a higher cost base and don’t want to be forced to accept low-margin walk-ins.

  23. Peter: you’re on the money with asking questions – and the reaction you may often get, since you are cutting into the doctor’s time to see more patients as well.

  24. I have a funny anecdote, although it definitely wasn’t funny at the time.

    For a couple of days I was having pain urinating so I went in to see a urologist. After a few tests the doctor told me I had an infected prostate. I was mostly concerned that it might be some kind of prostate cancer, but he said that with some antibiotics that the discomfort would go away eventually.

    This is where things went downhill.

    I asked what are the causes of this infection and how can I prevent it in the future. The doctor’s response was (and I’m not joking), “You need to stop going to fuzoku.”
    I was taken aback at this response, particularly because I’ve never been to one before, so I thought I would try again.
    “Are there any other causes of this? I’ve never been to a fuzoku, and I want to know how to prevent this in the future. Is it stress related? Should I cut back on working out?”
    The doctor just repeated, “No, you need to stop going to fuzoku.”
    By this point I was starting to lose my temper so I just decided to let it pass, get the antibiotics, and do some research on the net when I got home. The doctor gave me two weeks of antibiotics and told me to come back when I was done with the medicine.

    *Two weeks pass*

    I was already kind of bristling at the idea of meeting the doctor again, but I was still having discomfort so I decided to swallow my pride and see what would happen. After a few tests the doctor said he would give me additional antibiotics to see if that would clear up the problem. I said fine, but I once again asked how I could prevent this in the future. His response – “Oh, you know.” I pretty much snapped when I heard his answer and, with as much composure as I could muster, I grabbed his prescription and left for the pharmacy.

    But get this – even after having taken 2 weeks of antibiotics, he prescribed another MONTH of the EXACT same medicine. I might be an idiot most of the time, but I’ve heard enough about developing resistances to antibiotics to be just the tiniest bit concerned. I asked the pharmacist about taking the same antibiotic for a month and a half and she said that she had never heard of anything like that before, but since that was the prescription she had to fill it.

    To cut things short, I took the prescribed medicine with all of the test results to a different doctor the next day, and he had me up and going in no time at all. The kicker is this – I told him about the other doctor and his fuzoku comments and he laughed and said that a prostate infection is sometimes caused by STDs, but that’s just one of many causes. I’ve never been so angry at a medical professional in my entire life, and I’m just glad I got out of the first hospital without entering in rage mode.

  25. @sublight:

    Glad you’re better. Your experience underlines the need to not hesitate getting second, third, or however many opinions you need to allay your concerns. Docs here see so many patients that they have to make snap diagnoses and will often stubbornly refuse to change their opinion out of a sense of professional pride (a phenomenon not limited to J-docs by any means).

    -PS: scans are good, but watch out for CAT scans; they expose you to huge amounts of radiation. Make sure that they’re tightly targeted. Or get a PET scan or MRI instead if you can.

  26. “My US doctor gives me 10 days of antibiotics and tells me to get back to him if I still feel ill; the Japanese doctor gives me 48 hours worth of a cocktail of multiple medicines and tells me to come back as soon as possible.”

    Eh what, I’ve never got less than 5 days of the meds I’ve needed for a cold.

    “Doctors give medicines in little paper bags with instructions on how to take them, but the type of medicine and amount is rarely included.”

    Eh what, Maybe someone can’t read Katakana. I’ve wondered what’s in my pouches and pills. A bit of simple Japanese and some Google-fu has always shown me what I was getting.

    I love my Japanese insurance and doctors and I fear the day I have to go back to the USA and deal with that crap.

  27. In re sticks: M-Bone, I don’t consider Beppu, a major town of several tens of thousands, to be the “sticks.” I’m far more concerned about rural places I’ve visited such as: the entire coastal region of the Okhotsk Sea in Hokkaido; Tsushima Island; and southern Wakayama, to just list a few. All are regions where medical facilities are many hours drive by car, and even then, the care available is often antiquated.

    In re dental care: To all of you with good dental care in Japan, that’s great, but a question: do you get metal or porcelain fillings? I have about 8 cavities which are invisible because they were filled with white porcelain. Japanese cavities are often filled with generous amounts of metal that make the mouths of many look like a mining operation.

  28. Heh, regarding the huge number of dentists here, my wife descibes them as “working poor.” Quite a difference from American dentists, who always seemed to be saying things to me like, “Take it from my, don’t buy a yacht.”

    @Curzon: J-insurance pays for porcelain only for the front teeth; anything behind the canines and you have to pay extra. I needed a crown on one my back teeth; could’ve gotten an ugly metal one for free, but sprang for the 100,000 yen cost of a ceramic one – incidently about the same price as I would’ve paid in the US.

  29. Sometimes Logged: Glad your problem was solved. I had a similar problem with incompetent doctors when I had a middle ear infection during my time at university. It was misdiagnosed by three different doctors, each of whom gave me their own unique blend of medicines and bizarre mechanical treatments (audio pulse on the ear drum; draining my middle ear with specialized foreceps; blowing air into the estachian tube from the sinus to dialate it). The fourth doctor I went to identified the problem and cured my problem instantly with a betadine flush of my ear canal. When I complained to the university clinic that recommended the first and second doctor they blanched and said their recommendations were purely practical (i.e. what clinics were open at what times and close to my apartment or the campus) and there was nothing that could be done about incompetent doctors.

  30. catoneinutica: Where on earth do these super expensive US dentists come from? I come from a relatively wealthy county in a very wealthy state, going to a dentist with cutting edge technology, and he charges $160 for minor fillings (with porcelain) and $270 for a major filling (also with porcelain). I implore those of you paying thousands of dollars for fillings to look elsewhere.

  31. Mea culpa, Curzon, I was writing about crowns, not fillings. But yes, the “don’t buy a yacht” line is an actual quote from a dentist in Seattle (who charges about the same price for fillings as yours).

  32. “Eh what, Maybe someone can’t read Katakana. I’ve wondered what’s in my pouches and pills. A bit of simple Japanese and some Google-fu has always shown me what I was getting.”

    Not always so. Many years ago, when I was new here and constantly catching colds, I would come back from the clinics with wax paper pouches of pills, and call up the former pathologist parents for second opinions. They would ask me these pharmacology Inside Baseball-type questions, and I wouldn’t have a clue. Back then, where I was living, they didn’t have a handy printout with a close up of the pill. I had to read the *side of the pill* itself, and then jump on Google for answers.

    Now cross-checking prescriptions is much easier.

    Sometimes Logged,
    I’m surprised you exhibited the patience you did. I would have gone postal when advised about fuzoku the first time. Walk right out, and go to a different doctor…

  33. FWIW the three or four pharmacies I’ve been to in the past year or so have all included an A4-size printout of a chart containing photos of the pills, their names, the dosages I’m supposed to take, descriptions of what they’re for, and what I shouldn’t do/imbibe while I’m on each of them. I think this is SOP at a great many places (in large type, too, for elderly patients). In the past you used to get a single paper bag filled with barely labeled pills, but that isn’t the case any more at many pharmacies.

  34. I’ve had nothing but great experiences with my local dentist: very reasonably priced and very competent, and more than willing to schedule even complicated procedures (like a crown) at a moment’s notice — emergencies aside, it was always weeks to months of a wait at my local dentist in the USA.

    Like many of you, however, I’ve had very mixed experiences with actual doctors. My impression is that with checkups, bloodwork, and almost any “everyday” sort of illness that is easily diagnosable, you are in the clear with nearly any doctor. But for anything out of the ordinary, anything that might require even the slightest physical adroitness or actual sleuthing to uncover the root causes of, you need to be a very active and questioning patient. You can’t accept explanations that don’t satisfy and you have to be willing to shop around for second and even third opinions. From experience I actively avoid middle-aged to late-middle-aged male doctors like the plague; they’re just from a different generation that has a much higher chance of putting patient needs second.

    In my own personal horror story of sorts, a moth lodged in my ear canal during a nighttime film shoot. I tried the local ear-eye-nose-throat guy, who groaned and complained that he was “terrible at stuff like this.” I should have gotten up and walked out then, but in the process of trying to remove the dead critter, he tapped a nerve and knocked me totally unconscious — like a Vulcan neck pinch. It was crazy. I came to in a bed, and he was actually yelling at me “for passing out like a wuss” ( 格好わるい、気絶するなんて or something) — he wouldn’t even call my wife for me. I was so physically drained and incapacitated from the experience I had to take a taxi the two blocks home from the office.

    Topping it all off, the bug was STILL IN MY EAR! He hadn’t managed to dislodge it. My wife (who was practically shoulder-carrying me like war-wounded at this point) forced him to write a “recommendation” to the local hospital, and a young, female doctor pulled the bug out in less than two minutes with next to no fuss.

  35. I have had the same experience as Durf. I have also seen some posters in doctors’ offices advising patients to select a primary care physician who can liaise with specialists to make sure they don’t misdiagnose things or prescribe the wrong medicines based on an incomplete understanding of the patient’s history.

    Back to the dentistry topic:

    Ms. Joe (who is Japanese and has better teeth than me) once commented: “Why are Americans so obsessed with having perfect teeth? If the teeth are there and aren’t infected or anything, what difference does a little discoloration or metal make?” Most of my Japanese co-workers seem to share that attitude, at least based on the state of their mouths and conversations I have shared with them.

    The dental clinic I go to has both metal and porcelain available, but only metal is covered by dental insurance; porcelain ends up costing a lot more because it is considered “cosmetic” as opposed to “medical.”

  36. MattAlt,

    That moth story is whacked. My negative experience was also with a ENT doctor, but there wadn’t no Vulcan neck pinch….

  37. These stories are the reason Mrs Jade insists on using the university hospital for as much as possible, even though the university hospital doesn’t like that: they want a recommendation from your local GP, or pay extra.

  38. “These stories are the reason Mrs Jade insists on using the university hospital for as much as possible”

    I have had nothing but good experiences with the local university hospital (that’s where Mr. Moth got taken out). The equipment seems newer, the doctors/techs seem to skew younger, and there’s just a general sense of working with a patient. But man, the waiting times! Even with an appointment, I have never spent less than about three hours waiting my turn — and the one time I had a semi-emergency and showed up without an appointment, I must have waited close to five. Is this just my university hospital, or are they all like that?

  39. Yours is bad. I’ve had some waits, but maybe two hours at max. This is why they insist on referral notes as otherwise everyone would go. The thing about university hospitals is that they often have some specialists in a wide variety of bizarre fields as it reflects the research/teaching interests. My own one (also the uni hosp of the uni I went to) is quite well regarded apparently and is good for cancer.

  40. “When I complained to the university clinic that recommended the first and second doctor they blanched and said their recommendations were purely practical (i.e. what clinics were open at what times and close to my apartment or the campus) and there was nothing that could be done about incompetent doctors.”

    That’s one advantage to being a student at Kyoto University – no matter what you have wrong, they refer you to Kyoto University Hospital. In fact, although I wouldn’t have thought of going to a major hospital like that for fairly routine problems (coming from the American system), you actually can walk in their any weekday morning sans appointment and usually get to see a good quality specialist within a couple of hours.

    So, I go to Kyoto U. Hospital for all my medical needs that can’t be taken care of faster and more easily at the on-campus clinic, and aside from their Byzantine scheduling system I really have no complaints. Prices are ridiculously cheap, even without insurance (although I do have it), the doctors are good, record-keeping is fully electronic so if your usual doctor is out they still see your entire file, medications are accurately labeled and given in proper quantities instead of the 2-3 day nonsense, etc. However, as others have said, the waiting time can be pretty bad, and they tend to only accept walk-in registration before 11AM, which can mean delaying a visit for several days.

    MattAlt: The moth-in-ear thing happened to my friend Rick a few years ago, and I saw it! I was in the car with my friend Steve in front of Rick’s house while Rick went to get his wallet from his car, stuck his head inside, jumped, and just screamed at us “GUYS, I’m going to the hospital!” and just started the car and took off. We followed him in complete bemusement and arrived to find him checking himself in at the ER desk. After waiting around for about an hour, with Rick pacing psychotically up and down the halls muttering to himself “I can hear it flapping”, a doctor squirted a syringe of novacaine into the ear canal, waited a minute for the moth to die, and then flushed it out with a water spray.

  41. I will admit to a significant degree of variability of quality of doctors in the Japan system, and the problem with the population going to the doctor on a whim, but I am not convinced that the problems identified are medical “system” problems in so far that the mix of incentives is wrong. After all, it still costs a decent amount of money to go to the doctor – it is by no means free and for the individual once prescriptions are added on top – clearly its a cultural thing and not much to do with the system itself I would believe. The Japanese community here, where costs are close to free, always lament to me how their doctors suggest that they are basically sick of the sight of them, as they come in for every itch, spot and sniffle that one could imagine.

    Secondly, the variability of doctors – possibly Japan might have more than most places, but I have heard horror stories everywhere from everyone. Is their a generational issue at play? The only bad experience I have had is with an 80 year old doctor who looked like he himself needed medical care. Through our various family dealings while in Japan we have found GPs, chiropractors, dentists, psychiatrists and oncologists give straightforward, competent and timely assistance. Something I cannot say for most Western countries I have experienced.

    Good doctors in Japan are by no means hard to find – I always do “due diligence” on medical professionals here, I do not see why I would not in Japan either. The extra access, even if it comes at a price, but an affordable one, is something I always appreciated about the Japanese system. @Roy Berman – I agree, the Uni hospitals here are definitely the places to go!

  42. Although, the one systemic issue I have with the Japanese health system is the approach to approving new medicines and the politics around the decisions made to fund certain types of medications. Seems completely irrational to need to do their own post-FDA approval testing etc and as soon as their is some public “bad news” story about a medication, scientific research be damned, its gone. Most countries have independent agencies to make these decisions based on rational cost benefit analysis of high-quality double blind placebo tests.

  43. @Soma – there is always politics surrounding medicine. “Morning after pill” in the US ring a bell?

    Why should the US FDA be the be-all and end-all of drug approval? How would you feel about the FDA giving automatic approval to a drug based on a European approval, without even looking at the drug? Or blanket approving any drug from China just because the Chinese government says it is OK?

    And I can recall the FDA pulling approval lightning-fast after “bad news” stories.

    None of these are unique to Japan, or the US, or anywhere else. Drugs = big business = money = politics.

  44. @LB

    It is not just the FDA, but the absolute compulsion to disregard all international evidence about the effect of a given medication and reinvent the wheel so to speak. The time lag on certain drugs used to good effect everywhere, sometimes based on some faulty notion about “Japanese bodies being different” – ie the pill, ends up limiting the choices of Japanese people. This is particularly true in areas of psychiatry. Btw, even the FDA accepts international trials up to Phase II.

    Post-production Japanese trials are perfectly valid, so it would not be a matter of blindly accepting something approved elsewhere – although in NZ we do not do our own post-production trial and have no safety issues- problem here is that there is not enough variety of medications, actually.

    Anyway, it might be a moot point, Japanese pharmaceutical companies are finally looking at the money to be made from not only imitating overseas medications years later, but looking to compete in producing new ones which I figure they would be able to do very well.

  45. AR: The sentence that inspired this whole post was the absolute statement, “Japan doesn’t have medical bankruptcy.” I recognize the guy is probably an expert on the subject, but this is so wrong it infuriated me at the time I read, and then wrote.

  46. You know, for all the flack you’ve gotten on the post really, I appreciate it because it explains a lot. And I think the comments do too because they show the total unpredictability of care you can get at a Japanese doctor’s office, which to me is far more flaky than anything I’ve every experienced in the US, and yes, being a tattooed, pierced, girl with a history of mental illness on her record I’ve received a lot of whacked out care in America, the most infuriating being a case of strep throat a doctor took to be a relapse in my bi-polar ways by looking in my ear.

    However, that really pales to what I`ve experienced here, from supposedly English-speaking gyno`s prescribing medications that were apparently lethal for my weight class, to doctors wordlessly slamming doors in my faces to very competent dentists who were just total assholes. And the kicker is I pay MORE here than I ever had in the states. My premiums in the US were a monthly $100 through my office and a co-pay of $5 for most things. Shit.

    I think what MattALT said (I think…) about irregular things is very true as well. My friends experiences at the thyroid clinic speaks to it and I think a lot of expat experiences speak to it because I think Japanese doctors assume us to be irregular by default, before they`ve even taken a look.

    Simply beyond that though, the thing I am the most upset by and where I really feel care is failing in Japan is the way they deal with mental health. No one I have ever known to go to a mental health facility here has ever come out better for it and in a lot of (personal) experiences they`ve come out worse, batshit insane on too many competing medications or far far worse, dead by their own hands or an accidental overdose when combining one of many medications with the alcohol almost everyone consumes here.

    Part of it is cultural, and Japan has a very long history of shunning the mentally ill, but I think a lot more of it is a combination of psychologists here forcing the pills to do their job and using their patients as guinea pigs for whatever new drug a company tries to push at them.

  47. My wife and I have mixed experiences with Japanese healthcare. Some doctors were good while others needed to be put out to pasture. You really have to search for quality healthcare. A friend of mine had cancer and I use to accompany him to his visits to the doctor.

    His doctor took smoke breaks and had my friend attend “kikou” sessions to “compliment” the chemo treatments. The cancer was at a late stage so I guess everything helped. Anyway, the “gift” a.k.a. money passed during the visit was unbelievable. A thank you for treatment at a well-known university hospital. A hospital were my friends father once worked.

    My wife and I had very good dentists (both were trained in the US and one liked to practice his English so I found myself in the chair longer than usual). Unlike what I saw in the hospital, the equipment and technology was cutting-edge. Everything computerized, shoot and view, spelled out with reference in English and Japanese. I forgot the name of the dentist but he was located in the Dentsu Building.

    Anyway, thank for the great post and comments!

    This comment and Trackback link posted on Black Tokyo.

  48. Sheesh…you people should go read this blog (

    A parent blogged about her very recent bad experience with a doctor in Tokyo Medical & Surgical Clinic and the husband of the doctor is posting crazy comments in response. Certainly provides some entertainment with his brainless comments. There’s also an article talking about why you may be refused medical treatment in Japan. Something to do with doctors and civil law here.

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