A week and a half have flown by on my Neurosurgery rotation in Japan. Of course I am not qualified to analyze the differences of the healthcare systems of two countries after such little experience in either. But, as doctors often size up a situation in 15 minutes or less, I thought I would give my first impressions. It’s not possible to talk about healthcare without mentioning costs: the cost of medical education, physician salaries, healthcare expenses, and how the system is financed. I would like to explore this in more detail sometime, but suffice it to say that money drives many things in medicine, of course. At a glance, I will only mention costs related to medical training and physician reimbursement. I’m told that in Japan, there is much less discrepancy in earnings between specialties, and between residents and staff/attending physicians. This system seems to be rather opposite of our American Way, where training salaries are modest, and staff salaries take a jump into the six-figure “big leagues.”
It is still hard for me to imagine what the distribution of generalists/specialists would be like in the US if our specialists didn’t earn significantly more money. No doubt we’d have fewer of them, but by how much? Something like the Japanese system, where I’ve heard that there is a shortage of specialists, as doctors earn more by running private primary care clinics? I do not deny that the students going into “ROADE” (radiology, ophthalmology, anesthesia, dermatology, emergency medicine) love their specialty, but I do think fewer of them would choose that field if the pay were worse, hours were longer, and the balance between work and life blurred more.
Perhaps the personalities of people going into various specialties would be different also. I don’t like to stereotype, but stereotypes are born somewhere, and it’s no coincidence that surgeons in the US are not considered the most touchy-feely doctors in the world. Our highly competitive system feeds a super-star mentality that may develop in the people who “won” that competition. This is an exaggeration, but it does come from somewhere (h/t: PY).
Also of interest, public medical schools are the most competitive schools to enter in Japan, because tuition costs are subsidized by the government. Although state medical schools are highly competitive–especially for in-state residents–reputation appears to outweigh cost considerations for many incoming medical students in the US, since it’s so difficult to avoid enormous debt by the time you graduate, regardless of private/public school type. The residents here were surprised to learn that I’ll graduate with ~$150k of debt, and this is pretty average for students now.
Last but not least, I wanted to say a few words about patient care. From what I’ve seen, the Neurosurgery service here takes care of many patients who are being observed, who may or may not undergo surgery. On my surgical rotations in third year, patients on the service either were planned to undergo surgery or were post-op. Furthermore, once it was decided that they did not have surgical issues anymore, they were “turfed” to Medical teams. At one point on Neurology, we even had a consult from Neurosurgery to basically perform a neurologic exam. On the one hand, that meant the surgeons could focus on operating and perioperative management. On the other hand, they wouldn’t have the breadth of knowledge or experience to manage medical issues. “Medically optimize,” translated from surgical speak, meant something like: “let Medicine get the patient in shape for surgery.” One way or another, surgeons here are probably forced to be more holistic, since they do so much in addition to operating. I’ve seen the neurosurgery residents here perform tracheostomies, carotid endarterectomies, neurovascular angiography–all procedures that “belong” to other specialists at my home institution.
There are pros and cons to every system. Again, as I’ve seen so little of healthcare systems (only 6 years in the US, and 10 days here in Japan), I can’t say what is better. But, I do think there is something nice about working with colleagues in a specialty where you know that lifestyle and monetary motivations were less likely to influence their choice, hence they genuinely love their field. The neurosurgeons I’ve met here are certainly like that. And that has always been, and ought to be, the greatest reward of going into medicine.