As I have an interest in automated record keeping for anesthesia, I arranged to visit an old friend in Tokyo - Katsuyuki Miyasaka. Kats was in Toronto when I was there, and he came back to Japan, to work at the National Children's Hospital in Tokyo. A new hospital was built and the facility was combined with an Obstetrical unit to form a 460 bed hospital - the National Centre for Child Health and Development, Tokyo Japan in March, 2002. He was instrumental in developing this hospital, which is unique in Japan. You need not take your shoes off when you walk in the door - and you actually can walk through the OR in your street clothes. You do not need to wear a mask in ICU, unless there are issues with disease transmission. The entire medical record is electronic - No more paper for the majority of the medical record, and all staff use the terminals for documenting their care.
At the entrance to the hospital, there is an Inuit painting with a plaque which reads, "Presented by the Critical Care Unit, Hospital for Sick Children, Toronto in commemoration of the opening of the National Center for Child Health and Development and as a token of longstanding friendship. This work expresses the wealth of Canadian nature and productivity, which is passed from one generation to the next and defies all borders. This is an art work representative of Eskimo culture in the Baker Lake region of the Canadian Arctic."
I must remember to ask for the relationship we have with Mito to have similar acknowledgement in our new facility.
Kats has been very progressive in implementing change in his hospital. I visited to see this unique place, and I went with Kats to Gifu University Hospital to see a brand new 600 bed hospital with the latest version of the Electronic Medical Record. The EMR in acute care is provided by Philips Japan, and the back end for the HIS is provided by Fujitsu in Tokyo and IBM in Gifu. I was immersed in learning about these systems for two days.
Both the culture and the medical systems are different. I had an opportunity to see life from the other side this trip - taking the train at rush hour, and looking at more details of health care delivery. People work long hours, the trains are very crowded, and the focus on performance and service is unmatched anywhere.
In Japan, there is a population of 127 Million, with 6000 anesthesia specialists, and about 6000 part time non certified anesthesiologists (any physician can engage anesthesia in Japan) This would be an equivalent of about 10,000 fulltime providers for a caseload of 2-3 million annually. This compares with double the population in the US, with 30,0000 anesthesiologists and 30,000 + other providers looking after a caseload of over 30 million anesthetics. This means that about one sixth the providers deliver one tenth the caseload of the US. This is an outstanding difference in surgical procedures by population.
In Japan there are about 100 full time pediatric anesthesiologists; in Canada there are about 140, for a population 20% the size of Japan.
The amount spent on health care, as a portion of GDP in Japan is very different:
US - 14.9 (202)%
Canada - 9.6%
Japan - 7.4 %
Most of the myringotomies and tubes are done in children under local anesthetic, outside hospital. Bone marrow aspirations for transplant are done under GA at hosp, but most bone marrow aspirations for exam are done without an anesthetic.
The epidural analgesia rate for labor is less than 1% across Japan, and it is lower, even in the specialized centers -- at NCCHD, there are 1500 deliveries per year, with an epidural analgesia rate of about 30%. There are about 350 C-sections per year. Most obstetrical units in Japan do fewer than 500 deliveries per year. This compares with 15,000 deliveries per year at KK Hospital in Singapore, with an epidural rate of about 80%.
In Japan, nurses are paid closer to a physician salary - about 20% less than docs, but they work fewer hours, and doctors work longer. In fact, the doctors end up providing cheaper labor in the system.
There is no limitation on who can anesthetize children. There are about 100 full time Pediatric Anesthesiologists in the whole country in 26 children's hospitals.
Of the 4500 cases done annually at NCCH, less than 10% are outpatients. Each medical school may do about 50 pediatric cases per year, and their caseload is not concentrated.
It is interesting that any serious mistakes in patient care must be reported to police, even if medically explainable, but death rates and assessment of quality outside hospitals is difficult. Almost all the billings are based on governmental run health insurance fee schedule due to universal coverage,but tracking of caseloads is not possible. The world's lowest infant mortality of 3.0 and longest life expectancy are known, but there is no official number of anesthetics delivered annually. so tracking of caseloads is not possible. In the specialist community, the mortality rate for anesthesia is about 1 death/100,000.
ICU beds are too few in hospitals. Even in the 600 bed university hospital we visited, there were only 8 ICU beds for the whole place. Patients are ventilated on the general wards, and many minor events occur, where many patients may be cared for by a few nurses - there are no respiratory therapists.
The health system provides very little continued education, because "the medical school does education". Although physicians in hospitals are paid a salary, there are no arrangements for either sabbatical leave or for long service leave, as is available in Australia. My opportunity was unique, in their eyes.
Actually, my opportunity is unique, in my eyes, as well. In the old days, I would never have given myself the permission to do this.