感染症コンサルタント / 米国感染症専門医
Director of Clinical Training, Yao Tokushukai General Hospital.
Why has the proposed hospitalist system failed in Japan?
In order to address this very difficult question, I must first inform the reader about myself as a frame of reference.
I am a British physician trained in general internal medicine (GIM) with diabetes and endocrinology as my specialty. Therefore, I think I can provide an informed opinion on both GIM training and specialist medical training (SMT) alike; this includes how they can work in an integrated fashion and can provide superb care for patients.
I have been teaching for the Tokushukai Group in GIM mainly at Shonan Kamakura General Hospital for the last 15 years. The GIM service is the main medical service with over 120 beds. Specialty medicine services work alongside the GIM service. This is somewhat rare as an entity in Japan.
The British system has a very long history of integrating GIM with speciality medicine. This means that specialists also accept unselected general medical patients with problems outside of their chosen specialty. However, when specialists are unable to treat disorders that are outside of their area of expertise, they consult other specialist teams to work together for the patient with a concept of ‘shared care.’ That means several teams integrate their expertise for one patient at the same time.
SMT (which also includes GIM training) lasts for a minimum of six years, which follows a two-year foundation programme, which is similar to the Japanese two-year super-rotation. Hence, to become a chief (consultant), it will take a minimum of eight years of postgraduate training.
Such doctors are not general practitioners or GPs. Instead, GPs undergo three years of postgraduate training and they work solely in community clinics, and have no input in the care of their hospitalised patients.
What is a hospitalist?
Not being a U.S. trained doctor, I can only provide an overview from what I have researched. Hospitalist training is generally three years. Such doctors typically train as general physicians. They see the patient from their admission into the hospital through to their discharge, respectively. They provide medical care for the patient by themselves, and they also coordinate the input of specialists. They organise and integrate the care of the various teams attending the patient, and they also speak to the families. In essence, they are the linchpin of care for the patient during their hospitalisation. Because they do not have outpatient responsibilities, and that they are constantly in the hospital, they can attend the patient very rapidly 24 hours a day.
Hospitalists may spend one to two weeks working constantly within the hospital followed by significant time off to recuperate e.g. 1-2 weeks ‘on’ (working) and 1-2 weeks ‘off’ (holiday).
Hospitalists typically have on average 15 patients of their own, although this may vary.
As I mentioned, the U.K. does not have a hospitalist system. In that sense, the Japanese and British systems are similar.
However, from my observations some Japanese hospitals run a ‘German’ style system whereby a senior physician either sees their own patients, and/or they have several junior doctors looking after their care. In that sense, there is no direct team system or proper chain of responsibility. Each junior doctor may look after many patients who are under the care of different chiefs, particularly in smaller hospitals with fewer staff. In that sense, huge responsibilities are placed on inexperienced junior staff. This might be regarded as unsafe for patient care in some instances.
In reality, the senior physician in charge is typically sequestered to the outpatient department from where their orders emanate to the junior doctors to admit patients. This includes investigations and treatment for the inpatients. In some instances, the senior physicians do not attend the inpatients. Hence, inpatients, who are some of the most illest within the hospital are infrequently seen by senior physicians, which is to their detriment.
This means that inexperienced junior doctors traditionally spend many hours into the evening looking after their inpatients and they may not have the ability to return home on time, or at all. Even then, despite some junior doctors returning home, the hospital can still call them outside of regular working hours if their patient deteriorates or dies. The so-called ‘on-call’ system does not always take over the complete out-of-hours care of the inpatients, or when a patient dies under another team. The primary team doctor is typically called into the hospital. This also means that many doctors cannot take time off or utilise their annual leave. This can be demoralising because there is no true work-life balance.
The British system has a different team structure of care and responsibility. With senior physicians being trained in a speciality and GIM together, they see both inpatients and outpatients for both speciality and general medicine, respectively. Their outpatient duties are well defined and they also have time to see their inpatients on dedicated ward rounds. They have a well defined work rota and have adequate time off to be reinvigorated.
The medical teams admit patients under their specialty and/or with unselected general medical problems. If the problem is very specialised or they are known to a specialist team, they are transferred to that specialist team by mutual agreement. The current responsible team typically coordinate the care of the patient with other specialty teams (if required) and they manage all the medical problems under their remit.
For on-call, there is a dedicated medical team who will take over all responsibilities to see any inpatients and new admissions during the nighttime. They are contacted instead of the primary team doctors and they will also speak to families and attend patients who have died. They are essentially a temporary extension for the daytime medical teams. Such on-call teams change in accordance to a defined rota. Detailed instructions are given to the nighttime team via a shift handover discussion and with medical notes and summaries written in detail about the ongoing patient care plan. This means the on-call team can make decisions based on the information at hand.
Why has the hospitalist system failed to become popular in Japan?
I think that the hospitalist system has failed to gain popularity in Japan as a result of the medical culture and attitudes. From my observations, many junior doctors want to attain training in a highly regarded speciality rather than in GIM which has only gained accreditation in recent years. Why is this?
To be blunt, specialist training is regarded by patients and by other doctors much more favourably than GIM, which is generally looked down upon.
In order for the hospitalist system to succeed in Japan, it would require a 180 degree reorientation of the medical system. It would require that specialists relinquish responsibility and control for admitting medical patients; it would require them to give up ‘ownership’ of such patients.
If one was to imagine a sunflower, the center would be the hospitalists who are seeing the patients for most of the time, and who treats the majority of medical problems (if not all of them), and who coordinates the tests, consults other specialties, organises family discussions, coordinates discharge and who does the paperwork. The petals of the sunflower would be the specialists who are consulted by the hospitalist, when required, but who are not the primary ‘owners’ of most of the patients.
From my observations, specialists in the Japanese system regard themselves, and are regarded by others, as the most important healthcare providers. To then force them to accept, what might be perceived as a peripheral role, and where the hospitalist, a doctor of just three years training, suddenly starts to coordinate them, might be seen as insulting. It might be a request too hard to take. That is of course putting aside for one moment that this is done for the best care of the patient, and not the doctor.
From my observations, there is no real concept of ‘shared care’ in Japan for the best care of the patient. Although specialists are skilled in their areas of expertise, outside of that, they sometimes struggle to cope with the other patient problems. Hospitals that have GIM teams may be treated as periphery teams, or a proverbial ‘dumping ground,’ and their patients are ones that ‘no one wants’ e.g. the complicated patient with dementia, urinary tract infection, heart failure and chronic obstructive pulmonary disease. Such teams are generally small in terms of the numbers of trainees and the number of patients.
Hence, because of a lack of GIM services, patients tend to be moved from hospital service to hospital service to solve each problem in turn. This is far from the model of the hospitalist that puts the patient in the center and has the doctors rotating around them.
The Japanese medical system is still very much a top-down system or as some call it, pyramidal. The power resides with the specialty professors of the ‘ikyoku’ in the universities in many instances. For the hospitalist system to become mainstream, it would require a reorientation of the pyramid and hence, the power balance. I do not see this being a viable option.
I think another reason for the overall lack of acceptance of the hospitalist system in Japan is that many hospitals may be unable to accept the benefits of it (e.g. for the best coordinated care of patients) because it could upset the status quo of the specialty physician power balance. Many community hospitals have specialist doctors supplied to them via the universities. Failing to abide by the universities requests would lead to such doctors being withdrawn. With this real threat as a consequence of introducing a hospitalist system, which as mentioned would see a complete shift of the power balance, it could be disastrous if the ikyoku-system were to exert its power of retribution against the community hospitals.
Moreover, doctors who might have gone to the U.S.A for training in hospitalist medicine do not currently have any accreditation in Japan. However, such accreditation will be introduced from 2022. Given the very real problems of acceptance into the Japanese system, those trained as a hospitalist would likely be ostracised with them being unable to practice freely. They would probably only be able to practice outside of the ikyoku system, as many universities would be unlikely to accept them. If allowed to work as a hospitalist, their intervention for the good of the patients might inevitably lead to the fury of specialty physicians. As the saying goes, “The nail that sticks up will be nailed down.”
Despite the many benefits of training abroad, particularly to gain a different perspective and experience, those doctors may face massive readjustments coming back into the Japanese medical system. Training abroad can be perceived as an insult to the system which permitted their entry and training in the first place. Hence, to introduce new hospitalist concepts and methods that upset the power balance may be unpalatable, especially when it is not seen as necessary by some physicians, and even disruptive.
Is there a workaround that could have a hospitalist-like British system in Japan whilst still achieving many of the aims for patients and still maintaining the structure and power balance?
I do believe that with certain adaptations to the current Japanese system, a hospitalist-like British-style system can be created.
The change in the Japanese system would need to be generational though. No changes could happen abruptly as they would suffer with total rejection for challenging the current status quo. Hence, changes would need to be slow but purposeful.
I would suggest a change for all SMT. Currently, doctors trained on medical rotations have to rotate through various medical specialities for several years. They will also have SMT during that period.
I would suggest that an integrated general medical training (GMT) system be created, and that it trains doctors in all the major medical specialities over a three-year period. That might include cardiology, pulmonology, nephrology, gastroenterology, endocrinology, emergency medicine and gerontology. This would provide a thorough foundation in GMT. This would occur after the two-year super-rotation. Those doctors trained in GIM via the three-year GMT could then be accepted into ‘higher specialty training (HST).
Hybrid specialty-general (HSG) teams could be then created wherein those who are already trained well in GIM (over the preceding three years), also begin to receive HST in their chosen specialty. However, they would also look after all the medical problems of the patients and accept new patients with unselected medical problems. Hence, they would be practicing GIM whilst being trained in a specialty.
This would therefore produce a system that is similar to the British system.
The specialists might also acquiesce to allow their junior GIM-trained staff to manage the medical problems of the patients, but at the same time retain control of the ownership of them.
These HSG teams of specialist plus GIM trained junior ‘subspecialty trainees’ could then achieve a more integrated system of care.
The hospitalist-specialist ‘sunflower’ concept, as mentioned earlier, would be averted, as the specialists running HSG teams would not be seen as supernumerary to the ‘generalists.’ They would in essence be integrated teams working together.
However, the concept of sharing patient care would need to be developed further; hence, input from several teams concurrently, but still with the overall care for the patient orchestrated under the primary team.
However, the concept of on-call would also have to change dramatically. This would mean that the care of patients outside of normal working hours would fall on one on-call medical team. The on-call team would be one of these HSG teams. However, the care of the medical patients both on the wards and the newly admitted patients would fall under the responsibility of the GIM-trained members of the on-call HSG team; this would include deteriorating patients and all deaths.
In time, the specialty trained physicians will become the senior physicians who can then practice both their specialty and GIM, respectively. This would then be a system more akin to the British system that addresses all the medical problems and has an integrated system of care permitting shared care for the best of the patient.
I hope that leaders will look upon these ideas favourably. It will allow specialty medicine and GIM to flourish hand in hand.
Director of Clinical Training, Yao Tokushukai General Hospital.