JANAMEFメルマガ（No.5）

なぜ日本にホスピタリストが広がらないのか―長年日本で臨床教育に関わる「外人」の視点―

 
巻頭言

青木 眞
感染症コンサルタント / 米国感染症専門医

半世紀以上、米国の優れた卒後臨床教育は、世界各国から多くの医学部卒業生（Foreign/International Medical Graduate）を惹きつけて来ました。特に卒後数年までの系統的な臨床教育は内科系、外科系を問わず優れたGeneral Mindを養ってきたと感じています。日米医学医療交流財団（JANAMEF）も長年短期、長期の留学を支援し、とくに黒川清先生が会長に就任されてからはGeneral mindを持つ「日本版ホスピタリスト」の育成に注力してきました。しかし残念ながら総合診療方面に進む日本の若手もなかなか増えてこない印象をもっています。そこで今回、長年日本の卒後臨床教育、とくにホスピタリストの育成に取り組んでこられた「外人」の視点から「なぜ日本にホスピタリストが広がらないのか」を語って頂く事になりました。お一人目は米国のHospitalistで長年日本で卒後臨床教育に従事されてきたGautam Deshpande先生です。

Gautam A. Deshpande, MD FACP
Professor, Dept of General Medicine, Juntendo University Staff Physician and Senior Advisor, St. Luke`s International Hospital Post Medical Advisor, US Embassy Tokyo

Barriers to General Hospital Medicine in Japan

The hospitalist movement in the United States remains one of the fastest growing new areas of medicine in the United States in the last half-century. Since it’s founding a relatively short time ago in the late 1990s, it has rapidly became the dominant model delivery of care for hospitalized patients in the United States of America. In just one decade from 1995-2006, a study of Medicare claims showed that 61% of hospitalized patients-the majority of hospital patients in the US-received at least part of their inpatient hospital care from a general internal medicine physician.

Over the last 20 years, a plethora of studies have made the case for the benefits of hospital general medicine. Early studies showed that medical education was improved when trainees learned on a hospitalist service; multiple studies have shown decreased lengths of stay and decreased hospital-associated costs when patients are taken care of by a hospitalist (in comparison to general outpatient practitioners or specialists). Co-management of surgical inpatients between surgical specialists, such as orthopedists and neurosurgeons, and hospitalists has also become extremely popular and has been shown to benefit patient care. In addition, multiple studies have shown that there are no substantial differences in short- or long-term mortality when an inpatient is cared for by a hospitalist versus a specialist or outpatient provider.

With a rapidly aging population, and an older population that increasingly suffers from multiple medical comorbidities, Japan needs more well-trained physicians who can treat multiple diseases and solve multiple problems simultaneously. In light of the benefits of general medicine models, Japan should be poised to take excellent advantage of a hospitalist model of care. As Japan has markedly fewer doctors and other healthcare providers than it’s first-world peers, shouldn’t having a single provider who can care for multiple problems in an elderly patient be especially attractive to Japan?

Given its multiple benefits, why has hospital medicine, and general medicine more broadly, failed to be widely adopted in Japan? This is a complicated and multifactorial question, and challenging for a Japanese to answer, let alone a culturally foreign person like myself. But 11 years of working in general medicine environments in Japan, and visiting nearly a hundred hospitals throughout the country, I have perhaps gained some unique insight into this question.

First of all, the need for general outpatient and inpatient physicians is particularly acute in rural and suburban areas of Japan, like Ehime prefecture where my in-laws live, where the dearth of healthcare providers, both specialist and generalist, is substantial. Unfortunately, new medical innovation and policy is often driven from a few powerful University hospitals located in urban centers. With their relative oversupply of specialists, these large and powerful institutions are often the places that feel the least need for generalist-driven hospitalist medicine.
To make matters worse, there is likely little incentive for powerful central institutions to make change; the leverage that the urban-based 医局 hold over their countryside counterparts is in part predicate upon insufficient staffing at these smaller institutions. The hierarchical staffing relationships may contribute to keeping innovative models out of smaller hospital, as this protects the status quo of dominant institutions.

Second, the dominant care model in Japan remains a specialist-driven one, with significant stove-piping (administrative isolation) between departments even within a single hospital. This model promotes a “lone warrior” mentality, in which a single department feels both right (privilege) and responsibility (obligation) to care for a patient on their own. While perhaps romantically noble in an old-fashioned way, this goes against dominant patient trends in Japan: patients have increasing medical co-morbidities that require coordinated expertise and communication between multiple departments. The success of multi-disciplinary COVID care teams during the pandemic, such as the one run at Juntendo University, show that healthy clinical work-sharing in Japan is not only possible, it’s practical.

Finally, general medicine continues to be held back by a lack of clinical medical education in Japan-both for physicians and patients. In other economically-developed countries, a young physician graduates from 5-6 years of medical school possessing most of the basic faculties needed to triage and care for a patient’s basic healthcare needs. Not so in Japan, where a typical 6th year graduate is as naked as a baby bird, wholly unready to leave the nest. It is not until the trainee has completed 1-2 years of 初期研修 internship that they are ready to care for patients-at which point they are quickly shuttled off to specialty-oriented senior residencies!
Similarly, while Japan has one of the highest literacy rates in the world, studies have shown surprisingly low health literacy among patients in Japan. This lack of knowledge drives a wedge between patients and generalists; blinded by the ego of specialists, patients truly do not know what they are missing by not having a generalist at their bedside-not only as a well-rounded physician, but also as an advocate, and trusted healthcare guide.

I realize these criticisms may sound harsh to the ear unwilling to listen. Despite its advantages, some doubts remain on the efficiency of the US-style hospitalist system. The primary benefit of the hospitalist system in the US was to control rising hospital costs, but since it’s inception, healthcare-associated costs in the United States have continue to skyrocket.
In my own experience as a hospitalist in the United States, I saw both sides of the coin: I saw a patient whose care was made more efficient by having full-time hospitalists available; these physicians were able to quickly and efficiently take care of patient problems, getting patients in and out of the hospital quickly, and saving both hospitals and patients unnecessary costs. However, as a hospitalist, I was also assigned patients who had relatively simple, single organ problems--problems that could have been more efficiently handled by a single, “lone warrior” specialist, such as a gastroenterologist or a surgeon.
A system in which all patients see a hospitalist might add an unnecessary layer of bureaucracy and cost to the system. Instead of a wholesale importation of the US hospitalist model of care, Japan should carefully pick and choose which elements of the hospitalist model would best suit the needs of today’s Japanese healthcare.

Nonetheless, the benefits of having hospitalists go beyond just cost and efficiency. One advantage of having full-time doctors who focus on hospital generalist care is their ability to see the larger quality improvement picture, and leverage that expertise to make institutional policy changes. This may manifest as improved vaccination rates for hospitalized patients, more robust inpatient fall prevention programs, or safer ways to steward antibiotics to prevent drug-resistance. Other non-clinical roles played by the hospitalist include enhanced inter-professional development, medical education for clinical students and residents, and public outreach. The unique culture of Japan is often seen by the global community as pathologically “risk averse.” But Japan is also a brave country-it cannot be afraid to change and innovate in healthcare.

執筆：Gautam A. Deshpande, MD FACP
Professor, Dept of General Medicine, Juntendo University Staff Physician and Senior Advisor, St. Luke`s International Hospital Post Medical Advisor, US Embassy Tokyo

発行：公益財団法人日米医学医療交流財団【2021年6月1日】