A visit to Lao-China Friendship Hospital.

When we visited Laos in August, I went without any prior contact, since I knew nobody in the country, but still, I wanted to get a glimpse of what health care looks like, and listen to the actual health care workers in the country. So, one afternoon, we negotiated with a 'songthaew' driver to take us to Luang Prabang Provincial Hospital, more commonly known by locals as the 'Lao-China Friendship Hospital', or simply the 'Chinese' hospital.

Located off the main road four kilometers south of the city on a seven-hectare land, the hospital was completed in 2004 with assistance from China, as its name implies. It was already during the late hours of the afternoon, so the outpatient department had already closed and many staff gone home. Although without any contact beforehand, the staff at the counter in the deserted main hall kindly allowed us to walk around the hospital. Upon starting our 'tour', we noticed that all of the emergency exit signs and fire hydrant labels were written in Chinese and English only, and without Lao, no wonder the locals call it the 'Chinese' hospital.

While we were walking, we came into a nurse, who was apparently about to go home, and she was kind enough to let us hear about the hospital and her job. The hospital is divided into four major departments: inpatient, outpatient, labor room, and pediatrics. The outpatient clinic includes internal medicine, surgery, pediatrics, obstetrics and gynecology, family planning, otorhinolaryngology (ear-nose-throat), dentistry, and emergency. Depending on the day, the hospital sees about 25 to 100 patients per day, with Monday getting the highest number. Its medical staff comprises 97 nurses, 27 physicians, plus 10 volunteering nurses from South Korea. Some common medical problems include common cold, respiratory infections, cardiovascular disorders, gastroenteritis, and accidents. She said that an increasing number of people do not take enough exercise, something I am used to hearing in other parts of the globe as well.

After going through the examination rooms, we visited the ANC, or the antenatal care department, which they say is the busiest part of the facility. At least three staff must constantly be present here, so they are currently working on a 24-hour-work-and-24-hour-rest rotation. For vacation, they get 10 days off per year. According to them, the busiest months are February, March, May, and June, before the rainy season starts. Here we met some nursing students, who told us that they have a 2.5-year program. There were no medical students, but we found out that is because the sole faculty of medicine in Laos is in Vientiane, the capital.

For the patient, there are two often-encountered problems in the medical scene, although they do represent larger underlying issues. One is the lack of medicine matching that of international standards. In recent years, foreign aid, especially from China and Japan, has helped hospitals to update their out-dated facilities and equipment, and bring up more health care professionals, however, there still are often cases where the patient is asked to travel down to the capital of Vientiane, almost 500 kilometers away on a recently-paved mountainous road. And even at there too, the patient is often asked to cross the 'Friendship Bridge' to receive further treatment at a Thai hospital. In emergency cases, such as major traffic accidents, this clearly does not work. And, obviously the patient would have to pay for all of the transportation costs, and the fees skyrocket if you need to be transported across the border.

This leads to the second issue: money. Universal health care is still non-existent, so even in public hospitals the patient needs to pay. The same goes with ambulance, where patients pay by the kilometer, like a taxi. If she or he gets admitted, the average fee per night for a normal room is 40,000 kip (about US$4.80), but that is not easy for a country where people live on an average 10,000 kip (about US$1.20) per day, though the economic disparities are great. People who live in Vientiane, the nation's capital, are the richest, where over 50% of households have cars and 40% have air-conditioners, while next comes those living in the capitals of the provinces, like Luang Prabang, and the poorest are the farmers who live in the mountains and the countryside. According to the staff, patients who have financial difficulties paying fees may submit a request to receive aid from the government, but again, one needs to travel down to the capital to do so. It is not surprising that the 150 beds at Luang Prabang hospital are never near full.

The government seems to have started working on these issues over these few years, and is in the process of not only setting up a clinic in every village, but a primary school, and encouraging more villagers to have their children enrolled. Of course, the families would have to give up on earnings that would be made through having the child work instead and understand the long-term significance of education, so it's not easy, but at least they wouldn't have to walk hours to go to school anymore. They are also working to put more emphasis on preventive medicine, and moreover, health-building through community participation. Things have only started to change, and it will certainly take a long time, however, the interesting point about Laos is that they are going through the process at the same time their economy is developing, something other economically-developed nations went through at separate times, with economic development coming first.

How should we save more lives from cardiac arrests?

During the second week of September, I was in the Department of Emergency Medicine as part of my clinical rotations. Our university hospital focuses primarily on tertiary emergency medicine, therefore, only the most severe patients are carried into the ER here, such as cardio-pulmonary arrests (CPAs). However, there are exceptions, including cases where the ambulance had been refused by other hospitals, which is unfortunately, not rare at all. Through my four days here, there were some things I felt and thought I would like to share.

In emergency medicine, a CPA patient is defined as one who is unconscious, whose breathing cannot be seen, heard, nor felt, and pulse cannot be felt at the common carotid artery. When this patient is carried in, we basically follow either the Immediate Cardiac Life Support (ICLS) or Advanced Cardiac Life Support (ACLS) guidelines and attempt cardio-pulmonary resuscitation (CPR). However, through the days I was there, out of a total of seven CPA patients carried in, none recovered from coma and one reached recirculation but did not regain consciousness. The hospital admits 350 to 400 CPA cases per year, and circulation returns in approximately 50 of them, and total recovery is 10% of that, and that means a single digit number.

When one falls into CPA, which part of the human is most quickly damaged? The brain. Not only is it a damage, but an irreversible one. It is said that if recirculation could not be achieved within five minutes of CPA, chances of full recovery declines to 50%, and after 10 minutes, that plummets to somewhere extremely close to zero. With this considered, in the U.S., some local authorities have begun to adopt the termination of resuscitation (ToR) guideline. It supports termination in the out-of-hospital setting subsequent to failed basic life support (BLS) resuscitation by emergency medical services (EMS) personnel if all of the following are true: (1) no return of spontaneous circulation prior to transport; (2) no shock given prior to transport; and (3) arrest not witnessed by EMS personnel.

Our university hospital concentrates on tertiary emergency medical care, so in other words, patients carried in are those whose chances of full recovery are close to none. But no matter how the situation is, ER personnel will do whatever they can do to resuscitate. In Japan, the average time it takes for an ambulance to reach the site after the 119 call is seven minutes, and it takes 30 minutes from the time of arrival at the site to reach a hospital. It doesn't take a rocket scientist to see that that is well beyond the 5 minute 50-50 tipping point.

Without doubt, knowing the ICLS or ACLS procedure is a must for all health care providers. However, chances of a CPA patient being saved is extremely low, unless someone at the site knows BLS and carries it out. What I would like to clarify here is that yes, knowing the ICLS or ACLS guidelines and being able to perform it is important, however, teaching people the basics of emergency medicine and making sure they can perform BLS promptly and appropriately is the way to significantly cut the number of lives lost from CPA. The good news is, BLS seminars are becoming more common, and organizations from corporations to governments are placing automated external defibrillators (AEDs) here and there. Now, we also need to focus on how to help people keep up with their BLS skills. :-)

A visit to The Royal Infirmary of Edinburgh.

My first visit to Scotland, and Great Britain. It was months ago when I decided to participate in the three-week 'English for Medicine' course offered at the University of Edinburgh's (pronounced 'yeh-dinbra') Institute for Applied Language Studies (IALS), and what made me do so was that I wanted to see the Division of Community Health Sciences and meet a professor named Dr. Raj Bhopal there to seek some advice about how I should pursue my area(s) of interest. Having interest in family medicine and public health with a clinical taste, I also wanted to take a look at how general practitioners (GPs) work and get a general idea of the health care system there.

As in other countries as well, the U.K. has both public and private hospitals, the former of which is run by the National Health Service (NHS), a non-profit organization funded by the government but independent from, paper-wise. Now, in Japan, patients have the freedom to choose the hospital or clinic they wish to visit. Whether it's your local clinic or a university hospital or the cancer center, it is basically up to you to decide where to go, however, this is not the case in Great Britain. If you become ill and wish to see a physician, unless you have a contract with a private health insurance company, which will allow you to have access to a private hospital, there are only two ways you can see a physician: see your GP or end up in the accident and emergency department (A&E). GPs are allotted a certain population in an area, meaning from the patient's point of view, you are automatically determined who your local health care provider is depending on where you live. Only when your health problem cannot be solved at the GP or A&E clinic that you first have the chance to see a specialist, in the form of referrals written by your GP.

A GP has two major roles: an expert in general medicine providing primary medical care, and a gatekeeper of resources. The former role includes not only the clinical part (inside the clinic and also visiting homes), which includes pediatrics, maternal health, referring patients to specialist hospitals, and follow-up of patients with chronic illnesses, but also a variety of other tasks for community health, such as prevention and health promotion, and sex education and family planning. But in reality, most of the GPs in populated areas only have time to do the clinical part, which can be understood from the fact that patients are made to wait an average one week from when you make your phone call to the point of your appointment. No wonder an increasing number of patients, who can afford, are choosing private hospitals. If you're referred to a specialist, it will likely add more weeks or even months to that.

The GPs' latter task, as a gatekeeper of resources, is in two perspectives. A GP has to prevent inappropriate use of treatments and 'control' the patients' demands, thereby saving financial resources, and also guide the patient to the right care they need, as in referring to the appropriate specialist, thereby saving human resources. However, because of this, there are many GPs who face a dilemma, as they are also the closest health care personnel for the patients, and speaking out for them is the basis of a GP's job.

So, when I had an opportunity to follow Dr. William MacNee, a consultant physician and professor of respiratory and environmental medicine at the Royal Infirmary of Edinburgh (RIE), I wanted to focus on not only how he interacts with the patients but also how he communicates, or exchanges information with the patients' GP, system-wise, as good communication is vital between the specialist and the GP as well in a health care system like the U.K. Oh, how do I know him? Well, Dr. Patrick Barron, the passionate professor in charge of the International Medical Communications Center (IMCC) at my university, kindly introduced me to him.

In a typical medical consultation here, the physician only jots down notes, instead of scribbling on the official medical records, which makes reading them a decipherment for others. After the patient leaves the room, the physician will read aloud and record on a tape what he wants written in the official records. The tape will then be duplicated, with one copy going to the patient's GP and the other to the physician's (or the department's) secretary for transcription on to the electronic medical records. The one going to the GP is labeled urgent (red) or not (blue). This system saves a considerable amount of time for the physician, though that means more work and some medical knowledge needed for the secretary.

The RIE is a specialist hospital, so there are no GPs, except for those in the A&E. Tracing its roots back to 1729 as the oldest voluntary hospital in Scotland, it was incorporated into the NHS scheme in 1948, and the current facility, located south-east of the city, was completed in 2003 for 190 million British pounds and boasts 900 beds. Due to its location, it also serves Midlothian and East Lothian. Adjacent to the hospital is the medical school of the University of Edinburgh, which the hospital has maintained close ties with for years. Some noteworthy features of the facility include a 24-hour A&E unit, the Simpson Centre for Reproductive Health, giving birth to 6,000 babies each year (largest in Scotland), and the Scottish Liver Transplant Unit. In the hospital's main hall are banks, eateries, a general store, a bookshop, a barber, and the patients' information center. Brochures and pamphlets covering a variety of topics, from information of diseases to informed consent, or self-help guides, such as how to deal with stress, can be found here and the good thing is all are free for the patient to take home. Very useful and interesting.

Finally, I would like to share some phrases and expressions I heard in the patient-physician interactions, especially from Dr. Gourab Choudhury, who is Dr. MacNee's registrar. I spent the morning following him on the day I was at the RIE. When a patient kept on complaining over and over about how her dyspnea was so severe, he used the phrase "Oh dear." several times. It's sometimes not easy to think about how to react when your patient keeps on complaining, and I thought this was a nice and simple way to express sympathy. Another phrase is "Let's take it on from there.", which he often used when he was finishing up the medical consultation. I often find it difficult to find an appropriate phrase to end the conversation with a patient, but here it is, a simple, convenient expression with a positive-thinking meaning and a touch of sympathy. :-)

Banning fast-food in low-income communities.

On July 29th, the Los Angeles City Council voted unanimously to place a moratorium on new fast-food restaurants in South Los Angeles, an impoverished swath of the city with a proliferation of such eateries and above-average rates of obesity and diabetes. The action, which is yet to be signed by the mayor, is believed to be the first of its kind by a major city to protect the health of a people in a community, in this case, a low-income neighborhood.

An area with a population of 500,000 people, most of whom are African Americans and Hispanics, 28% of families here live on a budget of under 20,000 U.S. dollars a year. According to a report by the Community Health Councils, 73% of restaurants in this district are fast-food eateries, compared with 42% in West Los Angeles. These eateries alike are popular choices especially among the economically-handicapped. And not surprisingly, 30% of adults in this area are obese, compared with 19.1% for the metropolitan area and 14.1% for the affluent Westside, the Los Angeles County Department of Public Health found out.

The year-long ban of new fast-food restaurants is intended to give the city time to attract restaurants that serve healthier food. Often referred to the 'Food Apartheid' by the health-conscious, the number of stores selling fresh foods is less than a quarter of that in other areas of the big Californian city. Research has shown people will change eating habits when different foods are offered but cost is a key factor in low-income communities. If you are running on a low income, or don't even have a job, and you don't have a car or other means of easy transportation, fast-food restaurants in the neighborhood serve as a cost-saving and convenient option. Although depending on what products you choose, it is not difficult to eat three meals a day for under five U.S. dollars total. Cheap, unhealthy food and lack of access to healthy food is a recipe for obesity.

However, some people in the community believe this is not enough to solve the issue. Many people are aware that fast-food is unhealthy and it is not that they don't have any supermarkets selling fresh foods. Formerly called South Central Los Angeles, this is a part of town whose name was replaced by the current one in 2003, as 'South Central' had become almost synonymous with urban decay and street crime. One pointed out that local gangs dominate some areas near the supermarkets, and people wouldn't dare to take the risk of getting robbed, beaten, or shot. The same could be said for the supermarkets, as their numbers are actually dwindling, because they don't want to risk being attacked and robbed by the gangs. To add to that, even if the crime rate is lowered, many people in the area don't know how to cook, as they have never learned how to.

The ordinance comes at a time when governments of all levels are increasingly viewing menus as a matter of public health. By the year 2030, it is estimated that 86.3% of Americans would be obese. L.A.'s ban, which can be extended by up to a year, only affects stand-alone restaurants, not eateries located in malls or shopping centers. It defines fast-food restaurants as those that do not offer table service and provide a limited menu of pre-prepared or quickly heated food in disposable wrapping. It exempts so-called 'fast-food casual' restaurants, which do not have drive-through windows or heat lamps and prepare fresh food to order, such as El Pollo Loco, Subway, and Pastagina.

Meanwhile, representatives of fast-food chains said they support the goal of better diets but believe they are being unfairly targeted, claiming they already offer healthier food items on their menus. Not surprisingly, the California Restaurant Association and its members are considering taking a legal challenge to the action.

A former gangster in the area has said the ordinance would bring minimal change, and for fundamental change, it has to be done by the people in the community... and this is an idea that lies at the roots of primary health care (PHC). :-)

A visit to Wat Phra Baht Nam Phu.

Last summer, on August 8th, I had an opportunity to stop by the Wat Phra Baht Nam Phu, which translates to 'the temple of Buddha's footprints'.

At least one million Thais have been infected with HIV/AIDS since the first reported case in 1984. The rate was increasing at an alarming rate in the 1990s, however, with the society at that time not well aware of what was becoming a major social issue, those affected were cast aside and left to die. Situated in Lop Buri province, 120 kilometers north of Bangkok in central Thailand, the temple was turned into what it is now, an AIDS hospice, by a Buddhist monk named Alongkot Dikkapanyo back in 1992. Since then, the facility has expanded to accommodate 400 beds from an initial number of eight, thanks to the temple's extensive public relations strategies bringing in donations amounting to the equivalent of millions of dollars. Photos of the temple’s sick and emaciated patients adorn posters and donation boxes across the nation and television stations from around the globe visit to film documentaries. Wat Phra Baht Nam Phu is currently home to over 200 HIV-infected adults, and has been for a number totalling 10,000 over the past, most of whom died from the illness.

The temple's activities have always been controversial in recent years. Tourists from mostly western nations visit in thousands every week, taking tours that are guided by some of the relatively-healthy AIDS patients. They go through the wards where the relatively-weak AIDS patients are, without much explanation, and continue on to the 'Life Museum', a collection of dozens of mummified corpses of dead AIDS patients, who according to the staff, agreed to be put on exhibition prior to their death. That is followed by the crematorium, which is surrounded by what seem to look like sculptures or other pieces of art made from the bones and ashes of those who have been cremated here. Then they walk to a hall which houses a Buddha surrounded by piles of sandbags, or 'ash-bags', which contain the ashes of those who were cremated but have not yet found relatives to take it home. Visitors also have an opportunity to see a dance show done by AIDS patients too. And after all that, they leave behind tons of donations.

Yes, the hospice provides care and 'protects' those suffering from AIDS, but what is it doing to how people see HIV/AIDS patients? Dead AIDS patients whose bodies are not taken back by their relatives become sandbags or pieces of art, or part of the exhibits in the museum that has little explanation of the bodies. Those who are weak, and in their twilight of their lives, simply lie on the bed as tourists pass by giving them that look in the eye. You can often see the visitors covering their mouth upon entering the ward, then swiftly moving through wordlessly. Many don't even say hello. Those who are still relatively healthy host the tours or performances for the visitors, helping to attract more donations. I can't help myself from feeling that all of these together only exacerbate prejudice.

In Thailand, more than 400,000 have died from AIDS, however, it is also one of the few countries to have successfully curbed its epidemic with awareness campaigns, and later pioneered the widespread distribution of anti-retrovirus drugs (ARVs), which slow the progress of the incurable disease. In the 1990s, up to 100 patients died at the temple every month, but now, that number has been reduced to about 10. According to UNAIDS, fewer than 17,000 infections were reported in the country in 2006, compared with 143,000 in 1990, but officials are worried that the rate could climb again. HIV prevalence among intravenous drug users and sex workers remains high, while condom use among Thai teenagers is shockingly low. No time should be spared to come up with a new way to spread awareness.

In Thailand, generally speaking, monks are highly respected. Much more than the government, to be sarcastic. I believe that when it comes to bringing social awareness, they have a vital role to play. :-)

A visit to RTIC and Ta Nao Si Health Center.

On March 27th, I was able to visit Rajanagarindra Tropical Disease International Centre (RTIC) and Ta Nao Si Health Center, in Suan Phueng district, Ratchaburi province, near Thailand's western border with Burma (Myanmar).

How did it happen? Well, a very good old friend of mine from my high school days in Maryland, U.S. took me there. He was one of my best friends there, but an year after I returned to Japan he also needed to go back to his home country, Thailand, and as our lives got busier, our emails became sporadic. However, as our lives progressed, so did information technology, and one day he invited me to Facebook, a social networking service (SNS) which is especially popular among university students in the U.S. with well over 85% of them being members. We've been in close touch ever since, and I had a chance to see him this spring for the first time in nine years.

He majored in public health and epidemiology in university, and as that implies, shares a lot of common interests with me. We could go on talking for hours and hours, until our tongues became numb. And... he is also a humanitarian junkie. He's a highly-motivated, passionate, yet kind and thoughtful person who always used to talk about how he wanted to do good for his country and its people. So well, when I asked him if I could take a peek at some places he know that can be visited during my time frame there, he happily offered me to take me here.

RTIC, or the Suan Phueng Research Unit, run by Mahidol University's Faculty of Tropical Medicine and supported by the Tropical Disease Trust Fund under the Princess Galyani Vadhana, is one of the faculty's research stations for conducting research on tropical diseases. The facility's primary activities are (1) provision of health services (especially against infectious diseases) for the local people, (2) field epidemiology training for students from not only the faculty but from other countries as well, including Cambodia, Vietnam, Laos, and Burma, and (3) research of infectious diseases (mainly malaria) in the area.

Suan Phueng is a small district in Ratchaburi Province, located on the border with Burma, which is just a 15-minute drive from RTIC. It has an area of 2,545 square kilometers, consists of seven sub-districts with 8,254 households and a population of 66,972. Over 90% of the population are mainly Thai-Karen of low socio-economic status, some of who do not carry Thai identity cards. Along with 13 health centers, they also have a community hospital with 30 beds, about 30 minutes from RTIC. Common health issues of the people living in this area include malaria, dengue hemorrhagic fever (DHF), filariasis, tropical skin diseases, intestinal helminthiasis, and malnutrition.

When we visited, Dr. Maneeboonyang of Mahidol University was on duty at RTIC and he happily welcomed us and gave a brief tour of the center. According to him, this area has the highest prevalence of malaria in Thailand at around 12-13%. The kingdom is one of only a handful of countries that have succeeded in eliminating and controlling this notorious mosquito-borne disease, however, it still remains a big issue along the border with Burma. But still, the situation has been improving, since prevalence was around 30% only a decade ago, with at least one person in every single household having malaria in one of the hamlets. According to Dr. Maneeboonyang, RTIC sees 10 patients per day in the dry season (January - April) and over 30 during the rainy season, and out of that, about two and six people are diagnosed with malaria, respectively.

After the tour, he was kind enough to take us to Ta Nao Si Health Center, which is one of 13 health centers in Suan Phueng district. It provides primary medical care, immunization, and antenatal care for the local residents. We had a chance to have a short talk with the public health officer there, and according to him, the top three common diseases in the village are malaria, diarrhea, and flu, though hypertension (high blood pressure) and diabetes are becoming a problem especially among the elderly.

At the end, we had an opportunity to drive around the village to see some homes of the Thai-Karen, which look different from the traditional Thai examples. It was not long before the sun was starting to set and so we had to leave the area (local roads are without pavement and lights), but the staff at RTIC were kind enough to offer me to visit again, next time staying for a few days. And there is also Tak province, sometimes called the "humanitarian aid mecca of Thailand", and the Thai-Burma border area there, about an eight-hour drive from Bangkok. I definitely have to and sure will come back again.

Many thanks to my friend. :-)

JAIH-S International Health Training Camp 2008.

I was given an opportunity to participate in a four-day global health training program that was carried out by the Students' Division of the Japan Association for International Health (JAIH-S) from March 13th to the 16th. The main aim of this annual program is for the participants to be able to (1) create an image of what working in the global health field is like, and (2) know what you can do and how to start it.

We had lectures done by people currently working at the front lines in this field, including staff from the International Health Center Japan, a tropical medicine researcher, an epidemiologist, officers from the Ministry of Health, Labor, and Welfare (MHLW), and health specialists from NGOs, JICA (Japan International Cooperation Agency), and UNICEF. The lectures were followed by many group activities including discussions, debates, and a PCM (project cycle management) workshop which we had to work on through a night to complete.

My impression? Well... frankly speaking, I felt a little weird throughout the program. Of course, all the participants were highly-motivated, deep-thinking, yet thoughtful people who had gathered from around the country, and without question, the chats with them were really stimulating and one of those memorable times. However, most, if not all of them, were drawn by the terms 'global health' or 'international health', while on the other hand, my interest doesn't necessarily have to go beyond the border, as my 'theme' is community-based health care or primary health care (PHC). Yes, often times, these words have been talked about more in the developing communities rather than the industrialized ones so no doubt it does have a 'global health' taste to it, however, when you take a close look at the developed communities, you actually do see many forms of community health, and plus, there are many things these communities around the globe can learn from each other.

And, another reason for my feeling not right is probably due to the fact that many of the speakers have already literally abandoned the clinical part of being a physician. In other words, many of the doctors in this field do not see patients anymore at a hospital or clinic. Yes, it is true that so-called logistic-type jobs are more needed than specialized people like doctors or nurses. For example, when you take infectious diseases, the main underlying issues in the developing communities are more basic, such as sanitation or health education, and tackling these issues is the most radical solution. Treating patients and prescribing drugs is also a job that can not be cut, but it does little in terms of remedying the bigger picture. So what's needed in the field of international cooperation? Leadership, management, communication skills, and creative thinking. It's what one of the lecturers said, and I agree.

However, at this point, I have no thought of abandoning the clinician's work. Well, that's what I am studying medicine for right now! To obtain specialized skills. Yes, I am interested in public health, community health, and doing positive things for the bigger public, but I want to do that through interacting with the patients. So the image of my future I have right now could be called 'clinical epidemiology-based community health'. In other words, through interacting with the people, know the community, know its strengths, weaknesses, and hidden potentials, and do something creative to bring out their strengths to make the community happier as a whole, with the people in the community. This training program helped me reaffirm my interest.

By the way, I had a chance to talk with Dr. Honda, the founder and current chair of SHARE, the biggest non-profit organization in Japan specializing in international health cooperation, and I was deeply moved by his talks, as he and I had so many common interests... his 'theme' also sounded like community-based health care and primary health care (PHC). :-)

A visit to Ukima Clinic.

When I contacted Dr. Fujinuma to ask whether I could see Ukima Clinic, a community-based clinic operated by the Tokyo Hokuto Health Co-operative, he happily nodded. So, on November 6th, I had the chance to visit the clinic I had been wanting to visit since spring.

I invited three friends who also participated in the Exploring Health Care program this March at Stanford University and University of California San Francisco (UCSF) and now belonging to a clinical skills practice group called DOCS (acronym for Development of Clinical Skills), which we formed after knowing how much clinical experience the medical students on the other side of the 'big pond' are exposed to.

So that morning, the day there started out in the outpatient clinic. Of course, it was our first ever time shadowing a doctor, so there was so much to learn, both in terms of knowledge and the way the doctor interacts with the patient. However, what I felt here most strongly is that health care is truly patient-oriented, in other words, even if patient A and patient B have the same health issues, the medical treatment or the approach taken by the physician may not necessarily be identical.

For example, there's not much hope in persuading an alcoholic or a heavy smoker to quit or reduce the amount if he insists he earns money to drink or smoke, respectively, and if that is the ultimate joy for his life. However, a different approach may be taken towards a person who is more willing to care more for his own health. A woman who smokes five cigarettes a day to refresh herself during break at her work says she is aware that it's not good and she's thinking of cutting the amount, but just couldn't make the move. So, then the physician would actually show her some other ways of refreshing, for example drinking tea or coffee or having a light snack, and chatting with her fellow workers. Naturally, there are exceptions, but in general, the doctor does what makes the patient most happy.

In the afternoon, we participated in what is called an 'Oushin', which is a house call where a doctor goes and sees the patient at his or her home. This is a very interesting form of health care, since you really have the chance to see the environment the patient is in, including the lifestyle and the socio-economic background. There are households with various status, from seriously poor ones to rather wealthy ones. In this afternoon we visited seven.

There was a family where the only person in the house was a 90-year-old lady lying all day in the bed, having only one grandson living with her to look after her when he doesn't have work. Other members of the once big family have either died or are literally 'missing'. The house looked as if it's going to crumble with a couple more earthquakes (yes, common in Japan), and the physician, now used to visiting this home, told us the places in the room where the floor had become too weak to support us. There was also a relatively wealthy-looking family, living in a mansion. Nicely dressed ladies (apparently sisters) had gathered to look after their mother who had become ill. This was a first-time visit for this patient, so the doctor goes through the explaining and all the communication with the patient's family thoroughly and carefully with detail. After the visit, she added that it's essential to build a favorable first impression, since that leads to trust and will ultimately have a substantial effect on the future relationship with the family.

So the day ended roughly eight hours after we arrived at the clinic in the morning, though the physicians still had some paperwork left including reviewing the patients' medical records. It was a day where I had the chance to truly understand that there actually are various kinds of people with various backgrounds. I mean, I knew that by words, but this experience enabled me to put those words in my own context. It is often said that the socio-economic disparities have widened in Japan, but still not to the extent of those seen in the U.S., Europe, or developing nations, however, disparities do exist and those are not minute. It is all the more important to understand the true needs of the patient, considering the background and the environment of the patient, and think about what happiness means for each of the patients, and tailor health care to help them become happier.

At the end, Dr. Fujinuma summarized the day by giving us a small lecture about what primary health care (PHC) is, and what strategies the clinic is taking to make the community more happy as a whole. Through this talk, three key words got connected in one straight line in my mind: primary health care (PHC), public health, and community building and empowerment. There's a whole another story to this, so I'll stop here for now. :-)

Thanks for reminding me.

The other day I was talking about doctor-patient relationships with one of my friends who goes to nursing school, and it helped me remind myself of the image of the doctor I want to become.

Clinical rotations and training have started for her, and right now she's rotating through general hospitals to local clinics and health centers, while also shadowing nurses who are involved in various kinds of health care. And that day, she was complaining that some doctors really only look at the disorders the patients have and not the patients. In other words, these doctors are more focused on diagnosing and treating the disease, not the patient.

Then I thought... do I want to be that kind of doctor?
Well, I don't think so, but not to mean any offense to those doctors.

After all, I believe the doctors who immerse themselves in facing the diseases rather than the patients are the ones who bring new breakthrough technologies and advances in medicine. I also feel that many surgeons belong to that category too, as they're more like artisans or craftsmen, spending a significant portion of their life just to build up skills, sometimes just to treat only a couple of diseases. But that's still necessary, no question.

But the picture of the doctor I have in mind is more like a general practitioner, and probably more general and broader than the term actually means. I'm not attracted to craftsman-type doctors, and this just comes from my tastes, you either like it or not. I want to be able to serve people with various backgrounds. Not sure why, but I guess it has something to do with the fascinating discoveries and thoughts I've had in the past through meeting many people, many of which have helped me shape what I am now. Through examining the medical problem of the patient, I want to interact and understand more about the patient, including one's socio-economic background. If this is done at a certain community-based level, I have a feeling it would enable you to see the strengths of the community, as well as the social issues that are underlying.

Well, in conclusion, whether the doctor focuses on the disease or the patient, I don't think it matters much as long as it makes the patient happier than before. And as long as the patient is happy, what form or type of approach the doctor follows is up to the doctor's personal preference. The doctor should be happy and comfortable too, about not only what he does, but also how he does it. Anyway, there will always be a need for both types of doctors.

I've always been interested in combining the characteristics of general medicine and public health in a clinical manner. You know how you want to face your profession, but there are times when that picture gets blurred, and this recent talk with my friend helped me see it clearly again. Many thanks to her. :-)