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    On the Practice of Medicine and on the Culture and Customs in Japan: An Impression of an American Medical Student


    Douglas Berger

    New York Medical College, Valhalla, New York, U.S.A.

    Tokai Journal of Experimental & Clinical Medicine, 10:6, 637-645; 1985.

    (Received July 9, 1985)

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    Note: This paper was written in 1985 after only 2 1/2 months experience in Japan. Looking at the paper now as I put it on the internet in 1997, after over 12 years total of having close interaction with many Japanese, and after living and working here in Japan for about 6-years total over the past 12 years, it is clear that many of the topics discussed in the paper are only superficially discussed and clearly need revision. The purpose of the paper was more of a record of the experience than an academic endeavor; please read the paper with this in mind. The paper was not directly submitted to theTokai Journal of Experimental and Clinical Medicine, but was published to my surprise after submitting it as a record of the clinical experience to the exchange-student program coordinators.

    The original text is as follows:

    This report is based on my two and a half month experience in Japan. Almost all of my views herein were substantiated by readings or by the views of others, both Japanese and Americans, and I tried to stay as objective as possible. Many things that I was either unclear about or didn't know have been omitted and it is not impossible that some of the statements herein may be wrong, unclear, or debated about.

    In this essay I would like to discuss my experience and impressions as an exchange student at the Tokai University hospital from 3/5/85 to 5/17/85.

    Accommodations were provided by Tokai. I was met at the airport and spent the first night at the Hyatt Regency in Tokyo. My dormitory room was three minutes away from the hospital. It was spacious, carpeted, complete with a desk, bed, small refrigerator, and adjoining bathroom/shower. I was also given a food allowance which amounted to about $1400 for two and a half months. Travel expenses to various places and hotel expenses to Kyoto (for 3 days) were also paid for. The Japanese university was keen to make my stay convenient, pleasant, comfortable, and inexpensive.

    I first studied in the Dept. of Neurology where I was treated with much concern for my education. A curriculum schedule was given to me which included rounds, conferences, and assignments to different doctors for personal instruction. Most of my instruction was in English and was usually very good. At conference or rounds someone would translate for me when necessary.

    My studies included patient examination & diagnosis, observing autopsies, nerve biopsies, rat brain procedures, EMG, tensilon tests, lumbar punctures, and research including: palatonasal air flow, cerebral atrophy, blood viscosity, and cerebral blood flow studies. I also traveled to Fuji city to see NMR imaging, to Yokohama for a conference, and to Kyoto for three days for a national stroke conference .

    In summary, I learned the techniques of neurological examination, patient disease and treatment, neurological research methods, and was able to see some pathology that we see only infrequently in the U.S. I was able to speak all the basic Japanese necessary to make friends with the patients and to instruct them in the neurological examination.

    Next I studied in the Dept. of Psychiatry. At first I learned the practical techniques of EEG & EEG reading. I also saw psychopharmacoIogic research, biofeedback treatments, and learned about nercolepsy, and Naikan meditation therapy based on Zen-Buddhism. I then visited Minakawa Psychiatric Hospital for two days where I saw in- & out-patients and also began work on the in-pt ward and saw out-patients at Tokai. Before a patient interview I would be briefed on the case and there would be a discussion right after the interview about the patient's pathology. Because my Japanese had improved at this point I also had my own impressions of the case, and because the psychiatric doctors spoke English poorly, Japanese was very useful. At Tokai, the in-pts were mainly neurotics. My visit to Minakawa Hospital enabled me to see psychotic patients.

    My last weeks included a visit to Keio University where I observed techniques of eye movement tracking, evoked potential experiments on psychiatric patients, EEG wave density maps, and the only 3-D color coded graphic display of the visual evoked potential in the world. I also spent a day at a Morita clinic, and studied Morita therapy in-depth by reading many articles. Morita therapy is another meditation therapy based on Zen.

    A funny things happened once because I couldn't read Japanese. At a conference in Yokohama I thought the receipt to get the car at the garage was garbage and threw it out. We found it but realized that it was risky to leave me with important documents!

    One special experience was a visit to the Tokai laminar air-flow bio-clean room where patients awaiting bone marrow transplants are given psychiatric support.

    Here I should discuss a brief history of Japanese psychiatry. During the Meiji restoration in 1868, Japan opened its doors to foreign culture after over 200 years of self imposed isolation, and psychiatry became heavily influenced by the Gelman biological approach. After WWII more dynamic ideas filtered into Japan, however, even today only about 5 of 80 medical schools are dynamically oriented. Tokai is one of those 5.

    One reason that dynamics has not become popular may be that in Japanese custom there is less emphasis on physical contact. For example hand shaking, hugging, kissing, etc., are not proper types of interactions in traditional Japanese custom. Some of these actions are considered to express sexual behavior and as sexuality is [superficially] suppressed, this may be one of the reasons that the biological approach to psychiatry is so readily accepted.

    The Japanese psychiatrists though realize the importance of modifying the type of therapy to the type of patient. Some patients benefit most from the dynamic approach and some are best doing meditation therapy or having biofeed- back or behavioral modification.

    Now I would like to discuss some of the differences between Tokai and U.S. hospitals. At Tokai the residents are generally younger and more inexperienced at practical techniques than in the States. In Japan, medical school is 6 years long starting after high school, and the medical students are not allowed for legal reasons to perform procedures, not even take blood.

    Because the educational systems do not parallel each other it is very difficult to equate Japanese and American medical students or residents in abilities. The experienced Japanese doctors seemed to be on the same level of competence as in the States. Another difference was that the Japanese residents once at the PGY-3 level are required to be involved in more research oriented endeavors to the point that most of their time may be spent in the lab.

    The medical student curriculum differs in several respects. First, there is no liberal art course load. Besides courses in English and German the curriculum consists only of science and medicine. Second, is that clinical experience amounts to total of one year and the rest is class work. The Japanese clerks are also much more just observers than participants as we have in the States.

    Japanese students are also very reserved and rarely ask questions. The doctors all thought it was curious that I asked many questions about the patients diseases and treatments.

    In general the Japanese people come across as shy. There is a decreased expression of ones feelings in order to avoid any ill reaction by others. Because of this many Japanese are easy to get along with, but it can be difficult to get your Japanese friends to express their opinion on an Issue for fear it will cause a conflict. Other differences were that there is no elective time in the curriculum and that the female students make up only about 15% of the student body.

    In general, the Japanese work more than in the States. They have a 6-day work week with only one free Saturday a month. Work days tend to be l0-16 hours long. In some situations however calling for negotiations or decision making, the Japanese may spend much more time in discussion than in America to attain a decision. They also tend to spend much time In commuting to work and in work related travel.

    The Japanese marital system has a great effect on the female doctors and nurses. Because all the men work so much, the women are delegated to tend to the house and child rearing. Usually the children have a much closer relationship with the mother and less time with the father than in the States.

    I found that the nurses were generally younger than in the U.S.. I observed nurses who left their Jobs upon marriage in order to maintain the house even If there were no children yet. This may lead to a younger and more inexperienced nursing staff than in America.

    Japanese women usually marry in their early twenties It may be very difficult for a woman over 30 to find a mate. There is less emphasis on Individual subsistence, divorce is less sanctioned by society than in the States, and there is less chance for older unmarried individuals to meet. The older nurses at the hospital were few in number, usually single and may be heard to be referred to as "Oba-san" or old maid (lit. Auntie or Mom) behind their backs.

    The female doctors may also have trouble marrying. Men traditionally want a mate to tend to the needs of the house and children and may shy away from a career oriented woman. Many do marry but it's not uncommon to find a female doctor dedicated to medicine and who has resigned to find a mate. It's much harder in Japan to find such services as babysitters, maids, day care centers, etc. that cater to career oriented women.

    Another difference to American custom is that at times of Job-based social events, only those employed would attend. It was not custom for spouses to be present. This would also manifest on business trips where the husband would travel for up to weeks at a time without his wife. It was also interesting that at social events it is quite acceptable to act out in otherwise embarrassing ways. If a boss acts in some strange way at a company party because he is drunk, he is still respected the next day at work. Rarely though would there be any violence associated with alcohol ingestion as we see so often in the States. Classically, Japanese men's faces get a bright red and flushed when they are drunk. This was very striking to me and I have not as yet found out the exact physlologic mechanism (It's due to low levels of the enzyme alcohol dehydrogenase-1997 addition).

    Now I would like to discuss the Japanese view of foreigners. Because Japan is an island and because of the 200 years of cultural isolation, the Japanese are very Interested in foreign culture. Many aspects of Japanese culture have been assimilated throughout the centuries from other cultures. Some of the more obvious examples are the use of Chinese characters and the influence of Buddhism.

    Since WWII we see a form of westernization in the use of western clothes, western music business structure, technology, etc. This may be very misleading because this westernization is very superficial, covering over a very oriental base of culture, upbringing, and attitudes. This may also become a nidus for conflict and the genesis of psychopathology. Traditionally they are a very dependent society (called "amae" or feelings of amaeru) and the individual independence that is needed to compete in the westernized job market may provoke the development of the classic Shinkeishitsu neurosis. One example of this lack of independence is the lack of elective time in the medical student curriculum.

    Classically, the Japanese are described as feeling superior to all other orientals and inferior to the occidental races. Westeners are usually treated very well and they are often more helpful to us than to themselves. One of the reasons is that they respect the high degree of technology, arts, & the standard of living that we enjoy in the U.S., and they want to learn from us so that they may better themselves.

    An American in Japan may be able to break all social barriers and make friends with mere laborers as well as chiefs of medicine. Some Americans who are not very popular in the States come to Japan, find their social life is plentiful, and decide to spend the rest of their lives in Japan. The only problem with this is that there are few or no social services to aid the elderly foreigner who is too old to continue at his job.

    I must mention however that no matter how long a foreigner may live in Japan or how perfect they may be able to read, write, speak, and know the fine points of the culture, they can never assimilate into the Japanese society as a foriegner may do in the U.S.. There is much more of a native/foreigner distinction made in Japan than in the U.S.. More than once I heard people say "Gaijin" (foreigner) as I walked past.

    Although they don't have the blatant racism that we have in some areas of the States, it may still be very difficult for a foreigner to become a functional integrated member of the Japanese work force in a position not normally allotted to foreigners (i.e. English teacher) even if they have mastered the language.

    Usually foreigners are considered to be "different" without a great deal of better or worse emphasis. This difference though, relates to the high degree of conformism to a prototype necessary to be successful in Japan. The social image one emits is very important in Japan. Any deviance from a narrow norm might provoke social scrutinization by others and anxiety in the deviant individual. Foreigners cannot help but to be different, and although it is accepted that they are different, the problems of assimilation mentioned above still exist. Even Koreans born and raised in Japan have difficulty obtaining citizenship. Being born in Japan does not automatically entitle you to citizenship as it does in the U.S..

    I must clarify that the Japanese consider certain groups of foreigners better or worse on a global scale and just different on more of an individual basis. In Japan one notices the degree of sameness soon after arrival. All the men wear solid grey or black suits and plain ties and shirts. Hair styles are usually the same as well. Men are usually formally dressed no matter what the occasion. Hobbies and interests also tend to be similar. It is rare to find a Japanese person that does not play tennis, ski, and golf.

    School children through high school are seen in uniform. Girls wear what resembles a U.S. navy uniform and boys dress like West Point cadets. More than once it was mentioned to me that there are many military-like regimenting customs in Japan, School is also 6 days a week. This sameness may also be misleading to the casual observer. The conformism is very much directed toward a social image and under this one finds much more of a diversity in personalities. This may only be revealed after a longer interaction with the people and after friendships are made. Ability to speak Japanese also allows a greater understanding.

    The high degree of social sensitivity was evident to me in two interesting situations. One was that on the train, everyone seems to either read or sleep. Of course we do the same often in the States, but it was more striking in Japan. Very often a book would fly open or eyes would close before a person even got settled in their seat. In psychiatry I learned that these activities effectively cut a person off from outside social interaction and shield them from possible anxiety provoking eye contact situations. This is called anthropophobia and can reach pathological levels in the Shinkeishitsu personality.

    Another situation that I alluded to before, is that in a Japanese conversation the main object is to have a pleasant conversation and not to come to some conclusion or goal. They are very sensitive to others' reaction of what is being said and dislike stepping off neutral ground. One striking example of nonconformism is a "punk" style of hair and dress in some circles of the younger generation. Although they are usually very flashy in dress and hair style, and being deviant from the norm, they are all very conformist with in their own group. Many Japanese psychiatrists seem to feel this is good for the attitudes of the people and may help to instill some degree of an independence and individuality in them.

    Before going into some of the attitudes toward disease, I would like to say a few things about Japanese language and religion. The Japanese language consists of three sets of syllabaries. Two were developed in Japan, have a phonetic meaning, and about 75 letters each. The other was borrowed from the Chinese, has a conceptual as well as a phonetic meaning, and 2.000 characters are required to be learned in school. Although it takes a lot of study to master the Chinese characters, and they can be forgotten if one does not use them regularly (ie-prolonged work in another country in another language), they have the advantage of having an unambiguous meaning at a glance, they are part of the Japanese culture, and are used as often as possible in writing.

    One of the Japanese syllabaries, Katakana , is usually used for words of foreign origin. For example, I was given an ID card with my name in Katakana. Well, because of my "When you're in Rome do as the Romans do" attitude, I requested to have my name in Chinese characters as all the Japanese people do. Traditionally foreigner's names are not written in Chinese characters and this request created a confusion among my Japanese colleagues [some who were dead-set againt my having a name in Chinese characters]. I was told that the characters had a certain "feel" to them and one got a certain "feel" about another by the types of characters they used for their name. This seemed to reflect another example of the native/foreigner discrimination in Japan, but, because I was in a position as a medical student (not normally allotted to foreigners) and because of my sincere desire to assimilate and learn about Japanese customs [and also probably just to save face], I was granted a name in Chinese characters as long as I wrote the English below it. My name's meaning was "Feather Festival".

    The basic religions are Shintoism and Buddhism. Shintoism was developed in Japan and is based on Confucianism and ancestor worship. Buddhism was imported from India via the Chinese.

    Although the Japanese culture seems to thrive on the images of the temples and Buddhas it projects, the Japanese are more of an agnostic people. Belief in a God per se does not seem to be that important. In a psychiatry lecture one of the professors said to me "the Japanese are very unreligious and there is less discipline in ethical evaluation than in the States. You may see someone sweeping dirt from in front of their house to in front of the next house." I observed that on the trains the elderly were rarely catered to in being given a seat by another person and were often required to stand [this was seen less often years later because the railways put up big signs next to designated Priority Seats].

    The above paragraph is interesting in light of the little crime and violence in Japan. I think that the discrepancy lies in the fact that the Japanese code of ethics may be calibrated differently depending on the situation.

    There is a great deal of superstition in Japan however, and twice a year there are more religious events. One is Shogatsu (the new year) and the other is the Obon, where the living pay their respects to the dead. One superstition that relates to illness is evident in a custom that is done when someone is sick, especially a child. Because there is a story of a young girl with a terminal illness who made 1,000 paper cranes (origami no tsuru) before she died, some Japanese families make 1,000 paper cranes, hang them up in a temple and pray the child gets better. In the hospital there is a ceremony performed after a patient dies called Shoko o suru. This was more of a tradition, serving to better the psychological well being of the family and doctors and nurses, rather than because of a belief in God. I was fortunate enough to be able to attend one Shoko after a patient died of suspected encephalitis. I attended the autopsy and then went to the Shoko held in a small "chapel" in the hospital basement. In this ceremony (rooted in Buddhism), one pays their respects by lighting senko (incense) and then ringing a small chime. The incense symbolizes that the prayers of the people and spirit of the body will rise to heaven.

    After this, mutual respects are paid between the family and staff, and then the doctor discusses the autopsy results and cause of death with the family. The particular doctor I observed was very caring of the family's emotional state and carefully described what may have been the cause of death. From the hospital the body goes to the family's house for the Otsuya ceremony. Here the face is in view while the family and friends pay their respects. Then the body is brought to a temple and cremated. The ashes are commonly buried under ground and a monument is erected.

    In Japan, the definition of death is slightly different than in the States. Death is described in terms of cardiorespiratory arrest in Japan. Brain death alone is not legally sufficient even though most doctors do feel the patient's life has ended. This fact, along with the opposition of various social groups makes it very hard to acquire organs for transplants. A cancer patient's true diagnosis is not usually told to the patient as it would be much too psychologically damaging. A patient with a brain tumor might be told he has brain edema. The family, except for young children, will usually be told the true diagnosis. The family is often shocked, but there is usually no religious or social afterrmath. The family may opt to tell the young children if they wish.

    Here I should mention a little about Buddhism. It was born in northern India by an Indian prince who decided to isolate himself from society and philosophize in the mountains. His main theme was that one needs to help themself by proper meditation on the meaning of existence. Only then can one enter the state of Nirvana, the highest level of understanding, and be "saved". By the time Buddhism came to Japan many sects adopted the view that prayer to Buddha for help is the means for salvation, much like Christian thought. This idea did not catch on so much with the Japanese though, and today most are more or less agnostic. Most of the ceremonies are just to follow tradition or because of superstition. Buddhism is actually more of a philosophy toward self enlightenment rather than a means for "being saved" by Buddha. Most Japanese however don't know very much about the actual Buddist philosophies and this may relate to some of their religious attitudes toward disease.

    Now I would like to discuss the doctor-patient-nurse-family relationships. The doctors are on a friendly basis with the nurses and aren't condescending to them. The nurse speaks with the doctor concerning the diagnosis and plan and follows the doctors orders. The patient chart is very similar to that in the States and also serves as a means of communication between the staff. Japanese doctors are very fond of drawing elaborate pictures of CXR's, CT scans, and procedures performed on the patient in the patient chart.

    The doctor-patient relationship was very much like that in the U.S.. Although there is less hand holding and shoulder rubbing than we have in the states, the verbal courtesies were similar. Nurses have a friendly-formal type of relationship with the patients. In general, Japanese women by custom must be more polite in speech and actions than the men. They also have somewhat of a "be seen and not heard" social expectation over them. This may effect the nurse-patient relationship keeping it more formal and superficial than in the States. Consequently, the patients' psychological state may be more unknown to the Japanese nursing staff. The Japanese are very sensitive to nonverbal communication however, and this may make up for some of the superficiality in interpersonal interaction. The Japanese call this "ishin-denshin" which means something like "heart to heart communication".