by 1998 GSE team member Yuzo Shomura
Prologue
My main purpose in participating in the recent GSE program was to visit various facilities related to the medical treatment field. No one can deny the fact that the United States is the world's leading nation when it comes to medical technology, having made advances in genetic treatment, organ transplants, and many other technologies. The United States has achieved success in a variety of fields that Japan has not yet even begun to develop, and it is leading the world in the development and application of new medical technologies. In addition, America has a different system of treatment than we have here in Japan, such as the treatment of the terminally ill. Here in Japan, the aging of our society is becoming a very serious problem, and I think there are many things we need to learn from the American approach as we face the reality of having to deal with more and more terminally ill patients at home in the future.
The purpose of my visit to Arkansas was mainly to observe the American system of medical treatment, and in particular to experience the treatment received by the terminally ill, since the approach is quite different than here in Japan.
The Medical Treatment System in Arkansas
Arkansas is located in the southern part of the United States, and during this GSE program we visited medical facilities located in the northeastern part of the state. Arkansas is divided up into counties, which have populations ranging from 50,000 to 200,000 people, and there is at least one county hospital located in each county. These hospitals serve as the main treatment facilities in the county, dealing with general medicine and check-ups, and handling minor surgical procedures. However, they have a system in place in which major operations and those emergency cases and serious cases that are too difficult for these county hospitals to deal with are referred to the large hospitals located in Little Rock. These regional hospitals are quite different from county to county, with the number of patient rooms ranging from 50 to 400, and some of the larger county hospitals even perform bypass surgery. On the other hand, in Little Rock there are large hospitals which treat patients referred to them from the regional county hospitals and other hospitals. I was able to visit three of these large facilities during my recent trip to Arkansas: two private hospitals, the Baptist Hospital and the Methodist Hospital, and the Arkansas State University Hospital. Each of these hospitals appeared to have about 1,000 rooms, and they use state-of-the-art equipment and procedures in treating their patients, including those sent from the regional hospitals. These hospitals did not appear to be any different than Japan's large metropolitan hospitals.
The High Cost of Treatment
The one common impression I received from my visits to both regional and large hospitals was the large number of empty beds. At first, I thought that it was because there was a large number of hospitals proportional to America's larger population, but when I made a rough estimate, I found that in actuality, the number of hospitals is smaller than in Japan. So I thought that perhaps the number of patients checking into the hospitals is smaller than in Japan, and I found out that the number is remarkably different. The average length of stay in the hospital is extremely short compared to Japan. For patients receiving the same treatment, the time spent in the hospital is less than half that of Japan. For example, lung operation patients stay in the hospital for 2 to 3 weeks in Japan, but in the United States, it is only 4 or 5 days. Patient turnover is very rapid, and for this reason it is hard for hospitals to reach full capacity. The reason for this discrepancy between Japan and America is obviously the high medical costs in America. In most cases, hospital fees are paid for by the patients' private medical insurance company, but the basis of payment seems to be quite strict. As I mentioned earlier, in-hospital treatment, in particular, is quite restricted. Recently, medical insurance companies have been sending observers into the hospitals to look at their clients' clinical records, and in some cases to even discuss with the doctors the possibility of cutting back on some of the proposed treatment in order to cut costs. From my hospital visits, I can say that I received the strong impression that both the patients and those working in the medical treatment field are not satisfied with the current health insurance system.
Conditions of Terminal Patient Care
One of the main goals of my vocational study on this trip was to observe how terminally ill patients are cared for in the United States.
I was able to visit one hospice program and to visit two terminally ill patients in their homes. Before leaving for Arkansas, I had thought that the foundation of American treatment of terminally ill patients was the hospice program carried out in specialized medical facilities, and that the at-home treatment of terminally ill patients supports or assists the hospice program. In reality, however, what I learned from my visits is that the situation is the exact opposite of what I had imagined, with the majority of treatment taking place in the patient's home. Every county has at least one hospital with hospice facilities, but few of them are set up with patient rooms take actually care of patients there. Rather, these hospice facilities serve as general information centers for the hospital staff of that region who are involved in treating patients in their homes. Actually, most of the nursing care takes place in the patient's home, and the hospice facilities function as information relaying centers, passing on information about the patient's condition and treatment back and forth between the nurses and doctors. According to what I heard, this shift from in hospital hospice care to at-home hospice care began to take place several years ago. From the standpoint of the patient, being treated at home has many benefits, but it is clear that this is not the only reason for this shift. I also felt strongly that the high cost of in-hospital hospice care has played a large part in fostering this trend. The first thing that surprised me about the at-home care provided by the hospice nurses was the high standard of treatment these nurses are able to provide. In America, these visiting nurses are required to complete specialized training for at-home hospice care nurses after earning their general nursing license. These nurses do not simply take their patient's blood pressure, check on the medication dosages, etc., but they must also be able to explain the patient's condition and treatment to the family members and be able to carry out certain types of treatment normally handled by doctors. In comparing this level of expertise to the degree of practicality offered by Japanese visiting nurses, I feel that not only our nurses, but our doctors as well, can learn much about the importance of increasing the specialization of their knowledge and technical expertise. It seems that most of the patients who choose to be treated at home know the name of their illness and have discussed their prognosis with their doctor. Based upon this knowledge, they choose the method of treatment themselves, and because they have chosen their treatment by themselves, there seems to be very little dissatisfaction with the treatment they receive. It appears that in America, there is very little trouble (unlike here in Japan) with patients not knowing what illness they actually have or with there being a lack of informed consent regarding the treatment they received. I think this is made possible in part by the at-home treatment system which exists in the United States. Here in Japan, particularly in regard to terminally ill cancer patients, the practice of informing patients of what they have, and discussing their prognosis with them, is not common. I felt that before we can begin to establish a practical at-home hospice care system here in Japan, and before we can begin to make informed consent the norm, we will have to see radical changes in the amount of knowledge patients have, including knowledge about the possible treatments available to them.
In Conclusion
The experiences I gained through this GSE program did not simply involve the things I learned about the medical field. I also experienced many wonderful things during my visits to other places, and, more than anything, through my interaction with the people of Arkansas and American life. It goes without saying that meeting these people is something very important to me.
I feel that it is the mission of each one of the team members to pass on the things we have learned to those around us here in Japan, and I believe the true assessment of the worth of this GSE will be determined by how our experiences affect our individual lives and activities. Looking back on the one month I had in the United States, it was a rather short time for us to learn about customs, climate, etc., but I am glad that I have had the opportunity to share some of the aspects of my visit to Arkansas.
