Minami-Otsuka Institute of Technology, Minami-Otsuka Clinic, Tokyo, Japan
Received Date: December 4, 2014; Accepted Date: December 20, 2014; Published Date: December 29, 2014
Citation: Okamoto H (2014) Problems in the Management of Rheumatoid Arthritis in Rural Hospitals of Japan. Rheumatology (Sunnyvale) S4:009. doi:10.4172/2161-1149.S4-009
Copyright: © 2014 Okamoto H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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As reported by Drs. Slim and Uthman , it is important that primary health care physicians be equipped with adequate knowledge and competencies to manage musculoskeletal conditions and the activity of “Bone and Joint Decade” is indeed important). It is also true in Japan and every single clinician must have adequate knowledge of Rheumatoid Arthritis (RA) and its complications.
Recently several examples reveal a growing medical crisis in the rural hospitals of Japan. Given the widespread use of biologics for the treatment of RA, systemic care of these patients is critical for the better managements. As RA is not only a joint problem but also a systemic disease, complicating interstitial pneumonia, vascular problems, other autoimmune disorders, doctors who treat RA patients must have enough knowledge to manage any medical problems throughout patient’s body. The tragic case presented here is an example of the medical crisis in the managements of RA in the rural hospitals of Japan. In December of 2010, a 78-year-old Japanese woman who had a 50-year history of RA was admitted to a hospital affiliated with her nursing home for her regular check-up. Her arthritis had been stable with oral methotrexate (6 mg weekly) and 0.5 mg of betamethasone. She had high blood pressure but no chest symptoms. Her doctor explained that her chest X-ray was unremarkable and only an aortic protrusion was noted. In the autumn of 2011, she started suffering from edema from her left shoulder to her hand. She was admitted to the hospital, and her doctor noted that her chest X-ray was unremarkable and that the cause of the edema was unknown. In May, 2012, she experienced severe back pain and lost consciousness in a hypovolemic shock. She was transferred to the same hospital she visited originally and a chest X-rays revealed a rupture of aneurism in the thoracic aorta.
Itoh  has reported the findings in order to signal a growing medical crisis in Japan. In this report the following facts were revealed, (1) a severe shortage of medical doctors prevails in Japan especially in rural areas: the number of doctors per population is at the 4th lowest among OECD countries, and the number per hospital bed is the lowest, (2) the number of faculty staff in Japanese medical schools is 1/3 to those of Western countries, (3) the reported number of doctors working in hospitals and offices surpasses that by census for medical doctors by >40,000, (4) Japanese doctors work more than 60 hours per week, (5) although nursing homes in Western countries have beds to treat patients with subacute/ chronic diseases, this is not the case in Japan).
The aforementioned case, which happens to be my own mother, represents an example of the medical crisis on-going in Japan. This crisis is especially prevalent in rural areas. Most of the doctors working in rural hospitals are exhausted and may not have enough time to study. Thus some orthopedists that treat systemic disorders such as RA may not have enough knowledge to correctly interpret chest X-rays. In this case, the orthopedist who was responsible for my mother’s case failed to diagnose her thoracic aorta aneurism. As presented in Figure 1, chest X-rays of this case showed a marked enlargement of the thoracic aorta, which is easy enough to be diagnosed even by medical students. Although I asked the hospital about the cause of this misdiagnosis, the hospital representative provided no precise causes of this case. Thus, I do not have enough evidence to determine definitively how this orthopedist failed to diagnose the thoracic aorta aneurism, possible causes are as follows: (1) the orthopedist might not have had enough time to study diagnostic radiology, (2) that this orthopedist was the only doctor responsible for the treatment of the patient and no other doctor had a chance to examine the patient’s chest X-ray films, and (3) that this orthopedist was not diligent enough in medical school and his lack of knowledge is a personal problem. Even though the third scenario proved to be the case, the hospital could not afford to hire enough medical specialists of diagnostic radiology to compensate for the misdiagnosis of this orthopedist. Therefore, both the whole management system in Japan and the limited knowledge of this physician might be the causes of this tragic case and malpractice of this orthopedist has relevance to a medical crisis occurring in rural hospitals throughout Japan.
Tokuda et al. analyzed the relationships between working conditions, job satisfaction, job burnout and mental health among Japanese physicians. They found that burnout and poor mental health were directly correlated with job dissatisfaction and sleep deprivation, and indirectly related to a poor quality of work and extensive on-call duty .
Japan has a well-regarded medical insurance system in which every person has medical insurance. In addition to a good medical insurance system, a solid healthcare policy in which medical staff are better able to provide reliable medical service to his/her patients is also required to prevent a further medical crises in Japan. Although it is too hard to demand a physician to have every single knowledge of medicine, medical system must compensate the missing knowledge of individual physician by composing a team to provide sufficient medical service to each patient. To this end, I propose a four point plan to improve the medical system and to establish efficient manage system in Japan: 1) establishment of a governmental organization responsible for the reorganization of physician placement. This organization would control the number of hospitals throughout the country. The organization would be composed of medical doctors and several third-party organizations review this governmental organization. 2) Establishment of a law which forces every physician to work for the governmental organization for at least 10 years after acquisition of his/her medical license. If necessary, young doctors would have to work for rural hospitals under the control of this organization. 3) Establishment of a medical association in which all doctors would participate. There would be no associated membership fee. This medical association would also protect the rights of physicians, on issues including salary equality, equal job opportunity, paid leave, etc. 4) Establishment of an electronic medical record system to share the medical information of every patient throughout the country on-line. Establishment of such a system would also require implementation of rigorous procedures to ensure patient privacy.