Japan could benefit from hospital medicine expansion, leadership


The need for hospitalists continues to increase in Japan. There are approximately 9,000 hospitals in Japan, and approximately 80% of these hospitals are small- to medium-sized hospitals (<300 beds) where the need for hospital medicine is greatest. Historically, internal medicine subspecialists from nearly all subspecialties served as the primary attending physicians of hospitalized patients because inpatient internal medicine physicians, or hospitalists, did not exist.

Most subspecialists caring for hospitalized patients learned to practice internal medicine “on the fly” because they were not required to complete training in internal medicine before pursuing a subspecialty. After medical school, all graduates are required to complete a 2-year internship known as the National Obligatory Initial Postgraduate Clinical Training Program (NOIPCTP). The level of training during the NOIPCTP is similar to the third and fourth years of medical school in the United States.

Faculty development course in point-of-care ultrasound held November 2016 in Tokyo, in preparation for the first ultrasound course at the JSHGM annual meeting.
Faculty development course in point-of-care ultrasound held November 2016 in Tokyo, in preparation for the first ultrasound course at the JSHGM annual meeting.
After internship, medical school graduates can request a subspecialty training position in any hospital, as long as they have completed the NOIPCTP. There is no centralized application process or “match” for graduate medical education in Japan. Internal medicine, as a specialty with its own structured residency program, has not yet been formally established in Japan, and there has been no pathway to become an internal medicine–trained hospitalist.

The aging population and increasing complexity of hospitalized patients are the two main drivers of hospital medicine in Japan. Recently, the number of patients who have had adverse events because of inpatient medical errors has risen, and the transparency of these adverse events is making the need for hospitalists more apparent. In addition to improving the day-to-day medical management of hospitalized patients, hospitalists are needed to serve as champions of quality improvement, patient safety, and hospital throughput.

Leaders of the Japanese health care system recognize the need to improve the quality of inpatient care. The first step is to establish internal medicine as a specialty with dedicated internal medicine residency training programs. The Japanese Board of Medical Specialties approved establishing standardized, 3-year internal medicine residency training programs starting this spring, but that decision has been met with resistance for various reasons, namely concern for creating a disparity due to the shortage of internists in rural areas. Therefore, launch of this initiative has been postponed until April 2018.

In the meantime, the concept of hospital-based internists has been gradually gaining the support of subspecialists in Japan. Hospitalists are anticipated to work as the primary medical team leaders, directing and coordinating care among subspecialists in the future.
Despite its gradual spread, there are several challenges to growth. First, there are many terms for hospitalists, such as “hospital general practitioners” and “general internal medicine physicians.” A unified term for hospitalists would foster acceptance among Japanese physicians.
Additionally, some physicians, namely subspecialists, still question whether hospitalists are needed in Japan (even though potential loss of clinical revenue is not a significant concern among subspecialists).

Another challenge is lack of standardized training programs that define the skillset of hospitalists. Standardization of internal medicine training will also improve efficiency of communication between hospitalists and subspecialists.
An important milestone in the Japanese hospital medicine movement was the establishment of a society of hospitalists, known as the Japanese Hospitalist Network (JHN). The JHN has a quarterly publication (Hospitalist) targeted at junior faculty and residents that reviews topics in hospital medicine.

The JHN is affiliated with a larger society, the Japanese Society of Hospital General Medicine (JSHGM), which holds meetings twice a year. A unique offering at the next JSHGM meeting in March is a point-of-care ultrasound training workshop. Although this is the first such workshop for hospitalists in Japan, there are many training courses designed for the country’s hospitalists.

The emergence of such courses in Japan has paralleled the increasing need for hospitalists in Japan. We hope these courses for hospitalists will pave the road for the continued growth of hospital medicine in Japan.

Toru Yamada, MD
Dr. Yamada is an internist in the department of general medicine/family and community medicine at Nagoya (Japan) University and practices at Tokyo Bay Urayasu Ichikawa Medical Center in Chiba.

Taro Minami, MD
Dr. Minami is assistant professor of medicine in the division of pulmonary, critical care, and sleep medicine at Brown University in Providence, R.I., and director of ultrasound and simulation training at Memorial Hospital of Rhode Island.

Nilam J. Soni, MD, MS, FHM
Dr. Soni is associate professor of medicine in the division of hospital medicine at the University of Texas, San Antonio, and a hospitalist with the South Texas Veterans Health Care System in San Antonio.

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