Why go international?

Hello England!

As I return from my 8 months in Japan to come back to formally to the UK to take on my role as Chair of the RCGP Junior International Committee (JIC), I reflect on how different my path looks from 2016. Just over a year ago, I was a GP ST3 trainee, at Whipps Cross Hospital, knee-deep in CSA exam revision and portfolio preparation. Now, I have spent the good part of the year working at Fukushima Medical University, under the auspices of Professor Ryuki Kassai, and I am about 3 months in to being the Chair of the JIC. Both jobs are a million miles from the consultation room but both have opened my eyes to the importance of primary care as an integral part of a fair health system. Through this blog, I hope to share the viewpoint of a young (or not-so-young) GP navigating the world of international primary care and to impress on all those reading that we are more inter-connected than we imagine.

The British countryside. There are some things you don’t know you miss until you leave.

Japanese primary care

Primary care in Japan was only a twinkle in Professor Kassai’s eye 25 years ago when he returned from GP training, under Dr Ian McWhinney, in Canada. The first VTS was set up only 11 years ago and, although rapidly expanding, the specialty is trying to pave its way with only 500 registered GP’s. The future is uncertain but hopeful. Joining the Japanese primary care scene at such a dynamic and exciting time has been a privilege and a learning experience. In a country where the longest serving GP – we are talking about formally trained family physicians who pass the CSA equivalent rather than self-styled community doctors – has only been around for a decade, mentorship has been a problem.

The frustrating thing for me here has been how Japan looks to the U.S for its cultural influences, given the influx post-war. Everyone learns American-English and think that my British accent too incomprehensible. And this is no different when it comes to healthcare. Like the U.S, patients go to see specialists directly and there is no regular family doctor to overview their care from cradle to grave. Seeing your doctor seems almost like a consumerist process and, to me, seems like a minefield to navigate. How do you know someone is a good doctor? What’s the benchmark? Why should you be able to consult another doctor mid-treatment? For me, it really changes the doctor-patient relationship. What leverage do I have as a GP if I know my patient can see someone else at the drop of a hat? Anecdotally, the Japanese medical students I teach chorus that they want to visit the U.S if they want to go abroad at all. After about 10 minutes of explaining health equity, universal health coverage and agreeing that health is a human right, it dawns on my students that there are other systems to learn from outside that of the U.S and Japan. As Japanese culture favours collectiveness over individualism, the principle of universal health coverage, achieved in Japan in 1961, is not questioned. No one gets left behind. My real gut feeling is that Japan shares more with the UK culturally than with the U.S and it needs to open its eyes to other ways of providing for patients. As one of the countries deepest in debt word-wide, it wouldn’t harm itself by seeing what it can take from one of the most cost-effective, albeit imperfect, systems in the world.

Visitors from the UK

We had the pleasure of hosting many GP’s from the UK in 2017 and my first advice to them was always “throw what you know about the UK out the window – there are no parallels”. Japan is unique – “a cultural Galapagos”[1] –  and many friends who come to Japan comment on the culture shock – the familiarity of modernity but arriving from a stem alien to the “civilised West”.

(I suspect that it wasn’t that dissimilar from how the Portuguese explorers felt in 1543 landing on the coast of Nagasaki. The Europeans back then were nicknamed “the Southern Barbarians”, a reflection on their table manners, bathing habits and inability to read Japanese).

[1] Line stolen from Dr David Jameson

The JCPA-JIC Japan exchange 2017. (From L to R) Dr Mio Arakawa, Dr Naoko Kobayashi, Dr David Jameson, Dr Leka Satkunananthan, Dr Shaleen Khatri, Dr Rose Neary, Dr Daisuke Kato, Dr Ryuki Kassai

Watching the British GPs try to make sense of the Japanese health system was a pleasure every time. The concept that general practice as we know it might not exist also blew my mind when I first arrived. No one is registered with a doctor? How do they know who to see? Who overviews their care? There’s a CT machine in your GP surgery?!

Me with Dr Faye Stockton and elective student Jemma Mickleburgh. Hopefully Jemma has been converted to a career in GP!

As there are realistically very few GPs in Japan and no need to be registered with one doctor, there is no one who needs to take ownership of the patient. The town hall sends the residents letters reminding them to have vaccinations. Every citizen has an annual health check includes cancer screening (I declined a bariums swallow at my health check this year). Specialists are not obliged to collaborate and co-ordinate with each other thus leading to a huge repetition of tests.  This is not a backdrop that is easy to comprehend when viewed from the UK.

Me, Dr Sophie Redlin and Yuka (Fukushima university medical student) on our way to interview for Sophie’s research mypatientvoiceproject.com

But what Japan does well is the passion and the fire that the GP’s have for primary care. In the UK, we are taught that 50% of graduates need to become GP’s in order to keep up with demand. Because it is so ingrained in our system, perhaps it’s easy to lose sight of why a well-functioning primary care system is essential in providing population-based patient-centred care. Here, in Japan, no one has heard of general practice, so to become one, the hurdle is automatically higher. We have students visiting our established primary care unit in Fukushima as well as Foundation year doctors from across Japan. A lot of time is spent going to conferences and forums to spread awareness. Any mention of primary care in the newspapers is cut out and kept. Politicians are lobbied, health economists are invited. And there are certainly doctors who get left on the wayside – those who wanted to become a GP but were unnerved by the possibility of the career not existing in 10 years, discouraged by specialty doctors who don’t see the point, and preferring not to uproot themselves and their family to join one of the few training schemes in the country. This positivity and drive in the face of uncertainty is something that we, the British, could be inspired by the Japanese.

Dr Khatri in the local papers during her exchange to Japan

So why go international?

Before moving to Japan, I worked for a few months as a fully-fledged GP in the NHS and I found it busy. Depending on how busy I was, I could feel the hairs on the back of my neck prickle when I felt that the patient was asking me something outside my remit. Sometimes, dare I say it, I’ve even wondered why they bother me anyway. During my time away and seeing a country with a fragile primary care system, my perspective shifted. The system we have in the UK is valuable and worth protecting and the fact that my patient can come and bother me about something trivial is the other side of the flip coin to accessibility. Being able to develop a relationship with a patient through being the first point of contact and through continuity of care is a privilege that not all doctors worldwide indulge in. So now, as I travel back to the UK, I am looking forward to being part of a task force that truly provides patient-centred care. And I hope to be able to take the gratitude that I have learnt with me to the consultation room. I really encourage anyone who is having a wobble at the moment, understandable in the current climate, to plug in, recharge and rejuvenate. Through this blog, I aim to share with you the different ways to get inspired and get involved.

My JIC fam (minus a few) – we only get to meet in person a few times a year so it’s difficult not to get excited (even if I force them into a team meeting over lunch at the WONCA conference!)

For those of you who are interested in having a taster in Japanese healthcare, we run an annual exchange programme. Application process opens In February 2018. Email beyondeuropejic@gmail.com or Chairjic@RCGP.org.uk for details

We had the pleasure of hosting many GP’s from the UK at Fukushima Medical University – Dr David Jameson, GP from Manchester, Dr Sophie Redlin, GP trainee from London, Dr Clare Hurle, GP partner from London, Dr Faye Stockton, GP partner from Wales, and last but not least Jemma Mickleburgh, elective student from Sheffield. Thanks for all the fun and great chat!

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