This week, I have the pleasure of introducing my boss in Japan, Professor Ryuki Kassai. This is a man to whom I am eternally grateful for having taken a chance on me and allowing me to work for him in the Department of Family Medicine at Fukushima Medical University since 2016. He is widely accredited for introducing family medicine to Japan and works tirelessly to promote the core concepts of general practice but also to encourage young doctors to find their international voice. For those of you who have not had the pleasure of meeting him, he is a gem but also the busiest man alive. I have a feeling that he probably works whilst sleeping and I would often sit in awe listening to the distant corners of Japan that he travels to on a weekly basis to attend various meetings and presentations. His network of friends is extensive and has a GP contact in every nook and cranny of the globe. I was desperate to interview him because I wanted to know and share how one builds a primary care system from scratch.

When he graduated from Hokkaido University School of Medicine in Sapporo, Japan, in 1984, general practice did not exist as a specialty or even as a concept in Japan.

“When I was a 5^th year medical student, I came across an article written by a Japanese doctor about some informal training in the United States and he wrote about the characteristics of family medicine and general practice – the comprehensiveness and the continuity. There wasn’t much description of community-based but more of family-orientated medicine. That was family medicine in the United States. This was the first time I encountered the term ‘primary care’ and ‘family medicine’. This was exactly what I was looking for – I had wanted to be that kind of doctor when I had decided to go to medical school.”

I think we rather take our system in the UK for granted even though sometimes I do find it a bit prescriptive. We graduate university, apply for foundation year, collect our CV points, apply for specialty training. But not all other GPs worldwide have the opportunity that we have had. So what are you supposed to do if you want to be a GP in a system with no general practice?

“I graduated from Hokkaido University School of Medicine and there were no professors who knew about family medicine. But this paediatric professor, whose specialty was child immunology, had done some research work at Boston Children’s Hospital where he met some pioneers of family medicine in the United States so he was convinced it was an important area. He recommended that I joined his department first not to become a future paediatrician but as a future family physician. He said to me that if family medicine was to be born in Japan, a background in paediatrics will help you. I agreed with him and I joined the paediatric department. At the time I didn’t want to study abroad yet.”

“So now I reflect that, at the time, I didn’t explore very much the anguish or suffering of the children or the family that I had treated. I joined paediatrics because I really liked seeing kids. I even served a fellowship in child neurology. But my desire to take formal training abroad grew and I started to search which country would be nice for me.”

I’ve heard Ryuki say before that he is part of the BBC generation – “born before computer”. This research that he would have undertaken would not have been as easy as the modern-day Google search.

“I examined the American residency programmes but there seemed to be not much training outside hospitals so I didn’t like this but then I came across an article on the training programme in British Columbia in Canada. I decided to go there but there was no information on how I could get there and take a post in family medicine. So this is at a time when nobody had access to internet so I typed a letter in English and sent it to the Canadian Embassy in Tokyo but no one responded. So I sent a letter again and again. So after a few letters they sent me a letter saying “there is no information and you are the first person to ask this question so why don’t you ask the Canadian officials at the Embassy or Consulate in Hong Kong as they had the responsibility of activity of all Asian countries?”. So I sent a letter to Hong Kong but no one responded. So again I sent a letter and finally they wrote back saying “why is a Japanese sending a letter to us, why don’t you ask the Canadian Embassy in Tokyo?”. This is “taraimawashi” which I don’t know if there is a word in English [technically means acrobatic barrel-rolling but also handing off a problem to someone else to evade responsibility]. So several letters later I finally I got some information from Hong Kong.”

“There is an examination called MCCEE [Medical Council of Canada Evaluating Examination for Foreign Medical Graduates] which is only held in five areas in the planet. London, New York, Paris, and Toronto/Vancouver. Hong Kong was the only one in Asia. I went to Hong Kong and it was a very tough examination and I failed. For those who want to go to the United States there were already some examples of exams published in Japan in English but none for Canada.”

Luckily for Japan, Ryuki opted to have another go and to combine that with a trip to Canada to visit his cousin. Although he passed this time, the path to becoming a qualified GP did not become any easier.

“There was not much information about the interview and matching process but, in what I did find, the first line said “Canada doesn’t have posts for foreign medical graduates”. That was the first line. So we had to take an interview to at least be considered. 16 out of the 20 programmes said that they didn’t accept foreign graduates and four programmes that didn’t say anything about foreign graduates. So I sent a an application letter to those four programmes but only one sent me information. That was the University of British Columbia (UBC) province. And then I went to Vancouver again for an interview. Finally, I got a post.”

This entire process took just under two years and I keep wondering whether I would have the same tenacity. I had sent one email when I had decided that I wanted to work in Japan and was lucky to find my job but I know that I don’t have the patience to go through what he had.

We move onto his experiences in Canada where he spent two and a half years. It sounded like his trainee colleagues were kind to him (although I guess that is the international reputation of Canadians!). But how was it learning how to be a GP as an International Medical Graduate (IMG)? Although Ryuki’s English is virtually native now, there must have been difficulties at the beginning.

“Very much so! Monday, the week starts and I would struggle to use English. I would hear lots of different types of English – people would come to Vancouver from very different areas of the world. Wednesday was the toughest day for me. The third day of the week I would feel exhausted of using English. Thursday and Friday was relatively ok because I could see the weekend and also I would get used to using English a little bit. Over the weekend, I would spend time with my family and use only Japanese and then it was Monday again and I became the miserable foreign resident again.”

Anyone who has learnt a second language and lived abroad will know this feeling. My Japanese is pretty good but I still need an extra 10% of energy when I speak it or write it compared to my English. This usually manifests in feeling exhausted at the end of the day and needing to go to bed earlier (my bed-times are so much earlier in Japan!). But I’ve never had to practice medicine in Japanese. I’m not sure if I’m brave enough to!

“The difficult part of residency training was the on-call. We received phone-calls from the patients overnight from three different teaching practices in Vancouver of which I belonged to one. So I would always receive a phone-call from patients who were quite new to me and I wouldn’t know the context. I had to decide whether to go to their house to see what it was or to ask them to go to the emergency department where I would see them. I preferred to see the at home but it was very tough. Vancouver is a very big place and, first, I needed to write down their address but the street names were very difficult to catch especially by phone. So I would repeat what they would say and with the other hand I would record my voice with a tape recorder. I would then listen to my recorded voice with my tape recorder and then I would look at the map and then I would drive there.”

This reminds me of a conversation I had with an experienced British anaesthetist who used to be a GP in an earlier life. Apparently, his wife was interviewed at the same time as him for his GP job because, in the days before mobile phones, there was a possibility that she would have to answer the phone, day or night, whilst he was out on another house-call. The anaesthetist apparently loved general practice but had to leave it as, after a few years, his wife politely asked him to change career.

“When I went to Vancouver to have the interview, I dropped into the bookstore at UBC where I encountered piles of text books of family medicine by Ian McWhinney. I bought a copy and started to read it on my way back to Japan. It struck me that there existed principles of family medicine and that this was my specialty and that this was what I wanted to do.”

In UK general practice, we don’t come across the name of Ian McWhinney very often although he is internationally renowned. We are more likely to hear of Roger Neighbour (incidentally, one of Ryuki’s good friends) or Calgary, Cambridge or Balint. Ian McWhinney is thought of as the “Grandfather of Canadian Family Medicine” and one of Ryuki’s mentors.

“After arriving in Canada, as a resident, I asked my programme director and the Chairperson of the department of family practice at UBC to let me undertake a one-month elective to study family medicine with Professor Ian McWhinney. UBC residents were expected to do their elective training only within British Columbia and Ian McWhinney was in London, Ontario. But finally they agreed and the Chairperson kindly wrote a letter to introduce me to Ian Mcwhinney. Again, there was no email and I got a typed letter of acceptance with Ian McWhinney’s signature. He wrote “I look forward to meeting you”. So I went to London Ontario for only four weeks. But that changed my life.”

Four weeks of deep insightful philosophical discussions about family medicine. “He showed me his endeavour and his journey from a younger scholar to a mature expert in family medicine. His way of teaching was very humane. Every weekday I went to his office with a text book of family medicine and in his office we would read his text book and then discussed. So after we read, we would have lunch and again over lunch we would have several discussions. Over the weekend, he took me to his house or to his favourite restaurant with his wife, Betty. So we three would discuss several things. There were definitely many Canadians faculty doctors who envied me because, every day, Ian McWhinney was occupied by me for at least three hours a day for four weeks. Towards the end of the term, he asked me whether I wanted to stay in Canada after my training and I answered “yeah, I can do that but, in Japan, there is still nothing”.  In 1968, Ian arrived to Canada from the UK and he started from zero to found the foundation of family medicine and training in Canada. So he knew everything, success or failure, when he tried to establish family medicine in Canada. He wanted to teach and guide me toward o a structured primary care in Japan. And when I came back to Japan, he continued to support me.”

What I garner from this conversation with Ryuki is that he was deeply affected by this time and this was where he really learnt about the core philosophy of general practice. For me, this explains a lot about him and where the purity of his passion for primary care and his vision for Japanese healthcare comes from.

Something that resonated with me from my interview with Ryuki was that general practice was a product of many people’s endeavours. This really said something to me because there are moments when I wonder if any of my efforts, both as Chair of the JIC and with my collaboration with Japan, would amount to anything in the long-run. It certainly is fun for me but would it change the future? In the same way that oceans are made of drops and mountains move millimetres every year, I hope it will. Every new innovation moves primary care onto the agenda in Japan and every GP trainee and every student that visits the UK will bring something back to my beloved home country and will bring a fragment of the UK with them. I hope that every British person that is has an opportunity to meet my Japanese colleagues will be affected and I hope that this brings something new to UK practice, one person at a time.

One of the things I keep trying to pass onto people that ask me how to get into global health and primary care is to just start. Success is built on a thousand failures and for every 10 emails and phone calls that you don’t get acknowledged or returned, you will have one back. And it only takes one opportunity to start the ball rolling. Be inquisitive, be tenacious and be prepared to break the mould.