The Business of Medicine

Things are always more complicated than they appear to be. In the past, I was always very much behind the idea of socialized medicine, but learning a few things about medical care in Japan have cooled my ardor for it over the past year or so. I still think it's better than the situation with private insurance in the U.S., but I think a lot of care should be taken when developing a universal health care system given some of the problems I've been made aware of.

One of my students is married to a doctor and occasionally she offers me some insights into the business of practicing medicine in Japan. For instance, when I mentioned the recent news that yet another pregnant woman was turned away at multiple hospitals, she told me that part of the problem in Japan is that being a specialist, as opposed to a general practitioner (GP) isn't profitable. It costs more to become one and you get less business.

This particular student's mother and husband are both doctors and her mother ran a clinic as a GP which her husband later took over. Running such a clinic allows her husband to operate fast food medicine for people who want their coughs checked and their stomachaches medicated. He spends about 2-5 minutes with each patient and gets a cut of the sales of the prescriptions he makes. For the record, if you visit a Japanese doctor, you will (almost) always be given at least 3 kinds of medicine and one will always be a powder.

The average Japanese person goes to the doctor 14.4 times a year. Most of these visits are with GPs. The only way a person will visit a specialist is if that person is deemed to have a serious enough illness to require added care. This is why being a specialist in a particular area of medicine is less profitable than being a GP. My student further told me that being an obstetrician is the least desirable specialty. If you consider that the birth rate in Japan is low, this also makes sense. Not only are you a specialist, but your client base has been eroding for quite some time. This is one of the reasons why pregnant ladies are finding "no room at the inn" signs up when they are taken to the hospital.

This all relates to socialized medicine because the prices for services are fixed. The only way for a doctor to make more money is through volume rather than quality of care. Being a specialist not only limits your customer base, but it also increases the time you may have to spend with each patient because it's easier and faster to take a temperature and look at a throat then prescribe medicine for coughs than it is to deal with cancer.

A lot of people praise the health care system in Japan and there are good points to it for certain. It is better on the whole than the U.S. system, but it certainly is not perfect. The benefit is that people with common problems who want to be checked regularly can get what they need and health maintenance is affordable. The down side though is that emergency treatment and quality of care are vastly inferior to that in the U.S. Also, the system is certainly overused and abused by people who could just as easily wait out a cold, a headache, or a sore throat and get better on their own, but they don't hesitate to run to the doctor because costs are so low.

If you don't believe the latter statement, I can tell you something that my student wrote in a sociology paper she did for a recently completed college course which surprised me. This particular paper was comparing universal health care to a private system where medical care is treated as a commodity (the current U.S. model). She wrote that if she has a headache, the cost of buying aspirin is higher than going to a doctor so it is more economical to go to the doctor than to buy a bottle of aspirin over the counter. If this sounds absurd to you, then you've never bought a box of aspirin in Japan. Typically, a small box with 10-20 tablets will cost about $6-$8. A visit to the doctor, because only 30% of the tab is paid by the person and the other 70% is picked up by the taxpayers, may cost between $2-$3 with a small additional cost for the prescription. If you're retired, the cost to you is only 10% with the other 90% of the bill being covered by insurance.

The main problem is that the system should somehow reward people for not overusing the system for minor problems or at the very least fail to make it more economical to go to the doctor for every pimple and stubbed toe rather than buying and popping an OTC pill or buying some zit cream. The trick is to not penalize people for regular check-ups and for going when it is necessary such that they stop using the system as it is intended for health maintenance. Right now, Japan doesn't ration health care at all, but I have to believe that there should be some sort of limit on casual visits. Going to the doctor on average more than once a month per capita seems like far more than what is required for health maintenance for an average person.

Guests and Gifts

Because of serious back pain, it's hard for me to get out and visit people in their homes. I can do it, but it's something I have to plan out carefully to minimize walking and ensure rest stops as well as mentally prepare myself for the pain and the stress that comes along with the experience. People who can just walk out their front door and go anywhere they choose have no idea how liberated they are compared to the likes of me nor can they understand how I envy what they can take for granted.

Since it is so difficult for me to get around, I invite my friends to come to me and I really appreciate it when they make the effort. I know that it is time consuming and tiring to go to someone's house relative to having them come to you. Of course, there is preparation for guests coming to my place as well like cleaning and at least some food preparation, but I'm more than happy to do that as it's something I don't mind and I can operate in controlled circumstances which allow me to manage my pain.

Getting back to my kind guests though, because I appreciate their coming to me, I like to try and prepare a little something for them to take home with them when I have the time and energy to do it. Last time I had guests, I sent them home with some homemade brownies. Darryl (my former boss) came by yesterday and I decided to go for something a bit less sweet for him. He's not so into the overwhelmingly sugary stuff, I believe, though he is a fan of my peanut butter cookies. ;-)


I decided to revisit my sweet potato scones recipe after a very long absence so I could send Darryl off with a few of them (and toss some in the freezer for future breakfasts for me!). These are definitely the kind of thing that I can't make often because they are labor-intensive and require both boiling and baking. The hardest part of making them is forcing the cooked potatoes through a mesh sieve to make the mashed potato fluffy and airy. It's very difficult and messy, but I tried to make scones from sweet potatoes by just mashing them the quick way using a mixer and it produced scones with a less than desirable texture.

Sweet potato put through the mesh strainer looks like small bits of saffron rice but is very light.

I had two large potatoes which I steamed and peeled and forced through the mesh. My hand really hurt afterward, but it was actually enough potato for 3 batches worth of scones so I tossed the rest in the freezer for future goodness without the hand cramps. One lesson I did learn though was that it's a lot easier to mush up warm cooked sweet potatoes than cold ones.


I decided to modify the recipe I linked to because Darryl doesn't do artificial sweeteners. I upped the brown sugar to a half cup and I also decided to apply an egg wash this time so that the top wouldn't rise and would be shinier. The results were excellent with a crispy outside and a tender interior when they were fresh. Tiny bits of sweet potato are interspersed throughout the scones adding moisture and a good distribution of sweet potato flavor.

Unfortunately, the crispy top disappeared overnight as is often the case with baked goods, but the crispness may be revived by wrapping the scones in foil and giving them a little run in the toaster oven.


Darryl one-upped me (unintentionally and in the spirit of pure generosity) on the baking front though by bringing along 6 delicious and moist banana blueberry muffins. The CH was especially taken by them and I hope that Darryl will share the recipe with everyone on his cooking blog (drop by and leave him a message to encourage him to post it... this is my way of forcing his hand and getting him to blog as I already have the recipe in my in box). I was compelled to order some whole wheat flour from Tengu Natural Foods so that I could attempt to reproduce his fantastic muffins.

The visit was just like old times for us. Even though I quit 3 years ago, it's just comfortable with the three of us sitting around gossiping about things back at work and catching up. I only miss my former job when I think about how much I enjoyed working with Darryl as he's a jewel of a person and an ideal boss for the gaijin in Japan. I'm hoping we can manage to synchronize our schedules and get together more often in the future.

Teeth

When my mother was in her mid to late 20's, she had beautiful, straight, white teeth. Before she turned 30, she had no teeth at all and was wearing dentures. She lost her teeth to what was called "Pyorrhea" at that time and is now more generally referred to as "periodontal disease."

Since her teeth were perfect, this came as quite a shock to her and it was very painful having all of her teeth removed and her jawbone scraped of disease all at once. She relayed a story on multiple occasions about how she kept her face frozen with ice packs after the procedure because she saw a woman who had had a similar unfortunate experience whose face was nearly unrecognizable because of the swelling.

You'd think that someone who had endured what she had would have reared her children to take very good care of their teeth since she knew the suffering one might endure if disease struck. As a matter of fact, the opposite was the case. As normal kids who dislike spending time pursuing any sort of hygiene routine, we resisted brushing our teeth and she quickly gave up and didn't enforce any sort of oral hygiene behavior. This resulted in two gaping holes in my lower jaw where the second molar from the back was ripped out on both sides because of cavities when I was about age 10 and 12. My family was too poor to go the rebuilding route, so they just told the dentist to take them out and damn the consequences to my oral health.

When I became a teenager, I worked out a few things on my own about taking care of my teeth and became pretty fastidious about brushing. To this day, I can't tolerate the idea of going to bed without clean teeth and generally have not had any issues since getting them cleaned up and having all the cavities drilled and filled in Japan early on during my stay. It's a sad statement on the health care situation in the U.S. that I worked two jobs simultaneously just after college (one full, one part-time) and had no dental care plan (nor did I have one from the job I held in California). I had to go to another country to find a system that would take care of my problems in an affordable manner.

Fortunately, after that initial sequence of drilling and filling, all has been well for many years. Two years ago, I went to the dentist for a check-up and cleaning and he looked at my teeth for all of 10 seconds and said they were still fine. The same system of socialized medicine in Japan that took care of my teeth also encourages doctors to offer thumbnail consultations for those on the national plan, unfortunately. However, it's certainly better than the nothing I had in the States.

About a year ago, I started waking up with a bad taste in my mouth. For a lot of people, I'm guessing this is probably not unusual if all the "morning breath" allusions are to be believed. For the record, I've never had that problem. It seems that I've reached the age where being careful with brushing isn't enough and I had to break down and start with the flossing. Yes, I know you're supposed to floss regularly all your life, but I didn't have any issues so I was slack. Also, my gums are sensitive and it gave me terrible headaches from referred pain to do it so I gave up. I'm going to forestall any reminders about how sensitive gums are the result of not flossing and you have to do it for awhile to get past that by saying I'm already aware of that. That being said, I haven't had any gum disease.

This particular change has been yet another reminder of the fact that there are all sorts of lapses in judgment about your health that you can get away with when you're younger that you can't allow as you get older. I can't tell you how many times I've recognized that a body in its 40's isn't going to recover as quickly or effortlessly from bad habits as one in its 20's. I don't mind a lot of things about getting older, but the fact that your body no longer (seemingly) effortlessly and transparently looks after itself when you don't apply meticulous care is one I definitely mind.

What is the Placebo Effect?

These days, most people are familiar with the placebo effect thanks to the plethora of medical dramas on television. Back in the dark ages when I was in college and there were only 3 television networks, limited cable programming (which consisted mainly of Gilligan's Island repeats), HBO (which was mainly for movies with nudity), and MTV (which used to show music videos), there were fewer shows and they tended to underestimate the sophistication of the audience. The word "placebo" wasn't tossed around casually at that time, but, being a psychology major, I learned of it in one of my classes.

The idea behind the placebo effect is that we "fool" ourselves into believing an effect is being had on our bodies when administered treatment which biologically has no measurable effect. Though I've known about this for quite some time, I didn't really think deeply about until recently. Let's break down the placebo effect as it generally works:

1. An authority figure tells you your are going to receive a treatment which will solve or diminish the problem.
2. He gives you the equivalent of a sugar pill.
3. You take the sugar pills.
4. You get or feel better.

The placebo effect is a very handy effect for medical science in some ways. It allows them to explain how treatments that cannot be scientifically proven in the laboratory such as acupuncture, herbal remedies, and holistic applications appear to be effective while neatly discounting their viability as treatment.

What medical science obfuscates with a complicated-sounding word (placebo) is that the truth of what the placebo effect represents. It represents the ability of your mind to regulate your body's healing or pain management without the intervention of an external treatment. What the placebo effect really is, is a form of self-healing.

Encouraging self-healing is a tricky business. For one thing, it doesn't always work and believing it might work may discourage people from seeking proper treatment. It most certainly does not work when an injury is inflicted on the body which requires resetting of bones or stitching of wounds and this rather undermines the perception that we actually can self-heal in some cases. However, just because we cannot apply mental focus to achieving the equivalent of lifting a boulder over our heads does not mean that we can't do the equivalent of lifting a few pebbles. What I mean by that is that you may not be able to mend a broken leg by the use of mental processes, but you may be able to overcome a headache or diminish the intensity and duration of a leg cramp. You may even be able to maintain better health on a regular basis by mentally applying yourself to all aspects of its overall health.

The notion of self-healing is further undermined by the idea that it's some New Age pie-in-the-sky concept that is practiced by hippies who are interested in keeping their chakras aligned and their auras healthy. This is a notion that medical science prefers to perpetuate, not because of financial self-interest as many cynical sorts like to believe, but rather because they firmly believe it does not work and are afraid that people will be conned by opportunists or fail to seek life-saving treatment for serious problems.

The placebo effect is not some New Age myth though. It is a scientific fact. Many studies have been done on it and it works in a statistically significant number of cases. The reason placebos work and directed self-healing does not is that when an authority figure tells us we will get better, we believe it. When we tell ourselves we will get better, we often lack the true conviction to bring about the desired improvements. There is a vicious circle at work in this situation. If we believed we had more control over our body, we'd be better able to self-heal or pain manage. However, we don't believe it so we can't, and if we can't self-heal or pain manage, then we don't believe we can.

The curious thing about the placebo effect to me is that there is actual evidence of a concept that is embraced by a variety of spiritual beliefs, yet people still do not believe they can regulate their own bodies or cure themselves of some problems without involving an external application. This ability is written off as a mental trick or our ability to fool ourselves when it really is, for lack of a better word, "power" to control a situation we're frequently told is not under our control. Instead of allowing this power to be written off as part of a scientifically curious result, it should be regarded as a revelation of which we should explore the potential.

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As a personal aside, I will note that I have worked with controlling my pain and problems since I gave up on doctors ever helping me with my back problems. I also mitigated a lot of the discomfort of chilblains using what can best be described as a form of "active meditation" or "directed thought." It's my impression that this does help appreciably. When I went through my first bout of chilblains, it was excruciating. During the two subsequent bouts, I applied myself mentally to reducing the inflammation and discomfort from the itching and the two bouts that followed were each greatly less bad than the first one.

One of my motivations for this was the fact that I discovered during my research on back treatment that 1/3 of all people suffering from severe back problems in a controlled study got better with no treatment which is equal to the number of people who got better with surgery or non-invasive therapy (medication, exercise, topical treatment, etc.).

Another of my motivations was the fact that we communicate with every part of our body through various systems unconsciously. There's no reason to believe that we cannot communicate with them consciously or willfully as well except for the fact that we don't tend to believe it is possible.