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Dan's Adventure in Japan

The middle of my fourth week in Japan

I see it has been a while since I wrote a news story from Japan. Things
have been busy, so I have some stories.

I survived my first outing at a Japanese person's home with relative
success. My office mate, Chiaki (also my indispensible translator) and her
husband, George, hosted the event. George is from Romania and speaks
BBC-quality English. Chiaki speaks excellent English as well, so I feel
pretty comfortable around them...It never feels like I am missing a large
part of the puzzle. I went over to their house and tried a large variety of
Japanese and Romanian food. All of it was very good, especially the potato
salad, an interesting Romanian take on the staple.

Several other people were there as well. An English teacher from the UK was
there and a few Japanese folks. One of the Japanese couples brought their
baby along. She was about 1 year old. I am convinced that Japanese
children are much better behaved than their American counterparts. You
don't see them screaming in the store aisles or any typical American child
antic. So...if you want to have a child, have a Japanese one. :-) Chiaki
and George have a son, Andrei, who slept through most of the affair. He
woke up in the mid afternoon and (mark this day on your calendar) I actually
liked being around him. I read to him from an English language book, having
him identify items in the book. It was pretty fun and one of the first
times I felt comfortable around a small child (he is two).

The nature here is markedly different from that of the US, as one would
expect. I saw a large group of monkeys on top of an abandoned house
yesterday. They just sat there and stared at me, probably waiting to see
what I was going to do. I took a few pictures of them. I hope they turn
out okay. There's something that you won't see in Iowa, most of the time...

I am finding that my outings are less eventful as time goes on. I am better
able to find the items I wish to purchase. I finally was able to find rice
in the grocery store, a perplexing problem that I am still having trouble
understanding. I also bought a very nice tie last week and found a
reasonable deal.

I am still gazed at in awe by small children, who are completely shocked by
the presence of a rather large foreigner. Tonight, a little girl (probably
about five or so) walked up to me, looked me in the eye and said, "Hello.
Hi." I said, "Hello," in reply. She looked surprised and ran to her
father, grasping his leg. Her eyes never turned away from me. I was a bit
puzzled by that one. I can just see her thinking, "It talks!"

Work is also producing some interesting and novel experiences. My boss
teaches an English class to a small group of pathology employees on Friday
afternoons. I thought that these would be interesting, so I began to attend
the classes. The classes consist of people going over the news of the week
in the best English they can muster. It's usually a little rough, but I am
impressed that they are learning. On Friday, I am going to teach the class,
due to a business conflict. I will have to get the students using as much
English as I can, since I am poorly versed in their language. I am excited
about the opportunity, but a little nervous.

The English class had a good talk last week about informed consent in Japan,
ie. doctors telling patients about their conditions and treatments. This is
done very poorly in Japan. People with cancer may never learn about their
condition. How different from the American system! The differences in the
system that were pointed out led to a discussion of the litigious nature of
the United States. One of the students hypothesized that patient ID
bracelets identified the patient name, birthday, and lawyer name in the US.
He was making a joke, but I don't think his statement was that far off.
People here aren't nearly as likely to sue if they are wronged.

This leads to a real accountability problem in the healthcare system. What
motivation is there to improve if: (a) it costs you money and (b) it doesn't
give you money in return for your investment (by preventing lawsuits). With
the universal care system in place, choices of hospital based on geography
and not quality, and an absence of litigation, it must be difficult to start
and maintain quality initiatives in this country. There is simply no payout
for it.

A message from me would not be complete without a drinking story or two. It
seems that Wednesday has become drinking day here. Last Wednesday, Mr.
Wocher and I went to a tiny bar near the hospital. I would be surprised if
the place could accomodate 15 people. We sat at the bar and began drinking
these large beers. The bottles were about a liter and a half and the
contents were poured into glasses for consumption.

Our conversation discussed many of the interesting cultural phenomena that
foreigners in Japan can drink in during their time in Japan. As time went
on, and increasing numbers of empty brown bottles littered the counter, the
conversation deteriorated. I don't think either of us noticed or cared too
much at that point. It was an interesting time, and since sake was not
consumed, I felt okay the following day.

That proves my theory that sake should be consumed alone. It is poisonous
when mixed with beer, causing memory loss and vertigo. :-)

I am compelled to buy a digital camera. Though I like my regular camera, a
digital camera would be nice for my web page. I also think I would use it
more often, since I won't need to buy film and get pictures developed. In
addition, when I take a picture, I know what I am getting. I found a nice
model for just over $200 that I am considering ordering.

Like always, this is the section for my hospital administration oriented
colleagues. The rest of you will probably want to stop reading here.

I wrote a draft of an infection control paper for Kameda. I composed most
of it over the weekend and have been working on touching it up so far this
week. This is the third project I have worked on and may turn out to be
publishable. I don't know if I can be first author (though I did write it
and do the research) because of the subject matter. I will probably be a
second author on it with Kameda's infection control guru as the first
author. I am starting work on an informed consent paper. I have a lot of
research done and should be able to get that cooking this week. I like the
topic and some of the lapses of informed consent in this country are
particularly disturbing. It's very different in this country...full
disclosure is not in the vocabulary.

I had a tour of the nursing area the last couple of days. The nurses here
are pretty poorly educated. Very few of them have college degrees. In
addition, they are often in the field for a very short time. They get
married and stay at home with the kids. This is starting to change, but
there needs to be more done. Those few nurses with BSN degrees don't get
any extra pay or promotion incentive. Since quality is not an imperative
(poor incentives all around) the healthcare organizations do not feel
compelled to create incentives to improve their labor force.

Women here are just beginning to assert themselves. It's refreshing to see.
There is much progress to make and it saddens me to see how slowly things
are changing. Women are starting to look toward getting an MD more and
more. Women in politics here are also becoming stronger advocates for their
peers. Hopefully this continues and future Kameda students will see a Japan
with gender roles more closely paralleling the United States (ie. nurses are
not the slaves of the doctors).

I also toured the pharmacy last week. They run a pretty slick operation.
They put the drugs into little envelopes for you. If you get three doses a
day, you get three envelopes for that day. The pills are placed together in
the envelope if multiple pills are taken. I like that a lot, since it
minimizes patient confusion. However, there were a few strange things I
noticed in the pharmacy. If the prescriptions are not picked up, they go in
the box and are restocked. The patient is never called or contacted in any
way. Hmm...In addition, there are almost no pharmacy techs used in Japan.
That seems extremely expensive, when you employ an army of professional
pharmacists. I guess you need more pharmacists when your doctors prescribe
more drugs than any other industrialized country.

I can't recall who told me that if you know computers in any way, you end up
working on them the rest of your career...It might have been Jen. Whoever
it was can savor the joy of knowing that it's true. I am doing a little bit
of technical work and advising. The computer technology here is so far
behind, it's very easy to fix things. I haven't had to do very much
research to solve the problems I have been faced with. Regardless, it's
interesting to work on a new set of problems here. The computer work is my
strong suit, so I am probably going to be working with it the rest of my
career. I guess being a healthcare oriented/software patent lawyer isn't
such a bad fit, after all. :-)

Short anecdotes:
I always ask about infection control measures when I tour parts of the
hospital, since most people don't wear gloves when providing patient care.
Today, I was in the dialysis center, an area of hospitals rife with
infections. When I asked the charge nurse about infection control, she
proudly said they wear gloves. I was surprised, since every other
department goes sans gloves. I watched one nurse who was wearing
gloves...She treated one patient, went to another, talked on the phone, and
saw a third patient without taking off her gloves. Whoops.

In the lab, I asked about gloves last week, since they handle blood samples
routinely. The head pathologist, Kokobo-sensei (rough, older physician who
I went drinking with a couple of weeks ago) told me that people don't get
sick from handling blood. Since there is a lot of hepatitis here, I asked
for a percentage of blood that had hepatitis in it. He said one percent.
In other words, they are taking serious risks every day. Kameda won't pay
for their employees to get vaccinated, so they don't get the precautions.
Hmmm...I don't think I would want to work in the lab.

Sharps containers in Japan are unmarked. Hmm...

I toured Dietary last week as well. I kept hearing the Japanese word,
Aeoshe. That name is identical to a sushi place in Iowa City. I asked what
it meant. It means Dietician. That's a rather bold name for a restaurant,
isn't it?

I saw a rotoblader procedure performed to clear a partial blockage near a
patient's heart. That is an interesting procedure. It's much less invasive
than the alternatives. The guy getting the procedure was interesting. He
was 80 years old. He almost died from a poisonous snakebite six months ago.
He recovered and started experiencing chest pains a few months later. He
didn't want invasive surgery, so they gave him the rotoblader. That is one
tough old man.

I toured Medical Engineering. They save the hospital a lot of money, but
don't feel they get any credit. I guess if you don't have MD after your
name, most people don't care what you are doing.

I have been here for three and a half weeks. Here is my impression of what
the Kameda internship offers:
1. Seeing many clinical areas and procedures
2. Excellent supervision and professional advice
3. Access to low-priced sushi and sashimi
4. Chance to experience a third world (perhaps a little harsh) medical
system in a first world country
5. Challenging projects to work on that hold your interest
6. Seeing tentacles in the grocery store: $2.80 for a serving.
7. Exposure to diverse healthcare facilities in Japan. Kameda is in the
top ten hospitals in Japan. The other hospitals are scary and in desparate
need of an accrediting body.
8. Experiencing what people go through when they move to the US. I am
illiterate here, since the signs and labels on items are in Japanese
characters. It isn't completely disabling, but it makes things challenging
at times. Thankfully, many pictures are emblazoned around town and at the
9. Every day is an adventure.

I appreciate hearing from everyone. I really enjoy responding to your
messages, so keep it up.

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