Japan Studies

Patient patients: the Japanese are afraid to ask their doctors questions -- is there an opportunity in giving them the answers?

Until recently, doctors in Japan have had a kamisama (godlike) status, such that patients are reluctant to ask questions for fear that their requests may anger the doctor. And, with the fastest aging population in the world, the crowds at some major Japanese hospitals are such that one could sometimes be forgiven for assuming that one had mistakenly wandered into the central railway station.

So what is it like to be a patient in Japan, and what is the level of satisfaction of Japanese patients with the current system? In September 2000 the Statistics and Information Division of the Ministry of Health and Welfare (MHW) released the results of a major study entitled "Overview of the Study on Patient Medical Experiences." This study covered the experiences of patients at hospitals, as well as their satisfaction with the treatment received.

Fieldwork for the study was conducted on one specific day in October 1999 among both outpatients and inpatients at selected hospitals nationwide. Respondents at each of the selected hospitals were given a questionnaire, and were asked to put it after completion in a sealed envelope and leave it at the hospital. Outpatients were also given the option of mailing back the questionnaire. As a basic principle, the patient was asked to fill in the questionnaire himself/herself. Assistance in completing the questionnaire was provided by a family member or an interviewer for those patients unable to do so themselves.

Interviews were conducted in a total of 639 hospitals, covering a broad spectrum of large, small, and special institutions. A massive total of 193,706 completed questionnaires were received -- 115,108 from outpatients, 87,642 from inpatients. The study had an overall completion rate of 78%, and thus the data has a high degree of statistical reliability.

Time Spent Waiting
In Japan, it is still uncommon for hospitals to have an appointment system, and thus one of the questions in the study asks how long an outpatient was kept waiting before they got to see the doctor. Overall, among all hospitals, only 37% of patients spent less than half an hour waiting. (In large hospitals this figure dropped to 30%.) Overall, 25% of patients waited 30 to 59 minutes, and a further 25% waited for one hour or more. In larger hospitals, the percentage of those patients waiting over one hour was 30% or higher (13% of respondents did not respond to this question, and thus the true length of the waiting period is probably longer than the figures given above).

Respondents were then asked how much time they actually got to spend with the doctor after having waited this long: 66% spent nine minutes or less with the doctor (18% spent less than three minutes, with a further 48% spending three to nine minutes). Cynics have been known to describe the outpatient situation in Japanese hospitals as being a three-hour wait for a three-minute consultation. The above figures do not quite bear out this exaggerated characterization, but the situation can hardly be called satisfactory.

Explanation Received
Respondents were asked what sort of explanation they received from the doctor about their illness; 49% of outpatients and 57% of inpatients reported that they received a detailed explanation about their illness; 35% of outpatients and 29% of inpatients received a brief explanation; 6% of outpatients and 9% of inpatients received no explanation at all.

Among those who received an explanation, 75% of outpatients and 83% of inpatients were told the name or condition of the illness. A relatively low 58% of outpatients and 70% of inpatients received an explanation of the method of treatment.

Disclosure of Charts
Under current laws in Japan, doctors are not obliged to disclose medical charts to patients. In 1999, due to strong political pressure, the MHW abandoned a plan to introduce a new law that would have required doctors to show patients their medical charts. In the current survey an attempt is made for the first time to gauge patients' attitudes on whether they should be given access to their own medical charts.

Only 33% of outpatients and 30% of inpatients respectively indicated they would Very Much Like to Know the Content of Medical Charts. Overall, inpatients have less interest than outpatients do in knowing the content of their medical charts, a notable finding given that an inpatient's condition is usually more serious than that of an outpatient. (See Table 2.)

Those patients who stated that they would like to know the content of their medical charts were asked why. The main reasons given were Want to Deepen Understanding in Regard to Treatment Being Received and Want to Know the True Situation in Regard to the Illness/Condition/Treatment Content. (See Table 3.)

The latter reason may seem a little odd, but it is common for a doctor in Japan not to tell the patient the nature of his/her disease. In the case of cancer, for example, it is has been estimated that perhaps only one in five patients with cancer is actually told by their doctor that they have cancer.

Satisfaction
Using a five-point scale ranging from Very Satisfied to Very Dissatisfied, respondents were asked to describe their level of satisfaction with the treatment/ service they had received at the hospital.

Approximately half of the outpatients and inpatients respectively reported being Very/Somewhat Satisfied with the hospital on an overall level. However, on an individual attribute basis, among both outpatients and inpatients, the level of those claiming to be satisfied was below 50% for the great majority of the attributes covered. (See Table 4.)

Among outpatients, the level of satisfaction was particularly low for Cost of Medical Treatment (25%), Waiting Time (26%), Convenient for Public Transportation/Available Parking Space (33%), and Consultation Hours/Dates (35%).

In Japan, a monthly fixed amount (based on salary level) is deducted from each employee's salary for health insurance. When a patient visits a hospital for consultation/treatment, there is a copayment amount to be borne by the patient, with the remaining amount covered by insurance. For a worker paying into the health insurance scheme, the copayment amount was formerly 10% of the charge, and 20% for a dependent of that worker. The copayment amounts have now been raised to 20% and 30% respectively. This rise in the patient copayment level may partially explain the low satisfaction level with the Cost of Medical Treatment.

The high level of dissatisfaction with Waiting Time is self-explanatory when one is aware of the waiting times and amount of time spent with the doctor described earlier.

Among inpatients, satisfaction was particularly low for Pleasantness of Dining Room/Lounge Area (30%) and Content of Food (37%), the latter of which is probably a universal phenomenon.

Selection of A Hospital
Respondents were asked whether they consulted any information sources when selecting the hospital: 31% of outpatients and 28% of inpatients stated that they did so (18% of outpatients and 35% of inpatients stated that they went to the hospital designated by their doctor). Of those who did consult an information source, 74% consulted with family members and/or friends. Only 0.4 -0.5% of patients consulted the Internet regarding the selection of a hospital. (See Table 5.)

Information About Hospitals
When asked what information they would like to obtain about hospitals, the major responses from outpatients were Consultation Availability After Hours and on Holidays (43%), Specialty of Doctors at the Hospital (32%), and the Existence of Appointment System (32%). These three items scored highest among inpatients as well. (See Table 6.)

Interestingly, the next highest score (17%) is for an independent third-party evaluation of hospitals. At this point, Japan does not have a well-developed system of hospital accreditation. The seemingly nonstop spate of reports in the media about cases of medical malpractice in Japan may have had some influence on this score.

The other types of information desired tend to be practical in nature -- whether house calls are provided, home-care services are available, regular health checkups are offered, and so on.

So what does this all mean? Patients still do not appear to be willing to question a doctor, and a surprisingly high number do not want to see their medical charts. At the same time, the level of satisfaction among patients with the consultation and treatment received is not especially high. There is also considerable dissatisfaction with waiting times and consultation hours.

There would appear to be significant business opportunities for companies able to provide information to patients on a wide range of healthcare issues.

Already, books on "how to understand what medicines you received from the doctor" are selling very well.

The study shows that an extremely low percentage of patients use the Internet to obtain information on hospitals. Is this because there are no good Japanese-language Web sites on healthcare? Are the socio-cultural barriers against questioning doctors too strong? Or is it perhaps because older Japanese, the biggest users of hospitals, are not yet comfortable with the Internet?

The company that can develop an Internet-based breakthrough in this field stands to reap substantial benefits.


William Hall (williamh@isisresearch.com) is president of the ISIS/RBC/CORAL Group, which provides market research and consulting services in Tokyo.