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Workforce and regional distribution of anaesthesiologists in Japan

2002; Lippincott Williams & Wilkins; Volume: 19; Issue: 7 Linguagem: Inglês

10.1097/00003643-200207000-00013

1365-2346

Kiichiro Taga, H Fujihara, Hiroki Baba, Takuo Yamakura, Koki Shimoji,

Global Health and Surgery

EDITOR: Anaesthesiology is a relatively new medical field in Japan. It used to be one of the sub-units of general surgery in the same way as for other surgical fields, e.g. neurosurgery or plastic surgery, until the end of the Second World War. During the occupation of Japan by GHQ (General Headquarters, American Army), Dr Meyer Saklad was invited to Japan by the Japan-America Association of Medical Education to introduce modern concepts of anaesthesia practice. Saklad's lecture seemed to have a strong impact on those who were involved in post-war medical education in Japan. In 1962, The Japan Society of Anaesthesiologists (JSA) introduced an annual board examination system (written, oral, practical) that took account of the need for relevant physiology and intensive medical care. At the same time, the Japanese Ministry of Health and Welfare (JMH) licensed certain categories of medical doctors to practise general anaesthesia. These were doctors who had either trained for 2 yr under JSA board holders (Category 1) or those who had experience of more than 300 cases of general anaesthesia in evenly distributed fields of surgical operations (Category 2). The numbers of JSA board holders has been increasing (Table 1) for the last four decades [1]. Rather surprisingly, the numbers of JMH licence holders practising clinical anaesthesia exceeds those of JSA members [1], which indicates that there are many non-members of the JSA practising clinical anaesthesia. This might be due to the fact that JMH licence holders are legally permitted to practise clinical anaesthesia in Japan, but excluding dentists who are allowed to administer general anaesthesia only for dental treatment. In other words, these JMH licence holders are practising general anaesthesia as a part of their own surgical specialities because of the difficulty in getting anaesthesia specialists or to save on costs of general anaesthesia.Table 1: Changes in the numbers of the Japan Society of Anaesthesiologists (JSA) board holders, JSA members and Japanese Ministry of Health (JMH) licence holders from 1960 to 2000 in Japan.Despite the rapid increase in the numbers of JSA board holders in Japan, the total number of specialists is still far behind those in the USA, England and Wales, and the European Union (Table 2)[2-4]. Another characteristic feature concerning the manpower of anaesthesiologists in our country is the uneven distribution of JSA members among the prefectures [5,6]. Although anaesthesiologists, like other medical specialities, tend to concentrate in large cities such as Tokyo and Osaka, where there are many large hospitals, highly differential distributions are noted by regions. As a whole, the numbers of JSA members are low in the eastern part of Japan compared with those in the western part - excluding Hokkaido (the furthest outreach of eastern Japan): West high, East low (the phrase spoken frequently to express a wintry pressure pattern over the Japanese islands) (Fig. 1).Table 2: Comparison of anaesthesiologist numbers in Japan with those in other countries.Figure 1: Regional distribution of anaesthesiologist's manpower (JSA members per 105 population) in Japan. There are 15 prefectures in the West where the numbers of JSA members >6.50 × 10−5, whereas there are only four such prefectures in East Japan. 1: Hokkaido; 2: Aomori; 3: Akita; 4: Iwate; 5: Yamagata; 6: Miyagi; 7: Niigata; 8: Fukushima; 9: Toyama; 10: Nagano; 11: Gunma; 12: Tochigi; 13: Ibaragi; 14: Saitama; 15: Yamanashi; 16: Tokyo; 17: Chiba; 18: Kanagawa; 19: Ishikawa; 20: Fukui; 21: Gifu; 22: Aichi; 23: Shizuoka (East Japan); 24: Kyoto; 25: Shiga; 26: Mie; 27: Nara; 28: Wakayama; 29: Osaka; 30: Hyogo; 31: Tottori; 32: Okayama; 33: Shimane; 34: Hiroshima; 35: Yamaguchi; 36: Kagawa; 37: Tokushima; 38: Ehime; 39: Kochi; 40: Fukuoka; 41: Saga; 42: Nagasaki; 43: Kumamoto; 44: Oita; 45: Miyazaki; 46: Kagoshima; 47: Okinawa (West Japan).Low numbers of anaesthesiologists in Japan seems to arise from four factors. First, as described above, the independence of this medical field from general surgery was delayed until the end of the war. This still causes a lack of familiarity among the population; approximately 50% of the patients in this university hospital did not know about the nature of anaesthesiologists at the preanaesthetic interview. Second, Japanese medical school departments are still inclined to adhere to a bureaucracy that prevents radical and open treatment of patients under a medical team that includes the anaesthesiologist. Third, all payments and claims by national and private-sector medical insurance are made through one doctor (a front desk doctor) in a main department where the patients are treated, not by individual specialists such as an anaesthesiologist, radiologist or pathologist in the various departments. This system makes it difficult for anaesthesiologists to claim payment for their own anaesthesia practice from an insurance organization. Fourth, payment from medical insurance organizations in this country is based upon the total costs of treatment for each patient. This system again tends to favour staff without a JSA board licence or the owners of private hospitals who pay the specialist anaesthetist. Thus, there is a tendency for surgical anaesthesia to be administered by a JMH licence holder, or other surgical staff, without a JSA board licence. However, the background for high prefectural variability in the numbers of the JSA members seems to be due to regional differences for the first and second factors described above rather than the third or fourth factors. We believe that the JSA board holders are highly trained. However, they are generally overworked due to manpower shortages. We presume that maternal mortality is still higher in this country than in the UK due to the lack of anaesthetists in the field, but there are currently no reliable data in this country. It is likely that there has been no improvement in maternal mortality since Rosen and Fujimori's analysis [7]. Although it is difficult to define the anaesthesia workforce among countries because of their different medical insurance systems, a gross comparison might provide anaesthesiologists - particularly those in developed countries - to prepare for the education of the public. K. Taga H. Fujihara H. Baba T. Yamakura K. Shimoji Department of Anaesthesiology; Niigata University School of Medicine; Niigata, Japan