OPINION
What’s the Difference?
Comparison of American and Japanese Medical Practice
Masami Kitano

Diplomate in Neurology American Board of Psychiatry & Neurology(Received for publication on November 19, 2006)(Revised for publication on March 5, 2007)(Accepted for publication on March 15, 2007)

Abstract. Medical systems in the USA such as EBM., DRG., Informed Consent and Second
Opinion have already been introduced into the Japanese medical system. However, some ofthese systems have met resistance from a part of the population due to the differences ofsocial structures, morals and customs between the two countries. Briefly, I described the
medical education and licensure, the private practice and “open hospital system” of theUSA. The following 4 topics which drew great interest in Japan will be discussed.
1) Cerebral death and Bioethics: Cerebral death has been restrictively accepted as humandeath since the 1980’s only in terms of terminal cares in clinical medicine. The rather
simplified current neurological criteria for death are approved in the USA. In order for
an organ transplant to take place, a potential doner must be diagnosed as brain dead.
However, Japanese society has not accepted the concept of cerebral death completely
because of an accident in the 1960’s where an organ was improperly removed when thedonor who was not in the state of brain death. Recently, more people in Japan are showing interest in Dignity and Euthanasia from the point of view of “Right to die”.
2) Malpractice and Litigation: “To err is human” was introduced by the Institute of Medicine for Risk Management. Accidental deaths of patients under medical care ranks No.8
in total number of deaths in the USA. There are 100,000 malpractice cases in the “Lawsuit Society” of America, which is 100 times that of Japan. Furthermore, the legal fees
and insurance premiums are extremely high in the US as opposed to very low in Japan.
3) Health Care Insurance: To reduce medical costs, the insurance companies introduced“Competitive Managed Care” which resulted in the formation of “Health Maintenance
Organizations” (HMO). Furthermore, when you compare the two countries in respect
to those who have health insurance, 44 million in the USA carry no health insurance,
whereas in Japan, the government cover for everybody’s health insurance.
4) Disclosures in the USA: Medical bills and statements are sent to all patients. Maintenance records belong to the patient. The Medical Board discloses those physicians who
are facing disciplinary action. (Keio J Med 56 (3) : 96 －101, September 2007)
Key words: cerebral death , bioethics, malpractice , litigation, health care cost and insurance, disclosures

Introduction

the American medical system, which in many ways is an
improvement or can be detrimental such as, “informed
consent”, “second opinion”, and “evidence-based medicine (EBM)”, etc. Japanese physicians should learn
more about the American methods in the near future. If
so, then what? Why did the W.H.O. rate the health care

On each subject,1-4 I will discuss about the major differences of medical care in the USA and Japan. The Japanese are not only learning and introducing new advanced medical sciences but are also being introduced toAddress for Correspondence: Masami kitano, M.D. 960 Via Rincon Palos Verdes Estates, CA, 90274, USA
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Keio J Med 2007; 56 (3): 96 －101

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Table 1 Comparison of American and Japanese Medical Practice1) Cerebral Death and Bioethics
Simple neurological criteria
Organ transplant
Bioethics, Human Right of Dying, Dignity, Euthanasia, Living Will
2) Malpractice and Litigation[Institute of Medicine] 44,000 accidents in the USA and 8th leading cause of death“To err is human”
Risk Management
Litigation system
Lawsuit Society
Attorney, Excessive lawsuits, Malpractice insurance premium[Code of Medical Ethics] from A.M.A.: Fundamental elements of the Patient-Physician Relationship
William Osler Society: Medical Arts, “Humanology”
3) Health Care Cost and Insurance
High rising medical costs caused by: defending medicine, malpractice insurance premiums, moral support for
the illegal immigrants, increase of senior citizens, investment in medical equipment and AIDS.
Reconstruction of heath care system: Competitive managed care and Health Maintenance Organizations (HMO).
Hospitalist Autonomy
Indemnity
Federal Insurance: Medicare for the elderly, Medicaid for the low income
4) Disclosure
Explanation of benefits, medical bill
Medical records belong to the patient
Administrative action by Medical Board of California.
4,000 out of 700,000 physicians in the USA.
5) Headline in the Los Angeles Times
Physicians accused as criminals at a university hospital in Japan.
6) Statistical Views In the USA and Japan (Table 2)
Medical Education, Medical License
Private Practice in the USA: Open System Hospita, Tumor Board and Emergency Medicine

system in Japan #1 in the world? Why are many patientsunhappy or not satisfied with the health care system inJapan? Particularly those people who live in the ruralarea and those who are seeking emergency or cancer
care remain unsatisfied, for example, while the entire nation is fully insured by the federal government. It is truethat malpractice insurance premiums are very low in Japan while malpractice suits are rising. The Japanese
population in general, with or without needs of urgent
medical care, receive health examinations such as MRI,CT scans, PET, and “Ningen Dock” a thorough set of
medical tests, for prophylactic purposes, which are covered by health insurance or by one’s employers. The
health insurance covers the costs of these tests and medications, but compensates little for physician’s medical
skills. Why are full time hospital physicians working
long hours but get paid much less than those in private
practice? What is the reason for the Japanese government’s attempts to reduce medical costs, when the GDP
rate for medical costs in Japan is the lowest among the
top seven countries in the world? In the USA. ER physicians and diagnostic radiologists are available for 24
hour as well as for specialists on call for consultations.

What is the Difference: Comparison of the Americanand Japanese Medical PracticeMedical Education: Following the completion of four
years of a university education, an American medical
student will enter a four-year medical university. In Japan, after a high school education, a Japanese medical
student enters a medical university for six years. An
American medical student goes through eight years ofschooling, which is two more years than a Japanese medical student. In Japan, after passing the National Board
Examination, he/she is certified as a medical doctor(M.D.). Medical License is effective and valid for his/her entire life without any renewal process. In the stateof California, all physicians are required to renew theirlicense every three years, obtain 60 hours of certified
professional education within the three year renewal period and take the following two courses: “Pain Management” and “End of Life Care”.
In Japan, after graduating from medical school, a physician is required to go through a two-year internship.
Afterwards, most physicians who select their area of specialities get additional training and must take a Board examination. Some physicians go on to obtain a Masterand Doctor of Medical Science Degree (Igaku Hakushi),which involves medical research along with clinicaltrainings. In the USA, during specialty trainings, resi-

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dents concentrate only on clinical medicine and somephysicians obtain a Fellowship and take further trainings
for subspecialty. Recently, board-certified physicians are
required to re-certify for a Maintenance Of Certificate(MOC) every 10 years.
Private Practice in the USA: “Open System” All physicians attend and treat their patients at a community
hospital. Specialty board certification and malpracticeinsurance are required for the attending medical staff andscreened to determine whether the physician is proficientin performing specific procedures such as the use of anendoscope for gastroenterologist or surgical techniques
for a surgeon. The community hospital is managed by
Board members, which include medical staff, CEO (ascertified hospital administrator) and other hospital personnel. The hospital will also create various committees
such as a committee for bioethics, for peer review, andfor each medical specialty.
A tumor board meets every week, discuss and recommend further procedures and cares for every cancer patients. The tumor board includes an oncologist, pathologist, radiation oncologist, surgeon, diagnostic radiologist
and hospital staff including social workers nurses andphamacist. In Japan, universities or large public hospitals
have similar boards, but private hospitals do not havesuch a function. Caner patients are treated by a team of
two or three physicians, mostly surgeons, and patientsare referred to larger hospitals for further care if necessary. No oncologists had been available in the Japanese
medical system, but very recently, chemotherapists wereapproved as a cancer specialists.
Emergency Room Care: Emergency care (ER) is notwell established except the university and larger public
hospitals in Japan and the quality of care is different
from one hospital to the next, as well as the qualificationof the ER physician and care is particularly poor in rural
areas. The cost of requesting for an ambulance is free inJapan. In the USA, ER physicians and diagnostic radiologists are available for 24 hour as well as for specialists
on call for consultations.
Since it is impossible to discuss about the many aspectsof US medicine within such a limited time, I have chosento speak about 4 topics. I have been asked by my peers
to talk about these topics, which are highly debated withgreat interest in Japan (Table 1).
1) Cerebral Death and Bioethics 1,2
As a neurologist, I have been involved in the diagnosisof brain death. California is the first state, allowing cerebral death to be accepted as human death by law. In theearly 1980’s, several repeated Isoelectric EEG’s were required to confirm total brain death, however, in the past
years, tests were not necessary if the clinical neurological criteria were fulfilled, namely, a deep coma, apnea

Kitano M: Comparison of American and Japanese Medical Practiceand complete loss of brain stem reflexes. It is importantto keep note that life supportive measures should be disconnected only when the family members agree. Cerebral death must be confirmed by two physicians of whom
one have to be either a neurologist or neurosurgeon. Physicians working for organ transplant cannot be involved
in diagnosing cerebral death. Each person has a different
opinion and acceptance of human death. Particularly in
the USA, this is a highly debated topic because of various religious, cultural and moral differences. In certain
circumstances, the Bioethics Committee can assist thosefamily members in making the final decision.
The proper diagnosis of cerebral death patient is essential for the organ donation and transplant process. In theUSA, the concept of brain death is established independently as a clinical matter in terminal care, and is not partof the organ donor process. In Japan, the story is quite
different. Japan had a bad incident many years ago(about 30 years or more), where a cardiac surgeon in
Sapporo was forced to remove a heart from a donor who
was not in brain death state. Since then, the entire Japanese society, even the medical society has not accepted
the concept of “cerebral death” being equal to humandeath. Subsequently, the actual number of diagnosed cerebral deaths has been minimal, directly affecting thenumber of organ transplants performed in the country,
despite the fact that many patients, including children,
who are in need of transplant surgeries are in long waits
for donations. As a result, critical patients are forced toreceive the transplants in the USA.
Dignity and Euthanasia are the current major subjects
in Bioethics in Japan as well as in the USA. Currently in
the USA, routinely upon every hospitalization, all patients are questioned about the possession of “Living
Will” and informed about the “right to die” in a humanbeing (Durable Power of Attorney).
In Japan, on the 5t h day of hospitalization, a patientwith multiple myeloma, his respirator was disconnected
and given a muscle relaxant by a physician and passed
away. The physician was arrested and accused of murderer. In USA, more recently, the medical provider was
accused following the infusion of medicine for Euthanasia during a hurricane attack in New Orleans.
2) Malpractice and Liability 3
The proverb “To err is human” was introduced by the[ Institute of Medicine ] for Risk Management, and thisword became quite popular in the world.
In the past five years in the USA, risk management wasused to suppress malpractice insurance premiums andavoid legal liability for damage, rather than to reduce theerrors caused by medical care providers.

Keio J Med 2007; 56 (3): 96 －101

Rate of accident:4
2.9% (California Study)
4.7% (Harvard Study)
Subsequent death:
6.6% - 13.6%
Out of these deaths 30%, the medical provider is responsible.
Death caused by medical errors is the No. 8 leading
cause in the USA. In Japan, during the past six years,
risk management in medical practice has been a major
national project. Medication errors is the leading causeof medical errors both in Japan and the USA. Reports
from the media on medical liability claims has risen dramatically in JapanThe USA is known for their litigation system as a
“Lawsuit Society”. The trial system was necessary tounite the nation due to the multi-nationalities and different races, which brings various morals and cultures together into one society. Furthermore, relationships become complex and to settle the troubles and quarrels, thenation needed peaceful and equal means of settling thesedifferences through a fair system. In the USA, filing alawsuit is an easy process, because 1) costs are low, 2)
many lawyers are available as it is significantly easier tobe admitted to the bar and practice law in the USA as
compared to Japan (rate of lawyers to the population isNo. 1 in the world), 3) most cases are settled before going to the courts because verdicts in malpractice suits areoften in the grey area, 4) processed as civil cases and 5)
compensation for lawyers is high.5-9
Malpractice insurance premium for a physician is very
high in the US. For example, neurosurgeons and obstetricians may pay more than $100,000 a year for insurance. In Japan, the premiums are very low and consistent for all specialists ($500-600 a year), even for neurosurgeons. Also, the indemnity coverage is $1 million ―$3 million in both Japan and the USA. More recently,
mediator system was introduced to negotiate for the reduction of compensation following the physician’s apology.10
To mitigate the risk of malpractice lawsuits, physicians
refined their skills, improved how the practices were run,re-emphasized the importance of the physician-patient
relationship and the proper maintenance of complete
medical records. “Informed consent” is one of the byproducts of this initiative. 11-13
AMA (American Medical Association) published abooklet [Code of Medical Ethics] in which Fundamental Elements of the Patient Physician Relationship isemphasized in the first chapter.14-17
As known, William Osler Society emphasized the importance of “the Art of Medicine” in curing the patient,along with the medical techniques. “Humanology” isalso re-emphasized to develop the superb personality as
being a physician as well.

993) Health Care cost and Insurance
Medical costs soared as a result of defense medicine,increase in malpractice insurance premiums, increase in
the use of specialists, humanitarian support for illegal
immigrants, and increase in the population of senior citizens, investment in advanced new equipment and the
spread of AIDS. The insurance company reformed thehealth care systems to control the medical costs and introduced “Competitive Managed Care”. The businessoriented experts introduced another form of health carecalled a HMO (Health Maintenance Organization). And
as the result of this system, physicians lost their autonomy and decrease to the patient service. More than half ofthe nation now belongs to HMO’s. The Kaiser Foundation is an example of a successful HMO. The quality ofcare in a HMO has been improving, with the hiring offull-time physicians (hospitalists) into the HMO. In theUSA, an individual decides on whether he/she is coveredby health insurance, and approximately 44 million people are without health insurance, including business men
who make between $70,000 and $80,000 a year. In Japan, the federal health insurance covers the whole nation.
Individual patients are responsible in co-paying 30% of
the medical bill while the elderly is responsible to pay
10~30% of the medical costs.
Public federal insurance in the US and Japan is similar.
Medicare is covered for elderly people over 65 years old
and Medicaid is covered for people with low income.
Long Term Care Insurance: an individual is responsible in paying for this coverage in the USA. In Japan,
federal and local governments provide for some coverage for these services. The premium is relatively higheven for young workers.
4) Disclosure(1) The Medical Bill and Statements: The state medical insurance agency and private insurance companies send the detail of the bill and the “Explanationof Benefits” to all patients. If there is a discrepancy
in the information, the patient should report this tothe state or insurance companies. In Japan, briefnote is available, but, no details are described on thebill. The patient has to make a specific request for
details of their cares from the physician or hospitaland may be charged a fee for the request.
(2) Medical Record: The medical records belong to
the patient.18 Disclosure of these records could improve and the service quality of the physician andpractice and could mitigate the number of malpractice lawsuits and liability. In Japan, providing records to patients is slowly increasing and their records are maintained and available in computers inlarge hospitals, but the records are not readily available at private hospitals and practices. The patientis afraid that asking for a copy of their medical re-

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Kitano M: Comparison of American and Japanese Medical PracticeTable 2 Statistical View in America and JapanJapan
82 y/o3.8/1000
lowest in the world
Japanese Health Care is No.1 in The World
self
federal
44 million uninsured
all insured
Elderly 20% self
30% self
Elderly 10~30% self
Medical Cost
expensive
less expensive$2566 per person$1113 per person
High Payment For the Medical
For Tests and Medicine
Provider( Physician)CT MRI PET“Japanese like Tests” and Pay well, butless for Physician
GDP RATE
14.4%
7% < 8.8%, No. 20 in the world
Number of Hospital (total)
5000
9000
Number of Bed
1
2x of USA
Average Hospital Stay1
33.5 days, 5x of USA
Pharmaceutical Cost/person
No.2
No.1 in the world
Number of MRI CT/person
No.2
No.1 in the world
Administrative Action
4000/700,000M.D.s
40+/23,000 M.D.s
Malpractice Premiumvery highvery low$500 (all specialties)
e.g. Neurosurgeon $100,000
and more
Coverage 1 million / 3 million
1 million / 3 million
Medical License
Renew Every 3 years
for Life (No renewal)(California)With 60 hours education andduties of seminars for analgesics and terminal care
Medical Specialty
Oncology
Cancer Chemotherapy
Maintenance Of Certificate(M.O.A.)
Life Expectancy
Infant Death
WHO
Insurance

America
78 y/o7.2/1000

cords will offend physicians and damage their relationship.
(3) Administrative Action from Medical Board of California:19 Every three months, the Medical Board of
California publicizes the names of physicians who
are facing disciplinary action for fraud, malpractice,
tax evasion, drug abuse and alcoholism. Disciplinary action can include suspension of a license, taking educational courses and free community services. Approximately 4,000 physicians out of 700,000
physicians in the USA are facing disciplinary action
and is disclosed, however the number of physicians
facing disciplinary action in Japan only stand at
about 40 out of 23,000 physicians.
5) Headline in the Los Angeles (LA) Times20
The LA Times on the front pages in 2002 reported an
accidental death following the cardiac surgery for a septal defect due to the failure of a pump. This report also

discussed about the quality of medicine, inadequate clinical training, limited patient’s rights, and arrogant attitudeof physicians in Japan. In this case, the parties involved
forged the medical records and tried to cover up the incident, which led to the physicians being charged of murdere.
6) Statistical views in the USA and Japan 21(Table 2)
Comments
Some medical systems such as EBM, DRG, Informed
Consent and Second Opinion have already made theirways from the USA to Japan. Social structures and morals are quite different between the two countries. Bothsystems have their advantages and disadvantages to both
physicians and patients. We should be open in learningsome of the American medical methods and consider introducing them into the Japanese medical system.

Keio J Med 2007; 56 (3): 96 －101

Meanwhile, we may have to face the facts and reconstruct the current system in the near future in Japan. For
example as described in these materials, the physician’s
license should be renewed with required professional education, patient records should be made available to patients, the litigation systems need to be changed and emphasis should be made in increasing the number of physicians in some specialties in need.
It is very important that these reforms should be conducted by physicians themselves in Japan.
I hope this presentation has provided useful information to those particularly in private practice.
This summarizes the presentation given at the Keio
Medical Society on October 17, 2006.
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