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Moonlighting

アルバイト Moonlighting

Originally posted as: アルバイト in 南区医師会報

Bulletin of Minamiku Medical Society, No 304 pp12-13, Vol29 No6, 2004

Shuichiro Goda, MD

This is a story from a few years ago when I was working part-time at the internal medicine outpatient clinic of a hospital at night. The patient was a female in her 20’s. Her chief complaint was listed as a headache. She looked a little pale and groggy. There were a lot of patients that day, so we talked a little, and as I was thinking to get her a CT scan I noticed that she had a “self-funded” seal on her medical record. When I asked her if she had forgotten her insurance card she replied that she didn’t have one. Despite having a full-time job as a metal engraver, her employer didn’t cover her insurance as the national insurance premiums were too high for them to pay, and she earned too much for her to go on family insurance as his dependent.

It was at this point that I decided to take my first serious examination. For a practicing neurologist, CT scans are a very handy way to “put aside” the patients while they are waiting, and also serves to amplify income- which is wholly insufficient by consultation alone. It’s also true to say that there are many patients that wish to undergo it, even if it is felt unnecessary by the examiner. You could say that the doctor shouldn’t feel particularly conscientious about ordering a CT to an outpatient that comes in the night complaining of a headache.

If you add in the cost of the blood tests and the additional night-time initial consultation fee to the CT fee, the total cost might exceed 20,000 yen at one’s own expense. It should be a pretty painful expense to bear for those who can’t afford to pay the National Health Insurance premiums. Thinking about trying my first real examination with this in mind, it did occur to me that I too might have a problem, but I went ahead and examined her anyway.

In addition to the usual medical examination, I also carefully performed a neurological check-up not usually done here. She had a sore throat and she had a bit of a temperature. But there was no abnormal neurology shown, nor symptoms of meningeal irritation. I think it was safe to assume that the headache came from her cold, and that was what had her feeling tired. Sinusitis and the early stages of meningitis may have been on the cards, but I did not see a spinal tap or a CT scan being required. Although it would be an exaggeration to say that I had fully put to use my 20 years of experience as a neurologist during that session, I told the patient that it was a headache not worth being particularly worried about. Meanwhile, the expression on her pale expression returned to life. It seems likely that the source of most of her distress was the headache that she’d never experienced before. Her smile came out.

It was a very gratifying experience to be able to forgo unnecessary tests and make a diagnosis whilst relying only on one’s own knowledge and experience, and to gratify the patient. Although I couldn’t contribute to the profits of the hospital I worked part-time at, my own wallet was left uninjured due to the nature of the set-fees per visit, and so everything worked out in the end. I felt proud to be able to deliver a proper diagnosis at a minimal cost. I even felt as if I had done something good.

It seems strange at first- to say that by not relying on the National Health Insurance system, there are situations in which by contrast one will be provided the proper medical treatment. However, it’s certainly true that this insurance system has had an inexpressible influence on the ideal treatment style of doctors. It’s unbelievable coming from the days when we competed to see how far we could properly diagnose a patient without a CT or an MR, that the me of today spends the greatest effort instead on how to get a CT done without compromising the patient’s mood. This is because making a diagnosis without a CT is not evaluated within the framework of the insurance system.

So would insurance credits for neurological examinations solve the problem? I feel that it’s not the case. In the first place, this so-called idea of putting a price on all medical treatment causes the doctor-patient relationship to be distorted from the start, doesn’t it? You’re providing a service and so you should be paid. A price must be set for a consultation. It might be better to set the price a bit higher, so that when given a prescription without a consultation the fee is waived. And in that place, a 15-minute or 30-minute consultation could be a proper affair. To take a thorough medical history, perform a careful examination, and answer the patient’s questions 30 minutes may not be sufficient.

And as I write this, I realized that the patients themselves might not want such a troublesome examination. There are many patients that simply want their medicine. It is true that the current insurance system is skewed, but this may be the result of what the patients themselves wanted. And if that’s the case, then the doctors will have no choice but to persevere with this distorted system.

I don’t know what happened to that patient after that. I told her to come back whenever she had a bad headache and left it at that, but she may have put up with it and not gone to the doctor. In the end, she may have had various tests at another hospital and my diagnosis may have been shown to be wrong. Still, I believe even now that I made the right analysis during that time.

Part-time jobs are something you do for the money, but I realized that there are some part-time jobs that aren’t necessarily all about the money. I don’t believe that the health insurance system is going to get any better. It looks like my part-time job will continue for a while.

2020/06/22

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