[Feature: Post-Corona Healthcare Policy] Roundtable Discussion: Will Japanese Healthcare Change After the Pandemic?

Not only Japan but the entire world has spent over three years in the "COVID-19 pandemic," during which various points and problems regarding medical systems and medical policies were pointed out, and much was learned from them. Today, we have gathered experts from various fields to think about the future of medical policy and medical systems after the pandemic.

First, I would like to ask about the challenges that have come to light and the points where the Japanese medical system performed relatively well. Mr. Suzuki, could we start with you?

I retired three years ago as the Chief Medical and Global Health Officer at the Ministry of Health, Labour and Welfare, but since COVID-19 began to spread in January of that year, I was in charge of the response for about the first six months. At that time, naturally, there were no vaccines or treatments. The nature of the disease was not well understood, and it was extremely difficult. There are several things in particular that I thought were challenges at that time.

One is the "switching between peacetime and emergency." In Japan, during peacetime, medical care is handled firmly through decentralization, making use of the characteristics of each region. However, in an emergency, it is difficult to quickly unite the entire country under a single command.

A specific challenge I noted was that the definition of a severe case differed between the national government and the Tokyo Metropolitan Government. When comparing the number of severe cases, Tokyo used a different standard. While there are various opinions on this, I felt that in an emergency, definitions of cases must be aligned, and there must be commonality in how the country as a whole responds.

The second is the function of public health, represented by public health centers. As tuberculosis was largely overcome and they basically only dealt with a very limited range of infectious diseases, their functions had been steadily reduced. However, when a pandemic like this occurs, public health centers can naturally only do a limited amount with a limited number of staff and limited capacity.

In this COVID-19 crisis, the structure was such that public health centers had to do everything from case discovery to patient transport, identifying hospitals, and testing, which led to a dire situation. I felt that during a pandemic, we must adopt methods such as using apps, requesting other organizations, or having private institutions handle tasks while public health centers oversee the whole situation.

Finally, there is the issue of the supply chain. As you may remember, for about the first six months, there was a situation where there were no masks or medical gloves. In terms of cost-effectiveness, cheap and durable items are usually imports. However, under a global pandemic, factories stop, or goods are not easily sent out of the country.

As a result, imports are cut off, a supply-demand gap occurs, and items become very scarce. We must have a "Plan B," such as stockpiling medical necessities as strategic materials like oil, or supporting domestic manufacturers in Japan so they can produce at least a minimum amount when something happens, otherwise, what happened three years ago will happen again. I think we should reflect on these points.

What points of Japanese policy should be commended?

Looking at the number of deaths per population, Japan is about one-fifth that of the United States or the United Kingdom. I believe this is a combination of various reasons. One hypothesis is that normally, about one-third of the colds we catch in winter have been coronaviruses. These are different coronaviruses from COVID-19, but they are quite prevalent in East Asia, and people in East Asia, including Japanese people, may have had similar coronaviruses before and possessed a certain level of immunity. This is a fairly strong hypothesis. After all, mortality rates are low not only in Japan but also in South Korea, China, and Singapore.

Another factor is behavioral change. There is what is called a prospective survey, where you investigate who a person met after becoming ill to prevent the spread. Every country did this, but Japan also conducted retrospective tracing surveys. We investigated where people were and what they were doing a week before they fell ill. This allowed us to identify so-called "3Cs" (Closed spaces, Crowded places, Close-contact settings) locations, which led to behavioral changes and likely had a certain preventive effect.

Japan's mortality rate is lower than South Korea's. Given that the vaccination rates are similar and the medical levels are almost the same, I believe that Japanese public health policy did have a certain effect.

Dr. Haruta, you have been involved in community medicine as a specialist in general medicine. What is your perspective?

I work on the front lines as a primary care physician myself, but since the start of COVID-19, I have been continuously interviewing primary care physicians across the country. I would like to speak from those insights about what problems occurred in the regions.

Mr. Suzuki mentioned peacetime and emergency, and this time, there were clear regional differences in the response during emergency situations. What was seen in the Tokyo metropolitan area was the difficulty in ambulance acceptance. Information on how many beds were available between hospitals was hardly shared, and it is presumed that everyone thought that even if their hospital didn't take a patient, somewhere else would.

There were cases where more than 100 hospitals refused to take a severe patient. This was happening not only in Tokyo but also in neighboring Yokohama and Saitama. One reason for the inability to accept patients was the occurrence of infection clusters among staff within the hospitals. There were circumstances where this could not be made public because, in the early stages, there was a risk of reputational damage.

On the other hand, in some regions, information sharing was going well. What was happening at the hotels that became places for recuperation for mild cases, or at the public health centers that served as information hubs? There were doctors at core regional hospitals who investigated this thoroughly. As a result, they clarified that the information sharing and command systems between hotels, public health centers, and hospitals were not functioning as a system.

By setting up the infrastructure for patient acceptance among hotels, public health centers, and hospitals in that way, the acceptance of COVID-19 patients began to function smoothly. And by continuing that, the system began to run even without the doctors' direct involvement. This is one example where differences in initiatives across facilities resulted in differences in regional patient acceptance.

Also, as the number of COVID-19 cases increased, staff centered on internal medicine began to handle fever clinics, and at the same time, they had to see inpatients. They had to be on the front lines themselves while creating new acceptance systems and treatment protocols. As a result, they became physically and psychologically exhausted.

Meanwhile, I heard of a case where an internal medicine doctor asked a surgery doctor to provide certain information to the public health center, and the surgery doctor replied, "Is that my job?" This was a conflict caused by the "siloed" nature of internal medicine and surgery, where each other's tasks were invisible. While this was not a problem in peacetime even if tasks were invisible, it failed when everyone needed to cooperate in an emergency where the imbalance of tasks became prominent.

Similar things were happening between managers who saw the whole picture and the staff on the ground. In an emergency, what is visible differs depending on the doctor's specialty and position, so conflicts are likely to occur. I felt that relationships from peacetime are important to prevent this.

Furthermore, nursing care facilities were in a disastrous state. When a cluster occurred in an entire facility, they were forced to decide which areas to designate as red zones. For people with dementia, if alcohol disinfectant is placed in the hallway, they might drink it, so infection prevention cannot be done as usual. In such a situation, someone is forced to take command and make decisions.

Nursing care facilities are different from hospitals, so medical professionals often enter as advisors from the outside, but if they only impose medical restrictions, daily life becomes impossible. Understanding that, they had to balance life and medical care by requesting movement restrictions for the whole facility, such as making the entire facility or an entire floor a red zone. The necessity of solving problems in accordance with the medical or nursing care setting was highlighted.

Are there any characteristics that differentiate regions that went well from those that did not?

In cities with a population of about 300,000 to 1 million, where hospitals are somewhat limited, the hotels that can be used are fixed, and the heads of public health centers and hospitals, or managers between hospitals, are on a first-name basis, it may have been easier to move with a top-down approach when creating a rapid system for an emergency.

In a city of over 10 million like Tokyo, even a hospital in Shinjuku Ward may be seeing patients from a much wider area. Then, with hundreds of hospitals, coordination is difficult. Smaller villages and remote islands have limited resources, so if they could establish connections with the outside, they managed well through communication and consultation between the government and the leaders.

Therefore, I have the sense that cities of roughly 300,000 to just under 1 million were the ones that went well even without a specific driver.

I see. The relationship between the national and local governments in Japan is unique in a way. Since the 90s, decentralization has progressed steadily, and when bureaucrats from central ministries try to say something to local governments, they are told not to interfere, saying it goes against the spirit of decentralization. Even when COVID-19 started, things that seemed likely to go well if the center gave proper instructions because it was an emergency were met with local governments saying they would do it independently.

But then, when it comes to whether they will do everything, for things they don't want to do or can't do, they ask the central ministries to create guidelines, give instructions, or provide money. In a sense, I think there was a bad habit between the national and local governments.

Another thing is that even within the same prefecture, between designated cities and the prefecture, regarding who announces the number of infected people, it is often thought from the news that the prefecture takes it all on and announces it, but that's not actually the case; in some prefectures, designated cities announce it independently. There is a sense of rivalry.

Towards the end, the friction finally disappeared, but in the early stages, in terms of who holds the initiative, who takes responsibility, and who provides the money, the relationship between prefectures and cities, and between the national government and prefectures/municipalities, was unfortunately not one that could respond flexibly to infectious diseases. From the standpoint of someone researching public administration and finance, it was a very painful situation.

The relationship between prefectures and municipalities also revealed both good and bad points, didn't it?

That's right. Designated cities and prefectures often fight over who will take the lead. Designated cities are large, so their influence is naturally strong, but if they fall out with the prefecture, things that should run smoothly stop running.

Moreover, many designated cities have core medical institutions for tertiary medical zones (areas that handle specialized medical care requiring advanced technology), and if that city doesn't cooperate, it becomes inconvenient, yet there were times when the governor was slow to act. There are cases that become unfortunate for residents when an emergency is met with a lack of cooperation even where cooperation is necessary.

However, the Infectious Diseases Act has now been revised, so who takes responsibility in an emergency and how to build cooperative relationships with private hospitals have been improved by reflecting on the poor initial response. I think things are moving in a good direction.

Taking a cynical view, I think it's significant that the weaknesses of Japanese healthcare have been shared with the public. This is a blessing in disguise, as the weaknesses of Japanese healthcare, which had been pointed out since before COVID-19 as needing reform, have become clear.

Regarding hospitalization, everyone in the country came to know that the number of beds per population is excessive. It also became clear that the "family doctor" system had not been organized. Patients were told that a doctor they thought was their family doctor was not, or conversely, a doctor thought they were, but the patient did not. National understanding doesn't deepen until something actually happens, but we were able to understand it by facing COVID-19.

Another issue I think was the problem of the medical fee system being too dependent on fee-for-service. During the first state of emergency in 2020, people refrained from seeking medical care, and medical institutions suffered a significant drop in income. This made it clear that medical fees were dependent on fee-for-service; if they had moved a bit more toward bundled payments, I think medical income wouldn't have plummeted so drastically. It may be time to rethink the medical fee system.

Furthermore, looking ahead to the 2030s, there will be many regions where the number of patients will drop sharply. We must seriously consider what kind of medical provision system to prepare for that, but in addition to the problems on the side of medical institutions, we must also devise ways to provide medical fees. I believe COVID-19 has raised the important question of how to support community medicine in regions with declining populations.

Ms. Akiyama, what are your thoughts?

As everyone has said, I also felt that COVID-19 revealed in various fields the challenges that were not visible during peacetime, important things that were being postponed, and things that people were pretending to do but were not actually doing.

Speaking of digital transformation (DX), I think it was exposed that the digitalization of medical institutions, the government, local municipalities, and the public sector was actually not something usable, even though it seemed like it was being done.

When the infections first started, doctors had to sign reports of infected cases by hand and send them to public health centers by fax, and the staff at the public health centers who received them had to manually input them to perform aggregation work. The people at the public health centers were unimaginably busy, tasked with understanding the situation of each infected person, conducting epidemiological surveys, and coordinating medical institutions to accept those whose conditions suddenly worsened. It has become clear that the heavy burden of manual input there led to many human errors.

Moving slightly away from healthcare, in a more familiar area, there was also the turmoil surrounding the application for the 100,000 yen Special Fixed-Sum Cash Benefit. Although they said applications could be made online or on paper, when it actually started, a counterproductive situation occurred where online applications became a greater burden for both applicants and local governments.

The cause was that, in addition to the low penetration rate of My Number Cards at around 17% in mid-2020, even cardholders had to manually input household members and bank account information for transfers one by one on the Myna Portal. Input errors and duplicate applications at that time became problems later. In many municipalities, they further had to visually check and confirm this against the Basic Resident Register, which really only placed a burden on the front lines.

Behind these issues, which I think are fundamental problems in Japan, were various factors such as the siloed nature of ministries, a lack of leadership and drivers, an organizational culture that does not want to reform while maintaining the status quo, and vague public anxiety about personal information and privacy. Specifically regarding the digitalization of healthcare, I think there were silos between bureaus within the Ministry of Health, Labour and Welfare, and a lack of people with specialized IT knowledge within the ministry was also a factor.

Symbolizing this was the confusion surrounding the development of the app called COCOA. COCOA was originally based on a program developed as open source by private voluntary engineers. Its nature was not to create something perfect from the start, but rather for everyone to improve it if there were bugs and for everyone to add necessary functions.

For an app used by many citizens in an emergency like this, such a concept was likely unacceptable for the government. It was decided in May 2020 that the Ministry of Health, Labour and Welfare would lead the development, but I heard that the engineers were suddenly told that the money would be provided, so please release something perfect in three weeks. It seems it was a major confusion for the developers who had been doing it as volunteers.

In the end, amid criticism for various bugs, it was shelved without being able to fulfill the role initially expected of it.

Exactly as you say. Of course, it would have been good if there had been preparation in advance, but instead, we had to achieve a high threshold in a short period of time.

Another thing, and this is my understanding, is that there were parts where we had not faced ultimate choices until now. For example, if COCOA could use Bluetooth and had a mechanism where you could tell which person it was if a positive person came within about 1.5 meters of you, I think it would have been used quite a bit. However, even if you are told that there is a positive person but you don't know who it is, it's hard to use as a countermeasure.

If we could manage locations with GPS while people are at home, for example, there would be no need for public health nurses to call every day to confirm their location. But without a prior discussion that certain freedoms can be restricted during an emergency, I don't think such things can be discussed during that busy and difficult time.

I also have very regretful feelings; every day, the Ministry of Health, Labour and Welfare announced the number of infected people nationwide, but how were they announcing it? They listened to the announcements from each prefecture and added them up with a calculator. Moreover, because the announcement times for each prefecture were different, they hired about 30 part-timers in the basement of the Ministry of Health, Labour and Welfare to do it with calculators—it was an incredibly analog world, and I think that was really bad.

Furthermore, one thing I was asked by people on the ground and was at a loss to answer was: what if there is only one ECMO (extracorporeal membrane oxygenation) machine and three people need it? Who do you put it on? That is not something a doctor on the spot should decide alone; there must be a discussion about who to prioritize. However, such discussions have been considered taboo until now and have been left to the front lines. I think that discussion really should have been done during peacetime.

Discussions such as to what extent individual freedoms can be restricted for the benefit of the entire nation have not been held at all until now, have they?

There were also good things. Dr. Nakamura and I were public members of the Chuikyo (Central Social Insurance Medical Council), which discusses medical fees, just when COVID-19 started. Chuikyo meetings moved online, and instead of providing gallery seats, they started live-streaming every meeting on YouTube.

Until then, there were times when long lines formed in front of the Ministry of Health, Labour and Welfare's meeting rooms to observe, but now anyone interested can listen to the discussions by connecting to YouTube. I have actually heard from medical professionals in the regions and patient groups that they are observing online. Thanks to the forced trial due to COVID-19, information disclosure has progressed, and the number of people interested in healthcare has increased, which I think has resulted in benefits in some aspects.

Another thing that progressed was online medical care. Before COVID-19, online medical care had various restrictions, such as the diseases that could be treated being very limited and initial visits not being allowed. As a temporary and exceptional response due to the spread of COVID-19, it became permitted from the initial visit, and since the medical fee revision last fiscal year, it has become a formal system where online medical care can be performed permanently from the initial visit. This was something that the Council for Promotion of Regulatory Reform and others had been saying all along, but COVID-19 became a tailwind, and it progressed rapidly through a top-down agreement between ministers.

In addition to that, several peacetime customs and inefficiencies were improved by COVID-19. Multi-disciplinary conferences at the time of admission and discharge were in principle face-to-face in the past, but now medical fees are applied even if they are online. When a patient's place of treatment moves from the hospital to the home, it is important that multi-disciplinary professionals belonging to various organizations can easily participate in conferences, and I think this will lead to improved information sharing. Other areas, such as fees for online medication guidance by pharmacists, are also expanding the use of online tools in daily medical care.

Many Japanese people have the image that Taiwan and South Korea are more advanced in digitalization than Japan. On the other hand, when I hear reports of discussions with researchers from South Korea and Taiwan, they highly evaluated Japan's efforts, such as the low mortality rate.

Behind that, I think the hard work in the regions was significant. While there was talk of differences depending on the region, I think regions that had been able to communicate not only among medical professionals such as doctors and nurses but also with various levels of local administration since before the pandemic were able to respond to the COVID-19 crisis in their own way.

Until now, Japan has promoted initiatives such as community-based integrated care, where people think for themselves within the region and work on new things across professions and positions. Isn't it possible that those efforts enhanced the ability to respond to the COVID-19 pandemic?

Certainly, challenges emerged regarding centrally-led digital tools like COCOA, but the hard work in the regions and other points that should be evaluated cannot be overlooked.

It's true that it has become common knowledge that the governor handles the COVID-19 situation locally through press conferences and the like. The consensus that it is not the Minister of Health, Labour and Welfare has become part of daily life.

In other words, the correspondence that if the prefectural governor is not taking proper measures, the medical care in that region will be in chaos, became common sense during the pandemic. Therefore, naturally, prefectural governors respond with a sense of tension based on that, so there was also an aspect where the regions worked even harder. Of course, the fact that those supporting local community medicine worked hard was the primary factor.

So, how should we proceed in the future based on this experience with COVID-19? I would like to ask about what points should be structurally devised and what the next measures should be.

Regarding the talk about beds that Mr. Doi mentioned earlier, I don't think the reason medical care in Japan became strained was that the number of beds themselves was insufficient. In other words, while there are many beds, the number of doctors and nurses per bed is very small, and they were operating at full capacity normally. When a certain number or more of COVID-19 patients, who require a lot of care, arrive there, it quickly becomes strained.

Thinking about it that way, the number of beds is high as it is, so we must practice a bit more selection and concentration. However, if it becomes as low as in Italy or Spain, we would end up having to treat patients on stretchers in hallways, exactly as happened during COVID-19. I think Germany serves as a benchmark. In terms of the number of beds, it is somewhere between Japan and Italy/Spain. Moreover, in Germany's case, the number of ICU beds, that is, beds for treating people with severe conditions, is high.

The mortality rate for COVID-19 in Europe is low in Germany. Unlike Japan, Europe cannot block entry at the border at all, so the number of cases entering is probably the same for each country, but differences emerged in the subsequent hospital response and medical policy response. Regarding beds, I think a system improvement is necessary to practice selection and concentration with Germany as a target.

I completely agree with what Mr. Suzuki said from a financial perspective as well, and I believe we should move in that direction.

Hospitals still have a strong desire to have acute care beds themselves no matter what. Conversely, from a financial perspective, the recovery phase, where we want to expect more of a role, is not established everywhere across the country. Do you have any prospects for the future regarding that functional differentiation or division of roles?

I think hospitals are learning little by little. The number of acute care patients is decreasing. The bed occupancy rate, which used to be over 90%, has gradually dropped and became about 70% during COVID-19. With this, beds cannot be maintained. Another factor is the work-style reform for doctors. If overtime hours are strictly controlled, we cannot simply increase acute care and have doctors work more and more.

Furthermore, as the Ministry of Finance often says, if the way of payment is based on a ratio such as this many nurses per patient, hospital management will inevitably lean toward higher and higher costs. Instead, if payments are made by focusing on, for example, what kind of care was given to the patient and how they improved as a result, I think it will consolidate into the number of truly necessary acute care beds, so I think we also need to devise ways of payment.

This is a very important issue, and considering the changes in population structure, I also agree with reducing acute care and increasing recovery phase beds. However, since Japan has a high proportion of private hospitals, the structure is not such that private hospitals can reform immediately just because the government says so.

I think it is a difficult problem as to what kind of approach should be taken to limit regional beds, but do you have any ideas?

At the risk of being misunderstood, I believe two things are very important. Currently, bed regulations based on the Medical Care Act are being carried out. While this is certainly right in terms of not increasing beds, conversely, once you have a bed in a certain region, no matter how poor the quality, that bed becomes yours forever.

If that happens, innovation won't be born and management won't improve, so, while it's not exactly like the first and second divisions of soccer, if a hospital cannot meet the level of care it can provide, it should be removed even if it is in the regional medical plan's beds. Also, for those doing some acute care within the recovery phase, I think a system like allowing them to advance from there, or a replacement system, is necessary.

The other thing, which the Ministry of Finance is also trying to do now, is a kind of production adjustment policy. Owners of small and medium-sized hospitals have no successors. There are many cases where the son is a salaried doctor and says he doesn't want to run the hospital. We buy up those beds that can no longer be passed on. This costs money now, but considering the future, I think it is a rational policy with a set time limit.

That is exactly what is being discussed in various places as the Regional Medical Care Vision, but it seems the discussions are not progressing well.

We should probably create several undeniable absolute indices. Unless we make it so that if they can't meet those, it's no good, the administration won't be able to push through because they don't want to be hated.

But the Health Policy Bureau of the Ministry of Health, Labour and Welfare decided to have them report the number of surgeries and so on in the bed function report, relatively so as not to cause friction among those involved. What do you think of that?

It's very good.

It is indirect, but I also think it is quite effective. Although they hang a sign saying 'acute phase,' the numbers immediately reveal whether they are truly fulfilling that acute phase role.

Dr. Haruta, what kind of measures do you feel will be necessary in the future?

From my standpoint as a primary care physician, I believe the fact that the definition of a 'family doctor' remained unclear was a major problem. While the 19th specialty, 'General Medicine Specialist,' was established, their numbers are still small, and only about 5% to 6% of students choose it.

However, each specialized department does not want to reduce the number of doctors in their own field. While I believe general practitioners are indispensable when considering society as a whole, it is difficult for the general public and even healthcare professionals to understand that necessity. Therefore, it becomes important to clearly state the role of a family doctor and establish a certification system for them.

In addition, health consultations and preventive efforts are important. Personally, I believe that medical institutions where people can seek advice when something happens should be included in the role of a family doctor. However, at present, health consultations and prevention are not included in medical fees. Therefore, I think it is important to include health consultations and prevention in medical fees and to establish a common understanding of 'what a family doctor is' from both the perspective of the citizens and at the government level.

Particularly this time, there were many elderly people who could become socially vulnerable, and caregivers looking after them, who suffered sad experiences in the closed space of their homes because it was difficult to be admitted to a hospital. Among the patients I see, there was someone who tested positive for COVID-19 and ultimately could not be transported anywhere, passing away at home while still attached to an oxygen cylinder. That happened in Tokyo.

I would like people to know more about the reality of such things happening, and I think it would be good to have a forum where we can discuss what a family doctor is and what appropriate medical care as a whole looks like, without vested interests.

The pace may be slow, but I evaluate the fact that the institutional development of family doctor functions is progressing under the Kishida Cabinet as a first step that has never existed before. However, I also think that patients lack literacy.

Common sense regarding how to seek medical care and how to use nursing care services has not been established on the part of the public and patients; they are simply and unilaterally saying they want medical and nursing care to satisfy their needs. It might not be the best way to put it, but unless we also conduct something like enlightenment, patients will not be able to break out of the habit of choosing doctors arbitrarily by specialty.

I also think it is strange to have only one doctor as a family doctor; I believe it is fine to have a 'family doctor function' where multiple doctors at local medical institutions look after a single patient.

Coincidentally, Japan's medical system has an independent system for those aged 75 and over called the Medical Care System for the Advanced Elderly, so if we wanted to, I think it would be possible to create a separate medical fee system just for those 75 and over. Since the need for a family doctor is higher among the elderly than the young, I am dreaming that we could revise the medical fees after organizing the functions there.

As Dr. Haruta mentioned earlier, I also agree with focusing on prevention. However, the effects of prevention are difficult to visualize. Since the onset of a disease is related to various factors such as social background, I think it is quite difficult to provide incentives for prevention in the form of medical fees.

In this context, one of the new trends I am watching is the evaluation of Software as a Medical Device (SaMD) in medical settings. The first SaMD to be listed in Japan's public medical insurance was CureApp, a smoking cessation app developed by a venture company founded by Dr. Kota Satake, a Keio graduate. This was listed for medical fees after a paper was published providing evidence that using the app for guidance resulted in a higher smoking cessation effect than face-to-face guidance at a medical institution.

It used to be difficult for venture companies to enter such fields in Japan, but the Ministry of Health, Labour and Welfare organized a framework for the evaluation of SaMD in general, making the path to insurance listing easier to see. In the future, I believe combining apps and online services will become mainstream for blood pressure management, nutritional guidance, and general treatment of lifestyle-related diseases. Through this, medical care will become more efficient and of higher quality, centered on preventing severe cases, and eventually, we can expect to curb the growth of medical expenses.

Regarding public awareness, I believe the impact of COVID-19 was significant in that infection risks, treatment risks, lifestyle risks, and the perception of death—which were previously someone else's problem—changed and came to be perceived as personal matters close to oneself. Awareness of prevention and self-care also increased.

In policy formation, it is important for people from various positions to discuss and decide on resource allocation through deliberation. The actors participating in medical policy formation must diversify, and that is actually happening. Within that, it is important for the general public, not just patients, to take an interest in medical systems and policies as their own concern and participate in discussions. If I were to point out a challenge in that regard, I think there are points for improvement in how the national and local governments release information regarding policies.

For example, the malfunctions and risks that have come to light in promoting the use of My Number Cards as health insurance cards are currently being discussed, but for what purpose is the My Number Card being promoted in the first place? Because they try to promote it by dangling immediate benefits like points without explaining well to the public what the goal is, I think there is a sense of distrust among the citizens.

In order for the entire nation to enjoy the great benefits of digitalization, there are things like creating new value by linking information or improving the quality of services and consequently lowering costs by utilizing big data, but those true benefits have not been properly communicated.

I want the mass media to grasp and convey the essential issues firmly, and I want every citizen to think carefully and engage in discussion. And if they finally decide to accept it after being convinced, I want them to work together as one once the decision is made. I hope to see that kind of change.

That is exactly as you say. I am sure there is a background of wanting to link the practical needs of the government offices to the use of My Number Cards. However, if bureaucrats are told to handle the practical side responsibly, they oppose it because they say criticism will arise. If politics protects them properly, they can do it, but if not, there is an aspect where they feel it's fine for now because things are running on paper anyway.

Regarding taxes and such, the public thinks the tax office holds all information in one hand, but in fact, they do not hold any information that is unnecessary for the tax office. Therefore, while they know who is earning a lot of income, they only have rough figures for the number of people who are not earning income.

When there was talk of a flat 100,000 yen benefit during the COVID-19 pandemic, the idea of distributing it more intensively to low-income people could not be done because the information was incomplete. The government side can carry out daily operations even without information, so the tax office says they don't need information obtained from My Number, and the public increasingly loses track of what the My Number Card is for.

Therefore, it is necessary for motivated politicians to come forward and take responsibility. It is the same with the My Number insurance card; it will finally move forward when politicians emerge who say they will take responsibility if they plan it properly and the government officials work accordingly.

It really is compartmentalized, isn't it?

It is truly compartmentalized.

Furthermore, I think we will face increasingly troublesome issues regarding how to make medical insurance finance sustainable. In particular, as the number of people in the working generation who have supported it until now decreases, insurance premium income and tax income will decrease, leading to talk of asking the elderly to bear a certain amount of the burden. However, this could also fuel future anxiety, as people wonder if they will have to pay not only out-of-pocket medical expenses but also insurance premiums when they become elderly in the future, so it is a matter of how to balance that well.

Optimistically speaking, if the salaries of the working generation keep rising and per capita income increases even if the population decreases, those people will pay the insurance premiums—that is the rosy scenario for medical insurance finance, but it is not that easily achieved. In that case, we will have to adjust the balance between burdens and benefits skillfully.

To add regarding the future, there are 2 million people in Japan who hold nursing qualifications. However, 700,000 of them are not actually working as nurses. During COVID-19, even if hospital wards were difficult, I think those people could have worked sufficiently in roles such as assisting with epidemiological surveys at public health centers or administering vaccines.

It's not that all of those people don't want to work; many find it difficult to work every day including night shifts, but would be fine working for limited hours. So I think it is important to have a system where they can participate in training, receive a certain level of knowledge regularly, and be able to come and help in times of emergency.

Doctors, pharmacists, and dentists are always surveyed by the government regarding where and how much they are working through the 'Survey of Physicians, Dentists and Pharmacists.' But that is not the case for nurses, so it is not known where the people with nursing qualifications are or how they can be utilized. The need for healthcare professionals increases significantly during a pandemic, so I think it is a big deal to organize people who can help even a little at such times.

Regarding 'thinking of it as one's own concern,' there was something I found very difficult. Many infection guidelines were issued during COVID-19, but I was asked by several people from the general public, 'Ultimately, what should I do?' This means there were many people who did not understand what was dangerous.

People who cannot access the internet cannot reach the information. There is a huge gap in literacy, and since the regional hospital where I practice has many elderly people, there are differences in understanding even when they look at the small text on a computer or smartphone. I think there was a way of disseminating information that failed to protect the people we wanted to protect.

So they ask, 'Doctor, what should I do?' If I tell them specifically 'You should do this,' they will do it. Regarding vaccines, even though it's said they should get them, elderly people get confused when there are also anti-vaccine opinions. At times like this, I felt it was very important to have a trusted doctor right in front of them who says, 'It's okay to get it.'

They want the doctor to give them that final push.

Yes. If a doctor who knows them says so, they feel it's okay to get the shot.

That might be the role of a family doctor.

That's right. Schools also made students wear masks and held sports days in the summer. No one would say it's okay to take them off. When a doctor in charge of infectious disease control from the local medical association said, 'It's safe to take off your masks for the sports day if you do it this way,' they became able to do various things.

This time, it became clear once again that doctors had been shut away from society. I think that unless we convey correct information to local people in a slightly more understandable way, rather than just online information, they won't act and won't feel it as their own concern.

It's about communicating in a way that suits the recipient. That is the key to bringing about behavioral change, isn't it?

Providing many opportunities to improve communication skills is exactly one of the roles that a university should fulfill. If you have any opinions on what society should prepare regarding the relationship between medical care and society, including education at universities, please let us know.

Both the medical system and the nursing care system have been changing gradually over time. Former common sense can be overturned by new evidence. If one only receives education until graduation, from then on, unless they collect information very properly on their own, they end up not knowing.

But that is not acceptable, especially regarding medical and nursing care. For example, 'Support Needed' in the certification of needed long-term care is support for independence and does not mean that one's entire life will be supported. I want this to become common sense for the public, but the current situation is not like that.

Therefore, before becoming elderly, it is necessary for all citizens to learn the common sense of the medical and nursing care systems once. As nursing care services become increasingly sophisticated and the era of receiving detailed, complex services arrives, I would like the recipients to have the mindset of how to receive them skillfully.

As you said, for example, in the School of Medicine, students generally graduate at age 24, but by the time they reach their 40s or 50s, I think the knowledge they learned by age 24 will be mostly unusable.

Therefore, the mission of those of us involved in medical education is not to provide knowledge, but to teach the methodology of how to synthesize various analytical results available on the spot and apply them in practice. I think it is necessary to learn during university a way of doing things that can be accumulated throughout one's life while performing actual clinical practice—how to combine, analyze, and utilize it.

I believe this is the same not only for the School of Medicine but also for other medical-related departments. I feel this with self-reflection as someone involved in university education.

Looking ahead to the future 20 years from now, the quality and ability of 'Integration' was newly added in this revision of the Model Core Curriculum for Medical Education.

This includes looking at and approaching people from a holistic perspective, a life perspective, a regional perspective, and a social perspective. This is not something that can be done just by gaining knowledge; it is the ability to keep thinking about how people and issues can be perceived when viewed from those perspectives. For example, in EBM (Evidence-Based Medicine), one examines the certainty of evidence and whether that knowledge can be applied to the person in front of them, critically examining that process. Such a process is very important.

However, current students have been doing things since middle and high school like memorizing large amounts of knowledge and efficiently outputting it for questions that have a single answer, so people with fast information processing abilities win at university entrance exams. Now, even in the School of Medicine, there are an increasing number of students from combined junior and senior high schools who have received such training.

The current exam war is about how quickly one can reach a known answer. But the questions in our lives are not like that. It's about how to find one's own answer in a situation where the answer is not known at all. It would be good if that could be formed skillfully in various ways during university.

Faculty members in the School of Medicine who provide education also lack knowledge of education or don't quite know how to teach. The faculty themselves must learn about questions that have no answers as lifelong education, but the reality is that they are busy with daily clinical practice and research.

Now, it has become mandatory for visiting nursing stations and care stations to formulate BCPs (Business Continuity Plans).

Decision-making when something like a major disaster occurs often has no single correct answer; rather, there are many situations where people on the ground must make ultimate choices among options that are incompatible with everyday values. In such cases, rather than teaching knowledge or creating manuals, I think nothing is more useful than having staff discuss on a daily basis what kind of value judgment criteria they will use to determine priorities in an emergency.

On the premise that the unexpected will happen, the way education is conducted on the ground must also change in a direction that does not teach correct answers. I hope that university education can also be the kind of education that builds the power to see the essence of a problem for oneself and come up with one's own answer.

In order to think for oneself what should be done and put it into action, it is important to learn repeatedly and undergo training. Also, even after graduating from university, I think education that looks at things from a different perspective, such as recurrent education, is important.

For example, it is valuable for those who have studied medical and nursing care to learn how to increase the motivation of everyone engaged in medical and nursing care settings. In particular, maintaining and improving motivation during the COVID-19 pandemic was very important.

Furthermore, as digitalization and management perspectives become important in medical settings, providing opportunities for medical professionals to learn about digitalization or management is also an important role for universities to play. Graduate schools, in particular, can provide opportunities to learn in fields different from those studied at the undergraduate level.

That's exactly right. However, for such cross-disciplinary issues, undergraduate education remains compartmentalized. Keio also conducts joint education for the three departments of medicine, nursing, and pharmacy, but it ends as an event-type education where they gather for one day to have a discussion. We are in an era where we must think about how to solve social issues. For example, in the sense of thinking about regional issues from various perspectives such as economy, life, culture, history, and topography, not just medical care, humanities teachers might also be necessary.

I think Keio, as a comprehensive university, is a place where it is easy to implement such cross-disciplinary education for social issues. It would also be a social contribution, students could learn from each other, and I think there are things that we as faculty could gain from it as well.

Hearing the thoughts of teachers from different positions on a single theme is very educational for the faculty side as well. Keio might be the only place that can do this at a high level. In that sense, I felt that the role Keio can play is significant. Thank you very much for today.