Family Medicine as a Solution-oriented Medical Practice: A Letter from Kansai, Japan

The Kansai region in Western Japan includes Osaka, the central city of Western Japan; Kyoto, a famous ancient capital; Nara, an ancient capital older than Kyoto; and Kobe, one of the first international ports in Japan. Tokyo has a history of approximately 400 years, whereas Kansai has a history of approximately 1,800 years. Each city in Kansai has its own traditional and unique culture, where new and innovative ideas are often conceived. In Kansai, some family physicians are attempting to establish Japanese family medicine as a specialty in their medical systems and context.

Recently, a new era has begun in general practice in Japan. The Japan Primary Care Association, established in 2010 by the merger of the Japanese Academy of Primary Care Physicians, the Japanese Academy of Family Medicine, and the Japanese Society of General Medicine, has become the largest academic association of general practitioners in Japan. Members include practicing family physicians (primary care physicians), hospital-based general practitioners, and university-based general practitioners.

Hospital-based general practitioners in Japan are interested in diagnosis-oriented medical practice. They focus on common symptoms in uncommon diseases and uncommon symptoms in common diseases. Some family physicians and university-based general practitioners in Japan have more advanced medical education; however, most of them teach only basic clinical skills and diagnosis-oriented medical practices rather than specialization in family medicine.

Some family physicians who have studied in North America or Europe disconnect themselves from the Japanese style of practicing medicine. They seem to regard their way as the only correct way to practice medicine. According to them, their specialty is a combination of internal medicine, minor surgery, orthopedics, pediatrics, obstetrics, and gynecology, thus providing a patchwork of medical care. But a patchwork of medical care is only one side of family medicine, not a specialty. However some family physicians who have studied in North America or Europe insist that Japanese family physicians who have not studied abroad are not family physicians. Therefore, satisfactory answers as to what kind of specialty they should have can be difficult to find and hence, they often fall into identity crises. Unfortunately, some leave primary care and family medicine and move on to become alternative specialists. Due to such conditions, very few Japanese family physicians have pursued further education to become specialists of family medicine.

Family medicine can be considered a specialty in itself. It can be defined as care that is accessible, comprehensive, coordinated, continuous, and accountable (ACCCA). Interestingly, the practices of some Japanese specialists who establish private clinics also provide this sort of care. Thus, ACCCA is not exclusively confined to family medicine in Japan.

Then, how can we characterize family medicine, especially in Japan? Japanese patients tend to come to physicians in the early stages of their diseases because they are covered under a national health insurance system. Many patients are cured before severe symptoms develop. If the diagnosis is difficult, family physicians can consult hospital-based general practitioners. If patients may need palliative care, or they may have dementia, unexplained medical symptoms, and several other conditions, their diagnoses are easy, but solution is not. One of the roles of family physicians is to lead solutions by providing coordinated, multi-professional collaborative care to these patients. Some hospital- and university-based general practitioners are not interested in the care of such patients.

Thus, family physicians are more interested in providing solutions through collaboration than in diagnosing. But solution does not mean expedient treatment, for example, administering iron to an anemic patient regardless of the cause or Scopolamine for abdominal pain regardless of the cause. They are not what family medicine is about. Family physicians should treat such cases with varied approaches as well as perseverance to achieve a definite solution. These medical practice based on solutions can be called "solution-oriented medical practice," which is one of the essences of family medicine. Recognition of the solution-oriented approach is still uncommon. Appraisal of various medical practices and a commonly accepted definition of solution-oriented medical practice are necessary; this process should lead to a greater awareness of the true essence of family medicine in Japan, and help for many family physicians who suffer from an identity crisis.