[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 crisis." During that time, there were various points raised and issues identified regarding the medical system and medical policy, and I believe there was much to be learned from them. Today, we have gathered experts from various fields to think about the future of medical policy and the medical system following the COVID-19 crisis.

First, I would like to ask about the challenges that have come to light and the points where Japan's medical approach was relatively good. Mr. Suzuki, could we start with you?

I retired as the Chief Medical Officer of the Ministry of Health, Labour and Welfare three years ago, 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. During that period, naturally, there were no vaccines or treatments. We didn't even understand the essence of the disease well, so it was extremely difficult. There are several things in particular that I saw as challenges at that time.

One is the "switching between peacetime and emergencies." In peacetime, Japan operates under decentralization, with each region providing solid medical care by utilizing its local characteristics. However, in an emergency, it is difficult to respond to a situation where the entire country must suddenly unite under a single command.

A specific issue I noticed 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 public health centers basically only dealt with a very limited range of infectious diseases, their functions had been steadily scaled back. 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.

With COVID-19, the structure was such that public health centers had to do everything—from case discovery and patient transport to identifying hospitals and testing—which led to a dire situation. I felt that during a pandemic, we must adopt a method where, for example, apps are used, or tasks are requested of other organizations or private institutions, allowing public health centers to 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, after all, imports. However, under a global pandemic, factories stop, or it becomes difficult to ship goods out of a country.

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

What about the points that should be commended in Japanese policy?

If you look at the number of deaths per population, Japan's is about one-fifth that of the US or the UK. 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 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's 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 "look-back" 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 Japan's public health policy did have a certain level of effectiveness.

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 kind of problems occurred in the regions.

Mr. Suzuki mentioned peacetime and emergencies, 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 getting ambulances accepted. Information on how many beds were available between hospitals was hardly shared at all, and it is presumed that everyone thought, "Even if our hospital doesn't take them, someone else will."

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. In the early stages, there was a fear of reputational damage if that was made public, so there were circumstances where it could not be disclosed.

On the other hand, in some regions, information sharing was going well. There were doctors at regional core hospitals who thoroughly investigated what was happening at hotels that served as recovery sites for mild cases and at public health centers that served as information hubs. As a result, they clarified that the information sharing and command structures 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 being present. This is one example where differences in initiatives across facilities resulted in differences in regional patient acceptance.

Furthermore, as the number of COVID-19 cases increased, staff—primarily from 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 an instance where an internal medicine physician asked a surgery physician to provide certain information to the public health center, only to be told, "Is that my job?" This was a conflict caused by the "siloed" nature of internal medicine and surgery, where they couldn't see each other's tasks. While not seeing each other's tasks was not a problem in peacetime, it became an issue in an emergency when the imbalance of tasks became prominent and everyone needed to cooperate.

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

Also, 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 from the outside as advisors. However, if only medical restrictions are imposed, daily life becomes impossible. With that understanding, we had to balance life and medical care by requesting overall movement restrictions, such as designating the entire facility or an entire floor as a red zone. The necessity of solving problems in accordance with the medical or nursing care setting was highlighted.

Are there any characteristics that distinguish regions that did 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—know each other, 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 might be seeing patients from a much wider area. In that case, 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 administration and the leaders.

Therefore, I have the sense that cities of roughly 300,000 to just under 1 million were the ones that did 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. When bureaucrats from central ministries try to say something to local governments, they are told not to interfere, as it goes against the spirit of decentralization.

Even when COVID-19 started, even though things might have gone well if clear instructions were issued from the center because it was an emergency, the local governments insisted on doing things independently.

But then, when it comes to 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, there was the issue of whether the designated city or the prefecture would announce the number of infected people. Looking at the news, people tend to think the prefecture handles and announces everything, but that's not actually the case; in some prefectures, designated cities make their own independent announcements. There is a sense of rivalry.

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 and have a strong influence, but if they fall out with the prefecture, things that should work stop working.

Moreover, many designated cities have core medical institutions for tertiary medical zones (areas that handle specialized medical care requiring advanced technology). If that city doesn't cooperate, it becomes problematic, yet there were times when governors were slow to act. There are cases that become unfortunate for residents when cooperation does not happen even where it should.

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; the weaknesses of Japanese healthcare, which had been pointed out since before COVID-19 as needing reform, have become clear.

Regarding hospitalization, the entire nation 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 a doctor was not their family doctor when they thought they were, or conversely, a doctor might think they were the family doctor while 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 medical fee system's over-reliance on fee-for-service. During the first state of emergency in 2020, people refrained from visiting doctors, and medical institutions saw a significant drop in income. This made it clear that medical fees relied on fee-for-service; if we had moved a bit more toward bundled payments, 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 drops sharply. We must seriously consider what kind of medical provision system to prepare for that, but in addition to the issues 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 matters that had been postponed, and things that people were pretending to do but actually weren't.

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

When the infections first started, doctors had to manually sign reports of infected cases and fax them to public health centers, where staff then had to manually input that data for tabulation. Public health center staff were unimaginably busy, handling the status 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 led to many human errors.

Moving slightly away from healthcare, a familiar example was the turmoil surrounding the application for the 100,000 yen Special Fixed-sum Cash Benefit. Although it was said that people could apply either online or by paper, when it actually started, a counterproductive situation occurred where online applications became a greater burden for both applicants and local governments.

The reason for this was that, in addition to the low My Number Card penetration rate of about 17% in mid-2020, even cardholders had to manually input information such as household members and bank account details on the Myna Portal. Input errors and duplicate applications at that time became problems later. In many municipalities, staff had to further verify this by visually comparing it with the Basic Resident Register, which truly only added burden to the front lines.

Behind all this, and I think this is a fundamental problem in Japan, were various factors such as the siloed nature of ministries, a lack of leadership and direction, an organizational culture that doesn't want to reform and prefers 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 COCOA app. COCOA was originally based on a program developed as open source by voluntary private 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 to 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 they should release a perfect product in three weeks. It seems this was a source of great confusion for the developers who had been working as volunteers.

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

Exactly. Of course, it would have been better if there had been prior preparation, 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 areas where we had not faced ultimate choices until now. For example, if COCOA could have used Bluetooth and had a mechanism where you could tell exactly which person was positive if they came within about 1.5 meters of you, I think it would have been used quite a bit. However, being told that someone is positive but not knowing who it is makes it difficult to use as a countermeasure.

If we could manage locations via 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. However, unless there is a prior discussion that certain freedoms can be restricted during an emergency, I don't think such things can be discussed during that incredibly 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 do you know how they announced 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 a ridiculously analog world, and I think that was really bad.

Furthermore, one thing I was asked by people on the ground that left me at a loss for an answer was: 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 held during peacetime.

Discussions such as to what extent individual freedoms can be restricted for the benefit of the public as a whole have never been held at all until now, have they?

There were also good things. Mr. Nakamura and I were public interest 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 a gallery for observers, they began 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 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 regional areas and patient groups that they are observing online. Thanks to the trial necessitated by 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 consultations. Before COVID-19, online consultations 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 to the spread of the new coronavirus, they became permitted from the initial visit, and since the medical fee revision last fiscal year, online consultations from the initial visit have become a permanent, official system. This was something that the Council for Promotion of Regulatory Reform and others had been saying all along, but COVID-19 provided a tailwind, and it progressed rapidly through a top-down agreement between ministers.

Besides that, there are several points where peacetime customs and inefficiencies were improved by COVID-19. Multi-disciplinary conferences at the time of admission and discharge used to be in-person in principle, but now medical fees are applied even for online conferences. It is important to make it easier for multi-disciplinary professionals belonging to various organizations to participate in conferences when a patient's place of treatment moves from the hospital to the home, and I think this will lead to improved information sharing. In other areas, the use of online tools in daily medical care is expanding, such as fees being applied for online medication guidance by pharmacists.

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 between regions, I think regions that had been communicating not only among medical professionals like doctors and nurses but also with various levels of local administration since before the COVID-19 crisis were able to respond to the crisis in their own way.

Until now, Japan has been promoting community-based integrated care, encouraging people within a region to think for themselves and work on new things across occupations and positions. Perhaps that effort also enhanced the ability to respond to the COVID-19 crisis.

Certainly, issues emerged regarding centrally-led digital tools like COCOA, but the hard work in the regions and other commendable points should not be overlooked.

It's true that it has become common knowledge that the governor responds to the COVID-19 situation in the local area through press conferences and the like, and that it is not the Minister of Health, Labour and Welfare.

In other words, the common sense during the COVID-19 crisis was that if the governor is not taking proper measures, medical care in that region will fall into chaos. Therefore, naturally, governors also responded with a sense of tension based on that, so there was likely an aspect where the regions worked even harder. Of course, the primary factor was the hard work of those supporting local community medicine.

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 itself was insufficient. In other words, while there are many beds, the number of doctors and nurses per bed is very low, and they were operating at full capacity normally. When a certain number 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—beds for treating people with severe conditions—is high.

In Europe, Germany has a low COVID-19 mortality rate. Unlike Japan, Europe cannot block entry at the border at all, so the number of cases entering was probably the same for each country, but differences emerged in the subsequent hospital response and medical policy response. Regarding beds, I think we need a system improvement that practices 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. Conversely, from a financial perspective, the recovery phase beds, where we want to expect more of a role, are not established everywhere across the country. Do you have any future prospects 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. At this rate, 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 payment method is based on a ratio of, for example, 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 truly necessary number of acute care beds, so I think we also need to devise ways to pay.

This is a very important issue, and considering the changes in population structure, I also agree with reducing acute care beds 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's a difficult question 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 righteous in terms of not increasing beds, conversely, once you have a bed in a certain region, that bed becomes yours forever, no matter how poor the quality.

Since that doesn't lead to innovation or management improvement, I think we need something like a promotion and relegation system—not unlike the first and second divisions of soccer—where if a hospital cannot meet the standard for providing care, it must leave the regional medical plan's beds. Also, for those doing some acute care within the recovery phase, we should allow them to expand from there.

Another thing, which the Ministry of Finance is also trying to do now, is a kind of production reduction 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 beds that can no longer be passed on. This costs money now, but considering the future, I think it's a rational policy with a set time limit.

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

We should probably create several undeniable, absolute indices. Unless we make it so that failing to meet those means it's no good, the administration will find it difficult 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 the number of surgeries and other data reported in the bed function reports, relatively so as not to cause friction with 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 display a sign saying 'acute phase,' the numbers immediately reveal whether they are truly fulfilling that role.

Mr. Haruta, what kind of measures do you feel are necessary for 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 providers to understand that necessity. Therefore, it becomes important to clearly state the role of a family doctor and certify them.

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

Particularly this time, many elderly people who could become socially vulnerable, and the caregivers looking after them, suffered sad experiences in the closed space of their homes because it was difficult to be admitted to hospitals. 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 tank. 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 is as a whole, without vested interests.

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

The public and patients have not established common sense regarding how to seek medical care or how to use nursing care services; they are simply unilaterally demanding that medical and nursing care meet their needs. It may not sound good, but unless we also engage in something like enlightenment, patients will not be able to break away from choosing doctors on their own for each specialized department.

I also think it is strange to have only one doctor as a family doctor, and I believe it is fine to have a family doctor function where multiple doctors see one patient at local medical institutions.

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

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

In this context, one of the things I am watching as a new trend is the evaluation of Software as a Medical Device (SaMD) in medical settings. The first SaMD to be included in Japan's public medical insurance was CureApp, a smoking cessation app developed by a venture company started by Dr. Kota Satake, a Keio graduate. This was included in the medical fee schedule after a paper was published providing evidence that using the app for guidance was more effective for smoking cessation 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 coverage easier to see. In the future, I think combining apps and online services will become mainstream for blood pressure management, nutritional guidance, and the treatment of lifestyle-related diseases in general. This is expected to make medical care more efficient and of higher quality, centered on preventing severe cases, and eventually suppress 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 has also increased.

In policy formation, it is important for people from various positions to discuss and decide on resource allocation after deliberate consultation. 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 getting points without explaining well to the public what the goal is, I think the public feels a sense of distrust.

In order for the entire public to enjoy the great benefits of digitalization, there are things like creating new value by linking information together, 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 properly grasp and convey the essential issues, 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 such a change.

It is exactly as you say. I'm 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 they are told to take responsibility for the practical side as bureaucrats, they oppose it because they say criticism will arise. If politics properly protects them, 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 don't have any information that is unnecessary for the tax office. So, while they know who is earning a lot of income, they only have rough numbers 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 also says they can carry out daily operations without the 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's the same with the My Number insurance card; it will finally move forward when politicians properly plan it and say they will take responsibility if the government officials work according to that plan.

It really is vertically segmented, isn't it?

It is truly vertically segmented.

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

Optimistically speaking, a rosy scenario for medical insurance finance would be that the salaries of the working generation keep rising and income per person increases even if the population decreases, so those people pay the insurance premiums, but it's not that easy to achieve. If that's the case, we will have to adjust the balance between burdens and benefits skillfully.

If I may add something about 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 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's important to have a system where they can participate in training, receive a certain level of knowledge regularly, and come to help in times of emergency.

Doctors, pharmacists, and dentists are always surveyed by the government through the 'Survey of Physicians, Dentists and Pharmacists' to see where and how much they are working. But that's not the case for nurses, so we don't know where the people with nursing qualifications are or how they can be utilized. Since the need for healthcare workers increases significantly during a pandemic, I think it's 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 hospitals I see have many elderly people, there are differences in understanding even when they look at the small text on computers or smartphones. I think there may have been 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 to do this, they will do it. Regarding the vaccine, even though they are told they should get it, elderly people hesitate when there are also anti-vaccine opinions. At times like this, I felt it was very important to have a trusted doctor in front of them who says, 'It's okay to get it.'

They want the doctor to give them that final push.

Yes. They feel that if a doctor who knows them says so, then it's okay to get it.

That might be the role of a family doctor.

That's right. Schools also made students wear masks all the time and held sports days in the summer. No one said it was 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 were able to do many things.

I realized once again this time that doctors had been closed off 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 ways of communicating suited to 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 develop 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 you only receive education until you graduate from school, you will end up not knowing anything beyond that unless you collect information very properly on your own.

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

Therefore, before becoming elderly, it is necessary for all citizens to learn the common sense of the medical and nursing care systems once. From now on, the era will come when nursing care services become increasingly sophisticated and even complex services will be provided meticulously, so I would like those receiving them to have the mindset of how to receive them skillfully.

As you mentioned, for example, students in the School of Medicine 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 should not be 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 be taught during university how to combine, analyze, and utilize things while doing actual clinical practice throughout one's life, in a way that can be accumulated until the end of one's life.

I think this applies not only to the School of Medicine but also to other medical-related departments. I say this with self-reflection as someone involved in university education, that we must do so.

Looking ahead to the future 20 years from now, a new quality/ability called 'Integration' was 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 critically examines the process of whether that knowledge can be applied to the person in front of them. 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, the number of students from integrated middle and high schools who have received such training is increasing even in the School of Medicine.

The current entrance exam war is about how quickly you can reach a known answer. But the questions in our lives are not like that. It's about how to find your own answer in a situation where you don't know the answer 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 really know how to teach. The faculty themselves must learn about questions without answers as lifelong education, but the reality is that they are busy with daily clinical practice and research.

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

Decision-making when something happens, such as a major disaster, often has no single correct answer; rather, there are many situations where people on the ground have to make ultimate choices among options that are incompatible with everyday values. Then, 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 such that it builds the strength to identify 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, in the form of 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 the medical and nursing care fields. In particular, maintaining and improving motivation during the COVID-19 pandemic was very important.

Also, 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 that universities fulfill. Graduate schools, in particular, can provide opportunities to learn in fields different from those studied at the undergraduate level.

That's exactly right. However, undergraduate education remains vertically segmented against such cross-disciplinary issues. Keio also implements joint education for the three schools 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, lifestyle, culture, history, and topography, not just medical care, humanities teachers might also be necessary.

I think Keio, being a comprehensive university, is a place where such cross-disciplinary education for social issues is easy to implement. 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 professors from different positions on a single theme is very educational for the faculty side as well. Perhaps only Keio can do this at a high level. In that sense, I felt that the role Keio can fulfill is large. Thank you very much for today.