Rural island medicine in Minamidaito island, Okinawa, Southwest of Japan

By Ryuichi Ota

I am a young Japanese family physician working in rural areas of Japan. Training for Japanese family physicians has officially started recently, so there is a variety of training systems, though sometimes not always so systematic. I became a physician in Osaka and moved to Okinawa, southernmost part of Japan to become a rural island physician. I have experienced many fruitful things on my island to become a real rural physician. It can be said that rural islands and the citizens educate the physicians. This time, I want to introduce my experience in Minamidatio island, one of the rural islands, as a young rural physician.

I have worked as a young rural physician on a rural Japanese island. It is located in the most southeastern part of Japan. Its name is Minamidaito island, and it is located in Okinawa prefecture. It is about 400 km away from the mainland of Okinawa prefecture. By ship, it may take 14 hours from the mainland. Even if you use an airplane, it may take 1.5 hours. On this island, the population is about 1,400, and most of them work as sugarcane farmers. There is only one clinic without beds appropriated for admission. There is only one doctor, nurse and medical clerk. I went to this distant rural island after finishing my 3-year basic medical residency program, and I have been there for three years now. Is this a rare case in the world? This working style may be controversial in Japan. However, the experience as a young rural physician may affect their future as a physician in an effective way.

The responsibility of a solo physician in a rural island

First, the feeling of responsibility as a physician may increase. For example, on a rural island like my case, a physician has to take care of various kinds of illnesses. All of the patients there have to go to a clinic to get specific care, even if they do not like to go there. The rural physician cannot avoid studying various kinds of medical issues. Emergency cases are especially stressful for rural physicians. At rural island clinics, there are not enough instruments to treat the patients for a long time. The rural island physicians have to transfer their emergent patients to general hospitals on the mainland of Okinawa if they need long admissions or ICU care. However, to transfer the patients, doctor helicopters are needed. It takes 3 hours to reach the distant islands like my island (Ohta & Shimabukuro, 2017b). The rural island physicians must care critical patients until the arrival of the helicopters. The worse thing is, the duration of emergency may depend on the weather. The emergency case in summer was challenging for me. In one day in summer, one patient came to my clinic with the chief complaint of shortness of breath. He voluntarily stopped regular visits to my clinic one year ago. His past medical history was chronic obstructive lung disease. His symptoms had started a few days ago, which gradually exacerbated to the point where he came to the clinic. The vital signs were the blood pressure of 84/40 mmHg, heart rate of 132 beats/min, respiratory rate of 45 breaths/min, oxygen saturation of 79% in ambient air, the body temperature of 37.6 and Glasgow coma scale of E3V5M6 (total 14/15). I listened to his lung sounds, bilateral lung sounds, I diagnosed him with severe pneumonia causing septic shock. Soon, I intubated him and prepared for transportation. However, it did not come at once. This season, Okinawa is attacked by a lot of typhoons, and this year was not rare. This time, one big typhoon was approaching my island, and this prohibited doctor’s helicopter from coming to my island. To make matters worse, the typhoon approached the mainland of Okinawa after passing through my island. As a result, I had to observe this patient with only three members and restricted medical instruments (Ohta & Shimabukuro, 2017b). Without a ventilator, a nurse, a medical trainee, and I performed hourly vital sign measurement and did manual ventilation. Fortunately, his condition was stable with oxygen, antibiotic, and vasopressor. 27 hours after his arrival, he was transferred to a general hospital in mainland of Okinawa.

Diagnostic skills of rural physicians

Also, their diagnostic skills may be improved upon. It is only one physician, and he or she has to diagnose patients with vague symptoms or with certain diseases which they have not experienced yet. They may feel particular pressure and study hard. As they can get a lot of medical information by using the internet and communicate with their senior physicians via a social network, they may be able to approach their patients with various sources of help. For example, when I encountered patients with rheumatoid arthritis following ciguatera poisoning (Ohta, Shimabukuro, & Kinjo, 2017) or with vague bilateral shoulder pain leading to the diagnosis of Parsonage-Turner syndrome (Ohta & Shimabukuro, 2017a), I could diagnose them with literature reviews and my colleagues’ help. Through this process, rural physicians may become competent in diagnosis and inter-physician communication.

Challenge to community-based medical education

Second, a rural island may be a good practical learning situation for medical students and medical residents. They can learn specific things in various medical situations. Through the learning in rural islands, they may learn multiple important issues as physicians. There are many kinds of research to clarify the learning topics in rural areas, especially about community-based medical education (CBME). As learning contents have been shown to depend on the situation, we did one qualitative study to inquire about the learning contents of medical residents in Minamidaito Island. Through this research, we were able to identify four categories: a strong connection among the Islanders, the necessary abilities for rural physicians, islander-centered care, and the differences between rural and hospital medicine(Ohta & Son, 2018). In contrast to hospital medicine, various kinds of learning occurred in deep relationships with the Islanders. Furthermore, we clarified that the learning contents of medical students on this island, as a result, were alike. Rural physicians can learn not only medical issues but also CBME. They may acquire the possibility to become medical educators.

First trial of community-oriented primary care

Third, community-oriented primary care (COPC) should be mandatory in rural islands. Especially, in Minamidaito Island, there is only one physician and a nurse. They are the only medical resources. They have to collaborate with the members of the community to improve community health conditions. There are various stakeholders in the community. Empowering them may drive COPC. The stakeholders may play the central role in community health improvement. For example, public health nurses specialize in community health. They can analyze their communities and find various approaches to improve health conditions there. Their collaboration with medical staff in clinics may improve quality of life. There are two public health nurses on Minamidaito Island, for both pediatrics and older people. The public health nurse for pediatrics is interested in pediatric wheezing because of sugarcane harvesting. Through my collaboration with her, we were able to do a prospective cohort study. As a result, it was discovered that there was some cause and effect relationship between pediatric asthma and sugarcane harvesting (Ohta, Mukoyama, Fukuzawa, & Moriwaki, 2017). Additionally, we make up the specific approaches to diabetic patients on a rural island by using their feelings comparatively. Also, by collaborating with the public health nurses for older people, we were able to increase the opportunities for older people to have a dialogue with each other and share information about their conditions. Through COPC, rural physicians are able to learn the skills for how to approach communities such as leadership and empowerment, and how to analyze and make progress the community condition such as research skills.

The ecology of medical care in a rural island

Besides, an ecology of medical care in clinics is essential for understanding islands’ medical conditions. It is important to know what kinds of symptoms and diseases are common when medical staff inquire into information on epidemiology and do various interventions in communities. Also, the comparison of this data over several years may be useful for knowing the change in the prevalence of medical conditions there. For example, we collected the patients’ data based on International Classification of Primary Care-2 (ICPC-2) between 1990 and 2015(Ryuichi Ohta & Makoto Kaneko, 2017). As a result, in addition to the common cold, the frequency of asthma attack and other chronic diseases increased. This fact might lead to the consideration of the effects of aging population and the deteriorating air pollution. Rural physicians can express their opinions based on precise data and motivate their communities to improve their health conditions.

How to control negative emotion as only one physician in a rural island

At last, rural physicians need effective emotion control. On rural islands of Okinawa, every physician is only one medical staff that can perform medical treatment. They are special there, so rural citizens look at them as a physician wherever and whenever the citizens see the physicians. Additionally, they may feel the negative emotion in interprofessional collaboration. These conditions may lead to the physicians’ stress and negative emotions. Based on our research, rural physicians feel negative emotions in differences in recognition between rural physicians and patients, invasion of professionalism, suppression by one’s role as a rural physician, discordance with multiple occupations, and relationships with unfamiliar hospital physicians(R. Ohta & M. Kaneko, 2017). Also, to relieve negative emotions, time flow, refection, acceptance of islanders’ characteristics, and growth through their role were suggested(R. Ohta & M. Kaneko, 2017). Through rural experiences, physicians may improve their ability to control their negative emotions by recognizing the existence of controlling methods.

Working at rural islands, although there are lots of difficulties for your generation, can give various fruitful experiences for the future. Not related to their foreground carrier, these experiences can make them more balanced physicians and happier than ever.

References

Ohta, R., & Kaneko, M. (2017). Effects of practicing in remote Japanese islands on physicians' control of negative emotions: A qualitative study. J Rural Med, 12(2), 91-97. doi:10.2185/jrm.2934

Ohta, R., & Shimabukuro, A. (2017a). Parsonage-Turner syndrome in a patient with bilateral shoulder pain: A case report. J Rural Med, 12(2), 135-138. doi:10.2185/jrm.2933

Ohta, R., & Shimabukuro, A. (2017b). Rural physicians' scope of practice on remote islands: A case report of severe pneumonia that required overnight artificial airway management. J Rural Med, 12(1), 53-55. doi:10.2185/jrm.2925

Ohta, R., Shimabukuro, A., & Kinjo, M. (2017). Rheumatoid arthritis following ciguatera poisoning: A case report. J Rural Med, 12(1), 50-52. doi:10.2185/jrm.2921

Ohta, Ryuichi, & Kaneko, Makoto. (2017). Health Problems in a Rural Island of Okinawa: Changes Over 25 Years. An Official Journal of the Japan Primary Care Association, 40(3), 143-149. doi:10.14442/generalist.40.143

Ohta, Ryuichi, Mukoyama, Chikako, Fukuzawa, Yasunori, & Moriwaki, Yoshihiro. (2017). Relationship between Pediatric Wheezing Attack Frequency and Sugarcane Harvest Work: Prospective Cohort Study. An Official Journal of the Japan Primary Care Association, 40(1), 21-26. doi:10.14442/generalist.40.21

Ohta, Ryuichi, & Son, Daisuke. (2018). What do medical residents learn on a rural Japanese island? Journal of Rural Medicine, 13(1), 11-17. doi:10.2185/jrm.2950

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Ryuichi Ota is  a Japanese Family Doctor based in a rural remote island. 

Curatorship: Mayara Floss