Graham Easton: WONCA Asia Pacific Regional Conference 2005

Kyoto, Japan  – Thursday 27th/Friday 28th May (From Ealing to Kyoto)

What’s WONCA?

As I practice my in-flight DVT prevention exercises I reflect on how, for the last few days, I’ve been telling people excitedly that I’m going to Kyoto for a medical conference. It’s my first time in Japan. Initially they seem interested, even a little envious, but then ask what the conference is about. I tell them it’s a WONCA conference, and they dissolve into fits of giggles. I explain patiently that it’s not a meeting for chocolate factory owners, or even physicians with a special interest in auto-eroticism, but of the World Organisation of Family Doctors.

(All this makes me wonder whether WOOFdoc might have been a better choice of acronym, at least in the English speaking world. But back in 1972 when its eighteen member organisations were deciding on a name, they came up with the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. So we?re stuck with WONCA; at least it suggests that the worlds? GPs don?t take themselves too seriously).

What I?m doing there

Nowadays WONCA is made up of 97 member organisations in 79 countries, and over 200 000 GPs and family physicians from around the world. It?s a global forum for family doctors to exchange ideas and information, and to promote family practice. I?m a GP and I?ve been to a couple of European WONCAs before; this regional meeting is about general practice ?as a global standard?. I?ve been asked to run a workshop on how to get research published; but I?m not sure who the audience will be, whether they?ll speak any English, and whether I?ll be able to stretch it to last the required two and a half hours (or whether I should even try).

The long journey

The 11 hour flight from London Heathrow to Tokyo Narita airport is smooth, but then things get complicated. There?s a long bus ride to another airport and then an internal flight to Osaka; then another bus and a taxi to the hotel near the conference centre. Nearly 24 hours door to door. Normally all the airport waits and hanging around for buses would have left me flagging; but I?m distracted, soaking up every detail of the exciting new culture I?ve discovered.

First glimpses of Japan

The people seem efficient, polite and friendly with lots of the bowing I?d heard about. Enough people speak enough English for us to manage without any trouble. My first glimpses of Japan are of grand and shiny modern buildings jostling shabby housing blocks, and traditional Japanese architecture in the shadows of the golden arches of MacDonalds. Lots of Japanese cars, salary men and schoolchildren with their socks pulled up, internet cafes, noodle bars, and the occasional stunning Kimono. At this time of year the countryside is a vivid green, not unlike England, but the trees have unfamiliar silhouettes and there are some waterlogged fields growing crops that I assume are rice. (I later discover that a bullet train from Tokyo to Kyoto would have been a lot easier; although my first impressions of Japan would have been a blur).

Kyoto is renowned for its illustrious history: from 794 to 1868, the city reigned as Japan’s capital and home to the Imperial Court. The city embodies a wealth of traditional art, architecture and crafts that have been carefully preserved in more than 1,600 Buddhist temples and 270 Shinto shrines.

My BMJ colleague Nichola Roberts and I settle into the grand doughnut shaped hotel, nestled into the leafy mountains to the north east of Kyoto, and treat ourselves to some sushi in the restaurant. I make a quick phone call to my wife to boast about my new adventure and to find out whether the overflowing toilet at home has been fixed. It has. Relieved, I collapse into bed.

Saturday 29th May

A false start

After my first Japanese breakfast (bacon and eggs), I trot off towards the conference centre. There are the usual queues at the registration desk, but an extremely helpful woman sorts me out with my conference bag and programme. I lose my programme within 30 minutes of receiving it, and have to hunt down another, tail between my legs.

Life expectancy in Japan

The opening address is by Kiyoshi Kurokawa, MD, president of the Science Council of Japan. He talks about the challenges and opportunities in global healthcare, in particular sustainability and the growth of the human population. 100 years ago life expectancy in Japan was 40 years; now it?s 80 (the longest in the world). Dr Kurokawa reminds us that the major medical breakthroughs in that time have been fighting infectious diseases and unravelling the human genome; now the challenges are the growing human population, the environment, and the North ? South divide.

It?s a huge conference hall with Japanese royalty present, and if needed, we could all listen to a simultaneous translation through headphones, as they do at G8 summits. There are more than 2000 delegates. All very global village and exciting.

Patient?centred medicine

As always at these enormous conferences, there?s a constant feeling that something more interesting is going on in the room next door. But I have studied my re-discovered programme in some depth, and it pays off. Although tempted by a session on music therapy, and one on how to become a health service researcher in a day, I opt for a winning workshop on patient-centred medicine by Judith B Brown, Professor at the Centre for Studies in Family Medicine at the University of Western Ontario and Ryuki Kassai from the Hokkaido Centre for Family Medicine, Japan.

It?s extremely well attended, very ?learner-focused? and even has a role play element with a simulated patient (Professor Brown?s sister-in-law, as it happens). I?m reminded that patient-centred medicine isn?t about being a push-over for patients: sometimes it means being direct and prescriptive (if that?s what the patient needs/wants). The workshop is engaging, fun and instructive for everyone ? whether from Japan, Singapore, Australasia, UK, Scandinavia, and no matter what stage of their career. Tomorrow I?d like to go to the workshop on ?Acupuncture and Moxibustion Therapy in Japan?, but I think it clashes with my own workshop (?How to Get Published?), which now sounds rather dull in comparison.

Domestic violence and women

Later I sit in on the last couple of presentations from the symposium from the WONCA Working Party of Women and Family Medicine. Sadly I?ve missed the talk on ?The Asian Culture as it affects Women in Medicine?, but I?m in time to hear some of ?Family/Domestic Violence in the Medical Curriculum?. Vivien Seno, vice president of the Philippine Society of Teachers of Family Medicine, explains how these days physicians need to be able to detect family or domestic violence in women, even if the victims don?t present the problem directly to the doctor. I was interested to hear how she had managed to incorporate family and domestic violence into the medical curriculum (the teaching of it, that is). As the presentations wound up, we were all invited to join an intimate discussion circle on women in medicine. I crept out the back.

A bit of culture

In the evening there?s a wonderful WONCA cultural event organised by our hosts in the beautiful watery gardens of the conference centre. As well as a giggle of Geisha girls, there?s a Kabuki dance called Kagamijishi. Kabuki is a 400 year old traditional dance in Japan, with two parts. The first sees a young actor (tonight he?s actually a dentist living in Kyoto) play a young woman, and in the second, a beast with a large mane. Spellbound by the dramatic mane-tossing and beautiful butterfly dancers, I could easily see how the dance inspired Jean Cocteau to write The Beauty and the Beast.

Just before lights out, I have cold feet about my marathon workshop and get my hands on a laptop to add in a few more interactive elements. Two hours later, I?m asleep.

Sunday 30th May

Family practice in Japan

The highlight of the conference for me is the invited symposium on general practice as a global standard. It?s a fascinating whistle stop tour of general practice in 6 different countries: UK, USA, Hong Kong, Korea, Australia and Japan. Japan, for example, has no postgraduate training system for family practice; traditionally Japanese primary care has been managed by specialists who are self-trained to be generalists. According to Tomoyuki Kido, clinical professor at Osaka Medical College and Kyoto University, there are two big social phenomena which are driving the urgent establishment of a training system in family medicine. Japan has both the longest life expectancy in the world, and  the lowest birth rate in the world. Elderly people need family medicine, he says, and the declining paediatric population has meant a decline in doctors applying to be paediatricians. But the future is rosy, he reckons, for three reasons:

1. Members of the Japanese Society of Family Medicine have increased from 200 to 1000 in the last 8 years.

2. Last year the Ministry of Health, Labour and Welfare of Japan started manadatory 2-year rotating internship which may provoke interest in primary care among specialist trainees

3. In Japan, generalists in private practice earn twice as much as specialists working in hospitals on a fixed salary.

..and the United States

It was interesting too, to hear about what goes on in the United States, where apparently there?s been a bit of a backlash against family doctors and their managed care model of gate-keeping and a practice style that hadn?t changed much for a while. Trainees are turning to other fields that promise more money for less work. Family Physicians in the United States, said Professor Jonathan Rodnick, from the University of California, was working to reinvent itself and could learn from others.

?and Australia and the UK

Michael Kidd, the president of the Royal Australian College of General Practitioners managed to make Australian general practice sound up to date, high quality and good fun. It wouldn?t surprise me. Listening to Neil Jackson , dean of postgraduate general practice education for the London Deanery, talking about UK general practice reminded me just what massive changes we?re going through at the moment. Seeing it laid out in a 15 minute presentation really hammered it home: modernising medical careers, foundation programmes and general practice placements, the new Postgraduate Medical Education and Training Board (PMETB), a new contract, and of course, revalidation. UK general practice stands out as ?happening? ? but as Neil told me later, there?s always plenty to learn from other countries facing different challenges.

Family medicine as an antibody

Sadly the global tour symposium clashed with a keynote lecture by Henk Lamberts from the University of Amsterdam. He described an international study (using The International Classification of Primary Care, ICPC) in which 100 family physicians from the Netherlands, Japan, Poland, Malta and Serbia coded the reasons for every face to face encounter with patients, as well as the diagnosis and any intervention. What was fascinating about the research was that diagnoses were far more different by country than were reasons for the encounter. He concluded that family medicine appears to become what national conditions permit ? like an ?antibody reacting to the specific antigens of a nation?.

Stand and deliver

After a suchi lunch with Ryuki Kassai, I meet Professor Takeo Nakayama, an epidemiologist from the University of Kyoto. He too is charming, and is here to help me with my presentation. In the event, it?s fine. We stretch to 2 hours, the interactive bit (your chance to be a BMJ editor for 20 minutes) goes well, and there are even a few questions at the end. I think there is a genuine interest in research and evidence-based medicine in Japan. At least there is amongst the younger doctors ? my moles tell me that there is still a large fan base for ?eminence-based medicine? amongst the old guard.

In the evening, another cultural interlude at a local Japanese restaurant, with some Japanese interns, Ryuki Kassai, Judith Brown, Neil Jackson, Professor Rodnick and others.

Monday 31st

The conference proper is now winding down, so I?m spending the morning (well, a few minutes) looking at poster presentations and checking out the exhibition booths with foot massaging machines. This afternoon there are organised cultural excursions; not normally my cup of green tea, but tagged on to the end of a busy conference in Japan, it seems like a good idea. After lunch with Professor Nakayama we manage to visit a couple of shrines and temples in Kyoto as well as a stunning Japanese Zen garden. Unforgettable, and I?m now determined to bring a little Bonsai to Boston Manor.

Farewell party ? The Wonkies

In the evening, more evidence that GPs have a sense of humour and a broad range of talents; the farewell party. It?s a WONCA version of the Eurovision song contest, with performers from different countries competing for international recognition. My group decide that rather than the Oscars, or the BAFTAs, these should be called ?The Wonkies?. Here are some highlights:

Lovely buttocks

A Sri Lankan doctor and a Norwegian doctor stand up on stage. The Sri Lankan (a frustrated stand up comic) announces that if they put their heads together (they bend over and put their bald heads together), they ?make lovely buttocks?. It?s a visual gag.

A couple of Australian docs dance a tango, a Scottish GP plays the fiddle (beautifully), there?s a Japanese dance group, and a Swedish ?crooner?. There are occasional flashes of musical talent, like the Japanese doctor whose performance of Nessan Dorma brings a lump to the throat; the audience favourite, and a deserved winner. Unfortunately for him, The Wonkies adopt the same political diplomacy of the Eurovision song contest, and the prize goes to a visitor.

Three cheers for the organisers for a marvellous conference, and a call to arms for the next WONCA extravaganza.