What's it like to do a surgery in Japan?

In 2022 my doctor in Singapore recommended i undergo ankle microfracture surgery. It's a procedure to drill tiny holes into the bone to force blood into the area, to stimulate regrowth of cartilage. At the time, i was 3 months away from relocating to Japan. I had 2 options - to do the surgery immediately and undergo 2 months of rehabilitation, while dealing with the stress of moving, or defer the surgery until i was in Japan, and find a local doctor to do it for me. I opted for the latter.

Healthcare is, i think, something that has the same outlines everywhere. There's a doctor, there's a nurse, there's a hospital. There's also, hopefully, insurance. You'll get warded, someone will ask you to count to ten (and hopefully you don't get to ten), and you'll wake up a few hours later with a new <insert body part here>.

Of course, the devil's in the details. This is my experience in Tokyo, but i suspect it isn't that different in other parts of Japan.

An unsolicited medical history

I have bum ankles. I had a major sprain in 2018 that damaged ligament and cartilage. I underwent ankle surgery in Singapore to repair a torn ligament then, went through years of trying (and failing) to get it right, then another surgery to pseudo-repair cartilage in Japan last year. I always assumed that the primary injury was my ligament, but it turned out that cartilage damage is much more severe. If you don't know anything about cartilage, 1) cartilage bears weight between bones at the joint, and 2) cartilage never grows back the same once it's damaged. Damaged cartilage means your joint will never bear weight the same way again.

The implications of these surgeries on my life are a separate story. The outcome of these surgeries is that i have experienced medical care in both Singapore and Japan.

Life cycle of a surgery in Japan

The entry point to the healthcare system in Japan is a clinic. To get an appointment at the hospital, you must first be referred to the hospital by a doctor.

The origins of a doctor's visit, like the origin of a visit to anywhere in Japan, begins with a phone call.

Yes Japanese is okay.

Yes i'm a new patient.

Yes i'd like to see the orthopedic specialist.

Yes i have Japanese health insurance.

The doctor's visit was fairly standard. I was armed with a note from my orthopedic doctor in Singapore, which i presented to the doctor in Japan. It's not lost on me that the note was in English and my doctor was, well, Japanese, with a very limited command of English.

Fortunately this was very, very low stakes for him - his job was to pass on responsibility. I explained that a doctor in Singapore recommended i undergo ankle surgery. He swiftly wrote me a referral note to the nearest hospital and absolved himself from all decision making responsibilities.

The origins of a hospital visit, like the origins of a doctor's visit, like the origin of a vist to anywhere in Japan, beings with a phone call. Rinse and repeat. I was armed with a note from my orthopedic doctor in Singapore. Note in English, Japanese doctor is Japanese.

Here, paths diverge - unlike at the clinic, this doctor needs to assert responsibility. From past experiences with doctors i was fairly certain he'd act conservatively. He'd recommend something along the lines of physiotherapy and wait-and-see. I rehearsed a whole speech in my head, complete with timelines and my physical state over the past 5 years.

As luck would have it, my doctor could speak English. Not just medical jargon English, but proper English. Which meant he could read my doctor's note containing an explanation directly from another medical professional. I didn't need to give him my full presentation - an extremely fortunate turn of events because despite my best efforts at rehearsal, i probably only managed to verbalise half of what i really wanted to say.

I left that session with an MRI appointment the next week, and a follow-up review the week after that. At the review, the doctor agreed surgery was the best choice.

3 weeks from my first appointment, i was scheduled for surgery.

Entering the surgery's gestation phase

Along with my scheduled appointment, i received approximately fifty thousand paper documents and signed maybe ten percent of them. As a public health facility, hospitals generally treat people as consumers not customers. I consume the service on their terms - after all, doctors are busy and have a lot of patients to get to. The speed and sheer amount of information all but guaranteed i wouldn't remember what i was consenting to.

The irony is that these are acknowledgements to things like, "if the surgery goes catastrophically you might need a blood transfusion. What do i mean by catastrophically? Don't worry about it. The blood transfusion might also give you hepatitis. The risk is low, don't worry about it. Sign here. Ok, next"

Personally i'd like more than five seconds to absorb what i'm saying yes to, even if saying yes is the only option, but we're all captive to our circumstances sometimes.

At the end of it i was given a booklet with instructions, which read,

You are to be admitted the day before the surgery at 10am. Bring your own towel and toiletries, a change of clothes, your own tissue paper, and your own cups. If you forget anything we sell it at the convenience store downstairs. You'll have a TV at your bed but you'll have to pay to use it. You'll also have a fridge, but you'll also have to pay to use it. We'll feed you, but we'll charge you for it. This meal fee doesn't include water, bring your own. Staying here for 3 days? We have a vending machine, you can buy water from there.

I may have taken some liberties with transcribing the information here, but you get the point.

Contrast this with my Singapore experience - if i'd received a similar booklet then, it'd have read,

Arrive a few hours before your scheduled surgery time, we don't want you to stay any longer than you have to. We'll provide everything for you. Food is included. Water is free. We have wifi, we're not barbarians. You can bring your own towels and tissue paper if you want but why would you when its provided in your ward.

It struck me that healthcare in Japan (at least in my limited experience) is very much healthcare only - everything else is frills.

The day before the surgery, i followed their instructions and went to be admitted. At 10am. For a surgery at 1pm the next day. I emphasise this again, because it felt ridiculous (it still does) that i needed to be under observation for a whole 27 hours prior to surgery. I was admitted to a 8 person ward - private rooms are, apparently, not a common thing in Japanese public hospitals. During those 27 hours there was a parade of nurses. Standard procedure was to call me by my full name, then ask me to repeat back my birthday as verification. As far as authentication goes, this was pretty insecure. The 3 other strangers in the same ward could probably have taken my place after hearing my name and birthday twenty times.

These nurses (and some doctors) gave me more disclaimers and made me sign more forms. The forms all blur into one metaphorical Form that represents the fact that i am at the hospital's mercy. Healthcare happens to you.

When the time came i went downstairs to the operating theater. The doctor asked if i was nervous. I don't remember if i was, but i remember saying i was excited to get it done. Then i lay on a table, counted to four (five? Maybe six?) and had healthcare happen to me.

Surgery and post-surgery

The post surgery anesthetic haze meant that i recalled vague outlines of lying in a waiting area and answering some questions, but i don't recall the contents. I also don't recall how the waiting room looked like, or how i got back to the ward. I simply woke up hours later, with a splint bandaged against my leg.

Post surgery, the parade of nurses became more frequent. To gauge if i was in pain. To feed me medicine. To take my blood pressure. To change my IV drip. This occurred both day and night. An incantation of name and date of birth at intervals.

I was warded for another 2 nights, for a total of 3.

On the 2nd day i'm scheduled to visit the rehabilitation clinic to learn to use crutches properly. I'd used crutches before, and told them as much, but as a hospital its understandable that they didn't take my word for it and scheduled the appointment all the same. A nurse wheels me down in a wheelchair to the clinic on the 1st floor to meet the therapist, who tells me, you can't put weight on your operated leg. I say ok.

He says, you'll need to learn to use crutches. I say ok.

He says, we'll schedule time for you to do this, so come back later.

I say, I'm already here, can't we do it now?

He says no.

So I spend 5 minutes waiting for the elevator for a 60 second conversation, then another 5 minutes waiting to go back up. Then another 5 minutes to go back down again at a later time to see the physiotherapist.

The physiotherapist puts me through the paces of crutches training. I walk up and down the hallway, up and down stairs, and up and down slopes. Because i'm intimately familiar with crutches already, the session takes maybe 5 minutes. He pronounces me a master of crutches and sends me on my way.

5 minutes to go back up.

On the final day the doctor came to remove the splint and place the cast. Aside from 2 stitches marking the site of surgery, my ankle looked surprisingly ordinary. No swelling, no redness - just an ordinary ankle that can't bear weight for 6 weeks. He told me he'd see me again in 3 weeks to remove the cast, and wished me the best.

The final step was to discharge from the hospital. In true Japanese fashion, there's an inviolable operational process for this.

I first indicate my discharge to the nurse at my ward. The nurse then shows me some documents for me to validate the charges. Upon validation, she'll direct me to the 1st floor to make payment. After completing payment i will return to show proof of payment, and receive my discharge documents.

My ward is on the 5th floor, making this an inconvenience for someone on one leg. No problem, my partner will go down to make payment on my behalf. She goes and returns. Apparently they refuse, because i have do it myself regardless of how many legs i can stand on, or how long it would take me to go downstairs. It seems i'm the only one who can recite the undecipherable code of my full name and birthday.

What if i go down to make payment, and my partner comes back up to present the receipt on my behalf to receive the discharge documents? No can do, there's no way she knows the code of my full name and birthday and we can't hand over documents to people we can't validate.

I recall we ask for a wheelchair, which somehow flusters the nurse, either because they don't have one on hand or she isn't sure if she can loan it to me. After some verbal deflection about the challenges of obtaining a wheelchair for me, we give up and i decide to do it on crutches.

So the correct operational process is that i, a newly-minted handicap, have to lumber my way to the 1st floor independently, queue to make payment (reciting my name and birthday along the way), pick up the receipt, lumber my way back up to the 5th floor, also independently, and pass the receipt to the nurse, who will then give me the discharge document to complete the transaction, whereupon i will then go back down to the 1st floor to leave.

I see the outlines of why the process was designed this way, but as you can guess, i disagree with it.

What stood out?

Speed

From a macro point of view, getting from consultation to surgery was much faster than i'd expected. In total, it took 4-5 weeks from the moment i decided "i should finally do something about my ankle" to waking up with a new one, under Japan's public healthcare system.

From my previous experience, equivalent public healthcare in Singapore would take several months because of the bias to conservativeness. I've heard the opinion that healthcare in Singapore isn't meant to make sure you're fully healthy, it's meant to make sure you're healthy enough. When framed in this perspective, the conservative approach makes sense .

For someone in my situation, i'd have to see a polyclinic doctor, who would then prescribe basic rehabilitation exercises for a few weeks before providing a referral to the hospital. The referral appointment would be scheduled another few weeks later.

At that appointment, the specialist i'd see at the hospital would also prescribe rehabilitation exercises for a few weeks before considering alternatives. When that time comes, i'd have to convince the doctor surgery is truly the best option for my circumstances, and not, "let's do 8 more weeks of physiotherapy and see how it responds." If convinced, the surgery would be scheduled 4-8 weeks later.

A total turnaround time would be maybe 6-8 months (assuming they are convinced. Anecdotally, my first go-around with my first ankle injury, every public hospital doctor i saw agreed my ligament was fully torn, and every one of them also essentially said "you can walk, what's the problem?" Athletes are a truly misunderstood class in the local healthcare system.)

Private healthcare in Singapore, of course, is a completely different matter. The consultation can happen on Tuesday and the surgery on Thursday. The reason it can happen so fast is because you pay $30,000 instead of $3,000. If you're insured, you should absolutely see a private doctor.

Cost

Strictly speaking, the out-of-pocket cost for Japan's public healthcare system is lower than Singapore's. Arguably, although this is highly subjective, the quality is higher too.

Throughout my healthcare journey in Japan, i did several x-rays, an MRI, and a CT scan. The MRI was the most expensive, at a whopping... JPY5,000 (SGD45). My actual surgery cost roughly JPY140,000 (or about SGD1,000). When i had follow up appointments with my orthopedic doctor, each visit was JPY220.

The equivalent cost in Singapore? $800 for an MRI at a public hospital, several thousand dollars for surgery (if i recall the quote correctly) and just under $100 per session with the doctor.

The trade off for that lower out-of-pocket cost is that i pay national health insurance, that scales according to my income. According to the national health insurance website's calculator, where you can input your municipality and salary to see the exact amount you'd pay, the maximum payable for my ward is JPY870,000. (An interesting little fact from their summary sheet, Tokyo costs are on the lower end compared to the rest of Japan, and the region with the most expensive insurance is Ehime prefecture in Shikoku)

I personally paid quite a bit less than the maximum, but that number is certainly nowhere close to the $0 i'd have paid in Singapore. Even factoring in private health insurance i own in Singapore, Japan insurance remains 2-4x more expensive for me.

Experience

Here it gets truly subjective. I have to qualify that i've not experienced surgery under public healthcare in Singapore. Regardless, there were several things about Japan's that felt strange to me.

First, I struggle to understand why basic necessities like water aren't free, or factored into the cost of the provided healthcare. One of the nights i was warded, a patient in the neighbouring bed was struggling with a fever. The nurse came in to check on him and he said he needed water. She said, "you've run out. I can buy some for you (at the vending machine)." He gave her the money and she did exactly that - one 500ml bottle of water for JPY130. From the way it sounded he must have finished it in one go. The implication of this exchange to me was, if he didn't have money on him he'd simply have to go thirsty. Imagine a patient's condition deteriorating due to dehydration while under supervision at the hospital while the hospital goes "well its because he couldn't afford to buy water."

Along those same lines, food is also not factored in to the cost of the provided healthcare. In my provided surgery packet, a section mentions that i have to pay a JPY220 per day meal fee. It's a nominal fee, but still a charge nonetheless. The fact that its a separate fee means there's the option to opt out, which makes very little sense to me. In case you're wondering, water wasn't provided with the meals either, only a tiny cup of tea.

If necessities aren't part of the package, why would any other frills be? To use the fridge or television you'd have to purchase a prepaid card and insert it into the devices, whereupon it deducts its stored value for as long as you're using it. Toiletries, even arbitrary ones like a toothbrush or towels, aren't provided. Wifi isn't even payable - it doesn't exist. Given how they itemised and charged for everything, i was a little surprised when i plugged my charger into the socket and it worked. I guess electricity is free.

The only thing on this list that pertains to the actual surgery is Japan's inexplicable obsession with catheters. I chanced upon a twitter thread (that i can't find any longer because its search is a mess) where the collective experience seems to be, "i did a relatively minor surgery and woke up with a catheter." One of the replies was along the lines of, "i told them specifically no catheter. I did the surgery and still woke up with one." If you're not familiar with a catheter, its a tube they insert into your urinary tract to drain urine.

In case you couldn't already infer this by now, i, too, woke up with a catheter. At no point in time did anyone mention pre-surgery that a catheter would be involved, which leads me to believe this is simply the default practice for all surgeries whether you're doing an immobilising spinal surgery (valid) or, i don't know, a microfracture surgery for your ankle (decidedly not valid). Its as painful as it sounds (very) and nobody at the hospital seemed to think it was a big deal. It was so painful i couldn't sleep - ironic because it wasn't having a leg cut open and operated on several hours ago causing it - that i called a nurse and asked if i could remove it. And her response was, in essence, "sure, why not." And she removed it. In hindsight, this makes me even madder, because if there are no problems removing it within hours of the surgery, why do it in the first place? I told my doctor the next time i saw him that i didn't know there was going to be a catheter. He simply said, "oh, sorry" and moved on.

If you're considering doing a surgery in Japan for whatever reason, consider yourself warned.

Would i do it again?

This feels like a strange sentence to write about a surgery and hospital stay, almost like i'm reviewing it the way i would a hotel or a restaurant. But i think its a valid question to ask when there are options presented. If i had the choice i'd return to Singapore, deploy my insurance, and seek healthcare at a private medical facility.

I stayed in the hospital for 3 days, during which time melded together. Things happened to me rather than for me, and i existed in a constant state of discomfort. This made me realise two things. One, efficiency is of utmost importance - i don't want to spend a day (or two days, in this case) longer in the hospital than i have to... and two, the frills go a long, long way in alleviating discomfort. It's just a TV, you might say, but its a semblance of control in an environment where you're essentially non-autonomous.

And of course - and this is key! - no catheters.