Now Reports

Dr. Ronald Schlemper

Dr. Schlemper opened the International Medical Clinic near Tojinmachi subway station six years ago and is the only foreign doctor with his own clinic in southern Japan. Fukuoka Now had the pleasure to chat with Dr. Schlemper about how he managed it all, the interesting differences in two very different medical cultures and some easy steps to staying healthy. Read the full interview below.

How did you come to be a medical doctor in Fukuoka?
It was not my intention to be a medical doctor here. I wanted to master certain endoscopic techniques, Endoscopic Mucosal Resection (EMR), which is a technique to remove early cancers from the stomach, esophagus or colon in an elegant way. It’s small surgery through an endoscope where patients don’t need general anesthetic or get scars. At that time (15 years ago) that technique was performed nowhere else except Japan, so I studied EMR for two years at Showa University. I soon found that it was very difficult to be regarded as an equal member of the medical setting in Japan if you don’t have the Japanese medical license, even though I was a specialist in internal medicine and had my Dutch medical license for ten years.

So I intended to move back to Holland. I had two offers from Dutch universities but then I got a third offer from Fukuoka University Hospital. They gave me free time to do research and study for the Japanese medical license exam. I thought if I could practise as any other Japanese doctor, then I could learn to master these techniques best. So I got the license and stayed at Fukuoka University Hospital for five years.

How did you get the opportunity to start your own clinic?
I decided to open my own clinic so that I could really offer medicine in the way that I thought would be best. That was in 2004, over 6 years now. Until then I had already worked in a medical clinic in the center of Fukuoka for two years.

What was not being offered?
I studied medicine in order to make sick people better but if you are not your own boss, you have to do what other people tell you to do. For example, many employees of big firms came to the clinic for medical checkups but they didn’t come on their own will. That’s not a nice way to practice medicine. If people come on their own will and want to become better then that’s a good starting point for dealing with patients, but if they are forced to go somewhere and they are healthy anyway…well, I wasn’t trained to help healthy people against their own will. So a lot of time is consumed and it’s inefficient. Very rarely, at this clinic, do people ask for a medical checkup. Almost all patients come because they are ill.

Are you recommending that people should not have a medical checkup?
Not against their will.

Would you recommend that the average person see a doctor once a year even if they are well?
That’s a good idea but the Japanese medical checkups contain things that are questionable. For example, it’s Japanese law that at least once in two years (for firms with over 10 employees), people over 35 are offered stomach cancer screening, which is usually done with Barium meal exams. A contrast medium and air is put in the stomach and then many x-rays are taken. But there have been many warnings about these x-ray exposures. One of the most well respected medical journals, the Lancet, shows that Japan stands out from many other countries, not only in the most number of x-ray examinations per citizen, but also in the percentage of all cancer patients who get cancer because of the x-ray examinations with heavy x-ray exposures. Barium meals are seldom performed in the West, but in Japan, this is performed routinely from the age of 35.

Why it is performed so often in Japan?
In the beginning there was such a high incidence of gastric cancer. So they wanted to discover these cancers at an early stage. But these x-ray screening procedures started 30 or 40 years ago. Nowadays, we have other ways to discover early cancers. We have laboratory tests and endoscopy which is completely harmless and it’s more reliable. So, if these machines were invented today, they wouldn’t be used on a wide scale. But because these x-ray machines have existed for 30 or so years, people don’t change to endoscopy and won’t throw away all these machines. So, now that I have my own clinic, I can decide not to do x-ray examinations of the stomach. In this clinic I do endoscopic examinations but I don’t have any equipment for doing Barium meals. Previously, however, I was not only exposing my patients but slightly exposing myself in my opinion. So if you have your own clinic, it is much easier to do things you yourself find useful.

Was it difficult to start up your own clinic?
Actually, it was not. A patient of mine kept persuading me to start my own clinic and this patient happened to specialize in the construction of clinics! So after half a year of persuasion, I finally gave in. He did everything for me. He looked for a place, a guarantor and prepared all the paperwork. I planned the layout of the clinic but he did the rest. So it was quite easy actually.

Are there many other gaijin doctors in Japan?
In Tokyo there is the Tokyo Medical and Surgical Clinic. There’s another clinic in Tokyo run by a Russian doctor. I heard there might be one in Kobe but maybe that has already closed and there are a Dermatologist and a Gynecologist in Tokyo. So, I know of four other clinics where foreign doctors practise. There aren’t many. In the south of Japan, this is the only clinic.

Does Japan need gaijin doctors?
The differences between European and Japanese medicine are big. In the West we are trained to put a lot of attention on the interview. At medical school you are taught that 70-80% of all diseases can be found out just by proper interview. Then physical examination will lead you to 10% more proper diagnosis. All other laboratory and x-ray examinations etc. account for only maybe 10-20% better diagnosis than what you already know based on the interview and physical examination. But in Japan, some of my patients tell me that when they go to a Japanese doctor they only have a 3 minute interview, a few questions are asked, often a lot of laboratory examinations are done and they end up with 6 or 7 medicines for simple diseases. For every symptom they get a medication. It’s a kind of symptomatic treatment. In the West, we are taught to find the cause of the illness and then treat the cause. Many of my foreign patients don’t come for the language problem but because of the difference in medical culture.

Do you actually speak six different languages?
Yes. For a Dutchman four languages are compulsory for education: Dutch, English, German and French. Usually I only need to speak Japanese and English. I do speak Chinese occasionally because some Chinese people that come here don’t speak English or Japanese, but they pick up the Japanese language quickly.

What’s the reaction you get from some patients? As a foreign doctor, how are you received?
Most of the patients come because of word of mouth. Many patients who have a difficult medical problem and want to be listened to for more than 3 minutes come here. Also some patients don’t want a whole bunch of medicines without explanations. There is a lack of explanations by Japanese doctors according to many Japanese patients that come here.

What about challenges in the industry? Has there been anything negative?
With the Japanese health insurance system, you have to write down every examination you do for a patient and the reason (suspected diagnosis) for doing so. Japanese patients pay 30%, so to get 70% refunded you have to write everything down. It’s very time consuming. Then you get checked (not exactly audited) as to whether these exams were done and whether there were results because some Japanese doctors may cheat. Usually, these checks are once every 5 or 10 years. But when I started this clinic, I was checked every year. That’s very exceptional and probably has never happened to a Japanese doctor.

You’ve had the rare opportunity to practice medicine in Japan and in the West. What aspects of Japanese medicine are considered superior to the West?
The diagnostics of the gastrointestinal tract which is also the reason why I came to Japan. If gastric cancer is diagnosed in Japan, in 60-70% of cases it is an early cancer (very small and without metastasis). People then need a very simple procedure through the endoscope and they are cured. But in the West, even today, less than 5% of all gastric cancers are found in the early stage. So the difference is tremendous.

How do the Japanese detect them?
By their superior knowledge of how to use the endoscope. Even if Western doctors were able to practice in Japan, without studying the Japanese methods, they would miss most of these early cancers. I wrote a book about how to discover early cancer in the stomach, esophagus and colon. It’s difficult to see these early cancers because they are rather flat, but you can with training, and Japanese doctors spray a dye (Indigo carmine) which enables you to see it clearly. In Japan, every doctor does this routinely, but this is not so in the West. About 10 years ago, a famous American doctor in Gastroenterology said these flat lesions were a Japanese disease, not seen in western people. But a few years later, a Japanese doctor went to the US and did endoscopy for one year on American patients and found just as many of flat lesion cancers as he found in Japanese patients. When the results were published, American doctors finally agreed that this wasn’t a Japanese disease. They had overlooked early cancers for decades.

What are the common problems that are presented to you among the expat community/foreigners?
Every foreigner has different problems.

Is there anything that foreigners should be particularly aware of here in Japan?
Resistant bacteria are a big problem now in Japan because of over prescribed medications. About 80% of patients are over-treated with antibiotics when they have a fever. Often fevers are caused by a viral infection where antibiotics don’t work. So, after decades of this, you create a world like here in Japan, where many bacteria are no longer sensitive to antibiotics.

Have there been any funny episodes that you can share with us?
Plenty…but… [chuckles]. Well, we once had a British patient who asked what he should do with his ‘trousers’ before an endoscopy, as the nurse asked him to change. But the nurse didn’t understand him because although she trained for six years in America and her American English is perfect, her Oxford English is not so good… so…there was some funny thing about pants and trousers so I think he took something off that he wasn’t supposed to take off.

What’s your health routine?
I run for 20 minutes in the morning, then I ride my bike to work which is 20 minutes and then I ride back. So, I have at least one hour of physical exercise a day and I try to eat healthily. Is it similar to yours?…..

What’s your advice for staying healthy, particularly leading up to the flu season?
Stop smoking if you haven’t done already. If you get an infection, as a smoker, it will be much more severe. Smokers heal later from bronchitis or pneumonia than people who don’t smoke. Also, wake up every day at the same time. Important hormones in your immune system have extreme 24 hour rhythms and you make a mess of these hormones if you sleep in on Sunday for two hours or so. You can avoid feeling bad on Monday mornings by just not sleeping in on Sunday and waking up exactly at the same time that you wake up Monday to Friday. It can heal migraine headaches. To go to bed at the same time is not so important. But to wake up at the same time, that’s when all your 24 hour hormonal rhythms are set. Look at the animal world, animals get up at the same time, birds start singing at the same time in the morning. Only humans are so unnatural by using curtains, protecting themselves from the sunlight and sleeping in on Sundays.

For information on the International Clinic in Tojinmachi

Hometown: Groet, The Netherlands
In Japan: 15 years
Identity: Medical Director, International Clinic Tojinmachi

Interview and text by Veronica Ku

Originally published in Fukuoka Now magazine (fn143, Nov. 2010)

Fukuoka City
Published: Nov 1, 2010 / Last Updated: Jun 13, 2017