We enjoyed several lectures
regarding pharmacy practice and the overall healthcare system in this wonderful
country. Perhaps the most unique (and to me, the most unusual) aspect of
pharmacy in Japan is the continued existence and practice of Kampo pharmacy, a type of herbal/natural
medicine derived from ancient Chinese practices. Pretty much any natural
material (plant, animal, mineral, etc.) that can be dried, crushed, chopped,
and/or powdered is fair game for this unique type of medicinal practice. Our
first day on the KGU campus, we saw several displays of jars containing
different Kampo ingredients, ranging from leaves, branches and roots of many
plants to pieces of geodes, mollusk shells to whole, dried seahorses! With no
previous exposure to any form of herbal or homeopathic treatments under my
belt, the whole concept of Kampo medicine was an entirely new world for me. As
we brewed our own kakkonto
for colds, I couldn’t help but wonder how effective such concoctions could
really be. Of course, the origins of many of today’s pharmaceutical products lie
in compounds derived from plants and other natural products, so the idea of
isolating structures from the roots or leaves of different plants isn’t that
exotic. What I wonder about is the purity and potency of the desired
ingredients in any given dose of any given concoction. It seems to me that the
extraction methods are relatively inefficient, leading to undesirably low
yields of the desired compounds, with unwanted extracts (other compounds present
in any given natural product) to boot. Moreover, I feel that the overall
palatability of some of the mixtures is pretty limited. We were offered an
energy boost on our first day at KGU, which I think contained ginseng extract
in it – for me, it was completely inedible, and to be honest, the kakkonto we
made as a group for colds wasn’t much better. The diagnostic approach to
determining the appropriate formula to prescribe is fairly unique as well.
Essentially, it involves following a flowchart of several binary divisions
based on different aspects of the body and its response to illness or stress,
which can ultimately result in only 8 possible conclusions. To me, it seems
like an oversimplification of potentially complex disease states. Nonetheless,
it’s a fascinating area, and certainly seems like it will have a stronghold in
Japan for many, many years to come.
With regards to more Westernized
or ‘modern’ pharmacy practice, several key distinctions can be drawn when
compared to American pharmacy. Firstly, loose powders are still a common dosage
form in the country, which can be extremely difficult for kids to swallow in
particular. Many (if not all) pharmacies therefore have automated machines
capable of dividing a measured amount of powder into uniform doses packaged
into individual bags. For better ease of administration, thin sheets of a sugar
polymer paper can be used to suspend a bolus of powdered drug in a goopy,
gelatinous bulb, the result of a reaction between the paper and water. In general,
the use of powdered drugs seems like a messy, potentially ineffective (i.e. due
to spilled powder or poor dose measuring) means of administering drugs orally. What’s
more, many other common dosage forms, such as oral capsules/tablets, topical
ointments, etc., are sold solely in unit dose packaging. There are no large
stock bottles of anything but powdered drugs or Kampo ingredients. Thus, if a
pharmacy is combining multiple medications into a single dosing packet (common
practice for patients who take several medications at the same time each day,
which is in direct contrast to the American method of dispensing each different
medication in its own labeled prescription bottle), the pharmacists must first
punch out each tablet or capsule needed to fill a month’s supply for a patient,
individually by hand. As such, all of
the effort and material put into unit dose packaging by the drug manufacturers is
essentially undone, leading to a seemingly time heavy and waste producing means
of distributing drugs (in my opinion). Overall, a very different approach to
drug packaging and distribution compared to the States.
Finally, the actual role of and
work environment for the average pharmacist in Japan is varied in several ways.
Firstly, there are no pharmacy technicians in the country – this position does
not exist. All employees of a pharmacy are strictly pharmacists. Secondly, at
least in the community setting (not sure about hospital), pharmacists are
reimbursed based on a fairly complex formula that assigns point values to
various aspects of the filling and dispensing process (1 point is worth
approximately 10 yen). Thirdly, community pharmacists are limited to filling a
mere 40 prescriptions per day, by law
(we did not discuss hospital pharmacists in this context)! If a pharmacy is
expected to consistently fill more than 40 prescriptions per day, then another
pharmacist must be hired to handle the overflow. When you compare that to the
150+ prescriptions that a single pharmacist and technician can fill in an
average community pharmacy on a single day, in the words of my mother, ‘it’s a
wonder no one gets bored.’ This government-enforced limitation on daily
dispensing, coupled with the complex and often low reimbursements derived from
the reimbursement formula, result in the average pharmacist in Japan making
half (or less) the average annual salary of a pharmacist in the United States. It’s
rather unbelievable to me, actually. I never thought I’d prefer the often
hectic, 400-per-day filling mentality found at many American community
pharmacies. Although the hours and lifestyle are presumably longer and more
stressful in the States, it seems the rewards are significantly greater.
Overall, I tremendously enjoyed
learning the in’s and out’s of pharmacy practice in Japan, drawing parallels
and distinctions between their country and ours. It was an enlightening
experience, to say the least.
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