直精、直接精神科診療を行うことの問題点を精神科医が解説します。

Hello, good evening. I'm Takahiro Haga, a psychiatrist. Today, I'd like to talk about the "direct entry problem," even though it's a bit late to be discussing it. "Direct entry" refers to entering psychiatric or psychosomatic medicine practice after completing initial clinical training, without sufficient specialized training in psychiatry. It's similar to the term "direct entry" in cosmetic surgery. After graduating from medical school and obtaining a medical license, Japanese doctors typically undergo two years of initial clinical training. They rotate through various departments such as internal medicine, surgery, emergency medicine, and anesthesiology, acquiring the minimum necessary foundation as a physician. After completing these two years, they become eligible to manage medical institutions that provide insurance-covered medical care, that is, to become clinic directors or founders. This is a very important point. Japanese healthcare is almost entirely based on insurance-covered medical care. It's not realistic to run a general clinic solely on private medical care unless it's a very specialized field. In other words, after completing initial training, one becomes eligible to operate an insurance-covered clinic. This means that it becomes possible to work in a mental health clinic, or even open one's own practice, without undergoing specialized training in psychiatry. That's what I call "direct approach." I believe this presents a significant problem. Because it involves starting psychiatric practice without receiving specialized training in psychiatry. Of course, in this day and age, there are books and information available online. Many doctors, including myself, share information about practice on YouTube. However, there's a huge difference between listening to information as knowledge and actually treating patients in a clinical setting. This is a truly significant difference. The scariest thing is that even if you think you can handle it, you might actually be doing something completely different without realizing it. Psychiatric practice is not as simple as it appears from the outside. It's not enough to simply listen carefully to the patient and prescribe medication. It requires assessment, diagnosis, monitoring progress, detecting signs of worsening, evaluating family background and developmental characteristics, risk management, and determining when hospitalization is necessary. And many of these discrepancies and vulnerabilities can only be noticed through supervision from experienced senior physicians. I myself practiced internal medicine for 10 years before entering psychiatry. Therefore, I thought I was somewhat accustomed to interacting with patients and conducting medical treatment. Even so, when I entered psychiatry, I was often told by my supervising physicians, "Haga, I think that's a little wrong." The things I thought I was doing correctly were actually the most precarious. This was something I learned the hard way many times during my training. It's typical for young doctors to go straight into practicing at a mental health clinic without going through that kind of experience. So why do young doctors gravitate towards mental health clinics? The reasons are quite clear. One is the good pay. If you pursue specialist training, an annual salary of around 5 to 6 million yen is not uncommon. On the other hand, if you go straight to a mental health clinic, you might be offered an annual salary of around 20 million yen. That's almost a four-fold difference. Furthermore, specialist training requires treating inpatients, dealing with many severe cases, on-call duties, and heavy responsibilities. However, in an outpatient-focused mental health clinic, you tend to treat patients with relatively mild symptoms, and difficult cases can be referred to hospitals with inpatient facilities. It's easier, and the pay is high. If that's the case, it's somewhat natural that young doctors will gravitate towards that field. Another issue is that psychiatric care is being underestimated. Almost no one would jump into neurosurgery or cardiovascular surgery without specialized training. It's frightening. However, some people think that outpatient psychiatry might be manageable. This is evidence that psychiatry is being taken lightly. Certainly, acute schizophrenia with severe hallucinations and delusions, or severe depression that seems life-threatening, are clearly difficult for anyone to see. However, patients with anxiety or insomnia who come to the outpatient clinic alone and speak politely, or depressed patients who appear calm, might seem "not scary" or "manageable" to a novice. But in reality, it's precisely in these patients that risks and pitfalls can lurk. Furthermore, doctors with a strong track record are often pleasant. Please don't misunderstand; I'm not saying all doctors with a strong track record are arrogant. On the contrary, I think there are many doctors who are friendly, lis...