What to Expect at "Ningen Dokku," an Annual Physical Examination in Japan
At the heart of Japan's preventive medicine initiative, "human dock" health screenings are credited with contributing to the country's high life expectancy.
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What’s new: Earlier this week I had my annual physical examination in Japan. It is called ningen dokku (人間ドック), which means "human dock" in Japanese1.
Spoiler Alert: While I am still waiting for the final report, the doctor who delivered the initial results used baseball terminology to declare, girigiri sefu (ギリギリセーフ), which means "just barely okay" or "safe.” He immediately followed with a slightly raised, stern voice, "...but you need to lose weight." The results were consistent with last year, earning me a solid "C-" for "satisfactory performance" overall, on a scale where "A" might be used to describe the physical condition of a perfectly healthy contestant with not an ounce of fat on the popular TV show SASUKE Ninja Warrior. The final report literally has letter grades. While there are plenty of opportunities for me to improve my score, an "A" may be a bit out of reach at this point.
Zoom in: There are many types of ningen dokku examinations, but I seem to have gotten the "plain vanilla" one-day generic version subsidized by my local city government. While not directly covered by health insurance, the kihon dokku (基本ドック) or "basic dock" that I underwent included the following battery of tests recommended by our local city hospital for someone like me based on gender and age:
Blood test or ketsueki kensa (血液検査)
Physical measurement or shintai kensa (身体検査): Basic height and weight.
Various eye examinations for vision or shiryoku kensa (視力検査), intraocular pressure measurement or ganatsu sokutei (眼圧測定)2, and funduscopic camera or gantei kamera (眼底カメラ) to check my retina, optic nerve, macula, and other parts of the back of my eye.
Blood pressure measurement or ketsuatsu sokutei (血圧測定)
Electrocardiogram or shindenzu kensa (心電図検査)
Chest x-ray or kyobu rentogen kensa (胸部レントゲン検査): The Japanese word for x-ray is the katakana version of "Röntgen," named after the German scientist who discovered X-rays.
Abdominal ultrasound or fukubu choonpa kensa (腹部超音波検査): While the lubricant applied to the stomach helps, the technician must press hard to get clear results.
Lung test or hai kino kensa (肺機能検査): Do not do this after climbing stairs!
Urinalysis or nyo kensa (尿検査): Pee in the cup…
Fecal occult blood test or ben kensa (便検査): Finally got two days worth of my samples out of the fridge at home!
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This year, instead of a barium test3, I chose to be put to sleep for a gastroscopy or i kamera kensa (胃カメラ検査). I also agreed in advance to allow the doctor to remove any abnormalities such as polyps on the spot if he found anything - nip it in the bud so to speak - which fortunately he did not. Although I had tried this several years ago without anesthesia to put me to sleep, it was one of the worst experiences of my life. Since enough people have told me that the traditional barium test does not provide as clear an image as a gastroscopy, and therefore may cause the doctor to miss something, I was convinced that this would be a wise choice - but with full anesthesia this go around. Although being fitted for a "mouthpiece" just before being given a shot to put me under made me think of Marsellus Wallace being forced to wear a mouth ball in the 1994 classic Pulp Fiction, rest assured I woke up about an hour later none the wiser. While it will forever remain a mystery to me, I probably gagged convulsively and spit up enough mucus to soak the entire bib they also made me wear!
Like most mass screening facilities, each test or measurement was performed in a small examination room labeled with a number. Although I was having all of this done at a relatively small wellness screening center in a rural municipal hospital, the other 15 or so patients undergoing the same tests included people of a wide range of ages. When I lived in Tokyo, my employer arranged for the tests to be done at a private clinic that functioned more like a mini-testing factory, serving hundreds of test patients each day. The content, however, was almost identical.
Each of us was identified by our number, which was assigned according to the order in which we showed up in the morning. I ended up as number 12. Since the instructions were to check in between 8:30 and 9 a.m., I naturally showed up at about 8:25 am. Most of the other patients - at least the 11 before me - had arrived long before we were told. In any case, in keeping with patient privacy protocol, while I was initially simply referred to as Juniban-san (十二番さん), which means "Mr. 12," after the first station or so, as the only gaijin (外人) or foreigner, the nurses drawing blood and operating the test devices simply reverted to the familiar "Kennedy-san," which was fine with me.
All patients were shuttled from station to station in a different, random order. One stop included an actual physical examination by a doctor, called ishi shinsatsu (医師診察). At the very end of the whole process, there was also time for one-on-one consultation with the same doctor, which is called kekka setsumei (結果説明). I also decided to have another one-on-one session with the nutritionist on duty.
Go deeper: Including the hour or so of medication-induced sleep I took after the gastroscopy exam, it was about 12:30 p.m. when I was ready for lunch on site. A very nutritious lunch, mostly vegetables, was included as part of the whole program.
The “home-cooked” meal I was served for lunch was actually quite good, although it was a little heavy on shokumotsu seni (食物繊維) or fiber. Given the circumstances, however, this is to be expected.
Full Disclosure: In the lower right corner of the lunch photo, in that bowl of what appeared to be three pieces of broccoli along with a dollop-full of ankake4 mushrooms, was actually a cooked hamburger patty covered in enoki-like mushrooms. However, there were plenty of healthy "choices" on the pre-set menu, including shiroai (tofu, hijiki seaweed, etc. ), ankakei (あんかけ) mushrooms, konsai kinpira or braised burdock root, known as gobo, with carrots (根菜きんぴらごぼう), rice, onion soup, and a small dessert of sliced mango.
Suffice it to say, it wasn't the kind of place where you're asked, "Do you want fries with that?" In fact, the meal was served by one of the nurses! While suppressing a chuckle, she announced, "Kennedy-san, if you want more, you cannot have more. So today's meal will be a good place to practice 'hara hachibu' (腹八分)," which means eating until you are only about 80% satisfied instead of eating until you feel full. While "Nurse Ratched5" was enjoying her own joke, much to her chagrin, I was actually quite satiated after finishing lunch. I had eaten just the right amount of food.
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I was allowed to enjoy the lunch in silence, as conversation with other patients was discouraged. According to the sign, their rationale is related to infection control. This may be a relic of Covid that will most likely continue indefinitely for at least a few more decades.
Why it matters: Japan's nationwide system of ningen dokku routine checkups - including abbreviated versions that involve fewer tests for younger patients - is a shining example of how Japan's national health insurance system has preventive medicine at its core.
As noted in "Is Japan's Cancer Care System Sustainable? While out-of-pocket costs for patients are relatively low, Japan's public health insurance system is beginning to buckle as doctors continue to use increasingly expensive therapies to fight cancer," cancer has been the leading cause of death in Japan since 1981, and the number of cancer patients is increasing. In 2020, there were a total of 1.2 million cancer inpatients and 7.1 million cancer outpatients. The top three types of cancer in men are prostate cancer (about 50%), stomach cancer (29%), and colorectal cancer (21%). While breast cancer accounts for the vast majority of cancers in women (65%), colorectal cancer (19%) and stomach cancer (15%) are also common. Thus, ningen dokku physical exams are primarily designed to detect cancer and other common disorders such as heart disease at an early stage.
Context: While it is not mandatory for all eligible persons covered by Japan's National Health Insurance System between the ages of 35 and 74 to have a ningen dokku or similar type of "specific health examination," called tokutei kenshin (特定健診) in Japanese, it is strongly encouraged. Employers require mandatory medical examinations at the time of employment. This is called koyoji kenshin (雇用時健診). Many also require periodic medical examinations, which are called teiki kenshin (定期健診) based on the Occupational Safety and Health Law or Rodo Anzen Eiseiho (労働安全衛生法). In addition, special medical examinations called tokushu kenko shindan (特殊健康診断) are required by employers for employees who regularly perform certain hazardous jobs.
By the way, there are two types of health examinations for people 75 and older. A regular health examination similar to a ningen dokku is offered free of charge once every three years. In addition, a "brain dock" or no dokku (脳ドック) is performed free of charge once a year. It includes a brain MRI scan, brain CT scan, carotid artery echocardiography test, etc.
As a result, the concept of a routine annual physical examination is a way of life in Japan.
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By the numbers: While required for some, annual physical exams - including ningen dokku testing - are a choice for many in Japan.
Cost: Because the physical examination is not covered by insurance, the patient is responsible for the entire cost. In other words, the patient must pay out of pocket. The cost of a complete medical examination varies depending on the scope and the medical institution, but generally ranges from 30,000 yen (US$187) to 50,000 yen (US$311) for a one-day course, and from 40,000 yen (US$249) to 100,000 yen (US$623) for a two-day program including overnight hospital stay, which in practice may turn out to be a voucher for lodging at a bare-bones "business hotel" such as the Toyoko Inn (see "Ode to the Toyoko Inn: Try Staying at Japan's Undisputed Leader in the No-Frills Hotel Experience and You, Too, May Be Inspired to Praise This Chain for Its Superior Value" for an idea of what to expect).
However, one’s local government often subsidizes the cost, as in my case. Including lunch, my entire battery of tests cost only 15,234 yen ($95), which seems like a very reasonable annual investment in my own health. I am committed to doing this year after year at the same facility so that the doctors there can detect any changes in the short to medium term. At the hospital where I got this check up, 3 years of test results show up in every report.
Some companies may offer subsidies to cover all or part of the cost of a physical examination. Some private medical and life insurance companies offer discounts for such checkups.
Cancer Screening Rate: It turns out that not everyone who should get tested does. A poster hanging in the waiting room cited the following statistics from 2019:
Men: 48% nationally for stomach cancer, 48% for colorectal cancer, and 53% for lung cancer.
Women: 37% for stomach cancer, 41% for colorectal cancer and 46% for lung cancer, 47% for breast cancer and 44% for cervical cancer.
I would have thought these rates would be higher. The rates for my city were listed and they were lower than the national average, which is concerning.
Rate of Discovery of Cancer from Testing: At the facility where I underwent my exam, the rates for all types of cancer for both men and women were very low (<1%) in every year from 2016 to 2020, which was somewhat surprising. While these results are ultimately good news, they raise questions about the effectiveness of the tests, or at least whether the people most at risk for these diseases are being tested.
Commentary: As good as the ningen dokku wellness screenings are, it seems that some important tests are not included. For example, while a gastroscopy or even a barium contrast test is probably sufficient for early detection of stomach cancer, I would have thought that the following types of tests would have been included:
Low-dose CT scans for lung cancer screening
High-sensitivity prostate-specific antigen (PSA) test for prostate cancer screening
Colonoscopy for colorectal cancer screening
Human papillomavirus (HPV) testing for cervical cancer screening in women
These tests may be included as part of a second, more detailed screening if something is found in the first round of tests.
What’s next: As the old saying goes, "it ain't over till it's over," it's too soon to know for certain if I'm really okay. Further tests may reveal an abnormality. However, as I mentioned at the beginning, the doctor told me that although there is room for improvement, I am reasonably healthy and he doubts that any abnormality will be discovered (knock on wood).
If anything out of the ordinary does show up in the final report, a repeat of some or all of the tests will be recommended. In some cases, a detailed examination or seimitsu kensa (精密検査) could be required. Surgical or pharmacological treatment may be necessary. For example, if a stomach ulcer is found during a gastroscopy, a test to check for H. pylori and the condition of the stomach lining would be required.
In addition, some patients are asked to change their lifestyle (e.g. stop smoking, go on a diet, exercise more, reduce alcohol consumption, get more sleep, etc.).
Thanks to my consultation with the nutritionist, I now have a new weight goal that seems realistic. The dietitian gave me advice on how best to change my diet. More fish, vegetables, and tofu will be on the menu, which should not be too difficult to achieve while living in the Japanese countryside!
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What do you think? As a resident of Japan, do you get a medical checkup every year? Is it worth the time and expense? All answers are completely anonymous, even to the author.
#AnnualPhysical #PreventiveCare #WellnessCheckup #Checkup #EarlyDetection #DiseasePrevention #HealthScreening #PreventiveMedicine #人間ドック #生活習慣病 #早期発見 #健康診断 #検診 #精密検査 #ウェルネス検診 #予防医療
While the derivation of the term ningen dokku is somewhat unclear, it means "medical examination," “wellness screening,” or "physical examination.” The original basis seems to be the application to humans of a dry dock as a place to examine and repair ships.
You are probably familiar with this particularly fun test where a puff of air is shot into your eye. It's one of my favorites! Just kidding!
There are serious concerns about the tendency for patients to become constipated after barium contrast tests. At least one advantage of avoiding this test is that there would be no need to down a barium "milkshake," which of course is nothing like a real milkshake except for the fact that people often end up with a white "milkshake mustache" on their upper lip after drinking this concoction just before the actual tests. I once walked around for about three hours with such a "milkshake moustache" as I went from test to test among at least 100 other patients at a busy wellness screening facility in Tokyo. Not one person bothered to tell me that I had one! It was only at the end of the day when I reached the locker room to change out of my pajamas that I saw myself in the mirror. That must have been some good theater!
Anyway, the barium test is no fun either. It requires you to climb on top of a giant machine that spins your body while using gravity to slosh the barium milkshake around in your upper gastrointestinal system to make sure the barium contrast material shows up clearly on an X-ray video called a fluoroscopy. It literally requires the patient to stand upside down, albeit briefly.
Ankake is a thick, starchy sauce made from kuzu or katakuriko flour.
Nurse Ratched is a fictional character in the 1962 novel and subsequent film adaptation One Flew Over the Cuckoo's Nest. In American culture, the image of Nurse Ratched has become a stereotype of a tyrannical female nurse who exerts extreme control over her patients.
I go every year and my university foots the bill. It’s not much fun, but if there’s an issue I’d rather nip it in the bud, as you wrote.
Lung test? Lunch?! I'm in the cohort that has the whole operation brought to my workplace, lock stock and X-ray van. Great way to get talking to colleagues you hardly ever see, waiting in the blood test line.
Great system, and (presumably with actuaries going over huge data sets) it's interesting what questions/factors actually contribute to longevity. Smoking and drinking obviously, but also whether you eat within 2 hours of sleeping, or walk faster than the average person.