You were initially trained in Japan. You did your first surgical residency in Japan. Dr. Anton Titov, MD. Doctors in every country have different approaches to interaction with patients. Doctors select an appropriate treatment differently too. Dr. Anton Titov, MD. What are some of the differences between Japan and the United States in terms of how medicine and surgery is done? Perhaps you could discuss some differences in communications between doctors and patients in both Japan and Unites States. Dr. Tsuyoshi Kaneko, MD. I can start with the doctor-patient relationship. In Japan doctor-patient relationship is very paternal. Dr. Anton Titov, MD. The patients seek opinion from the doctors. Patients often follow what they are being told, because physician is "the father". The relationship is very very paternal. Dr. Tsuyoshi Kaneko, MD. The Japanese physicians tend to tell their opinion. The patients tend to accept them relatively easily. On the other hand, United States is different. I see the patient-doctor relationship in the United States in this way. A physician is more of a consultant. Many patients, especially in the Northeast of the United States [Boston, New York] are very well-educated. They actually study very well prior to seeing their own physician. The patient-doctor relationship here is more of a consultant-client. We get asked a lot of questions. We give recommendations. But it is up to patients whether they follow the recommendation. Or they can seek a medical second opinion if they don't like it. The concept of second opinion is trying to infiltrate in Japan. Dr. Tsuyoshi Kaneko, MD. But doctor-patient relationship in Japan is very paternal. I think medical second opinion is not really infiltrating as fast as many thought. A lot of patients in Japan tend to go to the doctor and just follow doctor’s recommendations. I think that has positive and negative sides. For the doctors, you can freely recommend what you think is correct. But it really puts the doctors in tough spot. Because they have to take the responsibility for all of their recommendations. The negative side of paternalistic patient-doctor relationship exists. If the doctors are not really thinking about patient's interest, then it can really harm the patient. I think it does have pros and cons. Dr. Tsuyoshi Kaneko, MD. It's very hard for me to say, which side is better. Let’s discuss the structure of training of surgeons. Japanese surgeons are very very hierarchical. They are much like the Europeans. They have one professor, who is the "big boss”. All other physicians have to follow the boss's lead. Dr. Anton Titov, MD. United States is different. Here we do have Division Chiefs, we have Department Chairs. But we are all individual surgeons under the Division Chiefs. So we are all treated equally. We have the voice to speak up to our Chiefs. That usually does not happen in Japan. It is much much more hierarchical. However, I did hear recently that hierarchy has been changing a little bit. Surgery training is trying to be more like United States format. But it's still ongoing process. I think Japan remains to be a very hierarchical community. Patients might seek a second opinion. But it is not because they disagree with their physician. It is because they just want to make sure that what doctors are recommending is correct. Patients try to learn about their disease through expert medical opinion. Dr. Tsuyoshi Kaneko, MD. Absolutely! Medical second opinion is not necessarily contradicting the treatment course that patients are prescribed. Dr. Anton Titov, MD. Medical second opinion allows a patient to be more proactive. Patient is learning and having more confidence. Therefore, the patient is following the recommended treatments better. Correct. But in a paternal world, I think medical second opinion is viewed as a rebellion against the recommendation. You are going against "your father". Dr. Tsuyoshi Kaneko, MD. I think that is a reason why medical second opinion is not viewed similarly as getting second opinion is viewed in the United States. In Japan, medical second opinion can be considered a rude rather than a smart move. Dr. Anton Titov, MD. Thank you for illuminating the differences between relationships between a patient and a physician in Japan and in the United States. It is important to make medical decisions with the cultural standpoint in mind.