When you feel unwell in Japan, your first instinct might be to seek out the largest, most well-equipped hospital nearby.
It seems logical—better technology, more specialists, right?
However, if you show up at a major hospital without a specific document called a “Referral Letter” (Shoukai-jou), you may face a harsh reality: being turned away at the counter or being charged a significant additional fee.
To navigate the Japanese healthcare system smoothly, you need to understand how it is structured.
1. The Golden Rule: Start at a Local Clinic
The Japanese medical system has a very clear division of labor:
- Local Clinics (診療所/医院 – Shinryojo/Iin): These are for common illnesses like colds, stomach aches, minor injuries, and initial consultations.
- Large General Hospitals (総合病院 – Sogo Byoin): These are reserved for advanced surgeries, complex tests, and inpatient treatment for serious conditions.
In Japan, your first point of contact should always be a small clinic near your home or office. Japanese people call this their “Family Doctor” (Kakaritsuke-i).
2. The “Referral Letter” is Your Passport to the Hospital
If a clinic doctor decides that your condition requires more specialized equipment or advanced testing, they will write a “Referral Letter” (紹介状 – Shoukai-jou) for you.
This letter is more than just a piece of paper; it contains your medical history and test results.
Think of it as a “Trust Transfer” from one doctor to another. With this letter, your transition to a large hospital will be seamless, and you won’t have to repeat unnecessary tests.
3. No Referral? Expect a “Refusal” or a “High Fee”
This is the part where many foreign residents encounter trouble.
If you go directly to a large hospital (specifically “Advanced Treatment Hospitals” or those with over a certain number of beds) without a referral, one of two things will likely happen:
- You May Be Refused (The “Door-to-Door” Rejection): Nowadays, many large hospitals operate on a “Complete Referral & Appointment System.” Without a referral, they may simply refuse to see you that day. You might travel all the way there only to be told at the reception to “Go find a local clinic first.”
- High Additional Fees (Sentei Ryouyou-fui): Even if the hospital agrees to see you, you will be required to pay a “Selection Medical Care Fee” on top of your standard medical costs. Depending on the hospital, this fee usually ranges from 7,000 to 10,000 yen and is not covered by insurance.
This strict rule exists to ensure that clinics handle minor cases while large hospitals focus on life-threatening or serious conditions.
Important to Note: This is not a rule specifically for foreign residents. Japanese citizens are subject to exactly the same regulations and must also provide a referral letter or pay the additional fee to access large hospitals. We all navigate the same system to keep healthcare efficient for everyone.
4. IMPORTANT: The Exception for Emergencies
There is one major exception to these rules: True Emergencies.
If you are in a serious accident, lose consciousness, experience severe chest pain, or have any life-threatening condition, do not worry about referral letters or extra fees. The Japanese medical system is designed to prioritize emergency patients at large hospitals. In such cases, call an ambulance (119) or go directly to the emergency room (Kyukyu Gairai).
The “clinic first” rule applies only to cases where you are well enough to walk into a hospital yourself for a consultation.
Conclusion: A System Built on “Social Consideration”
The Japanese medical system might seem inflexible or cold at first glance.
However, at its heart, it is built on a sense of “Social Consideration” (Omoiyari).
By directing minor cases to clinics, the system ensures that medical resources are always available for the people who need them most.
Finding a reliable local clinic (such as an Internal Medicine clinic, or “Naika”) should be your first step toward a safe and healthy life in Japan.
From the Author
Just like this hospital rule, there are many “invisible systems” in Japan that no one explicitly explains to you. These range from administrative procedures to unspoken social expectations.
I am currently creating a special guide to help foreign residents navigate these “invisible walls” and live in Japan with peace of mind.
It won’t be a typical manners book—it will be a survival guide for your real life in Japan. Stay tuned!