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"Patients who Don't Listen" And "Medical Staff who Are Inflexible"
Cultural Anthropology in the Medical Workplace

Maho Isono
Assistant Professor, Faculty of Letters, Arts, and Sciences, Waseda University

Patients who don't listen

"My blood pressure only goes up when the doctor comes."
"You measure my blood pressure so many times, so it's bound to be 120 at least once."
"I wonder if it's all right to keep taking all these pills until I die?"

Mr. Suzuki (name changed, aged 72) usually has a blood pressure of over 150 during examinations. The doctor points out to him the need to lower this figure, but Mr. Suzuki finds all kinds of reasons to deny that his blood pressure is too high.

The single reason for Mr. Suzuki's high blood pressure is valvular disease. Although he displays hardly any subjective symptoms, his laboratory test results have reached the level where he needs surgery. The doctor recommends early surgery because of the concern about the short life expectancy of patients who do show symptoms, but Mr. Suzuki will not give his consent. "I can't really make such a decision" he says, continually evading the doctor's advice.

He may as well stop visiting the hospital if he ignores the doctors so much. And yet he dutifully continues to attend examinations.

In short, Mr. Suzuki is a patient who doesn't listen.

The history of the "patient who doesn't listen"

However, Mr. Suzuki has the following background.

Just as he reached retirement age, he lost his only son. The son had been born after a series of miscarriages, but at 29 years old he was told he had a brain problem. When he went into hospital for tests, however, he contracted an unexplained fever and passed away.

"They kept doing more and more tests, but I should have brought him home right away" mutters Mr. Suzuki with his head held low. "No wonder I'm afraid of hospitalization."

That's why Mr. Suzuki cannot trust medicine. Aren't generic drugs being recommended by the government in order to bring down medical costs? And aren't skin rashes caused these days because he has taken the same drug for a long time? Mr. Suzuki distrusts drugs in such a way.

Although he is afraid of medicine and being admitted to hospital, Mr. Suzuki is also scared that the valvular disease could get worse anytime and lead to his death. So he sometimes thinks about consenting to the surgery. But although surgery could add ten years to his life, he also wonders what the point is of living that much longer.

Mr. Suzuki keeps coming to the hospital even though he denies he has high blood pressure and refuses surgery, but behind this behavior is a distrust of medicine born from the grief of his son's death. There is a conflict in his mind between fear and acceptance of his own death.

Medical staff who are inflexible

"Why did you eat? You were told not to, weren't you?"
"But I love nata de coco more than anything else in the world!"
"It doesn't matter how much you like it, you mustn't eat at the moment!"

This was the conversation that took place in the ward one evening between a nurse, Ms. Itoh (name changed), aged 26 at the time, and Mr. Hirabayashi (name changed, aged 73), a hospitalized patient with terminal liver cancer. She had discovered an empty cup of nata de coco jelly in his trashcan.

Not long after this incident, Mr. Hirabayashi passed away.

An inflexible medical professional, giving a stern warning to a patient who had very little time left to live rather than letting him eat what he wanted to eat - that is the impression Ms. Itoh may have given to the other patients at the time.

The feelings of medical staff who are inflexible

But the nurse's words were concealing something else.

Mr. Hirabayashi had repeatedly been admitted to hospital and was on the ward's blacklist.

His friends in the ward had put him in a wheelchair and sneaked him into the smoking room. And forbidden sweet wrappers had frequently been found in his trashcan.

For a terminal liver cancer patient, food is a matter of life or death. Depending on what the patient has eaten, ascetic fluid can rapidly accumulate and lead to breathing difficulties, or varicose veins that have formed in the esophagus due to the liver cancer can burst. Mr. Hirabayashi was restricted from eating snacks freely between meals, and things like nata de coco were out of the question.

Mr. Hirabayashi disobeyed all the doctor's instructions, and nurses were always told in meetings to continue warning him about his risky behavior.

Meanwhile Mr. Hirabayashi's condition became progressively worse. Ascites made his stomach swell out like a pregnant woman, his limbs became skinny, he could hardly walk and he was breathing so weakly. The medical team judged his life to be at risk and decided to visit his bed before all other patients and check his condition every other hour.

The nata de coco incident occurred in the midst of this strained mood within the whole team.

How could he have eaten such things while they were so concerned about him and his life was so at risk?

Behind Ms. Itoh's strong words of warning were the team's unexpressed feelings of frustration and sadness.

Now aged 34 and a dependable figure in her profession, Ms. Itoh often repeats this story when she hears other staff talking about how a patient's medical condition is worsening because he or she hasn't been following medical orders. "Why could I only respond with a warning when the patient wanted to eat something he loved?" she asks. "Why didn't I say that although it was impossible to eat all of it, perhaps he could try a little?" The episode with Mr. Hirabayashi has turned her into what she is today, a nurse who is willing to sympathizes with her patients' feelings.

But she says that even if she had held such a view on nursing when she was 26, she would have been unable to propose that they let him eat what he wanted to. Not being the nurse in charge and having little experience, she would have found it difficult to make such a suggestion that was known to be dangerous. Medical teams hold responsibility for the lives of their patients, and Ms. Itoh's entire team would have been responsible if Mr. Hirabayashi's condition had worsened as a result of what only she had said.

Patients as people, medical staff as people

Behind the communication between staff and patients at the medical workplace, medical personnel frequently have feelings and conflicts that are not expressed to their patients, while patients often experience confusion and hesitation that are not told to medical personnel.

However, I cannot find much value in trying to reduce misunderstandings between medical staff and patients by changing all voices that cannot be heard into voices that can be heard.

We can never fully describe the state of our mind no matter how many words we use, and so some unexpressed feelings always remain. And there is always the possibility that those remaining feelings are in fact our true feelings.

Rather than trying to see everything and thereby thinking we understand everything, I would like to believe that within the parts we cannot see or understand there exist human gentleness, vulnerability, and thoughtfulness toward others. I seek hope in the fact that patients and medical staff are all just fellow human beings, each with their own strengths and weaknesses, learning everyday from their mistakes.

There are probably some patients and medical staff who are indifferent to human pain. But at least the patients and medical staff I have met to date as a cultural anthropologist have all been kind-hearted people.

Maho Isono
Assistant Professor, Faculty of Letters, Arts, and Sciences, Waseda University

After studying exercise physiology at the School of Human Sciences, Waseda University, she obtained a master's degree in applied anthropology at Oregon State University followed in 2010 by a doctorate in literature at the Graduate School of Letters, Arts and Sciences, Waseda University. Her fields of specialization are cultural anthropology and medical anthropology.
She conducts cultural anthropology in the medical field, including psychosomatic illness and doctor-patient interaction. Her main written work is: "Eating disorders not talked about in medicine: An anthropological investigation into food in eating disorders" [Iryo no Kataranakatta Sesshoku Shogai: Sesshoku Shogai no Shoku no Bunka Jinruigakuteki Tankyu] (PhD dissertation, 2010)