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92 chapter five Our Diabetes Diabetes in the Japa­nese Exam Room It was 8:40 a.m.; Dr. Saito and Nurse Kurokawa ­were ahead of schedule. Outpatient hours did not begin for another twenty minutes and we had already reviewed the schedule for the day and checked the electronic medical rec­ ords for the first appointment of the morning. For Dr. Saito, the pe­ tite internist in charge of the hospital’s new type 2 diabetes clinic, this was a rare opportunity to relax during her workday, usually packed with morning outpatient hours, after­ noon inpatient ser­ vice rounds, and a new diabetes education program—­not to mention the endless series of meetings that are part of the real­ity of Japa­nese clinical practice. Dr.Saitowasnotinterestedinrelaxing.Shecheckedherwatchandlooked at her nurse, an experienced ­woman at least fifteen years her se­nior. “I won­ der if ­there’s time to visit the dialysis center?” she asked. She had been worried about a par­ tic­ u­ lar hemodialysis patient all week, ever since Nurse Kurokawa told her that she had heard from the nurses staffing the dialysis center that he had been having difficulties with “self-­ management” (jiko kanri). The three of us left the outpatient clinic. As we walked to the elevator bank, Dr. Saito explained the situation. ­ There was some question as to­ whether or not the patient, Ichiro, should be admitted as an inpatient. He was undergoing dialysis three times a week and had a home nurse ­ every morning to help him administer insulin injections. Even with ­ these aids, however, Ichiro was not controlling his blood sugar and was thought to be a nonadherent patient. Nurses reported that he was known to eat lunch in the hospital dining hall ­ after each dialysis treatment, where he would fill his coffee mug three-­quarters of the way with coffee, then pour in creamer and sugar to the top. Further, ­because he lived alone, ­there was no way to enlist the help of a wife or ­ daughter to manage his eating, drinking, and insulin. The best ­thing, Dr. Saito explained, might be to admit him so that he could spend more time at the hospital learning how to ”manage” himself. Arriving at the dialysis center, we met Ichiro. I had expected someone old or infirm, but Ichiro was middle-­ aged, perfectly lucid, and did not appear physically infirm beyond the usual way that dialysis patients’ bodies seem Our Diabetes 93 tired. The visiting nurse, dialysis center nurses, and doctors had been keeping a handwritten notebook for him in a style akin to—­but separate from—­ inpatient charts, which a nurse brought over for Dr. Saito as she consulted with the patient. ­Because patients receiving dialysis in Japan are required to temporarily check in to the hospital and occupy a bed, Ichiro remained prone during the entire consultation. Dr. Saito returned to the nurses’ station ­ after her short chat with the patient . ­ There, one of the nurses told her that a se­nior male physician had informally expressed concern about Ichiro’s be­ hav­ ior. Ichiro would wander into the same dining hall used by the medical staff in order to find creamer, so many of the staff ­were aware of his troubling coffee condiment consumption . This seemed to make up Dr. Saito’s mind; she squared her jaw and nodded her head. Ichiro would be admitted to the hospital. Approaching Ichiro’s bed again, Dr. Saito reproached him for the repeated creamer incidents using a formal speech register. The patient laughed ner­ vously and looked down at his hands. She frowned at him. In a moment, Dr. Saito was back to her usual, cheerful demeanor. She delivered the news. “Well, let’s admit you,” she said. (“Dewa, nyuuin shimashou.”) As we left, Dr. Saito explained that Ichiro would be admitted for the sake of controlling his blood sugar, in part through diet. He would be encouraged to attend the diabetes classroom and possibly learn to better manage his blood sugar and lifestyle. I asked if he was being admitted for bad be­hav­ior. “Yes, I suppose so,” she replied. “It’s best to admit him ­because his be­hav­ior is making him more sick.” Ichiro was admitted as an inpatient explic­ itly ­ because he was judged incapable of successfully managing his disease on his own, despite being literate , articulate, not suffering from known cognitive deficit or ­ mental disorder, and not being in acute danger. In the United States, admitting...


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