読者です 読者をやめる 読者になる 読者になる

Health, justice and a good life

地域での診療とヘルスポリシー研究、政策実践を横断中。

さて、いつ死ぬのか

ああ、今日も生きていた。

そうぼんやり考えながら目が覚める。時々、涙がでている。

日常的に死に関わる医療職の方なら、ときどきこういう朝がある。

生きている、しかも平気で生きていることは40歳を越えると結構難しい。

「悟りという事は如何なる場合にも平気で死ぬる事かと思って居たのは間違いで、悟りという事は如何なる場合にも平気で生きて居る事であった」正岡子規『病牀六尺』

僕の場合は、こういう時に何人かの既に会うことのできない友人や患者さんを思い出す。

そして自分の番はいつなのか、と考えながら、重たい身体を起こすのだ。

ノーベル物理学賞の報道があってから、戸塚洋二先生の本を読み返している。

 研究者なら、自分の研究に没頭して、先端で成果をあげる先生の生き方に強く共感するところがあるだろう。”We will rebuild the detector. There is no question.”で始まる、スーパーカミオカンデの事故のストーリーは、何度読んでも胸が熱くなる。身体に変調や疾病があっても、それはそれで人生を形作るひとつの要素でしかない。いつ命がなくなるとも知れないのなら、自分はどの程度の濃度や速さで生きていくのか。生き急ぐこと、それ自体が命を縮めることはないのか…と迷わずに、花が咲くように、赤子が泣くように、一途に生きよと伝わってくる。

 

別れの季節

年度末は異動や引っ越しで別れの挨拶がおおく、海外移動組は4月に入ってもその時期がつづいている。クリニックでも、単身赴任されている方がご家族の元に戻るときなどは、大きく生活環境が変わることから、今後の対策などを話し込んでしまい、結構外来時間が長くなってしまうこともある。ほっとしているような、自由な時間が少なくなる窮屈さを感じているような、複雑な表情でいるお父さん達と話すのは、人生の先輩方の生き方を伺うようで結構好きだ。

昨日の外来では、いつも家族でクリニックを利用してくれてる男の子が、家族と海外赴任するとハリキっていた。どこまでわかってるのかなーと思いながら、「きっとたのしいぞー」と声をかける。健診を担当している保育園にも通っていた子だから、その慎重な性格と、妹が生まれてからの成長も頼もしくみていたので、とても寂しい。保育園での英語の歌も大きな声で歌えていたから、きっと大丈夫。そうココロでいいながら、診察室を出ても、手を振り合う。予防接種も定期のものはすんでいるし、皮膚のケアさえすれば、健康もお墨付きだ。さあ、海外での生活は、泣きたくなることもあるかもしれないが、ぐっと踏ん張って。帰ってくるという数年後にまた会えるのがとても楽しみだ。

コミュニティの年輪論

覚え書き。

この年輪論のようなものを在宅訪問診療でずっと考えていた。

在宅訪問診療では、医師の位置はかなり外で、患者さんと家族が中心にあり、訪問看護師と介護士、ケアマネほかがその外を包む。特に自分のように、「つながり」が苦手な家庭医は、力のある方々のサポートにまわる。

machihoiku.jp

家庭医療や総合診療の戦略

まとめず、つれづれに。

以前、非常に優秀な戦略コンサルタントの方に

「家庭医療っていうのは、戦略的に負けるコンテンツなのだ」という主旨のお話しを伺ったことがある。「総合的」や「包括的」の部分が広報やプロジェクト組成しにくかったり、経営的に利益を出しにくいかつ政策依存的(診療報酬の動向に左右されやすい…)な収益構造だったり、日頃悩んでいるところをさらっと指摘されてしまったと直感的に感じたのを覚えている。もんじゃ焼きをつつきながらの話しだったので、その後銀座のおねえさんや新宿の飲み屋の話しにながれてしまい、詳細を聞きそびれたのだが、ずっとそのことが頭にひっかかっている。

家庭医側からすると、診断と治療を基本としながら、予防もやるし地域包括も関わる(主役は地域ではたらくの保健福祉の専門家達だけども)、必要な検査や病院紹介もアレンジして、もどってこられたらまた継続的に関わる。ケアもキュアもどっちもつかって、関わる方の健康や生活の支援に妥協しない、年齢や性別、疾病で分けず、どういった健康問題に関しても自分のできる範囲で対応する、外来で間口を大きくとり、訪問診療というオプションも準備している、という感じだ。

医療や健康が人生の中心にあるのは本意ではない、しかし不注意や無知、構造の不備や支援のミスマッチなどで苦痛や苦難を被るのはごめん願いたい、そういう思いだ。あっ、これは思いなのだな。

最近は「予防医学専門家」や「地域・コミュニティ専門家」といった新しい”専門家”がでてきているが、そのあたりもぐっと自分の診療圏にとどまって、自分の診療を積み重ねていく家庭医とちょっと違って、面白くみている。予防の範囲からはみ出ようと、地域と関係なくても、家庭医・総合診療医はしつこくあきらめないけれど。地味すぎる。

現在診療している地域では、医療機関が非常に非常にたくさんあるので、患者さん達も自由に?使ってくださり、

「午前中に他の診療所にかかったのだけど、これどう思う?」(2児の母)

といった、時々当院にかかる方の電話相談が診療時間内にくる、ということがよくある。クリニック事務の方も非常に優秀なので、適宜情報収集して、必要ならさらっとこちらに回してくれる。英国なんかは医師による電話相談の時間を設けたりしているみたいだけれども、まあ、担当させていただいている患者さんの範囲では、診療時間中でも十分に対応できる。そういうフリースタイルな感じが、日本の家庭医療・総合診療の現状だし、いいところだと思う。一方で、例えばまだ2週間毎の受診を全ての患者さんに強いる診療所もあったりして、経営者的発想としては合理的なのかもしれないが、優先順位が違っていることもよく聞くのが負の側面か。

パッケージとして出しにくい家庭医療や総合診療の戦略だけれども、最近所属する医療法人に「家庭医療専門医」や「認定医」が複数就職されていて、ああ、家庭医療・総合診療人材の育成を粛々とすすめていた先人達の戦略が、粛々と効果をあげていることを感じている。合理的な経営戦略にはのらないけれど、気がついたら周囲が家庭医だらけな人材戦略が、時間の力もかりながら最後には成果をあげていくとみている。これを見据えて10年以上も活動している方々を非常に尊敬している。

 

日本の疾病登録

f:id:tarogo:20150102130043j:plain

(この投稿は執筆中です)

お正月の京都は61年ぶりの大雪で、車の轍を、毛糸の帽子をかぶりながらポケットに手を突っ込んで通勤すると、北海道やボストンを思い出します。冬の間はマイナス21℃とかだったよなあ。吐く息の白さとともに、そのときの自分の気持ちもよみがえってきます。若かったなあ。

さて、先ほど日本の疾病毎にかかる医療費の推計について話しながら、人口集団ごとの疾病とその経過について知ることができる疾病登録にはどのようなものがあるかが話題になりましたので、以下に記録しておきたいと思います。

(順次、追加していきます) 

がん

 【地域がん登録】

地域がん登録全国協議会 + Japanese Association of Cancer Registries

【院内がん登録】


院内がん登録:[がん情報サービス がん診療連携拠点病院の方へ]

脳卒中

循環器疾患(脳卒中を含む場合あり)

感染症

特定疾患

 

 

Steve Jobs: Stanford commencement address, June 2005

f:id:tarogo:20150103074733j:plain

英語から日々遠くなっている。

30歳になってから英語で話し始めたので、小学生のようにあうあう言うだけだけれど、自分の考えを英語で表現して議論するとすっきりすることが多く、筋トレのようにできるだけ毎日使う習慣をつけたいと、新年の誓いを立てる。

さて、毎日読むテキストのひとつをうつしておきたい。この中の表現をいろんなところで使った思い出も残るスピーチ。さあ、今日も読みますか。

このスピーチ自体は2005年のもので、私が留学準備を始めた年に、臨床医からヘルスポリシー研究へ新たな舵を切り、海図なき領域にでる不安を、なんだか小賢しくなっているんちゃうか、腹からでてくる自分の信念にしたがうのだ、と後押ししてくれたものです。この時点でJobsは膵内分泌腫瘍の手術から快復し、Appleで勢いのある仕事をされていましたが、その後の健康を考えると改めて感じるところがありますね。このあと、この病気が原因でJobsは亡くなっていますから。いくら才能や経験や、そして圧倒的な財力があっても、「がん」から全く快復することは難しい。最近、診療をしていて感じていた「がんのプライマリ・ケア」への関心も高まります。外来診療しているときに意識を高め、知識や技術をまとめて共有し、広めていきたい。

そういえば、Macをつかっているヒトは、Finder→「移動」メニューの中にある「フォルダへ移動」、もしくは「Shift」+「Command」+Gのキーボードショートカットで下記パスを入力すると…

/Applications/Pages.app/Contents/Resources/

Apple.txt」と書かれたテキストファイルのなかに、このStanford commencement address, June 2005が隠れています!

本年もよろしくお願いいたします!


Text of Steve Jobs' Commencement address (2005)

I am honored to be with you today at your commencement from one of the finest universities in the world. I never graduated from college. Truth be told, this is the closest I've ever gotten to a college graduation. Today I want to tell you three stories from my life. That's it. No big deal. Just three stories.

The first story is about connecting the dots.

I dropped out of Reed College after the first 6 months, but then stayed around as a drop-in for another 18 months or so before I really quit. So why did I drop out?

It started before I was born. My biological mother was a young, unwed college graduate student, and she decided to put me up for adoption. She felt very strongly that I should be adopted by college graduates, so everything was all set for me to be adopted at birth by a lawyer and his wife. Except that when I popped out they decided at the last minute that they really wanted a girl. So my parents, who were on a waiting list, got a call in the middle of the night asking: "We have an unexpected baby boy; do you want him?" They said: "Of course." My biological mother later found out that my mother had never graduated from college and that my father had never graduated from high school. She refused to sign the final adoption papers. She only relented a few months later when my parents promised that I would someday go to college.

And 17 years later I did go to college. But I naively chose a college that was almost as expensive as Stanford, and all of my working-class parents' savings were being spent on my college tuition. After six months, I couldn't see the value in it. I had no idea what I wanted to do with my life and no idea how college was going to help me figure it out. And here I was spending all of the money my parents had saved their entire life. So I decided to drop out and trust that it would all work out OK. It was pretty scary at the time, but looking back it was one of the best decisions I ever made. The minute I dropped out I could stop taking the required classes that didn't interest me, and begin dropping in on the ones that looked interesting.

It wasn't all romantic. I didn't have a dorm room, so I slept on the floor in friends' rooms, I returned coke bottles for the 5¢ deposits to buy food with, and I would walk the 7 miles across town every Sunday night to get one good meal a week at the Hare Krishna temple. I loved it. And much of what I stumbled into by following my curiosity and intuition turned out to be priceless later on. Let me give you one example:

Reed College at that time offered perhaps the best calligraphy instruction in the country. Throughout the campus every poster, every label on every drawer, was beautifully hand calligraphed. Because I had dropped out and didn't have to take the normal classes, I decided to take a calligraphy class to learn how to do this. I learned about serif and san serif typefaces, about varying the amount of space between different letter combinations, about what makes great typography great. It was beautiful, historical, artistically subtle in a way that science can't capture, and I found it fascinating.

None of this had even a hope of any practical application in my life. But ten years later, when we were designing the first Macintosh computer, it all came back to me. And we designed it all into the Mac. It was the first computer with beautiful typography. If I had never dropped in on that single course in college, the Mac would have never had multiple typefaces or proportionally spaced fonts. And since Windows just copied the Mac, it's likely that no personal computer would have them. If I had never dropped out, I would have never dropped in on this calligraphy class, and personal computers might not have the wonderful typography that they do. Of course it was impossible to connect the dots looking forward when I was in college. But it was very, very clear looking backwards ten years later.

Again, you can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future. You have to trust in something — your gut, destiny, life, karma, whatever. This approach has never let me down, and it has made all the difference in my life.

My second story is about love and loss.

I was lucky — I found what I loved to do early in life. Woz and I started Apple in my parents garage when I was 20. We worked hard, and in 10 years Apple had grown from just the two of us in a garage into a $2 billion company with over 4000 employees. We had just released our finest creation — the Macintosh — a year earlier, and I had just turned 30. And then I got fired. How can you get fired from a company you started? Well, as Apple grew we hired someone who I thought was very talented to run the company with me, and for the first year or so things went well. But then our visions of the future began to diverge and eventually we had a falling out. When we did, our Board of Directors sided with him. So at 30 I was out. And very publicly out. What had been the focus of my entire adult life was gone, and it was devastating.

I really didn't know what to do for a few months. I felt that I had let the previous generation of entrepreneurs down - that I had dropped the baton as it was being passed to me. I met with David Packard and Bob Noyce and tried to apologize for screwing up so badly. I was a very public failure, and I even thought about running away from the valley. But something slowly began to dawn on me — I still loved what I did. The turn of events at Apple had not changed that one bit. I had been rejected, but I was still in love. And so I decided to start over.

I didn't see it then, but it turned out that getting fired from Apple was the best thing that could have ever happened to me. The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.

During the next five years, I started a company named NeXT, another company named Pixar, and fell in love with an amazing woman who would become my wife. Pixar went on to create the worlds first computer animated feature film, Toy Story, and is now the most successful animation studio in the world. In a remarkable turn of events, Apple bought NeXT, I returned to Apple, and the technology we developed at NeXT is at the heart of Apple's current renaissance. And Laurene and I have a wonderful family together.

I'm pretty sure none of this would have happened if I hadn't been fired from Apple. It was awful tasting medicine, but I guess the patient needed it. Sometimes life hits you in the head with a brick. Don't lose faith. I'm convinced that the only thing that kept me going was that I loved what I did. You've got to find what you love. And that is as true for your work as it is for your lovers. Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven't found it yet, keep looking. Don't settle. As with all matters of the heart, you'll know when you find it. And, like any great relationship, it just gets better and better as the years roll on. So keep looking until you find it. Don't settle.

My third story is about death.

When I was 17, I read a quote that went something like: "If you live each day as if it was your last, someday you'll most certainly be right." It made an impression on me, and since then, for the past 33 years, I have looked in the mirror every morning and asked myself: "If today were the last day of my life, would I want to do what I am about to do today?" And whenever the answer has been "No" for too many days in a row, I know I need to change something.

Remembering that I'll be dead soon is the most important tool I've ever encountered to help me make the big choices in life. Because almost everything — all external expectations, all pride, all fear of embarrassment or failure - these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.

About a year ago I was diagnosed with cancer. I had a scan at 7:30 in the morning, and it clearly showed a tumor on my pancreas. I didn't even know what a pancreas was. The doctors told me this was almost certainly a type of cancer that is incurable, and that I should expect to live no longer than three to six months. My doctor advised me to go home and get my affairs in order, which is doctor's code for prepare to die. It means to try to tell your kids everything you thought you'd have the next 10 years to tell them in just a few months. It means to make sure everything is buttoned up so that it will be as easy as possible for your family. It means to say your goodbyes.

I lived with that diagnosis all day. Later that evening I had a biopsy, where they stuck an endoscope down my throat, through my stomach and into my intestines, put a needle into my pancreas and got a few cells from the tumor. I was sedated, but my wife, who was there, told me that when they viewed the cells under a microscope the doctors started crying because it turned out to be a very rare form of pancreatic cancer that is curable with surgery. I had the surgery and I'm fine now.

This was the closest I've been to facing death, and I hope it's the closest I get for a few more decades. Having lived through it, I can now say this to you with a bit more certainty than when death was a useful but purely intellectual concept:

No one wants to die. Even people who want to go to heaven don't want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life's change agent. It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away. Sorry to be so dramatic, but it is quite true.

Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

When I was young, there was an amazing publication called The Whole Earth Catalog, which was one of the bibles of my generation. It was created by a fellow named Stewart Brand not far from here in Menlo Park, and he brought it to life with his poetic touch. This was in the late 1960's, before personal computers and desktop publishing, so it was all made with typewriters, scissors, and polaroid cameras. It was sort of like Google in paperback form, 35 years before Google came along: it was idealistic, and overflowing with neat tools and great notions.

Stewart and his team put out several issues of The Whole Earth Catalog, and then when it had run its course, they put out a final issue. It was the mid-1970s, and I was your age. On the back cover of their final issue was a photograph of an early morning country road, the kind you might find yourself hitchhiking on if you were so adventurous. Beneath it were the words: "Stay Hungry. Stay Foolish." It was their farewell message as they signed off. Stay Hungry. Stay Foolish. And I have always wished that for myself. And now, as you graduate to begin anew, I wish that for you.

Stay Hungry. Stay Foolish.

Thank you all very much.