Random Thoughts: Encounter With the Japanese Medical System (Part 3)

(continued from parts 1 and 2)

The third day (second day after surgery) was one that I knew would be the hardest. I woke up at 5:00 a.m. And paced the lounge for about a half hour. Considering how small it was, I'm surprised I didn't wear a groove into the floor. At least I was going to get solid food this time, though the doctor said breakfast at that hospital was “only bread”. Only bread sounded like ambrosia to me at that time. I also started taking copious notes in my little blue notebook so I could remember everything in detail and took pictures of various areas. It may seem silly, but I did want to remember it all, not merely as an experience in Japan, but a life experience in general.

The scene of my crime, the communal shower. Note the clip board hanging on the door where I foolishly recorded my crime for all to see. 

My sleep deprivation was accumulating and I knew I was going to feel quite a bit better by Thursday, though not particularly good. In fact, it was very boring and I had a hard time being patient remaining there past this point. I decided that I'd kill some time by taking a shower in the communal shower room. Since the nurse who showed me around when I checked in went out of her way to point it out and tell me to write my name on a sheet so they'd know what time I took one, I figured that I could just take one when I wanted. So, I did, though I was very careful not to get my bandages wet.

Several hours after coming back to the room, a nurse noticed my moistened hair and said, “oh, you washed”, and I said, “I took a shower” (in English). Her English wasn't great, so her response was, “No shower!” I said, “I already took a shower”. To this she made an “X” with her fingers and more emphatically said, “No shower!” I said, “Okay, no shower.” Triumphant, she departed in satisfaction. Though the hospital is well-known for its English-speaking staff, particularly the doctors, not every nurse was very good with it (though they tried and I always respond in whatever language I'm addressed in). Mind you, the burden was on me to deal with them in their language, but some things, like the fact that I'd taken a shower when I wasn't supposed to, weren't worth trying to explain because it would have only made matters worse. In this case, my life was made easier by not clarifying in Japanese, and it's not like I could undo the illegal shower anyway. 

When the doctor came by to change the dressing on my incision and remove the hated drainage bottle, I tried hard to hold my chin up as high as humanly possible, but they still managed to attach it too high on my neck. I had to tear it off at the top and re-position it if I didn't want to develop a cervical spinal problem. I also asked the doctor if I could just go home then, and he said the hospital didn't allow people to leave in the afternoon. Harrumph. I would have paid for the next day if they would just have allowed me to escape right then and there, but no dice. They got to spend another night finding out how often I went to the toilet and taking my blood pressure and temperature again and again. I got to spend another night not sleeping, and this one was even worse than before.

A little Christmas decoration hung above the room number. The colored circles indicated which areas were occupied. Note that visitors sometimes roamed the halls trying to find patients because there was no way of knowing who was where from outside. I don't know if this is usual everywhere or was just the way it was at this hospital. 

Two people were added and left our ward in less than a day, much to my surprise. I envied them both their quick escape. I figured they must have received simpler procedures, but I had no way of knowing. During my husband's visit on this day, I suggested we hang out in the lounge. This was because it wasn't about 85 degrees there like it was in my room, and it would leave my suffering ward-mate in peace. Also, I no longer needed to lie in bed all of the time so the courtesy to both my husband, who hates super hot places, and the poor woman on the other side of the room, wasn't costing me any pain or added fatigue. I left a note on my pillow telling them where I was and we talked, got stared at by other visitors in the lounge waiting with cell phones from the hospital in hand, and played Monopoly on his iPad until the doctor showed up and asked me to head back to the room to deal with my bandages.

You may think I'm exaggerating about the heat, but it was extremely warm. The beds came equipped only with heavy comforters and no light sheets so I had to sleep uncovered most of the time. This caused some consternation for the nurses, who would try to cover me up when they saw the squished up bundle of pinkness at the bottom of my bed and I'd have to say, “chotto atsui” (a little hot) to get them to leave me alone. Of course, I should have said “totemo atsui” (very hot), but I feared they'd try and offer me ice again for a fever.

Later Thursday evening, a nurse with almost zero ability to communicate with me and something strange and complex to tell me came in. The only thing I could figure out without difficulty was that she wanted to know if I wanted breakfast Friday morning because I was supposed to leave. I figured that, though I was supposed to bust out at 10:00, I didn't trust that it'd all work as planned. I didn't want to sit around with low blood sugar to couple with my frustrated escape attempt if that was the case so I said 'yes' to breakfast. The other half of the communication was more puzzling.

This nurse was also talking to me about tomorrow being a holiday and the bill, but it didn't make sense to me. My husband and I had already gone down to the reception area during his visit to iron out how much we were likely to have to pay because you can't leave the hospital in Japan until you actually pony up the dough. I'm not sure what they'd do if you couldn't pay, but visions of holding someone hostage with an inserted catheter to torture them into encouraging their relatives to pay the ransom so they can escape came to mind. We also asked if they'd take a credit card so we wouldn't have to worry about the cash. They told us that, because it was a holiday (the winter solstice, Dec. 23), we couldn't use a credit card, but it'd likely cost 120,000 yen (about $1,543 U.S.) that we should pay in cash.   (We went back a few days later and settled up - it was 103,000 yen ($1,324 U.S.), which is pretty reasonable.)

Since we'd already ironed out the whole pay thing, what the nurse was trying to say made no sense. It was at this point that my ward-mate's English skills were fully revealed as she volunteered to be a bridge between my crappy Japanese and the nurse's crappy English. The nurse was saying we couldn't pay at all on Friday because of the holiday and would have to sign a promissory note saying we'd pay next Monday when the office was open. Since we'd already discussed this and been told something else, I found this eleventh hour rush to confuse me on a matter we'd already covered very irritating. If we couldn't pay, why didn't the front desk tell us when we asked about paying? In the end, it turned out to be one of those “different rules for gaijin (foreigners)” situations. Japanese could sign a note, but foreigners had to pay a deposit which was a ballpark figure of the cost for which they'd receive a receipt and then come back and settle up properly on Monday.

Through this exchange facilitated by my ward-mate, I learned also that she was told about this situation because she, too, was leaving on Friday. Given her continued poor condition, she stood there with an I.V. still attached to her and holding her lower abdomen as she translated, I was shocked to hear she was being released. I was whizzing about the hospital and pacing the halls trying to fill my time. It was happening with great sleep deprivation and soreness in my throat and pain in my neck, but I was definitely okay to finish recuperating at home whereas she appeared to need the full Borg treatment so she wouldn't have to get up out of bed. She told me that there were two kinds of doctors and one type was “rough” (her word choice) and gave patients the boot as rapidly as possible and then there were ones like mine who were cautious and kept you there, perhaps longer than necessary. I felt incredibly bad for her and wished our doctors inclinations had been swapped for both of our sake, though not our actual doctors. I liked my doctor and thought he took good care of me. 

Upon hearing this, I thought about some of the things I've read by other foreigners who have been in hospitals in Japan and my gall bladder removal experience and how it never jived with what they said. Many foreigners say that Japanese hospitals keep you in for a long time to ensure that you are very well before you go, and because of that I wondered how I convinced them to admit me, operate, and release me in the span of about 8 hours when I was in the hospital 20 years ago. I don't remember fighting too hard, though I may have made a strong request. It turns out that you can't generalize from one experience. Some doctors will kick you out and some will hold you. It's not a universal experience or rule in this country that you'll stay in for a long time.

I have heard, however, that it is a contrast to American care in which people are booted out as rapidly as possible all of the time because insurance companies don't want to pay for any but the shortest stay. Even my doctor mentioned the fact that care in the U.S. is handled as one overall package price covered by the insurance company so that the hospital has an incentive to get you out to reduce their costs and keep as much profit as possible. In Japan, it's really in the doctor's hands because you're going to pay by the day anyway so the hospital doesn't care either way.

That final night, a new person was admitted after 11:00 p.m. so there was noise and there were lights to keep us up again. What was more, the new person didn't seem to care about how her actions bothered other patients and she crinkled plastic bags, loudly crunched on snacks, and opened and closed dresser drawers for about a half hour after arriving. Though that doesn't sound too late in the evening for normal folks, we were awakened between 6:00-7:00 a.m. Around midnight, a nurse with a flashlight strode over to my area, opened my curtain and looked in and said, “You're not asleep”. If I had been, she would have woke me up again. I've heard this is something that the sisterhood of nurses worldwide shares as they all like to sneak around with a flashlight and awaken any patients who may have accidentally fallen asleep. I'm sure it's something they learn in nursing school regardless of their country of origin.

The view from my room on my last sleep-deprived morning in the hospital.

The next morning, the nurses woke us at 6:40 a.m., though a malfunctioning monitor had roused me at 6:00. I'm not sure I have ever been quite as exhausted as I was after my 4 days in the hospital and I was dying to get out of there and go home where I could actually rest. I had my final meal, a slice of bread, strawberry jam, a small cube of cheese, vegetarian minestrone soup (very tasty), fresh pineapple, and whole milk, and then counted the minutes until I could call my husband to wake him and have him come and bust me out of there.

I packed my bag and got checked a last time. Apparently my blood pressure and temperature, which was often a degree or two high for their tastes was a cause for concern most days, didn't qualify me for delayed release. I kept getting asked (ridiculously) if I wanted ice for this marginal condition. Incidentally, foreign bodies are usually a degree higher than Japanese ones. That's why we're always too hot and they're acting like a snake in the Arctic when we're both in the same room. I may have been on the warm side, but it was because I'm not Japanese and I was pacing like a caged animal every 15 minutes. When the clock struck 10:00, I figured that, when the doctor said I could leave “after 10:00” that that meant I could actually leave after 10:00. It would seem it's not so simple to escape a hospital.

Neither my husband nor I recall having so much trouble getting out of the hospital 20 years ago after my gall bladder surgery, but this time it seemed that many people had to be satisfied before we could leave. A pharmacist came up and gave me “pain medication”, which my husband felt I should have and I believed didn't matter since I only had one pain killer directly after surgery. However, he just wanted to be careful on my behalf so I said I'd take it. I was given two blister packs with 10 tablets each and said, “They're samples, so you have to take two and they're just like Tylenol (yes, she actually said “Tylenol” even though I don't think it's sold in Japan).” Thank goodness they had a pharmacist deliver them because you wouldn't want some nurse or lackey dealing with such powerful drugs.

As part of the departure sequence, I had already filled out a survey in which I praised my doctor, the nurses, and the food (it was pretty good after the liquid stuff was out of the way), but mentioned that it was noisy and hard to sleep, but I knew it might not be something they could help. I had also signed a couple or documents that the doctor had also signed which I thought were releases. I bid my ward-mate goodbye and thanked her for her help and my husband and I happily bid the room adieu. However, when my husband and I went to actually leave, a nurse stopped us in the hallway.

The nurse wouldn't or couldn't explain what the deal was, but she got very upset that my husband was carrying my bag and insisted, more frantically as we resisted, that both the bag and I return to my room and remain there while he go off and do something else. She really didn't want him to take the bag, as if it was as much a ward of the hospital as me (though it was spared the catheterization, lucky bag). He went down and paid the deposit and got a receipt with a note saying we'd settle up for real next Monday. He returned to the room and we thought it might be over, but we were told to keep waiting. I put another note about heading to the lounge on my bed and we headed where it was comfortably cooler. A nurse intercepted us and brought two more pieces of paper. One was the appointment to have the staples removed from my now Frankenstein's monster neck next Tuesday and the other was another “bye-bye” document of some ilk. After that, with unconcealed relief, we fled the premises.

I have been told since that this sort of inability to go based on red tape is hardly confined to Japan. Who knew hospitals worldwide were the inspiration for the song “Hotel California.” In America, I've been told it is also difficult to get out due to their need to conduct things “just so”. I can understand the need to dot all the “i's” and cross all of the “t's”, but it'd be nice if people had all of their ducks in a row for people who are being released and if they explained the situation more clearly.

Rather than tell me to just go sit in my room with my bag and my husband could go take care of things elsewhere, they could have said, “There are more documents to sign”, but they just got weird and said, “Go sit down like a good girl”. This is very Japanese. They expect people to passively wait to be told when, where, how, how long, and in what manner to do things and to not complain about it, especially when the authority is a doctor or hospital. The idea that I would push to leave because I wanted to leave rather than lie in my bed until they were good and ready to deal with me in their own sweet time simply doesn't occur to them. After all, that's what my ward-mate was doing. She was just lying there, unpacked and lying back in bed watching television when I bid her farewell and told her I hoped she'd recover soon. Clearly, she was in the know about the way things were going to work and figured there was no use trying to break out before the warden issued a proper release.

I've been here in Japan for a long time and adapted to a lot of things, but I will never be okay with lying in a hospital bed far past the time to leave when I should have left a day earlier while people lollygag about deciding they're ready to get their finger out and bring me a few papers. Of course, I guess this would be par for my course as a “bad patient”. I ate solid food when I wasn't supposed to. I showered when I wasn't supposed to. And, in the end, I left before I was supposed to. While I'm all for reasonable cultural adjustment, I'm okay with being a bad girl sometimes if it means I get to put as much distance as possible between me and peeing through a tube again.

Final (very important) notes:

Though I exaggerate for comic effect at times, and express some genuine feeling regarding how little sleep I got and the discomfort at being hooked to machines, it would be irresponsible of me not to conclude by making it clear that I feel that I was very well-cared for. The truth is that receiving any medical care is never pleasant, especially when you're undergoing something as serious and invasive as surgery. It will never be a walk in the park or enjoyable. The best one can hope for is that it is as comfortable as possible given the circumstances and that one is treated well in the process.

Regarding this particular  hospital, the nurses were polite, kind, friendly, and well-meaning. My surgeon/doctor was excellent and I feel fortunate to have had him handle my case. Doctors often receive gifts from former patients, and now I know why they send them for years after successful treatment. I sort of want to do that, too, but I know from talking to doctors and their wives that they get so much of that crap already that they don't want anymore. Still, my gratitude is such that the impulse to send gifts is there just as a way to say, "thank you."

I have no doubt whatsoever that the quality of medical care I received at this hospital was as good or better than that which I would have received back home. I would go there for treatment again in a heartbeat and I feel nothing but respect and warmth for the people who helped me. If you are a foreigner and live in an area close to Ogikubo in Tokyo, I would not hesitate to recommend treatment at the Adventist Hospital. They really are great (as are the dentists at the dental clinic). I've also been told that they are one of the few hospitals in Tokyo at which women can opt to use drugs to kill pain during childbirth (I cannot confirm this as I've never had a baby nor do I plan to, but if you're planning on having a baby, it's worth thinking about). 

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Random Thoughts: Encounter With the Japanese Medical System (Part 2)

(Continued from part 1)

The lounge, such as it was. Actually, it was pretty comfortable. Santa didn't mind hanging out there. 

I was told that the surgery would happen in the afternoon of the 20th, but they didn't know when for sure because it depended on what sort of other operations were done and any complications or unforeseen issues. Admission would be from 9:30 am and they'd take me for surgery when they were ready. We checked in and a woman from the nurses station took my bag on her rattling metal cart and gave us the grand tour which included the vending machine in the hallway, the communal toilet locations, the communal shower (one for the entire third floor), and the lounge from which we must take or make any phone calls so as not to disturb patients with the noise. She also weighed me and measured my height, as they must do in order to properly calculate how much general anesthesia to administer in operations that you sleep through.

The ward area that my room was in only had one other patient when I arrived, but I had no idea what her age or situation was because curtains were drawn to protect everyone's privacy. The space was actually rather nice and included a desk and chair, dresser, and a very narrow closet as well as a bedside table with a T.V. and a tiny refrigerator. As was explained to me at the pre-admission interview, you needed to insert a card into the television and pay extra if you used it. Since I'm not a fan of Japanese T.V., that was not really a concern of mine. I had my “entertainment” mapped out with an iPod full of books on tape and my antique P.D.A. (a Palm device) full of eBooks. The space was bigger than expected with a “nice” view of an adjacent roof. Okay, so the view wasn't great, but I wasn't there to have a holiday. However, I did get to see the sunrise rather beautifully through the window on the last day of my stay.

My bedside. Yes, that's debu neko there to comfort me!

In addition to being told the bleeding obvious (there's your bed, your dresser, etc.), a little paper with columns and spaces for dates was placed on the bedside table and I was told to record the type and frequency of every trip to the bathroom. I found this slightly amusing on one level, but I do recognize the medical value on a less juvenile one. Such information assists in knowing about your recovery and any potential problems, particularly when compared with the pre-op survey data in which they ask about your usual toilet habits. The staff had helpfully assisted in the completion of such information with me in English during the pre-surgery consultation. Such questionnaires are frequently the bane of a patient's life when they are seeking routine treatment and they wonder why doctors need to know how often a patient poops when they're there for something like a bad back, but I know they need to know as much as possible and had no complaints.

Things moved rapidly from there as the nurse in charge of me on that day prepped me. This included changing my clothes and having me put on dark blue paper pants, a white cotton tunic, and a short lavender yukata (a sort of short kimono-like robe made of cotton that ties shut). This surprised me because you're told to bring your own pajamas and I figured that I'd go into the operation in just a paper gown and with no underpants at all. When I was 12 and had my tonsils out, I remember the nurse telling me I had to take the panties off prior to surgery and I recall wondering why on earth they needed my posterior all naked and exposed when they were dealing with my throat. No one explained to me that they were going to put a catheter in and they cut off my pants during the tonsillectomy. I realize that the notion of a catheter may be too complex for a kid, but all they had to do was say that I might pee myself during the operation so they would need to use a tube to catch it and then I would have understood and complied with their request instead of rejecting it as illogical.

At any rate, the paper pants weren't actually paper, but a fabric woven from light fibers. It turned out that the yukata and gown were actually very temporary attire as when I got to the operating room, they took it all off of me except the silly paper pants. After the preparation nurse got me undressed from my street clothes and re-dressed in hospital fashions, she struggled for a long time to get in an I.V. and connected me up to a bag of saline with “100 kcal” written on it. Mmm, breakfast! Of course, I know you can't actually eat because there is a high risk of regurgitating and asphyxiating during surgery if food is in your stomach. They also need to feed you glucose before the operation to deal with catabolism, but it does seem a bit like “all of the calories and none of the fun” when you're fed through a tube.

Because I'm neither vain nor stupid, I passed most of the check she did without difficulty. That is, I was not to be wearing jewelry or make-up and wasn't silly enough to have put on either. The thing that no one mentioned to me and that I certainly did not anticipate was that my fingernails would need to be cut off. Though they are hardly exceptionally long, they are also not short. Usually, I keep them at a medium length, or more truthfully, varying lengths depending on which ones have broken off in different points in time. I'm still not sure why I needed to clip them all off, but I complied without complaint. I'm sure there was a good reason someone wasn't telling me (like putting a pulse monitor on my fingers?), just as was the case with removing my undies when I had my tonsils out. My husband remarked that there would have to be at least one or two women who undergo one of those extremely popular long and glittery nail jobs who would be angry at having to send them all into the trash bin because of surgery. The final thing was that the nurse struggled to get my hair tied back and put it into two very long and ridiculous pigtails. It might be cute if I weren't 47, but it just made me look like I'd let a 6-year old play with my hair.

Four days, right here, and that's my husband's foot. The bottom drawer of the bedside table is the refrigerator.

At this point, we were playing the waiting game. I had to just lie in bed tethered to the I.V. and talk to my husband, hoping that the earliest possible time for my surgery would be the one. It turned out that it was and at 1:15 p.m. I was walked down from my third floor room to the second floor operating area. Even this I found a bit strange as I recall being wheeled down in my previous two surgical experiences. I didn't mind except that my glasses had to stay behind and I was slightly blind and wheeling my I.V. stand over some metal floor parts (like the elevator entrance). They let my husband go with me to an outer area and from there I was laid out on the table in a position which is now a little too familiar to me. My husband told me later that they told him he couldn't wait in the outer room of the 2^nd floor, which was odd since there were seats there and it looked like where people were supposed to wait, but they gave him a cell phone and said they'd call him when things were over. He went up to the lounge, which wasn't as stiflingly hot as my room, and waited.

In the operating room, they struggled with the I.V. bag to get me out of the tunic and yukata. They then asked me to put my hair in a net, which was probably better than them trying to do it as I have super long and voluminous hair. I was covered with a sheet and strapped down with Velcro so I resembled someone secured on a cross-shaped bed. This brought back a strong memory from my tonsil removal experience when my arms were taped down and my nose got itchy while I waited. I desperately wanted to scratch it but couldn't move. I remember fighting to get a free arm then the lights going out on me as the anesthesia kicked in. Fortunately, my nose behaved this time. A nurse brought over some things with Velcro attachments and strapped them to my calves. She told me that they were leg massagers and before I could fully process the strangeness of this, mentioned that they were to prevent embolisms (thrombosis).

I have failed to mention this before, and I'm sure, again, that this is standard medical procedure worldwide, but I was asked my name again and again by various people at various points in the pre-surgery preparation and in the lead-up to the surgery. I'm certain I was asked, “what is your name,” no less than six times before going under the knife. The final time was when the doctor himself came in and asked me my name and what I was being operated on for. It seems silly, but it was actually reassuring that they were so cautious about not doing the wrong surgery on the wrong patient.

About 10 minutes passed between my arrival and the doctor showing up and during that time, one of the assisting surgeons (possibly the anesthesiologist), asked me my name and told me when the doctor would arrive and that I'd be asleep and unaware while it was all happening. I know you're supposed to be in dead blackness while under anesthesia, but I recall clearly that I dreamed during my gall bladder surgery. In fact, I remember that I dreamed about my in-laws, oddly enough. This time, I dreamed again, though I don't remember what it was about. Unfortunately, dreaming contributes to confusion when coming out from under the anesthesia. They always say, “don't move”, but I am so disoriented by the move from the dream world to the new painful reality that I struggle in my bonds anyway.

As I lay there waiting for the doctor and trying not to be cold (they asked me if I needed a blanket, but I refused because I'm stupid like that), I tried to take careful note of everything happening around me. Lullaby music was playing to various tunes. The nurses counted to 5 (“ichi, ni, san, shi, go”) twice. I was later told by one of my students who is an operating room nurse that this is how they count the sponges (gauze) before the operation. They do it to make sure they don't leave one in a patient. Various staff went about their business largely out of my field of view from the table and the doctor showed up earlier than expected. They put a funny-smelling and ill-fitting oxygen mask on me and I wondered if my big, foreigner nose in a Japanese-size mask was the problem or if that's just the way they all fit sometimes. After the requisite identity check, the doctor told me that in Japan they show you what they remove at the end of the operation, but if I didn't want to see it that I didn't have to. I told him that I had heard they show you what they cut out, and that sometimes they even save some removed parts. He said they can't save them, though when I mentioned parents save the umbilical cord from their child's birth, he said, “Oh yeah, they save the umbilical cord.” He also said he felt Japanese folks were just curious about such things and I told him I'd have a look at what they removed, having no idea what to expect.

Pictures of Jesus doing miraculous things were dotted all over the hospital. It was surreal since it's not something I have seen much of in Japan.

The doctor said before starting, “Because this is a Christian hospital, we will pray before the operation,” and he said a brief prayer (in English) asking God to make the operation go well for me. Somehow using my name in the prayer specifically felt comforting because it made me feel very humanized by the doctor when I've often felt dehumanized, like a bit of meat that needs fixing, when being dealt with by some medical professionals. Of course, this is all in my head. I'm sure he recites this as a standard prayer and almost certainly is not a Christian (as few Japanese are), but I don't see any value in minimizing or dismissing feelings. I just remember them.

I'm not a Christian anymore as I couldn't reconcile the dogma with the way the world works and rejected it when I was 15 and sitting in a history class pondering such things in the mental vacuum of “self-study” time. However, the prayer made me feel a little better. If one can effectively appeal to a greater force to improve the outcome, I see no harm in making such a request and I appreciate the sentiment and positive energy regardless of the focus or words used to make it. This is why I am grateful when people pray for me and my health and safety, even if my beliefs differ from theirs. After all, they may have it right. Who am I to express greater certainty in this matter?

After the prayer, they told me they were going to give me the anesthesia and I watched them inject it into the I.V. and waited for the the lights to go out. After about 30 seconds, I was gone. When I came out of my dream, I could see the doctor standing to the left of the bed and he said the operation went well and he held up a small Ziploc bag and said that was my tumor. I was still pretty drugged up, but I said what I thought, “It looks small.” He said that it was actually pretty big, but to me it looked like a tiny bit of meat in a baggy. I guess it's all relative. He also said that, from a visual perspective, it didn't look to be cancer because it had no telltale signs and didn't encroach into surrounding tissues. Of course, they still have to test it to be sure.

A sheet was used to lift me off the bed and convey me to my room on a gurney and I was given the full Borg treatment. There was so much incredibly uncomfortable equipment attached to me that I really did feel like I had become one with the machines. I was fed through the I.V. and told there'd be no din-dins at all for me until tomorrow. I peed through the catheter. Oxygen was being pumped into my nose through tubes because apparently I couldn't be trusted to breath efficiently on my own. There was a drainage tube inserted into my chest and a little plastic bottle collecting blood pinned to my restored yukata. What was more, I was tethered to a device on the bed that continued to run the leg massagers which were attached via a cord design that would make H.R. Giger proud. On top of all of this, I had monitors attached to me that linked to a machine on my I.V. stand. This type of monitor was the bane of my existence during my stay. It kept ringing an alarm at random intervals believing in its tiny electronic brain that I had expired. During the night, when my ward-mate and I were trying to relieve our post-surgical misery with unconsciousness, it's incessant braying was maddening, though not nearly as aggravating as the fact that the nurses were in no hurry to come by and fix the screeching monstrosity.

The operation took about 2 hours and most of the rest of the day was spent lying in my bed and being grateful for the pain medication shot I was given. The odd thing, at least to me, was that after having my neck cut across about 6 inches (15 cm.) and a bit of a gland sliced out, they only gave me it after I specifically requested it. You know those movies and T.V. shows where the patient is sitting up in bed post-surgery looking all fixed up and in the pink? That's not the way it works in cases in which your condition is not very bad pre-surgery. I was fine when I entered and miserable when it was over. Now, I was wounded, exhausted, and suffering both the indignity of being hooked up to a bunch of contraptions meant to make sure I remained alive and I was in true pain. You're often in a much worse state after surgery, not better, unless it's an emergency. Even when I had gall bladder surgery, it was easier dealing with occasional pain than dealing with post-surgical distress. Of course, in the long run, I'm better off, but in the short run, I seriously wonder why I would subject myself to such torment to stave off potential future trouble. Of course, the answer is “the big C”. If cancer is lurking in that enlargement, it is better to take it out now rather than wait for it to develop.

Post-operation, I spent most of the remainder of the day lying there alternately nodding off and struggling to communicate with my husband despite the pain in my throat. This was after throwing up 9 times due to the effects of the anesthesia. I knew this was coming since it happened after my gall bladder surgery. Of course, there's no food or water in my stomach, so it's all yellow bile. That sounds gross, but it doesn't smell like and isn't as voluminous as normal vomit. So, while certainly unpleasant, it's not quite as disgusting as an after-drinking-binge hurlfest. My ever-supportive and patient husband sat by the bed touching my leg or holding my hand for hours until he had to leave at 8:00 p.m. when visitors were given the boot. Three hours after the operation, they wanted me to walk so they gathered up me and all of my various devices. After unhooking me from my “Alien-style” leg massagers, I trotted around the small third floor pushing the stand with my glucose bag at the top and a bag of pee dangling at the bottom of my attention-seeking monitor on a pole.

Upon standing up, I realized that they had taped my bandages to just under my chin such that I couldn't actually fully lift my head. Standing upright, I looked like I had a bizarre neck injury. There's nothing like roaming the halls in a semi-drugged and greatly pained state in a flimsy gown and ill-fitting short yukata in full visibility of patients, visitors and hospital staff with your excretions in full view. However, I trooped through without complaint, because there are certain things I know about getting out of the hospital and one of them is that they are more likely to let you go on-time, or early, if you show you can move.

The other thing I know about escaping from the hospital is that they watch how much pain medication you consume. The more you use, the more skeptical they become about your recovery. With this in mind, I didn't ask for another shot that first night. I was in pain, but it wasn't unbearable. I've had worse, which is to say I've had back pain so excruciating that it was unbearable and I wanted to die. This wasn't nearly that bad. Imagine ten times the pain of a paper cut for the incision (they do hurt a lot, you know) and three times the pain of the worst sore throat you ever had and that was where I was. So, if I could endure so much worse before with my back, I could put up with the aching in my neck and throat. Or at least that is what I told myself as I lay there suffering and being awakened by the monitor's alarm every few hours and thinking that all wanted to do was get out on time or early.

One of several enduring frustrations during the day after surgery was that I was tethered so completely to the bed, but I was clearly capable of walking. I could stand and walk with little difficulty (except pain from the stress of movement on my cut muscles), but they wouldn't unhook me and let me go to the bathroom by myself. If you've never been subjected to the indignity of a catheter, you're not going to understand why this was a big deal, but they're extremely uncomfortable and mine made me feel like I constantly needed to urinate, even though I was already doing so automatically. It made it extremely hard to rest and added another layer of discomfort.

The most lasting impression of being in the hospital that I had this time was that it was damn near impossible to get good rest there. If my machines weren't blaring, someone else's were in rooms down the hall, and loudly enough to wake the whole floor. The nurses were just as reluctant to attend to their screeching mechanisms as they were to mine so we'd be awakened at regular intervals throughout the night by their malfunctions. Sleep repeatedly interrupted was topped off with the nurses waking us up between 6:30 and 7:00 am because that's when we were supposed to get up. The nurses were unfailingly kind, helpful and cheery, but they were also loud. They thought nothing of having extremely noisy conversations in the ward or in the hall throughout the day. There was no way of making up for lost nighttime sleep with daytime napping with that racket.

In fact, like most professionals in Japan, the nurses were clearly trained in a method that they adhered to without question and without applying selective reasoning. One of those routines was that each morning the day and night nurses introduced themselves and said goodbye. This is all nice and friendly on the surface. However, I learned the drawbacks of it on the first day after surgery and being sleep-deprived due to the cacophony. I had breakfast and blissfully fell back asleep. Rather than thinking that it might be a good idea to leave sleeping patients in pain lie, the night nurse and day nurse cheerily yelled, “ohayo gozaimasu” (good morning) to me and woke me up from my short-lived peaceful slumber. I got about 20 minutes of post-breakfast napping then was aware of my full-body discomfort again and back to fatigued misery.

Regarding the food, that was the only aspect of the hospital stay that I was regarding with curiosity and anticipation. Since my gall bladder surgery was all performed and completed in one day, I had only eaten enough to prove I was ready to escape at that time and I wanted to see what Japanese hospital food was like. This hospital has a policy of serving “lacto-ovo vegetarian cuisine” (their words in their English pamphlet). That means dairy and eggs, but I'm guessing no fish and, of course, no meat. Unfortunately, 36 hours of nothing but bags of saline with glucose (100 calories per bag!) was followed by a liquid diet because of fears that my swallowing would be compromised by inflammation. Still, it was better than nothing, but not by much. I'm going to detail the food in a companion piece on my snack food blog, but speak of it a bit here.

First breakfast after the operation. The hobbits would also have been disappointed and hoping for a second one. 

Breakfast was a weird sweet kudzu soup called kuzuyu, decaf coffee that was little more than brown water (but, hey, I could put sugar in it... but no milk), vegetable broth that would need a lot more salt to come close to having some flavor and a tiny container of melon gelatin. It wasn't exactly the feast after my famine that I'd been hoping for, but I ate it all up nonetheless. The bigger problem was that I was shackled to my devices such that I couldn't even walk around to the other side of my bed, let alone go to the communal sink in the ward to get water, and the nurses seemed to be perplexed by my repeated requests to have my water cup filled. One thing I can say for sure is that pitchers of water are kept at hospital bedsides in the U.S. unless fluids are restricted and this hospital didn't follow that habit. Every time I asked for water, which was only when they came by to check me as I didn't want to bother them (though they did come by to poke or squeeze me pretty often), it seemed to take 20 minutes to return with a tepid 2/3 full medium-sized cup. I don't understand why it was so difficult to do when there was a sink not 15 feet away.

As I lay there tired and spending most of my time staring at the ceiling feeling exhausted and listening to William Shatner reading absurd Star Trek novels, I got increasingly frustrated with being dehydrated and having my urine siphoned off by a tube that hurt. They kept saying they wouldn't take it out and frowning at the output in the bag. I got the impression that they didn't want to remove it because they felt I wasn't peeing enough and they were concerned about kidney function. I wasn't going enough because they wouldn't give me any but the smallest amount of water! In the end, they finally agreed to unhook me from the catheter, but insisted that I “show” them when I went to the bathroom. They put a plastic container in there to catch it and I had to run for a nurse when I went. I did as ordered, she came in and frowned at the volume and said “not enough” and asked me to call her next time. If I'd known it was going to be a test, I would have tried harder.

In the end, and this reminded both my husband and I of a Monty Python sketch at an insurance agent's office, they gave me a freaking enormous jar (I'd guess about 6 liters) and told me they'd put it in the bathroom and I'd have to decant all of my urine into it for the next 8-10 hours. Frankly speaking, though I thought this was peculiar, I'd rather be emptying my pee into jars than have it siphoned off by a torture device. And though I wasn't exactly having a good time, I did understand their need to measure output. I just didn't like how they didn't give me much water and were not making a connection between these two issues.

My husband came to visit me as visiting hours began at 3:00 p.m., but that was quickly spoiled by my ward-mate hobbling over and saying he was too loud and could we quiet down a bit (though I wasn't actually speaking and spent most of the time typing sentences on the iPad due to my throat issues). At the time, I felt put out because, though his voice does carry and he can be loud, it was not exactly very early or late and he was entitled to visit me. Later, I felt bad about being irked because I gained a lot more sympathy for her need to rest. It turned out that she had come in for some gynecological issue and the surgery had complications so she was on the table for 6 hours. From the moment I arrived on Tuesday at 9:30 am to the time I left at 10:00 am on Friday, she was still wincing and whimpering in pain every time she moved. Given how noisy it was all night there, I'm guessing she also did not get enough rest and was far worse off than me in every way.

I learned later from her that she spoke English quite well, albeit with a German accent as she worked in Germany and Singapore. I assumed she didn't understand what we were saying, but perhaps part of the source of her frustration upon overhearing our conversations was that it was much more to her than verbal white noise. It was an actual distraction she comprehended. She also kept turning off the lights and I believe she was in so much pain that the over-stimulation of sounds and lights were just more than she could endure. Of course, the nurses kept turning the lights back on again for their own purposes. Personally, I didn't care about the lights being off because I could listen to books on tape in the dark.

By 8:00 p.m. the day after surgery, I had finally been fully de-Borgified except for the little drainage tube and bottle of blood pinned to my P.J.s and could fill my own cup of water, though I was still filling the giant pee jar well into the night. It was a lot easier to fill it up with having control of my own liquid intake. I'd also had two more lackluster liquid diet meals and was starving. I had brought a bag of snacks along with me and consumed two strawberry cookie-type bars. I know this made me a “bad” patient, but I knew the restrictions on my diet were not based on nutrition or blood sugar, but rather on my swallowing ability, and I knew I could handle it. It was no harder to eat those than to suck down the gluey little bowl of “rice water” that they fed me for both lunch and dinner.  

(To be concluded in part 3).

Random Thoughts: Encounter With the Japanese Medical System (Part 1)

I'm going to take a very temporary break from my usual posting style on this blog to do a three-part long-form piece to detail my recent experiences with the Japanese medical system. At the end of the third part, I will further deviate from form and allow comments. I have only one request of people who read this post and choose to comment and that is to take it at face value for what it is; it is a record of a personal experience with a certain type of surgery (partial thyroid removal) at a particular hospital in Japan. Nothing more. Nothing less. 

Talking about this experience is in no way meant to imply all experiences with this surgery in Japan (or any treatment in this country) would be the same. Noting things of interest to me is also not meant to imply that things would be different in other countries. I have very limited experience with medical treatment of any kind and remark upon things I want to recall from my subjective viewpoint. This is essentially an exhaustive notebook of my experience for any people who would like to know what I went through, but it is mainly for my own records. It may be of value if you're having surgery in Japan, or having thyroid surgery, or of no use whatsoever. Take it for what it's worth rather than extrapolate further meaning or see my speaking of it as my attempt to speak for all medical experience in Japan before commenting. To be clear, because willful misunderstanding is a favored practice among many folks on the internet, I am not saying this is what all medical experiences in Japan will be or are like. This is specific, not representative.

I will return to usual form with short, notational pieces at the beginning of next year (from January 2, 2012). 

The hospital. Looks nice, doesn't it?

I've lived in Japan for 23 years, but I've tried my best to avoid the medical establishment as much as possible. In particular, I've tried to avoid any sort of non-essential treatment such as the free annual health check-ups that all people who are registered with the Japanese national health care system can take. This was, perhaps, rather foolish on my part as I strongly believe these routine exams in which many people receive chest X-rays, blood and urine tests, EKGs, and dreaded testing for stomach cancer (a bigger issue in Japan than many other countries so it is routinely screened for) are responsible in no small part for the long-lived nature of the Japanese people. Catching small issues early and often decreases health care costs on the whole and allows for early intervention. In fact, given what I have witnessed about lifestyles in Japan (little to no formal exercise, less than the imagined stellar dietary habits), I wonder if it is greatly responsible for longer lives here.

This past year, for the first time, I decided to subject myself to the routine health check. I am quite phobic about medical situations, as many people are, but at 47, I decided I should just be a grown-up and do it. This wasn't by any means my first experience with Japanese doctors, but it was the first voluntary one. In the past, I've had treatment for persistent headaches that lasted for 6 months, intense and persistent back pain, tetanus shots, and, biggest of all, gall bladder surgery. I only went to the hospital when something was wrong enough to warrant attention. To me, this was the natural situation as it is the mindset I grew up with back home. I still fully believe that people in Japan are too quick to run to the doctor for trivial issues and don't trust their bodies to recover from minor ailments, but I equally strongly believe that routine check-ups are very important. The fact that I didn't do them when I could reflected on my fears, not on their value.

My routine examinations included the aforementioned free tests with an added round of tests for problems specific to women (pap test, mammogram) for the added trivial cost of 1000 yen (about $13) per test. Women in Japan can take these types of routine tests for that low price once every two years, but only if they fill out a special postcard and request them (at least the first time, after that, the local government may send out reminders). Despite my neglect of such tests for so many years, all of my results came back in the pink. You are told of annual check test results by mail in a lengthy report (in Japanese) and then can discuss them or have them explained in a follow-up consultation with a doctor (which is not free, but cheap because of the insurance coverage). It was at this meeting that my road to surgery began.

Though my test results proclaimed me free of any diseases that those tests and a cursory exam could reveal, the doctor looked at me and asked, “have you ever had your thyroid checked”. He then felt my neck a bit, asked me to swallow and asked to look at my legs. This was followed by queries about sore throats, difficulty swallowing or breathing, and heart palpitations and though I replied in the negative to all of these questions, he said that I should have my thyroid checked. At this point in time, I was actively annoyed at the suggestion that something was wrong when I was asymptomatic. I could have ignored what he said, but he planted a seed of worry so I made an appointment for an ultrasound test.

Part of the annoyance of socialized medicine is that the way in which treatment is offered is idiosyncratic and bureaucratic. Expediency is often not a part of the program and it can be frustrating. While the doctor suggested I had a thyroid issue at the follow-up consult and recommended a test, he was not allowed to actually schedule the test during that visit because the government rules say doctors can only do certain things during the free annual health checks. So, I had to make a second appointment in which the only thing the doctor did was schedule another appointment for me with a technician. I kid you not. I walked in and he asked what he could do for me to which I replied that he said I needed an ultrasound for my thyroid so I came back. He typed into his computer to schedule it and then we were done. A trip to the hospital and a waste of his time and mine because of the way red tape is written. It wasn't his fault and I did not blame him at all, but it was annoying.

At the next appointment, as I lay on a table having my jelly-slathered throat tested by the technician, I still didn't believe they'd find anything. When I looked at my neck, I saw the same neck I'd seen all of my adult life and no enlargement or weirdness of any kind. I kept asking other people if they saw anything and no one did. I thought they were being extra cautious or covering their asses, but I was wrong. An hour after the test, the doctor reviewed the results with me and said I not only had an enlargement but a lesion (tumor). It was both too big and possibly cancerous. He said I was “lucky” because a surgeon was available to test it a few days hence. At this point, I was filled with fear at the prospect of cancer and this doctor, who spoke English well but had what I have experienced as the very typical stoic and impassive manner of a Japanese physician, was not the least bit helpful in allaying my fears or contextualizing my situation by answering my questions. He essentially shrugged his shoulders and said that women got enlarged thyroid glands for a lot of reasons and they wouldn't know anything until the test results were done. He also instructed a nurse to give me a pamphlet on cancer detection before I left. That didn't exactly fill me with confidence that my situation was trivial. It made me think he knew more than he was telling.

Two days later, I was in the office of another doctor who was also Japanese, but had been educated in the United States (Loma Linda, California). His English was smoother, his manner more approachable and his answers to questions much, much more helpful. He performed an aspiration in which a long, thin needle was inserted into my neck and cell samples were removed for testing. And, no, it didn't hurt that much, but I'm fairly tolerant of needles relative to some people. In fact, I try very hard not to flinch, complain or react to pain during medical procedures or tests because I know it can't be helped and the people doing them do their best not to hurt me. As I've had the opportunity to remark all too often as of late, “I try not to be a big baby.” He also had me take more blood tests to see if my thyroid function was being affected by the tumor. That is, they wanted to know if I was hypo-(under) or hyper-(over) thyroid.

The manner in which this particular doctor answered my husband's and my questions showed that he understood how to handle foreigners, who tend to be much more aggressive about seeking information than Japanese patients, and he gave us all the time we needed. In my experience, this is rare for Japanese doctors who tend to shuffle people out as rapidly as possible. It's also one of the reasons that I tried to be very calm when he was late for my appointments with him. I figured that he may be giving another patient time they need as he gave me the time I needed.

Unfortunately, the fast food shuffling of one patient in and the next out is consequence of the managed care in Japan. Price controls are in effect for medical treatment so the only way doctors can increase their income is by seeing as many people as many times as possible. The situation is such that some doctors have to see patients every 10 minutes to maintain a profitable practice. I've been told that it's very hard for doctors running private clinics to make a decent profit because of price controls. In fact, for some treatment, doctors certainly lose money. I guess my doctor, who is a surgeon, may not have quite the same pay scale or concerns and for that I was grateful.

What followed my aspiration test was the most agonizing 15 days of my life while we waited for test results to see if I had cancer. I believe, based on queries with students and other people in Japan, that this was atypically long and the wait was linked to my particular hospital, not Japanese medical treatment in general. While the wait for tests is still generally longer (about a week is what I have been told) in Japan, two weeks is beyond what most people are going to experience. Coincidentally, one of my students had a cancer scare two weeks before my testing. He coughed up blood and cancelled his lessons during the test and the wait for results. He told me he “only” waited 8 days.

During the wait, my husband had researched all sorts of permutations of thyroid problems and the doctor had said there were 4 types of cancer and only one was fatal and it was very rare, but the favorable statistics are of little reassurance under such circumstances. I know this all sounds very dramatic to people who have never faced a situation in which they might receive such news, but it one of the scariest things you will ever experience. Daily life takes on a weird unreality and you feel like you're going through meaningless motions as you wait for something truly important to happen.

In the end, as my readers of my blog already know, the results of the aspiration proclaimed it benign and the blood tests indicated my thyroid function was not being affected, but it still had to come out for two reasons. First of all, it was 4.45 cm. (1.75 in.) and doctors believe anything over 4 cm. should be removed to prevent future problems. Second, though the two successful samples indicated there was no cancer, they can't really know until they take it out and test the entire enlarged area. One of my students is a nurse who discussed this with me and she said several of her friends had had thyroid problems. She said only one of them had any cancer and that was only about 2% of the entire tissue removed. Thyroid cancer is generally slow-growing and remains contained, but that doesn't mean it's a good idea to wait for it to spread or possibly grow. Because of this, I decided to have the surgery as soon as possible and scheduled it for three weeks from receiving the good news about the test results.

The hospital I went to is the TokyoAdventist Hospital. This is a public Japanese hospital, not a private one specializing in treatment of members of the foreign community so anyone who uses the Japanese national health insurance can go there to receive treatment and there will be largely Japanese patients being taken care of. It is also the place in which I had my gall bladder removed 20 years ago. At that time, I had been in Japan for only two years and we chose that place because they had an English-speaking physician or two (or three, or ten). It is also relatively close to where we live so it isn't too much of a trek. When I had my gall bladder surgery, the doctor told me that Japan tended to lag behind America in medical techniques. Laparoscopic surgery was relatively common in U.S. hospitals at that time, but somewhat new to Japan. Fortunately for me, an American surgeon was at that hospital teaching the technique to the Japanese staff and I was one of the first patients at that institution to have it performed upon her. I don't know if what that doctor said about medicine in Japan lagging behind that in America by about 5 years was true, but it has stuck with me and has been one of the reasons I stick with doctors who trained in my home country. There is also the fact that, no matter how super you believe your Japanese is (and mine is not), when it comes to health, I personally want to be dealing in my native tongue with someone who has second language skills sufficient to see them through medical school in a native English-speaking country. It's not something I want there to be any risk of misunderstanding about.

My surgery was scheduled for December 20, but I had to have a repeat of some of my annual health check medical tests before going in because they need to check you within three weeks of the operation. I'm sure this is standard procedure and for my own safety, but the blood samples this time were removed by less skillful technicians who couldn't find a vein and I had several holes and a huge black and blue mark. I must say, to be fair, that this was not about them, but about me. Later, prior to surgery when the I.V. was put in, the nurse also had problems and commented that she felt American nurses would do better with my American arms. I reassured her that nurses who tried to put in a line when I was 12 years old and had my tonsils taken out also had problems, so it wasn't her fault. That didn't make it hurt any less when she poked me deeply three times with a big needle, but I did not blame her or her nationality for the problem.

A view of the ward. My area is in the back left, hidden behind a curtain. During my stay, the two units in front had a revolving door of patients or were vacant. 

Two days before the surgery, I had to come in for a pre-surgery consultation in which they explained a wide variety of things to me and were supposed to talk about the results of the recent battery of tests, but they never mentioned them. Part of this was telling me what I needed to bring, when to show up, and, of course, not to eat within 12 hours of admittance. They also explained what the Japanese health insurance did and did not pay for. Again, the bureaucratic guidelines are rather strange at times and the room cost was not to be covered by insurance. Procedures are covered, but not the room. I should note that medical coverage for everything other than the annual health check-up is not free in Japan. The patient pays 30%, but because prices are controlled, this rarely is an oppressive amount of money. We were given three options for rooms: private, semi-private (2 people) and ward (4 people). When I last had surgery there, I opted for the middle option, semi-private, which cost about 11,000 yen ($139) a day. Private rooms are a whopping 23,000 yen ($290) whereas the ward option was only 3150 yen ($40). I went for the cheapest option and I did not regret it. Based on what I saw of the more expensive accommodations and my experiences, I doubt there was any benefit in having one of them.

One of my students fell down earlier this year and broke his knee-cap and he told me that he stayed in a semi-private room for 49 days as a result. Given the expense, I wondered how he could manage it on a retiree's income. He told me that some people in Japan take on secondary private insurance which covers whatever expenses are not covered by the national health care plan. He said he pays about 15,000 yen a month ($190) for this. Personally, I'm not sure that it is worth it, but I'm not as old as he is and perhaps not capable of grasping the idea that I could be hospitalized for an extremely long time. That being said, I've been told that you can't remain in the same hospital in Japan for more than three months. After that, you have to be discharged and re-admitted at another hospital or placed in a care facility (or returned home). Again, there are some idiosyncratic rules which sometimes do not necessarily make a lot of sense, but I'm guessing that one was created to stop people from trying to pawn their elderly relatives and their care off on the medical system rather than look after them at home or place them in a nursing home if it is at all possible. I'd also wager that Japan hardly has the market cornered on such regulations, but I have no way of speaking to the case in other countries.  

(to be continued in parts 2 and 3)

Won't Miss #402 - cosplay

A rack of costumes that young women can borrow for activities in a gaming center. 

The Wikipedia entry for cosplay ("costume play") claims it is a type "performance art". This has to be one of the most pretentious and inaccurate explanations I have ever heard of the tendency of some people to put on costumes resembling anime (cartoon) characters. In the U.S., I think cosplay tends to be a part of special events such as conventions. In Tokyo, you can see women putting on costumes at game arcades so that they can cram into photo booths and take their picture dressed in some ridiculous get-up. The costumes are not about the women adopting a different persona for their own enjoyment, but about some tiny little thing which they squeeze into so that men can be turned on by how they look in them.

I won't miss seeing this type of cosplay and how it reflects the fact that young women unwittingly embrace and support their own objectification. 

Will Miss #401 - the blue lights

I live along a Japan Railway (JR) line that is famous for attracting suicidal jumpers. The line is named the Chuo line, and foreigners waggishly call it the "Chuocide" line because it so frequently is disrupted by those intent on offing themselves. JR obviously would rather this not happen, but rather than do what many subways have done and put up walls with electronic gates that disallow access to the tracks (unless you climb over a 4 foot wall), they've come up with a novel and greatly cheaper solution. They have installed blue lights at a few points along the platform because blue is supposed to be a soothing color which will make people think twice before taking a fatal leap. This is like putting a band-aid on a gunshot wound and expecting it to be sufficient remedy. 

Seeing these blue lights reminds me that silly, short-sighted solutions are a part of every culture, and I will miss seeing them and what they really represent; that is to say they reflect corporate stupidity rather than a commitment to dealing with a societal problem. 

Won't Miss #401 - my huge address

This may be my imagination, but writing my address back home was always a lot faster and easier than writing my Tokyo address. The length could have something to do with the byzantine naming of streets and nearly incomprehensible way of laying out blocks that it requires a system of three numbers (chome-banchi-go) in addition to information on the building, apartment number, city within a city, ward and postal code. One of the reasons I'm pretty sure it's not "just me" thinking my American address was shorter is that when I fill in an on-line address field with an American business, the space in the boxes is always too short for my Japanese one. I have to keep spilling over into the next line and it screws up the proper order of the address. At the very least, it's a lot more characters when translated into roman letters.

I won't miss writing out this huge address as well as American businesses and friends getting it confused and sometimes incorrect. 

Will Miss #400 - east meets west xmas cards

Click for a bigger picture of Santas carrying a mikoshi in front of a temple. 

I realize that sending Christmas cards is a dying custom, but I still love them. Living in Japan affords me the chance to buy and receive unique designs that mix and match Japanese culture with traditional western Christmas imagery. Seeing this marriage between east and west, particularly when Santa is involved, is always a delight. There is virtually no place that the Japanese won't put old Kris Kringle, no matter how sacrilegious the juxtapositioning of the imagery may appear to be. There was once a story in The Japan Times about a department store that wanted an authentic nativity scene in their display window and sought the advice of a foreigner on the newspaper's staff. After setting up a manger with the  requisite components, the store decided it was all too solemn so they placed jolly old Saint Nick amongst those witnessing the savior's birth.

I will miss the amusing, quaint, and cute culturally mixed imagery that appears on Japanese Christmas cards.

Won't Miss #400 - natto questions

Most people who have never been to Japan but are interested in Japanese culture and cuisine believe the litmus test for tolerating said cuisine weirdness is an enjoyment of sushi, or perhaps, sashimi. If you can stomach raw fish, you may believe you earned your member's badge. If you've actually lived here, you know that adoring sushi is something only lightweights regard as an accomplishment. The real question, and Japanese people love to ask it, is "can you eat natto?" Natto is a slimy, sticky fermented soybean concoction that smells like gym socks that have been left to ripen in a dark, dank locker for a century and has the texture of something you'd spit up when you had a bad chest cold. It's disgusting, and there are many Japanese people who eat it for breakfast everyday. It's very healthy, mind you, but that doesn't stop it from being an acquired taste that you're likely to only acquire if you grew up with it or were forced to choose between starvation and this foodstuff. From a country in which some people say that mozzarella cheese is too stringy and that is what keeps them away from pizza, it is quite ironic that they think natto is the bee's knees.

I won't miss the knowing smirks, smug grins, and superior attitude I get when I answer the question, "do you eat natto," with "no."

Will Miss #399 - chinsukou

There are a lot of efforts in Japan to simulate Christmas, but most of it comes off as simply copying images without any of the concurrent spirit. Strangely enough, the thing that really tastes like Christmas to me are chinsukou cookies. They smell like what mom was baking for the holidays when I was growing up and taste like heaven. There are many things that are like them made in other countries, but there is nothing quite like the sugary, crumbly, crispy texture of these cookies. They are a specialty of Okinawa and I've tried many varieties (coconut, chocolate chip, chocolate, pumpkin) and they never fail to delight, though the original ones are really the best.

I'll miss these chinsukou cookies and how they are both unique and reminiscent of home at the same time. 

Won't Miss #399 - dogs in bike baskets

Perhaps I'm paranoid or overly sensitive about how people deal with their pets, but it makes me very nervous when I see an unsupervised parked bicycle with a dog sitting in it. The primary problem I have with it is that parked bikes are relatively unstable and I'm concerned that a careless pedestrian or cyclist, a gust of wind, or even a small earthquake will send the bike toppling and the animal will get hurt. None of these things are exactly rare in Tokyo. The other thing that troubles me is that most of the little dogs I see perched in these baskets are tethered on a short leash to the bike's handlebars. I'm sure this is done to keep them from jumping out, but I worry that this will just mean the dog will hang itself if it does try to jump out or at the least bring the bike down on itself if it attempts to jump out.

Seeing a pet sitting on a lone parked bicycle is not an uncommon sight and I think it's very irresponsible. I won't miss seeing this worrisome situation. 

Will Miss #398 - moai replicas

I'm not sure why, but Japan loves it some moai. If you don't know what they are, they're the Easter Island heads. Like the Statue of Liberty replicas, moai seem to show up in the oddest places for no reason other than people seem to think they are neat. In Kyushu, there are replicas of them. There are fan magazines devoted to them and many novelty items sold with a moai theme. I'm not sure what the basis of this fascination is, but I consider it a hyperactive version of the American interest in Kokopelli.

The images of moai that I see all over Tokyo remind me that all cultures have an affinity with simple, primitive images created by human hands regardless of the origin of those images, and I will miss that.

Won't Miss #398 - being a minority in the minority

Foreign women in Japan have a variety of support networks to help them cope with the difficulties of being a minority here. Unfortunately, I don't fit in with any of those groups. One of the biggest groups is the AFWJ, Association of Foreign Wives of Japanese. Since my husband is American, the "welcome" sign isn't hanging on that door for me. There is also the Tokyo American Club Women's Group, which is for expats. That means it's for the women who are here on expense accounts and live a specialized lifestyle. Since I'm not rich enough to join said club, and don't fit in with a set which shops regularly at over-priced import food shops and whines at the "small" size of their large Tokyo apartments, I couldn't have a "member" badge pinned on me there either. I'm also not one of the single women who explore the country for Japanese men so I won't be commiserating over a mixed drink in Roppongi with sisters in single-hood.

Sometimes, I feel it would be nice to have the support and camaraderie of people living in shoes similar to  mine, but I am an extreme minority in the minority as a married woman married to an American but not being sent over here on someone else's dime. I won't miss this feeling of isolation and a lack of empathy and support for the challenges I face due to my particular circumstances. 

Will Miss #397 - shops that serve tea

My husband and I were walking around Nishi-Ogikubo, one of many little stops that have little of note to offer that we decided to explore, and I decided to peruse a Japanese sweets shop. I found myself waiting to buy a couple of small bean cakes behind a woman who apparently needed a remedial class in how to purchase goods from a shop. In the few minutes that we twiddled our thumbs, one of the two ladies manning the shop scuttled out bearing a tray with two tiny cups of tea and about 1/6 of one of their cakes on little paper doilies. While it isn't as common as it once was, no small number of traditional Japanese shops will greet every customer, regardless of purchase, with cups of tea (and less frequently, accompanying merchandise samples). 

I will miss this way of welcoming customers and how it makes you feel more like a guest than a wallet that the shop wants to extract cash from. 

Won't Miss #397 - pregnancy badges

One of my students once told me about an experience she had while riding the train. She was sitting with several other people when a family of three, mother, father and child, boarded the train. The woman from this trio started loudly sniping about how no one was forfeiting their seat for her despite the fact that she was displaying a badge that indicated that she was pregnant. Like many people on the train, my student was in her own world and didn't notice the badge. Indeed, it was hardly on prominent display, and the woman was not visibly pregnant. While I realize that some pregnant women may experience difficulties when their child is still embryonic (or indeed a few cells), I think that a lot of women use these badges to bully people on crowded trains into giving up a seat. In fact, I'm not entirely convinced that all of the women showing them are actually pregnant. To be honest, if you aren't visibly pregnant (i.e., not carrying much in the way of extra weight) and too fragile to stand on a train, perhaps you're too delicate to be on public transportation at all. 

I won't miss the women who act aggressively entitled to a seat because they are displaying these badges when they are not at a stage of their pregnancy which requires special accommodation.