地方医療という檀家制度

80代の母親がふらついて倒れて、1週間動けなくなったという連絡を受けて、精密検査のために会いに来た。

結果は大きな問題は無かったという事で、安心してフグでも食べに行こうとなった。

診療情報提供書を見せてもらうと、並んだ処方薬は7種類。

正直に言えば、「さすがに多いな」という印象を持った。

高齢者は通常より脱水、肝機能低下があり薬も効き過ぎる。

医師は通常2剤間の相互作用は厳密に見ていると思うが、3剤以上の同時使用は経験と勘でしか動いていないのではないか。

ましてや7剤の化学物質の組み合わせでどんな事が起こるか想定できない。

もっとも、地方医療の現場を知っている身としては、驚く数字ではない。高齢者医療において7剤は、もはや“特別”ではないのが現実だ。

ただ、僕だったらこう考える。

80歳以上の高齢者では、血液データを根拠に漫然と出されてきた一次予防の薬は、エピソードがない限りいらないのでは？

薬を飲む事で、何年も健康寿命が伸びるなら賛成するが、一方で不健康な状態での平均寿命を伸ばすだけというネガティヴな影響もあるだろう。

国民医療費の観点からも疑問がある。これが国民皆保険の日本であれば無料で提供されるので飲むかもしれないが、例えば欧州で、月額の予防の薬が5万円ですと言われて、症状もないのに飲む人は果たしてどれくらいいるのだろうか？

さらに問題は薬の数ではない。その背後にある関係性の構造だ。

地方の開業医と患者の関係は、かつてのお寺さんとの檀家制度に似ている。

何十年も通い、家族のことも、人生の節目も共有してきた。

「この先生に診てもらっている」という事実そのものが、安心の基盤になっている。

その関係性は、尊い。同時に、とても強い。

強すぎる関係は、変化にブレーキをかける。

薬は「効いているから続く」のではなく、「問題が起きなかったから続いている」ことがある。

高齢になればなるほど、ふらつき、転倒、せん妄、食欲低下といった症状は、むしろ一つ一つの病気ではなく、薬の総和で現れる場合がある。

しかし、長年信頼してきた医師の処方を、ある日突然「減らしましょう」と言うのは難しい。これまで続いてきた時間の重みの方が、地方では勝る。

結局、誰かを否定するためではなく、第三者の視点で一度フラットに全体を眺めるため。

本当に必要な薬。

役目を終えた薬。

相互作用が疑わしい組み合わせ。

それを静かに仕分けてきた。

地方医療は、もはや近代的なサービス業ではない。

その土地の時間を一緒に生きる、半ば共同体装置のような存在になっている。倒れた、という出来事は不安だ。しかし同時に、「一度、全体を見直してもいい」という合図でもある。

地方医療という檀家制度。

その中で、どうやって“更新”を行うのか。

それは、これからの日本医療全体に突きつけられた問いなのかもしれない。

The Parishioner System of Rural Healthcare

I received a call saying that my mother, now in her eighties, had felt dizzy, fallen, and been unable to move for a week. I went to see her so she could undergo further examinations.

The results showed no serious problems, which was a relief. We even joked about going out to eat fugu.

When I looked at the referral letter, however, I noticed that she had been prescribed seven different medications.

To be honest, my first reaction was, “That’s a lot.”

Elderly patients are more prone to dehydration and reduced liver function, which means medications tend to have stronger effects. Physicians are usually careful about interactions between two drugs, but when three or more are used simultaneously, decisions are often guided more by experience and intuition. With seven chemical substances combined, it is virtually impossible to predict what might happen.

That said, having some familiarity with rural medical practice, this number did not truly surprise me. In elderly care, seven medications are no longer “exceptional”—they are increasingly the norm.

Still, if it were up to me, I would think this way:
For patients over 80, do we really need primary-prevention drugs that have been prescribed routinely based solely on blood test values, if there has been no actual clinical episode?

If taking medication clearly extended healthy life expectancy by several years, I would support it. But there is also the possibility that it merely prolongs average lifespan while extending years spent in poor health—a decidedly negative outcome.

There is also the issue of national healthcare costs. In Japan’s universal healthcare system, these medications are often provided at little or no cost, so people take them without much hesitation. But imagine being told in Europe that your preventive medications would cost ¥50,000 per month. How many people, with no symptoms at all, would still choose to take them?

Yet the deeper problem is not the number of medications. It is the structure of relationships behind them.

The relationship between rural private practitioners and their patients resembles the old danka system—the parishioner system that once tied families to local temples. Patients have been visiting the same doctor for decades, sharing family stories and major life events. The mere fact of “being under this doctor’s care” becomes the foundation of reassurance.

That relationship is precious. And at the same time, it is very strong.

Relationships that are too strong can put the brakes on change.

Medications do not always continue because they are effective; sometimes they continue simply because no obvious problems have occurred. As people age, symptoms such as dizziness, falls, delirium, and loss of appetite may not stem from individual diseases, but from the cumulative effect of multiple medications.

Even so, it is difficult to suddenly suggest, “Let’s reduce your prescriptions,” when they come from a physician who has been trusted for decades. In rural settings, the weight of shared time often outweighs rational reassessment.

In the end, this is not about blaming anyone. It is about taking a step back, as a third party, to calmly view the whole picture.

Which medications are truly necessary.
Which have already fulfilled their role.
Which combinations raise concerns about interactions.

These were quietly sorted and reconsidered.

Rural healthcare is no longer a modern service industry. It has become something closer to a communal institution—one that lives alongside the accumulated time of the land itself.

A fall is frightening. But at the same time, it can be a signal that “it may be time to review everything.”

The parishioner system of rural healthcare.
How can it be updated from within?

That may be a question now being posed to Japanese healthcare as a whole.