Heroes Not Zombies

I’m a Lord of the Rings fan – both the book and the movies. One of my favourite scenes is this one –

I find this inspiring. I think this is what we can do. If you have passion for life, you light a beacon. That beacon spreads light that changes lives. If I had to write down one tip for a better life it would be this – be passionate. Passion is flow. The Chinese have a concept of Chi – a kind of energy. Csikszentmihalyi espoused the concept of “flow“. In modern, Western terms, we are able to be very aware of energy. I often ask medical students to take a score from 1 to 10 where 1 is the worst possible energy they can imagine and 10 is the best possible and to tell me what figure they’d apply right now to describe their own energy state. They can all easily state a number. Then I ask them to do the same thing for their mental energy and they find that equally easy. Then I ask them how they came up with the numbers they picked. What did they assess, and how did they do that? What criteria did they use? Which parameters did they pick? They don’t know. We assess our own energy levels holistically and intuitively. We don’t have to break it down into components, and the strange thing is that the energy we are measuring is not measurable by either instruments or others. Only we are capable of assessing and experiencing our own energy levels.

I think this “energy” idea is related to flow. Flow can be thought of as the Western equivalent of Chi. When the flow is strong, and we are “in the flow” then we feel well, our energy feels good and we alive and healthy. When our flow is weak, we’re unwell. Passion is both a product and a cause of this flow. When we are passionate about life, our energies flow, our creative abilities surge, our resilience is strong and we touch, and are touched by, others. Passion is contagious.

Pass it on.

Research by Danny Dorling at Sheffield University has shown clear links between inequality and death rates.

Sure, there’s a kind of intuitive logic to the fact that poorer people suffer poorer health, but a slightly less intuitive finding is that the amount of social inequality (as indicated by the differences in income between the poorest and the richest) impacts on death rates in all countries, rich or poor. So, within any one country, when social inequality gets greater, mortality rates rise. Danny Dorling’s research has shown that this is an age dependent factor – he’s shown that the larger the inequalities in a society, the greater the mortality in people from 15 – 65 ie. people of working age.

there is an age related mechanism that results in higher mortality being experienced in societies where there is greater social competition, all else being equal. Higher rates of income inequality tend to reflect more competitive rather than more cooperative societies. Whatever the mechanism that results in harm from competition (or protection from cooperation), it has its strongest effects in early to middle adulthood.

One of his conclusions particularly struck me –

social inequalities as reflected through unequal incomes are damaging to health for those living in both rich and poor nations, and the direct mechanisms for such damage are likely to vary by area. Psychosocial stress is unlikely to be the only route by which income inequality damages health. However, the underlying mechanism may be similar—that, because humans are social animals, human health is best protected when people cooperate.

It’s that last phrase that really interests me. “…..because humans are social animals, human health is best protected when people cooperate”

It’s always been the case that the big impacts on the health of populations doesn’t come from the skills of doctors, or the power of drugs, but from the changes in the contexts of peoples’ lives. Education, housing, sanitation, food and water, and income are still the most powerful levers of power in the creation of health.

Yes, of course, there’s lots we can do as individuals. We can make choices about our own lives. And when we are sick individual treatments can make a difference, but if we want more people to have more health, if we want to reduce suffering from cancer, heart disease, mental illness and a host of other diseases, the big gains come from changes in these areas. How we behave towards others, whether or not we value competition or cooperation more highly, impacts on the prevalence of disease and on death rates in people under the age of 65.

One of the things I love about the net, is how it gives us a chance to build our links, to share ideas and thoughts, to encourage and inform each other. In short, to cooperate. And, well, who would have thought it, turns out that’s good for you!

I’ve a lot of respect for a London GP, Iona Heath, who frequently writes in the BMJ, . Last week she wrote an opinion piece about what she sees as the corrupting influence of money on healthcare. I know that healthcare is a big debate in the US, what with Rudy Giuliani throwing around mis-information about cancer treatment to bash what he calls “socialised medicine”. Well, I guess if he reads Iona Heath’s views he’ll confirm his current view that the UK has it all wrong. The system of payment for GPs in the UK has changed with the government paying them for carrying out certain procedures (actually mainly paying them for recording certain pieces of information, like whether or not a patient smokes, BP readings and so on). This has resulted in massive income rises for GPs and the advocates of the system say this shows that money motivates doctors to work according to best practice. Here’s what Dr Heath says –

But if money is thought to be the only motivation, hugely important human aspirations are systematically marginalised and our conception of what it is to be human and a member of society is diminished.

And, this –

In The Burial at Thebes, his translation of the story of Sophocles’ Antigone, Seamus Heaney gives King Creon these words: “Money has a long and sinister reach. It slips into the system, changes hands and starts to eat away at the foundations of everything we stand for. Money brings down leaders, warps minds, and generally corrupts people and institutions.” It seems an extraordinarily accurate description of the state of the NHS. Money is everywhere the driver of change but it is warping minds and corrupting both individuals and institutions. There seems no place left for the altruism of public service to flourish and this is taking a huge toll of the morale of those working in the frontline of health care, whose motivation has always gone beyond the simple question of money. The neglect of altruism seems likely to prove both destructive of social solidarity and ultimately extremely costly for individual citizens.

Let me put my cards on the table. I completely agree.

From the age of three I wanted to be a doctor. Don’t know where that idea came from because there were no family connections with doctors but I pursued that dream and became a doctor back in 1978. Graduation Day was one of the most thrilling days of my life. But it’s only after graduation that doctoring starts and my training jobs were tough, demanding and challenging. In 1982 I became a GP. From the start I’ve always loved working with patients and I always brought my constant curiosity and desire to improve and change things with me. I always made what others would consider stupid decisions about money, not least deciding to leave one practice and join another in 1986 resulting in a drop in income of 70% overnight. Money didn’t motivate my medical decisions. But the government always thinks otherwise and the trend to motivate doctors to carry out government-determined tasks by paying more for what the authorities wanted the doctors to do started to take off in the early 1990s. It drove me out of general practice. It just didn’t sit right with me that I might get paid more if I persuaded a patient to choose one particular course of action over another. I wanted to help every single patient to choose the action they preferred, not to choose the one that paid me more. And I realised that when patients became aware of the payment system they started to question whether I was recommending a treatment because it was good for them or good for me. That was it. I couldn’t do that.

So I stopped.

In fact that was my crisis point. I resigned as a GP and didn’t have another job to go to. For the next 8 months, I got by on one day of clinics at Glasgow Homeopathic Hospital, a weekly radio show (Phone Dr Bob!) and I wrote a textbook of homeopathy for GPs. Financially, it wasn’t clever! Then I got the job I still do – a full-time job at Glasgow Homeopathic Hospital with half the week seeing patients and half the week focussing on teaching. It’s a great job. I love every day of it. There is no greater thrill and sense of reward than I get from the privilege of meeting new patients, getting to know people over time and helping them to find relief from suffering and to experience better health. Financially, I’d be way, way, better off if I’d stayed as a GP (or if went back into general practice now) but in terms of satisfaction and fulfilling a life’s purpose? Well, this current job ticks those boxes for me.

That’s my personal story, but I don’t think my motivations are unusual. I don’t think most doctors become doctors for the money and I totally agree with Iona Heath that creating the health care system around money as a motivator is destroying the environment in which altruism and the desire to care can thrive.