Some musings

‘I went to the woods because I wanted to live deliberately, I wanted to live deep and suck out all the marrow of life; to put to rout all that was not life and not, when I had come to die, discover that I had not lived.’

Henry Thoreau

Benjamin Franklin was wrong – as well as death and taxes, there is, in this world, at least a third thing that can be said to be certain – and, in case you’re wondering, I’m not thinking of the defecatory habits of ursine mammals in areas with a healthy tree population. Instead, the certainty to which I’m referring is the notion that the NHS will continually be asked to deliver more than it can reasonably be expected to in the mistaken belief that it is the conduit to perfect health.

A few years ago now, a new health initiative to improve patient health by means of personalised care plans was introduced. It generated some interest. Doctors were encouraged to sit down with patients and generate individualised advice on how those patients should go about their day to day lives so that they might maximise their health. It was patient centre health care – with bells on.

Now nobody would deny that suggesting patients stop smoking, eat healthily and take more exercise is anything other than good advice but, no matter how good that advice is, there will be no benefit in giving it to those who are not motivated enough to follow it.

With apologies to Henry Thoreau:

‘I went to the health centre because I wanted to lower my BMI, I wanted to live to 103 and maintain a blood pressure of 130/70; to reduce my serum cholesterol below 5.0 and not, when I had come to die, discover that I really should have switched to a low fat spread.’

Somehow it doesn’t have the same ring to it. Working to achieve targets is not what life is about – not at work, nor indeed in our personal lives. But in a world obsessed by what can be measured, data is increasingly becoming more important than the people to whom that data relates.

And that’s not healthy.

Encouraging people to be too focused on improving their health parameters is to do them a disservice. Furthermore, it is never going to work. Instead, in order to motivate people to live healthily, they will first need to lead lives about which they are motivated enough to go on living. If, the best part of 2000 years ago, Juvenal was dismayed by the people being superficially appeased by ‘bread and circuses’, he’d be no less frustrated at our being far too easily satisfied by a packet of chocolate hobnobs and a Netflix subscription. Without, for one minute, denying the joys inherent in such things, you get my point – if that is all life holds out for you, if the biggest thrill you get in a day is the momentary pleasure of a fag, a bottle of scotch or a Happy Meal, you will continue to seek your pleasure in these things.

But if life is rich and rewarding, then people just might be motivated enough to give up these lesser pleasures and thereby improve their health. There is more to life than being alive and a preoccupation with health can become little more than a distraction to the important matter of actually living.

Furthermore, drawing people into ever more complex care pathways, even if it did produce improved health indices, may only serve to bring about a more healthy population of ‘dead’ people whose health becomes the sole goal of their lives.

We need to be less interested in health. Rather than it being the end in itself, we need to see it simply as the servant which enables us to live. The nation’s demand for health has steadily increased as medical science has made medical interventions possible that once could only ever have been dreamed about.

Health provision has risen hugely but, we must ask, are we any healthier? We may be living longer, but our sedentary lifestyle and epidemic levels of obesity suggest that the best efforts of healthcare professionals have failed to achieve the healthier population for which we would have hoped. Indeed medical advances may even be considered to have encouraged unhealthy practices by their promise of sorting the problems that such practices inevitably cause.

Now don’t misunderstand me. If one is suffering from appendicitis, then a doctor is undoubtedly a handy person to have about. But, if we are to be healthier as a nation, we are going to have to want to be healthier because the lives we are living are worth being healthy for. We’ll need to be drawn towards health rather than driven, cajoled and bullied towards it. If happiness promotes healthiness then might nor our current unhealthy lifestyles be explained by the fall that has been seen in the nation’s happiness in past years even if that downward trend may now be turning a corner. Addressing that unhappiness may, therefore, be a more effective way to improve our health.

And this makes me consider whether there is an arrogance about health care provision. Have we doctors got ideas above our station? Do we overestimate our significance, imagining we are the most important factor in bringing about health in our patients as we go on constantly about their cholesterol, blood pressure and smoking status? Do we set ourselves up as the high priests of the god of health – laying down the laws of wellbeing and threatening terrible consequences to those who contravene that law? The way we often talk about health advances suggest perhaps we do. How often do we hear of some new medical advance promising to save any number of lives when, in truth, such advances will, at best, only prolong some and save none.

Albert Einstein once said, ‘The only thing more dangerous than ignorance is arrogance’. He was right. And not only is an arrogance on the part of medicine bad for patients, it is bad for doctors as well.

An exaggerated sense of our own importance increases the responsibility we feel in our dealings with patients and with that sense of responsibility, the anxiety we feel also increases. Everyone who deals with patients will know the anxiety that results from that sense of responsibility coupled with the uncertainty that is so often intrinsic to such interactions. Dealing with this uncertainty is one of the challenges that I and every doctor has to learn to cope with. The problem, of course, is that none of us are quite as able as we’d like to think we are – we can not know what we can not know. Could it be then that our anxiety is another form of arrogance?

Now hold on a minute, you might think, that can’t be right. After all doesn’t anxiety convey feelings of uncertainty and inadequacy – hardly the characteristics of the proud? But think again. Could it be that my anxiety is bourn out of a belief that, once again, it all depends on me – that the outcome is entirely down to my interventions, that in some way I have the power to determine the future if only I could do the right thing guided by my god-like qualities of omniscience and omnipotence with which I must save the world or at least my little corner of it? Now that would be arrogance.

An example may help. Take that patient who attended the other day with a headache. For all the world it seemed like a common or garden tension headache with no sinister sounding features whatsoever. The advice to take two paracetamol and call me in the morning was never more apt. Yet as the patient left my anxiety began to grow. What if the patient has a brain tumour, what if they die, what if it’s my fault? Now the truth of the matter is that if the patient has a brain tumour then, though sad, there was no way that that could have been determined from taking a history and performing an examination. Sad to say I do not have the god like quality of an MRI built into my forehead enabling me to notice what is otherwise impossible to see. I have to accept that I am only a doctor.

All doctors have to learn to acknowledge the fact that that is all we are. We are limited in what we can do. Now that is not to say we shouldn’t do our best – of course we should but we would all, I think, be a lot less anxious if we realised it didn’t all depend on us.

Our patients’ health does not depend wholly on us, and what’s more, believing it does often serves to make us defensive when things don’t end well, more concerned to justify our actions rather than showing the compassion we would do well to express in such circumstances. Doctors can’t make everyone healthy any more than they can make everyone happy. Perhaps we should, at times, allow ourselves to step back as doctors and, rather than killing our patients with health advice, somehow encourage patients to look away from health as the source of their happiness to something bigger and better – something really worth living for.

Then we might see an increase in health flow from a reduced concern about health.

At general election time, our politicians promise a utopia that is way beyond what they have the ability to bring about and, though they should be encouraged in their efforts and we should be responsible with our vote, they, and we, must be realistic in what they can truly deliver. Politicians are no more solely responsible for the health of the nation than we are but, having said that, they could adopt policies that better promote happiness.

Finland has recently been voted the worlds happiest nation scoring highly on levels of healthy life expectancy whilst the US, despite it having the world’s largest economy is increasingly unhappy and struggles with an epidemic of obesity, substance abuse and depression. Why the difference? One answer seems to be that Finland, along with the other Nordic countries that sit alongside Finland at top the happiest countries list, has one of the highest tax bills in the world, one that limits the wealth gap and encourages equality. And that tax bill is one that is happily paid by a people who see it as necessary for delivering quality of life for all with free health care and university education for everyone.

Medicine is important but the causes, and the causes of the causes, of ill health need to be addressed if we are to become a healthier society. A little honesty about who we are and what we can do as a profession would go a long way. And individually too. We’re all pretty average, all pretty ordinary. Rather than pretending we’re more than we really are, let’s have a little humility. As Harry Callahan used to say: ‘A man’s gotta know his limitations’. We might just feel a little better by acknowledging them.

Furthermore, such an attitude may, as a result, help us to stop the constant berating of ourselves, and others, for not being what we, and they, could never be.

So what makes life rewarding? Certainly not the hitting of health targets so often imposed on us by ourselves and others, regardless of whether those targets be optimal blood pressure, BMI or cholesterol levels. Though all desirable in their way, a life that is genuinely rewarding is surely more than that and has something to do with experiencing life with all its ups and downs alongside others who, regardless of how close they come to some arbitrary notion of what is ideal, we love unreservedly and who love us equally despite our frailties, despite our failure to reach the mark. It’s acknowledging each other as equal and valuing each other accordingly, connecting with others, appreciating them for who they are and what they bring to the world, that makes life worthwhile.

And a rewarding life is also something to do with living in the hope that however hard, however difficult life is today, someday things can and will be better. If we are to live abundantly, experience life in all its fullness, we’ll need to stop constantly setting health targets and endlessly striving to achieve them imagining that they alone will bring about the better world we desire. Of course we can each make our small contribution to making our society a better place, good health care is part of that, but we’ll need to appreciate that we aren’t the most important people in the world, upon whom the whole fabric of the universe depends. We’ll need to acknowledge that we all need more help and to be shown more kindness than a mere doctor can offer.

Understand these things and we might live a little more happier, a little more deep – whether we take a trip to the woods or not.