The world of Policy and the Salzburg Statement

With his recent elevation to Taoiseach, something Leo Varadkar (who was supposed to work with me when I did a locum in Tallaght in May 2007… but he was occupied with some election or other) said in the late 1990s got a fair bit of coverage. This was to the effect that as a doctor you can help a few people, but as Minister for Health you can help millions. While at first glance this seems like a truism, it has for some reason got under my skin. There are various reasons for this, not all of which I will get into. Perhaps I am jealous of a road not travelled! (I am pretty confident I am not)

In a way it sums up a particular seduction – the seduction of the World of Policy. Get interested in any field – from the natural world to technology to medicine indeed – and sooner or later the siren song of policy will be heard. Wouldn’t it be great to Make A Difference not just on the piecemeal, day-to-day way, but on a grander scale? Increasingly I think not. Clearly someone needs to formulate policy and to think about things on a broad scale – but they should do so without illusions and with a certain humility. People have a habit of behaving in a way that the enlightened policy makers don’t foresee.  The circuit of conferences and “networking” can become an echo chamber of self congratulation. Doing good, perhaps, is best done on a smaller scale.

These thoughts are occasioned by reading about the Salzburg Statement. This is something I heartily approve of – a call for action to ensure all children enjoy the right to play in a nature rich space within ten minutes of their home.  The statement is made up of eight key actions:

Eight actions to transform cities for children

  1. Ensure children of all ages, backgrounds, income, and abilities have equitable access to nature and play regularly and in meaningful ways to promote good health and wellbeing.

  2. Embed nature in everyday places used by children, such as schools, backyards, parks, playgrounds and city streets, to make the city into a natural outdoor classroom.

  3. Involve children in designing and planning natural spaces for recreation, education, inspiration and health, to give them ownership and pride in their local communities, schools and parks

  4. Build curiosity, wonder, and care for nature in children (for example by greening school grounds and involving children with community gardens).

  5. Protect natural features across cityscapes and create an equitably distributed network of accessible green and nature-rich spaces that all generations can reach on foot.

  6. Connect cities with the broader ecosystems in which they are embedded, creating corridors for people, plants and animals to move safely across the city and into its surroundings.

  7. Establish more urban conservation areas to increase access to nature and connect cities to the broader protected area network.

  8. Work together through cross sectoral and multi-level partnerships to build an inclusive culture of health in cities.

 

There’s nothing there I would disagree with, though as with all these kind of interventions I would like more robust dissection of what, say, Item 3 would mean in practice.

I am always a little wary of dressing up worthy activity in the mantle of Health. What Resting a case for nature on the vagaries of purported health benefits can be a dangerous and debunkable game – especially with the media. This visual  handily shows how media can seize on single studies to generate headlines:statins.png

One can easily imagine a Katie Hopkins-ish journalist seizing on the inevitable ambiguities of research to “debunk” the claims for health benefits of nature.

I should state very clearly I have no reason to think that the Salzburg Statement is a wonderful initiative I look forward to hearing more of. But I am a little wary of the siren call of the World of Policy.

Beyond Knowing Nature – 5 Pathways to Nature Connection

Once again I am reblogging an interesting post by psychologist Miles Richardson on connection with nature and well being.

Particularly interesting is the research finding that factual knowledge does not necessarily correlate with emotional connection with nature. As Richardson writes, “the brain feels before it thinks”, and by focusing too much on how well species can be identified, we can miss the potential of emotional, experiential connection.

Finding Nature

Owing to the benefits to both human and nature’s well-being, and wide spread disconnection, a connection with nature is something many people and organisations are keen to increase. So there is a need to know how best to do this. We’ve already developed specific interventions, such as 3 good things in nature, but our wider framework of effective routes to nature connection has just been published in Plos One. I’m excited about this work is it provides guidance for those seeking to re-connect people with nature, indeed it has been central to much of our recent nature connections work, for example, guiding the type of activities promoted as part of The Wildlife Trusts highly successful 30 Days Wild campaign.

General nature contact and knowledge based activities are often used in an attempt to engage people with nature. However the specific routes to nature connectedness have not been examined…

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Leandro Herrero – “The best contribution that Neurosciences can make to Management and Leadership is to leave the room”

A while back I reviewed I Know What You’re Thinking: Brain Imaging and Mental Privacy in the Irish Journal of Psychological Medicine, and discussed a couple of studies which illustrate the dangers of what could best be called neuro-fetishism:

In 2010, Dartmouth University neuroscientist Craig Bennett and his colleagues subjected an experimental subject to functional magnetic resonance imaging. The subject was shown ‘a series of photographs with human individuals in social situations with a specified emotional valence, either socially inclusive or socially exclusive’. The subject was asked to determine which emotion the individual in the photographs were experiencing. The subject was found to have engaged in perspective-taking at p<0.001 level of significance. This is perhaps surprising, as the subject was a dead salmon.

In 2007, Colorado State University’s McCabe and Castel published research indicating that undergraduates, presented with brief articles summarising fictional neuroscience research (and which made claims unsupported by the fictional evidence presented) rated articles that were illustrated by brain imaging as more scientifically credible than those illustrated by bar graphs, a topographical map of brain activation, or no image at all. Taken with the Bennett paper, this illustrates one of the perils of neuroimaging research, especially when it enters the wider media; the social credibility is high, despite the methodological challenges.

I am becoming quite addicted to Leandro Herrero’s Daily Thoughts and here is another. One could not accuse Herrero of pulling his punches here:

I have talked a lot in the past about the Neurobabble Fallacy. I know this makes many people uncomfortable. I have friends and family in the Neuro-something business. There is neuro-marketing, neuro-leadership and neuro-lots-of-things. Some of that stuff is legitimate. For example, understanding how cognitive systems react to signals and applying this to advertising. If you want to call that neuro-marketing, so be it. But beyond those prosaic aims, there is a whole industry of neuro-anything that aggressively attempts to legitimize itself by bringing in pop-neurosciences to dinner every day.

In case anyone doubts his credentials:

Do I have any qualifications to have an opinion on these bridges too far? In my previous professional life I was a clinical psychiatrist with special interest in psychopharmacology. I used to teach that stuff in the University. I then did a few years in R&D in pharmaceuticals. I then left those territories to run our Organizational Architecture company, The Chalfont Project. I have some ideas about brains, and some about leadership and organizations. I insist, let both sides have a good cup of tea together, but when the cup of tea is done, go back to work to your separate offices.

It is ironic that otherwise hard-headed sceptics tend to be transfixed by anything “neuro-” – and Leandro Herrero’s trenchant words are just what the world of neurobabble needs. In these days of occasionally blind celebration of trans-, multi- and poly- disciplinary approaches, the “separate offices” one is bracingly counter-cultural…

Leandro Herrero – What I learnt from the monks: a little anthropology of leadership and space in one page.

Another Daily Thought from Leandro Herrero that I am tempted to simply cut and paste completely. The whole thing is worth reading. I have blogged on my other site a fair about both the positive side of monastic practice and the risk of romanticising monasticism with the attendant danger of spiritual pride.

Monasteries were, of course, key institutions in the development of Western institutional life and culture. We often like to think that we have moved way way beyond learning from the communal life of monasteries. Of course, the themes and patterns of human interaction recur in superficially different guises:

There is something special about creating space. For me, leadership is mainly architecture: create the conditions, find the spaces, protect them, make them liveable. Architects also have maps, and compasses. The leader needs to provide maps (frameworks, such as the non negotiable behaviours) and navigation tools (a value system). But, above all, it’s about space.

Providing spaces for people to breath, to growth, to deliver something, to get better, to think critically, to interact, to collaborate, to travel together. This is all about space. Space is the psychological sister of place. Space may be only, or mainly, mental. As such, it is a precious asset. No wonder the word space has been often associated to the word sacred. As in sacred spaces. To provide space, to create and protect spaces for others, is something a good leader does. It’s a great deal of his servant-ship.

But we, sometimes, are not very good at this. We take over other people’s spaces by insisting in discussing, wanting to ‘go deeper’, being intolerant with leaving things open, dictating our own terms and providing unreasonable borders to their spaces.

At a threshold point of two people living together in one place, they may come to inhabit one single space. It requires a lot of maturity to live in one single space with others. Occupying one single place, is the easier part, space is not. Indeed, that single space may end up being too much to ask. It may be better to have separate spaces to respect, often overlap. Psychotherapists have known for many years that a temporary split, or making tangential connections for a while, may be the solution to some problems. Un-bundle the spaces that have become blurred, that is.

#OceanOptimism, powerlessness, hope, and change.

The current BBC Wildlife Magazine has a fascinating article by Elin Kelsey, of the Ocean Optimism Project, on how media-fuelled environmental despair and nihilism ends up demoralising people to the degree that positive action seems impossible. She cites much research on the “finite pool of worry” and the paralysing effect of despair, and the power optimism to reverse this trend. The article isn’t available online, but in the post below from my other blog I highlight relevant passages from a Kelsey piece in Smithsonian Magazine on similar themes.

This article is obviously focused on ecology, but is all too true of our healthcare systems. For similar reasons to those Kelsey ascribes to environmentalists who are wary of being overly focused on good news, frontline workers in the health service naturally tend to focus on what is wrong, what is proving impossible, what needs to change. This is necessary, but can become an overwhelming counsel of nihilism, fostering cynicism and very often helping to entrench negative practices.

This is very relevant to the various themes on valuesmorale, “blame culture”, and possibility of positive change within not only the HSE but any healthcare organisation.

Séamus Sweeney

The current issue of BBC Wildlife Magazinehas a fascinating cover story by Elin Kelseyon hope and optimism versus despair in how we think about they environment. Essentially, much media discourse on the environment tends to be gloomy, doom, and generally despairing. Kelsey cites a wide range of research on how this negativity effects how we think about the environment and our beliefs about what can be done – and therefore what is done – to improve things. The full article is not available online. This article from Smithsonian Magazine is briefer, but captures her idea:

Things are far more resilient than I ever imagined. Me, green sea turtles, coral reefs blown to bits by atomic bombs. In a twist of fate that even surprised scientists, Bikini Atoll, site of one of the world’s biggest nuclear explosions, is now a scuba diver’s paradise. Bikini Atoll located in the Pacific’s…

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Stephen Westaby, “community focus”, and medical education

Not so long ago, surgery and (internal) medicine were the pinnacles of medical school, the final subjects before graduation. Surgery in particular possessed a dark, elitist glamour, its notoriously long hours and intensity attracting rather than repelling many. Of course, being attracted by a perceived mystique is different from having a sustainable career (and life)

In recent years, medical curricula have been reshaped by many factors, including the realisation that most doctors will practice not as surgeons but as general practitioners, and that the bulk of healthcare need is perhaps more mundane than what goes on in the operating theatre. While there is justice to this “community orientation” of medical education, there is also a certain sense of taking the surgeons and physicians down a peg or twenty. Perhaps there is also a certain anti-intellectualism at work – focusing on the behavioural acts that a doctor performs, rather than the academic disciplines (which include clinical disciplines)

Recently I have been reading Simon Westaby’s memoir of his surgical career, Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table. Indeed, the above paragraphs are taken from a first draft of my review (both paragraphs cut for reasons of space and general narrative flow of the review). Westaby’s book is a good read (there, that’s the review bit out of the way) and full of exciting surgical action, described deftly but dramatically. It is also something of an elegy for a certain time of medical and surgical training – an era of overwork and monomaniacal dedication, but also one of intellectual and moral curiosity and rigour, often absent from a modern practice subservient to bureaucratic imperatives. I have already blogged about Westaby’s thoughts (and research) on the impact of league tables on surgical practice. I do wonder whether, for all its manifold faults, “traditional” medical education created a breed of doctor with an espirit de corps to whom a resistance to bureaucratic imperatives came easier?

 

 

Friendship and Work in Medicine and Healthcare

In 2001, Digby Anderson wrote a short book, Losing Friends, about what he described as the decline of friendship. This New York Times “At Lunch With” pieces ummarises his argument:

”All past civilizations have declined, and Western civilization is about due to go,” he said, gamely piling his plate with assorted meats and salads. ”The death of friendship is one symptom of that.”

He says he believes political extremism has rendered friends powerless to help one another. Liberals’ insistence on equal opportunity and impartiality, he said, has led to ”egalitarian bureaucracy,” a muddling of what had once been smooth-flowing business networks based on friendships. Years ago, he said, friends happily helped one another find jobs; today they shy away, lest they be accused of favoritism.

”Even though it makes sense to hire a friend, or even a friend’s friend, there’s this feeling that you have to give everyone an equal chance,” he said.

The blow from the right, he said, has been a constant emphasis on the family as the ”repository of all virtues” — and, thus, the only institution worthy of trust and time.

”The ancient Greeks had a better idea: they considered their friends to actually be their family,” Dr. Anderson said.

My recollection of the reasons he gives in the book why “it makes sense to hire a friend, or even a friend’s friend”, is because of the special knowledge which friendship gives us about someone’s true nature. A friend – a true friend – is also less likely to screw over their friend… or at least thats the theory. I wonder how strong the evidence is for the counter argument, that hiring friends is somehow bad?

I am not sure how much I buy of Digby Anderson’s overall argument about hiring friends etc, but there is definitely something in his reflections on the decline of friendship.

The official blurb is also interesting:

“One loyal friend is worth 10,000 relatives”, said Euripides. Aristotle thought friendship the best thing in the world. Saint Augustine was devastated by the death of a friend, “All that we had done together was now a grim ordeal without him”. For men as different as Dr Johnson, Coleridge and Cardinal Newman friendship was a great, moral love. For Cicero it was a foundation of social order. For Burke “good men [must] cultivate friendships”. To try to lead a good life on one’s own is arrogant and dangerous. In past ages business thrived on the trust of friends; armies won battles on the loyalty of men to their comrades and people were attracted to and schooled in medicine, law and academe by friendship. This friendship of the past was high friendship, a friendship of pleasure but also of shared moral life.

LOSING FRIENDS contrasts this high friendship with the “pathetic affairs” which pass for friendship today. Friendship is in trouble. An institution once as important as the family, has been “diluted to mere recreation…passing an odd evening together…sharing the odd confidence”. It is being outsted from business through fear of cronyism and squeezed between the demands of work and the increasingly jealous family. Fathers neglect their obligations to their friends at the club or pub to bath their children. Many of us will have no friends in illness, in need or at our funerals. Bewildered letters to agony aunts ask how to make friends. Schools are absurdly introducing classes on how to do so. Our society has no public recognition of friendship and cannot even discuss it articulately. When it does it sentimentalizes it. Modern society is wealthy, healthy and long lived. Aristotle would ask what the point of such a life is if lived without friends.

I have (or had) a copy of the book somewhere. I read it in around 2004. The message did resonate, and since I have seen how social pressures that tend to squeeze out friendship intensity.

Healthcare in general, and medicine in particular, is on one level a fertile ground for friendship. One ends up spending a lot of time with other people engaged in what is  a highly intense, demanding role. It is natural enough for some strong bonds to form, as over the hurried coffees and lunches some small talk is exchanged. There has also been a boozy culture around medicine in the past at least, and while one could make many observations on the role of alcohol as a form of self-medication, there was a social side to all this.

And yet the structure of medical training in particular is not conducive to longer term friendships. One spends three, or six, or at most twelve months in a post as a trainee  doctor. The intense friendships of one rotation are suddenly severed. With the best will in the world, and my sense is the unreal interactions of social media have exacerbated rather than ameliorated this, it is hard to keep up. And when one completes training, the camaraderie of the res room is something that is closed to you.

The factors that Dr Anderson discusses – the suspicion of anything that might hint of favouritism, the dulling bureaucratic managerial discourse of healthcare management, a sort of idolatory of the family now as much a left as right wing feature – are present in medicine too.

How does friendship relate to the issues of morale and a healthy work culture I have blogged about before? The importance of “psychological safety” in team interactions is emphasised in Google’s Project Aristotle as key to successful team interactions. Fostering a sense that teams can communicate openly, without fear of recrimination or embarrassment, sounds to me very much like fostering friendship. Of course, perhaps this is falling into some kind of trap where friendship can be subservient to the interests of an organisation, and indeed denigrating friendship as something that needs to be justified in pragmatic, utilitarian terms.