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.

The Irish Smoking Ban – One Year On. Published 29th March 2005, Social Affairs Unit web log

In 2004 I contributed a piece to the web log of the Social Affairs Unit, a libertarian-leaning think tank affiliated to the Institute of Economic Affairs. I had come across Digby Anderson’s book Losing Friends somewhere along the way, was impressed with the scope of the book and discovered the SAU and its blog.

I was never asked to take a particular political or cultural line with the SAU. No piece I wrote was ever edited for politics, so to speak. The blog’s editor once suggested I write a review of the Dr Who revival, which I never did. Most of my pieces for the blog are fairly straightforward book reviews or pieces with a cultural bent – as can be seen here .

I don’t think any one political system or philosophy is enough to approach the world. I have concluded that I am not a full throated libertarian, after all. It is too inclined to rather simplistic solutions that involve abolishing this or that (the mirror image of statism) However, if there’s a binary choice between being a libertarian and a statist, I’m the former.

But there isn’t such a binary choice. Perhaps my political stance is best defined as anti-binaryism.

This piece is ultimately impressively non committal about its subject. I note the commentators include doctors who are keen to point of the evil of smoking, which I kind of take for granted in the piece. Someone chimed in with a similar comment on this more recent piece on the Manhattan Project.

What is also striking is how, 11 years on, the smoking ban is utterly taken for granted. This pieces was a rare attempt at topicality on my part (aside from occasionally writing about an anniversary, I find I don’t really do topical pieces)

Anyhow, here it is:

Towards the end of 2004 I bought a computer magazine which featured, for some reason, a timeline of the major events of the last half decade or so – not just in computing but in the wider world. Thus beside the launch the iPOD and Windows XP, we had September 11th and the beginning of the Iraq War. In the middle of these indisputable events of global importance, in March 2004 we read that “Ireland introduces a ban on smoking in public”.

March 2004 saw Ireland the focus of global media attention, for once not due to paramilitary activity of some kind. Smoking bans are all the rage internationally, and a live issue in British politics. For a certain mentality, there was something exciting about Ireland, for once, not following the trends of other more ‘progressive’ countries but setting them.

One of the ironies of all this was that the pub is so central to the Irish international image that it was the basis for all the coverage in the world media. Most commentators seemed struck by the piquant irony that the drinkin’, swearin’, fightin’ Irish would be embracing the healthy life in their drinking dens.

The ban, of course, is not by any means confined to pubs. All workplaces are included – with certain exceptions such as prisons and psychiatric hospitals. Pubs, of course, are one of this country’s most successful exports. No town of any size anywhere is complete without a pub called something like Dicey O’Reilly’s or Scruffy Murphy’s, filled with faux-Irish décor, wannabe Irish drinkers and indeed, rather embarrassingly, actual Irish drinkers crying into their Guinness.

A few months after the ban was introduced, the English movie actor Paul Bettany was quoted expressing his amazement that the ban was still in force; “I thought the Irish would have risen up as one to overthrow it”. For the ban, as became apparent within weeks, was – in its own terms – wildly successful. A pub in Galway announced its defiance and a few days later backed down, a bored Fine Gael T.D. (M.P.) lit up in the Oireachtas largely for publicity reasons and to get out of a rather tedious front-bench job. That was, roughly speaking, the extent of the mass civil disobedience.

Those whose experience of Ireland was based on more than a few nights on the beer singing rebel songs were perhaps less surprised. The Irish are far less the feckless anti-authoritarian individualists of popular legend than we are world leaders in radio call-in show whingeing.

Healthism with its ubiquitous health promotion messages is as strong in Ireland as anywhere else in the world. When I was in Australia, another country with an ostentatiously laid-back image, it seemed impossible to move very far without some public health message or other being shoved in one’s face. In Melbourne I finally found it going too far with little stickers on traffic meters warning pedestrians not to jaywalk. Ireland is heading that way too. Most ads seem to be related to some health worry or other these days. The papers are filled with apocalyptic warnings of the forthcoming Biblical plague of obesity – ignoring the recent report that we are one of the less obese nations of Europe, according to theInternational Obesity Task Force.

No doubt most readers will have their own opinion on the advisability or otherwise of smoking bans. As for myself, the freedom to smoke cigarettes in enclosed public spaces does not strike me as one of those immemorial freedoms you could give up your life for. The purpose of this article however is not to get stuck in that debate, but simply to report how life has changed – or rather how little it has changed – in the year since.

From a purely selfish point of view as a non-smoker, the ban has made things more pleasant on a night out. Indeed, many people I know are now much more prepared to go into a pub during the day for a meal as opposed to only on a night out. No longer do I come home from a night out with clothes smelling like a sweaty ashtray. No longer the coughing or streaming eyes as another diner or patron lights up at the next table. So, from pure self-interest, I am all in favour of the smoking ban.

The apocalyptic consequences the Vintner’s Federation had warned of – the Republic’s social life decamping en masse to the North, and the streets filling with starving publicans begging for their daily bread – did not come to pass. Soon billboards showing smiling, satisfied drinkers extolled “the breath of fresh air” that had swept the “greatest pubs in the world” – a certain megalomania is one of the unfortunate side effects of the economic boom in Ireland. One Dublin radio station proudly promotes itself as serving “the greatest city in the world”. Does anyone, even the most patriotic citizen, really believe that?

One wonders if, in the long term, there will be any fewer smokers as a result of the ban. The little knots of smokers outside each pub soon became a familiar sight, and in these little groups they often seemed to be having quite a bit of fun. Indeed, in its status as a social lubricant, the cigarette has been enhanced rather than diminished. In due course there will surely be smoking-huddle marriages, and no doubt smoking-huddle babies are already filling out their Pampers. The outlaw image of smoking is surely enhanced by bans. It has become a mysterious Other, the little world of the smoking huddle, and we all know the attraction of the mysterious Other.

The ban was originally meant to come in on January 1st 2004 – for a variety of bureaucratic reasons, it was delayed until March 29th, which was fortunate for its proponents. One wonders if this innovation had come during a freezing midwinter as opposed to a reasonable spring if there would have been the increase in general hooliganism that was widely touted pre-ban. Having said that, an orthopaedic surgeon did note a couple of weeks into the ban that there had been a sharp increase in fractured jaws as a result of smoking huddle melees. Little further has been reported on this phenomenon.

Many of my friends claim that in a nightclub, the odour of cigarette smoke acted as a sort of deodorant, and what formerly would have been a seductive, erotic haze is now replaced by an unappealing blend of sweat, flatulence and alcohol. Fortunately, perhaps, I have yet to notice this, or perhaps I was less than seduced by the odour of the average Dublin nightclub even before the ban.

If there has been a definite effect of the ban so far, it is that tolerance of smoking – in the most basic sense of being able to put up with it – has been greatly reduced. Any exposure to any smoke at all is now a big deal. In Birmingham last year for a course, wandering Broad Street on a Saturday evening looking for something to eat, I found myself at first irritated and then slightly baffled by the pub smokers. Thus, something which probably wouldn’t have bothered me a few months before became a source of (albeit minor) distress. Whatever the rights and wrongs of smoking bans, my stock of toleration has become ever so slightly diminished. Readers will have their own view as to whether this is a good or bad thin