Re-humanizing Medicine & Walking the Medicine – Books of the Month in the Royal College of Psychiatrists Newsletter

Royal College of Psychiatrists

Pan American Division Newsletter, February 2017 (Issue 26)

RCPsych PanAm Book club: Book of the Month

This month’s recommendation was sent by Dr. David Kopacz who responded to our call to “rediscover the soul of daily practice” and to connect with more members of our Division. Dr. Kopacz is a psychiatrist working in Primary Care Mental Health Integration at the Puget Sound Veterans Affairs in Seattle, Washington, US. He is the author of our two books of the month:

  • Walking the Medicine Wheel: Healing Trauma & PTSD By David Kopacz and Joseph Rael (Beautiful Painted Arrow) Millichap Books/Pointer Oak, 2016
  • Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine. By David Kopacz (Ayni Press, a division of John Hunt Publishing, 2014)

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Thanks RCP!

A Work of Joy.1 < What is Joy in Work, Where has it Gone, How can We bring it Back?

This is the first of a series of blog posts examining Joy in Work – maybe we’ll call it: A Work of Joy! It is part of an ongoing discussion between Dave Kopacz and Sandy Carter on this topic and will include each of our thoughts individually as well as our dialogue on Joy in Work. This first blog will provide a broad outline for subsequent work. We will each start with a monologue and move from there into dialogue.

Dave Kopacz, M.D. works as a psychiatrist at the VA in Primary Care Mental Health Integration. Prior to this he was Clinical Director at Buchanan Rehabilitation Centre in Auckland, New Zealand. He is Board certified in Psychiatry and Integrative & Holistic Medicine. He is the author of Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine.

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Sandy Carter, Ph.D. works as a physician coach and consultant. Sandy is a professional certified coach, holds a PhD in organizational management with a specialization in leadership, and Masters in Business Administration and Social Work. Her research is in the area of transformational leadership with physicians, and wellness and resiliency.She heads The Center for Physician Leadership Coaching. 

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What is joy in work?

Where has it gone?

How can we bring it back?

Dave: To speak of joy in work can seem like an oxymoron – work is work, after all, isn’t it? The Online Etymology Dictionary describes the roots of “work” as having elements of toil as well as creativity, it can mean a military fortification as well as an artistic labor, Mark Twain wisely points out that the difference between work and play is a matter of conditions or attitude.

Very busy business

Very busy business

Old English weorc…“something done…action (whether voluntary or required)… also “physical labor, toil; skilled trade, craft, or occupation…” “military fortification,” from Proto-Germanic werkan…from Proto-Indian-European werg-o-…“to do…”

Meaning “physical effort, exertion” is from c. 1200; meaning “scholarly labor” or its productions is from c. 1200; meaning “artistic labor” or its productions is from c. 1200…Meaning “embroidery, stitchery, needlepoint” is from late 14c. Work of art attested by 1774 as “artistic creation,” earlier (1728)…

“Work and play are words used to describe the same thing under differing conditions.” [Mark Twain]

“Work,” Online Etymology Dictionary, accessed 11/6/15 

We have a wide range of roots and definitions for the word “work,” at its most simple it is “to do,” and our judgements on that doing determine whether we view it as work or play, hard or easy, meaningless or meaningful. Doing for no reason feels meaningless and tedious, but Doing that is meaningful is rewarding, even if the work is difficult. Sandy notes that we can meet high demands if we have high resources – so in this way success in work depends not only on the external conditions and needs, but also our individual, relational and organizational resources.

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In the Judeo-Christian tradition, we read early on in the Bible that human beings have been cast out of the Garden of Eden for their transgression of eating from the fruit of the Tree of Knowledge. God curses Adam and Eve and their descendants, saying that man must earn his living from the ground with toil and that woman must give birth in pain. We have this deeply ingrained belief that our relationship with work and with our bodies is one that is filled with pain – not joy – and that we have the guilt of “original sin” that taints our lives in this world. (Not all theologian ascribe to this idea, for instance Matthew Fox writes in Original Blessing that there are other spiritual perspectives we can take in the relationship between spirit and matter and that we can find joy in our work in the world).

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However, there is also a long tradition in all religions of a sense of joy and joyousness that come from the mystical connection with Spirit. Dorothee Soelle, in her work on mysticism in, The Silent Cry: Mysticism and Resistance, lists five domains of mystical experience: Nature, Eroticism, Suffering, Community, and Joy. She describes joy as a state of being, rather than a sense of acquisition or momentary pleasure.

The Silent Cry

“In the mystical sense, joy is something not tied to objects or certain experiences of delight. Joy is a matter of ‘rejoicing in’ rather than of being ‘glad about,’” (The Silent Cry, 179).

Henry Van Dyke wrote “The Hymn of Joy,” written in English and set to Beethoven’s Ninth Symphony, which, in turn was inspired by Schiller’s poem, “Ode to Joy.” Here are Van Dyke’s lyrics as an example of spiritual joy.

Joyful, joyful, we adore Thee,

God of glory, Lord of love;

hearts unfold like flow’rs before Thee,

Opening to the Sun above,

Melt the clouds of sin and sadness;

drive the dark of doubt away;

Giver of immortal gladness,

fill us with the light of day!

All Thy works with joy surround Thee,

earth and heav’n reflect Thy rays,

stars and angels sing around Thee,

center of unbroken praise:

Field and forest, vale and mountain,

Flow’ry meadow, flashing sea,

chanting bird and flowing fountain,

call us to rejoice in Thee.

Thou art giving and forgiving,

ever blessing, ever blest,

well-spring of the joy of living,

ocean-depth of happy rest!

Thou the Father, Christ our Brother,—

all who live in love are Thine:

Teach us how to love each other,

lift us to the Joy Divine.

Mortals join the mighty chorus,

which the morning stars began;

Father-love is reigning o’er us,

brother-love binds man to man.

Ever singing, march we onward,

victors in the midst of strife;

joyful music lifts us sunward

in the triumph song of life

(“The Hymn of Joy,” Wikipedia, accessed 11/6/15)

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Work is our action in the world. Joy is the sense of connection to the greater meaning and purpose in our work.

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Native American visionary, Joseph Rael was taught by his grandmother that “work is worship,” (Ceremonies of the Living Spirit, 22). This brings a different perspective to work, as in the Native American tradition, every action is sacred and there is no separation between spirit and matter. Zen Buddhism takes a similar approach of spiritualizing mundane tasks, such as “polishing the mirror” or “chop wood, carry water.” In the tradition of Kashmiri Saivism, the ultimate Reality is considered to be “a compact mass of bliss (cidānandaghana),” (Dyczkowski, The Doctrine of Vibration, 44). The ultimate union of Being-Consciousness-Bliss is called “saccidānanada.”

Doctrine of Vibration

This is the “Sat, Chit, Ananda,” that Joseph Campbell speaks of when, after studying the wisdom of the Hindu tradition, he coined the phrase, “follow your bliss,” (Joseph Campbell & Bill Moyers, The Power of Myth, 149, 285).

Follow your bliss

In this work that we are undertaking, joy will refer to something deeper than a passing emotion such as happiness or the momentary satisfaction of a desire. We will be looking at joy as the underlying substrate of our Being. This comes from a sense of unity within ourselves and a sense of unity and connection with others. To put it very simply, suffering comes from separation and disconnection and joy emerges from a sense of deep connection and unity within one’s self, between self and other, and within community.

Jack Kornfeld, in his foreword to Awakening Joy, addresses this deeper level of joy. “Joy is our birthright…it is innate to consciousness. Joy is a reflection of our true nature,” (Baraz and Alexander, Awakening Joy, xiii-xiv). Kornfeld describes joy in such a way that we can imagine it to be the foundation of our life, the deep, internal ocean currents, strong and perpetual, beneath the passing, tossing waves of the ups and downs of our daily emotional life. The authors of this book (who have been teaching courses on awakening joy since 2003) describe that having a sense of joy is a choice. “Our joy and happiness is up to us. Our suffering and well-being is not solely determined by what’s happening in our present circumstances but to a large degree by our relationship to what is happening,” (Awakening Joy, xviii).

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Joy, in the way we will be discussing it, relates to connection, innate birthright, choice and a spiritual wisdom perspective on life.

The reason that we need to be talking about joy in the work of health care is because it has been lost in most health care work environments: physician burnout, patient dissatisfaction, long wait times, short appointment times, complicated insurance bureaucracies, costly co-payments and deductibles (for those lucky enough to have insurance) – in short, joyless experiences in giving, receiving, managing, and reimbursing health care. We take a holistic perspective that these variables cannot be dealt with in an isolated way: patient satisfaction cannot be considered without staff well-being and without considering the human needs of administrative and leadership staff. It is all of one piece. That is what we learn when we set off in search of joy – just like in the Wizard of Oz, we already have it within ourselves, but we must set off on a journey of self-exploration in which we support each other’s quest to realize and manifest what it is that we have lost or felt we never had in the first place.

In this joyful work we are undertaking, we will draw on diverse fields of human study, both ancient and modern, including: mysticism, spirituality, poetry, personal growth, well-being, positive psychology, business, economics, leadership, neuroscience, systems theory and relational science. We will look at how to manifest joy at the individual level, interpersonal level and communal level. Fundamental to manifesting joy at all these levels is the principle of connection – connection to dimensions of Self, connection between individuals, and connection in groups and communities. Joy is an emergent property that manifests from a sense of deep connection. We will then look at practical applications of joy at each of these levels and also in relation to leadership in health care and models of health care reform, such as the Triple Aim of the Institute for Health Care Improvement.

Next week we will publish Sandy’s monologue, then the dialogue will start…

A Work of Joy!

Guest Blog: A Counter-Curriculum of Self Care, at the Arnold P. Gold Foundation

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Check out my guest blog on the idea of the counter-curriculum in self care at the Arnold P. Gold Foundation blog.

The Gold Foundation is a great organization whose motto is: “Working to keep the care in health care.”

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Similar to the message in my book, Re-humanizing Medicine, the Gold Foundation states “Humanistic medical care is not simply compassion. It is the best of medicine.”

They are a good resource for research on humanism and compassion in medicine. They offer grants to practitioners and researchers (my mate, Hilton Koppe – @doc_hilton – from Lennox Head Australia recently received a Gold Foundation grant for his work on poetry and medicine).

I discuss the counter-curriculum in my book and in this blog I talk a little bit about the background of how I came to the necessity of that idea.

“Sometimes the things you most need to learn are not taught in school.”

Doctor appeals to colleagues: Do more than problem-solve

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Dave Kopacz at book reading at University of Washington Bookstore

HSNewsBeat article on Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine.

http://hsnewsbeat.uw.edu/story/doctor-appeals-colleagues-do-more-problem-solve

“The push toward evidence-based medicine can blind physicians to other aspects of human interaction, Kopacz suggests.”

 

 

 

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Re-humanizing Medicine: On the Radio and Book Reading!

 

Rehumanizing Medicine Book on Exam Table

Follow this link for an 8:30 minute interview with Dave Kopacz on KUOW public radio: “Doctor’s Push To Get People Talking About Health”

Join me for a book reading and signing

Thursday, 1/8/15 at 7 PM

University of Washington Book Store on the main campus

Address & Phone

4326 University Way NE
Seattle, WA 98105

Phone: 206.634.3400

De-humanization in Medicine A Review of Doctored: The Disillusionment of an American Physician by Sandeep Jauhar.

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I read this book quite quickly. It is a gripping, emotionally honest memoir and critique of contemporary medicine. Dr. Sandeep Jauhar is a cardiologist and author. His first book was called, Intern, about the first year of residency training, and he writes for the New York Times. With great emotional honesty, Dr. Jauhar charts his journey from finishing his cardiology fellowship and into the world of medicine on Long Island and into the underworld of private practice.

The book starts with a quote from Jung on the mid-life transition:

“Wholly unprepared…we take the step into the afternoon of life; worse still, we take this step with the false assumption that our truths and ideals will serve as before. But we cannot live the afternoon of life according to the program of life’s morning – for what was great in the morning will be little at evening, and what in the morning was true will at the evening have become a lie.”

As Jauhar, documents his own “mid-life crisis” (struggling financially, trying to balance the expectations of his Indian family and golden boy brother, dealing with problems conceiving children, then with the difficulties of being a single income family with small children) he, interestingly, portrays American medicine as being in a mid-life crisis of its own. I think this is a useful way of looking at our health care system today, particularly in light of Jung’s advice about the afternoon of life, that the truths of the morning no longer serve and that we require new truths to prevent crisis from becoming breakdown. There are thus three stories that Jauhar weaves together: the story of his own life, the local realities of cardiology practice in New York, and the larger story of the culture of medicine in the US and how we have gotten to this place. He tells a compelling tale on all levels.

The first story, of the life of Sandeep Jauhar, traces a first generation Indian immigrant to the US, who struggles to balance the “old world” expectations of his family with the “new world” expectations of someone who has spent his formative years in the US. Jauhar captures these cross-cultural struggles and these are just one of the many ways that he is trapped between different people, systems, cultures and expectations. (More on Indian-American immigration and cross-generational issues can be found in the great book by Indian American author, Jhumpa Lahiri, Interpreter of Maladies). Another place that Jauhar is trapped between is between the American dream of having his kids in good schools, providing for his family and his inner morality of not wanting to engage in unethical billing practices (which ties in with the next level of the story of local practice). This story of Sandeep Jauhar at midlife is told with brutal honesty, and the reader can feel the sense of being trapped between multiple forces with no clear way out. He tries ignoring his conscience and doing what everyone else is doing, but that doesn’t work for him. Jauhar points out that every day, one American physician kills him or herself as he weaves the story from the personal, to the local, to the national culture. He tries going to his wife’s family’s guru, but that doesn’t work for him either. The only helpful advice he gets there is slipped to him by another participant at the audience, “Once you know and accept that you are going to die, the future will not haunt you.”

The second story is utterly depressing and is like a never-ending nightmare. Dr. Jauhar, looking to increase his income to support his family in their one bedroom apartment and to pay off medical school loans for himself and his wife, peddles himself all over town, trying to take on more work. The cardiology private practice culture (and it seems he is mostly exploring a sub-culture of Indian and Pakistani immigrant physicians) is rife with over-billing and almost indentured servitude in which the boss brings in young doctors to do the busy work and takes the lion’s share of the profit. Sandeep Jauhar is just not cut out for this kind of work. He comes across as the kind of man you would want as your doctor, thoughtful, not arrogant, not putting himself forward, not focused on the money, but on “doing the right thing” for the patient. However, he portrays the painful clash of his personality and ethics with the ugly realities of private practice cardiology on Long Island. He explains the local history and the vectors of force acting in medicine today.

The third story traces the larger history of American medicine, to the point that Jauhar identifies as its “mid-life” crisis. Medicine today is in a crisis, for sure, and everyone in it is often unhappy, the doctors, the nurses, the staff, and the patients. Dr. Jauhar explains how we have gotten to this point and provides an intelligent critique. He moves from the personal to the cultural as he summarizes research on physician suicide and burnout. He writes,

“Most of us went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. The job for many has become just that – a job. Something fundamental is lost when physicians start thinking of medicine as a business,” (171).

I cover similar ground to that of Dr. Jauhar in my book, Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice and the Culture of Medicine. In addition to the critique of the economics of medicine, I also look at the effect of an over-emphasis on science and numbers to the detriment of the human aspects of medicine.

The solutions that Dr. Jauhar suggests are largely systemic, such as shifting the way medicine is reimbursed from fee-for-service to accountable care organizations, bundled payment, or paying doctors as employees rather than based on how much they can bill. He is realistic and sees how difficult it is to reform medicine, but he also points out that one in every six dollars spent in the US goes to health care. However, this still places the responsibility for change with the government, with hospital and clinic administration, with insurance and tort reform. Jauhar does point out that, “Doctors never seem to acknowledge that the widespread burnout in our profession is in part due to the behavior of doctors themselves,” (171). This is an excellent point, we can’t wait for reform and change to come from outside. I quote in my book from physician Peter Salgo’s New York Times piece where he says “we as doctors have felt powerless to change this,” and he puts out a call to patients to demand change. I take this statement to task a bit. We as physicians are the point of contact of medical care within the US. While there are many competing demands, vectors of force, and forces of dehumanization within the institutions of medicine (which both I and Jauhar document), we cannot relinquish our responsibility and the considerable influence we have as the providers of the actual care. However, it does mean that we have to look at our own behavior and challenge ourselves to change, even if it means going upstream and working, at what seems like cross-purpose to the system, by providing humane and compassionate care, in caring for ourselves first of all, and then our clients and colleagues.

Here is where I do take Jauhar to task. He has documented the problems in contemporary medicine. He has shown the painful struggles of physicians within our current system. He has portrayed the moral crisis and the mid-life crisis in medicine today. But, in the narrative of the book, it looks like the way that Dr. Jauhar solves these problems is to move to the suburbs and to reduce his expenses. Is this the best we can hope for in medicine today, a small personal reprieve? I like Sandeep Jauhar, I feel like I know him from how well he writes and how well he captures the existential dilemmas of contemporary medicine. I think in bearing witness and documenting the disillusionment of an American physician, he has done a wonderful service. I think we need to look at what he says, though, that burnout in our profession is in part due to the behavior of doctors themselves. This means that we can address this problem by changing our behavior and this is something that we can do now, we do not need to wait for political or institutional reform. I encourage Dr. Jauhar to read Parker Palmer’s article “A New Professional: The Aims of Education Revisited.” Palmer has written that “institutions are us,” and he outlines the way that professionals can take responsibility for the ethical direction of institutions. We need to move beyond critique and into change and transformation.

I found myself thinking as I read Sandeep Jauhar’s book, would my book work in his situation? Would it help at all? He documents dehumanization in himself and in the profession. I aim to re-humanize medicine through empowering individual professionals and encouraging them to develop themselves as whole people in order to provide whole person care to their clients. I encourage a counter-curriculum, which individuals have personal responsibility to create and maintain in order to preserve their precious humanity that is so needed in medicine today. I call for a compassion revolution in medicine. And I am not alone in this, Parker Palmer, Robin Youngson and Tony Schwartz, just to name a few, are out there trying to change the way that we think of ourselves as human beings in our work places. But as I read Jauhar’s book, I found myself wondering, is this enough? Is my approach practical or even feasible? Maybe it only works in psychiatry? How would if fare in the underworld of private practice cardiology in distant Long Island? I feel that my framework is generalizable, as I have developed while working in many different practice settings in two different countries. There are days when I despair about the systems we work in and all the ways that our institutions seem designed for the opposite of compassionate care of the whole person. But, I think my book can help. We have to do something. We can do something. Dr. Jauhar, if you are out there, I’d like to send you a copy of my book. Thank you for your emotional honesty and your excellent critique of the mid-life crisis of American medicine. I think we can do something more to nourish our humanity as well as that of our clients and colleagues.

Re-humanizing Hector

A Review of Hector and the Search for Happiness

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Hector is a psychiatrist, whose life seems perfect, ordered and predictable. The only problem is that he gradually realizes that although his private practice patients have so much, they are perpetually unhappy. Eventually he comes to realize, too, that he is unhappy. It is a classic midlife crisis, he is successful in the world, but the interior meaning and vitality of life elude him.

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Swiss psychiatrist, Carl Jung wrote that for men, the midlife period marks a time of moving from an external, materialistic orientation to a more inner, spiritual orientation. “Midlife is the time to let go of an overdominant ego and to contemplate the deeper significance of human existence.”

This is exactly what Hector sets off to do. His overdominant ego has controlled and limited his experiences in life, he feels compelled to break his routine and to go off on an adventure. The movie starts with a dream sequence, Hector is flying a biplane, his trusty childhood dog in the co-pilot seat. He loses his dog and instead an assassin attacks him from behind, the plane is running on empty and goes into a dive – and he awakes to another day of the same breakfast, the same patients with the same problems and a very pleasant, but measured life. His childhood dreams were of being a pilot, flying, exploring the world (he has Tintin memorabilia in his office), yet he lives his life in complete safety and isolation in his office. One of his most endearing clients is a clairvoyant who has lost her ability to tell the future and feels like she is inauthentic. She also gives Hector prescient advice.

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At first Hector thinks he needs to go on a journey to do research so he can better help his clients learn what true happiness is, but he eventually realizes that he himself is too controlled to know true happiness and that his quest is, in reality, for self, to live and experience happiness.

He travels to China, meets a businessman and sees all of what money can buy, but it is not happiness. He goes to Tibet and feels a brief glimmer of happiness, but he loses it. He goes to South Africa where his friend from university practices in a free health clinic. Here he sees his friend living a dream of service to humanity, and of being loved for who he is. But this is also a very dangerous place, as Hector soon finds out. He bumbles along, his kindness to others making him friends and people are changed in subtle ways around him (for instance he sorts out a drug lord’s wife’s psychiatric medication and this has a small humanizing effect on the man). Hector next travels to LA, where he seeks out his childhood sweetheart, who is now married, with two kids and pregnant with a third. She teaches him that happiness does not lie in the past. On the flight to LA, he is called upon as a doctor to take care of a woman with terminal brain cancer traveling to see her sister for one last time. He dismisses his kindness and work with the woman as nothing, but she teaches Hector that, “Listening is loving.”

The last lesson he learns is from a psychologist studying happiness through brain imaging. Hector reviews the wide variety of emotional experiences he has undergone, but is still holding back. At one point, something breaks through, and he learns that happiness is feeling everything all at once, fully and deeply. Happiness is a by-product of being capable of feeling everything. This fits with my experience working with clients and from my own self-observation. It is possible to stop “negative” emotions, but it is at the cost of dampening “positive” emotions as well. The way I think of it, they flow through the same channel, so to speak, and the only choice is to feel it all, or to try to dampen and repress emotions.

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All through the movie, Hector has a small journal that he doodles in and writes down his maxims of happiness. While he learns that lists and aphorisms do not make happiness, it is still worth sharing this list. The movie is based on the successful series of books by the French psychiatrist and author, François Lelord.

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Here is the list from the book:

  1. Making comparisons can spoil your happiness
  2. Happiness often comes when least expected
  3. Many people only see happiness in their future
  4. Many people think happiness comes from having more power or more money
  5. Sometimes happiness is not knowing the whole story
  6. Happiness is a long walk in beautiful, unfamiliar mountains
  7. It’s a mistake to think that happiness is the goal
  8. Happiness is being with the people you love; unhappiness is being separated from the people you love
  9. Happiness is knowing that your family lacks for nothing
  10. Happiness is doing a job you love
  11. Happiness is having a home and a garden of your own
  12. It’s harder to be happy in a country run by bad people
  13. Happiness is feeling useful to others
  14. Happiness is to be loved for exactly who you are (People are kinder to a child who smiles)
  15. Happiness comes when you feel truly alive
  16. Happiness is knowing how to celebrate
  17. Happiness is caring about the happiness of those you love
  18. Happiness is not attaching too much importance to what other people think
  19. The sun and the sea make everybody happy
  20. Happiness is a certain way of seeing things
  21. Rivalry poisons happiness
  22. Women care more than men about making others happy
  23. Happiness means making sure that those around you are happy

This movie is really lovely, funny, heart-warming, profound, and thought-provoking. It portrays a man becoming who he truly is, overcoming his fears and defenses, becoming engaged in the world and being fully human. Simon Pegg is great as Hector. Rosamund Pike does a wonderful job as Hector’s somewhat neurotic girlfriend, who creates medication names for a pharmaceutical company. All the actors are well cast and the movie flows well, despite moving through so many settings and characters. It was directed by Peter Chelsom, who also directed the 2001 film, Serendipity, amongst others.

I just read the recently released book, Doctored: The Disillusionment of an American Physician, by Sandeep Jauhar. I will write a review of this book soon, as the theme of this book, as well as the theme of Hector are relevant to my book, Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine. The joyless practice of medicine that Dr. Jauhar describes in painfully honest detail aptly captures the dehumanizing elements of medicine. Hector, while a bit of a feel-good romantic comedy, offers a portrayal of one doctor’s attempts at re-humanizing himself, his practice and the larger culture. He creates a counter-curriculum of life experience and he not only writes the book on happiness, he lives it, too. I give it 5 stars for being fully human. (The soundtrack was great, too, but not available yet).

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