ikigai- “reason to get up in the morning”
The refrigerator door stayed open a bit too long as I stood there grinning, transfixed in a spell of maternal happiness to see a gallon of milk in the door. A gallon of milk! This past year my husband and I became empty nesters, dropping our youngest off at college and returning to a home devoid of noise, activity, vibrancy, errant dirty socks, and gallons of milk. I would get a pang every time I opened the fridge and saw the tiny quart of milk that now rattled in the door, which more often than not started to spoil before we could finish it. We would make wan jokes about how lame the dishwasher had become, filled mostly with dirty coffee cups and spoons and an occasional plate or two. This past week my youngest son returned from a successful freshman year, his presence filling the house with as much thick color and warmth as the carpet of laundry now strewn on his floor. I love it. His older brother, one of the twins, returned home not long after, but he is only home for a brief stint as shortly he will be heading to New York City for a summer internship. He will be a senior next year, and the reality that soon real life (and the need to find a job) will be looming beyond college is not lost on him. He is coming to terms with something I have been thinking about lately, which is purpose.
He is 21 years old, with keen insight, a creative mind, a strong internal compass, and a desire to do something that matters, and do it well. So how does he begin his journey to find his purpose?
In the healthcare field, we are fortunate to have patient care at the center of our purpose. I for one never wake up the morning and go to work and then clock out at night and wonder what it was all for. There are sacrifices, for sure, the primary one for those of us who deliver direct patient care is that time is not our own. We chose to be in medicine, it is perhaps a calling and gives us purpose, but what about our patients? In my field of pediatric cardiology, they do not choose to be born with a heart condition, and they do not choose to undergo lifelong testing and procedures. We cannot change the fact that there are congenital conditions affecting children. However we can, and do, spend entire careers worth of time trying to research, understand, and ameliorate those conditions. Doesn’t the health care field then have an obligation to help our patients find their sense of purpose, for why fix a heart just so it can beat, or why provide insulin just to affect glucose, or why develop an inhaler just so air can go in and out? Don’t we do all of those things so a child can reach beyond their medical condition, and grow and thrive? Isn’t that the end game?
On of the most poignant lessons I have ever learned about purpose came from one of the senior cardiologists I know. She is a dynamic, internationally renowned physician and researcher, clear thinking and intelligently analytical, with scores of landmark journal publications, books, awards, and world wide speaking engagements. She has an amiable smile, twinkling eyes, and easily looks 20 years younger than her age. Her petite frame houses enormous warmth, compassion, and insight. I was sitting on the couch in her office (which serves as the seat for every wayward soul in the department who needs guidance and advice), surrounded by her piles of partially completed manuscripts and grants nestled among piles of patient information, journals awaiting her review and critique, messages of all types, and photos and awards hinting at the rich nature of her career. Despite all of the pressures and deadlines, she was taking a moment as casually as if we were meeting for a leisurely tea, and asking me about my boys who were about to head off to college. I confessed my angst about this transition, not for them as thankfully they were sure-footed and headed strongly in the right direction, but for me, as a mother, coming to grips with the end of my maternal role in one capacity, and unsure yet how to pick it up in a new one. She held my gaze for a moment, and said that she distinctly recalled when her children went off to college. With her children no longer needing her in the same way, she said, she had to ask herself, “what is my purpose?” I looked around her office. She of all people had to question her purpose? She has influenced countless trainees who have gone on to be leaders in their fields, cared for innumerable patients and families, and made an indelible mark of progress in our field. And yet, as we all do, she had to realign the definition of herself as a mother first and a professional second, and ask the all-important question about what gives us purpose in life.
What does this mean for our patients? How do they define themselves at their core, and how does their health condition influence that? Does “purpose” matter for health? It turns out there is a body of literature in adult medicine about how an enhanced sense of purpose makes for healthier people. Multiple studies have shown that people who have a sense of purpose in life (or “ikigai” in Japanese, roughly translated to mean “reason to get up in the morning”) have reduced cardiovascular risk, are more likely to seek preventive care and be engaged in their health, have less risk of Alzheimers, as well as a multitude of other effects that generally helps them live longer. In 2009, Elizabeth Blackburn won the Nobel Prize for her work on stress, aging, and illness, and her discovery of how the protective caps on our chromosomes (the telomeres) are damaged by stress and how our bodies work to repair them via an enzyme called “telomerase.” In one study, she found that patients placed in a 3 month meditation program, which develops an enhanced sense of purpose, had longer telomeres and increased telomerase activity. In the business world, the “health” of an organization is also linked to employees having a sense of “transcendent purpose” (this cool animated video by Dan Pink is a bit long, but well worth the watch, and will make you think differently about what motivates all of us in what we do).
I think a lot about the influence of that senior cardiologist and how she has shaped so many lives. If we could alphabetize the piles in her office, then somewhere between “patients” and “research” would lie “purpose.”
I have been rolling over this idea of meaning and purpose as it relates to children with chronic health conditions, and whether there is some concrete measure or measures we can promote and assess that will help children grow into this sense. If we can put our finger on it, and promote it, and then measure it as they grow, then we may have a useful measure of “thriving” or optimizing patient outcomes (see “What the Dickens are Optimal Patient Outcomes?“) that compliments our present outcomes measures. In one of the more interesting ventures I have seen to get a handle on patient outcomes, the National Institutes of Health funded measure “PROMIS” lays out three basic elements to assess how kids are doing in three health domains: physical health, mental health, and social health. Within mental health, they list “meaning and purpose” specifically. I wonder if they have figured out yet how to measure this. I am not sure if there is literature out there I have not yet discovered that discusses the evolution of purpose, but I think it must start out in a more nascent, basic building block form in childhood, such as with a sense of self-efficacy or feeling that “I Can” and not “I Can’t”. I think this is so vital, and with some relatively simple achievable measures that can be delivered by the health care team. If we infuse health care encounters with the right language and messaging (“Why Collective Well?“), give patients a “ring-in-the-hand moment“, and provide them with the tools to reach beyond their diagnoses, then I think they will be poised to optimize their well being. We invest tremendous resources in the health of these children, don’t we want to ensure the optimal “return on investment” for them, and in turn for us as the health care system (and as parents)?
While I mourn the closure of the chapter that was called childhood for my sons, I am warming up to the new chapter that is starting to unfold. I know my son has all of the building blocks he needs to step onto his path and follow his curiosity to a passion that will provide his purpose, his ikigai. I want to know that I have helped provide the same for my patients when they stand on the threshold of their adult years. I have a few ideas of specific pieces we can utilize within the health care encounter that will lead to this, and we need the proper metric to measure progress. Like my son, I feel like I am standing on the path, a bit unsure about where it will lead and who will help me along the way, but bound and determined to figure it out.