Douglas Flora: Introducing the Global Happiness Index

Douglas Flora, Executive Medical Director of Oncology Services at St. Elizabeth Healthcare, shared a post on LinkedIn:

“Introducing the Global Happiness Index: Finding Your Ikigai in Unsettled Times

It feels like such an unsettled time. Uncertainties abound in healthcare, in Washington, D.C., and beyond. I thought today’s reflection should be about relocating my personal “center,” so I broke out an old favorite book to revisit this morning. I am trying to follow my doctor’s orders and consciously chasing the stillness and zen that often elude me.

After postponing back surgery for longer than advisable, I find myself in the early days of recovery, newly graduated from bed to chair, with weeks of healing still ahead. My golden doodle, Penny, watches me closely as I hobble around on this first day out of bed, her eyes tracking my every tentative movement suspiciously. In this interval of enforced stillness, I’ve been revisiting ikigai, the Japanese concept of purpose that has traveled from the longevity-blessed island of Okinawa into global consciousness.

“The grand essentials to happiness in this life,” wrote Washington Burlap in 1848, “are something to do, love, and hope for.” Nearly two centuries before researchers began quantifying the relationship between purpose and longevity, Burlap had distilled the essence of what the Okinawans call ikigai—a reason for being.

Before encountering ikigai as a formal concept, I operated with my own meaningful existence metric: the GHI, or Global Happiness Index. It began as a family framework to orient my children toward values deeper than achievement or acquisition. “Did you help increase the GHI today?” I would ask as they returned from school. The question wasn’t about grades or victories. It was an invitation to consider: Did you notice the child sitting alone? Did you offer encouragement when someone struggled? Did you contribute, in some small way, to reducing the suffering around you?

What interests me now is how this seemingly whimsical family metric followed me into healthcare leadership, transmuting into a professional philosophy. The language became more formal—wait times, access metrics, patient satisfaction scores—but beneath these professional benchmarks flows the same essential question: Are we increasing the GHI? Are we reducing suffering? Are we creating space for dignity and connection even when a cure may not be possible?

The Science of Purpose

In the early 2000s, researcher Dan Buettner began investigating regions with unusual concentrations of centenarians, areas he would later call “Blue Zones.” (1) On the Japanese island of Okinawa, home to one of the world’s highest percentages of centenarians, Buettner observed something remarkable: unlike Western retirement where identity often becomes untethered from daily activity, Okinawan elders maintained a clear sense of purpose—ikigai—well into their tenth decades.

This observation transcended anthropological curiosity when subsequent research established concrete links between purpose and physiological outcomes. Dr. Patricia Boyle at the Rush Alzheimer’s Disease Center in Chicago followed 900 older adults over seven years, measuring their self-reported “purpose in life” alongside cognitive function. Her results were striking: participants with high purpose scores were approximately 2.4 times more likely to remain Alzheimer’s-free than those with low purpose. (2)

A 2019 study published in JAMA Network Open analyzed data from nearly 7,000 adults over 50. Those reporting a more substantial purpose in life showed lower all-cause mortality, regardless of when they found that purpose. (3) It wasn’t necessary to have spent decades aligned with one’s ikigai; the present strength of purpose mattered, suggesting it’s never too late to find meaning.

Research has since identified specific physiological mechanisms underlying these associations. A 2013 study in the Proceedings of the National Academy of Sciences found that individuals with greater purpose showed more favorable gene expression profiles, with reduced expression of pro-inflammatory genes. (4) Complementary work published in Psychosomatic Research demonstrated reduced allostatic load—a measure of cumulative physiological stress—among those reporting higher purpose. (5)

What fascinates me about this research is the correlation between purpose and physical health and what it reveals about our fundamental nature. We appear to be creatures who require meaning as essentially as we require nutrients—and our bodies themselves seem to recognize and respond to its presence or absence.

The Four-Quadrant Intersection

Image: The Enterprise World: Finding Your Ikigai

The ikigai concept is often illustrated through four intersecting circles: what you love, what you’re good at, what the world needs, and what you can be paid for. At their convergence lies purpose—that elusive state where work becomes more than labor, where contribution aligns with capacity.

This intersection manifests across healthcare environments, though it is rarely acknowledged in formal settings. In cancer care, purpose often reveals itself in the small moments between formal medical interventions: the careful explanation that reduces fear, the skillful venipuncture that minimizes discomfort, and the scheduling accommodation that allows a patient to maintain employment during treatment.

What’s striking about these moments is how rarely they appear in organizational metrics or performance evaluations despite their profound impact on patient experience. The technical excellence of finding a problematic vein on the first attempt seldom merits mention in quality reports, yet this skill directly reduces suffering for patients receiving frequent treatments.

The transportation aide who knows which routes avoid painful bumps for post-surgical patients won’t see this knowledge reflected in efficiency metrics, yet patients remember such considerations long after discharge.

These examples illustrate something crucial about ikigai: It doesn’t necessarily require dramatic career changes or grand societal contributions. It can manifest in how one approaches seemingly routine work—recognizing that each role, regardless of prestige or compensation, contains possibilities for reducing suffering and increasing what I’ve come to call the Global Happiness Index.

The Global Happiness Index in Practice

The GHI framework has guided numerous initiatives across cancer care environments. These include evening infusion hours that allow patients to maintain employment, transportation assistance that addresses access barriers, financial counseling that reduces economic toxicity, and digital monitoring tools that minimize unnecessary visits while maintaining clinical oversight. Each addresses dimensions of suffering beyond physical symptoms—the practical and emotional burdens accompanying serious illness.

Implementation rarely proceeds according to the initial design. The Okinawan proverb “nana korobi ya oki”—fall seven times, rise eight—captures this reality. When your compass points toward reducing suffering, setbacks become not failures but necessary recalibrations in service of purpose.

Research in BMC Medicine supports this adaptive approach. A 2018 study of successful healthcare improvement initiatives found that organizations achieving sustainable outcomes shared a critical characteristic: unwavering commitment to core purpose and flexibility in implementation methods. (6) They maintained a clear focus on their north star while remaining open to multiple pathways toward that objective.

Compass Over Maps: Navigating Complexity

In Whiplash: How to Survive Our Faster Future, Joi Ito proposes a navigation principle precisely relevant to healthcare: “It is much more important to have a compass pointing to a concrete objective than to have a map.” (7) Maps detail known territory but become obsolete when landscapes change—and in healthcare, change is the only constant.

Treatment protocols evolve, technologies transform, and payment models shift. Those navigating solely by maps—by rigid strategic plans or inflexible protocols—become disoriented when the territory inevitably transforms.

A compass orients regardless of changing terrain, pointing toward true north even when established paths disappear. In cancer care, this “true north” reduces physical, emotional, financial, and existential suffering. Specific interventions evolve as research advances, but the orientation toward alleviating suffering remains constant.

Complex adaptive systems theory confirms this approach’s efficacy. A 2015 study in Safety Science found that healthcare organizations maintaining the clearest connection to core purpose demonstrated the greatest resilience during periods of significant change. (8) When unexpected events rendered detailed plans obsolete, these organizations recalibrated quickly precisely because their fundamental orientation remained intact.

The Shadow Side of Purpose

Purpose-driven work carries distinct challenges in healthcare environments. When daily activities directly impact others’ suffering, responsibility becomes weighty. When a profession aligns closely with personal values, boundaries between work and self blur. When ikigai involves alleviating suffering that cannot always be resolved, disappointment and grief accumulate.

Research on physician burnout confirms these observations. A comprehensive 2018 meta-analysis published in JAMA Internal Medicine found that individuals reporting the strongest alignment between personal values and professional work showed initially higher satisfaction but increased vulnerability to burnout when organizational constraints prevented the full expression of those values (10). The passion that drives purpose becomes the source of distress when structural barriers impede its expression.

This phenomenon manifests across the healthcare spectrum: physicians report moral distress when administrative demands reduce time for meaningful patient interaction; (11) nurses experience burnout when staffing patterns prevent care delivery aligned with professional values; (12) and administrators face similar patterns when financial constraints force compromises in programmatic priorities. (13)

The risk of burnout appears paradoxically elevated in purpose-driven fields like healthcare, education, and social services. Those drawn to such work often possess the deep capacity for empathy—the very quality that makes them effective but also vulnerable to emotional depletion. The Japanese concept of “karoshi” (death from overwork) reminds us that purpose without boundaries can become destructive.

This suggests that sustaining ikigai requires finding meaningful work and creating conditions that allow that meaning to flourish over time. Research on healthcare professionals’ well-being identifies several protective factors: appropriate boundaries between professional and personal domains, regular renewal practices, community support, and organizational cultures that recognize the privilege and the burden of purpose-aligned work. (14)

The Moai: Community of Purpose

The Okinawan concept of “moai”—a lifelong circle of friends who support each other through life’s challenges—suggests that ikigai is not a solitary pursuit. Purpose flourishes in community, in the relationships that challenge and sustain us.

This principle manifests in healthcare environments through informal communities of practice that emerge across formal organizational lines. Research on resilience in healthcare professionals demonstrates that participation in such communities—whether formal peer support programs or informal collegial networks—significantly reduces burnout and enhances sustained engagement with purpose-driven work. (15)

These communities function as both practical resources and emotional sustenance, distributing the weight of purpose-driven work and providing perspective during inevitable disappointments. They recognize meaningful successes that are often invisible to conventional metrics.

For patients, community proves equally essential. Research on cancer support groups demonstrates outcomes surpassing expectations: improved symptom management, reduced anxiety, and suggestions of survival benefits in landmark studies by Spiegel and Fawzy (16, 17). Participants describe a form of understanding available only from others walking similar paths—a recognition requiring no explanation or justification.

These communities exemplify another dimension of ikigai: its expression through relationships rather than individual achievement alone. The network of connections between patients, clinicians, support staff, and families creates a collective purpose greater than the sum of individual contributions. Together, they form an ecosystem that reduces suffering and supports dignity throughout the cancer journey.

Ctrl+Alt+Cure: Rebooting Cancer Care by Doug Flora, MD, is a reader-supported publication. Please consider upgrading to a paid subscription: 100 percent of any proceeds will be donated to worthy cancer charities.

The Quotidian Practice of Purpose

Finding ikigai is not a destination but a practice—what Okinawans describe simply as “the reason we get up in the morning.” This framing strips away romanticism and grounds purpose in the quotidian, in daily choices to engage meaningfully with the world.

This daily practice becomes essential in cancer care, where outcomes frequently defy our hopes. Not every patient achieves remission, and not every suffering can be fully alleviated. Yet, within these constraints, purpose manifests in how we accompany patients through their journeys, the dignity we preserve, and the care that balances technical expertise with human connection.

The Japanese concept of “ichi-go ichi-e”—”this moment exists only now and won’t come again”—offers guidance here. Each patient encounter and clinical decision is unique and unrepeatable. Beach and colleagues’ research in the Annals of Family Medicine demonstrates that this present-moment awareness significantly enhances provider well-being and patient experience (18). Attending fully to the person before you—rather than operating on automatic pilot—transforms routine interactions into moments of authentic connection.

During this recovery period, I’ve been practicing ikigai in smaller ways: noticing the quality of light through my window, engaging fully with the books that have patiently waited on my shelf, and having conversations with family uninterrupted by the usual professional urgencies. These, too, are forms of purpose—paying attention, being present, and recognizing that even a period of apparent stasis contains unrepeatable moments worthy of engagement.

The Balance of Urgency and Importance

The research on resilience highlights another aspect of ikigai-informed living: the capacity “to stay focused on the important things in life rather than what is most urgent.” (19) This distinction between urgency and importance feels particularly relevant to both healthcare and our broader culture, where the tyranny of the immediate often overwhelms deeper purpose.

In cancer care, urgency abounds: test results requiring immediate action, symptoms needing management, and schedules requiring coordination. These demands are real and necessary. However, they exist alongside equally fundamental importance that may not announce itself with the same insistence: the patient’s emotional processing of their diagnosis, the family’s need for education about what to expect, the clinician’s need for reflection to prevent burnout.

The practice of ikigai invites us to maintain awareness of both domains—to respond appropriately to the urgent while not losing sight of the important. Research on effective healthcare leadership demonstrates that organizations maintaining this balance show better outcomes across multiple dimensions: patient experience, clinical quality, staff engagement, and financial sustainability. (20)

During my recovery, with its necessarily slower rhythms, I’ve experienced a recalibration of this balance. Freed temporarily from many urgencies, I’ve had space to reconnect with what’s essential: the foundational values that drew me to healthcare, the vision of what our cancer care centers could become, and the relationships that sustain both professional and personal life.

The Beauty of Imperfection

The Japanese aesthetic principle of “wabi-sabi”—finding beauty in imperfection and transience—offers another lens for understanding ikigai in healthcare. Our work exists in systems that will never achieve utopian perfection and operate precisely at the intersection of human suffering and ingenuity.

There is a stark beauty in this perpetual becoming, this constant evolution toward better, while understanding that “perfect” remains mercifully beyond reach. Cancer care exists in a similar state of permanent evolution. What was best practice a decade ago may now be viewed as unnecessarily aggressive or insufficiently personalized. The field advances through constant questioning, technologies that allow us to see deeper into the body’s mechanics, and treatments calibrated with increasing precision for the individual rather than the disease category.

Wabi-sabi invites us to find meaning not despite but within imperfection and transience. The cracked teacup is beautiful precisely because of its visible history. Similarly, healthcare systems bear marks of evolution—policies layered upon older policies, spaces adapted to emerging needs, workflows shaped by successive technologies. Rather than seeing only deficiencies, wabi-sabi suggests appreciating the evidence of continuous striving toward better care.

This perspective aligns with complexity science approaches to healthcare improvement. Plsek and Greenhalgh’s seminal BMJ analysis recognizes that perfect solutions rarely exist in complex adaptive systems. (21) Instead, effective change emerges through iterative cycles of implementation, evaluation, and adjustment—a process that necessarily embraces imperfection. Organizations unable to tolerate this imperfection become paralyzed, awaiting perfect solutions that never materialize.

The Return: Carrying Purpose Forward

As I prepare for the weeks of recovery ahead, I consider how we might more intentionally cultivate ikigai within healthcare environments. How might we create conditions where everyone—regardless of role—connects their work to our collective mission of increasing the GHI? How might we balance the necessary urgencies of healthcare with the equally essential importance of meaning-making? How might we sustain purpose throughout careers spanning decades?

The answers will emerge through practice rather than theory, through attention to what nurtures purpose in specific environments. Research offers guidance: purpose flourishes when people understand how their particular contributions reduce suffering; (22) it strengthens through community rather than isolation; (23) it requires autonomy to align work with personal values; (24) and it benefits from regular reflection on both meaning and boundaries. (25)

The centenarians of Okinawa describe ikigai simply as “the reason we get up in the morning.” Some mornings—like today’s careful negotiation with gravity and pain—demand more compelling reasons than others. Yet having a reason, whatever its specific form, appears fundamental to longevity and meaningful living.

What constitutes your ikigai?

Perhaps you’ve already been at the center of those four intersecting circles. Maybe you’re still orbiting the edges, feeling the gravitational pull without fully landing. Maybe economic necessity or structural constraints have complicated your search. Wherever you find yourself, the exploration itself holds value—the ongoing inquiry into what increases the GHI in your particular sphere of influence, what reduces suffering for those whose lives intersect with yours, and what constitutes for you a reason to rise each morning and engage with the day’s unique and unrepeatable moments.

I now adjust my position in this chair, watching the afternoon light shift across my bookshelves. Outside, seasons are changing incrementally, winter reluctantly yielding to the earliest signs of spring. Soon enough, I’ll rejoin the momentum of a life defined by purpose—by the ongoing work of increasing the Global Happiness Index in whatever ways my particular position makes possible.

Tomorrow, we will continue the work.

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