Recently I had the amazing experience of visiting Vergelegen (which translates approximately as “far away place”). It’s a beautiful wine estate, but what I really loved were the 300 year old Camphor trees. Look at the size of them! They are immense!

Have you ever touched a 300 year old living organism? I don’t think I ever have before. It’s really something to be in the presence of a creature (yes, it IS a creature) which has not only been alive for 300 years, but is flourishing. Yikes! Our human lives seem so short in comparison!

How wonderful that these ancient trees which were planted in such a far away time have grown so great in a far away place…….and how especially wonderful to get up close!

Does this comment surprise you?

“In order to fully engage our patients in treatment decisions, we must understand how therapies affect outcomes that are important to them,”

It shouldn’t really, but in recent years, certain flavours of “evidence based” enthusiasts have completely dismissed patients reports of differences in their health experience. Often the patients reports are dismissed as either “anecdotes”, as “soft evidence”, or as “just feeling better” (ie not REALLY better – whatever that means!)

I think health is a subjective experience as well as a state of potential change in objective signs or measures. I’m delighted, therefore, to see these calls for a PRIORITY to be given to “outcomes which matter to patients”. After all, whose life is it?

Here are a couple of examples from the BMJ articles -

Citing the 2010 report from the US Institute of Medicine, which urged much greater caution in how we use surrogates, Moynihan called for a shift “from numbers to people” so that patients and doctors stop mistaking “a numerical benefit for a genuine one.”

and

From their perspective within the world of diabetes they warn that surrogates like HbA_1c generally show much larger responses to treatment than “hard” outcomes that matter to patients, such as renal and visual impairment or quality of life.

Why are they arguing for this?

What’s the problem with surrogates?

Why have doctors become so invested in surrogate markers? The main reason is that the evidence base is built from trials that focus on the effect on surrogates. Since they respond sooner than outcomes that are important to patients, surrogates are better suited as end points in clinical trials that need to be completed quickly and at low cost. Evidence that builds in this way shapes practice and policy. Consequently, clinicians see this evidence converted into guidelines, quality of care measures, and pay for performance targets. We could speculate that the short term goals of the drug industry contribute to the predominance of surrogates in clinical practice. But this is an oversimplistic analysis. A historical view points more broadly to an alliance of public health advocates, scientists and clinicians, professional societies, and test and treatment companies who see their interests coincide. Idolisation of the surrogate end point has turned doctors away from the focal point of patient centred therapy based on hard end points. (Yudkin)

We need to change this primarily to reduce the potential harms caused by promoting drugs which don’t actually make patients lives better, but where the side effects can be fatal (think flecainide or rosiglitazone), but also….

Focusing on outcomes that matter to patients should improve decision making and patient engagement. It should also stop us spending money on treatments that deliver minimal or no benefit.

Nobody can define “benefit” better than the patient whose life is being affected by the disease and by the treatment.

There’s something lovely about flying a kite, but this flying WITH a kite is something else!

It struck me there’s a lot of this kind of activity in South Africa. It’s not that people try to conquer Nature, it’s that they challenge themselves in their interaction with Nature. You see it in their mountain climbing, their long distance cycling, their expeditions into the Bush, but most impressively, you see it in this kite-surfing.

I love how a kite surfer interacts with both the wind and the sea at the same time – what a great example of FLOW!

In Ian McCallum’s “Ecological Intelligence” he mentions how Copernicus brought about one of the great revolutions in human thought by convincing us that the Earth moved around the Sun, not the other way around. However, centuries later, we haven’t really managed to take this radical shift on board. We still tend to think of ourselves as being the centre of everything. We betray our perspective through the language we use.

We talk about sunset and sunrise. But the sun doesn’t set, it stays where it is. And the sun doesn’t rise, it’s the Earth which turns.

He postulates shouldn’t we be thinking instead of talking about the Earth rising into the night, and dipping into the day?

Stop and think about it for a moment. What does it feel like to think of the Earth rising into the night instead of the Sun setting?

Look at this fence -

I love how this fence instantly challenges the view that it is a “thing” – you can see it’s a living organism.

Whilst on holiday recently, I stumbled across a book by a South African author, Ian McCallum. Ecological Intelligence. [978-1555916879]

He argues that we need to reconnect to other animals and to Nature, and interestingly writes a lot about the concept of the “field”.
I find that concept so useful.
In my Be The Flow, I muse about the relationship between a wave and the sea. In this analogy, the sea is the “field” and the wave is a person. We emerge out of the field assuming distinct, identifiable, unique form. But we don’t leave the field. The wave is at no point separate from the sea. The wave constantly changes throughout its life. It is transient, dynamic, and, soon, its gone. Where does it go? It returns to the sea which in fact, it never left. It “disappears” into the field.

Oh, just look at this wonderful little chameleon. I’ve never seen one “in the wild” before. This was ONE of my moments of “emerveillement” this day. (I recommend you look out for at least one such moment every day….probably not a chameleon most days!)

As the cloud falls over Table Mountain at night it is lit by an ethereal pale light……caught it with this long exposure, propping my camera against the edge of the door to the balcony of the flat we’re staying in.

And used Photoforge 2 to create this image from it -