Heroes Not Zombies

There’s a website called Change This. They publish articles which they call “manifestos”. I just came across this one. Nassim Nicholas Taleb argues that unpredictable events are like “Black swans” – until one is seen we lack the imagination to even think such a creature is possible basing our expectations entirely on our previous experience. Taleb says a Black Swan is rare, its occurrence has a large impact, and it is predictable only retrospectively (we explain it with a narrative we make up after the event).

It’s an interesting idea. There’s a phenomenon described in complexity science which is similar to this. It’s called “emergence” and it means the kinds of events and behaviours that occur which are brand new and have never been seen before. For example, when a particular hurricane suddenly starts to behave differently from all previous hurricanes. I see this all the time in patients. There is a terrible tendency in Medicine to focus on diseases rather than the people who have the diseases. Once a diagnosis has been made (the disease has been named) a prognosis is made on the basis of how other cases progressed. But the thing is that again and again patients just don’t comply with statistics. Take Stephen Hawking as an example. He has a disease called Motor Neurone Disease. Usually people die within two years of a diagnosis of this disease. Stephen Hawking was diagnosed over 40 years ago.

People are different. It is impossible to accurately predict an outcome for any single individual with a particular diagnosis. The future is, and always will be, uncertain. That’s not a bad thing, though we crave certainty. I once had a patient who told me her husband had been diagnosed with cancer and had been told he had six months left to live. I asked her how she felt about this and her answer took me completely by surprise (you could say it was a Black Swan!). She said “I’m angry. Very angry. It’s not fair. How come he gets to know how long he’s got and I don’t get to know how long I’ve got?!” I had to explain that actually he might not die in six months time!

But Taleb’s idea about Black Swans makes another interesting point which is about the human use of narrative to make sense of things. Even though an event might be totally unlike any event we’ve ever seen before we’ll do our best to explain it as if it had been predictable all along. This further feeds our tendency to believe in certainty and predictability.

The contemporary practice of Medicine as strongly based on encouraging decision making on the basis of what’s already known (this is called Evidence Based Medicine), but as I once heard Dr Harry Burns (Chief Medical Officer of Scotland) say “If we base all our treatments on what we already know how can we come up with new, better treatments?”

We need imagination. Without imagination we cannot see what might be. Even with imagination however we’ll still have masses of experiences which we didn’t expect. That’s how life is… I don’t want a wholly predictable life. Do you? Understand me here, I’m not saying I want nothing to be predictable. I do want to know that when I catch the 0735 Glasgow train it’s got a good chance of getting me to Glasgow at 0820 (OK, maybe one day!!). I like routines and rhythms. But I like surprises too and the fact that every single patient I see tells me something I’ve never heard before makes my day. Every day.