Feeds:
Posts
Comments

Archive for December, 2007

Are we born empathic?

Posted in from the consulting room, from the reading room, neuroscience on December 10, 2007| Leave a Comment »

A colleague at work read my post on mirroring.

She said, if it’s true that different people have different scan findings in the areas of the brain associated with mirroring neurones (which, it is hypothesised, are responsible for empathic ability), then does that mean that some people are born with greater empathic potential than others? And can the potential be developed?

This is a common question in neuroscience – when we identify either physical structures within the brain responsible for certain behaviours and qualities, or differences in function in those areas as highlighted by functional scans, then are we saying that people are born with these brain differences which then determine their characteristics? Some people might make that claim but from my reading I’d say almost every scientist thinks that the physical characteristics of the brain, originating in genetic makeup and embryonic development, are important, and may even set the limits of possibility. However, the nervous system is more “plastic” (the specific meaning of this is nothing artificial, it means it can change), than a simple one-off scan will ever show. Neuronal pathways develop, grow or shrink, depending on demand. What this means is that while we are probably born with different potentials, everyone’s potential can be developed or suppressed by experience.

She asked the question because she was wondering why some doctors are more empathic than others. Specifically, she wondered if empathy could be learned. I’m pretty sure empathy can be learned. I’ve seen medical students and qualified doctors become more empathic as they train in homeopathy which emphasises the patient’s narrative and a clear understanding of the patients’ experience.

But the question got me thinking about the place of empathy in the consultation. How much is it a quality developed from “mirroring”? Difficult to answer, but I think there’s an even more important element – being interested.

If a doctor is not truly interested in what a patient has to say, then they won’t listen, won’t understand and won’t be empathic. Can being interested be faked? No, I don’t think so. You’re either genuinely interested in somebody or something, or you’re not. Pretending to be doesn’t work. I’ve often said, when discussing the art of medicine, that if I ever need to see a doctor because I’m not well, then I’ll want one who frankly gives a damn! I want a doctor who, at least for the duration of the consultation, is genuinely interested in me. In fact, I’d recommend that anyone who doesn’t find people totally, compellingly interesting, shouldn’t study medicine in the first place!

Read Full Post »

In houses it’s location, location, location. In health, it’s context, context, context……

Posted in from the consulting room, health on December 9, 2007| Leave a Comment »

…..same principle I guess. Without considering the individual and unique contexts of a person’s life we can neither understand their illness, nor help them find the best treatment and support. Iona Heath, who writes in the BMJ tackles the dumbing down of medicine in another article this week

We are witnessing a degradation of knowledge, which results from its bureaucratic application to whole populations. Too often, evidence from clinical trials is being shamelessly extrapolated across time, across population subgroup, and across condition. Again and again, efforts are concentrated on crude process measures, while clinical outcomes that are genuinely significant for patients because they reduce or delay suffering or prolong life are ignored. Thirdly, the present state of clinical evidence systematically neglects the reporting of harms

The point she is making is that we are abusing research findings which are conducted on specific groups of people by extrapolating the findings and conclusions and applying them to hugely diverse and significantly different groups of patients. The more we generalise, the poorer our understanding and effectiveness. She argues strongly for not applying the findings of the effects of a treatment on young people, to old people, for example. This is because of two main problems – first the setting of outcomes by the researchers (outcomes which might be important to the group under study, but not the most important to another group) and secondly because of a huge under-reporting of harms of a treatment.

As more and more treatments are directed at an intended long term outcome, the older patient is less likely than the younger one to have a chance of the intended benefit. However, as harms start straight away with treatments, the older patient is more likely to experience harm than benefit than the younger one. In addition, because of other body systems already failing, the elderly patient is more susceptible to harms from drugs than the younger patients.

And that’s just the consideration of age. What about other factors in other contexts which make a substantial difference? Sex, the presence of other diseases (‘co-morbidity’), and economic, social, cultural and psychological factors?

Context is all important in chronic disease especially. Here’s why…..

acute/chronic

In acute disease, as we see on the far left, the green circle represents the pattern of symptoms consistent with the disease, and pretty much determines the whole picture. Most patients who are rushed into hospital have obvious patterns of disease. As time passes however we see that the green circle becomes a much smaller subset of the overall symptoms. This is because as the years pass, the individual brings more and more of themselves and their unique contexts into the overall picture. If we only aim at the disease, we miss helping most chronically ill patients.

Read Full Post »

patterns

Posted in from the dark room, photography on December 9, 2007| Leave a Comment »

patterns, originally uploaded by bobsee.

Look at this.
A bit puzzling at first isn’t it?
It snowed last night
Out in the car park, I saw this.

If it still doesn’t make sense to you, take a look at this wider shot –

car park

Read Full Post »

Flow

Posted in from the consulting room, health, life on December 9, 2007| 2 Comments »

Flow

There’s something about the idea of flow which really seems to work when thinking about health. In Chinese medicine there is a concept of “chi” or “Qi”– a kind of energy. We don’t use such a concept in our Western model but maybe we should. Why? Well a couple of reasons –

First of all – measuring energy – I’m not talking about weird and wonderful machines that claim to measure energies in a human being – I don’t think we’ve understood what energy is in a biological sense. I don’t mean calories and basal metabolic rates and so on. I mean that sense of vitality, of well-being, of having a certain amount of energy, that’s hard to pin down but so, so easy to know. Think of the 1 – 10 scale and asking people to self-rate their energy level with 1 representing the worst possible energy they can imagine and 10 the best. They can do it in a flash. People have no trouble quickly assigning a number on scale to their current energy state. You can even break it down into different energies – mental, physical, emotional for example, assessing each using the 1 – 10 scale. People can do it easily. What are they doing? How do they assess their energy level? What are they measuring and how? It’s not at all clear but it still seems both possible and useful.

Secondly, there is the idea of energy as flow. In the Chinese system chi isn’t just energy that sits there humming away at a certain level. It’s something more dynamic than that. They have descriptions of this energy as flowing or becoming sluggish or even stopped. So for us, we can not only measure our energy levels but we can sense the flow – is my vitality flowing? Is my physical, mental, emotional energy flowing? Or have I become sluggish, or even blocked? Maybe we can just adopt the Chinese concept without looking for a thing called chi, and without taking on board all the detailed dogma of TCM chi?

Csikszentmihalyi uses the concept in relation to psychological processes in his studies of happiness. I like his work and I think he’s described something very real by using the concept of flow, but I’m meaning something more holistic than he does. I mean flow in the sense of the whole organism, not just a psychological state or a function of mind, but also the function of all the body’s systems and processes.

Read Full Post »

The art of medicine and the value of experience

Posted in from the consulting room, health, philosophy on December 8, 2007| 3 Comments »

There’s a doctor and bluegrass musician called Dr Tom Bibey left a comment on one of my posts and you know how it is with the net…..you can’t resist following the trails, so I popped across and browsed his blog. What a treat! Here’s a quote from one of his posts –

Folks who believe they know a patient by the paper they keep are so naive.  The impact of sitting at someone’s kitchen table and sifting through the array of pills from different Docs the patient ”thinks” they might be taking is powerful.  Everyone trying so mightily to pass rules to govern human behavior needs to make a few house calls before they get so dadburn high and mighty as to their perceived importance.

See, to me, that’s wisdom. Yes, we need our statistics and our research, and our science, but there really is something called the art of medicine, and people who have no experience of it, probably don’t understand it. To be a good doctor though I think involves making use of the whole self – the brain and the heart – understanding how things work, how to interpret science, but also learning how to relate, how to be compassionate and caring every single day, with every single patient. Without that, you never really get to know anyone and without knowing them, you’ve no way of understanding them, and without understanding you’re working in delusion not reality.

Read Full Post »

How scientists give science a bad name

Posted in health, science on December 7, 2007| Leave a Comment »

The irrational claims of “scientists”

Some people claim the term “scientist” as a label of authority. It drives them crazy when people don’t accept their authority. They believe that their views are the correct views and any alternative views are wrong views. I find that attitude horrendously arrogant. And far from rational.
Sir David King, the UK government’s Chief Scientist was complaining yesterday about people who promote views which are different from his own. Specifically he was complaining about people not supporting GM crops and nuclear power but decided to throw his hat into the anti-homeopathy ring while he was at it. Here are two of the irrational claims he made against homeopathy.

First he said homeopathy was not safe. This is a very hard claim to justify if you really claim to be objective and rational. I have heard it said that homeopathy won’t be taken seriously until it kills someone. Well, two hundred years on and there’s still total failure on that one!

Drugs are not safe. An estimated 10,000 people died from serious Adverse Drug Reactions in England in one year. £466 million was spent on hospital treatment of patients suffering serious reactions to drugs.

Surgery is not safe. My trainer when I was a trainee General Practitioner said to me “Be careful and remember if you send your patient to a man with a knife he’ll use it!” It was good advice. At an inquest into the death of a patient after cosmetic surgery –

Dr Steven Chan, who conducted the inquest, did not mince his words. “I have no doubt of the determination of the deceased when she agreed to go through with major surgery,” he said, “but the point must be made that all surgery could result in complications with devastating effects. There is no safe surgery.”

Hospitals are not safe. You wouldn’t want to be in hospital unless you really had to be.

But homeopathy is safe. Nobody has ever died from the effects of a homeopathic medicine. What people actually mean when they say homeopathy is not safe is that some practitioners who use homeopathy are not safe. Well you can say the same of doctors and surgeons, but the way to deal with that issue is training, clinical governance and regulation. The issue is the practice of unregulated or poorly regulated health care. “Where is the evidence that a homeopathically trained doctor is more dangerous than one without homeopathic training?” I recently asked the Editor of the Lancet who had claimed homeopathic practice was dangerous practice. So far, his reply is a deafening silence.

Second Sir David said there is not a jot of evidence that homeopathy works. Well, he can only say that if he hasn’t looked. There is evidence. Go here and read it for yourself. Having read and considered the evidence you might conclude that there is not enough evidence to be convincing enough to change your beliefs. But that’s not the same as saying there is no evidence. You might conclude that there is some evidence that homeopathy is more effective than placebo. Or you might critique the published research and highlight its methodological weaknesses but that’s normal in science. There isn’t a single piece of research into anything which is ‘perfect’. Every study can be, and should be, reviewed, analysed and criticised. What you can’t do is say the research doesn’t exist. What you can’t say is that “there is not one jot of evidence supporting the notion that homeopathic medicines are of any assistance whatsoever” which is what Sir David King said. Not unless you don’t know any better.

Scientists who claim to know The Truth and to tell the rest of us that they know absolutely certainly what is best for us give science a bad name. I enjoy science. It’s fascinating to explore and to learn about how things work. We need good science and good scientists. But science is increasingly showing us that life is complex and that if we want to understand how the world works we need to move away from the old habit of reductionism and simplification which promotes a two-value, unhelpful view of the world dividing everything into right or wrong, proven or unproven, true or false. Understanding and knowledge are never finished, never complete.

(thanks to mo79uk for drawing my attention to Sir David King’s remarks and for commenting –

A fair number of people, I think, have a fairly good or neutral opinion of homoeopathy because the swimming money pool of conventional medicine isn’t delivering all we hope for. And there’s no guarantee and infinite amount of time ever will. At least not for those of us living now. It’s fine to believe in conventional medicine, but when it doesn’t believe in making you better, it’s not foolish to entertain something we don’t understand.

People laughed when it was suggested the earth was round.)

Read Full Post »

MacNamara’s Fallacy

Posted in from the consulting room, health on December 7, 2007| 5 Comments »

I just came across something called the MacNamara Fallacy – as best I can see it was first described by Charles Handy in his book, The Empty Raincoat (haven’t read it yet but just ordered a second hand copy through Amazon marketplace for a penny!) – Robert MacNamara was US Secretary of Defence during the Vietnam War.

One of the worst characteristics of the current approach to health (an approach shared in other spheres like education, management and so on) is the tendency to measure what can be easily measured and then base every decision on that, disregarding as unimportant whatever cannot be easily measured.

Here’s the quote (this time referred to by Dr David Haslam in the RCGP journal –

Haslam D (2007). British Journal of General Practice 57:545, 987-993.)

  • The first step is to measure whatever can be easily measured. This is OK as far as it goes.

  • The second step is to disregard that which can’t be easily measured, or to give it an arbitrary quantitative value. This is artificial and misleading.

  • The third step is to presume that what can’t be measured easily isn’t important. This is blindness.

  • The fourth step is to say that what can’t be easily measured doesn’t exist. This is suicide.

Read Full Post »

Hospitals can be dangerous places

Posted in from the consulting room, health on December 7, 2007| 2 Comments »

I guess most people would agree with my attitude that if you can manage to avoid hospitals you should. Yes, they are necessary, but, yes, they are dangerous too. How dangerous? Well, a study from the University of York has taken the approach of reading through the records of a thousand patients admitted to one hospital and found almost one in ten of those admitted suffered from an adverse event. They reckon about 30 to 50% of these could have been avoided.

“Our research does confirm though that hospitals are not completely safe places, and that people should try to steer clear of them unless absolutely necessary.”

A Department of Health spokesperson said

“As the study suggests, many adverse events could be avoided if lessons were properly learned and fed back into practice.”

That’s the challenge and that’s part of the answer. Medicine is a person-intensive activity. We should be investing in the training and practice of everyone who works in hospitals. Not just the clinicians. The people who work in hospitals all have important jobs to do and if they don’t do them to the best of their ability all the time, patients suffer. We need to foster a culture of reflection and learning, of continual improvement, not of blame. It’s not about targets. It’s about people.

Read Full Post »

Community

Posted in from the dark room, life, photography on December 6, 2007| Leave a Comment »

old town Nice, originally uploaded by bobsee.

This is a photo taken looking up from a junction in the old town of Nice. The old town has very narrow streets and very tall buildings. It struck me that photos of cities built in recent years aren’t so different from this and a line or two of T S Eliot popped into my head – from his Choruses from The Rock

When the Stranger says: “What is the meaning of this city ?
Do you huddle close together because you love each other?”
What will you answer? “We all dwell together
To make money from each other”? or “This is a community”?

Metropolitan Plaza Ikebukuro Tokyo

(……looking up in Ikebukuro, Tokyo)

Read Full Post »

Happiness or meaning…..you have to choose?

Posted in from the viewing room, life on December 5, 2007| 5 Comments »

Catching up on some episodes of Heroes last night, and was watching Chapter 18, “Parasite”. This is the one where Nathan confronts Lindeman and Lindeman says to Nathan that he has to choose between a life of happiness and a life of meaning. He explains that to live a happy life you have to live in the present, but to have a life of meaning you have to focus on both the past and the future.

Well, I don’t know about you, but that analysis doesn’t work for me. Happiness, as Jean Kazez explains in her review of three interesting books about the subject, has not only been studied by a wide range of thinkers over the years, but there are a huge number of different opinions about it. Certainly the view that happiness is experienced by being “present” is one of them, but surely happiness can be experienced in reminiscence and recall, and certainly in sweet dreams and fantasies.

Jonathon Haidt, for one is quite clear that happiness is part of the experience of the creation of a meaningful life, and I agree with that. Happiness, meaning, mutually exclusive options? I don’t think so.

Lindeman’s point about a life of meaning spreading out beyond the present was a good one though. I really do think the way we create a sense of self is through the narratives we create about our lives. And all narratives are dynamic, they come from somewhere, to inform what is, and set the trajectories of what might lie ahead. One of my favourite books on the power of narrative in life is “On Stories” by Irish philosopher, Richard Kearney. He says –

When someone asks you who you are, you tell your story. That is, you recount your present condition in the light of past memories and future anticipations

and

Telling stories as basic to human beings as eating. More so, in fact, for while food makes us live, stories are what make our lives worth living

In fact, he makes it clear that as meaning-seeking and meaning-creating animals we use story telling to not only make sense of our life experiences but to make life itself meaningful.

So, Lindeman was right about a life of meaning involving an ability to sew together the past, the present and the future, and I suspect it was this, most seductive of options that helped Nathan make his choice.

Like all heroes, we become who we are by the stories we fashion out of our unique and individual ways of experiencing life.

Read Full Post »

« Newer Posts - Older Posts »