Archive for January, 2008

The people who come to see us bring us their stories. They hope they tell them well enough so that we understand the truth of their lives. They hope we know how to interpret their stories correctly. We have to remember that what we hear is their story.

Robert Coles in “The Call of Stories”.

Stories have always fascinated me. I love them. Every day when I sit in my consulting room patients tell me the most amazing, fascinating and unique stories. As a medical student I was taught how to “take a history” – I hate that phrase actually – who’s doing the “taking” and what exactly are they “taking” and from whom? Doesn’t seem right to me at all. Instead I prefer teaching medical students how to listen to patients’ stories. However, the point is that this is the beginning of all diagnosis. To a certain extent listening to the patient’s story is a diminished art. There’s an over-reliance on technology and a lot of doctors just don’t seem to be able to make a diagnosis without a test these days. Diagnosis is a form of understanding. It’s a process of trying to make sense of somebody’s experience.

If stories are so important in clinical practice, then how can I learn to handle them better I wondered? There is a developing area of medicine known as “narrative-based practice”, with associated “narrative-based research” methodologies, but materially-orientated, reductionist scientists look down on narrative. They prefer data. So, when I started to study narrative (which, technically is the story AND the way that story is told), I couldn’t find much work from a scientific perspective. I had to turn to the humanities.

One of the books which I really love in this area of study is “On Stories” by Richard Kearney (ISBN 9-780415-247986). Not only is it a fabulous exploration of the place of story in human life, but it’s written completely beautifully. Richard Kearney is a philosopher but he’s also a magnificent writer. This one book taught me more about the importance of story than any other.

Telling stories is 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.

This sets stories at the heart of human existence – not optional, but essential.

Aristotle says in “Poetics” that storytelling is what gives us a shareable world.

The key word there is “shareable”. It’s through the use of story that we communicate our subjective experience and its through the sharing of subjective experience that we connect, and identify with others.

Without this transition from nature to narrative, from time suffered to time enacted and enunciated, it is debatable whether a merely biological life could ever be considered a truly human one.

Beautifully expressed. Sets narrative at the heart of what it means to be human and stands it against those who would take a materialistic view of life which they claim can be reduced to data sets and DNA.

Every life is in search of a narrative. We all seek, willy-nilly, to introduce some kind of concord into the everyday discord.

This is one of my favourite lines in the whole book. This is exactly the power of story – it enables us to “get a handle on” life, to bring some kind of order out of chaos.

What does Richard Kearney mean by story then? Well, I’ll finish this post with two more quotes from his book which make it very clear and very simple.

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.

This shows that story collapses time, bringing the past and the future into the present. Story telling requires memory, imagination and expression.

Every story requires –

a teller, a tale, something told about, and a recipient of the tale.

Nice and simple, but what profundity lies in there. For every story, there is a unique human being doing the telling, there is the story itself and its subject matter, and, very importantly there’s the recipient – the listener or the reader. Story is, as Aristotle said, a way of creating a shareable world. That’s the greatest potential of blogs, I reckon. By sharing our stories we create a shared world. Yes, sure, stories can divide as well as connect, but without stories, there is no potential for connection, no potential for compassion and no potential for the creation of a meaning-full, and better world.

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Sunday 13th January, the Sunday Times in Scotland published an attack on homeopathy by one of their journalists, Joan McAlpine. (Sorry I can’t put a link in cos the Sunday Times doesn’t bother to put their Scotland-only articles on their website) The “stimulus” for the article was a written answer to a question in the Scottish Parliament which showed the cost of GP prescriptions for homeopathic medicines in Scotland. There was nothing really new in the attack – same old arguments really – but what bothered me most about it was the headline describing homeopathy as a “sick fantasy”, the claim that homeopathy was “dangerous” and the dismissal of patients’ reports as being just about feeling better (the implication being they were not really better).

The paper published an edited version of my letter on Sunday 20th but I thought I’d just put the full letter here for you to read.

Dear Madam

£250,000 spent last year by the Scottish NHS for “alternative” drugs? What an outrageously small amount! In the same year the Scottish NHS drugs footed a £1 billion pound bill to the drug companies for prescribed medicines. Yet, 90% of all drugs only work in 30 – 50% of the people who take them. Deaths from homeopathic medicines in the whole of the UK in 2006? Nil. Deaths from prescribed drugs? 1013 reported (over 10,000 estimated). Cost of Adverse Drug Reactions to homeopathic medicines? Nil. And to prescribed drugs? About £500 million a year.
Let’s be clear. Human beings are not machines. What works for one person may not work for the next. Health care needs to be diverse. We need more research into non-drug, non-surgical treatment options and we need to make more available on the NHS inexpensive, safer treatments, such as homeopathy which two out of three patients report is of benefit to them. And while we are at it, Joan McAlpine, let’s stop the arrogance of dismissing the relief of human suffering as “sick fantasy”. If someone says their pain has gone, it has. Prove it hasn’t! If someone says their depression has lifted, it has. It’s time to start putting patients first. At Glasgow Homeopathic Hospital we are, like all good doctors everywhere, successful because we listen to patients and believe what they tell us. We could do with more of that on the NHS.

yours faithfully

Dr R W Leckridge

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I just came across this ad. It’s clever.

Watch it right through. Then watch it again.

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Psyblog has a good post about happiness from the perspective of Confucian teaching in the light of modern discoveries. I was particularly attracted to the quote by Confucius at the start of the post –

“The one who would be in constant happiness must frequently change.”

I’ve often said that one guaranteed “fact of life” is that everything constantly changes. Nothing stays the same. There’s an old story told of a ruler asking for a speech which he could use in ALL situations, and several of his philosophers and teachers taking on the task and failing, until finally, one man gives him the speech which works in all situations (another version of this story involves King Solomon looking for a ring which will relieve his suffering which he fears will go on forever, and he is given a ring with a few words carved into it) What was the speech? Same as the words in King Solomon’s ring –


That’s a recognition of the reality of constant change. Japanese culture holds transience in much greater esteem than many other cultures. That’s partly why they greet the blossoming of the cherry trees every Spring with such enthusiasm. (if you’re ever in Japan in the Spring you’ll see thousands of people out photographing the cherry blossom and photos of the earliest blossom will appear on the front pages of the national newspapers). To be in touch with the cycles of the seasons and to celebrate the changes between them can bring great pleasure.

A fundamental characteristic of a complex adaptive system (CAS) is that it constantly changes, constantly adapts.

The first two lessons in the Psyblog post are “Invest in intimate ties” and “Embrace society”. Both of these emphasise the importance of engagement – along with adaptation, one of the key characteristics of a healthy CAS.

The other lessons are interesting too, including “have fun” and “educate yourself” – both of which are about creativity and growth – the third of the characteristics of a healthy CAS.

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Healing trees – Cinchona

In an earlier post I wrote about significant trees and said I’d tell a couple of healing tree stories. Here’s one of them.

The Cinchona Tree is famous in the history of medicine. It’s a member of the Rubiaceae family (the same family of plants which coffee comes from). Actually there are 25 different species of Cinchona trees, and the one in question is “Cinchona officinalis“, which is native to Peru. Here’s the story –

The wife of the Viceroy of Peru, the Countess of Chinchon, fell sick with a high fever shortly after arriving from Europe in 1630. The local Spanish Jesuit priests had been taught to treat fevers by the indigenous Peruvian people. They used a preparation of the bark of the Cinchona tree. So, they treated the Countess with this and saved her life. It’s most likely that the fever she suffered was malaria, and we now know that the Peruvian tree bark contained a lot of “quinine”, which is still a staple treatment for malaria.  Whether or not, the Countess of Chinchon ever really did get sick and was successfully treated with the bark of this tree will never be known but most historians think it is a myth.

Whatever the truth of the matter, the key players in the discovery of this tree’s power to cure malaria and the spread of that knowledge is down to the Jesuits. It was a Jesuit apothecary in Peru who heard about the local use of this bark to stop “shivers” in fevers and knowing the severity of the “shivers” in malaria he decided to try it out on sufferers with spectacular results. The Jesuits brought the bark back to Spain and Italy, where it became known as the “Jesuits’ powder“. It’s interesting that aligning the medicine so definitely with the Jesuits led to it being a highly controversial and contested form of medicine for decades. The Protestants were none too keen to accept a Catholic medicine! However, it was successful in case after case of fever, and it was produced, cultivated and distributed worldwide by the Jesuits.

The story of the discovery of quinine is beautifully told in “The Miraculous Fever-Tree” by Fiammetta Rocco (ISBN 0-00-257202-8). It’s a great read and brilliantly researched. In her book she gives many examples of the enormous impact of malaria on events in world history showing how both the disease itself, then, later, the successful treatment of the disease with this drug, probably determined the course of history on a number of occasions.

This “fever tree” is also a key part of the origin of a whole therapeutic practice. Dr Samuel Hahnemann, 1755 – 1843, a German doctor, was translating Cullen’s Materia Medica (the guide to medicines prescribed by doctors at that time) and he read of Peruvian Tree Bark (Jesuit’s powder) as a treatment for “Swamp fever” (malaria). Cullen said it worked by being an astringent (it dried the body up) and Hahnemann wondered if that was true, so he prepared some and took it himself to study its effects. Much to his surprise he developed all the symptoms of a patient with Swamp Fever. This was his discovery of the principle of “like cures like” which led to the creation of a therapy known as homeopathy.

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How do you think the brain and body work together? A lot of people reckon we figure out what we want to do first, then our brain moves into a kind of second phase and make the body do what we’ve decided we want to do. Seems logical, huh?

Well, it turns out it’s not like that. Here’s an interesting study which shows that the brain and the body work at the same time, not brain first, body later! A group of psychology researchers asked people (yes, college students again….you have to watch out for those psychology studies, they mostly use college students as their guinea pigs, and do you think college students are typical?), sorry, lost the thread a bit there, they asked people questions and observed what movements their arms made on the way to either the “no” or the “yes” buttons on the computer. They found that in response to the more ambiguous questions the students’ arms moved more between the buttons, than they did on straight forward questions. What that means is that they could be seen to dither a bit before answering the ambiguous questions. Their arms and brains were working together – simultaneously. It gets more interesting……..they dithered more towards “yes” when answering a “no” question than towards “no” when answering a “yes” question, suggesting that people have a general bias towards assuming a statement being true.

These dynamic data showed that participant arm movements had lower velocity and curved more toward the alternative response box during ‘no’ responses than during ‘yes’ responses—suggesting that we experience a general bias toward assuming statements are true,” the authors explained.

The authors conclude that this shows we lean towards “truthiness”.

You know, I’d never seen that word before, but when you go searching on the net about it you can find LOADS. Start here at wikipedia. The word seems to have been made up by, or at least given a specific, new definition by comedian Stephen Colbert. Here’s his explanation

Truthiness is tearing apart our country, and I don’t mean the argument over who came up with the word…It used to be, everyone was entitled to their own opinion, but not their own facts. But that’s not the case anymore. Facts matter not at all. Perception is everything. It’s certainty. People love the President because he’s certain of his choices as a leader, even if the facts that back him up don’t seem to exist. It’s the fact that he’s certain that is very appealing to a certain section of the country. I really feel a dichotomy in the American populace. What is important? What you want to be true, or what is true?…

Truthiness is ‘What I say is right, and [nothing] anyone else says could possibly be true.’ It’s not only that I feel it to be true, but that I feel it to be true. There’s not only an emotional quality, but there’s a selfish quality.

What lies behind this, as he highlights, is that old need for certainty. Human beings don’t handle doubt very well. There’s a strong tendency to seek certainty and when that is applied to beliefs (whether religious or scientific) it leads to that statement in the above quote – ‘What I say is right, and [nothing] anyone else says could possibly be true.’Don’t know about you, but I prefer to find a way to deal with doubt. It’s more real. Truthiness doesn’t leave much room for dialogue.

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Dr Tom Bibey’s blog is worth reading. He’s the kind of family doctor I like. He recently posted about laughter and I thought I’d post this just for him and his good wife. Hope you enjoy it!

While you’re here, and if you feel you need something to cheer yourself up try

this superb piece of video-editing or

this great mime.

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It’s Burns Night. Robert Burns. Another of my local heroes. Well, not  Stirling man, but a Scot.

I think it’s good to have at least one poet as a hero!

Robert Burns

Here’s a voice thread of me reading Burns.

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Blogger’s Code of Conduct

Science bloggers meeting at the North Carolina Science Blogging Conference have been debating the need for a code of conduct. You may have come across some pretty offensive and aggressive commenting from science bloggers – I know I have! (See my Commenting Policy bottom right). I think it’s a great idea. O’Reilly and others have developed a blogger’s code of conduct.

Here’s the first draft –

We celebrate the blogosphere because it embraces frank and open conversation. But frankness does not have to mean lack of civility. We present this Blogger Code of Conduct in hopes that it helps create a culture that encourages both personal expression and constructive conversation.

1. We take responsibility for our own words and for the comments we allow on our blog.

We are committed to the “Civility Enforced” standard: we will not post unacceptable content, and we’ll delete comments that contain it.

We define unacceptable content as anything included or linked to that:
– is being used to abuse, harass, stalk, or threaten others
– is libelous, knowingly false, ad-hominem, or misrepresents another person,
– infringes upon a copyright or trademark
– violates an obligation of confidentiality
– violates the privacy of others

We define and determine what is “unacceptable content” on a case-by-case basis, and our definitions are not limited to this list. If we delete a comment or link, we will say so and explain why. [We reserve the right to change these standards at any time with no notice.]

2. We won’t say anything online that we wouldn’t say in person.

3. We connect privately before we respond publicly.

When we encounter conflicts and misrepresentation in the blogosphere, we make every effort to talk privately and directly to the person(s) involved–or find an intermediary who can do so–before we publish any posts or comments about the issue.

4. When we believe someone is unfairly attacking another, we take action.

When someone who is publishing comments or blog postings that are offensive, we’ll tell them so (privately, if possible–see above) and ask them to publicly make amends.
If those published comments could be construed as a threat, and the perpetrator doesn’t withdraw them and apologize, we will cooperate with law enforcement to protect the target of the threat.

5. We do not allow anonymous comments.

We require commenters to supply a valid email address before they can post, though we allow commenters to identify themselves with an alias, rather than their real name.

6. We ignore the trolls.

We prefer not to respond to nasty comments about us or our blog, as long as they don’t veer into abuse or libel. We believe that feeding the trolls only encourages them–“Never wrestle with a pig. You both get dirty, but the pig likes it.” Ignoring public attacks is often the best way to contain them.

What do you think? Anything in that draft you wouldn’t agree with?

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This rather technical study has suggested one of the reasons why drugs work better in some people than they do in others is down to the rest of that person’s life.

We’ve known for a long time that most drugs don’t do what they are designed to do for many of the people who take them. This is not just drugs like painkillers which are trying to modify a subjective experience, but even drugs whose effects are mainly objective right down at cell level, like anti-cancer drugs.

Some researchers are pursuing a genetic explanation for this and a whole new area known as pharmacogenomics has arisen with the hope of combining genetic testing with prescribing so that a particular drug can be chosen in the light of the patient’s genetic make-up which may make them more responsive to the drug in question.

This study is interesting because it looks to an environmental explanation instead and shows that diet and lifestyle strongly influence the effects of particular drugs.

As always, we’ll find that both explanations are partly right and partly wrong. The trick will be to understand how to use these discoveries in the best interests of patients.

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