Archive for October, 2008

I’ve wrestled with trying to understand what health is – in fact, I often challenge doctors I teach to come up with a definition of health which makes no reference to disease or illness. Sure, WHO’s definition does say that health is more than the “mere absence” of disease, but that still doesn’t quite capture it. I think the three qualities of adaptability, creativity and engagement are good ones to consider when grappling with this concept called health.

But there’s another word doing the rounds now – “wellness”. Was does “wellness” mean to you, and does it mean something that “health” doesn’t?

Whatever definitions you come up with, I bet it doesn’t include what I just read about a new technology – a test card which, using a single drop of saliva or blood, can check for the presence of a bank of diseases.

I’m sorry, but that’s a “sickness card” not a “wellness card”! Even if it could test against 20 diseases, it will only tell you that you don’t have one of those 20 diseases – and that does not make you “well”!

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Shades of grey

birds in an october sky
birds on a stormy day
scottish autumn

Like most people, I enjoy a lovely blue sky, but the other day there I looked out of my window and flickering shimmer of silver caught my eye. When I looked more closely it was a flock of birds whose wings were catching the bright sun. The white of their feathers was such a dramatic contrast with the deeply grey, stormy sky that as they flew it seemed as if they were emitting light.

As I took the time to capture a photo or two I noticed how pleasing the greys of the clouds appeared over the autumnal tree tops.

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Although I get a genuine thrill out of scientific discoveries about how the body works, it’s never quite enough for me. I’m always aware of something else. It’s partly that knowledge that a complex whole human being is so much more than the sum of his or her parts. But it’s also the knowledge that characteristics such as consciousness and highly developed language/communication skills aren’t just other elements which make humans different from all other living creatures. Rather they transform us. Our capacities to remember and to imagine open up whole other ways of being for us.

I’m re-reading one of my favourite trilogies (actually I’m re-reading the first two books in anticipation of the publication of the third and final one…….coming soon in English). It’s Jan Kjaerstad’s The Seducer, The Conqueror and The Discoverer. In the first of these, I came across this dialogue.

I think what I’m trying to say is that every human being could be said to be as much an accumulation of stories as of molecules. I am, in part, all the things I have read over the years. They don’t leave me. They settle inside me like – how can I put it? – like sediment.

So you believe the stories you have heard are every bit as important as the genes with which you have been endowed?

Maybe that’s what life is about. Collecting stories, Axel said, building up an arsenal of good tales, that can be put together in all sorts of complicated ways: like DNA.

If you’re right, then it’s not a matter of manipulating our genes but the stories in our lives, said Jonas.

It’s not the sequence of base-pairs, the genes, we ought to be mapping out, but the sequence of the stories that go to make up a life, and who knows? Arrange them differently and you might get another life altogether.

I certainly find that I gain insights and understanding about life from novels, from painting, from music, from movies and photographs, which I don’t get from a reductionist/materialist science. And I think there’s a lot of truth in this dialogue. Sure, it helps us to understand the mechanisms of molecular function, but if we want to understand living, human beings, then we have to understand how to listen and how to tell stories.

This is a significant part of my work as a doctor…….to understand a person by mapping out their stories and, therapeutically, to help them rearrange those stories in ways which enable them to create a different life.

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I really enjoyed an Editorial in the Guardian about the unreliability of statistics – here’s the phrase which really made me laugh –

Research in 2005 suggested that only 36% of people think official statistics are accurate

I don’t know, what do you think……..do you believe it?

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The main news programme on the BBC tonight had the word RECESSION plastered behind the newsreaders for virtually the entire duration of the programme. Got me thinking about what on earth’s going on in our “global economy”. It seems the economic system we are all living with is designed around the concept of growth. Technically, a growth rate less than zero for two consecutive quarters is the official definition of a “recession”. Some of the items covered under this heading included fears of shop owners that people won’t buy so much this Christmas. But hold on a moment. Does this make sense? Can you really design a system that will work forever on the basis of consumption and production of more, more, more? We’ve already seen in recent weeks the consequences of a financial system geared around the mantra of making more and more money. In a finite world, does any of this make sense?

And what happens when human beings just keep consuming more and more? Oh sure, they grow all right – take a look at this map of the increasing levels of obesity in the USA – watch it spread across the whole continent like a contagion. This growth, this getting bigger, fatter, consuming more……this is health? This is a goal worth striving for? This is a system which will deliver good lives for the human race?

I don’t think so.

You see growth in a healthy way, growth in Nature isn’t about ever increasing consumption and accumulation. It’s about development. A healthy child grows into a healthy adult by maturing and developing. This involves learning, experience, acquiring skills, becoming resilient, adaptable and fit. That kind of growth is sustainable. That kind of growth is worth pursuing.

I don’t have the answers to this one, but it just strikes me that maybe we need an economic model which is based on a more natural and a more human concept of growth…….development, maturity and the fitness to be able to cope with what comes along. Not the current model based on greed, consumption and ever increasing production. The current model doesn’t work. It’s an illusion.

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I just stumbled across this quote and I liked it so much I thought I’d share it –

We are to regard the mind not as a piece of iron to be laid upon the anvil and hammered into any shape, nor as a block of marble in which we are to find the statute by removing the rubbish, nor as a receptacle into which knowledge may be poured; but as a flame that is to be fed, as an active being that must be strengthened to think and feel–to dare, to do, and to suffer.
– Mark Hopkins, Induction address as president of Williams College, 1836.

The flame metaphor really does work for me. I feel the same way about sharing ideas and insights – the things I put in this blog. When my flame adds to your flame there’s twice the energy, twice the heat and twice the light.

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First snow

When I came home this evening (October 21st) I noticed snow on top of Ben Ledi – first snow of the season!

first snow

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Sir Michael Rawlins, Chair of the National Institute for Health and Clinical Excellence, has recently criticised our use of RCTs (Randomised Clinical Trials). This particular type of research study is promoted by many decision makers as a “gold standard” but Sir Michael listed a number of objections to this practice. He gave examples of situations where RCTs are either unneccessary or impossible, questioned the practice of failure to complete studies (30% of recent trials in oncology have been stopped early because of apparent benefit from the treatment), and expressed his concern about the high costs of conducting such research. However, perhaps his most interesting remarks related to the generalisability of RCT findings and the elevation of this methodology above others.

RCTs are often carried out on specific types of patients for a relatively short period of time, whereas in clinical practice the treatment will be used on a much greater variety of patients – often suffering from other medical conditions – and for much longer. There is a presumption that, in general, the benefits shown in an RCT can be extrapolated to a wide population; but there is abundant evidence to show that the harmfulness of an intervention is often missed in RCTs. Sir Michael argues that observational studies are also useful and, with care in the interpretation of the results, can provide an important source of evidence about both the benefits and harms of therapeutic interventions. These particularly include historical controlled trials and case-control studies but other forms of observational data can also reveal important issues. Sir Michael rejects the trend to grade various kinds of clinical trials and studies on scales of merit which he says has come to dominate the development of some aspects of clinical decision making. “Hierarchies attempt to replace judgement with an oversimplistic, pseudo-quantative, assessment of the quality of the available evidence.” Sir Michael believes that arguments about the relative importance of different kinds of evidence are an unnecessary distraction. What is needed instead is for “investigators to continue to develop and improve their methodologies; for decision makers to avoid adopting entrenched positions about the nature of evidence; and for both to accept that the interpretation of evidence requires judgement.

The generalisation issue has been raised so often it’s surprising that it is dismissed so easily by decision makers. Not only are trials artificially created clinical experiences but the entry and exclusion criteria for patients admitted to such trials always excludes “co-morbidity”. In other words if somebody had more than one clinical problem they won’t be admitted to the study. However, in actual clinical practice patients presenting with more than one disease at a time occurs so frequently that it is considered usual. Other criteria also make it difficult to generalise the results of RCTs. But, Sir Michael’s main criticism is about safety. The problems with a new drug are rarely picked up by RCTs. The problems indeed are not usually evident until many more patients have taken the drug in real life circumstances. So if we want to understand the real life potential of a drug, then we need larger, observational studies to pick up the side effects and harms which the drug can cause.

His final point is about the use of “hierarchies of evidence” which give greater credence to some methodologies over others. His contention that this distorts both the nature of evidence and that it is used as a substitute for clinical judgement is an important one

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The other day I looked out of my consulting room window and saw the rain pouring down in the garden

driving autumn rain

I took a wander outside and photographed the effects of the rain on different surfaces. Here it is on wood –

rainy wood

Here it is on stone –

rainy stones

And here it is on leaves –

rainy leaves

beautiful, huh?

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The “self-help” industry has been around for many years, but it seems to be growing ever larger. There are countless books, websites and courses on this subject. However, it’s hard to find anything which takes a fresh angle on the subject. One change is that increasingly the explicit language used is about “happiness” or “wellbeing”. But the focus is still, largely, the same – SELF. We read about “self-help”, about “getting what you want”, about “personal growth”. Has it ever struck you how often it’s about “me”!

There’s a change in the air however. Roman Krznaric writes about “outrospection” as a counter to the predominance of “introspection”.  And Mark Vernon has recently written a book on “Wellbeing” which also seems to develop this way of thinking. Here’s a great review of his book on Mark’s own blog. The review is by John Armstrong, and he writes…

Losing weight, taking exercise and eating the right food, improving your looks, making a sea change or a tree change, simplifying your life: these are strategies for wellbeing and they are the stock topics of a million and one newspaper articles. But the avalanche of advice suggests collective desperation: we have to tell ourselves so much about how to be happy, and say it so often, because things aren’t going well. It’s striking that the kind of advice that’s given tends to target the body first: it’s all about how you look, how healthy, fit and active you are.

He goes on to say….

In this pointed little book, British philosopher Mark Vernon argues that we’ve been looking for happiness in the wrong places. He draws attention to two aspects of life that are deeply connected to living well: love and what he calls transcendence. Love involves caring profoundly for something apart from yourself, and doing so requires that you discover capacities for generosity and self-sacrifice. Love, in a curious way, is intensely unfashionable. That’s because love isn’t egotistical; it isn’t cool; it doesn’t focus on how sexy or hip one is; and you can’t possibly love another person for being trendy or famous or rich or wearing the right clothes. So real love is counter-intuitive in a shallow world. And that’s ironic because love is central to leading a good life, and to being happy. Our world is addicted to the idea of happiness but rejects a crucial way in which happiness isattained.

That particular sentence about love – “Love involves caring profoundly for something apart from yourself, and doing so requires that you discover capacities for generosity and self-sacrifice.’ – really struck home for me. I think “health” is a positive experience which has distinct characteristics, and one of these characteristics is “engagement”. When we are engaged with what lies outside us – Nature; other people; Art; community, and so on – then we experience “flow”, “happiness” and “wellbeing”. In that sense, “health”, strangely, isn’t really found inside a person, it’s found in the contextualised person, the connected person, not in a separate, discrete individual.

Even more of a challenge is what Armstrong writes about the place of suffering in life –

These are not in any way recipes for a painless life and that’s how it should be. Understandably, we seek to avoid pain. But much of what is important and valuable in life is inescapably connected to suffering. You cannot form a deep relationship with another person unless you worry about them, fear what could happen, get bitterly disappointed with yourself for letting them down or for causing them anguish or frustration. And eventually you will have to mourn for them or they will have to mourn for you. You can’t engage with the things that make for a good life unless you are able to cope with suffering. It’s the same with any worthwhile creative effort, with noble political hopes, with any desire to improve the world: worthwhile, valuable, but a hard road.

What this paragraph provoked for me was Wim Wenders “Wings of Desire” (remade in English as “City of Angels“) which tells the story of an angel who becomes a human in order to fully experience the pleasures and the suffering (ultimately, the mortality) of human life. It’s a great movie and is, I think, one of the greatest celebrations of what it is to be human.

There’s definitely something worthwhile and interesting here. What I like about it is a change of direction away from looking inwards, towards emphasising what we’re connected to which is greater than ourselves, towards looking outwards – it’s about becoming more loving.

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