Archive for November, 2008

I woke up this morning and looked outside. Thick fog. I couldn’t see more than a couple of hundred yards. Everything I could see was covered in white, icy frost. Brrr…… How horrid! At least it’s Sunday, and I can stay warm and cosy, tucked up inside my house!

Then I thought, hang on a minute, bet there are some amazing photos I could take out there. So I got wrapped up nice and warm, picked up my D70, and headed out along the country lane. Here’s some of the things I saw..

a frozen web……

frosty web

ice frozen onto the wire of a fence turning it into razor wire……

razor ice

how ice doesn’t form symmetrically on a leaf….

bearded leaf!

and how it doesn’t form symmetrically on a berry….

frozen particles on the berries

the amazing patterns it makes when puddles freeze…..

patterns on the puddles

the trees at the foot of the castle turning into a Christmas card….

Back Walk Stirling

frosted oak leaves……

oak leaves

frozen roses with thorns of ice growing out of their petals……

frozen roses

and, on this St Andrew’s Day, Robert Burns, covered in frozen webs….

Robert Burns statue

I’m glad I went out and took a walk.

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Here’s one way to think about the hurts and wounds in your life, and how to address them.

Gravity is a force we don’t understand. How can two objects exert an influence on each other at a great distance? There doesn’t appear to be any kind of invisible string connecting them! Einstein came up with an interesting theory, however. He proposed that space and time were warped – that rather than being spread evenly in all directions, there were dips and undulations. The best way to think about this is to imagine a cloth. If you place, say, two oranges on a table cloth they will just stay where you placed them. However if you stretch the cloth out and allow the first orange placed to make a dip in the middle, then the next orange will inevitably fall towards the first one. Here’s a drawing from wikipedia, to explain Einstein’s theory, which shows what I mean –


I think life is a bit like this too.

Events and experiences make an impression on us. Hurtful or painful ones leave dents in our psyche (or our bodies!) Death of a loved one is like this. It hits us, dents us, leaves a wound, changes our life forever. But, more than just a dent, this wound, or lesion, seems to have the power to draw life towards it. We find our minds constantly returning to it. The landscape of our life has changed. Things don’t look the same any more.

If we were like cars, we’d pop along to the body shop and have a panel beater knock the ding out making the surface nice and smooth again. He’d remove the dent for us. But we’re not like cars and there aren’t any panel beaters to take away a death.

One approach to deal with this is to try to remove the effects of the impact – drugs try to do this – antidepressants, sedatives to reduce anxiety or agitation, or to induce sleep for example. However, this approach doesn’t change the landscape. It doesn’t remove either the dent or its impact.

Another approach is the talking one. People are encouraged in counselling or psychotherapy to talk about the event or the experience and to in the process to try and change its impact on their present life. The difficulty inherent in this approach is that it can reinforce the strength of the dent. By focusing attention and energy on it, it can become all-consuming, increasing it’s pull and therefore its effect.

I think there’s another way.

Make more dents!

It’s not only negative experiences which make an impact. Positive ones can do it too. This is the approach used in positive psychology for example. By actively engaging in positive experiences we take an active role in fashioning the landscape of our lives. This is very different from the passive approach which can be utterly disempowering.

I know that when the impact of a negative event is large it’s effects are strong and long lasting, and the dent can be so deep it can be very difficult to climb out of it’s powerful influence. It acts like a black hole and draws everything to it. In such circumstances a combination of approaches might be needed covering all three of the main strategies I’ve written about above. There aren’t any right or wrong approaches here, but having a model to work with can help you understand what’s happening and find a way to change life when you feel totally trapped.

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evening clouds

  • The Celtic mind adored the light……….We need a light that has retained its kinship with the darkness. For we are sons and daughters of the darkness and of the light.
  • Every thought that you have is a flint moment, a spark of light from your inner darkness.
  • All creativity awakens at this primal threshold where light and darkness test and bless each other.
  • Light is the secret presence of the divine. It keeps life awake.
  • Light is a nurturing presence, which calls forth warmth and color in nature.

All quotes from “Anam Cara”, by John O’Donohue. (ISBN 0-06-092943-X)

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Complexity science

I wish someone could come up with a better name for this branch of knowledge and enquiry – calling it “complexity science” makes it seem so, well, COMPLEX! But actually it isn’t! It’s only the science of understanding reality in the raw. By that I mean understanding how natural and living systems function in the real world – in their connectedness and embeddedness. It’s the opposite of reductionism which takes the approach of breaking something down into small pieces (which actually don’t ever exist by themselves) and understanding the pieces as a way of understanding the whole.

I was interested to find this little article on Science Daily recently which mentioned the University of Vermont’s “Complex Systems Center”. It’s good to hear of universities bringing resources to bear on this area and I wasn’t surprised to hear it was part of their engineering and math Faculties. I do hope more universities expand their work on complexity and I wish more were multidisciplinary bringing together both physical and biological sciences with humanities.

The Center Director said –

“In its most simple form, a complex system is many distributed parts interacting in some distributed way,” Dodds says, “giving rise to some interesting, often unexpected, macrophenomena.”

and this reminded me of Linked by Albert-Laszlo Barabasi – I swear this is one of the most exciting books I’ve read this year and that if you want to begin to explore this whole area I couldn’t recommend any other better starting point than this. Read my review here first – but then go get the book!

The Science Daily article led me to explore the University of Vermont site. Here’s the link to their Complex Systems Center. And here’s a link to a video about “emergence” on the “PBS” site – and you’ll find links to John Holland of the Santa Fe Institute there (one of THE major thinkers and researchers in this area).

I hope you enjoy some of these resources – this really is a fascinating area of study. As best I can see, this is a MAJOR way forward to help us better understand our world and our lives.

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One of the things that frustrates me about clinical epidemiology (which goes by the name “evidence based medicine”) is how often it seems detached from the real world. Whilst researchers and statisticians pore over reviews of randomised clinical trials, real people with real problems turn up each day in the doctors’ consulting rooms. In the British Medical Journal there’s a regular column entitled “From the Frontline” and it’s written by a Glasgow GP called Des Spence. I always read his column because so often it reflects the daily reality I used to experience as a GP and which I still experience as a Glasgow hospital doctor. This week his column was particulary good – a healthy, realistic alternative view of the government’s “Quality Outcomes Framework” within which all UK GPs now practice.

It is not just the huge financial opportunity cost, nor the well made unwell, but the wanton consumption of our medical energies that I take issue with. Our energy has been spent bean counting the measurable while dismissing the most valuable aspect of medical care, the immeasurable. Perhaps I am wrong. But I will stand my ground of absolute scepticism until some redcoat finds real evidence to run through my Jacobean heart.

Well said, Des!

I especially appreciate your succinct “Our energy has been spent bean counting the measurable while dismissing the most valuable aspect of medical care, the immeasurable.” It’s a daily sadness to me that we increasingly pay attention to the measurable while dismissing the immeasurable in health care.

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Researchers at Ohio State University have just published a randomised clinical trial of pyschological interventions in women with breast cancer. Here’s the summary conclusion –

breast cancer patients who participate in intervention sessions focusing on improving mood, coping effectively, and altering health behaviors live longer than patients who do not receive such psychological support. The study indicates that reducing the stress that can accompany cancer diagnosis and treatment can have a significant impact on patients’ survival.

This was a study of 227 women who had been treated for breast cancer for an average of 11 years. Half of them were given an intervention designed to address stress and help them cope better psychologically (I can’t find the actual detail of the intervention yet!). The intervention group experienced about half the recurrence rate of the others and that group also had about half the risk of death from breast cancer.

Two things interest me about this trial. Firstly, it shows that non-drug, non-surgical interventions in serious conditions like cancer can both positively influence the course of the disease and even reduce the chance of dying from the cancer. Secondly, by reporting improved mood, and healthy behavioural changes, the researchers highlight the value of interventions which make living better. I recently wrote about death avoidance and made a plea for health care which is focused on living. This little trial is a piece of that jigsaw. It not only shows the potential for such interventions but it begins to make the case for such approaches to become routine.

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A few years ago I stumbled across the works of the “General Semanticists“. I won’t go into detail about this school of thought here, but it originated with a man called Alfred Korzybski in the early years of the 20th century. He wrote and taught about the way in which human beings reacted as whole organisms to their environment. One of the most interesting features of this way of thinking is the emphasis it gives to not only environment, but to what Korzybski called the “meaning environment” – in other words both symbols and the symbolic power of the environment itself. This focus raises all kinds of issues including change, transience, and context. The book which made this whole way of thinking clear to me was Samuel Bois’ Art of Awareness (ISBN 978-0965103701).

One of the ways of thinking they highlighted for me was “two value thinking” – we do this a lot. It’s the process by which we classify experience into one of two categories – us and them; black or white; and so on. Although generalisation and categorisation can be useful tools they are dangerous and frequently stop us seeing reality. You’ll come across this a lot in medicine. I’m sure you’ll have heard people talk about treatments as either “proven” or “unproven”; “evidence-based” or “not evidence-based”; “drugs which work” and “drugs which don’t”. But this is a silly and unhelpful way to think about treatments because all treatments need to be considered within the inescapable context of the individual. And you can’t even say a treatment “works” or “doesn’t work” for an individual – the same treatment can work at some point for a person, but then not work at another.

Think about painkillers as a simple example. Is there a “proven” painkiller which will kill pain for all individuals on all occasions? No. And, actually, it’s the same with all medical treatments. The only person who can tell you whether or not a treatment is beneficial for them, is that person – doctors have to listen to their patients and hear what their experience is. It’s very frustrating for patients to be told by a doctor that their lack of benefit they’ve received from a particular treatment is their own failure – because the treatment is “proven”. Similarly, it’s very frustrating for a patient to be denied a treatment which brought them benefit because somebody has ruled, on the basis of clinical epidemiology, that that particular treatment is “not evidence-based” or “does not work”.

The world is more complex than that. See if you can spot any two-value thinking today, and consider different contexts to see the weakness of this type of thought.

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I recently came across this quotation from Martha Graham

“There is a vitality, a life force, a quickening that is translated through you into action, and there is only one of you in all time, this expression is unique, and if you block it, it will never exist through any other medium; and be lost. The world will not have it. It is not your business to determine how good it is, not how it compares with other expression. It is your business to keep it yours clearly and directly, to keep the channel open. You do not even have to believe in yourself or your work. You have to keep open and aware directly to the urges that motivate you. Keep the channel open. No artist is pleased. There is no satisfaction whatever at any time. There is on a queer, divine dissatisfaction, a blessed unrest that keeps us marching and makes us more alive than the others.”

I think this is SO good! From my perspective as a medical doctor, I, too, see that in each of us there is a unique vitality. It’s not an entity but it’s certainly a reality. It energises us; it organises us; protects us and maintains our health. And on top of all that it’s the source of our growth. In times gone by people have considered this phenomenon to be some kind of entity and have named it either the “vital principle”, or the “vital force”. The most modern scientific understanding would be that it’s probably better understood as simply a characteristic of a complex organism. But this quote from Martha Graham is much more poetic than that!

It’s inspirational!

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What’s the point of health care? Does that seem like a question with an obvious answer? It would be reasonable to expect that the answer would be that health care is about caring for people’s health. But that’s an answer which is not really an answer. It raises the question, what is health? Stop and think about this for a moment, because it’s not a straightforward question to answer. My answer is that health is a phenomenon in its own right – it is NOT the mere absence of disease. It has distinct characteristics – adaptability, creativity and engagement. Others will have other answers, other characteristics to add, other qualities. It’s difficult to extricate health from the old concept of “eudaimonia” which tends to be translated as “happiness”, or even “wellbeing”, but I prefer the word “flourishing”. Surely health is about flourishing? The less we flourish, the less we rate ourselves as being healthy, well, or good.

This way of thinking about health is holistic. It demands that we consider the whole of a person’s life, and by that I mean the whole of their present time life (a biopsychosocial approach), and the whole of their life from start to finish. This has at least two consequences. Firstly, it means that all health care must take into consideration, not just objective disease in the form of pathology or lesions, but it must consider the individual patient’s story. No two patients have the same life, and therefore, no two patients share the same experience. With the same disease, two people will experience different symptoms and those symptoms will mean something different to each of them. In addition, each individual will have their own ways of coping, adapting to and dealing with their illness. Health care needs to relevant to the individual who is being cared for.

Secondly, it means that health care interventions will alter the experience and course of a person’s life, but they do not, ultimately, prevent death. The overall mortality for human beings is 100%. We do all die. But much of contemporary health care is predicated on the basis of death avoidance. We are bombarded with claims about “life-saving” medicines and Public Health policies which claim to reduce death rates. Statins, for example, are even promoted for healthy people, to reduce their risk of death from heart attacks and strokes. Whilst nobody would really like to have a heart attack or a stroke, no-one is asking the question, what do people who would have died from a heart attack or a stroke die from instead? The focus is on death avoidance. People are classed as being “at risk” – at risk of dying from disease x. But to make an informed choice about a treatment don’t you need to have an idea of the possible and likely consequences of that treatment? To say a treatment reduces your risk of dying from disease x is all very well, but it doesn’t say much about whether or not you’ll experience a life of greater flourishing. Especially if you develop another more disabling, painful condition instead. The logical extension of this death avoidance thinking is to try to avoid death from all causes. For example, some doctors and scientists have promoted what they call the “polypill” – a combination of drugs all in one pill, which, if taken by the whole population (or in this case the whole population over the age of 50), would significantly reduce the death rate from cardiovascular disease. Well, if you don’t die from cardiovascular disease, what do you die from? Cancer? Nervous system disease? Liver disease? Blood diseases? There’s no way to know of course but isn’t it true that it will be something else? Or do you think healthy people die disease-free?

It’s likely that a person will fight hard for life at all times. (Well, not everyone, as Dylan Thomas wrote, “Do not go gentle into that dark night. Rage, rage against the dying of the light.” exhorting his father to fight for life at the end of his life). Around a third of all health care expenditure is on people in the last year of their lives. (see New England Journal of Medicine 1993:328:1092-6 for example)  You might hope to live three score years and ten, and if you do, you can expect that most health care you receive will be in your last year of life. Think of it this way – assuming 70 years of life (I know, that’s quite an assumption!), one third of your health care will be in one seventieth of your life and two thirds for the other sixty-nine seventieths. Why is that? Because you can expect to flourish for 69 years and suffer for one? I’m not sure that’s most peoples’ experience. If health care is about improving life as opposed to merely trying to avoid death why don’t we direct more of it to life instead of death avoidance?

It seems that our so-called “health care” isn’t focussed on health at all. It’s focussed on death avoidance. That was the goal of the alchemists – the elixir of life which would produce immortality. But that’s a myth isn’t it? Shouldn’t we have health care which is more realistic? After all, if we do address illness holistically, reducing suffering, encouraging healing, resilience and growth, aren’t we likely to also increase the length of life? Might that not be a better way to avoid “premature deaths”?

Maybe we should be concentrating on increasing health, in a eudaimonic sense, instead of concentrating on avoiding death, which, realistically, is ultimately impossible.

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Platform 3 rainy morning

I took this photo while standing on a cold, wet platform waiting for a train to take me to work.
This is not an unusual experience. It’s not a rare experience. It’s very easy to bury your head into your shoulders, stand and shiver, and just wish you were somewhere else.

This year I’ve been reading some contemporary French philosophers, Jean-Philippe Ravoux, Pierre Hadot, and Bertrand Vergely. I’ve not read much, but both in interviews they’ve given and in the few books of theirs which I’ve read, I’ve found that they all three mention two common concepts. The two concepts are captured by these two French words – “quotidien” and “emerveillement”.

Quotidien means daily, but not just in the sense of “daily paper”, or “daily bread”, but in the sense of the “everyday”, of daily life. You’ve probably read a lot about the importance of living in the present. It’s certainly a common theme in Eastern philosophy, but it’s also a very common theme in the work of Western self-help writers and psychologists. Both the concept of the present, and that of the “quotidien”, concentrate us on a period of time – the period of time in which we are most alive. I find the concept of the present a little tricky. It’s very hard to pin down. You only have to breathe out and the present has already become the past. So we tend to stretch the boundaries of the present outwards from a moment to a period of time lasting maybe a few minutes, or hours, or even a day or number of days. The more we stretch the boundaries though, the more what we call the present loses its power. I like the French term, “quotidien”. It’s a period of time I can grasp. It’s today. Every day. It’s the time period in which we are alive, our conscious time, the time when we can act.

The second word, “emerveillement”, is about an attitude towards something. It means a state of wonder, of marvel, even of amazement, or awe. Probably the best way to understand this is to think about the way children engage with the world. Young children find the world a fascinating place. Think of how much fun a child can have even with the packaging in which a present is given. The world really is an amazing place. Ceaselessly fascinating. It’s just that on a day to day basis we slip into autopilot, and as we stumble through our days like zombies, our lives literally pass us by.

So here’s the alternative. Today, this very day, let something catch your attention, and just pause for a moment and wonder. That’s what I did as I stood on that windy, rainy platform. I noticed the lights and the way they reflected on the concrete and the rails. I noticed the row of lamps on the opposite platform, and their reflections stretching into the distance. And I saw the green light glowing at the end of the platform, signalling GO. Green for go. Green, the signal to start. The day was beginning. Another amazing day.

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