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Archive for April, 2009

In The Discoverer, Jan Kjaerstad mentions Liv Ullman’s “Changing”, and states that many people who read it changed their lives. Well, The Discoverer is a novel, so I wasn’t sure if such a book actually existed. A quick check on abebooks found that it did and I ordered up a copy for a few pounds. (Changing. Liv Ullman. ISBN 0297772856. Published back in 1977 and translated into English by Liv Ullman herself)

What an interesting book!

I really didn’t know anything about Liv Ullman before I read this book. I knew she was an actress and she’d starred in Ingmar Bergman movies but that was about it. This book is a kind of autobiography telling about certain parts of her life. It’s written in a mix of styles and a strange mix of first and third person sections. The third person parts strike me as most odd and feel the least natural but the first person writing (which is by far and away the greatest part of the book) reads very naturally. It’s as if she is chatting to you or sharing her thoughts with you.

What makes the book remarkable is how it shares the process of maturation and development of wisdom. Yes, wisdom. I’d go as far as to call this a wisdom book. It’s enlightening and inspiring and I say that as a man, even though much of what she writes about is sexual inequality and the struggle to be a single mother and a professional at the same time. I love her clear eyed, grounded focus on the real. There’s nothing polemic, and nothing starry eyed about this book. It’s a story of growing self-knowledge and with that self-acceptance, of the struggles with commitment and freedom, with mothering and professional development as an actress, with privilege and simplicity.

Here’s what she says about success –

The best thing that can come with success is the knowledge that it is nothing to long for.

And here’s what she says about the differences between men and women –

I try to put in words why I believe that all divisions of people into groups just increases our difficulties. Makes it harder to understand each other.

The importance of living NOW –

I think it is good to recognise what the moment is about and to accept it as a gift.

and

Why is it so frightening to reach sixty because one was once sixteen an believed that time existed in infinite supply? Why couldn’t one know that Time moves on with ever increasing speed and plays havoc with all the things we once thought we could leave for tomorrow?

But especially I like what she says about self-acceptance and finding what’s important within –

Sometimes the sense of security is within myself.

and

Pointless to seek refuge in someone else from what was my loneliness and insecurity

and

I realise I was brought up to be the person others wanted me to be, so that they would like me and not be bothered by my presence. That person was not me. When I began to be me, I felt that I had more to give. Life was richer.

and

Perhaps maturing is also to let others be. To allow myself to be what I am.

She completely grasps the dynamic of life –

Is this not where life’s possibilities lie? Not necessarily to arrive, but always to be on the way, in movement.

She says that one of the greatest compliments she ever received was a zen saying –

You have allowed the cloth to weave the cloth

I like that very much!

I don’t think reading this book changed my life but it was certainly an inspiring read.

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the tulip's tear

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Patients present their problems to doctors as stories. Stories are the way we attempt to communicate what’s invisible – the inner, subjective reality that only we can experience. Take pain as an example. There is no way to see pain, or to experience another person’s pain. There are no instruments to measure it. So when someone presents with pain, doctors try to hunt down any physical abnormalites, any “lesions”, which might be the source of the pain. The trouble is, whilst the physical, the objective, the “lesion”, can be seen, or measured, or even touched, none of those qualities make it more real than the subjective experience of the invisible, un-measurable, symptoms. That’s not the way most doctors see it though. There is an enormous tendency to rate the “lesion” above the experience. Why is that a bad idea? Well, not least because the relationship between lesions and symptoms is non-linear at best, and coincidental at worst!

I came across an interesting article recently about how misleading MRI scans can be. It cited two fascinating studies.

An infamous 1994 study published in The New England Journal of Medicine imaged the spinal regions of ninety-eight people with no back pain or any back related problems. The pictures were then sent to doctors who didn’t know that the patients weren’t in pain. The end result was shocking: two-thirds of normal patients exhibited “serious problems” like bulging, protruding or herniated discs. In 38 percent of these patients, the MRI revealed multiple damaged discs. Nearly 90 percent of these patients exhibited some form of “disc degeneration”. These structural abnormalities are often used to justify surgery and yet nobody would advocate surgery for people without pain. The study concluded that, in most cases, “The discovery by MRI of bulges or protrusions in people with low back pain may be coincidental.”

So lesions without stories are just misleading aren’t they?

A large study published in the Journal of the American Medical Association (JAMA) randomly assigned 380 patients with back pain to undergo two different types of diagnostic analysis. One group received X-rays. The other group got diagnosed using MRI’s, which give the doctor a much more detailed picture of the underlying anatomy. Which group fared better? Did better pictures lead to better treatments? There was no difference in patient outcome: the vast majority of people in both groups got better. More information didn’t lead to less pain. But stark differences emerged when the study looked at how the different groups were treated. Nearly 50 percent of MRI patients were diagnosed with some sort of disc abnormality, and this diagnosis led to intensive medical interventions. The MRI group had more doctor visits, more injections, more physical therapy and were more than twice as likely to undergo surgery. Although these additional treatments were very expensive, they had no measurable benefit.

You might have thought that the “better” imaging technology would reveal the “real” lesions and so guide the doctors to the best treatments. Turns out that just wasn’t the case.

It’s very frustrating for a patient when their symptoms are dismissed because no lesions can be found (no physical diagnosis can be made), but it’s equally frustrating when the removal of such a discovered lesion fails to produce any lived benefits for the patient. We are beginning to see a greater use of “quality of life” questionnaires, and of “PROMS” (Patient Reported Outcome Measures) but there’s still a huge tendency to rate what can be measured over what can’t be.

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Spring is a great time to be amazed. All the buds and blossoms……

budding

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Surgeons are doctors of the visible par excellence. They explore their patients’ bodies to find lesions, swellings, ulcers, abnormal pieces of tissue or abnormal organs. My trainer taught me “If you send your patient to a man with a knife he’ll use it”. That was good advice. When you present your symptoms to a surgeon he or she will try to find a lesion which might explain them. They use their eyes and their hands, and, increasingly they use technology to explore the inside of the body, and discover the lesions which can’t be seen with the naked eye. Their treatments, as you might expect, are similarly very physical, very visible. They use knives, lasers, needles and thread.

Physicians are also doctors of the visible, but their concept of the lesion which might explain your symptoms can be much more diffuse than that of the surgeon. Physicians increasingly focus on the physical changes which can only be revealed by technology. Not just the imaging equipment loved by the surgeons, but also the vast array of lab tests which reveal quantities of particular molecules circulating inside their patients’ bodies. They even explore the molecules within DNA to find the “causes” of disease. Physicians, in other words, as just as concerned about the visible, the physical, the measurable, as surgeons are. Their treatments similarly match their understanding of illness. Just as surgeons use highly visible, physical tools, so physicians use those tools which are visible – drugs. This is different from the surgical toolkit of course because although a tablet, or a cream, or an injection might be very visible, the actual tools which do the job are the molecules which the visible “medicine” contains. You can only make these tools visible by using technology. The molecules can’t be seen with the naked eye.

Psychiatrists are doctors of the invisible. They explore the subjective content of human minds. You can’t see anxiety, depression, compulsive thoughts or psychoses with the naked eye and you can’t find them with technology either. These symptoms are like the wind in the trees. You can only see the effects of the symptom, not the symptom itself. It’s interesting to see how psychiatrists have used both visible and invisible tools to address these invisible diseases. The main invisible tool they use is language. All the psychoanalytic and cognitive behavioural approaches are based on listening and talking. The patient tells their story, the therapist interprets it and works to enable the patient to tell a different story, one which is healthier. But psychiatrists also use drugs the way a physician uses drugs, either to modify behaviour, or to alter levels of brain chemicals and in so doing alter behaviour. The most physical/visible part of psychiatric treatment is brain surgery, removing or inactivating parts of the brain to alter behaviour or experience.

I’m a doctor of the invisible but I’m not a psychiatrist. My everyday work consists of listening to patients’ stories in order for them not just to reveal the subjective contents of their minds, but of their bodies too. I’m interested in such invisible phenomena as pain, nausea, light-headedness, itch, numbness, well-being and exhaustion, as well as more mental ones such as depression and anxiety. Because I specialise in the invisible, in most cases I refer visible manifestations of disease to a colleague, but in acute situations I’ll initiate physical treatments myself. However, most patients who are referred to the hospital where I work have already had the visible addressed and are referred because their continuing distress or disability caused by the invisible. It’s interesting that the treatments I use, homeopathic medicines, are also invisible. Not just invisible in the way that a drug is invisible until analysed, homeopathic medicines don’t reveal their characteristics to either the naked eye or to technology. They only reveal their characteristics to the individual patient. It’s the change in subjective experience which shows the effect.

I’ve compartmentalised here to make a point. However, the reality is that most doctors deal with both the visible and the invisible. Most doctors are concerned not just with the lesions which might be found, but also with the lived, inner, subjective experiences of their patients. It’s just that most doctors are trained with a biomedical model in mind, and that gives a huge priority to the physical, the visible. With the growth of understanding around concepts such as biopsychosocial models, phenomenological and narrative approaches, and so on, we are beginning to pay more attention to the invisible, to patients’ lived experiences. It’s not only the physical that matters, and subjective experience is neither irrelevant, nor is it less important than the presence of a lesion. What we are beginning to understand is that the relationship between the visible and the invisible is a non-linear one, and that the presence or absence of a lesion may or may not be relevant to a patient’s actual experience. The logic and the science of human functioning demands that we should at least redress the imbalance between the visible and the invisible in health care, and in many cases, actually reverse the current situation.

It turns out that what is most important in health care is what the patient tells the doctor, not what the doctor tells the patient.

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Kjaerstad

It’s about four years ago now since I stumbled across Jan Kjaerstad’s The Seducer (ISBN 978-1905147014). Kjaerstad is a Norwegian author and The Seducer was the first of his great trilogy to be translated into English. It hooked me from the very start. I loved it, wallowed it, swam in it, just became totally absorbed by it. Why? Well I’m quite clear why. It’s the quality of the writing. I’m a great lover of stories and the whole trilogy is not only one great web of hundreds, if not thousands of stories, but the whole premise of the books is that we understand each other and ourselves through the stories of our lives. Now that’s a theme very close to my heart. I am convinced that we construct a narrative self. Who I think I am is the result of the ever evolving, ever developing, intricate web of stories I tell myself about my life. And the way I communicate my self, my life, even my single experiences to others, is by telling them stories. That’s my first reason for loving these books so much. The second reason is the quality of the writing. On the back of The Seducer, Kjaerstad is described as a post-modern writer. I don’t know what the word “postmodernism” does for you. I know that for many people they have almost an allergic response to it, but I have the view that it’s had a bad press. I find the fundamental insights of postmodernism appealing and I really, really enjoy good postmodernist art, and, wow, can Jan Kjaerstad write great postmodernist art! What do I mean by that? Well, he is a complete master of telling a story involving an object, an event, or a particular word, then pages later, in another totally different story that same object or word arises again but now in a different context, but because it’s already gained a certain, particular significance from the previous story, in it’s second appearance it has a different meaning from what it would have had if you hadn’t read the story where it appeared the previous time. Then, later, in yet another story, up it pops again, and again with a new significance and meaning, related to the other two, but different, so echoes and ripples of the prior meanings deeply condition the third usage. And so it goes. Again and again. I find it exciting, thrilling, breath-taking even. This is how life is. Everything we experience has a unique meaning and significance for us which comes about through the precise and particular narrative of our life. It is absolutely true that none of us experience the same song, the same madelin, the same colour or scent even, in exactly the same way. Maybe if you’re not convinced of that then this trilogy might convince you. I do think this is writing which provokes, which challenges and which enlarges and deepens how we see ourselves, how we understand ourselves and how we might engage with our lives.
So what’s the main story? The Seducer is the first title, The Conqueror (ISBN 978-1905147168) the second, and The Discoverer (978-1905147366) the third. They tell the story of Jonas Wergeland, a Norwegian TV producer who makes the greatest series ever seen in Norwegian TV, Thinking Big. The series explores the lives of famous Norwegians and challenges the average viewer to give up his or her preconceptions in order to obtain a much deeper and clearer understanding of who each of these people were, and what made them tick. He designed the series to get his fellow Norwegians to wake up, to stop being passive observers of life, to think big! Yeah, I’m sure you’ve already thought it…..to become heroes not zombies! (he doesn’t use those terms of course, but he’s definitely writing about the same issue). At the outset of the first book, Jonas returns home to find his wife lying in a pool of blood, shot dead. As he stumbles about the house trying to make sense of what’s he’s experiencing we read story after story from his life. How did this happen? Who is Jonas? Who is Margrete who lies dead on the carpet? By the end of the novel, Jonas has been charged with her murder and he’s plead guilty. But did he actually do it? We still don’t know. In the second book, The Conqueror, Jonas is in jail, and a professor with the help of a mysterious, exotic woman, are writing a biography of him to try to uncover not just the truth of what happened but to answer the question, how could this great, creative man, also be a murderer? How is that possible? The third book, The Discoverer, opens with Jonas now having served his time, and it’s in this novel that we get to hear directly from him for the first time. Some of the chapters are his writings from his own notebooks, and with this element, he suddenly becomes much more real. I had the experience of feeling that although I knew a lot about Jonas from the first two books, I still didn’t know him. Now I get to know him. It’s only about three quarters of the way through the third novel that the truth is revealed. What actually happened? How did it all come about? I won’t tell you here of course but this was the point where suddenly the book hit my heart, moving me to tears.
This is a BIG read. The Seducer is about 600 pages long, and the other two about 450 pages each. Maybe The Discoverer could stand alone and be read without the other two, but I suspect the reader would miss a lot of full significance of many of its stories. However, for me, the best was left till last. I loved them all, but The Discoverer is my clear favourite.
I could say much more about these novels, about their overall structure, about the themes that he weaves together and the echoing questions he asks which are the essential questions in all our lives, but I’ll stop now. Let me just finish by making two further points. There’s a lot of very explicit sex in these books. Especially in The Seducer, (there’s a hint in the title!) If that would disturb you don’t read these books!  Secondly, this is not the kind of novel that will appeal to everyone. It’s not a thriller. It’s not a whodunnit. It’s a massive web of interconnecting stories which explore a man’s life.
In my opinion, I’ve never read anything better. I had to wait about two years between each of the books as they were translated into English and then published and I re-read both The Seducer and The Conqueror over the last couple of months while waiting for Amazon to send me The Discoverer on publication, then dived right into The Discoverer. I am seriously tempted to start reading it again straight away, and I have a notion I’ll go back to the beginning and read The Seducer, The Conqueror and The Discoverer one after the other yet again.

(By the way, who on earth is in charge of book design at Arcadia Books? I’m sure it’s very clever how the front covers of books two and three fit together but just how does the cover of book one fit in with that design??!)

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