Archive for December, 2010

Over the holidays I’ve been catching up on some of the TV programmes I’ve recorded on my hard drive and watched a spectacularly wonderful one about Norman MacCaig. There were many highlights for me, but the two which really stuck were his description of a friend as someone who showed him

the usualness of the extraordinary, or the extraordinariness of the usual

and a recitation of his poem, Small Boy

He picked up a pebble
and threw it into the sea.

And another, and another.
He couldn’t stop.

He wasn’t trying to fill the sea.
He wasn’t trying to empty the beach.

He was just throwing away,
nothing else but.

Like a kitten playing
he was practicing for the future

when there’ll be so many things
he’ll want to throw away

if only his fingers will unclench
and let them go.


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I love those days when the moon begins to set as the sun begins to rise and there’s a beautiful co-occurrence of the sun’s dawning rays around the shining moon.

moon at dawn

dawn moon

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I finished reading William Fiennes, The Snow Geese, this morning, then as I looked out of my window I saw this sight

flying south

I followed them round to the other side of my house….

flying south

I don’t really know what to make of these “coincidences” in life, but they certainly heighten the sense of emerveillement in le quotidien……

I really enjoyed ‘The Snow Geese’. It’s one of those books I’ve had lying around for a long time, but only recently decided to read. It has that wonderful combination of beautiful writing and fascinating, thought provoking facts, which I love. The main themes of the book, based around the writer following snow geese as they head north to their breeding grounds, are about freedom, our connection with nature, and the strong instincts to head home (migratory birds have two homes really…..one for the summer and one for the winter).

What I didn’t expect to find were some references to homesickness from a medical perspective, and, given that I’m a doctor, it should be no surprise that those passages leaped out at me.

Baron Dominique Jean Larrey, Inspector of Health of the French armies under Napoleon [described nostalgia in the following terms] First, an exaggeration of the imaginative faculty: patients thought of their homes as enchanting and delightful, and expected to see relatives and friends advancing towards them. Second, the appearance of physical symptoms: fever, gastric disturbance, ‘wandering pains’. Finally, depression, listlessness, weeping, and sometimes suicide.

How fascinating to see this holistic description and understanding, beginning with an individual’s inner, subjective, mental processes, leading onto whole body dysfunction with specific disorders in certain organs and systems, then progressing to a life-threatening state of mind. What cures did such doctors suggest? Larrey recommended distraction – through “music, recreation and regular exercise”.

In 1858, James Copland, in his ‘Dictionary of Practical Medicine’, described nostalgia as a cause of disease, rather than as a disease itself (where does a disease begin? Can you really say where health gives way to disease?) However, he still considered it to be a serious problem.

The patient nurses his misery, augments it until it destroys his nightly repose and his daily peace, and ultimately devours, with more or less rapidity, his vital organs.

Fiennes quotes from a 1996 edition of Psychological Medicine ….

What strikes one most in the sparse literature on help for the homesick is that often only returning to the old home environment brings real relief.

Well, well, well…..how often is it the case that the solution to a problem is to deal with the problem?! I know that seems obvious, but if it’s so obvious why do we persist in using drugs which merely mask symptoms as first line treatments for so many problems?

I’m particularly struck by the holistic, contextually bound understanding of the nature of homesickness in these works. How have we allowed the practice of medicine to decline to its currently dehumanised, mechanistic form? A doctor must understand the narrative context of a patient’s illness to arrive at a correct “diagnosis”, not just hunt a lesion and divide illness into real or imaginary, organic or functional. A person can only be fully understood as a whole person, body, mind and spirit, inextricably embedded in their unique physical and semantic environments……and, so, “cures” should be based on this perspective rather than the diminished, reductionist one, shouldn’t they?

We are connected. Intimately, complexly connected. ‘The Snow Geese’ reminds us how connected all creatures are to their environments and to the rhythmic change of the seasons. Good to be reminded of that in this snow and ice bound December in Scotland.

How are you going to spend your wintering?

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Look what I saw on my way to work this morning….

lunar solstice eclipse over stirling castle

There hasn’t been a total lunar eclipse on the winter solstice since 1638. Pretty special to get to see it today!

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The French have two words which when considered together actually create a great philosophy of living.

Emerveillement is a kind of wonder, amazement, awe, I suppose. It’s a completely enlivening disposition. The more we can encounter life from a position of wonder, the more wonder-ful life becomes.
Quotidien means the everyday. To live with a focus on the quotidien is to live in the now. It’s a way of being present.

Imagine how good it feels to be present and to find the present wonder-ful……

In this last week, here in Scotland, we’ve been surrounded by ice and snow. Here’s one single ice crystal, growing from the tiniest point of moisture under this iron bar….

one crystal

Isn’t it amazing? Isn’t it wonderful? Isn’t it awe-inspiring how such beauty is created right before our everyday eyes?

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There are a couple of common views about new drugs amongst doctors. Both are based on the same phenomenon.

The first is “use new drugs quickly……..before their benefits wear off”

The second is “don’t use new drugs quickly……wait till you find out what there real effects are”

The phenomenon these views are based on is that when a drug first becomes available as a new “proven” or “evidence based” drug, it often seems spectacularly wonderful. Remember barbiturates? Benzodiazepines? Steroids? Betablockers? SSRIs? and so on and so on. When they first come to market they are described as breakthroughs (I don’t mean all the me-too drugs which just copycat the new ones). The early studies show wonderful outcomes and precious few side effects. However, it seems that frequently not only do the side effects become more predominant and problematic but the early promises turn out to be not quite so spectacular as originally believed.

It’s interesting to see this phenomenon now being more formally described.

But now all sorts of well-established, multiply confirmed findings have started to look increasingly uncertain. It’s as if our facts were losing their truth: claims that have been enshrined in textbooks are suddenly unprovable. This phenomenon doesn’t yet have an official name, but it’s occurring across a wide range of fields, from psychology to ecology. In the field of medicine, the phenomenon seems extremely widespread, affecting not only antipsychotics but also therapies ranging from cardiac stents to Vitamin E and antidepressants: Davis has a forthcoming analysis demonstrating that the efficacy of antidepressants has gone down as much as threefold in recent decades. For many scientists, the effect is especially troubling because of what it exposes about the scientific process. If replication is what separates the rigor of science from the squishiness of pseudoscience, where do we put all these rigorously validated findings that can no longer be proved? Which results should we believe?

I’ve said it before……this binary thought process of dividing treatments into “those which work” and “those which don’t” is nonsense. The world is not so simple. And “facts” are a lot more slippery and context bound (in time as well as circumstances) than a lot of “scientists”, and certainly drug companies,  would like us to believe.

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Snow and fog


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cold calling

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Excuse the title – panto season is upon us!

Are you, like me, fed up with headlines suggesting that now “scientists” have found the gene for X then a cure for X is just around the corner? I think it’s such nonsense. This idea that we will be able to read someone’s DNA like a computer program and figure out exactly what diseases they are going to experience, and head those diseases off at the pass is mechanistic, reductionist nonsense.

A recent article in ScienceDaily is headed “The gene-environment Enigma”. What’s the enigma? Well, it turns out just having a gene doesn’t guarantee what effect that gene will have. What’s important is the “environmental” effect which is different for every individual so individuals experience different effects of the same genes.

The effects of a person’s genes — and, therefore, their risk of disease — are greatly influenced by their environment,” says senior author Barak Cohen, PhD, a geneticist at Washington University School of Medicine. “So, if personalized medicine is going to work, we need to find a way to measure a human’s environment.”

Hmm. Measure a human’s environment…..good luck with that one….ever encountered one of the characteristics of complex systems……that outcomes are not predictable in detail in individuals? It’s not possible to measure all the potential factors involved in producing the state of a unique organism which is embedded in multiple environments (physical, relational, social, cultural, semantic etc).

Still, scientists of faith find it hard to give up on their fundamental beliefs……

Cohen says he’s not hopeless when it comes to personalized medicine. As scientists conduct ever-larger studies to identify rare and common variants underlying diseases such as cancer, diabetes and schizophrenia, they will be more likely to uncover variants that have larger effects on disease. Even then, however, a person’s environment will be important, he adds.

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Doctors are taught to use two basic concepts – health and disease. Disease figures very predominantly on the medical curriculum. In fact, Davidson’s Textbook of Medicine is all about disease. There isn’t even an entry in the index for “health”. We create our “health services” around disease, with specialists who specialise in understanding and managing diseases of certain parts of the body. That’s why we have oncology departments, gynaecology departments, dermatology, cardiology, otolaryngology (ENT) departments and so on. Out in the world of Primary Care in the UK there’s an attempt to do it differently. Most Primary Care doctors work in “health centres”. However, especially since the introduction of the “Quality Outcomes Framework”, there’s been a further push towards concentrating on diseases rather than health.

This enormous emphasis on disease has led many doctors to act as if disease isn’t a concept at all. They treat it as if each disease is an independent entity. This is a misunderstanding. It’s also led to the development of so-called “evidence based” protocols for managing disease.

Where’s the attention paid to health (without reference to disease at all)? Where are the health experts as opposed to the disease experts? Have you ever wondered what a true “health” service would be like? One which addressed “health” either in addition to “disease” or as a first point of engagement with patients instead of the first point of engagement being once pathology has emerged? (and I do mean health as a whole organism state of being, not drugged psuedo-health!)

As I see it, it all depends on the timescale you consider. In acute illness, disease-focus strikes me as highly appropriate. It’s where we show the greatest effectiveness of pharmaceutical and surgical interventions. But in chronic illness, the disease-focus gets less and less useful. Here the emphasis needs to shift to a health-focus – and as health is a lived experience, that requires understanding and engaging with the human at an individual and whole-person level.

Disease is a biological dysfunction.

Health is a life state.

Disease impacts on health, and health impacts on disease. Don’t we need to address the issue of illness from both angles, emphasising what’s most important according to the time scale we’re considering?

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