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Archive for 2012

Rurbanismo

There’s an interesting change happening in Spain. They are calling it “rurbanismo” which is a term they’ve invented to describe the reversal of the long term movement of populations from the countryside into cities. It seems the Spanish are starting to move out of the cities and into the countryside in significant numbers.

Many have made the move for lifestyle reasons, and the ability to work remotely using new telecoms and internet technologies has contributed to that. But the economic crisis is forcing others to the same the move. There are old abandoned houses and hamlets scattered throughout Spain and although its tricky to track down the legal ownership of these properties, entrepreneurs are buying up clusters of houses and whole hamlets to create new communities.

One example is around Villanueva where a community of artists has developed from people who have restored farm buildings used to dry tobacco and peppers in the old days, and even bringing back to life the village’s dance hall which is now being used by a new circus theatre company.

Interest in organic farming and renewable energy production is contributing to this growth in rurbanismo, and some interesting innovative economies are developing, including an increased use of barter and the creation of “time banks” where hours of labour can be exchanged for goods and services.

This mix of entrepreneurship, innovation in local economic structure, value-driven movement towards living in small communities, growing organic food and using renewable energy resources to be at least partially self-sufficient feels a very human level, creative response to the current economic and social crises.

There are echoes here, too, of the “eco-villages” movement in Russia as popularised in the Ringing Cedars books.

 

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cleansing

This is one of my most favourite activities – to stroll around the temples and shrines of Kyoto and Nara…..

nara

kasuga

kasuga

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Now, to me, these shadows look like some form of kanji (secret messages from the ice?)

shadow crystals

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Ok, so I didn’t have a map on me, but I’m pretty sure that’s Mount Fuji popping its head up through the clouds – see it about a quarter way into the photo from the left hand border, on the horizon?

Mount Fuji from the sky

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Looking out of the window of a plane this morning the sun caught these crystals of ice on the glass. Aren’t they beautiful? What a sparkling start to a day!

ice on plane window

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Research studies routinely use different ways to present their conclusions. In particular they present “relative risk”, “absolute risk”, and/or “numbers needed to treat” information. Gigerenzer is brilliantly clear about this. He says

Gigerenzer shows how drugs companies and authorities routinely use Relative Risk to emphasise the potential benefits of their treatment while at the same time presenting the potential harms as Absolute Risks to minimize the impression of adverse potential.

This week in the BMJ, there is a study where researchers have looked at the use of relative and absolute risk reporting in studies which examine inequalities in health. Their argument is quite modest – that to fully understand any study BOTH relative and absolute risks should be reported. They say this is best practice. So, how often does it occur?

Almost never.

75% (258/344) of all articles reported only relative measures in the full text; among these, 46% (119/258) contained no information on absolute baseline risks that would facilitate calculation of absolute effect measures. 18% (61/344) of all articles reported only absolute measures in the full text, and 7% (25/344) reported both absolute and relative measure

But in fact, the literature is even more skewed than those conclusions suggest because

We found that nearly 90% of studies with quantitative estimates in the abstract presented only relative measures, and 75% of all articles reported only relative measures in the full text.

Why is the bias towards relative risk even greater in the abstract than in the full text? Because its the abstract which most people read, and it is probably the abstract which is used to write the PR headlines.

Does this matter? Yes it does. The authors argue that the choices of relative or absolute risk reporting influence policy making.

Makes you wonder how often the “evidence” is produced to fit the policy, rather than the policy being produced from the evidence…….and that applies across the board from the writing of guidelines and protocols, to decisions about health care spending, to individual doctors deciding what treatment to offer an individual patient.

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What’s the difference between a complex system and a complicated one?

It’s all in the number of connections.

A complicated mechanism is just that – a mechanism. Like a machine. It may be built up from lots of different components and parts (think of modern cars with their onboard computer systems), but each part interacts with very few other parts. So if you want to understand it you can take it to pieces and understand each part, then build it back up if you know how each part connects to other parts.

A complex system is not like a machine. It may also have many different components and parts (think of a brain with all its neurones) but each part has multiple connections with other parts, and each part can in turn be influenced by multiple other parts. You cannot understand this by taking it to pieces. Its characteristics are dependant on the whole interactive system. A single part, or even set of parts, will not necessarily behave the same way when considered in the entirety of the whole organ.

All life forms are complex systems, not complicated systems. Treating human beings as machines is a failure of understanding.

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The current set of concepts being used to organise health care prioritise a certain reductionist view and assume the ability to predict outcomes of actions – as if health and health care were linear systems (hint – they’re not! They are complex and non-linear). One of the consequences of this way of thinking is to break professional roles down to a series of tasks. Once a simple task is examined, it is usually possible to argue that only a little training and knowledge is required to carry out that task (just the skills and knowledge required for this particular task). What we lose sight of, is a person-level perspective, and hence a professional one.

Let’s consider one type of health care professional. A doctor. What is a doctor? What’s a doctor’s role? Actually,that’s not so easy to answer, but if you read “Tomorrow’s Doctors” by the General Medical Council, which is their attempt to describe what a doctor should be able to do, you’ll find a strong emphasis on leadership.

So, it was interesting to come across the concept of “humble leadership” which is beginning to attract attention.

In the midst of spectacular failures of the “superman” type of leader in the financial, corporate and political sectors, people are beginning to question the wisdom of seeking such charismatic but frequently arrogant individuals whose main strength seems to be the conviction of the rightness of their own decisions.

So what is a humble leader? Leadership humility…

generally involves how leaders tend to view themselves (more objectively), others (more appreciatively), and new information or ideas (more openly) 

And

The humble leader behaviors we identified (e.g. acknowledging mistakes, spotlighting follower strengths, modeling teachability) as well as the mechanisms (e.g. legitimization of uncertainty and personal development) were often described as directly challenging the more popular top-down conceptions of leadership.

As doctors are expected to be able to handle complexity and uncertainty, it would seem that humble leadership skills might be highly relevant. Wouldn’t you like your doctors to observe themselves more objectively, you and their colleagues appreciatively, and to be continuously open to new information and ideas?

Such a shift to humble leadership could completely change the doctor-patient relationship for the better. It is a much more appropriate way to deal with the reality of the complexity and uncertainty which is characteristic of human health and disease.

The researchers who are studying leadership humility identify two key characteristics or qualities – competence and sincerity.

Hard to argue with that!

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There’s a terrible tendency these days to reduce the practice of Medicine to a slavish following of protocols and guidelines. In society there is a strong drive to uniformity and conformity – but that drive doesn’t come from individuals. It comes from the machine-like models of corporations and corporate management methods.

Iain McGilchrist says, in The Divided Brain,

We kid ourselves that doctors, teachers, policemen are there to develop a ‘product’ which we can then ‘get’ or consume. But this is nonsense. We don’t know beforehand what it is we are to go after and ‘get’, because it varies in every single case, and is dependent on a relationship between individuals.

Yet it seems we are increasingly pushed to demonstrate “outcomes” which are set before we begin, and are measured (presumably) after we have “finished.”

I think the prime job of a doctor is diagnosis – in the old sense of the word – an understanding. In other words a doctor’s job is to understand. To understand a person and to understand what they are experiencing, whatever artificial label of a named disease we apply.

Understanding is never complete.

So, diagnosis is never finished.

The GMC, in “Tomorrow’s Doctors”, says that a doctor’s job is to be able to handle complex situations and to deal with uncertainty. We need a bit more of that. We need to shift the focus away from tasks, outcomes and targets, all of which imply products and endpoints, to human beings. Every single human being is unique, and nobody, but nobody, can accurately predict how the future is going to unfold for an individual.

Medicine is a relationship between two people. One acting in the service of another. It can’t be reduced to measurable tasks. And it certainly can’t be reduced to the act of writing a prescription!

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“In Praise of Love” by Alain Badiou [1846687799] presents a simple but thought-provoking idea about love. He proposes that love is about the creation of a two person view of the world, instead of the single, individual one. As understood from a complexity position, what emerges in this linking up is greater than the sum of its parts

the real subject of a love is the becoming of the couple and not the mere satisfaction of the individuals that are its component parts.

Quite poetically he describes it this way

It is like two musical instruments that are completely different in tone and volume, but which mysteriously converge when unified by a great musician in the same work.

What really resonated most strongly with me, however, was his key insistence that love is about difference – about seeking difference, creating difference, delighting in difference…

what kind of world does one see when one experiences it from the point of view of two and not one? What is the world like when it is experienced, developed and lived from the point of view of difference and not identity? That is what I believe love to be. It is the project, naturally including sexual desire in all its facets, including the birth of a child, but also a thousand other things, in fact, anything from the moment our lives are challenged by the perspective of difference.

Beautiful.

This is a different view of love from the traditional romantic love, which, sadly, I feel, too easily slides into something which turns one person into the love object of the other. I prefer Badiou’s idea – it’s more equal, and, ultimately, incredibly more exciting….

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