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Archive for April, 2013

From my consulting room window yesterday

Here comes the magnolia

Spring clematis

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Three kinds of antis

The aggressive anti

The aggressive anti is either verbally, or physically, aggressive. They attack the people they are against, either directly, when the attacks occur between known individuals, or indirectly, when they attack anyone they consider representative of those they are against – them, not us. Those who commit hate crimes, terrorists, bigots, religious fundamentalists or militant atheists. They troll, they mob, they bully and they attack.

The political anti

In democratic societies politicians frequently define themselves by saying what and who they are against (the opposition). “We will fight….” Well, what and who are they going to fight? The other guys….whoever they are, and whatever they say.

The medical anti

Fight this disease, fight that disease, eliminate this, eliminate that, control this, control that……The drugs our doctors use are usually anti-something….antibiotics, antihypertensives, anti-inflammatories, antidepressants, antispasmodics…..They control or suppress disease or disorder, but they do not directly stimulate, support or maintain health. They are aimed at disease, not aimed at resilience, vitality, adaptability or wellness.

OK, if you want to be an anti, my question for you is what are you FOR?

I’d like to know, all you fight this, fight that people, what would you promote, what do you believe in, how would you like to make the world a better place by the positives you have to offer. What solutions do you propose to which problems? What is your vision of a wonderful world? Persuade me. Share your great ideas for how we can ALL have better lives. Enthuse me with your passion for what you are FOR, not what you are against.

Can you do that?

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OK, so I’m getting older and I guess I’ve reached that age where I think some things aren’t as good as they were. In particular I’m concerned that the practice of Medicine has become more technical and less human. So, it wasn’t really a surprise to read the details of a study which measured how much time doctors were spending on different activities through their day. The details however are, frankly, shocking.

The study of first year internists at two of Baltimore’s largest academic medical centers, showed that the doctors spent 12% of their time examining and talking to patients, and 40% at a computer.

Now, I reckon only just a tenth of your working time as a doctor spent in direct face-to-face work with patients is surprisingly low, but to be spending almost four times as much time at the computer as you spend with patients?!

Here’s what the researchers thought about their study –

“One of the most important learning opportunities in residency is direct interaction with patients,” says Lauren Block, M.D., M.P.H., a clinical fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and leader of the study published online in the Journal of General Internal Medicine. “Spending an average of eight minutes a day with each patient just doesn’t seem like enough time to me.” “Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training,” says Leonard Feldman, M.D., the study’s senior author and a hospitalist at The Johns Hopkins Hospital (JHH).

The researchers are concerned that the trainee doctors aren’t getting enough time in direct patient care to learn their trade. But worse than that, what are they learning about the way to work as doctors?

Although this isn’t a perspective expressed by the authors, I do wonder if the whole drive towards a mechanistic, reductionist approach to health, coupled with a shift in emphasis from patient experience to group-based statistics, isn’t partly to blame for this finding.

Isn’t it time to organise the practice of Medicine in way which would allow doctors to spend most of their time talking to, examining or directly caring for, or treating, their patients?

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overhead on the train on my morning commute (two businessmen chatting)

“I saw the first butterfly in the garden yesterday”

“And two bumble bees”

“I saw a bee too, but no butterflies yet”

 

Don’t know, but its not the kind of conversation you usually hear on the Glasgow train. Warmed my heart a bit though…..

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I was really struck by an article in The Observer the other day. Dr Sam Parnia, a doctor specialising in resuscitation techniques, has studied the experiences of patients who die and are later brought back to life.

Pardon? Yes, people whose heart stops (a cardiac arrest) and whose brains stop working due to oxygen lack, but who are successfully resuscitated and fully recover. Not only does the person return but he has found that about half of them report very similar death experiences (people refer to these experiences as NDEs – “near death experiences” – but he says they are, in fact, ADEs – “actual death experiences”). These two phenomena raise interesting questions – where does the “person” go while they are dead? And how does this “person” observe and remember observations which they make while they are dead?

This particular paragraph really gripped me –

All I can say is what I have observed from my work. It seems that when consciousness shuts down in death, psyche, or soul – by which I don’t mean ghosts, I mean your individual self – persists for a least those hours before you are resuscitated. From which we might justifiably begin to conclude that the brain is acting as an intermediary to manifest your idea of soul or self but it may not be the source or originator of it… I think that the evidence is beginning to suggest that we should keep open our minds to the possibility that memory, while obviously a scientific entity of some kind – I’m not saying it is magic or anything like that – is not neuronal

Now, I’m very familiar with the idea that whilst there are neuronal correlates of mental activity, we cannot say that its the neurones which produce the thoughts, feelings, and indeed consciousness which we all experience. But what a way to put it!

That the mind uses the brain to express itself.

I had to get the book. (The Lazarus Effect. Dr Sam Parnia. ISBN 978-1-84604-307-9)

I raced through it. In the book, Dr Parnia describes his work in resuscitation and reports on his AWARE study into the reported experiences of those who return. The heart of the book, for me, is Chapter 6, “What it’s like to die”, which describes many of these reports in detail. I’ve read this kind of thing before but I had never, ever read reports from children as young as 3 years old. Those stories stunned and moved me. They are amazing. And the story told by the Consultant of his first experience of a patient’s cardiac arrest where he tells how once recovered the patient told him in detail not only what the doctor had done in the room whilst the patient was unconscious, but even what the doctor had thought, but hadn’t verbalised…….

Dr Parnia goes through the possible scientific explanations for these reports and shows how none of them actually credibly explain them. He believes we will uncover a scientific explanation one day, but not until we start to accept these phenomena as real.

Here are a couple of sentences which really struck me

Reality is not neurologically determined, then, but rather it is largely socially determined.

and

The bottom line is that no brain-based chemical change can define whether a sensation or feeling is real or not

I don’t see things exactly as he does – for example, he uses a machine model to explain how the body works – it isn’t a machine, its a complex adaptive system – and the crucial difference is that only complex adaptive systems demonstrate both emergence and self-organisation – ie the whole cannot be explained by the parts. And he says “the goal of Medicine is cure” – well, I wish! But in fact, what does Medicine these days cure? Rather, Medicine manages disease – there are no cures for asthma, multiple sclerosis, Parkinsons Disease, etc etc etc

However, these are not the key points of the book.

Let me just finish with a reference to Chapter 5, “The Orphan” where he says

Asthma has a home in pulmonary medicine. Cancer is in the domain of oncology. Parkinson’s belongs to the neurologist. But cardiac arrest is an orphan by virtue of the fact that it cuts across many specialities because it is death, and death happens in all specialities of medicine but is parented by no-one.

See, this is what I find so wrong about health care – we divide health care into specialities which focus on parts and diseases – not only does death then become an orphan, but so does health.

 

 

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darkening the light

In Goethe’s Theory of Colour he says that the primal phenomenon of colour is the lightening of dark to give violet and blue and the darkening of light to give yellow and red.

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a strange turn

What happened here?
And when?
What storm, or trauma, almost broke this tree apart? But didn’t…….
How did it manage to keep itself together and set off in a new direction?

And what happened here?
How did this particular shape develop?

tree mouth

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