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Archive for June, 2013

How to live. Well, there’s a question which always feels fresh. There are whole sections of book shops dedicated to this question and an enormous diversity of ways of addressing it. You’ll find some advice in the Popular Psychology section, some in the Philosophy section, some in the Mind, Body, Spirit section, the Religion section, and on and on.

What’s the secret?

Probably there is no secret, and anyone who claims to have everything all worked out….well, what do you think?

Still, it’s a question which won’t go away so when Sarah Bakewell published “How to Live. A Life of Montaigne in one question and twenty attempts at an answer” back in 2010, I couldn’t resist. I’d had a browse through some of Montaigne’s essays a few years previously but despite enjoying some of them, I can’t say he really hooked me. Sarah Bakewell’s book changed that.

Montaigne lived from 1533 to 1592 in the area around Bordeaux in the South West of France. I won’t tell the whole story here, but he was part of a wealthy family, and retired from Public duties as Mayor of Bordeaux at 39 years old. As the inscription hanging on the wall of his study says, he decided that after years of duties and responsibilities he was going to dedicate the rest of his life to freedom, tranquillity and leisure.

montaigne

 

 

What he did for the next twenty years was enjoy life, have conversations, read and study, travel, and write. He decided to write to explore what it was like to be Michel Montaigne. He described his writings as attempts – that’s why they are called “essays” (from the French, essais, meaning to try). With great honesty and humility he set about reflecting on his past and present experiences. Sarah Bakewell, who spent years studying his writings highlighted the fact that this exploration was about trying to discover how to live, and in her book comes up with twenty “answers” to explore aspects of his thought and his life.

He didn’t write a self-help book. He didn’t write a manifesto. He didn’t write “the key to the secret of Life”. But what he did write has turned out to have much more staying power than it might have done had he done so. Over the next almost 500 years, reader after reader comes across Montaigne’s essays and recognises themselves. We think, goodness, how did he know that’s what I feel? Or how I deal with that? Or what I think? Because in exploring himself and sharing that, he helps us to understand what it is to be human.

I can’t think of a better introduction to this amazing man and his writings than “How to Live” [ISBN 978-0099485155]. I’ll share a few of the attempted answers in future blog posts, but let me just quote you a nice little summary of some of Montaigne’s personal principles which I found in Antoine Compagnon’s “Un été Avec Montaigne” which I picked up in bookshop near Montaigne’s chateau this summer.

Prenons le temps de vivre; suivons la nature; jouissons du moment présent; ne nous précipitons pas pour rien

My rough translation of this is to take your time to live; follow nature; enjoy the present moment and don’t rush into anything. (If you are a fluent French speaker, feel free to improve my translation!)

In other words, he predated the current “Slow movement” by almost 500 years, encouraged us to live in the now (which Eckhart Tolle has popularised), to live mindfully (and isn’t mindfulness everywhere just how? 12,200,000 hits on google today!), and to learn from Nature so that we can live according to natural principles instead of trying to fight against them (a lesson we are a long way from learning with our contemporary technology, economics, health care and relationship to the global environment)

Let us permit nature to take her own way; she better understands her own affairs than we.

Montaigne was classically educated and drew on the teachings of scepticism, stoicism and epicureanism. In fact he was the kind of sceptic I thoroughly identify with (not the modern, arrogant, sure of themselves and their own opinions variety!). He felt that knowledge was never complete so we could always learn more, and that no one person could have access to all knowledge so everyone’s opinions, experiences and views were interesting to discover. This approach made him humble and this comes through everything he wrote and did.

He didn’t tell people how to live.

Instead he reflected on his own life and shared it.

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colour

 

Where do you think I took this photo? I love the colours in this, and it got me wondering what we see in a photograph which gives us a sense of the context of a shot. What is there about the architecture, the signs, the symbols the fashion, the design, the people, which helps us to know where a photograph has been taken.

It also got me wondering about memory and imagination. What memories does this image evoke for you? What does it stir in your imagination?

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Don Berwick, recently appointed to head up the post-Mid-Staffs Review, was the person who introduced me in 2001 to the concept of “complex adaptive systems” in Appendix B of “Crossing the Quality Chasm“.

I happened to be diving into the writings of the French philosopher, GIles Deleuze, at the time, and somehow this “CAS” concept fell right into place with Deleuze’s philosophy of rhizomes and of becoming…..so much so that in 2007, when I started this blog, I chose the subtitle “becoming not being….”

I know the American Republicans really don’t like him, but I’ve enjoyed a lot of what he has had to say, and when he praised the NHS at its 60th anniversary he said (amongst other things) this

First, put the patient at the center – at the absolute center of your system of care. Put the patient at the center for everything that you do.  In its most helpful and authentic form, this rule is bold; it is subversive.  It feels very risky to both professionals and managers, especially at first.  It is not focus groups or surveys or token representation.  It is the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself.  It means customizing care literally to the level of the individual.  It means asking, “How would you like this done?” It means equipping every patient for self-care as much as each wants.  It means total transparency – broad daylight.  It means that patients have their own medical records, and that restricted visiting hours are eliminated.  It means, “Nothing about me without me.”  It means that we who offer health care stop acting like hosts to patients and families, and start acting like guests in their lives.  For professionals made anxious by this extreme image, let me simply remind you how you probably begin every encounter when you are following your best instincts; you ask, “How can I help you?” and then you fall silent and you listen.

People throw around the words “patient centred” and “consultation” like mantras these days, but sadly, its often lip service. It’s NOT difficult to practice the way Don Berwick recommends. Check out his questions in that paragraph –

How would you like this done?

and

How can I help you?

When did a health care professional last ask you those questions? Do you feel treated as an individual? With your values, your beliefs and your wishes being held as CENTRAL? Do you feel treated as a guest in the lives of NHS staff? OR do you feel YOU are the host, and they are the guests in YOUR life?

Let me say again – this is NOT difficult. The doctor, the nurse, the physio, are there to help you. They are there to listen and there to help you find a better way to cope with these symptoms, or address this disease, or whatever has led you to seek them out (a desire for better health I expect)

Don Berwick is revisiting this ethic in his new post and saying that he can be confident that the NHS can be more made safe because

“One of the most important guarantors of continuing excellence in the NHS is the ability to include and invite and listen to the wisdom of patients, families, carers and communities”

There’s still way too much of the attitude that “we” (the “experts”) know best, and “you” the patients, families, carers and communities should just get on with swallowing the “evidence based” tablets we prescribe.

“nothing about me without me”

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Petal

I noticed this. I noticed it partly because of its colour, and partly because of its shape. A lot because of its shape. This is what we do. We notice patterns. We recognise patterns. Patterns kick off a train of associations in our memories and our imagination.  I noticed the shape of a heart. Then I held it in my hand. Not grasping, but holding lightly. I held it in my hand and I wondered about the little veins in the petal, and how they looked like the creases in my palm. And I wondered about the intricacy of the petal, and the intricacy of my hand. And I was amazed yet again how the universe creates such beautiful complexity, such uniqueness, filled with connections, intricate echoes of the past, continuously evolving through today. And I photographed it with my iPhone. And I shared it. This is what we do. This is us becoming more human every day……noticing, reflecting, sharing.

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The Mayo Clinic claims that 70% of Americans are taking at least one prescription drug.

More than half of these are taking at least two different drugs.

20% are taking five or more prescription drugs.

Here are the top five, in order of frequency –

  1. Antibiotics
  2. Antidepressants
  3. Opiate painkillers
  4. Antihypertensives
  5. Vaccines

Prescription drug use has increased steadily in the U.S. for the past decade. The percentage of people who took at least one prescription drug in the past month increased from 44 percent in 1999-2000 to 48 percent in 2007-08. Spending on prescription drugs reached $250 billion in 2009 the year studied, and accounted for 12 percent of total personal health care expenditures. Drug-related spending is expected to continue to grow in the coming years, the researchers say.

So, here’s what I’m wondering. What is our working model for health care? What are we trying to achieve? Health? And if that’s our goal, how are we doing? Does this study indicate we are on the right road? Is this a sustainable direction? How do we pay for every more expensive health care of this type every year?

Oh, and isn’t it interesting that three of the top five are called “anti-” something? This suggests that our only hope is that health will emerge as a side-effect of these treatments…..they certainly aren’t designed to improve health directly.

And just in case you think antibiotics create health, have a look here.

If 7 out of 10 people in a population are taking drugs, are those drugs bringing them what they hope for?

 

 

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We tend to look right through windows. We look as if the window isn’t there. But as I look at these photos of windows, I wonder two things. First of all, how beautiful the window itself often is. Secondly, how does the window itself influence what we see as we look through it?

 

glasswaves glassspeckles stonewindow paperwindow templewindow

What are your favourite windows?
What does the world look like through your window?

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Less disease = more health

More health = less disease

Which of those two statements do you agree with?

Of course, neither equation is that simple. Sometimes bringing a disease under control, or removing a pathological lesion, results in a person’s health increasing. It’s true in most acute diseases. But it’s a bit more complex in chronic illness. Better managed diabetes allows the patient a better health experience, and controlled asthma does too, but those chronic diseases don’t go away and a person with any chronic disease isn’t likely to experience health as fully as someone who doesn’t have any such disease. Sometimes increasing health, resilience and wellbeing not only reduces limiting symptoms, but allows the innate self-healing capacity of human beings to work so well that the disease is removed completely. Other times, again in chronic situations, it results in greater wellbeing but not erradication of the disease.

The lack of simplicity reflects the fact we can’t put parts of life into unconnected boxes. There aren’t two, separate, complete states – disease and health. But they influence each other. They influence each other in unpredictable ways because human beings are complex adaptive systems, and such systems have distinct types of relationships between their parts – non-linear links. Non-linear links are typical of human feedback loops. And that’s a good description of the relationship between health and disease – they are bound together in non-linear negative feedback loops.

Most health care focuses on the first statement. We have a disease-focused, disease-management service, not a health service. Health, if it increases, does so as a kind of side-effect of the treatment. Yet, health is still the goal. Taking a health-making focus creates or enhances the conditions for reduction, or control, of disease. But that too may not be enough. The human ability to self-heal is not perfect, and not omnipotent. Management of a disease really can contribute to better health.

Why don’t we do that more?

Are we doing our best to help people to experience as much health as possible?

Not if we only focus on disease. Not if we only focus on health.

We need an integrated health service – where disease management AND health making are available to all patients.

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