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Archive for June, 2013

fern

 

What a beautiful shape! Here is one stem of a fern unfurling, unfolding, becoming. If I came back next week and photographed this exact fern, it would look very different. If I could take a photo every few minutes and view it as stop motion video it wouldn’t look so still. We would see it was constantly moving, restless, stretching, curling and uncurling, spreading its leaves in the sun.

This single fern is a wonderful example of how, if we want to really know an individual, we have to follow them through their unfolding. Single moments, isolated snapshots of existence only hint at the complexity, the movement, the development which is at the heart of all Life.

Becoming, not being…….

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Feather

 

A little white feather, caught in grass which has pushed up through the Tarmac.

i’m sure you’ve seen LOTS like this before, but, wait a minute. Don’t rush. Take a look at it. It’s  beautiful. It’s delicate. It’s strong. And it’s complex. What an amazing structure.

The way my mind works I look at this and I think about becoming……..how does a bird make this structure? How can one cell, fertilised by one other cell, double and double in numbers, then differentiate so that some cells become eyes, some become brain cells, some become legs and some produce feathers. And all in just the right places. I was entranced by my embryology lessons at university and this incredible process still fills me with wonder and awe.

And I think about how the first feathers appeared on the Earth. Were there many stages of almost-feather which eventually become feathers? Did they appear suddenly? One day there were no feathers on Earth, then the next day, there they were?

And then I come back to this particular feather. Where is the bird which grew this feather? Is it a swan? A seagull? Does it live around here?

And. Then I remember that Paulo Coelho, the author, says he starts to write a new book only after he finds a white feather, and I wonder which bird, therefore, created The Alchemist!?

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the road

 

A few years ago they started to develop Leith harbour. They built blocks of flats, terraces of houses, laid roads……then, CRASH, it all stopped. I can understand how these projects hit the buffers, but this little false start of a road with its pointless, well-painted junction leaves me wondering.

Why would you tarmac the roads before laying the foundations for the buildings? But, really, why would you PAINT THE WHITE LINES on a road which, after three paces, ends in shrub and grass? Complete with the double dashed “give way” rule? Give way when you’re coming from where?

What do you think of this road less travelled? This road to nowhere? This abandoned little bit of hope and planning?

What do you think of bothering to mark the rules of the road so long before anyone can ever be subject to those rules?

I’m not sure what I think about all this, but I do know this image is disturbing to me. It keeps popping back into my head and asking me questions. It’s an image without answers.

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Oh when should we start?

Start living differently, if we reckon we’re not living the way we want to live? Eat differently, if we reckon we want to change our diet?

Start a project? Pursue a dream? Make a different choice?

I’m sure most advice is to start today. But then today passes and becomes yesterday and we haven’t started yet, so now what? The advice remains the same – start today.

I understand the wisdom of that advice…..I just have difficulties following it! If you do too, maybe this little excerpt will bring a smile to your face, the way it did to mine yesterday –

…Luigi Cornaro (1467-1566), a Venetian nobleman, published four editions of a work on “The Temperate Life.” He had been subject to digestive disturbances and gout for fifteen years, when at forty he took to dieting and hygienic living. Until within a few years of his death at ninety-eight he was able to write for seven or eight hours a day, conversed with his friends, attended concerts, etc. His first book was written when he was eighty-three, the others when he was eighty-six, ninety-one and ninety-five. The later ones contain apologies for the juvenile crudities of the earlier compositions!

A couple of interesting things about that story, huh? He had his illnesses for 15 years before he decided to live a healthier life. Having decided, aged 40, he went on to live another 58 years. We aren’t told whether or not his diseases went away, but we are told that for most of that time he was able to be creative, to be socially active and to enjoy music and attend events. That’s the important part isn’t it? What kind of life did he live? A fully engaged, creative life.

He published four books between the ages of 83 and 99, and his FIRST book was when he was 83, but how long had he been writing for 7 or 8 hours a day? Since he was 40?

Finally, don’t you love the humility of this man, and his understanding of the developmental nature of knowledge? In his final books, he apologies for the “juvenile crudities” of his earlier writing (the book he wrote when he was a mere 83!)

I guess one of the main lessons I take from this is that there is no “right time” to start, but the important thing is to start!

 

 

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As I was walking to work this morning, I was suddenly struck by a beautiful scent. I stopped, looked up and saw this honeysuckle.

Honeysuckle

Oh I wish there was a tag to insert scent into a post!

Which scent stopped you in your tracks recently?

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Montaigne was pretty critical of doctors and the practice of Medicine. You probably think that’s hardly surprising given he lived in the 16th century and wasn’t Medicine a pretty dangerous practice in those days, with harms frequently outweighing benefits. Maybe that’s all changed since those days? With the technological advances of the 20th century doctors have a range of interventions they can use now where the benefits outweigh the harms (for some of the people, some of the time). And at least we don’t bleed and purge patients to death any more, do we?

OK, let me reflect on the current benefits outweighing the harms argument. Let’s deal with harms first of all, because in some ways they are more straightforward. Here’s a couple of interesting facts. Medical interventions are the third most common cause of death in the US. Numbers of deaths decreased when Israeli doctors went on strike. So, there is still plenty of potential for doctors to harm you.

What about benefits? Many infections which previously could overwhelm and even kill patients can now be successfully treated with antibiotics (although we are never far away from predictions that our fifty or so years of success in that area are coming to an end as bacteria adapt, develop resistance to the drugs, and spread that newly acquired ability far and wide). In Surgery there have been enormous improvements. I’ve talked to two patients this week who recently underwent cholecystectomy (removal of the gall bladder) using four small cuts in their abdomens, an extremely short hospital stay and very rapid, complete recovery. Cholecystectomies weren’t like that when I was a young doctor. People having a heart attack who have a clot in a major artery can have it quickly dissolved, or a stent inserted to break through the blockage within hours now. Montaigne’s last two years of life were spent bed ridden, in pain, from kidney stones. You wouldn’t believe how easily that can be dealt with nowadays. I could go on. I’m sure you can add your own examples from your own experience.

But.

There’s a problem. And I don’t mean the harms problem. The problem is that interventions, especially drugs, but surgical ones too, don’t result in the same benefits for everyone who receives them. Roses, of GlaxoSmithKleine, famously gave the game away when pushing the case for pharmacogenomics. He said – We all know that most drugs (90%) don’t work for most patients most of the time (less than 30 – 50%). Why did that statement seem so shocking? Don’t we all know that? Why have all pharmacies got shelves full of drugs which all claim to do the same thing? Whether they are pain relievers, treatments for cold symptoms, allergies, or tummy upsets? Every prescribing doctor will tell you they are glad they have a number of drugs to choose from because no single drug gets the results every time it is prescribed (this is true of EVERY drug, from painkillers, to blood pressure pills, to treatments for asthma, heart failure, epilepsy…..you name it). And here’s where the next aspect of the problem arises. It’s a version of if you give a man a hammer everything will look like a nail. There are drugs and surgical procedures which effectively alter diseases, directly changing the characteristics or behaviours of dysfunctional tissues or organs. (These interventions are often claimed as cures, but I think doctors should retain a little humility here – there are no cures other than through the human being’s capacity to self-heal and self-repair. Treating diseases can increase the chances that self-healing will work, but no drugs or operations directly stimulate or support self-healing.) But what happens when all the drugs tried don’t work? Often one or a number of them are continued, in reality because the doctor doesn’t have anything else to offer. But continuing a drug which is not working tips the balance between benefits and harms enormously. The longer most drugs are taken, the greater the risk of harm. Almost worse than this is that this form of Medicine is used completely inappropriately. Many, many drugs are not prescribed to cure, to heal, or even to control a disease. Instead they are prescribed to reduce symptoms. Reducing symptoms can reduce suffering and whilst we can be supportive of that, it can inhibit dealing with the causes of the symptoms.  However, Palliative care in terminal illness can seriously reduce suffering completely appropriately. But when the cause of the suffering is not addressed, and is ongoing, then a symptom reduction strategy leads to the same problem as the ineffective drug one – the balance tips from benefit to harm.

So Montaigne’s experience and views are still relevant over four hundred years on. Dealing with doctors can be a dangerous experience, and giving them power over you is still not a great idea. I’m of the opinion that the less you have to deal with doctors, the better your life!

When I read some of Montaigne’s comments about doctors, one thing he said which particularly struck me was why don’t doctors have much better health than other people, given they claim specialised knowledge and skills in health?

So, I did some research to see if it was still true that doctors’ health and illness knowledge brings no advantages over others. It’s not entirely true. The famous phenomenon of doctors as an occupational group giving up smoking on reading of Richard Doll’s epidemiological work has resulted in doctors having less smoking-induced illnesses than others. However I can find no evidence that doctors live significantly longer than other people (of similar wealth, race and sex). Nor can I find any evidence that doctors are less likely to suffer from diseases over all.

Looks like Montaigne is right again – if doctors are the experts in health, how come they don’t have healthier, longer lives?

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Did you catch this news story about community nursing in the Netherlands recently? Click through to the BBC site to read the details.

There’s been a revolution in community nursing in the Netherlands in recent years. The company, Buurtzorg, set up six years ago, began with 100 nurses, and now has 6500 of them working in teams of 10, each team covering a neighbourhood of 10,000 people. That means that 60% of the community nurses in the Netherlands are now working for this company.

What’s so radical about what they do?

The completely human-centred, humane practice of nursing delivered with a high degree of personal autonomy by the nurses (there are no managers managing their case loads), emphasising continuity of care (reducing both the number of home visits required AND the number of different people visiting individual patients), and the focus on enabling both personal and community empowerment (they involve relatives, volunteers and friends in supporting the vulnerable elderly at home).

The company also runs a local radio show in Amsterdam (Radio Steunkous – which translates as radio “support-stocking”) which  “offers health advice, provides information on local services, and puts people in touch with each other.”

Instead of breaking down a patient’s life into “needs” which are then addressed by separate “tasks” delivered by a large number of different people, the nurse-patient relationship becomes the holistic centre of the care.

I love that this delivers quality care, more continuous care, and fosters independence and community, but I was also really taken by the comments of the nurses themselves –

“What we want to show is that if you have the autonomy, if you develop your skills and craftsmanship, then it’s the most beautiful job you can find.”

 

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