Archive for June, 2014

Red arrows Stirling

Well here we are at Z in the A to Z of Becoming, 26 verbs to help you make your life a better one. Z is for zigzag.


Years and years ago I read Susan Jeffers’ Feel the Fear and Do It Anyway, and one point she made in that book has stayed with me ever since. She described how an aircraft flying from A to B does NOT fly in a straight line, even though it looks like that, but in fact the pilot is continuously adjusting the direction of the plane turning now slightly to the right, now slightly to the left. Actually, I seem to recall, she said the plane is actually technically flying “off course” for more than 90% of the journey (if the “course” is a straight line from A to B).

I loved that insight.

This is what we do. We continuously adjust our direction of travel to stay on track. We travel in a kind of zigzag way because we are always checking to see where we are heading, and making adjustments to get where we want to go.

As with flying an aircraft, this is how we go through life. I think this example is a great counter to unrealistic perfectionism. Yes, we may be trying to achieve something, trying to get somewhere, and when we check we might discover that we have been blown a little (or a lot!) of course! But then we adjust and get back on track.

This example came to mind for me when I was taught how to practice TM – with the wonderful single piece of training which was “just gently return to the mantra” – I loved that way of teaching. When meditating, and you notice your mind has wandered off to remember something or to worry about something, just notice that’s what is happening, and “gently return to the mantra”.

That’s what the zigzag is about. Noticing, and gently returning.

Happy zigzagging!

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As I am about to enter my last week of 36 years of clinical practice, it’s probably inevitable that I find myself reflecting a bit.

Hilltop reflection

One of the things I’ve been thinking about is what good I might have done as a doctor, and, for me, I don’t think of that in terms of “outcomes”. What I’ve been thinking about instead is what did patients find valuable about their contact with me? The answer to that question has been made clear by the letters, cards and verbal feedback I’ve been receiving over these last few weeks.

There are certain themes which recur again and again amongst the thanks and good wishes people have expressed. Five of the main themes are in those verbs in the title of this post.

december gratitude

Listening. This is what is mentioned more than anything else. I’m not at all surprised by that. I just love listening to people’s stories. Endlessly fascinating and always unique. I don’t really see how any doctor can practice good medicine without being an attentive, non-judgmental, active listener.

Understanding. I think its important not just that I understand a patient, but that in the process of the consultation, they not only feel understood, but they come to understand themselves better. Making a diagnosis is a form of understanding. Diagnosing a particular disease process is a useful part of understanding…..but it’s only a start. As Osler said

The good physician treats the disease; the great physician treats the patient who has the disease.

Supporting. Many patients thank me for my support. That support isn’t just compassionate emotional support, but it involves supporting people in their choices and decisions, and supporting the natural capacity for self-healing which every human has.

Advising. I don’t think patients come to see doctors just to be listened to, understood and supported. They come for advice. Advice in the form of information, diagnosis, help in making choices, and in the form of therapies. All therapies are, in one sense, a form of advice. If I prescribe a treatment, that treatment takes some information and energy into the person’s body, and their adaptive system responds….it changes the inner state.

Inspiring. This is the word which pleases me most, and which is most repeated by patients, colleagues and students. I just love that people feel inspired by me, and I hope that, through my writing and photography that I inspire many more people in the years ahead.

A few years back I wrote a post listing the three verbs based on light which I thought were at the core of my values – lighten, brighten and enlighten………still relevant now.

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Rising demand on “health services”, year by year increases in prescribing and steadily increasing numbers of people with chronic conditions, indicates we are not delivering a sustainable form of health care.

One other indicator of that is the number of doctors taking early retirement, and now, figures showing drops in GP numbers.

The government is facing a GP recruitment crisis with new figures showing a fall in the number of family doctors since the coalition came to power amid warnings that the take-up of training places is the worst since 2007. Official data analysed by the House of Commons Library shows that at a time of ever increasing demand for their services, the number of GPs has dropped by 356 compared with its level in 2009/10. The proportion of family doctors serving every 100,000 people has also dropped, from 70 in 2009/10 to 66.5 now. At the same time, GP leaders have raised serious concerns about what they say are the “worst ever” figures on GP training, with the take-up of places having fallen to 62% of those available in the East Midlands and little over 70% in large parts of the north of England.

I don’t think its only the system of health care which is unsustainable…..Picketty’s economic analysis shows us we don’t have a sustainable global economy either. (And still we hear politicians in countries across the world claim that “growth” is the answer – but growth of what, and how do we get sustainable growth in a finite planet?)

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If you haven’t heard about Thomas Picketty, the economist, and his vast work, “Capital”, then start here. His formula which explains increasing inequality is succinct and clear –

inequality grows when the rate of return on capital (“r”) is larger than the rate of growth in the economy (“g”); or, in his already well-known formulation, inequality grows when “r > g.”

He makes many, well argued points, but I want to focus just on this one about wealth producing wealth and how that trends towards a greater and greater share of wealth being inherited.

the share of inherited wealth in total wealth has grown steadily since the 1970s. Inherited wealth once again accounted for the majority of wealth in the 1980s, and according to the latest available figures it represents roughly two-thirds of private capital in France in 2010, compared with barely one-third of capital accumulated from savings. In view of today’s very high inheritance flows, it is quite likely, if current trends continue, that the share of inherited wealth will continue to grow in the decades to come, surpassing 70 percent by 2020 and approaching 80 percent in the 2030s. Piketty says that the “normal” state of affairs in which anyone has a crack at fame and fortune is a blip in the long run of human history that has been largely characterized by a self-serving, greedy hereditary aristocracy whose comfort was only possible because of the enmiseration of nearly everyone else. Absent some kind of extraordinary intervention, hereditary wealth will reassert itself as the primary political mover in our world. The people at the top have always convinced themselves that they live in a meritocracy, because hey, they’re the best people they know, and they’re at the top of the pyramid. QED. But this story is impossible to square with the data

He claims we now have a new aristocracy who increasingly live on the wealth created by their wealth…..not by their efforts, contributions, activities or anything else.

Take a particularly clear example at the very top of the global wealth hierarchy. Between 1990 and 2010, the fortune of Bill Gates — the founder of Microsoft, the world leader in operating systems, and the very incarnation of entrepreneurial wealth and number one in the Forbes rankings for more than ten years — increased from $4 billion to $50 billion. At the same time, the fortune of Liliane Bettencourt — the heiress of L’Oréal, the world leader in cosmetics, founded by her father Eugène Schueller, who in 1907 invented a range of hair dyes that were destined to do well in a way reminiscent of César Birotteau’s success with perfume a century earlier — increased from $2 billion to $25 billion, again according to Forbes. In other words, Liliane Bettencourt, who never worked a day in her life, saw her fortune grow exactly as fast as that of Bill Gates, the high-tech pioneer, whose wealth has incidentally continued to grow just as rapidly since he stopped working. Once a fortune is established, the capital grows according to a dynamic of its own, and it can continue to grow at a rapid pace for decades simply because of its size.

Picketty’s proposed solution is a global wealth tax, but I can’t imagine that being agreed any time soon! A Marxist (as opposed to Capitalist) analysis I suspect would say only revolution or total collapse of the economic/social order will bring this concentration of wealth to an end.

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A seat in the garden

I took this photo the other day in the garden at the Centre for Integrative Care. It provokes certain thoughts for me, because in this view I see an abundance, a flourishing, a diversity of green Life and I see a place to facilitate its full enjoyment, a place to pause, to slow down, to be present.

So, here’s what I’m thinking today……Life is for living, and that living has at least two important aspects – the full enjoyment of Life, and the creation of uniqueness.

Whatever other reasons we might find for being here, we all, moment by moment, have the opportunity to fully enjoy this Life – that captures for me the sense of émerveillement du quotidien which I often to refer to, that sense of wonder, of seeing and experiencing everything as if for the first time and for the last time. It captures the teaching about slowness, of mindfulness and of being present in the NOW.

If there is one quality of Life I’d focus on it’s change. Change is constant. Nothing, but nothing, stays the same. Life is a continuously unfolding, creative, emergent process. We are creative creatures. We create our perception of reality. We c0-create our daily experiences with others, and with the world in which we are alive.

So, when I look at this photo I see these two phenomena – a full enjoyment of the flourishing diversity of Life, and the creative expression of the Universe.


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Wild rose

This is a photo of a wild rose (or, in this case, I believe, the “dog rose”)……one of my most favourite flowers.

Traditionally this flower is a birth month flower for those born in June – that’s me. And symbolically the rose is a flower of love, ideal love, and passion. For the homeopaths amongst you, Jan Scholten places the Dog Rose at Stage 10 in the Rosaceae family.

The rose in this photo lives in the garden at the NHS Centre for Integrative Care, where I’ve worked for many years…..(only another few days now, last day at work there will be July 4th – “Independence Day”).

I like that there is a rose in the garden there which will always connect me to that place and all the people there who make it such a special place.

I love the story of the rose in “The Little Prince”…..


“It’s the time you have spent with your rose which makes it so important.”


And I also like Saint Exupery’s insistence on the uniqueness of each rose…..


Let’s not forget the uniqueness of each and every flower, each and every person, each and every moment.

I also like that in this photo I have a “Wild Rose” which echoes so nicely with the Mary Oliver poem I read at our farewell retirement celebration last Friday – “Summer Day” – especially her closing lines……

Tell me, what is it you plan to do
with your one wild and precious life?


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Which of the constellations in the night sky do you recognise? I wonder if one of them is the seven sisters – “Pleiades”.

I read the following in Gary Lachman’s “A Secret History of Consciousness”

In a fascinating chapter of Cities of Dreams, Gooch sets forth the evidence that this undistinguished group, made up of fourth-magnitude stars—not particularly brilliant—was not only known to our ancient ancestors, but appears in the mythology of many disparate peoples, and in exactly or nearly exactly the same context. For example, for the ancient Greeks, the story went like this: Orion the hunter came upon six sisters and their mother one day in a wood. Burning with lust, he chased the sisters through the wood for five years, whereupon Zeus took pity on the girls and changed both them and Orion into stars, hence the constellations of Orion and the Seven Sisters. Strangely, a very similar myth exists among the Aborigines of Australia. Wurrunna the hunter was out in search of game, when he too came upon a group of seven girls. He grabbed two of them and took them as wives on the spot. However, the trees in the forest took pity on the girls and suddenly grew to a tremendous height; the five free sisters climbed to the sky, as did the other two, thus escaping Wurrunna……..The Pleiades are always known as the Seven Sisters, and they are always hunted. Likewise, they always escape, either through magical means or through the intervention of a god………The Pleiades also have the unchallenged distinction of being the only constellation noted and named by every culture on the planet, past or present.
What do you think of that?
The night sky has always fascinated me. I love the way we humans connect up the individual stars with invisible lines to create constellations, which we then don’t just name, but tell stories about…..stories which help us make sense of the Life and this World. But how did this happen? How did we end up with such similar clustering of stars and such similar stories attached to these clusters (or constellations)? I find that especially fascinating when there are these close similarities in the stories of such disparate and disconnected cultures.

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In the A to Z of Becoming, Y stands for “yearn”.

Afternoon moon

I’m not sure this is a verb we use a lot, but it has such a deep, heart felt quality.

Thomas Moore, who wrote “The Care of the Soul”, and “The Care of the Soul in Medicine”, captures what the word “soul” means to us by reminding us how we use the word. We talk of “soul mates”, “soul food”, “soul music”. It’s a deep, embodied concept. I think this is where we yearn from. To yearn is to become aware of what our soul hungers for.

Yearning involves longing. It’s more than desire, more than getting in touch with a goal, it’s a deep, heart-felt connection which fills us with its presence. Such a particular kind of presence…….the kind of presence which contains an absence. There’s something missing, and in yearning there is often an element of sadness, maybe even of melancholy. We’ve lost touch with the value of a feeling like this, I think. The thing is, we might yearn for something we no longer have, for the presence of someone who is no longer with us. But we can also yearn with an eye to the future, and it’s this yearning in particular which I think is of value for us.

If we stop to think about what we actually yearn for in the future, then we are likely to become aware of what matters most to us. We are likely to be able to clarify just what is that bliss which Joseph Campbell said we should follow?

I don’t think yearning is about joy. I don’t think it is about hope. And it’s about more than wishes, but its a way of revealing what is really important to us, what lies deep within our souls. To yearn is feel a sap rising…..


Tall pines

To yearn is to feel something deep unfolding….


What do yearn for?

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I think there are many problems with what is known as “Evidence Based Medicine” (not least being the influence of vested interests such as Pharmaceutical companies on the production of “evidence”), and there is an interesting consideration of some of the issues in the BMJ. The paragraph on patients with multi-morbidity ie patients who are suffering from more than one chronic ailment at the same time caught my attention.

as the population ages and the prevalence of chronic degenerative diseases increases, the patient with a single condition that maps unproblematically to a single evidence based guideline is becoming a rarity. Even when primary studies were designed to include participants with multiple conditions, applying their findings to patients with particular comorbidities remains problematic. Multimorbidity (a single condition only in name) affects every person differently and seems to defy efforts to produce or apply objective scores, metrics, interventions, or guidelines.

Both the first and the last sentences of that paragraph really strike me.

“the patient with a single condition that maps unproblematically to a single evidence based guideline is becoming a rarity” – really? Who actually “maps unproblematically” to a guideline? No wonder they say it is becoming a rarity. Was it ever not so? Every single human being is unique. Each one of us has a unique genetic code, is born in a particular place at a particular time and lives a unique life, full of specific life events, challenges, difficulties, opportunities. Each of us tells an utterly unique life story when we sit with a doctor. That story is influenced by the past which is still active within us, and by our values, beliefs, preferences, our sensitivities, our coping strategies and our personal priorities. Biologically each of us is an open, dynamic system. We are continuously being influenced by, and are influencing, the environments in which we live. We never stay the same. At each stage of life we have different bodies and different minds from what we had before and we live in a world which previously never existed. If you’ve ever sat in a consulting room day after day, with patient after patient, you’d know that mapping individuals unproblematically onto guidelines is a fantasy.

“Multimorbidity (a single condition only in name) affects every person differently and seems to defy efforts to produce or apply objective scores, metrics, interventions, or guidelines” Even the most diehard statistics fans know this one. The more conditions a person has, the more difficult it is to predict how things are going to go, which treatments are going to work well for them, and which are going to do them harm. It’s worth remembering that there is no evidence for polypharmacy. Anywhere. The truth is individuals are so unique that even those with a single diagnosis will not experience the same course of the disease, will not get the same results from the same treatments, and will not experience the same particular side-effects or harms. The problems which are highlighted in the situation of multimorbidity still exist in situations where a single disease has been diagnosed. The problems multiply for sure, but there isn’t a situation where they don’t exist.

Sometimes I think there is only one “best” evidence base when treating a person, and that is the ongoing, careful, humble, consideration and understanding of what this person is experiencing. Whatever treatment is given, only this patient’s unique experience is the final arbiter of its usefulness. Not some statistics-oriented guideline produced by a non-clinician who will never have any interaction with this patient.




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sparkle and wave

light and dark

reflect and ripple

The surface of water always amazes me….it’s texture, it’s colour, it’s interaction with the light.

The deep always makes me curious…..what lies below?

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