Archive for July, 2015

I graduated from Edinburgh University, with my medical degree, in 1978. The next four years were my foundational training to become a General Practitioner (I still think “Family doctor” is a nicer title).

Here’s four of the core teachings which I received.

Don’t practice “a pill for every ill”.

There was an assumption that drugs should only be prescribed if you thought they were really necessary. If you issued a prescription at the end of every consultation you weren’t practising good medicine.

Underlying this teaching was to prescribe as sparingly as possible.

If you refer your patient to a man with a knife, he’ll use it.

There were two aspects to this teaching – firstly, that you shouldn’t refer a patient to a hospital consultant unless you expected that doctor to treat the patient with their particular specialist skills. Secondly, a specialist was likely to try to treat your patient using only the particular specialist skills they had.

Underlying this teaching was to refer to secondary care as sparingly as possible.

Don’t arrange an investigation/test unless you think the results are likely to change what you otherwise propose to do.

I was taught that most diagnoses could be made on the basis of a good medical history supplemented with relevant clinical examination. Tests were only for when you couldn’t do that.

Underlying this teaching was to test as sparingly as possible.

The doctor is the drug.

This was a big one. Back in the 1980s Balint’s teaching still influenced General Practice, and Balint proposed that one of the most powerful therapies a doctor could offer was him or herself. The doctor-patient relationship was the most important part of therapy. Active listening, understanding, compassion, care and good communication were the core daily tools, employed with a sound knowledge of the natural history of diseases, the risks and harms of various potential treatments, and the ability to help patients to understand what they were experiencing, what this illness meant in their lives, and what they might do cope and to become well.

Underlying this teaching was to pay as much attention to, and to spend as much time with, each and every patient as was possible.

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The movie version of “Le Petit Prince” has just been released in France and, perhaps because of that, I stumbled on what turned out to be a French translation of an English language article in “The American Interest” last year – in it the author compares the two princes – Machiavelli’s and Saint-Exupéry’s.

The key difference lies in how the two books present the social urge that drives human political interactions. Machiavelli penned the incipient modern view that puts fear at the center of political order, turning politics into the craft of fear management. And it is a craft, properly speaking, not a science; yet the flavor of early modern times helped give rise to what we optimistically call today political science. The French aviator’s short book, on the other hand, describes the deep human desire to be social out of love toward others, not from fear of them. For the former, fear of others is the source of social cohesion; for the latter, the source is the need for others. The former would repel others, the latter attract them.

What the author is highlighting is the acute difference between these two authors in their view of their fellow human beings.

The modern approach to politics—one given to us in distilled form in The Prince and more elaborately in the Discourses, and is then expanded by later authors such as Thomas Hobbes—starts from the assumption that we humans do not enjoy each other’s company. Rather, we relentlessly compete with each other for things and for thoughts, for safety, and for status. It is a dim view of men, “ungrateful, fickle, pretenders, evaders of danger, greedy for gain” (The Prince, XVII). The outcome is a constant clash that often degenerates into the war of all against all. As Jean-Paul Sartre wrote in Huis Clos (“No Exit”) in the same year that Antoine de Saint-Exupéry plunged into the sea: “L’enfer, c’est les Autres.”

Well, this certainly rings a bell. We are force fed a daily diet of fear – fear of terrorism, crime, disease, immigrants…..you name it!

Le Petit Prince presents a very different picture. The Little Prince from a distant asteroid is also a keen observer of human affairs, but less jaded than the retired Florentine diplomat and his modern followers. He is a gentle soul in search of others whom he can befriend and love. In one of the many moving moments in this quirky little book, the lonely and somewhat sad Little Prince who had just landed on earth screams from a mountaintop: “Soyez mes amis, je suis seul.” Deriving apparently little pleasure from his loneliness, the Little Prince seeks others, not to dominate them but simply to be with them and engage them in conversations. As he says to a fox, “Come and play with me. . . . I am so sad.” (Ch. XXI).No Principe, no man in Machiavelli’s world, can fathom the idea of seeking others simply to enjoy their company. La tristezza of the Prince leads him to fear others; la tristesse of the Little Prince leads him to seek others.

If one of the key differences is the creation of a society based on fear vs one based on friendship, then the other key difference this author notes is between the quantitative and the qualitative.

Another crucial and related difference between the two Princes revolves around a question that is apparently limited to epistemology, but that has significant political consequences. The Little Prince observes that human interactions are not, and cannot be, based exclusively on visible, calculable features. As Saint-Exupéry famously puts it, “L’essentiel est invisible pour les yeux.” For Machiavelli instead, “Men in general judge more by their eyes than by their hands, because seeing is given to everyone, touching to few. Everyone sees how you appear, few touch what you are” (The Prince, XXVIII). Measurable appearances are more important in the life of the Prince than what is invisible to the eyes, but they are useless for the Little Prince. In anthropologist James Scott’s words, in order to function the modern state requires its citizens to be “legible”: to have a clutch of numbers citing address, age, and income, coded and used to place individuals in various categories. The Little Prince would find the very idea of legibility puzzling and inhuman, and Saint-Exupéry himself would not have been the least surprised to learn, had he lived long enough, that the Nazis tattooed numbers on the arms of their victims. The Little Prince’s criticism of the grown-ups, or us moderns, is that we approach others by focusing on calculable appearances. To know something or somebody, we measure it. When we introduce a friend to an adult, he asks: “How old is he? How many brothers does he have? How much does he weigh? How much money does his father make?” Similarly, when we try to describe a house, its price is one of the first features that we use to convey its beauty. “You have to tell them [grown-ups], ‘I saw a house worth a hundred thousand francs’. Then they exclaim: ‘What a pretty house!’” This is our scientific approach, another essence of our modernity: By counting and measuring, we think we assess the other side as rival or friend, we think we grasp his potential behavior, and, above all, we think we can manufacture benign social arrangements on this basis.This is not real knowledge, and consequently it cannot generate real order. The questions one ought to ask are different. Knowing the price of a house pales before a description of it as a “beautiful red brick house with geraniums at the windows and doves on the roof.” Similarly, if you want to get to know somebody, ask: “What does his voice sound like? What games does he like best? Does he collect butterflies?” Only by asking such questions can one start the long process of “taming.” The development of true social bonds is possible only when based on this deeper, yet far more elusive kind of knowledge. Knowing how much money one makes may be helpful to manage the Prince’s mechanism of fear, but it does little to develop true friendship and lasting order.

I’ve quoted pretty extensively from Jakub Grygiel’s article but I do think it really merits a full read – you can find it here.

Maybe this will whet your appetite to either go out and buy a copy of “The Little Prince” by Saint-Exupéry, or to go see the movie. Delight, pleasure and food for thought if you do!

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I read an article yesterday about the spread of sharing technologies and how they were beginning to challenge what we think about work.

It’s a hot topic here in France with authorities acting against the company, Uber, which was letting anyone with a car and the Uber app get paid for giving lifts to strangers. French taxi drivers protested vehemently (and sometimes violently) against this service which they saw as undermining their way of making a living. Taxi driving is a highly regulated job and the drivers have to pay a lot of money to get and keep their licences. It’s no wonder that technologies which underpin the likes of Uber are called “disruptive technologies”!

Whatever you think about the struggle between Uber, the taxi drivers and the State authorities, the service is a good example of how the nature of work might change.

The article I read (in a French magazine) pointed out that someone might earn some money driving their car using “Uber” in the morning, trade some antiques online using “leboncoin” in the afternoon, and welcome guests to sleep in a spare room using “AirBnB” in the evening. None of this makes the person a taxi driver, an antiquarian trader, or a hotelier.

So, maybe in such an example, this person would not define themselves by their work. They would also be experiencing a lot more freedom than any employee of a company, choosing not just their working hours each week, but the nature of their work, almost task by task.

Will this kind of working spread? Is this the new kind of “portfolio” work? What does that mean for regulators, tax inspectors and the State? And what does it mean for established tradesmen and professionals who are currently subject to the bureaucracy of employment and licenses etc?

In some ways this is a very libertarian version of utopia – each individual working for themselves without huge barriers in the form of regulations and the powerful interventions of the state. But this article referred to quite another interesting version of utopia – that of communism described by Karl Marx in “German Ideology” –

In communist society, where nobody has one exclusive sphere of activity … society regulates production and thus makes it possible for me to do one thing today and another tomorrow, to hunt in the morning, fish in the afternoon, rear cattle in the evening, criticise after dinner, just as I have a mind, without ever becoming hunter, fisherman, shepherd or critic.

I don’t think there are apps for hunting, fishing, or looking after sheep yet, but there are certainly lots of opportunities for critics!

So, what do you think? Are these new technologies the vanguard of change in the nature of work? Are they the place where libertarians and communists find something to agree about? In fact, are they challenging not only the nature of work, but the role of the State and the old labels we applied to political groupings?

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Sunlit raindrops on hollyhock
Ever since I was a child I’ve had a fascination with science. For me, science was, and still is, a form of exploration. It’s about learning and knowledge. Finding out how something works, how a creature lives, or learning the names of clouds, constellations, trees and birds. I’d say science is about wonder and curiosity.

Many, many years later I came across the writings of the French philosopher, Gilles Deleuze, who wrote that there were three ways to think – science, philosophy and art. I was a bit surprised when I first read that, but the more I came to understand it, not only the more it made sense, but it became, for me, a basic tool.

Briefly, he said that science was thinking about function – how something worked; philosophy was thinking about concepts – our frameworks and our world views; and art was thinking about percepts and affects – what we perceive and what we feel. I took all of that into my daily medical practice, figuring out what wasn’t working in somebody’s body, mind or life; developing my concepts of health, illness and disease; and working with both what I perceived and what I felt in a consultation.

A couple of years ago I had an experience on my daily commuter train which really woke me up – you can read about it here – but, let me just rehearse it for those of you who don’t want to diverge off down a link – I was sitting next to a student who seemed to be revising notes (I presume for an exam. Her subject was “clinical research” and what struck me was her key points about the “scientific method” – they were – Observation, Description, Explanation, Prediction and Control.

Well, I am very, very keen on observation and I like to describe what I observe. I’m also very keen on finding explanations for things (I think one of the definitions of a doctor’s job is “a person who tries to understand” – but that’s another story!). I also know that I was taught how to diagnose (which I see as a level of understanding) and to prognose (predict).

To be honest, neither diagnosis nor prognosis are nearly as simple as they are often taught. The older and more experienced I became the more I came to realise that diagnosis is never complete (you can always understand more deeply and/or more widely), and that prognosis is about possibilities and probabilities not about certainty.

So I was particularly surprised to find the student’s notes on “clinical” research describing the final step of the “scientific method” as “control”.

Since then, I’ve come to see that for many science is exactly about this – control. Scientism, the belief that everything can be explained using science, seems to be about power. This way of understanding and approaching science seems to be what has been adopted, not only by the industrial-commercial-military complexes, but by all those who seek control over others and over the world. It seems to be based on an understanding that if we take enough measurements, collect enough data, analyse it with statistical and computing tools, then we will be able to make accurate predictions which allow us a high degree of power to control.

Well, for some reason, I woke up this morning with this phrase in my mind – “The Power OR the Glory – two approaches to science” – and so, this post!

I’d like to re-state the case for a science based on wonder and curiosity instead of one based on power and control. For me, the joy of that scientific method is the revelation of, and the revelling in, the GLORY of this Universe and of our lives.

I was looking for some paper to start to jot down some thoughts about this and stumbled across an old notebook where I’d made some notes about the book “Planet Narnia” by Michael Ward (haven’t even thought about that book for a long, long time) – and here’s what I read –

The glory of science is to progress as new facts are discovered to be true, and such progress meanest that ‘factual truth’ is a provisional human construct. Which is why the wise man does not think only in the category of truth; the category of beauty is also worth thinking in.

Wow! How does that happen? How do I stumble across exactly the phrase “the glory of science” in a notebook stuffed away in a drawer full of scrap paper on exactly the morning I wake up with the phrase “The Power OR the Glory – two approaches to science”? In fact, who on earth wakes up with a phrase like that in their heads anyway? OK, I do!

Seriously, there’s way too much to explore there than I can write a post about this morning, so let me just finish with what I wanted to say in the first place –

There are two approaches to science – power (what I’d say is our current dominant model) OR glory – based on a humble curiosity and a joy in the awe and wonder of this life.

My hunch is, we could do with cultivating more of the latter, and less of the former!


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butterflyLooking up from my book I saw this butterfly and captured a photo of it with my iPhone. The sky looks pretty grey but it was actually just some clouds passing by as I was relaxing with a book out in the garden. Within a few moments there was blue sky again. I’m struck by how the sky changes so quickly. Clouds are a great reminder of the transience of Life with their constant making and unmaking of themselves, their constant appearing from apparently nowhere and disappearing apparently into nothing. The fact the sky looks so grey in this shot also reminded me of how often we take a moment in time and react to it, then the reaction can live for a long time afterwards. There’s no doubt that the ability to expand our focus of attention, stretching it in time and/or in space, can radically change our inner experience and hence our mood. I suspect that the relationship between moods and emotions is a bit like the ripples which spread out over the surface of a pond after a stone lands in the water. The moment the stone lands creates a condition – just like a word, a gesture or an action might trigger an emotional state in us – but that the state spreads out to become our longer lasting state of mind (a mood) – in much the same way that the ripples can be seen long after the stone has disappeared, or the wake can wash onto the shore long after the boat which caused it has sailed by.

the Charente

Butterflies can be a trigger for us to think of transience (but also of metamorphosis – I think I’ll return to that in another post) so, the butterfly against the changing sky worked as a strong prompt for me.

Sometimes we just need to place events into their larger contexts in order to alter the impact they can have on us. It’s great to be focused on the present moment, but it’s also important to be able to set the present moment into our larger story.

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The Mission

I recently received my first “Discover Weekly Playlist” from Spotify and so far, I’ve really enjoyed every single track. So, does Spotify “know” me?

We have more and more services like this around us – Amazon telling us what other people who bought “this” also bought (or even looked at!), Apple telling us what other apps other people bought who bought this particular one….and so on. This is something which Maria Popova has written about in her excellent Brain Pickings

I recently found myself in an intense conversation with a friend about privacy — why it matters; how much of it we’re relinquishing and what for; whether it is even possible to maintain even a modicum of control over our own privacy at this point…….It suddenly struck me that our cultural narrative about privacy is completely backward: What we really fear is not that the internet — or a prospective employer, or a nosy lover, or Big Brother — knows too much about us, but that it knows too little; that it fails to encompass Whitman’s multitudes which each of contains; that it reduces the larger, complex truth of who we are to a few fragmented facts about what we do; that it hijacks our rich, ever-evolving personal stories and replaces them with disjointed anecdotal data.

I hadn’t thought of it that way around when it comes to the internet, but she is definitely onto something. The underlying truth of what she is referring to is similar to what I read years ago in Mary Midgley’s “Wisdom, Information and Wonder” where she wrote –

One cannot claim to know somebody merely because one has collected a pile of printed information about them

That observation seemed absolutely true to me in the domain of health care where sadly, far, far too often, “data” or “information” is ALL that is known about a particular patient as individual narratives are dismissed as “anecdotes” or “unscientific subjectivity”. That dominant way of practising Medicine always seemed to me to be just the opposite of how it should be done. Information, or data, can tell you something about some aspect of a person’s disease but it’s a long way from the person’s own narrative.

One of the dangers of substituting data for narrative is the presumption of knowing – I used to say to patients that each of us spends a lifetime trying to really know ourselves (and I’m not sure any of ever complete that task!) so how can I presume to know them from hearing just a little of their story over the course of an hour or so? Frankly, reducing their stories to a few data points just takes doctors and nurses even further away from knowing their patients.

Maria Popova’s recommendation to counter this is to “master the art of personal narrative” –

Perhaps the most potent antidote to this increasingly disempowering cultural shift is to grow ever more thoughtful and deliberate about how we tell our own stories

Thought provoking, huh?

Even when someone uses the personal data we’ve shared to offer us more music, books, restaurants etc, that we may like, I think its best to keep these things as hints. That’s why “discover weekly” works for me – it doesn’t assume the impossible – they don’t know me – but I’m happy to have them help me discover new music. And I’ll use some of their suggestions to continue to make my own playlists.

Where are you with this issue of information, privacy and how we make ourselves known to the world?


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Have you found a niche yet?

Clearly in the spaces between the stones of this wall, a spider has found a place and made it his, or her, own.

When I saw this is inspired me in a number of ways.

Firstly, isn’t it amazing how Life appears everywhere on this planet? If its not an animal, bird, or spider, it might be a plant, a moss, a lichen, or, invisible to the naked eye but living probably everywhere – single-celled organisms like bacteria. There just doesn’t seem to be anywhere on Earth too inhospitable for Life. There is such a tremendous diversity of habitats.

Secondly, how opportunist Life is. What might seem the smallest possibility can be seized quickly. “Seize the day!”

Thirdly, how creative Life is. Look at this web. Isn’t it astonishing? Just how does something as small as a spider manage to create such a perfect structure – perfect for its purposes of protecting eggs or trapping food – and at the same time, perfectly beautiful?

Fourthly, as a Scot, I can’t help seeing things like this and remembering the story of Robert the Bruce who, it’s said, watched a spider try and try again to make a web in a particular cave and was inspired in his own life to always “try and try again” – to never give up.

Finally, it made me wonder about how we create a home and how we create a niche for ourselves.

Where have you chosen to create your home?

Have you found the niche you desire yet?

Are you still trying, and trying again?

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Here’s a shot of one of Monet’s water lilies paintings in the Orangerie in Paris. Look at the size of it, and stand back and see it as a whole.

Now walk towards it and look at part of it close up.


Isn’t that amazing?

How different the details look from the whole painting! In fact, one of the things which makes such a big impression on me in the Orangerie is just this difference – how does a human being manage to create such a fabulous, whole image which works the way this work by placing small brush-fulls of paint one after the other.

It’s this kind of art which often comes to my mind when I think about the need to understand anything in its details and at the same time in its wholeness.

Recently, BBC Two, made an episode of “Trust me I’m a doctor” focusing on the question of is it possible to reduce your cholesterol level through diet. For the programme the presenter look at three different approaches – sticking to a low fat diet, not changing the diet but adding daily oats, and not changing the diet but adding daily almonds. As an extra, he, himself, did all three (referred to as the “portfolio diet”).

What happened?

A number of interesting things – including significant levels of reduction of cholesterol in many of the volunteers – the biggest effect being in the presenter himself (I’ll return to that later)

In the almond eating group they concluded there was no over all change – because the average of the group showed little change. In fact, this averaging out effect obscured the reality of what happened – some people in that group experienced a drop in their cholesterol level, but in some it actually increased.

For me, this is one of the most interesting findings.

First of all it shows how averaging out and taking only whole group effects obscures the reality of what happens for individuals.

Second, it shows that you can’t take a simple, linear approach to the complexity of a human being – you can’t just add a bit of this or subtract a bit of that and see the same specific effect in every single person. We are all different. And that uniqueness extends to the different results of the “same treatments” (including elements of the diet) in different people. I think the kind of reports which suggest that some particular foodstuff is “bad” or “good” are pretty much always over-simplistic – to the point of being nonsense.

Third, it shows how the “same treatment” can have directly opposite effects in different individuals. We find the same with many forms of treatment – what has a certain effect in some, can induce the exactly opposite effect in others.

So, this part of the programme confirmed for me that we are all different and if we want to help individuals we must always, but always, pay attention to individual experience – it’s no good saying “this works but that doesn’t” based simply on statistical interpretations. Ultimately we have to come back to the reality of a human being’s experience.

The other striking element for me is what the presenter did himself – this “portfolio” diet – which actually consisted of taking a balanced and combined approach.

Time and again when I read about diets I find myself thinking about Michael Pollan’s food rules – “Eat food. Mostly plants. Not too much”.

There are no magic bullets.

Not drugs. And not specific foods.

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Everything comes down to the struggle between the network and the hierarchy”

That particular line in Paul Mason’s Guardian article about post-capitalism really jumped out at me.

It jumped out at me because for a long time I’ve become very disatisfied with the contemporary emphasis on hierarchies, bureaucracies, organisations and societies modeled on machines. The mechanical model with all its emphasis on measurement and its basic assumption that nothing is more than the sum of its parts has been useful in some ways, and remains useful in some areas of life – parts dealing with machines!

But when it comes to Nature and, in particular, to living organisms, that model just does not add up. With sufficient power and resources the mechanical model can be imposed on natural systems – but only for a while. Eventually, the mechanical model diverges too much from natural reality to be useful.

That’s where we are now – our economies, our societies, our systems of health care and education, our politics – are all being changed as the network model undermines the hierarchies.

With new information, communication and collaboration technologies we have more and more opportunities to work with others to create different ways of learning, different ways of healing, different ways of living.

That’s pretty exciting but for many people it’s more frightening than anything else. We have to support each other to build our ability to hope and to innovate or we’ll remain suppressed, controlled and stuck.

It’s going to be fun to imagine and create our new ways together. Are you up for it?

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Leaf veins

If it’s true that we are in the beginnings of major change, then I’d like to hope that we are moving towards more “natural”, more “realistic” ways of living.

This industrial, capitalist age, has not been based on either natural or realistic premises. Nature doesn’t produce anything like the machines and organisations we have created in the world. Why not? Because nature is not mechanical, it isn’t a closed system where everything can be controlled and outcomes can be reliably predicted in all circumstances. It’s just not true that if only we have enough data we can figure out the future in detail and then the way to get there.

What alternative is there?

For me, the alternative is found in reality. It’s found in Nature – including in our own bodies.

How do our bodies work?

They work by developing a diversity of elements which then create mutually beneficial bonds between them – think of the organs of the body for example. A human being has a liver, a heart, a pair of kidneys, a brain….and so on. Each of these organs grows from the same original seed cell, but each develops as a tight network of specialised cells which, when they work together, perform incredible feats. But when the different organs work together (NB NOT in competition with each other) in mutually supportive ways, then they become something else entirely – they become part of the workings of the body in which we find them.

So diversity is a key feature of Nature. Mutually beneficial bonds are a key feature. Networks of connections between the elements are a key feature. As we extrapolate this model up we find more and more elements and more and more complexity – the best model I know to represent this is the “complex adaptive system“.

Here’s an important feature of complex adaptive systems (exactly the kind of phenomena we find in living organisms everywhere in Nature) – they don’t have a central controller who is in charge of a hierarchy, setting the goals, laying out the strategy, tasks and jobs and the ensuring they are delivered to it’s own particular levels and standards.

Might sound attractive if it was like that, but it isn’t.

Instead we have networks of nodes, systems, feedback loops, influences, clusters, organs and so on, which TOGETHER ensure the integrity of the organism – self-defence, self-repair, reproduction, growth and maturity are functions of the entire system – not the prerogative of one particular part.

Take this model and scale it up to groups of organisms, to societies, to ecosystems, to an entire planet even – the principles remain the same – diversity and the creation of mutually beneficial relationships.

So, the industrial, capitalist, dare I say it, inhuman, system based on machines and hierarchies is probably coming to an end because, well it just ain’t natural!

Here’s a piece about control which I read a few years back –

The industrial age and the work of Frederick Winslow Taylor made control popular as we used humans to mechanize our factories.  Control permeated society down to the education systems that eliminated variability, encourage conformity, and produce the mechanized humans for the industrial machine.  But the control mentality does not have utility in a world that is co-creative and cognitive.  We must replace control with the creation of shared value, a fondness for contribution, appreciation for human uniqueness, and the embrace of uncertainty.  We need to create an atmosphere of humility where co-creative energies are released instead of subdued.  Our future depends on the cultivation of new ideas and shared knowledge — a future easily smothered by control.

Mike Rollings.

As I think about Paul Mason’s piece which I posted about yesterday, I think the important thing for us to do now, is look around and look within – the answers are here already – and they don’t include the creation of more controls.

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