Heroes Not Zombies

When you look at this photo I think it seems to be a mountain with clouds and sky just above it. But you immediately recognise that’s not quite right.

So then you see this and you think it’s trees with the sky above….maybe one of those forest pictures where the photographer directs the camera straight up to the sky and catches the topmost branches of several trees. But that’s not quite right.

In the first photo, the apparent mountain in the foreground is an odd shape. Mountains just don’t look like that, then, in the second photo, what’s that rock doing balanced on top of the trees?

The thing is, these are both photos of reflections on the still water of a loch. Once you know that, the whole image makes sense.

This inspires a train of thought in my mind…..about how we perceive and make sense of reality. It’s a complicated business but it involves context. It helps to know where you are when you are looking around and what you can see in the immediate environment. There is nobody standing at the edge of this loch wondering what they are looking at. They know where they are and how they got there.

We make sense of reality by spotting patterns, but we need to learn the patterns before we can spot them. A bit chicken and egg-ish isn’t it? In normal life these two aspects of the same thing are iterative…..we are constantly learning and spotting patterns, the more we learn, the more we spot, and the more we spot, the more we learn.

Medical Practice is like that. Doctors learn pathology and the natural history of diseases. In other words, they the patterns of illness. The better a doctor knows the patterns, the more easily they’ll be spotted – or diagnosed. And the more diagnoses a doctor makes, the better the knowledge of patterns. We call it experience. I always felt that a good diagnosis was crucial in good health care. If the diagnosis was wrong, the chances are the treatment would be wrong.

In my first Paediatric job, my mentor told me on the first day that his goal for my six months with him was to teach me how to recognise a sick child. When he said that I thought it was a pretty bizarre thing to say. I mean, wasn’t it obvious when a child was sick? Wasn’t the goal to diagnose ie name the sickness? Well, of course, he was right. I was wrong. What he wanted to teach me was that very first important step…..how to recognise, in an instant, that this child was ill and needed immediate attention. Working out exactly what the disease was and how to treat it came a close second, but if you didn’t recognise that the child was sick, all was lost. It turned out that learning was by experience, encountering sick children and healthy children of all ages, to become familiar with what was normal behaviour and demeanour at different developmental stages. That teaching was crucial for my practice as a GP. It let me walk into someone’s house and know instantly that this child needed close attention and help.

The clues, and the signs, were in the contexts, the environments and the relationships. Yes, some were in bodily or facial “signs”, but mostly they were in behaviours and responses.

I suppose it’s that kind of experience and learning which made me suspicious of reductionism and generalisations. Every individual is unique and can only be understood within their contexts, their environments and their relationships.

Diagnose, like pattern spotting, is like joining up the dots. It’s got a lot to do with connections and behaviours. It’s not all about “data” and “measurements”. Especially when considering the real, actual, unique individual here and now.