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Archive for the ‘education’ Category

In Eric Cassell’s “The Nature of Clinical Medicine”, he postulates that a key problem with Western Medicine is the focus on disease, at the expense of seeing, hearing and understanding the person who may, or may not, have the disease. At Medical School I was taught it was very bad practice to refer to “the gall bladder in bed 3” or to say “I admitted a case of pancreatitis last night”. Despite that we continue to think of disease as paramount in patient care, and we even create our health care services around the diagnosis and “management” of disease. Whole protocols of procedures are created, distributed and enforced around the concept of diseaes. Doctors and nurses are told what to do with a patient with disease X on the basis of “the best evidence”, where “the best evidence” refers to group studies which seek to “control for” individual factors – a process which prioritises the disease over the individual experience of it.

Eric Cassell enumerates “8 problems with using disease language”.

Disease names, for example, coronary heart disease or carcinoma of the breast, wrongly imply that a disease is a concrete thing (as opposed to an abstract concept) that can be found separate from the patient in whom it is found.

I read the phrase about disease being a concept, not a concrete thing, many years ago, and it had a big effect on me. Disease is exactly that – a concept. It’s a pattern of change which we name. Yet how many people, patients or health care professionals, think of a disease as being a thing? If you look at recent slogans used in health care, and in charity campaigns you’ll see the kind of thing. They are full of war metaphors about fighting this, beating that, kicking cancer’s butt, and so on. 

Disease names, for example, renal cell carcinoma or ulcerative colitis, incorrectly imply that the disease and its behavior are independent of the persons in whom they are found.

There are NO diseases which exist outside of people (or other living organisms). A disease is ALWAYS found in the context and the environment of the person who is suffering. 

Disease names, for example, lupus erythematosis or chronic obstructive pulmonary disease, mislead the unwary into believing that the name refers to one thing whose manifestations in individual patients are more alike than dissimilar. Just as the word tree refers to a class of things whose members are more alike than not, when, unless one wants to use trees or their wood, their variations are more important than their similarities.

What does every patient who attends an asthma clinic have in common? Asthma? How similar does that make them? Is this the most important fact to know about this person who is attending today? It’s individual differences, not the similarities, which are the most important.

Disease names, for example, multiple sclerosis or pneumococcal pneumonia, fool the unsuspecting into believing that what is referred to is a static entity, like the Bible, the Statue of Liberty, or the map of the New York City subways, rather than a constantly unfolding process that is never the same from moment to moment. The history of disease concepts depended on and furthered the classic separation of structure and function in which abnormal function was believed to follow from abnormalities in structure. This distinction seems to have been derived from the idea of form (which goes back to the Greeks) and its consequences that loomed large in 17th- and 18th-century medicine (King, 1978). The hard and fast distinction between structure and function itself is invalid. Structure is merely slower function, in that it changes at a lesser pace than the process called function—put in mind how bony structure changes in response to trauma or age so that it continues to perform its original function. Even the Statue of Liberty and the Parthenon are constantly changing.

As best I can understand, change is the nature of reality. There are no static entities. Even the ones which look static, are just changing more slowly, or less perceptibly. As Cassell says, “structure is merely slower function”.

Having named a disease within the patient, for example, diabetes mellitus or metastatic adenocarcinoma of the lung, physicians may be fooled into believing that they know what the matter is at this particular time and why. The disease may be the sole underlying reason why the patient is sick, but more often other factors—physical, social, or psychological (or all three)—have been crucial in the generation of the details of the illness and its losses of function (Cassell, 1979).

This is a common error. Just because an abnormal reading is found, that does not necessarily mean the explanation for the patient’s suffering has been found. For example, it has been clearly shown that there is no direct linear relationship between a lesion and the pain a patient is experiencing. Pain can change irrespective of the findings in the MRI scanner.

Disease names, for example, amyotrophic lateral sclerosis and psoriasis, inadvertently cause physicians to fall back on definitions of disease that are now accepted as outmoded because they fail to provide an adequate basis for treating the sick.

Disease names can, and do, change as we develop our understanding.

Using disease nomenclature to describe human sickness encourages the belief that only research into (molecular) mechanisms of diseases holds promise for understanding and treating human sickness.

You’ve probably encountered one of the ways in which “patient centred” is being used – pharmacogenomics. The idea that as long as we find not just the genetic code associated with a particular disease, but the genetic codes which seem to indicate responsiveness to certain drugs, then all we need is the genetic code. This isn’t to say that molecular or genetic research is not of value. It’s just not enough.

Finally, focusing on naming the disease takes attention away from the sick person.

Ultimately, this is Eric Cassell’s main message, and if only we made this the foundation principle of health care then we might have better medical education, more useful research, more effective treatments, and even health care organisations constructed around people, not diseases and drugs.

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What was/is your experience of school?

David Richard Precht, the German philosopher argues that our schooling system continues to be based on the industrialism of about 100 years ago. We still seek to teach sets of facts to all children of the same age, and then test their ability to recall those facts in examinations leading to qualifications. The intention of the education is to produce compliant workers and consumers who will conform to the demands of industrial society.

He argues that we are not fostering creativity, emotional intelligence or relationship skills which enable communities and teams to work together, and individuals to develop and express their unique talents.

He draws his ideas from philosophy, from neuroscience (NOT materialist neuroscience which seeks to reduce all human experience and cognition to identifiable areas of the brain), and from an understanding of how society has changed over the last few years.

Many of his recommendations are in line with teachings from people like Montessori and Steiner, so he can be understood to be part of a more child-centred, holistic movement in education.

I found myself agreeing with much of what he had to say in a recent interview published in Cles magazine (“Notre école est un crime”). He points out that asking children to sit still for an hour and pay attention is not a good starting point – most children, and indeed most adults, are able to concentrate on one topic for about 15 to 20 minutes (which is why TED talks do so well, and why youtube is the new television), and that one thing we know about health is that sitting still isn’t good for you!

He thinks schooling de-motivates learners and that the average 12,000 hours of education leading to the “Bac” qualification in Europe are experienced as pure boredom by most children.

He also thinks we are not teaching the right kind of skills for the 21st century – we need more innovation, creativity, diversity, the ability to use the internet to gain knowledge and to connect with others, more emotional intelligence and a greater ability to form and grow healthy relationships with others.

His proposals include moving away from classroom curriculae to a more project-based system of education which is by its nature multi-disciplinary and encourages children to pursue their own curiosity.

What do you think? How would you change the educational system?

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There are something like 100 billion neurons in your brain – a literally mind boggling figure.  Are you really able to imagine what a 100 billion of anything looks like?

As if that weren’t challenging enough, each neuron has up to 50,000 connections with other neurons, and each connection (a synapse) is an electro-chemical switch of a sort – passing information and energy across the gap between two neurons. This makes the total number of states of the brain (number of “on” or “off” neurons) a figure which is……well, unimaginably huge!

I was taught at university that a synapse was a pretty simple connection between two cells where on neuron released a chemical, which then crossed the gap and stimulated the next neuron. This, of course, is a huge oversimplification.

Researchers have recently managed to describe a single synapse much more accurately.

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The researchers say

 

 

The new model shows, for the first time, that widely different numbers of proteins are needed for the different processes occurring in the synapse,” says Dr. Benjamin G. Wilhelm, first author of the publication. The new findings reveal: proteins involved in the release of messenger substances (neurotransmitters) from so called synaptic vesicles are present in up to 26,000 copies per synapse. Proteins involved in the opposite process, the recycling of synaptic vesicles, on the other hand, are present in only 1,000-4,000 copies per synapse. The most important insight the new model reveals, is however that the copy numbers of proteins involved in the same process scale to an astonishingly high degree. The building blocks of the cell are tightly coordinated to fit together in number, comparable to a highly efficient machinery. This is a very surprising finding and it remains entirely unclear how the cell manages to coordinate the copy numbers of proteins involved in the same process so closely.

It’s not just the numbers which are astonishing, its the complexity, and that last sentence particularly struck me – “it remains entirely unclear how the cell manages to coordinate the copy numbers of proteins involved in the same process so closely”

Just how much DO we know about how the human body works? How much DO we know about how it evolves to this level of complexity, both through an individual lifetime from the fertilisation of a single egg cell to a fully grown human being, and throughout history from single celled life forms to the multi celled human beings?

Humility. That’s what we need as scientists. Humility. Our ability to discover and understand is astonishing, but so far pales in comparison with the complexity of a single human being.

I’m amazed.

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I’ve often thought about the question attributed to Albert Einstein (although I think he didn’t actually ever pose it!)

The most important decision we make is whether we believe we live in a friendly or hostile universe

Whether he said it or not, it’s still an interesting question which highlights how our beliefs inform our choices. If we believe the universe is hostile then we see ourselves in a constant battle for survival, if we see it as friendly then we call to it for support, and if we think it is neither then maybe we make choices based on the essential meaningless and randomness of life.

OK, I think that is too simplistic and in fact there are no clear answers to this question, but I do think the useful point is about influences. I do believe your choices are informed by your beliefs. Simple, everyday beliefs. Is it safe to walk down this street? Are strangers likely to attack you? Are your friends likely to act in your best interests? And so on…..

All this came to mind this morning having listened to Jim Carrey’s speech at the Maharishi University. Here’s the ONE minute edit…..

(you need to click the link to see the video for this one. Go on, do it now, then come back and read the rest)

So, here’s the key point to think about just now – are you making your choices based on love or fear?

Fear is the main weapon of persuasion in the world, but you don’t need to make it the basis of your life.

What choice will you make today if that choice is to be based on love?

What choice would you make instead if you are basing it on fear?

What are you going to choose?

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Diving for silver?

 

It seems we didn’t evolve into human beings in a smooth, seamless way, but more with a pattern of great leaps and long, slow changes.

One of these great leaps was in the growth of the size of the brain. One of our pre-human ancestors, Homo erectus,  had much smaller brains than we do, but over the course of 200,000 generations (2 million years), their brain size roughly doubled in size, taking them up to about the same size as brain as we humans have (since about 500,000 years ago).

As Stephen Oppenheimer states, rapidly increasing brain size was a key feature that set humans apart from the walking apes that lived before 2.5 million years ago. Since then our brains have trebled in volume. This increase was not gradual and steady: most of it came as a doubling of volume in Homo erectus 2 million years ago. The greatest acceleration in relative brain size occurred before 1.5 million years ago – early in our genus. Modern humans – and Neandrathals – living before the last ice age 20,000 to 30,000 years ago had bigger brains than do people living today. (from)

Interestingly, brain size in humans hasn’t increased over the last half million years (indeed it’s shrunk a bit!), but what has happened is rapidly increasing asymmetries in the brain. It’s not just that our massive cerebral cortexes are asymmetrical, but within each area of the brain there are highly specialised areas. In other words, its a story not just of an increase in size, of adding more and more neurones, but of complexity.

Here’s one of the puzzles about evolution though – how on Earth did brains evolve so quickly? You might say 2 million years doesn’t seem that quick but look at the speed of change.

cerveau_evolution

 

This is why some people refer to the growth of the human brain as the second “Big Bang”…….although I do like the idea of a “Great Leap”!

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When I learned neuroanatomy at Medical School I was taught that the two cerebral hemispheres were symmetrical. There was no mention at all that they were in any way different. But look at this image above. (This is referred to as Yakovlevian Torque)

Clearly, the two hemispheres are NOT identical. In particular the right one is bigger at the front, and sits just a bit in front of the left, and the left one is bigger at the back, and sits just a little further back than the right.

Why might that be? Why the larger frontal area on the right, and occipital (back) area on the left?

Iain McGilchrist nicely summarises it by pointing out that how the left hemisphere approaches the world is by trying to grasp it. We try to make sense of the world by literally getting a hold of it – we want to understand it, to measure it, to predict what it going to happen by matching the patterns we see to those we have already learned from our experience, and we try to manipulate or control it. This is what the left hemisphere is really great at doing. Interestingly, the areas at the back of the brain are primarily for processing the outside world (our visual and auditory areas are toward the back, and the cerebellum which helps us to know whether we are standing up or falling over by orientating where we are in 3D space, is also to the back). The right hemisphere majors in making connections and maps. It has a significant role to play in all the skills we need to act as social animals.

So, one nice summary of why there might be this asymmetry in the brain, is to enable us to both grasp the world and to be social creatures. Amongst all the creatures on this planet we are probably the most able to manipulate our environment and the most developed as social animals.

There’s a huge amount more to this left brain/right brain understanding but I do think this is a fabulous starting point. Oh, and by the way, look at this

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Interesting, huh? And how come this has been pretty much completely ignored for so long?

Well, Iain McGilchrist’s theory, written up in full in The Master and His Emissary, or summarised in the Kindle Single, The Divided Mind, is that we have over developed the left hemisphere approach so much that we have developed the tendency to see only what we have already “learned” – so if we were taught that it was symmetrical, and we haven’t explored the differences between the two hemispheres, then we’ve become a bit blind. Time to start using our whole brains?

 

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education

 

What’s education about? Qualifications? Marks? Something you do until you are 16, or 18, or 20 something?  I think it’s an ongoing, constant, way of living.

becoming educated, not being educated

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