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Archive for the ‘education’ Category

I was recently asked to give a talk at a Palliative Care Conference in Dundee. One of the organisers had seen me use movies as a educational tool when teaching doctors and wanted me to demonstrate that. It was well received and I thought I’d put up a series of posts based on the talk. I hope you like them.

TWO QUESTIONS FOR ALL DOCTORS

I think the core of a doctor’s job is to try and understand people. One thing I find helpful in that regard is to have two questions at the back of my head during every consultation –

  1. What kind of world does this person live in?
  2. How does this person cope?

With the first question, I’m trying to understand what’s important to the person and how they create a sense of self. I won’t go into this in much more detail just now but one well-known way of viewing the world is through the triad of body, mind and spirit. I find that quite helpful. We can consider each of these as a focus and for every one of us we can place ourselves on the this map – the body, mind, spirit map.

For the purposes of understanding where someone lives on this map, I think that the body represents the physical. These are people to whom physical security and physical reality are paramount. They prioritise material issues and they tend to prefer to have a rational, logical approach to problems – you’ve probably heard someone say “Don’t give me your touchy-feely nonsense!” when asked to discuss how they are feeling. Utility and practicality are their key values. For others, emotional security is more important. They are very aware of feelings and of relationships. They see themselves in relation to others. The third focus is spiritual and by this I mean the need to make sense of the world and the idea that there is something greater than each of us as individuals. This might be religious but it might not. What is important to that person is that they need to have a sense of purpose.

This map, by the way, is not a set of boxes into which people should be placed. The map is more like a map of three areas or neighbouring countries with flexible, moving, overlapping borders. Some people spend all their lives in only one of the countries but most move around!

This, for me, is a fundamental way of creating a sense of self – a way of answering the “who am I?” question. But related to this there is another way, which is how we see ourselves in relation to others. For all of us we live with a tension of two opposites – the need to be separate, unique, individual AND the need to belong, to love and be loved, to identify with others. I say this is related because I find that often the physically-focussed person is more towards the pole of individuality and separateness and the emotionally-focussed towards the pole of identification with others.

So take a look at this movie clip and listen the main character’s monologue. Here is a man who has a sense of being self-contained and who is materially-focussed.

“I am Ibiza!”

To see the opposite pole, have a look at this clip. Here are people whose sense of identity comes from the community –

“It is no bad thing to celebrate a simple life”

These are two good examples of very different ways of experiencing the world, different sets of priorities and different ways of creating a sense of self.

OK, so some of you will be saying hobbits?? They’re not real! But, trust me, the Hugh Grant character in About a Boy isn’t real either! But let me address that in Part 2 where I’ll show a couple of clips from one of my favourite movies, Brassed Off, which is set in a Northern English mining community. You can compare that to the lifestyle of the hobbits in the Shire.

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Just read Reckoning with Risk by Gerd Gigerenzer (ISBN 978-0140297867) and it’s one of those books that has changed the way I think.

It’s about the way statistics are presented to us to create an illusion of certainty. We don’t live in a predictable world. In fact, Gigerenzer uses a quote from Benjamin Franklin (there he is again!) about certainty –

In this world nothing can be said to be certain, except death and taxes.

He refers back to this from time to time throughout the book to remind the reader that when something is presented as certain, it probably isn’t.

Why would statistics be used to present us with an illusion of certainty? Well, two reasons mainly. Firstly, we can’t handle too much uncertainty. We need some predictability in our lives. If we really felt absolutely nothing was certain we’d be paralyzed. Every morning when I get on the Glasgow train I’m pretty sure I’ll end up in Glasgow (of course, being Scotrail, I’m not at all certain exactly when I’ll get to Glasgow! But I’m pretty sure I’ll get there all the same). Even though I have this degree of daily certainty I do know, somewhere in the back of my mind, that accidents happen, that people get sick and that one day I’ll die. And I have no way of knowing if any of those things will happen to me on the Glasgow train today. But if I tried to base my daily decisions on all of those possibilities I guess I wouldn’t even be getting on the Glasgow train!) The second reason, is that others – experts, organisations, authorities and companies – want to exert their power over us. (see how to make a zombie).

Gigerenzer’s response to this is education. His book illustrates how we are all innumerate. He bases the whole book on a small handful of scenarios which makes the book both easy to understand and quick to read.

Here are the two main things I learned from him.

We understand frequencies much, much more easily than we understand probabilities. Try this out on your friends (especially doctor friends) – here are two ways to present the same information about mammography –

The probability that a 40 – 50 year old asymptomatic woman has breast cancer is 0.8%. If she has breast cancer, the probability of a positive mammogram is 90%. If she doesn’t have breast cancer, the probability of a positive mammogram is 7%. Imagine a woman with a positive mammogram. What is the probability she has cancer?

When Gigerenzer tried this out on experts very few got it right! He then showed them this version –

8 out of every 1000 women has breast cancer. Of these 8 women with breast cancer, 7 will have a positive mammogram. Of the remaining 992 women who don’t have breast cancer, 70 will have a positive mammogram. Imagine a sample of women who have positive mammograms. How many actually have breast cancer?

See how easy the second example is? This is a very good mental tool for clearing away the confusion created by probabilistic statistics. He shows how to make a decision tree using this method. This is going to make it much easier to understand clinical trial results for me. How come I wasn’t taught something about this at Medical School?

The second lesson is more important because its about how to see through attempts to manipulate us with statistics. This is slightly more technical – there are three ways to present a comparison of two groups of people who have had, say, either two different treatments, or one group gets a drug and the other placebo. The three ways are Absolute Risk, Relative Risk and Number Needed to Treat. Let me quote one of his examples.

The West of Scotland Coronary Prevention Study published a Press Release about the use of statins (the lipid lowering drugs). It said that from a study comparing a particular statin to placebo is was shown that taking the statin “reduced the risk of death from coronary disease by 22%” – well, that seems pretty convincing doesn’t it? But look at the actual study. It compared two groups of 1000. One group got the statin. 32 of them died. The other got placebo and 41 of them died. The absolute risk is the proportion who died in the placebo group minus the proportion who died on the statin. That’s 0.9%. The relative risk is the absolute risk divided by the proportion who die in the placebo group. That’s where the 22% figure comes from. The Number Needed to Treat is 111. That is, that you need to get 111 people to take the drug for one of them to get the benefit of not dying. Well, I’m sure you’ll agree, not all three of these presentations seems the same. Gigerenzer shows how drugs companies and authorities routinely use Relative Risk to emphasise the potential benefits of their treatment while at the same time presenting the potential harms as Absolute Risks to minimize the impression of adverse potential. This is just manipulation. He makes a very good case for why we all deserve to give informed consent to treatments but how we rarely get the chance to be properly informed.

He makes the interesting point that experts often claim that their tests are absolutely certain – whether its cancer tests, HIV tests or DNA matching, but shows us how that cannot be so. There really are no such certainties and we shouldn’t believe anyone who claims otherwise.

I’d recommend this book. You won’t hear TV news the same way again. He’s right. Education is our way of liberating ourselves from the agendas of the experts and so called authorities. We should make up our own minds and learn how to do that.

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The Wellcome Library specialises in the history of medicine. It’s based in London but has recently put online a collection of images which you are able to use freely under the Creative Commons License. The Head of Wellcome Images says,

Wellcome Images is an invaluable tool for teachers and researchers of medical history, health, clinical and biomedical sciences. Through visuals users are able to develop a more profound understanding of human and animal biology, and can use them in their research and teaching. What is unusual for a picture library of this nature, is that the online service is completely free.

The collection is grouped into six sets (each starting with the letter “W”!) –

  • Wellcome
  • War
  • Wonderful
  • Witchcraft
  • Wellness
  • World

Some of the images are startlingly beautiful. Go have a browse. This is an especially useful resource if you teach biological or health sciences.

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If you like nature programmes, or enjoy bird-watching, this site – birdcinema.com will be a treat for you.

It’s kind of a Youtube for videos of and about birds!

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If you haven’t discovered it yet, take a look at http://www.ted.com

There are loads and loads of interesting, educational and entertaining videos of presentations and talks.

Start here.  This is a talk by Frans Lanting, a wonderful nature photographer. It’s a slideshow of his own photos that he’s put together and narrates to tell the story of LIFE, of evolution, of how LIFE is about continual becoming (see that “becoming not being……” byline at the top of my blog? You can see why this talk appeals to me).

The photos are just stunning.

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present.jpg, originally uploaded by bobsee.

Here’s a slide I made for one of the talks I give to medical students and doctors. I use this diagram during consultations with patients sometimes too.
Imagine that from the left to right here is your life line – the day you’re born on the far left and the day you’re going to die on the far right. We all know our left hand dates but none of us know our right hand ones! Let’s assume we are currently about half way along (I know, I know, but “middle age” seems to stretch for longer periods the older you get!)
Everything from the day you were born until now is in the past. It exists in our memories. Everything from now until you are going to die is the future. It exists in our imaginations.
If you spend most of your time thinking about and talking about the past, or most of the time worrying about what might happen in the future, the one place where you are not spending your time is – THE PRESENT.
So, if the past or the future is troubling you and consuming your thoughts and your energy, then draw your attention into the present from time to time. The more you do so, the less you’ll be spending time, attention and effort in your memories or in your imagination. You’ll be living NOW, experiencing life as it is actually happening.

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A three year study of treatment for “acute promyelocytic leukemia” adding arsenic into the mix has shown that doing this can increase the survival rates significantly.
What really struck me in this story though was this comment by the Reuters journalist

Arsenic has been used as a traditional therapy in China for more than 2,000 years, but its use in the United States is still rather novel.

Why is that? What is it about the tendency to certainty in Western thinking? I suppose we have a long history of believing we are right and that our ways are best. We live in a chaotic world where chance events change people’s lives forever every single day. When it comes down to the individual all the so-called certainty of our statistics-focussed view of the world is of little use. When I meet a patient with disease X, I have no way of telling whether or not they will CERTAINLY respond to the same treatment as other patients with the same disease, nor of knowing EXACTLY what will lie ahead for them. But as human beings we can’t cope with total chaos, and complete uncertainty. We need to have some idea of what’s happening in our lives and some idea of how things MAY turn out with particular choices we make. That’s just how we are. We need to juggle our knowledge of uncertainty and unpredictability of the particular with our knowledge of probability gained from the general. The problems arise once we turn those probabilities into certainties.
There was an interesting line of dialogue in CSI the other night – one character, a forensic scientist, said “I am confused”, and her boss replied “Good. That’s the best place for a scientist to be”. He was SO right. Well, not that scientists should always be confused but a scientist who stops doubting, stops looking and stops thinking.
Wouldn’t it be a good thing for us to look outside of our little boxes and see what phenomena are actually already well-observed (just by other people in other places – people who think differently from “us”)

I’m a homeopathic doctor and homeopathic arsenic was the very first remedy I had success with. Whether or not you believe in homeopathy, one thing a study of the subject brings is a greatly increased knowledge of substances used medicinally in different cultures over the centuries. It’s well known to homeopathic doctors that arsenic has traditionally been used to increase stamina and staying power (in fact, it was used to do just that in racing horses until it was made illegal!)  It’s also well known to us that arsenic is a commonly indicated homeopathic palliative treatment in cancer.

I wish we could replace the arrogant know-it-all and I-know-best in scientists and doctors with an attitude of lifelong curiosity and wonder.

What do you think? How would you change the education of scientists and doctors to increase open-mindedness, creative thinking and foster a spirit of humble, endless curiosity?

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According to the French philosopher, Gilles Deleuze, wrote that there are three ways to think. I know, you’re already wondering how you can think three ways with one brain! Well, you probably use the three ways all the time. In fact, Deleuze claimed it was important to know about the three ways so you could both see things more clearly and communicate more effectively. You’ve probably come across arguments where one person is saying “But what are the facts? Just give me the facts!” while another says “But what is your heart telling you here?” and a third wants to know “But what does this all mean?”. These three questions arise from three different ways of thinking and whilst they are all trying to get at THE TRUTH, they are all actually dealing with entirely different aspects of reality.

So here they are –

  1. Science – thinking about function. A scientific way of thinking takes a focus on how something works. Understanding how something works is very useful. It gives us the chance to try and make it work better, or at least to improve our experience by figuring out how the world works.
  2. Philosophy – thinking about concepts. Science uses concepts to design experiments and observational studies which will throw light on how the world works. Without the concepts though we wouldn’t know where to start. Many scientists unfortunately confuse concepts with facts, thinking that both are THE TRUTH which leads to closed minds and arrogance. This causes a kind of blindness – “my view is THE correct view, yours is WRONG”. We have to be able to think conceptually if we want to better understand our world.
  3. Art – thinking about percepts and affects. What do we perceive? And what feelings are associated with our perceptions? This is not about the how of perception or the how of feelings, it is about using conscious engagement with our perceptions and feelings to understand an aspect of reality which science and philosophy cannot achieve.

I really like this idea. When I meet a patient it’s important that I am aware of my perceptions and of the feelings that arise in me during a consultation. It’s important that I have a developing conception of illness and of health and it’s important for me to understand what isn’t functioning well in this person’s body-mind.

I also like this idea when it comes to teaching. We learn better when our learning experience engages our three different ways of thinking. We need education which shows us how things work, which teaches us to to conceptualise and which engages our feelings. Remember “Gradgrind” in Dickens’ Hard Times? His view of education was that children were empty vessels waiting to be filled with facts. Ring a bell? Oh, for more enlightened educators!

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