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Archive for the ‘from the consulting room’ Category

Who knows best?

Posted in books, from the consulting room, from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography, writing on November 20, 2015| Leave a Comment »

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What is good or bad for me?

Let me ask “what is good or bad for you?”

Are the answers to those questions going to be identical?

I don’t think so. We could get into a big discussion about what “good” and “bad” even mean, but without disappearing down that rabbit hole I’d just like to express the opinion that no-one can know you better than you can. No-one is better placed to know how you should live than you are.

We forget that in our increasingly controlling autocratic societies.

Here’s Montaigne –

Tiberius used to say that whoever had lived twenty years should be responsible to himself for the things that were harmful or beneficial to him, and know how to take care of himself without medical aid. And he might have learned this from Socrates who, advising his disciples, carefully and as a principal study, the study of their health, used to add that it was difficult for an intelligent man who was careful about his exercise, his drinking, and his eating not to know better than any doctor what was good or bad for him.

Socrates who lived almost 2500 years ago……his teaching on health?

Take care about exercise, your drinking and your eating.

Wow! Public Health advice has come such a long way! (hmm….)

But the main point Montaigne is making is one I agree with.

I’d be astonished if anyone claimed they knew better than I did what was good for me, or bad for me. Take the relatively common place circumstance of pain. Can anyone tell me better than I can whether or not a treatment I take for pain reduces my pain? No, they can’t. Only my personal experience will tell.

What better advice than to be aware, to be reflective and to learn about yourself?

Without that you end up swallowing the advice of someone who isn’t living your life.

(Oh, and what about today’s photo? It’s a fig. It’s a fig which grew and ripened on the tree we planted in our garden and it tasted….mmmmm….words fail me…delicious! Like no fig I’ve ever tasted before. Are figs good for me? Well that one certainly contributed towards my pleasure in being alive that day, and I’m looking forward to more figs growing next season. Are figs good for you? You’re the better judge of that one!)

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Habits and dents

Posted in from the consulting room, from the dark room, from the living room, health, life, personal growth, photography, psychology on November 12, 2015| Leave a Comment »

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Habits.

We all have habits – LOTS of them! People often talk about habits as if they are bad things, and they can be, but we have them for a reason and don’t we all classify habits into two types anyway – “good” and “bad”?

Before I go any further let me just reiterate that I’m really not a fan of what is referred to as “two value thinking” – categorising whatever we are thinking about into boxes – “good” or “bad”, “black” or “white”, “right” or “wrong”. So often what we put into one category doesn’t look like it fits there very well after a while. However, for the purposes of this reflection let’s think about what’s “good” about habits and what’s “bad” about them.

Habits are good in at least a couple of ways I can think of – they bring us comfort, and so, ease, security and familiarity. We all want those feelings. And they allow us to turn our attention to other things. For example, if I have a routine way of making a cup of coffee, I don’t have to start from scratch every time and figure out how to make a cup of coffee. If I have a habitual path I take to get from home to work (whether walking, driving or taking public transport) I can just set off each day and not have to figure out how to get to my destination.

Why do we think of habits as bad then? Either because they are behaviours which we’d rather not have – for health reasons, or because they are particular patterns which always make us sad or fearful. Or because they restrict us. Because, let’s face it, habits can be very hard to break.

I think there are two ways to change habits –

First, become aware. If I become conscious of my habit then I can choose to repeat it. For example, if there is a particular route I like to take I can consciously choose to go that way, instead of just finding myself following it unthinkingly – that’s the heroes not zombies thing – it’s moving from autopilot to conscious living. Becoming aware and actively choosing doesn’t mean we have to do everything differently. Choosing changes how we experience a routine or a habit.

The second is to create new habits. When discussing how to get out of the same old ruts and loops, I used to talk to patients about “making better dents” – read about that here if you like. The idea though stems from the fact that it is much easier to create a new habit, which can then replace an old one, than it is to try to wrestle an existing one into submission! People talk about the 30 day rule for new habits – start doing something differently, and do it each day for 30 days – that seems to make it more likely to stick!

So instead of beating yourself about the head about bad habits, or struggling to “break” them, why not try first becoming aware of what they are, then either consciously choosing to continue them, to using your imagination to create a new, potential replacement?

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Apprentices to Nature

Posted in from the consulting room, from the dark room, from the living room, from the reading room, from the viewing room, health, life, philosophy, science, video on November 10, 2015| Leave a Comment »

Good old “Cles” magazine! This magazine probably opens up more avenues for me to explore than any single other publication. There is currently a fifth anniversary special out with “5 reasons to be hopeful” forming a major section of the issue. The fourth reason is ecology taking root, and it’s here that I read about “biomimicry”.

It’s one of those concepts that when you read about it you think, why didn’t I know about this already?

From the home page at biomimicry.org here’s a short definition

Humans are clever, but without intending to, we have created massive sustainability problems for future generations. Fortunately, solutions to these global challenges are all around us.

Biomimicry is an approach to innovation that seeks sustainable solutions to human challenges by emulating nature’s time-tested patterns and strategies. The goal is to create products, processes, and policies—new ways of living—that are well-adapted to life on earth over the long haul.

The core idea is that nature has already solved many of the problems we are grappling with. Animals, plants, and microbes are the consummate engineers. After billions of years of research and development, failures are fossils, and what surrounds us is the secret to survival.

Here’s the founder, Janine Benyus, explaining it all eloquently and with fabulous imagery in a short (20 min) film.

 

I find this totally inspiring. What a fabulous way to look at life! To think that the solutions to all of our problems might just be there in the Natural world, just waiting for us to learn! What a different approach to technology – to develop technological solutions based on natural methods instead of much poorer, less efficient artificial ones. What a different approach to science – to apprentice ourselves to Nature in order to learn what has already been learned through adaptive processes over millions of years, instead of trying to find ways to control and battle against Nature.

And, potentially, what a fabulous research agenda, to learn how living organisms grow, defend and repair themselves – all without the use of any artificial or toxic “aids”. Now there’s the foundation of a new approach to health care.

Go on, take 20 minutes out of your busy day and watch that video. I hope you’ll be as inspired as I am!

 

 

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Hormone disruptors

Posted in from the consulting room, from the dark room, from the living room, from the reading room, health, life, neuroscience, photography, science on October 26, 2015| Leave a Comment »

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Over the last few weeks I’ve noticed a number of articles about “hormone disruptors” in the French language newspapers. I’ve not noticed this issue getting much coverage in English language media so I thought I’d share some of it here with you today.

“Hormone disruptors” are chemicals which have the power to affect the “endocrine system” in human beings. The endocrine system is the network of glands and communication channels in the body which produce natural chemicals called “hormones”. Hormones are the key to the regulation of a lot that goes on in the human body. As well as having specific effects on certain tissues, the whole endocrine system is intricately connected to both the nervous system and the immune system. There are even fields of study known as “psychoneuroendocrinology” and “psychoneuroimmunology” to research the connections between these whole body systems.

The first article which caught my eye was the report of a study published in Nature where the researchers had shown that two chemicals in the environment, neither of which had much of a biological effect on human cells, could combine to have a dramatic effect. Figaro described this as the situation where one plus one didn’t equal two, but maybe fifty.

Humans are chronically exposed to multiple exogenous substances, including environmental pollutants, drugs and dietary components. Many of these compounds are suspected to impact human health, and their combination in complex mixtures could exacerbate their harmful effects. Here we demonstrate that a pharmaceutical oestrogen and a persistent organochlorine pesticide, both exhibiting low efficacy when studied separately, cooperatively bind to the pregnane X receptor, leading to synergistic activation. Biophysical analysis shows that each ligand enhances the binding affinity of the other, so the binary mixture induces a substantial biological response at doses at which each chemical individually is inactive.

There are an estimated 150,000 chemicals in the world which are all licensed as safe but have been tested only singly, and not in combination with the others which are found in our environment, and indeed, in our bodies.

At the beginning of October, the International Federation of Obstetrics and Gynaecology (FIGO) published a warning about the effects of all these chemicals which are now routinely found in mothers’ bodies during pregnancy. They said –

Exposure to toxic environmental chemicals during pregnancy and breastfeeding is ubiquitous and is a threat to healthy human reproduction.’’ It cites research showing that virtually all pregnant women bear a chemical burden and that babies are born “pre-polluted”

What problems were these doctors concerned about?

« Miscarriage and fetal loss, impaired fetal growth, congenital malformations, impaired or reduced neurodevelopment and cognitive function, and an increase in cancer, attention problems, ADHD behaviors, and hyperactivity ».

In addition, they referred to other problems which have a hormonal element – obesity, diabetes, infertility, endometriosis and polycystitic ovarian disorder.

Where are all these chemicals coming from?

Hormone (or endocrine) disrupting chemicals (EDCs) are found in food packaging, pesticides, cosmetics and chemical coatings on household products.

Then, this week, in Le Monde, I read an article about the hormone disrupting potential of the chemicals used as fire retardants. A group of researchers at “L’Anses” concluded that

il est plausible que les retardateurs de flamme n’aient eu, en près de quarante ans d’utilisation, qu’une utilité marginale, voire nulle. Les risques, eux, sont bien réels : certains de ces composés sont cancérogènes, perturbateurs endocriniens, toxiques pour la reproduction, persistants ou neurotoxiques. Ou tout cela à la fois.

….in other words there is little evidence that they’ve done much to prevent serious problems from fires, but plenty of evidence to show that the health risks are significant – cancerogenic, hormone disruptors, fertility suppressing and neurotoxic.

Hormones are a key component in the maintenance of human health. As the obstetricians and gynaecologists pointed out disruption of the endocrine system may well be playing a significant role in our modern epidemics. If that’s true then we won’t achieve population health by just trying to persuade individuals to eat less carbohydrates!

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The strengthening placebo effect

Posted in from the consulting room, from the living room, health, life, science on October 24, 2015| 1 Comment »

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Here’s an interesting piece of news about the placebo effect – it’s getting stronger!

In an article on the BBC’s website, William Kremer explores the discovery that in RCTs (Randomised Controlled Trials) of drugs where drugs are compared to placebos, the size of the response to the placebos seems to be getting larger, making it harder for drug companies to demonstrate significant benefits of their drugs to the licensing authorities.

The article has a bit of a limited view of placebo, in my opinion, because the writer seems to focus exclusively on the idea that a placebo makes someone “feel better” – which implies that they aren’t “really better”. In fact, others have described the placebo effect as the “self-healing effect” because it involves the biological mechanisms of healing. In relation to pain studies, imaging has shown that the parts of the brain which are active in response to pain are stimulated both by pain killing drugs and placebos. I think we lose something by dismissing the placebo effect as a trick, or as something unreal.

As best I can see it does involve the imagination, and that is referred to in the article towards the end where they mention some of Ted Kaptchuk’s work.

But the part which really struck me in this article came in the discussion about how to minimise the placebo effect in drug trials –

There is also a drive to lower, through discussions with patients, their expectations of taking part in a trial. What is the best way to do that? “We tell them the truth,” says Dr Nathaniel Katz, the president of Analgesic Solutions, a consultancy that helps drug companies avoid trial failures.

“Telling the truth” means reminding patients that they are part of a trial for a drug that may not work, and which they may not even be given. “Even if it works,” Katz says, “it only works for about a third to a half of patients – that’s as good as it gets these days.”

Did you notice that sentence? –

“Even if it works,” Katz says, “it only works for about a third to a half of patients – that’s as good as it gets these days.”

How often does that fact slip right past patients and doctors? The way some people talk about “proven” or “evidence based” drugs, you’d think they “just work” – as in work every time for every person – wouldn’t you?

But we all know that isn’t true.

 

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One thing leads to another

Posted in from the consulting room, from the dark room, from the living room, health, life, narrative, photography on October 9, 2015| Leave a Comment »

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What if we built a health care system starting by ensuring that every patient gets enough time with the doctor, nurse or therapist for them to be seen, heard and treated as an individual?

Jacques Lacan said that the greatest gift we can give someone is to listen fully without judgement or interpretation.

What if we gave that gift to every patient, every time?

Also, so that every time a patient met a doctor, nurse or therapist, they didn’t have to start to tell their story all over again, but rather, the story could be deepened and extended enabling understanding to increase and a relationship to be built, what if we also built a health care system based around continuity of care?

If we started from there, what might that lead to…..?

Individualised care, enough time with every patient, continuity of care…..what would you add next?

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You don’t get to tell me…..

Posted in from the consulting room, from the viewing room, health, life, movies, personal growth, video on October 6, 2015| 4 Comments »

 

That’s one of my favourite Kevin Spacey movie lines.

It’s a phrase which often comes to my mind in relation to health care. We’ve developed a very bureaucratic way of providing health care in Europe and North America. It seems to me that the system comes first now instead of the patients and the doctors.

Health care is a supremely human activity. It involves one human being trying to help another. Both of those human beings are unique and when we reduce the patient to a case of a disease and a doctor to a person who implements a protocol then we de-humanise Medicine.

I think it is important to prioritise uniqueness. We should always be on the lookout for what is new and what is different in every situation. Instead the bureaucratic approach demands we look for what is the same and fit everyone into pre-set categories and treatment paths.

Does anyone know you better than you do? Does anyone really know better what choices you should be making instead of the ones that you are making? Who should finally decide what to do about your life? (How you should eat, how you should spend your time, what “treatments” you should subject yourself to?)

I think it is you!

So when I hear a manager or a “skeptic” tell a patient that they can’t have the treatment which they say is the one which made the most difference for them (relieved their pain, settled their panic attacks, made their breathing easier….whatever) because the “evidence” says that treatment “doesn’t work”, it amazes me.

There not a treatment on the planet which does the same thing for every person who receives it, so there is no such thing as only two categories of treatment – those which work and those which don’t – as some would claim. We need a wide diversity of treatments to be available because human beings are so, well, different….

But I think about this not only in relation to rationing health care, protocol based medicine and so on. I think it’s something to consider in every therapeutic relationship. Here’s the question I’m exploring –

Is it an expert’s job to tell people what to do, or to help them to see how to change, then to support that change?

I’m pretty sure I don’t want anyone telling me what to do!

 

 

 

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Energy

Posted in books, from the consulting room, from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography, psychology on September 27, 2015| Leave a Comment »

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William James wrote –

Practically everyone knows in his own person the difference between the days when the tide of this energy is high in him and those when it is low, though no one knows exactly what reality the term energy covers when used here, or what its tides, tensions and levels are in themselves . . . To have its level raised is the most important thing that can happen to a man, yet in all my reading I know of no single page or paragraph of a scientific psychology book in which it receives mention. (The Energies of Men, 1907)

What is this energy he is talking about? I’ve often wondered about that. When I gave talks to young medics I would often start by saying “Let’s make a scale for energy. Let’s say 0 is the lowest energy you can imagine experiencing, and 10 is the greatest. Where would you put yourself on that scale right now?” Then I’d go round the room getting everyone to say what level of energy they were experiencing. Everybody answered. Everybody instantly offered a number on the scale. Then I’d ask “How did you do that?” “What did you check to arrive at the number you gave?” Nobody knew.

Dan Seigel and his group who developed “Interpersonal Neurobiology” (IPNB) came up with this definition of “mind” (see if you can find other definitions of “mind”) –

A embodied, interpersonal process of regulation of energy and information flow

Pretty useful, isn’t it? But what is the “energy” which is being regulated?

Having read the IPNB definition it struck me that as complex adaptive systems, living organisms are constantly exchanging energy, molecules and information with their environments.

But again, just what is this “energy”?

What do you think? (And where are you right now on the energy scale of 0 to 10?)

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Constant creation

Posted in books, from the consulting room, from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography, science on September 24, 2015| Leave a Comment »

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Michael Foley, in his Life Lessons from Bergson, gives an excellent, concise description of the complex adaptive system model (even though he doesn’t actually use that term)

There is also the intellectual problem that, in a complex organism, the whole is never merely the sum of the parts and the parts are never entirely independent of the whole.
It’s amazing how often doctors forget this.
A whole person can never be understood from even the most comprehensive set of measurements from a laboratory and an imaging centre (where X-Rays and scans are carried out).
The whole person has to be encountered as the unique individual that they are.
As Mary Midgely, the philosopher, put it –
One cannot claim to know somebody merely because one has collected a pile of printed information about them
In complex systems, simple arithmetic doesn’t work, not least because the bonds between parts are so often integral parts of feedback loops, so a small change in one part can induce much greater change in another, and together the changes within the whole organism are way beyond what can be understood from analyses of single parts.
Also, there isn’t a single organ within us which acts by itself. In fact, there isn’t a single cell which acts in isolation. At all levels, from the molecular within the cell, to the whole person within a physical, social and cultural environment, nothing is “entirely independent of the whole”
An organism is a hectic, almost frenetic, process, operating far from equilibrium in a ceaseless metabolism that seeks out and draws in nutrients, converts them to energy, expels waste, and uses the energy to reproduce, and to regulate and renew its parts, so that its make-up is constantly changing though its structure is relatively stable.
We have such a sense of solidity, don’t we? We have such a clear sense of a unified identity which exists throughout the whole of a life. But our physical make up is really not so solid. As a living organism we are dynamic, always in motion, always processing energy, molecules and information from the environment and within us. We make ourselves anew every single day, our cells in a constant process of creation and destruction. I found that idea quite startling and exciting when I first encountered it. It means that life is a process of constant change and unceasing creation.
But there’s something else in that paragraph which I first read when studying the concept of complex adaptive systems – “operating far from equilibrium” – when I first studied biology I was taught about “homeostasis” – the processes which maintain the inner environment of the body is a state of equilibrium. I learned about many feedback mechanisms which sought to maintain a number of balances – blood pressure, muscle tension, the levels of various salts in the blood and so on. So learning that complex adaptive systems function “far from equilibrium” was a bit surprising. But then that’s how we change. That’s how we grow. It’s only by operating at the edge of the balance that we meet what is termed “bifurcation points” and undergo “phase changes” and “emergence”. I didn’t learn about those phenomena when I first studies biology or Medicine, but they are fundamental characteristics of all living organisms.
Shifting from a focus on checks and balances, to living complexity, can move us from seeing homeostasis as an end in itself, to seeing that it is only one element in the over all process of creativity and development.
As long as we live, we are never finished with these creative, developmental processes. As Michael Foley says –
there are no independent, isolated, finished organisms.

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Respect for the individual

Posted in books, from the consulting room, from the dark room, from the living room, from the reading room, health, life, narrative, philosophy, photography on September 22, 2015| Leave a Comment »

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Michael Foley, focusing on Henri Bergson’s philosophy in “Life Lessons from Bergson”, writes –

there is a tendency to see what things have in common rather than what makes them unique, the source of a dispiriting sense of sameness.
As a doctor I need to know how to make a diagnosis. I also need a knowledge of the natural history of disease. However to actually help any individual patient I need something else as well – knowledge of this individual. So, I have to be able to see what things people have in common (certain symptoms and signs which indicate particular pathologies perhaps) and I need to be able to see this person sitting in front of me right now.
This person sitting in front of me right now is not the same as all the others. Every narrative I hear is unique and individual. No two patients have led, or are leading, identical lives, with identical bodies, minds, values and beliefs.
Reducing the individual to what they have in common with others is, in my opinion, “the source of a dispiriting sense of sameness”. That’s why I have such an aversion to Medicine by flow-chart, and the distorted practice of so called evidence based medicine which seeks to replace subjective human experience with data.
In short, we do not see the actual things themselves but in most cases confine ourselves to reading the attached labels.
Our left cerebral hemisphere is great for analysing things, sorting them into categories and applying labels, but it’s not enough. We have to attempt to “see the actual things themselves” and not be blinded by the labels. For doctors, that includes seeing the actual patients themselves, and not confining their understanding to the “attached labels” – diagnoses, categories or types.
I think the creation and appreciation of narrative is an important part of a doctor’s job and it requires more than a knowledge of the “medical sciences”.
Here’s Michael Foley again –
A crucial function of the arts is to prevent, or break down, dismissive labelling and reveal the singular instead of the similar, the peculiar instead of the familiar, and the inscrutable instead of the understood.
This reminds me so much of Deleuze’s three modes of thinking – science, which is thinking about function; philosophy, which is thinking about concepts; and, art, which is thinking about percepts and affects. Deleuze was a great advocate of thinking about difference too.
What an elegant phrase too – revealing “the singular instead of the similar, the peculiar instead of the familiar, and the inscrutable instead of the understood”.
What a great way to enhance respect for the individual – seeing them as unique and knowing you will never achieve a complete understanding them….which reminds me of Saint-Éxupery’s teaching that “What is essential is invisible to the eye”

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