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Archive for the ‘from the consulting room’ Category

Opening

Posted in from the consulting room, from the dark room, from the living room, health, life, narrative, personal growth, philosophy, photography on March 6, 2015| 6 Comments »

opening

As this little plant opens up, it collects the morning dew.

Opening……I was recently reading an interview with Richard Sennett where he was talking about co-operation, and one of the things he was discussing was the difference between “dialogue” and “dialectics”.

Although that latter word might seem strange to you, it’s what we do a lot. As we converse with one another we each set out our views or beliefs and the idea of a dialectic discussion is to try to find “the truth”, or to achieve a shared view. (It’s not exactly that, but that’s probably close enough for this post!)

He proposed what we need to do if we want to live together, is dialogue.

In dialectic conversations, opposing positions (thesis and antithesis) confront one another with the goal of resolving conflicts (as a synthesis).  “In dialectic[s]…the verbal play of opposites should gradually build up a synthesis…the aim is to come eventually to a common understanding. Skill in practicing dialectic[s] lies in detecting what might establish that common ground.” Dialogical conversation, on the other hand, is much more open ended, not necessarily seeking the goal of resolution. “Though no shared agreements may be reached, through the process of exchange people may become more aware of their own views and expand their understanding of one another.” There is an openness of exchange in dialogics that is captured by idioms like ‘bouncing ideas off each other,’ ‘thinking out loud,’ or ‘brainstorming.’ Because the exchange is not structured as assertion, defend, assertion, etc. one has the space to be inventive, creative, and wrong. The value of dialogical conversation then is not the resolution of conflicts, but is to create a greater understanding, empathy, and sociability between parties; in other words, the goal is exposure

So, in dialogue, he says, we seek to understand the other. We don’t refute or challenge what they say in order to deny it, or modify it to suit our own views or purposes, but instead we ask more about why the person thinks that, or says that, and in so doing we might not achieve a “consensus” but we do achieve an understanding. Build that in with tolerance and you have a way of living with difference. (Dialectics, he says, seeks elimination of difference)

I found that in consultations with patients it was important to understand not just what they were experiencing but what sense they were making of that experience. And that sense might have a religious or a political/social basis which I personally didn’t share, but if I was to do my job well, I didn’t need to replace the sense they were making of things with my own personal beliefs and values. Rather I needed to understand, as best I could, what was different about this person – what beliefs and values were important to them in helping them to make sense of their experience.

That process is a process of opening up. It involves asking open questions, not ones where I have an answer or two up my sleeve, and I’m just waiting to produce the “right” one.

So, here’s what I’m thinking……when we talk to someone else, how do we open up the conversation, rather than close it down?

How can we be open to difference, instead of trying to eliminate it?

 

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March – playing to your strengths

Posted in from the consulting room, from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography, psychology on March 3, 2015| 3 Comments »

Dragon

A few years ago I wondered why the twelve months of the year have the names they do, and around the same time I was thinking, for many of us, there is a lack of awareness of rhythm and ritual in our lives, so I put the two ideas together and came up with a theme for each month of the year.

I use the theme as a touchstone of a kind. It’s a reminder, a meditation focus, a thought to return to each day….

March, the month which is named after Mars, has become, for me, the month to focus on strength.

There are two aspects of that which have come up for me this year as I reflect on this theme.

The first has been prompted by my reading of an article by Richard Sennett about “open cities”. He focuses on the issues which arise from us trying to live together – as we do as human beings, clustering together and building huge cities. That reminds me of T S Eliot’s Choruses from the Rock –

When the Stranger says: “What is the meaning of this city?

Do you huddle close together because you love each other?”

What will you answer? “We all dwell together

To make money from each other”? or “This is a community”?

And the Stranger will depart and return to the desert.

О my soul, be prepared for the coming of the Stranger,

Be prepared for him who knows how to ask questions.

Before I wander too far off topic, one of the key points Richard Sennett makes is about boundaries and borders. He says

The boundary is an edge where things end; the border is an edge where difference groups interact. At borders, organisms become more inter-active, due to the meeting of different species or physical conditions; for instance, where the shoreline of a lake meets solid land is an active zone of exchange where organisms find and feed off other organisms. Not surprisingly, it is also at the borderline where the work of natural selection is the most intense. Whereas the boundary is a guarded territory, as established by prides of lions or packs of wolves. No transgression at the boundary: Keep Out! Which means the edge itself is dead.

That’s a pretty new idea for me, but I’ve long since known the importance of healthy borders. In thinking about health, we need healthy boundaries which are maintained by our immune systems, but we also need healthy borders where we meet and interact with what is “other”.

So, here’s the first thing I’m going to reflect on this month, the month of strength – how are my boundaries and how are my borders? How healthy are they, and how might I make them healthier?

I think the answers to those questions are unique for each of us, but if you are inspired by this, why not reflect on boundaries and borders in your own life? See what you come up with?

The second aspect which has come up for me is Seligman’s idea of strengths. If you’ve never done it, or it’s some time since you did it, go and take the free questionnaire on his site and find out what your own core strengths are.

Just as I reflected on the difference between positive and negative hope, I think we can build our strengths by paying attention to them – not by beating ourselves up over our weaknesses!

So, there you are – March – the month of strength. What does that mean for you?

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Active breathing

Posted in from the consulting room, from the dark room, from the living room, health, life, personal growth, photography on January 18, 2015| Leave a Comment »

open

We have two ways of functioning as human beings. Automatic, unconsciousness ways where everything seems to happen without our having anything to do with it, and aware, conscious ways where we become active. It’s not that one of these ways is good and one is bad, but I think we’re missing out if we aren’t active enough.

The A to Z of Becoming verb series here is about considering the ways in which we can become active and exploring what that then feels like to us. This week let’s explore breathing.

Breathing is an automatic function for us. We don’t have to stop and choose to breathe in or breathe out. But when we turn our active attention to our breathing, watching to see the rhythm of our in breaths and our out breaths, we find that the pattern changes. Even without trying to alter it, just paying attention to it alters it. Try that for yourself and see.

Breathing can also, to a certain extent, be an active choice for us. We can choose to hold our breath and dive under the water to see what lies on the sea bed. We can choose the speed and depth of our breathing and in a way impose our active choice onto our default automatic function.

When we become actively engaged with our breathing at least two things happen. One is that whilst we are carrying out that activity (be it an activity of awareness, just noticing our breath, or be it a chosen pattern of speed and depth of breaths) then we are altered for the duration of that activity. Changing our pattern of breath alters our heart rate for example. It alters the chemical balance in our blood and in our cells as we change how much carbon dioxide we breathe out and how much oxygen we breathe in. It changes our brain cell activity and rhythm. It can alter our mood, our thoughts, our feelings. But, secondly, repeated sessions of active breathing change the underlying default patterns.

Let me put my doctor hat on again for a minute, and tell you about one scenario which I encountered a lot as a doctor and where I showed patients how this phenomenon of active breathing could change an underlying chronic problem.

Many people chronically over-breathe. It’s called hyperventilation. The pattern is of fairly shallow, fairly fast breaths. When this pattern occurs during sleep, the person wakes up feeling not so great……maybe headachey, tired, vaguely unwell, maybe with tingly or numb hands or fingers, or with crampy, achey limbs. You don’t know that your body is in the hyperventilation pattern overnight, but a clue it might be can be found in noticing the breathing pattern from time to time during the day. Most times when you look, you see your breathing is fairly shallow and fairly fast.

The proof of the pudding is in the eating as they say, or in this case, in the breathing. If you get someone to take a few minutes to do some diaphragmatic breaths (click through here to read the detail if you need it). And get them to do this three or four times a day. What will happen is that the underlying unconsciousness pattern will become disrupted and that disruption continues right through the night whilst the person is asleep.

I thought it was an odd thing when I first read about the sleep studies which showed this phenomenon, but time and again I found it made a big difference for many patients. Making an active choice to breathe differently a few times each day, alters the default, automatic pattern right through the 24 hour period.

Active breathing. You certainly don’t need to be doing it all the time, but taking a few moments, or minutes to do it a few times each day sort of resets your whole system.

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Living longer

Posted in from the consulting room, from the dark room, from the living room, from the reading room, health, life, personal growth, science on January 16, 2015| Leave a Comment »

Sometimes I read something that both inspires and concerns me. This recent article about the scientists working to “solve ageing” and a $1M prize for scientists to “hack the code of life”, is just one such article. The prize relates to a challenge to teams to restore “vitality and extend lifespan in mice by 50%”. Several wealthy individuals and coporations seem to be actively engaged in these pursuits.

There is an increasing number of people realising that the concept of anti-ageing medicine that actually works is going to be the biggest industry that ever existed by some huge margin and that it just might be foreseeable

It hasn’t taken long for people to ask the question about quality of life if we do manage to enable people to live 120 years or more. What I like within that discussion is the concept of “healthspan” instead of “lifespan” – how many years of quality healthy life can we have? And I was very glad to read this –

The standard medical approach – curing one disease at a time – only makes that worse, says Jay Olshansky, a sociologist at the University of Chicago School of Public Health who runs a project called the Longevity Dividend Initiative, which makes the case for funding ageing research to increase healthspan on health and economic grounds. “I would like to see a cure for heart disease or cancer,” he says. “But it would lead to a dramatic escalation in the prevalence of Alzheimer’s disease.”

This kind of thinking seems still far to uncommon. We cannot create healthy lives by “curing one disease at a time”. And even if we were able to cure a number of chronic diseases, we have to think through what it means for people. We are all going to die from something. Can we reasonably choose to avoid dying from one disease without increasing our chances of dying from others?

Instead this kind of approach is needed, and is beginning to be explored –

By tackling ageing at the root they could be dealt with as one, reducing frailty and disability by lowering all age-related disease risks simultaneously, says Olshansky.

I don’t know about ageing, but it does seem to me that we could do with researching how we maintain health, how we develop resilience and vitality, and how we support growth and development. In other words, how do we stay healthy exactly? And how do we become healthy again when we are ill?

But apart from the scary ideas of genetic engineering and other “bioscience” technologies held by the richest individuals and companies, what would it mean if we could enable the average person to live 120 years?

What would it mean for education? What would it mean for work? What would it mean for living together?

What do you think?

How might living to 120 change the way you are living your life now? How might it change your plans?

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The problems with disease language

Posted in books, education, from the consulting room, from the dark room, from the reading room, health, life, photography, science on January 7, 2015| 1 Comment »

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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The patient not the disease

Posted in books, from the consulting room, from the reading room, health, science on January 6, 2015| 2 Comments »

Eric Cassell has a new book out. The Nature of Clinical Medicine. Maybe not a title which grabs your imagination but I was very influenced by two of his earlier works – The Healer’s Art, and The Nature of Suffering. In particular, I appreciated the way he articulated the difference between “disease” and “illness”. It seemed to me that the patient’s illness could only be understood by including their story, their reports of the invisible, subjective experiences we call symptoms. 

When I studied Medicine in Edinburgh, the first three years of the six year degree course had a curriculum of “medical sciences” and so my first degree was a BSc in Medical Sciences. It was only when we entered into Year 4 that we were introduced to patients and to a curriculum of “clinical medicine”. So, the first time I saw “cirrhosis of the liver” it was in a perspex box marked “cirrhosis of the liver”. It was a full two years later before I encountered a person who had “cirrhosis of the liver”. 

I know Medical degree curriculae and teaching methods have changed a lot over the years, but what Eric Cassell does, so eloquently, in this book, is make the case for the practice of “Clinical Medicine” which does NOT focus on the disease. Instead, he argues, it needs to focus on the patient. 

The major problem is, simply stated, that when persons are sick, the sickness has an effect on every part of them, and if attention is paid only or even primarily to the pathophysiology, the disease, or the body, then the other aspects and particulars of sickness will get inadequate attention and the impact of the sickness may go on and on. That probably did not matter so much in the era of acute diseases because the patient was either soon well again or died. Now that the overwhelming majority of medical problems come from chronic diseases, from persons with enduring disability secondary to diseases, birth defects, or trauma, and from an aging population, the inadequacies of disease-centered medicine cause problems for individuals and for populations.

Even if this way of focusing on disease paid off in terms of managing acute illness, he makes the point that the world has changed, and now doctors primarily have to help patients who have chronic illnesses. A continued focus on pathophysiology, is a focus on disease, and it runs the significant risk of failing to understand or help the person who actually has that disease.

If no disease is believed to be present or cannot be found, generally the patients’ problems are shunted aside, symptoms are treated simply because there are treatments, or the patients are essentially dismissed or placed in a category of lesser interest.

This is one of the worst effects of a focus on disease. When the test results return normal readings, the patient is declared to be disease-free, and either dismissed, categorised as having a mental illness, or is prescribed medication to attempt to dull the symptoms they are experiencing even though the doctor can’t explain the presence of those symptoms. Sadly, this often results in loss of trust, breakdown of the doctor patient relationship, and ultimately a failure of care.

It is this almost single-minded focus on disease entities, especially hunting for their ultimately molecular origin, that marks Western scientific medicine and creates difficulties for physicians in the multiple other things they do, from counseling to treating suffering. 

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The Year of Light

Posted in from the consulting room, from the dark room, from the living room, from the reading room, health, life, perception, personal growth, philosophy, photography on January 4, 2015| 2 Comments »

UNESCO has declared 2015 as the “Year of Light” (“and light-based technologies”), so I thought I’d share a couple of thoughts about light.

For the last 52 Sundays I’ve published a post about an action to consider in the week ahead. To focus on actions, I’ve been writing about verbs. Verbs are tools for us. We use them to create the lives we experience. Verbs are doing words. They can’t quite be pinned down into one place or time. When we are doing something, we are experiencing continual change. Some even say that the best way to think of the “self” is not to think of self as a noun, but as a verb.

The practice of meditation invites us to investigate the flux of arising and passing events. When we get the hang of it, we can begin to see how each artifact of the mind is raised and lowered to view, like so many flashcards. But we can also glimpse, once in a while, the sleight-of-hand shuffling the cards and pulling them off the deck. Behind the objects lies a process. Self is a process. Self is a verb.

Verbs are our tools of becoming. Because we can choose our verbs and practice them, we can become active creators of our own experience.

I’m thinking of doing two things with the A to Z of Becoming series – develop them into a book which I hope to publish this year, and continue the Sunday series of posts about verbs.

This Sunday, I’m going to pick up on the UNESCO theme and think of verbs related to light. A long time back I figured that being a good doctor included practising three verbs related to light – lighten, brighten and enlighten. But now I think they are good value-grounded verbs which can add to anyone’s life.

So, this week you have three verbs to explore.

What or who lightens up your life? Can you find time to spend doing what it is that lightens up your life this week?

And what light do you shine in the lives of others? In your day to day interactions with others do you make their lives lighter, or darker (lighter or heavier maybe)?

What about brightening? To me, if you lighten someone’s life, you do something which eases any suffering they are experiencing. You help them to relax, feel less anxious, or down. To brighten someone’s life is to turn the light up in their lives. Think of sunshine, or of sparkling. Sparkling eyes brighten a day. Smiles brighten an exchange. Sharing a passion or an enthusiasm makes an experience more vivid. I’m thinking of brightening in those ways.

What can you do to brighten someone else’s life up this week?

And, how do you brighten your life? How do you add colour to it, richness or, variety? How can you increase the intensity of your experiences…..turn up the brightness…..hear, see, smell, taste, feel more vividly?

Finally, what about the idea of enlightening?

To enlighten is to understand better, to see something more clearly, to know what something means. How can you increase your understanding of another this week? How can you see something more clearly? We humans crave a sense of meaning and purpose. How do you make sense of what you experience this week?

There are lots of questions in this post, and I don’t expect you’ll explore them all in just a week, but maybe that’s why I’ve been thinking about them today. If this is to be a year of light, I can explore light in many ways over the coming days and weeks. I’ll do that with my camera, and I’ll do it with my journal. But mainly I’ll do it by coming back again and again to these three verbs – lighten, brighten and enlighten.

Here’s some amazing sunlight

sun

Some moonlight…..

moon

And some sparkles….

sparkles

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Data or people?

Posted in from the consulting room, health on December 31, 2014| Leave a Comment »

barometer

You maybe read the story about the Scottish nurse who came back to the UK after nursing Ebola patients in Sierra Leone?

Because she had travelled from West Africa she was “screened” at Heathrow – they checked her temperature. It was normal. She told them she felt fevered and unwell but they said her temperature was normal. She returned to the screening area an hour later because she was concerned that she was unwell and had her temperature checked “by officials” (did they have any medical training?) a further six times, but each time the thermometer said she didn’t have a fever so they sent her on her way to Scotland. She’s now (at time of writing) being treated in hospital for Ebola.

What amazes me, yet sadly doesn’t really surprise me, about this story is – imagine this – a nurse comes to see you, tells you she has just returned from West Africa where she has been nursing patients with Ebola and now she feels unwell. What would you do? Right. You’d listen to her story, hear what she was experiencing (feeling unwell), and hear what she’d been doing recently (travelling in West Africa and treating patients with infections in a hospital). Would you be happy to rely on the reading from a single piece of equipment (a thermometer) to determine what you should do next?

Nope, I wouldn’t.

Who would?

Only someone who had designed a “process” (probably described in a manual somewhere) which said check the temperature. A process that basically says something like if the temperature is normal, OK, say “on you go”. If not normal, do something (I don’t know exactly what the officials are told to do if the thermometer tells them there is a problem….we didn’t get that far in this case)

I was once told by a young doctor they were taught “Don’t listen to the patient, they lie all the time. Only the results tell the truth”

You know what? That wasn’t good teaching then, and it isn’t now.

When it comes to the practice of Medicine, you ignore the patient’s story at your peril.

And the same rule applies when designing a health care system.

Health and illness are experiences people have, not readings on equipment.

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Sensations as symptoms

Posted in from the consulting room, from the dark room, from the living room, from the reading room, health, life, narrative, perception, personal growth, philosophy, photography, psychology on December 29, 2014| 1 Comment »

In the London Review of Books, Hilary Mantel has written an extremely thought provoking review of Brian Dillon’s “Tormented Hope: Nine Hypochondriac Lives”.

For some of us, the question ‘Am I ill or well?’ is not at all straightforward, but contentious and guilt-ridden. I feel ill, but have I any right to the feeling? I feel ill, but has my feeling any organic basis? I feel ill, but who am I to say so? Someone else must decide (my doctor, my mother) whether the illness is real by other people’s standards, or only by mine. Is it a respectable illness? Does it stand up to scientific scrutiny? Or is it just one of my body’s weasel stratagems, to get attention, to get a rest, to avoid doing something it doesn’t want to do? Some of us perceive our body as fundamentally dishonest, and illness as a scam it has thought up.

 

We understand, almost instinctively, the nuanced difference between disease and illness. As Eric Cassell put it so clearly – “illness is what a man has, and disease is what an organ has”. Or “illness is what you go to the doctor with, and disease is what you come home with”. However, both doctors and patients are caught up in the blurred boundary between these two concepts. For doctors, once a sensation is classified as a symptom, it becomes a signpost to a pathology (or it is dismissed as “psychological”). For all of us, though, we live with the possibility that any sensation might be a symptom. For the hypochondriac, every sensation might be a symptom. As Hilary Mantel says – 

 

In hypochondria, the whole imagination is medicalised; on the one hand, the state is sordid and comic, on the other hand, perfectly comprehensible. It is the dismaying opaqueness of human flesh that drives us to anxiety and despair. What in God’s name is going on in there? Why are our bodies not made with hinged flaps or transparent panels, so that we can have a look? Why must we exist in perpetual uncertainty (only ended by death) as to whether we are well or ill?

Am I well, or am I ill? Who decides?

Brian Dillon consoles us that ‘hypochondriacs are almost always other people.’ The condition exists on a continuum, with fraud at one end, delusion in the middle and medical incompetence at the other end; he is a benefits cheat, you are a hypochondriac, I am as yet undiagnosed.

One issue is symptoms, which are a particular way of classifying sensations. Are some more real, somehow, than others? Do they need accompanying physical changes in the body to be real?  

Many people are simply hyper-aware of bodily sensations, and so are driven continually to check in with themselves, examining visceral events as a man about to confess to a priest examines his conscience; like the believer scrutinising himself for sin, they expect to find something bad, perhaps something mortal. Forgiveness, and cure, are only ever partial and temporary; there will always be another lapse, some internal quaking or queasiness, some torsion or stricture, some lightness in the head or hammering of the pulse, some stiffness in the joint or trembling of the limb, or perhaps even an absence of sensation, a numbness, a deficit, a failure of the appetite.

A researcher called Kurt Kroenke has published many studies where he shows, time and again, that not only is the percentage of people listing symptoms which they have equal whether they are attending medical clinics, or are simply stopped in the street and asked, but the actual symptoms people complain of are the largely the same whether they are attending for health care, or just going about their normal lives. Clearly, not only are sensations not usually symptoms but symptoms do not equal disease.

Bodily, and psychic sensations are part of being alive. But we humans are compelled somehow to try to find the underlying meaning of everything..including sensations. Isn’t this the crux of the issue? Who gives meaning to your daily life, your lived experience, your sensations, thoughts, and feelings?

In the days before internet information and misinformation became available, patients often came away from a consultation with the feeling that they did not own their own bodies, that they were in some way owned by the doctor or the NHS. Now perhaps Google owns our bodies; it is possible to have access, at a keystroke, to a dazing plurality of opinion. There is an illness out there for every need, a disease to fit any symptom. And it is not just individuals who manufacture disease. As drug patents expire, the pharmacological companies invent new illnesses, such as social anxiety disorder, for which an otherwise obsolete formulation can be prescribed. For this ruse to work, the patient must accept a description of himself as sick, not just odd; so shyness, for example, becomes a pathology, not just an inconvenient character trait. We need not be in pain, or produce florid symptoms, to benefit from the new, enveloping, knowledge-based hypochondria. We are all subtly wrong in some way, most of the time: ill at ease in the world. We can stand a bit of readjustment, physical or mental, a bit of fine-tuning. Our lifelong itch for self-improvement can be scratched by a cosmetic surgeon with his scalpel or needle, our feelings of loss assuaged by a pill that will return us to a state of self-possession. For hypochondria, the future is golden.

It’s not just doctors who interpret your sensations now, there are interpretations everywhere, and some of them are deliberately invented for marketing purposes. 

Living involves experiencing sensations, and being human involves sense-making. Trying to understand what is happening now may be an inescapable part of Life. Deciding what meaning fits best is, ultimately, down to the individual – either by simply accepting the interpretation of an other, or by consciously, rationally, working it out in our own terms.

Entangled as they might be, the untangling of sensations is up to us.

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Humilty and hope

Posted in from the consulting room, from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography, science on December 23, 2014| Leave a Comment »

I read a lot about complexity, and especially about complex adaptive systems, because it’s the most useful conceptual model I’ve found so far when I’m considering real life issues like health, illness, economics, personal growth (and so on!). An article entitled “Occupational Science and Social Complexity” by Aaron M. Eakman recently reviewed this model in the context of occupational science, and I thought I’d share a couple of the sections with you because he nicely clarifies some key points.

In the article there is a good summary of “characteristics [which] are common to complex systems”. He describes seven of them, and I’ve put in bold what I consider to be amongst the most important points to take on board –

1) Relationships between components of the system are non-linear,
meaning that a small perturbation may lead to dramatically large effects. By contrast, in linear systems the effect is always directly proportional to a cause.

2) Local rules affecting the relationships between components of the system lead to the emergence of global system order;

3) Both negative (damping) and positive (amplifying) feedback are often found in complex systems. The effects of an element’s behavior or the emergent behavior of the system are fed back in such a way that the element itself is altered.

4) Complex systems are usually open systems; they exchange some form of energy or information with their environment.

5) Complex systems are historical systems that change over time, and prior states may have an influence on present states.

6) The components of a complex system may themselves be complex systems. For example, an economy is made up of organizations, which are made up of people – all of which are complex systems.

7) Complex systems may exhibit behaviors that are emergent; they may have properties that can only be studied at a higher system level.

Think what these characteristics mean when you are considering a human being, an organisation, or a society. What are seeing are organisms or organisations which are undergoing constant, unpredictable change. You can guess how things are going to go, based on prior knowledge and experience of other situations which you judge to be similar, but you’re going to have to be constant alert to the fact that things are very likely to go some other way entirely, and you’ll need to adjust your choices accordingly.

In fact living creatures, particularly multi-cellular ones, like human beings can be thought of as a particular kind of complex system – a “CAS” (Complex Adaptive System).

Complex adaptive systems are special cases of complex systems which are adaptive in that they have the capacity to change and learn from experience. John Holland describes a complex adaptive system as a dynamic network of many agents (which may represent cells, species, individuals, firms, nations) acting in parallel, constantly acting and reacting to what the other agents are doing. The control of a complex adaptive system tends to be highly dispersed and decentralized. If there is to be any coherent behavior in the system, it has to arise from competition and cooperation among the agents themselves.

In other words, we don’t just constantly change, frequently in unpredictable ways, but we adapt – our changes are not entirely random, they are informed – informed by prior knowledge and experience and informed by constant feedback in the here and now.

That last point about coherent behaviour arising from “competition and cooperation” is a challening one. There are a lot of people who think that competition is THE key in understanding life and evolution. There are others who say, no, it’s cooperation which is the key. It seems the reality is, it’s both.

Complexity science eschews reductionism and determinism by focusing on the emergent properties of a system and the non-linear interactions of a system’s components. Complexity science recognizes that such systems cannot be understood simply by understanding the parts – the interactions among the parts and the consequences of these interactions are equally significant.

Modern Medicine is still stuck in the reductionist and deterministic paradigms. And the problem is they just do NOT reflect reality. We don’t just need the science which shows us how particular cells or organs work. We need the science which shows how what happens when active agents begin to compete and co-operate. We need to discover just how a complex system adapts, repairs, heals and evolves. The old idea of “fixing” the “wonky bits” only works (and only for a limited time) where the scenario conforms to reductionist and deterministic paradigms (in Acute Care for example)

One more thought provoking point from this article –

Finally, Byrne (1998) has asserted that as a basis for social action: Complexity/chaos offers the possibility of an engaged science not founded in pride, in the assertion of an absolute knowledge as the basis for social programmes, but rather in a humility about the complexity of the world coupled with a hopeful belief in the potential of human beings for doing something about it.

Byrne, D. (1998). Complexity theory and the social sciences. New York: Routledge.

I couldn’t agree more.

Humilty

and

Hope

Let’s proceed on that basis.

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