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Clocks and clouds

Posted in books, from the reading room, neuroscience, science on July 18, 2010| 4 Comments »

I recently read a great piece by Jonah Lehrer where he ponders about the way we pursue science. It’s worth reading the whole article, but here’s the paragraph which really grabbed my attention –

Karl Popper, the great philosopher of science, once divided the world into two categories: clocks and clouds. Clocks are neat, orderly systems that can be solved through reduction; clouds are an epistemic mess, “highly irregular, disorderly, and more or less unpredictable.” The mistake of modern science is to pretend that everything is a clock, which is why we get seduced again and again by the false promises of brain scanners and gene sequencers. We want to believe we will understand nature if we find the exact right tool to cut its joints. But that approach is doomed to failure. We live in a universe not of clocks but of clouds.

I think clouds are beautiful, don’t you? Their variety, their constantly changing shape and colour and size…..their unpredictability. Astonishing. So, yes, I agree with Jonah, (and with Karl Popper), the mechanistic view of the universe has brought certain understandings and certain powers, but the networked, complex view of the universe will bring us a new understanding of reality, with quite a different concept of power. Jonah sums it up this way –

So how do we see the clouds? I think the answer returns us to the vintage approach of the Victorians. Right now, the life sciences follow a very deductive model, in which researchers begin with a testable hypothesis, and then find precisely the right set of tools to test their conjecture. Needless to say, this has been a fantastically successful approach. But I wonder if our most difficult questions will require a more inductive method, in which we first observe and stare and ponder, and only then theorize.

I think it’s about learning to use the whole brain again. Read Ian McGilchrist’s “The Master and his Emissary”. He explains more clearly than anyone else just what these two ways of seeing the world are about and how we might recapture our ability to use both halves of our brain!

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Mindsight – it’s changing my life

Posted in books, from the consulting room, from the reading room, health, neuroscience, personal growth, psychology, tagged IPNB, mindsight on June 1, 2010| 8 Comments »

I like to read books which change my life. Lots of books do that for me. In fact, the books I enjoy most are those which do just that, the ones which open up new ways of thinking to me, new ways of seeing, expand my understanding, stimulate my creativity, books which, once I’ve read them, my world is not the same.
I’ve read a lot of books like that, and if you browse this blog reading the posts in the category “from the reading room” you’ll find reviews of several of them.
I’ve just read another. In fact, I can’t remember the last time I felt this excited reading a particular book. It’s Dan Siegel’s “The Mindful Therapist” [ISBN 978-0393706451]
Now, I haven’t come to this book cold. I’ve read, first of all, his “Mindsight” [ISBN 978-1851687619] (and if you’re inspired to explore this body of work I recommend you start with that), his “The Mindful Brain” [ISBN 978-0393704709], and “The Developing Mind” [ISBN 978-1572307407], before I got hold of this, his latest book, “The Mindful Therapist”.

I’m also well into his online course which I’m thoroughly enjoying.

So, a lot of the concepts in this “Mindful Therapist” were already familiar to me before I opened it up – the idea of the mind as “an embodied, relational process of regulation of energy and information flow”, the idea of the triangle of wellness – mind, brain and relationships, the understandings from neuroscience of integrated function of differentiated parts, of the key roles of the midfrontal cortex, and of neuroplasticity, and the practices of the wheel of awareness and other meditations
Despite my familiarity with all of that, and more, this particular book has blown me away. I’ve already begun to introduce patients to the idea of health as a flowing, adaptive, coherent, energised, stable river, with the opposite banks of chaos and rigidity which we end up on when we become unwell.

I’ve begun to share with some patients the deceptively simple wheel of awareness meditation. But now, I’ve got a whole new level of insight.
Into this familiar mix, which Dan expands and reinforces throughout “The Mindful Therapist”, he gives exercises in self-discovery, and models of personality and behaviour which I’ve never seen described elsewhere. I’ve said before I’ve got a synthetic brain – always making links, seeing patterns, associations, expanding through increasing connections – well, I’m pretty sure that’s how Dan’s brain works too. He draws on insights from a multiplicity of disciplines and together, (in a “consilient” way), they create a whole which is way greater than its parts.
If you’re a health professional of any kind, I urge you to read this book. You practice, your life, won’t be the same again. You’ll find new depths as well as new horizons.

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Evidence based medicine….with the human beings stripped out

Posted in from the consulting room, from the reading room, health on May 28, 2010| 5 Comments »

I think the original definition of “evidence based medicine” was a good one –

EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)

(from “what is evidence based medicine”?)

But what’s happened to it? Frequently it seems to be reduced to reading summaries of randomised controlled trials then applying those conclusions to everyone. In other words, forget the “clinician’s cumulated experience, education and clinical skills” because it might produce “variance”, and dismiss the patients’ “unique concerns, expectations, and values” as irrelevant. It’s that kind of thinking which led to a young doctor telling me she’d been taught “If a patient takes an evidence based drug and says they aren’t any better, then, either they haven’t taken the drug, or they’re lying.” Clinicians’ cumulated experience will tell you that there isn’t a drug on the planet which will deliver the same outcomes for every single patient who takes it, and as health is a subjective human experience, the patients’ concerns and values can only be dismissed at the cost of failing to deliver effective health care.

So, I was somewhat surprised when I got last week’s BMA Scotland newsletter. Under the heading “Healthcare Quality Strategy for the NHS in Scotland is published”, it said

The Healthcare Quality Strategy has been published by the Scottish government. BMA Scotland believes by focusing on evidence-based policy with proven clinical outcomes for patients, limited resources can be used effectively to deliver improvements to the care and treatment of patients.

I clicked the link to read more

Here’s what it says on the first page –

People in Scotland have told us that they need and
want the following things from the NHS and we have
built this strategy around these priorities:
● Caring and compassionate staff and services;
● Clear communication and explanation about
conditions and treatment;
● Effective collaboration between clinicians, patients
and others;
● A clean and safe care environment;
● Continuity of care; and
● Clinical excellence.

So, how does the BMA manage to get from the document to their summary? Why no mention of the priorities focused on care, compassion, communication, collaboration, cleanliness and continuity of care? Why pick only the last priority and characterise that as a way of rationing medical care according to “proven clinical outcomes”?

Really, it’s high time we put human beings back at the CENTRE of health care…..the patients and the carers……just as it says in the rather excellent “Healthcare Quality Strategy for the NHS in Scotland”. Read it for yourself and see if you agree.

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Joined up thinking

Posted in from the consulting room, from the reading room on May 21, 2010| Leave a Comment »

One of the main problems of reductionist thinking in health which considers each disease as complete and separate entities is that the real world is a joined up one. What changes you make in one place ripple through the networks and produce a wide range of unpredictable changes.

Here’s a recent rather unexpected story illustrating this.

Researchers at George Mason University have uncovered a link between smallpox and Aids. People who have been immunised against smallpox have a five-fold reduction in HIV-replication compared to those who have never been immunised. Could this explain the massive increase in HIV in Africa when it appeared? Smallpox was declared eliminated from the world in 1980 and nowadays only researchers working with smallpox are immunised. Could it be that stopping smallpox vaccination, left the population without some kind of protection against HIV?

It’s an interesting and plausible hypothesis.

How often, in Medicine, do we ever consider the potential increases in one disease as another declines. I often wonder what people are going to die from if the great targeted projects against heart disease pay off. After all, human mortality stubbornly remains at 100%, so which causes of death will we see rise, as other ones decline?

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Connected

Posted in books, from the reading room, life, psychology on May 15, 2010| 7 Comments »

Connected, by Nicholas Christakis and James Fowler, (ISBN 978-0-00-734743-8) is a fascinating study of social networks. In the Preface they write

To know who we are, we must understand how we are connected.

This is what Clay Shirky says in Here Comes Everybody, it’s what Johansson says in The Medici Effect, Andy Clark says in Smart World, and, for me, most powerfully what Barabasi says in Linked. So what does this book add?

The clear focus of Connected is social networks – you’ll be familiar with the idea of “six degrees of separation” where it’s been discovered there are an average of only six steps between any two human beings on the planet. Christakis and Fowler take this finding a step further by highlighting and explaining “three degrees of influence”. In social networks, you influence your friend, who influences their friend, who influences their friend (and the influences flow both ways), but after that, the power of the effect tails off or disappears. The power of the effect seems related to two things – how many connections a person has, and how many of those people to whom they are connected are connected to each other (in other words how many of your friends know each other?)

These simple characteristics create very complex webs and patterns of influence and can explain a wide range of events, from the spread of a viral infection in a community, to the collapse of the financial system, to the spread of obesity, a wide range of disorders, and both cultural and political changes.

It’s a bizarre thought to learn that obesity in a community is distributed the same way as an infection. If your friend’s friend becomes obese, you’re more likely to become obese (and vice versa)! Obesity seems to be contagious.

The book is packed full of interesting and mind-boggling examples. A couple that really struck me were the spread of back pain in Germany – before the wall came down East Germany had a very, very low incidence of back pain, and in the West it was one of the highest rates in the world. After the wall came down, the incidence in the East rose to match that in the West. A study of epidemic control showed that you needed to vaccinate 90% of the population to stop the infection, but if, instead you asked a random selection of individuals who their acquaintances were, then calculated which individuals were most connected, and vaccinated only them, you could control the infection by vaccinating only 30% of the population. I could go on…..but read it yourself, it’s truly mind expanding. Really the idea that we are all separate free-thinking individuals is at best a simplistic delusion. We are who we are because of the way we connect.

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The Brain That Changes Itself

Posted in books, from the reading room on May 12, 2010| 3 Comments »

The Brain That Changes Itself. Norman Doidge (ISBN 978-0141038872)

Read this book. It’s a long time since I read such an inspiring book. Norman Doidge is a great storyteller and in this book he weaves together a number of individual stories of pioneering clinicians and researchers and remarkable people who overcame enormous difficulties. One of the most remarkable elements of the stories of the researchers is contemporary rediscoveries of decades old findings which were totally dismissed by orthodox science of the time, and which met equally harsh criticism when re-presented and developed. There’s something about scientific orthodoxy which slows up progress as entrenched authorities dismiss new discoveries. Whilst scepticism is a healthy scientific stance, there are lessons to be learned about the negative impact of closed minds.
The stories told in this book show how careful observation of, and listening to, individuals, the ability to imagine what nobody else has considered so far, and the courage to break new ground by thinking differently, all combine to break through limits, deepen understanding and show what’s really possible.
The dominant model of the brain for centuries has been a mechanical one. In particular, we’ve had (and, amazingly, many still have) a model of the brain as being a machine of many parts, with fixed areas responsible for specific functions. The discovery of brain plasticity – the capacity of the brain to physically change – has blown this old model out of the water.
In chapter after chapter of this book, Norman Doidge shows that the potential for the brain to recover from serious damage is astonishingly greater than you’d ever have imagined. He also shows how the relationships between the brain and the mind, between the brain and the body, and between the brain and other people, is completely bi-directional. Our brains physically change with our thoughts – thought patterns create and reinforce physical connections of neurons – and those connections set up thought patterns. Our brains change our relationships with others, and our relationships with others actually change our brains.
This is an immensely convincing and satisfying alternative explanation to mechanistic reductionism.
Ultimately this is an exciting read, an inspiring read, a book that will change your idea of the limits of human potential.

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Science and certainty

Posted in from the reading room, science, Uncategorized on May 10, 2010| Leave a Comment »

Here’s an excellent post on the School of Life blog by David Eagleman. He says…

….science never fails to provide more questions. What we really discover from a life in science is the vastness of our ignorance. When we reach the end of the pier of everything we understand, we find all the uncharted waters of what we do not know. Given that, I’m surprised at the number of books in the bookstore that are penned with certainty.

This always surprises me too. The most strident promoters of scientism seem so sure of themselves. How can they be so sure and be scientists? Isn’t science about wonder, amazement, curiosity, and, indeed, a humble scepticism which never reaches the absolute, final last word on anything? For me, science is about trying to understand, and, maybe it’s because I’ve worked all my life as a doctor, but I’m never at the point where I’ve understood everything about anyone. And I never stop trying.

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The Renewal of Generosity

Posted in books, from the consulting room, from the reading room, health, narrative, philosophy on April 25, 2010| 2 Comments »

I recently stumbled over Arthur Frank’s “The Renewal of Generosity” (ISBN 978-0226260174). Many years ago I read and was hugely impressed by his “The Wounded Storyteller”. It’s a great small book which is an important contribution to the struggle to create a better way of practising medicine in the 21st century. Doctors and patients are increasingly demoralised by the reduction of health care to technical procedures and the delivery of products (what Dan Siegel describes as “diagnose and drug” in his analysis of contemporary psychiatry). The everyday, subjective experiences of both patients and doctors are dismissed as irrelevant in the pursuit of measurement, targets and throughputs. Isn’t it some kind of indictment of our current health care that he can say this on page one –

My conviction is that at the start of the 21st century the foremost task of responding to illness and disability is not devising new treatments, though I’m grateful this work will proceed. Our challenge is to increase the generosity with which we offer the medical skill that has been attained.

That’s the word which really struck me – generosity. I think a lot about compassion and its central place in good health care, but I’ve not really considered the work generosity. It’s such a good word. Somehow it not only encompasses compassion but it contains within it a sense of enlarging life – my own life, and the lives of others to whom I am generous. It’s a welcoming, loving, life growing word. It’s a good word to bear in mind when considering “how to live”, how to find happiness and how to create well-being.

His key theme in this book is to weave together the teachings of ancient Stoicism (a much misrepresented classical philosophy I believe), with the case for dialogue. He primarily draws on the writings of the Stoics, of Levinas and Bakhtin.

The practice of medicine is a relationship between two people. What are we to call these two people? As a doctor, I’m fairly comfortable with the term, “patient”, but it bothers me that it seems to imply something passive, expecting the ill person to just be treated, and that contains the seeds of objectification – treating people not as people, seeing them as instances of disease, instead of persons who suffer. I hate the word “client”. It’s laden with commercialism and contractualism for me. However, Frank pulls a different set of words out of the bag and they hit me between the eyes –

The renewal of generosity will be hastened if participants in medical relationships think of themselves not (at least not only) as patients and professionals, much less as consumers and providers, but as guests and hosts.

Guests and hosts! He elaborates and explains, but I won’t share that here. Just think about this idea for a moment. I’ve never encountered it anywhere else. Wonderful.

I love so much of what he has to say about the importance of dialogue –

Dialogue suggests that the world is co-experienced by two of more people. Each one’s perspective is necessarily partial, and each needs to gain a more adequate sense of the world by sharing perspectives.

I wrote about that from a neuroscience perspective recently here.

The enlarging of perspective, or, in the other words, the attempt to see a more full picture demands dialogue. It prevents us from dismissing others through judgement and classification.

…no final, finalising discourse that defines anything once and forever. No last word can be said about this you, whose horizons of possibility remain open.

“whose horizons of possibility remain open”……how often do we forget that? How often do we squash hope with the illusion of certainty? How often do we practice as if we know exactly what a treatment will bring about for the person undergoing it? Having open horizons of possibility is a characteristic of healthy living.

We have other good reasons for dialogue apart from sharing our perspectives to gain a fuller picture. We use dialogue to value the other.

…the moral demand of dialogue is that each grant equal authority to the other’s voice……it’s being willing to allow their voice to count as much as yours

[doctors] are taught monological medicine: the doctor is the one cognitive subject in the consulting room, and the patient is an object for that cognition.

Identification with others requires giving up monologue.

The other element which we have to consider when we focus on dialogue is the other part of the doctor-patient (or host-guest) relationship – the carer. I think our system of medicine dismisses this almost entirely. The focus on “randomised controlled trials” is a focus on the statistics of groups. Once a drug or treatment is “proven” it seems to be irrelevant who delivers it, or how. Yet that’s not our experience when we are ill. Who the doctors and nurses are is important to us. How they talk, how they listen, how they treat and care for us. The idea that its the treatment which is important and the not the person administering it seems inhuman to me.

We can keep the question before us: what do they think about how I am imagining them? and we can believe that what they think matters.

We should honour patients’ stories, not dismiss them as “subjective” or “anecdotes”. They matter.

Finally,

…the person who we see ourselves revealed to be is seen most fully in others’ responses to us

Isn’t that so true? What have you seen of yourself in others responses to you today?

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Believing your own eyes and the importance of sharing

Posted in from the reading room, life, neuroscience, perception on April 14, 2010| 5 Comments »

I read this fascinating fact in Scientific American recently –

Of the virtually unlimited information available in the world around us, the equivalent of 10 billion bits per second arrives on the retina at the back of the eye. Because the optic nerve attached to the retina has only a million output connections, just six million bits per second can leave the retina, and only 10,000 bits per second make it to the visual cortex. After processing, visual information feeds into the brain regions responsible for forming our conscious perception. Surprisingly, the amount of information constituting that conscious perception is less than 100 bits per second.

Wow! The first part of that whole story is startling enough, and one we don’t routinely consider. There is a vast amount of information surrounding us, but we can only pick up the limited amounts which our sensory organs are capable of handling. For example, we don’t see the same spectrum of colours as other creatures – a flower won’t appear to a bee, the way it does to a human! But, then when you consider the rest of this story, look at just how much “data loss” occurs between what the sensory organ can detect and what we can consciously appreciate!

Funnily enough, I’d just recently read the following in “The Renewal of Generosity” by Arthur Frank (ISBN 978-0226260174) –

Dialogue suggests that the world is co-experienced by two of more people. Each one’s perspective is necessarily partial, and each needs to gain a more adequate sense of the world by sharing perspectives.

Wouldn’t it make more sense to respect each others’ perspectives and enter into dialogue, than to assume that our personal (limited) view is THE right one? (I’m just thinking of the way the politicians are acting in this current election month in the UK)

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