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Archive for the ‘from the reading room’ Category

to see ourselves as others see us

Posted in from the reading room, health, life, perception, psychology on July 27, 2009| 1 Comment »

That famous line from Burns’ “To a Louse”…….Oh wad some power the giftie gie us, to see oursels as ithers see us – lovely sentiment, but just not possible! I was reminded of it as I read two related articles by Emily Pronin recently (published in Personality and Social Psychology Bulletin,Vol. 28 No. 3, March 2002 369-381 and the 30 MAY 2008 VOL 320 of SCIENCE Magazine)

Do you ever think why am I only person to see something rationally and reasonably, and everyone else seems biased?
Well, that’s a common experience. It’s also common to wonder why nobody really understands you, and to always fail to completely understand another person.
Why is that?
The practice of medicine is based on understanding……trying to understand what another person is experiencing in order to try and identify whether or not they are ill, and what kind of help they might need. Sounds simple, but it’s far from it.
I recently read two related articles which explain these difficulties very clearly. As with most insights, what they have to say seems clear and obvious once you read it. Both articles deal with the differences between self-knowledge and the knowledge of others.
In essence they show that for self-knowledge we have continuous access to our inner subjective experience of reality, including the full range of sensory inputs, our emotions, and our thought processes. However, when we try to have knowledge of another person we have no direct access at all to any of these phenomena. How exactly does another person perceive and experience a particular colour, or sound, or smell? What emotional experience are they having? And what are they actually thinking? We don’t know. We can’t know. We have to listen to what they have to say and watch how they behave then make our assumptions. Our assumptions, of course, are based on our perspective, not on theirs.
So it isn’t possible to know another person the way can know ourselves. On top of that, our subjective experience conveys a degree of authenticity to our sense of self, which can never be matched when interpreting the language or behaviour of another.
It’s just how things are. We function in a way which gives great weight to our subjective experience…..even our opinions and assumptions about others gain, for us, this high degree of authenticity. We have a tendency to think we can understand another person better than they can understand themselves. The reality, however, is just the reverse, and we should always doubt our understanding and judgement of others more than we do. That’s why true empathy requires a high level of humility.

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What will change everything? The idea of negative and iatrogenic science

Posted in from the reading room, science on July 23, 2009| 4 Comments »

EDGE questions attract such interesting responses every year. This year the question is “What will Change Everything?”

Nassim Nicholas Taleb, the author of The Black Swan, poses the response that “the idea of negative and iatrogenic science” will change everything. Here’s his main point…

I will conclude with the following statement: you cannot do anything with knowledge unless you know where it stops, and the costs of using it. Post enlightenment science, and its daughter superstar science, were lucky to have done well in (linear) physics, chemistry and engineering. But, at some point we need give up on elegance to focus on something that was given the short shrift for a very long time: the maps showing what current knowledge and current methods do not do for us; and a rigorous study of generalized scientific iatrogenics, what harm can be caused by science (or, better, an exposition of what harm has been done by science). I find it the most respectable of pursuits

What he’s highlighting is the tendency for some science advocates to suggest that science is not just the only way to know the truth, but to assume that the scientific approach is in all circumstances the one likely to produce the most positive outcome. This relates to his other work where he highlights “illusions of control” – this insight has been dramatically shown to be correct in the global collapse of the financial and banking system. I always find it disturbing when an “expert” claims absolute certainty about something….yes, pretty much always! The humility which comes with awareness of our limits of our knowledge or skill is a great quality in my opinion.

He highlights not only the limits of knowledge though, but the concept from medicine of iatrogenesis – the harm done from the attempts to help…

Let’s consider Medicine –which only started saving lives less than a century ago (I am generous), and to a lesser extent than initially advertised in the popular literature, as the drops in mortality seem to arise much more from awareness of sanitation and the (random) discovery of antibiotics rather than therapeutic contributions. Doctors, driven by the beastly illusion of control, spent a long time killing patients, not considering that “doing nothing” could be a valid option –and research compiled by my colleague Spyros Makridakis shows that they still do to some extent. Indeed practitioners who were conservative and considered the possibility of letting nature do its job, or stated the limit of our medical understanding were until the 1960s accused of “therapeutic nihilism”. It was deemed so “unscientific” to decide on a course of action based on an incomplete understanding to the human body –to say this is the limit of where my body of knowledge stops. The very term iatrogenic, i.e., harm caused by the healer, is not well spread — I have never seen it used outside medicine. In spite of my lifelong obsession with what is called “type 2 error”, or false positive, I was only introduced to the concept very recently thanks to a conversation with the essayist Bryan Appleyard. How can such a major idea remained hidden from our consciousness?  Even in medicine, that is, modern medicine, the ancient concept “do no harm”   sneaked-in very late. The philosopher of Science Georges Canguilhem wondered why it was not until the 1950s that the idea came to us. This, to me, is a mystery: how professionals can cause harm for such a long time in the name of knowledge and get away with it.

Ouch! That’s a pretty negative view of doctoring! It’s not often that you hear people say so clearly that the main improvements in health come from social, economic and political change rather from “therapies”, but it’s true, and it’s not only what I was taught at university, but it’s still a clear message conveyed by people like Prof Richard Wilkinson. It’s certainly worth re-iterating when we’re in the middle of a medical culture which assumes so often that the best thing to do is prescribe a drug or operate on a patient. It’s good to hear a challenge to that mind-set and for the question of “watchful waiting”, or certainly of caring but not intervening with a potentially harmful procedure or drug, to be raised for discussion.

I’m a bit amazed that Nassim Nicholas Taleb had never come across the concept of “iatrogenesis” before. It’s a well known phenomenon in the medical world. Would it be a useful concept in other sciences? I expect it would. Again, too often, there is far greater emphasis given to the potential benefit of a technology, than the potential harm. Yet to make informed choices, we need to know both these aspects well.

If these points made by Taleb aren’t thought provoking or controversial enough for you, I’ll leave you with this one…..

I have also in the past speculated that religion saved lives by taking the patient away from the doctor

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Bird warnings and bird life indicators of world health

Posted in from the reading room, life, perception, science on July 19, 2009| Leave a Comment »

You’ll be familiar with the idea the “canary down the mine” where a canary in a cage was carried down into the mine by the miners to give them early warning that the air conditions were deteriorating. Well, I just read an interesting variation on that tale in a French magazine called “Nouvelles cles”. The article was about Christophe Perret-Gentil, a biologist who became a herboriste. It began by telling an amazing story of a group walking in the woods in the Luberon very early one morning. They were learning how to recognise the different birds from their songs and to measure the quality of the environment through those sounds, when suddenly all the birds went quiet. Their expert leader, Christophe Perret-Gentil, commented that it was totally unprecedented for this to happen and stated that something serious, some “great event” must have occured somewhere on the planet. The following day, the group were amazed to read about the terrible earthquake in China which had killed many thousands. It had occured at precisely the time the birds fell silent.

Now I don’t know what to make of a story like that. It does remind me of the tales of the animals reacting to the approach of the tsunami before people became aware of it. Fascinating.

However, what actually interested me more was why this man was out counting bird songs in the first place. When he became a “herboriste” he thought about how to identify the plants which were of the highest quality and he knew that it couldn’t be done by measuring levels of anything in a lab. He thought about the indicators of a healthy environment and came up with an idea about birds. It’s quite a simple idea but he’s elaborated it into a detailed scoring system.

He goes to an area where a producer is growing plants which he might want to buy and from early in the morning he notes the range and variety of bird species living there. He has a whole classification system developed, with various levels of significance, from the common, indigent birds, through to the presence of endangered species. The more rare, or more endangered species scoring higher. This gives him an overall assessment of the health of the local ecology. He says it is difficult to actually see a lot of birds, but that it was easy to learn their songs so he charts the health of the environment by identifying the population of birds present as he hears them sing.

There’s something beautifully poetic about this method, and something entirely rational too. At a scientific level it draws together biology, ecology, ornithology, and botany, and at a human level it draws together music, observation, that brilliant human capacity to spot patterns and relate them to each other. Christophe then takes these threads and weaves them into a story which gives him a knowledge about quality, not mere quantity.

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Muriel Rukeyser’s how to be a hero

Posted in books, from the reading room, personal growth on July 15, 2009| 3 Comments »

I’ve just read Muriel Rukeyser’s The Life of Poetry (ISBN 0-96381-833-3). An extraordinary book.

Here is the paragraph which hit me right between the eyes. Here’s where she hits the nail, squarely, on the head….

If our imaginative response to life were complete, if we were fully conscious of emotion, if we apprehended surely the relations that make us know the truth and the relations that make us know the beautiful,we would be….what? The heroes of our myths, acting perfectly among these faculties, loving appropriately and living with appropriate risk, spring up at the question. We invented them to let us approach that life. But they remind us of our own lives. They offer us a hope and a perspective, not of the past in which they were made – not that alone – but of the future. For if we lived in full response to the earth, to each other, and to ourselves, we would not breathe a supernatural climate; we would be more human.

It’s hard to put this in other words, but her insight into the value of imagination, of being aware of our emotional responses, and of how our relations to ourselves, others and to the rest of nature is the key to becoming fully human is fabulous.

What do we become if we develop such a FULL response to LIFE? Heroes. The heroes of our own myths. And THIS is how we gain both perspective on life and hope for the future.

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Prince Charles gets it right – The Richard Dimbleby Lecture

Posted in from the reading room, life on July 9, 2009| 6 Comments »

Completely by chance I stumbled on the Prince of Wales’ lecture on BBC1 last night. You can read the transcript of his speech on his own website.

I liked what I heard. I thought it was an interesting and an intelligent speech. I know a lot of people criticise him for his views but I didn’t find anything significant to disagree with in this speech. Here’s a couple of paragraphs which will give you the gist of his argument……

So, Ladies and Gentlemen, we may well be told that we live in a “post-Modernist” age, but we are still conditioned by Modernism’s central tenets. Our outlook is dominated by mechanistic thinking which has led to our disconnection from the complexity of Nature, which is, or should be, equally reflected in the complexity of human communities. But in many ways we have also succeeded in abstracting our very humanity to the mere expression of individualism and moral relativism, and to the point where so many communities are threatened with extinction. Facing the future, therefore, requires a shift from a reductive, mechanistic approach to one that is more balanced and integrated with Nature’s complexity – one that recognizes not just the build up of financial capital, but the equal importance of what we already have – environmental capital and, crucially, what I might best call “community capital.” That is, the networks of people and organizations, the post offices and pubs, the churches and village halls, the mosques, temples and bazaars – the wealth that holds our communities together; that enriches people’s lives through mutual support, love, loyalty and identity. Just as we have no way of accounting for the loss of the natural world, contemporary economics has no way of accounting for the loss of this community capital.

The idea that we need to re-think our relationship to Nature by accepting we are an integral part of it, rather than separate and apart from it is, I believe, crucially important. The failure to grasp the complexity of life, reducing it to something simplistic, is harming us. We need to be aware of the dangers of radical materialism and simplistic egocentricism.  The mechanistic and consumerist model is failing us, as the economic and environmental crises are revealing.

He is right to emphasise the need for sustainability and diversity rather than consumption and uniformity.

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Affirmations, worst for those who need them most?

Posted in from the reading room, personal growth, psychology on July 8, 2009| 5 Comments »

A study by psychologists has looked at the common recommendation found in self-help books – affirmations. You know the kind of thing…..where you are encouraged to repeat over to yourself phrases like “I am a lovable person”, or “I accept myself completely.”

What they found was that in people who had high self-esteem, these affirmations helped them to feel slightly better, but in those who had low self-esteem, the affirmations made them feel worse!

As the authors concluded, “Repeating positive self-statements may benefit certain people [such as individuals with high self-esteem] but backfire for the very people who need them the most.”

As I’ve said before, one size fits all interventions are not what they claim to be. They don’t fit all at all!

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Passions and Tempers

Posted in books, from the reading room, health, tagged on July 5, 2009| 1 Comment »

I’ve just read Passions and Tempers, by Noga Arikha (ISBN 978-0-06-073116-8)

I expect you’re familiar with the four terms, melancholic, choleric, phlegmatic and sanguine. They might not be everyday words any more but they’re certainly still common enough currency for most people to have at least some idea what they mean. They are, of course, the four temperaments, each of which is expressive of one of the four humours. Noga Arikha is a historian and this book is astonishing in its range. She begins way back in the sixth century BC and traces the idea of these humours from then right up into present time. I found the book totally absorbing and convincing, not just because of the fascinating story of both the persistence and the development of this ancient idea, but because of the meta-narratives……what this particular history tells us about what it is to be human, what it is to be a physician, and how strong ideas can evolve with the expansion of human knowledge rather than be destroyed by that process.
The book is divided into seven main sections (and given Noga’s deep familiarity with cultural rhythms and divisions, I wouldn’t be surprised if this very structure wasn’t a nod towards the seven ages of Man!). Each section describes the humours in a period of history from antiquity right up to the end of twentieth century. Before I read this book I thought the humours were an interesting extinct idea, and it was the invention of the thermometer in the 17th century which did for them. I understood that when the body temperature of a choleric was compared to that of a phlegmatic type and found to be the same, that the theory was discredited. I now know that analysis was not only simplistic, it was wrong! I also thought that the autopsies performed in the great 16th and 17th century Parisian Public hospitals made the morbid anatomist the great medical authorities and turned illness from being a holistic imbalance, to being a physical disease which could be seen, touched and measured in the body (see The Anatomy Lesson of Dr Tulp) That too turns out to be way too simplistic an understanding.
Humoural theory was indeed a holistic one where the proportions and flows of the humours within a person were thought to be connected to, or influenced by, the environment in which that person lived, which was, in turn, intimately connected with the movements of the Cosmos. The humours themselves were invisible but there were plenty of theories created to explain their behaviour and significance. Dissections and, horrifically, vivisections performed back in third century BC not only developed our understanding of anatomy, but by both failing to show any humours, and by providing alternative, observable explanations for illness, began a train of thought which was indeed to take off in the 17th century with Descartes’ separation of the body from the mind, and in the 18th century with Julien-Offray de la Metrie’s description of Man as a Machine (L’homme-machine) becoming the dominant mode of thought in scientific medicine right up to the present day.
However, as Noga Arikha shows so clearly, the humours as a concept, (as opposed to humours as material entities), still help us to understand the body and the mind as one, not two, and to seek to explain the links between the various parts of the body and the mind. The fact that such modern ideas, as described by researchers in “psychoneuroimmunology”, and philosophers and neuroscientists who discuss the embodied nature of the mind, has such ancient roots is quite breath-taking.
As she says in the introduction…..

….there was a continuum between passions and cognition, physiology and psychology, individual and environment.

Even in Hippocratic writings we read…

every part of the body, on becoming ill, immediately produces disease in some other part.

and

Men do not understand how to observe the invisible through the visible.

Let me just share with you two features of ancient practice which I found highly thought provoking and relevant to current medical practice.
From the sixth to the second centuries BC Asklepieia were the temples of the healer who became a god, Asklepios. One particulary famous one was in his birthplace, Epidaurus. A sick person would have a stay in one of these Asklepieia (which were healing centres, or spas). On admission they would have a ritual bath, then settle to sleep in an area known as the “abaton”. Every morning they would discuss their dreams with the priests, and they would receive water treatments, herbs and even, if necessary, surgery. The lucky ones would be visited in their dreams by the “drakon”, a healing snake which would cure their wounds with its tongue. The patients were encouraged to write down their experiences and their case records became the basis of medical learning which the priest/healers used to develop their treatments.
I find many aspects of this quite fascinating. Don’t we still need such places of healing, where patients can be cared for (maybe we don’t use water treatments and bathing enough these days!), and where, not only can they share their dreams, but are encouraged to record their experiences of care so that health care professionals, and other patients, can learn from them? What strikes me about this story is how the focus was on health, not disease, and how the individual’s subjective experience was central to the care.
The second story which similarly provoked my thinking was captured in these two passages –

A learned doctor was one who had primarily read many books, rather than treated many patients.

Doctors could treat only symptoms that corresponded to cases which records or histories existed already.

The dominant current model is medicine is called “Evidence Based Medicine” and “evidence” is primarily published research. It stuck me as I read the first of those two sentences, that nowadays, those who claim authority in medicine are typically those who have read many articles, rather than treated many patients! Indeed I am often amazed at the pronouncements of professors who claim to know the best way to treat patients but who are not clinically active with real patients.
The second sentence stimulated two thoughts in my mind. The first was recalling what Dr Harry Burns, Chief Medical Officer of Scotland once said about his concern with the way “Evidence Based Medicine” was being used, and that was where was all the innovation to come from, if we only allowed the practice of what we already knew? The second was how difficult it is for many doctors to accept the reality of illnesses which don’t fit the models already described – chronic fatigue syndrome, and, fibromyalgia, being just two of the obvious ones.
So, I found this book stimulating and enlightening. It is a GOOD read and I think it has the potential to deepen any health care professional’s understanding of health and healing.

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More than bodies

Posted in from the reading room, health on July 5, 2009| Leave a Comment »

In Noga Arikha’s excellent Passions and Tempers, A History of the Humours, (ISBN 978-0-06-073116-8) she traces the history of the concept of the four humours, blood, phlegm, yellow bile and black bile, across cultures and centuries. Early in the book she describes the great library in Alexandria in the third century BC. The library was part of the Museion, a real hothouse of learning and research in the city founded by Ptolemy I Soter. What I hadn’t known before about this great academy completely shocked me. Ptolemy authorised not only human dissections of cadavers, but also the vivisection of condemned criminals.

Vivisection perhaps seemed cruel and gruesome, but, he wondered, was it really so terrible to hurt a small number of criminals for the sake of finding cures for the long term, and for a large number of good people? Whether the Ptolemies used such a justification or not, anatomical knowledge sprouted from the flaying of outlaws.

That paragraph stopped me in my tracks. Can you imagine? How does a person motivated to do good by reducing the suffering wrecked by disease, get to the place of justifying the live dissection of a human being? I know it was a different culture and a different Age, but what horrified me about this story was the appalling reduction of a person to, well, a piece of meat.
But then, I’m sure you’d be quick to point out to me, such awful cruelty has far from vanished from this Earth. There are plenty of reports of torture, mutilation and murder in the daily newspapers. But it was the context which really struck me. Maybe I’m naive, but I’ve always assumed that at least one of the motivations of physicians is compassion for those who suffer. But surely those Alexandrian physicians must have completely switched off their compassion to treat other human beings this way? Surely someone like Mengele, to give an example closer to our own lifetimes, was an abhorrent exception?
There are many aspects of this issue we could explore but the main thought which occurred to me as I pondered this tale, was how the reduction of a person to a mere body seemed to be a key characteristic of this behaviour. In that light, how much more important is it for us, to maintain a holistic engagement with those who are sick, and not reduce them to only material, physical bodies?
We physicians are not technicians of the body, we human beings struggling to understand and help other human beings.
We are all more than mere bodies.
We are conscious, sentient beings; heroes not zombies.

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Drugs for the healthy?

Posted in from the reading room, health, life on July 3, 2009| 3 Comments »

In this week’s BMJ there is vociferous criticism of a recent article which advocated treating everyone, yes everyone, over 55 with antihypertensives irrespective of their actual blood pressure. The authors claimed that this would be a good way to reduce heart attacks and strokes. There were a number of excellent criticisms of this suggestion and in their right to reply the authors rebuffed the claim that this would medicalise everyone over 55 with this statement –

Offering treatment to all above a specified age regardless of blood pressure does not “medicalise” people because they do not become “patients” with a medical diagnosis, but telling people they have “hypertension” does medicalise them.

Pardon? A person doesn’t become a patient unless they are given a medical diagnosis, but if they are treated with a drug they are just a person?? I’m sorry, but I don’t follow that logic.

Imagine my surprise when after putting down my BMJ I came across this quote in one of Montaigne’s essays –

…among all my acquaintance, I see no people so soon sick, and so long before they are well, as those who take much physic [drugs] their very health is altered and corrupted by their frequent prescriptions. Physicians are not content to deal only with the sick, but they will moreover corrupt health itself, for fear men should at any time escape their authority.

That’s from Montaigne’s Essais written in 1580!

I’m with Montaigne…..a medicated life is not something to aspire to! (I’m also pretty fed up with so called experts telling me they know what’s best for ME!)

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Seeing the world completely differently

Posted in from the reading room, life, tagged , , on June 29, 2009| Leave a Comment »

In the Aymara language (a high Andean Indian language) the future and the past are in exactly the opposite positions from where they are to English speakers. You and I say that the future lies before us, and the past somewhere behind us. In Aymara, it’s the exact opposite.

But the Aymara call the future qhipa pacha/timpu, meaning back or behind time, and the past nayra pacha/timpu, meaning front time. And they gesture ahead of them when remembering things past, and backward when talking about the future.

…….the Aymara speakers see the difference between what is known and not known as paramount, and what is known is what you see in front of you, with your own eyes. The past is known, so it lies ahead of you. (Nayra, or “past,” literally means eye and sight, as well as front.) The future is unknown, so it lies behind you, where you can’t see.

(this according to research published in “Cognitive Science”)

Just pause for a moment and wonder what difference that would make to the way you understand life, or, at least, how you understand how to move through the flow of time.

Lera Boroditsky of Stanford University gives us even more food for thought on this subject in an article in the Edge. Look at this example she gives –

Suppose you want to say, “Bush read Chomsky’s latest book.” Let’s focus on just the verb, “read.” To say this sentence in English, we have to mark the verb for tense; in this case, we have to pronounce it like “red” and not like “reed.” In Indonesian you need not (in fact, you can’t) alter the verb to mark tense. In Russian you would have to alter the verb to indicate tense and gender. So if it was Laura Bush who did the reading, you’d use a different form of the verb than if it was George. In Russian you’d also have to include in the verb information about completion. If George read only part of the book, you’d use a different form of the verb than if he’d diligently plowed through the whole thing. In Turkish you’d have to include in the verb how you acquired this information: if you had witnessed this unlikely event with your own two eyes, you’d use one verb form, but if you had simply read or heard about it, or inferred it from something Bush said, you’d use a different verb form.

She asks if this means that the speakers of these different languages end up remembering their experiences differently from each other, and if so, does that mean they actually see and understand the world differently?

How does this relate to the fact that we all live on different planets?

She gives us quite a mind boggling example of how we orientate ourselves physically in the world through our use of language by telling us about an Aboriginal tribe from northern Australia, the Kuuk Thaayorre.

Instead of words like “right,” “left,” “forward,” and “back,” which, as commonly used in English, define space relative to an observer, the Kuuk Thaayorre, like many other Aboriginal groups, use cardinal-direction terms — north, south, east, and west — to define space.1 This is done at all scales, which means you have to say things like “There’s an ant on your southeast leg” or “Move the cup to the north northwest a little bit.” One obvious consequence of speaking such a language is that you have to stay oriented at all times, or else you cannot speak properly. The normal greeting in Kuuk Thaayorre is “Where are you going?” and the answer should be something like ” Southsoutheast, in the middle distance.” If you don’t know which way you’re facing, you can’t even get past “Hello.”

The result is a profound difference in navigational ability and spatial knowledge between speakers of languages that rely primarily on absolute reference frames (like Kuuk Thaayorre) and languages that rely on relative reference frames (like English).2 Simply put, speakers of languages like Kuuk Thaayorre are much better than English speakers at staying oriented and keeping track of where they are, even in unfamiliar landscapes or inside unfamiliar buildings. What enables them — in fact, forces them — to do this is their language. Having their attention trained in this way equips them to perform navigational feats once thought beyond human capabilities.

This is not just an amazing skill but it’s a skill English speakers just don’t have. There is a complete synthesis of language and physical orientation that makes a huge practical difference to the skills needed to find their way around. These are fascinating pieces of evidence that supports Lakoff and Johnson’s theories about the basic conceptual metaphors we use being related to how we experience our physical existence. But she goes on to give other examples, such as how Mandarin speakers talk of time vertically where English speakers talk of it horizontally (“Point to a spot which represents tomorrow” leads English speakers to point in front of them, and Mandarin speakers to point vertically upwards)

What does this mean for someone who learns another language? In Lera Boroditsky’s work, she investigated this –

In our lab, we’ve taught English speakers different ways of talking about time. In one such study, English speakers were taught to use size metaphors (as in Greek) to describe duration (e.g., a movie is larger than a sneeze), or vertical metaphors (as in Mandarin) to describe event order. Once the English speakers had learned to talk about time in these new ways, their cognitive performance began to resemble that of Greek or Mandarin speakers. This suggests that patterns in a language can indeed play a causal role in constructing how we think. In practical terms, it means that when you’re learning a new language, you’re not simply learning a new way of talking, you are also inadvertently learning a new way of thinking.

That confirms what you probably suspected already….that learning a new language doesn’t just let you communicate with people who speak that language, but it provokes you to see and understand the world differently.

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