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Archive for the ‘from the reading room’ Category

Michikusa

Posted in from the reading room on September 16, 2007| 1 Comment »

I’m in Tokyo just now and this is such a fascinating city. It’s significantly different from not only Scotland but all the other places I’ve visited in the world. Firstly it’s vast. From my 18th floor hotel room I look out of mile after mile of skyscrapers and buildings. Each morning has been hazy outside but the weather forecast last night said a “typhoon was knocking at the door of Japan”, and although I’ve seen no sign of rain yet the wind had picked up a lot this morning. I love the cooling breeze when the temperature is 30 degrees plus and the humidity is around 80%! The winds have blown away the haze so much to my surprise I could clearly see the distant mountains way beyond Tokyo this morning (almost reminded me of home!)

The in-house hotel magazine is usually just glossy ads for expensive branded goods but this issue has an article about Tetsuya Chickushi promoting the idea of “Michikusa” (which roughly translated means “loitering on the way or taking a pause and looking round”). He promotes “Slow Life” and says he was inspired by the Italian “slow food” movement. He says michikusa is about stopping, allowing a little time to stray off the path and follow your curiosity and he mentions an activity of drawing up a michikusa map. What a wonderful idea!

Here’s his closing paragraph –

Traditionally, Japanese society has had a very strong homogenous nature, and the economic success of the modern age was attained as a result of everyone working together in the same direction without rest. And at very high speed, too. Even now, we continue to set our priority on speed, which is why we still tend to think about everything in a shallow, narrow and brief manner. But I believe that now is the right time for us to think pluralistically in a deep, broad and thorough manner. Perhaps, Japan is about to enter a phase when we should take a pause, sometimes even enjoying michikusa, and contemplate thoroughly on what true happiness is for us.

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Reckoning with Risk

Posted in education, from the reading room on September 14, 2007| 7 Comments »

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

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

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

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

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

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

Here are the two main things I learned from him.

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

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

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

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

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

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

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

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

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

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How to be creative

Posted in creativity, from the reading room, humour, writing on September 13, 2007| 1 Comment »

Have you come across gapingvoid? It’s the website of Hugh McLeod who draws business card sized cartoons. His top post of all time is this one on creativity. It’s long but it’s worth it! And some of the cartoons are hilarious.

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What a consultation with your doctor should be like

Posted in from the consulting room, from the reading room, health on September 7, 2007| 2 Comments »

In Kieran Sweeney’s “Complexity in Primary Care” he quotes from Toon’s “What is Good General Practice?” paper –

The consultation is the patient’s forum for coming to understand her illness, not merely a rational understanding, but an understanding which involves the emotions and which contributes to the growth of the individual.

Oh, how, very, very true.

Print that out. Take it with you next time you have to consult a doctor. That’s what the consultation should be about – it’s YOUR forum, for YOU to gain an understanding of what’s happening in a way that will “contribute to the growth of the individual”.

There’s your standard. Measure your doctor visits against it!

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Complexity, evidence and intuition

Posted in from the consulting room, from the reading room, health, science on September 7, 2007| 6 Comments »

I’ve just read Kieran Sweeney’s “Complexity in Primary Care” (ISBN – 1-85775-724-6) and found it both stimulating and agreeable. I am SO glad that books like this are being published. I’ve read both of his previous books – “Complexity in Healthcare” and “The Human Effect in Medicine”. He’s one of those authors who is bringing the fairly new ideas of complexity science to the attention of clinicians, I think with the intention of trying to redress the balance a bit. Medicine has become very reductionist and limited in its approach and whilst this has paid off in dealing with acute diseases it hasn’t helped in dealing with chronic disease OR in the wider desire to maintain health. In addition to this, the modern thinking he scopes out in these books really has a chance of helping us to reclaim a much more human-centred practice of medicine.

Here’s a couple of quotes from the book which really struck me –

The requirements of medical research are limited by insisting that an answer should be numeric, otherwise it is not a real answer.

That reminded me of what I just posted the other day there about the value of patients words over numbers. It also reminded me of this – I once heard a dentist describe his experience of replacing a retired colleague in a specialist facial pain clinic. He didn’t know that his predecessor had devised a scoring system for pain and had trained all his patients to report a figure as a way of telling him how much pain they were experiencing. Apparently, this man would become quite frustrated with patients who tried to talk about themselves and would even say “Stop. Not another word! I want the next thing to come out of your mouth to be a number. Nothing else! On a scale of 0 to 20 how has your pain been?” The dentist who was telling me this story was quite baffled when he took over the clinic and saw one patient after another come in for follow-up consultations and just say “17” or “12” or “9”, then refuse to say another word. They were too frightened! He didn’t find their answers very useful.

It seems that a lot of what I’m reading just now is challenging me to think about non-rational thought, intuition, gut-feelings, whatever you call that way of understanding the world. In particular I’m reading Solomon’s “Joy of Philosophy” and loving it – he argues this point. See what Sweeney has to say about it –

At the theoretical level chaos and complexity can help us to synthesise evidence and intuition. They dignify the notion of intuition, and re-establish the importance of experience and wisdom, seeing them as emergent properties of the thousands of iterative, recursive interactions in consultations.

Oh, I like that! He’s showing that from basic principles of complexity science we can understand intuition is a way of knowing which arises through our interactions with each other. Thank goodness someone is making a call for us to develop a form of medicine which is greater than the sterile world of “Evidence Based Medicine” with its mind-numbing protocols and guidelines.

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Systems Biology?

Posted in from the reading room, science on September 7, 2007| 1 Comment »

The European Science Foundation (ESF) has published a Forward Look (FL) report System Biology: a grand challenge for Europe. They are seeking to raise awareness of this “novel” way of looking at biology. The quote really caught my eye

“There is a growing awareness in medical science that biological entities are ‘systems’ — collections of interacting parts.”

Well I never! Holism comes to mainstream science! Seriously, this is good news. I think one of the main reasons why medicine has hit its current ceiling on the relief of suffering in chronic disease is its predication on a reductionist model of biology. Complexity science and the study of chaotic systems AND the development of scientific research under the headings of psychoneuroimmunology and psychoneuroendocrinology are beginning to shift the ground away from the reductionists who think that the study of parts is sufficient to those who acknowledge that we in reality, we live in a messy, complex world, which can only be understood through a holistic approach which studies contexts and connections.

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“Autopilot” or zombie?

Posted in from the reading room, life, personal growth on September 6, 2007| Leave a Comment »

Good post today on iwillchangeyourlife.com about how people go through life on “autopilot” with some points to make you ask yourself how much of your life is on “autopilot”.

This idea is right alongside my basic premise for this blog – living life unconsciously – whether you call that being on “autopilot” or living like a zombie – is just not a rich or healthy life.

The answer lies in recognising yourself as the hero of your own story – becoming more aware, engaging with life more consciously and actively creating your own path.

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The Secret

Posted in from the reading room, from the viewing room, health, life, personal growth on September 6, 2007| 13 Comments »

Do you know about The Secret? This was originally produced as a TV series by an Australian TV producer called Rhonda Byrne. It wasn’t shown by the TV channel which commissioned it and was turned into a DVD, book and now a whole movement it seems. Wikipedia has a pretty thorough article on the background story plus a presentation of the views of people for and against The Secret. According to their article, the book which inspired Rhonda Byrne was the 1910 The Science of Getting Rich by William Wattles. They also say the principles espoused are pretty much the same as those of the New Thought movement.

What is The Secret?

Well, it’s the “Law of Attraction” – which is the belief that if you ask for something, then the Universe will deliver it. Of course this will strike a chord if you ever read “Ask and you will receive” in the New Testament of the Bible, or if you came across the New Age “Cosmic Ordering” idea. These ideas have been around a long, long time but “The Secret” has packaged it up in a DaVinci Code kind of way to sell it to a new market.

I watched the film recently and found I had an enormous mix of responses. You can find a whole range of views and opinions about this film on the net – everything from the view that “The Secret” is the answer to life, the universe and everything to the view that’s it’s psychobabble nonsense. Actually, I think it’s neither of these things.

When I watched the film, which is basically a talking heads documentary, I enjoyed the graphics, but didn’t enjoy the rather trite little “drama” scenes used to illustrate the points, and the speakers, for me, ranged from inspiring to PU-U-U- LLEEEEZE – Let me OUT of here!!! (I’ll leave you to make your own judgement on exactly who fell into which category!)

It is EASY to be critical of this film – you could easily say it is simply positive thinking embellished to the point of magical thinking. However, there are useful and inspiring messages in it –

  • Starting your day with thoughts of gratitude orientates you towards an awareness of the positive in your life.
  • Having a positive mental attitude is likely to help you to greater happiness.
  • What you focus is on is what you experience most in life.

But where it goes wrong for me is pushing it into the magical realm of a belief system that we entirely create our own reality and that our thoughts will be responded to by the universe which will give us exactly what we think. This lends itself to a blame-the-victim mentality where suffering is seen to be a result of the person’s own thinking – they brought cancer, or violence, or abuse, or whatever, down on themselves. This is distasteful and naive. It also lends itself to the no-effort-required view that you don’t have to strive for anything you can just lust after it hard enough and the universe will deliver it!

And yet, and yet……….

Here’s the most interesting thing for me about it so far. It’s not the positive thinking bit. I reckon that idea is difficult to challenge. There’s ample evidence from psychologists and philosophers that taking a deliberate focus on the positive can be beneficial not just in terms of mental health, but in terms of physical health, and recovery from serious disease. It’s also quite evident in life terms – from personal to business success.

Now it is quite clear to me that just thinking you can be whatever you want to be will bring that about is nonsense – as a 53 year old, 5 foot 5 inch man I will never get to play for the Harlem Globetrotters and I won’t run in the British 400 metre Relay Team at any Olympic games! You can NOT just “be whatever you want to be” – there ARE limits!

No, the interesting bit to explore is the idea that you create your own reality. I think this cosmic ordering kind of idea has got it the wrong way round. It doesn’t seem credible to me that there is some mysterious magical force in the universe which delivers your every wish if only you visualise it clearly enough and apply a type of faith to believing that whatever you visualise will come to pass. I do believe, however, that if you focus clearly on something, you raise your awareness to daily phenomena, events and circumstances which are relevant to that focus. I also think if you apply a highly motivated creativity to your focus then you are way more likely to actually achieve your goals. But I think this direction of flow is the opposite to that espoused in The Secret.

Stuff happens. Good stuff and bad stuff. We live in a chaotic universe. The development of scientific understandings of chaos and complexity shows us that chaos has both features of cause-and-effect and of randomness. Some things happen as a consquence of the actions of ourselves or those of others. But some things happen that are literally random. Nothing to do with anyone’s thought processes. How we cope with that stuff, how we adapt to that stuff……..that’s what radically alters our experience.

So our reality is created both by our experiences and by our reactions to our experiences. It’s not created by an intelligent or magical universe and it’s not created just by our thinking.

I’m glad I watched The Secret. Yes, its tacky focus on materialistic consumerism feels small-minded and is uncomfortable. But, it’s also thought-provoking and inspiring.

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The richness of stories

Posted in from the consulting room, from the reading room, health, narrative on September 5, 2007| 4 Comments »

When patients consult me I begin the first consultation (after having made my introductions) with some variation along the lines of “Your doctor has sent me a referral letter which gives me some of the background information about your illness but it’s best you tell me your story yourself”. This allows the patient to set the agenda and to tell me whatever they want to tell me in their own preferred order. When they come back to see me for a follow-up appointment I tend to begin with a question like “How’s things?” – deliberately vague and open, again to let the patient tell their story their own way.

I try to write down their exact first words. How they are doing is often captured richly in those opening sentences. For example, something along the lines of “Doing well. Got back to work and really enjoying it now” or “Managed to have our first family holiday in years”, tells me that there has been a significant shift. The details follow but the essence and magnitude of the change is often right there in the first few words.

We use an “outcome scale” with our patients in Glasgow Homeopathic Hospital. “0” means no change; “1” means some improvement, but not enough to be of value in daily living; “2” means improvement of value in daily living; “3” is significant change which has brought a significant improvement in daily living; and “4” is hallelujah, I’m cured!

Whilst it’s satisfying to see that two-thirds of our patients score a 2 or more, these bare numbers really lack the richness of the actual words the patients use. What is more important really is to capture the “story” of the change. The story needn’t be a long one; the first few minutes are usually time enough the hear it because the essence of the story is conveyed literally in the first three of four sentences the patient utters.

Interesting that this issue was on my mind today as I was musing about to capture these changes more systematically, when I came across a post on Lifehack about stories. (This post, by the way is Part 6 in a series about Chip Heath and Dan Heath’s book Made to Stick: Why Some Ideas Survive and Others Die)

This phrase really struck me –

Stories, then, allow us to impart not just our conclusion, but the actual experiences by which we came to that conclusion.

That’s it! I thought. That’s it in a nutshell. Figures are so uninteresting because they present a conclusion. They are thin information. How much richer is the information conveyed in a story!

I can tell you that in all my years of practice I’ve never heard the exact same story twice. It’s by telling their stories, with their own preferred vocabulary, in their own preferred way, that patients convey the experiences of their illnesses to me. And healing is in no small measure a matter of enabling somebody to tell a different story, to start a new chapter with new vocabulary and to develop new themes – positive themes, health themes as opposed to illness ones. It’s such a treat!

Surely we must resist the current trend to do medicine by numbers where individual stories don’t matter, where individual people don’t matter!

Here’s to the richness of stories!

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To create is to be human

Posted in creativity, from the reading room, life, personal growth on August 31, 2007| 1 Comment »

Great post (in fact great series) across on successfromthenest on creativity. It was the title of the post which caught my attention “Saying you’re not creative is like saying you’re not human.” I couldn’t agree more.

I do find it helpful to understand people by considering how they adapt to (or cope with) changes and challenges, how they engage with the world and how they create – I agree with Tony Clark about this – a lot of people think they aren’t creative because they don’t draw or write but we are all creative every day. How you make decisions, how you problem solve and how you express yourself is all based on creativity.

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