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Archive for the ‘health’ Category

One thing leads to another

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

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

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

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

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

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

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

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You don’t get to tell me…..

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

 

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

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

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

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

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

I think it is you!

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

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

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

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

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

 

 

 

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Energy

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

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William James wrote –

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

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

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

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

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

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

But again, just what is this “energy”?

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

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Constant creation

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

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

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

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Respect for the individual

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

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

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

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Continuity and variation

Posted in books, from the consulting room, from the dark room, from the living room, from the reading room, health, life, neuroscience, personal growth, philosophy, photography, psychology, science on September 17, 2015| Leave a Comment »

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Reality no longer appears essentially static, but affirms itself dynamically, as continuity and variation. What was immobile and frozen in our perception is warmed and set in motion.

Those are the words of Henri Bergson, quoted in Michael Foley’s excellent “Life lessons from Bergson”.

I love that. The experience of life as dynamic, “warmed and set in motion”.

Life isn’t “frozen and immobile” to me, and that’s why I am wary of categories and labels. I’ve always resisted being put into a box, defined by one or two of my characteristics. When I think of that I recall the adage of the General Semanticists – “judgement stops thought”. So often fixing someone or something into a category or type stops us from really seeing, really understanding.

Reducing an individual to a type diminishes them in all senses of the word.

Every patient I ever encountered was unique, presenting experiences and stories unique to them. To reduce them to diagnostic categories, or to types of any sort, blocked my understanding of them. Everyone always has more to reveal, more to share, more to experience and be understood.

Michael Foley says he came back to Bergson’s work after dismissing it decades earlier. His way back is interesting. It’s not the same as mine. My first encounter with Bergson came when I was reading Deleuze but I didn’t find him easy. I later stumbled into complexity theory and, in particular, the idea of complex adaptive systems. At that point I remembered some of Bergson’s ideas and went back to explore his writings further. Michael Foley’s path was through his encounter with “process philosophy” and with particle physics –

I learned from twentieth century philosophy of mind that memory and the self are processes rather than fixed entities – and suddenly this connected with the theories of particle physics, which claim that at the heart of matter there are in fact no particles but only processes…….everything is process…and everything is connected to everything else.

In the process view nothing is fixed, nothing is final and no circumstances ever repeat in the same way.

This strikes me as very true. Dan Seigel, one of the founders of Interpersonal Neurobiology, worked with colleagues to come up with a definition of the mind. What they concluded was that ” the mind is a process of regulation of energy and information flow. ”

The mind is not an entity or a thing, it’s a process.

The body is not a fixed entity or thing either – it’s a dynamic ever changing network or community of cells.

Disease is not a thing either. That really startled me when I read that once I was a practising doctor. As a medical student I picked up the view that disease was pathology and pathology was the changed organs or cells. Once I became a GP I encountered dynamic, hard to pin down illnesses that certainly couldn’t be reduced to pathological entities. Hearing that disease was a process not an entity was liberating for me.

I will return to some of the issues raised by this thinking in other posts but let me finish this one by returning to the title, because once we gain the insight which shifts our attention from entities to processes we discover diversity – we find out that variation is a key characteristic of Nature and of Life. But I think we find out something else too – that the universe, the world, and our lives are not completely random, chance, accidental phenomena. Instead there is continuity. We are in a process of continuous creation and emergence. We are who we are in our networks of family, nature, society and the world. We emerge from the past, as the past encounters and interacts with the present. Our future doesn’t contain just anything you could ever imagine. It emerges from here and now, from that flowing river of life and connections.

Continuity and variation. Just like the flow of a river. Just like the natural history of a plant, an animal, or any other living organism.

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Plants and humans

Posted in from the consulting room, from the dark room, from the living room, health, life, photography, science on September 14, 2015| 1 Comment »

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Out walking in the vineyards the other day I noticed this plant with its strikingly unusual flowers and its little red berries.

It’s “dulcamara”, which is a plant I know from my homeopathic studies. Its fuller name is “solanum dulcamara” which helps us to realise it is from the same plant family which other “solan…” plants belong to. That family is the Solonacaeae family.

The Solonacaeae family is a fascinating one to explore if you want to look at the relationships between the plant and human worlds. Some of them are staple foods – potatoes and tomatoes for example. But others are hallucinogenics – belladonna, hyoscyamus and stramonium being striking examples. Witches were said to make up a paste which included some of these hallucinogens and applied it to their skin with a stick – the origin of the “flying sick” perhaps?

In fact a lot of these plants can be poisonous to humans and I often wonder how human beings first got the knowledge to enable them to distinguish between the nutritious and the poisonous – trial and error? Sickness and health? Life and death?

If you are at all interested in looking into “ethnobotany” this is a good family to start with!

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Getting real

Posted in from the consulting room, from the dark room, from the living room, health, life, philosophy, photography, science on September 6, 2015| Leave a Comment »

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The thing that’s always bothered me about reductionist science is how quickly it becomes so abstracted from the world that it no longer usefully models the world.

Human beings, as living organisms, are complex adaptive systems. We are inextricably embedded in multiple contexts, physical, social, and cultural. You can’t truly understand a human being when you consider them isolated from the air they breathe, the food and water they eat and drink, the extensive web of relationships they live in, from family, friends and colleagues, to the networks of production of goods and services.

We are dynamic, open systems. That is, change is the constant of our nature, and there is a permanent flow of energy, information and substances between ourselves and the world in which we live.

A team of researchers in Montpellier has just published an interesting study beginning to try to examine and understand how chemicals in our environment bring about changes in our bodies.

They examined forty common chemicals which are found in the environment and in human bodies. Each of these chemicals has been tested on its own as part of state regulatory processes. Each one on its own has effects on the body, but not large effects (according to the studies). But of course, in the real world they don’t exist in isolation, so what happens when more than one of them is present at the same time?

As the researchers said, one and one normally make two, but when they studied the effects of the different pairs of these forty chemicals (780 variations of pairs in total) they found that sometimes one and one made fifty, or even a hundred. What they mean by that is that as they work together two chemicals don’t have a simple additive effect. Instead their combined effect can be many, many times greater than simple addition would suggest.

There’s an obvious reason for this. As complex adaptive systems, the cells in a human body are connected in a non-linear way, not a simple, linear one.

This study examines the effects of these particular chemicals on a particular receptor in a cell, (“pregnane X” receptor). They looked at this because chemicals have been shown to affect hormone systems within the human body causing widespread changes in the immune and inflammatory systems by interacting with such receptors, potentially setting off chronic metabolic and physiological disturbances in a person.

There study showed that one particular pairing of chemicals worked together as a kind of double key i.e. neither chemical could fit the receptor site, but when the two types of molecule combined they made the shape of a key which resulted in a much better fit to the receptor. So, singly, they produced little activity in the cell, but together their effect was multiplied 50 to a hundred fold. (The two they highlight are a pesticide and chemical from the contraceptive pill)

This is a small study only looking at the effects of pairs of chemicals in a set of forty, and only looking at the effect on a single receptor site. They point out that there are over 150,000 man made chemicals in our environment.

I’ll say that again.

There are over 150,000 chemicals in our environment.

Not just 40.

How many combinations can there be? How many combination effects might there be? Besides this particular one they have demonstrated. And the receptor site they studied is only one of many such sites in human cells.

A bit scary, huh?

They say they would now like to study the effects of pairs of 1600 prescribed drugs.

Are you a little surprised that we know so little about the real world effects of the presence of combinations of chemicals and medicines in the human body?

Well, thank goodness, we are beginning at least to explore real life complexity and stop pretending that single agents can be sufficiently studies in isolation.

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Taste

Posted in from the consulting room, from the dark room, from the living room, health, life, personal growth, philosophy, photography on August 29, 2015| 1 Comment »

I moved to France last November, so this has been my first summer in the Charente. Before moving here I lived for many years in a top floor apartment on the edge of Stirling in Scotland. We had fabulous views of the mountains and the volume and light in the flat, created in an 1830s textile mill, was fantastic.

Moving to France gave us the chance to live in a traditional Charentaise “long house” with a garden and a “potager” (a vegetable plot).

Here’s a photo of yesterday’s harvest. We don’t have a large potager, but look at this!

What a photo can’t convey however is taste. The taste of vegetables straight out of the garden is something else. The yellow courgettes are a relevation to me. I could really take or leave courgettes up till now. These fresh yellow ones are like something I’ve never tasted before.

We’ve tried a range of varieties of tomatoes this year and they sure would all fail the supermarket standards of shape and size but, wow, what the supermarkets are missing out on! Turns out flavour trumps size and shape by a long, long way. I didn’t know tomatoes could taste this good. I didn’t know tomatoes could taste this different!

Finally, look at the huge, red chilli peppers. For some reason, fresh chilli peppers are not easy to find in this part of the world, and we were advised that whilst they might grow outside here, they wouldn’t have much taste. The advice was correct in that they sure do grow outside here. Our chilli pepper pland has produced these beauties in abundance, and there are many, many more just waiting for a bit more sun to turn this glorious red. But the advice was definitely wrong about taste. They could blow your head off! Zinging with spice!

My general theory of a good diet has been pretty similar to Michael Pollan’s food rules – “eat food, mainly plants, not too much”. But one of the things he misses in those rules is flavour. And is there any better reason to eat something than that it delights your palate?

So, what I’d add in is, try to eat food which has traveled as short a distance as possible from where it grew to your plate. When you do that, you get the following –

  • food which is the freshest it can be
  • food which has had the least amount of processing
  • food which has the greatest variety of sizes and shapes
  • food which is most likely to be seasonal

I reckon that, depending where you live, you might not manage this “rule” – let’s call it “advice” – too often, but you know what they say – “every little helps”.

Oh, the other thing I think that Michael Pollan’s food rules miss out on is where you eat and who you eat it with. There’s more to food than “fuel” or measurements of constituents – so much vitamin whatever, such a percentage of protein, fat, carbohydrate, and so on – food’s to be enjoyed, savoured and shared, as well as digested!

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Not knowing

Posted in books, from the consulting room, from the dark room, from the living room, from the reading room, health, life, personal growth, philosophy, photography on August 16, 2015| 1 Comment »

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The skies above this part of the world are often very clear so I’ve taken to star gazing at night when I can. Wherever I point the telescope it shows me more stars than I ever knew existed. It’s hard not to be humbled by the immensity of it all. But what struck me last night as I looked at the stars was how much I didn’t know.

It’s not a new thing for me to wonder about what I don’t know. I remember years ago reading an article in the British Medical Journal about medical education saying that all the best ongoing education starts with saying “I don’t know” – yet that was the one phrase we were all terrified to say as we our teachers singled us out to ask us questions on teaching ward rounds or in the lecture theatre. It’s a phrase which brought shame and condemnation. If you didn’t feel an idiot before you said it, you sure did afterwards! So, it was refreshing to read the opposite – to read the idea that only if you could say “I don’t know” could you open up the chance to learn something.

Many, many years later I came across the works of Montaigne, and was delighted to find that one of his most used phrases was “Que sais-je?” (not exactly I don’t know, but “what do I know” – still a humble admission of the limits of personal knowledge).

Throughout my career, although I practiced as a holistic doctor and was fortunate enough to work for much of my life in a service which prioritised time spent with patients, I often found myself saying to patients that even if they’d told me things they’d never told another soul (and that was a common remark made by patients), I thought it took a lifetime to try to really know yourself, let alone another person, so although I was about to share some insights with them about what was happening in their life, those insights were limited by the small amount I knew about them. You see, how much you know is always a relative term, but it surely is always (in the bigger scheme of things) a small amount.

When I posted yesterday about the Japanese lantern I had to check out on wikipedia just what those lanterns were and yet again I was faced by having to say to myself that I didn’t know enough about botany.

Strange that that awareness and the sharing of it is still something which comes with a discomfort, because, really, I believe that the world would be a much better place if we were all more aware of the fact that what we don’t know is always so much more than what we do know.

While I was writing this, Hilary (who didn’t know what I was writing about) read out a quote to me –

The problem with the world is that the intelligent people are full of doubts, while the stupid ones are full of confidence.

……Charles Bukowski

Earlier today, what provoked me to write this post was reading the following quotation from Parker Palmer on the Brainpickings site –

What I really mean … is be passionate, fall madly in love with life. Be passionate about some part of the natural and/or human worlds and take risks on its behalf, no matter how vulnerable they make you. No one ever died saying, “I’m sure glad for the self-centered, self-serving and self-protective life I lived.”

Offer yourself to the world – your energies, your gifts, your visions, your heart – with open-hearted generosity. But understand that when you live that way you will soon learn how little you know and how easy it is to fail.

To grow in love and service, you – I, all of us – must value ignorance as much as knowledge and failure as much as success… Clinging to what you already know and do well is the path to an unlived life. So, cultivate beginner’s mind, walk straight into your not-knowing, and take the risk of failing and falling again and again, then getting up again and again to learn – that’s the path to a life lived large, in service of love, truth, and justice.

I couldn’t agree more.

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