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Linked

Posted in from the reading room, health, life, science, Uncategorized on October 17, 2007| 23 Comments »

Smart World starts by acknowledging the work of two others – Albert-Laszlo Barabasi and Andy Clark. I’ve just read Linked by Barabasi. (ISBN 0-452-28439-2) It’s a fascinating book about the rather young science of networks. I agree with the author, that understanding how networks are created and function is going to be absolutely key to our future direction in science.

A network, quite simply, is made up of nodes and links. One example is social networks. Think of a piece of paper with the names of several individuals on it and lines drawn between the names of people who know each other. It’s remarkable how quickly information can spread around such a network. Maybe you came across the movie “Six Degrees of Separation” – a story based on the premise that there are only an average of six links between any two human beings on the planet. Turns out that idea, which apparently came from a Hungarian short story, is pretty accurate. But there’s a twist…….sometimes the number of links is way less than six (even between people who don’t know each other). Other kinds of networks you are familiar with are the maps of flight routes you see published in airline magazines, the power grid, and, yes, our dear World Wide Web. In fact, everywhere you look, you’ll see networks. Everything is connected. Nothing exists in isolation.

To try and understand how networks develop and how they function, Barabasi takes you on a journey through the world of mathematicians, physicists, social scientists and engineers. It’s quite fascinating. In the process he describes a very clear evolution of this new science. Intially, complex networks were thought to be completely random. But randomly created networks produced by computer modeling turn out not look like real world networks. Real world networks don’t have random distribution of nodes. Some nodes are way more connected than others. Barabasi calls these hubs. Once you introduce the concept of hubs, the mathematical modeling of networks reveal what are known as “power laws” (this is a bit beyond me I’m afraid – maybe Phil can help explain these?) but, as I understand it, if you take a single quality or characteristic in nature, say, height of individual human beings, you’ll get a bell curve. Bell curves look symmetrical and they have steep sides ie there aren’t many “outliers”. Complex, natural networks however have node distributions which can’t be described by bell curves. Instead you get a small number of highly connected nodes (hubs) and a huge number of less connected ones. This characteristic produces incredibly resilient and fast networks.

Real life networks are highly resistant to damage and they adapt to change. You can take out lots of nodes and not make much difference to the functioning. To really damage them you have to go for the hubs. Take them out and you bring the system down catastrophically. So, the structure of networks provides both their greatest strength and their greatest weakness.

Barabasi gives masses of great examples, from epidemiological spread of viruses like HIV, to the functioning of international economic markets, to the spread of ideas throughout civilisations. But one of his most interesting analyses is his critique genetics.

How often do you read about “breakthroughs” in mapping the genetic “origins” of various diseases – all with the promise of predictive genetic tests and of treatments based on what is known as pharmacogenomics – finding which genetic precursors determine the responses to which particular drugs. He dismantles this reductionist view very effectively and promotes a network model instead – making what I find to be a convincing argument that the genetic bases of diseases won’t be found in mapping the genome but in mapping the networks of genes.

This shift in perspective is crucial. It drives us away from a reductionist consideration of elements and parts towards a holistic consideration of system function by understanding nodes and their connections. He even terms this “postgenomic biology”. I like it! However, it’s at this point that he suddenly disappoints. His chapter 13 is very odd. It’s entitled “Map of Life” and in it he takes this idea of postgenomic biology and applies it in a bizarrely reductionist way, predicting that the future of medicine will be in tests and highly individualised drugs based on eliciting these genetic maps. He thinks you won’t need consultations with doctors any more, just simple blood tests which will be computer analysed and targetted, tailored drugs will then be kind of published on demand and delivered to your door and, voila! you have your own special cure!  I’m sorry, but I don’t buy this. I mean, I believe that if we could produce a new generation of highly specific drugs rather than the blunderbust ones we use now that would be great, but what happened to this idea of the science of networks, and how they would change our understanding of everything? Suddenly Barabasi leaps into a reductionist model of disease and healing which is predicated on the idea that each individual is indeed an island. Hasn’t he just spent the rest of the book showing us the importance of mapping connections? Isn’t every individual in fact massively connected not only to other individuals but to all kinds of environments. Isn’t it impossible to understand an individual as context-free?

However, don’t let chapter 13 put you off. He really is onto something extremely important here. Once you start to think this way you see networks everywhere and you begin to understand the inescapable importance of connections, and, interestingly, of hubs. We’re at the beginning of this science and I think it’s pretty exciting.

Those of you who have read other posts on this blog will be familiar with my references to Deleuze. His philosophy of networks – he preferred the model of the rhizome – predates this scientific development and has probably been one of the important nodes from which this area of study has grown. You’ll also be familiar with the concept of the Complex Adaptive System which I believe is the best model we have so far for understanding human health and illness.

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Patients first

Posted in from the consulting room, health on October 14, 2007| 3 Comments »

The easiest way to offend a patient is to fail to engage with their reality by projecting our assumptions, theories and realities upon them. – Brian Bloom. Meaningful Disease.

There’s an awful lot of arrogance around these days. So many people seem to assume they are the sole possessors of The Truth. In my own sphere of work, I frequently read pontifications from non-clinical “scientists” berating doctors and patients. The arrogance usually takes the form of a fairly abusive attack on anybody who claims a benefit from a therapy which the “scientist” doesn’t support. It’s a “Trust me I’m an expert” at best, and it’s “Just be quiet, I know better than you” at worst. Arrogance is never appealing.

My view is that a good scientist is a humble scientist and never claims to possess The Truth, never claims to know all that needs to be known about any subject.

A good doctor puts the patient first. As Brian Bloom says in the quotation at the beginning of this post, projecting their own assumptions or theories onto the patient is a failure to engage. A failure to engage is a failure to practice good medicine.

The balance of power has started to shift in the doctor-patient relationship. I’m glad. It’s time doctors cared about every patient they meet, put the patients’ agendas to the fore, and it’s time for us to reject one-size-fits-all treatments which actually never ever have fitted everyone.

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Why CBT is not the answer

Posted in from the consulting room, from the reading room, health, psychology on October 13, 2007| 3 Comments »

Darian Leader, co-author of Why do People Get Ill? has written an article about the proposal to expand CBT on the NHS in today’s Guardian. He points out that CBT (Cognitive Behavioural Therapy) has a high failure rate when considered over time. It is effective in the short term but many patients have either relapsed or developed other symptoms over an 18 month period. This is a common problem with a lot of medical care based on the very time-limited RCTs conducted for most treatments – in other words, whilst treatments can often be shown to do what they claim to do in the short term, very few several year long studies are conducted and pretty much almost NO whole of life ones which follow a life-course approach (please draw my attention to the right places if you know I’m wrong about this). This short-term-ist approach to health care keeps us all spinning round on the same hamster wheel. Until we tackle the harder questions of how to improve health, resilience, and the causes of disease, we’re going to be stuck with all these protocols of health care created on the back of short term solutions.

The issue of the problems with this current obsession with RCTs which are narrow in scope and short in duration is explored by Professor Paul Verhaeghe, Professor psychodiagnostics at Ghent University in his paper presented at Health4Life. There’s a twelve page pdf of his paper available at that link (It’s worth reading)

Darian Leader concludes –

Real mental health policy has to recognise that there are no easy answers, that human beings are complex and contradictory, and, most important, that we can never know in advance what will be best for a patient.

A true exploration of psychological suffering is perfectly possible in the framework of the NHS – if policymakers can think beyond mental hygiene and start listening to the patient.

How true! There are no easy answers. Human beings are complex and contradictory. It’s time to start listening to the patient.

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Empathy

Posted in from the consulting room, health on October 12, 2007| 3 Comments »

I’m big on empathy. I think it’s such an important quality for doctors. Cold, distant, doctors don’t appeal to me. But I also understand the importance of trying to keep the emotions which empathy stirs in check. If I sat in tears and distress with my patients all day, not only would I soon become lost in depression and despair, but I wouldn’t be able to meet any of my patients’ needs. There’s a balance to be struck, and the balance point changes constantly throughout the doctor-patient interaction. I can’t be a useful therapist unless I understand the patient. So, I have to begin, at least, with empathy. I need to do my best to put myself in their shoes, to try to understand their experience of the world and to try to figure out what’s going on in their lives. But then I need to call upon my knowledge and skills and access my previous experience and carry out whatever therapy seems appropriate. Actually this might not be a therapy stage yet, it might be a physical examination, or working out which investigations to suggest.

When I worked as a junior hospital doctor, one of my responsibilities was to be in charge of the cardiac arrest team. This was high pressure, dramatic work. Basically the shrieking pager was screaming that someone had just died and I had to run as fast as I could to their bedside to take charge of the other half dozen or so folk who had also run there to try and save this person’s life – to get their heart restarted, to get them breathing again. You can imagine how my heart was banging and how “wired” I’d be feeling. This was high energy, high stress. BUT everyone would say “I felt really anxious until Bob turned up, then you could see everyone became calm” Wow! I never understood that. How could people pick up “calm” from me when inside I was feeling anything but calm!

Well, here’s a fascinating paper where researchers decided to study empathy in doctors from a neuroscientific perspective. Actually, Clive Thompson’s most excellent blog, “collision detection” was where I read about this and he not only gives a superb summary but his reflections on it are also worth reading.

The researchers used a technique called functionalMRI scans which measures and displays brain activity as it happens. They got a group of doctors and a group of non-doctors to watch video clips of people having acupuncture needles inserted or of being touched with Q-tips. And they asked them to rate how much pain they thought the subjects were experiencing.

Among the control group, the scan showed that the pain circuit, which comprises somatosensory cortex, anterior insula, periaqueducal gray and anterior cigulate cortex, was activated when members of that group saw someone touch with a needle but not activated when the person was touched with a Q-tip.Physicians registered no increase in activity in the portion of the brain related to pain, whether they saw an image of someone stuck with a needle or touched with a Q-tip. However, the physicians, unlike the control group, did register an increase in activity in the frontal areas of the brain–the medial and superior prefrontal cortices and the right tempororparietal junction. That is the neural circuit that is related to emotion regulation and cognitive control.

They also asked the two groups to rate the level of pain they felt people were experiencing while being pricked with needles. The control group rated the pain at about 7 points on a 10-point scale, while the physicians said the pain was probably at 3 points on that scale.

So, it seems that doctors learn how to shut down the empathy functions of the brain. Now, you can argue that’s a good thing, or you can argue that’s a bad thing. I come back to my hero not zombie perspective. If a doctor goes on automatic pilot, he or she is likely to lose the ability to empathise and not even realise it’s happened. It’s important for doctors to be reflective and aware, so they can increase and decrease the empathy functions as is appropriate.

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Experience vs theory

Posted in from the consulting room, health on October 11, 2007| 9 Comments »

In the field of medicine there’s an interesting split between experience-based approaches and theory-based ones. I suppose it’s always been like that but in recent years Professor Sackett and colleagues’ approach to research has created something called “Evidence Based Medicine” (EBM) which, in it’s initial conception seems a very sensible idea, but which has, I feel, been distorted somewhat in recent years. Some people have taken Sackett’s method and applied the results to produce one-size-fits-all interventions and this was never the good Professor’s original plan. (He is in fact quite specific about the importance of the individual patient’s values and preferences in making treatment decisions). The one-size-fits-all approach is used to exert financial controls on health care and is promulgated by the “trust me, I’m an expert” brigade.

When it comes down to an individual patient, only this person can tell us about their pain or their other troublesome symptoms. Only this person can tell us what impact a treatment has made on their symptoms. In fact, we have all had the experience that a medicine which somebody else found helpful turns out to be hopeless for us (you can apply this to every form of medicine).

This was famously alluded to by Dr Roses of Glaxo who said –

“The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people,” Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

My daily work is as a practising doctor. My priority therefore is to try my best to help each individual patient I meet. Yes, if there is a theoretical benefit available from a particular drug, then I should consider it, but, it wouldn’t help the patient if I didn’t bow to their experience. There’s no point banging on with the same treatment which a patient is telling me is not working for them. I really dislike the arrogance of those who claim to know what is best for each and every patient on the basis of “research” or “evidence”. It turns out that many patients don’t actually get the benefits in experience which the “evidence” theoretically offers.

Let me be clear – research is a good idea. It helps us to see what potentials treatments hold. What it doesn’t do is tell us what this individual patient will experience as a result of this individual treatment. We need to retain our humility as practitioners and never assume we know for certain what a patient needs in the way of treatment.

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How we cope – learning from the movies. Part 5

Posted in from the consulting room, from the viewing room, health, life, movies on October 5, 2007| 2 Comments »

This series is about using the movies to help us understand how we are all different, how we experience the world differently and how we all try to cope with challenges and change in our own ways. One of the commonest responses to challenge, is to withdraw – to hide, retreat, shut down. It’s an especially common way to try to deal with hurts and disappointments. The downside of this strategy is that we disengage and can easily spiral down into depression.

To see all five parts of this series put the phrase “learning from the movies” in the search box up on the top right of the blog.

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How we cope – learning from the movies. Part 4

Posted in education, from the consulting room, from the viewing room, health, life, movies, narrative on October 5, 2007| Leave a Comment »

We all cope in different ways. In this series we’re looking at ways of coping in parts 3, 4 and 5. In part 3 we looked at the activist way of coping.

Now let’s consider control as a strategy. The world can be a very scary place. For many people the events that occur in their lives face them with overwhelming uncertainty and doubt. If we feel the world is scary and dangerous and random, one way to cope with this reality is to shrink daily life into containable, controllable pieces. People do this to try and reduce the uncertainty and randomness in their experience. They do this by introducing routines, habits and rituals. They do this by either trying to control their physical environment – cleaning and ordering – and/or by trying to control the people in their lives. Watch the following three clips to see what this is like if we take it too far!

I’ll consider the third strategy – withdrawal – in final part – Part 5.

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The celebration of who you are (the refusal to conform to stereotypes)

Posted in from the consulting room, from the reading room, health, humour, life, video on October 4, 2007| 3 Comments »

One of the things that depresses me most is the tendency to write off whole swathes of humanity by sticking a label on them and dismissing them. I sat on the train this week and two guys, a Scotsman and an American with a comb-over, spent the whole journey doing just that. Huge numbers of people were judged, given a label and dismissed.

Here’s an example “I work with medics. I know what they’re like. They’re only interested in one thing. Money.”

Here’s another “Everyone below the Mason-Dixon Line is an in-breeder”

Want more? No, I didn’t think you would.

So here’s a counter to all that. There is a beautiful piece of journalism in today’s Guardian about people with Down’s Syndrome. Read right down to the last paragraph – it’s the clincher! I meet people who says things like this every week. It never ceases to humble me.

And here’s another counter. Sugar Mouse in The Rain sent me a link to a video on youtube. (By the way, go see his blog. It’s lovely and he’s a lovely man) Here’s the video –

Thank you Sugar Mouse

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Sloppy thinking or sloppy reporting?

Posted in from the consulting room, health, science on October 4, 2007| Leave a Comment »

A study into herbal medicine hit the headlines in the UK today. It was conducted by a researcher at the Peninsula Medical School, Dr Peter Carter. What his team did was trawl through the world literature to see what randomised clinical trials into “tailored” herbal treatments – this means the practice of a consultation with a herbalist who makes up a particular prescription of herbs for each individual patient. They only found three studies and only one of the three showed the herbal treatment to be better than the placebo. Now, I’ve no knowledge or experience of herbal medicine, and I’ve no axe to grind for or against (although I would declare that the belief that herbs are safe because they are natural is a silly belief which could kill you!).

I don’t have something to say about herbal medicine but what strikes me about this report are the conclusions and/or the way they are reported.

The headline to this piece on the BBC news website is

Tailored herbal medicine ‘futile’

I read the article thoroughly and can’t find the word “futile” anywhere. Is it in the original study? It’s not anywhere in the BBC’s own report. So does the study show herbal treatment is futile? Actually, it doesn’t. It shows that if you look for randomised controlled trials of herbal treatments against placebo you’ll find only three and only one of them shows statistical superiority of the herb vs the placebo. Well you certainly can’t conclude from that evidence that herbal treatments work but you can hardly claim that the fact that almost nobody has bothered to study the subject scientifically means that herbal treatment is “futile”! This study doesn’t tell you that.

This is either sloppy thinking or sloppy reporting. As doctors say “There’s a lot of it about!” Remember this?

Have you come across any other articles or studies which make claims way beyond what the original research actually shows?

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How we cope – learning from the movies. Part 3

Posted in education, from the consulting room, from the viewing room, health, life, movies, narrative on October 4, 2007| 1 Comment »

One aspect of understanding someone is listen to their story and hear what they talk about – material, physical, practical issues? emotional and relationship issues? or spiritual issues of meaning and purpose? Another aspect is to find out what kind of ideas they have about themselves in relation to others – in particular to explore to what extent they see themselves as connected to, and identifying with, others, and to what extent they see themselves as separate and independant. I’ve explored this latter aspect in Parts 1 and 2.

But another key issue for all of us is how we cope in the face of challenges, and how we adapt to change. Just as I have a map of body, mind and spirit in consideration of the kind of world a person lives in, so I have a map of coping strategies, and again there are three – action; control and withdrawal. Let me reiterate that this is a dynamic map and whilst some people almost always seem to default to the same strategy, most of us are more flexible and use each and all of these strategies to different degrees.

Let’s explore to activist – the person who when faced with a problem or a challenge, rolls up their sleeves and gets stuck into it –

You can see it takes a certain self-belief to be able to cope with challenges this way!

We’ll have a look at control as a strategy in Part 4

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