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Archive for the ‘narrative’ Category

“one swallow doesn’t make a summer”

Yeah, I know, but, first of all I was trying to get a photo of about a dozen hyper swallows zipping and zooming this way and that above my head, but, hey, I only got one! And only just!

The fact I only got one (in the middle of a summer’s day, by the way) reminded me of that old adage about how spotting one swallow doesn’t mean that summer has arrived. Which brings me to the subject of anecdotes….

Since the rise of “Evidence Based Medicine” I’ve heard it said many times that anecdotes are not evidence, and that a whole bunch of anecdotes isn’t evidence either. Only rigorous, controlled trials, statistically analysed provide evidence. But my problem is that I spent my working life meeting, listening to, conversing with, and treating, one patient at a time. Each patient came and told me a unique story. Not a single patient told me an identical story to one I’d heard before. I tailored my treatments for each patient according to their unique story and the way things progressed from there was unique, and also unknowable.

I had no way of knowing whether or not an “evidence based” treatment would deliver the promised results in this particular patient. On the grounds of probabilities and experience, of course, I could go forward in good faith and with some confidence, but I learned that I always had to be prepared to be surprised when the patient returned. It seemed that no two patients experienced exactly identical effects of the same treatments. Didn’t matter whether I’d prescribed painkillers, antidepressants, anti-inflammatories, antibiotics (seeing a pattern here?) or whatever, the future course of an individual life was, and always will be, unique.

Unique and emergent.

Emergent – that means the future unfolds as it happens in ways which could not be wholly predicted from the knowledge of the past and the present. All living organisms display emergent properties. It’s a characteristic of all “complex adaptive systems”. 

So, whilst I could never generalise from an individual “anecdotal” experience to apply it to every other patient, the truth is, generalisations can’t be applied to every single patient either.

The tendency to dismiss individual stories as irrelevant to medical practice has always struck me as illogical. Irrational even. It might make sense in a research environment, but the individual story remains crucially important in the clinical one.

In deciding on a particular course of treatment with a patient I’d want to take into consideration what I’d learned was good practice, and what the research evidence had shown about the various different options, but, on the day, in the room, with this unique individual sitting with me, and, maybe even more importantly, when they’d return to report what had happened, THE most important thing was them – their story, their experience, their life.

I didn’t know any other way to practice – it was one patient at a time. Ultimately, the patient was always more important than any data – despite the fact a junior doctor told me, not that many years ago, that she’d been taught “Never listen to patients. They lie all the time. The only thing you can believe is the data”

Nope. That’s no way to practice Medicine!

Oh, before I finish, thinking of “one swallow at a time” reminds me of one of my most favourite books about creative writing – Anne Lamott’s “Bird by Bird”. Recommended.

 

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What do you see when you look up at a sky like this?

The first things to catch my eye are the patterns in the clouds. I just love seeing these ripples, waves and swirls. I can delight in densities and the transparencies. I love how the blue beyond shows through and appears as lakes, streams and rivers in the white land of the cloud.

Then the next thing that happens for me is noticing that some of these patterns here look familiar. They remind me of something else, in the same way that sketches and doodles do, in the same way that paintings and photographs do. My eyes are drawn to the blue zone in the cloud which I can easily see as a pair of lungs – well, I’m sure that’s at least in part due to my working as a doctor all my life – but the idea of a pair of lungs breathing this cloud into existence delights me! Bear with me for a moment longer, because, and this comes and goes for me, I can then see what looks like a head above “the lungs” with a face looking out towards the right hand side of the image. Sometimes that looks SO clear to me that it almost spooks me out! And then I look again and I just can’t see it.

If you’ve been reading the posts on this blog for a bit, you’ll know what’s coming next……the image sets of a train of thought for me.

This time what I start to think about is creation.

I love to see clouds emerge, change, and disappear before my very eyes. So often they look like a work of art, like a piece of performance art. I see it happen and it amazes and delights me.

This, I think, is the essence of the Universe – creation.

The Universe has been creating since its beginning. As best we know, first elements, like hydrogen and helium, then clouds and densities which form into stars, those sources of all the elements we know….and so on, with the rest of the Universe Story…..right up to the creation of the Earth – as far was we know, the only planet like this in the entirety of existence – yeah, I know, people tell you that there are chances there are other Earth-like planets out there somewhere, but we haven’t found any yet.

And on this Earth, creation continues, with the elements forming into molecules, molecules combining and synthesising to create cells, and so to living organisms, no two organisms living identical lives……to the most complex of living organisms in the universe (as best we know)….human beings, no two of whom have ever been, or ever will be, identical.

And so to this day, this day which has never existed before, and will never exist again, where every event, every experience, every body, is new today.

Creation. It’s the essence of the Universe. It’s the essence of Life. The constant, never-ending, creation of novelty, of emergence, of uniqueness.

Yep, all that from a cloud…..how’s that for a creative thought?

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One of the signature plants here in the Charente is the Hollyhock (“rose trémière”). They are astonishing plants which surge upwards of two metres and they produce glorious brightly coloured flowers. It’s not just their rate of growth and their ultimate towering stature which impresses me though.

What really attracts me to them is how surprising they are. You never know, from year to year, just where one is going to grow, you never know which ones are going to grow to the greatest heights and you have no way of knowing just when they are going to produce these fabulous flowers, not only at the tops of their stems, but apparently randomly along the length of each plant.

In a sense, I see them as the local Charentaise version of the Japanese cherry blossoms. In Japan the appearance of the cherry blossom is much anticipated and celebrated. More than their beauty, the blossom is a symbol of transience which inspires people to “savour the day” – because, like the blossom, nothing in life will last. It’s the transience of the cherry blossom which makes it so meaningful.

Well, for me, I equally anticipate the appearance of the hollyhocks and their glorious, towering flowers. I think because each and every one of these amazing plants stands alone, they inspire me to think about transience in a similar way to cherry blossom, but they do something else too. They remind me, every time, of how the future path of any individual life is so unpredictable.

Why should that be something to relish?

The essence of my working life as a generalist medical doctor was to meet with patients one at a time. I’d look forward to every Monday morning because it would be the start of a working week filled with people who would come into my room, sit down, and tell me the most amazing, unique stories.

No two people told the same story.

Understanding a patient’s story is a way of helping them to make sense of what’s happening in their life. It’s also part of what doctors call making a diagnosis. I always saw diagnosis as a level of understanding, not a conclusion, not a label, not a category to place a patient into, not a starting point in a protocol, but the beginning of an understanding.

With that initial understanding would come some sense of the past. In other words it could be the start of making sense of how the present illness had come about, what events and circumstances had contributed to it. But what also came was an opening up of a set of possible/potential futures. Doctors call such an analysis a prognosis. I’d look ahead, taking what knowledge and experience I had of people, of disease, of the typical life history of certain illnesses, and see this unique, particular patient in that context.

Doctors have to be careful when making a prognosis. It’s always only an estimate, an informed expectation. But at the level of the particular, the unique, the individual patient, the path ahead would only be revealed over time.

Remembering that kept reminding me to be humble.

Remembering that kept reminding me that in Life, we never have ALL the information. We always make our understandings and our predictions on the basis of partial, and limited information. There will ALWAYS be more to discover, more to learn, more to learn about everyone.

There’s a fairly new term in biology and philosophy to describe how the future unfolds this way. It’s called “emergence”. Emergence is the development of new patterns, new behaviours, new structures, which could not have been predicted in detail from the prior knowledge. It’s typical of all living organisms.

The individual hollyhock plants remind me of that. They demonstrate this “emergence” beautifully.

Their daily growth astonishes me. Their ultimate size astounds me. Their particular flowers amaze me. I know each seed holds this kind of potential, but I have no way of knowing which particular seed will grow a plant of this actual size, in this particular place in the garden, the driveway, the street, or the roadside.

See, for me, not knowing what lies ahead isn’t primarily a frightening thing. Sure, it’s possible to begin to imagine all the things which can go wrong, to press the fear and panic buttons, but that’s rarely very helpful. Instead, I found, and I still find, I look forward primarily with hope and a positive expectation, and if things don’t turn out that way, I reassess, take stock and consider a different future. It’s a process, not an algorithm leading to an end point. It’s a way of living, deepening and broadening knowledge and understanding at the level of the individual whilst looking forward, with realistic hope, as we interact with, and adapt to, the present.

It’s great to be astonished every day.

I love to be amazed and delighted at the unfolding present. I find it thrilling to witness the future making itself known through this phenomenon of emergence.

Hollyhocks do all that for me. Are there particular plants which are special for you? And why?

 

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One of my most favourite cities is Segovia, in Spain. Perhaps its most striking feature is the Roman aqueduct. It begins as a pretty average sized wall, then column by column, arch by arch it gets bigger and bigger and bigger, straddling the town below until it reaches the old castle.

In this first part houses have been built on each side of it. I don’t think I’ve ever come across such an astonishing structure running right down the middle a street!

One of the first of the town’s squares lies at the foot of the aqueduct just as it reaches its greatest height.

I find this SO inspiring! Here’s what it got me thinking last time I was there…..

Throughout my career as a doctor I saw time as linear. Perhaps because the second half of my working life was in a specialist centre for people with chronic (long term) conditions, I commonly heard patients tell me of the traumas which they had experienced prior to becoming unwell.

I was never someone who bought into a mechanical, linear view of human beings, or of life. Every patient I met convinced me that all these chronic ailments are multi-factorial. You could never say that “this” caused “all that”. But there was one question I frequently found revelatory.

“When were you last completely well?”

Sounds an easy question, huh? But, actually, it was often difficult, and took some time and conversation to find the time, perhaps even several decades ago, when the patient last felt completely well. I’d then ask about the year the patient moved from wellness to illness.

“Tell me about that year”.

It was often a year of significant trauma, or the culmination of many traumas. I don’t think that meant that the patient’s illness could all be attributed to that trauma, but it was a starting point in making sense of their experience and beginning to find the way forward.

Sometimes patients were clearly stuck with these unresolved hurts. Again and again they’d think about those times, feel bad about them all over again. Others were so traumatised that they were living lives of fear, continually looking ahead and wondering “what if….?” “what might happen?” “how will I cope if….?” and things like that.

In both of these scenarios I’d draw a straight line – and say, the left hand point of this line is your date of birth, the right hand, the date of your death. We know the first, and have no way of knowing the second. But right now, today, you are somewhere along that line. Where is your attention? Where is your focus? Because if it’s to the left of today, it’s in the past, and that doesn’t exist any more, except in your memory. If it’s to the right, it’s in the future, and that only exists in your imagination. You can’t have your attention in more than one place at a time, so what if you draw your attention into the present instead? How might that feel? And we’d then explore ways of living more in the present reality, than in the past traumas and future fears.

I think it was often helpful, but now it seems somewhat simplistic to me. Because I now see time is not as linear as I thought. In fact, seeing cycles and seasons of time makes rather more sense to me now. As I experience a place like Segovia I realise that the past doesn’t go away. It doesn’t disappear into memory. (and memory is not an artificial place anyway….it’s no dusty filing cabinet with the drawers all locked)

Rather the past is always present, always here, and always now. It fashions our every day. It colours our every experience. It sets the tone of today. It constantly challenges us to respond to it, to adapt. In fact, that’s how we learn isn’t it? By having an awareness of the past in the present? If we forgot and discarded everything we experienced how could we learn anything? We adapt by carrying with us the past into the present.

And although this is even more challenging, the future is here now too. Not least because the future is, in one sense, a “multiplicity of singularities” – a set of possible paths, which are, at least in part, fashioned by this present moment, and by each and every decision and action.

I don’t think the past goes away. I don’t think the old “time heals” is true in the sense that it makes the past go away. Instead I think we learn to adapt to it. When we become aware of the past in our everyday we have the opportunities to create new responses, new strategies of living under it’s influence.

OK, so, this is not where I thought this post would go when I pasted in those photos of the aqueduct! But here’s a related thought – how does the presence of the past in today, as we see in this colossal aqueduct stretching over Segovia, shape, fashion, influence, inspire, challenge, stimulate the thoughts, feelings and actions of the people living there?

And so, of course, even when the past isn’t as obvious as this aqueduct, how does it’s presence today influence our experience of today?

Here’s the final part of that story – we don’t heal just by shifting our focus, we heal by becoming aware, aware of the past AND the future IN this present day, and realising we can change how we respond to that. Realising our current patterns aren’t fixed. We can alter them.

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This small street in Segovia doesn’t look like much but up on the wall is this plaque –

Now, my knowledge of Spanish is very limited but I can see this is the name of the street – it’s the street of the door of the moon. The “Door of the Moon”! Oh, now, doesn’t that change things? What a name!

I’ve had a bit of a hunt online but I can’t find out much information about this street, or about the “door of the moon”, but I did discover there is also a “door of the sun” (of course!). When Segovia was a fortified town it had a wall around it, and to gain entry there were a number of “doors”, some of which were I think just wooden gates, and, as best I can tell, “the door of the moon” was one of those gates.

I haven’t come across any stories associated with these doors yet, but if any Spanish speaking readers here are inspired to do a bit of investigating I’d be delighted to hear what you discover!

For me, this is just such a romantic name. It inspires. It activates my imagination. Does it active yours?

See what a name can do? Doesn’t it whet your appetite for some stories? The stories which explain, or give meaning to, whatever has been named.

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Every year I’m amazed to watch the butterflies appear in the garden the very same day the buddleia bushes flower. I’m convinced they both appear at exactly the same moment. No idea how that happens! Are the butterflies just hanging out around the corner somewhere waiting for the blossoms to appear, then zip round as fast as they can the moment that happens?

However it happens, it’s a delight to see so many varieties of butterfly (and the hummingbird moths, which are incredible creatures!), to watch how they fly in such utterly unpredictable directions, how they spread their wings in the sunlight, or close them up so they look like little leaves.

But here’s one thought which comes up for me time and time again when I see butterflies….they make me more aware of the cyclical nature of life. These little creatures have such different life stages, so different you wouldn’t realise they were stages of the same life. Do we think of them as having a beginning and an end? Starting with an egg, progressing through their caterpillar stages, becoming a chrysalis, then emerging as a butterfly which lays eggs, then dies. Is that the life?

I suppose we do all think of ourselves as having a beginning and an end. But where do we begin, and where do we end?

It depends on whether or not you want to reduce a person to just a physical body. My physical body began with a single fertilised egg and this body will die.

But what about ME?

Do I really think I’m only a physical body? Don’t I have a sense of something immaterial too? A consciousness? A sense of Self? A personality? Characteristics, behaviours, values, beliefs, creative acts, destructive acts? Is there anything I can do which doesn’t ripple out into the world beyond me?

When I look at Rodin’s “The Kiss”, or “The Thinker”, what do I see? The product of the imagination and creative skill of the man called Auguste Rodin. When I listen to music composed and performed by people who are long since dead, isn’t there something I’m sharing there which only they could have created? Aren’t these great works of art the ongoing ripples of unique human beings? Or do you think these are just their footprints? (It doesn’t seem that way to me….these works seem full of life and the potential to continue to create and send out ripples into the universe)

And what about those characteristics, quirks or tendencies that I have which others in my “family tree” also exhibited, even perhaps before I was born? Anyone who explores their genealogy encounters remarkable “coincidences”, talents, life events, behaviours which echo down through the generations. Weren’t those threads present even before the egg which became me even existed?

I think it’s inadequate to narrow a person down to a physical body.

But even if we did, there is still the fact that the body changes continually. It never stops. There is a constant turnover of cells, new beginnings, new endings, every hour of every day. There is a continuous exchange of energy, materials and information between my body and my environment, and we all share the same environment, the same atmosphere, the same air, water…..we are all made from the same molecules, all created from the same “star stuff”.

So it seems to me that beginnings and endings are everywhere……wherever, and whenever, we happen to look.

But it also seems to me that they are nowhere. They just don’t exist. We all emerge from, and dissolve into, the great cycles of the universe.

Beginnings and endings are just where we choose them to be. But we can always make a different choice. We can always take a broader view, a bigger view, a longer view, a more holistic view.

I’m reminded of a song from my school days….it’s by Jeff Beck, and it’s called “Hi Ho Silver Lining” – he sang this truth right there in the opening line of this song…in the first five words……

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I see this sort of thing a lot when I look at old buildings in either France or Spain. This one is in Segovia.

What’s the first thing you notice?

The window?

Or the window in an arch?

See, when I look at something like this I really get to wondering….how did this come about? Did the original builders build a nice big entrance way, two verticals and a horizontal? Building a frame like a picture frame for an entrance? Maybe not….well, maybe not exactly anyway, because it looks like exactly the same bricks have been used to make the archway and some of the bricks seem to run between the two frames….the square frame and the arched frame. So maybe the original builders built an arched entrance and surrounded the arch with a frame?

But then it looks like somebody decided not to have an entrance there after all and filled in the space.

Then somebody else thought, hey, wait a minute, I’d like a window here and put in the window….but did they fit bars around the window at the same time?

So, has this window, this barred window, emerged over many years from a wall which was built in the space formed by an arched doorway?

And what was the thinking behind each of those steps in the development?

Make an entrance, an attractive, obvious entrance…..then block it up…..then make a window, but not one for letting that much light in, and certainly not one somebody might climb into, or out of…..was that, is that, a problem around here? People climbing in and out of windows?

Bear with me here but because I worked as a doctor for almost forty years this image sparks my thinking about patients and the problems they talked about in the consulting room. They’d bring the equivalent of this window….let’s say they’d talk about a pain (instead of a pane….ha! ha! sorry!)…..and I’d ask about the pain, asking them to describe it….its features, its characteristics, its exact location, what surrounded it, or accompanied it……and then I’d want to know how it arose. Tell me when it wasn’t there. What was there before it? What was happening when it began? And so, gradually, what a first glance might be a simple symptom turned into a unique, never before told, story…..and that’s where I began to understand what the problem might be.

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