Heroes Not Zombies

How we learn – teaching and training

February 2, 2008 by bobleckridge

Pick the Brain has a great post about teaching and learning. It’s called The Movie Director’s Guide to Effective Teaching. In it, Victor Stachura, the author refers to William Glasser’s theories. Well, this is new to me. I’ve never heard of William Glasser. If you have, what do you think about his ideas and his suggestions? There’s a William Glasser Institute and my little browsing there so far has interested me. I want to find out more. Victor Stachura highlights something he read about learning and teaching from studying William Glasser –

“We Learn . . .
10% of what we read
20% of what we hear
30% of what we see
50% of what we see and hear
70% of what we discuss
80% of what we experience
95% of what we teach others.”

I don’t know about you, but that seems intuitively correct to me. I might take issue with the actual figures used and I also think it doesn’t allow for the processing preferences highlighted from the work of things like the NLP approach which helps us to understand that we are different and some process auditory information better than others, some visual information, and yet others kinesthetic information. However, with that in brackets, the overall thrust of this seems right.

If you are involved in teaching this is an important observation and if you want to learn, it’s equally important. It certainly highlights the importance of what is known as active learning. Sitting attempting to learn passively by just listening or just watching something isn’t easy. But when you have something to read, something to see and to hear, and then you discuss it, you will learn so much more. The challenge beyond that I think is to experience and to teach. I don’t know if you can experience much in a classroom, can you? Don’t you need to get out and actually live what you’re learning? I certainly think that’s true of medical training. Can’t see how you become a good doctor without actually doing it! That last step of teaching so works for me! I find that almost every time I teach, not only in the preparation stage, but also in the delivery, I learn something new myself.

I ran a training day based around characters in Lord of the Rings last week and not only did it convince me that I’ve learned more about my subject than ever, but the feedback from the students was about the best I’ve ever had. The day involved film clips from the Lord of the Rings movies and various small and plenary discussion groups. It was active and interactive all day long.

If you teach, how much do you use movie clips? I use them a lot. I find that not only do they combine the auditory and visual stimulation we need, but they are great for getting discussion going and, fundamentally, they provide the group with an experience – usually something involving both thought and emotion.

To return to the blog post which has seeded this one – the main focus of the piece refers to the “primacy-recency” phenomenon – the finding that we remember the first and last things in a sequence better than the things in the middle. Victor Stachura recommends we deal with this in teaching not just by putting important information at the beginning and the end, but by breaking up the lecture every 15 minutes with some audience exercise, or discussion, to keep attention from waning. He points out that good movie directors know this and change the pace of the movie frequently to achieve a similar effect.

Posted in creativity, education, from the reading room | 4 Comments »

The statins debate

February 1, 2008 by bobleckridge

Des Spence highlighted the rather selective way statistics are used to support promotion of drug treatments to prevent disease. In particular, he has focussed on the heavy promotion of statins to control cholesterol levels in the blood. Several doctors have written in to the BMJ in response to this article.

Malcolm Kendrick, who has written The Great Cholesterol Con, says (in referring to the statistic that to prevent one death a year you have to treat 700 people)

let us assume thatyou do gain one entire extra year of life for every 700 yearsof taking a statin. Then, clearly, if you treat for 700 yearsyou will create one added life year.

Using this (overoptimistic) figure means that if you treatedsomeone for 30 years you can expect to provide them with 30/700added years of life. This is 15.64 days, or, a shade over twoweeks.

In short, if a 50 year old man asked you how much longer hecould expect to live if he took a statin for 30 years you caninform him “just over two weeks—max.”

(it’s also worth watching his exploration of what DOES cause heart disease – here it is……………it’s for a medical audience so is pretty technical!)

Peter Davies asks for inclusion of statistics of relevance to the patient who will actually be taking the medicine –

Any trial generatesfour summary numbers: relative risk reduction, absolute riskreduction, number needed to treat, and personal probabilityof benefit.

Each number is useful and gives some information, but no onenumber gives us the whole truth about the information. Usingone figure on its own, particularly the relative risk reductionabove all others, is very risky.

Each figure takes a different viewpoint on the evidence. Therelative risk reduction is a public health (area wide) prediction.

The absolute risk reduction puts the starting risk back intothe frame.

The number needed to treat measures the workload needed to achievethe relative risk reduction. It’s the beginning of healtheconomics.

The personal probability of benefit answers the patient’squestion, “What’s in this for me?”

Peter Davies has written an excellent piece in the studentBMJ about this problem with interpreting the value of “evidence”, with this excellent conclusion –

Acknowledging the various perspectives on data will lead us away from simple statements such as “this works” and “the evidence shows” towards more specific statements of what works for whom and when. It leads us away from guidelines and back to intelligent negotiation, to distinguish treatment of an established disease from treatment for reducing the risk of a disease, whether as primary or secondary prevention. The gradual reclassification of risk factors as diseases, “risk factoritis,” has lead to confusion over applying evidence derived from populations to individual patients who may not need or want our help.

The parties involved all need to admit that they know part of the truth, but never the whole truth—whether about the evidence, the patient, or the disease. The next time anyone tells you that “the evidence shows that this treatment works,” ask, “From what perspective does this seem to work?” If they do not understand your question, then they do not fully understand the evidence.

It’s good to see this discussion in a mainstream medical journal. There are some hard questions about the direction of medicine which need to be asked. The reliance on medication for a “healthier” life is one of them.

Posted in health | 10 Comments »

The importance of story

January 30, 2008 by bobleckridge

The people who come to see us bring us their stories. They hope they tell them well enough so that we understand the truth of their lives. They hope we know how to interpret their stories correctly. We have to remember that what we hear is their story.

Robert Coles in “The Call of Stories”.

Stories have always fascinated me. I love them. Every day when I sit in my consulting room patients tell me the most amazing, fascinating and unique stories. As a medical student I was taught how to “take a history” – I hate that phrase actually – who’s doing the “taking” and what exactly are they “taking” and from whom? Doesn’t seem right to me at all. Instead I prefer teaching medical students how to listen to patients’ stories. However, the point is that this is the beginning of all diagnosis. To a certain extent listening to the patient’s story is a diminished art. There’s an over-reliance on technology and a lot of doctors just don’t seem to be able to make a diagnosis without a test these days. Diagnosis is a form of understanding. It’s a process of trying to make sense of somebody’s experience.

If stories are so important in clinical practice, then how can I learn to handle them better I wondered? There is a developing area of medicine known as “narrative-based practice”, with associated “narrative-based research” methodologies, but materially-orientated, reductionist scientists look down on narrative. They prefer data. So, when I started to study narrative (which, technically is the story AND the way that story is told), I couldn’t find much work from a scientific perspective. I had to turn to the humanities.

One of the books which I really love in this area of study is “On Stories” by Richard Kearney (ISBN 9-780415-247986). Not only is it a fabulous exploration of the place of story in human life, but it’s written completely beautifully. Richard Kearney is a philosopher but he’s also a magnificent writer. This one book taught me more about the importance of story than any other.

Telling stories is as basic to human beings as eating. More so, in fact, for while food makes us live, stories are what make our lives worth living.

This sets stories at the heart of human existence – not optional, but essential.

Aristotle says in “Poetics” that storytelling is what gives us a shareable world.

The key word there is “shareable”. It’s through the use of story that we communicate our subjective experience and its through the sharing of subjective experience that we connect, and identify with others.

Without this transition from nature to narrative, from time suffered to time enacted and enunciated, it is debatable whether a merely biological life could ever be considered a truly human one.

Beautifully expressed. Sets narrative at the heart of what it means to be human and stands it against those who would take a materialistic view of life which they claim can be reduced to data sets and DNA.

Every life is in search of a narrative. We all seek, willy-nilly, to introduce some kind of concord into the everyday discord.

This is one of my favourite lines in the whole book. This is exactly the power of story – it enables us to “get a handle on” life, to bring some kind of order out of chaos.

What does Richard Kearney mean by story then? Well, I’ll finish this post with two more quotes from his book which make it very clear and very simple.

When someone asks you who you are, you tell your story. That is, you recount your present condition in the light of past memories and future anticipations.

This shows that story collapses time, bringing the past and the future into the present. Story telling requires memory, imagination and expression.

Every story requires –

a teller, a tale, something told about, and a recipient of the tale.

Nice and simple, but what profundity lies in there. For every story, there is a unique human being doing the telling, there is the story itself and its subject matter, and, very importantly there’s the recipient – the listener or the reader. Story is, as Aristotle said, a way of creating a shareable world. That’s the greatest potential of blogs, I reckon. By sharing our stories we create a shared world. Yes, sure, stories can divide as well as connect, but without stories, there is no potential for connection, no potential for compassion and no potential for the creation of a meaning-full, and better world.

Posted in books, creativity, from the reading room, life, narrative, philosophy | 39 Comments »

Response to another attack on homeopathy

January 30, 2008 by bobleckridge

Sunday 13th January, the Sunday Times in Scotland published an attack on homeopathy by one of their journalists, Joan McAlpine. (Sorry I can’t put a link in cos the Sunday Times doesn’t bother to put their Scotland-only articles on their website) The “stimulus” for the article was a written answer to a question in the Scottish Parliament which showed the cost of GP prescriptions for homeopathic medicines in Scotland. There was nothing really new in the attack – same old arguments really – but what bothered me most about it was the headline describing homeopathy as a “sick fantasy”, the claim that homeopathy was “dangerous” and the dismissal of patients’ reports as being just about feeling better (the implication being they were not really better).

The paper published an edited version of my letter on Sunday 20th but I thought I’d just put the full letter here for you to read.

Dear Madam

£250,000 spent last year by the Scottish NHS for “alternative” drugs? What an outrageously small amount! In the same year the Scottish NHS drugs footed a £1 billion pound bill to the drug companies for prescribed medicines. Yet, 90% of all drugs only work in 30 – 50% of the people who take them. Deaths from homeopathic medicines in the whole of the UK in 2006? Nil. Deaths from prescribed drugs? 1013 reported (over 10,000 estimated). Cost of Adverse Drug Reactions to homeopathic medicines? Nil. And to prescribed drugs? About £500 million a year.
Let’s be clear. Human beings are not machines. What works for one person may not work for the next. Health care needs to be diverse. We need more research into non-drug, non-surgical treatment options and we need to make more available on the NHS inexpensive, safer treatments, such as homeopathy which two out of three patients report is of benefit to them. And while we are at it, Joan McAlpine, let’s stop the arrogance of dismissing the relief of human suffering as “sick fantasy”. If someone says their pain has gone, it has. Prove it hasn’t! If someone says their depression has lifted, it has. It’s time to start putting patients first. At Glasgow Homeopathic Hospital we are, like all good doctors everywhere, successful because we listen to patients and believe what they tell us. We could do with more of that on the NHS.

yours faithfully

Dr R W Leckridge

Posted in from the consulting room, health | 18 Comments »

When you look at something from another angle, it completely changes

January 29, 2008 by bobleckridge

I just came across this ad. It’s clever.

Watch it right through. Then watch it again.

Posted in creativity, from the viewing room | 1 Comment »

Happiness the Confucian way

January 28, 2008 by bobleckridge

Psyblog has a good post about happiness from the perspective of Confucian teaching in the light of modern discoveries. I was particularly attracted to the quote by Confucius at the start of the post –

“The one who would be in constant happiness must frequently change.”

I’ve often said that one guaranteed “fact of life” is that everything constantly changes. Nothing stays the same. There’s an old story told of a ruler asking for a speech which he could use in ALL situations, and several of his philosophers and teachers taking on the task and failing, until finally, one man gives him the speech which works in all situations (another version of this story involves King Solomon looking for a ring which will relieve his suffering which he fears will go on forever, and he is given a ring with a few words carved into it) What was the speech? Same as the words in King Solomon’s ring –

THIS TOO SHALL PASS

That’s a recognition of the reality of constant change. Japanese culture holds transience in much greater esteem than many other cultures. That’s partly why they greet the blossoming of the cherry trees every Spring with such enthusiasm. (if you’re ever in Japan in the Spring you’ll see thousands of people out photographing the cherry blossom and photos of the earliest blossom will appear on the front pages of the national newspapers). To be in touch with the cycles of the seasons and to celebrate the changes between them can bring great pleasure.

A fundamental characteristic of a complex adaptive system (CAS) is that it constantly changes, constantly adapts.

The first two lessons in the Psyblog post are “Invest in intimate ties” and “Embrace society”. Both of these emphasise the importance of engagement – along with adaptation, one of the key characteristics of a healthy CAS.

The other lessons are interesting too, including “have fun” and “educate yourself” – both of which are about creativity and growth – the third of the characteristics of a healthy CAS.

Posted in from the consulting room, from the reading room, health, life, psychology | 5 Comments »

Healing trees – Cinchona

January 27, 2008 by bobleckridge

In an earlier post I wrote about significant trees and said I’d tell a couple of healing tree stories. Here’s one of them.

The Cinchona Tree is famous in the history of medicine. It’s a member of the Rubiaceae family (the same family of plants which coffee comes from). Actually there are 25 different species of Cinchona trees, and the one in question is “Cinchona officinalis“, which is native to Peru. Here’s the story –

The wife of the Viceroy of Peru, the Countess of Chinchon, fell sick with a high fever shortly after arriving from Europe in 1630. The local Spanish Jesuit priests had been taught to treat fevers by the indigenous Peruvian people. They used a preparation of the bark of the Cinchona tree. So, they treated the Countess with this and saved her life. It’s most likely that the fever she suffered was malaria, and we now know that the Peruvian tree bark contained a lot of “quinine”, which is still a staple treatment for malaria. Whether or not, the Countess of Chinchon ever really did get sick and was successfully treated with the bark of this tree will never be known but most historians think it is a myth.

Whatever the truth of the matter, the key players in the discovery of this tree’s power to cure malaria and the spread of that knowledge is down to the Jesuits. It was a Jesuit apothecary in Peru who heard about the local use of this bark to stop “shivers” in fevers and knowing the severity of the “shivers” in malaria he decided to try it out on sufferers with spectacular results. The Jesuits brought the bark back to Spain and Italy, where it became known as the “Jesuits’ powder“. It’s interesting that aligning the medicine so definitely with the Jesuits led to it being a highly controversial and contested form of medicine for decades. The Protestants were none too keen to accept a Catholic medicine! However, it was successful in case after case of fever, and it was produced, cultivated and distributed worldwide by the Jesuits.

The story of the discovery of quinine is beautifully told in “The Miraculous Fever-Tree” by Fiammetta Rocco (ISBN 0-00-257202-8). It’s a great read and brilliantly researched. In her book she gives many examples of the enormous impact of malaria on events in world history showing how both the disease itself, then, later, the successful treatment of the disease with this drug, probably determined the course of history on a number of occasions.

This “fever tree” is also a key part of the origin of a whole therapeutic practice. Dr Samuel Hahnemann, 1755 – 1843, a German doctor, was translating Cullen’s Materia Medica (the guide to medicines prescribed by doctors at that time) and he read of Peruvian Tree Bark (Jesuit’s powder) as a treatment for “Swamp fever” (malaria). Cullen said it worked by being an astringent (it dried the body up) and Hahnemann wondered if that was true, so he prepared some and took it himself to study its effects. Much to his surprise he developed all the symptoms of a patient with Swamp Fever. This was his discovery of the principle of “like cures like” which led to the creation of a therapy known as homeopathy.

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Think before we act? Turns out we don’t……and that’s the truthiness

January 26, 2008 by bobleckridge

How do you think the brain and body work together? A lot of people reckon we figure out what we want to do first, then our brain moves into a kind of second phase and make the body do what we’ve decided we want to do. Seems logical, huh?

Well, it turns out it’s not like that. Here’s an interesting study which shows that the brain and the body work at the same time, not brain first, body later! A group of psychology researchers asked people (yes, college students again….you have to watch out for those psychology studies, they mostly use college students as their guinea pigs, and do you think college students are typical?), sorry, lost the thread a bit there, they asked people questions and observed what movements their arms made on the way to either the “no” or the “yes” buttons on the computer. They found that in response to the more ambiguous questions the students’ arms moved more between the buttons, than they did on straight forward questions. What that means is that they could be seen to dither a bit before answering the ambiguous questions. Their arms and brains were working together – simultaneously. It gets more interesting……..they dithered more towards “yes” when answering a “no” question than towards “no” when answering a “yes” question, suggesting that people have a general bias towards assuming a statement being true.

These dynamic data showed that participant arm movements had lower velocity and curved more toward the alternative response box during ‘no’ responses than during ‘yes’ responses—suggesting that we experience a general bias toward assuming statements are true,” the authors explained.

The authors conclude that this shows we lean towards “truthiness”.

You know, I’d never seen that word before, but when you go searching on the net about it you can find LOADS. Start here at wikipedia. The word seems to have been made up by, or at least given a specific, new definition by comedian Stephen Colbert. Here’s his explanation –

Truthiness is tearing apart our country, and I don’t mean the argument over who came up with the word…It used to be, everyone was entitled to their own opinion, but not their own facts. But that’s not the case anymore. Facts matter not at all. Perception is everything. It’s certainty. People love the President because he’s certain of his choices as a leader, even if the facts that back him up don’t seem to exist. It’s the fact that he’s certain that is very appealing to a certain section of the country. I really feel a dichotomy in the American populace. What is important? What you want to be true, or what is true?…

Truthiness is ‘What I say is right, and [nothing] anyone else says could possibly be true.’ It’s not only that I feel it to be true, but that I feel it to be true. There’s not only an emotional quality, but there’s a selfish quality.

What lies behind this, as he highlights, is that old need for certainty. Human beings don’t handle doubt very well. There’s a strong tendency to seek certainty and when that is applied to beliefs (whether religious or scientific) it leads to that statement in the above quote – ‘What I say is right, and [nothing] anyone else says could possibly be true.’Don’t know about you, but I prefer to find a way to deal with doubt. It’s more real. Truthiness doesn’t leave much room for dialogue.

Posted in from the reading room, psychology | 5 Comments »

Laughter and smiling…..two great medicines

January 25, 2008 by bobleckridge

Dr Tom Bibey’s blog is worth reading. He’s the kind of family doctor I like. He recently posted about laughter and I thought I’d post this just for him and his good wife. Hope you enjoy it!