Tuesday, March 18, 2014

Failure of Democracy in The Ukraine

There is a serious issue behind the present problems in the Ukraine that nobody is talking about. There has been a dire breakdown of democracy that needs explaining.


That should never happen in a democracy. Democracy should exclude the possibility of that ever happening. The president was elected by the populace and should represent their views, especially on such a fundamental issue as international alliegances and plans to either become integrated with the European Union or Russia. 

Usually, rebellions in democratic countries are undemocratic and led by minorities, usually the military who do not like what the majority voted for because it reduces their power. It has been a common scenario, particularly in Latin America in the latter part of the 20th Century. However, the initial revolution in the Ukraine was by the majority of ordinary citizens against the government that they had elected of their own free will.

That is worrying for any country that has a freely elected government. It is broken the country and led it to the brink of civil war. Democracy is supposed to make that impossible. It is supposed to assure the peace.

Worryingly, Western governments have taken major decisions without popular backing such as the UK being involved in the second Iraq war. However, in that case it was a new situation that the populace had not voted on. The incumbant government took a decision.

It was not the case in the Ukraine. These were current issues at the time that the government was elected.

Did the government say one thing in the election and then impeach itself once elected by doing a U-turn? I have not read of that happening.

So was it that a significant proportion of the Ukrainians had voted for the person rather than the policies? Did they get a nasty shock once those policies were enacted resulting in revolution against their own democracy?

The party that lost that election were pro-European. They could have voted for them but did not. That excludes the other fatal flaw in democracy, that the voter is not presented with the candidate and the policies that they want to vote for, as has happened in the Crimean referendum. The voters were not given the opportunity to vote to stay as a part of the Ukraine as it progresses towards the goal of unification with Europe.

Those that would have a socialist government in the US would say that they are only presented with the opportunity to vote for one of two parties that are considered centre right and extreme right in Europe. They would say that the 99% can only vote for the 1% and the status quo.

They would say that the democracy in the Ukraine was freer and fairer than that. It should not have gone wrong.
Something like that occurred in Mexico with the 2012 elections. The ruling party was voted out because of the war on drug traffickers which was killing 10,000 per year. The streets were terrifyingly unsafe in large parts of Mexico. Something had to be done. So Mr Peña Nieto was elected.

The day after the election, Peña Nieto announced that he would be continuing exactly the same militarised strategy as the previous party. The populace had voted for exactly the same policies that they had tried to vote against!

Peña Nieto had managed to get himself elected without once clarifying his policies and intentions in the most important issue during the election! The voters had not known what they were voting for!

How can you win an election without mentioning your policies on the major issue of the election?

Of course, you can side track into more minor issues and come out with slick hollow rhetoric whilst avoiding the big issue. 
The most sensible reason for voting for Peña Nieto I have heard was his reputation, based on his successes as the major of Mexico City. Others voted for his charisma. Peña Nieto is not just slick and extremely attractive, with a warm and winning smile. He is also married to a soap opera star. He is the height of glamour.

Unfortunately, such physical attractiveness, glamour and a nice smile does win or lose elections. Forget the policies. Candidates that look like Herman Munster will always lose. Losing 5 or 10% of the most superficial swing vote is critical.

Particularly in the US, UGLYISM is rife. Studies have been done on conviction rates in court of actors deemed to be beautiful and ugly. The results were even more concerning than the statistics for racial discrimination in the American court system. If you are perceived as beautiful, you can get away with almost anything.....

The post-revolution, interim PM Yatsenyuk is not much of a looker. Ex-President Yanukovych appears to have had him beat on that front. Certainly, he has the stronger face.... who cares about the policies.... I know who I trust to run this country.....

Such shallowness in politics and voting is dangerous. It is a major threat to democracy once the voters discover what they have voted for behind the smile. It can create an explosive situation.

Be warned. It can cause civil war and revolution.

Democracy was never envisaged in this way. The safe and adequate functioning of democracy is not unconditional. It is conditional on adequate education so that the population can go beyond the winning smiles and the charisma and cast a rational, informed vote based on the policies on offer. They need to vote for the policies, not the person.

It all comes down to a failure of education in educating a rational, informed decision making process for life. It comes down to a failure of the culture of Indepednent Learning. When education fails, a nation's peace is at risk. Democracy can fall....

Thursday, February 27, 2014

Does The Sperm Really Decide Gender?

Put simply, I do not believe that we have enough genetic or epigenetic knowledge to be sure that the sperm decides the gender of a child. I have a competing theory that eggs have predetermined gender and under natural cirumstances, will only accept a sperm of the appropriate gender, containing an X or Y chromosome.

We are still in the adolescent stages of genetics, the study of DNA. We still do not know everything and the Human Genome Project has flooded us with information that we do not, as yet, fully understand. Epigenetics, the study of the proteins that surround the central helical ladder of DNA, really is in its infancy. Epigenetics are important because it is these chromosomal proteins that act as regulators and on/off switches for the DNA. They decide the activity of the DNA genes that we have.

The new subject of epigenetics is of great importance in this discussion. The questions asked here have not been asked elsewhere. Nobody has thought to ask them so no investigation has been done. There are no answers.

Historical Background
When objective evidence is lacking, subjectivity always creeps in and makes the decision.

The reason that science wholeheartedly believes in the former theory and will not consider the latter is historical and anybody who has been taught genetics has been heavily indoctrinated in this unquestionable 'truth'. This 'truth', that it is the sperm that decides gender, was an inevitable conclusion in a misogynistic society. It was the next step from the theory, a quite bizarre misogynist theory, that the father contributed the entire life essence of a child that the womb of the mother only nurtured.

There are certainly precedents in a process of excluding societally motivated, machista beliefs from genetics and reproduction using the evidence.

It took a very long time for science to even conceive of the possibility that the mother might contribute the majority of inherited material to a child but it is proven. The father only contributes 50% of the chromosomal DNA but that is not the only form of chemical inheritance in the cell. Much of the contents of the cell are self generating and self reproducing. They come from the egg and the egg alone.

So we should perhaps suspect and question any theory of genetics, reproduction and evolution that we have inherited from a misogynist past of subjective bias. The She-Devil's Advocate of objectivity would propose and try to justify theories that might well have arisen if science had a matriarchal rather than patriachal past. A female dominated society would obviously have promoted the belief that the mother was more important than the father.....

Two Types of X Chromosome
All X chromosomes are not equal. There are two distinct types of X chromosome in a human cell. One is active and acts like any other chromosome. It is in the centre of the cell nucleus and engages in metabolic functions, such as the production of proteins.

Everybody, male and female, has one of these active X chromosomes in every cell. A cell is in metabolic balance with a single, functional X chromosome. So what happens to the second X chromosome of the XX female?

The second X chromosome of the female would overload the cell and make it imbalanced. What has evolved is that this second chromosome is excluded to the edge of the nucleus of the cell where it is largely inactive in genetic and metabolic terms. It is called the Barr Body and little is really understood about it. Investigations into the Barr Body are still ongoing.

The question is whether the Barr Body is simply functionally different to the active X chromosome but in every other way the same or whether there is some profound difference between and active X chromosome and a Barr X chromosome. It boils down to a question of whether the X chromosomes are readily interchangeable; an active X can change into a Barr X. If they can change, how easily and how often does it happen.

The functional difference is not about DNA but about function and activity. Perhaps the answers are Epigenetic rather than Genetic in terms of DNA.... that is where the on/off regulators are to be found.

If the difference between an active X chromosome and a Barr X chromosome are Epigenetic, we may speculate using the general first principles of Epigenetics. The proteins of the epigenes are more fluid and susceptible to change in life in response to the internal environment of the body. However, that is not to say that they change easily. Epigenes are inherited and they can endure for human generations without changing. It can take decades or a century for an epigene to change. In  practical terms of cell division, that is an age.

The epigenetics of X chromosome that decides whether they will be active or the Barr variant can change but in reality, it happens very rarely. An active X chromosome will usually stay as an active X chromosome. A Barr X chromosome will probably always stay as a Barr X chromosome.

In effect, women are only superficially XX. To be more precisem they are, in practical epigenetic terms, XB.

The Inheritance of X and B
So half of the eggs will contain an X chromosome. The other half will contain a B chromosome.

Half the sperm carry an X chromosome and the other half carry a Y chromosome.

All males are XY and all females are XB.

That means that only Y sperm can fertilise an X egg and the B egg requires an X sperm.

BY is incompatible with life at a cellular level because there is no active X chromosome. XX is incompatible with life because there is a 'X-overload'.

The outcome is that eggs have predetermined gender. It may go beyond that. They may even select which gender of sperm can actually penetrate them gelatinous layer.

In general, Mother Nature does not like waste. It is quite conceivable that there is an unknown selection process has evolved that we have never suspected. Hence we have never looked for it.

Well that would explain why IVF programs that bypass the process of the sperm penetrating the gelatinous layer of the egg by injecting the sperm directly into the nucleus have approximately double the immediate failure rate of the natural process.

A Better Fit With Global Evidence
So there are two possible hypotheses here. Either the eggs are generic in gender terms and any sperm can fertilise any egg, hence determining gender, or the active X and Barr X are epigentically distinct, which would imply that the egg has a predetermined gender.

And we do not yet know enough about Epigenetics to confirm or refute either argument. It is simply too early to decide. Both should be on the table until conclusive evidence is available.

So against academic tradition, I will not decide or run a first past the post popuarity contest to decide the winner and exclude the possibility of the other for all time. Academic science has done enough of that, an example being the decision to definitively choose Darwinism over Lamarckism before they had sufficient evidence to exclude Lamarckism occuring over an evolutionary timescale.

I return to the basics of formal logic and Ockham's Razor. In the debate, the simplest theory which can explain the widest scope of the evidence with the least assumptions should be preferred. This is used and placed into practice in clinical thinking so I am familiar with its real world application. If a patient's symptoms, signs and test results can all be explained by a single diagnosis that is to be 'preferred' but a diabetic can still break a leg, in which case two diagnoses co-exist.

The concept of 'preferred in the debate' is essential. The debate can say that one theory is 60% likely whilst the other is 40% probable given present, incomplete knowledge. The ratio could be 95% to 5% but that still does not mean that the improbable theory is disproven or untrue. It should still be kept in mind as a possibility. The question should stay open and it should be researched.

And what decides the percentage ratio for theories under debate is consistency with the globally available evidence. The doubling of IVF embryonic failure rates from injcting sperm into eggs is one piece of circumstantial, corroborrating evidence. It is hard evidence that the 'eggs have predetermined gender' can explain but the hypothesis that sperms dictate gender cannot explain.

Another piece of circumstantial evidence that is suggestive of the eggs having gender is that the diet of the mother has been proven to have a significant effect on gender. The folk wisdom that butchers rarely have daughters has been proven by the evidence but it was found to be the mother's diet that was important, not the father's.

The easiest explanation of this is that the egg race, a race for the eggs to mature in the ovaries under hormonal stimulation considering the internal chemical environment in which they find themselves, influences the probability of which gender of egg is released. This fits better with the eggs having predetermined gender.

What Do I Believe?
I do not believe. I hypothesise.

I am also relaxed about saying that I do not know. We, with all of our scientific knowledge, do not know, at least not yet. In fact, I am excited at the prospect of new discovery....

Having looked at the commonly available evidence and thought about it with an open mind, I lean slightly towards the 'eggs have gender' hypothesis but I may well be wrong. I will call that my 60% hypothesis and the more traditional belief a 40% hypothesis.

Please Comment!
Especially if you know anything from Epigenetics that is appropriate to this debate

Sunday, February 23, 2014

An Introduction to The Tools of Cultural Change

Historical Background
Rare have been the times when a society, culture or profession have picked themselves up except when they have come out of the ashes of war or total economic collapse to start again from a clean slate. Post war Japan and Germany are examples of that. The winners of war just keep on doing what they have always done with more arrogance and do not change.
Internal revolutions usually fail. Somehow, as in Animal Farm by George Orwell, everything returns to the same with different names.
The successes of civilisation and its development have usually been external and due to major sociotechnological discovery, such as writing or oil. From there, history paints the familiar story again and again of decadence and collapse. Eventually the society goes into freefall.
Welcome to the modern world....

However, there has been one light of hope that this is not inevitable. In the 60s and 70s, the UK was in socioeconomic freefall. It was known as the Sick Man of Europe. It had slid into 9th place of the 10 members of the European Economic Community of the time and was descending fast.
Educationally, contrary to its international reputation, the UK was failing atrociously compared to the rest of Europe. It was failing to the level that the modern US education system is failing as portrayed in https://www.youtube.com/watch?v=Bx4pN-aiofw.
Like it or not, the UK government of the 80s and 90s successfully did something about the situation. It successfully did something about many situations of the time. It did so by designing the first systematic Tools of Cultural Change.
Many of the social changes were bitter pills and it is easy to think in retrospect only of their inevitable consequences and side effects. There was suffering. There were winners and losers. Some of what happened, such as the loss of heavy industry, was blame on these policies when the government had its hands tied behind its back by European Law due to structural anomalies of the UK's political system. They were untried social experiments that in some respects backfired but they did achieve their goal of returning the UK to the top flight of Europe.
More than anything, the population did not like change. It did not like change from its path of descent into decadent, arrogant decay. They did not like the central cultural objective of these socioeconomic policies.
It was a bitter pill. Not everybody would win. It was always bound to be unpopular but it worked.
While the UK population complained, the rest of the world saw the greater picture of a socioeconomic miracle.

The socioeconomic side of these policies will long be debated and often unfairly, the processes of the use of the Tools of Cultural Change that were applied to the professions such as health and education were almost unqualified successes. There were predicably some teething troubles and unnecessary, mismanaged conflicts along the way but this was a learning curve and lessons were learned.
In retrospect, yes, it could all have been done better. It could have been perfected. Still, the partial success was an astounding new historical precedent. In relatively stable time, the freefall of a society and its institutions had been reversed. That had never been achieved politically.

And it was in this way that the UK became the birthplace and home of the Tools of Cultural Change. The systems have evolved and continue to evolve. They are sold and instituted worldwide as the only systems that can turn around a society and its institutions. They are proven by the evidence and supported by international academics in their own subject.

They are the only systems that work. The outcome evidence is that anything less is pretty words and fiddling with the details as Rome burns.

The Secrecy
The Tools of Cultural Change are rarely discussed overtly. They are effective but not popular. People do not want to be changed. They will always offend one interest or other. They are usually offensively and objectively critical of the way that things are and the collective self-delusion of the population or a profession that supports the way that things are at present.
The Tools of Cultural Change are objective and evidence based. They are about action not words. They can only be judged on their objective successes.
They are the means to good ends in a society that focuses heavily on whether they like the means with little or no consideration of objective outcome.
The means are usually kept secret. Half of the ends are usually hidden, the half that the population will not like. Only the positive is openly promoted in a world that believes that it can have its cake and eat it. For instance, they cannot understand that absolute parental rights to do what the hell they like with and to their children are the traditional cause of child abuse.
Just the concept of changing culture and traditions is offensive to some. They think it is about changing external, superficial culture when it is not. The Tools of Cultural Change change something far deeper. They change the very way that the population or a profession thinks and fundamental belief systems. They challenge axioms and paradigms.
Of course, the population believes that the present beliefs and axioms that society practices are somehow sacred. It is a natural and inevitable consequence of the psychology of the subconscious mind and causes and emotional reaction when challenged. There is little societal understanding of its own psychology including the belief that the way that we presently think is in some way God-given rather than learned. The way that people think is hence sacred. Nobody has the right to interfere. Interference is impossible.
Perhaps they should ask the sales and advertising industry about that! However, they do not like to advertise their influence over how society thinks or the wider and greater side effects of their words and actions for short term gain.

The use of the Tools of Cultural Change are kept largely secret from every direction. Their means are hidden. Half of their objectives are hidden. Even when discussed, few understand them or can relate to them because they challenge such societal beliefs. Conspiracy Theories grow up around them even when they are focused on the societal good in the long term.

The Tools in Practice
Only the tip of the iceberg is seen. All that will be seen is what is meant to be seen. This is a carefully Machiavellian process in the positive sense of the original..... the prince was maliciously manipulative for the good of the people that he governed and used every means necessary to ensure the goal of preventing the most violent and abusive leaders taking control.
What will be seen is the positive side of the ends, the ones that all can agree on. The means will not be mentioned. Nor will the consequences and side-effects, which is easy to accept for a highly subjective society that believes that it can have its cake and eat it.
Inevitably, when society discovers that it has eaten the bitter pill and the predicatble side effects have happened, there will be blame. However, it will be too late. The eggs will have been broken and the omelette cooked. There is no going back. The very culture of how the population thinks has been irrevocably changed.
These are the minds that are being dealt with on the other end of the stick. They are minds informed in applied cultural psychology based on Cognitive Behavioural prinicples from the real world rather than the relatively ineffective academic knowledge of cultural psychology based on what is, not what could be and how to change it. They are determined to use that knowledge. If they have the political power or will to put that knowledge into action, they will outwit and undermine all resistance in the long term.
And they have the evidence on their side to convince politicians that their way is the only way. They have been very deliberate in that. They can even use that evidence to con the worst politicians into doing what they would never do and fool them into educating a thinking population that cannot have the wool pulled over their eyes.

The Ends
The ends justify the means has fallen into disrepute. It is always what is mentioned as an excuse for evil actions such as those of Hitler or Stalin. But hold on a minute! Look at the ends that they were trying to produce ranging from paranoid megalomania characteristic of cult leaders, world domination, slavery and creation of a master race. Their ends were evil too!
So what are the ends of the best, most ethical manipulators of The Tools of Cultural Change in the modern world?
Their ends are often abstract concepts. In education, the aim is Independent Learning and teaching a culture of appropriate mental and emotional life skills for high-quality, rational, informed and considerate decision making throughout life. It is to promote free-thinking based on the real world for the real world.
Who would argue with that? Well, we could start with traditional, hierarchical parents who believe that respect is their right rather than something earned. Their children will be educated to outthink them, even run rings around uneducated, thoughtless parents. Those that would limit the potential of their community or another faction of society to perpetuate class wars or their status in society will resist the concept of every human individual reaching their human mental potential.... Then there are those that rely on an ignorant, unthinking flock.
The noble ends of the educationalist are to produce not only a thoughtful society but an equal society by ensuring that everybody reaches their full potential. The artificial, learned limitations of individuals are erased.
Health ends are equally noble and egalitarian. It is the promotion of good health for all through education, prevention and treatment. It is a matter of good, rational and informed health decision making in everyday life so that society believes that it cannot eat all its cakes without getting obese, diabetes and heart disease.
Rational, informed decision making is, of course, the last thing that the fast food and other branches of the sales and advertising industry wants. Even the hospital lobbyists and various sales departments of the medical indistries do not want this culture to occur.
And this is a global culture of rational, informed decision making starting at school education and progressing into everyday health as an adult. It is an all encompassing culture of how people think, believe, act and treat life. A cluster is being taught that includes responsibility, altruism, patience, objectivity and psychological maturity. This cultural cluster of how society thinks is capable of creating a Utopia.
Those are the ends. That is the dream.
Many talk about the dream. They are not prepared to do what is necessary to make it happen. They would prefer to delude themselves with pretty words.

Actions Teach Actions, Words Teach Words
There is a simple psychological basis to the Tools of Cultural Change. It is a Cognitive Behavioural basis but it is also consistent with ancient, common wisdom epitomised in the sayings Practice What You Preach and Do As I Say, Not As I Do!
We are all innately hypocritical. A fundamental of the human psyche is to have an idealistic conscious mind that produces pretty words whilst the subconscious mind generally dictates our actions mediated by the overpowering stress/relaxation physiology of subconscious emotions. There is a gulf between the two, perhaps explaioned by a communication breakdown. The conscious and subconscious minds cannot understand one another because the former communicates in words and the latter in chemicals.
Human beings also have an unfathomable innate ability to excuse and ignore their own actions when they are contrary to the idealistic words of their conscious mind. Our ability to say one thing and do another without even noticing is quite staggering. We are not even aware that we are doing it.
This is a central concept to the Tools of Cultural Change and the reason that all other systems aimed at changing culture fail. They always focus on the beautiful words and forget the actions that come from the mysterious subconscious mind. They are judged on pretty words and not actions and outcomes.
Perhaps attempts at cultural change that are based purely on words are the worst case scenario for change. It blocks the possibility of future change by promoting the delusion that change is already happening or has happened. It pretends that there is nothing wrong with the way things are and creates a whole web of excuses and irrationalisations for the status quo. It concretes the status quo.
This is why the Tools of Cultural Change prioritise subconscious learning and actions rather than words. They focus on how the subconscious mind learns from its environment, through stereotyping, copying and reward/punishment. It focuses on increasing the conscious mind's awareness of actions through constant self-evaluation and self-criticism at a conscious level.
In effect, the abstract psychological process of the Tools of Cultural Change is to make the idealistic and rational conscious mind take control of the inferior subconscious mind and its actions. It is a battle against innate human hypocrisy and excuses. It is a war for rationally considered and thoughtful actions as opposed to subconscious, less than conscious behaviour.
The conscious, wordy side of the Tools of Cultural Change is to cut up the confused web of excuses that are made for hypocritical actions in life. It reduces the participants to the most basic, endeniable principles and ends so that they take ownership of the objectives at a conscious level. This is the participant's consent to the process of 'helping' their conscious minds impose this new, clarified morality on their subconscious mind however their indoctrinated stress/relaxation reactions feel about it.

Saturday, February 22, 2014

Hypertension at Altitude - A Conundrum Without Evidence

I was asked the other day about blood pressure at altitude, a subject that I knew nothing about because I had never worked as a doctor in a country at altitude. No part of the UK is at a significant altitude so it was not a part of my medical school curriculum.

The person in question is a diabetic already on treatment for hypertension and he had just bought an automated sphygmomanometer to check his blood pressure. He bought it at about sea level, a place that he regularly visits to work and play but he lives at 2200 metres.

An altitude of 2200m is not exceptional worldwide. It is not high enough to give altitude sickness, like Cusco (Peru) at 3400m. However, it is significantly higher than any major, highly populated geographical area in any of the countries that do the vast majority of the medical research into such health issues.

His blood pressure, on treatment (Amlodipine/Valsartan and incidentally Prazosin for his prostate) is 160/95mmHg at altitude where he sees his cardiologist, who obviously, according to all of the protocols and guidelines, is increasing his medication. However, his blood pressure at sea level is repeatedly and consistently 110/55. 


I wondered if it could be a problem with the sphygmomanometer that the pressure readings are erroneous because of the low atmospheric pressure at altitude. If the pressure difference of altitude were around 40 or 50mmHg, it would all make immediate sense. When I checked the numbers, I was shocked to find how much pressure has been lost in the atmosphere at 2200m- 160mmHg. 

At 2200m, oxygen pressure is only 80% of the sea level value. Water boils at 93 degrees celcius.

Yes, at this altitude, tea tastes terrible. Water does not boil hard enough to extract the full taste from coffee and you have to add 50% cooking time to pasta, rice or whatever else it is that you are cooking!

But this discrepancy was simply too much to suggest that the problem is a simple error of baseline. Can anybody advise on this topic of the need to recalibrate automated sphygs at altitude? 

Here is a bizarre thought that puts it all into perspective. Since we measure blood pressure relative to atmospheric pressure, his systolic pressure at altitude after compensation is effectively ZERO! He has a diastolic of minus 65 in absolute terms!

Does anybody know any evidence for the treatment of hypertension at altitude?

Should this blood pressure be treated? Or is this a natural compensatory mechanism that should not be interfered with?

Increased cardiac output, including increased pulse and blood pressure, is an acknowledged compensatory mechanism for high altitude. On treatment, this guy is almost 'narcoleptic' in his exhaustion as if not enough blood is getting to his brain. He also gets faintness and vertigo, symptoms of hypotension. He is generally weak and listless.

If the 110/55 blood pressure were representative, and with a normal pulse rate of 60-65 bpm, I would diagnose him as hypotensive! However, the numbers at altitude say he is hypertensive and in need of more hypotensive medication....

To complicate matters more, he has mild aortic stenosis....

Without this information that can be relied upon, I am left with educated guesswork from first principle theories. 

So what do we know? Well, this is what I know on the matter....

We know that elevated BP is a normal compensatory mechanism for altitude in order to get adequate levels of oxygen to the brain.

As far back as he knows, his family has always lived at altitude. As well as making temporary adjustments through the 2 3 DPG system to change haemoglobin oxygen carrying, he may well have genetic/epigenetic changes for high altitude living. Such long term changes are recorded in terms of evidence (without mechanism) in the higher regions of the Andes where the conquistadores could never fully adjust like the locals as seen in their fertility and abortion rates (which were essentially 0% and 100% respectively, the latter when a woman arrived in the area already pregnant).

So he could be of a significantly different genetic/epigenetic stock to whom western averages and guidelines from low altitude do not apply.... but they are the only hard evidence we have to go on and they say that he needs MORE antihypertensives.... The evidence suggests that not treating him could be fatal.

But is that evidence conditional and only applicable in the population tested? Chronic hypotension is also statistically life threatening....

The risk of high blood pressure is in part a direct risk factor and treatment directly decreases risks. It is also an indicator of other risk factors such as atherosclerosis and renal disease where the treatment of blood pressure does not necessarily, directly improve outcomes. Certainly, in terms of intra-arterial damage, one would imagine that it is the pulse pressure rather than the absolute levels of diastolic and systolic that cause turbulent flow and trauma.

At least focusing on pulse pressure allows us to forget that his absolute BP is -65/0.... which would explain his hypotensive symptoms....

Or is it just the syphgmomanometer producing spuriour readings? Should we forget the high altitude readings and treat the low altitude readings....

I am confused and really glad that I am not in the position of making this life and death decision. I am appreciative that this is only a fun, academic exercise for me. 

But really shows the conditionality of evidence and just how important it is to have the highest quality evidence specific to the situation on which to make these decisions....

Unless anybody knows of research in this area, research is desperately needed!

Friday, February 14, 2014

Independent Learning For MedEd III

A Group Work Model in Education

I have better things to do with my life than read school textbooks to analyse them for the quality of Independent Learning so I have not read many. However, there is one author that I have come across, Chuck Sandy, who stands head and shoulders above the rest. His use of the Independent Learning model is exemplary and to the letter.
Other school textbooks, which have been written by internationally acknowledged educationalists in their own subject, too often slip and get distracted from the basics. It shows the level of discipline that is required in Independent Learning. The writers start thinking about what is interesting to the reader and clever ways to put things and suddenly they have deviated. They have got the basics wrong....
Of course, we all know medical examples of those with experience and especially name and reputation who think that they know better than the basics and can do what the hell they feel like....
I have read Chuck Sandy textbooks for the pleasure of the educational experience and seeing an educational genius at work. He and his co-authors do not try to prove their genius by dumbing down for the sake of popularity. They get the basics absolutely right, dotting the ‘I’s and crossing every ‘t’. Their genius is to culturally add to this model rather than distort it and teach the cultural tools to really make the model work.
And it was in a Chuck Sandy book, Passages 1, that I found an ideal model for group work in the classroom. This impossible genius had used it as a comprehension text with somebody enthusiastically proclaiming how it had changed their life and recommending it to all.
Now that is what I call educational genius!

Corporate Team Building
I had been taught corporate team building by some very expensive experts. It was focused on boardroom decision making and projects using a multidisciplinary team as applied to medical and healthcare. It was not for the classroom or students who are learners rather than experts representing the various points of view and conflicting interests of departments but it was still an educational experience for all. It was a means of creating a whole picture in which all of the basics were taken into account and nothing forgotten. The educational experience of corporate team work is to teach each expert the most important basics of all of the other departments so that they can put their expert knowledge into context.
The short-term aim of corporate teambuilding is good, solid decision making that takes everything into account. The medium-term aim is harmony because every department understands why they cannot always have their own way. It creates a team that is working together rather than trying to tear themselves apart. However, the long-term aim is to create ‘T-shaped’ experts who are both generalists in everything as well as being specialists in their own area.
I learned this for medical purposes, mainly centred around the key worker role in primary care, working in multidisciplinary teams and administering healthcare as a business with varying priorities.
It is the responsibility of each expert to educate the rest of the team about the most basic concepts of their specialist subject as it relates to the issue at hand. The rest of the team must be educated to grasp those fundamental concepts so that they can apply them to the real world problem and solve that problem.

Education by Formal Group Working
The moment I saw this model of group working, I knew I had stuck educational gold. In the corporate setting, the decision making process is the primary consideration and education is an important but secondary part of the process. It is the long term process and effect.
So many elements of the corporate team working structure are appropriate in education. The Kolb Experiential Learning Cycle (http://clinicalarts.blogspot.mx/2013/12/independent-learning-in-meded.html) is all about grasping basic concepts in real world language, Plain English that can be applied to the real world.
Group work is primarily a tool of Reflective Observation where the participants deduce their own rules in their own words for the examples that they have been given in Concrete Experience. This is a fundamental of Reflective Observation before the students are introduced to the jargon of Abstract Conceptualisation.
Of course, practicing the skill of communication in Plain English dramatically improves communication with patients.
One of the main responsibilities of the Co-ordinator (team leader) is to prevent the experts from getting their own way by using incomprehensible language as a weapon of intimidation. They cannot make the non-specialists in their area buy them new toys by talking about the bench test speeds of the XYZ 472 chip as if anybody will know what that means in real life. They must explain how it will help productivity in real life, the cost of software to take advantage of the new computers and whether the secretaries are going to be confused by changing programs and need retraining.
It is the responsibility of the Coordinator to ensure that every member of the team understands what is being said and its real world implications so that they can vote on the issue in an informed manner. They can participate.
In education, this type of group becomes a self-educating process. Those that grasp the concepts are encouraged to explain them to those that did not grasp them. The student becomes the teacher.
The concept of the student teacher is acknowledged as highly effective in the modern educational world. Students often make more adequate teachers than the teachers themselves because they can easier relate to their peer groups and explain things in concepts that belong to their lives. It is enhanced individualised, small group teaching that the teacher cannot compare with.
This is cascading knowledge and understanding. The teacher only has to achieve the understanding of one person in the group. They spend the time explaining it in different ways until all of the group understands the concepts. The Coordinator is responsible for ensuring that all group members understand the concepts.
This is why bigger classes with multiple groups are preferred by the best international modern educationalists. Their humility is the unimportance of the teacher in the process of education. The best education happens in the group work. Counter-intuitively, small classes with more teacher attention are counterproductive to the learning process.
Mixed ability classes are also preferred. The quicker, more capable peers grasp the concepts and explain them better to their less astute peers than a teacher who was usually gifted at their favourite subject and succeeded in a traditionally dependent, theoretical teaching environment.
Traditionally, the failure to learn has been caused by a communication breakdown between the older, more academic teacher and those that do not believe that they are capable of academic competence. This further destroys their confidence in academic work. Cans come in cans, as educationalists say. Academic success breeds more confidence and success. As the lower students succeed more in understanding the subject, they gain confidence and ability.
And it is the role of the Coordinator to ensure that they do not drop out.
The more gifted students also benefit. They are known to clarify their theoretical knowledge as they teach it in the groups to the lower performing students.
It is a common experience that you only really think through and grasp a subject once you have tried to teach it to others. It brings a deeper knowledge and understanding that you did not have as a student. It brings true mastery of that knowledge in place of the superficial.
The participants are there to learn from each other and the experience. That is Independent Learning. Anything that comes from their peers comes from their equals proving what is possible. It does not come from the teacher as expected from somebody who is senior to them. Anybody is capable of it.
They are there to think together. They are learning the skills of making decisions in complex situations where many different factors must be taken into account.
This is a formalised, external representation of the everyday complexities of the best clinical thought processes. It treats the patients as individual, complex human beings with psychosocial influences as well as complex organic beings with multiple interacting organs. A balance must be reached. Nothing must be left to chance. The best treatment plans are multidisciplinary.
As an external representation of this gold standard clinical thought process, it can be observed, analysed and fed back upon. Clinical thought processes can be improved both by experience and evaluation.

Time Limiting Democracy
It is also the Co-ordinator’s responsibility to keep the group focused on the central points so that they cover everything that is important in the time allowed. It is like real life where time is the most precious of all resources. They cannot be distracted into going off at a tangent considering the small point details ad nauseam while neglecting important matters.
Everybody must participate. Nobody should be allowed to dominate the limited time of the group. Mutual respect means allowing others to have their turn too. Minorities of one get their chance to express their views and convince the group but they get no more than their turn before the vote takes place. From then, they must agree with the majority view when a consensus is not possible.
And they soon learn from experience to use their equal share of the time wisely rather than interrupting every discussion. They learn to be concise rather than verbose with their opportunity.
Sorry! You have had your share of time already. Now it is your turn to listen to everybody else.
John. You have not said much. What do you think?
Unstructured, hierarchical groups based on the loudest mouths significantly damage the confidence of those that start with little confidence. Formal and structured groups bring such people out of their shells and improve their self-confidence. They make the over-confident more respectful. They are learning to think of others too.
As the know-it-all, loud mouths are rotated to the role of the Coordinator, they learn some respect for the responsibilities and difficulty of the job. They are placed into this caring role and will be made accountable by their peers.
This is a really profound learning experience.

The Writer
Group work is always working towards a formal presentation that is also time limited to combat the culture of everybody saying whatever they want all at the same time as happens in hierarchical, unstructured groups. The Coordinator should stop this from happening and ensure democratic decisions of the majority or a consensus. The second member of the group’s administrative team that Sandy describes is a back up for this. Only one person in the team is going to write the presentation down.
This assures that the presentation of the opinions of the group is consistent rather than everybody writing down whatever they feel like saying without discussion or debate leading to a shared opinion.
Okay... so what do you want me to write/type for the presentation?

The Speaker
And only one person from the team is going to give the presentation. They are also going to have to field any questions from the audience about what the team thinks about the topic.
It is great for classroom structure. Structured group work kills the chaos.
Some things have to be learned by experience. Negative experience soon teaches in group work. My experience with teachers as participants is that it does not matter how many times you warn the participants. They will not get the fact that if they want their opinion to be expressed, they must express it to the group and particularly the Writer and Speaker or the class will not here that opinion.
As Facilitator, you have to laugh. The results of the first times that the participants work in this structured manner, they are seething. They seethe at the face that they are not allowed to express themselves in the question and answer session.
As they take turns as the Speaker, they appreciate the other side of this. They are standing up their exposed unless the group has fully discussed, debated and decided on its opinions on the matter. The worst case scenario is that the Speak did not have the basics explained to them by the rest of the group and is supposed to be answering question on them in front of the class.
I always get the Speaker to feed back to the group how they felt standing up in front of the class under such vulnerable circumstances. As the Speak role rotates around the group, they quickly learn to fully discuss the topic and educate one another.
It is matter of learning a new culture. It takes time but surprisingly little of it. Massive improvements in group work happen after only a single session and those improvements are dramatic in the third and fourth exercises.

The Final Outcome
This structure of three named and defined roles within the team gives three controls over the group work process. There are three key members of the team that must understand the subject profoundly. It is the responsibility of the rest of the team members to ensure that this happens. It is the theoretical responsibility of the Coordinator to make this happen. It is the practical responsibility of the Writer and Speaker to make sure that they know what the team thinks about every imaginable part of the theme that they have been asked to deal with. If they do not achieve that, painful, stressful disaster ensues.
The most practical team size is seven to eight. That means four or five team members are responsible for explaining all that they know to three others with varying abilities until they understand. This ratio almost guarantees that everybody will understand. It guarantees that knowledge and understanding are presented at a level where everybody can understand.

The Three Administrators
The role of the three administrators of the team, The Coordinator, Writer and Speaker, is to structure the team and its time management for both the group work and the presentation. They ensure that utopian, informed democracy occurs where everybody has an informed point of view and all opinions are heard and respected. Everybody participates and understands the questions involved. They have all been educated on the various points of views by experts with different experience and disciplines. They can make a good decision bearing in mind the greatest context available so that nothing basic is forgotten.
And that is all that the Coordinator, Writer and Speaker do during the formal, flat structured teamwork process. They organise the team. They do not express their own opinions.
The three administrators are already too powerful. No Coordinator will be perfectly fair and objective in their decisions about who talks and when to vote. That is their influence and power. The Writer will always colour what they write for the presentation with their personal opinion. The words of the Speaker are equally coloured.
So these three administrators are not allowed to contribute by expressing themselves in the discussion. They are there to structure and to listen. They do not get a vote either unless the vote is a tie.
If only medical administrators that are supposed to bring the best of corporate practices to the world of healthcare would follow these rules from the gold standards of corporate psychology. Say nothing. Listen to the experts. Make sure that everybody understands the complex issues from all direction and perspectives. Get them to vote without being able to further influence the decision. Accept their majority decision.
At every level, the world would be a much better place for learning the culture of formal, flat-structured teamwork ;) 

What is The Mind?

If there is one great mystery in healthcare and in everyday life, it is the human mind and its elements such as consciousness. The mind is our ever present experience. Its reality is beyond doubt as a result of that experience yet we cannot define or measure it directly.

The mind is proof of the existence and importance of the abstract in everyday life.

In healthcare, the question of mind and brain must be resolved to understand the relationship between medical psychiatry and clinical psychology. How do the use of drugs and 'talking therapies' interact and how can they be used most effectively and productively.

The mind also produces one of the most mysterious of all therapies, the placebo effect. Evidence is growing of just how important mental health and wellbeing are in preventing disease and the physical health consequences of stress, anxiety, depression and insomnia....

But what is the mind?

Here are some possible models.....

A Clinical Working Model

Clinical Psychologists generally use models of the mind rather than brain science and with therapies such as Cognitive Behavioural Therapy, they achieve clinically proven results under the strictest conditions of Evidence Based Medicine. They use these models to effectively deal with scientific mysteries such as the conscious and subconscious.

The scientific understanding of the brain's functioning in terms of chemicals, electricity and anatomy is of little practical help in Clinical Psychology. The patient cannot grasp it. The patient has no control over it. There is nothing that they can do directly about their neuronal interconnections or seretonin activity. They become dependent on the doctor and pharmaceuticals. They are disempowered by the language used.

It is like telling a Late Onset Diabetic that they have an autoimmune problem with their beta islet cells of the pancreas and peripheral insulin resistance. There is nothing that they can do about that science. The alternative is to tell them that they have eaten more sugars than their particular body can handle and that they have not burned those sugars up through exercise. That is something that they can relate to and that relates to their real, ordinary, everyday life. They can do something about it. They can participate in therapy by changing their diet and exercising more.

Clinical Psychology talks of thoughts, emotions, memories and beliefs that the patient can relate to and has direct power over. The educated and qualified therapist knows that these terms have some scientific backing. They are consistent with what is known of the brain but expressed in a more practical and accessible way.

Brain science will never be that accessible. It will never be that simple. The abstract concepts of the mind such as conscious, subconscious, thought, emotion, memories and belief are abstract concepts that encapsulate the science and make it much easier to deal with.

They are also capable of expressing and using what the science of the brain does not yet understand. That understanding is far from complete still. That does not stop Clinical Psychologists from using concepts such as the conscious and subconscious that science does not yet fully understand.

The Mind is The Bigger Picture

The abstract concept of the mind is larger than the brain. It is the whole of the nervous system at the very least. It incorporates the spinal cord, nerves of perception and the bodily organs that produce hormones, steriods and adrenaline. It can easily include the physiology of stress and relaxation as whole concepts.

The philosophical concept of the mind can include the fact that we can have silent, vocal discussions inside our heads with no physical explanation for this. It can include imagination and dreams when science can only talk of what happens in the body at these times.

Science can only talk of physical associations that can be measured, particularly with dreams but also with thought and consciousness. Reductionists will assume that what science can measure is causal based on their unproven axiom that science can explain everything, or nearly. Anybody without this faith can comprehend that this might be an interdependent relationship. Conscious, thought or dreams may just as well be causing these measureable changes in the body.

The Mind as A Reflection

One way to think of an interdependent relationship between the physical brain (and rest of the nervous system) and the abstract mind is to consider the mind as a reflection of the brain and body in a mirror. The reflection of the mind is not real. It is not physical but it does still exist. It can be perceived.

The mind can usefully be perceived just like our reflection in the mirror. We can use it to comb our hair into a particular style, apply war-paint or shave. We focus our attention on the reflection and use it to dictate our movements for real world, physical effects.

The object and the reflection are entirely interdependent on one another. When one moves, the other must move. When the reflection moves and changes, the body must have moved and changed.

Psychopharmaceuticals, street drugs, surgery and trauma change the reflection of the abstract mind. Clinical Psychology is like combing your hair in the mirror. Changes are made in the reflection of thought, consciousness and belief. They change the chemistry, even the micro-anatomy of the neural connections of the brain. They are used to change that chemistry and neuro-micro-anatomy that we cannot see directly.

With this model, both physical interventions and psychological interventions can be effective but combing the hair cannot change the gross nature of the brain or mind. They can only work with what they are given. Only major physical interventions can change the length or colour of the hair or the size of the nose.

Hardware and Software

This is simple metaphor. The brain is basically the hardware and the mind is a series of intangble software programs of learning, education, knowledge, logic, experience and memories. Of course, both are important. Both are interdependent on one another and work together to produce answers. Together, they produce thought.

In terms of major organic brain disease, obviously the usual software does not work. Trauma, brain diseases and congenital brain problems prevent the software from working. However, beyond that we all have the same brain anatomy and encoded genetic ability to produce the same neurotramsmitters. Only the more fluid epigenetic on/off switches dictate differences in levels. Beyond that, we all have the same hardware and the differences are in the programs.

We all have the same hardware throughout the ups and downs of life. A period of anxiety or depression does not change that. The hardware is essentially the same. These are differences in the software programs. They are learned differences. Clinical Psychology is based on the fact that anything that can be learned can also be unlearned.

Personally, I extend this metaphor or hypothesis to explain the conscious and unconscious mind. We have many different programs going on inside, each with its own logic and point of view. The conscious mind is like a screen that can only connect to one of these programs at a time. It knows what is going on with that program and follows its logic.

The conscious mind is only aware of one program and the other programs are subconscious. When anything in life, including a decision of the conscious mind upsets or unsettles them, they ring alarm bells felt as stress.

This ties in well with Freudian developmental psychology. As we age and mature, the conscious mind moves up a ladder of these software programs, each of which prodces its own specific mindset and worldview. Those worldviews that we have grown through and passed become the immature subconscious mind and they are in control of the physiology of stress/relaxation to express themselves.

This is also consistent with the laboratory psychology of learning, including reward and punishment, repetition and copying. It is consistent with Evidence Based Cognitive Behavioural Therapy models.

Those latent programs that we have not yet grown into, attuned to or learned to use are Freud's Super Ego. They are our conscience and the mysterious Higher Self that is talked of in spirituality. There is no mystery. They are just the programs that we have not gained the experience or knowledge to use yet.

The Brain as A Switchboard

A third metaphor or way to think of the mind and brain is that the mind is an invisible, intangible entity in its own right that is connected to the body, mainly via the brain. In this model, the brain can be thought of metaphorically as functioning rather like an old-fashioned, human-manned telephic switchboard with the operator directly plugging one call in to connect the call between the mind and body.

In this model, the mind is much larger with many different processes going on behind that scenes that are not plugged in. They are not conscious because they are not connected. They are unconscious but they are still happening somewhere behind the scenes. They may get connected to other organs such as the adrenal glands to produce adrenaline.

This model also gives primacy to the mind over the brain. Thought comes first. It is the caller. It is the thinker.

Perhaps that goes some way to describing the counter-intuitive fact that changing brain chemistry with anti-depressants does not have an immediate cause/effect relationship with the patient's mood or the hard symptoms of depression. It takes weeks to change. It is as if the anti-depressant blocks the switchboard and stops the depressed and depressing thoughts from coming through to consciousness. After a few weeks, the caller, the abstract mind gives up.

The same is true as brain injury or disease permanently damage an area of the switchboard. That area of the mind is permanently disconnected. That area of thought can never come through.

With this model, we are also moving towards an explanation of the placebo effect, the power of the mind over physical health. It is not conscious. This is an expression of the subconscious mind.

(I must find time to explain a theory that I have heard in the great oral tradition of medicine for the mind's map of cellular architecture that dictates cellular regeneration and differentiation....)

Is Higher Thought Beyond Present Science?

Could the mind really be an entity in its own right? Could it more than the brain and nervous system that current science comprehends?

I have never come across a serious attempt to explain rational thought or problem solving in science. In fact, everything I have heard conforms to the functioning of the subconscious mind as described in Cognitive Therapy. Memory as interrelated neuronal connects sounds just like a web of interconnected memories that create physiological knee-jerk reactions that typify the functioning of the subconscious mind rather than conscious thought processes.

It sounds to those that know the Cognitive Therapy model as if science is describing the subconscious mind rather than the conscious mind.

That would leave consciousness, thought and problem solving as scientific mysteries. My feeling is that there are parts of the mind that only a deeper understanding of these extra dimensions of SuperString Theory can hope to explain scientifically. Unfortunately, Super String Theory is not a science, at least not yet. It is a philosophy.....

My speculative hypothesis is that higher thought is in some way related to the Natural Laws of science. When science discovers where those laws come from, are recorded and how they are applied, they will have taken a massive step forwards in understanding the human mind in its totality.

The Highest Potential of Humanity in Medicine

Modern medicine is being dehumanised. Doctors, other healthcare professionals and patients alike feel it and are concerned. Something is missing. Something is being lost.
Confidence in the human abilities of the clinician is in decline. Even the clinicians’ own confidence in their own human abilities is degrading. So they increasingly delegate to the false certainty and security of science, technology and tests.
This is as much a societal issue as a professional one. It is vicious cycle as doctors conform to patients’ declining expectations of their human skills. Human, clinical acumen is devalued in practice and the motivation to learn those skills is lost. Acumen can no longer be trusted. Delegation increases.
Politicians, administrators and bean counters accelerate the process, cutting the clinical time to practice for cost cutting. Lawyers are turning practice into the second rate minimum standard of routines, algorithms and the hard evidence of defensive medicine. Every patient must be treated as standardised and average according to the science and technology of physical pathology and disease rather than complex, human individuals with particular psychosocial situations, desires and needs.
Medicine is being dehumanised from every angle. It is being dehumanised in reality.
This conflict of interests and expectations can only be reconciled in one way. The machines, technology and algorithms make all of the medical decisions and the human clinician is in their service. The human doctor or other healthcare professional becomes merely a human interface to the technology, firstly providing data entry services and then breaking and softening any bad news that the harsh tests and algorithms want delivering.
Or does the doctor have the right to ignore the protocols and technology just because the patient does not like what they say in terms of the diagnosis or the treatment?
That is the direction that basing medical practice on the lowest common denominator of Win/Lose, Lose/Win sales would take the medical profession and healthcare services. It is a situation in which everybody loses in the long term. Health suffers in every way. The once noble medical profession would be disgraced.
The endpoint is where society demands to know why it even needs doctors. Total dehumanisation is the inevitable conclusion of degenerating clinical skills and acumen. It is the consequence of medicine losing its human genius.
And this goes against everything that is believed of how modern medicine could and should be practiced. It is dangerously second rate medicine based on this discredited and disproven public trust in the certainty and safety of science and its technology in medicine. The evidence proves that they are neither certain nor safe.
False positives, false negatives and even complete errors are common and often endemic to the nature of the test. They have consequences and patients suffer and die as a result. Invasive and radiological investigations have significant short and long term risks. Surgery and anaesthesia obviously carry significant risks.
Over-medicalisation is bad for health at every level.
Pharmaceuticals are legally defined by their serious risks, side-effects and consequences. They are not primary defined by their therapeutic effectiveness. It is a secondary consideration. Many substances that are therapeutically effective according to the evidence are legally classified as food stuffs, additives or supplements because they are generally good for everybody and carry little in the way of risks or side-effects, including in overdose.
The list of therapeutically effective foods, additives and supplements is long and it starts with the water, dietary fibre, protein, calories, vitamins and minerals that are essential for the normal health of any life form to grow, develop and survive. Garlic, red wine, glucosamine and omega-3 fatty acids are amongst many examples of substances that have proven health benefits but that do not need a doctor’s prescription because they are relatively risk and side-effect free.
The license of the doctor is defined as having the education and training required to safely make individual, case by case, risk/benefit analyses for the use of investigations and therapies that are potentially harmful including the use of science and technology or anything that derives from them which requires a doctor’s professional signature or hand. Their legally defined role in society is the wise use and application of medical science and technology. They could and should be the masters of that science and technology, not its servant.
The dangers of over-medicalisation come into sharper focus with the modern understanding and evidence of the primary importance of the patient’s life style in maintaining their own health and preventing or managing diseases. The scientific and technological model of health fragments the whole patient. It fragments the complex human patient from their lives to leave what only the medical technology can do for the patients. Power and responsibility have been transferred. The patient has been disempowered. Hence, the monopolous use of science and technology in healthcare leads to medical dependency and the sick role.
Yet internationally, modern doctors are becoming dependent and reliant on science and technology. As they delegate decision making, they are losing confidence in their own human acumen and judgement despite clinical wisdom and the very definition of their license. The abilities and capabilities of the human clinician are being devalued, deprioritised and neglected.
It is happening in medical reality and practice because non-clinicians that only value the science and technology, including academics, lawyers and patients, and those intent on reducing the human cost of healthcare without understanding the costs and consequences of doing so, are eroding the culture that created the clinical arts. There is no time for the doctor to learn, practice or hone those arts. Patients are fobbed off with these tests, technology and over-medicalisation. A hollow veil of trust and satisfaction is created with this false paradigm that the science and technology of modern medicine are both safe and certain. Everybody suffers. Health suffers.
Of course, the bean counters shoot themselves in the foot by forcing doctors to order more expensive tests to create the illusion of good practice in lieu of finding out what is wrong or not wrong with the patients using their skills and acumen. Firstly, they need to see the patients a second time just for the results. They need to sort out the false positives and false negatives. Then the costs of the consequences and risks must be paid by the patient and the medical system.
I am put in mind of a TedX talk in which Dr Wen uses the case of one of her patients who came to hospital after doing a bit too much in the garden. His body ached including his chest so he was put into cardiac and respiratory protocols and was investigated invasively for everything. He nearly died, including pneumonia and major surgery for the aneurysm that was caused by the cardiac catheterisation.
Yes, clinical acumen is often just common sense but also having the confidence to use it rather than delegating to the science, technology and tests. However, it is becoming difficult in a medical world dominated by science and technology.
Dr Wen also gives herself as an example. She suffered asthma as a child and suffered not only pharmaceutical intervention but surgical intervention. An anomalous part of her lung was removed with no positive result. Then one day she was cured by a wise doctor who took the time to find out the cause of the problem. The irritation of her lungs was nocturnal as a result of sleeping with the window open. That window happened to be just above the extractor fan from the kitchen of a restaurant which was contaminating her supposedly clean, fresh air with smoke and fumes. The window was shut and she was cured.
These are becoming major issues in modern healthcare. A professional backlash is starting against the paradigm of science and technology in favour of a healthier balance with human clinical acumen. The science and technology are being put into their correct context. They are supposed to help medicine and health by assisting and supporting the clinical skills rather than replacing them.
Common sense, the wise and sparing use of science and technology on human risk benefit analyses and the importance of taking a full history of a patient’s life and thoroughly examining them are being replaced, especially in the US and any country that has followed their healthcare model and culture. These are just the basics of good, human medical and health care that are being forgotten and major literature and other media are now being produced to defend them particularly where they are most lacking.
Those are just the basics of human clinical abilities and skills that are being defended. Little is mentioned of the highest reaches of clinical acumen and the few that practiced to the fullness of their human potential.
Remember, human clinical acumen was once all that a doctor had. Their five senses and minds was all that they had to diagnose and treat. The possibility of reliance on the modern science and technology of medicine is very recent.
This created a generation of doctors who had learned to practice purely human medicine at the outset of their career. As science and technology came along, the best of them incorporated them into their clinical practice without detracting from the human side of medicine. The best of them also experienced, practiced and learned from the increasing importance of communication skills as their importance in healthcare became more apparent during their careers.
Far from all of the doctors of this generation achieved these highest standards of health and care. These are the stories of the exceptional few.
There was a spectrum. There were many very good to middling doctors but at the other end of that spectrum were a few dangerously arrogant and incompetent doctors who really did not care and got away with it at their patient’s expense. That was unacceptable to modern medicine and its reputation. Science and technology have been used to improve. They have provided a minimum standard of competence and care.
The problem is that the baby has been thrown out with the bathwater. The insensitive process of standardisation with science and technology has addressed the also-rans but at the same time denied medicine of its past geniuses.
This is the type of medicine of minimum acceptable standards that is being taught in medical schools and the academic teaching centres. It is all that many modern young doctors know or think possible. This is why they sit spellbound by another perspective of clinical practice that relied on human genius with science and technology playing second fiddle and a supportive role.
I was extremely fortunate to have had a series of past masters of the clinical arts as my mentors. I also learned from non-medical co-workers. Those arts were never restricted to just doctors. It was an environment where the human arts of medicine were valued and heeded as well as practiced.
The subtleties of the human arts of medicine often outperformed the science and technology in both their predictive accuracy and their specificity. Their human impressions and thought had greater predictive value than a number or hard radiographic image. These were truly geniuses of clinical intuition and inspiration. It could even be said that they actively inspired their patients to better health.
This is what is being lost, as students and junior doctors are only taught the mundane and routines of science, protocols and technology. The arts of medicine are in the realm of the old school of truly great human doctors and other clinical professionals whose wisdom is now retiring. Their experience is being lost.
To the mundane and closed mind of materialist science, which excludes anything beyond scientific comprehension, it seems infeasible that a human being can out-perceive a machine and out-think a computer algorithm. These are inexplicable and unimaginable feats. They make no sense, perhaps because we know so little scientifically about the human mind and brain as yet.
To doctors indoctrinated in this scientific culture, such feats and deeds needed to be seen to be believed possible. Rarely are they seen. Certainly they are no longer the norm and the expectation of every clinician. They have become feats of a gift of infeasible genius that cannot be reproduced. Or it is hoped that they shall be reproduced by experience and come with time as they did in the past. They should be a natural corollary of clinical experience as they were in the past when many doctors and other clinicians truly mastered their clinical arts. However the experience has changed.
The culture and environment has changed. The training has changed. The medical paradigms have changed. The societal context of beliefs, expectations and demands that medicine must conform to has changed.
The experience that allowed these genius clinical arts to develop over time is no longer what it was. The old norms and expectations are no longer normal. What was common once is now exceptional and incomprehensible genius never to be repeated or learned.
The environment that produced the highest levels of the clinical arts was like a evolved ecosystem that has been interfered with by those that did not understand its functioning or delicately interdependent nature. Nobody has really understood it beyond the vagaries of experience. Often the magical act of diagnostic intuition was put down to the words ‘I have seen it before’, that patients with a certain, perhaps unusual or atypical condition, all look, act, speak, feel or even smell the same. Something subtle but indescribable makes the diagnosis and that diagnosis is certain so long as the doctor does not try to think too much or rationalise what they know.
Perhaps all that can be said is that there is a mysterious part of the human mind that assimilates unconsciously the flood of sensory data to create a consistent picture that matches another picture from the past. It is certainly not the normal conscious mind and its linear, deductive thought processes. The subtlety and mass of the non-verbal information is simply beyond it. To the linear mind that can easily be expressed in rational words, this appears all but psychic.
The mystery deepens in that these ‘seen it before’ diagnoses can be made for conditions that have never been seen before. They are possible from getting a deep understanding and feeling for a disease from the very best textbooks when it fits into a perfected jigsaw of physiological, anatomical and pathological knowledge. The patient’s history and how it will be expressed is known. On examination, the hand becomes like a visual organ sensing and seeing how pressure makes the anatomy react as if scanning.
Clinical intuition is highly knowledge dependent. Knowledge is a part of the consistent jigsaws that are being created in this mysterious, non-linear part of the mind.
To the master of the clinical arts, the fragmented knowledge and understanding that was learned in medical school was never an end in itself. It was the first stage of a process in which it would all come together into a whole understanding of humanity. Fragmented knowledge is always floating in the background waiting to be put together into practice.
However, that scientific knowledge is only a part of the picture. It is possible to make a diagnosis before there is a single justifiable sign or symptom. The technological tests have not yet changed. It looks like pre-cognition, the ability to see the future from signs too subtle for the technology.
It has to be seen to be believed. Such feats of diagnosis make no sense to those who only believe in the science and technology rather than the potential of the human clinician. The science and technology cannot think like this. They cannot perceive like this. This is human potential that can only be practiced by the human mind.
To those that have only ever experienced linear, deductive rationality, this is magic. It is supernatural. It is beyond them. It is superhuman to their experience of human potential.
Actually, it is formally hyper-rational. Formal logic rejects their linear deductive processes as inferior to those that seek theories and diagnoses based on consistency with the entirety of the available evidence without exclusion. This is the highest standard of formal thought. It is seeing the whole picture.
It is also a higher state of the objectivity that academic science proclaims. This part of the mind appears able to extract the objective from the subjective and fill in the gaps. It sees between the words to know what is being expressed. It knows exactly which questions to ask to place all of the information in greater context.
Nothing can be hidden by words. Perhaps it is expressed by subconscious tone. Perhaps it is simply a matter of fully comprehending the non-verbal communication that is taking place.
Somewhere, deep within every patient, they know what is really wrong with them. Good nurses, even the best receptionists, see it. Often they feel it was a chill down their spine. They know it but they cannot express it. They do not have the words or concepts to express what they know. It is the intuitive doctor who has that knowledge. It is the inspired doctor who has the knowledge and power to do something about it.
Mothers know when something is seriously wrong with their child but know what is wrong. They do not have the words to explain it or concepts to express it. They can know before there is anything to find. In the textbooks this is described with undiagnostic vagueness as ‘how a child handles’. Attempts are made to rationalise and explain but the only real explanation is mother’s intuition if you know how to spot it. It is in her tone of voice and choice of words. There is a tranquil, uncertain, confused terror about her that she cannot put into words. She is concerned deeply but calm and compliant.
She expresses her intuition through her eyes. Meningitis can be diagnosed instantly on seeing a palpable silence in the mother’s eyes before the child even has a temperature, let alone neck stiffness or a rash.
Experience of doing this yourself is transformational especially when it saves a precious young life.
No, you cannot write that in a medical textbook or academic journal. It would offend those less able who rely on the linear, deductive mind. Their mindset demands the type of proof that can be measured by a machine rather than evidence. However, anybody who has worked at the sharp end of healthcare knows the importance of the silence. They know that silence foreshadows imminent death at the scene of a major accident. They seek the silence since that is where lives are saved.
Patients know the presence of death and they know that they do not have the energy to make a fuss. Their fear is contemplative and quiet as if their noisy ego dies first.
The silence affects on-lookers too. It can even affect those who are present but that do not see. Its presence affects all intuitively. Counter-intuitively, it does not cause panic. It clears minds. People intuitively quieten to efficiency and know what to do. Lay people know whom to call because it is the best that they can do under the circumstances.
And in these extremis circumstances, clinical egos vanish. Everybody knows what to do. Words are calm but deliberate. Experienced healthcare professionals function as a well oiled machine.
The core, ineffable mystery of the masters of the clinical arts is this silence.
This is the mystery of abstract, philosophical psychology of human potential that is beyond science. It is not considered in clinical psychology where the objective is only to get the drowning patient’s head above water. This human potential is usually only discussed in spiritual psychology and personal evolution.
To understand the past masters of the clinical arts and how those arts were learned and practiced requires that we delve into this abstract, philosophical psychology of human potential. True intuition and inspiration come from the silence of the superconscious, what Freud called the Super Ego.
Extending and clarifying Freud’s developmental model into later life, we can see the past masters of the clinical arts as having the wisdom of age. They conform perfectly to the idealistic traditional stereotype of the wise elder, matriarch or patriarch but empowered by knowledge.
For those that have never known an ideal matriarch or patriarch in this world of nuclear families and glorified youth, this person was a marvel. It was the person who could be trusted absolutely to always say and do their very best for you under all circumstances. They were secure enough in their position not to do what was popular but what would produce the best outcome and they were not frightened to tell you your part in a problem so that you could work on that and resolve it rather than simply blaming the other. They were unbiased and objective. At the same time, they were as caring as could be about their family or community. They were selflessly caring.
This seems entirely appropriate to medicine and the doctor-patient relationship. The miracle of traditional medical education and training was to accelerate personal development through the life stages to mature medical students and junior doctors to this advanced life stage by the time they were thirty.
Medical education and training was tough. It was done the brutal way without understanding or explaining why it was so and had to be so. The cultural purpose was to indoctrinate doctors to the deepest subconscious levels never think of personal interests but to always go beyond the call of duty for every patient regardless of hours or how the doctor felt.
This subconscious indoctrination was so profound that it overcame their natural physiology of stress and relaxation to allow them to function in otherwise untenable conditions. It even overcame their hormones. It overcame the doctor’s natural sexuality. They surrendered their gender to treat patients as a doctor should treat their patients rather than the average man or woman off the street. Psychologically, they did not have a sexual thought in their deeply professional life.
Certainly, all of the adolescent power games of sexuality had been erased from their conscious and subconscious mind. Adolescent egoism and competitiveness had been erased. They had been matured beyond such juvenile considerations. They would not talk or act for hollow popularity, only for health outcomes.
This calmed the chatter of the ego and allowed silence to be heard. It allowed intuition and inspiration to be heard.
To put this into perspective, the vocation of the monk was designed to achieve this in isolation and through blind faith rather than real world knowledge. After devoting their whole life to this path, they would perhaps reach this ecstatic state once or twice in meditation or prayer and perceive its peace and potential. They were mere observers of its peace and potential. The past masters of the clinical arts lived and used that selfless silence and potential as the source of genius in their everyday work.
This was also the source of their confidence in decisively taking the impossibly difficult decisions in the complexities of healthcare where every life and death decision carries risks and side effects. Their self assurance came from within. It came from the absolute knowledge of their objectivity and devotion at a subconscious level. They were absolutely assured that the decision that they took was cleansed of personal interest and selfish emotion. They had been forcibly cleansed of that by practiced indoctrination of the highest medical ethics.
Time limited medicine imposed by administrators and bean counters is the antithesis of absolute, uncompromising medical ethics. Enforcing defensive medicine is enforcing defensive egoism. The deep selflessness that once existed is eroded and lost. The silence of selflessness is lost.
Patients sensed this selflessness. In part, it was expressed as an aura of physical non-verbal communication that they recognised and trusted. However, it was also an intangible presence of greatness that many describe on meeting others who have lived a vocation to the highest level. Certainly it is missed in terms of an aura-like presence that could be trusted absolutely.
This reassuring presence appears to have acted as a placebo. Although the details of the placebo effect are still shrouded in mystery, the basics of the physiology of stress and relaxation are long known to have significant effects on healing, recuperation and disease. These great doctors knew how to massage and entrance relaxation and confidence in a smooth healing process in their patients.
Doctors who have not grasped this subtle psychology of health can inadvertently act as the opposite of a placebo. Rather than giving their patients confidence in their ability to heal, they frighten them into ill health through their verbal and non-verbal communication of their tension and fears.
In the presence of the past master of the clinical arts, all goes smoothly. Most patients run a smooth course. Any problems are predicted and pre-empted.
However, this cannot fully rationalise the well known concept of the ‘lucky’ doctor that dare not be spoken. It is well recognised in medicine that some doctors attract tragedies of health whilst others are assured to have a quiet time of it. Patients that they have never met do not get ill.
Lucky patients!
I was known to be one of those ‘lucky’ doctors. On call, my urgent work load was a tenth of that of ‘unlucky’ doctors working on the same ward. The ‘unlucky’ doctors just attracted trouble.
So I did an informal study teaching all of the doctors of a surgical unit and introducing them to my state of mind; to calmly desire patients to be healthy rather than to wish to be an all-saving hero. Emergency admissions fell by 90%. The hospital lost the evidence accidentally on purpose for fear of funding cuts or closure.
Now that is a truly mysterious clinical art but many practicing clinicians quietly accept its possibility. The evidence for the lucky doctor with luckier patients is overwhelming. It is just a rational, scientific explanation for the mechanism that is lacking.
That phenomenon I can only record. I cannot explain it. Humanity obviously holds many mysteries that are beyond present science. The past masters of the clinical arts were masters of such human mysteries. They used those mysteries for the health of their patients.
That art is dying. It is being strangled by time limited and rational, medico-legally defensible medicine. It is being replaced by the scientific and mundane. Students and junior doctors have never even heard of it. The gene pool of experience is thinning and will soon be extinct. Only science and technology will remain.
The human satisfaction of medicine and going beyond the call of duty in this noble vocation is being lost. Consequently, the selfless human rewards of medicine are missing as saving a life through individual genius is replaced by machines and algorithms.
No wonder the medical profession is burning out and demanding more societal, egotistical rights. They are demanding normality where once they challenged the limits of human potential.
It is a vicious circle and self-perpetuating cycle.
Can anything be done to break that cycle?
If there is a solution to be found, it will come from understanding the bigger picture of how the mundane and the subtle interact. Medicine is a complex, evolved ecosystem with many interrelated and interdependent levels at play. All these factors must be known and considered rather than fragmenting the greater picture and context.
Non-clinicians and society have interfered again with a complex ecosystem that they did not understand. They had not experienced it. A new generation of doctors has not experienced the traditional ecosystem of medicine as it used to be. They do not appreciate the extraordinary, almost superhuman side of medicine, as created and exemplified by the past masters of the clinical arts. The result is that they have tampered with that delicately balanced ecosystem myopically using a sledgehammer rather than treating it with respect.
It is all about a lack of understanding of the cultural complexity of medicine beyond the mundane and the statistics. Only that understanding can save the highest levels of the clinical arts.
Senior doctors who have tried to defend the old ways need the words and concepts to defend them more effectively and explain the consequences of interfering with the best traditions of medicine, its education and cultural training. They have tried and succeeded in preserving and even institutionalising a few of the very best practices of the past masters, such as the no blame culture of multidisciplinary audit. However, this has only been possible for the more mundane practices and the explicable end of the spectrum. The greatest esoteric arts of the human clinician, the ones beyond science and technology, have been lost.
A central reason that the clinical arts are in decline is that their traditional education and training was unacceptably brutal for modern societal sensibilities. The hours that junior doctors worked were not safe in the context of competitive role differentiation between doctors and nurses. Informally, it was understood that the body of the nursing staff used to be the right hand of the consultant and effectively outranked all junior and middle ranked doctors and provided a second opinion on every decision. The unspoken cultural result of this was a training in both selfless ethics and humility that allowed the exotic states of mind that made the practice of the highest levels of clinical arts.
It was this that allowed the silence to be heard. It quietened the chattering of the ego.
If only it had been understood how and why this harsh training created exceptional human clinicians.
If it can have been explained, perhaps some of the roughest edges can removed and medical education made more palatable. Maybe it can also be made more effective if everybody involved understands its purposes rather than resisting its process because they feel abused.
Knowledge of the real objectives provide the hope that those involved in the medical education and training process will willingly, even enthusiastically participate. Understanding can overcome resistance. Not only can that understanding make the process far gentler but it can also make it far more effective.
Maybe there is some hope for the survival of the highest levels of the clinical arts. There is some hope for the survival of the great contribution that the human clinician can make to patient health by achieving their very highest potential. It is only at that highest human potential that the human being outperforms the machines and protocols and becomes their master rather than their servant.
It is the only healthy and productive future for humanity in healthcare.

Please Comment!
(I am considering writing a book of experiences and cased studies based on this theme and would welcome any comments and guidance)