Anthony Burgess on decimalisation, the cashless society, and cognitive reserve

This quote made me wonder about the cognitive impact of decimalisation. There seems to be a consensus that cognitive challenging activities help to reduce and/or delay dementia, and I wonder, aside from the poetic and cultural losses Burgess enumerates, could the change from the rich arithmetic complexity of l. s. d. to the simplicity of the decimal system have had some kind of epidemiological effect? And now, with the abolition of cash openly mooted , the corresponding loss of the calculation of change – which I assume is one of the commonest conscious arithmetic calculations we make – well, who know what will happen?

Probably not all that much. Or possibly a lot. I haven’t been able to find solid empirical research or much theoretical discussion of the topic.

Anyhow, here is Anthony Burgess from his 1990 autobiography, You’ve Had Your Time  on decimalisation:

 

“Before the shameful liquidation of the British penny into a p, there had been an ancient and eminently rational coinage, with twelve pence to the shilling and twenty shillings to the pound. This meant divisibility of the shilling by all the even integers up to twelve. Time and money went together: only in Fritz Lang’s Metropolis is there a ten-hour clock. Money could be divided according to time, and for the seven-day week it was only necessary to add a shilling to a pound and create a guinea. A guinea was not only divisible by seven, it could be split ninefold and produce a Straits dollar. By brutal government fiat, at a time when computer engineers were protesting that decimal system was out of date and the octal principle was the only valid one for cybernetics, this beautiful and venerable monetary complex was abolished in favour of a demented abstraction that was a remnant of the French revolutionary nightmare. The first unit to go was the half-crown or tosheroon, the loveliest and most rational coin of all. It was a piece of eight, a genuine dollar though termed a half one (the dollar sign was originally an eight with a bar through it). It does not even survive as an American bit or an East Coast Malayan kupang. Britain’s troubles began with this jettisoning of a traditional solidity, rendering Falstaff’s tavern bill and ‘Sing a song of sixpence’ unintelligible. I have never been able to forgive this.”

Entertainingly enough, while searching for this quote online to save me having to type it out, I came across this page on the Royal Mint Museum’s website  – which quotes the “beautiful and venerable monetary complex” and nothing else!

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The Forgetting Health System

I promise not to make too much of a habit of this but I am reblogging another excellent blog post by Enrico Coiera on a “learning” health system and the necessary corollary, that what we have now is a “forgetting” health system.

The Guide to Health Informatics 3rd Edition

Learning health systems are the next big thing. Through the use of information technology, the hope is that we can analyse all the data captured in electronic health records to speed both the process of scientific discovery and the translation of these discoveries into routine practice1,2. Every patient’s data, their response to treatment, and final outcome, will no longer be filed away, but feed the care of future patients3. It’s an exciting vision, and if we can achieve it, there is no doubt healthcare delivery would be transformed.

If we were to step back, we might conclude that although this is an admirable vision, for all its failings, the machinery of science is already working faster than we can handle it. The arena where organizational learning most needs to take hold is in the way we deliver health services. It is clear that we…

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Evidence-based health informatics

Via this tweet  I came across this piece on Evidence Based Health Informatics.

What this reminds me of most is not so much Evidence-Based Medicine as Best Evidence Medical Education. It is interesting to read the author observe that in the 1990s there was much clinician resistance to evidence based medicine – now, while practice may vary, there is very little of that kind of resistance openly expressed. Education (not only of the medical kind) is also prone to extremes of apocalytpic (in the original sense of “unveiling”) utopianism and disappointing reality, and is also a field where rather dogmatic opinions can be expressed despite the existence of a strong and healthy evidence base.

The Guide to Health Informatics 3rd Edition

Have we reached peak e-health yet?

Anyone who works in the e-health space lives in two contradictory universes.

The first universe is that of our exciting digital health future. This shiny gadget-laden paradise sees technology in harmony with the health system, which has become adaptive, personal, and effective. Diseases tumble under the onslaught of big data and miracle smart watches. Government, industry, clinicians and people off the street hold hands around the bonfire of innovation. Teeth are unfeasibly white wherever you look.

The second universe is Dickensian. It is the doomy world in which clinicians hide in shadows, forced to use clearly dysfunctional IT systems. Electronic health records take forever to use, and don’t fit clinical work practice. Health providers hide behind burning barricades when the clinicians revolt. Government bureaucrats in crisp suits dissemble in velvet-lined rooms, softly explaining the latest cost overrun, delay, or security breach. Our personal health…

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A Natural History of Families. Scott Forbes. TLS January 2006

I would agree with Scott Forbes that any attempt to explain social behaviour without any reference to a Darwinian framework is futile. However using nothing but a Darwinian framework is also unsatisfactory, and as the closing paragraphs of this review make clear, evolutionary psychology’s tendency to just-so stories is something I have always found suspect (I recall reading a very unconvincing paper on experimental methods in some area of evolutionary psychology which I must dig up) . The Huxley quote “in every hedge & every copse battle murder & sudden death are the order of the day” seems germane to some of my recent maunderings on nature writing.

“We are not mice” – slightly too cute as a summing up line. We are biological entities, with our location in the animal kingdom in a phylogeny of our own making and probably masking the continuum nature of species. We are animals, but are we “just” animals?

Again, thanks to Maren Meinhardt for providing me with the published text.

 

A NATURAL HISTORY OF FAMILIES. Scott Forbes. 228pp. Princeton University Press.

Pounds 17.95 (US $27.95). – 0 691 09482 9.

You see a meadow rich in flower & foliage and your memory rests upon it as an image of peaceful beauty. It is a delusion . . . . not a moment passes in that holocaust, in every hedge & every copse battle murder & sudden death are the order of the day.

Thus T. H. Huxley punctured a fond illusion that many hold about “nature”.
A Natural History of Families, Scott Forbes’s account of what behavioural ecologists have learned about family dynamics, is concerned with linking this knowledge to an understanding of human family life. Forbes attacks the perceived arrogance of sociologists dismissive of sociobiological insights:

“The perspective that we can explain human behaviour without a Darwinian foundation -still the distorted view of many in the social sciences -is hubris”, he writes, though he acknowledges that “linking animal to human behaviour is no simple task . . . (and) has not yet helped me in resolving the seemingly endless disputes with my sons”.

In the animal kingdom, parents tend to create more offspring than they can raise to maturity -“parental optimism”. In cases of obligatory brood reduction, at least one offspring invariably dies. For instance, Harpy eagles lay two eggs, and once one has hatched, bury the other. Among Pelicans and Boobies, the first chick to hatch wages a war to the death against the second-born (and therefore smaller) chick. These species practise a form of insurance, reminiscent of the traditional hope for “an heir and a spare”, except with added infanticide. Primogeniture is the human behaviour most obviously similar to the concepts of “core” and “marginal” broods that Forbes discusses. The core brood is the one that survives, while the survival of the marginal is at best a bonus. If something happens to the core, one of the marginal offspring can be promoted and then have a much greater chance of survival.

Infanticide and siblicide may seem, at first, wilful behaviours from an evolutionary point of view. Darwin himself wrote, in The Descent of Man, that “the instincts of the lower animals are never so perverted as to lead them regularly to destroy their own offspring”. Here Darwin nodded, according to Forbes, and both sentimentality and a failure to recognize the true nature of genetic conflict still blind us. Genetic conflict does not occur only between organisms but within organisms. Many phenomena of human pregnancy -for instance, morning sickness, pre-eclampsia and gestational diabetes -Forbes describes in terms of genetic conflict between mother and fetus, or even between the fetus’s own paternal and maternal genetic inheritances.

An astonishing number of human pregnancies are spontaneously terminated, usually before the mother is aware that she may be pregnant. The figure rises from 50 per cent at age twenty-five to 96 per cent at forty. Forbes describes evolutionary reasons for these phenomena, with mothers “screening” their offspring before continuing with pregnancy. Furthermore, many more multiple conceptions occur than multiple births. Forbes suggests that the “vanishing twin” phenomenon is analogous to the brood-reduction phenomena seen more clearly in other animals.

Forbes’s writing is lively and generally clear, though at times rather irritatingly jocular (one tires of references to “mom and dad”). He explains evolutionary theory lucidly and well, though not perhaps clearly enough for an absolute beginner. Some may find that, while his opening chapter uses many examples from the animal kingdom, his later ones lean rather heavily on a more abstract discussion of genetic and evolutionary theory. However, Forbes is good at explaining the subtlety and frequent counter-intuitiveness of current thinking on these topics.

While Darwin is surely essential to an understanding of the complexities of family life, there is more to human family behaviour than primogeniture and infanticide. As with many who seek to apply Darwinian frames to human behaviour, Forbes makes the no doubt true observation that revulsion at the infanticidal practices of the Spartans, and the general sentimentality of the “family myth”, are a consequence of insulation from the rougher aspects of existence. But what does this self-insulation -which seems to be unique to our species -tell us?

Male mice routinely kill off offspring that are not their own. Female mice spontaneously abort unborn pups on smelling a strange male during pregnancy. As is well known, infanticide and abuse of all kinds are more commonly perpetrated by step-parents than genetic parents. But “more commonly” does not mean “commonly”.

We are not mice. Scott Forbes, thankfully, is well aware of this fact.

One In Three: A son’s journey into the history and science of cancer. Adam Wishart. TLS Sept 2006

 

Another ten years on (nearly) piece. I was very impressed with this book at the time. Tje tone and tenor of David Adam’s “The Man Who Couldn’t Stop”  , which I also reviewed for the TLS  and will post here at some point, reminded me of this a lot.

Re-reading the review I am struck by Adam Wishart‘s criticism of medical “detachment” (or what I report here as such) and perhaps will re-read the book itself to explore this more. Also struck (again) by the failure of the War On Cancer and the denigration of basic research which it involved, again as described by Wishart. I would like to read more about this and perhaps read other sources – certainly if Wishart’s account is at all accurate (which I have no reason to doubt) it  teaches us something important about grandiose research agendas. Again thanks to Maren Meinhardt at the TLS for providing me with the published text!

 

For my father
Seamus Sweeney
Published: 22 September 2006
ONE IN THREE. A son’s journey into the history and science of cancer. By Adam Wishart. 312pp. Profile. Pounds 15. – 1 86197 752 2.

When Adam Wishart’s father was diagnosed with the cancer that would kill him, he found that no book on the disease was available that father and son could “read and then discuss”. Initially this seems scarcely credible -there are a huge number of books about cancer but in Wishart’s words:

there were memoirs of celebrities who had “battled” through the disease . . . self-help guides that presented basic information but provided no wider context . . . books that described the science in detail, but they didn’t seem to connect to the experience of being a patient . . . academic histories that did not seem to bring the past alive.

The Wisharts were looking for something different. One in Three begins with the six-year-old Wishart clinging “to my Dad’s enormous hand”. They are striding through London on their way to Broad Street to look at its famous pump. John Snow, in the well-known anecdote, removed its handle, so ending the cholera epidemic of 1854. This is Wishart’s first memory of his father’s quest to educate him, a quest that directly leads to this book.

Recognizing that the Broad Street story is “a rather mythologized and child-friendly version of history”, he describes other stories of scientists and scientific progress with which his father regaled him. “For two men who never spoke about their feelings, our intimacy consisted in sharing our interests in politics, history or the progress of science.” Intellectual discovery seems to have been the substitute for emotional revelation between father and son, and One in Three is part of that process.

It is an account of medical progress and the rejection of “the false ideas of the Ancients”. Wishart’s aim is didactic: “we will all be touched (by cancer), in some way. And I have learnt that an amalgam of fear, archaic prejudices and ignorance is no way to deal with it”. Among the “archaic prejudices”, he particularly despises the Galenic idea of “humours” contributing to the disease, which is echoed in the still prevalent idea that certain temperaments are more prone to it than others; according to the doctor in Auden’s “Miss Gee”: “Childless women get it. And men when they retire; / It’s as if there had to be some outlet / For their foiled creative fire”. Nor has Wishart time for Galen’s prescription of a formal and authoritative bedside manner for doctors -“a mode of behaviour which continues to be enacted in many consulting rooms”.

From this Galenic precept, he traces the now much less prevalent but still extant medical “detachment” that can seem like callousness to a terrified, vulnerable patient.

Each chapter deals with a theme -for instance, surgery, or chemotherapy, or the rise of alternative cancer care, as well as stages of Wishart’s father’s illness, considered either directly, or through the mood of the family. So the chapter on surgery discusses Lister and Billroth along with Wishart Senior’s own experience of surgery, while that on alternative therapy discusses Penny Brohn’s disillusionment with her treatment and the foundation of the Bristol Cancer Care in the 1970s, together with the Wisharts’ occasional anger and doubts.

Wishart has an eye for what Yeats called “character isolated by a deed”, the incident that exemplifies a certain trend or moment in cancer care, or helps us to understand the personality of the cancer researchers. Many of the names in cancer treatment -Sidney Farber, Robert Weinberg, even Marie Curie -are familiar simply as names. Wishart brings these complex, driven figures to life, and it is a life that barely relates to the image of dedicated scientists piously labouring for the good of humanity. For instance, Farber’s development of a chemotherapeutic agent for acute lymphoblastic leukaemia is a story of dogged determination against discouraging clinical results -which in this context means dead children -and the opposition of junior doctors alarmed by his apparently cruel experiments and aloof, Galenic manner.

Among the most memorable characters are two formidable women -Mary Lasker and Penny Brohn, both of whom confronted the cancer establishment with apparent enormous success. Indomitable, passionate, endlessly energetic, Lasker expertly played the social and political worlds of New York and Washington to persuade President Nixon to launch his “War on Cancer”. She was contemptuous of the medical establishment’s insistence that funding should be confined to basic research rather than spent on the “moon shot” approach for a total cure (involving a massive federally funded project with a single big-picture aim, along the lines of the Apollo programme). Brohn, meanwhile, after a particularly bloody biopsy, appalled by the offhand manner of her treating doctors, became convinced that her tumour was the result of “an accumulation of un-discharged grief, pent-up guilt and layer upon layer of fear”, and this conviction prompted her to found the pioneering Bristol centre. Here care was homely and comforting. Even if an insistence on coffee enemas was unpopular, the antithetical approach to Galenic medical authoritarianism was not.

Both of these indefatigable women had equivocal legacies -towards the end of her life, Lasker admitted that basic research behind genetic manipulation, on which she would earlier have poured scorn, was far more promising than the grandiloquent “moon shot” approach. The alternative therapy movement was in one sense a reaction to the hubris of the “War on Cancer”, but often became far more dogmatic and promised far more than mainstream treatment. The medical profession learnt much from its 1970s critics, and duly became more empathetic. The Bristol centre is still operational, but is now complementary with medical oncology.

Wishart combines the story of his father’s illness and death, and medical history, with skill and dignity. Anger and disillusionment are acknowledged, but there are no intemperate judgements of past figures or of contemporary authorities. Indeed, the oly figure who emerges badly is Galen. In his final chapter, Wishart imaginatively reconstructs the possible series of events at a genetic and cellular level that led to his father’s tumour. This speculative passage, reminiscent of the chapter on carbon in Primo Levi’s The Periodic Table, leads to an epilogue focused on future tactics. As well as possible improvements in public health strategies, Wishart calls for “a thoroughgoing change in taboo-shrouded attitudes, a rejection of opinion rooted in the past, in Galen’s physiological melancholy or in Victorian fear of the incurable. And there has to be a reorientation away from the heady optimism that cancer can be cured, and its flipside that a failure to discover the ‘magic bullet’ is a tragedy for humanity”. As well as admirably filling the gap that the Wisharts identified for an intelligent and humane account of cancer, this wise, dignified book will contribute to a rejection of unsatisfactory theories and practices and the adoption of something better.

#irishmed, Telemedicine and “Technodoctors”

This evening (all going well) I will participate in the Twitter #irishmed discussion, which is on telemedicine.

On one level, telemedicine does not apply all that much to me in the clinical area of psychiatry. It seems most appropriate for more data-driven specialties, or ones which have a much greater role for interpreting (and conveying the results of!) lab tests. Having said that, in the full sense of the term telemedicine does not just refer to video consultations but to any remote medical interaction. I spend a lot of time on the phone.

I do have a nagging worry about the loss of the richness of the clinical encounter in telemedicine. I am looking forward to having some interesting discussions on this this evening. I do worry that this is an area in which the technology can drive the process to a degree that may crowd out the clinical need.

The following quotes are ones I don’t necessarily agree with at all, but are worth pondering. The late GP/anthropologist Cecil Helman wrote quite scathingly of the “technodoctor.” In his posthumously published “An Amazing Murmur of the Heart”, he wrote:

 

Young Dr A, keen and intelligent, is an example of a new breed of doctor – the ones I call ‘techno-doctors’. He is an avid computer fan, as well as a physician. He likes nothing better than to sit in front of his computer screen, hour after hour, peering at it through his horn-rimmed spectacles, tap-tapping away at his keyboard. It’s a magic machine, for it contains within itself its own small, finite, rectangular world, a brightly coloured abstract landscape of signs and symbols. It seems to be a world that is much easier for Dr A to understand , and much easier for him to control, than the real world –  one largely without ambiguity and emotion.

Later in the same chapter he writes:

 

Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

Now, as I have previously written:

One suspects that Dr A is something of a straw man, and by putting listening to the patient in opposition to other aspects of practice, I fear that Dr Helman may have been stretching things to make a rhetorical point (surely one can make use of technology in practice, even be something of a “techno-doctor”, and nevertheless put the patient’s story at the heart of practice?) Furthermore, in its own way a recourse to anthropology or literature to “explain” a patient’s story can be as distancing, as intellectualizing, as invoking physiology, biochemistry or the genome. At times the anthropological explanations seem pat, all too convenient – even reductionist.

… and re-reading this passage from Helman today, involved as I am with the CCIO , Dr A seems even more of a straw man (“horned rimmed spectacles” indeed!) – I haven’t seen much evidence that the CCIO, which is fair to say includes a fair few “technodoctors” as well as technonurses, technophysios and technoAHPs in general, is devoted to reducing the human to pure information. Indeed, the aim is to put the person at the centre of care.

 

And yet… Helman’s critique is an important one. The essential point he makes is valid and reminds us of a besetting temptation when it comes to introducing technology into care. It is very easy for the technology to drive the process, rather than clinical need. Building robust ways of preventing this is one of the challenges of the eHealth agenda. And at the core, keeping the richness of human experience at the centre of the interaction is key. Telemedicine is a tool which has some fairly strong advantages, especially in bringing specialty expertise to remoter areas. However there would be a considerable loss if it became the dominant mode of clinical interaction.  Again from my review of An Amazing Murmur of the Heart:

 

In increasingly overloaded medical curricula, where an ever-expanding amount of physiological knowledge vies for attention with fields such as health economics and statistics, the fact that medicine is ultimately an enterprise about a single relationship with one other person – the patient – can get lost. Helman discusses the wounded healer archetype, relating it to the shamanic tradition. He is eloquent on the accumulated impact of so many experiences, even at a professional remove, of disease and death: “as a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.