Paul,

So, in your first point you have discovered a tool, a trick, a heuristic (
maybe even a simple rule -  "if I don't like a patient think who else
doesn't like them") But what does complexity add that prior metaphors
haven't done?
For me perhaps this approach may be diving in a bit too deep. (complexity
advocate reverts to reductionist thinking horror).

My thinking at the moment is along three far less lofty themes which offer
opportunities for (dare I say it) measurement.  Perhaps these are good
places to start, possibly this is a research group posting but I wasn't at
Tufton this time and don't know who else is picking up the research angle.

1. Scaling and self-similarity are, I think, all around us.  "I think", but
actually I find it quite difficult to give examples that are originally
illuminating rather than trite.  Can anyone help?  (Yes, Chris... I can name
that fractal in one...)

2. The noisiness of dynamic systems: not just Tim Holt's chaotic diabetes
but mood or behaviour which swings between attractors ( for isn't that what
mood swings really are?).  This is the one which I think is great for
patients. I think (and would like to have data to prove) that recovery from
any illness which requires cognitive processes like confidence or esteem to
play a significant part is a dynamic process of quite striking swings, but
that most patients expect a fairly steady linear journey.  The simple
chaotic pendulum & magnet analogies seem to provide a grounding for the
individual's experience which means  that I can reassure the patient is "on
the road to recovery" whilst still validating their feeling  "like I'm back
to square one" without resorting to magical invocations that "because I'm a
doctor I know these things".

3. Power law scaling.  I'm intrigued by, but a bit baffled by this at the
moment.  I'll maybe do another post on this with some links.  Whilst
probably a feature of SOC systems rather than specifically complexity it
seems to move the arguments ( particularly about waiting lists) into a new
domain of rationality.

So yeah, Balint had a point but hid it in the psychobabble.  Let's try not
to do the same eh?

Chris
(ducks and awaits psycho-barrage)

----- Original Message -----
From: "Dr. Paul Hodgkin" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Saturday, December 08, 2001 5:47 PM
Subject: tipping points and shadow worlds


> Three points: firstly doctors clearly have attractors - Deliberately
making
> myself wonder whether many people disliked this man is an old habit (or
> attractor). My usual response on finding my dislike emerging  out of the
> shadow world  of my side of the consultation is to think 'if I dislike
> them, maybe this person suffers lots of dislike from many sides, so what
> must that be like for them?'  And to get out of the dead-end of dislike
> does take significant conscious internal energy - it feels as though I'm
> lifting myself out of a 'dislike' trough, over the hill, and landing in a
> more useful what-must-it-be-like-to-always-be-disliked valley. And
> sometimes I fail to make it and stay stuck in covert antagonism. So yes,
we
> definitely do have attractors. Or things that act like them.... but which
> might also be called habits or training or education.
>
> Which brings me to my second question which is epistemological - what is
> the nature of the insights that complexity brings to primary care? Are
they
> 'true' in some deep, or objective, or refutable way? Or are they just a
> handy suite of interlocking metaphors - similar to the psychoanalytic ones
> that Balint introduced to general practice - that provide a more coherent
>  set of explanations to doctors or patients? A better fitting shroud
> through which, indirectly, to continue our grasping apprehension of the
> consultation? I can think of ways that one could test the utility of
> complexity stories ( do they lead to consultations with better outcomes?
Do
> doctors or patients 'like' them?) but I find it hard to think of how they
> might be tested or refuted in any deeper way. Any thoughts from the
> research group?
>
> Finally  who or what is doing the culling on the fitness landscape? what
> mechanism takes the variety within the consultation and decides, and by
> what criteria, which strategy is going to be
> successful/propagated/repeated? The only candidate that I can see is our
> own internal judgement - that seemed to work, that did n't - which
> presumably is one reason why we get paid a lot of money  but which has
> little explanatory power. Maybe we should devise ways for patients to
> decide, devices by which they can 'cull' or at least more explicitly
> respond to our responses and statements about them. Or maybe this is a
> point at which complexity theory gives out,  part of the boundary marking
> the end of its utility?
> Paul
> Paul Hodgkin
> Primary Care Futures
> 21 Briar Rd, Sheffield S7 1SA
> tel: 079 46463698
> email: [log in to unmask]
>
>
>
>
>
> -----Original Message-----
> From:   Ceri Brown [SMTP:[log in to unmask]]
> Sent:   07 December 2001 23:15
> To:     [log in to unmask]
> Subject:        Re: tipping points, reply to AM Cunningham
>
> In a message dated 07/12/2001 19:55:05 GMT Standard Time,
> [log in to unmask] writes:
>
>
> > I'm a novice/munchkin with regards to complexity theory.
> >
> Liebe Munchkin, (Benign Witch of the North West writes:)
>
> >
> > I have a few questions:
> >
> > Firstly, as doctors/health professionals- can we only give energy to
help
> > people out of the holes rather than change the landscape.
> > I suppose in the model it doesn't matter whether you push or pull the
> > patient. All that's required is a transfer of energy from you (acting as
> a
> > conduit for the 'energy' of the medical world) to the patient. If you
> > prefer another physics analogy, transferring some of  your available
> > potential energy to add to the patient's kinetic energy in the hope that
> >
>
> > Also it seems a very doctor-centred model- Yes it is iatrocentric, I
> >
>
> could the patient find other sources of energy.
>  The general point is that 'energy' can be transferred from anywhere that
> the
> person thinks appropriate. Doctors are but one source. Social Services may
> be
> another, friends, groups etc etc. Get out of that 'potential well' by any
> means possible, but some means are more efficient, or more socially
> acceptable, than others
>
>
> Are we at the bottom of the hole/well?- or travelling about on the
> landscape
> too?
> The patient is travelling in her/his own landscape. We are travelling in
> ours. Maybe the  landscapes intersect at the point of consultation. NOW
> THERE'S A NEW THOUGHT!!!!!!. I don't think we're at the bottom of the
> patient's well, because we're not on the same fitness landscape. I can be
> at
> the 'peak of my profession' for the purposes of this argument, therefore
> demonstrably not in the well. However I am aware of the patient's location
> by
> her/his description of the surroundings - feelings, symptomatology etc. We
> just have to using similar conceptual frameworks to describe / understand
> the
> landscapes that others are on. Why did the conversation which started with
> 'crap' end up with a discussion of parents? ("They **** you up, your mum
> and
> dad..... Larkin) Presumably this is where the collaborative inquiry starts
> to
> fit in
> >
> >  I'd rather conceive of myself as someone- if I couldn't level the
> > landscape out altogether- who tried to help the patient develop better
> > skills at negotiating the landscape so that he doesn't feel a constant
> > dread of ending up in a hole, even though I could help him climb out
> > (rather than push him).
> >
> > You can only do what you can do. Tipping the landscape isn't easy, but
> look
> > what's happening in Afghanisatan in relation to women. No-one's
> > pushing/pulling them individually out of their Taliban induced wells,
the
> > whole landscape is being tipped to free them,or prevent them getting in
> the
> > wells in the first place. A medical analogy could be the introduction of
> a
> > health service or public health measures (back to the Victorian sewers
> > point), where the action/energy of many individuals tipped the
landscape.
> > Another option is that the peaky landscape was rendered flatter.
> >
> A
> > s for the dread of ending up in a 'crap' hole, I guess that's what
> education
> >
>
>
>
> T
> > here is obviously a lot more to be teased out of this. Maybe I should
> have
> > gone to the doctor-patient group after all! See you next time then?
> >
>
> Don't forget to polish the shoes!
>
> BWOTNW
>
>
> aka
> Ceri Brown
> Critical Care Programme
> Project Development and Research
> 0161 720 2342 (Secretary)
> 07659 120 038 (pager)
> 07876 230 561 (mobile)
> Thanks to my variable clinical commitments, calls to my mobile won't be
> answered promptly. Please leave a message, or page me.
>
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