1. I didn't like him any better at the end - but I felt the possibility of
understanding him more, and was less frustrated (with him and with myself).
And so would try to replicate this strategy in the future since at some
level it had proved its utility/fitness.
2.And if I have say, heart failure the objective refutable truth of
treatment with diuretics and ACEIs is 'more true' than any understanding
that - perhaps - I have got heart failure because in some metaphorical
sense my heart or my life has failed. Or at least it has more importance,
utility and practicality - doesn't it? (Shades of Bevan preferring to
survive through cold efficiency rather than expiring in a puddle of warm,
well-meaning incompetence.)
Or is it just that at the very least this (correct diagnosis and treatment)
is the primary task we have to get right before we start icing any
metaphorical cakes? In which case I cant help thinking that the truth
status of evidence about ACEI efficacy and our meandering through shadow
worlds and complexity ARE different.
Paul
-----Original Message-----
From: Iona Heath [SMTP:[log in to unmask]]
Sent: 09 December 2001 19:57
To: [log in to unmask]
Subject: Re: tipping points and shadow worlds
Two questions for Paul:
1 Did you like the man more at the end of the consultation than you did
at the beginning?
2 Since when has "objective refutable truth" been more true than poetic
(metaphorical) truth?
Iona
xxx
PS Years ago, one of my partners said that life was a pool of shit and that
his job, as a GP, was to direct people to the shallow end - somehow Ceri's
magnificent description of two dimensional phase space seemed to be saying
much the same thing.
-----Original Message-----
From: Dr. Paul Hodgkin <[log in to unmask]>
To: [log in to unmask]
<[log in to unmask]>
Date: 8 December 2001 17:45
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.
>
> << File: ATT00009.html >>
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