Sunday, May 22, 2016

The Good Doctor

There are four questions a patient might think about when he sees a doctor.

“Will he listen to me?”
“Will he make the correct diagnosis?”
“Will he prescribe the right treatment?”
“Will he do the right thing by me?”

That is, if the patient even thinks about it. More often a patient sees a doctor because of an ailment or injury which he believes the good doctor might help solve. Only if there are problems along this road might the patient think about such questions.

So the same questions are more often framed retrospectively.

“Did he listen to me?”
“Did he make the correct diagnosis?”
“Did he prescribe the right treatment?”
“Did he do the right thing by me?”

In the majority of cases a doctor can make a diagnosis within a few minutes of the patient sitting down in front of him. A specialist, who only has to deal with a limited number of possibilities, can often make a diagnosis within the first minute. But complex systems have many areas that can go wrong. Some are relevant to the presentation and some are not. Even orthopaedics, widely regarded as the least mentally taxing of the medical professions, has elements of obscuration. For example, a middle aged, diabetic woman presenting with carpal tunnel syndrome may also have trigger fingers. Surgery to address the obvious presentation (typically the carpal tunnel syndrome) can make the other condition worse. A middle aged man presenting with shoulder impingement may have a rotator cuff tear and a labral tear. Subtleties in the clinical presentation determine whether a repair of the labrum should be considered at the same time as the cuff repair if, indeed, either is required. Treatment algorithms help but cannot (and should not) dictate management.

When a client comes to a service provider - be it a mechanic or a doctor - he typically has a problem for which he is soliciting information and a solution*. A rumbling engine has many possible causes as does a rumbling tummy. The client is sometimes able to articulate the problem in language that makes it clear to the service provider. But more often than not it takes a bit of time to extract this information. The more complex the system the deeper the service provider has to listen and probe. Asking the right questions helps. Training and experience guides this process.

Clients should expect the service provider to have the capacity to provide the service advertised. In addition to this the medical industry as well as some other sectors of the workforce (eg the clergy, the police force and emergency services) are expected to have a certain duty of care. Some are legally binding whilst others fall in a vaguely-defined area of good social conduct. Medicine is specialised and complex enough that the clinical decision of it’s practitioners often lie beyond the critical judgement of those outside the profession. But not beyond the scrutiny of peers. A basic respect for humanity should underscore the wellbeing of the patient and the opinion of others. 

Not that I think it necessary for a doctor to “care” about the overall wellbeing of his patients. By this I mean he should take into account the factors that might play a role in the clinical presentation but not absorb any emotional burden that may come with it. A doctor’s life is hard enough as it is and there’s that fine line where “care” becomes unwelcome or just plain creepy. But a doctor, like all service providers, should focus on optimising results. After all, that is the job he is paid to do.

But, as elsewhere in life, shit happens.

There are four questions that a patient might think about when he sees a doctor.

“Will he listen to me?”
“Will he make the correct diagnosis?”
“Will he prescribe the right treatment?”
“Will he do the right thing by me?”

A good doctor makes sure the patient never needs to ask those questions. And if he does the answer is in the affirmative.

he could also be looking for a quote or a second opinion

Sunday, May 8, 2016

The Italian American

And the Captain.

In an alternate universe Steve Rogers was resurrected in the mid 1950s and didn’t mind the odd race car or two..

In keeping with the “off-topic’’ Marvel theme:

Monday, May 2, 2016

After Life

Elizabeth Strout tells us that we all love imperfectly. There are some things that we can but understand incompletely.

Here’s a thought.

Consciousness is a seething, seemingly tangled mess of neural and biochemical interconnections. Change any part of it and its character changes accordingly. Damage some key areas and it may cease to exist altogether. Abstract as it seems consciousness is rooted in the hardware that allows it to exist. So when we die and the hardware is, by definition, no longer able to maintain function and structure, then consciousness as defined by the awareness of ones self + agency (only because it would a tragedy to have the former without the latter) ceases to exist. 

By this reasoning consciousness is lost at the time of death.

Ok. That much seems pretty obvious. Or is it? Why can’t an “awareness of self” exist outside of a mortal vessel?  Some futurists and sci-fi fans imagine a world where an explanted brain can survive in a nutrient broth or a situation where consciousness can somehow be uploaded to a computer system. These are interesting topics in their own right and bring into play the concept of consciousness existing outside of the life form from which it evolved. But let’s talk about where we are now. Let’s talk about you, and me, and Joe Blow down the street thinking about where we go when we kick the bucket, bite the dust, karck it, move on.

For the sake of simplicity let’s also leave any idea of agency out of the discussion. The supernatural (as in something outside of the natural world having the capacity to influence a sequence of events within the natural world) has an unsettling odour. One reason why Doctor Strange remains on the periphery of the Marvel Universe (a universe populated by characters with superhuman capabilities) is that his power allows him to transcend dimensions and his magic has a reach that is potentially endless. We readily suspend disbelief for the superhuman but the supernatural grates against our modern, secular instincts. That’s partly because the inexplicable can be rendered with powers beyond reckoning (for what we don't know can simply be made up). And that sits uncomfortably with many of us. Marvel fans,on the other hand, have understood this relationship (explicitly or implicitly) for quite some time.

Stephen Strange. 
At the edge of a believable world.

Back on topic. 

It is human to wish that a lifetime of thought, emotion, lessons learnt and connections made, can somehow exist free of its mortal, carbon-based life form. Otherwise (some might argue) what’s the point of existing (or rather, trying to live a moral and righteous life) in the first place? But, as most adults will recognise, just because we want something to be a certain way doesn’t actually mean that that’s the way it’s going to be. So let’s wade through this with a modicum of thought.

The world is stranger than we can imagine. That’s not mumbo-jumbo. Or some soft statement to make us feel better about things we don’t understand. That’s science. Physicists tell us that Space and Time are not what we take it to be. To be sure, the locally-based, human experience has Time’s arrow pointing in one, singular direction. That is to say that, from the time of my birth to the time of my death, my local time metronomes to an annoyingly consistent, ever-dependable tick-tock with a past, present, and future. But problems arise when we make observations outside of our direct, local environment. And those problems magnify enormously when we look at the very big, the very small, and the very fast. There are complex equations that allow some very, very smart people to get a handle on this and thereby make calculations, predictions, and inventions (I have written about Einstein's relativity here:, and my favourite youtube video on quantum mechanics is linked here: The point is that our senses can only give us a perception of reality and not what physicists might regard as an ultimate truth. In particular, local time (and space) is exactly that. It applies locally within a static frame of reference and nothing more. Outside of our local experience we may observe space and time stretch, squash and contort in all sorts of ways. Time does not “move” as such in any particular direction. We just happen to experience it that way.

Unshackling Time’s arrow has a liberating effect on how we may conceive an afterlife. If Time does not draw a path that extinguishes itself as each event passes by then birth and death merely define the start and end of a mortal body: the start and end of a lifetime of experience of one particular vessel. It may be possible - even conceivable - that some metaphysical entity is free to rest anywhere along that timeline. And, indeed, allowing further latitude as the laws of physics cannot dictate to the metaphysical, such an entity may even travel freely along that timeline or, for that matter, along any other timeline as all possible events remain open *

But when I think about an afterlife I want to think about what that means to an irreducible element of my state of mind, my sense of self, my consciousness. And therein lies the problem. The problem is that consciousness carries a clock. That is to say that even if reality exists beyond our ability to perceive it with a time dimension that allows coexistence of past, present and future events; consciousness, as we understand it, only arises because there is a directional timeline of past, present and future. Consciousness is something that continually evolves and builds upon itself. My consciousness is very different to what it was a couple of decades ago, a little different from what it was a year ago, and subtly different than what it was a second ago. Consciousness has history. And, as far as we know, it doesn’t go backwards. 

I’m no physicist and I cannot understand most of what theoretical physicists have to say. And I certainly don’t read anything that has anything to do with philosophy, neuroscience, religion, self-awareness, and the betterment of self and humanity. But, like most humans I do, at times, reflect on the existential. The only way I can reconcile a suitable metaphysical entity bearing a consciousness that evolves in a time-dependent manner with a reality where time does not pass is to believe that I can choose some permanence of a point in time. So I want that time to be right now. In my middle age. At the height of my powers. With a belly full of food, a warm cup of tea in my hands, and my mind on the matter. But it would be just my luck to get stuck at a time I was a babbling two year old, or a confused teenager, or (somewhere in the future) as a demented 92 year old about to soil his underpants (if, indeed, I'm wearing any).

I guess I’ll find out. More likely, if there is such a thing as an “afterlife”, it would take the form of something quite beyond our imagination.

* The easiest way to represent this is to shrink our experience of three-dimensional space into two dimensions. Think of an ant walking on a piece of paper. The piece of paper defines the two-dimensional landscape on which the ant is constrained to travel. If we then move that piece of paper through space this adds a third dimension which the ant experiences as a “passage of time” moving in one direction. As the ant on the paper travels through space it traces a “timeline”. The “ant life’s timeline” through that space starts with the birth and ends with the death of the ant. Relativity tells us that our experience of time is like the ant’s experience of travel through space. We experience time sequentially with a past, present and future when in actuality it is another dimension with all available coordinates coexisting together. A “metaphysical” ant is able to liberate itself from the constraints of the two dimensional piece of paper and rest or, indeed, travel anywhere along the timeline it traced during life.

But why stop there. The ant on the piece of paper can travel anywhere it chooses on the two-dimensional surface. The coordinates on the piece of paper where the ant can travel at any given moment is a “possible event” in that ant’s life. It could have turned left but chose to turn right. Both choices open up other possible events and so on down the line. Starting from the time the ant is born such possible events increase exponentially. If we include all these possible events as the piece of paper travels through space we can see that the ant traces not just its own timeline through space but an exponentially increasing shadow thrown by all these possible events. There should be no reason why a metaphysical ant can’t explore any or all of these possible timelines and, as a bonus, still stay within the laws of physics. A metaphysical ant that defies the laws of physics can simply travel anywhere (ie even places where the ant could never have travelled in life). 

What about quantum theory? Can fuzziness at a subatomic level be applied to a discussion like this? That’s another strange world that if it wasn’t such a useful scientific tool would probably have escaped imagination. I don’t know. I certainly can’t see how it can be applied. In truth, a better question is whether it is appropriate to shoehorn a scientific tool into an arena that it was never created to address.