Scribblings and blether and haver

On Immunity: An Innoculation by Eula Bliss

This is a sensitive exploration of immunity and vaccines that occasionally digresses and certainly doesn’t follow the main thoroughfares of the scientific highways. It’s more like a version that takes the scenic road, meandering through the countryside, ending up at the same destination, but offering a very different experience for the traveller.

Reading the reviews on Amazon is an uncomfortable experience as it serves a very pointed reminder that the anti-vax sentiment is very much alive and kicking. One review stuck with me, suggesting that Bliss didn’t quote any papers or research, though the reviewer may well have been an anti-vaxxer who simply didn’t like Bliss’ viewpoint. Actually, I think On Immunity is very rich in scientific detail, it’s just wearing it in a very different style. Bliss couldn’t have written a book° like this without the depth of research she has done, it’s a rich vein amongst many other layers, not all of them familiar to those of us whose time is spent reading a certain type of dry academic article.

Here are just a selection of passages I highlighted:

“Having virtually invented a paid profession and being almost exclusively available to the rich, doctors were suspect to the working class.”

“When he taught me [Bliss’s father] to drive, he gave me this advice from his own father: you are responsible not just for the car you are driving, but also for the car ahead of you and the car behind you. Learning to drive all three cars was daunting, and inspired an occasional paralysis that plagues driving to this day.”

“As early as 1840, I learned, a doctor observed that vaccinating only part of a population against smallpox could arrest an epidemic in full.”

“The concept of a “risk group,” Susan Sontag writes, “revives the archaic idea of a tainted community that illness has judged.””

“Killing germs, rather than washing them away, reminded him of the Crusades, when an abbot who was asked how to tell the faithful from the heretics replied, “Kill them all—God will know his own.””

“But risk perception may not be about quantifiable risk so much as it is about immeasurable fear.”

“Our fears are informed by history and economics, by social power and stigma, by myths and nightmares.”

“Intuitive toxicology is the term that Slovic uses for the way most people assess the risk of chemicals.”

“But most people prefer to think of substances as either safe or dangerous, regardless of the dose.”

“But the use of natural as a synonym for good is almost certainly a product of our profound alienation from the natural world.”

“But vaccines are of that liminal place between humans and nature—a mowed field, Berry might suggest, edged by woods. Vaccination is a kind of domestication of a wild thing, in that it involves our ability to harness a virus and break it like a horse, but its action depends on the natural response of the body to the effects of that once-wild thing.”

““Probably the worst thing that ever happened to malaria in poor nations,” Rosenberg writes, “was its eradication in rich ones.””

“It spelled “munity,” from the Latin munis for service or duty. “Munity is what you are really writing about,” a colleague would say to me.”

“The debate over vaccination tends to be described with what the philosopher of science Donna Haraway would call “troubling dualisms.” These dualisms pit science against nature, public against private, truth against imagination, self against other, thought against emotion, and man against woman.”

“That croup, the kind that was frequently fatal in a short time, was caused by diphtheria and has virtually disappeared in this country since the introduction of the diphtheria vaccine in the 1930s. My son had viral croup, once distinguished from diphtheria by the French with the term faux-croup. While diphtheria kills as many as 20 percent of the children who contract it, faux-croup is rarely fatal.”

“The wise practice of waiting and watching is hard to sell, in part because it looks a lot like doing nothing.”

“The purpose of heroic medicine was not so much to heal the patient as it was to produce some measurable, and ideally dramatic, effect for which the patient could be billed.”

“Childbed fever, as puerperal sepsis was called, was spread by doctors who did not wash their hands between exams. But doctors blamed it on tight petticoats, fretting, and bad morals.”

“Autonomy is usually imagined as the alternative to paternalism. But in what is sometimes called the “restaurant model” of medicine, the paternalism of doctors has been replaced by the consumerism of patients.”

“And the doctor, who was a father in the paternalistic model, is now a waiter.”

““Where there is trust, paternalism is unnecessary,” the philosopher Mark Sagoff writes. “Where there is no trust, it is unconscionable.” And so we are caught in a double bind.”

“measles has killed more children than any other disease in history”

“Until the results of a small study are duplicated by a larger study, they are little more than a suggestion for further research.”

“Immunity is a shared space—a garden we tend together.”

Bad Samaritans by Ha-Joon Chang

I’ve read a number of books about economics in the past year or so. They have, undeniably, been written by economists who would self-identify as left wing and who are, on various levels, putting forward arguments to refute neoliberalism.

In a recent Debrief column for the BJGP° I wrote that doctors did, often, regard themselves as being beyond politics. Economics has also tried to pull off this sleight of hand. Economic is no more apolitical than medicine. The notion that the free market is currently unrestricted in some pure form, outside the interference of politics, doesn’t stand up to any reasonable scrutiny. We don’t let industries pollute indiscriminately and we have abolished child labour – both are fundamentally political decisions, made by society, for the greater good and the boundaries of the free market are always set in one place or another.

I’ve read the Chang books slightly out of order and I’ve just read Bad Samaritans.° This one puts forward his myth-busting approach to economics, so well exemplified in 23 Things They Don’t Tell You About Capitalism° and puts it in the context of the developing nations which is Chang’s main interest. I find Chang to be lucid and compelling. We castigate developing countries who dare to suggest economic policies that we ourselves used to nurture our own infant industries°, and we strong-arm them into accepting a free market approach that will continue to enrich us more than anyone. It’s hard to shake a lurking outrage, if not shame, when our hypocrisy is so grimly exposed.

Strava update for 2019

Here, apropos of not all that much, are my Strava stats for 2019. I’m fairly diligent about recording all my activity on Strava and I find it a convenient way to monitor how much exercise I’m getting. I’m no longer indulging in the social media side of it at all. Over the past 5-6 years I’ve hit around 250-270 hours each year and that’s evenly spread over the months. I’m almost tediously regular. I rarely have single activities that are particularly long but I am super consistent. And, no matter how hectic life gets I can almost always get something in. Measuring it keeps me honest and if I have to have a lighter week or two, or I have a quiet month, I just try to lift it back again a little.

This works for me incredibly well. I don’t go through any binges of exercise and I simply have no prolonged periods without any exercise. I no longer have to go through that pain of trying to get back into running when I’ve laid off for a few months. Doing half as much, on a consistent basis, month upon month, is something most people could manage. It’s surprising how little will work if you can just keep doing it, week in week out, building the habit, accumulating the benefits.

Around 200 hours is running and most of the rest is made up of weight training. I’ve done a minsicule amount of cycling in the past year. That is, on reflection, the one thing I’d like to do more of in 2020. I do go up hills for most of my exercise and my elevation stats reflect that. However, I’d add that I don’t go up them very quickly. The main benefit is that it probably helps with my leg strength and I think it makes me less injury prone. I also get to enjoy a nice view…

December 2019 reading list

Here are the books I’ve got through in December 2019. There are certainly more than usual as there are several shorter volumes here. And, I had some leave as well so I hared through a few more then.

I’ve provided some links above when I’ve written something about them. I don’t use Amazon or affiliate links so click away with impunity.

Darkness Visible: A Memoir of Madness by William Styron

This is only a short book but it is a harrowing tale of one man’s plunge into the abyss of depression. I picked it up via a comment in Christopher Hitchen’s autobiography. Styron spends quite a bit of time emphasising just how utterly inexpressible depression is as a disorder. How the language doesn’t exist and the words just don’t match up to the horror. Styron himself is quick to point out that an individual experience is just that, unique and idiosyncratic, but I’m certain there will be some deep resonances for many people in this slender volume.

I should add that the doctors don’t fare well yet Styron is admirably restrained, even generous, in his descriptions. Styron is right to highlight the complexity of predisposing factors and triggering events but the iatrogenesis of the benzo prescribing is very ugly and I blush to read of it. Some of the medical perspective is of its time as Styron’s depression, so starkly painted in Darkness Visible°, affected him in the 1980s. Much of it remains frighteningly pertinent.

Some selected quotes:

“The most honest authorities face up squarely to the fact that serious depression is not readily treatable.”

“Frighteningly, the layman-sufferer from major depression, taking a peek into some of the many books currently on the market, will find much in the way of theory and symptomatology and very little that legitimately suggests the possibility of quick rescue.”

“The intense and sometimes comically strident factionalism that exists in present-day psychiatry—the schism between the believers in psychotherapy and the adherents of pharmacology—resembles the medical quarrels of the eighteenth century (to bleed or not to bleed) and almost defines in itself the inexplicable nature of depression and the difficulty of its treatment.”

“This is to say more specifically that instead of pleasure—certainly instead of the pleasure I should be having in this sumptuous showcase of bright genius—I was feeling in my mind a sensation close to, but indescribably different from, actual pain.”

“Nonetheless, for over seventy-five years the word has slithered innocuously through the language like a slug, leaving little trace of its intrinsic malevolence and preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control.”

“Bloody and bowed by the outrages of life, most human beings still stagger on down the road, unscathed by real depression. To discover why some people plunge into the downward spiral of depression, one must search beyond the manifest crisis—and then still fail to come up with anything beyond wise conjecture.”

“I used alcohol as the magical conduit to fantasy and euphoria, and to the enhancement of the imagination.”

“Alcohol was an invaluable senior partner of my intellect, besides being a friend whose ministrations I sought daily—sought also, I now see, as a means to calm the anxiety and incipient dread that I had hidden away for so long somewhere in the dungeons of my spirit.”

“I couldn’t rid my mind of the line of Baudelaire’s, dredged up from the distant past, that for several days had been skittering around at the edge of my consciousness: I couldn’t rid my mind of the line of Baudelaire’s, dredged up from the distant past, that for several days had been skittering around at the edge of my consciousness: “I have felt the wind of the wing of madness.””

“But never let it be doubted that depression, in its extreme form, is madness.”

“The madness of depression is, generally speaking, the antithesis of violence. It is a storm indeed, but a storm of murk.”

“Over two years before my siege, an insouciant doctor had prescribed Ativan as a bedtime aid, telling me airily that I could take it as casually as aspirin. The Physicians’ Desk Reference, the pharmacological bible, reveals that the medicine I had been ingesting was (a) three times the normally prescribed strength, (b) not advisable as a medication for more than a month or so, and (c) to be used with special caution by people of my age.”

“Then, after dinner, sitting in the living room, I experienced a curious inner convulsion that I can describe only as despair beyond despair. It came out of the cold night; I did not think such anguish possible.”

“Much evidence has accumulated recently that indicts Halcion (whose chemical name is triazolam) as a causative factor in producing suicidal obsession and other aberrations of thought in susceptible individuals. Because of such reactions Halcion has been categorically banned in the Netherlands, and it should be at least more carefully monitored here.”

“While my own carelessness was at fault in ingesting such an overdose, I ascribe such carelessness to the bland assurance given me several years before, when I began to take Ativan at the behest of the breezy doctor who told me that I could, without harm, take as many of the pills as I wished.”

“More or less the same can be said for Art Therapy, which is organized infantilism.”

“It is of great importance that those who are suffering a siege, perhaps for the first time, be told—be convinced, rather—that the illness will run its course and that they will pull through.”

“A tough job, this; calling “Chin up!” from the safety of the shore to a drowning person is tantamount to insult, but it has been shown over and over again that if the encouragement is dogged enough—and the support equally committed and passionate—the endangered one can nearly always be saved.”

“To most of those who have experienced it, the horror of depression is so overwhelming as to be quite beyond expression, hence the frustrated sense of inadequacy found in the work of even the greatest artists.”

A note

I may well add categories and such like in the future. For the moment, I’m keeping it simple and focused on the writing.

Email if you want to get in touch: scribbles@euanlawson.com

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Home visits and GPs

There is just one story that is getting bandied around in GP circles this week. It’s the Kent Local Medical Committee (LMC) motion,° debated at the national meeting, that home visits should be removed from core contract work.

Now, I’ve little sympathy for the heart-tugging nostalgic view of general practice that is peddled by dewy-eyed traditionalists. But, really, what on earth were they thinking? It takes about 30 seconds to spot the flaws in this suggestion. It fragments care, disrupts continuity, and it wages its effect on the most vulnerable people in society. It throws the housebound, disabled, and terminally ill under the bus. Did we learn nothing from the 2004 contract when we gave up out of hours care? The splintering of primary care into separate pockets damages services and will always have a disproportionate impact on the most needy.

I’m all for radical thinking and I appreciate that GPs are hard-pressed but this is so desperate I wonder if it is incredibly Machiavellian. Bear with me, I’m trying to be charitable. Maybe it’s actually a clever way of highlighting how parlous the situation is, that GPs would even countenance such a policy. It might yet have that effect, and things are undeniably hard, but this doesn’t seem conspiratorial. It has cock-up written all over it.

Taking notes on audiobooks

Audiobooks are big business. I’ve been listening to a lot of them this year and the combination of my regular driving commute and running means I get through them quickly. I’ve developed my own system for taking notes when reading and it’s an important part of my reading process. I’ll detail that another time but here’s my immediate problem: how do you capture notes and thoughts when listening to an audiobook?

It’s straightforward if you are sitting down and listening as you can keep a notebook handy. However, one of the attractions of audiobooks is that they are consumed while you are doing other things. Usually I’m driving but I have started listening when out for a walk or sometimes a run.

So, I’ve been mulling over the possibilities.

Just use your usual system

Stop what you are doing and make a note using your preferred medium. Not very handy when engaged in some activity but I do fall back on this when I can.

Dictating notes

It’s an audio medium so using audio to record notes has some logic. There are some options here. You can use the phone that is playing the audiobook to record a voice memo. It may involve hitting some buttons if you don’t have a plan. I’ve never been happy to try this when driving as any fiddling with buttons is almost certainly not legal and definitely unsafe. It can be done without a massive fuss when out walking although it is disruptive when running.

So a no-hands system is needed. I have tried keeping a dictaphone in the car and I have found it quite straightforward to use for the occasional quick note. It does involve fiddling with a device (so isn’t really no-hands), though with mine I can do this without even looking at it. Being safe is clearly the priority. For complete hands-free safety then Siri (or equivalent) could be the way forward. It is possible to set up Siri to open an app like Bear and one can just dictate directly into that. (Although I have discovered that when CarPlay is enabled then Siri won’t allow it.) Alternatively, it is even easier to get Siri to open a voice memo and speak your thoughts. I use the voice memo option as I think it reduces any temptation to look at the screen. The voice memo is also super-easy if you are out walking or running with headphones that have a microphone.

Make a bookmark

It is possible in some audiobook apps, and the Audible one does this, to press a button and make a bookmark. I use the Bound app for iOS° for DRM-free audiobooks as it has a bookmark function. This is just the digital audio equivalent of turning over the corner of a page and you have to come back later and re-listen to the section and take any notes. This is quick and easy but I have found that I’ve been rubbish at going back and re-listening.

None of these are hugely easy and they often risk additional distractions. As well as the obvious safety concerns I also find it jolts me out of my reverie – both from the book and the activity. More and more I’m not worrying about notes and treating audiobooks as a different experience to reading. I’m not trying to replicate the note taking. If that truly bugs you then you could stick to books that might not need any notes or just let them wash over you. Fiction is the obvious example where you’re less likely to want to take notes. I realise this is unsatisfactory but if I genuinely have an insight while listening to an audiobook then I’m finding it sticks with me long enough to get captured later.

A passing thought on the D-word

What is it about the verb “to die” and the word “death”? In recent weeks and months I find myself more and more distracted by the inability of our journalists, politicians, or anyone on the media, to state plainly that someone has died. They have, more often than not, ‘passed away’. I heard a DJ on Radio 2 do it earlier in the week and, this evening, I even heard the newsreader on BBC 5 Live refer to a ‘passing’ to avoid using the word, death.

We are tiptoeing around death. There seems to be a self-imposed ban, a moratorium, if you will, on the D-words. I don’t want to over-play it but is it related to our increasing need to cure every ill, our inability to tolerate any ailment? We can’t face our own mortality in an age of individualism. Death is a dirty word. I spent part of the afternoon re-reading a Belgian paper, which will be published this coming week in BJGP Open, that extends the debate around euthanasia and dementia. Belgium and the Netherlands are two countries who have already enacted legislation. Yet, how can we possibly have a sensible conversation in the UK about death and one’s right to choose, to exercise control, if we’re unable to even speak its name?

Doing one thing

Wilf Taylor’s Passage, Lancaster Hole

It was Eleanor Roosevelt who is attributed with the quote: “Do one thing every day that scares you.” She was a political figure in her own right and most prominently was First Lady of the United States for over 12 years until April 1945.

It wasn’t difficult to come up with my one thing today.

I got invited along on a caving trip to the Ease Gill Caverns. The strange thing about this is that, despite living locally for well over a decade, I had no idea about this cave system. It’s the longest system in the UK° coming in at around 41 miles. It’s just a few miles from my home. The entrance involved a 34m abseil down a shaft known as Lancaster Hole. It’s a little difficult to describe the route after that. Mainly because, as a caving novice generally, and very much new to the Ease Gill Caverns I had only a vague notion of where we were. Apparently though, according to one website,° the “Lancaster Hole through trip is a classic.” This seems to involve finishing at a place called Wretched Rabbit while we exited via the ‘Manchester Bypass’.

It was impressive. And, I’m certainly not ‘cave-fit’ with the whole experience offering a full body workout. The last hour was a lot more physical and there was a lot of scrambling around and over greasy boulders, some tight crawling at times, and much thrutching, bridging, and cursing as we gradually covered ourselves in mud from head to toe. There was one, er, interesting traverse on a slippery shelf above a large drop, but we had the reassurance of fixed ropes and ‘cow’s tails’ to clip into them. By caving standards I don’t think any of the crawls would be regarded as tight but they didn’t feel too loose either. I had to consciously work to suppress any bubbling panic.

It could certainly be parked in the ‘scary’ slot today but it never got out of shape. The “scary” part of Roosevelt’s sentiment feels like it just about nudging ourselves out of our comfort zones. It doesn’t need to be a new sport, especially one, if you’ll pardon the pun, is rather niche. Perhaps the best aspect was the chance to spend a few hours with some like-minded people who I got to know a bit better. I will ache for a week though.

Image by Langcliffe under CC-BY-4.0

Black Friday and the Diderot effect

Black Friday, much like Christmas, has gradually extended in scope. The word “Friday” is doing some heavy lifting to justify the sales blitzkreig that will sweep over us for a fortnight. This is, patently, for no other reason than to extend the opportunity for us to be parted with our money and accumulate more stuff. Scarcity may have some economic value but it is not, so it seems, as effective as a relentless dogged exposure to the ‘deals’ on offer.

If you do find yourself eyeing up the latest Black Friday bargains then I’d point you towards the Diderot effect.° The adverse consequences of the Diderot effect happen when you buy something that isn’t complementary to one’s life. The risk is that your spending then escalates as you seek more products to match this item and you lose control. Frenchman Diderot wrote, around 250 years ago, an essay with the wonderfully humdrum title: Regrets on Parting with My Old Dressing Gown.° He tells the sorry tale of how a smart new scarlet dressing gown left him feeling rather dissatisfied with the other rather tawdry and threadbare possessions in his life. He went on a spree and accumulated debts. Actually, the essay is not a terribly easy read and the popularisation of the term is thanks to an anthropologist, Grant McCracken.

The point, however, is well made. The culture of consumerism is exemplified by Black Friday. We are being manipulated. It is intrusive. And, as well as the unsustainable environmental costs, it doesn’t even make us happy.

Recently, I found myself coveting a smartwatch. A GPS device that could tell me how far I had run, my heart rate, and a million and one other metrics. The new Garmin Fenix 6 caught my eye and I perused the reviews, making my decision on which one I should get. Then, I caught myself. I don’t need one of these. I don’t think it will make me life better. I have a perfectly serviceable watch and I’m not going to get more joy from my running by measuring it in any more detail than I already do. One of the best things one can do to avoid getting sucked in is to avoid advertising. Or, if you are like me, develop strongly contrarian responses when exposed to advertising. The moment I realised I didn’t need a Garmin Fenix 6 was when I saw a TV advert with Ant Middleton° trying to sell it to me. He’s a picture of rugged masculinity, battling the elements with his Garmin. Absolute fucking bullshit, I thought. I’ll stick with my Casio watch.

My Casio is the W-735H version. I would have the wonderfully light and very retro Casio F-91W° but I found the alarm was sometimes lost on me and the light is rubbish. The W-735H can usually be found for under £20, and it has a vibrating alarm that has never failed to wake me. It also has a clear light that is easy to read in bed at night. (Actually, I have to cup it with my hand to avoid dazzling my wife.) What more do I need?

As Seneca said: “It was nature’s intention that there should be no great need of great equipment for a good life: every individual can make himself happy”.

De-Googling

I have taken another small step today towards minimising the Google effect in my life. I was an early adopter of Gmail in 2006 (back in the days when it was still Googlemail) and I remember a medical student being kind enough to send me an invite to get me into the system before it was opened up. Over the past year I’ve been more and more concerned, admittedly in a low level way, about the impact of the tech giants. Their absolute dominance and cavalier approach to privacy should unnerve us all.

The knee-jerk response to concerns about privacy is to cast it back to the person. The suggestion being that ‘if you are doing nothing wrong’ then you should have nothing to fear. This seems to stem from a view that the tech corporates are beneficent giants. They are not. It’s become more and more apparent that they are no different to any profit-seeking corporation. They avoid tax in the same way. They have had little compunction in breaching privacy of users to maximise their income, only rowing back when the tide of opinion has risen to threaten them. They have allowed bad actors to use our data to influence our politics and undermine our democracies. We should all be alarmed.

Marching on the streets is hardly proportionate but we can tweak our lives to reduce our dependence on them. I gave up social media but I appreciate that is not for everyone. You could stop using the Google search engine: DuckDuckGo° and Smartpage.com° are very good alternatives and have policies tailored around privacy. Use Firefox° rather than Google’s Chrome browser. And, give up using Gmail. I’ve now moved my work and personal email addresses to Fastmail.° I do have to pay but when you consider the amount of time spent on email it feels like a reasonable cost. It’s quick, they have excellent customer service, and I’ve extricated myself from the Google infrastructure.

Best book with an awful title

First, I should say that I like this book. I like it a lot. So much so, I’ve read it three times. And, at my age, books have to work damn hard to get a re-read.

Still, my winner for Best book with an awful title is: So Good They Can’t Ignore You by Cal Newport

I think the title gives entirely the wrong impression. It comes from a quote by Steve Martin, the comedian, and it is perfectly appropriate, but when it stands alone as a title I am not sure it’s hitting the spot. It just gives this rather unsatisfactory aura of self fulfilment by belief. That, somehow, if you are magical enough then you will get your reward.

It is particularly unfortunate that I get that vibe from this title because it’s almost entirely the antithesis of Newport’s book. He spends considerable time debunking the “follow your passion” approach to life and instead advocates for a much more workman-like approach. He makes the case that the passion that many people have comes from the slow accumulation of skill and experience. It grows from a deep understanding of the niche and an engagement with the subject that simply doesn’t happen without, commonly, many years of work. Yes, these people are “good”, as the title suggests, but it doesn’t even necessarily mean you will then garner some kind of externally validated success. However, it’s likely you will, either way, get personal satisfaction.

The book is aimed at those who are looking to develop a career but there is still a lot of resonance for me. Perhaps more. It’s easy in many careers to cast around looking for the next thing. It’s an easy trap for the portfolio GP. The desire to move through the jobs onto the next and ‘better’ thing is a common trait. In many industries, and academia is no exception, we’re often managed by these people. And, the overwhelming feeling is that they rarely get good at their jobs. They simply don’t stay in them long enough. Sometimes it is better to stay, keep improving, and let one’s passion grow.

Notes on a fell race: Ring of Steall 2017

R unning up hills is not most people’s cup of tea. I’m not sure if I will do another fell race. The Ring of Steall Skyrace was one of the most painful runs I have had in a long time. Memory is an unreliable indicator for this sort of pain. The temptation is to shake it off and come back next year. Not me. This one didn’t even count as Type 2 fun.° My climb up the second 1000m ascent from Glen Nevis was as humbling a physical experience as I’ve had. Writing this two years later and it still smarts.

The hills above Glen Nevis were among my very first experiences of Munros when a mate and I made a summer trip circa 1989. Actually, my very first Munro was a winter ascent, in crampons, of Sgùrr nan Gillean° on the Skye ridge but that’s a different story. I remember walking the Ring of Steall on a long glorious summer day and being thrilled with the journey and the adventure of it. The Ring of Steall does, it have to be said, lack the aesthetic qualities of a natural horseshoe walk with the start situated in Kinlochleven. A quick glance at the profile will tell you all you to know. In its 29km it packs in 2500m of climbing as, Grand Old Duke of York style, it marches you up and down again.

The race centre in the Leven Hall in Kinlochleven was well organised. We got there the night before the race at 7pm and were ushered around in 20 minutes. First, we had our kit checked. Not every single item was scrutinised but they looked at the hooded jacket, waterproof trousers, and our shoes. Tick, tick, tick. A stamp on the hand and we moved to the next table in the hall. They did a photo ID check and we were given an additional race briefing sheet and our maps. Our dibbers were strapped to our wrists. We then shuffled around and got our race numbers and a GPS tracker was taped to our race sacs. We were stood up against a wall and had our photos taken. Cue general macabre comments about body identification. Finally, we got our T shirts and I collected a little bivvy bag I had pre-ordered. That was it.

We were back the next morning for a civilised 10am start. They got us in the pen at 0945 and after 15 mins of batting off the midges we were set loose. We had 2-3km of road and track to get ourselves onto the start of the hill and the first checkpoint. Then the climbing started in earnest as we made for the first proper checkpoint (CP2) on the Steall Ridge. It was foul underfoot. Black cloying peat over waterlogged ground. I was going fine but worrying that I was going too hard. I was right to be worried. I could already feel myself getting a little rough towards the top of that first climb.

I hit CP2 and two guys were ready to ‘dib’ us in. One of them wearing a pink tutu under his waterproof. Legend. He would still be there when I came back hours later.

The wind was cutting right through us and once past the checkpoint I hastily pulled on my windproof and a pair of gloves. The Devil’s Ridge lay ahead. Unfortunately my own physical demons were lurking just behind me. The rising nausea as I hit the ridge quickly reached critical point. Had I gone too hard? Not drunk enough? I was only 1hr 10mins in, there was no way I should be having problems yet. It was almost like motion sickness, an all-consuming nausea. Looking back I now it’s easy to wonder why I didn’t shake it off, didn’t just eat, drink and get on with it. But if you’ve been laid low with proper sea sickness you will know the feeling. Utter lethargy was blanketing me. I was heavy-lidded and felt sedated. I slowed to a crawl up the hills. The weird part of the experience is that almost as soon as I was on the flat, and certainly going downhill, the worse of it faded away. I was getting passed on every hill but regaining every time we went down again.

The ridge was relatively short and we were then faced with the long descent into Glen Nevis to CP5. A drop of 1000m all laid out before us. It was magnificent but thighs were battered.

The descent into Glen Nevis
The descent into Glen Nevis

My stomach wasn’t happy at CP5 but I knew I had to eat. I got a cup of coke and had a few crisps. I also pulled out half of the honey sandwich I had made that morning. I set off from the checkpoint and slowly munched it at walking pace. Better just to keep moving. Unfortunately, the food didn’t transform me. The nausea was still there and rearing its head whenever I hit a hill. I mostly stuck to a fast walk uphill. Glen Nevis came to an end with a slithering peaty slide back down to the river. We had to wade the river. The slope back up to the top of the ridge kicked up in front of us. The climb back to the top of An Gearanach beckoned.

And so began one of the more miserable 70 minutes I have, er, enjoyed in the hills for many years. I’ve probably had worse but they were all 15-20 years ago. It was excruciating. The nausea blanketed me. Other runners, though to be fair we were all walkers now, streamed past. I lost count. Dozens of them. I wanted to tell someone. I wanted someone to see how I felt. I wanted to say that I would be fine if this sickness could just go. I simply kept going. That was the one thing I couldn’t face. Stopping. If I stopped moving then it was never going to end. If I kept putting one foot in front of the next then it had to finish at some point.

Bill Tilman memorably described this disorder as Tilman’s Foot.° The inability to put one foot in front of the other. Every step is a small victory. I was now aware that my fluid and calories intake for the run was woefully inadequate. I couldn’t even drink. If I started retching then I was certain I couldn’t take another step. I would have to retreat in ignominious shame to CP5 and abandon.

I was heading up, heading on, but it felt like the most fragile progress. A precarious progress. A false summit and I looked west to the Devils’ Ridge we had already traversed. I could see we were still well short of the same height. Spirits sunk. I could have wept. I wanted to give up. I was trapped in this earth-bound manufactured hell. More people passed.

Then, I heard the shouting. The marshall at CP7 was hollering and whooping whenever anyone crested the ridge. I stood there almost mute. I told her I was nauseated. She offered some sage advice. God knows what it was. I knew it was futile. But at least I had some flat and some downhill to ease the way.

The cold was bitter now. I wondered how aged I was as I pulled on 25-year-old dachstein mitts and several 20-somethings passed in shorts and T-shirts. The cold was grinding my bones. One young blonde girl in a startling yellow T shirt and shorts had come past me on the way up. I looked at her and wondered how she wasn’t hypothermic. I wasn’t generating any heat with my forward movement. And so it went on. There was some scrambling for interest and it was a blessed relief.

The climbs to the tops were stiff. These are separate Munros so I shouldn’t have been surprised. The last one was brutal. At this point the men and women around me had coalesced into a clot as we tried to push on. I was no longer the slowest. Everyone was fighting their own battle. I have to admit that seeing everyone else suffer gave me hope. What a bastard I am. I had felt like the only one on the earlier climb but the will to live was seeping back into me. One guy paused to stretch a cramping hip.

Then, glorious relief. The final summit of Am Bodach. Now it was all downhill. And immediately, my nausea eased and I found my rhythm. I passed people. I hailed, as a long-lost friend, the legend in the tutu marshalling at CP2 and plunged down the hillside to Kinlochleven. It was foul. Bog, bog and more bog. But, I kept passing runners. I like running downhill. The final stretches of trail were more agony but it was too near the end to hurt as much. Thankfully the road run was barely a kilometre. I jogged it in. I was feeling chipper. I was going to live through this one. I smiled at the passers-by. I willed myself to enjoy it. I crossed the line in 6hr 49 mins 48 secs

Nine tips for writing essays on research for medical students

This is a summary of the advice I’ve been giving to medical students for years. However, the advice is quite generic and it may be helpful for anyone writing an article on a particular medical subject area where you have to synthesise evidence into a coherent report.

It assumes that there is a general topic area and the writer has the freedom to fine tune the aim and exact niche they want to cover. If you have been given an assignment with a very specific pre-cooked title and aim then much of this advice won’t fly. Non-student writers may not need to state the aim so explicitly but I’d still recommend having one in mind to ensure your writing sparkles. Nothing kills off the impact of an article or report as quickly as rambling digressions.

1. Choose your topic well – niche down

One of the best ways to confuse the hell out of yourself is to pick an enormous topic where there are thousands of papers. Yes, the intro will start with a big topic but you have to focus.

There are several ways to reduce a topic down to sensible proportions. You can concentrate on a sub-group – women, or women over 60, or women over 60 from BME groups, or women over 60 from BME groups with an ‘r’ in their name. You get the idea. Another option is to concentrate on a single intervention. Intervention-based essays and reports can work very well as they can have laser-like focus. There is no temptation to stray into other areas.

More than anything, one of the best strategies I’ve found for students is that they need to get to the bottom of the literature and start dredging there. What I mean is that you need to get all the way down to the original studies, the nuggets of research on which the wider reviews and the guidelines are then built. If you write about a topic which is too broad then you’ll end up trying to critique systematic reviews, narrative reviews, and meta-analyses. That is incredibly hard to do as the full-time academics who have spent their life immersed in the topic will be much better at it than you. That way leads to stress, anxiety and overwhelm.

If you get down to the original literature then you will be able to flex your critical appraisal muscles. All papers, even the very best ones, have flaws in some shape or form. There is no perfect research. Handily, most papers kindly point out their own flaws in the Discussion section.

If you can narrow your niche down to the original research where there are just 5-10 papers with all the knowledge on that topic then you are well on your way.

2. Get the structure of the introduction sorted

Now, there are several different options for how you start an introduction but I’ll describe here the most basic one – the general overview. A well-written general overview is a gem. Some of the best papers have wonderfully succinct summaries of the most important and relevant evidence in the topic area and, regardless of the rest of the content of the paper, could stand alone as brilliant articles.

Think of the intro as funnel or upturned triangle with a number of sections. If each section is a paragraph then you will know exactly what to write. Start with the very big picture, the global, then the next paragraph will be the national, and then get into the specifics of the niche you are looking at. You may need a paragraph on the intervention and sub-group. Finally, the final sentence or two should bring it all together in the pointy bit of the triangle – a description of the aim. The aim should by then feel completely logical and you’ve set the reader up for the findings of your report.

3. Work hard at the aim – and keep working it

The aim is the cornerstone of your report. Don’t just dash one off and abandon it. Re-write it, work it over. It is the formal written expression of the purpose of your report, its raison d’être. Spend some time to get it right and it will make writing your report a lot easier. It is a common flaw in reports that the title and the aim don’t match – make sure they do. More worryingly, it’s common in the poorer reports for the content of the report not to match either the title or the aim. These are the ones where the student has wandered around the research literature, bewildered and disorientated, latching onto occasional snippets.

It is OK to adjust and tweak the aim as you go – it may be too specific and need to be widened. This is not a research project so it is OK to adjust the aim. It’s a written report and if you get to choose the topic then you also should be able to shift the aim. It’s not cheating and it’s not ethically wrong. It is essential if you want the report to have some coherence. Remember, nobody will read your early drafts so you are free to develop the work.

You might be lucky and get it spot on first time. More commonly, as you get into a subject and get to know the papers, it often becomes apparent that it’s too narrow and confined or, more commonly, it’s still too big. Recognise that there is only so much you can squeeze into 2000, 3000, or 4000 words. Tailor your aim to suit.

4. Make sure the report itself answers the aim

Gee, now this might seem obvious, but it is a surprisingly common problem that I regularly see as an editor as well as from students. People get enticed by shiny baubles. Beware interesting tangents and fascinating digressions. Make sure that everything you right about in the report or article can be linked back to the aim.

Look at everything you write (and this might be more of a task for the editing phase) and ask yourself: does it address the report’s aim? If not, it probably needs to be binned. Alternatively, if you are convinced of its importance then you might need to tweak the aim: see #3.

5. Get your notekeeping sorted

Do this right and your report or article will practically write itself. Get it wrong and you will end up in horrible confusion. Make sure, particularly in the early phases of literature searching, you keep detailed notes on the search strategies.

When it comes to reading, start making short brief notes in your own words on each of the papers (carefully referenced) rather than simply underlining and highlighting. This will help enormously when it comes to the drafting stage. Do not think you will just remember and don’t copy and paste from papers. You will forget and, worse, if you then use that pasted text in your essay you will be plagiarising. Don’t go there.

A good notekeeping system will help you make sense of your reading and make connections between themes in the research you read. This is a whole subject area in its own right but if you want to read more then pick up a copy of Sönke Ahrens’ How to Take Smart Notes.° I also spoke to him on the Blokeology podcast

6. Write the first draft fast

Don’t linger on the first draft. Get it down and then re-write. Procrastination is the enemy here. Get comfortable with the fact that your first draft will be rubbish. That’s entirely normal. This is where you will find that those notes, written in your own words, are incredibly helpful. You can paste these in the appropriate areas – they are your words right? So, no problem. With these you’ll quickly build the basic building blocks of your report.

7. Writing is re-writing, so, give yourself time to edit

You can only expect to turn that rubbish first draft into quality work if you give it enough time to re-write it. I often find that I have three, four or five passes at a piece of work before I start to feel it’s coming together. Sometimes, it’s longer, but I have learned to trust the process and that if I keep working at it then the quality will improve and I get to a stage where I am satisfied. It is hard to put aside your anxiety in those initial drafts but try to be patient and keep moving forward. Of course, this is all dependent on making sure you have enough time. So, you have to work backwards from the submission date and allow that leeway. The most important thing is to get the first draft down quickly and then you’ve got something to work with.

9. Follow the formatting guidance and don’t throw marks away with sloppy presentation

This is just one of those very basic things. Don’t forget to follow the formatting guidelines for the submitted report. Check the student handbook. I don’t care if you hate Calibri (I’m not a fan myself), if that’s the font they want, then use it. Otherwise you are throwing away marks.

Getting rid of typos is not the only thing you need to do. The overall readability of the report is usually considered here. You need to present a coherent report. Sub-headings are strongly recommended to help the reader follow the logical flow. You may know what a given paragraph is about – make it easy for the half-wit reader (me) to follow that too. Walk around and read it out aloud. If you stumble over it then it needs a rewrite.

9. Write the abstract last

This should be written at the end. It’s a summary of the overall report – how can you do that until you finish the full report? Don’t be coy and offer teasers. It’s not some ad copy. You are not trying to avoid giving the findings here – spoilers are expected! It is a mini version of your report. Write a couple of sentences summarising each section and then put it all together. Think of it as the 280 character version or Instagram post of your report. It will take more time than you think.

A note on typography

Something completely different this Sunday. I just wanted to add a few words about the typography on the website and highlight a little bit of styling I’m using.

I’m using the Merriweather font – it’s a serif font that has good readability on the web. I like the slightly old-fashioned look to it. You can read more at the designer’s website.° I’m not sure what Matthew Butterick would make of Merriweather. He’s the author of the excellent web book, Butterick’s Practical Typography (2nd Edition).° It is a treat. I would highly recommend paying for the book and I’ve a huge amount of respect for Butterick’s approach and commitment. If nothing else, read the summary Typography in ten minutes° and cast off your foul Arial and Times New Roman fonts forever.

As well as adjusting font size and line spacing I have also made a couple of other tweaks with the behaviour of hyperlinks and the use of small caps. Both of them needed some CSS tweaking to get them to work. I don’t profess any great coding knowledge but I can cope with the basics and some persistent Googling will usually solve the problem. In fact, with the small caps I was struggling and, in the end, I worked it out by finding a site and using the Inspect function in Chrome to take a sneak at the code. I thought I’d add them here.

Changing the behaviour of hyperlinks

My hyperlinks don’t look coloured and they only appear if you roll over them. I use a degree symbol (°) to flag them if it is not utterly obvious from the context. I find it less intrusive and distracting when reading. You’ll need to add this snippet of code to your style.css file (or your theme might have a convenient box embedded within the backend).

a:link {
color: black;
background-color: transparent;
}
a:hover {
  color: black ;
  background-color: #D3D3D3 ;
}

CSS code to add small caps

As I said, this took me a while to work out. The CSS code you need is here:

.smallcaps {
    font-family: "Merriweather";
    font-variant: small-caps;
    text-transform: uppercase;
    font-stretch: ultra-condensed;
    font-weight: bold;
    font-size: .95rem;
    letter-spacing: 1.5px;
    line-height: 100%;
}

When you are in the post editor you need to jump into the html view to use this little bit of code: <span class=“small caps”>Whatever you want in small caps</span>

And that’s it. 

Cormac McCarthy on academic writing

Cormac McCarthy in 1973. Public Domain, https://commons.wikimedia.org/w/index.php?curid=81220614I’m not much of a fan of Cormac McCarthy. Not yet anyway, but I hold out hope. I’ve found it difficult to get into his novels but I do keep promising myself to return to them and try again. A few weeks ago he provided his advice in Nature° on how to “write a great science paper”. And it’s damn good.

His most important tip is “to keep it simple while telling a coherent, compelling story”. From the editor’s seat there is no doubt that a lot of people manage to turn academic writing into an exercise in drudgery. Worse, it often results in a paralysis when it comes to other writing. The habit of academic writing infects all that writing too and leeches it of passion and, where necessary, opinion. Writers conditioned by this style often seem to find it challenging to express any opinion.

One could argue that research writing itself doesn’t need to have that wow factor of readability. One might say, it serves a purpose, if it has to be a little dull in order to achieve the appropriate objectiveness then so be it. I’m not mandating anything other than the necessary accuracy to get across the message. It’s just that often the case the writing is a pompous notch or three above clarity. All too often academic authors, as Tim Albert suggests,° put on the posh overcoat.

Cormac McCarthy’s advice is actually quite generic. Most of it can be applied to any writing. Indeed, it should be applied to all writing. There is plenty in the article and I won’t regurgitate it. I thought his point to “avoid footnotes because they break the flow of thoughts…” was interesting. I’ve read a number of books recently that were riddled with them and I have become acutely aware of how much they disrupt the reading experience. And, of course, the best advice: “Try to make life as easy as possible for your editing friends”. Though, to be fair, McCarthy has perhaps slipped slightly into his experience as a novelist as he writes about finding a good editor.

Gender bias in clinical case reports

Some of the best books are the ones that tilt your perspective completely. I’ve been working my way through Invisible Women: Exposing Data Bias in a World Designed for Men°. I haven’t yet finished but it is a tremendous read and it has the potential, rather remarkably, to change the way you look at the world. The bias towards men in our society, in all the tiny details, is completely baked in, making it astonishingly difficult to see, never mind take action against it.

At the time of writing, I haven’t got to the medical sections so there is the possibility this is covered in the book. My brain was ticking over as I listened to the audiobook and I had the brilliant idea to check if there was a gender bias in clinical case reports in the medical literature. And, of course, because it is a good idea to check that, it has already been done. Not all that long ago either and the full results were published in PLoS ONE in 2017.° They looked at 2742 case reports in the ‘big five’ medical journals. Here is the all important forest plot.

 

 

It’s obvious on this. A clear bias towards men.

The authors also ran the numbers again to make sure that this wasn’t, in their words, “a NEJM problem”. It wasn’t. The pooled results remained significantly biased towards men. There is no reasonable explanation for this other than bias. Women are not seen less by the medical profession, indeed, without rooting out the evidence, I’d venture to suggest it is likely to be the contrary. Ignoring any stereotypes, there is the simple nature of pregnancy and childbirth that puts women in contact with services. The study results are, as Caroline Criado Perez shows in myriad ways, just another bias towards the male.

I would add that I’ve not found the book completely plain sailing. (I always wonder if this shouldn’t be plane sailing. Turns out it used to be – more on that here°. But I digress…) So far, I have found that some of the points made by Criado Perez have tortured the data beyond its reasonable conclusion. I want to shout: stop, stop, you’ve made the point, now you are actually weakening your argument! I have then, in a liberal angst tailspin, worried this was nothing more than my own implicit bias manifesting itself. Perhaps I just didn’t like the message and it was causing me to find reasons to nitpick. It was a bit of a relief when I was chatting to a female GP about the book, an undoubted expert when it comes to evidence with a hawk-eye for injustice and inequality, and she raised, unprompted, the same concern. Not just me then. There is hope yet that I’m not ageing into a reactionary misogynist.

None of that changes the underlying message – the biases are all still there. As the PLoS ONE study shows the male bias can be found in unpromising and unexpected areas. One just wouldn’t assume there should be a bias there. It is difficult to imagine why men should be more interesting and therefore more likely to appear in case reports. As an editor, it is a good lesson in being vigilant for gender bias.

Mobile drug consumption rooms

What I love about this research paper is that I simply hadn’t heard of mobile consumptions rooms before I found it.° It cheered me up to find out about something I didn’t know – there’s just that frisson of excitement of learning something new and it immediately clicking. Mobile consumption rooms? Of course! Great idea.

Taylor H, Curado A, Tavares J, et al. Prospective client survey and participatory process ahead of opening a mobile drug consumption room in Lisbon. Harm Reduct J 2019;16:1–7. doi:10.1186/s12954-019-0319-1°

I’ve been well aware of the evidence around supervised injection sites or drug consumption rooms for a long time. Obviously, having edited the Harm Reduction Journal they are in perfect alignment with that harm reduction philosophy and the Vancouver project has always been particularly research active.

Portugal is well known for their radical drug policy when their 1999 National Drug Strategy shifted them away from repression and punishment. They embraced an ethos of pragmatism and 2001 legislation included the provision of drug consumption rooms (DCRs). One limitation was that DCRs had to be in areas where the population was not as dense – not very handy for providing services in the heart of cities.

Enter the mobile consumption van.

They found an incredible willingness amongst users to take advantage of the facility. The participants cited reasons such as: security, fear of overdose, and police violence (89%); privacy (89%); hygiene and access to a clean space (100%); and support from a specialist team (78%). The main reason not to use a mobile consumption room was if they already had a space to consume and only a couple of people stated they would be ashamed to consume in front of a technician.

One of the major difficulties with drug consumptions rooms is getting politicians and local residents to buy into it. Less public injecting and a reduction of needles and syringes in public places are obvious benefits. Yet, understandably, there is always going to be a lingering nimby-ism around a drug consumption room. The mobile facility can sweep aside many of those concerns around planning and it can also respond to demands in a flexible way.

If you want to read more then I highly recommend the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)° for a briefing. They also have a PDF version° of the report. The image used is from their site and you can see that DCRs, while certainly not approaching universal coverage, are not a fringe concern. The Transform Drug Policy Foundation° also has a briefing paper° and that has a nice little picture of a mobile drug consumption room van (the only one I can find).

Blackpool is dancing and smiling

This is the week that Strictly Come Dancing bigs up Blackpool. They all build up Blackpool and the Tower Ballroom and there is tremendous excitement.

I had some clinics in the substance misuse services Blackpool today and I was hoping to take a stroll at lunch, perhaps enjoy a coffee in the Winter Gardens, and soak it all up. (The BBC has invaded the Ballroom itself this week so chance of that.) Sadly, the day was breathlessly busy. First thing in the morning, we had a long meeting to decide on who would go forward for detoxification. I’ll write in the future on the contortions we have to do and the financial imperatives. There was then a stream of fairly complex clients, including some home visits to the housebound and the seriously ill.

But I wanted to avoid despair. Blackpool does deserve some optimism. And it deserves a bit of love. There is a risk, perhaps only in medical circles or those concerned with inequalities, that Blackpool is becoming a byword for deprivation. There is a litany of markers of a deeply damaged society: sky high levels of obesity; devastating numbers of drug-related deaths; alcohol and drugs like Spice tearing out its soul. But, of course, like almost any community there is a pride, a sense of ownership, and perhaps they are all the more fiercely loyal to Blackpool because of the adversity that can also be found here.

The cases with which we work involve multiple physical health problems, intractable and enduring mental health disorders, and social circumstances which are nothing short of harrowing. We have to shout about them in order to get them attention, to get them some help. God knows no one else is going to do it. And I will continue to shout about it. Quite probably I will use Blackpool as an example but I don’t want to drag it down. So I just wanted to be a little positive in this week in November when millions of people turn to it, watch some light entertainment on the TV, and smile a little.

Art deco in the Winter Gardens, Blackpool

The November 2019 Debrief

My monthly Debrief was published in the new November 2019 issue° of the BJGP last week. This time the title was Bounded rationality for generalists. Inevitably, in writing a 600-700 word article a lot of stuff has to be dropped out or skimmed over. This month the article covers some thoughts around the work of Herbert Simon, bounded rationality, and the paradox of choice. It is an expression of alarm at the endless choices and decisions we are forced to make. I tentatively suggest it threatens the very viability of the medical profession.

I look on with some horror at the relentless production of evidence which often feels far beyond the ken of any one person. Often my thoughts are simply: Stop the world! I want to get off. Yet, I also recognise that the niches within which we work have gaps but my overriding emotion is one of anxiety. We have more evidence than we can use in a lifetime yet we’ve precious little time to reflect on it. What is this life, if full of care, We have no time to stand and stare? It’s the first line of the poem Leisure by WH Davies°. It is most assuredly not musing on the challenges of research implementation but it wouldn’t be a bad approach to take.

While I’m on the poetry kick, there is a touch of the Ozymandias° to evidence-based medicine. Look on my Works, ye Mighty, and despair! Who would dare speak against the edifice? Sometimes, it is a tyrant, one that towers over us and proclaims its own wonder, its very vastness unknowable, arrogant in its greatness. I don’t think the same fate as Ozymandias awaits but there’s a lurking hubris and a need to accommodate the stony realities of human nature.