Writing stuff

You’ll find various musings and writings below. 

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. 

Talking to My Daughter About the Economy by Yanis Varoufakis

I finished off this wonderful little audiobook this weekend. My vague sense of Varoufakis was that he was a disruptive, if not obstructive, rebel influence when Greece went through their agonising economics ruptures a few years ago. I’ve nothing concrete to base this on but it’s the impression, the ghost of an opinion, that lingers in my memory. Now, I look back and wonder how much of that has been driven by the media’s pen strokes, the picture they drew, and the prevailing blame climate that was foisted onto Greece. I feel some irritation as I suspect I’ve been duped. Perhaps not, but I certainly recognise that I’ve only had one side of the tale.

The premise of this book is that Varoufakis is giving an overview and brief history of capitalism and economics to his daughter. It works. It’s a neat mechanism to put the philosophies and contradictions in context. There is plenty of politics here as well and Varoufakis is quite plain speaking about his own opinions. I’m not far off them. More than anything, it makes me think that my view of the man was truly driven by the media and that annoys the hell out of me. One can only maintain sceptical thoughts about so many subjects at once – what can we trust in the newspapers and on the television? Is it all completely tainted? It’s a frightening thought. I am going to try to remedy my understanding around Greece – starting with other, longer and more detailed, books by Varoufakis and others about the crisis, starting with Adults in the Room.°

Howgills in November

The late Alfred Wainwright° was the one that called the Howgills “sleeping elephants”. It’s a brilliant and much-used (overused?) description. You’ve seen them for sure. If you have ever driven north on the M6 then they slumber on your right as the motorway kicks up at the southern boundary of the Lake District. They are the first hills you see. And, coming south they mark the end of the uplands. You’ve also got the option of the southbound-only Killington services that enjoy a stunning view across Killington Lake to the Dales and Howgills beyond.

It was a beautiful sunny day. But I’m going to show these in black and white this time. I enjoyed a couple of hours over The Calf°(676m) and back home via Arant Haw. There was just a dusting of snow at the tops. I think that might be my first contact with snow this year.

I took my time and ambled up, jogging down. It is amazing how much more enjoyable the experience of being out is when you dial the effort back. It’s also very obvious that very little time is gained for going so much harder. So, why not kick back and enjoy the experience? (There is a counter-argument here about the benefits of high intensity exercise but, really, it’s not worth having. No one ever mused on life during a brutal interval – unless you count wishing you were dead…)

Engines of Privilege

I just finished listening to the audiobook version of Engines of Privilege by Francis Green and David Kynaston.° So, first things first, I’m state school educated and I hadn’t been particularly militant about private schools. Yet looking back I can see that in the 1990s the majority of the people I knew at medical school were privately educated (though some were via bursaries and sponsorships). The 7% problem° has received coverage in recent years and I’ve become more and more gripped by the injustice and social division. How on earth can we have any positive impact on social mobility until we tackle it?

And I found myself having quite an emotional reaction to this book.

I listened to the audiobook version and it has taken me far longer than usual to get through it. I just couldn’t stick with it. Not because I wasn’t impressed or engaged, but simply because I was so utterly infuriated and maddened by the evidence and detailing of the imbalances and the privilege. I was just upset by it. There’s no doubt which side of the fence Green and Kynaston are on (both private school educated it should be noted) but it feels, at least as they present it, as a normal and rational conclusion to oppose ‘the 7% problem’ on the basis of the evidence. I had to keep stopping after 20 minutes and then having a day or two off otherwise I found myself ruminating on it all. It’s powerful, if not downright toxic, stuff.

The problem with the public discussion is that it quickly gets ugly. My reaction is typical of the responses one can expect on all sides. Anger. Indignation. Outrage. G&K call for a debate that doesn’t stigmatise parents or accuse them of hypocrisy if they do send their children to private schools. When the system is so comprehensively loaded in favour of those who receive education in the independent sector it’s just not reasonable to expect parents to ignore that when deciding for their children. I agree that we need to work hard to de-individualise this discussion and throw out the endless anecdotal, n=1, spurious arguments.

They also appreciate that many parents who send their children to independent schools often make sacrifices to afford it. The super-rich Eton, Harrow etc are the exceptions and not the private school rule. I find it quite annoying when those institutions are trotted out as exemplars of class privilege. They are freaks, complete outliers, with vast resources at their disposal. It’s the independent schools further down the scale where some reform might be feasible. And, as G&K point out, it doesn’t have to involve a wholesale bulldozing of the independent sector. There are several measures that could be considered which would help tilt the scales.

Email apps: why don’t they all have a ‘working offline’ button?

This feeds into one of my golden rules for getting control of email in your life. There are several other elements I use to tame the email beast but this is one of the basic rules: Do not work out of your inbox.

To which I’ll add: not an online one anyway.

If you spend your life in your email inbox with new emails constantly pinging and popping then you are sentencing yourself to a life of email misery. You’ll almost certainly never get on top of anything. Worse, you make it harder to do all the other tasks well. We all need to refer to email conversations or documents as part of the process of larger pieces of work – but you can never really concentrate properly on those while you are getting intermittently disturbed and distracted. It’s just dismal.

It’s important to me that when I turn on my email app I can check past messages without new work coming in. That gets managed in batches at other times.

The only way to make that work is to be able to turn your email app offline.

It is the most basic function, yet it is crucial to email and your wellbeing.

Outlook is a dog. Not a lovely cute fun, puppy-like one. A grumpy snarling barely fit-for-purpose mutt. But at least it has a work offline button. As basic as it seems, I’m depressed about how few apps have these. Even the latest and greatest just don’t seem to regard it as important functionality. One could become cynical about this. Naturally, people making email apps want you to think of email as being tremendously important. They don’t want you to adopt a position where it is just a quick tool, one that doesn’t necessarily dominate your life. Could that be a factor in their unwillingness to just turn off email?

It makes me mad as hell. What I would actually like is an email app that allows you to turn each email account on and off at will. It’s very common for people to have more than one email account and it would be unbelievably helpful to be able control the flow of work with an account-specific offline button. A nice clear button and no chance of email sneaking through. I’m no programmer but how hard that can be?

In the meantime, here is my fix: use Radio Silence

Spark with ‘Inbox zero’ and the Radio Silence dialogue box open on top

 

Radio Silence lets you control which apps can access the internet. Mac only I’m afraid and I’m not sure of a PC equivalent – though I’m sure a quick Google will turn up some options. 

Spark is a lovely email app° to use and they even have the utterly brilliant ‘send later’ functionality baked in. (I’ll write on that another time.) As good as Spark is, they also lack in the offline options, so I use Radio Silence° (well worth the $9) as my hack of choice. I have to open another app but it means I can securely turn off Spark and concentrate on the task in hand without the dreaded ‘boing’ of another email dinging in my brain.

Selected quotes from Bird by Bird by Anne Lamott

It has taken me a while to get around to reading this. I did have a couple of false starts with it but, it’s such a stated classic, I wanted to persist. I’ve written down some of the quotes I highlighted. It is particularly well suited to fiction writers but there is plenty here for everyone. It’s not all my cup of char, some of the stories feel just a little strained, but Lamott does write beautifully and very honestly.

One reviewer on Amazon UK commented on the number of mentions of God. I don’t usually cope well with that either but BbB is certainly not a book that’s trying to convert. It just happens to be a big part of Lamott’s life. She’s also quite happy to be a potty-mouthed and demonstrably flawed person – and you have to love her for that.

Selected quotes

– Writing and reading decrease our sense of isolation. They deepen and widen and expand our sense of life: they feed the soul.

– If something inside you is real, we will probably find it interesting, and it will probably be universal. So you must risk placing real emotion at the center of your work. Write straight into the emotional center of things. Write toward vulnerability. Don’t worry about appearing sentimental. Worry about being unavailable; worry about being absent or fraudulent. Risk being unliked. Tell the truth as you understand it. If you’re a writer, you have a moral obligation to do this. And it is a revolutionary act—truth is always subversive.

– Annie Dillard has said that day by day you have to give the work before you all the best stuff you have, not saving up for later projects. If you give freely, there will always be more.

– Publication is not going to change your life or solve your problems. Publication will not make you more confident or more beautiful, and it will probably not make you any richer.

– To live as if we are dying gives us a chance to experience some real presence. Time is so full for people who are dying in a conscious way, full in the way that life is for children. They spend big round hours.

– I told her I thought she’d been very honest, and that this was totally commendable, but that you don’t always have to chop with the sword of truth. You can point with it, too.

– So much of writing is about sitting down and doing it every day, and so much of it is about getting into the custom of taking in everything that comes along, seeing it all as grist for the mill. This can be a very comforting habit, like biting your nails.

– I taped Hillel’s line to the wall by my desk: “I get up. I walk. I fall down. Meanwhile, I keep dancing.” The way I dance is by writing.

– My deepest belief is that to live as if we’re dying can set us free. Dying people teach you to pay attention and to forgive and not to sweat the small things.

– Writing is about hypnotizing yourself into believing in yourself, getting some work done, then unhypnotizing yourself and going over the material coldly.

– Sometimes intuition needs coaxing, because intuition is a little shy. But if you try not to crowd it, intuition often wafts up from the soul or subconscious, and then becomes a tiny fitful little flame. It will be blown out by too much compulsion and manic attention, but will burn quietly when watched with gentle concentration.

– If you have a message, as Samuel Goldwyn said, send a telegram.

– To be engrossed by something outside ourselves is a powerful antidote for the rational mind, the mind that so frequently has its head up its own ass—seeing things in such a narrow and darkly narcissistic way that it presents a colo-rectal theology, offering hope to no one.

– Fix instead on who your people are and how they feel toward one another, what they say, how they smell, whom they fear. Let your human beings follow the music they hear, and let it take them where it will.

– Find out what each character cares most about in the world because then you will have discovered what’s at stake. Find a way to express this discovery in action, and then let your people set about finding or holding onto or defending whatever it is

– Don’t worry about it. More will be revealed over time. In the meantime, can you see what your people look like? What sort of first impression do they make? What does each one care most about, want more than anything in the world? What are their secrets? How do they move, how do they smell? Everyone is walking around as an advertisement for who he or she is—so who is this person? Show us.

– it may help to remember this great line of Geneen Roth’s: that awareness is learning to keep yourself company

– Sometimes it actually gives them hope, and hope, as Chesterton said, is the power of being cheerful in circumstances that we know to be desperate.

Monthly reflection on activity: October 2019

I do record most of my exercise activities on Strava°. It does make a difference to the amount of training I get done. I record my runs and cycles on my smartphone using the Strava app and I add other entries, like weight training, manually as needed. I’ve been doing it for several years so I have built up a good record of my activities and patterns.

It has been very helpful to get me through periods when I’ve felt less like exercising or when I’ve picked up injuries. Helpful in the sense that I’ve been able to maintain a base level of exercise and achieve a huge amount of consistency. That consistency has been hugely important to me. Typically I do about 250 hours of exercise a year – about 20-21 hours per month. I get the occasional month where I do a little less (perhaps if I have one of those niggly calf injuries I went through a phase of getting or I’m on holiday) and sometimes more (usually when I get a bit more cycling in).

So, I like to watch it weekly and if I do less than four hours I feel a bit crotchety. If I do about six hours or more then that’s a heavy week and I usually feel noticeably more tired. Curiously, it now almost never happens that I do more than seven hours per week and those are rare weeks indeed. Which, by the standards of many amateurs, is quite modest. Of course, by the general standards of the population it is plenty.

I aim for about 20 hours per month. In October 2019, as you can see, I hit 21 hours 14 minutes. A good solid month. There was over 14 hours of fell running, just under five hours of weight training, and a couple of hours on a bike. I’m particularly happy as I went through a bad patch in the middle of the month. I was very low, very demotivated, just struggling. I’ve no idea if I had a bug, maybe a virus lurking in the background, or whether it was some stress reaction or mental health thing. Who knows? My habit was good enough that I was able to keep plugging away with the exercise and the black cloud drifted off again.

I like to think the physical activity helped and got me through it. 

London Review of Books: How to Buy Drugs by Misha Glenny and Callum Lang

I read Misha Glenny’s book Dark Market a good few years ago and it was a fascinating exploration of the dark web. The London Review of Books article in the title,is available online° at the moment but I have, thanks to a kind friend, a gift subscription to the LRB so I read it on old-fashioned paper.

The substance misuse clinics where I work in Blackpool are mostly filled with people with problems with heroin and crack cocaine. Alcohol, of course, and there are frequent problems with benzos, sometimes Spice, and the occasional amphetamines. Standard stuff. Party drugs don’t feature all that much although I don’t doubt our clients will have dabbled with them over the years. I also think that supply of drugs like heroin and crack is still relatively old-school – it’s hand-to-hand street (or near street) deals in the way it has been done for years. As Glenny and Lang suggest, this is the riskiest, with a worrying risk of getting caught or brutalised or simply ripped off.

Glenny and Lang go on to discuss the ‘county lines’ model and also the “urban full-service party supplier” with its emphasis on reliable courteous service and customer satisfaction. The fourth service and the main thrust of the article is the dark web. There’s an interesting angle that results in a kind of self-policing of quality – the admins of one site buy products themselves and get them tested. Clearly it is done for self-serving reasons but contaminated drugs or ones with highly variable purity can kill. The customers benefit.

One wonders where the drug trade on the dark web will lead. Apparently some 29% of illegal drugs are now bought online (though there is no reference for this and the way it is written in the article is a little ambiguous). It is almost impossible for law enforcement to shut it down permanently at present. That said, Glenny and Lang describe an elegant, and slightly convoluted, takedown used by law enforcement recently. Another will pop up soon. I wonder how much this kind of access to illicit drugs will increasingly normalise their use – it’s hard to predict but the relatively safe (safer anyway) access to drugs, where there is a reasonable expectation of quality, moves use into a much wider section of the population. That will ripple out through society in the years to come.

Smith: Why are doctors so unhappy?

I only recently read this short editorial° from the former editor of the BMJ, Richard Smith. It was published in 2001 article and it has over 100 citations – which is remarkable and testament to how much it has resonated, and continues to resonate, with doctors. I think this may be the first time he refers to the ‘bogus contract’ and it is one that is memorable and easily recognisable to all doctors (and probably plenty of patients as well).

There is a mawkish sentimentality that many doctors cling onto – the classic painting by Luke Fildes is one that doctors get dewy-eyed over. Here is Smith’s pointed comment on that:

Luke Filde’s 19th century painting of a contemplative doctor alone with a sick child might now be replaced by a harassed doctor trying to park his car to get to a meeting on time.

Ouch. It is devastatingly accurate. He goes on to highlight that “curing a sick child” is a very different form of gratification to that which comes with attending a meeting and agreeing to take an “abused child into care”. I don’t think that’s entirely fair here as there was precious little curing going on by Filde’s doctor but it is certainly true that’s the romantic notion of it. The reality of modern medicine doesn’t come within a country mile of that idealised version.

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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