An eye to the underworld

The weather over this Bank Holiday hasn’t exactly been blazing sunshine, and most of August was pretty variable, but it can’t be denied that we’ve had a fair bit of hot weather over the summer and July in particular was almost continuously sunny with very little rain.

According to English Heritage, this has led to a bumper crop of archaeological discoveries. Crops naturally grow at differential rates over areas of buried archaeology compared to the natural soil. This pattern of differential growth is most pronounced – and visible – when the weather is hot and dry. This summer was nearly perfect for revealing hidden subterranean ruins, as can be seen by the photo illustrating this article.

I find it symbolically compelling that the cropmark pictured strongly resembles an eye (specifically, the Eye of Horus, commonly used on funerary amulets for protection in the Underworld), letting us see through the earth to the archaeology below. It makes me chuckle to remember that similar extended periods of drought and stress in our own lives can be used to let us see through our surface projection to meaningful content below.

This year’s crop may not flourish without rain, and yet we still grow.

Related Articles

• Dry weather makes 2010 ‘vintage year for archaeology’ says English Heritage (telegraph.co.uk)
• Dry early summer turns 2010 into a vintage year for archaeology (guardian.co.uk)
• A vintage summer for new discoveries (independent.co.uk)

Testing Times

It may be the August Bank Holiday, but there’s no rest for the wicked this weekend.

I’m busy teaching on the Get into Medical School course I run alongside my good friend Neel. Today was training on the UKCAT course we offer specifically for that exam; tomorrow will be our regular general course covering all aspects of applying to study medicine, including how to choose a medical school, the application process, writing a good personal statement and interview advice.

The course is generally fun to teach, and it’s good to meet tomorrow’s doctors. But I have to admit that the UKCAT day (and the BMAT one we run for that exam later in the year) can be a little tiring due to the vast amount of content we have to cover in a relatively short space of time. There are a lot of worked examples we have to get through, and those can feel a little repetitive at times. That’s good for the students of course, as that’s how they will learn, but it is quite draining for those teaching.

More fundamentally, I find it a shame that these students have to sit all these extra exams. When I applied to medical school, we just had to sit our A-levels. UKCAT and BMAT didn’t exist, and if you were applying to Oxford, you could opt to sit a special entrance exam instead. If you chose to do so, and did well on that exam and the subsequent interview, you could obtain an unconditional offer to get in, which really took the pressure off the rest of the final year at school. I was fortunate enough to get one of those offers, and it certainly made that last year lots of fun!

Exams such as UKCAT and BMAT were introduced with the dual aims of better distinguishing between candidates with equally good A-level predictions, as well as being fairer in terms of testing potential and intelligence rather than differentially rewarding those from schools with the funding to coach students towards good A-levels and those with fewer resources.

I would argue that they more or less meet the first objective; they certainly provide universities with more data with which differentiate candidates. However this would not have been necessary if A-levels themselves adequately distinguished between the merely good and the truly great. The introduction of an A* grade at A-level may help reverse this trend, but given the experience of the starred grade at the lower GCSE level, I rather doubt it will do more than encourage further grade inflation.

The tests certainly fail the test of levelling the playing field between rich/well-resourced students and those from less privileged backgrounds. Firstly, the very act of creating more hurdles will discourage those from traditionally less aspirational, poorer-prepared and system-unsavvy backgrounds. Secondly, each of these extra exams carries with it a entry fee. This is set at a relatively trivial level for the well-off, but this is not always the case for others. Finally, both tests reward extra coaching and preparation since familiarity with the tests improves performance dramatically, regardless of what the examiners claim. Thus, those with the awareness to practice in advance, get coaching from their school, or attend courses like ours, will score better results than those who do not. In a very real sense, our course negates that general bias somewhat, since at least our course is a relatively small one-off cost, compared to ongoing expensive school fees, though of course it still rewards those who attend as opposed to those who do not.

The real solution would be to make A-levels themselves more challenging and more discriminatory (in the best sense of the word), to distinguish not just between good and bad candidates, but also between good, very good and excellent students. And then to prevent that discriminatory challenge from being eroded by progressive grade inflation.

If all that could be achieved, we could return to the older, simpler, days when A-levels alone were sufficient exams and candidates would not be subject to so much unnecessary stress from the whole process.

Working Freelance

Part of my portfolio career could accurately be described as freelance work, carrying out urgent Mental Health Act assessments as an independent psychiatrist when one is needed.

It’s enjoyable and interesting work, blending acute psychiatry with legal issues, and it’s flexible so fits in well with the other elements of my career. It helps keep my skills up to date, applies the training I’ve received to potentially complex situations and it also appeals to my strong sense of civil liberties. That may seem paradoxical, given that assessments can result in detention under the Act. But detention is always the last resort and being present at the assessment allows me to be sure that other ways of resolving the situation have been fully explored, to prevent somebody’s wishes being overriden if at all possible.

That highlights one aspect of working freelance that I think is often ignored. People sometimes think freelancers don’t care about the organisation they happen to be working for at the time, or about the quality of the work they do. While there may be a minority of freelancers for whom that is the case, I think for most the reverse is true. Working independently, one has to maintain the highest of ethical and professional standards, since ongoing work and remuneration is dependent on maintaining a good reputation.

The illustration above is Il Condottiere, by Leonardo da Vinci. Condottiere was title given to the Captain of a mercenary force in mediaeval Italy. The rich Italian city-states such as Milan, Venice and Genoa lacked large standing armies and so at times of armed conflict they employed professional soldiers, captained by a Condottiere. These mercenary captains worked hard to refine military strategies and tactics into a science, precisely because they wanted to minimise loss of life, and to maximise earning potential. They developed techniques based on out-maneouvering the opposition and destroying their ability to conduct warfare operations, and avoided full-scale engagement where possible.

Similarly, the modern freelancer has a built-in incentive to be efficient and thorough, and to not waste time on processes irrelevant to the successful conclusion of their work. They can cut through a lot of unnecessary systems by focusing on the core professional task required of them. And every freelancer, like his Condottiere predecessors, aims to become so invaluable to potential employers, that he can pick and choose the work he does.

Loaves and fishiness

At the height of McCarthyism in the early 1950s, the CIA was busy conducting a series of covert and illegal experiments on human volunteers. The project, codenamed MKULTRA, was designed to investigate interrogation and mind-control techniques. It exposed unknowing human test subjects to a range of mind-altering chemicals such as LSD.

I mention that background to put this news story today into context. It discusses the possibility that a famous outbreak of ergot poisoning in a small French village was one of those experiments. Ergot poisoning, incidentally, is thought to have played an important role during another time of public lynchings, it being a likely causative agent for the bewitchings leading to the Salem Witch Trials… but that is another story.

In our 1951 case, it is claimed that the ergot story was a cover-up for LSD experiments. It is alleged that loaves of bread were laced with LSD (or another psychoactive substance) to monitor the effect the drug had on the population.

Personally, it doesn’t strike me as a particularly useful experiment to conduct, given the lack of control over the subjects and the inability researchers would have had monitoring their behaviour in a meaningful way. It would be pretty difficult to gather any useful actual data. It also seems to duplicate some other MKULTRA work. But bad methodology doesn’t mean the experiment didn’t happen, and the truth is that we’re unlikely to ever know for sure.

Regardless of whether Pont-Saint-Esprit was another example or not, MKULTRA remains a salutory lesson to the psychiatric profession of the importance of maintaining its own sense of professional ethics, independent of the government of the day. It was a prominent psychiatrist, Donald Ewen Cameron, who was recruited by the CIA to run the experimental side of MKULTRA. By ignoring the concept of informed consent, he let himself become part of a system that authorised abuse on a wide scale. It wasn’t the first time the profession has been used in this way. And at the same time as MKULTRA was happening in the USA, psychiatrists were busy declaring political activists in the USSR insane for not believing in Communism.

But it is a reminder that the State – whatever State – should not be allowed to easily overwhelm the individual. The starting point should always be a sense of valuing liberty, freedom and individual choice above the needs of Leviathan.

Opportunity Cost

So few people understand opportunity cost.

It’s such an essential part of making sensible decisions that I find it a little frightening how few people grasp this basic concept. They get caught up in a quandry of right or wrong, difficult or easy, expensive or cheap, and completely forget to take into account the real, full, costs of making a decision, which crucially includes opportunity cost.

Opportunity cost was conceptualised by the philosopher John Stuart Mill, probably better known for his discussions on liberty and tyranny. But for me, he should be better recognised for formalising our understanding of opportunity cost. It is the cost associated with making a choice between options. Not just financial costs of acting, but the extra cost to your emotional state, psychological well-being and the time lost by spending it on one course of action that could otherwise be spent on another.

People have a tendency to make decisions in a form of tunnel-vision, focusing on one element of the overall cost, without fully taking on board the overall opportunity cost of their actions. MCDA, which I discussed recently, is one way of formally considering all the costs of an action. But even without using that methodology, a cursory calculation of opportunity cost is important in deciding whether to act in a particular way or not.

At my former workplace, all the senior medical staff are going to be re-interviewed for their existing jobs. This is part of a wider process of achieving efficiency savings, but I found it interesting listening to some of their complaints that this was happening. About five years ago, another reorganisation led to all the junior medical staff being re-interviewed for their jobs at the time. At the time, apart from some vague disapproving noises about the process from some, senior staff did little to actively protest the introduction of that reorganisation (which was not done for necessary cost reasons, but for bureaucratic/political ones), and some even supported and helped implement the changes.

It is perhaps unsurprising that few voices are now willing to defend them against their own turn to unexpectedly face an interview panel. Failing to take into account the full opportunity cost of that previous decision has resulted in something of a cultural shift in how such reorganisations are viewed.

Martin Niemoller’s famous quote comes to mind; another example of not fully taking opportunity costs into account…

Wicked Problems

Last time, I discussed the power of Multi-Criteria Decision Analysis to cut through even complex decision-making problems. But as I hinted in the last paragraph of that article, the technique would break down if it becomes impossible to identify at least most of the Scenario variables, or if Outcomes resulted in a recursive feedback effect on those variables.

This is the root of so-called “wicked problems“. The linked article describes the nature of wicked problems in more detail, but the essence of them is that they are problems requiring a decision where the Scenario is unique, and difficult to quantify accurately, such that you cannot analyse all the potential Outcomes and where every time you make a decision you fundamentally alter the Scenario so you can’t try again but are instead potentially faced with a second, fresh, wicked problem.

A classic example is solving a complex social problem such as drug abuse or poverty, and a newer example would be climate change, where you have the added complication of a ticking clock, which incrementally cranks up the pressure of the need to find a solution.

But wicked problems also occur in individual everyday lives. For instance, and to use an example close to my heart, deciding to leave a job. If you try to use MCDA as outlined in my previous article, you will find that you can get close to an answer, but because you cannot identify all the potential variables and outcomes, you end up in a recursive roadblock, going round in circles. Essentially, the problem is that you cannot identify the problem and so cannot weight the variables accurately.

You will end up in analysis-paralysis, never make a decision and instead indulge in displacement activity or repress the problem and retreat into manic ego defences to occupy your conscious time while you brain “spools” subconsciously, trying to process all the data and being unable to.

The answer is to accept the possibility of being wrong.

Wicked problems remain wicked because of the self-imposed judgement that you cannot run the risk of being wrong. But sometimes, the correct choice is not to try make a right (or least-wrong) decision, but to make any decision at all. Because a wicked problem is inherently unquantifiable, you can only ever make a best guess.

Use MCDA to get close to whittle down the options and then trust your gut instinct to make a leap of faith. This is the problem-solving equivalent of rolling the dice, but at least you’ve narrowed down the choices. And if the only other option is doing absolutely nothing at all and that would result in the problem is never being solved, then making a reasonable stab at the right answer IS the right answer.

It turns the tables on the very nature of the wicked problem. Because every wicked problem is unique, any change that doesn’t result in a solution, results instead a fresh problem – and “fresh” is the key point – rather than a recreation of the original one. And if it’s a fresh problem, it may well be more solvable than the original one.

So next time you can’t make a decision, and MCDA fails to reach a decisive answer, don’t be afraid to take a chance and go with your instincts. In the long term, at the very least you’ll have fewer regrets.

Go on, roll those dice.

One reason is never enough

Every day is a decision day.

Some decisions are trivial, such as deciding what to have for dinner. Others are more important, such as whether to change career. Most people are frightened of making important decisions because they think they’re harder than the trivial ones. In fact, they can both be approached in exactly the same way, and if you become accustomed to this technique, the important decisions become just as easy as the trivial one.

No decision, not even trivial ones, are simple equations. What I mean is that no decision is ever quite as simple as Action A resulting in Outcome A. There will always be multiple potential Actions, and multiple potential Outcomes, and even trivial decisions require you to consider all of them before making a decision. The reason a problem seems trivial is often not because it is less complex, but because you assign less subjective importance to the difference between the Outcomes.

Let’s take the example of deciding what to eat for dinner as an example of how to approach even a trivial problem with a degree of intellectual rigour:

Step One: What is the Scenario?

You must clarify what the situation is, and what are the outcomes by which you’ll measure the success of your decision. Let us set the scene:

• back home, feeling tired after a long day at work
• hungry
• craving something gloriously unhealthy and greasy
• plenty of raw ingredients at home, but nothing ready to eat

Step Two: What are your possible Actions?

• Go out to a restaurant for dinner
• Get a takeaway burger
• Cook something at home

Step Three: What would be the Outcomes of each of my Actions on the variables I identified in the Scenario?

Restaurant:

• would have to go out again, but would then be served, but still take longer than a takeaway.
• Satisfy hunger
• Could be suitably satisfying

Takeaway:

• would have to go out again, but would be fast and simple
• Satisfy hunger
• Definitely suitably unhealthy

Cooking at home:

• no need to go out again, but would take time at home
• Satisfy hunger
• Would probably satisfy at least part of the craving

Step Four: Assign Values

Assign an arbitrary emotional value to each outcome, and add up the scores for each option. Highest score wins, and so is the option you should choose in order to maximise your happiness. This allows you to apply a subjective weighting to each outcome based on how you feel about them. If you really, really have a craving for a burger, that would favour the takeaway option to such an extent that it would override almost any other option.

This technique sounds ridiculous when used for a trivial decision, but the basic approach is incredibly powerful. It can be used for even the most complex decision, with the direst potential consequences.

It is called “Multi-Criteria Decision Analysis” (MCDA), and is used by governments and other large organisations to try to sequentially consider every variable that could be affected by each potential course of action. The value assigned to each variable’s outcome is weighted in proportion to the importance of the variable and severity of the change. This value can be modified to allow some changes to becomes near-absolute “dealbreakers” or “dealmakers” where the outcome caused by the change is either so unwelcome or so wanted, that it almost mandates the choice.

For instance, in our trivial example, the satisfaction created by getting the burger is a virtual dealmaker, overriding the other options, and – crucially – the drawbacks of this option on other variables.

On the other hand, suppose we introduce a new variable in the Scenario. Suppose you are on a diet. In this setting, you might assign a high-enough value to your long-term objective of weight loss that the loss of points created by eating the burger would override the points gained by satisfying the craving. The burger now becomes a dealbreaker instead, because of the high value assigned to the diet variable.

The power of this technique is that it allows for a comparative analysis of multiple actions and multiple outcomes on multiple variables, whilst allowing the decision-maker to assign subjective values to those variables. It is neither wholly scientific nor wholly instinctive, but a powerful amalgam of the two. Emotion is allowed and valued, but kept under the watchful brief of Reason. It also encourages the development of better self-knowledge and insight.

In most problems, each action has both positive and negative consequences, and it’s often a case of picking the “most best” (or “least worst”!) option. Only a multivariate technique like this allows for a decision to be made with a clear conscience.

In short, one reason is rarely enough to make a decision, but the corollary is that a good decision tends to have mutiple benefits.

Next time you have to make a decision, try this technique out; the more you use it, the easier and more powerful it becomes. You will refine your ability to identify both variables and outcomes, and your intuitive sense of how much value to assign to each outcome.

Astute readers will have noted that the technique would break down if it becomes impossible to identify at least most the Scenario variables, or if Outcomes resulted in a recursive feedback effect on those variables. This is the root of so-called “wicked problems”, the solution of which I’ll talk about next time.

Organisation as Organism

Funny thing, synchronicity.

Forced to read The Independent over a lazy afternoon latte, due to lack of my usual paper at the coffee shop, I masochistically put myself through one of Johann Hari‘s rants. For once, it was possible to make it through the entire opinion piece before my eyes rolled so far back in my head from amused disgust that I could read no further. He was lambasting management consultancy (not an entirely unworthy choice of ire, it must be said) and one quote stuck in my mind from Frederick Winslow Taylor, the original “scientific management” advocate who compared human workers to “intelligent gorillas”.

It just so happened that within half an hour, I got a perfect demonstration of the importance of good management skills. I popped into the local Waitrose to buy some fruit and while queing at the tills, the power went down. Primary generator, emergency generator, the works. Instantly, the staff froze and the entire system ground to a halt. It was remarkable to witness just how quickly the usually well-oiled operation seized up. Till operators stopped working as the barcode scanners were down, the shelf-stackers stopped refilling as the refridgeration units ceased their interminable hum and even the security guards seemed lost as the automatic doors they watched no longer glided open and shut.

Enter the store manager, a slightly rotund fellow with unfortunate facial hair, but with a very controlled and competent style. He quickly organised the staff, opening more tills, instructing them to use manual barcode entry, getting the guards to open doors by hand, getting regular temperature checks on all refridgerated areas and generally ensuring that maintenance help was on the way while preventing customers being inconvenienced by more than the absolute minimum.

It was really quite impressive to behold; a rare glimpse of competency and natural ability to contingency plan in a manager. I was able to leave Waitrose with my purchases with only a marginal delay, despite the power remaining down.

What was most striking was just how frozen the operation became when something went wrong. It reminded me most strongly of a deer caught in the headlights of a car, unable to move. The manager became the brain of this malfunctioning organism, overcoming the startle reflex, forcing frozen muscles into action. Individual “intelligent gorillas” needed the alpha male to tell the tribe what to do.

One of the great goals of life is surely to develop independent coping skills and insight so we can act as our own command and control centre. To be able to understand ourselves, what may go wrong and how to contingency plan around that, so that when crisis strikes we can contain and respond to the situation flexibly and retain a sense of purpose, direction and self.

Universe to last forever; let’s fit more into it

Today scientists have told us that the universe will endure forever, becoming “a cold, dead wasteland with a temperature approaching absolute zero”. Leaving aside the obvious jokes between the similarity of that fate and the environment of the average NHS meeting, I was struck by the contrast between this infinite expanse of time, and the increasing amount of multi-tasking we now each perform in an effort to squeeze more activity into every moment.

We spend half our waking lives accessing media, and because of multi-tasking we manage to squeeze 9 hours worth of entertainment access into a mere 7 hours of time. A big part of this ability to multi-task is down to the rise in mobile internet access via smartphones.

I’ve certainly noticed how intertwined my life has become with my phone, and not just in terms of internet access. Even small things like the ringtone can have an effect. Up until my recently leaving full-time work, I used one particular ringtone for many years. Unlike other doctors, psychiatrists here don’t carry bleeps/pagers even within hospital and in any case many do a lot of work out in the community, so most of the time we’re contacted on our mobile phones. Like Pavlov’s dogs, or rats in a Skinner box, I underwent a conditioning process by which I automatically associated that  ringtone with the day-to-day hassle of work.

One of the first things I did on leaving was to promptly change my ringtone, to eliminate that automatic negative thought of “Oh bother, what now?”.  Instead, now when the phone goes off to the strains of the Magnum PI theme, I have a much more enjoyable “Ooh, who’s calling?” feeling (still waiting for a Ferrari 308 GTS though). It’s surprised me just what a difference that change has made to my core attitude to my phone.

As in the contrasting news stories, the potential for the infinite can sometimes run up against the aggressive intensity of the mundane.

Djinn: A Strong Spirit

An unwell gentleman I assessed today believed he was being stalked by magical beings called Djinn. His beliefs were not just spiritual/religious belief, but part of a wide and complex mental disorder with many other symptoms, but his mention of Djinn led me to do some reading-up on these interesting creatures.

Unlike Adam, who the Koran says was made of clay by Allah (similar to the Biblical account of God’s creation of Man), the Djinn were made from “smokeless flames of fire”.

They possess freedom of action. The Djinn Iblis used this to rebel against Allah. He was thrown out of Paradise, and became Shaytan (Satan). This mirrors Lucifer’s revolt against God in Christian tradition, though the remaining Djinn are neither angels nor devils. Allah then bound the Djinn to be servants of King Solomon (Sulaiman in the Koran), and they worked tirelessly for him as builders of beautiful structures and as makers of many useful things. But upon his death they were freed, never again to be fettered by Man. Instead, they shadow men.

Unlike the Christian concept of a Guardian Angel, the Djinn are more mercurial. Powerful beings, with the abilities of precognition, deception, selective invisibility, shape-shifting to human or animal form, telekinesis and astral projection, they are also possessed of a mischief-making nature.

They are feared for this unpredictability of action, epecially if not appropriately warded away through the appropriate rites, as all are thought to share the same nature and thus potential to be a Satan as Iblis. Unlike devils, they are not inherently evil, and indeed have genders, can reproduce, and may be of any denomination, including Islam. They are also thought to share many of the same emotions as humans, and to be strong empaths.

The Djinn seems to be a fairly typical Trickster/Chaotic-Neutral motif, something which carries over strongly in most of their Hollywood Genie incarnations. Neither inherently evil nor good, their unpredictability and deceptive nature makes them dangerous to tangle with. Strong spirits indeed and no simple tonic!