Archive for March, 2010

Mission of GOD – 8

I will confess I have been somewhat distracted. Mainly by Steinbeck and Robinson and so it’s taken me  while to get back to Chris Wright.

But sitting here off work on the sick for a day to give me close proximity to a toilet, has given me the chance to catch up a bit.

In this penultimate chapter Wright covers GOD’s vision for the nations in the OT. From sunday school memories I remember a lot of violence, a lot of blood shed. In fact if you asked me to recall what happened in the historical narratives of the OT then that is what would immediately jump to mind.

The violence and the judgement happened, but it would be negligent to say that that was all that was going on. Although hardly unexpected the Bible gives a somewhat fuller and more nuanced account than what I seem to have immediately retained.

Here Wright articulates how the Mission of GOD involved and included the pagan nations of the OT accounts.

GOD’s mission is what fills the gap between the scattering of the nations in Gen 11 and the healing of the nations in Rev 22

He uses the example of the story of Jonah – which we see as the reluctant missionary who is eventualy persuaded. Perhaps because this is the closest thing we can find in the OT that looks like mission to us.

Wright argues that

the real missional challenge of the book is undoubtedly and intentionally lies in its portrayal of GOD. If Jonah is intended to represent Israel, as seems likely, then the book issues a strong challenge to Israel regarding their attitude to the nations and regarding their understanding of GOD’s attitude to the nations

It is here that we see GOD correcting Israel’s opinion of themselves. Yes – you are my chosen people, but chosen to fulfil my mission.

So why then all this focus on Israel- revelation. The fact that YHWH has revealed himself in word and deed and person to Israel. If they are special of favoured then this is why.

Israel stood visible to the nations, at the crossing point of the great civilisations, as conquerors, conquered and exiles they were visible as the people to whom the living GOD had revealed himself. Their ethical responsibilities were to reflect the revelation they had received.

GOD’s mission involves GOD’s people living in GOD’s way in the sight of the nations

Wright goes on to cover in some detail an array of texts that again and again state how GOD plans to reveal himself to the nations and how he will call them his people. A good example is Zech 9:7 when talking of the Phillistines

I will take the blood from their mouths, the forbidden food from between their teeth. And the remnant, even it will belong to our GOD. And it will be like a clan in Judah, and Ekron will be like the Jebusites.

The Philistines – the nasty Philistines that we’re forever hearing about in the OT – even they GOD wants a remnant of. Note that this same hope of a remnant is exactly the same hope offered to Israel.

And it is in verses like these that we now see where Paul was coming from in his mission to the gentiles. It was of course not his mission – it was the mission GOD had been pursuing since the beginning.

Battle of who could care less

In an excellent post on healthcare, post personal and international, Vinoth Ramachandra says this:

Economists limit their discussions of healthcare to the provision of medical services. But healthcare involves much more than good hospitals: concern for social justice in healthcare forces us to look at everything from sanitation, waste disposal, and climate change to the ethics of TV advertisements and food companies, the quality of secondary education and disparities in income and work opportunities. Prevention is far more effective than cures- and prevention mostly requires cash transfers to develop education and infrastructure, whereas curative medicine absorbs real resources.

Health is so much more than medicines and tests and doctors. We doctors may be the main determinants of healthcare costs (often unnecessarily) but we are certainly not the main determinants of health.

I’ve got your number

Found this on the EMA site, by Rick Bukata

NNT (number to needed to treat) is a great concept for getting some kind of message across to patients. That yes we have medicines to treat you but we cannot guarantee that you will personally benefit. Overall out of 200 or so people someone will benefit. I’m just not sure that’s you.

NNTs are generally lower for treating things that already exist. Eg most people with appendicitis will benefit from having their appendix removed.

NNTs are generally a lot higher when it comes to screening and preventing conditions developing.

He provides a few examples:

Mammographic Screening
How many women between the ages of 50-59 need to have a mammogram yearly for five years to prevent one death from breast cancer?  The number is about 2,500 such women.

Lipid Treatment
71 patients with known cardiovascular risk factors have to be treated with a statin for 3-5 years to prevent one serious adverse cardiovascular event.  But no increase in total mortality or total serious events can be expected.  To put this into perspective, at $1,000 per year per patient for statins, for 71 patients taking them for an average of four years, the cost to prevent one serious adverse cardiovascular event is 71 patients x $1,000 x 4 years = $284,000

(See http://www.ti.ubc.ca/pages/letter48.htm)

Prevention of Colon Cancer Death with Occult Blood Testing
The number needed to screen for five years to prevent one death from colon cancer is 1,374 patients.

Prevention of Hip Fracture by Treatment of Osteoporosis
In women without risk factors, approximately 2,000 women between the ages of 60-64 need to be screened and subsequently treated for osteoporosis for five years to prevent one hip fracture (1,000 women if there is at least one risk factor).

Detection of Diabetes in Men With and Without Hypertension
The number is 13 in 55-year-old men with hypertension, and 19 in those without hypertension.

Simple Antihypertensive Treatment for Mild Hypertension
700 patients would need to be treated for one year to prevent one stroke, MI or death in that year.

Prophylactic Antibiotics for Dog Bites
Only about one in 16 patients will benefit.

Compression Stockings to Prevent Post-Op DVT
One in nine patients may be expected to benefit.

Antibiotics to Improve Short-Term Outcomes in Otitis Media
Only one in seven patients can expect to benefit from antibiotics (i.e., decreased symptoms at 7-14 days post onset of treatment).

Aspirin in Healthy Physicians to Prevent an MI or CV Death
The number is 500 over one year.

All of these numbers are only as good as the data that you’ve calculated it from but still it puts some things in perspective.

Harder to Breathe

Even the non-medics will find this kind of cool.

Anyone fancy doing it on their local, friendly, useful med students?

[Via Life in the fast lane]



The magic numbers

This [Via wee Phil]

Experts in the math of probability and statistics are well aware of these problems and have for decades expressed concern about them in major journals. Over the years, hundreds of published papers have warned that science’s love affair with statistics has spawned countless illegitimate findings. In fact, if you believe what you read in the scientific literature, you shouldn’t believe what you read in the scientific literature.

I have a very dubious and incomplete knowledge of statistics. Unsurprisingly we had modules of it in medical school. Also unsurprisingly I didn’t go to any of the classes. They were were quite staggeringly dull and I had better things to do like read CS Lewis.

These days I spend a lot of time reading medical studies and trying to critique the numbers and methodologies found there in. There is a tremendous amount of Bad Science out there. And don’t be fooled into believing that it’s just the SCAMs (Supplements, Complementary and Alternative Medicine) – there’s plenty of badly done stuff in the professional and published medical literature.

People say statistics can be used to prove anything. People say that 62% of statistics are made up. These things may be true. I just can’t prove it.

Doctors bow before the throne of the randomised clinical trial. Where a bunch of people get one drug and a bunch of people get placebo and no one knows what anyone got till after the trial is over and the scientists go back and look at how people did on either the drug or the placebo.

If more people lived while on drug then they compare the numbers and calculate the probability that the observed positive results of the drug would be due to chance alone (this involves assuming a null hypothesis) and if this number is less than 5% (ie the chance of the observed results being to chance alone is less than 5%) then it is called a significant difference.

[Apparently this idea was birthed by a chap called Fisher in the 1920s who was looking at agricultural yields with fertiliser]

The problem being that statistical significance has little to do with clinical or actual significance.

If you do a big enough trial involving 1000s of people on a certain drug you can prove a stastistically significant benefit from your drug even if the actual difference between the two groups was 3 people out of 10000 dying in the placebo group and 2 people out of 10000 dying in the wonderdrug group (incidentally you could also quote a 50% relative reduction or a 0.01% absolute reduction in death in this trial).

So you see that the numbers appear very different depending on how you quote them.

The 5% number (p<0.05) is an arbitrary number. Let that sink in. Someone just decided that 5% defined statistical significance. In the name of objectivity and scientific rationalism surely that can’t be right!

But these are the tools we have and the tools we use to misunderstand and spin the medical literature.

This is how lots of people build their CVs and careers – you can’t get anywhere without publishing. And this is how lots of people make large amounts of money from new drugs that are basically stereo-isomers or other barely changed molecules from the previous ones.

Worth reading anyhow.

Bottle up and explode

This is the X-ray you’re never meant to take. So we’re told

This is the x-ray i took on Friday morning.

93 year old lady (background of chronic lung disease, but in pretty good nick considering, gets out and about once a week, no other co-morbidities) , short of breath for a week, worse on the day of admission.

She was breathless but alert, orientated and able to speak. Minimal air entry on either side of the chest, normal BP and heart rate, no distended neck veins.

Mild to moderate type II respiratory failure on her gas. Seemed like a good candidate for non-invasive ventilation.

Got a quick CXR and popped her on the ventilator while waiting for the film to print out. After 10 minutes on the vent she’s improving, less work of breathing, resp rate dropping.

X-ray comes back and yes of course there’s the tension pneumothorax.

Mea Culpa.

So what about the x-ray you’re never meant to take? Most medical dogma is just that. Based on cliche and things grey haired consultants say on post-take ward rounds. They have little relevance to real world medicine.

In the real world of frail, crumbly elderly patients (and this is a large part of our population, not the young professionals of ER and House) “classic” presentations are rare and examination findings in acutely sick people are frequently unreliable.

If you work in emergency medicine long enough you learn quickly not to make dogmatic statements or speak with too much certainty. If you have no room for doubt and uncertainty then find another job.

One of my last referrals last night was a 52 year old lady whose Dad died at the age of 50 with an MI and with chest pain that just might have been ischemic in nature (we see 20 of these patients a  day and maybe one of them rules in for ischemic heart disease).

I wanted her admitted for serial ECGs and enzymes. The response of the medical reg was the she was too young to have anything significant. I suggested that we should have told the patients father that when he died at the age of 50 with the same symptoms.

Medicine is a complex and often unpredictable beast and as much as we’d like it to be it’s not nearly as scientific as we’d like it to be.

Mission of GOD – 7

Chris Wright now turns to GOD’s image bearers – us, and looks at what the Bible says about us and how that impacts on how we do mission.

To be human is to be the image of GOD.

Kind of powerful. And several books in itself.

To briefly summarise Wright covers 4 points

  1. All human beings are addressable by GOD
  2. All human beings are accountable to GOD
  3. All human beings have dignity and equality
  4. The biblical gospel fits all

my favourite quote was this, regarding the ethics of mission:

Anything that denies other human beings their dignity or fails to show respect, interest and informed understanding for all that they hold precious is actually a failure of love.

He goes on to cover how our image bearing status has a lot of important aspects in how we live.

  • we were commanded (as image-bearers) to rule over the earth – the other creatures were given no such command (they had no need of commands or instruction it seems). And in the context we are to exert this as a King not a tyrant over creation
  • we were created in relationship – the first not good of the Bible follows on from a long list of …and GOD saw that it was good… – and that not good was applied to the man’s state as being alone. This was not that he was emotionally and needed a companion – a merely emotional, psychological not good (though it includes that) – it is much more. The fact is that as bearers of GOD’s image we need to be in relationship as GOD is in the trinity, and with us. We are created relational because GOD is relational.

Wright goes on to cover the impact that sin has on us as GOD’s image bearers and uses HIV/AIDS as a paradigm of how we are broken and how the church should respond.

He closes he chapter with a review of the wisdom literature and the common place finding of doubt, questions and suffering. It is here, in the context of a people steeped in YHWH montheism and the law that we find people holding up what appear to be contradictory.

They contrast Deuteronomy 30:15-20 with with what seems quite clearly to not be the case. Often it appears that the wicked prosper and the innocent suffer. The wisdom literature is the Bible’s own candid and honest struggle with questions it cannot wholly answer – either within the limits of our own experience or even the limits of GOD’s revelation to us.

Pay for what you get

My brother had a friend in 1997 who came back from America brandishing a copy of Crash and a few weeks later I was printing tabs off the internet and furiously trying to play the fiendishly impossible slides and hammer ons of So Much to Say. Me and Woodsy invented the word nequethiel to describe the mood of Two step. I played Crush very loudly the day I passed my driving test

I was a big Dave Matthews Band fan. Till Everyday and I kind of lost interest.

I am still not sure why they are so damn popular. Who would want to listen to obscure drum viruoso rhythms accompanied by violin and sax with a lead singer who looks like an Accountant (direct quote from wee Liz). It’s hardly “what the kids are listening to.”

So finally I got to see them last night. In the very neat and tidy but horribly sterile and commercialised O2 Arena. Incidentally I like the way they still call it The Point on the LUAS.

And they are as brilliant as they sound. The quality of the songs they’ve produced in recent years is far below the old days in my opinion but my those boys can play. Though maybe not dance.

Leroi Moore (the sax guy) died a couple of years ago and this coupled with the arrangements of the new songs appears to have left the wonderful Boyd Tinsley (violin) some what out in the cold. He spent most of the first half of the gig standing at the side of the stage holding his violin while being drowned out by an overly loud Tim Reynolds on electric.

Dave – I say this for your own good, Tim is great and all that but you don’t need him. Stick to the brass and violin, it kind of made you more interesting and less like a band led by an accountant. I’m just saying.

We left before the encore (just after All along the watchtower of course) so we didn’t get locked out of our car park. We missed two songs I’d never heard of. I’m not bothered.

So I’ve had my old Dave Matthews Band on repeat all morning. I’m not sold on the new stuff. If Dave goes back to writing Two Step again and I go back to being 16 then we’ll both be happier.

Mission of GOD – 6

environmentalism –  as a movement, or an articulated concept is a fairly recent idea. The idea that we need to look after the place, environment and planet that we live in is hardly new. In fact it was a great unwritten rule and only when we developed the technology to destroy our environment did its protection become a topic of discussion.

There has been a recent explosion in writing and talking about how we protect the place where we live and how our lifestyles impact it.

This has got a lot of attention in both secular and Christian circles.

Here Chris Wright gives a theological articulation of what GOD’s mission is in relation to the earth itself.

The obvious place to begin is Genesis where we are told that the earth was created and that it was good.

He goes on to talk about the important distinction that was stated in Israel’s belief about the physical environment – that it was sacred but not divine. This was of course one of many things that set them apart from the nations around them who typically divinised the earth, the moon etc…

The earth itself is a part of GOD’s mission. The great redemption and “making new” that GOD is doing includes the creation. We will not be siphoned off as spirits to be with GOD. GOD comes to be with us and is making all things – both our bodies and the creation around us – new.

If this is how GOD’s mission relates to the earth then that affects how we as the people of GOD relate to it. If we are trying to build the Kingdom of GOD then how we treat the physical environment is important.

to avoid overconsumption and unnecessary waste…

And we as the great consumers on our planet shoulder perhaps the biggest responsibility for change.

It’s all gonna break

Maybe I could start a blog called “things that go wrong with my apple products and how to fix them with common  house hold items”. Max O’Malley would like it at least.

I’ve noticed the trackpad and keyboard on my MacBookPro has stopped working for no apparent reason of late. This leaves a fully functioning computer and programs working but no way of controlling it without plugging in an external keyboard.

Most of the time a hard reset solved the problem.

Until 3am on Monday morning when I got back from work and wanted to read up on all the obscure medical conditions that i’d misdiagnosed in work.

Several hard resets later i was no better off. A quick google search on the phone found lots of people with similar problems all of which were resolved when the people concerned took their computer to Apple and paid 250 quid to have a new keyboard and track pad fitted.

Till I found this guy

I’ll reproduce his fix with photos from my computer here

  • Get a small piece of sticky tape and roll it up
  • With the power on, battery out and machine on:

  • Place the Sticky tape onto the ribbon cable whilst pressing the caps lock key to identify that the keyboard is working

  • Close the screen and turn over your mac book.
  • Replace the battery so that it presses on the sticky tape and ribbon cable

Note the slight dent on the ribbon cable in the photo –  it was there before I even began fiddling. I found I didn’t even need the bit of sticky tape, just a bit of fiddling with the ribbon cable did the job.

Kid go get it

Been a while since I’ve had any new music worth talking about.

Inevitably when it comes it’s all Northern Irish indie bands

Just before Christmas SixStarHotel released their new album. These guys have been about fro years and their musicianship goes from strength. With Tides and Tides I think they’ve perfected it.

Two Door Cinema Club are annoyingly young and talented and make me wish I’d dedicated my youth to floppy hair and playing crappy indie venues instead of wasting my time in education…

They’ve received a lot of press and have been on tour since some time before they were actually born it seems. They finally have a deal and an album and it rocks.

And last and of course best we have the Lowly Knights. It has been a pleasure seeing these songs develop live and  become the wonderful creations they are on the Hollows EP. In an ideal world I’d love my music to sound like Mumford & Sons, but it would have to be with a hefty does of the Lowly Knights. Sharing a house with the pianist probably makes me a bit biased but hey.

The beginning stages of

I say this a lot but I got into medical school for wont of anything better to do.

I blame Gilly Carson. Me and Ricky Mayes spent a day with himin A&E when we were 16 and I remember sitting in the foyer of Craigavon Hospital with Mayesie and the pair of us were talking

“so do you fancy doing medicine?”

“aye why not, seems fun…”

That was 12 years ago. Mayesie is driving endoscopes around the large bowels of the population of East Belfast and cutting out the tumours he finds.

And I’m trying my best to kill as few as possible in the same hospital I worked as a cleaner in for 4 years.

Seems fun.

The selection process for medical school was the UCAS form. That was it. Not even an interview. I had no human contact to get into medical school.

I spent 5 years in medical school having an awful lot of fun, playing a lot of footy and guitar and doing precious little study. I didn’t attend a full week after the first one. I never got a mark above average. No one ever told me that wasn’t really good enough.

I now consume medicine like oxygen and spend an awful lot of time studying and reading and learning all the things I should have learnt in medical school.

I now know really quite a bit (though never enough) and believe that I am above average in how I do my job.

That I actually ended up in a job I like was – like I suggested at the beginning – more by chance than design.

Which brings me eventually to something resembling a point.

This week’s BMJ carries an article on selection for med. school. The UK recently introduced an aptitude test (the UKCAT) to assess people for being doctors – you need a certain score to go in.

So some very smart people looked at how this has impacted on who gets in to medical school.

Bottom line – it still selects white, middle class, smart kids. The only difference being it seems to be a bit better at picking out cognitive ability than A-levels.

The accompanying editorial concludes that there is still a gap when it comes to

information on the non-cognitive characteristics and personal qualities that are fundamentally essential in the generic good doctor

Who you are – your personality, your disposition, your interpersonal skills are a huge part of what you do as a doctor. We have been, and still are in danger of breeding generations of doctors who have the brains (or at least the ability to get the right scores) but couldn’t talk their way out of a paper bag.

Every now and again I give a patient to many (or just the right amount) drugs and they mention as they leave what a nice doctor I am. I always respond with the question – would they like a nice doctor or a good one?

I think we deserve both, i’m just not sure how to pick them out yet.

If it ain’t broke, break it

Not sure if this is a common problem with other phones but I’d recently noticed problems with getting connections between my head phones and the socket on the iPhone.

It finally gave up completely today and I managed to pull all of this out with the tip of a sewing needle. Now works great.

Remarkably similar consistency to belly button fluff.

Mission of GOD – 5

the common opinion that the Bible is a moral code book for Christians falls far short, of course, of the full reality of what the Bible is and does

The Bible is essentially the story of GOD, the earth, and humanity; it is the story of what has gone wrong, what GOD has done to put it right, and what the future holds under the sovereign plan of GOD.

Wright spends a large portion of this chapter addressing the first part of the quote – yes of course the Bible has ethical implications for us, just because it is not it’s sole purpose does not mean that the ethical demands are irrelevant.

There is a big focus on Gen 18:18-19, Wright’s own translation quoted here:

Abraham will indeed become a great and mighty nation, and all nations on earth will find blessing through him. For i have known (chosen) him for the purpose that he will teach his sons and his household after him so they will keep the way of YHWH by doing righteousness and justice, for the purpose that YHWH will bring about for Abraham what he has promised to him.

In this verse Wright finds election, ethics and mission tied together in theological sequence.

And in doing so I find one of the really useful things that this book has reinforced. That the process of GOD’s mission through us did not begin in the great commission at the end of Matthew but that it was always there, right from the beginning. GOD’s plan and mission never changed, it was fulfilled.

The chapter covers a lot more biblical ground in relation to the ethical mandate and commands GOD has given us – with particulat focus on their purpose. That is to declare the character of GOD, for the benefit of the nations.

Again, even through what we see as obscure ritualistic commands we see GOD laying out his purpose of using Israel as a light to the nations (ring any New Testament bells?) for the benefit of the nations. Again and again we see GOD’s mission as being universalistic – GOD’s mission has always been to include the pagan nations.

As usual all the OT background overflows into the writings of the NT with Paul and the apostles, sometimes quoting, often alluding and always referring to how the OT scriptures were understood in their context.

Wright summarises three points about the the ethical life of the people of GOD to close the chapter:

– a people who are a light to the world by their good lives
– a people who are learning obedience and teaching it to the nations
– a people who love one another in order to show who they belong to.


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March 2010
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