Patternicity in ECG Analysis

Part 1: Starting with Mr Sherlock Holmes

I have been listening to an audio version of a book by William Gibson called Pattern Recognition. It was published in 2003, and the action occurs between August and September 2002. The September 11th 2001 attack on the Two Towers is part of the plot, acting as a transition point between the twentieth and twenty first centuries.
The novel's central theme involves the examination of the human desire to detect patterns or meaning and the risks of finding patterns in meaningless data' []

I will return to this novel later, but I want first to revisit one of my favourite books that was published 116 years before Gibson's novel. This is the 1887 detective novel A Study in Scarlet by Arthur Conan Doyle. Here Sherlock Holmes meets Dr Watson for the first time:
"As he spoke, we turned down a narrow lane and passed through a small side-door, which opened into a wing of the great hospital. It was familiar ground to me, and I needed no guiding as we ascended the bleak stone staircase and made our way down the long corridor with its vista of whitewashed wall and dun ­coloured doors. Near the farther end a low arched passage branched away from it and led to the chemical laboratory.
This was a lofty chamber; lined and littered with countless bottIes. Broad, low tables were scattered about, which bristled with retorts, test-tubes, and little Bunsen lamps, with their blue flickering flames. There was only one student in the room, who was bending over a distant table absorbed in his work. At the sound of our steps he glanced round and sprang to his feet with a cry of pleasure; "I've found it I I've found it,' he shouted to my companion, running to­wards us with a test-tube in his hand. "I have found a reagent which is precipitated by haemo­globin, and by nothing else." Had he discovered a gold mine, greater delight could not have shone upon his features:
"Dr: Watson, Mr; Sherlock Holmes," said Stamford, intro­ducing us.
"How are you?" he said cordially, gripping my hand with a strength for which I should hardly have given him credit. "You have been in Afghanistan, I perceive."
"How on earth did you know that?" I asked in astonishment.
"Never mind'" said he, chuck­ling to himself. "The question now is about haemoglobin. No doubt you see the significance of this discovery of mine ?"
"It Is Interesting, chemically, no doubt;" I answered, "but practically - "
"Why, man, it is the most practical medico-legal discovery for years. Don't you see that it gives us an infallible test for blood stains. Come over here now!" [A Study in Scarlet]
Many of the characteristics of Sherlock Holmes were modelled on those of Dr Joseph Bell (1837-1911), a Scottish Surgeon and lecturer at the University of Edinburgh. Here is Conan Doyle's description of Dr Bell and his diagnostic skills:
"Case No. 1 would step up. 'I see,' said Mr. Bell, 'you're suffering from drink: You even carry a flask in the inside breast pocket of your coat.' Another case would come forward. 'Cobbler, I see.' Then he would turn to the students, and point out to them that the inside of the knee of the man's trousers was worn. That was where the man had rested the lap-stone - a peculiarity only found in cob­blers.
All this impressed me very much. He [Bell] was continually before me - his sharp, piercing eyes, eagle nose and striking features. There he would sit in his chair with fingers together - he was very dexterous with his hands - and just look at the man or woman before him"
And here Dr Bell discusses the writing technique of Conan Doyle:
"Dr. Conan Doyle in this remarkable series of stories has proved himself a born story-teller. He has had the wit to devise excellent plots, interesting complications; he tells them in honest Saxon-English with directness and pith; and, above all his other merits, his stories are absolutely free from padding.
He knows how delicious brevity is, how every­thing tends to be too long, and he has given us stories that we can read at a sitting between dinner and coffee, and we have not a chance to forget the be­ginning before we reach the end."

Bell and Conan Doyle lived in an unimaginable (for us) age of empire, certainty, confidence and arrogance, under a golden Edwardian sun. For the comedic writer PG Wodehouse, in his 1909 novella Mike: "All was for the best in this best of all possible worlds."

Dr Bell was less certain about the attitude and motives of the 'lower classes'. He wrote:
"It is not entirely a bad sign of this weary, worn-out century that in this, its last decade, even the petty street-bred people are begin­ning, as the nurses say, to take notice. An insatiable and gener­ally prurient curiosity as to the doings of the class immediately above us is pandered to by the society journals, and encouraged even by the daily newspapers. Such information is valueless in­tellectually; and tends to moral degradation; it exercises none of the senses, and pauperizes the imagination. Celebrities at home, illustrated interviews, society scandal on all levels merely titil­late the itching ear of the gossip. Memoirs, recollections, anecdotes ......... still only amuse and help to kill the time of which we forget the value.
But in the last few years there has been a distinct demand for books which, to a certain poor extent, encourage thought and stimulate observa­tion. Something of the same interest is given to the "crowded city's horrible street" by the suggestions of crime and romance, of curiosity and its gratification, which we find written with more or less cleverness in the enormous mass of so-called detective litera­ture under which the press groans. Every bookstall has its shilling shocker, and every magazine which aims at a circulation must have its mystery of robbery or murder.
Most of these are poor enough stuff; complicated plots, which can be discounted in the first chapter, extraordinary coin­cidences, preternaturally gifted detectives, who make discoveries more or less useless by flashes of insight which no one else can understand, become wearisome in their sameness, and the interest, such as it is, centres only in the results and not in the methods." [Dr Joseph Bell From the Introduction to A Study in Scarlet]

I have included this part of the introduction because the passion and conviction (and quaintness) of his words still resonate 130 years later, even if they are from a less en-lighted or tolerant era (cough, cough: social media, click bait). The words and attitudes also have a melancholy and sadness.
But the real strengths of these nineteenth century doctors were their powers of observation, their skills at pattern recognition and their deductive abilities.

To continue with Dr Bell's comments:
"There is nothing new under the sun: Voltaire taught us the method of Zadig; and every good teacher of medicine or surgery exemplifies every day in his teach­ing and practice the method and its results. The precise and in­telligent recognition and apprecia­tion of minor differences is the real essential factor in all success­ful medical diagnosis.
Eyes and ears which can see and hear, memory to record at once and to recall at pleasure the impressions of the senses, and an imagination capable of weaving a theory or piecing together a broken chain, or unravelling a tangled clue, such are implements of his trade to a successful diagnostician.
[James] Syme* [1799-1870], one of the great­est teachers of surgical diagnosis who ever lived, had a favourite illustration ...... "Try to learn the features of a disease or injury as precisely as you know the features, the gait, the tricks of manner of your most intimate friend." Him, even in a crowd; you can recognize at once; it may be a crowd of men dressed alike, and each having his complement of eyes, nose, hair, and limbs; in every essential they resemble each other, only in trifles do they differ; and yet, by know­ing these trifles well you make your diagnosis or recognition with ease.

So it is with disease of mind or body or morals. Racial peculiarities, hereditary tricks of manner, ac­cent, occupation or the want of it, education, environment of all kinds, by their little trivial im­pressions gradually mould or carve the individual, and leave fingermarks or chisel scores which the expert can recognize.
A fair sized and valuable book has lately been written on the one symptom, the pulse**; to anyone but a trained physician it seems as much an absurdity as is Sherlock Holmes's immortal treatise on the one hundred and fourteen varieties of tobacco ash.

The experienced physician and the trained surgeon every day, in their examinations of the humblest patient, have to go through a similar process of reasoning, quick or slow according to the personal equations of each, al­most automatic in the experienced man, laboured and often erratic in the tyro, yet requiring just the same simple requisites, senses to notice facts, and education and intelligence to apply them. Mere acuteness of the senses is not enough. [Dr Joseph Bell From the Introduction to A Study in Scarlet]
* John Brown, a former pupil, said that Syme "never unnecessarily wasted a word, a drop of ink, or of blood." [The Butchering Art Lindsey Fitzharris Allen Lane 2017]
** Possibly: The study of the pulse. Arterial, venous, and hepatic and of the movements of the heart. James Mackenzie. Edinburgh: Young J. Pentland. 1902

Part 2: Neuromancer & Pattern Recognition

Neuromancer is another of my favourite books. It is a 1984 cyberpunk-ish SF novel by William Gibson. Events unfold in a

'...filthy setting of an environmentally damaged, alienated, dystopian society dominated by global computer networks in which characters battle “artificial intelligences, monopoly capitalism and a world culture as ethnically eclectic as it is politically apathetic and alienated,”' []
The protagonists in Neuromancer are Case (an unemployed computer hacker) who teams with Molly (a cyborg) and Peter Riviera (a thief and illusionist). They are innately brilliant hackers who work in cyberspace - a term coined by Gibson in 1982.
The heroine of the 2003 novel Pattern Recognition is Cayce Pollard, a 32-year-old with a psychological hyper-sensitivity (allergy) to logos and advertising. She is a "cool-hunter" and her reaction to a corporation or brand logo is used by corporations to select or reject the logo.
In the novel a character comments that "Far more creativity, today, goes into the marketing of products than into the products themselves." - which of course could be applied to the promotion of some internet based courses.


Cayce makes her living from pattern recognition, from "finding whatever the next thing might be" ......... She is also one of a large number of people hunting for brief clips from a nameless film that have been posted, on incredibly obscure sites, around the internet ...... [a film with] mysterious and melancholy footage.'
"Homo sapiens is about pattern recognition... Both a gift and a trap." Pattern recognition, as a human phenomenon, becomes something else when it goes too far; it becomes "apophenia... the spontaneous perception of connections and meaningfulness in unrelated things".[Guardian Book Review Toby Litt 27April 2003]

Part 3: Apophenia

Apophenia is
' .. the process of perceiving patterns or connections in random or meaningless data......coined ...... by the German neurologist, Klaus Conrad. He originally described this phenomenon as a kind of psychotic thought process, though it is now viewed as being a ubiquitous feature of human nature. Science historian Michael Shermer has called the same phenomenon patternicity.
Our brains are pattern-detection machines that connect the dots, making it possible to uncover meaningful relationships among the barrage of sensory input we face. Without such meaning-making, we would be unable to make predictions about survival and reproduction.’ [Bruce Poulsen Psychology Today July 31 2012]


‘.... if I .......... [am] seeing a pattern where none really exists, I am making what statisticians would call a Type I error, also called a false positive ......... we are prone to seeing patterns rather than missing them. The Type II error ...... [of] seeing no pattern where a pattern exists, turns out to be more dangerous. Far better - from a Darwinian perspective - to erroneously interpret danger where none is present than miss out on important cues that put our survival on the line. ‘ [Bruce Poulsen Psychology Today July 31 2012]


Examples of apophenia, or patternicity, are everywhere. Many people perceive faces in seemingly random places - such as in clouds, in patterns of dirt left on cars or ......... the face of Jesus on a piece of toast. We are fooled by optical illusions - apophenia of the visual cortex - but we don’t take such cognitive errors personally [Bruce Poulsen Psychology Today July 31 2012]

Source: Bruce Poulsen Psychology Today July 31 2012

Source: Bruce Poulsen Psychology Today July 31 2012

....... [in] psychoanalysis immediately thinks of free association - a clinical tool that specifically focuses on meaning generated from word associations. Rather than merely viewing apophenia as a kind of unfortunate side effect of our cognitive architecture, psychoanalysis pushes us to look at meaning where it seems least obvious. In this way, patternicity is the point, not the problem. [Bruce Poulsen Psychology Today July 31 2012]

Because this is a blog about ECGs here are a few thoughts about pattern recognition in ECG interpretation:
"You cannot find patterns if you do not look"
Do I know what to look for - am I ignorant of my ignorance (Dunning-Kruger Effect)?
Am I missing a subtle pattern or have I just missed an obvious abnormality?

This ECG of a life threatening pattern* was provided by Dr Alfredo Mori

This ECG of a life threatening pattern* was provided by Dr Alfredo Mori

Am I being influenced by confirmation bias?
My own endpoint in ECG pattern assessment is binary: "important/significant/dangerous - needs investigation or intervention or observation" versus "normal/not significant/not dangerous/no investigation/no intervention".
(I think that) I have, with experience, gone from being prone to making a Type II endpoint error to making a Type I endpoint error. In simple terms, I err on the side of over-caution, accepting that this may merge into apophenia.
*The patient's serum potassium concentration was 8 mmol/l

Zager & Evans: "In the Year 2019"

I thought this blog should have some nonsense. In July 1969 the Eagle landed on the moon and a song by two Americans ( 'Zager and Evans') called "In the Year 2525" was number one on American radio. The dystopian lyrics included such lines as

Ain’t gonna need to tell the truth, tell no lies
Everything you think, do, and say
Is in the pill you took today
Ain’t gonna need your teeth, won’t need your eyes
You won’t find a thing to chew
Nobody’s gonna look at you
Your arms are hanging limp at your side
Your legs got nothing to do
Some machine’s doing that for you
Ain’t gonna need no husband, won’t need no wife
You’ll pick your sons, pick your daughters too
From the bottom of a long glass tube
— In the Year 2525

The song is from another time of books, typewriters, hand-held phones, film based cameras, black and white television (in Australia), vinyl records and hand written medical notes. When doctors wore white coats and nurses wore uniforms (like ants trapped in the amber of the nineteenth century), but were ignorant of the benefits of computer-based surveillance and the promises of privatization. Where most health carers would spend time talking to, and laying hands on, patients. Where there were no personal computers, or smart phones, or CAT scanners. Where the working conditions were harsh and punishing, bullying was part of the environment, and Socratic type questioning on medical rounds (bedside questions to challenge or assess knowledge or make a teaching point) was routine and accepted as a way of teaching accountability (1).

Those times were different. And what about now, when we are nearly in the year 2020? Let's carry out this thought experiment. Imagine a hospital environment where medical care is based not on a clinical "Golden Hour" of lifesaving intervention (as introduced for Trauma Care in the 1980s) but instead is designed by administrators trained in the University of Pol Pot. Administrators who are smart enough to understand that a 'Year Zero' approach of "no families, no sentiment, no expression of love or grief, no books, no learning, no holidays, no music: only work and death" is inefficient.

But these new generation experts 'know' that computer based rules of engagement with (the inconvenient objects called) patients are better than uncontrolled ethical or humanistic or clinical interactions, because they produce improved numbers that benefit the administrators and politicians. So in Australia we saw the adoption of (the abomination called) the Four Hour Rule in the Emergency Department. This was agreed to in principle In the Year 2010. In the rest of this blog I will not discuss the relative success or relative failure of this decision, but I will indulge in a Zager & Evans fantasy about the possible outcomes.

In the Year 2025 - in a imaginary hospital called St Cuthbert.
There is a 3D hologram above the entrance to the Emergency Department that reads: "The Four Hour Rule Frees Us All".
The Coronary Care Unit is called The Donne CCU, with this inscription at their front door:
"Where Billing and Saving Lives are Never Donne"

No CCU is an island,

Entire of itself.

Part of our billing

Adding strength and health
To our private wealth.

Any uninsured life
Or times past four hours
Diminishe thee and me.
For I am the cash flow ace
Master of the procedural interface.

Therefore, send not to know

For whom the bonus tolls,

It tolls for me, not thee.

The importance and value of books for learning has been rediscovered, and there are a mixture of old and new books in the John Doone Library of ECG Books. There are cryptic inscriptions or jottings on the pages of some of the older books:
"Plato's Nouse" is often seen - perhaps this refers to the adventures of a philosophical mouse.
There is an occasional 'Fr?d' and a strange term 'keto diet', sometimes followed by the letters AM. Debate rages about whether this a corruption of "keto diet is" or "keto diet was" or "keto diet for breakfast."
Here are some of the more requested books (2):
• Beyond Fear of the ECG
• Codependent No More - Internet Free ECG Interpretation
• Myths of ECG Interpretation
• Cognitive Therapy and Laddergrams
• The Gestalt of Frontal Plane QRS Analysis
• Emotional Intelligence and ECG Interpretation
• (Essentials of) Hypnosis for ECG interpretation
• (Mindful) or (Gentle) ECG Interpretation for Generation Z
• Everyday ECG Survival Guide
• Why Smart People Do Stupid ECG Interpretations
• Facing Shame: Wrong ECG Interpretation
• ECGs and How to Survive Them
• PTSD and the The Goldman-Hodgkin-Katz Equation
• Experiential ECG Interpretation
• Gender Issues and Einthoven's Triangle
• How to Describe ECGs Over the Phone (So Others Understand & Believe You)
• In a Different Voice: Psychological Basis of Arrogant ECG Analysis
• The Psychology of ECG Over-interpretation
• Using NPL for ECG Analysis
• That's Not What I Mean: Dealing with ECG Disagreement
• The Jungian Interpretation of ECGs in Dreams
• The Rhythm Strips of Desire
• Adventures of Randy Andy the Naughty Cardiac Action Potential
• Retrograde Memories - Diary of an Inverted P Wave

1. As is well stated here:
"This brings up a very strong and often overlooked point. I hear my administrators say all the time that residents should be more accountable. Accountability must be clearly defined and, at times in medical education, it is not. Sure, we have ACGME benchmarks and standards of what a “normal and average resident should be achieving by the time of independent practice.” At times, the sense of urgency and accountability seems to be lacking within the millennial generation. Learners expect to be spoon-fed lectures with important concepts and have protected time to learn those concepts, yet a very few seem to really possess that internal drive or accountability to own medicine, own the concepts, own the pathophysiology and disease process, and own their patients, because ultimately it is about their livelihood."
“Pimping”: Malignant or Not? By Joseph Cooper, MD
January 5th 2017 Published in Insights on Residency Training
2. My wife Julia Linaker was a clinical psychologist, and these titles are pastiches of her books. Silly but fun, and some of the titles identify real issues in the interpretation of the ECG
Linas Dziukas

From Rats to Cats


Graffiti on a wall in Smith Street, Fitzroy, in Melbourne, in 2008

This is a slightly edited version of a blog from September 7th 2018 called ‘From Rats to Cats”

'The Sounds of Silence' is a song that was written by Paul Simon between 1963 and 1964. The concluding lyrics are:

And the sign flashed out it’s warning

In the words that it was forming

And the signs said, ‘The words of the prophets

Are written on the subway walls and tenement halls’

And whispered in the sounds of silence

The graffiti ('words of the prophets') sprayed on the local suburban walls is more visual than textual, but two messages that I remember are "Each day I wake up on the wrong side of capitalism" and "Strength through superior firepower". Once I saw a scrawled plea "Free Bill Posters" under the printed sign "Bill Posters Will Be Prosecuted".
Sometimes you find graffiti that is both clever and insightful, as in this "Good Rat vs Bad Rat" poster on a wall in Smith Street Fitzroy in 2008
In 2015 Amit Maini and I were looking for a title for a website based on ECGs, and for a while we considered calling it 'Good Rat - Bad Rat', using the above image. Hence the reference to 'Rats' in the blog title. In the end we called the site ECGMojo. The content in was 'live' and updated until November 2016.
What did I learn from the initial blog? If you are interested in and passionate about teaching, then adapting your teaching content for the internet is alluring: it can be like a (Dunning-Kruger) candle flame to a moth. The eager moth will most likely be burnt by some myths or realities:

Anyone can be a good teacher on the internet
Lengthy answers are always best
There’s no longer an agreed upon body of knowledge everyone needs to know [Source forgotten]
"Only two things justify the publication of a book*, viz., the author must either communicate something new, or he must have a new method of stating what is already known". [From the preface of The Anatomy of the Joints of Man - Henry Morris - J. & A. Churchill 1879] [* or a blog]

What is the Dunning-Kruger effect? This is well explained in this abstract to an article (in Advances in Experimental Social Psychology 2011 44:247-296) by David Dunning:"The Dunning-Kruger Effect: On Being Ignorant of One's Own Ignorance"

“In this chapter, I provide argument and evidence that the scope of people’s ignorance is often invisible to them. This meta-ignorance (or ignorance of ignorance) arises because lack of expertise and knowledge often hides in the realm of the “unknown unknowns” or is disguised by erroneous beliefs and background knowledge that only appear to be sufficient to conclude a right answer. As empirical evidence of meta-ignorance, I describe the Dunning-Kruger effect, in which poor performers in many social and intellectual domains seem largely unaware of just how deficient their expertise is. Their deficits leave them with a double burden - not only does their incomplete and misguided knowledge lead them to make mistakes but those exact same deficits also prevent them from recognizing when they are making mistakes and other people choosing more wisely. I discuss theoretical controversies over the interpretation of this effect and describe how the self-evaluation errors of poor and top performers differ. I also address a vexing question: If self-perceptions of competence so often vary from the truth, what cues are people using to determine whether their conclusions are sound or faulty?”

Amit and I have decided to revive our Blogging partnership. The new site is called Plato's Nous, and refers to our patron cat named Nous. The term 'nous' comes from the Greek concept of 'mind' or 'insight'.
We will include most of the material from ECGMojo

LJ & AM & PN