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