Seth's Blog

This excellent NY Times Magazine article by Katy Butler describes the awful price paid by the Butler family when her father was given a pacemaker that kept him alive too long. The hospital, surgeon, and pacemaker manufacturer benefited by thousands of dollars. Her father was too out-of-it to make decisions about his health. His wife, who made the decision, was given too little information (not told of a much better alternative, not warned of the eventual outcome, which was likely) and, Butler seems to say, decided too fast. The pacemaker was implanted so that he could have a hernia operation — the hernia surgeon wouldn’t operate without it.

Butler’s article is excellent because it is personal, moving, and sheds light on a big issue that I rarely read about: the way “informed consent,” in practice, favors overtreatment. The patient or their representative makes the final decision, yes, but in most cases their decision is based mainly on information they’ve been given by their doctor or hospital, who benefit from one decision (yes, do something) but not the other (no).

The incentives for overtreatment continue, said Dr. Ted Epperly, the board chairman of the American Academy of Family Physicians, because those who profit from them — specialists, hospitals, drug companies and the medical-device manufacturers — spend money lobbying Congress and the public to keep it that way. . . The profit margins that manufacturers earn on cardiac devices is close to 30 percent. Cardiac procedures and diagnostics generate about 20 percent of hospital revenues and 30 percent of profits.

I liked Butler’s article partly because I’d had a similar, much smaller experience. I’m still pissed that during a discussion with Dr. Eileen Consorti, a Berkeley surgeon, of the costs and benefits of surgery to fix a nearly-undetectable hernia, she said nothing about side effects other than death. There are other possible bad effects of general anesthesia, which the operation would have involved. I complained to her assistant about her incomplete description of the risks. She didn’t respond, other than to threaten legal action (for not removing criticism of her for something else, I suppose).

Of course doctors, hospitals, and so on benefit from treatment. For me, the problem arises when (a) the benefits to patients are slight (compared to the benefits to the doctor, etc.), zero, or unknown or (b) the costs to patients are not well described. In both of these cases — the Butler family’s and mine — both (a) and (b) were true. Condition (a) is overtreatment, but Condition (b) makes things worse. If you propose to do something to me that could have an awful outcome, and from which you benefit, I would like to be warned of the awful outcome.

Dept. of Amplification. My original mention of Consorti was about how I couldn’t find any studies supporting her recommendation of surgery. She had said such studies existed. When I couldn’t find them, she promised to find them for me, but, several years later, has yet to. In the meantime, a reader of this blog found a relevant study (thanks, Kirk). Its results support my decision not to have the surgery that Consorti recommended.

Robin Hanson on doctors. How could we be this wrong about medicine? Thanks to Peter Spero.

I have yet to see Matt Ridley’s new book The Rational Optimist, which is related to stuff I’ve said about human evolution. But George Monbiot seems to consider it damning that Ridley was chairman of the bank Northern Rock when it failed. Bailout of Northern Rock was an example of government intervention — which The Rational Optimist is against, Monbiot says. Hey, why not attack Ridley for drinking government-supplied water from the tap in his kitchen? What a hypocrite!

Rereading an old post, I found this:

Today I had my teeth cleaned and was told my gums were in excellent shape, better than ever before [due to flaxseed oil]. They were less inflamed than usual. “What causes inflammation?” I asked. “Tartar,” I was told.

I believe that reddish gums are a great sign (so easy to see) that overall your body has too much inflammation, putting you at higher risk for many common diseases. (Perhaps due to too little omega-3, which the body uses to make an anti-inflammation hormone.) Every day my dentist measured, or at least saw, a great correlate of health (the redness of his patients’ gums) and failed to notice. It’s like failing to notice an oil field under your property. If dentists became experts in measuring gum redness and helped their patients lower overall inflammation, the public health contribution would be great. (Writing this makes me wonder why I haven’t become skilled at measuring the redness of my gums.)
Experimental psychologists are in a similar position. I believe brain health is closely correlated with health of the rest of the body. In other words, the foods that make the brain work better make the rest of the body work better. I discovered the anti-inflammatory effects of flaxseed oil because it improved my balance. The brain is much easier to study (via behavior) than the rest of the body — it’s a model system for the rest of the body. Experimental psychologists are as unaware of their good fortune as dentists. By using their skills to figure out how to have the healthiest possible brain, they could make a great contribution to human welfare.

A problem with much nutritional epidemiology, as I blogged earlier, is “the narrow range of intakes within a given population”. For this reason Ernst Wynder thought it better to make between-country comparisons. Of course different countries differ in many ways other than the ones you care about. A solution to both problems is to study an unusual country — a country with a wide range of intakes of the nutrient you care about — in depth.

This is what a new paper about omega-3 has done. The researchers measured the blood of about 400 Eskimos, who had a much larger range of omega-3 levels in their blood than Americans or Europeans. The results aren’t easy to sum up because there were plenty of non-linear associations. Here’s what I think is their most interesting result:

Associations of EPA and DHA with C-reactive protein were inverse and nonlinear: for EPA, the association appeared stronger at concentrations >3% of total fatty acids; for DHA, it was observed only at concentrations >7% of total fatty acids.

C-reactive protein is a marker of inflammation. Notice that, due to the details, the combination of (a) high intakes and (b) a wide range of intakes makes this correlation much easier to see. This result suggests that EPA and DHA (or something correlated with them) indeed reduce inflammation, as is often proposed. Perfectly consistent with my dentist’s observation that my gums looked a lot better (less inflamed) right after I started drinking 4 T/day flaxseed oil. Plus a reader’s observation that his sports injuries healed much faster after he started drinking 4 T/day flaxseed oil. (And here.)

Previous epidemiology had had a hard time detecting the anti-inflammatory correlation of omega-3s. My self-experimentation plus other people’s observations made it obvious there was something to it (and provided experimental evidence for causality: more omega-3, less inflammation). Better epidemiology has now supported this.

Thanks to Dave Lull.

Nassim Taleb has honed his replies to common questions:

Why did economists get the crisis so wrong?
That’s like asking why fortune-tellers don’t get things right. Their tools don’t work, but they continue to use them. And the Nobel committee gives prizes to people who aren’t scientists.

Which is what I’m saying about geneticists — their tools don’t work (also here) and the Nobel committee fails to notice (e.g., the recent award for teleomere research, which hasn’t yet had practical value).

You have a great phrase in The Black Swan: “Don’t drive a school bus blindfolded.” Is that still happening?
Worse. I was talking about Bernanke – they’ve given him a bigger bus.

Thanks to Dave Lull.