Seth's Blog

Oral rehydration therapy (ORT) is given to people (usually children) suffering from diarrhea, which before ORT was often fatal. It is very simple: The sufferer drinks water with sugar and salt ad libitum (as much as they want). You probably haven’t heard of ORT — at least, I hadn’t. Everyone has heard of antibiotics. Yet “in 10 years [ORT] saved more lives than penicillin had in 40.” Infant diarrhea was once (and may still be) the main cause of death in poor countries.

A history of its discovery supports several things I’ve said on this blog. One is Thorstein Veblen’s point about the disdain among professional scientists for useful research:

ORT might also have been developed long before 1968 but for the attitudes of the dominant medical establishment toward practical experimentation, which the Cholera Research Laboratory and the National Institutes for Health shared. Nalin believes that “the people at the lab … got kudos for the extent to which [their] work was not practical. As soon as it became practical it was discarded like a soiled towel–it was too common, too hands-on… so the prestige went to people who measured trans-intestinal fluxes or electrical currents”.

No one who has attended an elite law school, medical school, or graduate program in education will be surprised by this.

Another is the great resistance among the medical establishment to cheap and effective solutions:

The formidable and persistent ignorance of the Western medical establishment, which continues over twenty-five years after the discovery of ORT, is phenomenal. While its refusal to advocate ORT may be due in part to the notion that ORT is only necessary for people in the developing world, its actions appear to be driven also by financial considerations. Most hospitals do not train physicians in the use of ORT since they have no financial reason to do so. [I think "since" overstates what is known -- Seth] The use of intravenous therapy, which often involves keeping a dehydrated child overnight, assures [greater] insurance reimbursement. Sending children home with ORT would [reduce] profits. Furthermore, recent studies show that diarrhoeal illness among the elderly may incur even greater health care costs that could also be reduced by the use of ORT. At a time of heated discussion about cost-containment in health care, it seems all the more ironic and egregious that a superior, cheap, and proven therapy [fails to replace] a far more expensive one. Estimates based on the cost of hospitalizations and physician visits suggest that ORT could save billions of dollars annually.

As an example of the resistance of American doctors to a better therapy, an ORT researcher, who had used it on Apache reservations in America, told this story:

I had an anthropologist friend who adopted an Apache child from the [Arizona] reservation where we were working. He used to be the anthropologist on the reservation. And then he [left the reservation and] went to Arkansas to teach and the Apache child came down with severe diarrhea and he called me up and he said desperately, “Look, my son’s in the hospital and they’re giving him all sorts of intravenous fluids. The diarrhea’s not stopping, he’s losing weight, they’re not feeding him. I know that you did this work in Arizona [on the reservation] and it didn’t look like that. . . . Would you call this professor of pediatrics and just collegiately talk to him?” So I called up the professor and told him that in our experience with Apache children this is what we found and here’s the publication and so on. And he said to me, “Doctor, doctor, our [Arkansas] children are not the same as your [reservation] children”. He was treating an Apache child from the same reservation.

Shades of Downton Abbey (where Lady Sybil died because a London doctor was listened to instead of a rural doctor).

• Bone broths may have too much lead. “Broth made from skin and cartilage taken off the bone once the chicken had been cooked with the bones in situ and chicken-bone broth were both found
  to have markedly high lead concentrations.”
• Upcoming discussion of the work of Renata Adler (in New York City)
• Ben Casnocha on Aaron Swartz
• The silence of doctors about bad medicine. “The silence of other doctors apparently gave company executives the upper hand; in meetings with Dr. Nargol, they said that he seemed to be the only doctor having trouble.”
• Dietitians for Professional Integrity. Some dietitians are fed up with their professional organization’s links to junk food makers, such as Coca-Cola

When she was a little girl, a Korean friend of mine, when asked, said she wanted to be a doctor. She got the idea from her mother — it is what her mother wanted. When she was older, she had a friend whose father was a doctor. The friend told her that when her father was sick, he had to pretend that he wasn’t sick, and that this made her sad. After my friend heard that, she decided she no longer wanted to be a doctor.

A few weeks ago I blogged about undisclosed risks of medical treatments. Undisclosed risks are common. They might be the norm. The situation would be even worse — in some sense, much worse — if doctors knew of these risks and failed to tell their patients. It was unclear if doctors knew of the undisclosed risks I wrote about.

Recently Tyler Cowen quoted a newspaper story about Israeli doctors giving birth control injections to Ethiopian women immigrants ”without their knowledge or consent.” Every commenter thought this was repugnant.

The latest RadioLab podcast (“The Bitter End”) is about the dramatic difference between how doctors want to be treated when they are near death (they want no CPR, no ventilator, no dialysis, no surgery, no chemotherapy, no feeding tube, no antibiotics, nothing except pain medicine) and how the general public wants to be treated (most people want CPR, ventilator, dialysis, surgery, chemotherapy, feeding tube, antibiotics, and so on).

The RadioLab guys were puzzled by the difference.   (more…)

• A Mathematician’s Lament about how mathematics is taught (pdf). A little abstract. What about student diversity?
• Ten strange self-experiments.  One is different from the rest. “As a teenager, Frederick Hoelzel adopted a strange method of weight-loss. He curbed his appetite by eating non-caloric food substitutes such as corn cobs . . . . His favorite meal was surgical cotton cut up into small pieces, which became part of his daily diet.”
• More about the Terrence Deacon case
• Denmark rescinds fat tax
• Interview with Marty Makary about his book Unaccountable. Medical mistakes, he says, are the #3 cause of death in the United States.

Thanks to Casey Manion.

Brent Pottenger, who is a medical student at John Hopkins, writes:

Today, as a required activity for our Hopkins Med endocrinology course, we watched excerpts Supersize Me and Tom Naughton’s Fat Head. Our professor then engaged us in a discussion comparing the two films. Our professor told our class that the lipid hypothesis is incorrect, said that the USDA Food Pyramid is the product of corn and wheat subsidies (and lobbies), and definitely stirred up some uneasy responses from my classmates.

I asked Brent what had made them uneasy.

What the professor said contradicted what they believe. Every professor before this has demonized saturated fat, meats, etc., so this was the first time someone questioned that belief.

How did they express their unease?

They expressed unease by getting up and leaving the lecture hall, by whispering in disgust to their neighbors, etc. — you could see it on their faces. Then, some of the more curious classmates who are always inquisitive followed up with genuine questions, wanting to know more about the validity to the statements made in Tom’s movie about Ancel Keys, the McGovern Report, the USDA, the science of the lipid hypothesis, etc.

A few days ago I wrote about a study that suggested that people who’d had bariatric surgery were at much higher risk of liver poisoning from acetaminophen than everyone else. I learned about the study from an article by Erin Allday in the San Francisco Chronicle. The article included this:

At this time, there is no reason for bariatric surgery patients to be alarmed, and they should continue using acetaminophen if that’s their preferred pain medication or their doctor has prescribed it.

This was nonsense. The evidence for a correlation between bariatric surgery and risk of acetaminophen poisoning was very strong. Liver poisoning is very serious. Anyone who’s had bariatric surgery should reduce their acetaminophen intake.

Who had told Allday this nonsense? The article attributed it to “the researchers” and “weight-loss surgeons”. I wrote Allday to ask.

She replied that everyone she’d spoken to for the article had told her that people with bariatric surgery shouldn’t be alarmed. She did not understand why I considered the statement (“no need for alarm”) puzzling. I replied:

The statement is puzzling because it is absurd. The evidence that acetaminophen is linked to liver damage in people with bariatric surgery is very strong. Perhaps the people you spoke to didn’t understand that. The size of the sample (“small”) is irrelevant. Statisticians have worked hard to be able to measure the strength of the evidence independent of sample size. In this case, their work reveals that the evidence is very strong.

If the experts you spoke to (a) didn’t understand statistics and (b) were being cautious, that would be forgivable. That’s not the case here. They (a) don’t understand statistics and (b) are being reckless. With other people’s health. It’s fascinating, and very disturbing, that all the experts you spoke to were like this.

I have no reason to think that the people Allday talked to were more ignorant than typical doctors. I expect researchers to be better at statistics than average doctors. One possible explanation of what Allday was told is that most doctors, given a test of basic statistical concepts, would flunk. Not only do they fail to understand statistics, they don’t understand that they don’t understand. Another possible explanation is that most doctors have a strong “doctors do everything right” bias, even when it endangers patients. Either way, bad news.

• Trouble with The Long Tail concept (2008 article)
• Computer-assisted diagnosis is better than ordinary diagnosis but doctors don’t want to use it. “Most of us don’t think we need help at diagnosis, especially with routine cases, which account for the majority of our work,” says a doctor. The first malpractice suit (failure to use computer diagnosis) cannot come soon enough.
• Human stool transplants reverse antibiotic damage.

Thanks to Charles Platt and Adam Clemens.

Presumably Dr. Jenny Kim is a good dermatologist because the author of this NPR piece chose to quote her:

UCLA dermatologist Dr. Jenny Kim says many people don’t realize it’s bacteria that cause acne. “Some people say your face is dirty, you need to clean it more, scrub more, don’t eat chocolate, things like that. But really, it’s caused by bacteria and the oil inside the pore allows the bacteria to overpopulate,” Kim says.

If I were to ask Dr. Kim how she knows that acne is “caused by bacteria” I think she’d say “because when you kill the bacteria [with antibiotics] the acne goes away.”  Suppose I then asked: “Is there evidence that the bacteria of people who get acne differ from the bacteria of people who don’t get acne (before the acne)?” What I assume Dr. Kim would answer: “I don’t know.”

There is no such evidence, I’m sure. It is quite plausible that the bacteria of the two groups (with and without acne) are exactly the same, at least before acne. If it turned out, upon investigation, that the bacteria of people who get acne is the same as the bacteria of people who don’t get acne, that would make it much harder to say that acne is caused by bacteria. As far as I can tell, Dr. Kim and apparently all influential dermatologists have not thought even this deeply about it. To do so would be seriously inconvenient, because if acne isn’t caused by bacteria, it would be harder to justify prescribing antibiotics. Which dermatologists have been doing  for decades.

It isn’t just dermatologists. Many doctors believe that H. pylori causes ulcers — wasn’t a Nobel Prize given for discovering that? The evidence for that assertion consisted of: 1. H. pylori found at ulcers. 2. Doctor swallowed billions of H. pylori and didn”t get an ulcer. (Not a typo.) It was enough that he got indigestion or something. 3. Antibiotics cause ulcers to heal. That was enough for the two doctors who made the H. pylori case and the Nobel Prize committee they convinced. The doctors and the committee failed to know or understand that H. pylori infection is very common and almost no one who is infected gets an ulcer. Psychiatric causal reasoning has been even simpler and even more self-serving. We know that depression — a huge problem — is due to “a chemical imbalance”, according to many psychiatrists, because (a) antidepressants work (not very well) and (b) antidepressants change brain chemistry.

Dr. Kim’s false certainty matters because I’m sure most people with acne don’t know what causes it. I didn’t. Dr. Kim’s false certainty and similar statements from other dermatologists make it harder for them to find out.  I wrote about a woman who figured out what caused her acne. It wasn’t easy or obvious.

Thanks to Bryan Castañeda.

I recently posted about Unaccountable by Mart Makary, a book about the bad behavior of doctors. One of his points is “The when-you’re-a-hammer problem plagues modern medicine at every level.” He illustrated this with a case where transplant surgeons said an otherwise-healthy person with a small liver tumor should get a liver transplant. Which struck Makary as ridiculous.

A lawyer who reads this blog sees the same thing in lawyers. He told me the following story:

One of the sixteen defendants we sued moved to transfer the venue of our case from [Southern California city] to [Northern California city]. Both plaintiffs, all of his doctors (over a dozen), all of the witnesses (again, about a dozen), and all of locations where the incident took place are in or near [N. California city]. When we got the motion I took it to my boss who said, “Huh. We should’ve filed it in [N. California city] to begin with. I don’t know why we didn’t.” It would’ve been inconvenient for us, b/c we’re in [S. California city], but we’ve filed cases up there before, so we could handle it.

So, did we stipulate with the defendant and just transfer the case up north? No. We filed a pathetic, perfunctory opposition. We had an argument, but it was very weak: one of the defendants was located in [S. California city]. That’s basically all we had to hang our hat on.

We filed our opposition, defendant filed their reply. We all trekked down to court to argue our positions in front of the judge. The hearing should’ve taken 30 seconds – “Defendant’s motion granted.” — but the judge actually entertained oral argument. Finally, he granted the motion.

When I got back to the office, I noted to my secretary what a huge waste of time all of this was. The law was clear, virtually all of the facts were on opposing counsel’s side, we should’ve filed up north to begin with, so why fight it? Why not save everyone — us, opposing counsel, the judge and his staff — time and just agree? “Well, you gotta take a shot,” was her reply. Which is what I hear from attorneys all the time. “You gotta try, you gotta make the argument.” In other words, we have hammers so the hammers must be used no matter what.

No, it isn’t quite like a transplant surgeon who says a new liver is needed b/c of a small tumor – no one’s life or health is at risk — but how much time and resources are wasted in the legal system on bullshit like this?