Seth's Blog

Shortly before Obama took office, many American banks, including the largest ones, were given a huge amount of money by the Federal government (“bailed out”). Why? Because Secretary of the Treasury Henry Paulson, Chairman of the Federal Reserve Ben Bernanke and other economists (not necessarily independent of Paulson and Bernanke) predicted a second Great Depression if they weren’t. I didn’t believe Paulson et al. — their track records of prediction were terrible. They hadn’t foreseen the crisis. Why should I think they knew how to fix it? I believed their predictions of disaster were too confident.

At the time I didn’t know this bit of history:

The blood-curdling threats [now] being issued by Eurocrats should sound familiar to British readers. We went through precisely the same experience 20 years ago, when we were stuck with an over-valued exchange rate in the Exchange Rate Mechanism.

As in Greece, our leaders – all the main parties, the CBI, the TUC, the Bank of England – assured us that leaving the ERM would be disastrous. On September 11, 1992, John Major solemnly told us that withdrawal was ‘the soft option, the inflationary option, the devaluer’s option, a betrayal of our country’s future’.

Four days later, we left the system, and our recovery began immediately. Inflation, interest rates and unemployment started falling, and we enjoyed 15 years of unbroken growth

Those who don’t know the past are doomed to over-trust experts.

Michael Ellsberg has an excellent article about the American Dietetic Association’s attempts to make it illegal for anyone they haven’t approved to give nutritional advice. In this document, they are frank that this is their goal. After Ellsberg drew attention to it, it was taken down. I look forward to learning why it was taken down.

The Washington State chapter of the ADA, now called the Washington State Academy of Nutrition and Dietetics, is responsible for taking down the document. The organization has this mission statement:

Empowering the people of Washington to improve health with safe, effective and reliable food and nutrition information.

Our Vision:  Optimize the health and well being of Washington State individuals through food & nutrition.

Our Mission:  Empower members to be Washington State’s food and nutrition leaders.

Long ago, in the civil rights or suffrage movements, for example, empowerment meant removal of barriers. This organization preaches empowerment by creation of barriers. Their empowerment is someone else’s disempowerment.

The newly-released climate scientist emails (called Climategate 2.0) from University of East Anglia (Phil Jones) and elsewhere (Michael Mann and others) show that top climate scientists agree with me. Like me (see my posts on global warming), they think the evidence that humans have caused dangerous global warming is weaker than claimed. Unfortunately for the rest of us, they kept their doubts to themselves: “I just refused to give an exclusive interview to SPIEGEL because I will not cause damage for climate science.”

This is a big reason I have found self-experimentation useful. It showed me that experts exaggerate, that they overstate their certainty. At first I was shocked. My first useful self-experimental results were about acne. I found that one of the two drugs my dermatologist had prescribed didn’t work. He hadn’t said This might not work. He didn’t try to find out if it worked. He appeared surprised (and said “why did you do that?”) when I told him it didn’t work. Another useful self-experimental result was breakfast caused me to wake up too early. Breakfast is widely praised by dieticians (“the most important meal of the day”). I have never heard a dietician say It could hurt your sleep or even a modest There’s a lot we don’t know. My discoveries about morning faces and mood are utterly different than what psychiatrists and psychotherapists say about depression.

As anyone paying attention has noticed, it isn’t just climate scientists, doctors, dieticians, psychiatrists, and psychotherapists. How can you tell when an expert is exaggerating? His lips move. There are two types of journalism: 1. Trusts experts. 2. Doesn’t trust experts. I suggest using colored headlines to make them easy to distinguish: red = trusts experts, green = doesn’t trust experts.

Imagine if, to get the news, you had to go somewhere and have it read to you! What a joke. From an article in the Washington Monthly about on-line education:

If Solvig needed any further proof that her online education was the real deal, she found it when her daughter came home from a local community college one day, complaining about her math course. When Solvig looked at the course materials, she realized that her daughter was using exactly the same learning modules that she was using at StraighterLine . . . The only difference was that her daughter was paying a lot more for them, and could only take them on the college’s schedule. And while she had a professor, he wasn’t doing much teaching. “He just stands there,” Solvig’s daughter said.

The excellent article misses something big, however:

A lot of silly, too-expensive things—vainglorious building projects, money-sucking sports programs, tenured professors who contribute little in the way of teaching or research—will fade from memory, and won’t be missed.

Via Aretae.

A friend of mine, who lives in Shanghai, has a 3-year-old son. She gets all her parenting advice from the Internet. This would be uninteresting except that her mother lives with her. (So does her husband’s mother.) On a daily basis, in other words, whatever her mom thinks about how kids should be raised is being ignored. My guess is that her mom actually likes the situation because it removes a source of conflict. But I didn’t dare ask.

Atul Gawande might be the best medical writer ever. He is the best medical writer at The New Yorker, at least, and the best one I’ve ever read. He consistently writes clearly, thoughtfully, and originally about the big issues in medicine. That is why his recent article about health care costs (my comment here) and his graduation speech at the Univesity of Chicago are so telling. And not in a good way, I’m afraid.

The graduation speech starts off with an excellent story:

The program, however, had itself become starved—of money. It couldn’t afford the usual approach. The Sternins had to find different solutions with the resources at hand.

So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.

Bill Gates, Jeffrey Sachs, are you listening?  Gawande goes on to say that to improve medicine, there needs to be the same sort of study of “positive deviants”. Here is his first example:

I recently heard from one such positive deviant. He is a physician here in Chicago. He’d invested in an imaging center with his colleagues. But they found they were losing money. They had a meeting about what to do just a few weeks ago. The answer, they realized, was to order more imaging for their patients—to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.

No kidding. The contrast between mothers who figure out creative iconoclastic new ways to feed children on tiny amounts of money and a doctor who merely refuses to be a scumbag could hardly be greater. But Gawande uses the same term (“positive deviant”) for both! This is the depth to which a writer and thinker of Gawande’s stature has to descend, given the straitjacket of how he thinks about medicine. Gawande thinks that doctors will improve medicine. He’s wrong. Just as farmers didn’t invent tractors — nor any of the big improvements in farming — neither will doctors be responsible for any big improvements in American health. The big improvements will come from outside. I’m sure they will involve both (a) advances in prevention and (b) patients taking charge of their care.

When these innovations happen, where will doctors be? Helping spread them or defending the status quo? That’s what Gawande should be writing about. One big advance in patients taking charge was home blood glucose testing. It came from an engineer named Richard Bernstein. Best thing for diabetics since the discovery of insulin. Doctors opposed it. When I invented the Shangri-La Diet, and lost 30 pounds, my doctor didn’t ask how I lost all that weight. Not one question. Like all doctors, he had many fat patients; the notion that I, a mere patient, could know something that would help his other patients didn’t cross his mind. When I was a grad student I did acne experiments on myself that revealed that antibiotics (hugely prescribed for acne) didn’t work. My dermatologist appeared irritated that I had figured this out. That’s a little glimpse of how doctors may react to outside innovation involving patients taking charge. Of course doctors, like dentists, cannot do good prevention research.

If Gawande took the first story he told to heart, he might realize it is saying that the improvements to health care won’t come from doctors, just as the improvements to the health of those village children didn’t come from experts. As I said earlier, doing my best to channel Jane Jacobs, a reasonable health care policy would empower those who benefit from change. That’s what the village nutrition program did. It empowered mothers who were innovating.

From BBC News:

A specialist light treatment for psoriasis is just as effective and safe when given at home as in hospital, say Dutch researchers. Phototherapy using UVB light is rarely used in the UK because of limited availability and the number of hospital visits required. But a study of 200 patients found the same results with home treatment. . . .

One reason that the treatment is usually done in hospital is because most dermatologists believe that home phototherapy is inferior and that it carries more risks.In the latest study, patients with psoriasis from 14 hospital dermatology departments were randomly assigned to receive either home UVB phototherapy or hospital-based treatment. Home treatment was equivalent to hospital therapy both in terms of safety and the effectiveness of clearing the condition. And those treated at home reported a significantly lower burden of treatment and were more satisfied.

There was a time when blood-glucose testing (for diabetes) was only done in laboratories, with blood drawn in doctors’ offices or hospitals.

Long ago the RAND Corporation ran an experiment that found that additional medical spending provided no additional health benefit (except in a few cases). People who didn’t like the implication that ordinary medical care was at least partly worthless could say that it was only at the margin that the benefits stopped. This was unlikely but possible. Now a non-experimental study has found essentially the same thing:

To that end, Orszag has become intrigued by the work of Mitchell Seltzer, a hospital consultant in central New Jersey. Seltzer has collected large amounts of data from his clients on how various doctors treat patients, and his numbers present a very similar picture to the regional data. Seltzer told me that big-spending doctors typically explain their treatment by insisting they have sicker patients than their colleagues. In response he has made charts breaking down the costs of care into thin diagnostic categories, like “respiratory-system diagnosis with ventilator support, severity: 4,” in order to compare doctors who were treating the same ailment. The charts make the point clearly. Doctors who spent more — on extra tests or high-tech treatments, for instance — didn’t get better results than their more conservative colleagues. In many cases, patients of the aggressive doctors stay sicker longer and die sooner because of the risks that come with invasive care.

Perhaps the doctors who ordered the high-tech treatments, when questioned about their efficacy, would have responded as my surgeon did to a similar question about the surgery she recommended (and would make thousands of dollars from): The studies are easy to find, just use Google. (There were no studies.)

It’s like the RAND study: Defenders of doctors will say that some of them didn’t know what they were doing but the rest did. But that’s the most doctor-friendly interpretation. A more realistic interpretation is that a large fraction of the profession doesn’t care much about evidence. In everyday life, evidence is called feedback. If you are driving and you don’t pay attention to and fix small deviations from the middle of the road, eventually you crash. You don’t need a double-blind clinical trial not to crash your car — a lesson the average doctor, the average medical school professor, and the average Evidence-Based-Medicine advocate haven’t learned.

These glasses can help everyone, not just the poor:

The wearer adjusts a dial on the syringe to add or reduce amount of fluid in the membrane, thus changing the power of the lens. When the wearer is happy with the strength of each lens the membrane is sealed by twisting a small screw, and the syringes removed. The principle is so simple, the team has discovered, that with very little guidance people are perfectly capable of creating glasses to their own prescription.

[Josh] Silver [a retired professor of physics] calls his flash of insight a “tremendous glimpse of the obvious” – namely that opticians weren’t necessary to provide glasses

Speaking of not needing opticians and making glasses more affordable, a year ago I discovered by accident something extremely useful: Wearing one contact lens is better than wearing two.

Wearing just one contact lens, I get good distance vision from the lensed eye and and good close-up vision from the unlensed eye. Wearing two contact lenses, I have poor close-up vision. Another benefit of one rather than two contact lenses is that one eye is contact-lens-free for a long time. And I go through contact lenses half as fast. I wear lenses that last one month so I switch monthly which eye has the lens.

No optician told me this. No optician has even figured this out, as far as I know.

The most telling detail in Robin Hanson’s lecture about doctors was about a nurse assigned to measure hand-washing rates among surgeons at her hospital. After she measured the hand-washing rates, she — as ordered — correlated them with death rates. It turned out that the surgeon who washed his hands the least had the highest death rate. For reporting this — as she was ordered to — the nurse was fired. Robin learned this story from his wife, who was a friend of the ex-nurse.

I was very impressed by Robin’s lecture, which was both accessible and profound, and it was one reason that during my next encounter with a doctor I was more skeptical than most patients. As I blogged earlier:

I have a tiny hernia that I cannot detect but one day my primary-care doctor did. He referred me to Dr. [Eileen] Consorti, a general surgeon [in Berkeley]. She said I should have surgery for it. Why? I asked. Because it could get worse, she said. Eventually I asked: Why do you think it’s better to have surgery than not? Surgery is dangerous. (Not to mention expensive and time-consuming.) She said there were clinical trials that showed this. Just use google, you’ll find them, she said. I tried to find them. I looked and looked but failed to find any relevant evidence. My mom, who does medical searching for a living, was unable to find any completed clinical trials. One was in progress (which implied the answer to my question wasn’t known). I spoke to Dr. Consorti again. I can’t find any studies, I said, nor can my mom. Okay, we’ll find some and copy them for you, she said, you can come by the office and pick them up. She sounded completely sure the studies existed. I waited. Nothing from Dr. Consorti’s office. After a few weeks, I phoned her office and left a message. No reply. I waited a month, phoned again, and left another message. No reply.

Yesterday Dr. Consorti finally got back to me, by posting a comment:

Seth, While I am in the process of finding papers in the literature to satisfy your scientific curiosity on why this hernia should or should not be fixed I am additionally trying to care for around 30 new patients referred to me for their new cancer diagnosis in the last 3 months. This may or may not explain why I have not been motivated to answer your call regarding your ambivalence about fixing your hernia. Yes, it is small and runs the risk of incarceration at some time. I will call you once I clear my desk and do my own literature search. Thanks for the update. Eileen Consorti

Fair enough. She’s busy. And I am glad to have her reply and her view of the situation. On the other hand, I am pretty sure the studies she was so sure existed — that justified the surgery — don’t exist. To call my curiosity about whether the proposed surgery would do more good than harm “scientific” has a bit of truth: No doubt scientists understand better than others that you can test claims such as “you need this surgery”. But it isn’t “scientific” in the least to worry that a medical procedure will do more harm than good. Everyone, not just scientists, worries about that. Surgery is scary. Let’s set aside the death rate, which is low but non-zero. How many brain cells are killed by general anesthesia? Dr. Consorti doesn’t know, nor do I. The number is plausibly more than zero. I suspect a power-law distribution: Most instances of general anesthesia kill a small number, a small fraction kill a large number.

I pointed Robin to Dr. Consorti’s response. He replied:

I wonder if she even realizes that she in fact doesn’t know why you should get surgery.

What I know and Dr. Consorti, very reasonably, doesn’t know, is that my mom was a librarian at the UCSF medical library and has done a vast amount of medical-literature searching. If she can’t find any relevant studies, it is very likely they don’t exist. And my mom did find a study in progress, which, to repeat myself, shows that my question about cost versus benefit is a good one. Others had the same question and launched a study to answer it. Robin’s lecture helped me ask it. Thanks, Robin.

More. Robin’s version of the fired-nurse story is here. Thanks to Charles Williams.