Seth's Blog

The other shoe drops. A year ago Atul Gawande wrote in The New Yorker about the Apgar score, a low-tech measurement of newborn viability that led to vast improvements in obstetrics. That’s the “how to improve?” side of things. Now Gawande has written about something equally simple and powerful on the “here’s how to improve” side of medicine: the use of checklists to improve ICU treatment. The first article was called “The Score”; this one is called “The Checklist”.

Checklists are the idea of Peter Pronovost, an ICU doctor at Johns Hopkins Hospital. His first checklist, in 2001, was designed to prevent infections on tubes inserted into patients. Nurses made sure that doctors followed the checklist. It’s like the Ten Commandments: the top and bottom getting together to improve the behavior of people in the middle. Checklists involved the empowerment of nurses (bottom) by hospital administrators (top) to improve the performance of doctors (middle). No coincidence, I’m sure, that the Apgar score also involved female empowerment: Virginia Apgar was one of the first powerful women in medicine.

Pronovost told Gawande:

The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.

Not to mention a sick person’s perspective. I completely agree. Several years ago I heard an industrial designer give a talk to an interface design group. He said that new high-tech products go through three stages: (a) used only by gadgeteers and professional engineers (e.g., the first home computers); (b) used by experts (e.g., billing software for lawyers); and (c) mass market (e.g., cell phones). The discipline of engineering, he said, was good at designing for the first two stages but not the third.

The similarities suggest a common explanation. I think one reason goes back to Veblen: It is low status to do useful work. It may also have to do with male dominance of medical research and engineering. When balancing status versus usefulness, men may weigh status more highly.

More innovation in the delivery of medicine: house calls. No kidding. More about Peter Pronovost.

Ian Ayres’ interesting new book, Super Crunchers, has a chapter about expert prediction versus predictions from math models. Almost always, the math models do better than the experts. I learned about this in graduate school when I read stuff by Paul Meehl, a psychology professor who compared the predictions of clinicians and regression equations in the 1950s. The idea has gathered strength since then and now the persons in some jobs — such as loan officers — are required to follow an algorithm for making decisions. Their expertise is ignored. Obviously they no longer derive as much self-worth from their job, Ayres points out.

It’s like the beginning of agriculture. Lots has been written about the physical problems caused by the change to agriculture. Stature decreased, tooth decay increased, and so on. I’ve never read about the mental problems it must have caused. I can only speculate, of course, but here’s an possible example: Hunters derived self-worth from bringing meat to their families. Taking that away caused problems. (Watching Once Were Warriors, a terrific movie, should make this more plausible.)

I have never read anything about how to reintroduce into everyday jobs crucial mental elements that hunting had and farming lacked. Nutrition education, vitamin supplements, dietary fortification, and other nutrition programs push us toward a pre-agricultural diet, which was far more diverse and better balanced. There is no similar set of things that move us closer to pre-agricultural ways of making a living. My self-experimental research is all about the value stuff that ancient life had but modern life lacks — such as seeing lots of faces in the morning — but I have never figured out how to simulate elements of hunting, beyond being on one’s feet a lot.

Philip Weiss has written an excellent (as usual) article about Matt Drudge.

“Matt Drudge is just about the most powerful journalist in America,” said Pat Buchanan.

And he’s self-employed. He started way down:

This is an incredibly lonely kid, [said a friend]. He doesn’t have a sister, his mother is in and out of hospitals [diagnosed with schizophrenia], the father was beside himself. In high school they treated him like shit. He was starting to lose his hair in high school; think what that does to a kid.

According to Publisher’s Weekly, a new program at amazon.com called

Amazon Vine rewards the site’s elite reviewers by giving them access to advance copies. According to a representative at Amazon, invitations have gone out to the site’s “top reviewers,” deemed so by their review rankings, to become Vine Voices.

I once read about a Los Angeles catering business that wasn’t doing so well until they doubled their prices. This is the opposite of that.

From Seth Godin:

When the Times switched from 10 books on the Hardcover [Best Sellers] list, they created a list of 15 Hardcover [Best Sellers] and a list of 5 Advice, How To and Miscellaneous [Best Sellers]. I wrote in and asked the editor why they only had 5 titles on this list and 15 on the others. She wrote back and said,

“Because we don’t want people to read those books.”

Pride goeth before a fall.

An article in this week’s BMJ about problems with clinical trials makes some of the points I made in a recent post. The article is based on a London conference held last week. In my post, I said the evaluation of the Shangri-La Diet going on at the SLD forums was in many ways better than a clinical trial.

At the conference, a speaker complained that

key groups of participants were often excluded from clinical studies

I pointed out that anyone could post at the SLD forums.

Doug Altman, professor of statistics in medicine at Oxford University, said that the presentation of statistical results of clinical trials “lacked transparency and precluded any further analysis.”

I said that the forums are more transparent.

Paul Glasziou, director of the Centre for Evidence Based Medicine at Oxford University, warned that many clinical trials described treatments that were difficult to replicate in normal clinical settings.

I said that the forums were more realistic — meaning that the treatments being tested were closer to what actually could happen.

“Religion is extremely important to the Tibetans,” says Wikipedia, but what does that mean? The Tibetan Buddhism entry is no help. Last night at dinner, however, I did learn what it means, at least in part. Tibetans spend a vast amount of time on religious observances — what the observer (Bryan Ng, a Berkeley engineer) called a “religion tax.” One example was a well-observed month-long annual religious festival. Another was a sensationally slow method of travel: Take a step or two, bow down, lie down on the ground, get up, take another step, bow down, and so on. This method is used to cover long distances, such as 20 miles or more. The extremely devout do this along highways.

The Chinese government wants to reduce the influence of religion, he said. Goods imported into Tibet from China via the new railway should increase commerce, for example. The power of the Chinese government makes it likely they will succeed.

The education improvement program — merit pay for teachers as part of a larger package — promoted by the Milken Family Foundation received a big public boost last week with this NY Times article about a similar program in Minnesota.

A consensus is building across the political spectrum that rewarding teachers with bonuses or raises for improving student achievement, working in lower income schools or teaching subjects that are hard to staff can energize veteran teachers and attract bright rookies to the profession. . . Minnesota’s experience shows . . . that an incentive plan created with union input can draw teacher support.

The plan that is gaining support was devised by Lowell Milken, according to Jana Rausch, who works for the Milken Family Foundation on this initiative. Before he started the foundation, Lowell Milken was a lawyer. As far as education goes, he is self-taught. Yet the program he devised seems to be working better than other programs. Of course many people have proposed merit pay for teachers; but it is the Milken Family Foundation that has managed to make it work. We need engineers to build a better plane. But we do not need education experts, apparently, to build better schools.

1. foreign-aid experts
2. medical doctors
3. book writers
4. clinical trials
5. psychotherapists
6. psychotherapists again
7. education experts
8. spiritual experts
9. clinical trials again
10. book reviewers
11. journalists
12. expert vs math models
13. ICU doctors
14. fugu processors
15. surgeons
16. opticians
17. medical doctors again
18. psoriasis treatment
19. mothers (parenting advice)

Among the community of psychotherapists, according to Dr. Marion Arom, a psychotherapist friend of mine, “it is common knowledge that in many traditional therapies, if the therapy fails — if the desired change doesn’t occur — it’s due to client resistance or lack of motivation to change or unconscious motivation. The role or skill of the therapist is not examined, ever.”

Dark Age Ahead by Jane Jacobs has a chapter about the failure of highly-respected professions to police themselves.

Directory of Twilight of Expertise posts.

In The Starfish and the Spider (2006), a book about decentralized organizations, one of the examples is Alcoholics Anonymous, started in 1935, in which local chapters are almost entirely autonomous from headquarters. Of course AA led to many similar programs: Narcotics Anonymous, Overeaters Anonymous, and so on. All of these twelve-step programs offer therapy without therapists — for free. A little like the Protestant Reformation, which I mentioned earlier.

At a recent party I met a woman who runs an outpatient program for persons with mental disorders, including major depression. She asked me what I would suggest. Based on my faces research, I suggested early morning face-to-face meetings, especially for persons with depression. Very interesting, she said, AA folk wisdom is that morning meetings have the best success rates.

If you want to attend an early morning meeting (non-twelve-step), and you live in San Francisco, you may have a communal breakfast ($5 plus tax, served 8:30-9:30 am) at OneTaste (1074 Folsom at 7th St.), an “Urban Retreat Center”. If you can do this, I’m jealous. OneTaste is a group of 50 people who live and work together. They appear to support themselves by teaching yoga and giving other classes. They have been at their SF location for two years; before that they were at many different locations. The receptionist told me it was a “sensual community.” What’s that? I asked. “We try to activate our sensuality” etc., she said. I didn’t know what she meant. Is this on the website? I asked. Yes, she said, so I didn’t bother to take careful notes. I wish I had. The website puts it more bluntly: “Our purpose at OneTaste is to return to connection by researching our relationship to orgasm.” A recruitment video, to prepare for breakfast.