The Twilight of Expertise (part 2)

The first experts were shamans, an occupational category that eventually divided into doctors and priests. As the Catholic Church became more and more powerful, abuses of priestly power became more and more apparent and upsetting, leading to the Protestant Reformation.

Now — half a millennium later — doctors are under much greater scrutiny. The results of that scrutiny are unfavorable — perhaps highly unfavorable. A RAND study suggested that the overall benefit of a substantial amount of health care was small, except in certain special cases such as eyeglass prescription. A large fraction of surgeries are unnecessary, says one critic–and by large he means large:

Stanford University urologist Thomas A. Stamey, M.D., generally regarded as the father of PSA testing, says that 90 percent of all the prostatectomies performed at the Stanford hospital over the past 5 years have been unnecessary.

Earlier post on this topic.

Addendum: According to Biotech Blog,

There’s been a shift in the past 50 years away from the doctor-centric model of healthcare to one in which patients expect, and demand, better information and control over their treatments.

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A 70-293 is a much better choice than 70-296 for someone who plans to do 70-291 later. If the future plans revolve around 70-526, it is alright otherwise.

The Twilight of Expertise (part 1)

In a TED talk, Stewart Brand pointed out that all over the world, poor villages — the same villages that Jeffrey Sachs seems to want to preserve — are vanishing. The people who lived in them have moved to squatter cities, where, according to Brand, there is zero unemployment and a much better life. Because Jeffrey Sachs’ interest in poor African villages seems to be recent, I am not surprised that he may end up on the wrong side of the helped/didn’t help ledger.

This is the general pattern with experts today: Sometimes they help, but often they make things worse. In a comment on an earlier post, Dr. Erika Schwartz called modern medicine “a system that more often harms than helps.”

We are living in the twilight of expertise because we now have alternatives to experts — better alternatives. Squatter cities are a new thing. They solve a very difficult problem (poverty) because they combine three things: (a) People care about themselves and their children (far more than any expert will ever care). (b) The technological knowledge behind the many small businesses (e.g., hair dresser, copy center, pirated videos, cell phones) that allow squatter cities to exist. And (c) something that brings the first two things — caring and know-how — together, namely the cities themselves. Of course, squatter cities owe nothing to Sachs-type experts.

The self-help self-experimentation I have done is another new thing. I solved the difficult problems of how to control my weight, my mood, my sleep, and a few other things related to omega-3, such as my gums. None of which I am expert in — I am not a weight-control expert, a sleep expert, etc. I attribute my success to the combination of the same three elements that come together in squatter cities: (a) I cared. I care about myself far more than experts care about most of the people they try to help. (b) Scientific knowledge — both statistical methods (e.g., exploratory data analysis tools) and basic behavioral science (e.g., the rat experiments of Israel Ramirez). (c) The ability to combine (a) and (b). Self-experimentation was a big part of this, but not the whole thing. My job as a professor and the research library system allowed me the time and opportunity to learn the scientific stuff. The flexibility of my job helped a lot. For example, I almost never had to use an alarm clock to wake up, which allowed sleep self-experimentation. The solutions I discovered are quite different from conventional solutions, but no more different than squatter cities are from what Jeffrey Sachs has prescribed.

Addendum: More info about squatter cities here. A blog about them. More about foreign-aid experts doing more harm than good.

How Blogging Made Philip Weiss a Better Writer

Did the invention of the piano make the first piano players — the ones who started on harpsichords — better musicians? Probably. Long before blogs, I thought Philip Weiss was the best columnist in America. His weekly or biweekly pieces in the New York Observer were usually original, well-observed, and deeply-felt. He now tells how blogging made him a even better writer.

I had smart readers, whose comments were often better than my posts, and I felt more accountability to them than I had to my print readers. The flippancies and profanities I used to go in for began to vanish. The Internet is not the Wild West, it is more like a great ballroom. Yes, it permits disguise and anonymity, but it is, in the end, a social space in which one’s words have consequences. I felt a sense of responsibility when I finished an item and had my finger poised over the enter key. I stopped posting pictures of my dogs.

Why blogs are better written in general.

My Theory of Human Evolution (scrapbook edition)

At the scrapbook store the clerk smiled as I paid. (I have a Shangri-La Diet scrapbook.)

“You’re amused because I’m a professor?” I asked.

“Because you’re a man. Never see men in here,” she said. “My husband hasn’t been here.”

“I think scrapbooking is very important,” I said. “Everyone’s an artist.”

“There’s no right or wrong,” she said.

Exactly. There’s no right or wrong in art but there is better and worse. Unlike technology where there is “right and wrong”: the tool works or it doesn’t work.

Suppose you are trying to guess a number between 1 and 10000. Contrast two kinds of feedback:

yes/no

and

too low/correct/too high

The first is discouraging, the second encouraging. With the second you can find the number; with the first you will give up.

Suppose you are trying to learn how to make steel. To make useful steel requires doing several things almost exactly right. There really is right or wrong. Trying to guess what to do is hopeless because the feedback is of the yes/no variety. And, in the beginning, all of it is no.

In contrast, suppose you are using steel-like materials in art. There is better and worse in art; as a result, you will slowly learn better control of your materials. You will be slowly guided toward the knowledge you need to make steel. The evolutionary reason for art, I believe, is that paying artists paid for research in material science, which eventually led to better tools. Just as ramps and curb cuts help people on wheels, art helped ancient man. It replaced step functions of utility vs. knowledge with ramp functions.

For fascinating recent comments on sex differences see Rebecca A. and Tyler Cowen. Just as scrapbooking releases the inner artist, blogging releases the inner story-teller.

Previous posts in this series: Christmas; American Idol; business book.

Atul Gawande on Unofficial Research


Regardless of what one ultimately does in medicine—or outside medicine, for that matter—one should be a scientist in this world. In the simplest terms, this means one should count something. . . . The only requirement is that what you count should be interesting to you.

When I was a resident I began counting how often our surgical patients ended up with an instrument or sponge forgotten inside them. It didn’t happen often: about one in fifteen thousand operations, I discovered. But when it did, serious injury could result. One patient had a thirteen-inch retractor left in him that tore into his bowel and bladder. Another had a small sponge left in his brain that caused an abscess and a permanent seizure disorder. . . I found that the mishaps predominantly occurred in patients undergoing emergency operations or procedures that revealed the unexpected—such as a cancer when the surgeon had anticipated only appendicitis.

The numbers began to make sense. If nurses have to track fifty sponges and a couple of hundred instruments during an operation—already a tricky thing to do—it is understandably much harder under urgent circumstances or when unexpected changes require bringing in lots more equipment. Our usual approach of punishing people for failures wasn’t going to eliminate the problem, I realized. Only a technological solution would—and I soon found myself working with some colleagues to come up with a device that could automate the tracking of sponges and instruments.

From Better: A Surgeon’s Notes on Performance. Part of Gawande’s answer to the question: How to matter?

Thanks to Sean Curley.

Say No to Genetic Determinism

James Watson, co-discoverer of the double helix, gave the Alumni Convocation address at the University of Chicago last weekend. His genome had been sequenced, he said, but he didn’t want to know if he had “the Alzheimer’s gene”. This is misleading. It implies too much certainty, like a measurement with too many digits. It is entirely possible that this “Alzheimer’s gene” determines one’s vulnerability to low levels of omega-3s and that with sufficient omega-3 it makes no difference. My flaxseed-oil research suggests that almost everyone is omega-3 deficient (because the optimum amount of flaxseed oil was so high). A study of persons 65 or older found that more fish consumption was associated with less cognitive decline.

Am I saying there is gene-environment interaction? Well, is there a “scurvy gene”? Surely there are genes that affect one’s sensitivity to low levels of Vitamin C. But no one cares about them — because most people get enough Vitamin C to avoid scurvy.

Addendum: More and more about Watson and celebrity genomes.

Librarians vs. Soft Censorship

The Shangri-La Diet was published because a paper I wrote was amplified by blogs. Here (from 2002) is something similar: one person’s opinion amplified by a listserv. A librarian persuaded HarperCollins to publish a book by Michael Moore (Stupid White Men) that they had decided not to publish.

“They [HarperCollins] said it would be ‘intellectually dishonest’ not to admit that Bush has done a good job, and that the other things in the book wouldn’t be believable if I didn’t at least give Bush that much,” says Moore. The author was certain that HarperCollins would cancel and destroy the book if he didn’t accede to its demands.

Science in Action: Sunlight and Sleep (update)

Today I had lunch with a friend and said, “I’d like to sit outside.” I answered my phone indoors and went outside. I answered my email sitting outside.

I’m now convinced that more outdoor light exposure makes me sleep better — better in the sense that I wake up feeling like I have slept more deeply. Whatever sleep does, it has done more of it. I’m convinced because I have gotten this well-slept feeling after six or seven days during which I spent several hours more than usual outdoor and did not get this feeling after two days when I spent an average or less-than-average amount of time outdoors.

I have slept this well before, but only after standing for 9 or 10 hours, which wasn’t easy. (Nowadays I stand about 6 hours/day.) Whereas spending more time outside is easy. I’ve ordered a sunshade for my laptop.

I am going to start to measure my sleep quality with a rating and keep track of how long I spend outdoors.

Science in Action: Sunlight and Sleep (background)

Daniel Kripke, a professor of psychiatry at UC San Diego, has done lots of research on the effect of exposure to varying amounts of natural light. His subjects often wear meters that record the illumination level. His latest paper (2004) on the connection between outside light and sleep reports several weak correlations between amount of light exposure and sleep quality:

mesor log10[lux] [a measure of light exposure] was . . . positively correlated with sleep quality (rp = 0.17, p < 0.005), and negatively correlated with reported trouble falling asleep (rp= -0.17, p < 0.005), waking up several times a night (rp= -0.18, p < 0.001), waking up earlier than planned (rp= -0.09, p < 0.10), and trouble getting back to sleep (rp = -0.11, p < 0.025).

The introduction states:

Bright light has been recommended for treatment of various sleep disorders [13], but very few experimental trials have been reported.

“Very few” seems to mean none, given the absence of citations.

The paper ends:

In conclusion, low illumination has a small relationship to . . . sleep disturbances.

Science in Action: Omega-3 (conference submission)

A few days ago I submitted a title and abstract for a talk to be given at the November 2007 meeting of the Psychonomic Society, a group of experimental psychologists:

Rapid Effects Of Omega-3 Fats On Brain Function

I measured the effect of omega-3 fats on my brain by comparing flaxseed oil (high in omega-3) with other plant fats (low in omega-3) and with nothing. Flaxseed oil improved my balance, increased my speed in a memory-scanning task and in simple arithmetic problems, and increased my digit span. The first three effects were very clear, t > 6. The effects of flaxseed oil wore off in a few days and appeared at full strength within a day of resumption. The best dose was at least 3 tablespoons/day, much more than most flaxseed-oil recommendations. Supporting results come from three other subjects. Because the brain is more than half fat, it is plausible that type of dietary fat affects how well it works. The most interesting feature of these results is the speed and clarity of the improvement. The tools of experimental psychology may be used to determine the optimal mix of fats for the brain with unusual clarity.

If I ever made a time line for my life, this submission would be one of the events.

Directory of my omega-3 posts.