Month: January 2011

Thinking Like a Doctor

Seth Roberts11 Comments

Atul Gawande’s latest article in The New Yorker (gated) is one of his best. It is about attempts to reduce health care costs by focusing on the most expensive patients. A tiny fraction of people produce something like 30% of the total cost. You can save a lot of money, it turns out, if you try hard to help them.

To help them, it turns out, you need to do things that aren’t obvious, such as hire someone whose last job was at Dunkin Donuts (as a “health coach”). It turns out that not everyone is happy with what you’re doing.

[One high-cost patient] had seen a cardiologist for chest pains two decades ago, when she was in her twenties. It was the result of a temporary inflammatory condition but [the cardiologist] continued to have her see him for an examination and electrocardiogram every three months, and a cardiac ultrasound every year. The results were always normal. After the clinic doctors advised her to stop [having the tests], he called her at home to say her health was at risk if she didn’t keep seeing him. She went back.

To me, the most revealing part of the article was about a young woman with persistent migraines. During the last 10 months she had required $52,000 of medical care (“twenty-nine E.R. visits, fifty-one doctor’s office visits, and a hospital admission”). Yes, dealing with a persistent migraine by going to the E.R. over and over isn’t getting anywhere. But here is what Gawande (a doctor at Harvard, who writes for The New Yorker) recommends:

She wasn’t getting what she needed for adequate migraine care–a primary physician taking her in hand, trying different medications in a systematic way, and figuring out how to better keep her migraines at bay.

During those fifty-one doctor’s office visits, the woman wasn’t prescribed all possible medicines? And, if she was, she needs a doctor’s help to figure out if they work — which they obviously don’t? How stupid does Gawande think that she and her doctors are?

I don’t think Gawande thinks they are stupid; I think he is unable to stop thinking like a doctor, which means thinking that every serious problem has a solution that includes prescription drugs or other medical care. (Unless it’s obesity, in which case the solution is the ancient advice to “eat less, move more”.) This woman needs to explore lifestyle solutions to her problem. She doesn’t need a doctor for that. But most doctors, judging by their actions, cannot imagine such a thing.

Economic Police

Seth Roberts1 Comment

There exists in China a branch of law enforcement called economic police (I don’t know the Chinese name) whose job is to make sure government officials aren’t getting rich — that is, corrupt. Only government officials, no one else. The brother of a friend of mine is one of them. He has been doing it for six years. In college he double-majored in police work and economics. He carries a gun but has only used it once — to stop a government official trying to flee from Shenzhen to Hong Kong.

Inside the Chinese Government (2)

Seth Roberts1 Comment

I showed a Chinese friend of mine the famous Chinese Professor commercial. In Beijing, 2030, a Chinese professor tells his students about the fallen American empire. It is a commercial against “government waste”.

My friend said that in China you would be put in jail for making such a commercial. There is lots of waste in the Chinese government, she said. I asked her for examples. One is restaurant meals. Government officials go out for extremely expensive meals and eat just a few bites. I have heard that one quarter of restaurant spending in China comes from the government. There is a restaurant near my apartment with absurdly high prices; one of my students said that only government officials would eat there. Another example of government waste is cars. Government officials have big expensive cars.

Inside the Chinese Government.

Law Schools Deceiving Students

Seth Roberts3 Comments

In an article about how law schools deceive prospective students, one way astonished me. Thomas Jefferson School of Law in San Diego reported that 92% of their graduates are employed 9 months after graduation. That 92% included the 25% of the students they couldn’t locate. Which is in accord with the guidelines, said the associate dean of student affairs.

What Global Warming Science Really Says

Seth Roberts8 Comments

To see the usual arguments for global warming, look no further than this list, which gives the most popular “skeptic arguments” with rebuttals. The person who made this list presumably read lots of stuff and tried to select the best rebuttal in every case.

That reading led to this:

Skeptic argument: Models are unreliable.

Rebuttal: Models successfully reproduce temperatures since 1900 globally, by land, in the air and the ocean.

Notice what it doesn’t say. It doesn’t say Models have successfully predicted temperatures . . .Â

These models have many adjustable parameters. With enough adjustable parameters, you can reproduce anything. The only reasonable test of a model with many adjustable parameters is how well it predicts.

Hal Pashler and I wrote a paper pointing out that psychologists had been doing something similar for 50 years — passing off models with many adjustable parameters as reliable when in fact they hadn’t been tested — when their ability to predict hadn’t been measured. One explanation of the current global warming scare is that there is something to be afraid of. A more plausible explanation, I believe, is that — again — one group of scientists is passing off complex models with many adjustable parameters as reliable when in fact they haven’t been tested.

Design Farmer

Seth Roberts3 Comments

A friend of mine majored in design at Tsinghua and is now working as a designer. Her opinion of her education has gone down. Designers from other schools are better trained than she is, she sees.

At Tsinghua, her teachers denigrated learning to use this or that software program. To design something using a computer program was to be a design farmer, they said. They preferred to talk about big ideas. “I hate big ideas,” said my friend.

Her comments reminded me of law professors who would rather teach philosophy than how to be a lawyer (and are surprised when students play solitaire during class) and education professors who don’t teach their students how to teach.

Inside the Chinese Government

Seth Roberts30 Comments

A Chinese friend of mine said that if you are at a high level in the Chinese government, you have a great deal of freedom. Below that level, however, you have very little freedom: You spend all your time doing exactly what your bosses want. And you have no idea how long the slavery will last. American government is different, she said. High American officials have less freedom than those outside government. I agree.

My friend disliked Obama because he constantly spoke about big ideals (“liberty” and so on) that my friend thought were very difficult to achieve. In other words, he constantly made promises that he was not going to be able to keep. She noted Obama’s inexperience and said that people in other areas of government are very smart and would outmaneuver him. (Exhibit 1: Goldman Sachs.) This doesn’t happen in the Chinese government because the people at the top are very old and have come up through the ranks, all the way from the bottom. Because of that long experience, they better understand how to get the rest of the government to do what they want.

In China, rich people fear the government. They must do what the government wants or they will be squashed. In America, she said, rich people do not fear the government. If anything, they tell the government what to do. I agree. Many people, such as Hayek and Milton Friedman, want less government. But I have yet to hear one of them answer the point that if government becomes too weak, rich people will control it.

Preposterous Health Claims of 2010

Seth Roberts1 Comment

Katy Steinmetz, a writer for Time, made a list called “Nutty Health Claims of 2010″ and “2010: The Year in Preposterous Health Claims.” The list of 12 includes:

Preposterous!

Marion Nestle, the New York University nutrition expert, has often said she thinks the health claims made for yogurt are bogus — at least when big companies make them. She recently called Dannon’s claims “a case study of successful marketing”.