Month: November 2011

Assorted Links

Seth Roberts7 Comments
  • Doctoring to the test. Megan McArdle describes the medical equivalent of “teaching to the test”. Although she had the usual symptoms of too-little thyroid hormone, her doctor would not give her more synthetic hormone because her Thyroid Stimulating Hormone (TSH) level was within “normal range”.
  • The Rotten Heart of Europe: The Dirty War for Europe’s Money by Bernard Connolly is out of print, but you can buy a used copy ($600) or download it (free).
  • More evidence that butter is good for you.
  • The trouble with lab mice. Nobel Prizes in Medicine, I’ve said, show the continuing failure of researchers to make significant progress on all major diseases. This article is a closer look at the problem. “We’ve had thousands of mouse studies of tuberculosis, yet not one of them has ever been used to pick a new drug regimen that succeeded in clinical trials. ‘This isn’t just true for TB; it’s true for virtually every disease,’ he tells me.”

Thanks to Ivy Hsieh and Allan Jackson.

Fruit Juice Kombucha

Seth Roberts9 Comments

A reader of this blog named Heidi noticed the discussion of “kombucha” made by fermenting fruit juice with a kombucha culture (SCOBY) started by Parker Bohn. She wrote as follows:

I read somewhere on the internet that kombucha was traditionally brewed with rosehips and elderberries. Since then I’ve been combining tea (either green, black, or raspberry leaf) with several kinds of wild fruit and making some absolutely amazing kombucha! (Before then I experimented with lots of different herbal kombuchas with different medicinal properties.) Black current, rosehips, elderberries, sumac berries, autumn olive berries, black cherries, and raspberries all made excellent kombucha. The best results seemed to be from tea combined with two different fruits, one tart and the other with a unique flavor. I also tried wild grape juice and hawthorn fruits but wasn’t as happy with the results, though the kombucha was still good. Also the SCOBY grows thicker with the tea and fruit combos.

I still used the same amounts of sugar and tea that I had been using, but I was using tart wild fruits that weren’t as sweet as store brought juice. My brew of tea, wild fruits, and sugar was a lot stronger and more flavorful than the weak tea and sugar combo that most people use. I would have two or more people sample the results. Different people would have different favorites, but everyone agreed that the fruit and tea combos were the best kombucha they’d ever had.

I also created herbal kombuchas to target different health issues that people had. For example I made a kombucha with wormwood and other parasite killing herbs. After awhile, I pushed it too far with the herbs though, and the SCOBY stopped fermenting well and started to mold. I was able to nurse it back to life though. Certain herbs work much better than others.

Perhaps a mixture roughly half tea and sugar, half fruit juice will work best. At least, that’s where I’ll start exploring these possibilities. I may never go back to traditional kombucha. Because they are more complex, I can easily believe these newfangled brews taste better. It’s interesting they aren’t available commercially. Flavored kombucha drinks in stores are kombucha with small amounts of fruit juice added at the end.

Evidence-Based Medicine Versus Innovation

Seth Roberts6 Comments

In this interview, a doctor who does research on biofilms named Randall Wolcott makes the same point I made about Testing Treatments — that evidence-based medicine, as now practiced, suppresses innovation:

I take it you [meaning the interviewer] are familiar with evidence-based medicine? It’s the increasingly accepted approach for making clinical decisions about how to treat a patient. Basically, doctors are trained to make a decision based on the most current evidence derived from research. But what such thinking boils down to [in practice — theory is different] is that I am supposed to do the same thing that has always been done – to treat my patient in the conventional manner – just because it’s become the most popular approach. However, when it comes to chronic wound biofilms, we are in the midst of a crisis – what has been done and is accepted as the standard treatment doesn’t work and doesn’t meet the needs of the patient.

Thus, evidence-based medicine totally regulates against innovation. Essentially doctors suffer if they step away from mainstream thinking. Sure, there are charlatans out there who are trying to sell us treatments that don’t work, but there are many good therapies that are not used because they are unconventional. It is only by considering new treatment options that we can progress.

Right on. He goes on to say that he is unwilling to do a double-blind clinical trial in which some patients do not receive his new therapy because “we know we’ve got the methods to save most of their limbs” from amputation.

Almost all scientific and intellectual history (and much serious journalism) is about how things begin. How ideas began and spread, how inventions are invented. If you write about Steve Jobs, for example, that’s your real subject. How things fail to begin — how good ideas are killed off — is at least as important, but much harder to write about. This is why Tyler Cowen’s The Great Stagnation is such an important book. It says nothing about the killing-off processes, but at least it describes the stagnation they have caused. Stagnation should scare us. As Jane Jacobs often said, if it lasts long enough, it causes collapse.

Thanks to Heidi.

Assorted Links

Seth Roberts11 Comments
  • Scientific heresy, a lecture by Matt Ridley mostly about climate change. “Jim Hansen of NASA told us in 1988 to expect 2-4 degrees [of warming] in 25 years. We are experiencing about one-tenth of that.”
  • The continuing influence of Jane Jacobs. “Rouse spoke first, recalling the words of Daniel Burnham, “Make no little plans, for they have no magic to stir men’s blood,” he said. Jacobs followed and began, “Funny, big plans never stirred women’s blood. Women have always been willing to consider little plans.””
  • A self-experimental study of lactose intolerance. ” I came across an article that pointed out that levels of [lactase, the enzyme that digests lactose] peak in the morning and evening hours. So I experimented with having either ricotta products or a half cup of milk with my supper. It worked like a charm, and sure enough, if I tried having any between 11 AM and about 4 PM, I would get sick.”
  • A rather dramatic Google bug. Google the phrase “first let them get sick”. You will be told there are hundreds of thousands of results — perhaps 250,000. Look through them and you will see the correct number is much less (recently, 47).
  • Lorrie Moore reads one of my favorite short stories, “Day-Old Baby Rats” by Julie Hayden. “[In a confessional:] ‘I have missed Mass.’ ‘How many times?’ ‘Every time.’”

Thanks to Dave Lull and Nile McAdams.

Is Health Data Ever Harmful?

Seth Roberts16 Comments

In yesterday’s post I described how searching the medical literature helped me avoid a dangerous surgery with no obvious benefit. The surgeon I consulted, who recommended the surgery, said that published evidence backed her up. I could not find that evidence, however. Others found evidence that contradicted her recommendation.

Among the comments on that post were similar stories: Searching/reading the medical literature had been helpful. Learning what had happened (in research studies) was better than relying on an expert (a doctor). Here is an example:

A little over two years ago, I was “depressed”. My psychiatrist wanted to prescribe an SNRI [serotonin-norepinephrine reuptake inhibitor]. I related, once again, my poor experience with an SSRI and asked for evidence that an SNRI would be any more effective. He said there was evidence that SSRIs [selective serotonin reuptake inhibitors] worked. I pointed out the 2004 meta-analysis that showed no meaningful difference between SSRIs and placebos. Then I asked whether there was any better evidence for SNRIs. Since he wasn’t able to provide any, I told him that since we know that extremely low Vitamin D blood levels, poor diet, no exercise, and no social life can cause depression (all things I had at the time), I’ll try fixing those things first and then resort to drugs if that fails. It did not fail and I quit seeing him.

None of the stories in the comments described the opposite outcome: Knowing the data made things worse.

Are there exceptions? Is it always helpful (or at least not harmful) to know what happened (i.e., know research outcomes)? Has anyone reading this had an experience where knowing health research data was harmful?

Dr. Eileen Consorti and Patient Power

Seth Roberts30 Comments

My alternative to Testing Treatments (199 pages), I said recently, is three words: Ask for evidence. Ask your doctor for evidence that their recommendation (drugs, surgery, etc.) is better than other possibilities. A few years ago, I asked Dr. Eileen Consorti, a Berkeley surgeon, for evidence that the surgery she recommended (for a hernia I couldn’t detect) was a good idea. Surgery is dangerous, I said. What about doing nothing?

To reread what I’d written about this (here and here), I googled her. I learned she has a blog. It contains only one post (June 21, 2011). That post is only seven words long. I also learned she has two very similar websites (here and here). Both use her full name and title where most people would use she. Perhaps I caused the blog and websites.

Here’s what happened:

1. In 2008, during a routine physical, my primary-care doctor finds that I have a hernia, so small I hadn’t noticed it. He says I should see Dr. Consorti. Do I need surgery for something so small? I ask. Ask her, he says.

2. Dr. Consorti examines my hernia. She recommends surgery (that she would perform). Why? I ask. It could get worse, she says.

3. Eventually I realize that’s a poor reason. Anything can get worse. Influenced by Robin Hanson, I speak to Dr. Consorti: Surgery is dangerous. What about doing nothing? Is there evidence that the surgery you recommend is beneficial? Dr. Consorti says, yes, there is evidence supporting her recommendation. She says I can find it (studies that compared surgery and no surgery) via Google.

4. I try to find the evidence. I use Google and PubMed. I can’t find it. My mom, who used to be a medical librarian at UC San Francisco, is an expert at this. She has done thousands of medical searches. She too cannot find any studies supporting Dr. Consorti’s recommendation. Moreover, she finds an in-progress study that compares surgery for my problem with doing nothing. Apparently some researchers think doing nothing may be better than surgery.

5. I tell Dr. Consorti that my mom and I couldn’t find the studies she said exist. Dr. Consorti says she will find them. She will let me know when she’s found them and make copies. I can pick them up at her office.

6. Months pass. I call her office twice. No response.

7. In August 2008, I blog about Dr. Consorti’s continuing failure to produce the studies she seemed sure existed.

8. A reader named kirk points out “ what looks like a relevant hernia study“. It concludes: “Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe.” This argues against Dr. Consorti’s recommendation. No one points out studies supporting her recommendation.

9. Two weeks after my post, someone who appears to be Dr. Consorti replies. She’s busy. She has 30 new patients with cancer. She terms my question “scientific curiosity”. She says “I will call you once I clear my desk and do my own literature search.”

10. More than a year passes. In 2010, I receive a call from Dr. Consorti’s office. An assistant asks me to remove my blog post about her failure to provide the studies. Why? I ask. It makes her look bad, he says. He says nothing about inaccuracy. I say I would be happy to amend what I wrote to include whatever Dr. Consorti wants to say about it. The assistant asks if I have any “further questions” for her. No, I say. The conversation ends.

11. A little later, I realize I do have a question. In 2008, during the conversation when I asked Dr. Consorti for evidence, I had said surgery is dangerous. In response, she had said no one had died during any of her surgeries. By 2010, I realized that such an answer was seriously incomplete. Many bad things can happen during surgery. Death is only one bad outcome. How likely were other bad outcomes? Dr. Consorti hadn’t said. She knew about these other bad effects much better than I did, yet, in a discussion of the safety of surgery, she hadn’t mentioned them. By not mentioning them, she made surgery sound safer than it actually is. Why had she not mentioned them? That’s my question. I call Dr. Consorti’s office and reach the person who had called me. I ask my question. As I wrote ,

He tried to answer it. I said I wanted to know Dr. Consorti’s answer. Wait a moment, he said. He came back to the phone. He had spoken to “the doctor”, he said. She wasn’t interested in “further dialogue”. She would contact a lawyer, he told me.

I haven’t heard from her since then.

This story illustrates a big change. As recently as twenty years ago, the doctor-patient balance of power was heavily weighted toward the doctor, in the sense that the doctor exerted considerable influence on the patient (e.g., to have surgery). One reason, Robin Hanson has emphasized, is human nature: The more fearful we are, the more we trust. Patients are often fearful. Another reason for the power imbalance was information imbalance. The doctor knew a lot about the problem (had encountered many examples, had read a lot about it). The patient, on the other hand, knew almost nothing and could not easily learn more.

During the last twenty years, of course, this has changed dramatically. Patients can easily learn a great deal about any health problem. Google, PubMed, on-line forums, MedHelp, CureTogether, and so on. The story of Dr. Consorti and me illustrates what a difference the new access to information can make.

Personal science (science done to help yourself) has two sides. One is: collect data. My self-experimentation is an example. To improve my health, I gathered data about myself. It worked. My skin improved, I lost weight, slept better, improved my mood, and so on. The other side is: use data already collected. That’s what I did here. My search for data (including my mom’s search) showed that data already in existence (including the absence of evidence supporting surgery) contradicted Dr. Consorti’s recommendation. My search was not biassed against her recommendation. I didn’t care whether she was right or wrong. I just wanted what was best for me. As Feynman said, science is the opposite of trusting experts — including doctors. My first glimpse of the power of self-experimentation was when it showed me that one of the two medicines my dermatologist had prescribed didn’t work.

Overtreatment is an enormous problem in America. Overtreated by Shannon Brownlee and Overdiagnosed by H. Gilbert Welch, Lisa Schwartzl and Steve Woloshin are recent books about it. Overtreatment could easily be why Americans pay far more for health care than people in any other country yet die earlier than people in many countries. A large fraction of our health care may do more harm than good. A common view is that the incentives are wrong. As one commenter put it, pay for treatment, you get treatment. The solution, according to this view, is to change the incentives. That’s a good idea but will not happen soon. I believe overtreatment can be reduced now. You can (a) ask for evidence (as I did) and (b) search for evidence (as I did). The difference in lifespan between America and other countries suggests this might add years to your life.

I would like to find out what happens when people ask for evidence and/or search for evidence. Please send me your stories or post them in the comments.

More Two days after I posted this, Dr. Consorti replied to this post and the earlier one with essentially the same comment, which is here.

Chinese Medicine As Now Practiced

Seth Roberts8 Comments

In America, I often hear praise for “Chinese Medicine”. By this they mean Traditional Chinese Medicine, which includes acupuncture and techniques that harness hormesis. I tend to agree. Medicine as now practiced in China is a different story.

Last night, I had dinner with some of my students. I asked them what their parents thought of their decision to major in psychology. One of them had a surprising answer. Her mom was happy that she was majoring in psychology because among the required courses was a human anatomy and physiology class. If her daughter took this class, her mom believed, it would be harder for doctors to cheat us.

Chinese doctors “cheating” patients is a big problem, in other words. They prescribe drugs that don’t work, said my student, and perform useless surgeries. Little different than Western medicine, except perhaps the drugs are less dangerous. Just as in Western medicine, drug reps try to bribe doctors to request their drugs. Unlike Western medicine, doctors steal the drugs of hospitalized patients, my student said, which they then sell. After a friend of mine was badly burned, she had (wisely) turned down the recommendation of a skin transplant. This angered her doctor, who would have made money from the operation. Later, when he changed her bandages, he did so roughly, which was very painful. Revenge.

“Don’t see the doctors at Tsinghua hospital [the campus hospital],” said my student. She had had a bad experience. She had gotten injured and gone to the hospital. She had had to wait half an hour to see a doctor; who had taken a mere 30 seconds to prescribe a cream that did almost nothing. That evening I watched The Poseidon Adventure. A doctor visits a sick woman in bed in her cabin. After a long wait, he gives her cursory treatment.

HUSBAND (to doctor) Hold it, hold it. You mean to tell me we had to wait all this time just for you to come in here and kiss her off with a couple of pills and some crap about staying in bed? How do you know she’s just seasick? Look at her! It could be something else! You didn’t even examine her.

Same complaint.

Seth Roberts Interview With Pictures

Seth Roberts12 Comments

This sidebar appeared in an article about self-tracking (only for subscribers) by James Kennedy, who works at The Future Laboratory in London. The top photo is at a market near my apartment. Below that are photos of my sleep records, my morning-faces setup, my butter, and my kombucha brewing jars. Back then I was comparing three amounts of sugar (each jar a different amount). Now I’m comparing green tea/black tea ratios.

Danny Kahneman’s Decision Making

Seth Roberts3 Comments

A lovely article by Michael Lewis about Daniel (“Danny”) Kahneman, my former Berkeley colleague, emphasizes his indecision whether to write a popular book about his work. Should I or shouldn’t I? He doesn’t like what he’s written so far. Finally he decides to pay some experts for their opinion:

He called a young psychologist he knew well and asked him to find four experts in the field of judgment and decision-making, and offer them $2,000 each to read his book and tell him if he should quit writing it. “I wanted to know, basically, whether it would destroy my reputation,” he says. He wanted his reviewers to remain anonymous, so they might trash his book without fear of retribution. The endlessly self-questioning author was now paying people to write nasty reviews of his work. The reviews came in, but they were glowing.

Uh, why would anonymous experts trash his book? They gain in two ways from having it published: 1. It draws attention to their field, making them more important. 2. They can use it as a textbook. I love that Michael Bailey wrote The Man Who Would Be Queen (pdf). It allows me to assign my students a book I admire.

I think Danny has raised two great questions here:

  1. How can we set up a situation so that others will tell us the truth (= what they actually think)?
  2. How can we tell if we’ve succeeded — if they’ve told the truth?

The answers aren’t obvious, at least to me. The best answer I can give to Question 1 (what situation?) is write a blog. I take positive and negative comments to be what their authors actually think. Variations on Question 1 are common. Robin Hanson’s blog is about how bias distorts what we say and do. Hot or Not provides truthful answers to how attractive you are. CureTogether tries to get truthful answers about health care. The best answer I can give to Question 2 (how to assess) is do a test. Wear something ugly. Do your friends say you look great in it? Why do I think the comments on my blog are truthful? Well, my recent post about E-Cat was poorly-informed (unintentionally). The comments quickly and overwhelmingly said so. That supports my belief. In contrast to Question 1, Question 2 is rare.

The last time I talked to Danny was in the 90s. I was thinking of writing a book based on my introductory psychology lectures. I wrote a sample chapter based on my possessiveness lecture. The center of that lecture was the endowment effect (we value what we possess much more than the same thing when we do not possess it). Danny had written about it and loss aversion is part of prospect theory. By then Danny was at Princeton. I spoke to him on the phone. Does the endowment effect affect your everyday life? Does it affect what you do? I asked. He thought about it. No, he said. Or at least he couldn’t think of examples. In contrast, Richard Thaler chatted happily about the everyday implications.

One everyday sign of the endowment effect is a car in front of a big garage. The car isn’t in the garage because the garage is full of “junk”. Another is garage sales (also called yard sales). Such sales are held when the clutter becomes unbearable. They illustrate the everyday relevance of the effect. My point isn’t that Danny was unobservant, it’s the difference between his answer and Thaler’s. There is definitely room for two answers to my question. Humans are traders. We specialize and trade. This is central to economic life. Early papers about the endowment effect (I haven’t looked at recent papers) didn’t notice the problem/puzzle. How can we both (a) hold on to stuff tightly (= the endowment effect, loss aversion) and (b) trade easily? John List noticed.

My friend Michel Cabanac, whose research was behind the Shangri-La Diet, has criticized Danny. In a book (p. 140), Michel wrote:

At a lecture in Jerusalem on January 19, 2001, he [Danny] was kind enough to inform the audience that the recent reorientation of his research toward what he calls “experienced utility,” which he acknowledged to be a synonym of pleasure, had been inspired by my 1993 lecture at Princeton University and by previous readings of my publications on pleasure.

In an email he elaborated:

However the “lecture” [at Princeton] was a only an invited seminar in his laboratory with an audience limited to him and his team. If I remember well, he reimbursed my travel and housing expenses. Yet, the Jerusalem mentioning of my contributions was only verbal [i.e., spoken], as I failed and still fail to find reference to Cabanac in his publications.

Michel’s whole research career has centered on the idea that pleasure guides our actions, including “cognitive” ones. Faced with an arithmetic problem (2 + 7 = ?), for example, some answers will seem more pleasant than others. (2 + 7 = 9 is more pleasant than 2 + 7 = 10, not just more familiar.) He has especially stressed that changes in pleasure — the same events become more or less pleasant — help us self-regulate. We stop eating when food becomes unpleasant, for example. The food stays the same, we change. No one has understood the role of pleasure — which is at the center of all human decision making — better than Michel.

When I get a copy of Danny’s new book, Thinking Fast and Slow, I will be curious to see what he says about the endowment effect, loss aversion, and Michel Cabanac.

More Via scrbd, I have found that Danny’s new book does reference Michel — see p. 488. And, in a chapter about the endowment effect, I found this: “Knetsch, Thaler, and I set out to design an experiment that would highlight the contrast between goods that are held for use and for exchange.” He goes on to discuss List’s research. I am unable to find anything like the phrase “the contrast between goods that are held for use and for exchange” in the paper that the three of them wrote about the effect. Jack Knetsch began to study the effect because different ways of trying to establish the value of the environment (e.g., clean water) produced enormously different answers. The endowment-effect chapter is weak on everyday examples — nothing about garage sales — but does include an unsourced quote: “She didn’t care which of the two offices she would get, but a day after the announcement was made, she was no longer willing to trade. Endowment effect!”

Thanks to Dave Lull, who suggested online searching.

Testing Treatments: The Authors Respond

Seth Roberts2 Comments

In a previous post I criticized the book Testing Treatments. Two of the authors, Paul Glasziou and Iain Chalmers, have responded. I have replied to their response. They did not respond to the main point of my post, which is that the preferences and values of their book — called evidence-based medicine — hinder innovation.

Sure, care about evidence. Of course. But don’t be an evidence snob.