Hard to Say Whether Medicine Does More Good Than Harm

Seth Roberts6 Comments

A draft article by Spyros Makridakis about blood pressure and iatrogenics takes issue with the statement that “The treatment of hypertension has been one of medicine’s major successes of the past half-century.” Over the last half-century, the article says, the death rate for people with high blood pressure decreased by almost exactly the same amount as the death rate for people without high blood pressure. Apparently “one of medicine’s major successes” is a case where the health benefit no more than equaled the health cost — leaving aside what the treatment cost in time and money.

Because very high blood pressure (systolic > 180 mm Hg) is quite dangerous and blood pressure drugs really work, this is a surprising outcome. Makridakis points out that doctors start treating high blood pressure when it rises above systolic = 140 mm Hg, a point when there is little or no increase in death rate. This article tells doctors to immediately prescribe drugs when systolic blood pressure is above 160. Yet death rate clearly increases only when systolic blood pressure is above 180. Makridakis concludes (as do I) that blood pressure drugs have significant health costs as well as benefits. The drugs are so often prescribed when they do no good and the costs are so high that the overall health costs of blood pressure treatment have managed to be as high as the overall benefits. Even when handed a relatively easy-to-measure problem (high blood pressure) and a relatively simple solution (blood pressure drugs), our health care system managed to achieve no clear gain. If this is “one of medicine’s major successes”, medicine is in bad shape.

The last paragraph of Makridakis’s article makes a surprising statement: “We strongly believe that medicine is extremely useful.” It does not explain this belief, which is contradicted by the rest of the article. I was puzzled. I wrote to the author:

I recently read your paper on “High blood pressure and iatrogenics”. The main part makes good sense. Then it ends with something quite puzzling: “We strongly believe that medicine is extremely useful.” No doubt a few areas of medicine are extremely useful. For large chunks of medicine, it is hard to tell whether they do more good than harm, because so many drugs and other treatments have undisclosed or unnoticed bad effects.

For example, tonsillectomies — for a long time the most common operation — is associated with a 50% increase in mortality in one study. The notion that cutting off part of the immune system is a good idea makes as much sense as the idea that cutting out part of the brain is a good idea. Another example is sleeping pills. They are associated with a three-fold increase in death rate soon after they begin to be taken. I am not saying that medicine overall does more harm than good. I am saying that a strong belief about the outcome of such an assessment (does medicine overall do more good than harm?) doesn’t make sense.

Makridakis replied:

Thank you for your email. The paper you mention is a draft posted for comments. I agree with you that my statement is wrong. It should have read: : “We strongly believe that medicine can be extremely useful”. For instance, this could be the case in treating heart attacks, strokes, traumas from car accidents or bullet shots. But in most other cases the harm from treatment can be greater than the benefits. In addition, the harm from preventive medicine can exceed its value. Thank you for pointing out this mistake to me.

Puzzle resolved.

Sleeping Pills are Very Dangerous

Seth Roberts8 Comments

Do you know how dangerous prescription sleeping pills are? I didn’t, and I do sleep research.

I came across Dr. Daniel Kripke’s book Dark Side of Sleeping Pills while finishing yesterday’s post on undisclosed risks of medical treatments. I had written an almost-complete draft a year ago. One line in the draft said “undisclosed risks of sleeping pills” with no additional information. I couldn’t remember why I’d written that so I googled “dangers of sleeping pills” and found Dr. Kripke’s book. I was unaware the evidence was so strong. I asked Dr. Kripke to tell the story of how he came to write it. He replied:

It is almost a life-long story.

As a young psychiatrist, I learned that the American Cancer Society had done a questionnaire survey of a million people which showed mortality related to long and short sleep. [People who sleep less or more than average have higher death rates.] In 1975, I asked if they would collaborate with me on a more complete analysis of the data on sleep length and insomnia. As a control variable, we included analysis of their one question about sleeping pill use. To my surprise, it looked like sleeping pill use was a strong predictor of early death, while insomnia was not (if you controlled for sleeping pill use by insomniacs).

There were many reasons why these results needed further study, so I asked if I could refine the questions for the new Cancer Prevention Study II (CPSII) which the American Cancer Society commenced in 1982 with 1.1 million participants. Imagine my surprise when I observed that sleeping pill use was associated with a comparable mortality hazard ratio as cigarette smoking! These studies, and about 20 more done all over the world with similar results, had two important limitations: in general, the studies did not identify the sleeping pills used and did not measure whether those taking sleeping pills at the start of the study continued the drugs, or whether those who were not taking sleeping pills (the comparison group) started taking them. So another study was needed.

Meanwhile, sleeping pills were never my main scientific concern. I was mainly interested in bright light treatment of depression and trying to understand how light worked. When I saw that patients needed information about light treatment, I wrote a very short book called “Brighten Your Life”, but it wasn’t long enough to publish, so I added information about sleeping pills to make it longer. When we found no publisher for the book, I made the information available at two web sites: www.BrightenYourLife.info and www.DarkSideOfSleepingPills.com. I found that the web site about sleeping pills was more popular than the advice about light treatment–indeed, one of the most popular sources about sleeping pills at Google. Therefore, over the years, I have worked to revise and update both web sites to try to help patients. It costs some money to program and maintain the web sites, but people write me to tell me how they have benefited. I see so much misinformation coming from the drug companies that I want people to have an alternative source.

Five or six years ago, my friend Dr. Bob Langer was working at the Geisinger Health Research Center, which had access to electronic health records about sleeping pill use from a large number of people. It took us five years to plan a study, obtain approval from ethics committees, retrieve the complex data from computer files in anonymized form, and analyze the very complex results. When these were published by the medical journal BMJ Open, the new information became available at https://bmjopen.bmj.com/content/2/1/e000850.full. It is an interesting web site which includes more data in a supplement to the main article and some comments and debate about the article. The interest in the article was world-wide, with stories on the BBC, at Agence France Press, in major newspapers in Japan, India, and China, and even mentions in far-off places like Myanmar and Ruanda. The new data showed that people taking drugs such as zolpidem and temazepam had about 4.6 times the mortality rate of people of the same age and sex who took no sleeping pills. The new data confirm that sleeping pills might cause as much death as cigarettes, and also some cancer, so I feel a big responsibility to make the information available. There may be hundreds of thousands of lives at stake. People need to know that sleeping pills are too risky to use, and I wish I had more help in telling people.

Recently we updated the Dark Side Of Sleeping Pills and Brighten Your Life and made them available together in a Kindle book, which is easy to purchase at Amazon and read off-line. The books have some new information which we have not yet had a chance to put in the web sites.

Even with, now, more than 20 scientific papers showing that taking sleeping pills is associated with more death and more cancer, many people don’t believe it. They imagine there is some other explanation, though nobody has been able to demonstrate an alternative explanation. Of course, statistical association is not quite the same thing as proof of causality, but if it is good enough for the American Cancer Society to advise avoiding cigarettes, it is enough evidence of risk to stay away from sleeping pills, in my opinion. The problem is that the drug companies have never done a controlled trial study large enough to prove one way or another whether the sleeping pills cause death and cancer, and I think they never will. The cigarette companies have never tried to prove that cigarettes are safe, and they know better than to try. It is the same. Whereas the FDA requires the very large studies for heart and diabetes drugs and so forth, the FDA has dropped the ball with sleeping pills. For more information about that, please see the Kindle book. There is, however, a new alternative to large, expensive, and dangerous controlled trials called a Mendelian randomization study, which uses the new genetic methods to determine causality when a genetic variation causes a risk factor such as sleeping pill usage. Since the genetic data already exist to do the Mendelian randomization studies, it is a matter of doing the difficult statistical analyses. I hope scientific colleagues will join in this task, because I can’t do it by myself. It is crucial to determine for sure the risks of sleeping pills. Too many lives are at stake.

Sleeping pills are astonishingly dangerous for something that is treated as more or less safe. In some cases, they are associated with a five-fold increase in death rate after only a few years of use. Cigarette smoking is associated with only a two- or three-fold increase in death rate after long use. And doctors don’t prescribe cigarettes. Is there anything else treated as safe that is associated with such a large increase in death rate? I can’t think of anything.

Undisclosed Risks of Common Medical Treatments

Seth Roberts10 Comments

Millions of tonsillectomies have been done, mostly to children. Were any of their parents told that tonsils are part of the immune system (taught in high school biology and known since the 1960s)? A Cochrane Review of tonsillectomies (the “highest standard” in evidence-based medicine) fails to mention that tonsils are part of the immune system. A recent study found tonsillectomies associated with a 50% increase in heart attacks. (I write about tonsillectomies here.)

Are tonsillectomies unusual? Several recent news stories suggest no, they aren’t. Failure to tell patients the full risks of medical treatment may be common:

1. Undisclosed risks of hernia surgery. From the Wall Street Journal: “More than 30% of patients may suffer from long-term chronic pain and restricted movement after surgery to fix a hernia . . . studies show.” The article says “many patients don’t consider” this risk — meaning they don’t know about it. A Berkeley surgeon named Eileen Consorti told me I should have surgery for a hernia I could not detect. I have previously written about her claim that evidence supported her recommendation when no such evidence existed — or, at least, no one including her has ever found it. I said I wanted to see the evidence because there were risks to surgery. She replied that none of her patients had died. I was shocked by the incompleteness of her answer. There are plenty of bad outcomes besides death — as the Wall Street Journal article shows.

2. Undisclosed risks of sleeping pills. A book called The Dark Side of Sleeping Pills by Daniel Kripke, a professor of psychiatry at UC San Diego, goes into great detail about risks of sleeping pills that few doctors tell their patients. For example, one study found that “patients who took sleeping pills died 4.6 times as often during follow-ups averaging 2.5 years [than matched patients who did not take sleeping pills]. Patients who took higher doses (averaging over 132 pills per year) died 5.3 times as often.” Insomnia alone was not associated with higher mortality. Tomorrow I will post Dr. Kripke’s answer to the question “why did you write this book?” Here is a website about the dangers of Ambien.

3. Undisclosed risks of anticholinergic drugs. From the NY Times: “After following more than 13,000 British men and women 65 or older for two years, researchers found that those taking more than one anticholinergic drug scored lower on tests of cognitive function than those who were not using any such drugs, and that the death rate for the heavy users during the course of the study was 68 percent higher. That finding, reported last July in The Journal of the American Geriatrics Society, stunned the investigators.” Anticholinergics are “very very common” said a researcher. They include many over-the-counter drugs, such as “allergy medications, antihistamines and Tylenol PM”.

4. Undisclosed risks of statins. A recent NY Times story says “the Food and Drug Administration has officially linked statin use with cognitive problems like forgetfulness and confusion, although some patients have reported such problems for years. Among the drugs affected are huge sellers like Lipitor, Zocor, Crestor and Vytorin.” Prior to this official linkage, the reports of forgetfulness and confusion were mere anecdotes that evidence-based medicine proponents ignore and tell the rest of us to ignore.

5. Undisclosed risks of metal-on-metal hip replacements. They leak dangerous amounts of metal (e.g., cobalt) into the rest of the body. “Despite the fact that these risks have been known and well documented for decades, patients have been kept in the dark,” says a recent article in the BMJ. By 2007, the danger was so clear that a British regulatory committee said that patients must sign a form saying they’ve been warned. This didn’t happen — a surgeon told the BMJ that “surgeons were unaware of these discussions.” Other materials could have been used.

These six treatments (tonsillectomy, hernia surgery, sleeping pills, anticholinergic drugs, statins, and hip replacement) are so common they raise a scary question: What fraction of the risks are patients usually told?

The surgeon or drug company gets paid no matter what happens to you. Malpractice lawsuits are very rare on a per-patient basis — and no one will be sued for performing a tonsillectomy on a child who gets a lot of colds or prescribing sleeping pills to someone who has trouble sleeping. In a Freakonomics podcast, Steve Levitt said that doctors terrify him. And his father is a doctor. Given the undisclosed risks of common treatments, he is right to be terrified.

Thanks to Allan Jackson, Alex Chernavsky and Tim Beneke.

Brain Tracking: Early Experience

Seth Roberts7 Comments

Brain tracking — frequent measurement of how well your brain is working — will become common, I believe, because brain function is important and because the brain is more sensitive to the environment (especially food) than the rest of the body. You will find it easier to decide what to eat if you measure your brain than if you measure other parts of your body. For example, I have used it to decide how much flaxseed and butter to eat. I have used R and the methodological wisdom of cognitive psychologists to make brain tracking tests. Alex Chernavsky, who lives in upstate New York, recently tried the most recent version:

In August, Seth solicited readers to help him test a new brain-tracking program. I said I was interested. I had a number of reasons for volunteering:

  • My job involves working a lot with computers, so I thought I had a decent shot at ferreting out any bugs or usability issues.
  • I have been tracking my weight daily for over eleven years, so I was confident that I would have enough motivation to do the test on a regular basis.
  • I have a long-standing interest in neuroscience, so I was eager to help advance the field, even if in a very small way.
  • I’m in my late 40s, and I’ve noticed a distinct increase in my forgetfulness. There are probably other, less-noticeable decreases in my cognitive function. Thus I have an interest in finding ways to boost the performance of my brain. Hacking brain function is obviously much easier if you can assay it via a quick, reliable proxy (i.e., reaction time).

The program itself was relatively easy to set up. The code is written in a free, open-source scripting language called R, so you have to install R on your Windows computer in order to run the program. Upon downloading the script (which is contained within an R workspace), you have to edit a function to specify the Windows folder that contains the workspace file. After that, you’re ready to go.

The three-month pilot study did not involve testing any hypotheses with regard to the effectiveness of interventions (for example, measuring reaction times before and after flaxseed oil). My task was simply to perform the test once or twice a day.

Taking the test involves hitting a number key (2 through 8, inclusive) to match a random target number that is displayed on the screen. The program measures the latency of your response. If you hit the wrong key, the program forces you to repeat the same trial until you press the right key. Reaction-times from these “correction trials” are not used in any subsequent data analysis. A session consists of 32 individual trials and takes about four minutes to complete.

I performed the test daily for three months, although I did miss two days. The test stopped short of being fun, but it was certainly not onerous. The biggest hassle was having to wait for my laptop to boot into Windows. If I had to do the pilot study over again, I would install R on both my home and my work desktop computers, so I could perform the test more easily (perhaps as a way to take a short break from whatever other task I happened to be working on).

The original plan was for me to email the R workspace to Seth once a week or so. However, I suggested to Seth that we could improve efficiency by using a shared DropBox folder. He agreed, and that is the method we adopted. Using this system, Seth had ongoing access to the latest data, and he could also easily make any bug-fixes or other edits that would take effect the next time I ran the script.

I did identify one bug in the script. After each trial, the script briefly displays some feedback in the form of your reaction-time (in milliseconds) for that trial, your cumulative average for that session, and a percentile figure that compares your latest speed with past trials for that same target key. I noticed that the percentile scores didn’t seem to make sense for some of the keys. Seth examined his code and agreed that this was indeed a bug. He made some adjustments and the bug was fixed.

I found that over time, as expected, my scores improved substantially. They seemed to plateau after six weeks. However, my accuracy suffered. During the third month of the pilot study, I made a conscious effort to reduce my error rate. I had some success, but I also found myself frustrated by my inability to reduce the errors as much as I would have liked. Making errors, despite my best efforts, was the only vexing part of taking the test.

 

 

 

 

 

Assorted Links

Seth Roberts5 Comments

Thanks to Hal Pashler.

How to Write: What One Student Learned

Seth Roberts2 Comments

Yesterday I gave lessons from my academic writing class based on all student answers. One student, Wang Lingjie, did an especially good job saying what she learned. Here are four things:

Lesson 1: Be genuine. In the last class, Seth showed us a pair of personal statements and its revised form. [I showed a personal statement before and after revision.] Rethought about it, I do feel that the original form would be more like a true person who want to tell his story and show his willingness for a master’s degree. [In class, Lingjie had preferred the revised version.] True self expressed more like a vivid individual.

Lesson 2: Keep the sentence simple. Chinese students normally have their technique to produce a fancy article. One of the tips is their substitution list, by which they can switch normal words into long and seemly educated ones. This kind of decoration seems like showing off. Also, when I went on to write personal statements according to the college’s requirements, I understand the importance to be succinct under words limitation.

Lesson 3: Talk to your readers as you speak. I get the inspiration from the guest speaker [Jon Cousins]. Then I took on to read my passages out when I write twitters for my internship. Though the effect of the new promotion tone has not emerged yet, I personally like the latter ones better.

Lesson 4: Raise readers’ emotions. Stories help. I realized its importance when we discussed Ashley’s 3 outlines. [Students wrote 3 outlines on the same subject.]

How to Write: Lessons From My Writing Class

Seth Roberts8 Comments

I just finished teaching an undergraduate class called Academic Writing at Tsinghua. One semester, pass/fail, about 10 students. The last assignment was list six things you’ve learned. Combining the answers, I came up with this:

1. Don’t tell readers what they already know. This came up a lot when I discussed how to write a personal statement. “Your university has an excellent program in X” — no, don’t say that.

2. To make your writing moving, focus on your own thoughts and emotions. Moving = evoking emotion. Evoking emotion was enormously important, I said.

3. Use simple words and sentences (don’t show off). As one student put it, “Received the blames from one class, changed all my GRE words into understandable words.”

4. Give examples.

5. Avoid boasting (say “I like X”, don’t say “I am good at X”).

6. Do not write about things that are “too big”.

7. Have clear connections between sentences. We spent several classes on the various ways adjacent sentences can be related.

8. Say things that are honest and true. In contrast to what you think your reader wants to hear. A friend asked for advice on her personal statement for a graduate school application. She sent me a revised version. I thought the unrevised more honest version was better.

9. Begin with something interesting.

I asked which of these lessons they already knew. The consensus answer was #1 (don’t tell readers what they already know) and #4 (give examples). Their personal statements flagrantly violated #1. One student said they had learned it, yes, but needed to be reminded.

Jon Cousins of Moodscope, in town for a Quantified Self conference, gave a guest lecture. From his talk the students came away with four main things:

1. Copy someone’s writing you admire.

2. Imagine your audience. Are they busy? Curious?

3. Write as you speak.

4. Revise after a period of time. Like a month.

Another of Jon’s lessons was use punctuation sparingly. An editor told him, “Using an exclamation mark is like laughing at your own joke.”

 

Rent-Seeking Experts

Seth Roberts18 Comments

Two thought-provoking paragraphs from Matt Ridley:

From ancient Egypt to modern North Korea, always and everywhere, economic planning and control have caused stagnation; from ancient Phoenicia to modern Vietnam, economic liberation has caused prosperity. In the 1960s, Sir John Cowperthwaite, the financial secretary of Hong Kong, refused all instruction from his LSE-schooled masters in London to plan, regulate and manage the economy of his poor and refugee-overwhelmed island. Set merchants free to do what merchants can, was his philosophy. Today Hong Kong has higher per capita income than Britain.

In July 1948 Ludwig Erhard, director of West Germany’s economic council, abolished food rationing and ended all price controls on his own initiative. General Lucius Clay, military governor of the US zone, called him and said: “My advisers tell me what you have done is a terrible mistake. What do you say to that?” Erhard replied: “Herr General, pay no attention to them! My advisers tell me the same thing.” The German economic miracle was born that day; Britain kept rationing for six more years.

This is standard libertarianism. I like the stories but I don’t agree with the interpretation. I don’t think it is “economic planning and control” that causes stagnation in these examples. I believe it is expertise — more precisely, rent-seeking experts who know too little and extract too much rent. There are libertarian experts, too. They too are capable of doing immense damage (e.g., Alan Greenspan), contradicting Ridley’s view that “economic liberation” always causes prosperity. In both of Ridley’s examples, the experts give advice that empowers the experts. In the first example, Cowperthwaite is told by “LSE-schooled” economists to “plan, regulate and manage the economy.” All that planning, regulation and management require expertise, in particular expertise similar to that of the experts who advised it. Which you cannot buy — you have to rent it. You must pay the experts year after year after year to plan, regulate, and manage. Because the advice must empower the experts, there is a strong bias away from truth. That is the fundamental problem.

Freud is the classic rent-seeking expert. You are sick because of X, Y, and Z — and if you pay me for my time week after week, I will cure you, said Freud. Curiously no treatment that did not involve paying people like Freud would work. Curiously psychoanalytic patients never got better. Therapy lasted forever. You might think this is transparently ridiculous, but professors at esteemed universities such as Berkeley still take Freud seriously. Millions of people pay for psychotherapy. The latest psychotherapeutic fad is cognitive-behavioral therapy — which again requires paying experts to get better, week after week. Berkeley professors take that seriously, too.

Evidence-based medicine advocates are among the newest rent-seeking experts. Like Freud, they focus on process (you must follow a certain process) rather than results. (What they call process in other contexts is called ritual. Rituals always empower experts.) Rather than trying to learn from all the evidence — which might seem like a good idea, and a simple one — evidence-based medicine advocates preach that only a tiny fraction of the evidence (which you need a Cochrane expert to select and analyze) can actually tell us anything. Again, this might seem transparently ridiculous, but many people take it seriously. Evidence-based medicine has an amusing twist which is that its advocates tell the rest of us how stupid we are (for example, “correlation does not equal causation”).

The workhorses of the rent-seeking expert ecology — the ones that extract the most rent — are doctors. They are incapable of giving inexpensive advice. However they propose to help you, it always involves expensive treatment. This might seem like a recipe for crummy solutions, but again many people take a doctor’s advice seriously (by failing to do their own research). My introduction to the world of rent-seeking solutions was the dermatologist who told me I should take antibiotics for my acne. I was to take the antibiotics week after week — and because I was taking a dangerous drug, I should also see my doctor regularly. During these regular visits, the doctor never figured out that the antibiotic did nothing to cure my acne. I learned that by self-experimentation.

Like anthropologists who fail to notice their own weird beliefs (a recently-deceased Berkeley professor of anthropology took Freud seriously, for example), the profession that came up with the rent-seeking concept has failed to notice that many of them do exactly that.

One clue that you are dealing with a rent-seeking expert is that they literally ask for something like rent. Religious experts tell you to attend church week after week. Psychotherapists want you to attend therapy week after week. Psychiatrists tell you to take an anti-depressant daily for the rest of your life. My dermatologist told me to take an antibiotic daily (and to renew the prescription I needed to see him). And so on. As these examples suggest, rent-seeking experts thrive in areas of knowledge where our understanding is poor. Which includes economics.

“Rent-seeking experts” in education.

More What I call “standard libertarianism” Tyler Cowen calls “crude libertarianism”. Maybe I should have called it “off-the-shelf libertarianism”. In addition to what Tyler says, which I agree with, I would say that governments and their “central planners” have sponsored innovation (e.g., the Internet, the greenback, basic scientific discoveries) much better than Ridley seems to give them credit for. Innovation is a huge part of economic development.

Assorted Links

Seth Roberts9 Comments

Thanks to Dave Lull.

Success on the Shangri-La Diet

Seth Roberts7 Comments

Over at Mark’s Daily Apple forum, someone named heatseeker posted this:

I hesitated to post a thread about this because I feel like these forums have been overrun with “fad” diets and hacks lately–and because it’s honestly so bizarre-sounding that I feel a little silly admitting it–but my success on the Shangri-La Diet has been such that I felt I should share. I’ve had serious body fat setpoint issues since, oh, college, I guess–six years–and after watching my setpoint slowly creep up throughout my 20s with absolutely NOTHING making any difference, I’m finally losing weight steadily. I’ve lost 13lb and it’s still coming off like clockwork. Nothing else in my diet or exercise regimes changed, and I’ve experienced no strength losses (I’ve continued to make gains, actually).

I use refined coconut oil, 2tbsp/day. I was using unrefined at first but the flavor was too strong.

Has anyone else done the SLD, and had success? I just felt like I should spread the word, because I know there are some other setpoint-challenged people on these forums, and this has been a big breakthrough for me.

“I haven’t heard about it,” responded zoebird. Then someone posted several links.