A friend sent me some photos taken on a mountain hike. They seemed to derive from the following rules:
1. Carry a small camera in a big bag.
2. Always take a picture of a flower.
3. Change clothes from one picture to the next. (For example, wear pants in one picture and shorts in another picture, or a blue shirt in one picture and a white shirt in another picture.)
4. Make a funny face (for example, press finger into cheek).
5. Wear a funny shirt.
Thanks to Rashad Mahmood.
The gist of Unaccountable: What Hospitals Won’t Tell You — and How Transparency Can Revolutionize Health Care (copy sent me by publisher) by Mart Makary, a med school professor at Johns Hopkins, is that doctors have failed to regulate themselves. Nobody else regulates them, so they are unaccountable. In many ways, Makary shows, bad behavior (e.g., unnecessary treatment, understating the risks of treatment) is common. Hospitals hide how bad things are. Makary mostly discusses surgeons — he’s a surgeon — but gives plenty of reasons to think other specialties are no better.
The book is one horror story after another. At one point, Makary quit medical school. He was disgusted and appalled by seeing doctors — his teachers — push an old woman to consent to an operation she didn’t want and didn’t need. She refused, again and again, but the doctors kept pushing. Makary objected. He was ignored. Finally she agreed. The operation killed her.
I know Peter Attia as a co-founder, with Gary Taubes, of the recently formed Nutritional Science Initiative. Makary met him when Attia did a surgery residency at John Hopkins Hospital. Attia had seen a doctor about back pain and had been told he needed surgery. They operated on the wrong side, causing damage that prevents Attia, an excellent athlete, from playing most sports. Eventually Attia left medicine. He felt “modern medicine was too frequently dishonest with patients, at times understating risks and overtreating patients as a matter of reflex” — “as a matter of reflex” meaning “as a matter of course”, i.e., usually. And Johns Hopkins Hospital is one of the better hospitals in America. “Almost everyone I talk to has a story about a friend or a family member who was hurt, disfigured, or killed by a medical mistake,” writes Makary. He has six such stories, including his grandfather and his brother. His grandfather died from unnecessary surgery.
The “when-you’re-a-hammer problem” says Makary, “plagues modern medicine at every level.” He witnessed a case conference where a young otherwise-healthy patient had a small liver tumor. “The transplant surgeons [more than one] in the audience recommended a liver transplant. I was flabbergasted. Why on earth would any doctor recommend a transplant?” Makary asked around. He discovered there was nothing unusual about the transplant surgeons in the audience. He called a friend who was one of the few surgeons trained in both cancer treatment and transplants. His friend said “there was a battle for turf taking place nationwide between transplant surgeons and cancer surgeons. Both claim to be liver experts.”
Makary tells about trying to obtain informed consent for a surgery when he was an intern. He didn’t know much about the surgery. The patient didn’t agree. “It was well-known among interns that if an attending senior surgeon found out that a patient refused surgery close to surgery date, duck for cover. Mine would surely be livid.” Makary spoke to an upper resident. He couldn’t get approval. They went to the chief resident. He got approval. Congratulations all around amongst the doctors, “glad that the wrath of the attending surgeon would be averted.”
Supposedly state medical boards oversee doctors. Makary devotes part of a chapter to describing how they don’t. He asked state medical boards why they don’t search a national database before issuing a medical license. “My favorite excuse was that they could not afford the four-dollar-per-doctor fee.”
In 1978, the Shah of Iran needed an operation. The United States government set him up with a Texan named Michael DeBakey, “considered by many to be the best surgeon in the world.” During the surgery, DeBakey failed to take “a simple standard safety measure.” Due to this failure, the Shah developed a serious complication, became very sick, and died. The Shah and the United States government had failed to realize — and, more important, none of the experts they consulted had told them (I assume) — is that DeBakey was a famous heart surgeon. The Shah’s operation involved his spleen. DeBakey knew little about such operations and had done almost none — but (I assume) didn’t point this out.
A survey done at many hospitals asks employees if they “feel comfortable speaking up when [they] sense a patient safety concern.” At the median hospital, the percentage is about 70%. In the Milgram experiment (where subjects are ordered to give painful shocks), when audiences were asked by Milgram to predict what they would do in that situation almost all said they wouldn’t give the shocks. In fact, most people did give the shocks — indicating that people vastly overestimated their likelihood of resistance and speaking up. So 70% is likely an overestimate. (A study of nurses found that about 95% of them broke safety rules when ordered to do so. Roughly all of them had said they would never do such a thing.) Since talk is cheap, why is the median percentage as low as 70%? No doubt many respondents had seen themselves fail to speak up.
These aren’t the worst stories, these are average, I just opened the book here and there. There are dozens more. No previous book has spelled out so clearly the depth and width of doctor misbehavior, especially how common it is, and the failure of those supposedly responsible, such as hospital administrators and state boards, to do anything about it.
Title from 12 extremely disappointing facts about popular music.
Thanks to Chuck Currie, Grace Liu, Alex Chernavsky and Dave Lull.
Ecologists understand the exploit/explore distinction. When an animal looks for food, it can either exploit (use previous knowledge of where food is) or explore (try to learn more about where food is). With ants, the difference is visible. Trail of ants to a food source: exploit. Solitary wandering ant: explore. With other animals, the difference is more subtle. You might think that when a rat presses a bar for food, that is pure exploitation. However, my colleagues and I found that when expectation of food was lower, there was more variation — more exploration — in how the rat pressed the bar. In a wide range of domains (genetics, business), less expectation of reward leads to more exploration. In business, this is a common observation. For example, yesterday I read an article about the Washington Post that said its leaders failed to explore enough because they had a false sense of security provide by their Kaplan branch. “Thanks to Kaplan, the Post Company felt less pressure to make hard strategic choices—and less pressure to venture in new directions,” wrote Sarah Ellison.
Striking the right balance between exploitation and exploration is crucial. If an animal exploits too much, it will starve when its supply of food runs out. If it explores too much, it will starve right away. Every instance of collapse in Jared Diamond’s Collapse: How Socieities Choose to Fail or Succeed was plausibly due to too much exploitation, too little exploration (which Diamond, even though he is a biologist, fails to say). I’ve posted several times about my discovery that treadmill walking made studying Chinese more pleasant. I believe walking creates a thirst for dry knowledge. My evolutionary explanation is that this pushed prehistoric humans to explore more.
I have never heard an economist make this point: the need for proper balance between exploit and explore. It is relevant in a large fraction of discussions about how to spend money. For example, yesterday I listened to the latest EconTalk podcast, a debate between Bob Frank and Russ Roberts about whether it would be a good idea for the American government to spend $2 trillion on infrastructure projects (fix bridges, etc.). Frank said it would create jobs, and so on — the usual argument. Roberts said if fixing bridges was such a good idea, why hadn’t this choice already been made? Roberts could have said, but didn’t, that massive government shovel-ready expenditures, such as $2 trillion spent on infrastructure repair, inevitably push the exploit/explore balance toward exploit, which is dangerous. This is an argument against all Keynesian stimulus-type spending. I have heard countless arguments about such spending. I have never heard it made. If you want examples of how the American economy suffers from a profound lack of useful new ideas, look at health care. As far as I know, there are no recorded instances of a society dying because of too much exploration. The problem is always too much exploitation. People at the top — with a tiny number of exceptions, such as the Basques — overestimate the stability of their position. At the end of The Economy of Cities, Jane Jacobs says that if a spaceship landed on Earth, she would want to know how their civilization avoided overexploitation. When societies exploit too much and explore too little, said Jacobs, problems (in our society, problems such as obesity, autism, autoimmune disease, etc.) stack up unsolved. Today is China’s birthday. Due to overexploitation, I believe China is in even worse economic shape than America. Ron Unz, whom I respect, misses this.
My broad point is that a lot of economic thinking, especially about growth and development, is one-dimensional (measuring primarily growth of previously existing goods and services — exploitation) when it should be two-dimensional (measuring both (a) growth of existing stuff and (b) creation of new goods and services). Exploration (successful exploration) is inevitably tiny compared to exploitation, but it is crucial there be enough of it. If there is a textbook that makes this point, I haven’t seen it. An example of getting it right is Hugh Sinclair’s excellent new book Confessions of a Microfinance Heretic (copy sent me by publisher) that debunks microcredit. Leaving aside the very high interest rates, the use of microcredit loans to buy TVs, and so on, microcredit is still a bad idea because the money is, at best, used for a business that copies an existing business. (The higher the interest rate, the less risk a loan recipient dares take.) When a new business copies an already-existing business, you are taking an existing pie (e.g., demand for milk, if the loan has been used to buy a cow and sell its milk) and dividing it into one more piece. The pie does not get bigger. As Sinclair says, the notion that dividing existing pies into more pieces will “create a poverty-free world” is, uh, not worthy of a Nobel Prize.
Sure, it’s hard to measure growth of useful knowledge. (It is perfectly possible for a company to waste its entire R&D budget.) However, I am quite sure that realism does better than make-believe — and the notion that growth of GDP is a satisfactory metric of economic growth is make-believe. If you’ve ever been sick, or gone to college, and have a sense of history, you will have noticed the profound stagnation in two unavoidable sectors (health care and education) of our economy. That are growing really fast.
I have just submitted a paper to Statistical Science called “The Growth of Personal Science: Implications For Statistics”. The core of the paper is examples, mostly my work (on flaxseed oil, butter, standing, and so on). There is also a section on the broad lessons of the examples — what can be learned from them in addition to the subject-matter conclusions (e.g., butter makes me faster at arithmetic). The paper grew out of a talk I gave at the Joint Statistical Meetings a few years ago, as part of a session organized by Hadley Wickham, a professor of statistics at Rice University.
I call this stuff personal science (science done to help yourself), a new term, rather than self-experimentation, the old term, partly because a large amount of self-experimentation — until recently, almost all of it — is not personal science but professional science (science done as part of a job). Now and then, professional scientists or doctors or dentists have done their job using themselves as a subject. For example, a dentist tests a new type of anesthetic on himself. That’s self-experimentation but not personal science. Moreover, plenty of personal science is not self-experimentation. An example is a mother reading the scientific literature to decide if her son should get a tonsillectomy. It is personal science, not professional self-experimentation, whose importance has been underestimated.
An old term for personal science might be amateur science. In almost all areas of human endeavor, amateur work doesn’t matter. Cars are invented, designed and built entirely by professionals. Household products are invented, designed and built entirely by professionals. The food I eat comes entirely from professionals. And so on. Adam Smith glorified this (“division of labor” — a better name is division of expertise). There are, however, two exceptions: books and science. I read a substantial number of books not by professional writers and my own personal science has had a huge effect on my life. As a culture, we understand the importance of non-professional book writers. We have yet to grasp the importance of personal scientists.
Professional science is a big enterprise. Billions of dollars in research grants, hundreds of billions of dollars of infrastructure and equipment and libraries, perhaps a few hundred thousand people with full-time jobs, working year after year for hundreds of years. Presumably they are working hard, have been working hard, to expand what we know on countless topics, including sleep, weight control, nutrition, the immune system, and so on. Given all this, the fact that one person (me) could make ten or so discoveries that make a difference (in my life) is astonishing — or, at least, hard to explain. How could an amateur (me — my personal science, e.g., about sleep is outside my professional area of expertise) possibly find something that professional scientists, with their vastly greater resources and knowledge and experience, have missed? One discovery — maybe I was lucky. Two discoveries — maybe I was very very very lucky. Three or more discoveries — how can this possibly be?
Professional scientists have several advantages over personal scientists (funding, knowledge, infrastructure, etc.). On the other hand, personal scientists have several advantages over professional scientists. They have more freedom. A personal scientist can seriously study “crazy” ideas. A professional scientist cannot. Personal scientists also have a laser-sharp focus: They care only about self-improvement. Professional scientists no doubt want to make the world a better place, but they have other goals as well: getting a raise, keeping their job, earning and keeping the respect of their colleagues, winning awards, and so on. Personal scientists also have more time: They can study a problem for as long as it takes. Professional scientists, however, must produce a steady stream of papers. To spend ten years on one paper would be to kiss their career goodbye. The broad interest of my personal science is that my success suggests the advantages of personal science may in some cases outweigh the advantages of professional science. Which most people would considered impossible.
If this sounds interesting, I invite you to read my paper and comment. I am especially interested in suggestions for improvement. There is plenty of time to improve the final product — and no doubt plenty of room for improvement.
Thanks to Anne Weiss and Dave Lull.
It was generous of Sady Doyle, a New York writer in her thirties, to use her real name when writing about her bipolar disorder for Rookie, the website for teenage girls. (“Because of this article, you’ll always be able to Google me and find out that I have this sickness.”) It is what I expect from Rookie to post this sort of thing — I was a big fan of Sassy, an earlier magazine for teenage girls that tried hard to be truthful. But I was surprised to see this:
Here’s the part of the story that matters: once I got the diagnosis, got the pills, and got in touch with a therapist I really liked, I woke up in the morning. And I was happy, genuinely happy, for the first time in a very long time. That’s what matters about my nervous breakdown—or yours, or anyone’s. When I got the help I needed, I was able to recover.
Okay, that’s what happened, as Brave New Worldish as it may sound. But is it true “that’s what matters” — meaning that’s all that matters? No, I don’t think so. I think it also matters (a lot) that Doyle has been told she must take pills (such as lithium) for the rest of her life and those pills usually have bad side effects (lithium causes weight gain, for example). It is seriously misleading for Doyle to fail to make these points. Doyle vaguely implies she has been told she will need to take pills for “a long time”, which is an understatement, and says nothing about side effects. Maybe she omitted this stuff because she didn’t want her readers “to be afraid to seek treatment” (as she might put it). That is the opposite of truth telling.
Here’s something about current treatments for bipolar disorder (a comment left on an article about drug company deception) that is as true now as when I quoted it three days ago:
Thirty years of bipolar disorder taking virtually every possible anti-depressant over time, and at times when hospitalized, forced to take them under the duress of threatened sectioning under the Mental Health Act. Throughout those years I told the psychiatrists that the drugs didn’t work beyond an initial “placebo effect” lasting about 2 weeks, and that the side effects were often awful.
I am not saying bipolar disorder drugs are worthless. I am saying they have bad side effects so often that any description of what it’s like to have bipolar disorder that makes claims of universality (“That’s what matters about my nervous breakdown—or yours, or anyone’s”) should point this out.
One of the main reasons I think we need to eat fermented foods to be healthy is that their flavors correspond neatly to the flavors we like. Fermentation of fruits and other sweet foods changes sugars to acids, making the food taste sour — and we like sour food. Fermentation of proteins produces glutamate, which produces an umami flavor — and we like umami-flavored food. With many foods, their fermentation produces many microbial byproducts, giving the food a complex flavor — and we like complex flavors.
The connection between fermentation and complex flavor is well-put in a Saveur article about fermented foods:
[As a child] I only knew Claussen and other vinegar-cured pickles, the kind you buy in jars off the supermarket shelf, and I liked them just fine. But when I finally tasted a real pickle—the kind made the old-fashioned way, fermented with nothing more than salt, water, and time—I realized what I had been missing. A vinegary pickle plows through your palate with its tartness (often in a most pleasing way), but a live-cultured, salt-cured, fermented one tells a more multifaceted story. It is sour, to be sure, but it tastes of something more, something elusive: It’s the flavor of Middle Europe captured in one bite. When I started cooking for a living, I realized that the complexity I’d tasted in that pickle is the hallmark of well-made fermented foods, which include some of my very favorite things to eat and drink: not just pickles, but aged cheeses, tangy sourdough breads, blistering kimchis, tart yogurts, winy salamis, and of course, wine itself.
The New York Times recently ran a story about a 107-year-old woman named Juliana Koo, who lives in New York City. Her longevity secrets are remarkably close to what I say on this blog:
“Somebody asked her the secret of long life,” said Ying-Ying Yuan, a step-granddaughter of Mrs. Koo. “She said, ‘No exercise, eat as much butter as you like and never look backwards.’”
Shirley Young said her mother also likes pork bellies, “especially the hot part, but she doesn’t overdo anything.”
“And she doesn’t take any medicine,” she said. “When doctors give her medicine, she usually hides it, or when she takes something, she takes half a pill. People keep on giving her Chinese herbs, things like that. She never takes them.”