Lame Response of the AMA to HealthTap

Seth Roberts3 Comments

Many years ago, when I was a professor at Berkeley, I sought out David Freedman, a professor of statistics, for comment on an idea of mine. I knew he would dislike it — he was negative about everything — and I wondered how strong his reasons for disliking it would be. It turned out, as I expected, that he disliked it but — I was glad to see — had no convincing reasons. That was helpful, I thought.

Likewise, it is obvious that the AMA would dislike HealthTap, a website that solicits doctors’ answers to medical questions (along the lines of “I have X symptoms. What should I do?”). Here’s the AMA response:

Dr. Peter W. Carmel, president of the American Medical Association, says he is concerned about the use of online medical information, which should “complement, not replace, the communication between a patient and their physician,” he wrote in an e-mail. With online health information sites, “a medical history is not taken, a physical exam does not occur and any suggested treatment is not monitored or assessed,” he said. “Using this information in isolation could pose a threat to patients.”

These comments could have been made by someone with no medical training. Practically everything has a hypothetical downside (“could pose a threat”). Since he fails to call into question the obvious upside (patients will get questions answered much faster and cheaper), he is practically endorsing it.

Stephen McIntyre on Gleickgate

Seth Roberts3 Comments

Gleick might as well have signed the fake document. Mosher identified him as the author almost instantly. The fake memo, unlike the actual documents, put Gleick in a position of prominence in the climate debate, whereas, in his actual encounters with skeptic blogs, Gleick has come across as an erratic and even comic figure. The style parallels came afterwards.

From here. I sat next to Peter Gleick at a friend’s dinner party about five years ago. He seemed to me staggeringly accomplished, not erratic (or comic) at all. Yet recently I too found him to be comic. Remember that famous New Yorker cartoon — “On the Internet, no one knows I’m a dog”? The bitter truth is “On the Internet, no one knows I’m a nice person.” I don’t mean Gleick is not a nice person — if anyone is a jerk it is me for what I just quoted — I mean that his recent actions strike me as weirdly uninhibited.

Assorted Links

Seth Roberts4 Comments

Thanks to Peter Spero and Allan Jackson.

Excellent Customer Service From Fidelity Investments

Seth Roberts6 Comments

Because I am in China, I want my new credit card sent here. After 45 minutes arranging this, my credit-card company asked me one last security question: What were the last four digits of the bank account used to pay my most recent bill? I told them. They said my answer was wrong. Huh?

I pay my credit card bills through Fidelity Investments (which is not a bank). I contacted them. I was routed to their BillPay department. The person who helped me, whose name I wish I had written down, said that he was as puzzled as I was. It was not clear at all why my answer was wrong. He suggested a conference call. He started a conference call with my credit-card company. Within a few minutes, he and the credit-card company representative figured out that there was a mistake in the number listed by the credit-card company. Their software had lost the last digit of my account number, so that if my account number had ended in 12345, their records would have showed 1234. (Yet the payment still went through.)

I was greatly relieved. “At least the problem had a solution!” I told the credit-card-company representative. Imagine not being able to control one’s money because of a software error. I was/am grateful to the Fidelity representative for quickly solving a problem that had nothing to do with Fidelity.

You might think that such heavily-used software would by now be free of bugs. But it wasn’t.

Vitamin D3 in Morning (1000 IU) Improves Rosacea (Story 19)

Seth Roberts2 Comments

A reader named Bob H left the following comment:

I’m on 1000 [IU] a day D3 in the morning. I have not noticed any difference in sleep, but my rosacea has cleared up considerably.

Rosacea is not usually believed to be due to Vitamin D3 deficiency. For example, Wikipedia lists many causes, but not that. Here is another list of causes that does not include Vitamin D3 deficiency. The Vitamin D Council says Vitamin D “cannot be used to prevent or treat rosacea” (but without supporting evidence). On the other hand, when people with rosacea consider the question, they find evidence that D3 helps rosacea. If you have rosacea and have tried D3, please comment or email me about what happened.

I asked Bob H for details.

Tell me about yourself.

47 year old, white, IT worker, 230 lbs, runner, beer drinker, Maryland, but I lived in the Netherlands from Jun-2008-Jul-2011.

When did you start taking 1000 IU/day D3 in the morning? Were you taking D3 before this?

I started taking it about 6-8 weeks ago, in the morning, about 9:00 am 1000 IU – my first time for D3.

Please describe your rosacea before you started 1000/day D3 in the morning. please describe your rosacea now.

I’ve had consistent rosacea for years on my chest. It has not gone away completely, but it’s much better.

Please describe your sleep.

My sleep was good before I started taking D3, and is still good.

Most of the success stories about Vitamin D3 in the morning have involved 4000 IU/day or more. Why did you decide to try 1000 IU/day?

I wanted to start out at a lower dose and build up.

What brand and form of D3 do you take?

1000 IU NatureMade gel.

Vitamin D3 in Morning Makes Waking Up Easier (Story 18)

Seth Roberts13 Comments

David Cramer left the following comment here:

Since you started posting these, I’ve been taking D3 in the mornings and notice that I wake up much more easily. I started with just 400 IU, then increased it to 800 IU. One day I took 1200 IU and woke up at 4:00 AM the next day. I’ve gone back to 800 IU since 4:00 AM seems a bit early. For the past week, I’ve also been giving one of my daughters (11 years old) 400 IU each morning, and she seems easier to wake up in the morning (normally it’s quite difficult.

I asked him for details.

Tell me about yourself.

I’m in my 40s and live in Austin, Texas and have two daughters. I first encountered your work when I read about the SLD in Levitt and Dubner’s blog. I read the pdf of your papers linked from that blog post and tried the SLD with sugar water. At the time, I was at the high end of my ideal weight, but was not motivated by weight as much as curiosity. I found the irony and absurdity of the SLD appealing. I also liked the idea that it could be tested easily and cheaply. I went from ~170 to ~145 lb in couple of months, but really only did SLD for ~3 weeks. I now occasionally have a nose clipped green smoothie in the morning.

How long have you been taking D3 in the morning? What time do you take it?

I started a couple of weeks ago after you started blogging about it. I take it around 7:00 AM. That would normally be about an hours after I wake up.

The most obvious change since you started taking it is that you wake up more easily? How soon did this start after you started the D3?

Yes, that’s the change I notice. It may be improving my sleep quality, but that’s very subjective and not something I track closely anyway. The effect started almost immediately.

Could you describe (a) how easy it was to wake up in the month before you started the D3 and (b) how easy it was to wake up after you started the D3?

I would often set three alarms on my cell phone and return to bed formore sleep after dismissing the first two. After D3, I usually wake up before my alarm and don’t feel the need to go back to sleep (e.g. after going to the bathroom). Post-D3, when I wake up, I’m awake. Previously, I was still very drowsy for some time, even after getting up.

What time do you usually wake up? get out of bed? do you use an alarm clock to wake yourself in the morning?

Usually 6 or 6:30. Occasionally a little earlier if I have an early meeting at work.

Did D3 have any effect on how easily you fall asleep in the evening? On how often you wake up in the middle of the night?

I haven’t noticed any difference in falling asleep. I don’t typically wake up in the middle of the night.

How much sunlight do you get on a typical morning?

Although I live in Texas, I doubt I get much in the morning this time of year. I do bike to work a couple of times a week, but my arms and legs would be covered. I might even wear gloves if it’s cold. I work inside in an office during the day.

What brand of D3 do you use? what form (e.g., gelcap)?

NOW gelcaps.

How can you tell your daughter “seems to find it easier to wake up in the morning”?

She’s a sound sleeper. Normally it requires repeated reminders and threats to get her up. Even after you get her out of bed, she’ll fall back asleep on the couch. With 400 IU, I’m noticing less of that. I plan to up to 800 IU this week to see if there’s a difference.

Hot Miso with Cream and Sweetener: Coffee/Tea Substitute

Seth Roberts12 Comments

A few weeks ago, I wondered if I drink too much tea. Is 4 cups/day too much? What about 2 cups/day? To learn more, I needed to drink a lot less tea.

What about miso? I wondered. I had some high-quality miso paste in my refrigerator. I got it in Tokyo at a miso store (thanks to Gary Rymar for taking me there). I made a cup (about 25 g miso paste — 2-3 teaspoons? — mixed with 1 cup hot water). It was delicious. The complex taste reminded me of coffee and chocolate. I added a little cream and a half packet of sweetener (Sucralose). It tasted even better.

I did the same thing with miso from Berkeley. It was still very good.

I cannot imagine not drinking tea. But I can now imagine drinking less tea because miso is much healthier. Replacing tea with miso is an easy way to eat more fermented food. A cup of miso is easier to make than a cup of tea.

Incidentally, don’t waste your time with powdered miso. It is much worse than the refrigerated miso (paste) sold in tubs.

“We’re Economists. And We Don’t Care About Innovation”

Seth Roberts21 Comments

In a Planet Money show about whether Super Bowls help host cities, a sports economist named Victor Matheson, a professor at College of the Holy Cross, described himself and other sports economists:

We’re economists. And we’re concerned about equity and we’re concerned about efficiency. And what most economists see . . . “

He didn’t say “We’re concerned about innovation”. The way he ignores innovation reflects the whole field of economics. Here’s the same thing from Christine Romer. In an editorial about whether manufacturing deserves special treatment, she considers only productivity and equity:

It might be better to enact policies that will make all American businesses and workers more productive and successful. . . Today, we face a profound shortfall of demand. . . .We need actions that raise overall demand. [She doesn’t say we are in a period of profound stagnation in most industries, which is also true.] . . . More aggressive monetary policy that lowered the price of the dollar would stimulate all our exports . . . Moving is very costly for dislocated workers with ties to their communities. . . Manufacturing jobs are seen as one of the few sources of well-paying jobs for less-educated workers. . . . Public policy . . . should be based on hard evidence of market failures, and reliable data on the proposals’ impact on jobs and income inequality.

As if innovation (and lack of it) don’t exist. Here’s an example from Robert Reich, in a post “rebut[ing] the seven biggest economic lies”:

Shrinking government generates more jobs. Wrong again. It means fewer government workers – everyone from teachers, fire fighters, police officers, and social workers at the state and local levels to safety inspectors and military personnel at the federal. And fewer government contractors, who would employ fewer private-sector workers. According to Moody’s economist Mark Zandi (a campaign advisor to John McCain), the $61 billion in spending cuts proposed by the House GOP will cost the economy 700,000 jobs this year and next.

Nothing about the effect of shrinking government on innovation. Many types of innovation increase jobs.

This is like doctors ignoring the immune system. Ignoring the effect of this or that policy on innovation is likely to lead to decisions that reduce innovation in favor of something easier to measure or defend, such as productivity or equity. The cumulative effect of ignoring innovation is stagnation and decline, caused by problems that got worse and worse as, due to lack of innovation, they failed to be solved.

Tyler Cowen (The Great Stagnation) and Alex Tabarrok (Launching the Innovation Renaissance) are absolutely right to focus on innovation and the lack of it. The obesity epidemic is 30 years old — a good example of a problem that has gotten worse and worse. Judging by Tara Parker-Pope’s reporting, mainstream weight researchers don’t have a clue — in the form of empirical results — how to solve it. Outside mainstream academia, the dominant weight-loss idea is a low-carb diet. That idea is a hundred years old (Banting). How little innovation there has been. That Parker-Pope failed to criticize researchers for their lack of progress shows how deep the problem is. She appears not to grasp the possibility.

One Doctor’s View of Personal Science (more)

Seth Roberts17 Comments

A few weeks ago I blogged about a leukemia doctor’s disapproval of self-experimentation (“you won’t learn anything and others won’t learn from it, either”). What I wrote was reposted at The Health Care Blog, where it elicited this comment (by “rbar”):

Sigh. Mr Roberts did it again, he simply does not (want to) understand that anecdotal evidence is of little value (let me give you an example: I self experiment with traffic signals; I noted that I can considerable cut down on travel times when ignoring red lights and stop signs; there are no drawbacks whatsoever, no one get hurts, and even my gas mileage/carbon footprint got better) .

Individuals who have similar questions as Mr. Roberts should look up the following key words, because they may understand why controlled studies are far superior to anecdotal evidence:
-placebo effect
-regression to the mean
-misattribution error [apparently rbar means error in determining the cause of a change]-self limited conditions/natural fluctuation of chronic conditions
-and in terms of drawbacks of experimentation: primum non nocere, and also the fact that anecdotal evidence adds relatively little to humanity’s knowledge base

Does all that mean that patients should not be well informed, active and making suggestions to their treating physicians? Of course absolutely not. Being knowledgeable about one’s condition is different from self experimentation. Is that intellectually challenging?

One reply to this comment said we should be aggregating data across patients. “I believe Mr. Roberts is alluding to the power of aggregating real-world data across patients to generate insights into what may and may not work, not to giving undue weight to any single anecdotal case.” No, I was looking at it from the point of view of the self-experimenting patient. If you have a health problem, and you can measure it often (daily, weekly) you can find out what works faster than your doctor — often much faster. You can test many more possible solutions. This is what Richard Bernstein taught the whole world of diabetes, starting in the 1960s, when he pioneered home blood glucose testing. Apparently rbar also objects to that.

Rbar’s comment is dismissive (“Sigh”, “Is that intellectually challenging?”) and partly obscure (“ignoring stop signs and stoplights” — huh?). Because patients who self-experiment may make “misattribution errors” they shouldn’t self-experiment? That’s like saying because people may make reasoning errors they shouldn’t reason.

The true meaning of rbar’s comment may be hidden in his statement that it’s okay for patients to “make suggestions to their treating physician.” Which shows who he thinks should be boss in the doctor-patient relationship. When a patient self-experiments, the doctor is no longer boss. Maybe rbar is a doctor. Maybe he feels threatened by self-experimentation. If so, I hope he’s right.

More A later reply to rbar put it well: ” Your list of possible pitfalls . . . is similar to lists I remember seeing back in graduate school in various research handbooks. I do not see how you go from the fact that these effects and errors are possible to the conclusion that the whole endeavor isn’t worthwhile.”

 

 

Father Versus Surgeons and New York Presbyterian Hospital

Seth Roberts3 Comments

I decided to read this book review because of a brief description (“A father describes, and rages at, the loss of his teenage son.) in an email. Then I found this:

Weber’s story becomes more spirited and urgent when Damon’s health begins to fail more seriously, and his father is forced to locate his true enemy: the received wisdom and arrogance of the American medical establishment.

Weber père . . . admits he doesn’t trust “any single voice on Damon’s illness.” And he’s wise not to, as he discovers in short order that health care for his son is first and foremost a business, and that surgeons frequently talk out of their hats.

Heart transplants represent big money for hospitals: at half a million dollars each, 20 pediatric transplant operations a year make a significant contribution to the finances of New York-Presbyterian ­Hospital/Columbia University Medical Center, where Damon’s surgery is eventually performed. Hospitals compete to attract patients (every transplant center Weber speaks with wants to perform his son’s operation) and stringently guard their surgical outcome data, as Weber discovers when he tries to find out if the blithe assurances of the Columbia transplant team are scientifically valid. He quickly realizes “each hospital is a fiefdom.”

Worse still, the medical barons who run the fiefs care as much [i.e., as little] for protocol as they do for patients. Over Christmas of 2004, Damon is casually “listed” as a potential heart recipient — meaning he has to be ready to receive a new heart at a moment’s notice — without his father’s knowledge. His doctors then disappear for a week and more.

Before Weber can truly blow his stack, he discovers Damon’s doctors have also misclassified his son’s transplant status as less urgent than it is. Dad bulls [sic] them into fixing the problem, and 11 days later, a heart is found for Damon. The transplant in turn initiates a tragic cascade of doctor errors so egregious that Weber eventually sues both the medical director of pediatric heart transplants at New York-Presbyterian Columbia hospital and the hospital itself for malpractice. (Three years into the lawsuit, the medical director claimed Damon’s post-op records couldn’t be located.) All this happens at one of the country’s best heart transplant centers.

“Passively relying on the medical establishment and trusting them to manage my son’s care in his best interest is not . . . a luxury I have allowed myself,” Weber writes, with good reason.

Maybe I should start a series called “The Culture of Surgeons”. Entry 1: Eileen Consorti, a Berkeley surgeon who told me I should have surgery for a hernia I could not detect. Entry 2: Martin Burton, an Oxford ear nose and throat surgeon whose Cochran Review about the pros and cons of tonsillectomy failed to consider that tonsils are part of the immune system.