Category: health care

Does Blood Pressure Medicine Always Work?

Seth Roberts3 Comments

Apparently not:

I was a very naughty patient and, after taking Atacand for 135/75 blood pressure (benign essential hypertension was the description) for a number of years on my doctor’s prescription, decided to do a little experiment. That is, I cut back on it gradually, monitoring my BP every day. No change.

 

I eventually got to no Atacand at all and have been there for the past four years, during which time the BP has remained the same as when taking the drug. Now, whether the BP is going to kill me is perhaps a separate question (I seem to be in excellent health at 65) but the Atacand doesn’t appear to have made much difference at all — except for the $600/year it cost me, even after insurance had picked up on some of the expense.

I began to grasp how helpful self-experimentation could be when I discovered that tetracycline, an antibiotic that my dermatologist had prescribed, did not reduce my acne. When I told my dermatologist about the research that revealed this, he said, “Why did you do that?”

Had this person’s doctor told him that Atacand might not work? Clearly not. Did the doctor even know that Atacand might not work? Apparently not, since there was no doctor-guided attempt to find out. Perhaps the doctor who prescribed Atacand would defend himself by saying, lamely, that all he knew is what the drug company told him. I wonder what the drug company knew.

How much money could be saved by stopping the prescription of drugs that turn out not to work? Should all drugs come with a label that says the fraction of patients for whom this drug doesn’t work? It is a warning that is truly needed.

Thanks to Rajiv Mehta.

The Great Stagnation (Part 1)

Seth Roberts16 Comments

Tyler Cowen has written a short Kindle book called The Great Stagnation. I have a lot to say about it. This post is about the context, how it fits into a bigger picture. In a later post I’ll discuss its ideas.

At the end of The Economy of Cities (her favorite among her books), Jane Jacobs said if a flying saucer came to Earth she’d want to know how they avoided stagnation. The main battle in any society, said Jacobs, is not between rich and poor or owners and labor but between those who benefit from the status quo and those who benefit from new ways of doing things. The status quo usually wins, no surprise. And the status quo tends to become more powerful over time, which is why Jacobs didn’t know if profound stagnation could be avoided as a kind of terminal state. When she wrote The Economy of Cities (published 1969), she saw stagnation mounting in the American economy — in transportation, for example. By stagnation she didn’t mean lack of growth; she meant lack of useful innovation, causing problems to stack up unsolved. If you keep doing the same things, but more intensely, you will grow in conventional economic terms (e.g., GDP) but you aren’t solving your problems. Doing more of the wrong thing (e.g., treating all diseases with pills) counts as growth but such growth makes things worse, not better, because bad ways of doing things become more entrenched.

Most people see Jacobs as someone who wrote about cities. She saw herself as someone with new ideas about economic development — especially innovation. Cities are important above all because city people are more innovative than rural people. Tractors, for example, grew out of city inventions (the internal combustion engine, etc.). The same person (same IQ, same wealth) will be more innovative in a city than outside of one.

Stagnation is a major problem at all levels of the economy. A few years ago, a friend of mine who worked at the Chicago Tribune said it was clear newspapers were in trouble long before craigslist. As early as the 1980s, he said, there were bad signs. They were ignored. The people in charge kept doing the same things. Had they started trying new things at the first signs of trouble, they might have found a way out. But they were complacent. By the time they stopped being complacent, it was (apparently) too late. Gone (1999) by Renata Adler, a great book, is about the disastrous consequences of stagnation at The New Yorker. The Innovator’s Dilemma by Clayton Christensen is about stagnation at industry-leading companies, such as DEC, GM, and Microsoft. Failure to innovate enough was what Christensen found when he tried to understand why industry-leading companies frequently lost their lead. Not only do these companies lose their lead, they often go out of business.

How to avoid or recover from stagnation, Jacobs was saying, is the central question of economic life, with no clear answer. Yet it is roundly ignored. In the Berkeley Public Library a few years ago, I picked up an introductory economics textbook for junior colleges, 700 pages long. It had one page — fact-free, poorly-written — about where new goods and services come from. This is typical of the introductory economics textbooks I’ve seen. It reflects the profession as a whole: I estimate about 1% of mainstream economic research is about innovation. It should be half the field.

To study innovation is to study what controls it, what makes the rate of innovation go up or down. Thorstein Veblen (not a mainstream economist) wrote one essay and two books about it. Adam Smith wrote nothing interesting about it, as far as I know, nor did Keynes. I remember nothing interesting about it in The Worldly Philosophers by Heilbroner, including the chapters on Schumpeter and Veblen. There have been no Nobel Prizes about it. (Among the Economics prize-winners, Robert Fogle has done the best work about it, whereas Samuelson’s textbook is a monument to lack of understanding of innovation and its importance.) Ed Glaeser’s new book The Triumph of the City emphasizes that cities boost innovation but Jacobs said this 40 years ago. Because cities tend to grow (increasing innovation as they grow), why do whole societies stagnate? Apparently a countervailing force overcomes the innovative power of cities. I have never heard an economist make this point nor say what the countervailing force might be.

In Collapse, Jared Diamond showed how whole societies collapsed (ran out of food and disappeared) when they failed to innovate enough. Instead of blaming lack of innovation, Diamond blames overfishing, overhunting, soil problems, and so on. His list of “different” causes of collapse is like a list of “different” kinds of paranoia: persecution by the FBI, persecution by the CIA, persecution by the police, and so on. If a society does the same thing over and over, at increasing intensity, eventually it will collapse. The collapse may have many proximate causes.

Tyler does not assume that all growth is good. Perhaps influenced by Robin Hanson, he points out that vast health care spending has done little for American health. Much poorer countries get the same results. When you spend four times as much but get the same results, it implies stagnation. Presumably the 20% we share with poor counties is spent on the oldest stuff. If so, the most recent 80% of growth was worthless and a great deal of it has been a kind of churning, useless research passed off as useful. It entered the health care system, people paid for it, but it didn’t help them. It is entirely possible that some of the expensive health care found in America but not poor countries is beneficial and some of it is harmful.

Tyler sees the forest — a society-wide failure to solve important problems. The tremendous accomplishment of his book is to bring the puzzle of stagnation to mainstream economic attention (“the most talked-about economics book of the year so far” according to this review). I am too far from economics to guess what influence it will have on research, but if mainstream economics becomes even 2% about innovation and stagnation (= lack of useful innovation), that will be great intellectual progress.

Assorted Links

Seth Roberts3 Comments

Growth of Quantified Self

Seth Roberts6 Comments

The first Quantified Self (QS) Meetup group met in Kevin Kelly’s house near San Francisco in 2008. I was there; so was Tim Ferriss. Now there are 19 QS groups, as distant as Sydney and Cape Town.

I believe this is the beginning of a movement that will greatly improve human health. I think QS participants will discover, as I did, that simple experiments can shed light on how to be healthy — experiments that mainstream researchers are unwilling or unable to do. Echoing Jane Jacobs, I’ve said farmers didn’t invent tractors. That’s not what farmers do, nor could they do it. Likewise, mainstream health researchers, such as medical school professors, are unable to greatly improve their research methods. That’s not what they do, nor could they do it. They have certain methodological skills; they apply them over and over. To understand the limitations of those methods would require a broad understanding of science that few health researchers seem to have. (For example, many health researchers dismiss correlations because “correlation does not equal causation.” In fact, correlations have been extremely important clues to causality.) Big improvements in health research will never come from people who make their living doing health research, just as big improvements in farming have never come from farmers. That’s where QS comes in.

The first QS conference is May 28-29. Tickets are still available.

Thinking Like a Doctor

Seth Roberts11 Comments

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

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

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

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

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

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

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

Dissent Over DSM-5

Seth Roberts3 Comments

I liked this article by Gary Greenberg about one psychiatrist’s criticism of the upcoming DSM (Diagnostic and Statistical Manual) revision. The DSM is the diagnostic manual of the American Psychiatric Association.

This paragraph stood out for me:

This new disease reminded Frances of one of his keenest regrets about the DSM-IV: its role, as he perceives it, in the epidemic of bipolar diagnoses in children over the past decade. Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold. Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes. In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose money he’d received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times reported that Biederman told the company his proposed trial of Risperdal in young children “will support the safety and effectiveness of risperidone in this age group.”) Frances believes this bipolar “fad” would not have occurred had the DSM-IV committee not rejected a move to limit the diagnosis to adults.

Emphasis added. Hundreds of thousands of children given brain-damaging drugs because . . . well, one big reason is that Harvard allows its faculty to do what Biederman did. Forced to choose between Harvard and drug company money, Biederman would choose Harvard. I am glad Professor Ross Anderson, a Cambridge computer science professor, turned down an industry request to censor a student, but I am sorry he said the person making the request had “a deep misconception of what universities are and how we work.”

American Psychiatric Association incompetence.

Via The Browser.

Which Should You Trust: Scientific Literature or Anecdote?

Seth Roberts16 Comments

In a comment on a BMJ paper critical of alternative medicine (the author submitted a fictional abstract to a conference then criticized the program committee for not rejecting it), a retired chemist named Joe Magrath said:

The scientific literature tells us that acupuncture, cupping and reflexology are all nonsense.

I haven’t looked into it but I’ll take his word for it.

Around the time Magrath said that, James Fallows said this:

During our years in Malaysia in the 1980s, and more recently in China, my wife and I became unlikely converts to a lot of Asian medical practices. I had serious back pain cured by an acupuncturist (who used needles the size of aluminum baseball bats) in Kuala Lumpur. In her book, my wife describes how the gruesome-seeming therapy of fire-cupping, applied in an all-night massage parlor in the city of Yueyang, snapped her out of a serious bout of the flu. Sure, she had big red welts on her back for the next ten days, but her fever was gone!

Which do you believe?

Dr. Charles Nemeroff “Writes” A Textbook

Seth Roberts2 Comments

The stench was too great. I learned from this article that Charles “Disgraced” Nemeroff, once one of the most respected psychiatry professors in America, has moved from Emory University (where he badly deceived university officials) to the University of Miami. The article tells of more Nemeroff dishonesty: He put his name on a textbook he didn’t write. This letter shows how the book was written. The words in the book came from a company named Scientific Therapeutics Information, whose fee was paid by GlaxoSmithKline. Scientific Therapeutics won’t answer questions about what it did. Nemeroff says he and his co-author “conceptualized this book, wrote the original outline and worked on all of the content.” Worked on, huh? Leslie Iversen, an Oxford professor of pharmacology, may have “worked on” the passages he plagiarized (a few words were changed) harder than Nemeroff and his co-author “worked on” their book. The New York Times added a correction to the article worthy of Wittgenstein: “While documents show that SmithKline (now known as GlaxoSmithKline) hired a writing company for the book, they do not indicate that the [writing] company wrote the book.”

In twenty years perhaps Nemeroff will forget that he “wrote” this book, just as the first President Bush forgot about a book he “wrote”.

Thanks to Alex Chernavsky.