Category: health care

Jane Jacobs and Traffic

Seth Roberts10 Comments

This excellent post by Alex Tabarrok about the effect of removing traffic lights — traffic improves — reminds me of how I discovered the work of Jane Jacobs. Browsing in the Transportation Library at UC Berkeley, I came across The Economy of Cities.

That order arising from below (from individual drivers and pedestrians) can be much better than order imposed from above (by traffic engineers) was a point Jacobs made often. The details in Alex’s post and the video he embeds don’t just suggest that traffic lights in thousands of places could be profitably removed, they also support more radical thinking:

  • Traffic engineers were completely wrong in all these cases. Trying to improve something, they made it worse. How did we get to a world where this is possible? Surely it isn’t just traffic engineers.
  • What would happen if students were given more power to control their own education? Perhaps we would need far few professors. I gave my students much more control and found (a) my job got easier and (b) my students learned much more.
  • What would happen if all of us were given more power to control our own health, rather than rely on gatekeepers, such as doctors? Perhaps we would need far fewer doctors.

The essence of my self-experimentation is that I took control of my health. Rather than seeing a doctor about my early awakening, or waiting for sleep researchers to find a solution, I found a solution.

Journal of Participatory Medicine

Seth RobertsLeave a comment

The Journal of Participatory Medicine has released two issues (first, second). They help explain what participatory medicine means. The best article I have found among them is called “What It Will Take to Embrace Participatory Medicine: One Patient’s View” by Kate Lorig. Here is one bit:

In one of my regular clinics, I am met with a sign that tells me that if I am a half hour late, my appointment will have to be rescheduled. I once asked what would happen if I were not seen in a half hour and was told to sit down and wait. Last year while waiting for scheduled appointments I read five full-length books (five hours each).

But overall the articles, even this one, are long on generalizations and short on specifics.

“Give Us Our Dammed Data”

Seth Roberts1 Comment

A large painting by Regina Holliday called “Give Us Our Dammed Data” shows 17 book authors, each holding the book they’d written about struggle with the health care system. For example, Lisa Lindell, who wrote 108 Days, which describes

her successful campaign to keep her husband alive. She was astounded when she read her husband’s medical record. The nurse’s notes specified that she had an “unreasonable” belief that her husband should live.

Is It Obvious to Walk to Control Blood Sugar?

Seth Roberts8 Comments

I discovered via self-tracking that I could get my fasting blood sugar much closer to optimal by walking an hour per day. This took me a year to figure out and I discovered it by accident. Phil commented that I could have learned the same thing more quickly by searching websites or asking my doctor.

Whether I was rediscovering the fairly obvious is important to me. This website by Janet Ruhl, who has diabetes, is named “How to get your blood sugar under control”. Its advice says nothing about exercise, much less walking. Here’s one reason why:

I [Ruhl] currently control my own diabetes using a fairly low carbohydrate diet and very low doses of fast acting insulin at meal time. . . . At one point I exercised daily for a year and got my body fat down to 24%, which put me into the “Fitness” category for a woman my age. Despite what my doctors had told me, weight loss and intense fitness didn’t do a thing for my blood sugars, which got worse.

Emphasis added. I too did recommended amounts of aerobic exercise. I too found my blood sugar was nevertheless unpleasantly high. The usual recommendation of aerobic exercise may make it less likely you will do the long low-intensity exercise (ordinary walking) that my results suggest works. You may think: I’ve already exercised. I’m tired.

“Be very paranoid about any new drug.”

Premier of Canadian Province Gets Involved in MS Research

Seth RobertsLeave a comment

How strange:

I n a striking departure from his political counterparts across the country, Saskatchewan Premier Brad Wall says his government will finance clinical trials of liberation therapy, a contentious experimental procedure for multiple sclerosis patients.

Of course, the heads of provinces don’t usually get involved in research at this level of detail. However, “Saskatchewan has the highest rate of MS in the country,” says the article.

In Part 5 of The Story of Science (BBC), Michael Mosley, the presenter, said that for hundreds of years medical students were shown a human liver and told it had three lobes. They were told that because that’s what Galen had said. However, human livers do not have three lobes. As the students could see. Mosely is a doctor. “When I was a medical student,” said Mosley, “there was tremendous pressure to conform.” MS researchers have said for a long time that MS is an autoimmune disease. Could this have been as misleading as Galen’s description of the liver?
Thanks to Anne Weiss.

Fasting Blood Sugar Reduced by Walking (cont.)

Seth Roberts15 Comments

In an earlier post I described how I discovered that walking normalized my fasting blood sugar. In a comment on that post, Phil wrote:

You could also have consulted a doctor, or a diabetes website, and probably found out about the benefits of walking for controlling blood glucose a lot sooner.

My initial reaction was that this was wrong–that a search on the web would find hundreds of suggestions for managing diabetes and walking would be just one of them. Diabetes, after all, is a huge problem. A doctor would probably prescribe something. But what if Phil were right?

What would I find if I looked? I didn’t actually know. So I looked. Under “diabetes”, the Mayo Clinic website has two sections about treatment. Under “ treatment and drugs” are six suggestions, such as “healthy eating”. The suggestion called “physical exercise” recommends aerobic exercise. “Get your doctor’s OK to exercise,” it says. “Aim for at least 30 minutes of aerobic exercise most days of the week,” it continues. My walking was not aerobic. Obviously one does not need a doctor’s approval to walk at a normal pace. In a second section called “ lifestyle and home remedies” were ten suggestions, such as “make a commitment to manage your diabetes”. No mention of walking.

What about the American Diabetes Association website? Their “ Treatment & Care” page says nothing about exercise. It mentions drugs and transplants (e.g., kidney transplants). There’s also a “ Food & Fitness” page. There are dozens of comments about what foods to eat. The “Fitness” section begins like this:

Exercise is part of a healthy lifestyle for everyone, and it’s especially important for people with diabetes. But exercise doesn’t necessarily mean running a marathon or bench-pressing 300 pounds. The goal is to get active and stay active by doing things you enjoy, from gardening to playing tennis to walking with friends. Here are some ideas for getting moving and making exercise part of your daily life.

The fitness section goes on and on about such topics as “What is Exercise?” and “Top 10 Benefits of Being Active”. Surely the ADA hired some hack to write it. It’s useless.

I conclude that if you already know that walking helps you can find evidence to support this. But searching the web will not lead you to try walking any time soon. You will be too busy changing your diet and trying all possible aerobic exercises. (And I did aerobic exercise several times a week and still had too-high blood sugar.) My initial reaction was wrong, it turned out: I found a large number of suggestions and my actual activity (walking 30-60 min/day) wasn’t one of them. No way could I “walk with friends” every day. (I’ve tried and failed miserably.) The next time I see my doctor I will find out what he would have recommended.

Kombucha Eliminated Heartburn

Seth Roberts10 Comments

In a comment on an old post — in which I described how a friend’s acid reflux was greatly alleviated by kombucha — Dave Schulz says he had a similar experience:

My heartburn occurs daily unless a) I stick to a strict diet with no carbs, dairy, or greasy/fatty food, like the Paleo Diet or b) I drink kombucha daily. It’s not always possible to do a), so kombucha has literally been a life saver for me.

Daily kombucha eliminates his heartburn for long periods of time, not just for a few hours after drinking it. Due to the current ban he can no longer get it and his heartburn came back. He got the idea from a friend. Before kombucha, he’d tried many remedies that didn’t work. The three doctors he saw were no help.

On the Mayo Clinic website a doctor says that “until definitive studies quantify the risks and benefits of Kombucha tea, it’s prudent to avoid it.” This is what the Protestant Reformation was about: Speaking directly to God rather than waiting for “definitive studies” by experts that “quantify the risks and benefits”.

The Zamboni MS Procedure in Canada

Seth Roberts11 Comments

Because his wife had multiple sclerosis (MS), the Italian surgeon Paolo Zamboni discovered that a simple surgical procedure helped a large fraction of patients with MS. The Canadian MS society and some Canadian neurologists have not reacted well to this discovery:

In November 2009, an elated Jamie Chalmers went to his neurologist and handed him a stack of print-outs on the new findings. Without so much as a glance, the neurologist tossed the papers in the garbage. He told Chalmers it was nothing but junk science.

In fact, cause and effect are utterly clear:

The vein-opening procedure involves snaking a balloon through the groin up to the neck and then inflating it where the veins are believed to be narrow. It didn’t hurt, says Stock. “I could feel it . . . it was like plugging your nose and blowing.”

Almost immediately afterward, says Stock, he felt a change: his compromised sense of balance had improved. By the time he touched down in Canada [the operation was in India], he was convinced he had done the right thing. Before the procedure, he couldn’t read a full paragraph. Now, he is reading whole chapters again. Before, he couldn’t stand without support for long and was always hunched over his cane. Now, he can stand and walk for as long as an hour.

Doctors have believed that MS is an autoimmune disease. For example, the Mayo Clinic’s website says:

Multiple sclerosis (MS) is a potentially debilitating disease in which your body’s immune system eats away at the protective sheath that covers your nerves.

Thanks to Anne Weiss.

The Problem with Evidence-Based Medicine

Seth Roberts11 Comments

In a recent post I said that med school professors cared about process (doing things a “correct” way) rather than result (doing things in a way that produces the best possible outcomes). Feynman called this sort of thing “ cargo-cult science“. The problem is that there is little reason to think the med-school profs’ “correct” way (evidence-based medicine) works better than the “wrong” way it replaced (reliance on clinical experience) and considerable reason to think it isn’t obvious which way is better.

After I wrote the previous post, I came across an example of the thinking I criticized. On bloggingheads.tv, during a conversation between Peter Lipson (a practicing doctor) and Isis The Scientist (a “physiologist at a major research university” who blogs at ScienceBlogs), Isis said this:

I had an experience a couple days ago with a clinician that was very valuable. He said to me, “In my experience this is the phenomenon that we see after this happens.” And I said, “Really? I never thought of that as a possibility but that totally fits in the scheme of my model.” On the one hand I’ve accepted his experience as evidence. On the other hand I’ve totally written it off as bullshit because there isn’t a p value attached to it.

Isis doesn’t understand that this “ p value” she wants so much comes with a sensitivity filter attached. It is not neutral. To get it you do extensive calculations. The end result (the p value) is more sensitive to some treatment effects than others in the sense that some treatment effects will generate smaller (better) p values than other treatment effects of the same strength, just as our ears are more sensitive to some frequencies than others.

Our ears are most sensitive around the frequency of voices. They do a good job of detecting what we want to detect. What neither Isis nor any other evidence-based-medicine proponent knows is whether the particular filter they endorse is sensitive to the treatment effects that actually exist. It’s entirely possible and even plausible that the filter that they believe in is insensitive to actual treatment effects. They may be listening at the wrong frequency, in other words. The useful information may be at a different frequency.

The usual statistics (mean, etc.) are most sensitive to treatment effects that change each person in the population by the same amount. They are much less sensitive to treatment effects that change only a small fraction of the population. In contrast, the “clinical judgment” that Isis and other evidence-based-medicine advocates deride is highly sensitive to treatments that change only a small fraction of the population — what some call anecdotal evidence. Evidence-based medicine is presented as science replacing nonsense but in fact it is one filter replacing another.

I suspect that actual treatment effects have a power-law distribution (a few helped a lot, a large fraction helped little or not at all) and that a filter resembling “clinical judgment” does a better job with such distributions. But that remains to be seen. My point here is just that it is an empirical question which filter works best. An empirical question that hasn’t been answered.