Open access journals

Scientific research is distributed in journals, a system which has a number of flaws, one of which is it is expensive.  Journals charge authors to publish their articles, readers to read the articles, and advertisers for space in the journals. This smells like bullshit before you know that both publication and access fees are often paid for out of government grants, with the second most popular source being “companies that want you to buy their product based on the publication.”  It’s why I’m often forced to work from abstracts, rather than full journal articles.  I can get the authors’ conclusions from abstracts, but they rarely contain enough information to evaluate the experimental methodology.  The US government has made various efforts at enforcing “open access” policies, which would force research funded by public money to be accessible to the public, but they’ve always been defanged.

The system persists because publishing is a prestige based system.  Scientists are most rewarded for publishing in the most respected journals (in biology that’s Cell, Nature, and Science), none of which are open access, and have no incentive to be as long as they are the first choice for scientists.  An individual scientist can make a principled stand and insist on publishing in open access journals, and I’ve known some who’ve done it.  After they get tenure. Before then, they can’t afford the risk that some committee member who still thinks the internet is a dump truck will take publishing in a less glamorous open access journal as a sign of failure.

But not all research is funded by the government or for-profit enterprises.  The Gates Foundation has just declared that any research they fund must be published under a creative commons license.   They also require the underlying data to be publicly available, which might be even more significant.  It’s not clear to me how this will play out: maybe a bunch of awesome Gates-funded research will be publicly available.  Maybe promising young academics will refuse to take Gates money (although given the relative availability of talented academics and money, they’re probably replaceable).  Maybe this will start a marginal revolution of ever higher prestige journals going open access, giving the public access to additional non-Gates research as well.

Either way, I think the Gates Foundation did a really good thing here, and I really want to see what happens.

Harm mitigation vs. cure

Scott Alexander has a very good post up about semantics and gender, which you should read in its entirety even though it is very long.  I have nothing to add to his main thesis, but there is a cute little anecdote about a woman with OCD whose life was nearly ruined by her fear she’d left the hair dryer plugged in, no matter how many times she checked it or how far she was from her house.  She was on the verge of living on SSDI for life despite trying every therapy and medication in the book.

Finally, a psychiatrist suggested she keep the hair dryer with her.  This transformed “checking if the hair dryer is unplugged” from a 40 minute task (to drive home and back) to a 2 second one.   The psychiatrists at the hospital were divided on this.  Scott doesn’t specify, but I assume the argument against was that you have to rip the problem out by its roots.  OCD is anxiety in search of a cause and if you assuage this one she’ll just find something new to worry about, and if you keep treating the symptoms she’ll end up loading her car with every appliance she owns every day.

This strain of thought is not baseless, and I think it’s important to keep in mind when developing population-level guidelines for treatment.  I also think that any doctor that argues that hairdryer therapy for this particular woman should be sent to a reeducation camp, because

  1. it worked, so shut up
  2. root-cause psychiatry and psychology had their shot.  They had in fact emptied an entire clip into the problem and had no more bullets.  At that point, unless something is actively and immediately harmful, they need to gracefully exit the field.

There’s also the matter that the problem was not just “she felt bad”, but also “she’s about to lose her job.”  Jobs are important.  They provide the money and health insurance that let you go to fancy psychiatrists that don’t believe in hair dryers.  Even if you’re independently wealthy, jobs are important psychologically and socially.  SSDI is oriented around the problems of factory workers who lost limbs, and really does not work well with people with high-variance mental disabilities, who can do some work some of the time but cannot function at the level society demands.   If hair dryer therapy does nothing more than buy you six more months before she experiences a negative shock from which it is very difficult to recover, that’s actually pretty good.

Even more than that, I think the psychiatrists are underestimating palliative care.  I absolutely do not think overcoming mental disorders is a matter of will power or wanting it enough, but I do believe that human brain and body are very good at repairing themselves, and that this implies that any non-traumatic disorder that persists must be in a self-reinforcing loop.  Chronic pain lowers your pain tolerance, worry that something will trigger a panic attack makes you anxious.  Pain and depression are mutually reinforcing.  Mental Illness saps your energy and cope and time, which makes it difficult to seek and follow through on treatment.  “Palliative” care like pain killers and anti-depressants give people energy they can use to heal, which is why oncologists sometimes prescribe them. For big scary things we don’t know how to cure, freeing up the patient’s own resources may be the most helpful thing we can do.

Meanwhile, my EA group is debating this article on charitable giving, which articulates something I’ve been trying to say for a long time, and not just about charities.  American capitalism is set up to encourage shooting the moon.  We’ve carried that over to charity, trying to find The One Simple Trick To End Poverty.  That is toxic on many levels: it doesn’t exist, we can’t measure finely enough to detect it, the most effective thing now is not going to be most effective thing after we’ve done it to death, finding things that work is a massive expense in its own right, and oh, poverty is a system of many millions of moving parts.  Waiting for the silver bullet is doomed and immoral, and perhaps a bit like refusing to let this patient adopt a hair dryer as her constant companion.  Yes, treating the root cause would be better, but it’s not on the table.

But that doesn’t mean we can stop doing RCTs and start firehosing money again.  It is tragically easy for aid to make things worse.  This is what the anti-hair dryerists were afraid of: that putting a salve on the symptoms will make the root problem, and thus eventually the symptoms, worse.  Possibly much worse.  Most people who gave food aid did it with the best of intentions: even the American agricorp executives who benefited probably convinced themselves this was a way of giving back .

So: you can’t tell people it’s cure or nothing, but you also have to be really careful with palliative care.  It’s even harder for charity, because you have to consider the externalities, not just the affect on the recipients.  This is one good argument for donating local, even if distant recipients are dramatically worse off: you will naturally get and give more feedback on a local charity’s effectiveness.  It’s also a very good argument for restricting yourself to charities that measure their effectiveness, almost independent of what the measurement says.  When we don’t know what to do, gathering new data is a good in and of itself.  And small pareto improvements may eventually free up the resources for societies to heal themselves.

Damnit

1.5 years ago I did a food sensitivity test, and it came back “yes”.  I gave up wheat, eggs, and milk.  After 4 weeks my chronic heartburn was gone and I generally felt better.  Not better enough to stick with it indefinitely- at the beginning of 2014 I fell off the wagon due to a combination of stress and changes in my access to food.  The problem with sensitivities is that it’s a very delayed feedback mechanism.  One bite of foods I am sensitive too doesn’t bother me at all, in the moment or later.  Conversely, giving up all those (delicious) foods doesn’t immediately make me feel better.

After many false starts, I re-gave up all the sensitivity inducing foods in August, and was pretty irked when my heartburn continued for weeks.  But like last year, I suddenly noticed that only do I not have heart burn, but I haven’t for weeks.  I forgot that it was a thing I had.  And sometime in the last three weeks my skin became flawless.

No, one subject-aware case study does not prove a thing.  But when you consider how much the subject wanted the opposite result because that was where the ice cream was, it becomes deserving of further study.

HAES pre-check

I’ve been meaning to do a “science of fat and health and food” series for a while now, but have never quite gotten it together. There’s too much stuff I remember reading in some blog years ago but can no longer find.  The library has finally delivered Health at Every Size to me (just in time for Thanksgiving), and I’m hoping to use that as both a serious source and a jumping off point for other research I want to do.  In the spirit of inquiry, here are my basic beliefs, as cobbled together from an undergrad biology degree, personal experience, things people said on the internet, and scientific studies I read the abstracts of.  When possible I’ve included a citation but mostly this is just stuff from my brain.

  1. Some diets are lead to a better functioning body than others.
    1. The healthiest diets supply all necessary trace nutrients, including ones we haven’t identified as necessary yet.
    2. Protein, fat (of multiple kinds) and carbohydrates are all necessary for proper functioning.  Right now a lot of people are pretty sure that you should minimize carbs and especially sugars, but 20 years ago they were equally sure fat was evil, so I’m unconvinced even though their numbers look very shiny.
  2. Exercise is super good for you right up until the point it is super damaging.
  3. Despite our astonishing lack of genetic diversity, humans have a pretty wide range of how they react to identical food and exercise inputs.  Additionally, the same person can react differently to things over time.
    1. For example, people’s beliefs about the deliciousness of the milkshake they are about to receive affects ghrelin production, which definitely affects satiety and probably affects nutrient and calorie absorption.
    2. Medication can do the same.  Cortisol makes you gain weight. Several psychiatric medications lead to severe weight gain.  Hormonal birth control definitely used to make you gain weight. Many scientists claim the newer drugs haven’t been shown to do so, but my feeling is that “baby chemicals lead to weight gain” is the default assumption and the burden on them is to prove it doesn’t.
    3. Past deprivation, including in utero, can decrease basal metabolic level, or make it more likely to decrease in the face of further calorie deficits.
  4. At the same time, people are remarkably resilient to environmental changes.  A given person can eat a wide range of calories and stay at the same weight.  No one understands why.
  5. So while calories in/calories out is literally true, in the sense that everyone is taking in and using calories, it’s not useful, because so many things affect intake and output.
  6. It is possible to have an excellent diet and exercise routine and still be fat.
  7. But any given person will probably be fatter the worse their diet and exercise.
  8. When you tease these out, fat is mostly a symptom of things that lead to bad health, not a cause of bad health.  Extreme amounts of fat are hard on the joints and heart.  But all evidence says (good diet, good exercise, 40% body fat) > (bad diet, no exercise, 20% body fat)
  9. Nonetheless, the general and medical public alike seem extremely fixated on fat, and this is hurting fat people.
  10. Shame around fat seems to contribute to both fat and the negative health outcomes associated with being fat.  Shaming fat people for the health is right up there with rescuing prostitutes by arresting them.
  11. To the extent fat itself affects health, the ideal body fat % from a health perspective is much higher than the ideal body fat % from an American aesthetic perspective.
  12. Lab animals are fatter than they were a generation ago despite provably identical conditions.  This has got to mean something about our food, and it’s probably not good.
  13. It is possible to be both fat and undernourished.  Most poor Americans are.
  14. Your body needs calories to run.  Faced with a calorie deficit, your body may choose to cut programs (like the immune system, or thinking) rather than dip into savings (stored fat).  This means that maintaining even an “unhealthy” weight may be the healthiest choice a person can make.

Antibiotics: is there anything they can’t do?

Until fairly recently, gastric ulcers were a disease of stress and spicy food.  Those things probably did make it worse, but it turned out ulcers were almost always caused by overuse of NSAIDS or an H. pylori infection.

Back pain is the prototypical malingerer’s disease.  The medical establishment isn’t saying you’re faking it, but given that back pain is positively correlated with low job satisfaction, to the point that job tenure and unemployment are considered when predicting someone’s recovery time.  The most charitable explanation is that the pain is real, but working through it is ultimately more beneficial than rest, so people who love their job or hobby enough push themselves through it, and people who hate their job don’t have the incentive.  The uncharitable explanation is that they’re faking it because they are lazy.

Or maybe they have a severe bacterial infection.  There’s new evidence that people who fail to recover after a herniated disk are suffering from a bacterial infection that can be treated with prolonged antibiotics.  Patients treated with antibiotics continued to improve after the antibiotics were discontinued, suggesting they got to the root of the problem.

And then there’s a bunch of non-specific symptoms that may or may not be associated with chronic Lyme disease, which may or may not be cured by antitbiotics.  And even though Toxoplasmosis is not a bacteria, the treatments are commonly used antibiotics.  Part of me wants to recommend everyone take a broad spectrum antibiotic holiday every few years, just to sweep up all the low level things that must exist but we don’t know to look for.

But you still can’t have them for the flu.  That’s just stupid.

…and the Wisdom to Tell the Difference

I haven’t gotten too much into my own dental stuff because I spend enough time thinking about it as is, but the current count is:

  • 3 completed surgeries
  • 2-5 more planned, depending on what you count as a surgery
  • painful nerve damage on the lower right
  • a hole in my lower left gum.  You can see a good chunk of bone if you look in my mouth.

After the last surgery (wow, two months ago now), my pain level actually dropped significantly.  We took out a major part of the problem, which not only helped on its own merits, but meant I stopped clenching/grinding, which made the nerve damage on the other side stop hurting continuously.  It was still touch sensitive, but I can handle that.  My ability to focus skyrocketed, limited only by my exhaustion.  I dropped CBD in favor of naproxen, and then didn’t need anything at all. I read a book a day for a month.  You can roughly see this increase in focus in my blogging, although the signal on your end is a little messy because publish can come long after writing, unless wordpress screws up, which it usually does.  I went on forays to the library to practice thinking around other people.  I even started to program a little bit.*

Then the surgery site started to hurt.  And my upper right (which needs surgery but hasn’t had it yet) began to ache from the sudden chewing burden.  I saw myself faced with two possible paths: a life where the pain just kept increasing and no amount of treatment could keep up with it, and I was never able to accomplish anything because it rendered me stupid, or a life where I was never in pain and I went on to be Brene Brown’s more medical second coming.   Obviously future #2 is better than future #1, and in future #2 I don’t take pain medicine, so I needed to just keep not taking pain medication and everything would be fine.

Causality does not work that way

If you’d tracked self reported pain it probably wouldn’t have gone up that much, because I have a lot of practice pushing dental pain out of conscious awareness.  But my reading rate plummeted, and I stopped going to the library.  Blogging which had felt like a thing I needed to do to clear my head a week before now felt like a chore.

I had just started to give in and take more CBD when I had a follow up appointment with my dentist, who explained that there was a hole in my gum where the jaw was growing in order to push out an infection.  I started crying the minute he said it.  I went home and took real pain meds.  A few days later, when I didn’t have to drive anywhere, I took twrugs o days and took way more pain medication than I consciously thought I needed.  Since then I’ve continued taking more-than-forebrain-thinks-is-necessary at night, but NSAIDs only during the day.  My reading and writing productivity has picked up significantly, talking barely hurts anymore, and I feel safe being in touch with my pain level again.

This is what I call the “nuke if from orbit” pain medication option, and it really seems to work.  Catching the pain before it “settles in”, or sending a surge against it, moves the baseline pain level back significantly, and lets you use less drugs over all.  The reluctance or inability to do this is another casualty of our awful attitude towards pain, where medication is essentially viewed as a failure of the individual to tough it out.

But nuke it from orbit doesn’t always work either.  Right now I’m in a tiny bit of pain.  It would take a lot of drugs to get that to zero, possibly an infinite number.  I faced a stronger version of this problem right before the last surgery, where the nerve damage side just kept upping the pain level to keep up with whatever amount of drugs I took.  In that case, I was better off simply accepting that pain was the state of being I was in right now.  The most helpful thing to do was meditate, except that while meditation often helps by relaxing the jaw, meditation for the goal of pain relief doesn’t.  Since most of the emotional impact of the pain was frustration and fear over my ability to think (read/write/plan) while in pain, practicing thinking while hurting would definitely lead me to look back more fondly on the experience, although it probably would have led to more distress at the time.

The first lesson here is to treat for the pain level you have, not the pain level you wish you had.  The second is to aggressively counteract pain at the first peep of its head.  The third is to learn to live with pain instead of fighting it.  I guess this is one of those “wisdom to tell the difference” situations.

*Fine, I started to set up a dev environment and that took two weeks because I was still very sleepy and android development studio is stupid.

Costly Signalling and the Scheherazade Effect

One of my great frustrations in life is how evolutionary psychology, a fascinating scholarly subgenre that provides unique and valuable insights into many problems across the disciplines of biology and psychology, became evopsych.  Click bait before there was click bait, evopsych is justifies whatever the author believes by using the (white, middle class, suburban families of the) 1950s as the evolutionary relevant time period.  So now I can’t talk about cool things like costly signalling without a disclaimer that it’s not one of those evopsych articles.

Costly signalling is the act of doing something stupid to prove your genes are so good you can afford to do so.  The most popular example is the peacock’s tail: it is energetically expensive and makes you attractive to predators.  Surely if you have it you must posses many great genes that I, a female peacock, would like to secure for my offspring.  The tail is also a canvas for parasites, so if it looks good, you must not have many.  That is good for me and implies good genes for our future offspring.  Let the peacock sex commence.  Costly signalling doesn’t have to be about mating.  Certain ugulates will signal a predator that they see them and are not worth chasing by stotting (jumping in a uniquely pointless way).

The key here is that the signals are very expensive.  A weak peacock who attempts to grow a beautiful tail will be eaten.  A weak ugulate will have an unimpressive stot.  Males of a bird species whose name I can no longer remember get more female attention when their breast is redder, but are also challenged more by other males.  Males artificially reddened by experimenters temporarily attract more females, but they also attract more fights from other males, and are ultimately worse off.  That cost is what makes the signal work.

My second favorite theory hypothesis speculation about humans and costly signalling is that it, and not utility, led to male upper body strength.  If the hypothesis that humans broke out from the other hominids via endurance hunting is correct, upper body strength is mostly dead weight.  Useful in some circumstances, but a cost during hunting.  I want to be really really clear that this is basically me making something up after reading a book that wasn’t even that scientific, but you have to admit it would be super interesting if it were true.

My favorite speculation about humans and costly signalling is the Scheherazade effect, which I learned at school rather than making up but is only slightly proven.  The Scheherazade effect can refer to two related but distinct things.  The first is that individual humans can signal how much energy they have to spare (implying they are good hunters or have efficient energy usage elsewhere) with pointless feats from our most energy intensive organ: the brain.  Humor?  Art?  Chess?  All attempts to impress the opposite sex.  This + the fact that male reproduction is tournament-style and female reproduction is roughly linear with respect to fitness may explain why men are more likely to pursue truly stupid wasteful hobbies.*

The second Scheherazade effect is the cumulative effect of the first.  After tens of thousands of generations, individual attempts to impress one another via kick ass drumming actually humans better at drumming.  Or juggling.  Or story telling.  Or joke telling.  Or that it may even be the origin of language itself.

The Scheherazade effect is unfortunately untestable, so it’s only real use is to parallel “he’s so hot” when telling your friends about someone who became impressive to you via feats of intellect.   But if you travel in the right circles, that is pretty useful.

*Although it is impossible to separate this effect from that of socialization.

Intro to EA/Giving What I Should

Update 11/19/14: I had the format of the pledge wrong.  Read Jonathan’s correction here, more comments on the bottom of this post.

People often ask me what EA is.  I tried describing it as “trying to make charity as effective as possible”, but that’s kind of implies that everyone not in EA is not doing that.  Like evidence based medicine, it’s either obviously correct or horribly mislabled.  I can say “we believe in randomized control trials”, but a lot of what I do in the local group is push for everything except RCTs.  And my favorite part of GiveWell is not their research into existing charities, although that is excellent for specific problems, but their deliberate seed funding of projects to find the best way to approach unsolved problems.  That they picked something I’m passionate about (criminal justice) is a bonus, but the principle would stand either way.  So I think that I will describe EA, or at least my interest in EA, as “generating and advertising the evidence for evidence based charity.”

Recently my EA group talked to Jonathan Courtney from Giving What We Can.  Giving What We Can has two functions: assessing charities, and taking and monitoring pledges individuals make to give 10% of their income.  On charity assesment, they’re basically Pepsi to GiveWell’s Coke.  They tend to agree with each other’s research but make slightly different recommendations based on differences in their beliefs about the future.*  GWWC also encourages people to register a pledge to donate 10% of their lifetime pre-tax income to what they (the pledger) believes to be the most effective charities for helping developing countries.   The pledge is not legally binding, and deliberately refers to lifetime income and not income in a given year (so you can consumption smooth), but they do ask people to log their giving, and perform audits of pledgers at the end of the year.

My EA group had a really great discussion about this, and my tentative opinion is:  it’s hard to fault them for what they’re doing, but I sure hope they’re an incremental step. GWWC’s main selling point, simplicity, is also an enormous limitation.

GWWC’s main goal is to head off decision paralysis by giving you a simple number.  A subset of this is giving people who feel equally guilty/anxious about retaining 2% and 45% of their earnings because even 2% is better than living in the Democratic Republic of the Congo, but really don’t want to live on 2% of their income so default to giving nothing.  Solving that problem is not insubstantial, and I give them credit for that.

The downside is that 10% is unlikely to be the best number for everyone.  If you’re childless, in perfect health, and earn $5 million a year for 40 years and have no extenuating circumstances, I think you should give more than 10%.  If you take a 50% paycut to work for a good cause**, I think you get to count all of it.  How does volunteering count?  How is that changed by whether it’s Effective Volunteering or Personal Satisfaction Volunteering?  What if you’re receiving a ton of charitable and government aid for your disabled child?

On the other side of it, I worry about the emphasis on money.  Lots of things require mass action that can’t be bought- like the Ferguson protests, or lobbying for net neutrality.  Western society has a personal connection deficit, and one of my big concerns with EA as a whole is that it commodifies altruism and in doing worsens the connection deficit.

Lastly, there is fear.  I have been out of work for five months due to dental work, and it could easily be another two months before I can start even part time work.  I was originally told my (astonishing) disability insurance (that I’m incredibly lucky to have) would cover at most a week of of that time, because “seriously, no one gets that much time for that small a problem”.  I eventually prevailed***- last week.  That’s 4.5 months without a paycheck, plus the immense cost of the dental and medical care I’ve received.  If I hadn’t had the money to wait that out- and to know I’d survive even if I was never paid- I would have had to handle it much differently, and I honestly don’t know how.  Beg from my parents (an option very few people have)?  Drug myself up to the gills so I could show up at the office, at the cost of, at best, a much longer recovery, and at worst never truly getting better?  Debt?  Forgo the physical therapy and IV nutrition, at the cost of, at best, a much longer recovery, and at worst never truly getting better? Even if I never actually had to do these things, just worrying about them would have been a huge tax on me when I had very little to spare.  At a gut level, I see this pledge as a threat to the sense of safety my savings gave me.

Proponents frequently counter with “It’s not legally binding, you can always withdraw.”  But I don’t want to take a pledge on the condition I don’t have to uphold it.  That seems wrong.

What I find a lot more appealing is a private consumption tax.  For every dollar I spend on things, or things excluding certain expenses, or all things after a certain amount of money, I have to donate.  This fits really well with how I donate now, which is often based on a need to restore balance.  I use the library a lot, so I give them some money.  When I got my shiny new job, I found a family on Modest Needs that needed money to move to a better job.  When I got expensive designer antibiotics for SIBO, for which even a diagnosis is a sign of privilege, I donated to a food bank.  After a lot of dental care I donated to families needing dental care on Modest Needs****.  When I’m feeling especially privileged about how my parents supported my education I donate to Treehouse, which is dedicated to giving foster kids the same support I had.  And when I just generally feel rich or need to use up my remaining employer match, I give to GiveDirectly*****.  These sound a lot like indulgences, but indulgences buy off the guilt from things you shouldn’t have done.  I don’t think anyone thinks I shouldn’t have access to the medical care or library books I do, the problem is that other people don’t have them.

These aren’t exactly consumption taxes.  Often what I give is based on what I didn’t have to pay because I have amazing insurance.  Actually, that feels really fair to me.  There’s an overwhelming amount of evidence that being well off is actually cheaper than being poor, in part for exactly the reasons I listed in the fear paragraph.  If my savings (that I was able to accrue due to an incredible amount of privilege) saved me a bunch of credit card debt, paying half of the hypothetical interest on that debt seems pretty fair, and avoids the “I’m punished for being successful.”  I’m not being punished, I’m just not getting to keep all the gains for something that was partially given to me out of luck.

Okay, so some sort of sharing of the benefits of privilege (for when I get things everyone deserves, but many people are denied), generally going to share that specific privilege with others, plus a consumption tax, because living in America is a privilege in ways I will never fully consciously comprehend.  Either a low general consumption tax, or a higher tax on luxuries.  This seems right.  I will need to figure out exact numbers and how I will calculate spending, but that is a practical problem.

*E.g. GiveWell no longer recommends giving to the Against Malaria Foundation because they already have a large stockpile they’re unable to move without lowering their ethical standards, GWWC recommends them because they believe a larger stockpile will serve as an incentive to make partners meet their ethical standards.  GiveWell doesn’t even advise against the AMF, they just believe there are three charities that are better.  Both sides sound plausible, and there’s no way to know who’s right without a control universe.

**And you’re doing it because you believe it’s the best way to help the world, not because it’s a better work environment.  There are EA charities devoted to this question.

***Despite a dentist so incompetent at paperwork I was beginning to suspect malice.

*****Although I haven’t for this round, possibly because none of the previous care actually helped

*****GiveDirectly ends up getting by far the most financial support but the least thought.

Update 11/19/14: it turns out the pledge is 10% every year, the year you earn it, not accumulated over time.  In defiance of all rationality, this makes me feel less anxious about it.  I need to give this more thought and then it probably gets it’s own full entry.

Rededication

When I started this blog, it was intended essentially as prep for a career as a psychiatric NP.  But let’s go further back.  When I was 12 a search for air conditioning at the national zoo led me to dedicate myself to become a behavioral biologist. I worked on the academia-research track for 10 years, until I realized academia was terrible (and also I didn’t get in to grad school).  I’d picked up a CS degree to facilitate the biology, and for lack of something better to do I jumped onto the programming track.  I found parts of it I loved to succeed at, but was never happy long term.*  After another company failed to make me happy, I decided the problem was me and started looking for a new track to jump to, which is how I got to psychiatry.

It’s only 10 months since I started the blog but almost exactly a year since I made that decision.  I spent five of those months not working, recovering from/prepping for dental surgery (and there are a few more months to come).  This was painful and I would have rather never had these problems, but the enforced break did give me some distance and some time to think.  Combined with my volunteer work and reading, this is what I’ve figured out:

  1. I really, really want to improve adolescent mental health.
  2. Psychiatrist, or any other mental health job, or any job at all, has its downsides.
  3. Programming is a rare and valuable skill it would be silly to just throw away.  Plus it really is fun when it works.
  4. I have gotten used to finding programming jobs by throwing a rock and waiting.  There’s a lot of them and I interview well.  But there is no plug and play position that uses my skills to accomplish the things I want to accomplish.
  5. So I will need to make my own.
  6. Beyond mental health, my goals are helping people take care of themselves.  I don’t want to detail a particular vitamin, I want to teach people how to research their own vitamins.  I definitely can’t do individual doctor recommendations, but I can help people evaluate their own doctors.

In parallel to this, I joined the local Effective Altruism discussion group back in April, and within six months rose to power/got conned into doing 1/3 of the organizational work.  I don’t know where I’m going with EA, which as a philosophy applies to anything but as a movement seems to have almost no overlap with the goals I’ve listed above.  EA’s big pushes have been in third world poverty (which I care about, but the only useful thing I have to give them is money), animal suffering (which our meeting made me care about enough to give up factory farmed animal products, but still doesn’t fit as a calling), and existential threats like meteors and malicious AI (which intellectually I think are important but I cannot bring myself to have an emotional response about).   EA is expanding, which is wonderful, but by design they work on a very large scale, and in some ways what I want to do is very small.  And yet, I think it is really important I keep doing it.  Even if it all it provides is a social group that thinks saving the world is a good and achievable, that is really valuable.  And I think it might be more than that.

So my plan for now is to see what I can do with the resources I have.  My primary job is having dental surgery, and that limits my moonlighting options.  But I can read, I write this, I can go to and organize EA events (even if I have to leave my own event early from pain and exhaustion).  I’ve done some work at crisis chat, and there was a brief window in which I was even able to program.*  I’m talking to a local charity that works at the intersection of childhood poverty and education about their best practices, and I’m hoping to turn that into a lesson about how to give when GiveWell doesn’t have the answer.  I have an idea for an Android app that looks pretty achievable but doesn’t exist yet, which I’m excited about.

Long term, I want to find a programming job on a project I care about, and I want to be in a position to design, not just implement.   Between that, EA, and my own projects I’m hopeful something awesome will emerge.  My thinking here is highly influenced by The Economy of Cities, which describes that new industries arise from small incremental changes and combinations in old ones.  I think that can work on a personal scale too.

The main implications for the blog are that video game posts will now be considered on topic, and I will stop feeling vaguely guilty for the low number of hard core medical posts.

*This window opened because my pain level was so much lower after the surgery.  It closed when the surgical incision in my gums failed to heal/my jaw bone started growing out through my gums, which is intensely painful.  But we had a good thing going for a week.

Narrative Dessert Doesn’t Spoil Dinner

Spoilers in media have never bothered me.  I put this down to a preference for Shakespearean tragedies, where knowing the outcome makes it worse, and therefor better.  I also find anxiety about the outcome of a story distracting- the worst of this was when I watched Serenity, and genuinely believed they might all die, mission unaccomplished.  In one sense that was a triumph of story telling, but I found my own anxiety blocked me from empathizing with the characters’ emotions, which is what I actually watch movies for.  Now my pattern is start movie-read plot on wikipedia-finish movie.  One of the funner parts of comic book movies is I can simultaneously read a lot of deep background (from the comic book universe) without knowing exactly what is going to happen with the actual story in front of me.

Apparently I’m not alone.  Mythcreants has a great post pointing to research about how knowing the ending affects enjoyment of a story.   They studied three genres- ironic twist stories (e.g. anything O. Henry ever wrote), mysteries, and grown up literature stories.  On a 10 point scale, subjects reported enjoying the spoiled stories about half a point more, across all three genres.

The problem with this and most psychology studies is that it was done primarily on undergrads at a fairly competitive university, many of whom are taking psychology classes.  Aside from the usual demographics issues, this is also the population cliff notes was invented for.  More generously, college students are reading difficult texts for comprehension all the time, and that particular brain-muscle may be tired.  It seems entirely possible that a factory worker who spends their work day on rote might have more reserves to enjoy the challenge of interpreting text without knowing where the story is going.

Revealed preference evidence is mixed.  TV is full of formulaic sitcoms and reality TV, but the long tail of rich, complex, ambiguous shows grows fatter every year.  What was once a freak thing HBO did to create an artistic backdrop for nipples is now fairly common.  Although “gritty morally ambiguous middle aged white guy” has become its own trope.  I guess the take home message here is that if you think you enjoy spoilers, you are probably right.

*Meanwhile my greatest regret about GRRM not finishing the 6th book is that it means I can no longer google where the TV show is going.