Review: The Decision Tree (by Thomas Goetz)

My trail of discovery to The Decision Tree was as follows:

  • Discover Iodine’s in-browser medical translator, become fan for life.
  • Watch Iodine CEO’s (Thomas Goetz) TED talk on the problems with how medical information is currently presented, and his solution.  Become very impressed.
  • Discover Goetz has a whole book on this stuff.  Order from library.

This was maybe not have been the best order to do it in.  Decision Tree is really, really good, but it lacks the specificity of the TED talk or Iodine’s recent work.  If I’d read it first, the other work (which was produced later)  would have been fulfilling the promise of the book.  But reading it last, I kept waiting for the other shoe to drop.  It is an amazing launching pad, but I went in expecting to see what had landed.

That may not even be fair.  Goetz points to a lot of specific things, like the Quantified Self movement,, and actual research on how Dr. Internet affects people.  It’s just that none of these so singularly improve the signal to noise ratio the way Goetz’s work on presentation of test metrics did.  I guess what I’m saying is you should watch that TED talk.

Now that I’m over the fact that Decision Tree is not a 250 page TED talk, I can appreciate it for what it is, which is a reasonable 101 text on the concept of individuals monitoring and improving their own health.  It doesn’t give many specifics for either of those because the answers are so specific and so personal, but it does leave the reader better prepared to evaluate possible solutions they find.   That’s actually pretty hard to do, and really useful.  I could also see it as useful for medical professionals who are on the fence about patient-driven care.*  It is extremely helpful in explaining why over-testing is so dangerous, while respecting individuals’ right to data.  And if you’re not reading it during or immediately after a painful, stressful medical procedure, it’s actually a pretty light read. So if this book looks interesting to you I’d recommend it.

*Goetz is unreservedly pro- patient led decision making and research.  I am too, until I remember a lot of the anti-vaxxers have put an enormous amount of research into their idiotic, dangerous, anti-social position.  I don’t know how to preserve the rights of me + my friends to know our own data and correct our doctors’ mistakes while preserving the rights of children to not die of entirely preventable diseases.

Animal Rights Deep Dive Pre-Check

I haven’t written a ton about animal rights/animal suffering because any position I have is guaranteed to get me yelled at by two sides, possibly more.  I will only write things like that when I am absolutely certain of my grasp of the facts and the rigor of my thought process.  That does not describe me and animal rights at all.  My opinions on balancing animal rights with human needs/desires can best be described as “intuitions attempting to balance to several different gut feelings.”  But that is hopefully about to change.  John Salvatier, some other people, and I are going to dig in to Animal Charity Evaluators’s research on the best way to alleviate animal suffering.  This doesn’t actually require me to investigate my beliefs about the health impact of eating animal products, but I probably will anyway.   In the spirit of science and accountability, I’m going to share my starting beliefs (like I did with HAES), so you can see if research changed them.

A note on comments: this is a pretty scary thing to write, because I’ve seen so many personal attacks in animal rights threads in many different Effective Altruism forums.  If you have a pointer to information I would benefit from, please send it along, I would really appreciate it.  If you think my beliefs are immoral, please hold off commenting until the Post-Check, which will contain only opinions I am willing to defend.  If you believe that there are no trade offs or your trade off is the only moral trade off, please go share this opinion with people who agree with you.

Okay, that said, here is my existing knowledge: I watched Earthling and Farm to Fridge with my EA group.  John has already read a few studies and passed links and comments on to me, I skimmed some of the studies he linked to while I was tired.  I have read a few EA facebook threads on animal rights that had minimal informational content, relative to the emotional vitriol.  Without further adieu, here are my current opinions:

Animal death for the purpose of food is okay, animal suffering is not.

Everyone dies eventually.  A good life and a clean death is more than animals get in the wild.  Ecosystems without predators are very unhealthy for the remaining prey animals.  So while unnecessary suffering bothers me a great deal, death seems not to.  This is pretty close to my attitude with humans; I’m frequently angry at how the medical system focuses on postponing death rather than improving health/quality of life.

Modern factory farming produces unacceptable levels of suffering

Even if everything I saw in Farm To Fridge was outliers, the implied bell curve is unacceptable.

Animal death or suffering for the purpose of clothing is not okay

I didn’t so much reason this out as found myself in a shoe store trying to talk myself into leather being okay, and realized it would be much easier to just not buy leather.  I am not entirely convinced I will stick to this if I find something amazing that can only be had in leather, but I am definitely willing to put a great deal of energy into finding vegan alternatives.  This leads me to believe…

My position that animal death for the purpose of food is morally okay is dependent on my belief that eating animals is essential to human health

This is a weird position for me because I didn’t eat meat until I was 28, because I couldn’t digest it, which 4 year old me translated to “it’s gross”.  I was the least bothered of anyone when we watched Earthling and Farm to Fridge, and I believe that’s in part because for everyone else they were learning something horrible about something they enjoyed.  My thought process was more along the lines of “Of course meat is disgusting, but you have to grit through it for your health.  Gastric acid pills will solve a lot of this problem.”  My forebrain knows HCl does not actually have anything to do with pigs eating necrotic flesh off of other pigs, but the hindbrain worked so hard to overcome it’s visceral disgust that the new reason to find meat disgusting just bounced off.

I’m not claiming people will literally die without meat.  I do think that the healthiest diets involve small amounts of meat, and any deviation from that platonic diet is a blow to your health.  If you are otherwise healthy and health has thresholds, that blow may not make a perceptible different in your life.  If you are me, it does.  To the extent healthy vegan diets are possible, they will generally be some combination of less delicious, more expensive, or more work than the omnivore alternative.

This doesn’t mean meat is some sort of magic salve.  My gut feeling is that a even really bad vegan diet is probably better for you than a really bad American-style meat-based diet, although this will depend somewhat on genetics.

Not all meats have equal moral density

I have almost-but-not-quite given up pig (which was the first meat I was able to stomach, because bacon) because pigs are smarter and I think that makes them more capable of suffering.  Meanwhile crickets barely rank above plants (and may end up being more humane, depending on how many bugs and rodents die to produce those plants).  All this is strictly from a suffering perspective: if you want to consider environmental impact things get even more complicated.

I prefer Mercy for Animals’s approach (lessening the amount of suffering in meat production) to The Humane League’s approach (convincing people to go veg*n)

Some of this is because I was coming at it from the framing of meat-offsets (donating to a charity to balance out meat consumption).  Originally I framed it as “paying someone not to do something you just did is stupid”, like I do with carbon offsets.  It also galls me that what you’re paying for is not making it easier for someone to veg*n, via cooking classes or covering the difference in cost, you’re paying to convince them that veg*nism is a good idea.  Being inspired to convince people to do something by doing the exact opposite feels incredibly broken and toxic to me, but I could never articulate it more than that.

As I’m writing this I see that this is actually tied in with my justification that meat (or at least animal products) are necessary for health.  “This is necessary for my health so I’ll pay someone else to sabotage their health” is sick and immoral.  “This is necessary for my health but I’m going to work to make others suffer for it as little as possible” seems much more reasonable.

I do think that convincing people to eat much less animal protein is a good idea, and I’d support efforts to change norms around meat and lessen the cost/effort/taste differential between vegan and meat meals.

Also leafletting is dumb

Seriously, I just don’t see it helping.  They say leafletting but according to John they actually mean canvassing with leaflets.  My understanding from PIRG is that the vast majority of money raised by canvassers goes to paying the salaries of the canvassers.*  Humane League isn’t trying to raise money, but “convincing people to do a lot of work to avoid something they see as a staple” seems like a strictly harder pitch than “give me $10 and I will go away.”

But if it’s going to work anywhere, it will be at colleges

College students are much more open to new ideas, and cafeterias lessen or even eliminate the work to avoid meat.

But I don’t think we’ll ever know the absolute effectiveness because it’s really hard to measure

Unless they’re actually following people (without telling them) and charting what they eat, how could they possibly know?  And spying on people is expensive and possibly illegal.

Wait, I just thought of a way to measure it.  College students (especially freshman, who are often segregated from other students) eat at college cafeterias.  You could total measure consumption of meat vs. vegan items and see if it changes after leafletting.

*Whether or not particular canvassers are paid or are volunteers is mostly irrelevant, because their time still has value.

The Kitten Pain Scale

I very briefly flirted with Quantified Self and then jumped off the bandwagon because it was making my personal signal:noise ratio worse.  But my neuroendodontist* has given me several drugs, and he wants to know how they work.  Allow me to give you a brief list of things that make measuring this difficult

  • Treatments are all on varying schedules- some daily, some daily with a build up in blood stream leading to cumulative effects, some as needed to treat acute pain, some on my own schedule but hopefully having longer running effects.  Some are topical and some are systemic.
  • I have several home treatments like tea and castor oil.  I’m not going to not take them in order to get more accurate assessments of the drugs, both because ow and because pain begets pain.
  • Taking treatments as needed + regression to the mean = overestimate of efficacy.
  • Pain is affected by a lot of non drug things: sleep, stress, temperature, how ambitious I got with food, amount of talking, number of times cat stepped on my face in the night, etc.
  • We are hoping some of these drugs will work by disrupting negative feedback loops (e.g. pain -> muscle tension -> pain), which means the effect could last days past when I take in.  In the particular case of doxepin it might have semi-permanent effects.
  • Or I could develop a tolerance to a drug and my response to a particular drug will attenuate.  That is in fact one reason I was given so many choices as to medication: to let me rotate them.
  • We have no idea how these drugs will interact with each other in me.  We barely have an idea how the interact in people in general.
  • If I believe something will help my pain will lessen as soon as I take it, long before it could actually be effective.  Not because I’m irrational, but because my brain reinforces the self-care with endorphins, which lessen pain.
  • At the same time, having more pain than I expected to feels worse than the exact same pain level if it was anticipated.
  • Side effects: also a thing.

“I think I feel better when I take this one” was not going to cut it.

Then there was the question of how to measure pain.  Ignoring the inherent subjectivity of pain, neuralgia is a weird beast.  I already hate the 1-10 pain scale because pain has threshold effects and is exponential.  I could create a single pain number at the end of the day, but my pain is not constant: it spikes and recedes, sometimes for reasons, sometimes not.  What I would ideally like to track is area under the curve of pain**, but that requires polling, which would create horrible observer effects.  If I ask myself if I’m in pain every 15 minutes, I will increase my total pain level.  I could poll less often, but the spikes are random and short enough that this was not going to be accurate enough to evaluate the treatments.  I could count pain spikes, but that ignores duration.  Determining duration requires polling, so we’re back where we started.  I could deliberately poke a sore spot and see how bad the resulting pain is, but

  1. Ow
  2. A treatment that doesn’t affect sensitivity but does keep me from spontaneously feeling pain because the nerve is bored is a success.  If we wanted me to be numb we would do that.

It’s just really hard to measure something when your goal is for it to be unnoticeable, and measuring it creates it.

So I came at it from the other side.  What happens when pain is unnoticeable?  I enjoy life more and I get more things done.  Could I measure that?  Probably.  They have the bonus of being what I actually care about- if something left me technically in pain but it no longer affected my ability to enjoy or accomplish things, that would be a huge success.  If something took away the pain but left me miserable or asleep, it is not solving my actual problem.**

So one metric is “how much I get done in a day”.  Initially this will be the first number between 1 and 10 that I think of when I ask the question at the end of the day, but I’m hoping to develop a more rigorous metric later.  You’d think enjoyment of life couldn’t ever be rigorously measured, since it’s so heavily influenced by what is available to me in a given day, but I say that brave men can make it so.  And so I introduce to you: the kitten pain scale.  Kitten videos vary a little in quality, but I think my enjoyment of any single video reflects my internal state more than it does the video. Three times a day (shortly after waking up, shortly before screen bed time, and sometime mid-day that can vary with my schedule but must be selected ahead of time to avoid biasing the data), I will watch a cute kittens video and record how much I enjoy it.  The less pain I am in the more I should enjoy the video.  This will give me a (relatively) standardized measure of pain without risking inducing it.

This is still not what you would call a rigorous study.  An individual choosing what to take among known options never will be.  But I seriously think the kitten pain scale could be a contender to replace the stupid frowny faces.  My first draft is available here.  Right now it’s set to measure over the course of a day, because that’s the scale I expect from these meds, but you can add bonus measurements at set times after taking meds if you like.

Possible additions: cups of tea drunk in day.  Right now that seems like too much work to measure, but when tea is available it’s a pretty good indicator of how much pain I’m in.

*I am still angry that I know what that is, much refer to one using possessive case.  But given that, I am extremely grateful I live within biking distance of a world class research facility in the discipline.  Even if the physical facility could be a case study in how economic insulation leads to bad user experience.

**This is why none of my treatment options are opioids.  Strong ones technically reduce pain, but they also leave me miserable.  The fact that some people take them for fun is all the proof of human variability I could ever need.

Adventures in Dentistry and Neurology

I forget if I mentioned it, but I had nerve damage from the first dental surgery, way back in June.  Everything else healed up more or less all right, but that one kept hurting.  Actually it felt like two damages- one that was healing, albeit slowly, and one that was staying static or getting worse.  The prospect of living with that pain for the rest of my life was really daunting.  Medical marijuana, which had been so helpful at first, was having more side effects with fewer desirable effects every day.  It eventually became clear my surgeon had no idea what was going on or how to fix it so I went to a neuroendodontist, a subspeciality I really wish I wasn’t already familiar with.

toenailectomy looks awful but feels like nothing at all.  A neuroendodontal exam is the exact opposite.  It looks like some guy very gingerly touching around your mouth, but he is not only deliberately provoking pain, he needs you to pay attention to the pain and report on in it excruciating detail, while you remind yourself that inaccurate reporting leads to inaccurate diagnoses.

For all that pain, I actually got very good news.  Even though it feels like I have two distinct damages, it’s actually only one, and it is healing.  Nothing is guaranteed in neurology but existing data is consistent with this eventually healing itself.  And in the meantime, he gave me new and different medicines.  We’ll see what the side effects are, but at the very least I have options to rotate through.

Adventures in Podiatry and Neurology


Recently I learned toenails aren’t supposed to be under the skin of your foot and hurt constantly; this is an ingrown toenail and it’s a solvable problem.  By “recently” I mean a year and a half ago, but a little pain when I flexed my toes in a shoe did not seem as important as the pain in my mouth or my inability to digest food, so I only got around to seeing a podiatrist now.  If you develop an ingrown toenail there are home treatments to coax it better, but if you’ve always had it the cure is a little more drastic: they cut off the bit of the nail that has grown under the skin and cauterize the nail bed so it never grows back. If you are curious, here’s a video of the actual medical procedure:

The worst part is the lidocaine injection. There’s a topical anesthetic, but they root the extremely thin nail around under your skin in order to find the nerves and inject directly over them. The podiatrist will describe it as slightly painful, but they are lying, and it will make you doubt them when they promise the rest of the procedure is painless. That part turned out to be true: with enough lidocaine you genuinely can’t feel them slip the scissors/pliers under the nail bed, or the burny stuff*, unless you are a freak who processes -cain very quickly, in which case they will give you more and it will stop hurting.  But the anesthetic injection was pretty brutal.

That is not actually the interesting part. In between the lidocaine and the scissors/pliers, they test your numbness with what looked like a large blunt toothpick. My podiatrist, which more flourish then was strictly necessary, brought it down from a great height onto my toe.

I screamed.

Then I realized it didn’t hurt at all. My brain had combined the memory of the painful needles and the visual information about incoming sensation and preemptively sent a scream response before it noticed I couldn’t feel anything. I never had quite that strong a reaction again, but there was an extremely weird dissonance as I watched something I knew should hurt, yet got only vague reports of pressure from the area.

This works in reverse too.  Phantom limb syndrome is a condition in which people missing a limb (even one they never had) experience excruciating pain where their brain thinks that limb should be.  One of the only effective treatments is mirror therapy, where a mirror is used to simulate the appearance of the missing limb, and somehow the brain goes “oh, I guess it’s fine.”  This clip from House is not quite as accurate as the matrixectomy one (mirror therapy rarely involves kidnapping), but the science is sound.

The lesson here is that even something that feels incredibly simple and real, like pain, is in fact an artifact of post-processing on several different inputs.

*Dr. Internet says phenol but I could have sworn it started with an M. In my defense, he gave me the proper name after the needles bit and I was fuzzy.

Depression as a false negative

Slate Star Codex points out that rates of suicide and depression are weirdly terrible metrics for how good a society is.  I wonder if some of that is a definitional effect.  Depression is more or less defined as occurring for no reason.  If you have a reason for sleeping poorly and feeling unable to do everyday things (e.g. fibromyalgia), you’re diagnosed with that instead.  As society gets worse, people who were chemically destined to be depressed are given reasons to be sad, and so stop contributing to the depression statistics.

This is related to but slightly distinct from the idea that depressed people are less likely to commit suicide when conditions are objectively miserable than when they are good because bad conditions leave room for hope in a way good conditions don’t.  That is about individuals specific reaction to their depression.  My hypothesis is about how the number “% depressed” is measured.

Of course, my suggestion doesn’t account for increased suicide rate.  The expectations hypothesis does account for that.  One other factor I think may be in the mix is coping mechanisms.  Before the AIDS cocktail, someone noticed AIDS patients actually got better when co-infected with another virus.  The reason turned out to be interferon, an intercellular signal to ramp up anti-viral defenses.  HIV didn’t trigger it, or didn’t trigger it enough, but when another virus did the resulting interferon protected from HIV as well as the original virus.  Maybe external bad events trigger coping mechanisms in a way depression doesn’t, and they incidentally fight depression.  This could be true even if  “coping mechanism” just means disassociating until things get better.

The FDA strikes a blow for HIV virus everywhere

Part of the FDAs job is making sure the pill you swallow is the pill you think you are swallowing.  It would be very bad if you thought you were taking penicillin and instead took sugar, or Prozac.  This is a government task even a libertarian could love.


Sometimes enforcing a definition is harder than penicillin vs. Prozac.  For example, condoms.  The FDA has definition of a condom, and if your product doesn’t meet it, you can’t sell it, or at least you can’t call it a condom.  Some of this is good.  You want condoms tested for structural integrity, and you don’t want flat pieces of latex being sold as sexual health devices.


The FDAs definition of a condom does not appear to account for human variation.  Condoms must be at least 160 mm in length.   Condoms are not allowed to be wider than 54 mm (-> diameter of 170 mm).   I’m not sure exactly how closely condom dimensions need to match penis dimensions, but that is longer than ~70% of penises and (using a condom width to girth conversion I don’t understand) narrow than ~18% of penises (source).  Yes, condoms are stretchy and will fit over your leg if you try- but they’re more prone to break, and your leg isn’t kept rigid via blood flow.  A too loose condom will just fall off, but a too long condom bunches, which also causes breaks and reduces blood flow.

I understand why we had to put up with this 100 years ago, but condoms used to be custom made, and some genuises in England are bringing that back.  But thanks to our FDA and its scrupulous definition of condoms, it is illegal to sell them in the states.  And it would definitely be illegal to use the cheap package forwarding service they link to, unless you are an EU citizen.

Why I donated to the EFF this year

I applied for a patent this year.  While I sincerely believe my invention is patentable under the current definition applied by the US Patent Office, I also believe the US Patent Office’s current definition is bullshit, and is stifling innovation by giving exclusive rights to obvious ideas and creating a culture of fear that hurts start ups more than big companies.

The incremental effect of my patent in reinforcing this bullshit system is very small.  Even if you internalized all the negative externalities, I believe the cost is trivial next to the benefits of applying (shiny resume line and a $5,000 bonus).  But no single snowflake believes it’s to blame for the avalanche, and I was really not comfortable justifying material gain because everyone else was doing it.  My compromise was to donate half the bonus to the Electronic Frontier Foundation, which fights for a variety of pro-individual and pro-start-up positions, including patent reform.  There’s no way my patent did $2500 worth of damage to society, so everyone comes out ahead except the patent trolls.

One friend asked if I thought patent reform was truly the most important cause in the entire world, and if not, why not donate to the more important one?  I have a few explanations, but I must acknowledge I made the decision first and then looked for why I made it.  The easy answer is that the world is complicated, and when the developing world catches up with us, I want what they catch up with to be not just materially comfortable, but… well honestly I want some sort of Star Trek utopia where all material needs are sated and people do things for sheer love of learning.  But failing that, I at least want a world where individuals can invent things that improve the world.  I don’t want us getting stuck at any particular rung on the ladder.

The other reason is that donating to the EFF isn’t supposed to be penance or an indulgence, it’s supposed to undo a specific harm I did.  I am deeply uncomfortable with justifying unethical behavior by helping some greater good.  For one, humans are bad at math, so it’s easy to see that doing net harm.  But even if all the trades are strictly advantageous it complicates the system, which ultimately makes it harder to get my Star Trek utopia.  Sometimes that complication is necessary and moral, but if you are in a situation where that is necessary you should probably find someone else to do it.  My talents lie in simplifying.

Problems in need of generalizable solutions

What to do if you have some intrinsic motivation but not enough?

Sometimes I spontaneously feel like exercising.  Sometimes I don’t, but I prod myself a bit and am really glad I did.  Sometimes I prod myself a bit and am not glad I did.  Sometimes I didn’t want to be because of important but subconscious reasons, and doing the Healthy Thing makes me feel actively worse.  I worry that every time I push without getting a reward at the end I’m making myself ultimately worse off by eroding my intrinsic motivation.  That worry is itself a negative reinforcement that makes the outcome more likely.  If someone could send me a general solution that works for regular exercise, physical therapy exercise, cooking, eating well, cleaning, work, and extroverting I would super appreciate it.

What to do with an initial burst of enthusiasm?

I assume we’ve all had the experience of getting an initial burst of enthusiasm for something (e.g. clean all the things), only to overdo it and burn out.  Then we are sad, because our hopes have been dashed.  I assume many of us have learned from this to scale back our initial efforts and channel that enthusiasm into long term sustainable action, only to discover the enthusiasm has an expiration date either way, so now our hopes are dashed *and* we had the unpleasant feeling of bridling ourselves *and* we accomplished strictly less than we would have if we’d run with the initial enthusiasm.  Is there a third way that would let me accomplish all the things without every feeling burnt out or overextended several of the things with a minimal amount of overextension or artificially holding myself back?