Luck-based medicine: My resentful story of becoming a medical miracle

You know those health books with “miracle cure” in the subtitle? The ones that always start with a preface about a particular patient who was completely hopeless until they tried the supplement/meditation technique/healing crystal that the book is based on? These people always start broken and miserable, unable to work or enjoy life, perhaps even suicidal from the sheer hopelessness of getting their body to stop betraying them. They’ve spent decades trying everything and nothing has worked until their friend makes them see the book’s author, who prescribes the same thing they always prescribe, and the patient immediately stands up and starts dancing because their problem is entirely fixed (more conservative books will say it took two sessions). You know how those are completely unbelievable, because anything that worked that well would go mainstream, so basically the book is starting you off with a shit test to make sure you don’t challenge its bullshit later?

Well 5 months ago I became one of those miraculous stories, except worse, because my doctor didn’t even do it on purpose. This finalized some already fermenting changes in how I view medical interventions and research. Namely: sometimes knowledge doesn’t work and then you have to optimize for luck.

I assure you I’m at least as unhappy about this as you are. 

Preface to the Preface

I’ve had nonspecific digestive issues since before I have memories. In pre-school my family joked that I would die as a caveman because there were so few things I would eat, and they were mostly grains. This caused a bunch of subclinical malnutrition issues that took a lot of time to manage and never got completely better. And while I couldn’t articulate this until it went away, food felt gross all the time

It’s hard to convey just how bad this was for me, because it feels like it undermines everything I did to work around it. I’ve always been functional but decidedly less healthy than my friends. I got sick more often and it hit me harder. I was slower to heal from injuries and scrapes and that limited my interest in the more athletic sort of hobbies.  I couldn’t work the same hours, and working hours traded off really sharply against energetic hobbies. I had to spend a lot of time managing food where other people can just show up and eat, which was a constant source of social stress. My genetics say I was destined to have anxiety issues, but the low level malnutrition and justified feelings of food insecurity despite apparent abundance did not help anything.

Eventually in my late 20s. I saw a nutrition-focused psychiatrist who listened to my observations (I could only eat protein with soda), immediately formed a hypothesis (I produced insufficient stomach acid), asked questions to rule it out (which I no longer remember), suggested a test (take stomach acid pills and see if they gave me heartburn), and when it came back positive (no heartburn) suggested a course of action (keep taking stomach acid pills) that showed immediate benefits in practice (indigestion removed, but only when I took the pills). My protein and produce intake increased enormously, and I felt overall much better. 

This is exactly how I want medicine to work. I gathered good data and took it to an expert who immediately formed a model, definitively tested it, and prescribed a course of action that made mechanistic sense.  If you forget that it took almost 30 years and I took those exact same symptoms to other doctors beforehand, it’s a stunning success. 

But it was not a total success. My protein intake maxed out at 50 grams/day, and that was if I made consuming protein a hobby and nothing went wrong. I was doing much better than I had been, but my nutrient tests showed I still had a lot of issues. Eventually the stomach acid pills stopped working, although that seems to be “my stomach started producing more acid and a different problem became the bottleneck”  rather than the pills ceasing to contain acid. But the problem was not solved, and more of the existing treatment did not help.

Standard Preface

I worked with a number of doctors on fixing the remaining digestive, for ~another decade. I had a lot of conversations like the following:

Me (over 20 pages of medical history and 30 minutes of conversation): I can’t digest protein or fiber, when I try it feels like something died inside me. 

Them: Oh that’s no good, you need to eat so much protein and vitamins

Me: Yes! Exactly!. That’s why I made an appointment with you, an expensive doctor I had to drive very far to get to. I’m so excited you see the problem and for the solution you’re definitely about to propose.

Them: What if you took a slab of protein and chewed it and swallowed it. But like a lot of that.

Me: Then I’d feel like something died inside me, and would still fail to absorb the nutrients which is the actual thing we want me to get from food.

Them: I can’t help you if you’re not willing to help yourself.

Or sometimes…

Me (over 20 pages of medical history and 30 minutes of conversation): I can’t digest protein or fiber, when I try it feels like something died inside me. If I make it my top priority I can get maybe 50 grams of protein a day.

Them: Oh that’s no good, you need 70 minimum, and really more like 100. Also because I’m a naturopath I’m morally obligated to tell you to give up eggs, dairy, and wheat.

Me: That’s gonna be hard seeing as those three are 90% of my protein intake and by far the easiest forms of protein to digest.
Them: What if you ate pea protein?

Me: Well that’s harder so…worse.

Them: What about hemp?

Me: That is even harder than pea protein.

Them: If you’re not going to try why are you even here?

These exchanges were incredibly draining for me, so I didn’t have them that often. Every year or two I’d get my hopes up for a new doctor, pay a shitton of money (these doctors are never covered by insurance) for several emotionally draining appointments, and then get told they couldn’t help me and this was a failure on my part.

After several years of that pattern I gave up and went back to my old PCP. She hadn’t solved the problem either, but she had solved other problems, had ideas to try for this one, and believed it was a physical rather than moral problem. Unfortunately she is very busy, and sometimes pawns me off on her assistant doctors, who are idiots. That second conversation was with one of those, although in the real conversation I was less witty, and was more like “*sob* no *sob* I told you *sob* I CAN’T”. 

I refused to see that doctor again, but this left me little leverage when they assigned me a different sub-doctor to handle a post-covid rash back in April. You know how naturopaths complain about western medicine being mechanical and reactive and not taking the time to reach a systemic understanding? Well this guy, who we will call Dr. Spray-n-pray, was determined to fight for equality by taking the same approach with unregulated supplements. He guessed I had an allergic reaction and threw 5 different antihistamines of varying legitimacy at me, with no mention of testing the hypothesis, monitoring my progress, expected changes, duration of treatment… 

And it worked.

Not on the rash; I eventually had to go to urgent care for that. But shortly after I started the pills, I found myself eating 50 grams of protein in a sitting and then going back for more the next meal. I also started chowing down on produce, and at some point realized I couldn’t remember the last time I’d had dessert. I had known I had some aversion issues with food but didn’t realize how gross I found it until the feeling went away and I could just eat without feeling contaminated. About here is when I started a food diary and found I was regularly hiting 100g of protein/day. When I crashed my scooter I ate 350 grams of protein over two days, suggesting I could do that any time I wanted but chose not to, suggesting my body was getting all the protein it felt it needed, all of the time.

I’m not sure I can convey what a big deal this is either. I would have paid several years’ salary for this cure without thinking. It is now possible for me to feel okay at an emotional level it wasn’t before. Plus, you know, I can actually get the nutrients I need to run my body and stuff.  My injuries after that scooter accident healed noticeably faster than past injuries. The fact that I haven’t caught an illness since April’s covid isn’t conclusive, since it’s summer and I haven’t done anything high risk, but it is interesting. 

[I do have covid antibody results from the December (8 months after my vaccine) and August (4 months after catching covid)  and my levels have gone way up, but that’s more likely due to the more recent and stronger immune stimulus.]

But that evidence came later. Back in May the timing of the miracle suggested that one of Dr. Spray-n-pray’s pills was responsible. This was more or less confirmed when I weaned off the various pills and the subtle grossness around food started to return. I could also feel growing sugar cravings. So it was important to figure out what the miracle pill was and get back on it immediately.

[If any of you are thinking “well it could have been a coincidence”: no it fucking couldn’t. I did not carry this around for 35 years and try everything to fix it only to have it suddenly go into remission for no reason. I’ll believe covid fixed it before I believe that.]

I had always assumed the reason doctors turned on me was that it was easier than accepting that they couldn’t solve my problem. But this one had fixed my problem! Not on purpose or anything, but I was fully prepared to pretend it was. Now we just had to figure out what had worked and why, in case it suggested any additional actions. I made a spreadsheet tracking the changes as best I could – when my diet changed (using grocery order data), when I’d started and stopped which pills. Surely my data plus his doctor ego would help us get to the bottom of this.

At the time of my follow-up appointment I had a strong guess which supplement had helped based on timing, but it didn’t make any sense. The active ingredient was Boswelia (specifically BosPro brand (affiliate link). I’m afraid to try another in case it breaks the spell). Boswelia is sometimes described by alt medicine websites as helping digestive issues, but in the same way they describe every supplement as helping digestive issues. “Helps anxiety, allergies, autoimmune disorders, inflammation, and digestion” should just be a stamp. This isn’t even necessarily illegitimate – the body is complicated and lots of things are entangled, especially with inflammation.

But I’ve tried a lot of these supplements at one point or another and there was absolutely no reason to predict this one would be different, even if I had researched it ahead of time. is pretty positive on Boswelia but doesn’t list digestion as an issue it solves. Everything is connected to everything else in the body and it was still pretty hard for me to make a causal chain between Boswelia’s alleged mechanisms and improvements in my digestion. So I was extremely excited for Dr. Spray-n-pray to explain why it had worked.

All this was on my mind when I finally got to ask Dr. Spray-n-pray why his treatment had worked. He mumbled something about inflammation and moved on. He had zero interest in my spreadsheet or a more mechanistic understanding of what had changed. I confirmed the miracle was from BosPro when I resumed taking it and the digestive improvements returned (including the creeping feeling of grossness going away). It’s now 5 months since I started taking it and it still works but I have no idea why.

This is not how I want medicine to work, at all. A medic who clearly was not trying for a systemic understanding recommended a lot of stuff and one of them happened to fix a problem as unrelated as could be that I’d spent a decade+ searching for without success? Even knowing definitively that it works we have no idea why, and what would help or hinder it? And there’s ~0 evidence this would help other people with the same condition?

This is bullshit. But bullshit is working where logic feared to tread.

Other Evidence

This experience isn’t what got me on the path of luck-based medicine though. I was already at that point when the supplements were prescribed, which is why I took them instead of doing 5 hours of research and ignoring Dr. Spray-n-pray’s suggestions as the ravings of an idiot. There were a lot of contributors to my shift, but a few stand out.

A few years ago I ran a series of epistemic spot checks on various self-help books, and found that how helpful they were had no correlation with how rigorous or true their theoretical backing was.

Then last year I ran that ketone ester study. I and a handful of people I know get insane gains from using ketone esters – better than Ritalin with none of the side effects – but when I ran an RCT (n=8-12 depending on how you count) no one reported any benefits. 

Or take Slime Mold Time Mold’s all-potatoes-all-the-time diet study (which happened after I started on the magic pills, but is too good an example to pass up). I have an extremely long list of complaints about their hypothesis and follow up study:

  • They failed to contextualize it as a monodiet and discuss the classic monodiet problems.
  • Potatoes aren’t nutritionally complete and don’t have enough protein for people to thrive. They gestured at some of the nutritional deficiencies but I think not hard enough, and believe potatoes have more protein than reported but have not pointed to any evidence to that effect.
  • They tracked weight loss over 28 days but will not be doing a follow-up for six months. Since the default after rapid weight loss caused by an unsustainable diet is immediate regain, this is unconscionable.
  • I haven’t had time to dig into the object-level facts in the argument between SMTM and a persistent critic, but with my monkey social brain it sure does look like SMTM is blowing off well-founded criticism (given in a super aggressive manner).
  • They treat weight loss as an unalloyed good no matter how fast or what the person’s starting weight was.
    • I have not looked into the popular “weight loss not safe above 2 pounds per week” claim and it wouldn’t shock me if it were made up, but if I had an intervention with double that impact I’d spend an hour investigating the claim.
    • Weight loss beyond a certain body fat percentage is bad. You need that stuff.
  • They did warn people about solanine poisoning but I think they should be more concerned about it.
  • Analysis featured a lot of stories along the lines of “Did X on Wednesday and lost 2 pounds on Thursday” and fat loss does not work like that. Two pounds overnight is either water weight or has a lookback period longer than 24 hours.
    • I’m deeply confused about that second part, I don’t understand why or how weight-loss-that-is-definitely-not-changes-in-water-retention comes in chunks. If you have an answer I’m quite curious.

That’s a lot of epistemic sins. OTOH, their potato diet results inspired me to try the minimal potato diet, which consists of eating some potatoes every day (I started with ~100g of baby potatoes), and I’ve lost 15 pounds in 3 months. That level of weight loss with zero sacrifices buys you a lot of epistemic forgiveness, especially when my miraculous dramatic dietary improvements did fuck all to the number on the scale.

[ People already writing their “potatoes can’t possibly be the cause it must be psychosomatic” comments in their head: I see you. Your hypothesis is perfectly reasonable; in your position it would be my first reaction too. But in this particular case you’re going to need to explain why potatoes caused that magic mental shift when giving up soda, a dramatic improvement in diet and removal of dessert entirely, complete emotional reorientation to food, a mild prescription stimulant, and varying levels of exercise did nothing, and ketone esters worked better than all of those but much worse than potatoes. Comments not attempting this will be deleted or mocked as I see fit.]

If you are thinking “ah, but clearly those all did contribute and the potatoes were just the last step”: I agree that’s likely. If I’d started minimal potato diet before BosPro it either wouldn’t have worked or would have been extremely bad for me. But since it seems to work for at least some other people who didn’t have all this baggage I think we need to update in that direction.]

Or take every person who got a second opinion on their cancer and was recommended diametrically opposing treatment plans. Doctors as a class are not as epistemically virtuous as I’d like, but that’s not (always) why they propose wildly divergent treatment plans. In most cases it’s because the answer isn’t obvious, or at best has only been obvious for a few years.

And then there’s the absolute shitshow that is nutrition research. No one knows what the average optimum nutrient level is and even if we did it wouldn’t be that helpful for figuring out the optimum level for a given individual, because humans are so unbelievably variable.

I could go on here, but if you’re reading my blog you’re probably already on board with shit being extremely complicated and I don’t want to belabor the point.

Moral of the story: when intellect fails, try luck guided by intuition

Some medicine is very deterministic. Antibiotics, most of the time. That daylong IV drip when I had norovirus that probably turned the infection from deadly to a kind of annoying 36 hours. We may not know the optimum level of a given nutrient but most severe deficiency diseases can be solved by giving you the thing you’re severely deficient in. My impression is statins work pretty reliably.

But a lot of medicine just seems to be kind of random. People go through 10 antidepressants and then somehow the 11th one works great. Ketone esters increase my energy level so much I gave up soda and caffeine entirely but do nothing for most people. All those books where the cure was a miracle for someone, and it can’t just be a placebo because there’s no reason for the 35th placebo to be the one that works but nothing else makes sense.

All of which leads me to conclude that once you have exhausted the reliable part of medicine without solving your problem, looking for a mechanistic understanding or even empirical validation of potential solutions is a waste of time. The best use of energy is to try shit until you get lucky.

Not at random or anything. My guess is the world contains metis and you do better-than-chance preferentially trying things that helped one guy on a message board for your condition (even though it was shown to make no difference in real studies) or going to alt-modality practitioners (even the one with proactively stupid justifications they insist on sharing). The latter is especially true if you can find a practitioner that accepts that their treatments don’t always work and have a system to notice that and change course, but I think maybe even the really gung-ho ones sometimes have good ideas (you just have to set up your own system for deciding when to quit). Just don’t get hung up on “do we understand why this works?” or “does this work for other people?”

Also please remember that side effects and drug interactions are a thing. Anything with a real effect can hurt you. I gave a very caveated suggestion of BosPro to someone on Twitter and it caused something akin to niacin flush in them. This is the same brand that does nothing to me but makes me better at digestion and uninterested in sugar.

So I guess the full and accurate statement of my beliefs is “Try solving problems with understanding first, but accept when you’ve hit diminishing returns and consider if your energy isn’t better spent increasing your surface area to luck”.

Parting shots

Fuck you every doctor who told me my digestive problems were in my head or my fault for being a bad patient and you couldn’t help me until I solved the problem that drove me to you. You were factually incorrect and you should feel terrible.

For potential clients in particular

People sometimes approach me for medical literature reviews aimed at their specific problem. There are forms of these I will do, but those forms do not include producing a mechanistic model and high-probability treatment for someone’s persistent, sub-clinical, amorphous problem that medicine has failed to solve. There are a few reasons accepting these commisions would be wasting the clients’ money, and one of them is that by the time they come to me they have found all the low hanging deterministic fruit. The best I can do is spend a ton of time generating lists of things that might work. Sometimes I do offer that, but people tend to prefer my other offer of a referral to a researcher that’s better at individualized treatment.

The Balto/Togo theory of scientific development

Tragically I gave up on the Plate Tectonics study before answering my most important question: “Is Alfred Wegener the Balto of plate tectonics?”

Let me back up.


Balto is a famous sled dog. He got a statue in NYC for leading a team of dogs through a blizzard to deliver antibody serum to Nome, Alaska in 1925, ending a diphtheria outbreak. Later Disney made a movie about how great he was.

Except that run was a relay, and Balto only got famous because he did the last leg, which had the most press coverage but was also the easiest. The real hero was Togo, the dog who led the team through the hardest terrain and covered by far the most miles as well. Disney later made a movie about him that makes no mention of Balto for the first 90%, and then goes out of its way to talk about what a shit dog he was, that’s why he didn’t get included in any of the important teams, but Togo had had to do so many hard things they needed a backup team for the trivial last leg so Balto would have to do.

Togo’s owner died mad about the US mainland believing Balto was a hero. But since all the breeders knew who did the hard part Togo enjoyed a post-Nome level of reproductive success that Ghengis Khan could only dream about, so I feel like he was happy with his choices.

plus he did eventually get some statues

But it’s not like Togo did this alone either. He led one team in a relay, and there were 20 humans and 150 dogs that contributed to the overall run. Plus someone had to invent the serum, manufacture it, and get it to the start of the dog relay at Nenana, Alaska. So exactly how much credit should Togo get here?

The part with Wegener

I was pretty sure Alfred Wegener, popularly credited as the discoverer/inventor of continental drift and mentioned more prominently than any other scientist in discussions of plate tectonics, is a Balto.

First of all, continental drift is not plate tectonics. Continental drift is an idea that maybe some stuff happened one time. Plate tectonics is a paradigm with a mechanism that makes predictions and explains a lot of data no one knew was related until that moment.

Second, Wegener didn’t discover any of the evidence he cited, he wasn’t the first to have the idea, and it’s not even clear he did much of the synthesis of the evidence. His original paper refers to “Concerning South America and Africa, biologists and geologists are in close agreement that a Brazilian–African continent existed in the Mesozoic”

So he didn’t invent the idea, gather the data, or even really synthesize the evidence. His guess at the mechanism was wrong. But despite spending hours digging into the specific discovers and synthesizers that contributed to plate tectonics, the only name I remember is Wegener’s. Classic Balto.

On the other hand, some of the people who gathered the data used to discover plate tectonics were motivated by the concept of continental drift, and by Wegener specifically. That seems like it should count for something. My collaborator Jasen Murray thinks it counts for a lot

Jasen would go so far as to argue that shining a beacon in unknown territory that inspires explorers to look for treasure in the right place makes you the Togo, racing through fractured ice rapids social ridicule and self-doubt to do the real work of getting an idea considered at all. Showing up at the finish line to formalize a theory after there’s enough work to know it’s true is Balto work to him. This makes me profoundly uncomfortable because strongly advocating for something unproven terrifies me, but as counterargument arguments go that’s pretty weak.

One difficulty is it’s hard to distinguish “ahead of their time beacon shining” from “lucky idiot”, and even Jasen admits he doesn’t know enough to claim Wegener in particular is a Togo. But doing work that is harder to credit because it’s less legible is also very Togo-like behavior, so this proves nothing about the category. 

So I guess one of my new research questions is “how important are popularizers?” and I hate it.

Dependency Tree For The Development Of Plate Tectonics

This post is really rough and mostly meant to refer back to when I’ve produced more work on the subject. Proceed at your own risk.


As I mentioned a few weeks ago I am working on a project on how scientific paradigms are developed. I generated a long list of questions and picked plate tectonics as my first case study. I immediately lost interest in the original questions and wanted to make a dependency graph/tech tree for the development of the paradigm, and this is just a personal project so I did that instead.

I didn’t reach a stopping point with this graph other than “I felt done and wanted to start on my second case study”. I’m inconsistent about the level of detail or how far back I go. I tried to go back and mark whether data collection was motivated by theory or practical issues but didn’t fill it in for every node, even when it was knowable. Working on a second case study felt more useful than refining this one further so I’m shipping this version. 

“Screw it I’m shipping” is kind of the theme of this blog post, but that’s partially because I’m not sure which things are most valuable. Questions, suggestions, or additions are extremely welcome as they help me narrow in on the important parts. But heads up the answer might be “I don’t remember and don’t think it’s important enough to look up”. My current intention is to circle back after 1 or 2 more case studies and do some useful compare and contrast, but maybe I’ll find something better.

(Readable version here)

And if you’re really masochistic, here’s the yEd file to play with.

Scattered Thoughts

Why I chose plate tectonics

  • It’s recent enough to have relatively good documentation, but not so recent the major players are alive and active in field politics.
  • It’s not a sexy topic, so while there isn’t much work on it what exists is pretty high quality. 
  • It is *the only* accepted paradigm in its field (for the implicit definition of paradigm in my head).
  • Most paradigms are credited to one person on Wikipedia, even though that one person needed many other people’s work and the idea was refined by many people after they created it. Plate tectonics is the first I’ve found that didn’t do that. Continental drift is attributed to Alfred Wegener, but continental drift is not plate tectonics. Plate tectonics is acknowledged as so much of a group effort wikipedia doesn’t give anyone’s name.

Content notes

  • This graph is based primarily on Plate Tectonics: An Insider’s History of the Modern Theory of the Earth, edited by Naomi Oreskes. It also includes parts from this lecture by Christopher White, and Oxford’s Very Short Introduction to Plate Tectonics.
  • Sources vary on how much Alfred Wegener knew when he proposed continental drift. Some say he only had the fossil and continental shape data, but the White video says he had also used synchronous geological layers and evidence of glacial travel.
    • I tried to resolve this by reading Wegener’s original paper (translated into English) but it only left me more confused. He predicted cracks in plates being filled in by magma, but only mentions fossils once. Moreover he only brings them up to point to fossils of plants that are clearly maladapted to the climate of their current location, not the transcontinental weirdnesses. He does casually mention “Concerning South America and Africa, biologists and geologists are in close agreement that a Brazilian–African continent existed in the Mesozoic”, but clearly he’s not the first one to make that argument.
    • I alas ran out of steam before trying Wegener’s book.
    • I was stymied in attempts to check his references by the fact that they’re in German. If you really love reading historic academic German and would like to pair on this, please let me know.
    • I stuck to just the fossil + fit data in the graph, because White is ambiguous when he’s talking about data Wegener had vs. data that came later.
    • White says the bathymetry maps showing the continental shelves had a much better fit than the continents themselves didn’t come out until after Wegener had published, but this paper cites sufficiently detailed maps of North America’s sea floor in 1884. It’s possible no one bothered with South America and Africa until later.
  • A lot of the data for plate tectonics fell out of military oceanography research. Some of the tools used for this were 100+ years old. Others were recently invented (in particular, magnetometers and gravimeters that worked at sea), but the tech those inventions relied on was not that recent. I think. It’s possible a motivated person could have gathered all the necessary evidence much earlier.
  • Sources also vary a lot on what they thought was relevant. The White video uses continental shelf fit (which is much more precise than using the visible coastline) as one of the five pillars of evidence, but it didn’t come up in the overview chapter of the Oreskes book at all.
  • This may be because evidence of continental drift (that is, that the continents used to be in different places, sometimes touching each other) is very different than evidence for plate tectonics (which overwhelmingly focuses on the structure of the plates and mechanism of motion). 

Process notes

  • At points my research got very bogged down in some of the specifics of plate tectonics (in particular, why were transform faults always shown perpendicular to mountain ridges, and how there could be so many parallel to each other?). This ended up being quite time consuming because I was in that dead zone where the question was too advanced for 101 resources to answer but advanced resources assumed you already knew the answer. In the end I had to find a human tutor.
  • This could clearly be infinitely detailed or go infinitely far back. I didn’t have a natural “done” condition beyond feeling bored and wanting to do something else. 
  • I only got two chapters into Oreskes and ⅔ through Very Short Introduction. 
  • I didn’t keep close track but this probably represents 20 hours of work, maybe closer to 30 with a more liberal definition of work. Plus 5-10 hours from other people.
  • In calendar time it was ~7 weeks from starting the Oreskes book to scheduling this for publishing.
  • You can see earlier drafts of the graph, along with some of my notes, on Twitter.


Thanks to several friends and especially Jasen Murray for their suggestions and questions, and half the people I’ve talked to in the last six weeks for tolerating this topic.

Thanks to Emily Arnold for spending an hour answering my very poorly phrased questions about transform faults.

Thanks to my Patreon patrons for supporting this work, you guys get a fractional impact share.