Author: Aceso Under Glass

Bug or Feature? SAT edition

A few weeks ago there was a Less Wrong thread about truly brilliant people, especially mathematicians, who often got good but not perfect SAT scores.  The consensus was that the SATs were a better test of how long you can go without making a mistake than of genius.  At the time I read this I (who got good but not perfect SAT scores) was all “yeah, the SATs are bad at measuring brilliance.  And I did better in more advanced classes than I did in the intro ones, because the intro ones were about how close you came to matching their expectations, and the advanced ones were about original thought.  In fact the smartest people will do worse, because this is so trivial to them it is boring.  I sure hope the SATs feel bad for failing to recognize my their brilliance.”

I was about 10% of the way through Safe Patients, Smart Hospitals when I realized that if I am recovering from dangerous surgery and need a central line*, it is more important that my doctor can follow the safety checklist without getting bored than that he be capable of original thought.  Like, way, way more important.  We need doctors capable of original thought somewhere, so they can invent new procedures and drugs and things, but outside of their magesteria they do more harm than good.

dr_house_brain
Gregory House would be terrible at inserting central lines. That’s why he has Taub.

So maybe the SATs are doing a valuable service by injecting a little bit of what it takes to succeed in the real world into their otherwise-pretty-much-an-IQ-test.  And maybe we should start selecting doctors for what they actually do most of the time.  Alternately, maybe we should move central-line-type work to techs and computer algorithms and use doctors for research and cases weird enough to be on TV.  But what we should definitely not do is select people for brilliance and make lives depend on their ability to work methodically.

*Central lines deliver fluids better than IVs but are more vulnerable to infections, which can be fatal, especially in people recently weakened by trauma or illness, which is everyone who is getting a central line.  You can greatly reduce the chance of an infection by following a fairly simple list of steps like “use gloves” and “sterilize skin”, but these are often skipped.

Review: Immune Defense Video Game

Medical-inspired video games have a long history of disappointing me.  For example, real pathogens don’t ride rocket ships around your organs (Trauma Center)

nor does every single member of the species worldwide suddenly develop a new trait all at once (Plague, Inc)

And Surgeon Simulator does not follow Atul Gawande’s best practice surgical checklists at all

Plus Trauma Centers’s difficulty curve is insane, and they found a way to make repeating unskippable cutscenes worse. But one of the nice things about game development getting cheaper is they can make games for me and the four other people who will appreciate a cross between an immunology textbook and Majesty, which is the best way to describe Immune Defense.  In Immune Defense you play as the immune system, releasing various immune cells (each with different skills, and customized to different pathogens), which you do not directly control (it isn’t pac-man) but can lure over to the bacteria with antibodies if the %^&*ing macrophages will stop eating them.  In place of the usual Hit Points it has an inflammation count, which is actually pretty reasonable.  It has some biological inaccuracies (I’m reasonably certain real neutrophils don’t change receptor types instantaneously), but it’s still overall educational. Note the lack of rocket ships in this trailer.

That said, it’s obviously still in beta, and if the phrase “immunology x majesty” doesn’t grab you, you’re probably better off waiting.  The tutorial is really lacking and they need to smooth out some of the controls.  But I had a ton of fun until tendinitis forced me to stop playing, and if “immunology x majesty” does inspire joy in your heart you will probably enjoy it a lot, so check out the IndieGoGo and demo.

Oral Probiotics for Dental Health

Bias disclosure: I started taking oral probiotics because my doctor told me to and I have vaguely positive feelings about probiotics.  I kept taking them because simple inspection with my tongue showed I was developing fewer dental plaques.  But the friend I recommended them to wanted actual data, so I did some digging.  The results were overwhelmingly positive.  They reduced not only cavities, but in the study that checked, total antibiotic usage.  In your face, friend who asked for data.

But only one of those tested a probiotic lozenge, the rest were milk products supplemented with Lactobacillus rhamnosus.  Not all Lactobacillus species scored so well, so I went to check what my supplement had.  Turns out it has no Lactobacillus at all.   So I went back to google scholar and checked the bacteria I was actually taking (Bacillus coagulans and Streptococcus salivarius).  Luckily the news was still good: in head to head trials, Bacillus coagulans was found to be as effective as a mix of Lactobacillus rhamnosus and Bifidobacterium species, and Streptococcus salivarius also performed well.

Then I found the motherload: someone did a comparative survey.  This was less helpful to my cause.  Oral probiotics were almost universally found to be helpful to children, but results in adults were mixed.   My first argument is “well, yeah, adults develop fewer cavities per unit time than children, so you’d need a bigger sample over a longer time period to detect a difference.”  But the studies looked at intermediate results like “bad” bacteria presence, and even the 15 month trial in older and elderly people didn’t see a difference.

My conclusion is that oral probiotics are definitely good for children, and in light of the additional data for my personally, good for me, but possibly not for all adults.  I still feel confident recommending other people try them, but not that they stick with them if they don’t see results.

ETA 12/24/19: I’m currently using Florassist (affiliate link).

ETA 08/27/21: I’m currently using Life Extensions Oral Hygiene (affiliate link)

Activism Field Trip

One of my ongoing concerns about Effective Altruism is that it doesn’t handle activism or political change well, because the marginal value of any given activity is essentially zero.  You can do some relative effectiveness- Martin Luther King Jr apparently scouted out towns most likely to react violently to his nonviolent protests, in order to get more sympathetic publicity- but it’s no where near the certainty of Against Malaria Foundation’s cost per life saved (which itself has a huge confidence interval).  And yet, political activism is essential as a tool for improving the human condition.

Recently I participated in a FreePress.net-organized visit to one of my senators, to convince them to more vocally support net neutrality, and specifically Title II classifying cable utilities as common carriers.  This is a thing that seems important as long as cable has a stranglehold on broadband in the US, and my impression was that all I had to be helpful was live in the senator’s state (check) and show up.  That is within my power, and now was a relatively easy time to do it (still on leave for dental surgery but at a relative high in my ability to talk).  I think on some level I expected it to be a more fleshy version of phone calls for the EFF, where they do all the dialing and give you a script to read, and your job is just to demonstrate to powerful people how many unpowerful people are willing to spend their time annoying them over a specific issue.

The plusses: I was shocked by how diverse the delegation was.  I was expecting a bunch of 20-35 year old tech nerds, but the age range was probably 30-75, with me as the only programmer, and a wide range of political orientations.  Several of the people were longtime activists.  At the end of the visit the senator had agreed to do what we wanted.

The minuses:  the visit could have been much better organized.  There was a real disconnect between what FreePress said our senator’s position was, and what the senator’s aid said their position was.  We didn’t so much convince the senator to change positions as ask for something they were already doing.  Maybe FreePress didn’t bother to investigate, maybe the senator’s aid was weaselwording.  There was no one who knew and no one had the authority to shift our collective gears.

This was the first time in a while I’d experienced the gap between talking with EAs and talking with politically and socially active non-EAs.  The groups have different skills.  None of the people who took point could have persuaded anyone I know out to pour water out of a boot if the instructions were written on the bottom*, but they did organize rallies of 1000+ people, which I have never done and have never heard of being done in the history of effective altruism.  We’re more a blogging type of people.  And the dailykos reporter is better than me at that, in the sense of “many more people read him”.  This is bothersome when he is complaining about rising rents and construction in the same paragraph, but useful when shining light on police misconduct.

So EA is still my home, and probably will be for a while, even if I’m drawn to areas that don’t have any officially blessed EA charities, like mental health and first world education.  I would like us to have more thought diversity than we do, but really enjoy not having to explain why you can’t complain about rent and construction at the same time, or at a bare minimum knowing that if I do have to explain it I’ll have social support.

*”But what if there is a faster or less energy-intensive way to empty the boot?”

Review: Selling Sickness ( Ray Moynihan, Alan Cassels)

(Previously)

Selling Sickness‘s goal was to convince the reader that pharmaceutical companies manipulate perception to create an impression of disease where none exists.  I was going to say it failed, but no, it didn’t.  It actually has some pretty good examples of how pharma manipulates perceptions.  I just find it’s own view problematic as well.  E.g. Pharma is trying to make the diagnosis of Female Sexual Dysfunction equivalent to male impotence, when it clearly isn’t, and that’s bad.  But Selling Sickness’s  implication that the components of FSD (low libido, anorgasmia, pain during intercourse) should not be taken seriously by medics is ridiculous.  Sexual pleasure is important to many people in its own right, and any of those issues could be a symptom of a serious underlying problem.  Testosterone is a bad treatment for low libido because it’s a major hormone with far reaching effects, but it is an excellent treatment for low testosterone, a serious health problem for which low libido may be the most obvious symptom.

Selling Sickness talks about how pharma companies manipulate disease definitions (by sponsoring educational conferences and key decision makers), but it doesn’t explain anything else about how those decisions are made, or what would happen in the absence of pharma money.  Without that information it’s hard to draw conclusions.  Which I guess is how I feel about the book as a whole: its advocating a very specific point of view rather than informing you on the topic as a whole.  There’s nothing wrong with that, except that it (rightly) condemns pharmaceutical companies for doing the same thing.

*Obviously there’s a lot of variation and some doctors respond to those symptoms properly.  My sense from the literature and anecdata from my friends is that they’re going against the grain when they do so.

ETA: Slate Star Codex provides an example of pharma criticism done right, because he talks about the cracks in the system capitalism is filling.

Selling Sickness: Depression and Anxiety

Previous: Aceso Under Glass Valentine’s Day Special

Like many people, the authors of Selling Sickness believe that drugs for depression and anxiety are over-prescribed, that they are used to escape everyday emotions, and that this is terrible.  Again, I wish they’d defined their terms better.

For example, it sounds ridiculous to give someone Prozac because they’re sad their mom died.  That sadness is categorized as natural and healthy, in fact barring very unusual circumstances it would be viewed as sick not to feel sad at that point.  But you only get anti-depressants for “being sad” if it lasts more than two years.  Until then, anti-depressants are given only when negative emotions* start destroying a person’s ability to run their own life, and thus become self-reinforcing.  It’s completely natural and healthy to still be morning your mom’s death two months later, but if you’re unable to shower or eat for that length of time it doesn’t matter that the depression has an obvious external cause, it’s hurting you and there shouldn’t be any shame in accepting medical treatment for that.

A common fear I hear around anti-depressants is that they make people tolerate situations which should be depressing, and thus impede their exit.  That’s a real concern, and I think we should watch for it.  On the other hand, there are lots of people who want to leave but are unable to do so because they’re so depressed, and anti-depressants give them the activation energy and hope in the future that lets them leave.  And the same drug can have both effects in different people, or even the same drug at different times, because humans are weird and we don’t understand what we’re doing.

“We don’t understand what we’re doing” is not a great endorsement for something that’s screwing with the chemicals inside your brain.  I do think we need to use caution, that the risks are poorly understood, especially by GPs, and that nutrition and exercise are underutilized as treatments.  I also think that even when anti-depressants are the best individual decision, mass use of them can indicate a problem (I’ve heard 50% among PhD students, which cannot be okay).  And there will always be room for debate- should you be expected to work productively a month into grieving?  To work in a really difficult, dehumanizing office environment?  Would you need anti-depressants to take care of your kids if you had better community support?

But big pharma is not the one creating those societal conditions, and destigmatizing mental illness because it benefits them financially seems like a success story to me.  If we’re going to counter over prescribing let’s look closer to the problem (doctors) or further away (societal structure), not question the people receiving needed help.

*Not necessarily sadness.  In fact in men depression often manifests as anger, which leads to under-diagnosis.

Gender-based variation in grading and teacher attitudes.

Jezebel (via NYT): “Girls Outscore Boys on Math Tests, Unless Teachers See Their Names”
New York Times:  “How Elementary School Teachers’ Biases Can Discourage Girls From Math and Science”
Study Abstract:  “We’re going to skip explaining how we proved gender bias and just talk about its effects”
Actual Study (no public link): “Young Israeli girls outscore boys on anonymously graded national math exams but receive lower classroom grades, but eventually begin to underscore them in national exams as well.  The size of the discrepancy in scores is positively correlated with discrepancy in teacher attitude reported by boys and girls.  This pattern does not hold for English or Hebrew.”

I went in to reading this study pretty guns blazing, but it actually looks quite well done and robust.  You could argue that the teachers and tests are evaluating different things and the teachers’ goals are not necessarily worse, but

  1. Stereotypically, girls are better at pleasing teachers than boys.  And that is in fact the pattern we see in Hebrew and English.
  2. Low-biased teacher grades was correlated with a decrease in performance among girls in later grades (beyond that that would be predicted by low grades alone). The best case scenario is that the teachers are spotting some hidden weakness in the girls that the lower grade tests didn’t cover.  Except…
  3. Grade bias was positively correlated with negative student reports of the teachers attitude, and specifically discrepancies in the attitude reported by girls and boys.

So the actual study is pretty impressive, and astonishingly so for being in the field of education.    Touche, Lavy and Sand.  I also found it interesting that bias against girls was strongly correlated with the socioeconomic status of girls in the class as a whole, but not with any individual girl’s SES.  E.g. having a poor girl from a large family with uneducated parents lowered the grades of other girls in the same class, regardless of their own status, which suggests all kinds of unpleasant things.

The popular reporting on this paper is less impressive.  Jezebel flat out lies, implying that the same test was graded blindly and with the name (but no other data) available, which led to 100 comments asking how math grades could even vary that much, and 100 other comments saying “partial credit for showing work”.  The New York Times isn’t quite so egregious but does describe the input as “The students were given two exams, one graded by outsiders who did not know their identities and another by teachers who knew their names.”  That’s technically true, but implies that the two exams were much more similar than they actually were.   I expect this kind of crap from Jezebel, but the New York Times shouldn’t have to sensationalize results that are already this interseting.

Aceso Under Glass Valentine’s Day Special

My original plan was to finish Selling Sickness and write an overall book review, but I have reached that stage where I can’t continue reading it until I get some of my current thoughts out of my head, so we’ll be doing this in stages.

There exist many, many criticisms of the pharmacutical industry, all of which I dislike for framing it as the fault of the pharmaceutical companies and not the FDA.  If you want to learn more about this, Bad Pharma is a good source.  Selling Sickness‘s is more specifically about claim is that pharmaceutical companies deliberately manipulate both the public’s and the medical field’s view of illnesses, and “defines health people as sick” for their financial benefit.

I really, really wish Selling Sickness had defined its terms better.  Let’s use heart attacks as an example, because it is Valentine’s day.  No one questions that heart attacks are extremely bad, that they are associated with high blood pressure and high cholesterol, and that giving medications that lower blood and cholesterol to people who have already had a heart attack lowers the chance of a second one and increase life expectancy.  From this some people concluded that high blood pressure and cholesterol cause heart attacks, and we should lower them with drugs even in people who have never had a heart attack.  Selling Sickness describes that as turning healthy people into sick people.

Let me say out several different possibilities that would account for all available information:

  1. High blood pressure and/or high cholesterol damage your coronary system, causing heart attacks.
  2. Sufficiently high blood pressure and/or high cholesterol damage your coronary system, causing heart attacks, but we have drawn the cut off in the wrong place.
  3. High blood pressure and/or high cholesterol damage your coronary system, causing heart attacks, if and only if you have already had a heart attack.
  4. High blood pressure and/or high cholesterol and heart attacks share a root cause, the common treatments treat that cause, and the indicator numbers go down as a result.
  5. High blood pressure and/or high cholesterol and heart attacks share a root cause, the common treatments treat only the symptoms and leave the chance of a first heart attack unchanged, but coincidentally help after a heart attack.
  6. There are multiple causes of high blood pressure and high cholesterol have multiple causes, one of which also causes heart attacks.  Drugs happen to attack root cause if you have it, lower blood pressure and cholesterol to no effect if you do not.
  7. High blood pressure and/or high cholesterol damage your coronary system only in conjunction with an unidentified third factor, and so drugs reduce lifetime mortality if and only if you have that factor.  People who have a heart attack have that factor by definition and thus benefit from blood pressure/cholesterol medications.  They would benefit from them before their heart attack as well, but we have no way to identify them ahead of time.

Under which of these scenarios would you call someone with high blood pressure sick?  It’s a trick question because sick and healthy aren’t actually medical terms. The term for something given to an asymptomatic person that keeps them from developing symptoms in the future isn’t “making them sick”, it’s  “preventative medicine”, and it’s generally considered a good thing.

If high blood pressure and cholesterol don’t immediately cause symptoms but do damage your coronary system, taking drugs to combat them is a good call (dependent on side effects).   You could call them sick or not, it doesn’t matter.  If there was a pill that kept you at your physical and mental peak for 100 years you’d take it, even if your only health condition is being mortal.  Or maybe high blood pressure/cholesterol does indicate illness, but for one of the reasons outlined above, medication helps the numbers without improving symptoms or outcomes.  Then you’re sick but shouldn’t take medicine.  How useful medicine is has nothing to do with the English words “sick” and “healthy'”.

To be fair, researchers make the same mistake.  What we ultimately care about is if medication improves an individuals quality and quantity of life (with exact weightings dependent on the individual).  That takes a long time to do because people take forever to die.  You only get 20 years total from when you first register the molecule.  For a drug intended to prolong life given to people in their 50s, the drug could go off patent (destroying any ability to recoup the cost of the trials) before it got out of trials.   Even waiting for heart attacks takes a very long time and a very large sample size,because heart attacks aren’t actually that common.  So researchers use proxy measures like high blood pressure and cholesterol, on the assumption that anything that lowers those must prevent heart attacks.  Even researchers who aren’t trying to recoup financial costs do this, because they would like to produce results some time before they retire.  The problem is that even if high blood pressure and cholesterol are tightly coupled with heart attacks, this method will inevitably over-include things that somehow affect the proxy measures without affecting heart attacks, and miss things that decrease heart attacks or lifespan without affecting the proxy numbers.  And of course it’s entirely possible the FDA let pharma companies nudge the cut offs for treatment much lower than they should be, because that’s easy.

So yes, there are a lot or problems with aggressively treating proxy numbers, but “applying the sick label to healthy people” isn’t one of them.

Things I Say a Lot in Crisis Chat: You Are Worthy of Help Too

I talk to a lot of people in crisis chat who feel bad taking up my time, or are reluctant to seek treatment from a professional, or would pay for help but are reluctant to accept free help, because there are so many people out there with more serious problems.  How serious their problem is varies: sometimes it really is a mild problem, sometimes it is years of horrendous abuse that is still technically not the worst thing a human being has ever experienced in the history of time.

The most useful response I’ve found is: “We treat people with sprained ankles even though there are other people with broken bones.  Be honest about your situation and trust the doctor/therapist/charity to prioritize their resources appropriately.”  Nothing works all the time, but I can’t think of a time it didn’t at least help.

Anticholinergic agents and dementia

A new study came out this week suggesting use of a particular class of drug after age 65 was associated with dementia.  Here’s what you need to know.*

The study is retrospective, meaning it took people who developed the disease of interest and then looked backwards at their medications.  Retrospective studies are prone to a number of problems, the biggest one being that even young people with healthy memories are crap at giving you their drug history over the past 10 years, and this is a study of people with dementia.  The researchers dodged this by using an HMO database of the subjects complete medical history, which is a neat trick.  The second problem is that retrospective studies can easily end up being painting the bulls-eye after they’ve fired the arrow.  Mere chance dictates that if you track enough traits, any random subset of a population is likely to have something more in common with each other than with the rest of the population.  If you use the traditional bar of statistical significance (5% chance of results arising by chance), checking 20 traits gives you an expected value of 1 false positive.  To be fair, this study has a much higher significance level, and the effect was dose dependent, which is a very good sign that it’s legit.  The authors heavily imply they deliberately studied anticholinergics rather than shotguning it, but without preregistration there’s no way to be sure.

Anticholinergics come in two forms: antimuscarinics, and antinicotinic.  Short version: these work on different types of neuroreceptors, which live in different parts of the body and do different things . Every example drug they give is an antimuscarinic and of the classes of drugs they list, many have no antinicotinic members.  Even if they technically included antinicotinics in the analysis, they would be such a small portion of the sample that their effect could be overwhelmed.  So I don’t think you can apply this study to drugs like bupropion, which is an antinicotinic.

I don’t like the way they calculated total exposure at all.  Essentially they counted the normally recommended dose of any medication as One Standardized Daily Dose.  But those dosages vary wildly (even the examples they give span an order of magnitude), as do the particular drugs’ ability to cross the blood-brain barrier.  The drugs are prescribed for a huge variety of causes, and what’s sufficient to stop incontinence has nothing to do with what’s sufficient to slow Parkinson’s.  This oversight may cancel out with the fact that they created buckets of dosages rather than do a proper linear regression, in the sense that low-def pictures cancels out bad skin.

The obvious question is “but maybe the same thing that drove people to need anticholinergics increases the likelihood of dementia?”  This study has a much better retort for that than most, which is that anticholinergics were prescribed for a variety of causes, and it’s unlikely they all correlate with dementia.  I find that explanation extremely satisfying, except that they only evaluated the drugs as a single unit.  Antidepressants make of over 60% of the total SDDs taken.  The next most common is antihistamines at 17%.  But since more than 60% of the population took at least one SDD, it seems likely that those were taken intermittently, as opposed to the constant drip of antidepressants.  This leaves open the possibility that the entirety of the effect they attributed to anticholinergics was in fact caused by tricyclic antidepressants alone- and that the real culprit was depression.  The obvious controls were to evaluate the anticholinergics separately, and to compare rates of dementia among TCA treated patients with those treated with other antidepressants.

The subtler version of this question is “what if anticholinergics prolong life, giving you more time to develop dementia?”  I don’t see anything where they checked for that either way.  They did ask for people’s perception of their own health, and that was negative correlated with TSDD, but if TSDD is correlated with depression it’s hard to know how to interpret that.

For all those criticisms, this is an amazingly strong result for a medical study**.   No one study can prove anything (even if i think they had the data to do more than they did).  It definitely merits further investigation (ideally some with animal models, so we can do the causality experiments that would be super unethical in humans), and maybe even behavior change in the meantime, although a lot of the drugs studied are already obsolete or second line.  Plus it another piece of data that will help us figure out how to fight dementia, and that makes me really hopeful.

*Read: here’s what I learned.

**Yes, this should worry you.