Review: The Remedy: Robert Koch, Arthur Conan Doyle, and the Quest to Cure Tuberculosis (Thomas Goetz)

I love this book so much I gave it to my cats to cuddle, which would have made a more impressive visual if I hadn't gotten the kindle version.
I love this book so much I gave it to my cats to cuddle, which would have made a more impressive visual if I hadn’t gotten the kindle version.

I don’t even know where to start.  This book was fun to read and I felt like I learned a lot.  It covered both the specific facts of Robert Koch’s quest to prove germ theory and cure tuberculosis, and provided a good general sense of how science and medicine move forward and don’t.

A couple of specifically interesting points: doctors fought germ theory tooth and nail.  They also rejected stethoscopes as technological interlopers to be disposed of because they threatened the doctors importance, while using so many leaches prosperous countries had to import them.  The naive interpretation is “doctors are idiots, their reluctant to use quantified self data is proof they haven’t changed.”  This is the first time I’ve seen any hint as to why they found germ theory so implausible.  In the particular case of tuberculosis, everyone was exposed all the time, and it took the infection years to become symptomatic.  Preventing any one exposure wouldn’t have had noticeable results.  Another early-identified bacteria was Anthrax, which didn’t follow a typical exposure pattern either.  The doctors still come out looking pretty bad for refusing to wash their hands between autopsies and childbirth, but marginally less than they might have.

I knew this already, but it was good to have a reminder that the first person to suggest the germ theory of disease, Ignez Summelweis, died in an insane asylum.  This either means that people with truly visionary ideas can be broken when we reject them, or germ theory was so crazy it took a crazy person to see it.  Goetz doesn’t mention it but according to my dad Summelweis was also an asshole, which I try to remind myself every time someone mean says something I disagree with.

Remember last week when I suggested using microchips to force people to finish their antibiotics?  Several friends seriously questioned the effect of that, since they didn’t estimate the contribution of unfinished antibiotics to antibiotic resistance as very high.  The Remedy says that the current protocol for drug resistant TB is to have a medic visit a patient every day for 6 -24 months to observe them taking their pills, because drug resistant TB is that big a problem and the pills are that unpleasant.  So at least in that situation swallowable microchips would be an enormous improvement.

Apparently syphilis is always the [nationality] disease, where the nationality is not the speaker’s.  French is the most popular, but far from the only

I’ve always found the methods section the most boring of any paper or textbook.  I want to know what we learned, not how.  But The Remedy (and to a lesser extent Neanderthal Man, which I reviewed last week) made it seem interesting.  I’m still not terribly interested in microscopy, but it was deeply interesting to see how advances in technology enabled scientific advances.  Using or inventing new technology is how you move the world forward.  And when I thought about it, the modern field that most reminds me of the wide-open-ness of microbiology in the mid 1800s is programming.  That is where I get the most sense of possibility.  I still really care about translational health (in fact this book taught me that that is the word for what I am trying to do with this blog) and mental health, but I am feeling more and more like staying in programming would be the best way to accomplish that.

The Science of Blood Types

Yesterday I made an offhand remark that the Red Cross was so persistent in stalking me because I was O-.  Here’s why that’s important:

Your red blood cells can have two different proteins on them (A or B), or both, or neither.  If you receive a transfusion with red blood cells with a protein you don’t have, your immune system will mark it as a foreign invader and attack it.  If you get too much of these cells, you will die.  Parallel to this is another protein Rh factor, which you either have (Rh+) or you don’t (Rh-).  A- means you have A proteins, but not B or Rh factor.  If you are Rh- and receive Rh+ red blood cells, same problem.

You cannot bluff the immune sytem.

O- red blood cells have no immune-triggering proteins on it, and so can be given to anyone.  That makes O- blood extremely useful when you don’t have time to type a patient, or have limited carrying capacity.  Moreover, O- red blood cells are the only type O- patients can accept.  So O- is often the first to run out.

You might think this makes donations from AB+ people pointless, but that is not the case.  Their red blood cells are of limited use, but their blood plasma (which is the part that contains the antigens that trigger attacks on foreign matter) contains no antigens to any blood type.  Meanwhile everything looks like an invader to my O- plasma, and it will react accordingly.  This also means you can only do whole blood donations between complete type matches.  A B+ person can take my red blood cells, but would need plasma from someone else.

And that is why typed-matched blood is preferred and donations of all types are necessary.

Is Blood Donation Effective? (Yes)

Seattle is apparently not the only Effective Altruism group to talk about doing volunteering meetings, only to remember that the traits that make volunteering useful are almost antithetical to the traits that make it fun and doable to for a group on a drop-in basis.  I am kind of hoping that blood donation can bridge that gap.  So here’s my math on how effective donating blood is.  The Red Cross estimates a single donation can save three people, but what they mean is “a single donation can go to three different people.”  To get the actual value we need to see how many units of blood were donated and how many deaths they prevented.

The most recent data I could find was the 2011 National blood Collection and Utilization Survey Report (PDF), which couldn’t make it harder to do this kind of calculation if it tried.  They were extremely loose with what “unit” referred to, so I’m going to stick with the whole and red blood cell transfusions, so my numbers are consistent.  There were 15,721,000 units collected, of which 14,589,000 were deemed usable.  13,785,000 were used, of which 37,000 were directed to a specific patient, and 65,000 were self-donations, which are less effective for various reasons.  The collections numbers don’t call out general vs. specific donations and the numbers are small, so I’ll just use the total number used.  If some blood donations are also generating plasma and white cells in addition to the red blood cells counted here, that would only increase effectiveness.

A single donation is one pint.  Health and Human Services fails to define what they mean by unit, but it appears to mean “whatever you get from one donation after some filtering“, so let’s assume it’s 1:1.  The average recipient receives 2.75 units.  If you assume each person who received a transplant would otherwise die (supported by this sourceless FAQ), that means each donation saves ~1/3 of a life (discounting for donations that are rejected).  Using GiveWell’s $5,000/life number, that’s still equivalent to donating $1,667.   That is overstating the case, because some portion of recipients (I can’t find out how many) have diseases like sickle cell anemia that require chronic transfusions, and the fair thing is to count their lifetime transfusion count, not their per treatment count.  To get an upper bound I’ll use the Red Cross’s number that a car accident victim can use up to a 100 pints of blood, which means each donor saves 1% of that life, which is equivalent to $50 to an extremely effective charity.

But the question isn’t “what is the average value of donated blood?” but “what is the marginal value of your potential donation?”  I can’t find any direct numbers for this, but we have the following evidence:

  • Very little blood is thrown out.
  • People are spending lots of time and money developing artificial blood substitutes.  Despite this there are no generally accept substitutes for blood’s oxygen-carrying capacity.
  • The Red Cross spends a lot of time and money harassing people to donate.  They called my parents’ house for years after my one donation (I’m O-).
  • Some blood is able to reach the “too old” state, but then used to ill effect, indicating lumpy supply or demand.  Unless you can predict demand spikes you should use the average efficacy.  If you can predict demand spikes, there are probably more effective things to do with that power.

So I’m just going to use the average effectiveness as the marginal effectiveness for now.

What are the costs to the donor of donating?  The one time I donated it was high because I slept for the next two days.  If you’re my friend Elena who went into shock after donating, it cost you days and several thousand dollars in ER visits.  So it is probably not worth it for either of us to donate.  But for a typical person with no side effects, it’s plausibly useful.  If it’s replacing work time, then effectiveness depends on their hourly wage.  Multiple websites list the time to donate as 60-90 minutes, which translates to a minimum psuedowage of $33/hour and a maximum of $1667.  The average hourly American wage is $24/hour, although I would estimate the average wage of people earning to give as somewhat higher than that.  So that’s extremely plausible on its face.  But if the time isn’t coming out of work, and is made rewarding to the participant, blood donation is hugely effective.  This suggestions that an event that induced people to donate without replacing work would be effective, more so if it could be made into a positive experience.  So a blood donation event could be a huge win for an EA event.

[Side note: if you decide to do this yourself, I would recommend donating anywhere but the Red Cross if at all possible.  I’m going to try for Bloodworks NW, because if I get enough people they will send a truck and we can make it an actual party]

Bloody cupcakes
Do not GIS “blood donation party” with safesearch off

Hunger Tracker 0.1

When I started this blog I intended to leave programming for medicine fairly soon.  After a long medical leave that let me recover from burnout, I realized that programming is actually a really valuable skill and before I throw it away and spend several years in school, I should see how far it can take me towards my goals.  My goals are unchanged (mostly around nutrition and mental health, but with some bonus input from Effective Altruism), but maybe there’s a better way I can contribute.

Eventually this means founding or joining a company working on something I care about, but I’m still not capable of consistently working sufficient hours to work with other people.  But I can play on my own projects with no coordination costs, so I started learning to program for android.  Meanwhile on the health end, my nutritionist informs me there are states of hunger between “unpleasantly bloated” and “would shank an infant for juice” that are useful to experience, and that the first step to achieving that is tracking my hunger consciously.  She meant with pen and paper, but I am an engineer, so I wanted something on my magic pocket computer to do it for me.  I’m sure something exists on android that would do this, but I couldn’t find it, so I did the logical thing and started developing my own.

Thus was born the Hunger Tracker app.  Here is my dream feature list for Hunger Tracker:

  • Alarm goes off at pre-set or random times (your choice), to shut it off you enter a number between 0 and 9, representing your fullness level.
  • Timestamp + fullness level data is dumped…somewhere, I don’t know.  A google docs spreadsheet would work for me but there’s probably other services I should integrate with.
  • UI not actively offensive

Here’s what version 0.1 does

  • No alarm, user must manually call up app.
  • User enters number in ugly ass UI.  Actually user can enter any arbitrary string, but don’t, it will break the retrieval.
  • User can retrieve first 10 numbers entered.  Any further entries are skipped, if there are too few entries the last one is repeated.
  • It’s a debug build rather than a release build because Android Studio won’t produce a working release build and fixing that is not at the top of my priority list.

If you are interested, you can download version 0.1 here and install it the usual way for non-market apps.  If you are spectacularly interested, you can check out the source code at github.  Comments are extremely welcome

My next step is not actually features, but testing, which I will explain in the next entry.

Alternate Birth Control

Hormonal birth control was a world changing invention that gave women a lot of new freedom and power.  I am so, so glad it was invented.  I am less glad that we as a society somehow got stuck on hormones as the ultimate way to prevent babies.  Hormones are weird and unpredictable and involved in every part of metabolism.  It would be extremely weird if they didn’t have side effects beyond preventing ovulation.  And yet the past 40 years of contraceptive history are mostly people refining hormones, rather than inventing something more awesome.

If you want permanent birth control there are some very good options, but temporary and reversible options are pretty scarce. There’s condoms, which are amazing at some things and cause inconveniences way less than those caused by hormones, but more than zero.  There vagina based barrier + spermicide methods, which are more convenient but less effective, and regularly putting anti-microbials in the vagina has its own health costs.  There’s the copper IUD, which is great at preventing pregnancy but causes horrendous cramping in the vast majority of users.

This is how I got interested in fertility tracking.  There are actually only a few days each cycle sex can lead to pregnancy.  If it’s more than 5 days before ovulation or 1 day after, you can put all the sperm you want anywhere in the body, and it’s not going to cause a pregnancy.  The old way to try and find these days was “counting”, but that doesn’t account for inter- and intra- person variation in cycle length and has a subsequently high failure rate.  Luckily (?) there’s a lot of changes in the body that precede and follow ovulation, because ovulation is caused by hormones which are as previously mentioned extremely complicated and involved in a lot of different things.  These include temperature, cervical mucous,  and saliva electrolyte level (seriously).  Tracking all of those still seems like a lot of work, especially since they need to be done first thing on waking up to avoid contaminating the very subtle signals by doing something like moving.  But there are some newer options on the market that ovulation with a lot less work, and those seemed worth investigating.

The first of these is to directly measure hormone changes in the urine to detect imminent ovulation.  Conveniently, there are hormonal changes that start 5-6 days before actual ovulation.  There is no way to do this yourself.

The second option is temperature monitoring.  Your temperature dips right before ovulation, and is slightly higher for the ~two weeks after ovulation than the ~two weeks before.  For years if not decades, people have tracked this themselves using regular thermometers and paper, and it theoretically works, but you have to do it the second you wake up to dodge the wake up temperature increase, and I personally don’t want to stake contraception on my ability to do fine motor work and record three significant digits exactly when I wake up.

There’s a few other scattered options including monitoring cervical mucus, cervical position, and the shape your saliva dries in (no, seriously).  But science x  capitalism have provided me with magic computers to track the first two things, and not the any of these, so I’m going to ignore them.  Science has patented a toothbrush that will look at your spit for you (no, seriously), but capitalism has yet to put it into production.  There are also tools that could be combined with graph paper to turn them from fertility devices to contraception devices, but I’m going to focus on the options that require the least thought possible.

Note that none of these devices are available in the US for the purposes of contraception.  You can buy hormone tests to predict ovulation for the purposes of creating babies, but not preventing them.  Purely for educational value I’ve looked up the prices on, but you should definitely not circumvent the wise and benevolent FDA by ordering from them.

Persona tracks hormones alone.  It costs  52 pounds (~$76) for a starter kit and an additional 13 pounds (~$20) per month.  It requires peeing on a stick 16 mornings out of your first month and 8 on subsequent months, and you have a good six hour window in which to do it.  You feed the sticks into the magic computer machine and it tells you when you are close enough to ovulation that you should abstain from unprotected sex.  It reports 94% success rate.

Lady Comp  tracks temperature alone.  It costs 415 pounds and claims 99.3% rate.  That’s higher than a hormonal IUD, which does everything short of going back in time and murdering your partner’s mother to prevent pregnancy, and it seems unlikely that that could be matched by something that could be confused by me using my mattress heating pad.*

Cyclotest is tracks temperature and optionally several other indicators.  It costs 150 pounds (~$220 dollars).  You need to monitor your temperature for approximately half your cycle.  It allows you to enter your cervical mucus viscosity and cervical position to provide additional data but declines to teach you how to do so.   Its display is nuanced enough to be used both for contraception and trying to conceive, and if you’re trying to conceive you can supplement the temperature data with hormone tests (~15 pounds/month).  It too reports a 94-99% success rate, which makes me think that is either the hard limit of predicting ovulation (maybe failures come from super long lived gametes rather than bad timing), or that Persona and Cyclotest are using the same data to support their different methods.

Of these three, Cyclotest was my favorite before I even looked at the data, because Cyclotest’s website explains both the science of how it works and the mechanics of using their system, whereas Persona organizes it very counterintuitively and Lady Comp just repeats Natural and No Side Effects until your ears bleed.  I think I went to amazon to find out what it actually did.

I managed to find the study Lady-Comp must have gotten their 99.3% success rate from.  To be fair, that is what it says (full text PDF).  And it’s the real world success rate, not the theoretical rate.  But it was a retrospective study, meaning they just reached out to people who have previously purchased the device and asked them if they had gotten pregnant.  A number of people were unreachable, and not all that were reachable returned the survey.  They don’t even report the full number of surveys they sent out, which makes the data completely unusuable.  The paper also indicates Lady-Comp requires significantly more data than temperature alone, which would sure be a good thing to indicate on the website.

Persona has a publications section on their webpage, but their contraception page only has articles on awareness, not efficacy, so really this is just one more reason to hate the word awareness.  I was unable to find the source of their quoted 94% success rate, but I did find a paper criticizing it.

Cyclotest’s quoted 1-6% failure rate is as good or better than condoms, which surprises me.  This paper doesn’t give an absolute failure rate but does say it misidentified fertile periods as non-fertile a vanishingly small percent of the time, which would be more impressive if that were based on hormones or actual conception rates rather than simple calendar checks..  This paper puts the actual failure rate of temperature only methods at up to 3% per month, which is way too high, but not necessarily worse than actual use rates of other methods.

This paper puts the correct use pregnancy rate of an unknown computer aided system at 2%/year and the actual use rate at 12%/year.  It’s always hard to parse the real world failure rates.  Take condoms.  I don’t think someone simply forgoing condoms half the time counts as a strike against condoms.  But “correct” use of condoms is actually a lot of work, and at a certain point I feel like condom manufacturers are just trying to pass the buck.   Using lube to reduce friction to prevent breakage is a reasonable action you either do or don’t, but no one has ever defined for me exactly how much  “vigorous or prolonged thrusting” necessitates changing a condom.  And it’s just bad design to have something break exactly when people are least likely to want to check or fix it.

I was really hoping for better than this.  Another beautiful theory, killed by an ugly gang of facts

*Which is, side note, the best thing ever and you should totally get one.

Pain, ADHD, and happiness

I jokingly referred to pain-induced ADD on Monday, but I’m becoming more and more convinced that is actually what was happening.  After prior surgeries I was too exhausted to notice anything, but this time I was energetic enough to experience the pain.  I mean, unless I tried to go outside or something.  That led to a really entertaining systems crash in the supermarket.  But if I stayed inside I was able to do things like get food and put away dishes without strain.  Contrast with when my pain meds sabotaged my cortisol production.  Intellectually I was there and able to do things like read and blog, but physically it was a struggle to make myself a smoothie.

After surgery I could not read or write or even enjoy a movie.  It was more than pain making everything 70% less fun, it was that everything was annoying and frustrating and no fun at all.  I couldn’t enter a state of flow or concentration or even relaxing for any length of time.  Except when I played video games or the piano.  Neither were fun, exactly, and I was still in pain, but they were at least distracting and rewarding.  Looking back, this explains a lot of my behavior when I was in constant pain last year, it just took being out of pain and then very sharply in a lot of pain to make the pattern obvious.

At first I thought this was  Harrison Bergeron type thing, where pain was sending out interrupts too often for me to get into a groove on anything.  But then I read this blog post (blogs were just about in my power) by Sara Constantin on dopamine, explaining Peter Redgrave’s hypothesis that the spike (phasic increase) of dopamine is not itself a reward (which is how pop journalism usually describes it) but a timestamp that lets you know what actions should get credit for the actual reward chemicals you are about to receive.  That would explain why humans and animals with broken dopamine systems do feel pleasure when eating but will nonetheless starve to death unless you put the food directly in their mouth.

Many of the drugs used to treat ADHD inhibit dopamine reuptake, which raises your tonic (baseline) dopamine levels.  Constantin hypothesizes that if the baseline is too low than stimuli that should be ignored suddenly are interpreted as important, leading to a lot of SQUIRREL.

[ I was going to make this a gif but putting unpausable moving pictures in a post on ADHD just seemed cruel]

If this is correct, it offers an explanation for why ADHDers are so drawn to things like videogames and sex:  the time gap between doing the correct thing and getting the chemical reward is so short they can still determine causality, even against the a background of SQUIRRELs.  This needn’t be purely about hedonism- if it was, something consistently pleasant would work.  I think it’s about having an internal locus of control and self-efficancy.  Humans are happiest they feel like they have the power to change their own circumstances and have an impact on the world.  It’s hard to feel those things if your attention is constantly being torn away from what you choose and you can’t (on a neural level) determine what made you feel the emotion you are currently feeling.  This is one reason the toll of ADHD shouldn’t be measured in lost productivity alone; even people with very successful coping mechanisms are being denied that internal locus of control, and that’s miserable.

Here’s my contribution: my description of being in pain sounds a lot like other people’s description of ADHD, right down to video games being rewarding without strictly being fun.  And as it turns out the basal ganglion, the area Redgrave believes is using dopamine to timestamp causes so they can be matched with effects, also releases dopamine in response to pain.  It seems entirely possible to me that high baseline levels of dopamine could diminish the effect of a spike.  Instead of everything being timestamped “good job”, nothing is, with similar results

But let’s make it even more interesting.  Several anti-depressants are also useful in treating chronic pain, and NSAIDS (usually mild pain killers) treat depression.  I had previously put this down to “pain is depressing”, “depression appears to be connected to inflammation in ways we don’t understand” and plain old “brains are squishy and they don’t make sense”, but if there was a causal link?  The symptoms of depression include fatigue, feelings of helplessness and lost of interest or enjoyment of previously liked activities, which sure sounds related.  Quick googling found a very tiny study showing a connection between low dopamine and suicide, and this fascinating study suggesting that inflammation reduced the basal ganglia’s production of dopamine, which would tie all of this up in a very pretty bow.  Something causes pain and/or inflammation (the two often go together), which long term causes inflammation in the basal ganglia, which causes depression and reduces your body’s natural analgesics.

Look body, if you were worried about us getting high off of pain, maybe you could have releases fewer happy chemicals in response to pain, instead of making it just as fun but also cause depression some time later.

This would also explain why ADHD medicines are promising in treating depression (source, source, and a large showing among my friends), and why ADHD and depression so often go together.*

I cannot stress enough how unqualified I am to make this hypothesis.  Lots of people know lots more on all of these things than me.  But it comes together to be an extremely plausible explanation for both the literature I’ve read and my personal experiences.

*There’s a lot of evidence that depressed parents correlate with ADHD kids, but it’s probably environmental.

Simple Screening for Depression?

A  new study by Reid et al claims to demonstrate a biological marker for the presence of depression.  First we have the boring criticisms, like “32 is not a real sample size, “shotgunning 20 RNA markers and noticing which ones were increased in depressed patients and decreased after treatment is painting the target after you shot the gun” and “you’re comparing treatment group re-draws to control group baseline draws” but anyone could make those.  The authors make several of those points themselves.  And there are some statistical criticisms that pretty much invalidate the whole thing.*  What I find interesting is that even if the results are correct, they may not be useful.

If you look at the table comparing the marker rates in depressed and non-depressed patients, there are 9 markers that differ in a statistically significant way. The problem is that they’re still not very far apart.  What you would ideally like to see in a diagnostic test is the following:

Two bell curves with no overlap
Two bell curves with no overlap

because then it easy to translate a test score into a health status.  But the markers in this study are more like

two overlapping bell curves
two overlapping bell curves

Which means that if you know someone is depressed you can generate a pretty good idea of their marker score, but there’s a wide range where knowing their marker score doesn’t give you a good idea if they’re depressed.   That makes it pretty useless for a screening test.

But it’s actually worse than that.  There are many more undepressed people than depressed people, so the curves could look more like


Under this graph, the sick mean could be four standard deviations out from the health mean, and yet a person with a low marker score is approximately equally likely to be depressed or not.  This is a bayesian reasoning problem and doctors are frighteningly bad at those, but then, they’re worse than chance at frequentist statistics too.

In summary, I’m not hopeful this proves to be a useful screening tool for depression.

*They don’t actually prove that the marker values of cured people converge with those of never-depressed people, they just fail to prove they’re statistically different.  Those are different things.  They also switch between two (equally valid) statistical tests (T-test and Fischer’s) without saying why, which means there is a high probability the answer is “we liked those answers more.”

Review: How to Be Sick (Toni Bernhard)

Everything this book says is absolutely true.  Mindfullness is awesome.  Spending energy being angry at reality for not living up to your expectations is not useful.  A calm acceptance of where you are now without attachment to the future is useful in almost any situation.  But my primary feeling reading the book was “This is fine for you, but I’m going to get better, so I’m just going to go wait for that.”  I told that to someone in the waiting room at the IV place who was probably suffering from something pretty serious*, thinking I was making a funny joke about how I had failed at zen, and she said “good for you, keep fighting.”

This captures a lot of the tension around health problems that are prolonged or chronic or ambiguous as to where they fall between the two.  If you “accept your limitations” too hard you end up putting yourself in smaller and smaller boxes until there’s nothing left.  If you don’t accept your limitations enough you push too hard and make yourself worse.  How to Be Sick isn’t falling into those traps.  It’s describing a third way, of zen acceptance that doesn’t overly narrow or widen your vision for the future because it’s not about the future.  The problem is that this is hard to teach.  The author had been practicing Buddhism for 10+ years when she fell ill, and most of the book feels more like describing the benefits or appearance of a mindfulness practice rather than how to achieve it.   I did get one really useful technique out of the book, enough to justify all of the time I spent reading it, and I suspect that will be true for a lot of people so I do recommend it.  It’s just not magic.

Although maybe it kind of is.  I ordered the book from the library when my doctor looked at me and said “maybe being pain free isn’t a realistic goal for you and you need to redirect your energy to learning to cope with it.”  But then I saw a specialist who told me that the damage was healing, would probably be finished in about a year, and in the meantime enjoy this pain medication that leaves you almost pain free.  So I can’t rule out that this book actually is magic, and if you are at the point where you’re considering books with subtitles like “A Buddhist-Inspired Guide for the Chronically Ill and Their Caregivers”, you probably are going to try weirder things in your attempt to heal yourself.  So give it a shot and please report back.

*I’m there to mainline protein because my teeth and stomach aren’t up to the task of eating enough to heal me, but a lot of people are there for debilitating but poorly understood collections of symptoms like fibromyalgia, or better understood but more terminal diagnoses like cancer.  Nothing makes me you feel grateful for your health after having dead bone scraped out of your jaw like seeing an eight year old get cancer treatment.

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.

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: Selling Sickness ( Ray Moynihan, Alan Cassels)


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.