“An epidemic of unnecessary and unhelpful treatments”

This article is long, but extremely good. It matches up with both my overall dim view of modern medical care—I haven’t seen a doctor in fifteen years, and hope to extend that stretch greatly—and my recent brushes with the system on behalf of someone else.

Some favorite quotes:

What the patients in both stories had in common was that neither needed a stent. By dint of an inquiring mind and a smartphone, one escaped with his life intact. [The other died.] The greater concern is: How can a procedure so contraindicated by research be so common?


Even if a drug you take was studied in thousands of people and shown truly to save lives, chances are it won’t do that for you. The good news is, it probably won’t harm you, either. Some of the most widely prescribed medications do little of anything meaningful, good or bad, for most people who take them.


According to Vinay Prasad, an oncologist and one of the authors of the Mayo Clinic Proceedings paper, medicine is quick to adopt practices based on shaky evidence but slow to drop them once they’ve been blown up by solid proof. […] “We have a culture where we reward discovery; we don’t reward replication,” Prasad says, referring to the process of retesting initial scientific findings to make sure they’re valid.


It is, of course, hard to get people in any profession to do the right thing when they’re paid to do the wrong thing. But there’s more to this than market perversion. On a recent snowy St. Louis morning, Brown gave a grand-rounds lecture to about 80 doctors at Barnes Jewish Hospital. Early in the talk, he showed results from medical tests on the executive he treated, the one who avoided a stent. He then presented data from thousands of patients in randomized controlled trials of stents versus noninvasive treatments, and it showed that stents yielded no benefit for stable patients.

He asked the doctors in the room to raise their hands if they would still send a patient with the same diagnostic findings as the executive for a catheterization, which would almost surely lead to a stent. At least half of the hands in the room went up, some of them sheepishly. Brown expressed surprise at the honesty in the room. “Well,” one of the attendees told him, “we know what we do.” But why?


So it’s not hard to understand why Sir James Black won a Nobel Prize largely for his 1960s discovery of beta-blockers, which slow the heart rate and reduce blood pressure. The Nobel committee lauded the discovery as the “greatest breakthrough when it comes to pharmaceuticals against heart illness since the discovery of digitalis 200 years ago.” In 1981, the FDA approved one of the first beta-blockers, atenolol, after it was shown to dramatically lower blood pressure. Atenolol became such a standard treatment that it was used as a reference drug for comparison with other blood-pressure drugs. […]

That odd result prompted a subsequent study, which compared atenolol with sugar pills. It found that atenolol didn’t prevent heart attacks or extend life at all; it just lowered blood pressure. A 2004 analysis of clinical trials—including eight randomized controlled trials comprising more than 24,000 patients—concluded that atenolol did not reduce heart attacks or deaths compared with using no treatment whatsoever; patients on atenolol just had better blood-pressure numbers when they died.


According to interviews with surgeons, many patients they see want, or even demand, to be operated upon and will simply shop around until they find a willing doctor. Christoforetti recalls one patient who traveled a long way to see him but was “absolutely not a candidate for an operation.” Despite the financial incentive to operate, he explained to the patient and her husband that the surgery would not help.

“She left with a smile on her face,” Christoforetti says, “but literally as they’re checking out, we got a ding that someone had rated us [on a website], and it’s her husband. He’s been typing on his phone during the visit, and it’s a one-star rating that I’m this insensitive guy he wouldn’t let operate on his dog. They’d been online, and they firmly believed she needed this one operation and I was the guy to do it.”

So, what do surgeons do? “Most of my colleagues,” Christoforetti says, “will say: ‘Look, save yourself the headache, just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account’s not going to be upset with you for doing the surgery. Just do the surgery.’”


“Yes, we can move a number, but that doesn’t necessarily translate to better outcomes,” says John Mandrola, a cardiac electrophysiologist in Louisville who advocates for healthy lifestyle changes. It’s tough, he says, “when patients take a pill, see their numbers improve, and think their health is improved.”


The public grossly overestimates how much of our increased life expectancy should be attributed to medical care, and is largely unaware of the critical role played by public health and improved social conditions determinants.

Wise words from Tucker Carlson

I don’t know much about Tucker Carlson except that he is suddenly a hot cable news interviewer, a line of work that doesn’t interest me at all. So I was pleasantly surprised that in this short interview he said three (!) wise things.

One:

The SAT 50 years ago pulled a lot of smart people out of every little town in America and funneled them into a small number of elite institutions, where they married each other, had kids, and moved to an even smaller number of elite neighborhoods. We created the most effective meritocracy ever.

But the problem with the meritocracy is that it leeches all the empathy out of your society … The second you think that all your good fortune is a product of your virtue, you become highly judgmental, lacking empathy, totally without self-awareness, arrogant, stupid—I mean all the stuff that our ruling class is.

Two:

Intelligence is not a moral category. That’s what I find a lot of people in my life assume. It’s not. God doesn’t care how smart you are, actually.

Three:

Putting smart people in charge of things is fine, but what you really want is wise people.

It’s strange to me that someone who believes those things could achieve fame as a cable host, but they are clear and direct statements that I wholeheartedly agree with.

Know your own mind

Over the years I’ve come to see living as ongoing character work, shaping mine so that my automatic response in any given situation is a righteous and loving one. As Jacques Ellul wrote, “God may act, or He may not act, and when God wishes to act He ought to find instruments which are supple and obedient, ready for his use.” We aren’t born that way, there’s more than a lifetime’s work needed to reach that state, and I don’t know of a more satisfying way to spend my time.

At this late stage I thought my time would be devoted to refinement, steadily applying what wisdom I had already gained. Wisdom is hard to come by and harder to digest, and I figured my time would be better spent living out what I knew rather than looking for more. But I’m pleasantly surprised to have stumbled across one more critical tool, courtesy of Eastern philosophers: knowing one’s own mind.

By knowing one’s own mind I mean recognizing that one’s self is not identical with one’s thoughts, and then going on to observe exactly how one’s thoughts arise and pass away. It’s a practice that all the Eastern meditation traditions emphasize, but it doesn’t seem to yield easily to rational (as opposed to common sense) explanation. I think there’s no substitute for sitting and watching the activity of one’s mind as a means of grasping this truth—or at least for me the practice has led to a gut understanding of it, while rational explanations did not. For me the most helpful approach has been to watch for times where I am getting caught up in a story, then taking a close look at how much the story diverges from the bare facts. It always does, in a way that flatters me or irritates me or worries me. And I’ve gotten better at not getting caught up—at recognizing an oncoming story as it first arises, detatching and watching, letting it fade away as I choose not to feed it.

Before meditating I had learned to confront difficult situations with a large degree of detachment and objectivity, through a combination of practice and teeth-gritting. Early results encouraged me to work at the skills I needed, and the approach became ingrained habit. But it was all purely instinctual—I had little understanding of the forces at work.

My experience with meditation hasn’t really changed the overall approach, but I’ve become much more effective at responding automatically with love, kindness, and clear-headedness, I think because I no longer identify thoughts with the thinker, either my own or those of others, which makes it way easier not to ascribe motives or to spin stories in my head about people that go beyond the bare facts.

The past couple of weeks have been objectively stressful, but I haven’t experienced much stress. I was often short on sleep, forced to negotiate tricky circumstances on behalf of others, dealing with difficult people, confronting an unending series of events that I could easily have found irritating and often infuriating. Before meditating I would have probably done a decent job of navigating those rough waters, but I also would have bottled up a lot of irritation and a bit of fury, which would have slowly ebbed away but still left a cynical residue. This time around I was able to let the irritation and fury go as it arose, watching it arise in me and then pass away with interest, even absorb and defuse some on behalf of others.

It sounds magical and mystical, but is actually mundane. The best concrete example I can give came one morning a few days in, when I needed to be downtown and had arranged to leave early enough so I would miss the worst of the traffic. But one small thing after another came up to delay me. I dealt with each one fairly calmly, and didn’t feel any growing pressure. As I finally managed to step out the front door I was suddenly overwhelmed with feelings—mainly anxiety, some self-pity, some exasperation. But I had enough presence of mind to recognize that those feelings were totally out of proportion to the situation. And so I went back in, sat on a couch, closed my eyes, and let the feelings wash over me without getting caught up in them. They paraded themselves before me, but I just watched, and eventually (five minutes later?) they faded. There was no residue beyond relief that they had left. And reviewing them as I drove downtown, I confirmed that they were baseless—the traffic was hardly worse than it would have been, heavy traffic doesn’t bother me anyway, I didn’t really have a deadline for arriving, everything was proceeding nicely without me. I still don’t know where those feelings came from, but I knew that they weren’t me, that they were a mental and physical response to a long, grueling stretch, and that as long as I didn’t get caught up in them they would pass on.

If these are successes, they are small ones (though I’m still very grateful for them). I still get caught up in stories, and the most I can say so far is that I recognize when it is happening, and can detach myself enough to let them slowly lose their grip on me—very, very slowly. The very next morning I spent the same drive downtown engaged in a long one-sided conversation with someone who had said something to me in passing, cycling between pointing out to myself that this was just the chattering monkey-mind at work, and drifting back into the conversation to score another devastating point against my opponent.

I knew it would pass away, and after thirty minutes it did. But I’m going for five!

Difficulties

I mentioned yesterday that Jacques Barzun’s distinction between problems and difficulties has been an important one for me. But it took a long stretch of practicing the distinction before I saw the genius at the heart of it—problems call for changes in the external environment to reduce or eliminate the challenge, while difficulties call for adjustments in how one deals with the challenge, which may or may not change objectively as a result.

Twenty-five years ago I developed Reiter’s syndrome, an odd form of rheumatoid arthritis which is triggered suddenly and can disappear just as suddenly, but has no known cure. Initially the effects were pretty bad—I could barely walk 100 yards, climb a staircase, or hold my newborn son. I was diagnosed and put on a combination of methotrexate (a chemotherapy drug!) and massive doses of ibuprophen, which got the pain and swelling under control but by no means eliminated it.

Soon after the diagnosis and initial treatment we relocated to the Austin area, and I found a rheumatologist there. He checked me over, ran down all the possible treatments (gold injections, surgery, …), and asked me if I wanted to pursue any. I asked him in turn: what would you choose to do? He said that since the chances of improvement were small and the risks of making things worse were significant, as long as he could stand the pain he’d leave things alone. Excellent honest advice, which I took.

What I noticed over the next ten years was that although my condition didn’t improve, by constantly working to accept it my attitude towards it did. The pain and swelling, and the limits it put on me, became the new normal. The difficulty eventually became a non-difficulty. So much so that it took me awhile to notice that the pain was ebbing. Something inspired me to eliminate the methotrexate, and then gradually cut back the ibuprophen to nothing. I still have pain and limitations, but due to the joint damage which the arthritis did—the arthritis itself is gone.

I like the idea of the new normal. It reminds me of a point Scott Adams made in his book about failing one’s way to success: goals are for losers. Literally. If you set yourself a goal, the only end states are winning and losing—usually losing. Adams suggests adopting systems instead of goals, and by systems he means a methodical approach to a situation. In which case (he claims) you always experience improvement: your approach helps you to handle the situation better, or you tweak the approach until it does, or you decide it won’t and abandon it after having learned something important.

This is a secular engineer’s version of what I think is the path to shalom, as defined by Cornelius Plantinga:

In the Bible, shalom means universal flourishing, wholeness and delight – a rich state of affairs in which natural needs are satisfied and natural gifts fruitfully employed, a state of affairs that inspires joyful wonder as its Creator and Savior opens doors and welcomes the creatures in whom he delights. Shalom, in other words, is the way things ought to be.

May the shalom of Christ be with you!

Scapegoating

I know I took new philosophical and theological studies off the table, but the work of René Girard barely made it under the wire—I first looked at it about a year ago—and if I was going to relax my determination for anyone it would be Girard. (Oh, and Ivan Illich … how many exceptions am I allowed again?)

This FAQ gives a very quick overview of Girard’s mimetic theory. By itself it isn’t enough to fully convey what Girard is getting at, but if you’ve already had your own suspicions about the phenomena which Girard explains the FAQ may inspire you to explore his thought further.

Problems vs difficulties

A month ago I thought I would be returning to regular writing on this blog, but then life intervened. It may still happen, but in the meantime here’s an email to a friend that is worth sharing.

Thanks for this. I thought the video was very good, as well as the website describing their Time Well Spent project. And the practices they recommend sound good to me, though I can’t give first hand testimony (except for ad blocking, a critical tool!) since I don’t have a cell phone.

I also like the idea of a “hippocratic oath” for designers, with caveats–I can’t imagine that companies will embrace the idea unless they see profits in it … but that could happen if people want it. And promoting the idea will increase people’s awareness of the possibility.

There’s a touch of historical ignorance at work here. Technology broadly defined has presented us with similar challenges for hundreds of years, which we’ve mostly failed to meet (or even recognize). Looking more deeply at some of those, e.g. the rise of the advertising model since it was invented in 1830 or so, would add some important perspective.

The proposed response reminds me of a distinction I first ran across in Jacques Barzun, one that has become a credo for me. Here’s a description (from someone writing about Barzun) that’s worth quoting at length (boldface is mine):

There is, however, a philosophical–even an existential–component to Barzun’s writings.  “The purpose I gradually fashioned took the form of a resolve to fight the mechanical,” by which he means any ossified system of beliefs and the behaviors based on them. Our great mistake, according to Barzun, is that we try to affect mechanically what is actually a condition–the human one: “The supposition is that what we face is a problem to be solved; and it is a foolish supposition. Human affairs rarely contain problems with solutions. They contain predicaments and difficulty, which is a very different thing.” And because life “overflows ideologies and coercive systems” and makes everything possible (including ideologies and coercive systems), he views our span on earth not as something to engineer to our advantage, but as a natural state whose unpredictability we must adapt to.

That’s an important two-kinds-of-people distinction for me: some folks think that life presents us only with problems to be solved–“just tell me what to do”–while others (a few, anyway) see the great majority of challenges as difficulties to be addressed on an ongoing basis. Here’s how Barzun put it:

A problem is a definable difficulty; it falls within certain limits and the right answer gets rid of it. But the difficulty–not the problem–the difficulty of making a living, finding a mate, keeping a friend who has a jealous, cantankerous disposition cannot be dealt with in the same way–it has no solution. It calls for endless improvisation, some would say “creativity”.

I thought about that when I read this answer in the Time Well Spent FAQ:

We don’t need more apps or technology, but we need to change the fundamental design for how devices orchestrate the interactions between us and the things that want our attention. Today the Attention Economy is like a city with lots of pollution and accidents. We don’t fix the city by telling residents to leave (turn devices off). We also don’t fix the city by extending the same structure of the city that led to the problems. We fix the cityby adding bike lanes, blinker signals and crosswalks to restructure people’s interactions so there’s less pollution and fewer accidents. We can do that with Time Well Spent.

I think the assumption here (a very common one) is that when difficulties exist in the environment, our job is to eliminate the difficulties rather than equip the inhabitants to deal with them. When they say “We don’t fix the city by telling residents to leave”, they locate the work to be done in the environment, not the inhabitants. As long as we adopt that attitude, we leave people prey to difficulties that are not solvable–which is most of them.

Positivity

51sqvxnwhhlCartoonist Scott Adams (Dilbert) has a unique take on, well, just about everything. I’m reading his book How to Fail at Almost Everything and Still Win Big: Kind of the Story of My Life, which articulates some things I’ve suspected and taught me some new ones.

Adams’s approach in this book may itself be unique—at least I don’t think I’ve encountered it before. What he does quite deliberately is to lay out his thinking about life together with the events in his own life which led to that thinking. The result is a sort of intellectual memoir, but of an everyday practical sort—as he says, kind of the story of his life, but only the parts which ground his outlook.

One anecdote he tells I just love. It happened during a Dale Carnegie public speaking course:

Eventually someone volunteered, and then another. Our speaking assignment was something simple. I think we simply had to say something about ourselves. For most people, including me, this was a relatively easy task. But for many in the class it was nearly impossible.

One young lady who had been forced by her employer to take the class was so frightened that she literally couldn’t form words. In the cool, air-conditioned room, beads of sweat ran from her forehead down to her chin and dropped onto the carpet. The audience watched in shared pain as she battled her own demons and tried to form words. A few words came out, just barely, and she returned to her seat defeated, humiliated, broken.

Then an interesting thing happened. I rank it as one of the most fascinating things I have ever witnessed. The instructor went to the front and looked at the broken student. The room was dead silent. I’ll always remember his words. He said, “Wow. That was brave.”

My brain spun in my head. Twenty-some students had been thinking this woman had just crashed and burned in the most dramatically humiliating way. She had clearly thought the same thing. In four words, the instructor had completely reinterpreted the situation. Every one of us knew the instructor was right. We had just witnessed an extraordinary act of personal bravery, the likes of which one rarely sees. That was the takeaway. Period.

I’m with Adams. I wouldn’t have seen it that way. And I’m glad for the young lady, and for the lesson it teaches me, that the instructor had been trained to see more deeply than me into such a situation.