Month: May 2013

“Because It Costs More”: An Example of Medical Reasoning

Seth Roberts10 Comments

Melody McLaren, a friend of mine, lives in London. Her husband has Parkinson’s Disease and receives treatment through the National Health Service. His treatment has included “ deep brain stimulation” — implantation of an electrical device that stimulates subcortical brain areas. It is a standard treatment for Parkinson’s. It cost the National Health Service about £35,000.

She was surprised to discover that in the United States, the same procedure involved implantation of two batteries, one for each side of the brain. The device implanted in England has only one battery. It worked fine. My friend wondered why two batteries were used in the United States. She asked her husband’s neurologist, a French woman practicing in London. “Because it costs more,” she said. There was no other reason.

At the San Mateo Maker’s Faire a few weeks ago, I heard a talk by a doctor named Amy Baxter, who had developed a device for pediatricians that makes shots hurt less. (She had a child and noticed the problem.) She went to considerable trouble to develop a product that could be used by working doctors and presented the product several times to potential buyers. Again and again she was told It has to be disposable. Meaning one use per package. Nothing else will fit the supply chain. She did not say why she was told this, but the obvious reason was that disposable products are more profitable.

Steven Brill’s cover story in Time two months ago was about one way American health care takes advantage of sick people with little choice — hospitals, including nonprofits, charge patients for products and services far more than what they cost the hospital. This is another way.

Hospitals and Their Employees: Stuck in the 1800s

Seth Roberts3 Comments

An article in the New York Times describes how difficult it has been for hospital administrators to get their employees to wash their hands. Hospital-acquired infections are an enormous problem and cause many deaths, yet “studies [in the last 10 years] have shown that without encouragement, hospital workers wash their hands as little as 30 percent of the time that they interact with patients.” Hospitals are now — just now — trying all sorts of things to increase the hand-washing rate. The germ theory of disease dates from the 1800s. Ignasz Semmelweis did his pioneering work, showing that hand-washing dramatically reduced death rate (from 18% to 2%), in 1847.

So hospitals are only now (in the last few years) grasping the implications of facts and a well-established theory from the 1800s. What goes unsaid in the usual discussion of how awful this is — how dare doctors refuse to wash their hands!, a sentiment with which I agree — is how backward both sides of the discussion are. A discussion in which many lives are at stake.

The Times article now has 209 comments, many by doctors and nurses. The doctors, of course, went to medical school and passed a rigorous test about medicine (“board-certified”). Yet they don’t know basic things about infection. (One doctor, in the comments, calls hand-washing “ this current fad“.) They appear to have no idea that it is possible to improve the body’s ability to resist infection. I read all the comments. Not one mentioned two easy cheap low-tech ways to reduce hospital infections:

1. Allow patients to sleep well. The body fights off infection during sleep, but hospitals are notoriously bad places to sleep. Patients are woken up by nurses, for example. You might think that everyone knows sleep helps fight infection . . . but apparently not hospital administrators nor the doctors and nurses who commented on the Times article. It was in the interest of these doctors and nurses to suggest alternative solutions because they dislike washing their hands.

2. Feed patients fermented foods (or probiotics). Fermented foods help you fight off infections. I believe this is because the bacteria on fermented food are perfectly safe yet successfully compete with dangerous bacteria. In any case, plenty of studies show that probiotics and fermented foods reduce hospital infections. In one study, “use of probiotics reduced the new cases of C. difficile-associated diarrhea by two thirds (66 per cent), with no serious adverse events attributable to probiotics.” Maybe this just-published article (Probiotics: a new frontier for infection control”) will bring a few people who work in hospitals into the 21st century.

That hospital administrators and their doctors and nurses — and, in this discussion, their critics — are stuck in the 1800s is clear enough. What is slightly less clear is that our understanding is better now than it was in the 1800s and some of the new knowledge is useful.

Thanks to Bryan Castañeda.

Assorted Links

Seth Roberts8 Comments

Thanks to Grace Liu.

Useful Knowledge: Arithmetic and Chinese

Seth Roberts2 Comments

Long ago, a friend told me that when she was in first grade, she had a lot of pennies. She knew how to add but not subtract so after she spent some, she would have to count them again to know how many were left.

I have finally reached the last lesson (Lesson 12) in my beginning Chinese textbook, which I have been using (fitfully) for more than a year. Later lessons build on earlier lessons. When I didn’t know a word in a later lesson, I scanned the new-word lists from earlier lessons to find it. I have just discovered there is a word index.

Anti-Procrastination Software Available

Seth Roberts10 Comments

 

This graph shows how much work I did in early 2013 (one point = one day). It gradually rose from about 2 hours/day to about 8 hours/day. I did not literally get to 8 hours/day because some tasks got counted extra. For example, one minute of Chinese counted as 2 minutes and one minute of book writing counted as 1.5 minutes. The data is in three blocks because sometimes I didn’t use the tracking program (e.g., due to travel).

I gathered the data with a program that gave percentile feedback. Percentile feedback compares where you are now (measured in various ways, such as time of day, e.g., 3 pm) to where you were at the same time on previous days and summarizes the comparison with a percentile: 75 means more work done than on 75% of previous days at the same time; 50 means more work done than on 50% of previous days at the same time. Displays of such feedback, I noted earlier,

are curiously likable. They usually praised me, in the sense that the percentile score was usually well above 50. . . . They are calm, in the sense that they do not change quickly. . . . Every improvement was noticed and rewarded — and every non-improvement was also gently noted. It was as if the display cared.

Nick Winter used with an earlier version of percentile feedback (video). “The percentile feedback has been a huge success,” he wrote. “I’m getting way more done than I ever did, and I’m much better at prioritizing toward my main project.”

The new version has several improvements. The biggest change is weights — different tasks may have different weights. Tasks that are more valuable or more difficult get more weight. If you keep failing to do something important, you increase its weight, making it more attractive. For a long time, I have had trouble making myself study Chinese. This has helped a lot.

It has also pushed me away from blogging (less valuable) toward book writing (more valuable). I am writing a book about personal science. The chapter I am writing now is about procrastination.

This program has been a big help with procrastination and has improved my use of time in other ways. To get material for the procrastination chapter, I am making the program (written in R) available, along with a draft of the procrastination chapter. I want to find out what happens when other people use it.

To get the program and use it, you need to install R (which runs under Windows, MacOS, and many UNIX platforms), use Dropbox, and use PayPal. You can do some work away from the computer but it won’t work unless you do most of your work at or near the computer.

For better or worse I have learned it is a waste of time to give software to others for free. If you are interested in using it, please send me an email with the following information:

1. Your job.

2. Why you want to try this.

3. How much you will pay (non-refundable after 2 days).

4. How long you will commit to using it.

5. How much you will pay if you don’t meet the commitment (= a refundable amount).

I’ll pick the highest bidders. If you’re one of them, you’ll give me the amount in #3 plus the amount in #5 via PayPal. I’ll install the program on your computer via Dropbox and show you how to use it (in addition to the written instructions). If you use it for the promised length of time, I’ll refund the amount in #5.

 

 

Next Meeting of Make Yourself Healthy Group is Tomorrow (Thursday)

Seth Roberts1 Comment

The next meeting of the Make Yourself Healthy Meetup group is tomorrow (May 23, Thursday) at the Telegraph Ministry Center (5316 Telegraph, Oakland). Social time will start 6:30 pm, the meeting proper at 7:00 pm. It will last about 2 hours. Admission is $3, payable at the door, to cover the cost of renting the space.

The first speaker will be Robin Barooah, who will tell how he cured his RSI (Repetitive Strain Injury). What his doctors told him to do didn’t work.

More on the Synergy of Walking and Learning

Seth Roberts11 Comments

A few years ago, I discovered that walking made studying Chinese more pleasant and studying Chinese made walking more pleasant. It’s a big effect. While walking on a treadmill I could easily study Chinese for 40 minutes; while sitting or standing still, 5-10 minutes. The general idea seems to be that walking creates a thirst for novelty, for dry information. An evolutionary explanation is that this effect caused us to better explore our surroundings. Such exploration paid off too rarely and/or with too-long delays to be supported by the usual reward-action mechanism.

Jeremy Howard, the president of Kaggle, discovered the same effect independently while studying Chinese. A few days ago, I heard from Patrick Roach, a medical student in the Midwest, who also discovered the same effect independently — in his case, studying anatomy rather than Chinese. He blogged about the Anki/treadmill combination. I asked him if walking on a treadmill made it easier to study Anki? He replied:

Absolutely. I originally tried this with a 3100 card deck I created while studying anatomy in med school. The format (Image/Name) was perfect for reviewing while walking, as there wasn’t too much text to read. I imagine your experience with learning a new language was similar. Anyways, Treadmill + Anki (+Music) along with my Tablet / Wiimote combo was much more productive than either task alone. I could easily spend 1-2 hours and not notice the time passing in the same way it dragged on when trying to study endless flashcards sitting in a quiet room. Getting tired or losing focus was less of an issue as well – I noticed I had less distractions/extra attention to spare while walking.

Thanks for getting in touch, Patrick. As Lewis Carroll said, “What I tell you three times is true.”

 

 

More about Give and Take by Adam Grant

Seth Roberts3 Comments

Yesterday I commented about Give and Take by Adam Grant, a professor at Wharton who teaches organizational psychology.

When Grant was a graduate student (at the University of Michigan), he was asked to help people at the university’s fund-raising call center raise more money. They call alumni, asking for money. The person who ran the center had tried the usual motivational tactics, such as offering bonuses. They hadn’t worked.

Grant noticed that most of the money being raised went for scholarships. He tried various ways of making the call center employees aware that the money they raised helped students directly. The most effective way turned out to be a 5-minute meeting with a scholarship recipient. This had a staggering effect:

The average caller doubled in calls per hour and minutes on the phone per week . . . Revenue quintipled: callers averaged $412 [per week] before meeting the scholarship recipient and more than $2000 afterward.

A huge effect — and a useful huge effect. And one that is not even hinted at in countless introductory psychology books. Notice that physical conditions of the job and the “physical” payoff (the salary) didn’t change. All that changed was employees’s mental models of their job.

I conclude that people are far more motivated by a desire to help others than you would ever guess from reading psychology textbooks — and, even more, from reading economics textbooks. Grant says nothing about this, at least in the book, but I’d guess that the employees were considerably happier at their jobs as well. You might think that there has been so much research on job design that there were no big effects left to be discovered. You’d be wrong.

Give and Take by Adam Grant

Seth Roberts10 Comments

The publisher sent me a copy of Give and Take by Adam Grant after I sent several emails asking for a review copy. I expected it to be the best book about psychology in many years and it is.

The book’s main theme is the non-obvious advantages of being a “giver” (someone who helps others without concern about payback). Grant teaches at Wharton, whose students apparently enter Wharton believing (or are taught there?) that this is a poor strategy. With dozens of studies and stories, Grant argues that the truth is more complicated — that a giver, properly focussed, does better than others. Whether this reflects cause and effect (Grant seems to say it does) I have no idea. Perhaps “givers” are psychologically unusually sophisticated in many ways, not just a relaxed attitude toward payback, and that is why some of them do very well.

I was more impressed with two other things where cause and effect is clearer. One is a story about communication style. It is the best story in a book full of good stories. About ten years ago, Grant was asked to teach senior military officers how to motivate their troops. His first class was a four-hour lecture to Air Force colonels in their forties and fifties. Grant was 24. The feedback forms, filled out by the students after the class, reflected the age — and presumably wisdom — discrepancy. One comment was: “More quality information in audience than on podium.”

Grant taught the class again, to another group of Air Force colonels. Instead of talking about his credentials at the start of the class, he began like this:

I know what some of you are thinking right now: What can I possibly learn from a professor who’s twelve years old?

Everyone laughed. Grant does not say what he said next — how he answered the question. He went on to give the same lecture he had given before. The difference in feedback was “night and day”. Here is one of the comments: “Spoke with personal experience. He was the right age! High energy; clearly successful already.”

This is great. A non-obvious, seemingly small change produces a huge outcome difference. Grant clearly understands something enormously important about communication that isn’t not found in other psychology books, such as introductory textbooks. It isn’t easy to interpret (why exactly did Grant’s new opening have its effect?) nor study experimentally — but that’s fine. In Give and Take, Grant follows this story with research about what is called “the pratfall effect”: Under some circumstances making a blunder (such as spilling a cup of coffee) makes a speaker more likeable. But Grant’s opening (“what can I learn…”) isn’t a blunder. Grant calls it an “expression of vulnerability”, a category broad enough to include pratfalls — fair enough.

What can we learn from Grant’s story? Above all, that something mysterious and powerful happens or might happen at the beginning of a talk and that ordinary feedback forms are sensitive enough to detect it. What Grant did was highly specific to the situation (young speaker, older military officers) so you can’t copy it. To use it you really have to grasp the general rule. Which remains to be determined.

Tomorrow I will blog about another impressive part of the book.

“You Can’t Change Something Unless You Love It”: The Case of Dr. Gilmer and Dr. Gilmer

Seth Roberts6 Comments

“It’s a funny thing,” Jane Jacobs told an interviewer in an interview I cannot find, “you can’t change something unless you love it.” (By “change” she meant improve.) She had seen that people who disliked cities gave poor advice about improving them and understood that it wasn’t just cities. To improve something, it isn’t enough to have a good idea. You also need to (a) pay close attention and (b) overcome obstacles. (a) and (b) aren’t easy. You are unlikely to do them without strong motivation, such as love.

Jacobs’s point is at the heart of the success of my personal science. My personal science is hugely different from professional science, but different may or may not be better. It has succeeded, I’m sure, because of what Jacobs says. How did I manage to find new ways to sleep better, lose weight, and so on? I had good ideas, yes, but so do many people, including professional scientists. One reason for my success: I observed myself closely. Now and then I noticed outliers (e.g., nights when I slept unusually well, days when I lost my appetite). These gave me ideas to test. In professional science, this rarely happens. For one thing, they can’t wait for outliers. They are under pressure to get results soon. Another reason for my success: I persisted. For many years, I measured my weight, sleep, mood, and so on. Unlike a professional scientist, I had no required output. I could spend as much time as necessary.

I keep coming back to this because Jacobs’s point is absent from conventional American thinking, such as New York Times op-eds. But it is illustrated again and again. A recent episode of This American Life, titled “ Dr. Gilmer and Mr. Hyde“, is about two doctors named Gilmer: Dr. Benjamin Gilmer and Dr. Vince Gilmer (who are unrelated). VG kills his father and goes to jail. BG replaces him at a rural clinic. His patients tell him what a nice man VG was. This puzzles BG: Why would such a nice man kill his father? The legal system had ignored this question or at least not provided a convincing answer. BG, on the other hand, actually cares. (Spoiler alert.) He gathers information about the case and visits VG in prison. With the help of a psychiatrist friend, he comes up with a new idea: VG has Huntington’s disease, whose symptoms include aggression (such as murder). In prison, VG has been far too aggressive. His hands shake some of the time; this had been called “malingering” (faking) by a psychologist. When tested, it turns out VG does have Huntington’s disease, in the sense that he has the gene for it. When VG was given medication appropriate for Huntington’s disease, he got much better.

BG, who cared about VG, managed to improve his condition. The legal system, which did not care about him, did not. The implication for all health care, including research, is straightforward: Empower those who care.