Health

Doctors and Smart Drugs

Posted by Peter on December 23, 2010
Posted in: Health, The Human Mind.

Doctors are more willing to prescribe Viagra than cognitive enhancement drugs.

Why?

The report wonders whether it’s due to conservative tendencies among doctors. But Viagra and Modafinil both became available in the U.S. in 1998. Conservatism doesn’t explain why doctors are slower to accept Modafinil than Viagra. Although maybe combined with more patients asking for Viagra it would be plausible.

Concern over side effects might explain why doctors are less comfortable with Ritalin, but not why three different cognitive enhancing drugs all produced similar comfort levels – about half that of Viagra. And I see no signs that Modafinil is much riskier than Viagra.

Could it be concern that Viagra has an equalizing effect (making people more normal), whereas cognitive enhancers make people who can afford them smarter than the less fortunate? Partly – doctors were more willing to prescribe cognitive enhancers for older patients than younger ones. But the cross-drug comparisons were done for a case where “the patient was a 40-year-old reporting symptoms consistent with the label indications for the respective drug”. I’m pretty sure the label indications describe a patient who is functioning well below normal.

The obvious conclusion part of what’s happening is that doctors believe sex produces larger benefits than cognitive enhancement. If we ignore potentially important externalities such as sexually transmitted diseases versus improved science/technology (would doctors admit to doing that?), I could make a decent case for sex being more valuable. There’s no shortage of evidence that sex makes people happy, whereas there seems to be little or no correlation between cognitive ability and happiness.

(HT YourBrainonDrugs.net).

Counterclockwise

Posted by Peter on December 15, 2010
Posted in: Book Reviews, Health, The Human Mind. Tagged: , .

Book review: Counterclockwise: Mindful Health and the Power of Possibility, by Ellen J. Langer.

This book presents ideas about how attitudes and beliefs can alter our health and physical abilities.

The book’s name comes from a 1979 study that the author performed that made nursing home residents act and look younger by putting them in an environment that reminded them of earlier days and by treating them as capable of doing more than most expected they could do.

One odd comment she makes is the there were no known measures of aging other than chronological age at the time of the 1979 study. She goes on to imply that little has changed since then – but it took me little effort to find info about a 1991 book Biomarkers which made a serious attempt at filling this void.

She disputes claims such as those popularized by Atul Gawande that teaching doctors to act more like machines (following checklists) will improve medical practice. She’s concerned that reducing the diversity of medical opinions will reduce our ability to benefit from getting a second opinion that could detect a mistake in the original diagnosis, and cites evidence that North Carolina residents have an unusually high tendency to seek second opinions, and also have signs of better health. But this only tells me that with little use of checklists, getting a second opinion is valuable. That doesn’t say much about whether adopting a culture of using checklists is better than adopting a culture of seeking second opinions. The North Carolina evidence doesn’t suggest a large enough health benefit to provide much competition with the evidence for checklists.

One surprising report is that cultures with positive views of aging seem to produce older people who have better memory than other cultures. It’s not clear what the causal mechanism is, but with the evidence coming from groups as different as mainland Chinese and deaf Americans, it seems likely that the beliefs cause the better memory rather than the better memory causing the beliefs.

Two interesting quotes from the book:

certainty is a cruel mindset

to tell us we’re “terminal” may be a self-fulfilling prophecy. There are no records of how often doctors have been correct or not after making this prediction.

The bacterial part of our bodies

Posted by Peter on November 3, 2010
Posted in: Health.

Some quotes from Bacteria ‘R’ Us:

the vast majority — estimated by many scientists at 90 percent — of the cells in what you think of as your body are actually bacteria

researchers describe bacteria that communicate in sophisticated ways, take concerted action, influence human physiology, alter human thinking and work together to bioengineer the environment. These findings may foreshadow new medical procedures that encourage bacterial participation in human health.

Many researchers are coming to view such diseases as manifestations of imbalance in the ecology of the microbes inhabiting the human body. If further evidence bears this out, medicine is about to undergo a profound paradigm shift, and medical treatment could regularly involve kindness to microbes.

bacteria “have to have a reason to hurt you.” Surgery is just such a reason.

bacteria that have antibiotic-resistance genes advertise the fact, attracting other bacteria shopping for those genes; the latter then emit pheromones to signal their willingness to close the deal. These phenomena, Herbert Levine’s group argues, reveal a capacity for language long considered unique to humans.

Doctor/Hospital ratings

Posted by Peter on October 14, 2010
Posted in: Health, U.S. Politics.

Despite strong opposition, a little progress is being made at informing consumers about medical quality and prices.

Healthcare Blue Book has some info about normal prices for standard procedures.

Healthgrades has some information about which hospitals produce the best outcomes (although more of the site seems devoted to patient ratings of doctors, which probably don’t make much distinction between rudeness and killing the patient).

Insurers are trying to create rating systems, but reports are vague about what they’re rating.

One objection to ratings is that

such measures can be wrong more than 25 percent of the time

A 25 percent error rate sounds like a valuable improvement over the current near-blind guesses that consumers currently make. Does anyone think that info such as years of experience, university attended, or ability to make reassuring rhetoric produces an error rate in as low as 25 percent? Do medical malpractice suits catch the majority of poor doctors without targeting many good ones? (There are some complications due to some insurers wanting to combine quality of outcome ratings with cost ratings – those ought to be available separately). Are there better ways of evaluating which doctors produce healthy results that haven’t been publicized?

More likely, doctors want us to believe that we should just trust them rather than try to evaluate their quality. I might consider that if I could see that the profession was aggressively expelling those who make simple, deadly mistakes such as failing to wash their hands between touching patients.

Medical Tourism Seasteads

Posted by Peter on October 28, 2009
Posted in: Freedom, Health. Tagged: .

How can a hospital-like business operating outside of existing territorial jurisdictions avoid harrassment by governments whose medical lobbies want to spread FUD?

Given that these businesses will initially have no track record to point to and less protection than existing medical tourism providers from whatever government provides a flag of convenience to the business, merely providing comparable quality medical care won’t be enough for such businesses to thrive. So I’m proposing practices which could enable those businesses to argue that current U.S. hospitals are more dangerous. I’m not suggesting this just for marketing purposes – I want safe hospitals to be available, and regulatory costs in the U.S. make it easier to start an innovative hospital offshore than in the U.S. (especially for types of innovation that don’t respect doctors’ prestige).

It has been known since 1847 that doctors kill patients by failing to wash their hands often enough. Yet this threat is still common. An offshore hospital could offer patients documentation showing when medical personel who touch the patient washed their hands (e.g. by providing the patient with video recordings of the procedures sufficient for the patient to verify cleanliness), with a double your money back guarantee. There are many other less common errors that patients could use such videos to check for.

The book Counting Sheep argues that hospitals often impair patients’ health by disturbing their sleep. Paying patients if night-time noise or light levels exceed some pre-specified limits should reduce this problem.

Next, I want the hospital’s fee structure to give it increased incentives to avoid failure. For procedures with objectively measurable results, I want the hospital to charge the patient only if those results are achieved, and to pay the patient some pre-specified amount if results leave the patient measurably worse off. (For hard to measure results such as change in pain, this approach won’t work).

The article You Get What You Pay For: Result-Based Compensation for Health Care has more extensive discussion of incentives and of strategies that hospitals might use to reduce the rate at which they harm patients.

Life Expectancy and the Business Cycle

Posted by Peter on October 18, 2009
Posted in: Health, Idea Futures.

I once proposed using life expectancy as the primary indicator of what society should try to maximize.

Recently there have been reports that life expectancy is negatively correlated with standard measures of economic growth. I accept the conclusion that depressions and recessions are less harmful than is commonly believed, but I want to point out the dangers of looking at only the life expectancy in the same year as an event that influences life expectancy. Depressions may have harmful effects that take a decade to show up in life expectancy figures (e.g. long-term wealth effects, effects on willingness to wage war, etc). So I’d like to see how life expectancy averaged over the ensuing 10 or 15 years correlates with a year’s gdp change.

Human Enhancement

Posted by Peter on July 10, 2009
Posted in: Book Reviews, Health, Humor, Science and Technology. Tagged: , , , , .

Book review: Human Enhancement, edited by Julian Savulescu and Nick Bostrom.

This book starts out with relatively uninteresting articles and only the last quarter of so of it is worth reading.

Because I agree with most of the arguments for enhancement, I skipped some of the pro-enhancement arguments and tried to read the anti-enhancement arguments carefully. They mostly boil down to the claim that people’s preference for natural things is sufficient to justify broad prohibitions on enhancing human bodies and human nature. That isn’t enough of an argument to deserve as much discussion as it gets.

A few of the concerns discussed by advocates of enhancement are worth more thought. The question of whether unenhanced humans would retain political equality and rights enables us to imagine dystopian results of enhancement. Daniel Walker provides a partly correct analysis of conditions under which enhanced beings ought to paternalistically restrict the choices and political power of the unenhanced. But he’s overly complacent about assuming the paternalists will have the interests of the unenhanced at heart. The biggest problem with paternalism to date is that it’s done by people who are less thoughtful about the interests of the people they’re controlling than they are about finding ways to serve their own self-interest. It is possible that enhanced beings will be perfect altruists, but it is far from being a natural consequence of enhancement.

The final chapter points out the risks of being overconfident of our ability to improve on nature. They describe questions we should ask about why evolution would have produced a result that is different from what we want. One example that they give suggests they remain overconfident – they repeat a standard claim about the human appendix being a result of evolution getting stuck in a local optimum. Recent evidence suggests that the appendix performs a valuable function in recovery from diarrhea (still a major cause of death in places) and harm from appendicitis seems rare outside of industrialized nations (maybe due to differences in dietary fiber?).

The most new and provocative ideas in the book have little to do with the medical enhancements that the title evokes. Robin Hanson’s call for mechanisms to make people more truthful probably won’t gather much support, as people are clever about finding objections to any specific method that would be effective. Still, asking the question the way he does may encourage some people to think more clearly about their goals.

Nick Bostrom and Anders Sandberg describe an interesting (original?) hypothesis about why placebos (sometimes) work. It involves signaling that there is relatively little need to conserve the body’s resources for fighting future injuries and diseases. Could this understanding lead to insights about how to more directly and reliably trigger this effect? More effective placebos have been proposed as jokes. Why is it so unusual to ask about serious research into this subject?

Ending Aging

Posted by Peter on July 31, 2008
Posted in: Book Reviews, Health. Tagged: .

Book review: Ending Aging: The Rejuvenation Breakthroughs That Could Reverse Human Aging in Our Lifetime by Aubrey de Grey and Michael Rae.
This book makes a strong argument that the most important medical need in developed countries is to cure the damage associated with aging, rather than to combat the diseases which become serious as a result of that damage. It outlines a set of solutions which, if they can be implemented, look like they would add at least a decade or two to healthy lifespans.
All of the solutions look like they have a reasonable chance of being implemented within 20 years. But the probability of all of them working within that time is a good deal lower than the probability of any one solution working, and there’s no obvious way to analyze whether we can get significant health benefits without implementing all of the solutions.
The authors seem somewhat overconfident about most aspects of their proposed solutions, but that doesn’t affect the substance if their arguments very much. Even a small chance of postponing death and disability is worth a good deal of effort.
The parts of the solutions that appear hardest are the ones that rely on techniques similar to what are already being attempted by mainstream scientists (genetic engineering to add and delete genes from most cells in the body, massive use of stem cells, and moving enzymes across the blood-brain barrier). My impressions about the effort that has been put into these techniques and the results that have been produced so far suggest that at least one of these is likely to take much longer than the book asks us to hope for. The book gives one clear example of important research not living up to the hype surrounding it when it gives arguments that most cancer research is directed toward modestly postponing cancer rather than providing a full solution to cancer. I see no obvious way for a layman to tell whether the authors are relying on similarly overhyped research.
So even though the book gives convincing arguments that the goals of medical research ought to be reframed to focus on aging as the primary threat to be solved, it’s far from conclusive about whether that should imply a large change in actual research. It may be that the hardest and most valuable tasks are the ones that are already being worked on. Or it may be that one of the critical tasks is sufficiently hard that the most important need is to invent tools that are substantially more sophisticated than what’s used in existing research (i.e. that we most need something more radical that what’s proposed in the book, such as nanomedicine).