Treatment decision making

I study how people make decisions about medical treatments, and how they talk with their doctors about those decisions. That's what I do for a living.

So now I'm trying to observe myself, and see what I can learn from it. That's surprisingly difficult.

The story is that I have arthritis in my left hand. Specifically, I have a total loss of cartilage at the base of the thumb -- the joint between what's called the carpal bone, and the metacarpal. The carpal at the base of the thumb is called the trapezium. This was very painful; for much of a year, it ached constantly. I finally got a cortisone injection, which stopped the aching, but didn't stop it from hurting when I use it. The issue has really been forced since my friend talked me into buying a guitar, and getting back into playing it. I also can't really play the sax comfortably, because the left thumb operates the register key, and I realize that's why I pretty much put the sax down as well.

So, the choice is surgery. What they do is to completely remove the trapezium and fill the gap with a tendon harvested from the wrist. Supposedly I won't miss  the tendon. However, the procedure means I'll be in a cast for a month, then have to go in for physical therapy twice a week for several weeks, and it may take a full year to completely get back to full functioning. After that, supposedly, more than 90% of the time, you have great results and never have pain again.

So, that's a bit of a daunting prospect. The difficulty is that I don't really have much insight into how my own brain is processing this decision. I would hope to get at least 20 and preferably 30 years of having my left hand working perfectly, playing music, woodworking, farming, and all the things I want to do which will help make life worth living; to get there, I have to go through a few months of pain and inconvenience.

It seems like a no-brainer when you put it that way but it's actually hard. I have to screw up my courage to make the call to schedule the surgery. Of course there's an instinctive aversion to having my body cut open and pieces chopped out and rearranged. There's a fear of the small chance of something going wrong. And there's time discounting -- the pain is in the near future, the gain in the farther future. All this may be classified as "irrational" but I'm not sure that makes sense -- it's how our minds work.

Well, here goes . . .

Why are rich people stupid?

Kevin Drum notes that Walmart is suffering because it's customers don't have any money to spend. Less food stamps, loss of long-term unemployment insurance, shrinking value of the minimum wage, continued high unemployment due to austerity . . . Their sales and profits are down and so is their stock price.

Well now I wonder whose fault that is? Hmm. Could this have anything to do with it?

The Walmart Political Action Committee spent more than $2 million influencing federal elections in three of the last five federal election cycles, according to a report released Tuesday by Making Change at Walmart, a group of advocates, Walmart workers and others aimed at transforming the company. The report also said that members of the Walton family, the billionaire heirs to the Walmart fortune who own over half of Walmart common stock and hold three seats on the company's board, spent more than $1.3 million on federal elections last year, along with hundreds of thousands more at the state and local level. . . . .

In the case of both the Walmart PAC and the Walton family, much of their spending has gone to candidates supporting conservative causes, the report found.

Go figure. But make sure you don't use any of that fuzzy math with letters in it.

Having it too good?

Connecticut lacks any major league pro teams, unless you want to count the WNBA. So the state is divided between Boston and New York. But, we do have UConn basketball. Both the men's and women's team have been successful over the years, but the women much more so, making this one of the few places in the nation where a women's team is the top media interest and sells the most tickets. Indeed, it's because of the interest inspired by the UConn team that we have the WNBA franchise.

That said, maybe there's such a thing as being too dominant. Since the NCAA championship was inaugurated in 1982, Connecticut and Tennessee have each won 8 times. No other school has won more than twice. Tennessee maybe gets an edge in all-time dominance because they have also lost 5 championship games. Connecticut has never lost one, meaning they have no runner up ribbons. On the other hand, the main reason Tennessee has lost so much is because UConn has beaten them 4 times.

Tennessee last won in 2008, and their long run among the top teams may be over with the retirement of head coach Pat Summit due to early onset Alzheimer's disease. Since then, UConn has won 3 times, including last year. That team is mostly back only better. In spite of having only 8 scholarship players on the active roster, they absolutely crush everybody. They've had only one meaningfully competitive game this year, against Baylor, which they ended up winning by 11 points. More typical was last night's 92-41 demolition of Houston.

They haven't played Notre Dame this year, which is the only remaining plausible rival, but it seems there are two subdivisions of NCAA division one women's basketball: UConn and everybody else. It's hard to say whether this is good for fans or not. You always want your team to win, but it's those nailbiters and comebackers that mean the most. Rolling over everybody like a Sherman tank in a cabbage field is kind of fun. You never have to feel disappointment and you don't risk a heart attack. It may be good for the game in the short run, just as the domination of UCLA under John Wooden was good for the men's game, and the young Tiger Woods was good for golf. It creates interest among casual fans and non-fans. The phenomenon creates fascination.

But it's only good if it inspires more people to start playing the game and more universities to invest in their programs, so that competition finally emerges. The story right now is that there just aren't enough players at the level of Breanna Stewart and Stephanie Dolson and Moriah Jefferson to go around. Jefferson, the diminuitive 5' 7" point guard, is cat quick and whippet fast, and has astonishing inside moves along with a jump shot and 141 assists and 69 steals in 26 games. She is completely alone in her skills.

So, we'll see what happens. If it goes on like this for too many years, it will get boring. But it's fun for now.

This and that from the BMJ

Yes yes, America is the Greatest Nation on Earth, a Beacon to All the Nations, with better Pizza than Italy and better marijuana than Mexico. That said, we don't have the greatest medical journal, in my opinion. BMJ gets the honor because for them, medicine is just as much about society as it is about biology. A few tidbits from this week that caught my eye:

Switzerland, which has the second most costly health care in the world because it essentially has Obamacare, which is better than whatever it was we had before but not by much, is considering dismantling its screening mammography program. That's because their medical board can read and has gotten the 4-1-1 that it is very unclear that screening mammography does more good than harm. It certainly costs a boatload of money. And, of course, we get the fully predictable howls of outrage from the radiologists and oncologists. How are they going to pay for their Rolexes and giant wooden trumpets? My guess - not going to happen. But we shall see.

Australia now requires "plain" tobacco packaging, which means no branding and also isn't exactly plain because it does have to carry the quitline number. Result? A 78% increase in calls to the quitline. Don't know yet into how much quitting, or how much less starting, that leads to, but it can't be bad. Of course, the Supreme Court won't allow that here because Freedom. Like being addicted to tobacco is Freedom.

Children who live near a lot of fast food outlets are more likely to be obese. Now, this could be an error of causal inference. Presumably those are more socioeconomically underprivileged areas. Still, intriguing enough to be worth further study.

This meta-analysis finds that people who quit smoking end up being happier with less diagnosed psychiatric disorders. The authors attribute this to not continually going through incipient nicotine withdrawal but it could be simpler than that: you have more money in your pocket, you're less worried about lung cancer and heart attacks, you don't have to keep ducking out of the office into the rain and freezing cold, and you're free baby, you're in control, you beat this thing, you rock. Yay!

Home sick

No post yesterday because I was suffering from a Flu-Like Illness, as we say, and still forced to spend half the morning digging my car out of a snowbank.

If I had posted, you would have learned about my proposal for a revised version of speed golf in which the strokes aren't counted at all, it's only time that matters. (There is an untimed break between holes, other rules  I won't go into -- it works though.)

Also, the four different ways that science fiction does interstellar travel, e.g. the Star Trek method in which the ship just accelerates past the speed of light and you can see stars streaking by through the window; the "jump" version in which the ship gets from here to there nearly instantaneously in a special condition of reality; the "wormhole" version in which you need to use pre-existing flaws in space-time; and the actually possible version in which the journey between stars takes 1,000 years or more and you need to have either suspended animation; frozen zygotes, artificial wombs, and robot nannies; or multi-generational voyages.

Also too, proposals for humanitarian interventions to kill Kim Jong Un.

Fortunately, I refrained from spilling the ravings of the febrile brain. A real post later today.

The needle and the damage done

The Guardian has asked heroin addicts to describe their thoughts and experiences. These responses are often eloquent and always revealing. One says,

Heroin encases you in a little cotton-wool house and nothing hurts anymore. When times are hard, heroin encases you in a little cotton-wool house and nothing hurts anymore. If you haven't put in the work to become truly mindful, it's very easy to relapse. We know what heroin feels like, even twenty or thirty years after a hit. The memory of that wonderful warm feeling remains.

I have had vague thoughts that in years to come, growing old with heroin wouldn't be such a bad way to fade out of this life. But those thoughts are emanating from my 'addict brain' not my rational brain.

And this:

Hoffman's death has not resulted in feelings of sorrow, but thoughts and feelings of nostalgia. After been clean for 3 months. I am at a stage now where I'm starting to feel good again about myself and my life. But Hoffman's death has aroused a whole new fresh public discourse around heroin addiction, and I must say that its effect on me has not resulted in feelings of sorrow, or relief, but thoughts and feelings of nostalgia. The fact that nostalgic thoughts and feelings have been aroused from hearing about the tragic death of this great actor, just shows how utterly irrational the addicted mind is. It's not thoughts of relief that I have, such as "Wow that could have been me, I'm so lucky." But rather it is thoughts of reminiscence; thoughts of how euphoric he must have felt in those last few weeks of relapse, or even in his last few moments. The addicted mind is a selfish mind, no doubt, but also an utterly helpless one.

And many more like that. The point is, heroin addiction is not a moral failing or a lack of willpower. It is a permanent change in the brain, a physical fact about a person. First of all, of course, don't start. Second, don't put people in jail, that's utterly absurd. Third, provide treatment on demand -- and that includes methadone and buprenorpine maintenance therapy, because for most addicts, that's the only thing that works. Fourth, needle exchange and naloxone availability to keep people alive while they are using.

Oh well, dream on.

Cognitive bias

By now most people have heard about the Canadian breast cancer screening trial, just published in BMJ. Hate to say "I told you so," but I did: screening mammography of the general population of women is a bad idea. This ought to be the nail in the coffin, but it won't be.

So here's the 4-1-1. Back in the 1980s, Canadian researchers randomized almost 90,000 women either to get mammographic screening every year for 5 years; or not. Twenty five years later, there was no difference in the mortality rate from breast cancer between the two groups. None. Zip. Zero. In fact, more of the women who were 40-49 who had been screened died than those who had not, although the difference was not statistically significant. But, there were 106 more cancers diagnosed in the screening arm. Doing the math, 22% of diagnosed cancers represented "overdiagnosis," i.e. cancers that would never have become clinically significant, in other words those women underwent unnecessary and in fact very harmful surgery, plus chemotheraphy and/or radiation.

This is a randomized controlled trial with long-term follow up. It is the strongest possible study design. But it confirms what we have already been seeing from epidemiological studies. Now don't get me wrong -- this is a study of indiscriminate screening of the total population of women. The math might be different for women at higher risk but it also might not be. It turns out that with modern treatment, the difference between a lesion detected through screening and one detectable through physical examination might be too small to make a difference, in other words early detection isn't important after all. That's what the evidence seems to be saying.

By coincidence, in the New England Journal of Medicine, appearing the day before, Lisa Rosenbaum, M.D., discusses the meaning of breast cancer within the culture, and particularly among women. She starts off wondering why women seem to be so much more worried about breast cancer than they are about heart disease, while in fact heart disease is overwhelmingly a more common cause of death, and far more prevalent. (We are talking 400,000 deaths every year from heart disease, vs. about 40,000 for breast cancer, in other words 10 to 1.) Then she says this:

In 2009, the U.S. Preventive Services Task Force recommended decreased frequency of mammography for most women younger than 50 years old, noting that the potential harms outweighed the benefits. Although the recommendations were based on an unbiased review of decades' worth of data, a public outcry ensued. The recommendations were criticized as an assault on women's health, and a 2009 USA Today poll found that 84% of women 35 to 49 years of age planned to ignore them.

So intense was the outrage over these evidence-based recommendations that a provision was added to the Affordable Care Act specifying that insurers were to base coverage decisions on the previous screening guidelines. Rather than acknowledge this blatant dismissal of new guidelines, many political leaders, physicians, and advocacy organizations argued that we simply didn't have enough data to justify the new recommendations. But data have shown for years that early mammography screening doesn't save lives, just as data show that preventing heart disease, through certain lifestyle modifications and appropriate use of medications, does. So why do we resist these data?

Her answer is essentially that preoccupation with breast cancer is a symbol of female solidarity and a feminist cause -- it's a marker of tribal identity, in a sense. That's part of it, but it is also the case that the American Cancer Society represents the interests of surgeons, oncologists, radiologists, and pharmaceutical manufacturers -- that's who finances it. And they all make money off of screening and ensuing unnecessary treatment. So they scream and yell that this cannot possibly be true and they lobby congress, successfully.

They also routinely misinform women, as by for example making claims about five year survival being better for cancers detected through screening. As they well know, this is caused by what's called lead time bias and ascertainment bias. Lead time bias means that, if the cancer is going to kill you, of course it will take longer if it's detected earlier; but that doesn't mean you wouldn't have died at the same time anyway, it's just that the diagnosis came earlier -- subjecting you to earlier futile treatment. Ascertainment bias means, as we have already seen, that many of the "cancers" found through screening are harmless, so of course you survive. You would have anyway, and you would have been better off because you never would have been told that you had cancer and you would not have had surgery and been poisoned and irradiated.

It is also true that it's very difficult for most people to perceive that doing less, and even knowing less, can actually be better.  Of course we want to know! Of course early detection is better! But it isn't.

However, this information is not going to shut down the industry. It probably won't make much difference at all. But, I told you so.

Moral Idiocy

I've written a few times about the epidemic of opioid addiction and overdoses. There is an antidote, called naloxone (brand name Narcan) that can be injected or used as a nasal spray. EMTs normally carry it, but there's a movement to expand availability to other first responders, to friends and loved ones of opioid abusers, and to abusers themselves. You can read more about it here, and props to JAMA for making this article available to the rabble. (Most of JAMA is still subscription only, but I have to give a scrap of credit for this.)

Opioid overdose is now the most frequent cause of accidental death in the United States, ahead of motor vehicle crashes. We're talking more than 38,000 deaths a year. And it's particularly appalling that most of them are young people. Phillip Seymour Hoffman died alone, so presumably naloxone couldn't have helped him, but lots of opioid addicts use the drug with others, or live with family or friends who can intervene. A shot of naloxone costs just 8 bucks. Boston Mayor Marty Walsh wants to have all first responders -- police and firefighters, not just EMTs -- carry naloxone. And there's a bill in the Maine state legislature to do the same, which sounds like a good idea, because heroine overdose deaths in Maine quadrupled in one year.

Well, the depraved lunatic who Maine voters somehow elected to be their governor opposes the bill, because he thinks it would give addicts a feeling of "invulnerability." This is the same reason many people oppose needle exchange programs to prevent HIV -- and it's the law that federal funds can't be used for needle exchange, and many states continue to outlaw it.

What this means is that people -- conservatives, actually -- think that addiction is a moral failing so profound that addicts deserve to die. That's the entire logic of it. There is absolutely no evidence that making naloxone or clean needles available encourages drug abuse. On the contrary, people who engage with these services that can save their lives are more likely to enter treatment because there's an opportunity to talk with them and refer them. Also, too, you can't get treatment and you can't get clean if you're dead. But if you're a junkie, according to governor Paul LePage, that's what you deserve.

LePage is the scum of the earth. And an idiot.

Well duhhh . . .

Farm Bureau report says "enforcement only" immigration reform will lead to a sharp increase in food prices. Now, it is true that if farm labor offered better pay and working conditions, we'd need fewer undocumented immigrants to fill those jobs. And yes, food would cost more. The teabaggers may or may not understand this, but to the extent they do, they are likely to say that instead of us letting furrriners into the country, some of those shiftless moochers who are currently getting Medicaid and food stamps should take those jobs even under current conditions.

Of course, if they took those jobs, they'd still be eligible for Medicaid and food stamps. It's one thing to come up north for nine months out of the year, work 70 hours a week and send enough back to Michoacan to keep your kids alive, it's quite another to try to do that for your family in LA. The Farm Bureau wants to split this baby with a guest worker program that would at least make the people legal -- even though they wouldn't be allowed to stay in the U.S. long term -- and give them some legal protections. But that doesn't seem quite right either.

Here's what I think. Farm workers should be paid better, meaning that food should be more expensive, but we should raise the minimum wage and create a full employment economy -- by making investments that put people to work -- so that everybody could afford that more expensive food. No need to split any babies!  We just need for rich people to pay taxes. Oh wait, that's never going to happen.

 

Coriolis Effect?

I notice that the figure skaters exclusively spin counter-clockwise. No idea why that is.

I think they should get extra credit for being able to spin in both directions. Maybe the rules should even require that they do one or two clockwise tricks. It would be twice as interesting to watch.

Two easy ways to stay alive

1) Don't eat sugar. This is the tobacco "controversy" of our day. The linked study notes that refined sugar accounts for more than 10% of the energy intake of most U.S. adults. They're getting it in soda, baked goods, and even processed savory products such as sauces. (Ketchup is largely sugar.) If you get more than 10% of your calories from sugar, they find that your chance of dying from heart disease is 30% higher. If you get more than 25% of your calories from sugar, as many people do, your risk is 2.75 times as high. This is after controlling for body mass index. In other words, it's not the calories, it's the effect of eating sugar on your metabolism. (I've talked about this many times.)

Now, the "food" industry denies all this and resists all public policy initiatives to get people to eat less sugar. Soda and so-called "energy drinks" are poison. This is very easy. You want something sweet? Drink fruit juice. Eat fruit.

2) Don't talk on the phone while driving. I can't tell you how many times I've nearly been run off the road or run over while crossing the street by some moron with a phone stuck to the ear. I always give the finger to people who are talking on the phone while driving. It's just as dangerous as driving drunk, maybe more so. What the hell is wrong with people? Fifteen years ago, this was impossible, and we got along just fine. Who the fuck are they talking to? What are they talking about that can't wait ten minutes?

Don't be an irresponsible, dangerous, selfish idiot! Don't do it!

One very good reason Bill Nye should not have agreed to debat Ken Ham

This is exactly what we feared. CNN is promoting the debate and treating it as a legitimate discussion between two equally credible points of view. That's what Ham wants out of this -- to be granted equal status with science by the corporate media. And he got it. That's why we don't have public debates any more with holocaust deniers, HIV denialists, tobacco denialists, or global warming denialists.

There is nothing to debate. They are all either deluded or liars. The facts are not in question. But the purveyors of anti-scientific nonsense have a big advantage in these public debates precisely because they feel no responsibility to be honest, logically coherent, or parsimonious in their conclusions. Scientists feel compelled to assert their open-mindedness and say things like, "rabbit fossils in the Cambrian would change my mind," but to the average viewer, that just makes it seem like they are unsure of their beliefs. Which makes them less credible.

The science denier can just spew out a whole bunch of preposterous assertions, which the defender of science then tries to systematically rebut but he can't get through 1/10th of them, and meanwhile he doesn't get around to what he wants to say. Viewers don't have access to the large body of evidence or the technical means by which scientists evaluate it so argument by assertion works just fine. All you see is two people making contradictory claims, one of whom is ponderous and hard to understand, never manages to present a complete and coherent argument, and seems to lack the courage of his convictions; the other speaks in simple sentences, manages to marshal 5 times as many [apparent] facts, and to present a coherent whole argument. 

It's a fool's errand, Mr. Nye. I wish you wouldn't do it.

It's in the New York Times!

A few things today, actually, that stimulate me to comment.

The blogosphere is aflame over Nelson D. Schwartz making official (by saying it in the Times), what has been widely noted elsewhere, i.e. with all the money flowing uphill, businesses that serve people with moderate incomes are losing customers. It is a very obvious point that such as Krugman, DeLong and Duncan Black keep repeating -- if people don't have money, they can't buy stuff, and that means, if you are in business, you can't sell your crap. Ergo, we're stuck in a listless economy and ultimately, the Gilded Age is unsustainable. Capitalists figured that out in the 1930s, but the class of plutocrat we have today is evidently as stupid as it is psychopathic. Go figure.

The death of PS Hoffman has shocked people around the world, but we shouldn't be so shocked. I've said it here many times, we have a horrific epidemic of opioid addiction in this country and it typically follows the pattern we saw with Hoffman. People get hooked on prescription drugs but they're relatively hard to get (and expensive, though that probably didn't matter to Hoffman) whereas heroin is everywhere and cheap. So they go on to heroin. Unfortunately, the dose is not precisely measured as in prescription drugs, and sometimes people get a hot shot, which kills them. So why is heroin everywhere and cheap? Well, therein lies a tale. It's because after all the blood and billions of dollars we have spent on the military occupation of Afghanistan, the country is still completely lawless and the opium growing and heroin manufacturing industries are cranked up to the max. When the Taliban ruled the country, they outlawed it. And it worked. Just sayin'. (Go here for the latest on Afghanistan. My post yesterday was particularly interesting.)

And, right next to the other two stories on page A1, Gina Kolata discusses the Center for Medicare Innovation getting some criticism for funding demonstration projects, but not randomized trials to fulfill its mandate to study innovations in health services organization, financing and delivery. Well, this is pretty much inside baseball. I think their procedure has been reasonable -- analogous to doing Phase 1 and Phase 2 clinical trials before going to full scale RCTs. We need to learn a little bit about how to implement changes and get a sense of what works and how before we invest in controlled trials. Yes, people are impatient but that's life.

Now, go to the op-ed page and check out Krugman (of course), and Harlan Krumholz (who you probably haven't heard of before but who is a big name in my field.)

The Gray Lady comes in for her share of criticism, but she is an indispensable institution. We need her to stay financially healthy so that we still have an aggressive, investigative newspaper of record.