Quotulatiousness

May 23, 2017

QotD: The dangers of career “dualization”

Filed under: Business, Economics, Quotations — Tags: , , , , — Nicholas @ 01:00

This concept [of dualization] applies much more broadly than just drugs and colleges. I sometimes compare my own career path, medicine, to that of my friends in computer programming. Medicine is very clearly dual – of the millions of pre-med students, some become doctors and at that moment have an almost-guaranteed good career, others can’t make it to that MD and have no relevant whatsoever in the industry. Computer science is very clearly non-dual; if you’re a crappy programmer, you’ll get a crappy job at a crappy company; if you’re a slightly better programmer, you’ll get a slightly better job at a slightly better company; if you’re a great programmer, you’ll get a great job at a great company (ideally). There’s no single bottleneck in computer programming where if you pass you’re set for life but if you fail you might as well find some other career path.

My first instinct is to think of non-dualized fields as healthy and dualized fields as messed up, for a couple of reasons.

First, in the dualized fields, you’re putting in a lot more risk. Sometimes this risk is handled well. For example, in medicine, most pre-med students don’t make it to doctor, but the bottleneck is early – acceptance to medical school. That means they fail fast and can start making alternate career plans. All they’ve lost is whatever time they put into taking pre-med classes in college. In Britain and Ireland, the system’s even better – you apply to med school right out of high school, so if you don’t get in you’ve got your whole college career to pivot to a focus on English or Engineering or whatever. But other fields handle this risk less well. For example, as I understand Law, you go to law school, and if all goes well a big firm offers to hire you around the time you graduate. If no big firm offers to hire you, your options are more limited. Problem is, you’ve sunk three years of your life and a lot of debt into learning that you’re not wanted. So the cost of dualization is littering the streets with the corpses of people who invested a lot of their resources into trying for the higher tier but never made it.

Second, dualized fields offer an inherent opportunity for oppression. We all know the stories of the adjunct professors shuttling between two or three colleges and barely making it on food stamps despite being very intelligent people who ought to be making it into high-paying industries. Likewise, medical residents can be worked 80 hour weeks, and I’ve heard that beginning lawyers have it little better. Because your entire career is concentrated on the hope of making it into the higher-tier, and the idea of not making it into the higher tier is too horrible to contemplate, and your superiors control whether you will make it into the higher tier or not, you will do whatever the heck your superiors say. A computer programmer who was asked to work 80 hour weeks could just say “thanks but no thanks” and find another company with saner policies.

(except in startups, but those bear a lot of the hallmarks of a dualized field with binary outcomes, including the promise of massive wealth for success)

Third, dualized fields are a lot more likely to become politicized. The limited high-tier positions are seen as spoils to be distributed, in contrast to the non-dual fields where good jobs are seen as opportunities to attract the most useful and skilled people.

Scott Alexander, “Non-Dual Awareness”, Slate Star Codex, 2015-07-28.

May 19, 2017

QotD: Outpatient psychiatry

Filed under: Health, Quotations — Tags: , , — Nicholas @ 01:00

Now I am halfway done with my residency. I will be switching to outpatient work. Everyone who sees me will be there because they want to see me, or at worst because their parents/spouses/children/friends/voices are pressuring them into it. I will be able to continue seeing people for an amount of time long enough that the medications might, in principle, work. It sounds a lot more pleasant.

I have two equal and opposite concerns about outpatient psychiatry. The first is that I might be useless. Like, if someone comes in complaining of depression, then to a first approximation, after a few basic tests and questions to rule out some rarer causes, you give them an SSRI [Selective serotonin re-uptake inhibitors]. I have a lot of libertarian friends who think psychiatrists are just a made-up guild who survive because it’s legally impossible for depressed people to give themselves SSRIs without paying them money. There’s some truth to that and I’ve previously joked that some doctors could profitably be replaced by SSRI vending machines.

The second concern is that everybody still screws it up. There’s an old saying: “Doctors bury their mistakes, architects cover theirs with vines, teachers send theirs into politics.” Well, outpatient psychiatrists send their mistakes to inpatient psychiatrists, so as an inpatient psychiatrist I’ve gotten to see a lot of them. Yes, to a first approximation when a person comes in saying they’re depressed you can just do a few basic tests and questions and then give them an SSRI. But the number of cases I’ve seen that end in disaster because their outpatient psychiatrist forgot to do the basic tests and questions, or decided that Adderall was the first-line medication of choice for depression – continues to boggle my mind. So either it’s harder than I think, or I’m surrounded by idiots, or I’m an idiot and don’t know it yet. In which case I’m about to learn.

Still, if it’s a disaster, it will be a different type of disaster.

Scott Alexander, “Reflections From The Halfway Point”, Slate Star Codex, 2015-06-29.

May 13, 2017

Psychedelic Drugs: The Future of Mental Health

Filed under: Health, Law, Science, USA — Tags: , , , — Nicholas @ 04:00

Published on 12 May 2017

LSD, mushrooms, and ecstasy are finally getting attention from serious medical researchers. And their findings are astounding.
—-
A recent study found that MDMA-assisted therapy could help veterans suffering from PTSD. Another paper from Johns Hopkins presented evidence that therapy in conjunction with psilocybin mushrooms can help ease the mental suffering of terminal cancer patients.

These findings, among others, were presented at the 2017 Psychedelic Science Conference in Oakland, California, where researchers gather every few years to discuss the potential medical applications of psychedelics, including LSD, psilocybin mushrooms, and MDMA. The field has exploded thanks to reforms at the Food and Drug Administration that allow researchers, for the first time in decades, to study the effects of these drugs.

The organizer of the conference was the Multidisciplinary Association for Psychedelic Studies (MAPS), which is also funding much of this breakthrough research.

“It’s a fundamental right to explore one’s own consciousness,” says MAPS founder Rick Doblin. “We have the freedom of the press, the freedom of assembly, and the freedom of religion, and all those are based on the freedom of thought.”

At this year’s conference, Reason talked to researchers about the past, present, and future of this controversial and promising area of medical research.

Produced by Zach Weissmueller. Shot by Alex Manning and Weissmueller. Music by Kai Engel, Selva de Mar, and Lee Rosevere.

April 29, 2017

“Don’t count fat; don’t fret over what kind of fat you’re getting, per se. Just go for walks and eat real food”

Filed under: Health, Science — Tags: , , , — Nicholas @ 03:00

Earlier this week, Colby Cosh rounded up some recent re-evaluations of “settled food science”:

Their first target was the Sydney Diet Heart Study (1966-73), in which 458 middle-aged coronary patients were split into a control group and an experimental group. The latter group was fed loads of “healthy” safflower oil and safflower margarine in place of saturated fats. Even at the time it was noticed that the margarine-eaters died sooner, although their total cholesterol levels went down: the investigators sort of shrugged and wrote that heart patients “are not a good choice for testing the lipid hypothesis.” Their data, looked at now, shows that the increased mortality in the margarine group was attributable specifically to heart problems.

The team’s reanalysis of the Minnesota Coronary Experiment (1968-73) is more hair-raising. This study involved nearly 10,000 Minnesotans at old-age homes and mental hospitals. The investigators had near-complete control of the subjects’ diets, and were able to autopsy the ones who died. But much of their data, including the autopsy results, ended up misplaced or ignored. Some of it disappeared into a master’s thesis by a young statistician, now a retired older chap, who helped with the 2016 paper and is named at its head as one of the authors.

In the Minnesota study, replacement of saturated fats with corn oil led, again, to reductions in total cholesterol. This finding was touted at major conferences, and it became one of the key moments in the creation of the classic diet-heart myth. This time nobody but the guy who wrote the thesis even noticed that the patients in the corn oil group were, overall, dying a little faster. The 2016 re-analysis uncovered a dose-response relationship: the more the patients’ total cholesterol decreased, the faster they died.

The Sydney and Minnesota studies themselves may have caused a few premature deaths, which is a possibility we accept as the price of science. But the limitations and omissions of the researchers, and the premature commitment of doctors to a total-cholesterol model, helped create a suspicion of saturated fats. This flooded into frontline medical advice and the wider culture, and it put margarine on millions of tables, pushed consumers toward deadly trans fats, and put millions of people with innately high cholesterol levels through useless diet austerity. The scale of the error is numbing, unfathomable.

March 18, 2017

Catherine the Great – IV: Reforms, Rebellion, and Greatness – Extra History

Filed under: Europe, Government, History, Law, Russia — Tags: , , — Nicholas @ 02:00

Published on 18 Feb 2017

Catherine had great ambitions to reform Russia according to her own highest ideals, but she soon found that the reality of governance made those ideals difficult to achieve. She also found herself tangled in war, rebellion, and (scandalously) smallpox.

February 21, 2017

Medical Treatment in World War 1 I THE GREAT WAR Special

Filed under: Europe, Health, History, Military — Tags: , , , — Nicholas @ 05:00

Published on 20 Feb 2017

Some sources say that during the four years of World War 1, medicine and medical treatments advances more than during any other four year period in human history. The chances for a soldier to survive his injury were far greater in 1918 than in 1914.

February 14, 2017

Reconstructive and Plastic Surgery During World War 1 I THE GREAT WAR Special

Filed under: Europe, Health, History, Military — Tags: , , , — Nicholas @ 04:00

Published on 13 Feb 2017

Filmed at Romagne 14-18 museum: http://romagne14-18.com

Plastic and reconstructive surgery saw rapid development during World War 1. Modern medical care and better equipment increased the chances of survival for the soldiers. But these survivors were often disfigured or lost limbs as a result. To help them return to a somewhat normal life, reconstructive surgeons developed methods to restore their faces and aided them with prosthetics.

January 23, 2017

Five easy fixes to improve US federal health policies

Filed under: Bureaucracy, Government, Health, USA — Tags: , , — Nicholas @ 03:00

Scott Alexander finds, to his surprise, that two of the candidates for the post of FDA commissioner in the Trump administration are following his blog or social media profile. To mark that, he offers five easy-to-implement policy fixes that would make a difference:

1. Medical reciprocity with Europe and other First World countries […] Right now, Europe has a licensing agency about as strict as the FDA approving medications invented in Europe. Any pharma company that wants their medication approved in both the US and Europe has to spend a billion or so dollars getting it approved by the FDA, and then another billion or so dollars getting it approved by the Europeans. A lot of pharma companies don’t want to bother, with the end result that Europe has many good medications that America doesn’t, and vice versa. Just in my own field, amisulpride, one of the antipsychotics with the best safety/efficacy balance, has been used successfully in Europe for twenty years and is totally unavailable here despite a real need for better antipsychotic drugs. If the FDA agreed to approve any medication already approved by Europe (or to give it a very expedited review process), we could get an immediate windfall of dozens of drugs with unimpeachable records for almost no cost. Instead, in the real world, we’re cracking down on imported Canadian pharmaceuticals because the Canadians don’t have exactly our same FDA which means that for all we know they might be adding thalidomide to every pill or something. This is exactly the sort of silly anti-competitive cronyist practice that a principled intelligent libertarian could do away with.

2. Burdensome approval process for generic medications […] How come Martin Shkreli can hike the dose of an off-patent toxoplasma drug 5000%, and everyone just has to take it lying down even though the drug itself is so easy to produce that high school chemistry classes make it just to show they can? The reason is that every new company that makes a drug, even a widely-used generic drug that’s already been proven safe, has to go through a separate approval process that costs millions of dollars and takes two to three years – and which other companies in the market constantly try to sabotage through legal action. Shkreli can get away with his price hike because he knows that by the time the FDA gives anyone permission to compete with him, he’ll have made his fortune and moved on to his next nefarious scheme. If the FDA allowed reputable pharmaceutical companies in good standing to produce whatever generic drugs they wanted, the same as every other company is allowed to make whatever products they want, scandals like Daraprim and EpiPens would be a thing of the past, and the price of many medications could decrease by an order of magnitude. […]

3. Stop having that thing allowing companies to “steal” popular and effective drugs that have been in the public domain for years, claim them as their private property, shut down all competitors, and jack up the price 10x just by bringing them up to date with modern FDA bureaucracy.

4. Stop having that thing where drug companies can legally bribe other companies not to compete with them. I like this one because it sounds anti-libertarian (we’re imposing a new regulation on what companies can do!) but I think it’s exactly the sort of thing that the crony capitalists would never touch but which principled intelligent libertarians like O’Neill and Srinivasan might be open to, in order to bring more actors into the marketplace.

5. Stop thwarting consumer diagnostic products and genetic tests […] Srinivasan comes from the genetic testing world himself, so he’s likely to be extra sympathetic to this.

September 1, 2016

Don’t blame the market for the EpiPen price hike – blame the FDA

Filed under: Bureaucracy, Government, Health, USA — Tags: , , , — Nicholas @ 03:00

Scott Alexander explains why “the market” has very little to do with the outrageous price hike for EpiPens:

EpiPens, useful medical devices which reverse potentially fatal allergic reactions, have recently quadrupled in price, putting pressure on allergy sufferers and those who care for them. Vox writes that this “tells us a lot about what’s wrong with American health care” – namely that we don’t regulate it enough:

    The story of Mylan’s giant EpiPen price increase is, more fundamentally, a story about America’s unique drug pricing policies. We are the only developed nation that lets drugmakers set their own prices, maximizing profits the same way sellers of chairs, mugs, shoes, or any other manufactured goods would.

Let me ask Vox a question: when was the last time that America’s chair industry hiked the price of chairs 400% and suddenly nobody in the country could afford to sit down? When was the last time that the mug industry decided to charge $300 per cup, and everyone had to drink coffee straight from the pot or face bankruptcy? When was the last time greedy shoe executives forced most Americans to go barefoot? And why do you think that is?

The problem with the pharmaceutical industry isn’t that they’re unregulated just like chairs and mugs. The problem with the pharmaceutical industry is that they’re part of a highly-regulated cronyist system that works completely differently from chairs and mugs.

If a chair company decided to charge $300 for their chairs, somebody else would set up a woodshop, sell their chairs for $250, and make a killing – and so on until chairs cost normal-chair-prices again. When Mylan decided to sell EpiPens for $300, in any normal system somebody would have made their own EpiPens and sold them for less. It wouldn’t have been hard. Its active ingredient, epinephrine, is off-patent, was being synthesized as early as 1906, and costs about ten cents per EpiPen-load.

Why don’t they? They keep trying, and the FDA keeps refusing to approve them for human use. For example, in 2009, a group called Teva Pharmaceuticals announced a plan to sell their own EpiPens in the US. The makers of the original EpiPen sued them, saying that they had patented the idea epinephrine-injecting devices. Teva successfully fended off the challenge and brought its product to the FDA, which rejected it because of “certain major deficiencies”. As far as I know, nobody has ever publicly said what the problem was – we can only hope they at least told Teva.

[…]

Imagine that the government creates the Furniture and Desk Association, an agency which declares that only IKEA is allowed to sell chairs. IKEA responds by charging $300 per chair. Other companies try to sell stools or sofas, but get bogged down for years in litigation over whether these technically count as “chairs”. When a few of them win their court cases, the FDA shoots them down anyway for vague reasons it refuses to share, or because they haven’t done studies showing that their chairs will not break, or because the studies that showed their chairs will not break didn’t include a high enough number of morbidly obese people so we can’t be sure they won’t break. Finally, Target spends tens of millions of dollars on lawyers and gets the okay to compete with IKEA, but people can only get Target chairs if they have a note signed by a professional interior designer saying that their room needs a “comfort-producing seating implement” and which absolutely definitely does not mention “chairs” anywhere, because otherwise a child who was used to sitting on IKEA chairs might sit down on a Target chair the wrong way, get confused, fall off, and break her head.

(You’re going to say this is an unfair comparison because drugs are potentially dangerous and chairs aren’t – but 50 people die each year from falling off chairs in Britain alone and as far as I know nobody has ever died from an EpiPen malfunction.)

Imagine that this whole system is going on at the same time that IKEA spends millions of dollars lobbying senators about chair-related issues, and that these same senators vote down a bill preventing IKEA from paying off other companies to stay out of the chair industry. Also, suppose that a bunch of people are dying each year of exhaustion from having to stand up all the time because chairs are too expensive unless you’ve got really good furniture insurance, which is totally a thing and which everybody is legally required to have.

And now imagine that a news site responds with an article saying the government doesn’t regulate chairs enough.

June 10, 2016

A breakthrough in our understanding of the causes of depression

Filed under: Health, Science — Tags: , , , — Nicholas @ 02:00

Scott Alexander takes a quick look at a recent discovery in medication for depression:

A few weeks ago, Nature published a bombshell study showing that ketamine’s antidepressant effects were actually caused by a metabolite, 2S,6S;2R,6R-hydroxynorketamine (don’t worry about the name; within ten years it’ll be called JOYVIVA™®© and you’ll catch yourself humming advertising jingles about it in the shower). Unlike ketamine, which is addictive and produces scary dissociative experiences, the metabolite is pretty safe. This is a big deal clinically, because it makes it easier and safer to prescribe to depressed people.

It’s also a big deal scientifically. Ketamine is a strong NMDA receptor antagonist; the metabolite is an AMPA agonist – they have different mechanisms of action. Knowing the real story behind why ketamine works will hopefully speed efforts to understand the nature of depression.

But I’m also interested in it from another angle. For the last ten years, everyone has been excited about ketamine. In a field that gets mocked for not having any really useful clinical discoveries in the last thirty years, ketamine was proof that progress was possible. It was the Exciting New Thing that everybody wanted to do research about.

Given the whole replication crisis thing, I wondered. You’ve got a community of people who think that NMDA antagonism and dissociation are somehow related to depression. If the latest study is true, all that was false. This is good; science is supposed to be self-correcting. But what about before it self-corrected? Did researchers virtuously say “I know the paradigm says NMDA is essential to depression, and nobody’s come up with a better idea yet, but there are some troubling inconsistencies in that picture”? Or did they tinker with their studies until they got the results they expected, then triumphantly declare that they had confirmed the dominant paradigm was right about everything all along?

March 19, 2016

The Monopoly Markup

Filed under: Economics — Tags: , , , — Nicholas @ 02:00

Published on 18 Mar 2015

Ever wonder why pharmaceuticals are so expensive? In this video, we show how low elasticity of demand results in monopoly markups. This is especially the case with goods that involve the “you can’t take it with you” effect (for example, people with serious medical conditions are relatively insensitive to the price of life-saving drugs) and the “other people’s money” effect (if third parties pay for the medicine, people are less sensitive to price).

March 16, 2016

The Social Welfare of Price Discrimination

Filed under: Economics — Tags: , , — Nicholas @ 03:00

Published on 7 Apr 2015

Now that we’ve learned a little about price discrimination, we can begin to think about whether or not price discrimination is bad for society. How does price discrimination affect output, and what is this effect on social welfare? If price discrimination increases output, it is likely beneficial for society. If output isn’t increased, social welfare is reduced. What are some examples of perfect price discrimination? Universities practice perfect price discrimination all the time. Students pay different amounts for their education based on many different factors surrounding each student’s ability to pay. This practice increases profits and also increases the number of students able to attend college. For this reason, price discrimination by universities likely increases social welfare.

March 6, 2016

European Socialists During WW1 – Frontline Medics I OUT OF THE TRENCHES

Filed under: Europe, Germany, History, Military — Tags: , , , , — Nicholas @ 02:00

Published on 5 Mar 2016

Indy sits in the chair of wisdom again to answer your questions about World War 1. This time we are talking about the German parliament, the European socialist movement and frontline medics.

January 20, 2016

QotD: Nursing

Filed under: Health, History, Quotations, Science — Tags: — Nicholas @ 01:00

In the company of medical people who know the history of their craft you can get a good discussion going about the exact date after which medical attention was more likely to help than harm you. Opinions generally settle somewhere between 1910 and 1940.

That’s within living memory. People of the generation before my own had little to hope for from medicine. The more realistic among them knew this. My own father, born 1899, regarded the entire medical profession with fear and mistrust. A hospital, he believed, was a place where poor people went to die. A major theme in the background noise of my childhood was the voice of my mother — a professional nurse — nagging Dad to go see a doctor about some ailment he was suffering. “Why won’t you at least go see him? He won’t HURT you.” Dad knew better. Most things mend by themselves. He lived to be 85, dying at last of pneumonia, which was known to people of that generation as “the old man’s friend.”

It wasn’t all negatives before “the early 1950s, when medicine was turning into a science” (Lewis Thomas). There was nursing; there was surgery; there were a handful of useful drugs.

Nursing — the art of keeping patients clean, comfortable, and cheerful — must have saved far more lives than doctoring in the long dark ages before antibiotics. Florence Nightingale (a significant mathematician, by the way) has to be reckoned one of the great benefactors of humanity.

John Derbyshire, “The Scariest Science”, Taki’s Magazine, 2014-11-13.

January 19, 2016

Non-conspicuous consumption of quality

Filed under: Economics — Tags: , , , — Nicholas @ 02:00

Don Boudreaux on the amazingly thin line that now separates many of the quality consumption goods of the ultra-rich from the nearly as high quality goods of ordinary North American consumers:

This list includes also non-prescription pain relievers, most other first-aid medicines and devices such as Band-Aids, and personal-hygiene products such as toothpaste, dental floss, and toilet paper. (I once saw a billionaire take two Bayer aspirin – the identical pain reliever that I use.) This list includes also gasoline and diesel. Probably also contact lenses.

A slightly different list is one drawn up in response to this question: When can median-income consumers afford products that, while not as high-quality as those versions that are bought by the super-rich, are nevertheless virtually indistinguishable – because they are quite close in quality – to the naked eye from those versions bought by the super-rich? On this list would be most clothing. For example, an ordinary American man can today afford a suit that, while it’s neither tailor-made nor of a fabric as fine as are suits that I suspect are worn by most billionaires, is nevertheless close enough in fit and fabric quality to be indistinguishable by the naked eye from expensive suits worn by billionaires. (I suspect that the same it true for women’s clothing, but I’m less expert on that topic.)

Ditto for shoes, underwear, haircuts, corrective eye-wear, collars for dogs and cats, pet food, household bath towels and ‘linens,’ tableware and cutlery, automobile tires, hand tools, most household furniture, and wristwatches. (You’d have to get physically very close to someone wearing a Patek Philippe – and you’d have to know what a Patek Philippe is – in order to determine that that person’s wristwatch is one that you, an ordinary American, can’t afford. And you could stare at that Patek Philippe for months without detecting any superiority that it might have over your quartz-powered Timex at keeping time.) Coffee. Tea. Beer. Wine. (There is available today a large selection of very good wines at affordable prices. These wines almost never rise to the quality of Chateau Petrus, d’yquem, or the best Montrachets, but the differences are often quite small and barely distinguishable save by true connoisseurs.)

I’ve made this point about the wines before (I’ve tasted each of those wines, but don’t believe the price difference justifies buying them over nearly-as-good equivalents that lack the prestige factor), but Don is talking a much wider range of goods and services where there’s barely any real quality difference between “ordinary” and what the very richest among us can obtain.

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