So, what if the solution came along?

Posted on August 1, 2011. Filed under: medical ethics, Medical marketing, Protandim, Self-deception |

Nothing here since January, 2009! Why? I’m reminded of the parents who had a child who never spoke. They took him to pediatricians, speech therapists, witch doctors: everyone they thought could help. Not a syllable came forth. They accepted that he was mute, and got on with it. One day at breakfast, when the child was six years old, he said, “This toast is burnt.” The parents almost collapsed, and with tears in her eyes, the mom said, “Johnny, you can talk!” The child responded, “Of course I can talk; I’m six years old.” Bewildered, his mom asked, “So, why haven’t you ever said anything before?” Without hesitation, the boy replied, “Up ’til now, everything’s been OK.”

So, here’s the deal. I wrote a number of posts in 2008 and 2009 about the medical profession and medical marketing.The blog generated about 10,000 hits, but not much discussion. At the time, I didn’t have anything else to say that I felt was important or revelatory. Now I do. If you have ever read my posts, you know that I am searching, and that I am a student of bias. I rejoice in learning how things work: not how they seem to work, nor how we would like for them to work, nor what the majority thinks about how things work, but how the evidence describes how things work.

Enter Nrf2. Nrf2 is an abbreviation for Nuclear factor (erythroid-derived 2)-like 2, also known as NFE2L2. Your doctor knows this, right? Wrong! When we matriculate into medical school, our teachers typically are not medical doctors, but PhD’s, who have extensive, up-to-the-minute knowledge of their niche. Among the first things they teach us are these two:

  • a vocabulary that is the equivalent of a foreign language, and like any foreign language, it is mastered when the words themselves cause concepts to appear in the brain without translation.
  • basic medical sciences.

Your doctor (and I) have mastered the vocablulary.We can read the peer-reviewed articles, and we have at least the potential to understand what they say. But the basic sciences? There are few practicing physicians who could pass a current freshman medical school test on any of the basic sciences, and the  information is changing at an almost exponential rate. Nrf2 is one of those things that basic scientists, in this case, biochemists, know about that your doctor does not.

Here’s the story. Did you know that oxygen is the source of our ultimate demise? We have to have it to survive, and to create the energy we use daily. But, in producing that energy, one of the products is a nefarious substance called “reactive oxygen species” (ROS). ROS will kill any oxygen-dependent organism. So, it is not surprising that all aerobes have evolved a method for dealing with these destructive ROS “free radicals”. The 25,000 or so genes in the human genome include hundreds of  genes that have evolved specifically to deal with ROS. That’s a significant portion of all the instructions that make us who and what we are. How do they do this? By up-regulation of protective enzymes that neutralize ROS, and by down-regulation of associated inflammatory and fibrotic processes stimulated by ROS. This is important. For me, it is revelatory. For your doctor? Maybe not so much.

It was a biochemist who first discovered the protective enzyme, SOD (superoxide dismutase). His name is Joe McCord. Your doctor has his own Wikipedia page, right? As Dr. McCord puts it, the discovery of SOD was the beginning of the solution, but no one knew the problem it solved. And what is the problem? Aging and degeneration itself! What is aging? Surprisingly, to a biochemist/medical school professor like Joe McCord, aging is defined as a ratio. The numerator is the level of protective antioxidant enzymes one’s genes produce, and the denominator is the amount of oxygen one consumes. Up until about the age of 18 -20 years, that ratio in genetically “normal” folks is such that very little degeneration occurs. You’ll starve if you are a doctor specializing in teen-age heart attacks, strokes, hypertension, osteoarthritis, type 2 diabetes, Alzheimer’s, Parkinson’s Disease, coronary bypasses and stents (continue the list to include almost everything non-infectious that eventually gets us), but you’ll be overworked with the same disorders if your field is geriatrics. Why? The ratio of protective enzymes to destructive ROS declines as we age, and oxygen gradually destroys us all.

What if we could stimulate our genes to rev up the protective enzyme levels to what they were when we were young? It would make front-page headlines! Fox News and PBS would find common ground featuring it! Your doctor would be calling YOU to make sure you were aware of this wellness breakthrough! NOT!!

Nrf2 was described and isolated in 1994. It’s role as the key activator for all the “survival genes” has been known to biochemists for over 10 years. There are 2088 peer-reviewed articles about it (as of today) listed on the National Institutes of Health website, Researchers in both independent university roles and as employees of pharmaceutical companies have been frantically searching for methods to activate Nrf2 safely, both to prevent and to treat the ravages of human physical degeneration. It could play a major role in reducing our runaway healthcare costs. EVERYONE’S TALKING ABOUT IT.

Well, maybe not. In fact, among all my physician friends to whom I have mentioned Nrf2, only one has ever heard of it. Furthermore, that one physician is the only one of my doctor friends who seems remotely interested in the concept. What’s going on here?! Artificial-intelligence researcher Eliezer Yudkowsky has observed: You know better than to think that a random doctor will have extraordinary clarity of mind and the power to find truth within confusion. Our medical education system stops teaching science and the scientific method after the early years of medical school; from then on, we learn and memorize prescribed solutions for various problematic scenarios.The system eschews independent thought and investigation. In fact, we are held legally liable for employing methods that deviate from the accepted norms. Those norms come down to practicing physicians through established channels, as I’ve previously mentioned here, herehere, and here. Currently, none of the established channels involves Nrf2 nor its activation, and few doctors make the effort to search for the truth within the confusion.

Enter what I will call a form of “intellectual attribution bias”. According to Michael Shermer in his book, Why People Believe Weird Things, because of this cognitive bias, smart people are about nine times more likely to attribute their own position on a given subject to rational reasons than they are other people’s position, which they will attribute to emotional reasons. Although major pharmaceutical companies are trying to develop synthetic Nrf2 activators as prescription drugs, the only currently available clinically effective Nrf2 activator is a compound of natural phytonutrients called Protandim. It is classified by the FDA not as a drug, but as a dietary supplement, and it is available not by prescription or in pharmacies, but only through network marketing.

In spite of peer-reviewed studies listed on documenting the compound’s ability to raise Nrf2 activation to unprecedented levels, and subsequently lower oxidative stress to unprecedented levels, practicing physicians are not likely to give it any credence because it doesn’t fit in the mold of their established channels of information. Their position seems to be: “I am an expert, and I haven’t heard of Nrf2 activation. Now you’re telling me that a network marketed supplement could be the most important advancement yet in my own specialty, and I don’t know about it? It’s bulls**t.”

UPDATE: Biogen’s synthetic Nrf2-activator drug Tecfidera was approved in the Spring of 2013 for the treatment of Multiple Sclerosis. Available by prescription only at a cost of about $50,000 annually. Biogen’s research shows that Tecfidera has about 50% of the Nrf2 activation of the natural-ingredient compound, Protandim, which costs $40/month, without Tecfidera’s side-effects.

Here’s an exercise your doctor hasn’t done: go to, and in the search box enter “Nrf2” followed by the name of any disorder that interests you, e.g., “Nrf2 diabetes”. As one enters disorder after disorder, and sees the scientifically documented correlation with levels of Nrf2 activity, one comes to realize that we have evolved to deal with oxygen consumption in a healthy way until we reach the years of reproduction, and then our Nrf2 activity drops off and we begin to die. We can begin to control that now by controlling Nrf2 activation. Doctors treat symptoms and the results of disease. Nrf2 activation removes the cause. The solution, or the beginning of it, has come along: Nrf2 activation. Your doctor doesn’t know about it. Tell him/her. He’ll tell you it’s bulls**t.

If you want to know more, click on “contact retired urologist” at the top of the page and send me a message.

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What if doctors were tenured?

Posted on October 31, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Personal philosophy, Self-deception |

Reason is the unique path to knowledge. This is the credo of rationalism. Existence as a pure rationalist may be a highly-prized state, but getting there certainly is not “half the fun”. There is a lot of pain involved in recognizing and discarding long-held positions when they do not pass the rationality test. On the lead page of this site, I state that retired urologist has launched a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry. The sticky point in the quest is the concept of knowledge, a goal that can be approached only along the path of reason, yet, as Robin Hanson has pointed out, doctors are “lousy at abstract reasoning”. I have agreed with him profusely in this earlier post, yet I still had a knee-jerk defensive response to it’s reiteration recently on his Overcoming Bias blog. I, and you, are wired that way.

It seems like a quid pro quo thing going on. “If I’m going to go through the pain of admitting my long-practiced deficiencies, those who so readily identify them for me should do likewise,” or something like that. But no. Not going to happen. Actually, can’t happen may be a more appropriate description. I have become convinced that the human brain is hard-wired to ignore certain of one’s own biases, while readily identifying those same biases in others. It’s not a new concept, nor original. Long before neuroscience was a word, the Biblical writer of the gospel of Matthew asked, “Why behold you the mote that is in your brother’s eye, but consider not the beam that is in your own eye?” Why indeed? Perhaps because it’s unavoidable. It bears repeating that those gifted with more intelligence are more likely than those with pedestrian IQ’s to exhibit this defect (skill?). Via intellectual attribution bias, smart people are about nine times more likely to attribute their own position on a given subject to rational reasons than they are the position of others, which they will attribute to emotional reasons, even if that position is the same as theirs (Michael Shermer). Via confirmation bias, smart people tend to seek or interpret evidence favorable to their already existing beliefs, and/or to ignore or reinterpret evidence unfavorable to their beliefs. Hanson considers confirmation bias to be a major contributor to ideological fanaticism, the greatest threat to the world, yet he employs it frequently. He can’t help it: he’s very smart.

In fact, he’s so smart that he has tenure. Now, there’s an interesting concept for a libertarian supporter of free markets, idea futures, and outcome-mediated health care plans! Tenure is, at best, an arbitrary system which may or may not reflect effectiveness, yet which virtually guarantees employment and facilitation. Hanson’s espoused ideas revolve around the establishment of “betting markets on controversial issues, in which the real experts (maybe you), would then be rewarded for their contributions, while clueless pundits would learn to stay away.” (quoted here) Yet his own job doesn’t work that way. One would think that when offered tenure, such a person would have turned it down, on philosophical grounds. Ah, but there is the consideration of responsibility to one’s family. Intellectual attribution bias facilitates just such paradoxical behavior, not just in Hanson, but in humans generally.

So comes the question: what if doctors were tenured? Immediately, it comes to mind that all the things Hanson finds wrong with doctors, and the health care system in general, would be magnified. Doctor arrogance, a frequent topic of Hanson’s concern, would soar, perhaps approaching the level of university professors. Health outcomes, as bemoaned in Hanson’s analysis of the Rand Experiment, would surely, and predictably, worsen, as there would be no correlation between quality of work and job security. If there were a doctor agency similar to the insulating university, one could predict soaring rates of malpractice among tenured doctors, since the consequences would be borne by their institution. On the positive side, doctor-related felonies, such as Hanson documents here, would likely decrease, since commission of a felony would be grounds for revocation of tenure. Doctor supply would surely increase, as would the average age of doctors, since, once tenured, there would be no reason to retire and no pressure to perform effectively. In summation, it seems that university professors would view tenure as an excellent idea for university professors, but a very bad idea for doctors. Personally, I agree with the free markets that Hanson talks about, as opposed to the closed market in which he participates.

I am trying to learn how to think differently (more effectively), since my education and profession actually did not include any courses, or even any experience, in clear thinking, sad to say. I know there is a strong bias about the arrogance of doctors, especially given their rather well-documented failure to make a positive impact on *overall* health care in the USA. I abhor the “doctor arrogance” as well. Any arrogance seen in my posts is (usually) unintentional, and comes not from being a “arrogant doctor”, but from the failing of being an “arrogant person”, a quality that seems widespread among intellectuals. The more I learn about how such “ninja-brained” people think, the less I have to be arrogant about. I’m here to learn.


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Do you know the way to San Jose?

Posted on October 24, 2008. Filed under: Layman's AI, Personal philosophy, Self-deception, The Singularity |

Long-time reader, first-time visitor to Silicon Valley. I just arrived for the Singularity Summit. It will be interesting to see how out-of-place a redneck sex doctor will be in this sea of geniuses. More to follow.

Add-On: see today’s Summit summary.

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Out of my league

Posted on October 14, 2008. Filed under: Book excerpt, Good ol' days, Self-deception |


The students at Park Shore Junior High came from “feeder” elementary schools, back in the days when no one went to private schools, and you lived where you learned. I didn’t have much experience with kids from the “haves” neighborhoods; I was a “have-not”. I don’t mean I was homeless or raised by beggars, but I didn’t know anyone with an air-conditioned car or wall-to-wall carpets. It didn’t take long to learn that the “haves” ran the school, but there were more of us than there were of them. The have-nots were just waiting to be inspired, a la Victor Hugo. I played on the chronic disgust and unmitigated jealousy they had for those to whom things came easily, and I got myself elected freshman class president. And editor of the newspaper, a position that kept my name before the masses. And “Best Citizen”. But I was short. Really short. Shorter than any of the girls. And I only had about three pubic hairs; actually, it was exactly three, as I knew from careful and frequent inspection.

The freshman prom was the biggest social event of the year, and I didn’t have a date. About two weeks before the dance, after an intense internal battle between lust and sensibility, bad judgment stepped in. I cornered Leslie Batson by the book lockers and blurted in a pubescent voice that squeaked on the word “prom”, “Will you go to the prom with me?” 

Leslie was the head cheerleader, a big-time “have”, and a fifteen-year-old goddess. She was in several of my classes, so it wasn’t like I didn’t know her. I had even talked to her from time to time. As I waited for her response, I wish I could tell you that she went all gaa-gaa and gushed, “I’d love to!” Hell, I wish I could even tell you she said, “No.” But the truth is, she didn’t dignify me with any verbal reply at all. Her head just sort of fell back in an act of incredulity, her blond ponytail waggled in the space between her shoulder blades, her blue eyes squinted tightly, her mouth opened and her iridescent lips turned upward at the corners as she began laughing. Her orthodontic appliances sparkled as she shook. Her maroon and white cheerleader outfit emphasized the vastness of what I’ve come to know as the “time-space dimension” that separated us, and the “Warriors” logo emblazoned across her chest bounced on her never-to-be-seen-by-me teenage breasts with each guffaw. True, she never did actually say she wouldn’t go with me, but as she walked away with her “have” friends, the pleats in her short skirt bouncing back and forth across her society derriere, I got the feeling she wouldn’t. In point of fact, she clichéd the event by going with the football quarterback, who later played for the Atlanta Falcons. 

It is some comfort that the quarterback eventually became a unemployed druggie. But it would be more comfort if she had married him.


NOTE: this is a modified excerpt from Chasing a Light Beam, a late-draft short novel about one man’s reaction to the discovery of quantum reality.

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Doctor education #2… more real-life drama

Posted on October 7, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medical marketing, Self-deception |

I got a call from a pharm rep for a company that markets one of the three well-known pills for treating erectile dysfunction one day about five years ago. She lived and worked in the alluvial plain area of the Mississippi delta. If you have never listened to a woman from “the delta”, as they say, you owe it to yourself to call someone in that area. The female version of the accent is melodiously syrupy; a conversation about anything is musical entertainment. “Yankees” seem to think the drawl is an indicator of ignorance or low intelligence. I assure you, that is not the case. There is a reason that William Faulkner spent most of his time in Oxford (Mississippi, not England), and it wasn’t because it was full of “hicks”. 

She sought me out because I was a “consultant” for her company. At the time, I justified that position by using what I now know is “confirmation bias”. I distinguished myself from the “medical whores” I have previously discussed by reasoning that I never consulted for competing products; that I promoted the one I actually used with my patients; and that I truly believed the product was the best in its field. I saw no conflict of interest, because I was only saying what I would have said anyway, pay or no pay. I should have considered things this way (as told by Kenny Tilton):

Once upon a time my sleazebag ward politician buddy and I were cruising the singles bars back when they had such things and he got nicely eviscerated by a woman we were chatting up. My buddy had said something cynical and she had challenged him on it.

“Oh, I have compromised my principles a few times,” he conceded with a sly grin.

“You can only compromise your principles once,” she replied. “After that you don’t have any.” (more…)

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Bias on the hoof: Hanson and RU continued

Posted on October 5, 2008. Filed under: Everything you wanted to know about doctors, Personal philosophy, Self-deception |

Today’s post is a study of bias in the intellectually gifted (at least as pertains to one of the parties; I’ll let you guess which one). 🙂

In my October 4 post on Disagreements, I used a disagreement between Robin Hanson and me as subject matter for a set of disagreement analysis questions Hanson had requested readers of his blog to use. To refresh the particulars, we disagreed on the suitability and veracity of this anecdote in an article he posted called “Doctors Kill”:

A colleague of my wife was a nurse at a local hospital, and was assigned to see if doctors were washing their hands enough.  She identified and reported the worst offender, whose patients were suffering as a result.  That doctor had her fired; he still works there not washing his hands. Presumably other nurses assigned afterward learned their lesson. 

A reader (not me) saw coverage of the post on the blog of Seth Roberts, and asked Hanson “whether you actually ever met and talked to the fired nurse, how strong her evidence was that she was fired for the reason in the story, etc.? Did your wife actually know her, or know someone who knows her (who might turn out to be someone who knows someone who knows someone), that sort of thing? ” Hanson replied: ” the nurse was a close co-worker of my wife, who I’ve met.” (Nothing more.)  

I contacted Hanson privately to express all the factors mentioned in yesterday’s post, as well as the fact that the article quoted was not evidence against doctors so much as against other hospital employees. In addition, I told him:

I cannot imagine a hospital administrator telling a nurse, “We are firing you because a doctor you reported has requested your dismissal”. If that statement were not made, the nurse could not know that it was the reason for her dismissal.

Hanson replied, making no mention of any of my evidence of inaccuracy, lack of veracity, and bias, save this:

If you think no one in a work place can know anything other than what people say through official channels, you don’t know much about ordinary workplaces.  

According to his curriculum vitae, Hanson has never spent time in an “ordinary workplace”. I, on the other hand, have been a printer, electrician’s helper, warehouseman, assistant to television repairman, gasoline station employee, yardman, laborer in an asphalt plant, infantryman in Army (PFC), university information employee, delivery-man, ER doctor, breath-spray franchisee, computer technician for a beer/whiskey distributor, employee in a medical practice, owner/director of a medical practice, owner-partner of a hospital, chief of surgery at two hospitals, and laboratory research assistant in a psychiatric hospital (that I can recall; never fired, by the way, even though none involved tenure). I am particularly experienced at job relations and administration in hospitals, and especially at doctor-nurse relations. This would, if nothing else, seem to give some credence to my claim that Hanson should take another look at the value (truth?) of the story. (more…)

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Posted on October 4, 2008. Filed under: Everything you wanted to know about doctors, Personal philosophy, Self-deception |


Robin Hanson and I had a disagreement about the accuracy of an anecdote he used to illustrate doctor arrogance. I was dissatisfied with the lack of resolution to the disagreement, unless one considers “no change at all in either party’s postion” to be a “resolution”. He titled his piece “Doctors Kill“; it’s subject is nosocomial (hospital-acquired) infections. The anecdote:

A colleague of my wife was a nurse at a local hospital, and was assigned to see if doctors were washing their hands enough.  She identified and reported the worst offender, whose patients were suffering as a result.  That doctor had her fired; he still works there not washing his hands. Presumably other nurses assigned afterward learned their lesson.  

I objected that this anecdote was based on a third-party uncorroborated snippet amounting to gossip, and certainly in the category of ad hominem criticism. The statement “he still works there not washing his hands” is indicative of the inflammatory intent of the anecdote, since Hanson had no way to know what the doctor may have been doing subsequently. I pointed out that the anecdote added nothing to the statistical presentation of evidence, and as such was egregious expression (and strong evidence) of personal bias. I expected that Hanson, an extreme advocate for eliminating personal bias, would have seen that his personal bias against doctors had crept into his writing. Instead, Hanson replied that the nurse was also a a personal acquaintance of his, so the story must be true, and that his readers had found it to be valuable.

Analysis of Disagreement:

Recently I have come across Dr. Hanson’s post on “disagreement case studies“. Today, I will use his questions for analyzing our disagreement. (more…)

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Vanity, thy name is “expert”

Posted on September 29, 2008. Filed under: Everything you wanted to know about doctors, Layman's AI, Personal philosophy, Self-deception |

As my medical school years drew to a close, each of us faced the choice of residency that would determine how we spent our professional lives. A close friend and member of AOA, the medical honor society comparable to Phi Beta Kappa or Law Review, declared that he had chosen OB/GYN. He and I had shared what I felt was a miserable experience as “acting interns” on the obstetrics service our senior year, so his choice astounded me.


His answer was seminal: “Have you noticed the size of the textbook?” Indeed, the OB/GYN text was far smaller than that of any other subject we studied. “I think it’s possible to learn everything there is to know about OB/GYN. I can be an expert.” Perhaps he was citing the mental comfort associated with mastery of a skill, and the unlikelihood that he would find himself in a situation beyond his capabilities, akin to a world-class martial arts expert walking alone at night. I suspect the knowledge that one’s work was done as well as could be done would provide substantial comfort, especially if one were well-paid, and the importance of that work were protected and promoted by a guild system. [NOTE: in those days, there was little concept of medical malpractice, a scourge which subsequently would hit the OB/GYN specialty harder than any other.]

Yet, I think his answer (and his career choice) may have been more instinctive, and perhaps outside his conscious awareness: the possibility of being an expert may have been subsumed by the possibility of being recognized as an expert. Dr. Robin Hanson, on the Overcoming Bias blog, initiated a discussion of a similar concept, referring to “expert at” versus “expert on, in which the former could perform successfully and the latter could talk about it successfully. I’m referring to a third entity: an expert on a topic who also is an expert at that topic. He is an expert by all practical considerations, and he is well-remunerated. Is that enough? Perhaps not.

I have observed a distinct change in attitude when the expert-aspirant is exposed to his peers. In my own field, I wanted to be, planned to be, and worked to be the best in the world. In my own mind, I achieved that (male surgical sexual medicine is a very small pond for any size frog), and I was compensated financially in adequate fashion. I want to be satisfied with the knowledge that my work was of superior technical and ethical quality. But it’s a self-edited summary; often (not always) at the highest levels of anything, self-satisfaction seems overrated, and inadequate. At a conference of IPP (inflatable penile prosthesis) technical experts, early in my career, I was seated at dinner next to a surgeon who was prolific in numbers of successful operations. In fact, studying his methods had caused me to take a number of steps that benefitted both my technical skills and my practice success. Because of his influence, and my subsequent personal experience, he and I both used the same brand of IPP in our patients. Neither of us was in academics, so our “fame” came only from our patients and from the recognition of the manufacturer. He mentioned that he had performed “3- or 4-hundred” procedures that year. Unlike some areas of surgery, the number of IPP surgeons who ever perform more than 100 procedures in a year can be counted on two hands. My pride was piqued, and I replied, “I did 201, and Mr. X (the manufacturer CEO) told me that was tops in the world.” When I was just starting, this same surgeon had asked me to join his practice; after the dinner encounter, he was never friendly to me again. It was vanity versus vanity. Of note, I am very unpopular with the “experts on” in my field, those I call the “thought leaders”, none of whom are “experts at”. It’s the recognition, stupid.

Lest you think that the self-satisfied expert at/expert on doctor is immune to this vanity, give him a chance for recognition. Pharmaceutical and device manufacturers have caught on to this weakness in spades. The opportunity to be the star at doctor-to-peer lectures and presentations has changed the attitude of many a current physician, and strongly influenced his practice habits. Even when one has reached the pinnacle of both actual and recognized expertise, the vanity drive remains strong. Dr. Michael DeBakey gave the AOA visiting professor lecture during my junior year. I don’t remember much of what he said, but one quote has stayed with me: “I could make a career simply correcting the mistakes of other vascular surgeons.” Probably a true statement, especially at the time, but of what value was this knowledge to junior medical students? Could there be any doubt that recognition was the driving force?

Recently on Overcoming Bias, the smartest of the smart have shown not only are they are not immune to the vanity of the experts, they actually are as pedestrian as the rest of us when it comes to this human frailty. In the posts and discussions here, here, and here, it’s all about who is the smartest, who is the best qualified, and who is the leading expert. One would think pride in one’s intelligence is severely misplaced. As one of the main posters, Eliezer Yudkowsky, has said, “We are the cards we are dealt, and intelligence is the unfairest of all those cards.” Yet note the ego-involvement. One would think that accomplishment was a far better source of pride. And if that accomplishment has not yet occurred? Such encounters as this are the result. I choose Mr. Yudknowsky as an example only because he is a dedicated student of the human thought process, and one of two main writers on a blog dedicated to eradicating bias. If it can happen to such as him, perhaps it’s innate.

*Pro tip*:The ultimate goal is not only that I succeed, but also that you fail.

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The truth will set you free… but first, it will piss you off.

Posted on September 25, 2008. Filed under: Everything you wanted to know about doctors, Medical marketing, Personal philosophy, Self-deception |

David J. Balan, on Overcoming Bias, writes about the difficulty of responding honestly when people say, “Give it to me straight.” Generally, it’s such a bad idea that the Cajuns in my neighborhood have a story to illustrate:

Boudreaux was a widower whose most valued possession was his cat, Felix. Boudreaux won a trip to Europe, and he asked his friend Thibodeaux to look after the cat in his absence. “Thib,” he said, “I’ll call you from England to check on Felix.” Three days into the trip, Boudreaux indeed called Thibodeaux and asked, “How’s my cat doin’?” Thibodeaux replied, “Mai, Boudreaux, your cat died.” Boudreaux was beside himself, first with grief, then with anger. “Thib,” he wailed, “You don’t just tell somebody flat out that their cat died. You got no sensitivity. You should ease into it. Like, you should say, ‘Boudreaux, your cat’s on the roof, but I’m pretty sure we can get him down.’ Then when I call the next day, you say, ‘We got your cat down, but he caught pneumonia. The vet’s pretty sure he’ll be OK.’ Then on the next call, you say, ‘The cat took a turn for the worse, but the vet’s giving him some powerful medicine.’ Then the next day, you finally say,’Boudreaux, we did all we could, but your cat passed on.’ That’s the way you handle bad news like this.”

Thibodeaux expressed his remorse for his insensitivity and vowed to be more thoughtful. Two days later, Boudreaux called again. “Thib, how’s my mother?” Thibodeaux replied in his kindest voice, “Boudreaux, your mother’s on the roof.” (more…)

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Posted on August 23, 2008. Filed under: Layman's AI, Self-deception |

A couple of years ago, I saw a reference to a new book in New Scientist magazine: The Singularity Is Near, by Ray Kurzweil. My leisure reading interests had turned to physics, evolutionary biology, and the quest for the Theory of Everything in recent years (I know that doesn’t sound like “leisure”, but one man’s trash is a sow’s ear, as the saying goes), and Kurzweil’s tome seemed to be about a curiously related issue. I bought the book, and read it. I haven’t been the same since.

Kurzweil discusses the almost certain (in his mind) upcoming emergence of the technological Singularity: the development of smarter-than-human intelligence. Among my friends, and apparently people in general, this is a topic that, once broached, causes severe polarization. I admit, it’s not sweeping the country with polarization; most people have never heard of the concept, except in movies and sci-fi books. But once they become aware that serious scientists with ninja-brainpower are working on it, most reactions that I have seen fall into one of two categories: 

  1. reject it out-of-hand, or
  2. think about it carefully, and then reject it. (more…)
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We don’t wanna hear it

Posted on August 21, 2008. Filed under: Everything you wanted to know about doctors, Self-deception |

I have an investment partner whose gainful employment, unlike mine, cannot be succinctly described. Truly he is an entrepreneur. He uses his superior intelligence and education to take an entity’s high-potential, low-performance business, reorganize it, and sell it for enormous profit. He manages the affairs of people who have marketable talent, but no financial skills (popular bands). He buys onto the boards of tech companies that have wonderful products and no knowledge of how to sell them. He buys small oil and gas companies whose owners have no idea of the actual worth of their companies (plus or minus), and resells them. He wears a lot of hats. He is a gazillionaire.

I met him because he realizes that doctors have very marketable skills, which are always in demand, but virtually no business expertise (because of the channeled educational curriculum they followed), and who are so arrogant about their abilities to handle anything, in any field, that they will run into bankruptcy most of their personally-managed investments outside their own practice  post haste. Our acquaintance occurred when a number of my colleagues (doctors) decided to start a private, for-profit cardiovascular hospital. This businessman could never be productive, in the sense of directly generating income (he has no license to practice medicine), but his non-productive (again, business definition) efforts are the only reason we are viable. The resistance of the other doctors (never me) to his involvement in our our project is part of a future post. Suffice it say, it never occurred to me in college simply to obtain my diploma, and then use my intellectual ability to make a living by thinking better than the competition. In fact, my first senior surgical partner told me, “Just do the work. The money will take care of itself.”

Recently, the businessman and I were having a conversation about my current status: professionally disabled. I sustained an injury about three years ago that prevents me from continuing as a surgeon. I was relating this sad story, along with details of a nearly concomitant divorce for which I was not liable in any moral way, yet lost my shirt, and the necessity to sell my house in a down real-estate market for the division of the equity. I wasn’t looking for sympathy (I probably was), but the effect on him was immediate and total. He said, “I admire you for what you went through to get your credentials, and for your skills. It’s too bad the way things have turned out. But don’t ever tell that story to anyone again. The average man does not want to hear about the rough life of a surgeon. You’re living far better than 99% of the people, and the business world will reject you if you make that story your mantra.” This is the first time I’ve mentioned it since.

In recent times, chasing a better understanding of the quest for the technological Singularity, I began reading (and unwisely commenting) on the posts at Overcoming Bias. This has brought about several realizations, unfortunately all later in life:

  • Most branches of true science rely heavily on math as the language. Some mathematical concepts literally cannot be put into words, yet another mathematician knows exactly what they say.
  • Medicine is not a true science; doctors are not mathematicians.
  • Scientists base all their conclusions on falsifiable evidence; doctors, for the most part, are not even familiar with the methods for evaluating evidence in their own fieldsSee this, for example. I didn’t come close to the correct reasoning.
  • Anecdotal experience, to a scientist, is no different from lies; anecdotal “experience” plays a major role in the decisions doctors make about patient management.
  • Doctors have an incredibly positive influence on the health of some individuals, at some particular times, but for the most part they are unaware of, or unwilling to accept the statistical evidence for, their ineffectiveness regarding the health of the American populace as a whole. See the evidence here and here, for instance. I have been in medicine for 38 years, and I was unfamiliar with these statistics. As Eliezer Yudkowsky chided one doubtful responder about this information: “I don’t think you understand what statistics mean. They are not a sort of weak extra argument that you weigh in addition to your much more reliable personal experience; statistics are a stronger, more reliable way of looking at the world that summarizes far more evidence than your personal experience, even though it just looks like a little number on paper while all that other experience weighs so heavy in your mind.” Elegant, and a statement that I guarantee most of my colleagues would reject.

Of course, I’m not yet aware of what, if at all, studies have to say about the marginal value of professions other than medicine. I suspect another post will follow addressing that. But for now, I’m reminded of the original United Negro College Fund ads that asserted, “A mind is a terrible thing to waste.” American physicians are smart; the selection system almost guarantees it. But, we’re not the smartest of the professions, and much of our smartness is wasted by our undisciplined thinking.

I think I know one very good reason for this, and I’ll discuss it soon.

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How do you like this education, doctor?

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medical marketing, Self-deception |

Chances are, if your doctor seems quite successful, he is a drug rep. He may not even know it. He surely won’t admit it, especially not to himself. It probably started out as a part of his continuing education.

I wrote: In my next post, I’ll talk about the real leaders in doctor “education”; they weren’t included in this one because it’s not official CME. I’ll also throw in some first-hand, saw-it-with-my-own-eyes anecdotes. Here it is; I know you’ve been waiting with bait on your breath.

You’re sitting in your doctor’s waiting room. You have the first appointment of the afternoon, yet there are five others waiting as well. They are all relatively young women in very nice outfits. They’ve got some cleavage working, and they’re shod in FMP’s, the good kind, maybe Jimmy Choo’s. They don’t seem to be ill. They’re pharmaceutical reps. (NOTE: if your doctor is a woman, these people will instead be athletic-looking youngish men, or perhaps an occasional older, plainer chick, no cleavage. Nothing suggesting competition). They are waiting to help your doctor with his continuing medical education. In fact, statistically, they are the major source of your doctor’s new knowledge about medicines. You will be ushered to an examining room and told, “The doctor will be with you shortly.” One or two of them will see him in his private office before he comes to see you. And so the day will go. (more…)

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    The director of the Sexual Medicine Center leaves penile implants behind, and launches a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry.


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