kw: book reviews, nonfiction, medicine, economics, motivation, biases
You're 48 years old. You have a pain in your gut. Over the next few days it gets worse, and you begin to have diarrhea. You see a doctor, who says it might be an ulcer and suggests an OTC antacid. That seems to help, but not 100%. Being an agreeable sort, and in the midst of a demanding career, you carry on for several months. The diarrhea and pain come and go, come and go. Then the pain gets worse, and the diarrhea gets worse, and gets darker, even tarlike. What now?
This happened to a young friend's mother, and "What Now? meant seeing her doctor quickly, getting a colonoscopy at age 49, and dying of colon cancer a month later.
Now suppose the age above was not 48 but 52. The fourth sentence and what follows is likely to read, "You see a doctor, who orders a colonoscopy. Cancer is confirmed, and removed in an operation. Several months of chemotherapy follow, and you live many more years."
When I had gut pain at age 53, the doctor should have ordered a colonoscopy, but didn't. Why? The insurance industry scores doctors badly who order too many of the more costly tests! I eventually did have a colonoscopy, but I had to order it myself! I soon had a serious operation, half a year of chemotherapy, and now I am 78. Had I waited for this rather passive doctor to get around to ordering the test, I'd have died 25 years ago. I didn't go back to that doctor. There's a further wrinkle in this, which I'll return to.
What's the difference between age 48 and age 52? I could have used 49 and 51. The cutoff for "elevated risk of colon cancer" is age 50. Not only is it hard to get the insurance company to pay for a colonoscopy if you are "too young", the guidelined cutoff is a mental barrier for your doctor, who probably just won't think of investigating more deeply.
Such cognitive biases and blind spots are the subject of Random Acts of Medicine: The Hidden Forces that Sway Doctors, Impact Patients, and Shape Our Health, by doctors Anupam B. Jena and Christopher Worsham. Dr. Jena is host of the podcast Freakonomics, M.D., and the book takes an approach similar to that in Freakonomics and Superfreakonomics by Steven Leavitt and Stephen J. Dubner, two books I have close at hand. Together, these three books emphasize that at its root, economics is the study of motivation, of why people do things.
In the dozens of cases reported in the book, the doctors and their associates plumbed the databases of Medicare and the CDC for information that allows them to winkle out the little anomalies that reveal biases such as the "first digit bias" that puts age 48 or 49 into the "forties" bin and 51 or 52 with the "fifties". Untimely deaths can and do result form such biases.
If these two doctors stepped into the waiting room and you had the chance to choose one of them to perform your yearly physical, which would you choose? (The image was generated using Leonardo AI)
Granted, neither you nor I will be offered the chance to choose a doctor "on the spot," but if you were…? Here's the wrinkle from above: Fifty years ago I would have been more inclined to choose the man, not because of race but because he's male. Since then I've had to change doctors a number of times because of my moving or doctors moving elsewhere or retiring (or the passive doctor I "fired"). I've had both male and female doctors. By age forty, a man starts getting the "digital prostate exam", sometimes called the "golden finger". Having been probed by both male and female doctors, I found that I really prefer a doctor with long, slender fingers! A female musician who happens to be a doctor fits the bill perfectly. I've also learned that women are more willing to take an extra few minutes, and more likely to think sideways in case there is a second factor, not just "the diagnosis". My current doctor is female, and is tied for best doctor I've ever had.
What do doctors Jena and Worsham have to say about that? They studied Medicare records of 1.5 million hospitalizations, and gathered information about the outcome of care by 58,000 doctors, of which 32.1% were women. The criteria were thirty-day survival and rate of readmission. After the data were normalized to eliminate confounding things, here are the key facts:
- 11.3% of the patients died within 30 days of being hospitalized.
- For women internists, mortality was 11.1% and readmission rate was 15.0%.
- For men internists, mortality was 11.5% and readmission rate was 15.6%.
Are these differences small enough to be negligible? No. More than 10 million seniors are hospitalized for medical conditions (excluding accidents) yearly. The doctors conclude, "…if male internists were performing at the level of women, there would be thirty-two thousand fewer deaths…each year." 32,000. That's 80% of the death toll from highway accidents.
Earlier in the book, we find that the month a child is born influences the likelihood of getting a flu shot during yearly pediatric exams. That influences the number of kids that get the flu. Why? The new flu shots become available in autumn, preparing to deal with the surge of influenza in the wintertime. A parent of a youngster whose checkup is in May or June is told to return to the doctor in October for a flu shot. Less than half do so. Some may take the child to a drug store clinic or instant clinic, but that is a small percentage. So kids with birthdays in the spring or fall, or even late winter, are less likely to be vaccinated, and more likely to get the flu, or to get a bad case.
The last chapter of the book dwells on the COVID-19 pandemic, and the role of politics in medicine. Humans have been called "the political animal"; politics gets into everything! The struggle for power is the source of the world's greatest evils. I'll leave it up to you to read their insipid take on the matter (sorry, docs!). Instead I'll riff on the experiences of myself and my wife.
We were reluctant to get the mRNA agent that was being called a vaccine. We learned some stories of people who survived the disease well enough, but had "Long Covid" and in some cases were debilitated for months. That tipped the scales; we decided to get the shots, which we did in April 2020. We were generally compliant with things like masking and "social distancing". By the time various "boosters" were announced, we'd done sufficient research to realize that the "vaccine" was usually useless and often harmful. Here is a point I wish the doctors had put in the book: The yearly number of serious adverse reactions to the mRNA agent is just a little greater than the sum total of serious adverse reactions to all other vaccines combined!
How many remember in the middle of the controversy, Dr. Anthony Fauci saying, "I AM Science!" He had already admitted to lying a couple of times, and had been caught in a few other lies. Here he lost all remaining credibility. He doesn't understand science, not even a little bit!
Here is what the mRNA agent does: It induces your body to create a particular protein found on the spike of the SARS-Cov-2 virus. That protein triggers the immune system to create antibodies to that single protein. It is a two step process. By contrast, a vaccine consists of broken-up viruses or proteins extracted from them, which triggers the immune system to create antibodies to most or all of the proteins in the vaccine. The extra step that came before increases the variability:
- Different people have different levels of response to a "foreign" protein. One person's immune system may produce ten or one hundred times as many antibodies as another's. This is why vaccines aren't 100% effective. Flu vaccines in particular show this effect.
- Different people have different levels of response to the mRNA agent. One person may wind up with ten or one hundred times the level of "spike protein", which in turn is subject to the range of variable response noted above.
A good portion of my career I used the statistics of distributions. I'll save you the agony of figuring out any equations. Rather, let me just say that when you have two distributions, the mathematical tool used is called convolution. The final, overall distribution is very wide indeed. In this case, a range of a few thousand to one. Also, you may have heard of the "Gaussian distribution", also called the "Normal curve", a smooth curve with a symmetrical hump in the middle. That's not what we have here. The response distributions here are more likely Lognormal distributions, which have a small number of large values and a much larger number of small values. Convolving two of these yields an extra-wide distribution, but heavily weighted toward very few powerful responses, a large-ish number of "middling" ones (centered on the "target" response the pharma company aimed for), and an overwhelming number of small to almost nonexistent responses. These small responses led to the "breakthrough" cases of COVID-19 disease among those who took the shots. For some people, the shot may as well have been distilled water.
My wife and I count ourselves lucky. We had mild reactions to the mRNA shots, a little stronger than the "sore arm" we get from a flu shot, but not too bad. The same-day response was to the mRNA itself, and the next day's soreness was in reaction to the protein thus created. We learned later that some people dropped dead on the spot! These must have been those with a super-strong response in both steps of the process. Their immune responses overwhelmed the body.
I have several friends who are doctors. One of them, because of his work, was doubly treated; he received both the Pfizer and the Moderna mRNA agents. He has since had COVID twice. But before that, he and I worked out a strategy to deal with the infection: Stop eating for a couple of days. Those who died from the infection actually died from pneumonia, which was caused by the body's overreaction to the virus. The ones with the strongest immune systems died first! What is the gooey junk that fills the lungs during pneumonia made from? Sugar. This is why diabetics have the highest risk. What happens when we skip meals? Blood sugar is reduced. It drops a lot. This hinders pneumonia.
Secondly, the two "Democrat-hated" drugs, Hydroxychloroquine and Ivermectin, are useful not because they are anti-viral. They aren't. It is because they tamp down the cytokine reactions that lead to pneumonia. HCQ works in the first day or two, and Ivermectin later on. My doctor friend obtained supplies of both medications for himself and for my wife and me.
At the end of August, 2022, I caught COVID. Here I found out that the joke was on me. The primary symptom I had was powerful nausea. I threw up everything, and I couldn't even drink water! So I couldn't take HCQ!! I went to the one clinic in the area with antivirals on hand, and was given those plus anti-nausea pills so I could swallow the meds and keep them down. Although I'd moved to the spare bedroom the day I woke up sick, my wife got sick a week after I did. She had a very sore throat, making it painful to take any pills. She went to the clinic and also got the antiviral. Both of us recovered quickly. By the way, I had lingering low appetite, my kind of "long Covid", and I took advantage of it to lose some weight, around 30#.
A year and a half later, the above scenario was repeated. Same symptoms, same need to get the antivirals, same quick recovery. I was able to lose another 15#, and I learned what it takes to hold my weight. So I count SARS-Cov-2 my friend!
Another year or so has passed. My family doctor is in agreement with what we've done and with my determination never to get a "booster." They're too dangerous.
That is a long digression from a wonderful book. Doctors Jena and Worsham show how and why doctors make certain kinds of errors, and discuss ways these errors are being mitigated. Reading this book is useful to all of us as patients, so we have the mental tools to work with our doctor(s). We can't replace them, but we can either help or hinder their work. We all know that something will get us sooner or later. Together we can make "later" be even later, and thrive in the meantime.