Freakonomics with a stethoscope

 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.

Unreasonable and Beneficial

kw: book reviews, nonfiction, motivation, creativity, nonconformists

Do you know the old song "High Hopes"? Part of it says,

Just what makes that little old ant

Think he'll move that rubber tree plant.

Anyone knows an ant, can't

Move a rubber tree plant!

But he's got high hopes, he's got high hopes;

He's got high apple pie, in the sky hopes.

So any time you're gettin' low,

'stead of lettin' go

Just remember that ant:

Oops! There goes another rubber tree –

Oops! There goes another rubber tree –

Oops! There goes another rubber tree plant!

Then there was Harlan D. Sanders…you know, Colonel Sanders. I am not sure how he lived to age 65; by then he had failed in business a number of times, and in the legends that swirl around his name the range is from seven to more than 1,000. One might think he'd get discouraged, but he was too scrappy to keep an ordinary job; he had to be self-employed. When the timing was right, his fried chicken business finally made him wealthy. Apparently his "business failures" had kept body and soul together until then.

In Originals: How Non-Conformists Move the World, by Adam Grant, we read of a number of people who didn't settle for the status quo. They didn't conform. That's all it takes to be a non-conformist. The thing is, there are a lot more non-conformists than there are successful non-conformists. But, really, there are a lot more musicians than there are successful musicians. Are you a non-conformist, but feeling dragged down? The book may have some useful ideas for you.

The book's focus is people who caused good things to happen, who were Originals. George Bernard Shaw put it this way:

"The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man."

Thus, each chapter presents and a principle or maxim that an Original must deal with, and shows how someone did so. We learn quite early that it is risky to go against the grain (or against the tide). The first chapter, "Creative Destruction" (headed by the Shaw quote above) tackles that notion. The author highlights the origin of the online eyeglasses industry by four young men who started Warby Parker, in the face of enormous, "Nobody will want that!" -style criticism. I've used Warby Parker. I heard of them long before I tried them out. They're actually losing the marketing edge to some even less reasonable competitors, but they're the big dog in that arena. Adam Grant had passed up the chance to invest in WP in 2009, "…the worst financial decision I've ever made…", he tells us.

As much as we might idealize those who "speak truth to power," we recognize that most of those who do so get effectively squashed. In Chapter 3, "Out on a Limb", we find that we need to build credibility and status to be heard by the powers that be, assuming that is relevant. In the CIA of thirty years ago, Carmen Medina saw the need for faster communications in all directions within "the Company". She thought electronic communications—which weren't all that new—could help. After persistently speaking up she was "sent to Siberia" within the agency, and lucky she wasn't fired outright. By building credibility and status from her "Siberian" post, several years later she was able to co-create Intellipedia. Now it is indispensable. 

That reminds me of Martin Luther. He was a nobody, a monk in Wittenberg, a rather nowhere place 80 km southwest of Berlin. The changing political climate (and newly invented printing press) set the stage for his "95 Theses" to "go viral". A generation earlier, he'd have soon wound up in prison or the grave. And he soon gained political protection from anti-clerical German princes, or he'd be forgotten today and any Protestant Reformation would have started decades later, if at all.

To quote Shaw again, a quote R.F. Kennedy used:

"You see things; and you say 'Why?' But I dream things that never were; and I say 'Why not?' "

I count it a character flaw of mine that it seems I always fail at "speaking truth to power", and quail in the face of opposing authority. Yet somehow I build a career on doing things I'd been told not to do by supervisors whom I was able to hoodwink long enough that they saw I was making clients happier, and "overlooked" my insubordination. But it took dying (and being resuscitated) on the operating table to give me the gumption to take a stand and stick to it when I thought it was warranted, which capped my career with significant success.

Few of us are in such a position that being a non-conformist will really get us anywhere. But look around. Nearly everything that makes this old world livable started with an idea, but even more, with a person who went against the tide to make the idea a reality. As Henry Ford said, "In 1890 people just wanted a better horse." Ford was not the first to produce a working and practical automobile (that was probably Carl Benz). He was one of a host of dreamers (including Olds, Nash, the Studebaker brothers, Cadillac, and DeLorean) who shaped the industry. The most powerful force is an idea.

I could say that I suggest this as a book to be read by any entrepreneur, (or wannabe). Maybe. Or maybe it's best to let folks with a gleam in their eye dive in and duke it out in the public arena. A key characteristic of Originals is that they are, well, Original! I think they ought to read it anyway.

There is a quirk in the eBook I read. At the bottom of nearly half the screens (virtual pages) I find the first syllable or two of a word, often in the middle of a line that ends prematurely. There is no hyphen. The next screen begins with the rest of the word. I don't find this in any of the other eBooks I have read, so far.

Can we be even more human?

kw: book reviews, nonfiction, motivation

I once worked for a wholly-owned subsidiary of the corporation. While I was in the process of transferring to a new job in the "mother corporation", the subsidiary got a new president. Early on he gave a speech with the title "A Passion for Profits." I went right to my desk and wrote him an e-mail recounting my career and its basis in a passion for excellence (also the title of a great book by Tom Peters, which I read several years after applying the term to my own attitude toward work). I explained that producing excellence reliably had always been followed by substantial profit and profits.

I also noted that "passion for profits" is a synonym of "love of money", which, a Bible verse tells us, is "a root of all kinds of evil." I'd been told he is an active Bible student. His reply was so self-serving and disingenuous that I did not continue the contact. I was SO glad to be leaving that subsidiary.

The fact is, in pursuit of excellence, it was great to be a software developer for the 1960s-1990s. A computer application either delivers or it doesn't. People will love it or hate it. I learned early on to train one or two high-energy customers, then recruit them to write the "help" text. Then the help was much more helpful. As a developer, I knew too much about the ins and outs of a program, and I could not write "help" that would be very useful to someone who was new to it.

Based on a lifetime of such experiences, I was interested to take the little assessment at Dan Pink's 'Drive' site, to see where I fit on the Type X versus Type I scale. To my surprise, the summary stated, "…we assess your behavior as mostly type X." I was as honest as I could be with the assessment questions, and being brutally honest about it, I realize that, while I require a lot of freedom in my own workplace, I am less willing to afford those benefits to others. It's a good thing I am not a boss! I have joked this way in the past, "If I lead a horse to water, and it won't drink, my impulse is to drown the horse." Sadly, it is more true than I'd wish.

I am thus very glad to have read Daniel H. Pink's new book Drive: The Surprising Truth About What Motivates Us. It is definitely raising my consciousness. It helped me understand just how good some of my own bosses have been. If they were not expressing Type I behavior, I'd be in real trouble!

So what are Type I and Type X? As the author explains, we have three levels of motivation: Survival, Production, and Fulfillment. He calls the first Motivation 1.0, using the analogy of an operating system. It is how the human race operated for its first million years, and how animals operate. In the recent past, civilization arose, and with it the division of labor became more formalized. Motivation 2.0 emphasizes efficiency of Production, and efficiency experts such as Frederick W. Taylor built an industrial machine with humans as cogs needing to be coerced (rewarded and/or punished) into producing goods and services.

Motivation 3.0 is our third drive. We exercise it when pursuing a sport or hobby that we enjoy. The key word here is "enjoy". The only way Motivation 3.0, or Fulfillment (my word, not his), can work is if three elements come together: Autonomy, Mastery and Purpose. An internally motivated person is typically more productive than an externally motivated person, yet the productivity is a side product of the joy of the work itself. Type X, then, refers to eXternal motivation (2.0), while Type I refers to Internal, or Intrinsic, motivation (3.0). The latter outperforms the former, hands down.

Case in point. Before I left that subsidiary, I worked several years in a "skunk works" that developed a workstation for geo-scientists to use. We numbered twenty, including our supervisor, who also loved to write computer software. We were all "superprogrammers". The term was coined by Caper Jones in 1977 to describe computer programmers who were ten to 100 times as productive as their fellows. A good journeyman programmer could produce 2-3 debugged, tested, "correct" lines of "high level" (Fortran or COBOL) computer code daily. Superprogrammers breezed along producing up to 200 lines daily—tested, debugged, and correct. My typical production rate in the 1980s-90s was 100 lines daily of Fortran code. As a result, our small shop outproduced software corporations that employed 100-200 (or more) programmers to develop commercial workstations that we were competing with. And we loved the work. Our proverb was, "A vacation is when you work only eight hours a day."

In such a work environment, we had lots of autonomy. "Flex time" was "start any time before 7:30, go home any time after 4:30". While nobody had a cot in their office, the idea did get raised, and not by any bosses, either. But a fellow has to eat and see the family once in a while… As the prior paragraph demonstrates, we also experienced mastery. And as for purpose, nothing could be simpler. We wanted to produce the best workstation system to help our customers find more oil than anybody else in the business. We wanted to beat the pants off our competitors, which included Microsoft. We did so, year after year.

All good things must end. Mr. "Passion for Profits" was deeply distrustful of people who are internally motivated, was blind to the evidence of superior productivity, and had the group broken up. The company uses a commercial product now. I escaped intact. I am 1,500 miles away, and have worked my way into a near-skunk works situation. I hope it can last another couple of years until I am ready to retire. People love my work, and I love doing it. The "managers" keep their hands off as much as possible. So far, no blindness.

I wonder how I would fare at Atlassian, a company touted in Drive as one of the most Type I companies, if not the most. One thing they practice is "FedEx Days", a day in which individuals and groups can work on anything they like, so long as they have something to report to everyone else the following day. The results are so outstanding, sometimes it seems that those quarterly events yield half the company's products. We use an Atlassian product, Confluence, at work.

The book doesn't just explain Motivation 3.0 and the research behind it. It contains a substantial section of tools and suggestions for persons and organizations. Type I behavior, particularly for control freaks like me, cuts both ways. It is, for me, a new level of the Golden Rule, learning to offer the same autonomy to others I demand for myself. The author conveniently provides several condensed versions of his theme, including a Twitter tweet: "Carrots & sticks are so last century. Drive says for 21st century work, we need to upgrade to autonomy, mastery & purpose."

Side thoughts on brief riches

kw: musings, wealth, motivation

I lived for several years near Ponca City, Oklahoma, when I worked for Conoco. The most famous town landmark is the Marland Mansion, built in 1925 for E. W. Marland, founder of Marland Oil, which became Conoco. This image is from Wikimedia Commons.

I remembered something one can see at the mansion while reading about motivation, a quote by Marland: "Who knows why people do what they do? I spent money like water on my town and my people, and they thrived and prospered."

As is plainly visible, he spent money on himself at a pretty good clip also. So much so that by the time the mansion was finished, he was nearly broke, and never lived in it! He had always wanted to live in a palace. Like Moses and the promised land, he saw it but did not enter in.

There is another quote by him that I find poignant. He was a scientific innovator, and invented a number of the techniques of geophysical prospecting for petroleum. At a speech in, I think, the late 1920s he said (I paraphrase), "We have learned where oil is to be found, and how to find more."

When he was saying this, he did not know that he had already found every drop of oil he was ever to find. All of what we now call "easy oil" had been found. It required further innovations by many scientists to refine the techniques he pioneered so as to see further and more clearly into the earth, then refinements in drilling technology so as to reach the oil once it is found.

At the time I transferred out of Ponca City, the first "deep water tension-leg" drilling platform was installed in 1,500 feet (450 m) of water. It was a technical success, but at then-current oil prices, a commercial failure. Oil prices are now four times higher. Current technology, such as that used for the problematic BP well Deepwater Horizon, allows drilling in water four times as deep. Marland would be impressed. He would not be surprised.