Books that make you dumb? I don't think so.

Time for another statistics lesson. I'm not the world's greatest statistics whiz (not like the super-geek on TV's "NUMB3RS" show), but that's part of my point: you don't have to be a super-geek to detect major mistakes in statistics that come your way.

This isn't a rant - it's just an interesting example of what to be careful about, with a little entertainment along the way.

I just got an email with something that, on the face of it, is fascinating:

Some one matched up the most popular books in Facebook college groups with average SAT scores at colleges to see what people commonly read at different intelligence levels. http://booksthatmakeyoudumb.virgil.gr/

Nice graphics, and a decent explanation about his method. On the face of it, pretty interesting.

But there's this thing about statistics: you've got to be careful about (at least) three things:

1. When you see a pattern, are you really seeing a pattern you can count on, or is it just a momentary coincidence? (If the first two people to walk into your office are men, does that mean only men will walk in today?)
   
   
2. Even when you do see a pretty reliable pattern, can you be reasonably sure it means what you think it means? (A relationship between the behaviors of two variables is called a correlation, but that doesn't mean you can say one caused the other. A famous example: for some years there was a correlation between wolverine population and the number of sunspots. Did either cause the other? Not likely, and besides, who could tell? The lesson: Similar behavior of two figures could just be a coincidence.)
   
   
3. Finally, you've got to be really careful about whom you actually measured. (If you interview people who are hanging out in skid row bars at 2 a.m., you may reach some interesting conclusions about the opinions of people in skid row bars at 2 a.m., but you can't say they're conclusions about people in general.)
   

Returning to the email: this guy saw patterns in which books were favorites at colleges with different average SAT scores. Addressing #1, he correctly didn't count colleges with very little data. But he blew it on #2, when he titled the page "books that make you dumb," revealing a pretty massive fixation on one aspect of the whole picture, and flying in the face of his assurance that "I know correlation doesn't equal causation."

And besides, on #3, he doesn't even mention the gross sampling error of making an assertion about the book, based on data from Facebook readers who read it AND who participate in listing their favorites. Example 1: the Jesuit scholars at Boston College are highly intellectual, and I imagine that if they ranked their favorite books, the Holy Bible would rank high; but I doubt the Jesuits are ranking books on Facebook, and the Bible ranks among the lowest on this guy's charts.

Example 2: if some book actually made many people so brilliant they ditched Facebook, those people would disappear from this ranking entirely, and all that would remain would be the people who completely didn't get it. And, that book would show up as "making people dumb."

Besides, there's the whole issue of whether SATs are any indication of smartness, not to mention which type of smartness (Gardner's Multiple Intelligences).

He woud have been better off titling it BooksThatLowAndHighSATSchoolFacebookMembersLove.

This isn't just an academic issue - these errors can lead us to drive off a cliff. When we think we see something, and we don't, then with the best of intentions we can make serious mistakes in our conclusions, our policy decisions and our life choices.

Colas and kidneys

Short piece in today's Times about kidney disease.

"In a study published in the journal Epidemiology, the team compared the dietary habits of 465 people with chronic kidney disease and 467 healthy people. After controlling for various factors, the team found that drinking two or more colas a day — whether artificially sweetened or regular — was linked to a twofold risk of chronic kidney disease."

It's specific to colas, not carbonated drinks in general. The problems are kidney stones and kidney failure; cancer isn't mentioned, and I haven't been a big cola drinker for a long time, so I doubt this was a factor in my kidney cancer. But it's good to know.

What's next - Google Health??

Well, what won't Google dip its (extremely large) toe into next? My, it's Google Health. Download your medical records from hospitals and pharmacies, and just give it all to Google and they'll take real good care of it.

Some of us get the creepies just THINKING of how much Google knows about our private stuff. Now "privates" could be more literally true than before.

Mind you, there's a large and legitimate move afoot to create some sort of universal (but private) form of medical records storage, some universally accessible database so when there's an emergency, physicians can treat you accurately and rapidly. (Heck, accurate and up to date information would be useful in non-emergency situations, too. It's amazing how difficult that is to achieve. Many healthcare bloggers have talked about it.)

When I attended a dinner meeting at BI-Deaconess last fall, we saw a new gadget that a patient can wear, a little USB disk drive containing all their medical records. If you were to be away from your usual care when an emergency befell you, this could be immensely valuable. It's a good thing. And if you read my cancer journal last year, you know I love online access to my medical information.

At work I spend a lot of time dealing with Google tools, particularly their "search engine marketing" tools. They write some amazingly good software.

But it'll be a cold day in hell before I hand them my medical data. Sure, they say I'll "own" it. But who could possibly police what they do with it?

Of course, the site says:

Google Health privacy policy: Google respects the privacy of your health information.

But I'm not comfortable that there's integrity behind that. See, there's this motto "don't be evil" that's espoused by CEO Eric Schmidt when discussing issues of privacy when Google reaches into your online underpants and reports its findings to the world. And I'll never forget 2005, when Google (particularly Schmidt) showed its real stripes on that issue.

CNet.com wrote a fairly balanced article about Google and privacy under the uncritical title "Google Balances Privacy, Reach." To illustrate the topic, the writer Googled Eric Schmidt himself, for just a half hour, and published what she found - about him, his salary, his neighbors, his political donations, etc.

And what was the response of The Goog? Why, CNet.com got its goolies chopped off by ... let me see... my, it was CEO Eric Schmidt! This CNN article relates how Schmidt banned CNet from getting any access to Google employees for a year. And when you're a tech news site, that's a major punishment.

GOOG's stock is doing great and I love their free tools, but there's no way in hell I'm giving them sensitive personal data, regardless of what their policy says. New motto for 2008: Don't Be Stupid.

On the health of complex systems

Somewhat related to my "nature of wellness" post is the general question of what is health.

I've known Dorron Levy since November of 1994, and for almost the whole time he's devoted his career to figuring out how to tell whether a system is healthy, with the goal of enabling early detection, which allows solving a problem before its consequences spread, becoming more costly and eventually becoming urgent.

His work that's been published is about computer-based systems, but the underlying theoretical work is quite generalized, and I expect it'll lead to sophisticated early detection of human health problems. He's started a blog, SystemHealth.blogspot.com, to lay out his thinking in easy-to-digest chapters. If you're at all interested in how things work, you might enjoy reading it.

What is the nature of wellness?

Today I was reflecting with wife Ginny about the immune system. My cancer treatment last year involved getting very large boosts to my immune system, and a number of things about my body have responded, beyond the cancer’s retreat. When I combine that with the much-studied interaction between the mind and the immune system, I saw this pattern: “The immune system’s way of being is ‘I am, and I have a right to be,’ and it fights anything that says ‘No you’re not’ or “No you don’t.’”

So the question arises, what has the brain be on one side or the other of that tug of war?

I assert that one factor – a big one – can be the presence of an affirming community that says “Yes you are.” My own blog community during my 2007 cancer experience was a big boost to my sense that I matter to people, and I have no doubt that boosted my sense that I deserved to survive.

About the mind-body connection, years ago I read that in a very real sense, the immune system is a sixth sense, bringing information to the brain about what’s going on in the “corners of the empire” and carrying instructions back. Googling leads to some similar items here (“the nervous and immune systems use a common chemical language for intra and inter-system communication”) and here (“the immune system [serves] as the sixth sense that notifies the nervous system of the presence of entities, such as viruses and bacteria, that are imperceptible to the classic senses”).

The New York Times “Well” blog has a conversation with Michael Pollan, author of In Defense of Food.I am no nutritionist but this makes sense to me:

Americans are a people so obsessed with nutrition yet whose dietary health is so poor. That strikes me as a paradox. We worry more about nutritional health, and we see food in terms of health. Yet we’re the world champs in terms of obesity, diabetes, heart disease and the cancers linked to diet. I think it’s odd. It suggests that worrying about your dietary health is not necessarily good for your dietary health.
…
I think health should be a byproduct of eating well, for reasons that have nothing to do with health, such as cooking meals, eating together and eating real food. You’re going to be healthy, but that’s not the goal. The goal should just be eating well for pleasure, for community, and all the other reasons people eat. What I’m trying to do is to bring a man-from-Mars view to the American way of thinking about food. This is so second nature to us — food is either advancing your health or ruining your health. That’s a very limited way to think about food, and it’s a very limited way to think about health. The health of our bodies is tied to the health of the community and the health of the earth. Health is indivisible.

My favorite brain author is Robert Ornstein. I heard him speak once, and he too puzzled about all the talk about not ingesting fats, when (at that time) there was no evidence at all that changing your intake made any difference in what showed up in your blood. Rather, he said, "What about the salutary effects of enjoying a great meal?" Shortly after, he published Healthy Pleasures. (If this concept interests you, check other mind/health books he's co-authored.)

I personally have a strong sense that our beings - our physical beings and our metaphysical ones, be they "souls" or something else - do resonate with each other, and there's something about the very nature of being well that's worth looking at. And it includes having a strong, supportive community.

More about this in future posts, I expect. For now, think about it, and if you have personal experiences to share, post a comment (at the link below).

Don't fall for SEIU

Some of you may have received an email today from MoveOn. I urge you not to donate to this particular campaign, and to go to MoveOn's suggestion form and warn them, as I did:

Be very, very careful about SEIU. I'm a strong progressive myself, very pro-union philosophically, but these people give unions a bad name. They lie, distort, send subversive emails and letters full of half-truths or outright untruths. Creating a strong union movement must not depend on such Bush-like tactics!

I'm quite disappointed to see them showing up in a MoveOn email.

Watch out - they open you to what could be well-documented claims of fraud and deception. That is NOT something MoveOn needs!

Here's why I said that.

These people are weasels. Those of you who've been following Paul Levy's blog, as CEO of my hospital (Beth Israel Deaconess Medical Center, aka BIDMC), and who perhaps have met him, know what kind of man he is: competent, compassionate, committed, honest. SEIU wants to unionize his hospital, and they've been claiming he's a slimy liar who uses manipulative tactics more appropriate to the Bush administration.

Here's a blog post from the other day about a packet they just sent to 500 affiliated doctors (who don't even work for the hospital!). The package suggests, among other things, that Levy is failing to honor the Jewish tradition of social justice.

Furthermore, SEIU is trying to prevent putting the issue to a secret ballot of the affected workers, supervised by the National Labor Relations Board, and has even supported legislation to eliminate those elections. Note - NLRB elections were created specifically to prevent manipulative employers from blocking workers' free choice.

Paul advocated in an August 2006 post for a free exchange of views: "we will vigorously oppose any efforts to short-circuit the legitimate process by which employees of this hospital can consider, debate, and vote on this issue."

Several months later he again advocated that the vote be by secret ballot. Last summer he spelled out specific tactics the union has used in other cities. One commenter said

The initial cause for unions was to avoid worker exploitation and unsafe working environments. I don’t see this happening at BIDMC. If a Hospital or business provides a good safe place to work with decent benefits and livable wages for all its employees than there is no need for union intervention. That being said I do feel there are still places of business that could use a union…Maybe the SEIU should be looking at Wal*Mart????"

I couldn't agree more. I wonder why on earth they're not doing that. Or, consider Nike, which in 2003 went to court to claim the right to lie about whether they'd cleaned up their sweatshops! They finally gave up, six months later, and agreed to donate $1.5M to a workers' rights group.

Paul's "pages from the playbook" post contains comments spanning three months, with back and forth between Levy and various attackers (and supporters). You can decide for yourself whether he's open and honest. Consider in particular the August 13 comment by an employee, which criticizes several things about life as a nurse at BIDMC - Paul published it unedited. This man is not a manipulator.

We need unions where there are rampant abuses, as with Nike and Wal-Mart. But SEIU does not give unions a good name.

I personally believe the Reagan administration did us all a great disservice when they started busting up unions, starting with PATCO... that's one reason the middle class is disappearing in the US, with grave consequences throughout the economy. But the solution is not to lie and go after great not-for-profit institutions. Shame on them - not only are they not attacking the problem, they're giving the solution a bad name in the process.

Thank you, Harvard Pilgrim!

The rant below is about statistics, not insurance companies. But I want to take a moment to thank my health insurance company, Harvard Pilgrim Health Care. My cancer adventure (and house-selling adventure) this year had enough challenges of their own, but the year could have been sheer hell if my insurance company had been a jerk. Harvard Pilgrim was the polar opposite of that.

This year I’ve run up almost a half million in costs, including dozens of doses of Interleukin-2 at $7,000 a dose. As I chronicled in my journal, the Interleukin (and skillful hospital staff) saved my life, and I don't think I paid a penny for it, and only paid about a grand for everything else.

Early in March HPHC assigned a cancer coordinator to me. At first I was worried that she was a snoop, trying to find out if I was going to break their bank so they should ditch me. But she turned out to be a genuine supportive friend, helping me find information when I needed it, and truly making sure I was getting what I needed.

It's easy for me to see what they've again been ranked the #1 health insurance plan in America. Such rankings aren't perfect (don't get me started) but this one happens to reflect my experience perfectly.

In my first post here, I mentioned my admiration for a CEO who can accomplish great results for people while also managing for good business results. So many people think business is a zero-sum game, where if the company wins, somebody somewhere loses. Great organizations prove it doesn't have to be that way, and great managers (at all levels) make it happen. Blessings on them.

Don't let anyone tell you it can't be done. Thanks to all of HPHC, including both the management team and all the individual workers (like my Helen) who prove it can be done. They made an immense difference in my cancer.

For prettier statistics, omit inconvenient people.

Occasionally I’ll use this bully pulpit for a rant. The two top rantables on my agenda right now are statistics and silos. This time it’s statistics.

I’m irked because I keep seeing a mistake that blows the kneecaps off any well-intentioned effort to improve policy by looking at statistics. People need to be aware of it, spot it, and cry “BS!” when it rears its head.

Earlier this week, in Paul Levy’s blog I got into a discussion in the comments section of a post. Frequent and knowledgeable contributor Barry Carol had wondered if high health care spending around here might be caused in part by a large supply of hospital beds and specialists locally. I said, in part:

I'm intrigued with Barry's observation. (I don’t have an opinion – I don’t know the data he cites; I’m just intrigued.) Is it accurate to say the *cause* is too many beds? Or is it that more are available, so it's possible to give someone the care they need? [I then recounted a story of my father’s care in his final decade, where the hospital staff only seemed to become competent when it was time to kick him out.]

If motorists were spending lots of money on fixing flats, would we say the problem is that we have so many tire repair shops? It's not a perfect analogy, but it's worth looking at. Some cultures think women are the cause of rape, because if there weren't all those women, there wouldn't be all those rapes.

I feel strongly that any statistics about costs and outcomes in a system should have an accountant's note specifying what proportion of the population goes without coverage in that system, so they don’t even have an outcome. Until we get honest about that, all we're doing is chasing a bubble under the blanket.

There’s the rub, the itchy spot. In cases like this, the goal of statistical analysis is to better understand things, particularly to know what a batch of data does or doesn’t represent so we can predict the best way to approach future situations.

And if we don't know what those statistics left out, we don't know what we'd be getting ourselves into by relying on them. We cannot rely on findings until we know what cases were and weren't included.

Increasingly, what might be getting omitted is you. Or someone you love.

As the boomers age, and their decades of productivity and home buying convert to decades of home selling and health costs (who, me?), this is gonna be a big skull-knocking issue. There will be claims about which system works better, with all kinds of statistics being flung around like monkey dung. (Sorry, but monkeys do fling dung when they’re fighting, and when policymakers start fighting, they fling statistics, claiming they're proving reality.)

For health policy, all kinds of claims can be made with good statistical support – but you damn well better ask who got left out, making the picture prettier, whether it was intentional or not.

Personal story: in Massachusetts insurers must price all group policies the same, without considering who’s in the group; New Hampshire has no such law. My wife and I started 2007 with insurance at her job in NH. Without warning, in June her (small) employer’s group rate went up 60%. Why? Because she had turned 60. Young people generally incur lower health costs, so in most states a company can choose to be competitive by selectively offering lower rates to more attractive groups. But when she turned 60, the entire company’s rates went up 60%.

I work in Mass., and it turns out we could get equivalent coverage from my employer (from the same insurer! See my next post) for 40% less.

Now here’s the killer: in NH the disenfranchised can find themselves in real trouble, as policies evolve and unattractive individuals are increasingly isolated. Next personal story: I know a healthy, athletic 20-something whose coverage was costing $2,300 per year (for one person) because she has a minor murmur that’s never caused a symptom, but she wasn’t in a big group. Now she works for a big company, so she’s swallowed up into a big group and gets group rates.

What is the justification for this???

I also know two young families who simply go without coverage because there’s no room for it in their budget. Statistically they are of course counted in the 46 million uninsured – but I say they should also be factored somehow into the total cost of health care, including what it WOULD cost to provide the care they don’t get but would if they could. (Which brings us back to Barry's point about how many hospital beds we have.)

Worse, while excluding those cases, you can bet that the insurance companies (all of them) talked about how good their rates are, and they mean it. (I would - I'm in marketing, and when I believe my company is doing a super job, you bet I say so.) But again, I say you can’t talk about costs and outcomes without specifying whom you’ve excluded.

Final first-hand story: some years ago, when self-employed in NH, I myself found that I couldn’t afford health insurance, because at the time things had evolved to where almost all the AIDS patients in the state were in the category “not a member of any group” – same as me. So any statistics about insurance prices in that state at that time would have been a fat load of crap – flingable crap.

Overlooking the inconvenient people isn’t limited to health care costs. Consider the following, from the US Dept of Labor’s Bureau of Labor Statistics (BLS):

• Unemployment statistics don’t include everyone who wants a job but can’t find one. Once your unemployment benefits run out, they simply stop counting you. You don’t even exist as a problem anymore, as far as the BLS is concerned. I cannot figure out a legitimate reason for this.
  
  
• There are no statistics for people who eventually gave up on their previous career and are now working for half their previous pay. People in that situation are, again, simply not counted as a concern.
  
  
• Nor are there statistics for the loss of benefits. Employers certainly pay less for no-benefit or feeble-benefit jobs, but if you or I change to a job with no benefits, it doesn’t even make a dent in the pretty statistics.
  
  
• Worst of all, the “jobs created” statistics are a cruel joke. When a full-time job with benefits is carved up into three part-time jobs with no benefits, the BLS counts it as job growth. (I called my Senator’s office and had them check it out; a senior BLS statistician got back to me and confirmed it.)
  
  

This is insane. It's as if King Solomon chopped up 1,000 babies and declared a population explosion.

What is wrong with these people?? In May of 2006 an erudite observer in the New York Times remarked with surprise about the 200,000 “new jobs” that had been created in April: “employment [is] doing well, yet core inflation has remained remarkably subdued." Remarkable indeed, until you know what they're calling “job creation."

As I say, until we get honest about this, all we’re doing is chasing a bubble around under the blanket. With the best intentions, we'll make misguided policy decisions. And believe you me, policy has impact at the personal level. The time will come when you (or a loved one) is the bubble everyone wants to chase away. Do whatever you can to stop this crap. Now. Wake up! And wake others up.

What's it gonna take?

What's it gonna take to be so present that I reliably do what I said I was gonna do?

I say I'm going to practice singing, then I do something else. Three days later I say I'm going to pay my bills, then I do something else.

The point isn't that I'm being "bad" when this happens. It's not that I "should" pay my bills that day, or sing that day. The point is that I said I was going to, and I meant it - so what the heck happened?? It's as if I turned on my blinker, turned the steering wheel, and nothing happened.

Well, actually something happened - I went straight, maybe I hit something, and I certainly didn't go where I said I was going. In any case it wasn't what I said would happen, and not what I put effort into. Isn't that weird??

So what's it going to take to be fully alert, present, and "connected to my wheels" so I'm actually the one who says how my life is going?

The irony of this, of course, is that I've spent the past year SAYING how my life is going to go, and succeeding. Nothing could stop me, because everything was at stake. I was, quite literally, living as if my life depended on it.

This reminds me of something from the "est" training (precursor to Landmark): "A game is what you have when what's not so, is more important than what is so." A current example might be CalvinBall, where they make up rules on the fly - none of it is real, it's all an agreement about what's important. Of course, Calvin & Hobbes supposedly know it's all made up, because they change the rules whenever they want, and it goes the way they say.

And est continued: "When what is so becomes more important, the game is over." Like, Calvin & Hobbes are just there, standing at what used to be the goal line. Except now they're just present.

I'd say, when you know what you want but you're not getting there, it's a pretty sure sign that you're playing CalvinBall and you don't know it.

I want to get back to where I was when I was sick. Isn't that weird? But - and I'm not making this up - as I wrote this post, in the background there was an episode of the TV show "House," about a cranky doctor, and in it, a character was ticked off because his diagnosis of terminal cancer turned out to be false. "I've never been as present and alive as I was these past few months - and now you took that away from me." Yeah well, you and I know nobody took anything away from him - it's all in his mind. Mine too.

So the question is, what's it gonna take, to be that present all the time, so I actually do what I say? I know from recent experience that I get a lot of joy when it goes the way I said.

More on this in later posts.

Thank you, Dr. Drew Wagner!

Y'know, as I posted my thanks to the hospital the other day for the cancer care I received this year, I knew I was overlooking someone. I asked a couple of people who it could be, and they too didn't see anyone missing from the cancer team.

Then it hit me: oh yeah, I forgot the miracle surgeon who relieved me of that stinky kidney in the first place! Until he did his work, the oncology team couldn't start theirs. (See, their work was to get rid of all the metastases throughout my body. But that wouldn't have been too productive as long as the source of trouble was still there.)

Dr. Drew Wagner is the surgeon who did the deed for me. He does the really fancy stuff, laparoscopic kidney removal. Three little incisions to stick the instruments through, and a 2-3" bikini incision (yes, I have a bikini scar, and no you can't see it) through which they remove the culprit.

Now, here's the thing, and I really want you to get this: they inflate the belly to give themselves room, then they stick the tools in through the tiny incisions, and do the work by watching it on a TV. They remove the organ (which is large) by basically snipping it off, putting it in a Baggie, zipping it up, and sliding it out through the bikini cut.

Of course, they have to do this with surgical precision, in the dark except for the flashlight they stuck in there. And here's the thing: the TV is 2D, but your guts (including the location of blood vessels etc) are 3D. And p.s., you don't get to accidentally bump into anything with your knife.

In my case, it got a bit tougher than that. Here's how my sister wrote about it in my cancer journal (March 7, 1:29 a.m.):

The procedure took longer than expected for two reasons: 1) the adrenal gland was involved with the tumor and was also removed (as planned) making for two surgeries in one for all intents and purposes; and, 2) the tumor had attached to the wall of the bowel as well as the psoas muscle which embraces the side of the lumbar spine and had to be very carefully peeled away from both surfaces. Dr. Wagner was concerned that he might have to effectively start all over with a more commonly used incision but was remarkably able to perform the very intricate procedure laparoscopically.

"More commonly used incision" is a bit of an understatement. It's a very large incision, and they have to (permanently) remove a rib. It hurts like hell and takes 6-8 weeks to recover. Instead, I was out of the hospital in 2 days and off all pain meds in less than a week.

I had a unique opportunity to experience what laparoscopy is like. Beth Israel Deaconess has an amazing simulation and training center, where students can actually handle laparoscopic equipment. The very first training exercise involves holding two long-armed gripper tools, and all you have to do is use them to pick up some little white beans and put them in a cup. A foot away, and several inches higher.

That's plenty rough when you can see what you're doing. But when you're good at it, they put a drape over the plastic box that contains all this, and you lose all depth perception because now you're watching it on TV.

Then, don't get nervous or anything, but just remember that while you're trying to do this, the patient is bleeding (or might be) and every extra minute under anesthesia adds risk. So don't screw up. Oh, and pick up that bean you just dropped, because it rolled under the pancreas and it's really a piece of tumor. Or something.

And don't nick any blood vessels or other organs.

And then they tell you that this is the first of the laparoscopic training hurdles. You don't get to move to the next machine until you can move 50 beans from lower left to the cup in one minute, with no depth perception.

Until I tried this myself, it had never dawned on me that a surgeon has to be damned athletic as well as smart. And when I think of this guy going into my inflated belly through these little incisions and delicately peeling that super-aggressive tumor off the bowel, and off that muscle attached to my spine.... both of which the tumor was on the verge of invading... and then the adrenal gland got away, and had to be chased down ... well, the surgery took 5.5 hours,* almost had to convert to the rib-removing version, and yet I went home two days later.

Is this guy good, or what?

My gratitude: well, as that cancer journal excerpt said, when I finally got back to my room all I could say was "Mommy, they hurt me!", and I meant it. And when I (groggily) laid eyes on my cane, I (groggily) considered using it to whack the surgeon. But he moved faster than me, and took it out of my reach. (I am not making this up.) It seems somewhere along the line he developed quick reflexes and manual dexterity.

So thank you, Dr. Drew. You are an amazing guy, and I'm really glad your fingers work that well.

* See comment for update.