Thursday, March 27, 2008
Ariely sets out to confirm, through well-designed yet simple experiments, that we do in fact behave irrationally. What he finds, however, is that we are irrational in the same way when faced with the same choices: we are consistently, predictably irrational. And there is hope in this.
For example, when faced with three choices of DVD players on sale, ranging in price from low to high, we will predictably choose the middle one. This because the other two have set "anchors" for us. Knowing this, we can see how salespeople can manipulate us to make the choice they want us to make. Knowing this, we can go to the store armed with unbiased research and choose the model we actually want and ignore the manipulation. Knowledge is indeed power.
But that doesn't mean we will be able to escape our inner irrationality every time. Even Ariely admits to being caught up in a choice between equals that cost him time and money and didn't lead to a better decision. In cases like his it is good to step back and look at the consequences of either decision and then just get on with it. When there isn't much difference between them why agonize - just choose.
Many of the research experiments were designed to ferret out basic human inclinations. In some cases there are factors that can make a big difference, however, that may make the real situation lead to different results in some people. For example, Ariely offers the example of his wife when she was pregnant. She wanted to have a drug-free birth. To determine if she was up for the ordeal, the birth coach suggested that she simulate the pain by putting her hand in ice water for a certain period of time. If she could handle it, then she should feel good about her decision to avoid drugs. She felt she could not handle it and therefore was persuaded to have an epidural when the time came. I believe there are factors that influence such decisions that have little to do with how much pain we can handle. My own experience differs in a significant way from that of Dan's wife and not because I have a high pain threshold:
When I was pregnant I too determined that I would have a drug-free birth. I prepared for it by attending Lamaze classes and having a coach with me during labor. Although the pain was intense, far greater than I had anticipated, and although it went on for a long time, it never occurred to me to ask for pain relief (beyond the breathing exercises). The reason is twofold: 1) I knew drugs would get into the baby and would affect the experience negatively for both of us; 2) I knew labor has an end point. I would not be in pain forever. This knowledge kept me strong throughout and I successfully delivered both of my children without drugs.
However, if I had a severe migraine headache I would take relief in a second, even a painkiller I knew was not good for me in the long run. I would seek any kind of relief. Others have said that when in the grip of a bad migraine headache we just want someone to shoot us. In that case taking a drug affects only me and if I don't take it there may not be an end to the headache for a very long time. Different circumstances indeed. I don't think simulating labor the way Ariely's wife did was an accurate way to simulate the entire experience - even though in her case she did opt for an epidural. My point is that sometimes we have knowledge that changes the experience for us in the individual case.
I do believe the experiments Ariely and friends undertook offer great insights. And we should pay attention to the results, even while we may find that we have some variations in our own responses to similar circumstances.
Another objection I had to the book was with the recommendations Ariely made at the end of each chapter. He would sum up the type of irrational behavior and then offer ways we can overcome our own irrational tendencies in similar circumstances. The recommendations are weak and general and left me feeling a bit lost. I almost felt it would have been better if he'd offered no recommendations at all.
Of particular usefulness should be the chapters on "Free!" and the use of placebos in studies. Reading these chapters should make us aware of why we tend to choose more expensive medical treatment (even when identical to or even worse than the cheaper version) and why free stuff isn't necessarily free. Understanding these concepts could make major differences in our lives and our spending.
Wednesday, March 26, 2008
In this book Gawande focuses on performance: how well doctors do what they do.
He finds a few who step out from the rest, who are in effect "rogues" because they won't settle for "standard practice". Especially representing this group is a doctor who works on patients with cystic fibrosis. He invented a special jacket these patients can wear that pounds their chests (using air) to loosen mucus inside (previously patients had to depend on family and friends to pound their chests for them). He also insists on higher levels of performance from his patients and asks them directly what they have noticed about their illness, as a way to developing more specific care for them. The proof is in the result: his patients live far longer than average cystic fibrosis patients.
Through each of the little stories in this book Gawande looks at results. Instead of peering into a microscope to look at causes of illnesses he looks at how doctors get results. And he concludes that medical miracles are not the answer; rather, doctors using what they have at their disposal and using it well will get better results.
I had some quarrels with some of his conclusions but I could not fault his reasoning. For example, he compares the use of forceps in difficult deliveries to the use of ceasarean section. A C-section is easier to learn and perform for all doctors and therefore can more reliably be used than forceps, which require special skill to use correctly. He hints at the overuse of C-sections but does not challenge current medical practice enough for my satisfaction. But I can't argue with his conclusion that if our goal is to achieve more healthy live babies the increased use of C-section may be the correct route (personally I think less interference is better, that proper vaginal deliveries are preferable and especially without drugs, but this route requires greater understanding of the process and a willingness to let nature lead). He does note that nobody is keeping track of the condition of the mother, however, and that this is a focus that needs to be changed.
I also wondered about his conclusion that increased use of mammography is where it's at in breast cancer - many studies have concluded that mammography is only helpful in specific older age groups and that in others it is a waste of resources. However, his real emphasis is on a bigger question: how do you change a population's habits for the better? (In the case of mammograms the massive public information blitz changed women's habits and led to greater numbers of mammograms being done.) It's a question that needs answers.
The book provides great insight into the medical profession and where it is headed. It's thoughtfully and compassionately written by a surgeon who pays attention and takes notes. The afterword offers five actions a doctor can take to become a "positive deviant" - a doctor who achieves better results. It may be surprising to discover that Gawande, as much as he admires the stand-out rogues, is trying instead to reach the majority of doctors, to encourage them to use what they have better rather than to reach for unattainable stars.
Saturday, March 22, 2008
Levitt and Dubner repeatedly say that this book does not have a "theme". And in the sense that Blink or The Tipping Point have themes, they are right. But it does have a fundamental focus: on "conventional wisdom".
Levitt, as an economist, has made his name by asking different questions - like "do teachers cheat?" - and by finding ways to sort data to get the answers he is looking for. Dubner interviewed Levitt for a NYT article a while back and soon a collaboration was born - the collaboration that yielded this book. Both Levitt and Dubner appear to be good writers, as evidenced by the Freakonomics blog at http://freakonomics.blogs.nytimes.com/, where both post individual as well as joint articles. I sense that the overall style of the book is more Dubner than Levitt, based on my seeing Dubner speak at Prosper Days (see my articles on Prosper Days at http://fightdebt.blogspot.com/search/label/Prosper%20Days).
In this book we find answers to a wide range of questions that few people would think to ask, about topics from sumo wrestlers to parenting. What does it have to do with economics? Simply that it has to do with how people get what they want - and how people can be encouraged to do the right thing and avoid doing the wrong thing. The outline of the entire book can be found in Dubner's original article, which is included as part of the additional material in this book, along with selected blog posts and heavy-duty footnotes.
I for one really did want a bit more of a theme than this non-theme, but I do think the basic premise is sound and a good reason for people to read the book - it is important to question conventional wisdom. For example, at one point another economist read Levitt's original article on the relationship between abortion and the drop in crime, and he said (I'm paraphrasing), "I have read this over and over and I can't find anything wrong with it, but I still don't believe it.". This is how most of us are: we can be faced with incontrovertible evidence but we find it difficult to let go of what we have believed for so long.
Wednesday, March 12, 2008
Near the end of the book Abramson, a long-time family doctor who has an extensive background in statistics, epidemiology, and health policy, puts it simply: the bad news is that many of our celebrated advances in medicine, including new drugs, medical procedures, and sophisticated equipment, do not perform as well as older treatments and cost a great deal more. The good news is the same! If we knew what really works, based on unbiased well-designed studies, we would not need to use expensive treatments, equipment, or drugs nearly as often as we do, and we'd be better for it. In other words, our health care costs would drop and our health would improve.
Our health care system has gone so far astray that in comparisons with other developed countries the U.S. pays twice as much for abysmal results. And it really is not an accident. And it isn't because we eat too much fried food (although, of course, we do have to take responsibility for choices within our power). Read this book and find out for yourself. It's easy to read, clearly written, easy to understand. And so important. I would like every one of our political leaders to have a copy.
Thursday, March 6, 2008
The reviewer comments on the back cover of this book say “An inspiring portrait of the human-animal bond...”. “Funny, touching, and insightful...”. “Rewarding memoir...”. I might have said as much about other books on humans and animals, but not this one.
Jon Katz tells us straight out that his goal in taking on the care of three border collies, a herd of sheep, and two donkeys is to better himself, to “become a better human being”. It's an admirable goal – but at what sacrifice? When does it seem a good idea to experiment on animals for your own so-called personal growth? What kind of growth is that really?
Obviously I am in a different camp from Katz. Long ago I concluded that there is no animal on this earth who is safe from humans. I also concluded that human destruction of much of the natural world means that some animals, including cats and dogs, no longer have a natural habitat, that in fact their natural habitat now is with us, in our homes. A corollary: it is our responsibility to care for homeless dogs and cats humanely (which does not mean killing them); we created this situation and we are responsible for them. I offer this paragraph as a disclosure that explains part of the reason I take issue with the way Katz approaches the animals he takes on.
Katz sells his mountain hideaway (the subject of previous books) and purchases a run-down farm in upper New York state. He brings his three dogs there and accepts delivery of 16 sheep and the first donkey. Later he travels to the farm of a self-described “donkey lady” and purchases another, younger donkey as companion for the first. He works with his dogs, trying to train them to herd the sheep, and he spends much of each day cleaning, repairing, doing the chores associated with this life. He also spends part of his day writing about it and appears to spend nearly 100% of his waking hours trying to figure it all out. By which I mean he sorts through his relationship with the different animals and comes to conclusions about himself, those animals, and other people and their animals. Forcing himself to be responsible for all of these animals is supposed to make him a better person.
What others have characterized as “introspection” I see as justification. Katz spends endless paragraphs justifying actions that he suspects others may see as wrong somehow. He tells us honestly what trainers have told him (that, for example, he needs to stop yelling at his dogs) and that he bemoans his failures as a human being, and then he obstinately reverts to pattern (keeps yelling at his dogs). It is as if he wants to become a better person but retain all of his prejudices and habits in the process.
Again and again he describes occasions when he has gone against the advice of people he trusts, only to find out that their advice was good. A trusted trainer said don't bring another puppy into the mix until you have resolved the issues with Homer. Katz wants a new puppy so he gets it anyway, only to find out after much work with all of the dogs that perhaps that wasn't such a swell idea. I can't help but conclude that he is going after what Jon wants rather than what the dogs want or need.
When Katz wants a new dog he heads for the breeder. He chooses a breed and a specific puppy for its characteristics. He wants a border collie to herd sheep. He wants a labrador for companionship. He snipes at those who frown on obtaining dogs from breeders with this argument: some people adopt babies but most of us want one of our own. Is that a fair comparison, though? The comparison fails on more than one level:
* When Katz goes to a breeder it's like he's going to an adoption agency, not “having his own”. He also deludes himself by assuming he can specify exactly the dog he wants. Even when you choose a puppy of a breed that tends to have certain characteristics, there is no guarantee that the puppy will grow up to be the dog you expect. Katz's own experiences with different border collies are testament to this variability in dogs. All dogs. (not to mention all people)
*Even the best breeders produce dogs that are “not acceptable”: dogs they can't sell. These dogs are a result of the breeding process. Even the champion dogs tend to have physical or mental issues that are genetic, a result of the breeding process. The best breeders will claim that they find homes for all of their dogs, whether or not they are “perfect”. But every time a breeder's dog goes out the door the people who take that dog do not instead take another dog that needs a home. Thus breeders contribute to pet overpopulation and contribute as well to the population of genetic misfits.
* Approximately 40% of the dogs in shelters are purebred dogs. Many breeder dogs do not come to good ends.
* Katz ignores statistics because he wants his own chosen dogs, not some “rescue”, even though he has rescued dogs in the past, from inappropriate homes. Therefore he justifies his decision.
When Katz takes out his rifle and shoots a feral cat it is at the end of many paragraphs explaining he never thought he'd ever shoot anything and his dogs were being attacked and he did not have a choice. Actually, he did have a choice, but it would have taken more work of the kind he chooses not to do. It would also have labeled him some kind of bleeding heart there in the country, and we can't have that. He desperately wants (maybe needs) approval from the old-time “real” farmers and ranchers. Katz is no lazy person. He simply makes his choices for his own comfort and supposed better-personhood rather than for animals.
Katz does come to the conclusion that he cannot provide the kind of home needed by his sweet Homer. After agonizing and justifying this decision – a justification not needed, believe me – he places Homer with a family that can give him what he needs. In this Katz has done the right thing. He wears the hair shirt, however, over and over expressing distress that it was his own bad training practices that complicated life for Homer and made it necessary for him to go to another home. Enough already. He protests too much.
I have come to the odd conclusion that perhaps Katz is not the dog person he says he is.
He would say he's not a “Dog Person” too, but his definition of “Dog Person” is not what I mean. He describes his sister and others he has met as dog persons, and what he means is people who actively rescue “unadoptable” dogs, who care for them with every last scrap of their incomes, who let them overrun their lives in every respect, shutting out people – except other “Dog People” who meet the same definition. This type dog person is a small subset of the whole, the dog people I know personally.
Katz is not afraid to reveal what he sees are the problems in his own personality: a lack of patience, a tendency toward anger, especially quick anger. He refers frequently to a childhood of chaos where he learned these ways of keeping other people at bay. He obviously truly wants to find and keep a genuine long-lasting closeness to those who matter to him, and does not want to continue to alienate friends and family with his bursts of anger or silence.
He finds his salvation in the animals. Through them he learns patience especially. Through them he harnesses his will toward the care of others. Through them he finds a connection to his sister that had been lost. Clearly this is the message of the book. Animal people will all tell you that animals change you, make you better than you were. I have no argument with that. What concerned me throughout this book was the total me-ness of it. It was always about Katz and what he wanted and needed from the animals. Even though he went on various trips to find out what the animals needed, the need of the donkey to find her “inner donkeyness”, for example, ultimately he did these things because they would make him a better person. There is something backwards about this approach that simply bothered me the whole time I read this book.
At the end of the book Katz is laying in supplies and readying the farm for another winter. We are expected to believe that he has found his place at last. I for one doubt it. It was good enough for one book but the adventure will not be enough for many more.