Write Shallow, Narcissistic Prose, Become a Published Author in the Times!

With our limited audience at the Billy Rubin Blog, we pine for the kind of attention that Lori Gottlieb has received throughout her professional career. Dating back to her days as a post-bac premed student, she was earning a name for herself in national publications: here, for instance, she dished up the skinny in Salon on interviews with mean people at Harvard Medical School back in 1999. Since then she has undertaken a rather dizzying set of career changes (for instance, she dropped out of med school after two and a half months because "she didn't like being around sick people"--even though the first two years of med school involve almost zero exposure to sick patients) but all the while pumping out essays and eventually, books, mostly memoirish accounts of her various professional adventures and misadventures. Today she has the kind of legitimate following that would make us pee our pants out of delight. Our envy is unadorned.

That said, much though we covet her following--or at least the idea of a following, though not so much hers in particular--we'd never stoop to the type of writing in which Ms. Gottlieb engages. Key recent examples include last year's offering in The Atlantic, "How to Land Your Kid in Therapy", as well as this week's remarkable meditation on the decline in psychotherapy, "What Brand is Your Therapist?", which appeared in the Friday edition of the Paper Of Record. "Remarkable" in that it really isn't an analysis at all of the profession and the challenges it faces, although it does provide some verbal window dressing in the first few grafs to make it seem so. Instead, it's the kind of piece for which Gottlieb is justly renowned: a me-me-me account of her experiences trying to start up her practice. Fully, three out of the 39 paragraphs do not contain the words "I", "me", or "my"--and the remaining 36 typically feature one of those three words in the first or second sentence. You may think you're reading about the modern state of psychotherapy; actually, you're reading about--may we use her first name?--Lori.

Here at the Billy Rubin Blog we have no qualms with the memoir, nor with centering a narrative around the concept of me. We are huge fans of Hunter Thompson, Ruth Reichl, PJ O'Rourke, Bill Bryson, Joan Didion, and Calvin Trillin--all fine writers whose central subject is often (sometimes only) the first person. But Gottlieb is playing at something else entirely: she's posing as a serious analyst about serious issues when in fact she is, at best, a shoddier version of the above masters of the craft. "How to Land Your Kid in Therapy" is in essence the uninformed musings of a trainee. She displays no evidence of having spent any serious time studying such an important topic or having considered what the research might have to say about parenting styles. Basically, she used her media persona to spin a couple of therapist-patient sessions (while a greenhorn, no less) into a full-fledged theory of childhood emotional development. Was The Atlantic doing anyone any favors by publishing this? Is the New York Times doing the same this week?

We think not, so waste not your time when you see her name in print, unless you, like us, can't avert your eyes from disaster in the same manner as watching the aftermath of a car accident. Which is, in summary, an apt description of her oeuvre.
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One Offs: MA Question Two and Nate Silver F/U

Normally at the Billy Rubin Blog we like giving a good 12 paragraphs to explore the intricacies of an idea, but no time for that today. Before the election, though we want to follow-up on two themes about which we have been writing this year: Physician-Assisted Suicide and, more recently, the phenomenon of Nate Silver.

In Massachusetts this year, Question Two on the ballot proposes a legalization of PAS. It is often described as a "liberal" issue. I don't think it is, and I'm voting No--as emphatically as one can, given that voting consists of coloring an oval black, but there you have it.

The reasons to oppose PAS, especially from a lefty point of view, are twofold:

a. Hospice is wildly underutilized; and
b. PAS should only be practiced in a place in which all citizens have equal access to good health care, and even with the Affordable Care Act we are still a long way from that.

PAS has the feel of a hot-button issue--strong opinions on both sides with heated rhetoric and fierce stands based on core moral beliefs. But unlike, say, abortion, PAS is mostly a smoke-and-mirrors debate where there's very  little "there" there. Even in Oregon, the PAS pioneer, there have been only about 600 "prescribed" suicides in 18 years since legalization. But PAS has substituted for a more substantive discussion about how we will treat end-of-life issues in the US. At a time when we need to examine how we spend money on our health because we cannot sustain our current model (which isn't a good model anyway), that's lousy politics for the left, right, and center.

Onto Nate Silver.

We wrote that being "against" Nate Silver generally showed a contempt for science and mathematics, and we still stand by that claim. However it's important to note that Silver isn't a stand-in for Truth, and that if his success in political prediction matches that of his baseball analysis acumen, the Dems may be in for a very rocky night tomorrow and the Billy Rubin Blog staff will have one phenomenal hangover Wednesday morning. That is, Silver's statistical baby for baseball, named "PECOTA", hasn't performed significantly better than other models predicting player performance and has done so using a cranky, Rube Goldberg-like statistical contraption. Colby Cosh of Maclean's (a Canadian publication) heaps reams of skepticism on the Silver phenomenon here.

Cosh's writing is really good and provides some fresh insight from a guy who appears to be steeped in the numbers, although that said I think he's mostly missing the point. As can be found here and here (and talked about over here), there are number-crunchers who can provide plausible scenarios of why we might wake up trying to familiarize ourselves with the phrase "President Mitt Romney". But this is a question of "what is the underlying reality of the campaign, and how do we find data to help make an accurate prediction?" That question of late has frequently become morphed with "which guy do you want to win?", and Silver, who is almost completely a numbers geek with very few overt partisan leanings, has gotten pegged by conservatives as being in the tank for the Obama cause: right wing paranoia if ever there was any. This is why people have been giving pushback on Silver attacks.

Indeed, there were plenty of Dem-leaning commenters on the Cosh/Maclean's piece that welcomed the critique, because they endorsed the idea of data-driven analysis and not cult-of-personality devotion to Silver. Said one commenter: "I think Silver is a good thing for journalism, but it is misleading to call him a statistician or a scientist. He's something else entirely: a data journalist. He's a very bright guy to have spotted the gap in the market which opened up thanks to the easy availability of data, which mainstream journalists have no training or inclination to use." That sounds right to me, and is the best explanation of King Nate's popularity. Indeed, Silver's book Signal and the Noise is mostly a journalist's account, and it's a really good read.

We will wake up Wednesday morning and will know, given many Senate and House races in addition to the 50 state Presidential races, whether Rasmussen's polls, which have always favored Republicans by about 2 points this year, are more accurate than Quinnipiac's or anyone else's. If so they're probably doing something right and have a better model. Sure, some on the left have foolishly conflated support for Silver with support for liberal political issues, but crying foul against libs who Don't Get It is an exercise in false equivalence. The vast majority of the right wing screeching about Silver has not had to do with an opposition to Silver's possibly errant calculations, but rather with a resistance to any data that does not support one's ingrained assumptions.

More than anything else, this is why we find the Republican Party as currently constituted a menace to society, and until this problem is fixed, we have a very deep political problem in this country.
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What Being "Against" Nate Silver Really Means

Here's a prediction:

Barack Obama is going to win the Presidency.

Does that mean he's definitely going to win it? No.

Is he likely to win it? Yes, he is. He's got about a 3 in 4 chance of winning. It's not a coin flip. Romney has to have a lot of things break his way on Tuesday to capture the White House.

Why am I fairly--but not absolutely--confident that this will be the outcome? Because I've been following the polling for the past two months. There are a lot of sites that analyze various kinds of data and have a computer model to predict who is going to win, including elecotral-vote.com, the Princeton Election Consortium, Votamatic, Real Clear Politics, and a host of others (see Votamatic's blogroll for the others). I have been keeping up with them, and for the most part, they're generally in agreement that Obama is the clear favorite.

The most famous of these predictors is a geeky stats guy named Nate Silver, whose blog fivethirtyeight.com back in 2008 became so popular that the New York Times incorporated it into their product. And as the campaign has proceeded, Silver has analyzed the race and provided reams of commentaries, caveats, and digressions worthy of a Talmudic scholar. But he's been extremely clear about the bottom line over the past few weeks: Obama is the favorite.

That means he is likely to win but is not a lock. A very simple analogy will suffice: as of today, with three days to go in the race, Obama is up by two and Romney has the ball on his own 17 with one timeout and 1:20 on the clock. Most teams in that situation won't win, although of course some will. Now, if you were to bet on Team Romney, you'd want something better than even-up odds. If you offered a bet with anyone at that moment in the game that Team R would win, you would find no end of people willing to take you up on the bet. This is where we are in the Presidential Race, and this is what Silver has been writing for some time.

The bet scenario is in fact quite real, as Silver, in what appears to have been a fit of pique, took an even-up bet on Obama with Joe Scarborough, host of MSNBC's "Morning Joe". Two grand will be donated by the loser to the Red Cross. The bet arose from some trash talking on Morning Joe, where Scarborough called Silver "a joke" and more-than-implied that he was in the tank for Obama. See here for further explanation (including the incoherent warbling of NYT's most famous tweedle-dee, David Brooks), and here for a rundown of other attacks on Silver.

The comments indicate that Scarborough is either irredeemably stupid, or frightfully uninformed for a TV news anchor, or deeply cynical, or some combination of all three. A casual perusal of Silver's blog indicates that he's a guy fascinated with statistical analysis much more than he is of partisan politics. There is never a potshot laid at Romney, even when he so richly deserves it. Yet because he happens to be a guy delivering news that one with a Republican bent doesn't want to hear, suddenly Silver himself becomes the subject of personal attacks due to his perceived partisanship.

Ladies and gentlemen: the Republican Party of 2012.

What being against Nate Silver really means is that you are against a particular way of thinking about the world, and the boundaries go well beyond calling the Presidential horse race. It's a mindset that refuses to accept any information that does not fit with predefined conceptions about the world, whether that information relates to an increase in global temperatures, the existence of evolution, or the value of public health. In short, it is a medieval understanding of the world, and the contempt shown for Nate Silver--an otherwise harmless and bright dweeb--is an exemplar of that way of thinking, if it is worthy of the term "thinking" at all.

I am distrustful of Republican political philosophy for a variety of reasons, all of which may be wrong. But I will be voting for Barack Obama--a politician for whom I now have very little enthusiasm--not so much because of these differences in philosophy, but because of the Brownshirt-flavored anti-intellectualism of the modern Republican party.
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ps. Also worth noting that Silver's new book, The Signal and the Noise, is an exceptionally good read.

Ezra Klein's Medical Metaphor of Congress

With which we agree entirely: "If Congress was your doctor, they'd give you too few antibiotics and, when that failed, give up on the idea of antibiotics altogether".

We'd frame it ever-so-slightly differently here: first they'd give you the wrong antibiotic (military spending), then underdose it (budget sequestration), then give up on the idea of antibiotics altogether (threaten to default), then claim you do not suffer from an infection (return to embrace of Bush 43 economic policies), and then deny that there are such things as germs in the first place and allege that your illness is due to insufficient faith (self-explanatory). Only Twitter will not allow for that length, which is among the reasons why we've never been able to embrace Twitter.
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The Psych Approach to David Brooks

My mother and I tend to agree about most political issues, but we have a long running dispute about the wisdom of one political pundit, New York Times columnist David Brooks. The role Brooks occupies is a relatively new entry in the NYT columnist lineup, not really replacing the true "House Conservative" position of William Safire, one which was adopted by Bill Kristol and is currently held by the ever-fascinating Ross Douthat. No, he's more of a living, breathing embodiment of what George Bush 43 referred to as the "compassionate conservative"; he's a man who believes in the policies of the Republican party--at least the economic and tax-regulatory ones--while showing an interest in social issues related to the quality of how people live and what can be done to make people's lives better. Also unlike the Saffire/Kristol/Douthat crew, Brooks's rhetoric is milder and more gentle. Not that someone like Douthat is in the same camp as, say, Mark Levin, but you get the point.

Momma calls this "centrism" and thinks he's nifty; I call it "inherently contradictory for the most part" and think he's shallow but coated with a thin patina of gravitas...which fools people like Momma, bless her soul. "Nitwit" seems too strong a word, especially as he has such a fine command of the English language, but his analytical mind doesn't seem to far off that description from where I stand.

Comes this week's entry: The Psych Approach, a column devoted to taking a look at the social science research known as the Adverse Child Experiences, or "ACE", study. ACE is a survey of about 17,000 people, and looks at particular formative experiences (such as alcoholism in a parent) and current life/health issues (self-reported alcoholism, stress, depression, smoking) in an attempt to look for correlations. For instance, this report demonstrates a significant correlation between alcohol use in a parent and current drinking problems. Further, they go so far as to say in this flyer that "[adverse child experiences] account for one-half to two-thirds of drug use."

I haven't seen the academic data, and while it looks a little slippery--for instance, it's never made clear what constitutes "alcohol problems" so different responders may have wildly varying definitions, making absolute comparisons tricky--it nevertheless seems like a solid piece of epidemiologic research, one that not only documents the importance of formative experiences on current social and health issues, but quantifies it as well. Thus a useful body of data for someone interested in thinking about public policy, like, say, a politician...or at least his or her staff that have the time to read such stuff and think about how government policy can have an impact on such issues.

And here's where Brooks takes his cue. He starts off by noting that maybe government has been looking at fixing the wrong thing:

In the past several decades, policy makers have focused on the material and bureaucratic things that correlate to school failure, like poor neighborhoods, bad nutrition, schools that are too big or too small. But, more recently, attention has shifted to the psychological reactions that impede learning — the ones that flow from insecure relationships, constant movement and economic anxiety. 

And the fix for this? Well, in short, get everyone on the same page to work creatively and for the common good in a "failure is not an option" mode:

When you look over the domestic policy landscape, you see all these different people in different policy silos with different budgets: in health care, education, crime, poverty, social mobility and labor force issues. But, in their disjointed ways, they are all dealing with the same problem — that across vast stretches of America, economic, social and family breakdowns are producing enormous amounts of stress and unregulated behavior, which dulls motivation, undermines self-control and distorts lives.

Maybe it’s time for people in all these different fields to get together in a room and make a concerted push against the psychological barriers to success.

It's a provocative thought. It also is exactly the kind of thought that someone who believes that government policy can make a difference in people's lives would express.

Now, once upon a time, it was a thought that could have been expressed out loud by a member of the Republican party. The disagreement, the Republican would insist, is not whether government can affect change but simply how the government should go about doing so. But that Republican party is long gone, and what appears to be an interesting observation from Hypothetical Presidential Candidate David Brooks would have been derided by his opponents for being "socialist"--which, in the language of modern Republicanspeak, means "anything with which I disagree".

It's a sentiment that would have been expressed by the kind of Republican who, twenty years ago, would have endorsed a public/private solution to the problem of tens of millions of Americans lacking health insurance. In fact, such a solution was proposed and became known as "Obamacare" and was met with fanatical opposition by the current Republican party. Yet the law is thoroughly Republican in its philosophy and was a disappointment to people who a generation ago would have been considered "centrist Democrats". Though now, through the magic of political alchemy, they somehow have been branded "far-left radicals" (and, of course, "socialists").

In short, it's a habit of looking at the world that is not welcome by the modern, Tea Party-dominated Republican party. For David Brooks to find himself fascinated by such research--sponsored as it was by the US Federal Government via the CDC--and to think that such research might somehow lead to the world being a better place is nice. For him to think that the tail-wagging-the-dog Republican party which he so often lauds gives a damn is naivete in the extreme. Which we're used to from him by now.
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Why Romney Failed...Wait, You Say the Campaign's Not Over?!

In the immortal words of Brad DeLong, why oh why can't we have a better press corps?

Even casual political readers this week can feast themselves on any number of Romney campaign obituaries and detailed post-hoc analyses of how the campaign stumbled--in past tense, no less!

Except the game ain't over. Yes, it's late in the third and Obama's up by 8 with the ball. But as the Arizona Cardinals discovered yesterday to their near-horror, even seemingly sure things can evaporate with an unfortunate error. An interception pick-six from Team Romney (a memorable one-liner zinger during the debates a-la "there you go again"--even though Carter's point was correct) and a two-point conversion (hundreds of millions of dollars of TV ads complements of Karl Rove & Co.) and you are headed down to the wire. This game ain't over, folks--but you might get a different impression from reading news analysis this week.

If you were reading all the political stories this week from Politico to Wall Street Journal (well, the op-eds anyway) to TPM you would have been reading story after story obsessed with the horse race rather than the underlying substance of the campaign. As political junkies, we don't mind a little bit of horse race analysis with our news, but the POTUS campaign coverage is alas mostly devoted to who's-ahead-other-campaign-in-chaos topics. As Sahil Kapur trenchantly observes, "once the 'Romney in disarray' narrative gets stale, it'll probably shift to 'Romney's comeback." And neither "narrative" should have any bearing on why someone should or shouldn't vote for Governor Romney or President Obama.

The central problem is that these stories crowd out much more important news. A little noted item in early September involved Romney saying that global warming is real and caused in part by humans. This is a policy statement of tremendous importance and should have been major news since it indicated a Romney policy shift away from one of the more insane anti-scientific tenets of the Republican base. (Although given Romney's previous slippery, contradictory statements on the subject, it might have simply been another "Etch-a-Sketch" moment in his say-anything-to-please-everyone campaign.) We should note that we think President O's response to sciencedebate.org on this and other topics makes much more sense. However, either way, Romney's statement was important--really important--and hardly anyone noticed it.

The Billy Rubin Blog is contemplating what to write in the event of a Romney loss: suffice it to say that we agree with the central premise of this article by Charlie Pierce. But before the media calls the game, maybe they should spend as much time and effort as possible to get actual news out about what the campaigns are saying. Yes, we thought the Clint Eastwood stuff was amusing, and maybe says something about whether Romney is qualified to be President...but not that much. Analyzing his statements on the middle class, however, really is important.
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Media Avoids Numbers: Now There's a Surprise

There's a quick little ditty about raising the speed limit in Texas to a whopping 85 mph in the Paper Of Record this week. It quotes some local politicos as they talk with a certain puckish pride of these new autobahn-worthy speed limits. It details that Texan spirit of just-wanna-get-there, and includes a yarn about Governor Rick Perry getting pulled over a few years ago outside Austin when he was Lieutenant Governor. It mentions the almost incomprehensible size of the state and the vast stretches of nothingness between the big cities.

Cute. But what it doesn't mention is any kind of data to indicate how dangerous such new speed limits are.

This isn't difficult in the internet age. With a couple of clicks and the right words entered into Google, one can come up with a range of popular news pieces as well as scholarly articles about the actual, known dangers of such high speed limits. There's a lot of data out there to pluck off the tree. NYT couldn't even give a nod to this? I mean, if you're going put up a postcard about a fantastic speed limit--even if it's mostly intended to be a puff piece--don't you think it might be important to consider an obvious implication of the change? And we haven't even talked about gas consumption.

Not every article has to be a grim humorless slog through public policy. But one sentence about the potential dangers (not speculation, but the objectively known data!) of moving the speed limit well above where it was one generation ago doesn't seem to me to be too much to ask.
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When A Few Isolated Deaths Should Be Important News

As we have recently discussed here and here, we're not big fans of the "One Person Dead Somewhere From Something Weird, Be Scared Shitless" news stories that frequently populate the health sections of various news organizations. But we think the story of these two deaths associated with the use of Neti Pots bears some careful attention.

Why is that, you ask? Isn't that a complete contradiction from what you've been writing--in recent entries, no less? Plus haven't you already castigated the media for covering deaths associated with this very organism (Nagleria fowleri)?

I don't think it's a contradiction, but a quick explanation of Neti Pots is required. The Neti Pot is used mainly for people with sinus congestion: the goal is to flush the sinuses via the nose with a salt-water solution and clear the mucus away. Having had major sinus problems over the past year for the first time ever, I've become a fan (though reluctantly, for sure--it's no fun cramming 200 ccs of salt water in your nose!).

There is one simple catch to the use of a Neti Pot: you have to use sterile water. Boiling water in your tea kettle and letting it cool down will work perfectly fine. Why? Because your tap water isn't perfectly sterile. Depending on where you live in the US and the type of water treatment facilities your state government runs, there can be a small number of various types of microbes living in your tap water. Note that I say living and not lurking: these guys are perfectly harmless if they travel down the gullet into the highly acidic environment of the stomach where they go no further. Tap water is one of the great advances of civilization--and one at which the libertarian wing of the Republican party appears to be at odds.

Anyway, while drinking tap water is harmless (unless, of course, if you're living in a place where fracking is commonplace), your nose ain't built to defend itself from these microbial badasses in the same way the stomach is, so flushing one's sinuses with a healthy amount of tap water constitutes a game of Russian roulette. As the NYT piece documents, two people have died from the tap water Neti Pot flush. True that in a country of 300 million it ain't much, but this news piece comes with a simple public service announcement. Boil the water, folks. And diphenhydramine or loratidine and their ilk work too.
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Labor Day Links

A commentary in the NYT by economist Uwe Reinhardt looks at whether or not there is a physician dearth or glut. Not being highly conversant in the byzantine vocabulary of the dismal science, I cannot evaluate the merits of the article--nor am I totally sure that Reinhardt comes squarely down on one side of the argument (though he seems to imply we have too few physicians as a consequence of bad policies dating back to the mid-90s). The relevance here is that if you are contemplating attending medical school, you shouldn't let a story like this sway you one way or another. Yes, all sorts of things in medicine are changing, and yes, we have no way of knowing how those changes will affect things like salary and lifestyle and what subspecialties will be available; but we'll still need doctors a generation from now, so just apply.

NYT also notes a new strain of swine flu has claimed its first human victim, in addition to the fact that the CDC has stated that the strain can be spread human-to-human instead of the (less scary) pig-to-human manner. As we recently noted with the breathless coverage of the spread of West Nile Virus, fear can quickly warp a realistic sense of the danger this virus poses. Cheeseburgers, beer, and cigarettes continue to be considerably more lethal for the moment. (Though that said, we maintain a healthy respect for influenza here at the Billy Rubin Blog. When available, get your vaccinations!)

Sarah Kliff, a health policy reporter at WaPo, writes about health legislation in California defining the phrase "essential health benefits" to make explicit to insurers what services must be covered for the new customers being delivered to them compliments of the Affordable Care Act, aka Obamacare. (We could just as easily call this "Romneycare", though the Republican Presidential nominee would deny this to the point of an epileptic fit, so desperate is he to prove his bonafides to various Brownshirt constituencies. Whatever. At any rate, while the law is Federal, the States become the arbiters of local coverage to be provided by insurance companies.)

What's beyond mere wonkishness in this post is that the legislation includes acupuncture in the "must cover" list, while leaving out infertility treatment as well as hair restoration. Also off the list (so far) is chiropractic, as well as "massage therapy". This is an early signal of the kinds of battles that may well be looming as we begin to make hard choices about how we will spend money on health care in the years to come. Well-organized special interest groups may come to define what kind of care gets reimbursed, regardless of whether or not there is scientific evidence to support claims for health benefit. For instance, "acupuncture" is covered--but for what indication? Is it just acupuncture in general? Psychologists doing talk therapy are currently hamstrung by much tighter regulations than that, having to provide a specific psychiatric diagnosis for each session, even if several of those sessions could be easily described as "normal people working through normal problems".

I don't hold a strong opinion about this right now--there is a sufficient amount of incredibly expensive procedures in "mainstream medicine" that have little data to support their practice (back surgeries, anyone?). I am, however, concerned about medical reimbursements driven more by advocacy groups than by a rational analysis of studies designed to discover whether a given treatment really does have a benefit. I have no beef with people who want to go to their weekly rolfing session; I do not feel particularly inclined to subsidize it through my annual insurance premium.
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Let's All Calm Down About West Nile, Folks

Between trying to avoid the coverage of the Republican National Convention (no offense, guys--I will do the same for the Dems shortly) and winding down my vacation time, I haven't been soaking in much news this week. That said, it's almost impossible not to turn on a radio or flip through internet news sites without hearing some story about how West Nile Virus is sweeping the country. Normally I offer links for curious readers, but there are so many stories right now there's no point to it, as all one needs to do is to google the virus for the latest.

But before we all lose our collective heads over this outbreak, let's traffic in some numbers. As of  August 28 there have been 66 deaths attributed to West Nile out of 1,590 known cases of the disease. Now a 4 percent mortality is nothing to sniff at, but the overall number of cases is incredibly small. By comparison, as of mid-August the number of children who died from influenza--a disease whose mention hardly registers a batted eyelash at Labor Day cookouts--numbered 34, with a considerably higher number in adults (measuring adult influenza deaths is trickier, but suffice it to say that it's a much much larger number than that).

I could go on in this vein for awhile using different diseases for comparison. The point is that 66 deaths or 1500 illnesses in a country of 300 million people is not cause for panic. Getting into your automobile is considerably more dangerous than getting bitten by a skeeter while going for an evening run in Texas, the state with the most cases and deaths by far in the US. Don't put those sneakers away just yet (though the Rubin Blog does recommend putting on an inspect spray before lacing up). So let's all take a deep breath, folks.
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