Dying in hospital

“Good morning, it’s Gregory the surgical SHO. You bleeped – how can I help?”

To contact a doctor overnight, you generally paged them, and I had a well-rehearsed patter when replying. The delivery was slightly too jaunty for 2AM on a Saturday morning, but there were worse images to project than eccentric enthusiasm.

“Hello, it’s Sabine the sister on ward eight. Can you review Mr. Amir? I think his breathing has gotten worse.”

My heart sank. I was on call, and although Mr. Amir wasn’t under my team when I was working normal shifts, I knew him by reputation. Metastatic colorectal carcinoma, resection was unsuccessful, leaving him with both a poor prognosis and a major operation to try and recover from. I had heard his team talking about him with little hope – the best case scenario would be he would recover from our forlorn attempts to help him and could go home with palliative treatment. The worst case would be that he would die in hospital. I knew he wasn’t doing well: recurrent chest infections, multiple courses of antibiotics – ineffective, poor wound healing, bedbound.

“Of course. Is there a purple form?” Continue reading →

Log-normal lamentations

[Morose. Also very roughly drafted.]

Normally, things are distributed normally. Human talents may turn out to be one of these things. Some people are lucky enough to find themselves on the right side of these distributions – smarter than average, better at school, more conscientious, whatever. To them go many spoils – probably more so now than at any time before, thanks to the information economy.

There’s a common story told about a hotshot student at school whose ego crashes to earth when they go to university and find themselves among a group all as special as they thought they were. The reality might be worse: many of the groups the smart or studious segregate into (physics professors, Harvard undergraduates, doctors) have threshold (or near threshold)-like effects: only those with straight A’s, only those with IQs > X, etc. need apply. This introduces a positive skew to the population: most (and the median) are below the average, brought up by a long tail of the (even more) exceptional. Instead of comforting ourselves at looking at the entire population to which we compare favorably, most of us will look around our peer group and find ourselves in the middle, and having to look a long way up to the best. 1

normal

Yet part of growing up is recognizing there will inevitably be people better than you are – the more able may be able to buy their egos time, but no more. But that needn’t be so bad: in several fields (such as medicine) it can be genuinely hard to judge ‘betterness’, and so harder to find exemplars to illuminate your relative mediocrity. Often there are a variety of dimensions to being ‘better’ at something: although I don’t need to try too hard to find doctors who are better at some aspect of medicine than I (more knowledgeable, kinder, more skilled in communication etc.) it is mercifully rare to find doctors who are better than me in all respects. And often the tails are thin: if you’re around 1 standard deviation above the mean, people many times further from the average than you are will still be extraordinarily rare, even if you had a good stick to compare them to yourself.

Look at our thick-tailed works, ye average, and despair! 2

Continue reading →

Notes:

  1. As further bad news, there may be progression of ‘tiers’ which are progressively more selective, somewhat akin to stacked band-pass filters: even if you were the best maths student at your school, then the best at university, you may still find yourself plonked around median in a positive-skewed population of maths professors – and if you were an exceptional maths professor, you might find yourself plonked around median in the population of fields medalists. And so on (especially – see infra – if the underlying distribution is something scale-free).
  2. I wonder how much this post is a monument to the grasping vaingloriousness of my character…

Funding cannibalism motivates concern for overheads

Summary: Overhead expenses’ (CEO salary, percentage spent on fundraising) are often deemed a poor measure of charity effectiveness by Effective Altruists, and so they disprefer means of charity evaluation which rely on these. However, ‘funding cannibalism’ suggests that these metrics (and the norms that engender them) have value: if fundraising is broadly a zero-sum game between charities, then there’s a commons problem where all charities could spend less money on fundraising and all do more good, but each is locally incentivized to spend more. Donor norms against increasing spending on zero-sum ‘overheads’ might be a good way of combating this. This valuable collective action of donors may explain the apparent underutilization of fundraising by charities, and perhaps should make us cautious in undermining it.

Continue reading →

Against the internal locus of control

What do you think about these pairs of statements?

  1. People’s misfortunes result from the mistakes they make
  2. Many of the unhappy things in people’s lives are partly due to bad luck
  1. In the long run, people get the respect they deserve in this world.
  2. Unfortunately, an individual’s worth often passes unrecognized no matter how hard he tries.
  1. Becoming a success is a matter of hard work; luck has little or nothing to do with it.
  2. Getting a good job mainly depends on being in the right place at the right time.

They have a similar theme: the first statement suggests that an outcome (misfortune, respect, or a good job) for a person are the result of their own action or volition. The second assigns the outcome to some external factor like bad luck.

People who tend to think their own attitudes or efforts can control what happens to them are said to have an internal locus of control, those who don’t, an external locus of control. (Call them ‘internals’ and ‘externals’ for short).

Internals seem to do better at life, pace obvious confounding: maybe instead of internals doing better by virtue of their internal locus of control, being successful inclines you to attribute success internal factors and so become more internal, and vice versa if you fail. 1 If you don’t think the relationship is wholly confounded, then there is some prudential benefit for becoming more internal.

Yet internal versus external is not just a matter of taste, but a factual claim about the world. Do people, in general, get what their actions deserve, or is it generally thanks to matters outside their control?

Why the external view is right

Here are some reasons in favour of an external view: 2

  1. Global income inequality is marked (e.g. someone in the bottom 10% of the US population by income is still richer than two thirds of the population – more here). The main predictor of your income is country of birth, it is thought to explain around 60% of the variance: not only more important than any other factor, but more important than all other factors put together.
  2. Of course, the ‘remaining’ 40% might not be solely internal factors either. Another external factor we could put in would be parental class. Include that, and the two factors explain 80% of variance in income.
  3. Even conditional on being born in the right country (and to the right class), success may still not be a matter of personal volition. One robust predictor of success (grades in school, job performance, income, and so on) is IQ. The precise determinants of IQ remain controversial, it is known to be highly heritable, and the ‘non-genetic’ factors of IQ proposed (early childhood environment, intra-uterine environment, etc.) are similarly outside one’s locus of control.

On cursory examination the contours of how our lives are turned out are set by factors outside our control, merely by where we are born and who our parents are. Even after this we know various predictors, similarly outside (or mostly outside) of our control, that exert their effects on how our lives turn out: IQ is one, but we could throw in personality traits, mental health, height, attractiveness, etc.

So the answer to ‘What determined how I turned out, compared to everyone else on the planet?’, the answer surely has to by primarily about external factors, and our internal drive or will is relegated a long way down the list. Even if we want to look at narrower questions, like “What has made me turn out the way I am, versus all the other people who were likewise born in rich countries in comfortable circumstances?” It is still unclear whether the locus of control resides within our will: perhaps a combination of our IQ, height, gender, race, risk of mental illness and so on will still do the bulk of the explanatory work. 3

Bringing the true and the prudentially rational together again

If it is the case that folks with an internal locus of control succeed more, yet also the external view being generally closer to the truth of the matter, this is unfortunate. What is true and what is prudentially rational seem to be diverging, such that it might be in your interests not to know about the evidence in support of an external locus of control view, as deluding yourself about an internal locus of control view would lead to your greater success.

Yet it is generally better not to believe falsehoods. Further, the internal view may have some costs. One possibility is fueling a just world fallacy: if one thinks that outcomes are generally internally controlled, then a corollary is when bad things happen to someone or they fail at something, it was primarily their fault rather than them being a victim of circumstance.

So what next? Perhaps the right view is to say that: although most important things are outside our control, not everything is. Insofar as we do the best with what things we can control, we make our lives go better. And the scope of internal factors – albeit conditional on being a rich westerner etc. – may be quite large: it might determine whether you get through medical school, publish a paper, or put in enough work to do justice to your talents. All are worth doing.

Locusofcontrol

Acknowledgements

Inspired by Amanda MacAskill’s remarks, and in partial response of Peter McIntyre. Neither are responsible for what I’ve written, and the former’s agreement or the latter’s disagreement with this post shouldn’t be assumed.

Notes:

  1. In fairness, there’s a pretty good story as to why there should be ‘forward action': in the cases where outcome is a mix of ‘luck’ factors (which are a given to anyone), and ‘volitional ones’ (which are malleable), people inclined to think the internal ones matter a lot will work hard at them, and so will do better when this is mixed in with the external determinants.
  2. This ignores edge cases where we can clearly see the external factors dominate – e.g. getting childhood leukaemia, getting struck by lightning etc. – I guess sensible proponents of an internal locus of control would say that there will be cases like this, but for most people, in most cases, their destiny is in their hands. Hence I focus on population level factors.
  3. Ironically, one may wonder to what extent having an internal versus external view is itself an external factor.

Saving the World, and Healing the Sick

When I applied to medical school, I had to write a personal statement: selling how exceptional my achievements were, what wonderful personal qualities I had, and my noble motivations for wanting to be a doctor. The last of these is the most embarrassing in retrospect:

I want to study medicine because of a desire I have to help others, and so the chance of spending a career doing something worthwhile I cannot resist. Of course, Doctors [sic] don’t have a monopoly on altruism, but I believe the attributes I have lend themselves best to medicine, as opposed to all the work I could do instead.

These “I like science and I want to help people” sentiments are common in budding doctors: when I recite this bit of my personal statement in a talk (generally as a self-flagellating opening gambit) I get a mix of laughs and groans of recognition – most wrote something similar. The impression I get from those who have to read this juvenalia is the “I like science and I want to help people” wannabe doctor is regarded akin to a child zooming around on their bike with stabilizers – an endearing work in progress. As they became seasoned in the blood sweat and tears of clinical practice, the vainglorious naivete will transform into a more grizzled, realistic, humane compassion. Less dying nobly, more living humbly; less JD, and more Perry Cox.

I still have a long way to go. Continue reading →

How far can hard work take us?

There’s a perennial question about how much achievement something depends on talent, and how much on hard work. Perhaps genius (or even garden variety exceptional performance) is written into someone’s genes, or perhaps what separated Einstein from his peers had more to do with his work ethic than his IQ.

Evidence points in both directions. On the one hand, most high performers, whatever their field, emphasize how important hard work – rather than ‘just talent’ – is to their achievements (e.g. Terrence TaoWill Smith, Ira Glass, Thomas Edison). Some, like Malcolm Gladwell, talk about a ‘10000 hour rule‘ as the required hard work before one can truly excel. Perhaps the main proponent of the ‘Arbeit uber alles’ approach is Erikson’s work on deliberate practice. On the other hand, there are lots of instances where innate physical or mental characteristics play an important role: the average height of NBA players is 6’7″, Intelligence (albeit imperfectly measured by IQ) seems to predict lots of things (including various intellectual achievements) – and it appears to remain predictive even into the very high range.

So perhaps it is a mix. But the precise mechanism of the mix could be important; how do innate talents and amount of training relate to one another when it comes to achievement? Could some maths help?

A Growth-mindset model

Here’s one suggestion, implied by Uri Baum:

Performance = Talent + Practice intensity x Time practising 1

On this sort of model, talent counts, but as time passes, practice matters more. Unlike talent – a static given – one can grow a stock of practice over time, and time invested in practice and hard work has a rich return on performance (c.f. Hamming’s remarks). An attractive corollary is that if one can improve one’s practice intensity, be that through more focused training, deliberate practice, better learning styles, etc. this acts as a multiplier – working smarter, as well as working harder may be a stronger determinant of success than talent.

If so, extraordinary talent may be a curse – it could let us coast. Bram suggests there might be a mechanism where if we select for exceptional achievement, we select for people with varying mixes of raw talent and hard work. The group which skew more towards the latter may overtake those skewing to the former former over time: those who skew towards more practice time and intensity will be able to grow faster, whilst those who mainly got to where they were ‘just’ on their talent may find they are hitting a wall unless they can improve how they develop. Continue reading →

Notes:

  1. Perhaps even better would be to use a time integral here, as likely practice intensity will vary over time. But multiplication is simpler, and simplicity is better than precision for toy models.

How many lives does a doctor save?

[This is cross posted on 80,000 hours: 1 2 3. Particular credit to Ben Todd for basically writing the third section.]

Doctors have a pretty solid reputation as do-gooders. There are regular news stories about how advances in medical science promise to help more people than ever before. Many of us have had the experience of being ill, seeing our doctor, and being made better.

So it seemed a pretty good career move for a 17-year old wanting to make a difference. Like thousands of others, I applied to read medicine. This is what I wrote on my personal statement:

I want to study medicine because of a desire I have to help others, and so the chance of spending a career doing something worthwhile I can’t resist. Of course, Doctors don’t have a monopoly on altruism, but I believe the attributes I have lend themselves best to medicine, as opposed to all the other work I could do instead.

Was I right? Is medicine a good career choice for someone wanting to ‘make a difference’? Continue reading →

Talks on Giving What We Can

I’m involved with Giving What We Can, a community that pledges to give 10% of their income to whatever best helps in the fight against global poverty. I’ve done a few talks on this over the years, here are the Prezi’s. Feel free to re-use them or their contents (most are permutations on similar points, although the tone and emphasis has varied depending on the audience – it is worth noting many of the figures are a bit out of date). If you want me to give a talk, get in touch!

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Why you shouldn’t believe the resurrection happened

The 12th (and final) part in “20 Atheist answers to questions they supposedly can’t.”

  1. What accounts for the empty tomb, resurrection appearances and growth of the church?

Short answer: We shouldn’t be that confident of these facts, but in any case the base rate fallacy and selection bias nixes the confirmatory power.

Longer answer: The argument implied in the question is that the historical record of Jesus provides strong evidence to believe he actually died and rose again, which provides evidence that Christianity’s central claims (e.g. God exists, Jesus is the son of god) are true. The question neatly summarizes the three main ‘planks’ of evidence usually offered:

  1. The Empty Tomb. When Jesus died, his body was placed in a tomb. Not only was a stone rolled in front of it, but also the authorities posted sentries outside the tomb to stop anyone stealing the body. Despite this, the stone was discovered to be rolled away, and the body had gone. (e.g. Mark 16:4, Luke 24:2-3)
  2. Resurrection appearances. Several different groups of people (the disciples, some women, etc.) are reported to have seen Jesus after he died. (e.g. Luke 24:15-31, 36-48; Matthew 28:9-10)
  3. The growth of the church. After Jesus died, his apostles (and figures like Paul) were committed to the message of Jesus, and helped the church spread rapidly. (cf. Acts, but also the historical record re. the Holy Roman empire, etc.)

The idea is this data is very hard to explain via purely atheistic means. Maybe Jesus didn’t really die, but is it plausible he could have got up and escaped the guarded tomb after being crucified and speared for good measure? Maybe the disciples managed to steal the body, but how did they manage to get that past the guards? (And what was in it for them? Why would many of them go on to die for a belief they knew to be false?) Maybe the appearances of the resurrection were just hallucinations, but how could there have been so many hallucinations, of so many different people, and why didn’t the authorities just squash the story by presenting the public with Jesus’s corpse?

So, it’s argued, the best explanation for the historical data is the Christian one: Jesus rose from the dead and left the tomb miraculously, and then appeared to people like the apostles and women who visited the tomb, and these people, convinced by the truth, to go on and grow the church. Continue reading →