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y to do a lot better than baseline by building a smart hospital that runs on checklists statistical prediction rules outcomes monitoring and other evidence based practices intermountain is the closest thing i know about and they do get great outcomes but that s an epically hard problem it s political as much as medical and technological and we weren t in a position to make any headway on it ai diagnosis we were also hoping to automate diagnosis and treatment planning in a personalized manner given your symptoms demographics and genetic lab test data and given published research on epidemiology and clinical experiments what are the most likely candidate diagnoses for you and what are the treatments most likely to be effective for you i used to be a big believer in the potential of this approach but in the process of actually trying to build the ai i ran into obstacles which were fundamentally philosophical no it s not machines don t have empathy or anything like that it s about the irreducible dependence on how you frame the problem which makes expert systems dependent on an impractical expensive amount of human labor up front connecting patients with experimental therapies yet another personalized medicine problem we were trying to solve is the fact that patients with incurable diseases have a hard time learning about and getting access to experimental therapies and could use a consultant who would guide them through the process and help get them into studies of new treatments i still think this is a real and serious problem for patients and potentially an opportunity for entrepreneurs either on the consulting model or more on the software side via creating tools for matching patients with clinical trials since clinical trials also struggle to recruit patients in order to focus on this model though we d have had to invest a lot more than we did into high touch relationships with patients and building a network of clinician researchers we could connect them with when standard practice doesn t match scientific evidence one kind of medical error we did see on occasion was when the patient s doctors are dutifully doing the treatment that s standard of care but the medical literature actually shows that the standard of care is wrong there are cases where large well conducted studies clearly show that treatment a and treatment b have the same efficacy but b has worse side effects and yet first line treatment is b for some reason there are cases where there s a lot of evidence that standard cut offs are in the wrong place subclinical hypothyroidism still benefits from supplemental thyroid hormone higher than standard doses of allopurinol control gout better standard light therapy for seasonal affective disorder doesn t work as well as ultra bright lights etc more dakka there are also cases where a scientist found an intervention effective and published a striking result and maybe it was even publicized widely in places like the new yorker or wired but somehow clinicians never picked it up the classic example is ramachandran s mirror box experiment it s a famous experiment that showed that phantom limb pain can be reversed by creating an illusion with mirrors that allows the patient to fix their body map there have since been quite a few randomized trials confirming that the mirror trick works but maybe because it s not a typical kind of treatment like a drug it s not standard of care for phantom limb pain i think we were pretty successful at finding these kinds of mismatches between medical science and medical practice by their nature though these kinds of solutions are hard to scale to reach lots of people n 1 translational medicine for rare diseases this is the use case of personalized medicine that i think can really shine it harnesses the incredible motivation of patients with rare incurable diseases and their family members it s one of the few cases where genetic data really does make a huge difference and the path to scale is relatively obvious if you discover a new drug or treatment i think we should have focused much more tightly on this angle and that a company based on bench to bedside discovery for rare diseases could still become the real world durona group i think doing it right at metamed would have meant getting a lot more in house expertise in biology and medicine than we ever had more like perlara and q state which have their own experimental research programs something we never got off the ground speaking only about myself and not my teammates while i was at metamed i was deeply embarrassed to be a layman in the biomedical field and i felt like why would an expert ever want to work with a layman like me so i was far too reluctant to reach out to prominent biologists and doctors i now know that experts work with laymen all the time especially when that layman brings strategic vision funding and logistical operational manpower and listens to the expert with genuine curiosity laymen are valuable just ask mary lasker i really wish i d understood this at the time people overestimate progress in the short run and underestimate it in the long run biohackers and citizen science and n 1 experimentation have been around for a while but they haven t i think gotten very far along towards the ultimate impact they re likely to have in the future naively that can look a lot like a few people tried that and it didn t seem to go anywhere when the situation is actually the big break is still ahead of us march 4 2019 srconstantin 10 comments the tale of alice almost strategies for dealing with pretty good people suppose you value some virtue v and you want to encourage people to be better at it suppose also you are something of a thought leader or public intellectual you have some ability to influence the culture around you through speech or writing suppose alice almost is much more v virtuous than the average person say she s in the top one percent of the population at the practice of v but she s still exhibited some clear cut failures of v she s almost v virtuous but not quite how should you engage with alice in discourse and how should you talk about alice if your goal is to get people to be more v virtuous well it depends on what your specific goal is raising the global median if your goal is to raise the general population s median v level for instance if v is understanding of how vaccines work and your goal is to increase the proportion of people who vaccinate their children you want to support alice straightforwardly alice is way above the median v level it would be great if people became more like alice if alice is a popular communicator signal boosting alice will be more likely to help rather than harm your cause for instance suppose alice makes a post telling parents to vaccinate their kids but she gets a minor fact wrong along the way it s still ok to quote or excerpt the true part of her post approvingly or to praise her for coming out in favor of vaccines even spreading the post with the incorrect statement included while it s definitely suboptimal for the cause of increasing the average person s understanding of vaccines is probably net positive rather than net negative raising the median among the virtuous what if instead you re trying to promote v among a small sub community who excel at it say the top 1 of the population in terms of v virtue you might do this if your goal only requires a small number of people to practice exceptional virtue for instance to have an effective volunteer military doesn t require all americans to exhibit the virtues of a good soldier just the ones who sign up for military service now within the community you re trying to influence alice almost isn t way above average any more alice is average that means you want to push people including alice to be better than alice is today sure alice is already pretty v virtuous compared to the general population but by the community s standards the general population is pathetic in this scenario it makes sense to criticize alice privately if you have a personal relationship with her it also makes sense to at least sometimes publicly point out how the alice almosts of the community are falling short of the ideal of v probably without naming names unless alice is already a famous public figure additionally it makes sense to allow alice to bear the usual negative consequences of her actions and to publicly argue against anyone trying to shield her from normal consequences for instance if people who exhibit alice like failures of v are routinely fired from their jobs in your community then if alice gets fired and her supporters get outraged about it then it makes sense for you to argue that alice deserved to be fired it does not make sense here to express outrage at alice s behavior or to punish her as though she had committed a community norm violation alice is normal that means that behavior like alice s happens all the time and that the community does not currently have effective reliably enforced norms against behavior like hers now maybe the community should have stronger norms against her behavior but you have to explicitly make the case for that if you go around saying alice should be jailed because she did x and x isn t illegal under current law then you are wrong you first have to argue that x should be illegal if alice s failures of v virtue are typical then you do want to communicate the message that people should practice v more than alice does but this will be news to your audience not common knowledge since many of them are no better than alice to communicate effectively you ll have to take a tone of educating or sharing information alice almost a well known member of our community just did x many of us do x in fact but x is not good enough we shouldn t consider x okay any more here s why enforcing community norms what if alice is inside the community of top 1 v virtue you care about but noticeably worse than average at v or violating community standards for v that s an easy case enforce the norms that s what they re there for continuing to enforce the usual penalties against failures of v and making it common knowledge that you do so and support others who enforce penalties keeps the floor of v in your community from falling either by deterrence or expulsion or both in terms of tone it now makes sense for you to communicate in a more judgmental way because it s common knowledge that alice did wrong you can say something like alice did x as you know x is unacceptable forbidden substandard in our community therefore we will be penalizing her in such and such a way according to our well known established traditions code policy splintering off a remnant the previous three cases treated the boundaries of your community as static what if we made them dynamic instead suppose you re not happy with the standard of v virtue of the top 1 of the population you want to create a subcommunity with an even higher standard let s say drawing from the top 0 1 of the population you might do this for instance if v is degree of alignment agreement with a policy agenda and you re not making any progress with discourse collaboration between people who are only mostly aligned with your agenda so you want to form a smaller task force composed of a core of people who are hyper aligned in that case alice almost is normal for your current community but she s notably inferior in v virtue compared to the standards of the splinter community you want to form here not only do you want to publicly criticize actions like alice s but you even want to spend most of your time talking about how the alice almosts of the world fall short of the ideal v as you advocate for the existence of your splinter group you want to reach out to the people who are better at v than alice even if they don t know it themselves and explain to them what the difference between top 1 v virtue and top 0 1 v virtue looks like and why that difference matters you re in effect empowering and encouraging them to notice that they re not alice s peers any more they ve leveled up beyond her and they don t have to make excuses for her any more just like in the case where alice is a typical member of your community and you want to push your community to do better your criticisms of alice will be news to much of your audience so you have to take an educational informational tone even the people in the top 0 1 remnant may not be aware yet that there s anything wrong with alice s behavior however you re now speaking primarily to the top 0 1 not the top 1 so you can now afford to be somewhat more insulting towards alice you re trying to create norms for a future community in which alice s behavior will be considered unacceptable substandard so you can start to introduce the frame where alice like behavior is immoral incompetent outrageous or otherwise failing to meet a reasonable person s minimum expectations expanding community membership let s say you re doing just the opposite you think your community is too selective you want to expand its boundaries to say a group drawn from the top 10 of the population in v virtue your goals may require you to raise the v levels of a wider audience than you d been speaking to before in this case you re more or less in the same position as in the first case where you re just trying to raise the global median you should support alice almost as much as possible without yourself imitating or compounding her failures laud her as a role model and not make a big public deal about the fact that she falls short of the ideal most of the people you re trying to reach fall short even farther what if alice is diluting community values now what if alice almost is the one trying to expand community membership to include people lower in v virtue and you don t agree with that now alice is your opponent in all the previous cases the worst alice did was drag down the community s median v level either directly or by being a role model for others but we had no reason to suppose she was optimizing for lowering the median v level of the community once alice is trying to popularize or expand the community that changes she s actively trying to lower median v in your community that is she s optimizing for the opposite of what you want this means that not only should you criticize alice enforce existing community norms that forbid her behavior and argue that community standards should become stricter against alice like 1 level failures of v virtue but you should also optimize against alice gaining more power generally but what if alice succeeds in expanding the community size 10x and raising the median v level within the larger community by 10x or more such that the median v level still increases from where it is now wouldn t alice s goals be aligned with your goals then yeah but we can assume we re in a regime where increasing v levels is very hard a reasonable assumption if 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