The recent, seemingly inexhaustible and rapidly accelarating development of ubiquitous technology and multi-tasking behavior and information & social “overload” it undoubtly promotes has a nearly unsurmountable/inscrutable, diverse and continually evolving impact over the global, highly connected human society. In order to evaluate its influence at any point in time one has also to consider additional factors such as cultural background and even very specific, almost individual-based, deep-rooted, hard-wired, brain chemistry/anatomy features. Over time, a huge number of most often vaguely defined and much disputed terms have appeared in the medical, psychology and sociology literatures as a means to satisfy the great urge of the media to artificially simplify and classify some behavioral phenomena supposed to be directly related to this technology advancement, especially concerning the increasing centrality and pace of the Internet on society.
Computer and Internet speed and automation of an ever increasing set of “normal” tasks also induces a heavy musti-tasking behavior and speed up expectancies, within the workplace/academia and outside it. Now, we have to add in other, eventually more complex and highly parallel taks. For some people, technology has promoted a significant (sometimes self-)pressure to get things done as quickly as possible in order to accelerate results and personal success. A proportion of these people evolves to forms heavily “addicted” to severe multi-tasking behavior, drawing upon the constant stimulation and the instant gratification their multiple gadgets made possible. People become anxious/frustrated/bored if there’s no tasks to do, but also if there’s a lot of accumulated tasks. Therefore, this extreme action- and anxiety-packed work/lifestyle comes with clear “side-effects”, mainly irritability and a drastic reduction in the attention span. The ubiquity of technology has created a subculture of the Always On + a brewing tension between productivity and freneticism. The gadgets designed to lighten our loads and to promote readily connection and communication among people also unsnare us as they can disrupt our work, our thoughts and what little’s left of our private lives(1). Unlike the competent, “addicted” multi-tasker, the majority of people don’t feel good with task parallelization and overload; frequently, they are unable to prioritize and they can demonstrate distractability, impulsiveness, haste + feelings of guilt and inadequacy. There’s a panicky feeling that you can’t keep pace with accelerating workplace/academia demands.
The january/2006 issue of the Harvard Business Review publishes a paper by Dr. Edward M. Hallowel, MD (Psych.), relating these common phenomena to a work-related variety of a condition known as Attention-Deficit Disorder (ADD). New names have been coined: Attention-Deficit Trait (ADT) or pseudo-Attention-Deficit Disorder (pADD). There’s a long-held principle in psychology that, adapted to the case at hand, says that some individual-related, optimal amount of multi-tasking would increase arousal, perhaps leading to greater efficiency. Abose this probably fuzzy threshold, multi-tasking would be detrimental to efficiency and, as a result, to mental and physical health.
The technologies that are supposed to overload our circuits are in the main front to address these problems. Proposed improved technological solutions range from intelligent office-communication systems to revolutionary user interfaces(2). But to truly take control of our productivity, we also have to stop fooling ourselves about our capacity to juggle. At the same time, we have to stop pretending that we are machines that can endlessly process tasks without a break.
Here’s a quotation by Richard Meier in Communications Theory of Urban Growth, published in 1962:
“The quantitative estimation of the information value of messages transmitted in the various communications channels, and the identification of the human capacity for information handling by experimental techniques, suggest that the problems of widespread saturation in communications flow may arise withing the next half-century”
In that same paper, Mr. Meier coined a term that now, not quite a half-century later, not only become a cliché but it’s also almost demodé: information overload. In fact, some way we have gone beyond mere overload to the point of wallowing in information pollution, the contamination of a person’s life by excessive data. Some people respond with information environmentalism, but most people simply get tired of the onslaught. Some of those people develop the following symptons: constant searches for more information, increased anxiety and self-doubt in decision making, sleeplessness and paralysis of the analytical capacity. By and large, it doesn’t matter what kind of data people can find. People keep searching and, most often, what they find are more and more options, which confuses them and makes them more indecisive and then more anxious. You just have to find and collect. You just have to know. And it’s not always high quality or somewhat useful data. Not only that, you also enjoy sending this information to others - i.e., to info pollute. There’s a bunch of terms/concepts that can possibly be applied to this setting.
Infornography, selon Wikipedia, is one of the many terms used to define an “addiction” to information. People addicted to infornography overly enjoy sending, receiving, exchanging and digitizing information. Moreover, in modern society, information is not only a valuable commodity from a practical point of view, but it’s also something that generates an almost sexual thrill, something that we lust after and enjoy hunting, because it’s special and gives us power. A portmanteau word formed by the combination of the words “information” and “pornography”, the term was popularized as the title of the eleventh episode of the cult cyberpunk anime series “Serial Experiments Lain” (1998). In a sense, information can facilitate the development of an alternate world for “escapism”, therefore people who use information to strive can subtly be called “infornographers”. The “addiction” can polarize one’s worldview: there are the Junkies (nowadays little crowds of highly connected people probably with a sense of auto-sufficiency) and there are the large majority of Regulars. As a junkie usually doesn’t have the ability to fully comprehend the regulars and to engage in face-to-face relationships with them, there’s a significant risk that people affected will have no real social life(3).
While some people argues for the existence of an “Internet addiction“, this consideration seems to involve a logical impossibility, a category error. Here’s an important (and subtle) distinction: if you’re compulsive, there’s something you want to do again and again (confusingly called an “addictive” thing in everyday language), but if you have a fully-fledged behavioral addiction for something you keep doing that thing even when it clearly has serious damaging effects. An addiction is a specific biological disorder of the brain’s reward system that permanently alters the survival “system”, hence your motivational priorities. An additional hallmark is a component of denial. Sometimes the addictive behavior is first triggered by a pharmacological agent, which is a useful figure here as it relates to an external driving force, while in a compulsive behavior there’s internal driving forces (e.g., food, sex, Internet)(4). In this sense, the Internet instant gratification only plays into underlying, pre-existing obsessive-compulsive tendencies or enables an avoidance behavior - i.e., people would do something else if they have no access. Therefore, the Internet might provide powerful tools to amplify “predispositions”. In fact, Internet use was generally associated with positive effects on communication, social involvement and well-being, but for extroverts only! People who are dysfunctional in daily life, having problems with mood and motivation are in a group with above average risk(5).
Here, again, some improved technological solutions are being offered/promised - e.g., the next generation, semantic web. Meanwhile, technological ubiquity, the large availability of all types of information and the current state of the Internet are fueling strong ideas involving an open, decentralized, collaborative and student-centered/owned education, especially in order to satisfy a list of specific 21st century skills. As too many divergent and delusioned “experts” spoil clarity, this list includes various types of media literacies for consistent citzenship formation. All kinds of hybrid publishing products are rapidly emerging, putting an end to the traditional structures of journalism and science communication and discussion. In government issues, people are increasingly cooperating by supporting petitions for transparency (accessability, approachability and promotion of information) and (public) decentralization. As anyone can add information to the network, the real question is how to deduce/synthesize it, use it, analyse it, generate ideas, create and keep meaningful and open conversations - i.e., how to equilibrate the 3 elements of the information ecology: production, distribution and processing.
(1)Statistics of the costs on productivity of these (in)voluntary interruptions continue to appear, from business to academia (e.g., see “Getting Things Done in Academia“)
(2)These can comprise an office-communication system that calculates whether an interrupting message should be immediately transmitted or delayed on the basis of, say, that worker’s appointments and projects that day, his past preferences and habits, and the organizational-chart between sender and receiver (difficult privacy issues here). Furthermore, in next-generation systems interruptions can be designed to be less intrusive: incoming messages may just provide enough information for the worker to judge whether to grab it or ignore it until later. More revolutionary, there’s a tendency towards natural language user interfaces and the return to physical controls.
(3)As technology somewhat partially removes people from their biologically “programmed” states, entire industries have sprung up to foster this growing tendencies (e.g., sports, TV, pornography, religion, computer games). However, many activities largely considered to be normal parts of a healthy existence (e.g., eating, exercise, sex) can also become avenues of escapism when taken to extreme. Meanwhile, there’s also of note that escapism can have a healthy element of emancipation, in it’s attempt to figure a different reality (see fairy-stories).
(4)Note that here you also have to account for different lifestyles and cultural backgrounds (e.g., sexual-positive practices).
(5)A particularly illustrative example comes from the mainly japanese social phenomenum of the hikikomori - i.e., reclusive individuals who have chosen to withdraw from social life due to various personal and social factors in their lives. Many of their remaining (solitary) activies involve heavy use of the Internet. Clinically speaking, there’s little difference between hikikomori and more formal clinical definitions of severe social withdrawal due to depression. In fact, obsessive-compulsive behavior and depression can both lead to or be a consequence of this extreme form of social withdrawal. In the local discourse, the cause and the marked prevalence in Japan has been generally attributed to several cultural factors. In one hand, there’s often soft parenting tendencies or even a codependent collusion between mother and son. There’s often a sense that one is unable to fulfill the rigid and high level expected social roles, as they have not yet formulated a sense of “true self” and one’s “public facade”, both needed to cope with the daily paradoxes of adulthood. There are several arguments claiming the modern society failure to provide sufficiently meaningful transformation rituals for promoting certain susceptible types of youth into mature roles within society.
February 1st, 2009 in
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There’s more to User Interface (UI) design than just aesthetics and fluffy feelings; actually, there’s hard theoretical work turning a typically guru-istic field into hard engineering(1). The goal is to start from the basics of human psychology and information theory to derive a quantitative means for analyzing and designing UIs. And perhaps nobody has achieved so much in this field as Jef Raskin(2), popularly known as the inventor of the Macintosh. However, his central characteristic seemed to be his inability to accept the status quo. Lately, Jef Raskin believed that we probably reached a dead-end in the development of interaction paradigms for text, and envisioned a profound change in the entire model of computing: From an application-centered model to a content-operator model, meaning you should eliminate the artificial differences between Operating Systems (OSs) and applications - i.e., in very practical terms, to add a different capability to the system, you need just to leverage the already existing commands rather than writing a specialized application, with its specialized command structure. The application-centered model of computation is most often characterized by inconsistencies of operations and the need to rebuild many functions already existing in other applications. In the new world of the content-operator model of computation, there’s only 2 objects: Content and operations on that content, so you can use any command on any content, at any time. There’s no fiddling with the tool; no bloatware.
But, hey, did you really mentioned … “commands,” in the above paragraph? Well, yeah. Why not? This is what you will most probably testify in the next, say, 10 or at most 20 years from now, in case you’re not a hermit: The next generation UIs, or, if you prefer, the next UI breakthroughs will be a kind of return to the “fundamentals”. Paradoxically, this much possible technological path tends to make computers more transparent to the user, so you don’t have to think as much about using the computer while … you know, while actually using it.
As a matter of fact, Graphical User Interfaces (GUIs) were a big step forward in terms of making computers … well, (I couldn’t help myself) usable by people who are not part of that all-important group of “nerdy little bowtied fissiparous creatures” (now seriously, no offense here(3)). Even today, there are some brilliant developers producing good open-source & free software who, when confronted with people asking for easier UIs insist to (angrily) say something like “All these whinners should either RTMF and learn how to use the command line, or they should shut up and go away”. Underlying this simple phrase there’s a serious attitude based on 3 common mistakes:
- they’re assuming that improving the UI means exactly making it more like Microsoft’s;
- they’re assuming that improving the UI is something only novices will benefit from;
- they’re assuming that non-technical users are inherently dumb.
Overall, they’re completely overestimating the importance of their software in people’s lives. Non-technical users just don’t have time or the inclination to learn the implementation of their software; they probably contribute to society in some other way - e.g., by trying to correct the pronounced lordosis on that same software developer. Finally, the quote-unquote the status quo is good enough is not an attitude that has ever lead to progress.
In fact, there are lots of lessons we have learned from both, the good old Command-Line Interfaces (CLIs) and GUIs.
With CLIs you can get a lot more done with just a few keystrokes, thanks to features as: very short command names, tab-based autocompletion, the command history that let you easily repeat or modify earlier commands, and its highly customizable nature. This make it a very efficient interface in a quantitative, information-theoretic sense. Furthermore, CLIs are not just a set of commands, they’re an entire very expressive computer language (e.g., the Bash is Turing-complete): Pipes, stdin/stdout redirections, backticks, environment variables et al form the grammar, while the executables form the vocabulary. Every written command line is a little one-time program you can make reusable with shell scripting. OK, we have to accept that that’s beautiful, but if we will consider a wider market share there are some serious misfeatures:
- CLIs are not inherently discoverable, since there’s no guidance given to the first-time user;
- from the point of view of the non-technical user, that same very short command names that save a lot of the time of the software developers are nothing more than cryptic, unnatural, unfamiliar names, so they have to be learned by rote;
- in the same pace, the myriad command options that makes for an almost unbelievable wide range of control over the computer are hard to remember, and
- it’s also unbelievably easy to make mistakes (and there’s no undo!)
(OK, some of you already know or will discover that a significant part of the open-source community has made a huge effort to make the internal functioning of Unix-based systems more transparent to the user, but note that this often means large steps toward the common desktop metaphor - i.e., there’s little to no real UI innovation.)
Now to the GUIs, there are some valuable lessons too. Experience is showing that the combination of tagging and searching is sufficient for navigating vast ammounts of content(4), but the visual/spatial representation and organization of GUIs are unbeatable when the task at hand depends on optimal and exhaustive navigation on smaller ammounts of content. However, in the anxious run to abandon CLIs for GUIs we totally left behind the versatility of language, with all its immense (”infinite”?) ammount of descriptive power (e.g, for capturing abstractions) that pictures haven’t. The current overuse of icons doesn’t necessarily makes a program easier to learn; meanwhile, it makes it completely language-agnostic(5).
For some people the next generation of UIs are just behind our eyes: search command languages - i.e., search engines (retrieve information) converted into answer machines (retrieve knowledge), controlled by a modern version of CLI. Think of the address bar in a web browser, or Google Search. Googling something is almost always faster than wading through your web browser’s bookmarks menu. Consider also the quick-add features of Google Calendar that forgo the clurky and time-consuming forms that make you think the way the designer thought: You just have to type an event’s information. However, these instances are not correctly classifiable as command line languages. They are more of form interfaces, because generally they can execute only one command: Go to this URL, add this event, search the web for this word or expression, etc. (However, some often unkown advancements are also in place here:
- Google Search actually performs some calculations, define words, recognizes US addresses and telephone numbers, suggests and gives you a clue for the number of results of each “anticipated’ search input;
- In the Opera web browser you can go to the address bar and type something like “imdb ‘horton’” and directly get the search results from inside the IMDB database.
This kind of intelligent parsing and matching of inputs are clear and undeniable improvements in form interfaces.) The underlying control languages are yet more ad-hoc than systematic and the language forms are still spotty and idiosyncratic, but there are already some virtues: they are somewhat tolerant to variations(6) (robustness) and exhibit slight touches of natural language flexibility. Then, if you use an illegal command format the answer engine can retreat to the status of a search engine, often returning pages that are of direct relevance. I.e., there’s no need for strict adherence to syntax and form. Gmail has no hierarchical menu structured for storage, but a search line interaction that’s good enough, provided you attach labels (the equivalent of folders in natural language) and make use of keywords and whatever is available and necessary for organization and information retrieval.
For the desktop itself, there’s a bunch of find-n-launch applications over there, so you no longer have to always think the way the computer does. On Microsoft Vista’s Desktop Search, you can search folders and save dynamically changing results. The Mac OS X’s Quicksilver is a traditional find-n-launch application which provides an additional and very efficient way for emailing a selected file, to skip a song on iTunes, to append some text to a file somewhere, etc. Just to name a few more: Google Desktop Search, JPSoft’s 4NT and “Take Command”, AppRocket and Gnome Deskbar. Different programs, different capabilities. Some require a hold of one key while you type the verb “open”, a clear loss of efficiency as you have 4 more necessary keystrokes and can’t use one finger anymore.
The old Jef Raskin has suggested the concept of humane interfaces as a more explaining term than usable interfaces. (See his book “The Humane Interface: New Directions for Designing Interactive Systems.”) Here’s a current general definition: “An interface is humane if it’s responsive to human needs and considerate of human frailties.” OK, it seems a better term, at least in the sense that “human needs/frailties” are concepts accurately catalogued by more than 50 years of Cognitive Psychology. However, what are the desired levels of responsiveness and considerateness? An alternative, simpler definition is “interfaces optimized for the human brain and anatomy,” at many different aspects: efficiency, comfort, pleasure of experience. That sounds good, as some of the abovementioned find-n-launch applications requiring a significant ammount of finger gymnastics appears to be optimized for monkeys, as their foots are much more flexible than the human hands.
The ideal, humane UI combines the efficiency and expressiveness of conventional CLIs with the ease of learning of (some) GUIs. Here’s a short list of some of the extremelly chalengeable general features the ideal humane interface must have, according to Aza Raskin:
- it must autocomplete a partial word with a keystroke, while giving you suggestions about other commands it “thinks” you might be looking for, e.g., according to your working context or to the type of data you’ve selected, while giving you clues about what you can type next and what the current would-be command will do if executed, while helping you understand what ranges of arguments to a command are valid and what they mean, while remembering suggestions you’ve chosen in the past and pop them up next time you give the same input, while giving you a sensible way to resolve eventual input ambiguities;
- it must handle commands with multiple arguments and various data types, while letting you chain commands together, while allowing you to compose complex commands out of small parts, while allowing you to save this complex command with a simple name for future use;
- it must provide a simple and efficient way to create and share commands with interested people.
I’ve found one different, more interesting and worth describing vision about the future, ideal, humane UI: A context-sensitive, implicit command-based interface driven by collected user data. In fact, the vision encompasses a socialized text-based interface where the computer uses statistics to find the best matching actions other users have performed before. Actually, data mining on human contributed data can be much more powerful than today’s Artificial Intelligence systems trying to be humane in terms of understanding user behavior, syntax forgiveness and so on. The envisioned implementation involves ubiquitous desktop search boxes where users will frequently formulate a task in terms of a text search. Eventually, they will receive, as a result, step-by-step instructions that will compose a new “interface”: Now, the user will just type the query in a DoIt-box, instead of the search boxes. Unfortunately, there’s a huge set of requirements here:
- context information about what the user’s currently doing, and
- a public database which records users’ interactions with their computers.
Some standard protocol will be required for polling application’s states. There are obvious and serious privacy issues involved in building the aforementioned database, but a less comprehensive approach could build it from specialized help forums - i.e., current forums’ “explain me” mode would be replaced by “do it for me once”. Common queries (the FAQ-analogon) will not charge the forums as they will yield succesful results first. Despite being automatically filtered by the ranking system, some sort of trust system will also be needed in order to overcome spam queries properly. Parameters inherent to non-digital tasks should be ranked on frequency of usage. Here’s a real syntax-free implementation: There’s no use of verbs in imperative form and no need to learn commands - i.e., you just have to guess which words other users have used to describe the task at hand.
Footnotes:
(1) There’s 3 basic tools in a UI designer “toolkit”:
- the GOMS model analysis, created in the early 80’s, for predicting how long it will take a user to use an arbitrary interface;
- the Fitts’s law, “discovered” in the 50’s, helps predicting how long it will take a user to target an object, based on object size and distance from the user (most common use in UI design: predicting how long it will take the average user to move the cursor to an on-screen bottom or menu), and
- information theory, the most general of the 3, is actually a full-blown mathematical theory and gives you an absolute rating for how good an interface is (compared with the theoretic-best interface).
(2) Along his life, Jef Raskin has collected a remarkable set of achievements: He was a Professor of Art & Photography and a competent bycicle racer, orchestral soloist and model airplane designer; he was also a published mathematician.
(3) Despite being the 2nd time I use this infamous expression in my writeups.
(4) I.e., avoid the indiscriminate use of hierarchies; imagine yourself visually navigating through 1GB of stored email, 700 folders, 6,000 files and 4,500 digital photographs.
(5) The range of options a text interface gives us effortlessly is huge: take just 5 alphanumeric characters (something some people can type in, roughly, 1 second) and you can choose one out of 100,000,000 possible sequences.
(6) E.g, when faced with spelling inaccuracy, the system can correct the spelling errors or at least suggest variants; often, synonims and related terms are used.
February 1st, 2009 in
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Any animal that uses emotions to focus its attention has a evolutionarily relevant fear of death. When something supposedly death-related appears in its immediacy, the animal must attend to identifying and responding to possible threats, each in its own way. We humans have inherited this fear of death, but human intelligence allows many new ways for environmental cues to suggest death to us. This is a clear comparative advantage, but it brings us some problems too. So we usually have a hard time trying to manage our wandering thoughts, in order to avoid triggering this fear too often, and to avoid a more than necessary level of response to the identified threat. This trouble in thinking about death is often used to explain “irrational” behavior like delay in in writing wills, or arranging for life insurance or HIV tests, or interest in odd religious believes.
Death as a great mistery
People in every culture believe in some kind of afterlife or, at the very least, are unsure about what happens to the mind at death. Why do we wonder where our mind goes when the body is dead? After all, the mind is what the brain does - i.e., it’s more a verb than a noum.
The common view of death as a great mistery usually is brushed aside as an emotionally fueled desire to believe that death isn’t the end of the road. According to the proponents of the Terror Management Theory, a school of research in Social Psychology, we possess a “secret” arsenal of psychological defenses designed to keep our death anxieties at bay. Writing books, for example, would be interpreted as an exercise in “symbolic immortality”, even if we are no believers in the afterlife: We write them for posterity, to enable a concrete set of our ephemeral ideas to outlive our biological organisms. Other, less obvious, beliefs, behaviors and attitudes would also exist to assuage what would otherwise be crippling anxiety about the ego’s existence. Actually, this is only a part of a wider machinery: Our innate, dangerous and necessary art of self-deception, something that, e.g., Adam Smith, Freud and Sartre have placed at the core of their theories of human behavior and emotions. But the concept of self-deception, in its various forms, has a longer history in the western thought. E.g,. Penelope doesn’t really want Odysseus to come back home, nor is he truly so sad to be leaving again at the end of the story; Romeo and Juliette were not quite sure of their love.
Here’s a brief sequence of daily facts representing common instances of human self-deception. “Marital aggrandizement” is an unrealisticly positive assessment of one’s spouse and marriage, a technical term often used by psychologists to refer to the all-important selective forgetfulness, one of the basis elements of a satisfactory marriage. Most people think they are smarter than average; if necessary, we redefine the dimension of the “competition” so we can “win”. People talk down some of their skills in some areas to signal and maintain a self-image of modesty. We look with an artificial skepticism to our previous selves, seeking to confirm the (usually false) impression that we are capable of taking a long, hard look at ourselves, and, most of all, to support our current and largely positive self-image. When people cannot claim a credit themselves, they often seek the glory of affiliation, and then they cannot fathom that their affiliated causes couldn’t be always nation-worthy. Debates and exchange of information between experts often polarize opinion rather than producing even partial convergence. This reluctance to defer not always appears to be a well-grounded suspicion of others. Many people are deliberately dismissive and irrational in their points of view, while maintaining a passionate self-righteousness. They are the opposite of how “information gatherers/processors” would behave; i.e., people don’t behave as having “rational expectations”, so their biased perception of the world is one of the most important factors for understanding incentives.
We usually don’t feel very afraid of death, and we are not aware of thinking about death much. However, it seems that we are just not very aware of how much the fear of death directs our thinking. Psychologists have found that even weak death cues measurably change our thinking, usually in the direction of larger self-deception. Some people think the religion and other supernatural beliefs exist primarily to help people deal with death fears. However, a small number of researcher on psychology are now increasingly arguing that these irrational beliefs are an inevitable by-product of the evolution of self-consciousness. All the abovementioned behaviors/beliefs were fully functional for our distant ancestors: By believing more in themselves and in their affiliations, they would credibly signal their ability and loyalty, which might inspire their neighbors to help to protect them more from threats. They also “suffered” the illusion that their minds were immortal. Unmistakenly, we have inherited all these gross irrationality from them, so that we, by virtue of our evolved cognitive architectures, e.g., had trouble conceptualizing our own psychological inexistence from the start. E.g., be you an “extinctivist” or a “continuist”, your own mortality is unfalsifiable from the first-person perspective. Instead of the usual “cultural indoctrination hypothesis”, this new theory assumes the falsifiable “simulation constraint hypothesis“: As we’ve never consciously been without consciousness, even our best simulations of “true nothingness” just aren’t good enough, then in order to imagine what it’s like to be dead we appeal to our background of conscious experiences(1). Indeed, from an evolutionary perspective, a coherent theory about psychological death is not necessarily vital, sufficing, instead, that we understand the cessation of “agency”, something even a baby can do.
Despite the underlying reasons, some kind and level of self-deception is often OK or even necessary. E.g, depressed people, even though their thought processes are often quite irrational, tend to have more accurate views about their real standing in the world. However, self-deception can also exist for our great disadvantage. Individuals often stick with their political views even when a contrary reality stares them in the face. Entire sectors of today’s modern economies are based on self-deception. E.g., people spend their money with gym memberships because they are unwilling to confromt their illusions about how much they dislike exercise. (Or they might think, incorrectly, that the flat fee will get them to go to the gym more often.) This clear cost of a specific self-deception (about exercise) demonstrates how strong an incentive we have to self-deceive. Add to this the higher and not so measurable long-run health costs of actually not doing the exercises.
Fairy Tales and Quack Cures
We usually believe that all that abovementioned tales of self-deception are not that applicable to modern society’s ever advancing medicine and resulting health/life span improvements. As we understand a great deal about the mechanisms of life, we have generated reasoned hypotheses about the causes of death and the interventions that might prevent it. But biological systems are far too complex for us to have so much confidence in such hypotheses. Furthermore, informal medical judgements often fall short of statistical standards, so that clinical experience cannot by itself assure much thing. Indeed, doctors mostly just copy what doctors around them do and don’t rely on specific scientific studies.
Drugs approved by the regulatory body to treat a certain condition can be freely prescribed to treat any other condition, regardless of what studies say. Even within the approved uses there are serious doubts. Today’s blind randomized clinical trials (RCTs) have being under hard criticism for more than 10 years. Three common problems are most often cited:
- drug companies often do a bunch of trials, but only report the trials that make their drugs look good;
- drug companines usually run best case trials - i.e., on patients most likely to benefit and under doctors most likely to make good decisions;
- patients who experience side-effects are assured that they are getting the real treatment (the enhanced placebo effect, or unblinding).
The antidepressants (ADs) debate is a particularly “hot” instance of this problem, with formally published populist titles as “Listening to Prozac but hearing placebo” and “The Emperor’s new drugs”. Although the pooling of various studies, including previously unreported “negatives”, results in a highly statistically significant effect in favor of ADs (agains placebo), the cause and the size of this effect are much disputed. Even if we assume or conclude that at least the Emperor’s clothes are made of “real cloth”(2), remains the “weaker” argument that the effect is small enough to be clinically unimportant. Aside from the discussion about how big an effect is required to be clinically important, the fact is that today’s standard RCTs are not designed to determine the size of the effect in usual clinical practice (i.e., their effectiveness). Indeed, to be able to estimate the real added value of ADs in particular patient groups is generally recognized to be no easy task.
Generally speaking, there’s increasing concern that in modern medical research, false findings may be the majority, or even the vast majority of published research claims. In august, 2005, PLoS Medicine published a paper by John P.A. Ioannides, in which he argues that this should not be surprising, as it can be “easily” proved. Ioannidis derives the following list of corollaries about the probability that a research find is already true (some of them are pretty intuitive):
- the smaller the number of studies conducted, the less likely the finding are to be true;
- the smaller the effect sizes, the less likely the finds are to be true;
- the greater the number and the lesser the selection of tested relationships, the less likely the findings are to be true;
- the greater the flexibility in desings, definitions, and analytical modes, the less likely the findings are to be true;
- the greater the financial and other interests/prejudices, the less likely the finds are to be true;
- the greater the number of scientific teams involved (i.e., replications), the less likely the findings are to be true(3).
At his framework, findings from underpowered, early phase clinical trials would be true about one in four times, or even less frequently if bias is present. A fact: The majority of modern (bio)medical research is operating in areas with very low pre- and post-study probability for true findings. Furthermore, assuming a “null field” (i.e., one with absolutely no yield of true scientific information(4), then one for which is usually expected that all observed effect sizes vary by chance around the null in the absence of bias), all deviations from what’s expected by chance alone would be simply a pure measure of the prevailing bias. It follows that, between many “null fields”, the fields that claim stronger effects (often with accompanying claims of medical and publich health relevance) are simply those that have sustained the worst biases. It means that too large and too highly significant effects may actually be more likely to be signs of large bias and then should lead researchers to careful thinking about what have gone wrong with their data, analysis, and results.
Correlations-in-the-world studies usually see little to no effect at all of marginal medical care - i.e., the care some people get and other people not get, that is, an useless-in-average care - on health, while gender, exercise and social status, for example, can change lifespans by 10 to 15 years or more. Even a large, randomized trial conducted in the late 1970s by the RAND Institute found no significant difference in general health between people with more (public) health care and those with less(5). Furthermore, it can also be concluded that common/basic care (roughly two thirds of the spending) and marginal care (the remaing third) had the same fraction of “innapropriate” hospital admissions and care-days, and the same fraction of major and catastrophic desease presentations (relative to moderate and asymptomatic desease manifestations; as reviewed a posteriori).
Thus, the strange fact is that we cannot be so sure about why we now live so much longer. However, this type of reasoning is largely ignored by society as whole, as the idea that we mostly don’t understand and actually cannot control death, despite all the advancements of medicine and technology in general, is just not a message people want to hear. Then, nations and families spend now a significant proportion of their incomes on medicine, even though at least a third of that has been clearly demonstrated to be on average useless (marginal care), and even though we have good reasons to doubt the value of most of the other two thirds (common care). Meanwhile, we seem relatively uninterested in living longer by trying the things the evidence suggests to work, at an individual basis, such as gaining high social status, exercising more, smoking less, and living in rural areas. We eagerly hand over all our life/death decisions to doctors, in order to think about other things. It’s easier just to trust our doctors than having to think about death, or any serious desease at all.
In summary, humans evolved particular health behaviors because of specific contingent features of our ancestors’ environments, features that are largely irrelevant today. Furthermore, evolution has lead us largely unware of how self-serving and in-group-oriented (e.g., favouring our families) the functions performed by those behaviors were.
Psychiatry is being lead by the siren call of semiotics, and it’s saying, follow me, I’m made of words
[A phrase by a psychiatrist whose online idientity is called “Alone”.]
For quite obvious reasons, psychiatry provides one the best examples of the vicious of the current medical research and clinical practice, and of how a completely unresponsive demand-side have contributed to this state of affairs.
Like everything else in life, the problem is on the demand side. It clearly follows from the above description that the demand-side of the market for medicines, or, more generally, for medical treatment, are actually the doctors, rather than the ultimate user of the medical products and services - i.e., you, the patient. It was mentioned also that doctors are highly biased and actually don’t merit our blind trust in them, at least in general terms. Not to mention the preposterously biased and uninformative medical journals.
As a matter of fact, plugging in the supply-side of the equation, it appears that the actual efficacy of some would-be drug or treatment could heavily work against it: The doctors (the real demand-side) who would use it were, frequently, the least likely to want to do so. Not necessarilty because they are bad and corrupt, but because they usually have a hard mini-paradigm, and they simply couldn’t see anything beyond it.
Medicine is politics, not science: Doctors are generally resistant to published data, journal studies and even to logic, so that to break that mini-paradigms drug companies may often have to recurr to key opinion leaders in the specific field, usually a little group of distinguished academicians, to change perceptions and practices.
So medicine is practiced by what works for the doctors, not the patients, and all the incentive drug companies have is to “discover” drugs that will sell to the doctors (and that can be approved by the regulatory body). And that’s all the incentive medical researchers always have had, within drug companies or even in government-sponsored studies: to gain regulatory approval for their would-be drugs, not really future sales, not to mention usefulness for the patient.
Doctors have no current incentive to consider the cost (effectiveness) of the meds they prescribe, therefore there’s no incentive to drug companies to create cost-worthy products and services. Within this framework, the best business model the entire supply-side can adopt is the “blockbuster drug model“. A common criticism here is that it entices other companies to invest in “me too” drugs, so we always have a quite big number of products of the same class, addressing the same problem/condition, usually the “condition of the moment”, without clear differences between them. It means no real incentive to investment in innovation. On the feedback, the model makes the doctors think that its action mechanisms is the only or the most important one, creating a paradigm that’s hard to thing outside of. It means that the model confuses science.
There are staggering social consequences attached to this state of affairs. In psychiatry, at least from 1980 to 1998, doctors were all obsessed with Serotonin-Selective Reuptake Inhibitors (SSRIs), to the point that they tried to explain nearly all psychiatric phenomena by means of serotonin mechanisms - i.e., they have prescribed SSRIs for everything. 1998 marks the beggining of the abovementioned AD debate, at least in US. Although increasing over time, the vociferous group of critics was, until recently, just a minority. The cited “Alone” used to refer to April 4th, 2007, as the day when the ADs finally have dead. In this day, the prestigious New England Journal of Medicine published a paper by a group of very distinguished academicians concluding that ADs didn’t provide additional benefit to mood stabilizers. In practice, they were declaring the actual abandonment of ADs and the abandonment of their support of the diagnosis “major dipressive disorder” (MDD) as a whole. They were also signaling that the future was indeed in the bipolar spectrum and in the wide use of atypical antipsychotics. After that the arguments of that vociferous minority subtly become mainstream: SSRIs aren’t that effective at all, the old “10% better than placebo” is just a statistical trick with little clinical utility, MDD is overdiagnosed, etc. Three interesting facts are worth mentioning here:
- these are the same authors who have pushed psychiatry into polipharmacy with ADs (to “everything”) long ago;
- the data used to corroborate their conclusions are 10 years old;
- this was not a big drug company-sponsored study, but a NIMH one.
In fact, distinguished and manipulative academicians are no longer getting the drug companies money; they are now getting the easier and flexible government money, and so they are dangerously pushing the government line.
In summary, all this means some squeeze out of MDD into “life” and the bipolar spectrum, and atypical antipsychotics are now 1st line agents. The clear signal is to psychiatry to use them to replace everything. According to said “Alone”, there’s no many changes like this in psychiatry, maybe one every 10 years; the last one was the beggining of the Depakote era, before were the SSRIs, each one with its egregeous semantics (e.g., “the kindling model”, “the serotonin model of depression”). Being more precise, the recent semantic trick was the following: “mood stabilizers” now include atypical antipsychotics and we’ve gone from “polipharmacy is not better” to “monotherapy with mood stabilizers - i.e., atypical antipsychotics in this case - is just as good as 2 drugs at once.” This little tinkering with language and loyalties brings psychiatry from the (serotonin-based) depression mode to the manic(-depressive) mode. Suffice to say that the developments suffer only some degree of delay in the rest of the world.
Furthermore, note that psychiatry doesn’t explain, it only identify. What it commonly does is to call the symptom itself a disorder, which makes it definitional, safely axiomatic, then unrefutable. You’re not depressed because you lost your house, you always have depression, and one of the triggers was losing your house. The real problem here is that people are demanding any easy relief, instead of confromting the root causes. In going to a psychiatrist, their socioeconomic problems get demoted to “factors” and their feelings become pathologized. Society needs that illusion/lie, because it has created unrealistic expectations in people, and no real ways of fulfilling them. Furthermore, people “cannot look directly at either the sun or the death” (La Rochefoucauld).
Footnotes:
(1) Note that, as the “nothingness” of unconsciousness cannot be an experienced actuality, the common assumption that we experience periods of unconsciousness, e.g., when in dreamless sleep, is actually impossible.
(2) I.e., if we admit that RCTs of ADs are producing meaningful results, in the scientifically and regularorily important sense that they are telling us which compounds work (i.e., have efficacy) safelly.
(3) The rapid early succession of contradictory conclusions is usually called the “Proteus Phenomenum.”
(4) At least based on our current understanding.
(5) Since this was a randomized but not blind clinical trial, this no-effect result also includes any health benefits people can get from feeling that they are being cared more.
February 1st, 2009 in
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“New flesh”, said Robert, taking his coat off in the process of walking through the door. “What we need is new flesh. Great slabs of it, cut in precise geometric fashion and abutted. Most lying flat in mute fascination, some rearing perversely into the air. Yes, definitely new flesh.”
“You’re nearly fourteen minutes late,” said Walter. “You’ve forfeited your turn.”
“It could be wrong,” said Robert. “Watches have been known to be wrong. This is one of your problems, Walter, your overreliance on technology. That, and the mistaken notion that time is somehow dictated by the will of the masses. The true time is independent of your opinions as to what you think it is. Reality cannot be dictated by the majority.”
“By any standard time you’re late,” said Walter obstinately. “Adrian has begun.”
“I’ll start again for you,” said Adrian, hoping his eagerness would avert an argument. Robert finish taking his coat off and sat down at the table. He looked about the living room, whose walls were bare and painted flat white. The bookshelves were empty, and the furniture had been stripped off all ornamentation. The table was round, with three chairs surrounding it, and was lit by a single bare electric bulb. Walter was presently attempting to reject the influence of other people’s design strategies upon his own creative processes.
“You’ll have to do something about the furniture,” Robert had said immediately, though he preferred it to Walter’s previous attempt at interior decor, which involved displaying the sum total of his knowledge on the walls.
“It’s just plain, functional furniture.”
“But the mere fact that you can put labels to it indicates that it, as one of your choices, can categorize you, and thereby limit you in the precise manner you had hoped to avoid.”
Robert’s statement disturbed Walter. Each of them resented the other for drawing them into hairsplitting metaphysical discussions, which both detested but neither could resist.
Adrian cleared his throat, and started again.
“The first sign of the changes came of the last runs of the Belvedere’s street car, in Belo Horizonte. It had been kept running for the tourists, but it was not serving the needs of the greater metropolitan area, so plans were made to replace it with a light monorail system. But, one afternoon, as the 04:10 car neared the U-bend marking the western terminus, it went straight instead of turning. The passengers were only slightly shaken as the car leapt the tracks and continued to roll down the grassy boulevard. The conductor, who was also to be retired that week, kept his hand on the throttle, which continued to respond to his movements even though electrical contact had been broken. It was well over an hour before the police correlated the reports of startled suburbanites and realized what was happening. But it was too late. The streetcar, waving a lenght of wire from it power antenna like a flag of freedom, had vanished north, into the swamps.”
“What about the lake?” asked Robert.
“What lake?”
“Lake St. Lucia,” said Robert. “If it went north it would have to cross Lake St. Lucia, and I doubt it could get over the causeway without being stopped by the cops.”
“There’s no need to be pedantic,” said Walter. “As long as internal consistency is maintained, we haven’t the right to object. It’s the creative effort we’re interested in, not the niggling details.”
Robert shrugged. It was at least better than the previous session, when Walter had taken them on a long journey through his cancelled checks of the past three years. He hadn’t prepared well, and the result lacked even internal consistency, though Walter claimed that it was a “preparatory treatment … prior to a more complete version augmented with actual receipts”. Walter’s descriptions of his own works always sounded like grant proposals. Adrian claimed to see in the performance an ironic allegory of capitalism; Robert felt that there was something obscene about the way he lovingly recalled each penny spent.
“All over the world,” Adrian continued, “people were coming to new realizations, as if waking from a long and troubled sleep.”
“Is there any beer in the house?” asked Robert.
“Will you stop interrupting,” said Walter. “There’s no beer anywhere in the house. Refrigerator’s empty.”
“I don’t believe you,” said Robert.
“The truth is independent of your opinions,” said Walter maliciously.
Robert got up and went into the kitchen, which was also painted white. He opened the fridge, and found it completely empty. The fridge hummed; gases circulated in tubes, and expanded and contracted, to cool the air filling it’s vacant interior. Robert considered advancing the thesis that this was the greatest statement Walter had ever made, but instead he went back to the table and sat down.
“Perhaps the greatest symbol of our hopes was the voyage of Maria and Leo. It was Maria’s vision that made them leave their hostel in Nova Lima in the early morning twilight and make the short journey north, the journey they had been planning to make as soon as they had the cash ready. Maria couldn’t explain her vision to Leo; she shook her head mutely, and he didn’t press her.
They make their way to the airport, which was filled with people walking every which way. Maria led them to a gate, where a plane for Manaus sat ready. The crew were unsure as to their new roles; they didn’t take board passes, and walked like robots through the pre-flight rituals, the demonstrations of the seatbelts and the oxygen masks. ‘What them,’ Maria whispered to Leo. ‘Watch where they go and what they do.’”
“When everyone was seated, the plane left the gate and started to taxi toward the runway. ‘One of the men went to the back,’ said Leo. ‘All the other are visible.’”
“‘Good,’ said Maria. ‘Now we wait for the permission to leave.’ She sat still, though her hands were clenched with the intensity of the knowledge flowing in her veins. Clearance from the tower came, audible to all over the cabin speakers, and the plane began to roll forward increasing speed. The engines whistled with their effort, and they all felt the slight shake as the plane left the ground. ‘Now,’ said Maria.”
“They rose from their seats and walked towards the rear plane. A few curious passenger followed them. One of the stewardesses arose from hear seat the near exit. ‘I’m sorry, miss, the seat-belt sign is still illuminated,’ she began, but stopped whem she saw the light blazing in Maria’s eyes, and let her pass without a word. Maria stopped beside the back lavatory, and pointed to the wall panel next to it. ‘This one,’ she said.”
“Leo and two of the passengers put their fingers to the edge of the panel and heaved. It tore off, revealling a small space inside. There was a large open window in the wall of the plane, through which they could see the ground receeding. There was a seat, occupied the missing flight attendant, a stick and two pedals on the floor, a few switches on a panel. The man turnes toward them and brought out a gun. Leo hit it out of his hand and, enraged, tore the man from his seat and threw him out the window.”
“‘This is where the plane is controlled from,’ said Maria. ‘The place up front, with all the lights, is for show.’”
“‘My God,’ murmured one of the passengers, peering in at the tiny room. ‘An open window. All those flights, packed in like sardines, breathing caned air.’”
“‘The plane will continue to rise,’ said Leo. ‘Where shall we make it go?’”
“‘Any place that we know how to get to doesn’t need a plane like this,’ said Maria. ‘Let it rise. We’ll see where it takes us.’”
“‘But we can’t rise forever,’ said a passenger. ‘We’ll run out of air.’”
“‘They told you there was no air up there,’ said Maria. ‘They told you also that there could be no windows in an airplane. And what of the things that they didn’t tell you?’”
“‘But why?’”
“‘To better control us,’ said Maria. ‘If people are free to go anywhere, quickly and easily, they shouldn’t stay where they were poor and where they had to work for cruel masters. Once they controlled the means of transit, they could easily crush the rest of our ambition, and we would never want to go anywhere. But we are free now, and we must go to places that they didn’t want us to go. So, let us rise.’”
“And, because of the intensity of her vision, the passengers agreed. So, it was that they set off on the greatest voyage man has so far undertaken, and with them went our love and our hopes for the future.”
Adrian was silent.
“Well?” said Walter.
“That’s it.”
“That all?!”
“There wasn’t any more,” said Adrian despairingly, “You told me to force it. Nothing more came.”
“Hell of a saturday night,” said Robert.
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