[Link] Low-Hanging Poop

Related: Son of Low Hanging Fruit

Another post on finding low hanging fruit from Gregory Cochran's and Henry Harpending's blog West Hunter.

Clostridium difficile causes a potentially serious kind of diarrhea triggered by antibiotic treatments. When the normal bacterial flora of the colon are hammered by a broad-spectrum antibiotic, C. difficile often takes over and causes real trouble.  Mild cases are treated by discontinuing antibiotic therapy, which often works: if not, the doctors try oral metronidazole (Flagyl), then vancomycin , then intravenous metronidazole.  This doesn’t always work, and C. difficile infections kill about 14,000 people a year in the US.

One recent trial shows that fecal bacteriotherapy, more commonly called a stool transplant, works like gangbusters, curing ~94% of patients. The trial was halted because the treatment worked so well that refusing to poopify the control group was clearly unethical.  I read about this, but thought I’d heard about such stool transplants some time ago.  I had.  It was mentioned in The Making of a Surgeon, by William Nolen, published in 1970. Some crazy intern – let us call him Hogan – tried a stool transplant on a woman with a C. difficile infection. He mixed some normal stool with chocolate milk and fed it to the lady.  It made his boss so mad that he was dropped from the program at the end of the year.  It also worked. It was inspired by a article in Annals of Surgery, so this certainly wasn’t the first try.  According to Wiki,  there are more than 150 published reports on stool transplant, going back to 1958.

So what took so damn long?  Here we have a simple, cheap, highly effective treatment for C. difficile infection that has only become officially valid this year. Judging from the H. pylori  story, it may still take years before it is in general use.

Obviously, sheer disgust made it hard for doctors to embrace this treatment.  There’s a lesson here: in the search for low-hanging fruit,  reconsider approaches that are embarrassing, or offensive, or downright disgusting.

Investigate methods were abandoned because people hated them, rather because of solid evidence showing that they didn’t work.

Along those lines, no modern educational reformer utters a single syllable about corporal punishment: doesn’t that make you suspect it’s effective?  I mean, why we aren’t we caning kids anymore?  The Egyptians said that a boy’s ears are in his back: if you do not beat him he will not listen. Maybe they knew a thing or three.

Sometimes, we hate the idea’s authors: the more we hate them, the more likely we are to miss out on their correct insights. Even famous assholes had to be competent in some areas, or they wouldn’t have been able to cause serious trouble.

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Obviously, sheer disgust made it hard for doctors to embrace this treatment.

I'm not sure this is obvious. As the H. pylori story shows, it's sufficient that an idea seem "weird".

Relative to other fields, doctors face an unusually large disincentive to unilaterally change treatments. The preferred defense in a malpractice case is to literally argue that you were doing what everyone else does. You don't have to defend the recommended treatment, just show that what you did was the "standard of care".

The inherent bureaucratic incentive is to stick with the status quo, and to resist any change (good or bad), until everyone can move in lockstep.

Also, are doctor's really that disgusted by poop? I'm told medical students actively compete to become specialists in the examination of assholes.

Relative to other fields, doctors face an unusually large disincentive to unilaterally change treatments. The preferred defense in a malpractice case is to literally argue that you were doing what everyone else does. You don't have to defend the recommended treatment, just show that what you did was the "standard of care".

I was under the impression that the stories about doctors being conservative and not good scientists date far before, and more universally, than the legal changes which made malpractice suit feasible rather than impossible.

For that matter, malpractice suits seem like a uniquely US phenomenon.

They still happen here in Scandinavia, but they're fairly rare.

The weird thing is most doctors are not trained to be scientists, but many of them are expected to do science.

There are ways to punish "malpractice" that aren't lawsuits, on many different levels, so I think the status quo argument still holds.

Malpractice suits are supposed to be compensatory. Punitive action is supposed to be handled through regulatory and criminal processes, not civil ones, but it often doesn't work that way.

I would guess that, prior to malpractice suits, the main threat to a doctor was a bad reputation, spread by word of mouth among patients. This still provides an incentive to do nothing too weird, but now "weird" means "weird as judged by patients and their loved ones."

Would this have made for more innovation or less? It's not clear to me. On the one hand, patients had less experience in medical matters than doctors, so things that other doctors might have considered normal would have seemed weird to the patients. This might have encouraged doctors to be even more conservative than their peers would allow. Another doctor might say, "Yeah, that's how this rare condition is treated, on those few occasions when it is treated." But the patient hasn't heard of those "few occasions", and so the treatment will just seem weird. If the treatment fails, surviving loved ones might spread rumors about how the doctor killed the patient with weird treatments.

On the other hand, patients would probably often defer to the authority of their doctors. Maybe the patient would think, "Well, this does seem a little weird. But doctors often do things that seem a little weird. I'll trust him if he tells me that it's not too weird." In that case, a doctor might be able to get away with weirder treatments than his peers would allow, because patients, unlike other doctors, wouldn't feel comfortable gainsaying him, even if things didn't work out.

A friend and I are starting a marketplace to connect fecal transplant donors with people who need them. Let's make this happen. Check out fecalnet.com.

Aw crap, one time I could give a shit and it is apparently US only.

Your donor questionnaire asks if the donor is willing to take tests to demonstrate that they're healthy. You might specify at that point who will be paying for the test.

Are you sure you're not practicing medicine without a license?

Obviously, sheer disgust made it hard for doctors to embrace this treatment.

This is a blatant failure at imagining what a doctor's work day looks like. Doctors who would treat resistant cases of diarrhea would be gastroenterologists, that is people who pretty much specialize in dealing with poop.

I agree with the general argument, though.

ETA: Did I misunderstand this article? I thought the whole feces with chocolate thing was there just to spice up the story. They don't make people eat feces and I'm not sure they ever have. it's done through a tube and I think these things have been around for several decades.

I assume the "disgust" being referred to was the potential patient's disgust at the suggestion.

I don't think so, that would have been made clearer, but let's assume it was:

He mixed some normal stool with chocolate milk and fed it to the lady.

This is not how it's done, they use a tube. Stool transplant is usually the last option when nothing else works, the patient is desperate and might die without treatment.

The linked study suggests stool transplant is more effective than antibiotics. This doesn't necessarily mean that antibiotics shouldn't be tried first, as they are simpler to administer and more readily available.

I'm a bit surprised the stool transplant is given orally rather than anally.

I suppose upstream is done too, but actually, I think it's usually given nasally ;)

I guess it's simpler and more comfortable that way, you're going downstream so peristalsis and gravity does the work. You don't need to wait with a rather bulky tube up your colon. A thin feeding tube doesn't feel like anything once it's in place.

ETA: wait, did someone actually think they make people eat feces?

He mixed some normal stool with chocolate milk and fed it to the lady.

It seems you find inferential distance from where you least expect it. Judging from the story that was ages ago and the guy must have been short on feeding tubes. If not, I would've fired him too.

Stool transplant is usually the last option when nothing else works, the patient is desperate and might die without treatment.

I'm wondering why it is the last option, if it seems to work about as well as antibiotics on average?

The infection is relatively common and ab treatment failure is rare. In Finland we have free health care, so I'm looking at things from the resources pov.

Antibiotics: give the patient a pill, four times per day for a few days, no infrastructure needed. The patient might even get to stay home. It's very rare this doesn't work.

Transplant: Admit the patient to a hospital and have them take someone elses place. Isolate the patient from other patients. Make staff wear protective clothing when dealing with the patient. Find the right kind of poop donor (I'm not sure if poop can be stored). Have someone prepare the transplant. Have an already busy gastroenterologist explain the treatment to the patient and insert the tube.

Before a discussion on corporeal punishment is started, I want to caution against this happening. It might be that children of people who find corporeal punishment effective are similar enough to their parents to respond well to it, and vice-versa.

Along those lines, no modern educational reformer utters a single syllable about corporal punishment: doesn’t that make you suspect it’s effective? I mean, why we aren’t we caning kids anymore? The Egyptians said that a boy’s ears are in his back: if you do not beat him he will not listen. Maybe they knew a thing or three.

On the basis of studies on corporal punishment by parents, I suspect that this is probably quite effective for controlling chidren's behavior while you have them under your authority, but also that it's likely to make them more likely to resort to violence in their own lives.

People may reject methods which work because they find them distasteful, but it's worth keeping mind that there may be sound reasons for rejecting some such methods even if they are effective.

Also, with punishment generally, there's a problem that people almost inevitably overestimate its effectiveness. Punishment generally follows exceptionally bad behavior, exceptional behavior is, obviously, exceptional, so punishment would be expected to be followed by behavior which is not exceptionally bad just because of regression to the mean, even if punishment were totally ineffective or even mildly counter-productive. But, unfortunately, people are almost totally oblivious to regression to the mean, and so what should be the expected result regardless becomes for them evidence of the effectiveness of punishment.

Because punishment tends to immediately terminate the punished behavior, while not preventing it in the long run, punishment reinforces the punisher. The person doing the punishment is an agent under conditioning as well, but most folks fail to notice this.

Upvoted for the insight.

while not preventing it in the long run

I don't agree with this, but rewarding is clearly better, of course. It's easy to get tunnel vision when thinking about punishment, many of us have memories of injustice done in its name.

but rewarding is clearly better, of course.

What do you mean by this? Rewarding everyone who fails to exhibit bad behavior? This has two problems:

1) Since most people behave well most of the time, this gets expensive quickly.

2) Human psychology is such that if there is a regularly given reward, people will simply readjust their baseline and thus will perceive being deprived of it as a punishment anyway.

I think you could have done the steelmanning yourself, but here you go:

1) Rewards can be social, in other words virtually free. You don't have to reward all good behaviour, in fact that probably makes it less effective. (like you already said yourself?)

2) Here's how I would do it: Always reward exceptionally good behaviour, sparingly reward ordinarily good behaviour.

This doesn't mean punishment should be never used, but it's difficult to build a positive relationship with someone you're punishing constantly.

sparingly reward ordinarily good behaviour.

Of course, that means that unless you also punish bad behavior, it won't stand out from the ordinary good behavior.

but it's difficult to build a positive relationship with someone you're punishing constantly.

It's also difficult to build a positive relationship with someone who is constantly engaging in bad behavior.

This is actually the biggest problem with torture, in my opinion.

Punishment generally follows exceptionally bad behavior, exceptional behavior is, obviously, exceptional, so punishment would be expected to be followed by behavior which is not exceptionally bad just because of regression to the mean

I don't think treating human behavior as a simple random variable is a good model. See here for a better model.

If you have a point to make, I think it can be made more effectively than "Read this article".

I can identify behaviors that please me more than others, creating an ordinal structure on the set on the set of possible behaviors. I can also observe a frequency distribution of those behaviors. From the frequency distribution and the ordinal structure, I can identify a median. From there, it's not too difficult to identify reasonable assumptions such that the frequency of a bad behavior being followed by a worse behavior is less than the frequency of a bad behavior being followed by a better behavior, where "bad behavior" is "behavior that is worse than the median".

If you have a point to make, I think it can be made more effectively than "Read this article".

But Eugine made a point and his point was:

I don't think treating human behavior as a simple random variable is a good model.

He then backed up his point to give context to suggest what a better model might be, i.e. one that models a human as a temporal process with habits.

On the basis of studies on corporal punishment by parents, I suspect that this is probably quite effective for controlling chidren's behavior while you have them under your authority, but also that it's likely to make them more likely to resort to violence in their own lives.

So the studies find that corporal punishment has immediate benefits, but insert a disclaimer that there are bad effects in ways that are less obvious (and therefore easier to fudge). This is just what one would expect if the scientists doing the study aren't willing to outright lie but don't want to seem pro-corporal punishment.

No, the studies I'm aware of did not research what immediate benefits might be available, they were just researching whether children who received corporal punishment were more likely to express violence, and found that this was the case. That corporal punishment might be effective in the short term is my own presumption based on the fact that it shows effectiveness in controlling crime when used as a legal punishment against adults.

I was hoping the article would be about finding and getting rid of simple-to-identify-and-remove problems.

Along those lines, no modern educational reformer utters a single syllable about corporal punishment: doesn’t that make you suspect it’s effective?

Not really. I generally assume that experts in their field know more about it than I do, so the fact that they don't suggest it makes me suspect that it's less likely to be effective. This doesn't always work as an inferential method, but probably works more often than not.