Do hospital investigations alter patients’ choices?

In the UK health care system, the Care Quality Commission can conduct high-profile investigations of hospitals. In a recent article published in Health Affairs, we investigated the impact of such investigations on patients’ behavior. For three investigations, we analyzed the trends of non-emergency patient admissions and other utilization indicators. Controlling for secular trends and using a control group, we employed a difference-in-difference approach. We found that the investigations only had an impact for one hospital with significant declines in inpatient admissions, outpatient surgeries, and in numbers of patients coming for their first appointment, but the effects disappeared six months after publication of the investigation report. Apparently, the publication and dissemination of the highly critical report does not have a sustainable impact on patients’ behavior like avoidance of the hospital. Assuming that hospitals implement improvements also without the threat of losing patients, public reporting has no adverse effects on the number of patients for the hospital.

Evolution of Generosity

Human interactions are often based on co-operation. How did co-operation evolve? If co-operation returns a higher pay-off than defection, the answer is obvious. However, many situations – like the famous prisoner dilemma – have a higher pay-off if one defects while only mutual co-operation has a higher pay-off than mutual defection. In this case, Axelrod (read summary here) showed with computer simulations that only in repeated interactions co-operation is sustainable. Psychological experiments don’t support this finding as even if the experimentator ensures that there won’t be any further interactions, people still co-operate. Is this irrational?

A new contribution to embryonic stem cell research

Last year, we published an article in Nature (read my summary here) linking the so-called hmC DNA modification to an enzyme and its mutation in a subgroup of leukemia patients. At this stage, it was still not clear whether the DNA modification hmC indeed has a functional role at the molecular level or whether it is just an intermediate product in a reaction chain.

In our new article in Nature (here), we shed some new light on this hypothesis. Therefore, we developed two new biotechnological methods, which allow us to detect the positions of hmCs very accurately in the DNA with a resolution of a a few basepairs up to a few hundred basepairs. Based on a sophisticated statistical analysis, we are able to analyze the patterns of the hmC regions (around 100,000). The less randomly the regions are distributed, the more likely it is that hmC has a functional role. Indeed, we observe a strongly non-random pattern of hmC regions. More specifically, we discovered that hmCs are significantly more often co-located in the regulatory regions of genes with other known histone modifications. Therefore, we hypothesize that hmC plays a fundamental role in the regulation of developmental genes.

Are women too stupid for Physics?

Women are under-represented in Mathematics, Physics and other Sciences. Why? Do women just have different intellectual strengths than men? In other words, are they incapable of excelling in Physics and Math? Or does discrimination limit achievements of women in these subjects? Lots of speculation and public discussion accumulated about this topic – especially after Lawrence Summers bold statement that there might be a good reason for the under-representation of women (read here). Last week in Science, psychologists focussed rather on over-coming the inequality than in understanding it – with astonishing success.

Miyake et al. describe in their Science article the results of a double blind experiment. One group of students in Physics were asked to write a value affirmative essay at the beginning and the end of the term. This mini-psychological intervention takes 15 minutes and is known to increase self confidence. Only for women, writing the essay significantly increased their grades from C to B level. Hence, the intervention closes the gap between men and women. It is surprising that such a 15′ essay not related to the course work can have such a big effect. Furthermore, the effect might be long-lasting as it can lead to a self-enforcing gain in self-confidence.

And what can other students learn from this study? Low self-confidence can limit achievements and successes resulting in a vicious circle. Indirectly, it confirms that peer-group pressure and competition is destructive while peer-group assurance is support is beneficial. Actually, it is very sad that such an idea ‘woman are bad in Physics’ can become a self-fulfilling prophecy. We should believe in the opportunities of individuals rather than in their inborn limitations!

New DNA Modifications in Cancer Patients

[No idea what DNA is? Don't worry, skip the first paragraph and continue with the second!] In our latest research contribution (read here), we showed that a new DNA modification identified in our lab about a year ago is altered in some cancer patients. We discovered the responsible enzyme as well as the mutations, which corrupt its functionality. A comparison of the cancer patients with and without the mutated enzyme show other biochemical differences, which strongly proposed to individualize current cancer treatment for this subgroup of patients. And if you are lost reading this, here is a more down to earth explanation:

Each cell has DNA which contains the information about all our proteins. You should imagine the DNA as a long book with four letters A, C, G and T. Although this sounds like a rather abstract model, it is more realistic than one might think. The DNA is a huge biochemical molecule built by many smaller molecules. The most important part of DNA is a chain of millions of one out of four molecules. These four molecules – you can guess – are called Adenine, Cytosine, Guanine and Thymine. They correspond to our letters. Other molecules read them as if they would be letters. Depending on the order of the letters, enzymes can build all the different proteins in our cells. The region, which describes a protein, is called a gene.  However, all cells contain the same DNA but a liver cell is obviously rather different from a brain cell. Both cells produce different proteins. This is done by regulating which genes of the DNA are used to produce proteins. And who tells which genes should be used? The DNA itself. The DNA contains so-called regulatory regions, which tell other enzymes whether certain genes should be used to produce proteins or not. That’s the basic biochemistry in our cells. And one more step and we can talk about our research.

Some years ago, researchers realized that often the letter C is modified to an mC. This biochemical modification is important as it can change the regulation of our genes. Hence, some people talk about five instead of four letters in the DNA. The group I joined in Boston discovered just before my arrival that C is sometimes further modified to an hmC in embryonic cells (also published in Nature, click here). This was the starting point of a lot of research to understand the function of hmC and how hmC itself is regulated. The result of these efforts are now published in our new article:

Based on a suggestion of the first article, we analyzed an enzyme called Tet2. We could show that Tet is indeed involved in the modification of C / mC to hmC. How do we know this? We found that the function of Tet2 can be disrupted by mutations. The disrupted enzyme is dysfunctional and cells with the disrupted version of the enzyme have much less hmC than normal cells. Investigating the mutations of Tet2 in more detail, we realized that a subgroup of cancer patients have exactly these disrupting mutations. Using tissue samples of these patients (and, of course, control patients), we discovered that tissues from patients with dysfunctional Tet2 have less hmC than the controls. Hence, our findings of mutated Tet2 and altered DNA modifications is not just a special lab case but specifically occurs in a subgroup of one of the most terrifying diseases in the world.

Next, we analyzed the tissues in more detail. In addition to the difference in hmCs, they also differ from control patients by having less mC than C. This is rather strange because cancer patients usually have much more mC than C. In fact, cancer drugs try to reduce the abundance of mC to C in cancer patients. This is current clinical practice. However, for these special patients with mutated Tet2 and, hence, less hmC and less mC, this might be the totally wrong treatment. Besides the biochemical insights in the regulation of hmCs, this is our main finding.

Who is smart?

We got used to classify our friends, colleagues and class mates with attributes like ‘smart’, ‘bright’ and ‘intelligent’. Does this make sense? What do we want to say? And what are we saying?

With such a proposition, we assign a certain amount of intellectual capabilities to a person. There are three problems. How do we come up with this assessment? Is such an assessment meaningful? And what is its range? We come up with the assessment after observing the person and evaluating its problem-solving capabilities as well as education. If this would be so easy to obtain an estimate for intelligence, psychologists wouldn’t have invented such sophisticated tests. Even worse, one (uni-dimensional) measure of intelligence is not meaningful as intellectual capabilities are multi-dimensional as I’ve pointed out in an earlier post here. And intelligence is meant to be objective – hence, it might be a little pretentious to make such a claim casually about someone else.

Am I taking all this too serious? Is this hair-splitting? Maybe. However, one should consider that intelligence has a well-defined meaning in our language. Hence, it is not convincing to claim that one would use intelligence in a different meaning. There are better words for it. One can totally express his bliss about someone else by calling him ‘interesting’ – inherently subjective. And interestingly – as a friend remarked – people in the US tend to say that someone is ‘interesting’ or doing interesting work while people in the UK rather classify by ‘intelligence’.

Your boss is a better liar than you are!

Why should your boss be a better liar? Lies can be detected by emotional, chemical and behavioral factors. Liars usually have negative emotions, are cognitively impaired, have a cortisol reactivity and tend to one-sided shrugs and prosodies.

In an experiment from Prof. Carney at Columbia University, they randomly assigned test persons to a leader role or a subordinate position. After ensuring that the test persons felt correspondingly as the role suggests (dominant, high status and so on for the leaders), they asked all test persons to find a 100$ note in a book case. Half of the people were randomly instructed by a computer either to steal or to put back the money. As the experimenter asked whether they stole the money, everybody had to deny it. The persons, who stole the money and successfully convinced the experimenter that they didn’t steal it, were allowed to keep the money.

So, half of the test persons were lying. Afterwards, the emotional, chemical and behavioral factors were measured from each test person. For all measured factors, the ‘subordinated’ test persons, who were lying, had significant higher values than all other groups. Hence, the lying leaders had the same levels as the non-liars (except for cortisol reactivity, which was significantly less than for subordinate liars but still more than for non-liars). Thus, powerful people seem to be the better liars. Why? Maybe, they are adjusted to have less stress, are less scared of being detected and feel more comfortable in there position. Probably, they also consider lying less negative since they are making the rules. The link to this ‘research at work’ is here.

Confused about life? No worries – it’s a developmental stage! Or not?

In a recent article in New York Times (recommended by Elisa), I read about ‘emerging adulthood’ as a developmental stage propagated by Jeffrey Arnett Jensen. As most people in my generation realize, we live a different life than our parents in the same age. Many of us don’t aim at a straight career, a house, a car and a wife / husband with kids – rather we appear confused. We don’t have any substantial obligations – we don’t need a house or car since we don’t have kids; in turn, this means no significant financial obligations. And as we can always imagine a more interesting job, we change our career, try another job, continue studying or just travel around the world. (And we do yoga and are vegetarians.)

Jensen claims that this distinguishes us form our parents but more importantly also from ourselves in adolescence (ending between 18 and 21) and proper adulthood. He calls this ‘emerging adulthood’ and defines it as a new developmental stage between adolescence and adulthood. Earlier generations didn’t have the opportunity to act out this natural confusion about career and family due to social norms. Jensen argues that it is likely that ‘emerging adulthood’ is an important stage in life and that it should be supported by social institutions. However, there are two obvious problems with this view. Some people do have a straight career and family already in the early twenties – is something wrong with them? Others might keep up the ‘emerging adulthood’ lifestyle for the rest of their life – are they retarded?

The first problem becomes even more prominent by studying the psychological perspective of developmental stages. In the traditional view, adolescence is the essential previous step after childhood before adulthood can emerge. This is one of the defining criteria for developmental stages. Whoever does not have an adolescence cannot become an adult. The previous stage is essential for the rise of the following stage. As also the article points out, this makes it hard to argue that ‘emerging adulthood’ is a developmental stage.

The second problem is tightly connected to the first problem. If ‘emerging adulthood’ is not a developmental stage, it cannot block the advent of adulthood. Hence, a zigzag career without house, car and (traditional) family might not even conflict with an adulthood. Rather, the characteristics of ‘emerging adulthood’ should be seen as an alternative lifestyle, which was hard to execute in the past due to social norms. Now, we have the opportunities to live such lives but it is not more natural than the traditional life style. It is an alternative without downgrading any other lifestyle. Otherwise, we would lose the freedom to choose a lifestyle by forcing people into ‘emerging adulthood’. Therefore, it is rather dangerous to connect these characteristics to a developmental stage instead of an alternative lifestyle.

The [Im-]Moral Life of Babies

Last night, I was referred to an article in the New York Times supporting the idea of certain in-born mental capabilities in terms of moral assessment. The article is written by Prof. Bloom from Yale University, whom’s group conduct the respective research. I’m highly skeptical about the interpretation of the experiments.

In the historical introduction, Bloom explains the advent of a new epistemological approach to the mental life of babies. In the eighties, researchers found that babies tend to look longer at new, surprising and pleasing things. Therefore, measuring the ‘looking-time’ gives insights into these mental categories. Bloom cites a study where magical tricks were shown to babies. As the babies looked longer at scenarios apparently contradicting the laws of physics, one can conclude that babies have an innate understanding of the physical world including its physical laws. In my opinion, this is a far-reaching claim, which cannot be necessarily concluded from the experiment. Babies already lived in the physical world before the experiment. In this world, they mainly encounter scenarios where physical objects comply to physical laws (since childhood is not a never-ending magician show). Hence, magic tricks are rather new observations, which don’t fit into the already observed scenarios. Thus, an innate capability to ‘study’ (look at) something longer the less often it has been observed is sufficient to explain the outcome of the experiment. And though babies might be able to expect certain behavior of physical objects, this doesn’t mean that they think about physical objects as units of mass subject to gravity.

Similarly I think about the claim that babies can do rudimentary math. Put two dolls behind a screen such that the baby can observe that you put the dolls behind the screen. If the screen is removed and there are one or three dolls on the stage, the baby is surprised (looks longer). That’s nice and I would be interested to know whether any animal can do this, too. However, neither I would call this math nor counting. It obviously doesn’t even tell anything about the understanding of numbers.

Then, the discussion turns to moral. Bloom tells us that the claim of a universal moral code is controversial because of the wide variation between societies. This already points to the fact that Bloom might have a very broad definition about moral. Many philosophers believe that regional morals cannot exist in a secular moral theory because a moral statement is necessarily unconditional. If I claim that you are behaving morally wrong, I don’t say that I wouldn’t do this (if I were you) – since this is purely a reproach of irrationality. Rather, I claim that it is universally wrong. Otherwise moral sanctions (which are necessary for a moral society) wouldn’t work since one would always be required to reassure that the subject of the sanction is part of the moral society. For example, if someone kills someone else (and not in self-defence), it doesn’t sound very convincing if someone would claim, “uuh, ok, you belief in moral or religion X, hence, it is totally fine if you kill this guy”. A exculpation like this is only appropriate for cultural differences (and, hence, obviously not for moral issues). Bloom cites a study showing that different populations have different behavior towards strangers. Instead of seeing this evidence for cultural-dependent morals, one might rather realize that this is a cultural in contrast to a moral issue.

In the remainder of the article, Bloom is using his super-broad definition of moral to show that babies are innately moral. Bloom claims that behavior is moral and doesn’t require an explanation why one behaves in a certain way. Hence, he would probably assign moral behavior to a bunch of animals as well. Based on Wittgenstein, I belief that moral is a concept which only exists in language. The reason is that we need language to have intentionality (another purely purely linguistic concept), hence, neither does it make sense to say animals are moral nor that they are unmoral (read here my post about consciousness of animals). Returning to babies, I think it is a wrong question to ask whether they are moral (as if neuroscientists try to answer the question what consciousness is) before they can use the respective concepts in their language.

Looking at Bloom’s experiments where babies are able to select a good guy, the experiments are, again, over-interpreted. There are three puppets on the stage and the middle one has a ball, which it passes to either side. One of the puppets passes the ball back while the other puppet runs away with it. If the baby can choose between the two ‘side’-puppets, it tends to select the one, which passes back the ball. Bloom claims that this would show that babies can distinguish between good and bad. I think the explanation is much simpler and the babies selects the one puppet, which it would like to play with itself. Obviously the one which passes back the ball. And why it this so? Since the babies already have experience in playing with others and the neuronal reward system releases more good-feeling substances in the brain if the game goes longer. Hence, the baby might be able to select what is good or bad for itself and making the connection that the puppets consistently behave as they did. For me, it has nothing to do with moral or to distinguish between good and bad in a moral sense.

In summary, I do believe that babies are capable of doing a lot of things and I appreciate the corresponding research. However, it looks to me that results are over-stated and decorated with fancy buzz-words to create interest. Though, I’ve to note that Bloom admits some of those problems in the second half of the article. Unfortunately, he continues talking about moral behavior…

Eugenics in a different world?

In my last blog post, I summarized Gould’s empirical arguments against intelligence as an innate, inheritable, immutable, unified and ranked value with low variation within a group. Each of these properties are required to argue for any type of eugenic program ranging from birth control over discrimination to extermination. The usual plain argument for eugenics is concerned about the purity of a race / group for societal benefit (or survival).

The argument is empirically wrong if any of above properties of intelligence is wrong. For example, if there is not one single (unified) intelligence value, which we can rank, there is no way to talk about purity of a group / race in terms of higher or lower intelligence. If intelligence is not immutable, education will help everybody. If there is high variation in intelligence within a group, an average group differences have negligible effect on individual differences between groups. A group with a smaller average might even have higher variation and, thus, contribute the ‘weakest’ and ‘strongest’. Hence, selection based on membership to a group is a bad predictor for high / low intelligence. As empirical studies show, none of above properties is valid. Inheritance might be disputable but with respect to the eugenics argument, one would require that environment has hardly any influence on intelligence, which is evidently wrong. Empirically, the eugenics argument doesn’t hold. This is pretty satisfying but what would we say if the world would be different such that above properties would hold. Intuitively, most people still feel that eugenics is wrong. Why?

Quotations of the scientists from the beginning of the last century, who showed (wrong) evidence for above properties, often contain statements to dissociate themselves from any political program. They claim that they objectively investigate an empirical question without being biased by a wanted or unwanted result. After obtaining results, they often admit the support for an eugenics program but refer to Nature’s dictum and, hence, for moral exculpation. I think that this excuse doesn’t work since it is based on the naturalistic fallacy (already formulated in the mid 18th century by David Hume). Although it might be ‘natural’ for a man to rape any woman to enhance his prospect of genetic survival, it doesn’t mean that this is good. In general, Nature shows how things are while moral is about how things should be. These are different categories; Nature is empirical and can be described while moral is normative. This shows that we cannot use an empirical finding for the usefulness of an eugenic program as an argument against moral objections. If we can show that eugenics is unmoral, this claim is independent (and superior) to any empirical findings about eugenics.

Breeding is very common among animals. To obtain a good running horse, one selects two horses, which are good runners. Here, the definition of the breeding goal is clear. For a running horse, we might want a fast and enduring horse. Chickens are selected either based on growth rate and meat mass or egg production. If one would want to apply breeding to humans, one needs to define the goal or the criteria for optimization. Although we assume here that general intelligence would be measurable in one single value, it doesn’t follow that intelligence is the attribute to optimize for a ‘good’ society. Following Hans Jonas, we don’t know and we cannot know the universal but specific goal of society. Hence, we don’t even know which criteria we should select for. Therefore, eugenics cannot work.

This argument can be enhanced by incorporating the human dignity. It is essential for the concept of dignity that the carrier of the dignity (the person) has freedom of choice. In other words, the person doesn’t involuntarily depend on another person. Directed genetic modifications (like positive selection in eugenics) create such a dependency. A forced and inescapable dependency destroys the freedom of choice and the openness of life. Therefore, eugenics is patently not compatible with human dignity. Hence, eugenics is clearly unmoral – independent of any empirical results.