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Comment by borroka | Hacker News Reader

I read them as sloppy caricatures that provide little value to the conversation.

Let's take the security guard: "The only problem is: he now provides literally no value. He’s excluded by fiat the possibility of ever being useful in any way. He could be losslessly replaced by a rock with the words “THERE ARE NO ROBBERS” on it."

That is blatantly not true, the guard provide value since the wanna-be robbers don't know whether the guard will be of any value, and a rock could not provide any deterrent. Losslessly?

The doctor (if there is someone skeptical of doctors it is me, if I were less lazy I would have greatly enjoyed fighting to make some useless US dermatologists lose their license): "Her heuristic is right 99.9% of the time, but she provides literally no value. There is no point to her existence. She could be profitably replaced with a rock saying “IT’S NOTHING, TAKE TWO ASPIRIN AND WAIT FOR IT TO GO AWAY”.

This is an unhelpful caricature, too, because if we add "and call back if it does not", it looks like a very reasonable approach.

Un-nuanced and quite sloppy presentation of heuristics.

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Are you reading the deeper lesson though? The individual examples aren't meant to be authoritative. He was trying to illustrate the very thing you are bringing up. Namely that lazy heuristics create information cascades. The information cascades can have positive effects, as you point out, but they can have profoundly negative consequences, which is the point of the whole article.

We shouldn't use or intellectually tolerate lazy heuristics because they can create immense amounts of counter-productive sense-making, and consequent negative social outcomes (a poorly managed pandemic, for example). The reason this article is hitting a nerve is because he is basically describing the current state of sense-making in the US (and maybe even the West more broadly?), which is quite poor — worse in some areas than others, but still quite degraded all around.

On your doctor take, you do know that the other author of this post is a licensed and practicing Physician, right?

Right. I think it has to be boiled down to a simple parable to be sufficiently clear, but it is really attacking a belief that is quite common.

I like this essay on Overconfident Pessimism[0] because I think it gets at the same thing, especially in the context of confident dismissals of important future technological changes:

>There may also be a psychological double standard for "positive" and "negative" predictions. Skepticism about confident positive predictions — say, that AI will be invented soon — feels like the virtuous doubt of standard scientific training. But oddly enough, making confident negative predictions — say, that AI will not be invented soon — also feels like virtuous doubt, merely because the first prediction was phrased positively and the second was phrase negatively.

[0]. https://www.lesswrong.com/posts/gvdYK8sEFqHqHLRqN/overconfid...

"On your doctor take, you do know that the other author of this post is a licensed and practicing Physician, right?" --

Your observation is indeed much more interesting than the whole article, since it shows a reasonable (and not a caricature with zero value) heuristic. You are saying that I (who may or may not be a physician, but for argument's sake let's say I am not) should not have an opinion that is different, when discussing the behavior of doctors, from the opinion expressed by a licensed and practicing physician. Valuable heuristic?

As for the article itself, my problem with is was not on the problems that reasonable heuristic can generate, but with the useless caricatures.

A doctor who does not visit any patient and simply gives aways a couple of aspirins, is criminally negligent. A doctor who does not call for an MRI for any common symptoms (think headache) that may have been caused, among many other possible causes (dehydration, stress, tension etc.), also by something much more serious (brain cancer) is using a reasonable heuristic, which sometimes may go wrong because for very aggressive cancers, a couple of weeks of delay in starting treatment or having surgery can make the difference between life and death.

A personal case. I went to a doctor with a dermatitis and the doctor recommended, guess what?, a topical steroid cream, which is recommended by dermatologist like a barber recommends a haircut. The heuristic is, dermatitis of unclear origins --> let's try a steroid cream. After I did a bit of research on my own (5 minutes, maybe less), I found out that for my conditions the steroid cream should be absolutely avoided since it makes the condition worse. The question is and I let you choose the answer: (1) was the doctor using a reasonable heuristic?; (2) was the doctor incompetent and/or an idiot; (3) was the doctor negligent (there is some overlap with (2))? Should I wait for the opinion of a "licensed and practicing Physician" or I can have my opinion?

I'm confused. You say it's a bad caricature, then provide an anecdotal example that seems to closely match the caricature.

I think OPs point is that the article ignores the reason why the heuristic is used in the first place, which is to optimize the process at scale.

The real cost of gathering additional data and knowledge about the circumstances in the 0.01% chance you know that you have at this point, at scale, means you'll end up with worse overall outcome by not being able to scale to all events that need the attention.

Now, if a doctor is just being lazy, doesn't check anything, says you'll be fine take Tylenol and then spends the next half hour reading a book until the next appointment. Or simply wants to go through twice as many patients to make more money. Ya sure, that's just being lazy and useless, and negligent, replace them by a rock at that point.

But if there are 100 people with initial symptoms, and only 1 doctor. And the deep dive to properly asses the likelihood of a 0.01% chance event in the case of symptom: "My hip hurts when I walk" takes multiple hours, a lab test, many follow ups, etc. While this happens and maybe out of the 100 patients waiting, some have symptoms like: "I'm actively bleeding out my mouth.". "I have spores on my skin." "I'm in so much pain I can't fall asleep." All with known much higher likelihood of something pretty bad and urgent.

That's why triage is so important. And this use of the heuristic at scale might make sense when considering the cost/time and available resources trade off.

At the individual level, it means eventually someone will get shafted by this, they'll be sent home with Tylenol, and 3 days later will have a stroke and it would have turned out they are the really rare case where hip pain could indicate a risk of stroke due to say a blood cloth.

But at a larger scale, many more people will have received the treatment they needed more urgently.

I agree: Null-confirming signals should not be considered evidence to discard the null hypothesis. Decision trees are OK, esp those that have "wait and see" near the root. "See if it goes away" is indeed an information-seeking behavior, and a low-cost one at that.

In other words, your doctor could have been losslessly replaced with a rock that says “apply a steroid cream”, and that heuristic would have harmed you.

If it had benefited thousands of others, does it matter in the larger view?

The naive alternative is the doctor always spending time to get to more nuanced advice, that will be more often than (every time the rock was as good) a waste of resources (time/money/opportunity cost), and which in a lot of cases would also be more harmful (iatrogenic harm) than the rock advice.

"But, why 'always'? It's enough that the doctor goes for more nuance when he sees a reason to!", you'll say.

Well, that's what doctors actually do. They are not glorified rocks, they are bimodal (rock mode vs looking deeper mode) - and they're most rock because (even if the miss a few 'loop deeper' cases) because it's way more efficient than the alternative (always or mostly non-rock, that is, digging deeper without first seeing strong indications that they should dig deeper).

Perhaps it could be more helpful to think of the caricatures as "spherical cow" models the author is using when trying to isolate and illustrate a particular social (?) dynamic.

Of course real-world models will be much more nuanced, but the really interesting bit is that you don't need all that nuance to produce the particular pathology outlined in the article. Specifically, selecting on "who is most right most of the time?" can end up causing your city to be covered in lava, missing a store break-in, or what-not.

There are even more levels to explore with this idea. For example, should you always ignore the heuristics and go for the earest, honest experts? Maybe. In the volcano example, the cost of a false negative is so high that you probably are okay with the incurred costs of false positives by the experts.

However, in the case of the Futurist, the false-positives incurred for a non-rock opinion might end up netting you less karma points or whatever. It's somewhat fun doing a re-read trying to evaluate the cost-benefit tradeoff yourself in each case!

> Are you reading the deeper lesson though?

The "deeper" (?) lesson and subtext I'm hearing from the OP is that we should get excited like little children about each and every new fad, because, you know, this may just be the 0,01% when it actually matters, and we don't want to miss it.

Well, I don't mind using "lazy heuristics" and waiting around a little to see if something happens. No need to hurry or jump around. Plenty of time.

...no the surface lesson is that lazy heuristics produce habits that provide the illusion of certainty without any rigour backing up those beliefs; the outcome may correspond with reality but the process getting you there isn't rational or dependable, because it always produces the same output regardless of input.

The "deeper lesson" if there is such a thing here is that experts are people too, and just as fallible, only in ways that are generally invisible to everyone but another expert.

Maybe we should replace you with a "THIS NEW IDEA ISN'T NUANCED ENOUGH TO REPRESENT THE WORLD" rock.

I agree with you. The value of the heuristic is in the 99.9% and the value of the person is in the 0.01%. That's why doctors are so valuable. It's for those times when someone comes back and says, "It didn't work." If we waste the doctor's time on the 99.9%, then they lose their primary function of being the expert during the unexpected. For an individual, they may seem interchangeable with a rock, but for a society, they are not. This is because while the probability of cancer per unit of human doesn't change (enough to matter for this illustration), the more people there are, the probability of cancer per unit of time does increase. 0.01% of a lot is still something.

Crucially, however, the security guard and doctor are roles that have value in their responsive nature. Then you have the part of the article where you are talking about roles that have value in their predictive nature. And for those, yeah, the author has a point.

> If we waste the doctor's time on the 99.9%, then they lose their primary function of being the expert during the unexpected.

I don't agree that this is a waste of time. The reason why we go to the doctor when we have unusual pains and aches is because we are not qualified to decide whether it's a minor annoyance or a symptom of a life-altering problem. We're seeking out an expert to help make that determination.

If two people could walk in with the same described symptoms, but one just ate something that disagreed with them, and the other has stomach cancer, then doctors must do at least a basic diagnostic exam on the spot, and not turn the patient away for days or weeks to see if the problem goes away on its own. This isn't a "waste" of time at all.

I just saw a PA a couple weeks ago about a knee injury. The end result was that she did tell me to take ibuprofen for a few weeks and then report in how it feels. But, before that, she spent a good 20 minutes asking about the history of the injury, and then felt around to see if there was anything noticeably wrong. And after that she gave me an idea of what the next steps would be if it doesn't get better on its own. The entire experience gave me confidence that she was attentive to what I had to say, knew what she was talking about, and had a plan in case things don't get better.

If she had merely listened to me for 5 minutes, and then told me to take ibuprofen for a few weeks and call back if it's not better, and that was it, I would not have felt good about that encounter, and would have gotten a second opinion from another doctor.

Of course, this also raises the question of whether or not doctors who put in that bare-minimum, insufficient amount of effort (as described in the article) actually are common. I really hope they aren't! But maybe they are, I dunno. The author is a medical professional (albeit on the mental health side), so I would expect he'd have a better idea of how common that is than I do.

The Hydroxychloroquine discussion is pretty bad as well.

We were confidently against Hydroxychloroquine because it was well tested in the RECOVERY trial in June 2020 [1].

The time to be optimistic was during the trial-phase of the test. Once that time passed, everything beyond that point was unnecessary and unhelpful hype.

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What's amazing to me, is that the RECOVERY trials showed that Dexamethasone cut the death rates in half [2]. Where did the Dexamethasone hype go? Why was the political discussion on the snake-oil Hydroxychloroquine?

Even months before we had a vaccine, doctors had discovered how to save roughly 10% of lives in the most severe category. (29.3% death rate vs. 41.4% death rate for those on ventilators). Doctors quickly started using the $20 steroid to save so many lived throughout the pandemic.

Instead of hyping the stuff that _WORKED_, the political system was hyping snake-oil like Hydroxychloroquine and Ivermectin. Why were so many people optimistic on such bullshit?

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Here is where being skeptical helps. Whenever Hydroxychloroquine or Ivermectin came up in a stupid discussion, I'd pivot the discussion towards Dexamethasone and Monoclonal antibodies. People need hope. People want hope. Before we had vaccines, people wanted to know that doctors had an idea of what to do. Dexamethasone and Monoclonal Antibodies did the job and did it properly (saving lives long before vaccines were developed). No one cared if it was "hydroxychloroquine" or "dexamethasone", these are all just giant chemical that few people memorize. People wanted hope, and it was important we kept that hope factually correct.

You can't promise the world with bullshit snake oil. When someone gets COVID19, they'll demand Ivermectin (yes, my sister is a doctor and she's seeing patients who are literally dying and demanding Ivermectin from her). Ivermectin has given these people false hope and is turning them away from the actual care that would save them.

[1]: https://www.recoverytrial.net/news/statement-from-the-chief-...

[2]https://www.nejm.org/doi/full/10.1056/nejmoa2021436

Perhaps it's the very fact that dexamethasone was useful (and therefore used) that explains why you never hear about it.

Since you mentioned the political context, it's not necessarily just "something that works" that you're looking for in a political sense, but "something that works that THEY don't want you to have." If everyone agrees on it, there's no action, no wedge.

The fact that most people are going to recover anyway is also fertile ground for snake oil, as everyone runs their own uncontrolled experiment and declares success when they survive, and most do.

I think you missed the point. The idea here is that there were people that said before any results were in that hydroxychloroquine was not gonna work, operating with a heuristic that almost always works. And in this case they were correct, which the article doesn't seem to disagree with. The point is that at some point the heuristic will fail, not that it did in the case of hydroxychloroquine.

I remember hearing hydroxychloroquine conspiracy theories well into the election of November 2020. In particular, when Trump revealed his positive diagnosis, plenty of people were talking about Hydroxychloroquine at that point.

That crap was disproved 5 months earlier, and plenty of people still didn't get the news.

...ok? Again, not the point being made by the article so not sure what point you're trying to make.

The article ignores useful treatments like Dexamethasone and monoclonal antibodies.

The correct skeptic was pro dexamethasone anti Hydroxychloroquine.

Seeing things from only an anti-htdroxychloroquine perspective is 100% misleading. There were working drugs that saved many lives during the stupid Hydroxychloroquine hype.

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What timeframe are we talking about here? What else was known and tested? There is a political group who kept pushing HCQ for months, and then mislead the public again with Ivermectin a few months later.

Ivermectin was entirely a 2021 phenomenon as well. Not only did we know that Dexamethasone + Monoclonal antibodies worked, we also had 3 competing vaccines and the "Pfizer anti-viral pill". Why the hell were people talking about the snake-oil Ivermectin?

The article gives fluvoxamine as an example of a useful treatment that the heuristic-following skeptic would have been wrong to criticize:

"(shame about the time she condemned fluvoxamine equally viciously, though)"

But we weren't "heuristic following skeptics" with regard to the pandemic.

The RECOVERY trial basically tried everything that had a chance of working. Hydroxychloroquine was part of the tests and did very poorly.

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After the RECOVERY trial in June 2020, it was no longer about "what worked", the question was "what works better?". By the time Ivermectin became a discussion point in 2021, it wasn't good enough to just "work", you had to prove that it was at least as good as Dexamethasone + Monoclonal antibodies.

Its not about being a "heuristic following skeptic". Its about knowledge of treatments that do work and the tests they underwent to prove their efficacy.

The correct answer for Ivermectin was "Hey, we have this test with Dexamethasone + Monoclonal antibodies that showed efficacy over 3000 people. Where is the evidence for Ivermectin?"

Oh, you don't have evidence yet? How about we wait until you have evidence before you claim that IVM is more useful than the current Dexamethasone + Monoclonal antibodies cocktail?

But it's a strawman because sceptical people were in confused "wait for the science" mode not "it is impossible" mode.

But it's worth pointing out that (i) the medical profession, who are the appropriate people to be evaluating HCQ, didn't rely on their heuristic but did the test and (ii) if you as a layman abandon the heuristic that you shouldn't be receptive to the advice of conspiracy theorists and alternative therapists protesting the medical profession because they might be right about something, following that advice isn't largely cost-free unlike the other examples Scott Alexander set up, and is in fact more likely to harm you than the heuristic

"Extraordinary claims without evidence or rationale are bogus" as a heuristic seems pretty good to me?

When presented with a problem and infinite solutions, you need to start narrowing down which paths to investigate somehow. Come back with evidence and the conversation goes further.

You have a very weird idea of what security guards do. They don't sit in front of the entrance all night, scaring off would-be robbers. They are inside the building, in their booth, probably looking over some monitors. They do not provide a deterrent, they just call the cops if something does happen. Robbers have no clue if they are there or not. The heuristic works fine.

There are plenty of places with visible security guards.

Well, robbers might in fact know if a particular place has security guards, and they would definitely notice once society replaced them all with rocks.

If they replaced them with rocks its probably not worth robbing the place. I mean, it says so on the rock?

I have a very clear idea of what security guards do and I don't know where you got that I believe they "sit in front of the entrance all night" (which they do very often in South America, by the way, among other locations).

Any "reasonable robber", which means maybe not your early teen looking for some adrenaline or the out-of-their-mind tweakers, knows or checks whether there are any security guards in a building in which they intend to make a robbery.

You may attract lot more robbers if anyone can easily know there is no security guard but just a stone.

Where I come from, companies don't waste real estate with monitor rooms for security guards. Instead the monitoring is outsourced, and the security guard has a fixed position and a set number of patrols they need to do.

I agree with your take on the doctor heuristic. But there is also the worry that the patient won't call back for longer than they should, and the underlying disease could have a chance to get a lot worse in that time. If a doctor really isn't doing any basic diagnostic work, and is just telling people "take some aspirin, and call back if it doesn't go away after X days", that is still IMO negligent. If I have cancer, I don't want to wait 2 weeks or a month longer than necessary to start treatment. That could be the difference between life and death.

On the security guard, you're right, but I think it's still interesting to think about. If the security guard really does just assume any noise heard is not robbers, then they are effectively not doing anything. Their deterrence value is non-zero, agreed, but maybe it's cheaper and more productive to install motion-activated security cameras at ingress points, and big honkin' signs at the perimeter that say "Security monitoring in effect 24/7". Yes, you have to pay for the monitoring, but that's probably cheaper than paying for a butt-in-seat. And safer, too! Most security guards at most places probably aren't trained for much beyond the basics. I think it's more likely than not that someone will get hurt if robbers do show up and a security guard gets involved. I would much rather some stuff get stolen than people get hurt. (Certainly there are some things that are critical enough that require a well-trained security force. I just think these things are less common than most people would think.)

> Un-nuanced and quite sloppy presentation of heuristics.

I think the lack of nuance is in part the point. We should be examining places in our lives where we go by our gut feeling, or by the common case, when we probably should actually be doing research, diagnosis, or testing. Even if the results aren't as dire as some of the non-nuanced takes, they're still bad enough to warrant some thought.

At least in the case of the doctor, the numbers are also way off. A typical doctor sees thousands, if not tens of thousands of patients in their career. This would certainly translate to _way_ more than two or three misdiagnosed cancers.

Definitely. I suppose it's like an on-call engineer with a dodgy metric that "cries wolf" very regularly. There are hundreds of deadly conditions that have "flu-like symptoms", cancers that manifest in a myriad different ways (from anemia to blurred vision), and other serious conditions that start out as plain old lethargy or listlessness and get diagnosed as depression. I have encountered a complacent doctor who misdiagnosed my sister's cancer as "pain" (??) prescribing pain killers for weeks while the cancer spread and additional symptoms appeared. [Edit: I misremembered as months not weeks, but it was about 6 weeks]. (She died). My father is 95 years old, and had extremely low blood pressure for months, making him constantly sleepy. My mother accidentally made the discovery after she bought a blood pressure monitor for my sister (who has high blood pressure). They took him off the medication, and he's back outside chopping small pieces of firewood and taking short walks. As far as the doctor was concerned he was tired because he was old, and his body was "winding down like an old clock". Too lazy to take his fucking blood pressure. Doctors get extremely complacent, burnt-out, depressed etc. They frequently miss the 1:1000 time that the symptoms are something serious, so I literally never trust a doctor to make a diagnosis without carrying out actual tests. If I'm ever ill enough to need one, I'll have done my own research before visiting one. I don't care if it pisses them off.

It wouldn't change much if the rock said "IT'S NOTHING, TAKE TWO ASPIRIN AND WAIT FOR IT TO GO AWAY AND CALL THIS NUMBER IF IT DOES NOT"

So where can I found the trial for rock-based medical care?

I know of a doctor who gave a seminar at our workplace.

His case was. The cure for most non serious illness, is mostly to wait. Not even medication.

This is why most people think homeopathy works.

>I read them as sloppy caricatures that provide little value to the conversation.

That about sums up the whole movement AstralCodex is part of.

Exactly this.

Null-confirming signals should not be considered evidence to discard the null hypothesis. Decision trees are OK, esp those that have "wait and see" near the root.

These derogatory calls to action and flame-posts against arbitrary "experts" are just tiring. Bring the evidence.

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