More Dakka in Medicine (2019) | Hacker News Reader

More Dakka in Medicine (2019)

qualiacomputing.com

54 pointsapsec11228 comments

The point of this blog post was totally lost on me. I can’t even say it is a critique of the practice of medicine - or maybe therapeutic development (?) - because literally every example given by the author is a solution rather than a problem.

Also the author clearly does not know what they are talking about. For example, them calling for the use of surrogate endpoints - they clearly did not know the term of the art - when a whole regulatory framework around this concept has already been developed, formalized, and implemented!

To me the piece has a mix of smugness, hubris, and gross ignorance that would make for truly masterful work trolling if I did not believe the author were sincere.

It’s just an observation that “if violence didn’t solve the problem, you weren’t using enough” is sometimes true with other things substituted for “violence”.

I think that’s a useful thought.

Sure. Unfortunately people already thought of this long ago.

Drugs often have more than one active pharmaceutical ingredient in them. For example, rybelsis vs mounjaro. The average senior citizen is taking four medications.

Pase 1 trials test doses of therapeutics far above what ends up on the market. In general there is a trade off between safety and effectiveness. Note that safety is evaluated in the context of the underlying condition. So worse side effects are tolerable for treating something cancer or HIV, than for treating something like a common cold,

The drug in the example given by the author, Alopurinol, is very hepatotoxic so cranking up the dosage is not something you can do without risk of killing someone. Or you could just use rasburicase - recombinant urate-oxidase - instead.

"So “single antibiotics don’t work for chronic Lyme but cocktails do and this wasn’t realized for decades” isn’t an unprecedented story. It could turn out that way."

...this leaves me extremely skeptical of the author's argument for this.

Also, properly, multi-drug therapy for HIV is less "More Dakka" in the way of some other examples, and more "Different Dakka". Massive doses of any given antiretroviral don't solve your problem.

"This didn't work, have we tried more of a drug, or just more drugs" are two different treatment approaches.

The TvTrope jargon here is (for those wondering):

    "The theory goes like this: You pull the trigger on a machine gun until the whole world turns into blood, and it is awesome. You can't argue with that; that's science."

    More Dakka is the art of solving problems by unloading as many rounds of ammunition at them as possible.

https://tvtropes.org/pmwiki/pmwiki.php/Main/MoreDakka

The LW version of the phrase is the idea that oftentimes a seeming solution fails because it hasn't been tried hard enough; by doing it even harder it becomes effective.

I've usually heard it as "If it helps but doesn't entirely solve the problem, try doing more of it." rather than trying more even if it doesn't seem to be doing anything. (See this Zvi post: https://thezvi.wordpress.com/2017/12/02/more-dakka/ )

And also the origin is from Warhammer 40k

"The Trope Namer is Warhammer 40,000, where it is the Ork onomatopoeia for machine gun firing, and their general term for rapid fire capacity: "dakka-dakka-dakka-dakka...""

Also the concept of needing "more dakka" imply that at some point a state where there is "enough dakka" is attained.

Of course the possibility of reaching such theoretical state is still largely debated.[1]

[1] https://www.youtube.com/watch?v=iAI6uft4GPo

There is also the opposite effect, where a beneficial substance becomes harmful above a certain threshold (hormesis):

https://en.wikipedia.org/wiki/Hormesis

For example, a very small amount (0.5-1 mg) of melatonin helps you sleep, but a large amount can keep you up.

Probably not what the author had in mind, but there's a funny thing where sometimes having bigger and bigger problems (or physical pain) makes the previous problems go away. At least temporarily.

A little bit of necrosis is bad, but if its everywhere, all your problems magically go away! (/s)

The medical profession starts from "First, do no harm." for reasons learned quite painfully over time.

This is directly in opposition to "More Dakka" for good reason.

Claiming chemotherapy as a success directly undermines almost all the other arguments. Chemotherapy is an unmitigated disaster--it's just the only thing we have most of the time.

Chemotherapy is going to be one of the things that future doctors study and laugh at and will be calling our era the "Dark Ages" of medicine.

The first thought I had upon reading this is: How do we make sure we don't have another thalidomide diasaster?

With chemotherapy, unlike thalidomide which was used for morning sickness, you're trying to cure someone who is already in a default dead situation.A higher tolerance for risk in a default dead situation is natural.

> The medical profession starts from "First, do no harm." for reasons learned quite painfully over time.

I started the 2023 New Year, for 5 consecutive years now, by vowing to use my gym membership.

https://www.hopkinsmedicine.org/news/media/releases/study_su...

> This is directly in opposition to "More Dakka" for good reason.

Does "more Dakka" not get any magic allowance during evaluation as well? That hardly seems fair.

I'm training to become a nutritionist and I've worked with an elderly woman(83 years old) for about 8 weeks. I don't have a background in medicine, but I've suffered ptst and depression my whole life and reddit and hackernews has always helped me to make small improvements.

symptoms: water in the knee, weak legs and arms, week skin with red spots, ptsd/depression, takes calcium and vitamin D for the arthritis. Also has polyneuropathy in the feet and takes something for that - imo it's sugar related. She doesn't get treated for diabetes.

She'd show up every day at the bakery and eat bread and cake, drink multiple cups of coffee with 3-4 cubes of sugar

Things I recommended: - Protein shake for breakfast: Most elderly don't meet their daily protein needs (about 1.6g/Kg of body weight), to help the weakness

- cut out sugar and white meal, to see if it helps with the inflamed knee and the polyneuropathy

- eat pork-belly every day, to balance the calories, also to use the vitamin D u need cholesterol and magnesium

- take gelatine, to help with joints and to give the calcium something to hold onto

- magnesium citrate, to help with the cholesterol and the vitamin D

- I also recommended she'd start yoga for mobility in the legs - but she pushes back on it. - I'd talk to her every day for 2-3 hours to help her understand her ptsd better, I'm not certified, but I suffer from my own ptsd and I've had therapy and I read a lot, so I told her what I knew and also advised her to seek professional help, which she also refuses.

2 weeks in her mobility and mood has improved

6 weeks in her mood has stabilized, and she can walk better

8 weeks in, the knee swelling has gone back, the skin has stronger texture now.

hope it helps someone out there

edit: formating

Less sugar is probably good but why not do some testing for it instead of guessing?

she already has 3 doctors who could have done all these things, I don't even know what to test for, I just know my own experience.

Over the years I've been tested for a few things they've always come back negative though.

>magnesium citrate

Won't taking this mean she'll need to supplement calcium considerably?

she already is for bone density and joint pain, but hasn't done much for the pain until she added gelatine

The concept and framing and exact joke has been done in the past with the same examples

https://www.lesswrong.com/posts/z8usYeKX7dtTWsEnk/more-dakka

That article (on the thezvi blog) is hyperlinked in the first sentence. I guess this post is meant to be a summary with some extra thoughts.

The rationalist community has a really irritating offhand way of using hyperlinks where for aesthetic reasons they don't structure the sentence around the hyperlink, but they also give no indication whether following a link is required to understand the text or it's just an offhand joke.

After steelmanning this article, I think the message is to try to use multiple therapies at the same time? Or that biological responses are not always dose dependent? Certainly, medicine is biased towards single diagnoses and prefer mono-therapies to combinations, but shotgun approaches frequently lead to overtreatment. Also, patients frequently complain of side effects, or are averse to medications, therefore dakka is not a good approach. Maybe in lab rats.

I'd argue that the steelman position might be: "Understand the treatment dynamics". Treating a linear-response in the vitamin deficiency case with a binary threshold, and treating the bifurcation point in exponential battles (infection, cancer) as linear are the same class of error (just in opposite directions).

Still as another response noted, almost all of the examples are success stories of medical science, so I don't know if there is a wider point of "medical science/practice is slow to notice these nuances" or if it is just a collection of cool examples of "hey: sometimes doing a single treatment MOAR/multiple treatments simultaneously has a counter-intuative result, isn't that neat."

>Light therapy barely works for SAD; two internet-famous people have independently found that REALLY BRIGHT light therapy completely fixes SAD.

I wonder when anyone is going to invent anti-SAD contact lenses with built-in LEDs that shine a small amount of extra light into the eye just to keep it healthy. Or better yet just collect and amplify extra light from the ambient environment.

Is it just the eye? I was under the impression it was mostly tied to lack of skin exposure.

a shirt then, which has way lower tech methods of testing

I love this. I wish we got more of this kind of thinking in medicine.

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