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Fifty-One.

18 April 2014

Yesterday evening I stepped on a scale and it said 183.5 pounds. I haven’t specifically been trying to lose weight, exactly. I’ve been trying for about 6.5 years now to be a healthier human. I quit drinking. 18 months later I quit smoking. 18 months later I started running. And about 2 years after that, after I moved, I sold my car entirely and now I walk everywhere in addition to running. Though that means that my running has dropped off a bit, because when I walk 15-25 miles a week, my motivation to run 10-20 more is limited. And I have restructured my diet to diminish (but not eliminate) sweets, and to revolve around whole foods that are minimally processed. This means a lot of peanut butter and jam sandwiches on whole grain bread with skim milk.

183.5 pounds is a drop of 51.5 from what I believe is my peak weight of 235. I remember seeing 235 on a scale. I may have been a few pounds heavier at some point, but 235 is what hits my ear as correct for my peak weight. If I had not taken this path, I would certainly be diabetic at this point. I might be anyway, though my blood numbers are good. My doc says, “Definitely insulin resistant.” But it’s in control with diet and exercise. My last A1c was 5.4 and I’m happy with that. Anyone with metabolic risk factors should be. And I have them.

But I also don’t want to go patting myself on the back too much. At 183.5, my BMI is still 26.7 (Quick! How tall am I?). I need to get down to 171 to be “normal” weight. Even at the high end. I don’t know if I will. I don’t know if that’s even a goal. My goal is to be healthy, feel healthy, and look good naked. I don’t feel like I’m at that last one yet. I know BMI is a rough guide and doesn’t work for everyone, but for me it feels really accurate and it tracks my blood numbers well. When I’m below 27, I’m objectively healthier.

Having spent so much of my supposed wild and care-free youth essentially in the grips of a terminal illness, I cannot begin to explain quite how remission from that feels. It feels wonderful, and it feels like work. I’m proud, but I’m grateful. I worked for this. But I didn’t earn it, exactly. I feel like I am a confluence of effort and serendipity and immense, immense thanksgiving. There are a lot of challenges and problems and difficulties and bullshit in the world. I’ve had my share, and I’ve been granted incredible opportunities and privileges as well.

Tomorrow, I intend to put on a pair of light, bouncy shoes and then run in them for two hours without stopping. It’ll be a hell of a thing if I succeed. And if I fail, well, I’ll try again another day. One day after one day and then another. Here I am.

The Easier, Softer Way.

17 April 2014

I have found that the only path to freedom from addiction is in embracing it. That’s not to nullify others’ experiences, everyone is welcome to their own. But my experience, and that of many others that I know who have recovered by taking the same path I have, is that the only true release from alcoholism is to acknowledge and accept that I am an alcoholic. That I will never be cured. That I cannot fight it. That the only relief is through total abstinence. And that alone, I have no hope of recovery. Alcohol is bigger than I am, and more powerful. And finally, that alcohol itself is really only a symptom of my problem. As long as I focus on alcohol as the source of my miseries, I am neglecting my recovery.

In the third chapter of the book “Alcoholics Anonymous”, there is a discussion of how we approached treating our alcoholism prior to recovery. It talks about how we may have tried switching beer for wine or liquor. Tried to drink only at home, or only at bars, etc.. All the things we tried to do to manage our drinking and assert power over alcohol. And then, in the fifth chapter, it names this behavior: we tried to find an easier, softer way. We seek to find the way to live in the world and still do what we want. But it doesn’t work. Because what we want, usually, is to emotionally isolate ourselves and drink to insensibility. From there, we become hazards.

And so, when finally ready, many of us are willing to abandon the easier, softer ways that don’t work for us and embark upon the steps. And when we do that earnestly and thoroughly, most of us recover, we’ve found. I have.

This is a long-winded way to coming round to homeopathy, and similar “miracle cures”. I was reading the Science Based Medicine blog, exposing more quackery and pseudoscience in health care today. (And I’m sure they have serious problems with AA, because it isn’t an “evidence-based treatment*” according to their narrow definitions of evidence. But where we know how to measure, we ought to be applying evidence.) I think people are always looking for the easier, softer way. It’s not unique to alcoholics.

Wouldn’t it be lovely if Vitamin C cured cancer? This person who puts letters after their name says it does. Give it a try! Wouldn’t it be great if water that once had a little bit of sulfur in it cured allergies? This person wearing a lab coat says it does. Give it a try. And because of placebo effects, people are likely to feel better, at least transiently, and believe it works. But these methods not only have no evidence, there’s powerful evidence against them. They are proven to fail.

And yet we consume them. Because medicine is expensive, and may have side-effects. And treating disease with the things that work best is often invasive and unpleasant. And even then, we often die. Inevitably we die. It would be fantastic if an eyedropper of water negated the need to have a colonoscopy. But there’s no easier, softer way. There’s just sedation and a camera that goes up your butt in a room full of strangers.

Science is hard. Medicine is hard. Human health and wellness is bafflingly complex and subject to peculiar vagaries we are – in many ways – just beginning to understand. My health starts with not drinking. But it doesn’t end there. Because my sobriety, my quality of life, requires that I also examine how I live. My relationship with the truth. My willingness to accept things I don’t enjoy and don’t like. My understanding of my alcoholism and how my mind will occasionally turn against me. How my emotions can be brittle and quixotic.

I know that not everyone looks for shortcuts. Some people are invested, seemingly from birth, in doing things the right way. Indeed, some people make things deliberately difficult for themselves. I find myself searching for easier, softer ways. But I have to recognize that that’s a character flaw. Doing things cheaply means doing them badly, for the most part. And when it comes to medicine, and ethics, and science, there are no shortcuts. There are no miracles. There’s only taking the right road. One step at a time.

I don’t believe my recovery from alcoholism is a miracle. I believe it happened because I somehow found the willingness to recognize my disease and work a program, buoyed by others as part of a community and network of people in recovery, that allowed me to abandon fighting alcohol and surrender to it. I stopped fighting, so the war ended. But why that happened, why I was able to find recovery and others – better souls than mine – don’t? That still falls into a realm of ignorance. We don’t know. We may never know. But I know this: there’s no easy, soft way out of hell and up into the light.

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*And as soon as anyone learns how to meaningfully measure sobriety, I’ll be happy to review, consider, and comment upon evidence-based treatments for addiction. Until then, people who criticize AA for lack of evidence should come to open meetings and see all the changed lives.

Drinking My Education.

15 April 2014

Yesterday I wrote about not being good enough to be a professor of systems engineering. But if you’ve read this blog long at all, you know that I’ve wondered if, in different circumstances, I might have been. I don’t know. I’ll never know. I find myself, often, tempted to blame woes in life on my alcoholism. The thinking goes, “If only I weren’t an alcoholic, I’d have…” and then whatever is currently bothering me fills in the ellipsis and is magically solved in the fantasy world where I didn’t spend a decade-plus drunk.

This is seductive thinking. At least, it is for me, and I know it is for many alcoholics. I want to blame any troubles I have on anything but myself. This is a mechanism by which my alcoholism attempts to reclaim me. If I cannot influence my life for the better, if the difficulties I have are the fault of some unconquerable malady, then I get to despair. Despair is wonderful. Despair is someone else’s fault. I’m not responsible. This was done to me, not by me. So it doesn’t matter what I do anyway. It’s hopeless. Let’s drink.

Now, let’s be clear. It is neither my fault nor anyone else’s that I am afflicted with the disease of alcoholism. That’s just a thing that happened by accident of my birth and genes and brain. Seems to happen to a fairly large number of people. There’s no point lamenting it any more than lamenting that I was born with a predisposition toward type II diabetes. It’s my life. We’re all born with good things and bad things, and on the whole, I came into this world spectacularly high up on the privilege scale.

Even drinking or not drinking is not in my own power. When I decide how to live my own life, I make bad choices with respect to alcohol. However, when I am part of a strong social network of people who suffer from the same malady as I do, and have found away to address it and live sober, I am capable of following that path, that program, and living a sober, useful life. I have gained so much through this process. Through descending into alcoholic misery and then being lifted back out of it.

But I also cannot help but wonder what I might have lost. If I hadn’t spent the years from 21 to 33 drinking as much as I could – wholly encompassing graduate school – would I have been able to do the math? Would I have ended up on a different road that might’ve included a professorship in systems engineering? What life would I be living today? but through long and – hopefully – honest self-appraisal, I think I know the answer.

A worse life. I was always pretty darned smart, but I was never very diligent. Because school was easy, I didn’t work very hard at it. I had a B+ average in high school, and a B+ average in college. I went on to have a B+/A- average in graduate school, which is kind of disgraceful. I was allowed to skate through on privilege and potential. And I think my grades would have been almost exactly the same if I had never picked up a drink. Because I got B+’s before I drank, and B+’s after I drank. The fact of the matter is, I am a B+ person. I am willing to work that hard and not much harder.

My alcoholism has taught me to take responsibility for my behavior. I may not be able to control my drinking without help, but it is unequivocally my own responsibility, and no-one else’s, to get the help I need to keep sober. It’s my life. It’s my disease. It’s my charge. I am the one responsible for my life. As much as it is appealing to offload the responsibility for my alcoholism to doctors or parents or circumstances, it’s mine. It simply is. I am the one who has to face the truth of it, recognize my powerlessness, and do the things required to remain in recovery.

My alcoholism taught me to look at myself, give up my need to control all of my life, and other people’s lives. To examine how I contribute to my own problems. To focus inward for the solutions to my discontent, instead of expecting other people to solve my difficult feelings for me. To focus outward for my efforts and interactions, to make my life about being useful to others and contributing instead of expecting the world to cater to me.

But I wish I hadn’t drunk my education. I don’t remember the elegant math I learned. I couldn’t shift gears from my current work in healthcare simulation and go to putting rovers on Mars (or similarly math-intensive engineering work). Not anymore. Probably not ever. I just didn’t retain faculty with nearly as much of my training as I could have or should have. I was capable of it. Never of the truly theoretical work, but I was good enough to solve problems like that.

But I like working in healthcare. I think I’d be working in healthcare engineering no matter if I’d been an alcoholic or not. I simply suffer from grass-is-greener disease sometimes. The truth of my life is, I probably have a better life than I would have if I hadn’t been an alcoholic. I’m almost certainly happier than I would be as a professor even if I had been able to take that path. I don’t work as hard as most professors. And I don’t like to work that hard. My chosen profession uses the training I remember how to do, and compensates me more than adequately.

I’m an alcoholic. Being an alcoholic has taught me to live. Not just sober, but free. There are living oceans of experience I will never grasp. But I can cup a bowl of water in my hands, and marvel.

Not Good Enough.

14 April 2014

Ed Yong is one of the English language’s better science writers. He often weighs in on issues facing academia, in addition to reporting science. One of the biggest issues facing academia right now is the pipeline problem: too many PhDs are graduating compared with the number of professorships that will ever be available for them. This has led to the creation of intermediate steps like “post-doctoral scholar”, and in some places “instructor” or “assistant researcher”, which each have their own bars to hurdle, and their own attrition mechanisms. At each level some people leave. Too often, those who leave are considered, and called, failures by those who advance. Especially those who advanced long ago, before the pipeline narrowed as much as it does today.

This has resulted in people being considered “junior” investigators for nearly half their careers, usually. Because universities and funding agencies are so risk-averse, they expect scientists to be mentored and coached and coddled until “young” can be used only in jest. Or sarcastically. In many ways, it’s degrading and infantilizing to tell a scholar, trained for decades and published many times over, that they must still be buttressed against failure by crouching obsequiously beneath the umbrella of a grey-haired magister. Failure is incredibly useful. A topic for another day.

But on the other side of it, perverse incentives lead to the graduation of so many PhDs. Grant money is scarce. It’s much less expensive to pay a graduate student or a postdoc to do lab work than it is to hire full-time accomplished technicians or full-time researchers to collaborate. So more and more cheap labor is hired. More PhDs are trained. And the wide end of the pipe gets wider. Meanwhile, universities continue to divest themselves of tenure-track and equivalent positions. The narrow end gets narrower. I’ve read (but don’t recall the source – treat as speculative) that fewer than 10% of graduating PhDs can expect to end up in tenure-track positions. There are massive structural reasons that people cannot and do not advance.

And people write about it. Many people, when they leave, describe these structural reasons. Or family reasons. Or any number of reasons that they don’t advance. But something it seems we rarely read is, some people surely must not advance because they just aren’t good enough. Ed Yong put it this way:

Well, I haven’t exactly left academia. But I trained to be a professor of systems engineering. I have a Doctor of Science in Electrical and Systems Engineering from one of those fancy, elite universities. I had good connections and a prominent advisor. But I am not, and I will never be, a professor of systems engineering. And the reason is, I’m not good enough.

Studying systems engineering at the graduate level means doing a lot of theoretical mathematics. I spent five years doing proofs. Mostly, systems engineering revolves around being able to model and control how large numbers of objects interact with one another in complicated ways with respect to time. Usually, this means doing vast systems of nonlinear, time-varying, partial differential equations. Now, a lot is known about this field. In fact, it is provable that most such systems cannot be solved with what we call “closed form solutions”. Meaning, it is impossible to simply solve the equations and use them to calculate how the future state of a system will unfold. We have to manipulate. Approximate. Linearize.

I took an entire class on control systems on free-floating locally-Euclidean manifolds. So, imagine being on the surface of a doughnut, and you want to negotiate a spiral and end up where you started. That kind of thing. Your point-mass vehicle weighs X and has control functions Y and Z. You want to get from A to B in minimum time. What do your controls need to be and for how long? How do you stitch together locally-Euclidean reference frames that allow you to numerically solve the equations of motion for the brief period you’re located in each one? Before the non-linear effects overwhelm the linear approximations. This is the kind of work that put Curiosity on Mars. I got a B+ in that class.

I got a lot of B+’s in graduate school. B+’s are just a step above failing in graduate school. I even got a C in my class on Linear Dynamic Systems. Once we added in stochastic noise that needed to be filtered out, I got very confused. I needed to take the class a second time to understand it. The second time I got an A. And I deserved it. I worked hard for it.

Now, a real theoretical mathematician will read the above things and say, “that’s not theoretical math”! And they’d be right. It’s not. It’s applied math. Very, very difficult applied math. And I could do it. At least, I could follow along while the professor did the math on the chalkboard. Remember chalkboards? God I miss them. I could do that math well enough to understand the proofs and do most of my homework. But doing that applied math isn’t the real job of a professor of systems engineering. Sure, they do a lot of it, and solve problems and consult for NASA and other such organizations who need people who are really good at applied math.

The real job of a professor of systems engineering is to invent new math. That lets us solve new engineering problems. Or solve problems that we can’t currently solve because they’re too big, or too non-linear, or happen too quickly. A professor of systems engineering, a good one, isn’t so much dedicated to solving problems. They’re dedicated to building tools. That allow us to dream new problems to solve. A professor of systems engineering is a theoretical mathematician.

I am not. I’m not good enough. And I learned that pretty rapidly. Today, I use fairly simple math, and reasonably cool computer science, to solve huge, interesting, and relevant problems. I am a practicing engineer, not a theoretical engineer. I publish. I teach sometimes. I am an adjunct professor in a department of emergency medicine. I am a principal investigator at a hospital. But I’m not really an academic. I’m not a full-time professor. I’m not a full-time researcher. Mostly, I solve the problems my hospital asks me to solve. I’m good at it. And I’m happy at it.

I didn’t fail at academia. And the academy didn’t fail me. I’m a success story. While training to be a professor, I discovered I wasn’t very good at doing the things a professor in my field is expected to do. So, like the engineer I am, I built something. I built a career that didn’t exist when I started: a professional simulator of health care systems. I can’t do the theoretical math of a systems engineer. I can’t do the theoretical computer science of computer scientist. But I can use these tools to solve problems in healthcare delivery that no one has looked at in this way before. And that’s of interest to both the practical world, and to the academy. Just, not the same academy as the one I trained in.

To call what I did a failure, either of me, or of the system, is absurd! I’m doing interesting work, publishing it. I’m employed and my employer is happy with my work. But it is completely fair to say that I am not a professor of systems engineering because I am simply not very good at it. I confess.

Unpaid Work in Academia.

9 April 2014

I currently have two interns. They’re undergraduates, and they’re getting ready to move on. I only have money to pay them through April. They knew that going in. Actually, going in, they thought it was only until last December, but I scrounged up a little extra dough. Right now we have a draft of the manuscript. I’m intending on submitting it as soon as we can, with them as co-first authors (a conversation for another day!). Will it be done by the end of April? I don’t know. Probably not. We need to really tighten it up a great deal, and then get edits from collaborators, and then send it off to this enormously famous dude whose clinic we modeled for his comments. That’s a courtesy, but it could have big dividends.

If we can’t submit it by the end of April, what expectations am I, as a PI, allowed to have from these interns? They did a lot of the work. The data collection. The simulation code. The data interpretation. I will certainly need to understand and examine these things to respond to review. Am I entitled to their labor in responding to review, or conducting new experiments, or revising the manuscript after they’ve moved on and I can no longer pay them?

Absolutely not. I have no right to expect them to work for free. Trainees in academia often continue to work long hours for former PIs to get out old papers. And if both parties treat that collegially and believe they have benefits to gain, then that’s wonderful. One of my interns has said she wants to continue the work if she can. One is going off to medical school. I’ll never hear from her again. And that’s fine. I am not entitled to her labor.

That’s the risk a PI takes when they bring on trainees: that they will move on with unfinished work. They have that right. And holding a recommendation hostage, or demanding they produce for free after everyone has agreed they’ve graduated, or after they’ve taken another position is exploitative. And this bizarre arrangement exists only in academia. In any other industry, whenever a person leaves a post, they leave unfinished work, and the people who remain suck it up and move on with their lives and jobs.

“But!”, academics argue, “This work is so important, and we invest so much! It must be completed and published! For the PI, and for the world!” Then pay for it. If you need additional work from a trainee after they leave, set aside some of your budget and pay them hourly as a contractor. I might be able to arrange for my undergraduate to receive credit towards her degree for continuing to work on this manuscript. But there needs to be a tangible, measurable benefit. The unquantifiable “value” of being an author on a paper isn’t enough.

Academia is an exploitation machine. Grad students, postdocs, undergrads, adjunct professors. All are asked to work for far too little, or for nothing, or for nebulous, vague rewards. And PIs who pressure ex-trainees to continue working, without pay, on projects after they’ve left are participating in the exploitation engine. The risk of taking on temporary workers and trainees is that they don’t finish. That’s the PI’s risk, from the outset. Own it. We can’t demand free labor.

Speaking.

9 April 2014

I know that most of my readers read me for the writing on alcoholism, not on science or medicine, or meta-science and meta-medicine. I have a meta-science post brewing about the treatment of trainees after they have graduated/moved on, but this post isn’t about that. In fact, this is barely a post at all. As I wrote a few days ago, I was asked to speak last night at an AA meeting. I recorded my talk (but not, of course, anything anyone else said). It’s here. It’s just my story, told ramblingly and with many bits left out. I get emotional a couple of times, but I won’t apologize for it. It’s 22 and a half minutes. I hope you enjoy it.

Round on Systems.

8 April 2014

Behold! Two posts on health care delivery in a row! This morning I was meeting with the leadership of our cardiac surgery center for a project I’m working on. We’re upending the schedules of our surgeons and cardiologists in order to improve our service thresholds, and it looks like there’s going to be a lot of positive impact. I’m excited. That’s what gets me out of bed in the morning as a health care engineer: personal glo… I mean making a difference in the lives of our patients.

While having that discussion, we were also discussing the next phase of our analysis, which will likely be to examine the effects of different types of discharge strategies. Every hospital in the world, I’d wager, struggles with discharge processes. There are a lot of things that have to happen, in a particular order, at particular times. All while ensuring that the patient is well cared-for and doesn’t have status changes during the process. It’s complicated. It can seem like, the night before when discussing which patients should be ready to leave the next day, the actual discharges are totally unrelated to the predicted discharges.

And I had a simple idea, that our leadership liked: round on systems. Just like MDs round on patients, we need to round on the systems. For each of those predicted discharges, the next day, when patients either have or have not been discharged, we should review how the discharge process went: why were they, why weren’t they, which ones went smoothly, which ones didn’t? Who was discharged early in the day, who was discharged late? Don’t just take the data and look for predictors and covariates of discharge. Talk about the systems.

We recently had a briefing in which we discussed how US Navy aircraft carriers operate. They’re about the most complex system in the world: a warship, an airport, a hospital, a nuclear reactor, and a massive living and feeding quarters. They’re operated almost entirely by very young sailors. And they have a stellar safety record, considering they are towing around enough dangerous material to vaporize the Eastern Seaboard. How do they do it? They round on systems. Every carrier landing is given a post-mortem discussion by the pilot, other pilots, and air traffic controllers, flight crew. They talk about what went right, what went wrong. Every person understands the system, and their role in it.

There is no reason that health care delivery can’t do this. We should embed systems thinking into the process of patient care, either by training some of the MDs and RNs in it, or by including systems personnel in the rounding. Talk about the systems. Learn from experience what went right and what went wrong. Share the insights. Every patient admission, discharge, and bed move should be discussed as part of the rounding process. Why did it work, what could have been done better? Until you can land a fighter jet on the ICU. Or some metaphor that makes sense.

We can do better with delivery systems. We have to. Because bad systems engineering (or even worse, no systems engineering) is inimical to the mission of hospitals, providers, and the human endeavor of medicine generally.

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