Mixed Results.
As I’ve written many times, my main fitness goal is to avoid diabetes. I went to my new physician here in ECC, and had my blood numbers run. They just came back. The good news? My cholesterol was the best it’s been in years. Total 189, and a 122/55 LDL/HDL split. The bad news? My A1c, a number which measures blood sugar levels over about a three month average, was 6.0. That’s at the absolute top of the normal range, trending towards not good (higher is worse). Though my fasting glucose was 79, which is also the best it’s been in years.
Now, over the past three months I’ve been running less, and eating more sugar. I’ve put on about 5-10 lbs from my low weight. In short, I’ve been lazy. Part of me wonders if I let the really good numbers from the spring influence me: “I’m doing great, I can slack off!” Well, nope. Time to rededicate. Get back on my horse and run. Drop the weight. Lift some weights. Quit eating the little bag of potato chips at lunch (that’s 1000 cal/wk I don’t need).
So. Time to work.
Mentoring Questions.
There’s been a decent amount of discussion in the science blogscape recently about mentorship. See Tenure She Wrote, and Michael Tomasson. Now, as I’m not a traditional academic, I don’t have formal mentoring relationships. However, I have always worked to maintain opportunities for mentored internships, and I’ve published about how I believe they should be structured, specifically for undergraduate engineers in hospital environments.
And now that I’ve started work on my grant, I have two young engineers working for me on my big, exciting project. Two young women, one from Very Fancy University (VFU) and one from University of High Regard (UHR). One a senior, the other a fourth-year-of-five dual degree student. They’re both very competant and driven.
I just want to make this a kind of an open thread, and hopefully some of my scientist friends will engage. I’ll be with the students for about 3 months. What’s the one best best thing I should do to be a good mentor? How can I maximize my usefulness, beyond teaching them something of value academically, and providing them with exposure to real-world engineering in healthcare?
How can I be the best mentor I can be?
Jokes that Reveal Truths.
When I was first getting sober out in Malibu (because I’m fancy), I went to a lot of meetings where there were a lot of really famous people. It’s no secret that Hollywood has its share of alcoholics. What is less well-known is that it also has its share of recovery. I met a lot of big movie stars who are not known as alcoholics, because they’ve been sober for years now and have the kind of lives that sober alcoholics working a program of honesty and accountability have: quiet, productive, and sane.
At the meetings I went to in LA and Malibu, there was a tradition that people celebrating sober anniversaries would speak for a minute about how they did it. At one such meeting, I heard the following joke, told brilliantly and to a rapt audience by a famous person:
A man, sober for many years, is taking an airplane flight, and he’s upgraded to first class for the first time in his life. As the plane is sitting on the tarmac, a stewardess asks the man if he’d like a cocktail prior to takeoff.
“No thank you, miss, I’m fine.” The man says.
Leaning across him, the stewardess asks the same thing of the suited businessman sitting in the window seat, who declines as well. The sober alcoholic begins thinking to himself, puzzled by the other man’s refusal: is he an alcoholic too? Why else would one turn down a free cocktail before a long flight? It seems like it would be the perfect thing to take the edge off. As he turns it around in his mind, he becomes more and more curious about the man. If he’s an alcoholic too, perhaps they could pass the long flight talking about AA, or telling old “war stories” about the drinking days. Finally, curiosity gets the better of him:
“So, are you a friend of Bill?” he asks.
“Bill who?” the man, clearly confused, replies.
The alcoholic realizes that the man in the aisle seat is not a recovering alcoholic, but feels the need to explain himself.
“I’m sorry, it’s just, I’m a recovering alcoholic, that’s why I turned down the free drink. I was wondering if you were too.”
“Nope, sorry.”
“Well, then, do you mind if I ask? Why on earth would you turn down a free cocktail before a long flight like this, if you don’t have any trouble with booze?”
The businessman in the aisle seat stares at the sober alcoholic for a beat, and then replies:
“Because it’s six fucking o’clock in the morning.”
We laughed. Because it was told well, and because to us, this is a good joke. It describes how we think very well: even in sobriety, we simply don’t understand how normal people relate to alcohol.
New Sponsorship.
I have lived in ECC now for seven months, and been at my new job at MECMC for six months. I’ve settled in. I like everything. For the last couple of months I’ve been really lazy and I need to push myself a little to get out of that rut. But luckily, my interns are coming online next week, which means I’ll be responsible for their education and industry, which means I have to appear to be a good PI. Have a plan. Etc.
But the big news today is that I have a new sponsor. My previous sponsor, Mickey S, was my sponsor for more than five years. From when I had less than six months sober until I had more than five and a half years. He took me through the steps, one by one, from the beginning to the end. At the time it felt like a nice, slow, measured pace. But I have come to see that it was actually pretty fast compared with many people I’ve watched go through the steps since I’ve been in the program.
I had already worked steps one through three when I met Mickey. But he had me go through them again with him. And then we ploughed through the next nine in about six months. I was deeply invested in getting through them. I really wanted to do the things I had to do in order for my life to change. And Mickey showed me how to do them. And I did. And it did.
But after seven months of living far away, and discovering that without my roughly weekly meeting with him, I was calling him less. Less than every week. One of the things we tell sponsees when they start is: “Don’t drink, and call me everyday.” I did that for a long time. But after a year or two, it was probably every two or three days that I called Mickey. Since I moved to ECC it’s been every 7-10. And I need more connection than that. Having him so far away was just too alienating.
In my Wednesday night men’s meeting there’s a guy named Scott M. He actually works at MECMC, but in a different building, in a different department. I’ve never seen him at work. I met Scott before I even started my job. He’s a little older than me, maybe just shy of 50. Maybe a touch past it. He doesn’t have all that much more time than I do. I think he’s coming up on 9 years. But he’s go what I want.
That’s what we say about picking a sponsor: pick someone who’s got what you want, and ask them to show you how they got it. Scott is a runner. For a guy in his late 40s or early 50s, with a visible paunch and a bad MCL, he can run like hell. He did a half marathon last week in 2:20. He’s got a wife and a couple of grown kids. A house in the same area of town that I want to move to. A good job and a good life. He knows ECC. He’s friendly and content. All the things that look like success and happiness to me.
And since I’ve gone through the steps, we’re just going to pick up in the maintenance phase. I’ll call him a few times a week. See him at meetings. Go to dinner. And I’ll be accountable to him for my meeting attendance and my ongoing step-work: admitting it when I’m wrong; meditation and reflection; carrying the message. I think it’s going to be good. And I think it’s important for me to make sure I’m adhering to the program despite the fact that my life is going so well that I don’t really know what to do with myself.
There’s an old saying to “dance with the girl what brung ya”. Well, I got where I am by doing the work that we do in AA to have a good, sober life. If I want that to continue, then I need to keep doing the things that got me where I am. So here I go.
The Things I Miss.
I’m pretty healthy these days. I haven’t had a drink in well over five years. I haven’t had any tobacco in more than four. I run. I’m happy. I know I’ve written about euphoric recall here; when we recall our drinking days as great fun and conviviality. When we can’t see the consequences and focus on what we loved about drinking. It can be a real stumbling block for some alcoholics. Especially when we have a little time, and are removed from the serious effects of our drinking. I have bouts of that – all of us do – but for the most part it’s not a factor for me. Because I don’t really miss the good days.
I miss the sickness. My disease is one of seductive degradation. Of deliberate self-destruction. I saw something artistic and important about being a drunk, a smoker. A cutter. I took on a narcissistic depression. I imagined I was some intellectual – studying math and reading literature and writing poetry and composing music and drinking and smoking and bleeding in the bathtub. I fantasized that my diaries would be read posthumously like Dickinson’s poems. Grandiose arrogance intertwined with a virulent hatred of my self.
I say I miss the sickness. I don’t miss it. Being liberated from that is now the core of my foundational identity. But I remain, from time to time, compelled by the juvenile impulse to self-destruction for the sake of self-destruction. Waste for the sake of watching things burn.
It changed when I realized, and I still don’t quite know how, that my behavior and my fantasy of my future were incompatible. If I was to be successful, happy, have a family, gain the respect of my community, I couldn’t proceed along the path I was walking. Crawling. No matter how much the spiritual squalor appealed to me. What I was doing wasn’t leading me to what I knew I wanted.
And so I found that I had to make changes to either my behavior, or to my dreams. A lot of alcoholics make a different choice that I did. I wish I knew what the difference was. I wish I knew what it was that allowed me to change, when so many die. But I don’t. All I know is that I did not have the power to change alone. My best efforts led to me staring at myself in the bathroom mirror, full of hatred and shame, with another shot of vodka, forcing myself to watch myself drink it. When I knew it was lethal to me and to those I loved.
Now, I don’t miss the alcohol much. I know I would still love the taste, and the effect. I know that a drink is both seductive and deadly. I don’t miss it much, because I know what it is. It’s just toxic anesthesia. The soap-bubble film I used to like to watch the world through, so I didn’t have to see it, to see me, as it really was. No. I don’t miss the alcohol.
What I miss sometimes, it hating myself enough to drink it.
Little to Report.
Life is good. I’ve written very little here because I’ve been happy. Happy is good. Things with my girlfriend are proceeding very well. This feels like a serious relationship with real potential. We’re travelling internationally together over Thanksgiving. It’s a good holiday to travel. We’ll be going somewhere warm and beachy, surrounded by saltwater.
Work is going well. I’ve been lazy the last couple of months, and am having a bit of trouble with general working motivation. But it doesn’t stem from any dissatisfaction. Simply from six straight months of work with only one day off, and a heavy travel schedule on the weekends (not that I’m complaining about that). One paper received a “revise and resubmit”, and had one extremely positive review. I’m feeling confident about its prospects upon revision (resubmitted about a week ago). Another paper, after two go-rounds with the editorial board at a major glamour journal appears destined for rejection.
I’m going to a conference next week in Washington DC to present my first simulation work. I’m hoping it’s well received. I’ve submitted the same work to IMSH 2014, which I hope will accept it. I had a poster there last year, and this year I’m probably going to be part of a panel on discrete event simulation.
I have lapsed some in my communication with my sponsor. It’s hard, having him so far away. It is time, I think, for me to get a local sponsor. I know who I want to ask. He already has a couple of sponsees, but I’m pretty sure I’d be a low-impact assignment. I’ve done the steps and the work, and in my maintenance phase. I just need to be checking in more than I am now. Accountability is important for us alcoholics, and I’m not feeling especially accountable right now. Not in the program. So I’m going to take action. Because that’s what we do.
But this little lapse in active sponsorship has not led to any desire to drink or feeling of discomfiture. I’m just aware that it’s not the best situation for me to be in for a prolonged period. Similarly, my Wednesday-Sunday meeting schedule isn’t really working. So I need to find another meeting to go to. It’s hard to find meetings where I connect. A new city and a new “flavor” of AA. It feels a little weird. I just need to acclimate.
But overall, my life is better than I have any right to expect it to be. Yesterday I ran for 64 straight minutes without stopping, covering 6.2 miles. Unbelievable. I feel fantastic, and I am happy. The gifts of sobriety are myriad and limitless.
The Debate Wrap Up.
Last night’s Open Access debate was fun, and I hope I acquitted myself reasonably well. The video is about 90 minutes long and can be watched here:
The tone was friendly and convivial. I didn’t get to make every point I wanted to. I had hoped to shoot some holes in the basic economic model while Eisen was there to defend it. But overall, I think that it was made pretty clear that there are lots of positives, lots of questions, and plenty of room for more debate.
Though I wonder how well any of us did at taking Dr. Isis’s fundamental point a few days ago: are any of the established faculty, especially the highly privileged, actually listening to and asking questions of people with other perspectives? Or is this yet another arena where old, rich, white men are attempting to dictate the future to everyone else?
And where do I fit in that? I am certainly incredibly privileged from a socio-economic perspective, but I am not even faculty, much less established. I have very little funding. I have no influence at journals and no record of academic excellence. What can I do, aside from participating in debates like this, to help guide this industry that I’m on the vague periphery of? Should I even try? Or is it really any of my business?
Maybe I should just walk away, and when I show up on the academic field to play, as I do from time to time, play by whatever rules the real stakeholders have decided upon.
Debate Tonight!
Right now is a good time to be joining the Open Access debate, for me. I currently have four papers under review. I suspect that that’s not many for the average assistant professor, but it’s the most I’ve ever had at one time. [ed.- Informed this is a “humblebrag”. Apologies.] Exactly zero of them are being reviewed by open access journals. Now, I’m on the record as supporting the fundamental ideals behind the open access concept (despite some reservations), and I’ve published open access before, more than once. So what’s my deal?
Well, two things. First, no money. MECMC is a huge and very wealthy institution. One of the richest hospitals on earth, I think. But my department is not a traditionally academic department, and has never published before. They are somewhat skeptical of the entire concept, though they’re coming around fast. If I were to tell them that not only am I going to spend some of my time that they’re paying me to do quality improvement work writing papers, and also they need to pay $1000-$5000 per paper to publish them? They’d simply refuse. They’re not paying for it. If Open Access were the only model, my work would go unpublished.
Probably. There are a few OA journals which waive fees for financial distress, but frankly, MECMC doesn’t deserve any such dispensation. I’d feel bad taking it from some other researcher slogging away in a truly impecunious environment. But they cannot waive fees forever, or the model will fall apart. And in my experience, the OA journals that waive fees tend also to be the ones which are non-exclusive. Which leads me to my other point.
Personal prestige. I want my work to be recognized as good work and valuable. As I wrote in the previous post, for good or ill, journal reputation is one of the primary proxy indicators that people use to judge your work. If I get published in JAMA, or NEJM, or PNAS, or The Lancet, people take notice. Now, it would be lovely if we lived in a world where all of our science were easily and widely distributed and the right people knew how good it was. But that’s simply not the case. If I ever do decide to apply again for a professorship, and I have a paper in one of those journals, it increases exponentially the likelihood that I get offered an interview. If I have a paper in one of those journals, and I submit for a grant here at MECMC, it tells reviewers that I know how to turn research projects into important published research.
Now, we can argue until we’re blue in the face that that shouldn’t be how it is. But that is how it is. And I’m not interested in being the martyr who sacrifices my academic ambitions on the altar of someone else’s utopian vision of universal access.
And I’m not ashamed of wanting a little personal prestige. I think I do interesting work, and I want to be recognized for it. I’m fond of saying that I’m going to make a career out of small papers in small journals. And so far that’s been true. I don’t have a lot of publications, and only a couple in journals anyone would consider of reasonable quality. So far, I am essentially uncited. I have had virtually no impact on the state of my field (which in many ways is in shambles from unqualified physicians trying to play engineer). A paper in a major journal would change the profile of my other work as well.
OA advocates like Michael Eisen see that as a moral failing. But I do not believe that anyone needs to apologize for ambition. The Open Access zealots (and not all supporters are zealots!) are simply the new flavor of shamers. People who believe the “the science is the only thing that matters” and that we should all have a monastic devotion to truth. This is the same attitude that demands that we work 80 hours a week and put off having children and never take vacations, because the science is the only thing that matters, and if you were a True Scientist you’d sacrifice everything!
Bullshit. Our lives and livelihoods matter. And here’s what the zealots don’t seem to understand: some of us are motivated by different things than they are, and it’s ok that we are. I do my best work when I am being paid well, sleeping enough, and feel like I have the chance to be recognized for it. I don’t have to be ashamed of that. This is simply not a moral issue. I am allowed to have my own set of motivations. My own aspirations. It is not a moral failing that I refuse to adopt your political agenda.
And that’s a fundamental issue here for me. Despite the generally admirable goals of the Open Access advocates, I am nauseated by the zealotry, and the conflation of a political agenda with a moral crusade. Eisen et al consider their vision of science dissemination to be noble and righteous to the exclusion of any other path. It is a religious position, and a political one (and in many arenas, there is no discernible difference between political positions and religious ones; they’re all based on faith in an unknowable outcome).
Once a person finds themselves staking out a position where they must assert that all those who agree with them are nobler than all those who do not, they have claimed indefensible ground.
Open Access Debate.
I’ve written here about the Open Access (OA) debate many times. On Tuesday evening, at Pub Style Science, I’ll be participating in a friendly debate about the merits and shortcomings of OA scientific publishing. A quick overview:
Open Access – A system by which papers are published online and freely available to anyone with an internet connection. Authors or their institutions generally pay anywhere from $1,000 to $5,000 to publish. The good OA journals (like those run by the Public Library of Science or Biomed Central), conduct rigorous peer review by qualified editors and reviewers.
Traditional Publishing – A system by which authors and institutions generally pay nothing (but some journals may have page charges) to publish. The good traditional journals conduct rigorous peer review by qualified editors and reviewers. Libraries pay for access to the journals, and those without library access can buy individual articles for anywhere from $20-50, usually. Individuals may also purchase personal subscriptions, though they are often very pricey.
Fundamentally, the only differ only in the “who pays” aspect. But many other issues confound the debate. Many OA journals are deliberately non-exclusive. The journal PLoS One, for example, accepts every paper which passes peer review, and reviewers are explicitly told not to judge papers on novelty or impact. Only on the soundness of methods. To my knowledge, no traditional journal does this. This results in the inability to use the journal’s reputation as a proxy for the impact (and perhaps quality) of the science published in it.
Now, for some, this is a feature: science should be judged on its own merits. Read the paper! Judge its quality yourself! For some, this is a bug: I can’t possibly evaluate every paper, especially those not in my direct field. Using journal-reputation as a proxy allows me a higher probability that the papers I find are important, interesting, and valid. There are flaws, of course. Bad science gets published in good journals fairly frequently. But as a general guideline, well-known prestigious journals usually publish science that is correct, interesting, and important.
Other confounding factors: a huge number of bogus OA journals have sprung up, allowing the patina of legitimacy to be appended to bad science, or pseudo-science. It’s true that there are bogus traditional journals as well, but the fact that you must pay for access means that they are less likely to be exposed to large numbers of the public. Paying for publication means that researchers must often use grant money to pay for publication that otherwise would go to research, further stretching limited budgets. Though this is also true of traditional journals with page-charges.
The revenue model is troubling too, for critics of OA. Because journals make more money the more they publish, and are generally unrewarded for how widely their published articles are distributed, they have incentive to publish as much as possible. It’s easy to see how this can result in pressure to publish more, and scrutinize less. As long as the journal is run by the original True Believers, it may maintain integrity. But as time passes, and the original founders retire and are replaced by professional administrators, will that continue?
Another argument that is made is that OA allows for the publishing of small results that traditional journals will not publish because they’re not impactful enough. And that’s true, it does. But, it’s also easy to see how the pay-for-publication model will actually suppress publication of small results. Labs with limited budgets may well be unwilling to publish small or negative results because they cost money. They may well want to save their publication fees for what they decide are “important” papers. After all, they have careers. However they’re published, impactful articles are always going to be important and desirable. A traditional low-impact journal may be precisely what is needed to publish that negative result.
So, the discussion on Tuesday is going to include Michael Tomasson, Dr. Isis, Michael Eisen (co-founder of PLoS), Ethan Perlstein, and almost certainly a few others.
I will be staking my standard territory, for which I’ve been vilified: traditional publishing is not evil, both models have flaws, and there is room for two models. Furthermore, I’ll be reiterating the basic philosophy of my field of study: the publishing system is a massive complex system. When OA proponents tell you what will happen when OA is universally adopted and traditional publishing is dead and buried, they’re making it up. They can’t know. It is a non-linear, hybrid, time-dependent, memory-dependent dynamic system. And we can prove that we can’t predict how those will behave. With a good model, we might be able to gain basic insights, but no one has built the model yet. And it would be a vast and baffling undertaking.
Who is AA for?
Standard Disclaimer: I do not speak for Alcoholics Anonymous. This is my opinion.
Over the weekend, Michael Tomasson sent me a link to this article by Dr. Markus Heilig in the Washington Post. It correctly identifies that alcoholism remains a vexing problem both societally and from the perspective of medical research. I’m generally unqualified to comment on the state of the medical research in the neuroscience of addiction, but the usual suspects are. However, on the epidemiology side, I have both experience and (some) training. Luckily, my training was not really needed to analyze this minimally researched article. I don’t dispute the numbers, though AA’s own reporting on its retention rate should be considered highly suspect because there’s no systematic means of taking surveys.
Dr. Heilig makes a few basic mistakes, such as the unsupported assertion that “…medications targeting brain function continue to be viewed unfavorably in many 12 step programs.” While it is true I have heard some reluctance to adopt psychoactive medication in AA, I have heard the same reluctance outside of AA. And, I know many people in AA, myself included, who take or have taken psychoactive medicines while members of AA and sober. We do this under the care of physicians. One of AA’s crucial assertions is: “We are not doctors.” Meaning, the principles of AA should not countermand the things your physician tells you about your health, when that physician is fully informed about your addiction. I’ve seen no evidence that psychoactive medicines are preferentially avoided by the population in AA compared with the general populace.
Heilig also makes the mistake of conflating rehab facilities with AA. For example, the Betty Ford Clinic. Now, I know almost nothing about Betty Ford, and I have nothing negative to say about them. But AA does not endorse them, or any other rehab facility. AA runs no rehabs, clinics, hospitals, halfway houses, meeting houses, coffee shops, or anything else along those lines. AA conducts no research, nor supports anyone who does. AA has no governance. That’s explicitly stated in our Traditions: “Our leaders are but trusted servants. They do not govern.” So, quoting how medical facilities react to research availability and evidence based medicine may well be relevant to how alcoholism is treated in America, but it has no relevance to AA.
And obviously, AA doesn’t react to the medical evidence, institutionally. No one has anything like the authority or influence to guide the organization. AA is a bunch of drunks, getting together, working (or not) a program of sobriety and recovery which works for us, and telling our stories. That’s it. Asking AA to react to the medical evidence is like asking traffic to react to the latest city-planning models. Not only is it not equipped to, it’s not the right body to avail itself of the information.
And fundamentally, Heilig misunderstands the nature of AA in another important way. He criticizes AA for “insisting on total abstinence”. But that is not what we do. I had a sponsee once, David. He came to AA. He was a drunk. He did the first five steps. He got a job and moved to Italy. He started drinking socially. He kept drinking socially. Now he’s married with a kid, his lifelong dream. And to my knowledge, he continues to drink socially. And you know what? I’m happy for him! I’m glad he’s drinking socially. I’m glad he’s happy and fulfilled and able to drink like a gentleman.
I cannot. Nor do I any longer have any true desire to. Sure, I still occasionally have wisps of a longing for gentility and sophistication mixed with alcohol. But I am not the kind of alcoholic who can go and drink normally, because I do not have any desire to drink normally. If I could drink normally, I’d get drunk every day. Because I love drunkenness more than I love any other thing about alcohol. I love the taste and the chemistry and the social lubrication and the sophistication, absolutely. But what I really love is the effect of inebriation.
While we in AA welcome anyone with a desire to stop drinking, our program is not really designed for those who have the ability to transition to normal drinking. And those people exist. They exist by the millions. So many people binge-drink when young and then shape up and drink normally as adults. And bless them. I’m so happy they can and do. I’d never change it. Nor would I prescribe abstinence for them.
The people AA helps are the people who have finally limited themselves to jails, institutions, or death. People for whom the only, final choice, is abstinence. People who drank like me: hell-bent on isolation and death. Suicide by alcohol. People for whom alcohol is not only the most important thing, but the only thing that matters. We may be mystified that our lives are not going as we want them to, because we cannot see that alcohol is the only thing we love, but that is the truth of it nevertheless.
When people write essays like Dr. Heilig’s essay, what they’re saying is: “AA doesn’t act like I think it should act.” Generally these people have the best of intentions. They believe that AA would be more effective if only it changed to suit their opinions. Often opinions informed by the best available medical evidence. This pill has been shown to reduce relapse rates in triggering circumstances, Heilig writes. No, thank you. I’m declining not because I think there’s anything wrong with taking medicine, but because I don’t want to offload the responsibility for my sobriety to anyone else.
Taking a pill that curbs cravings may very well curb cravings, and aid my ability to achieve short-term abstinence. But it cannot cure the way I think about alcohol. The way I will tell myself lies and rationalize my use. And the way I will blame anyone other than myself for my failures when I drink. If I take a pill that curbs my cravings, it is easy for me to “forget” to take the pill, suffer a craving, and succumb because I haven’t done what I need to do, haven’t built a support network, haven’t come to understand the reasons I drink. Relying on a pill for abstinence is a recipe for self-sabotage.
It is wonderful that there are strong efforts being made to address alcoholism medically. But to criticize AA for not adopting them betrays a fundamental misunderstanding of what AA is, who we can help, and how we are structured. But most importantly it misunderstands one of the deep contradictions that exists in alcoholics of my type: If I don’t want help, then nothing you have can help me; If I do want help, then (other than acute withdrawal) I don’t need the kind of help that medical science can offer.
Infactorium 