On Triple Crowns and Alcohol.
This season saw some truly remarkable baseball. Three (3!) perfect games and four other no hitters. Astonishing. A knuckleballer won twenty games and will probably win the Cy Young in the National League. And of course, Miguel Cabrera won the Triple Crown. The first player since Carl Yazstremski to do so, back in 1967. The Triple Crown goes to any player who leads his league in Batting Average, Home Runs, and Runs Batted in over the course of a championship season. It’s only been done a few times, and for the most part, we know the names of the legendary baseball men who’ve done it. Frank Robinson. Ted Williams. Mickey Mantle. Rogers Hornsby. Ty Cobb. It’s a list of the VIP section of the Hall of Fame.
Now, thanks to science, we now know that two of the three Triple Crown stats are not extremely important. Batting Average is a pretty lousy measure of a hitter’s quality. And Runs Batted In depends too much on the quality of his teammates. Nevertheless, it’s a venerable distinction, rarely won. And anyone accomplishing the feat is a great hitter and worthy the praise.
Miguel Cabrera is a special case too. He struggles with alcohol. I won’t call him an alcoholic, because I don’t know if he calls himself one. But he has been in treatment for alcohol, and he has been arrested with a blood alcohol content of 0.26%. That’s a pretty astonishingly high number. By comparison, when I had my DUI, that evening I had drunk two bottles of wine and a tumbler full of bourbon, and my BAC was 0.19%. The legal limit, which I’ve been told comes out to about two drinks in an hour for a healthy, ordinary-sized man, is 0.08%.
To my knowledge, Miguel Cabrera is not currently drinking at all. The media makes a big deal out of mentioning that he stayed away from the champagne celebrations when his team clinched a playoff berth. He’s a good example, I hope, to people who struggle. Being an alcoholic doesn’t mean we can’t excel at our trades. In fact, among the alcoholics I know, I generally find them to be exceptional as the rule. Of course, my sample is biased to those who have found sobriety.
Now, Miguel Cabrera’s sobriety isn’t really any of my business. It’s his journey and I wish him well on it. I was just inspired to write about it because of a tweet I saw from @PalMD, saying:
miggy cabrerra’s triple crown is almost as impressive as his gaining control over his etoh problem. I’m happy for him for both.
— PalMD (@palmd) October 4, 2012
I’m troubled by this. Now again, I don’t know that Miguel Cabrera is an alcoholic like I am. But for alcoholics like me, there is no “gaining control over [our] etoh problem”. In fact, trying to control our alcohol problem is an excellent indication that we are not ready for sobriety. And I should say too, twitter is an abbreviated medium, and this is almost certainly just a shorthand way of indicating the pleasure a physician takes in seeing a person suffering from a disease achieve remission. I’m not trying to indict @PalMD here. All of our interactions have been good. I’m just using the tweet as a springboard to my own ideas, not trying to take him to task (which would be inappropriate).
But it matters to me to get this right. The people I know who have gotten sober, and who have happy lives in sobriety, are the ones who recognized that they had no control over alcohol. That striving to control the alcohol in our lives was pointless. We lose every time. To be sober, we must abandon control. Abandon battle. Surrender. Peace, serenity, an end to our alcoholic misery, comes from recognizing that we cannot win any fight with alcohol. We can never drink like normal people can. We are lost.
And when we recognize that there is no safe way to drink, when we accept that alcohol has utterly defeated us, when we surrender to our desolation, then we can begin to rise again. And we can rise to magnificent heights.
The Latest Career News.
I was cornered by my prospective department head at LRU (Local Research University) today. The back story is that about 18 months ago, he asked if I was interested in taking an Assistant Professorship at LRU, to be a joint appointment with my current institution. My hospital routinely sets up joint appointments with universities, where researchers will be a few 1/8ths here and a few 1/8ths at the school. And we’re allowed to have the total sum to as many as 12/8ths. So, the deal was that I would remain 8/8ths at my hospital and take on 2/8ths at LRU. I said yes. The faculty approved me.
But there was no money for the position. Seasons of bureaucratic tape ensued. Finally, today, I was told that a big contract for corporate money has been signed by LRU, and that there is money in it for my position. The corporation is expected to sign it today or tomorrow. After that, it will take a few weeks to float the position and hire me. But my prospective boss is confident enough in the process to ask me to come with him to Nashville in a few weeks on a field trip to meet with our new corporate overlords. So I may end up having to list COIs in the future. I can handle that.
So, the way this will work is that I will have a 25% position at LRU. That means it’s just about 15 hours a week, no benefits. Decent pay for that amount of time. But it’s a job. And I will be able to submit grants to the NIH and AHRQ and NSF, finally, which I cannot do from my current position. Which means that my current R01eq that I’m working on may just end up as an honest-to-pete R01.
And I will be able to start designing a course or two, and maybe taking on students, if they have additional % effort to give me. And then, when my current position with my hospital ends, I’ll still have a real world job, with the title “Assistant Professor”. But I also don’t want to get too ahead of myself. This has been dangling for 18 months. I’m dying for it to happen. I really am. But I don’t want to count chickens.
So: To explain. No. There is no time. To Sum Up: It looks very, very hopeful that within a month or so I will actually be 25% time Assistant Professor at LRU. LRU is, as its name suggests, local. No move. From there, I move forward.
What’s Actually Wrong with Romney’s Emergency Care Comments.
I’m late to this party, but I wanted to make a comment about Mitt Romney’s comments from a week ago about emergency care. First of all, there’s absolutely nothing wrong with this quote, from his “60 Minutes” interview:
“Well, we do provide care for people who don’t have insurance. If someone has a heart attack, they don’t sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital, and give them care. And different states have different ways of providing for that care.”
It is entirely appropriate to provide emergency care for people in cardiac distress, in emergency rooms, regardless of insurance status. So people freaking out about that aspect seem to me to be grasping at straws with which to condemn someone they already dislike. However, I think the broader context of health care delivery and emergency care is deeply important here, and this quote suggests that Romney either hasn’t thought about the issue, or simply gets it wrong.
That’s this: while it is appropriate to provide emergency care to people in life-threatening distress regardless of insurance status, if that is the manner in which you are providing care then the system has already failed. And the care we provide for those patients in acute distress will be severely compromised. Because it’s a system. And the system has to respond to more than just those in acute distress.
The lack of insurance causes many millions of people to treat the emergency department as if it is primary care. Because they cannot afford to see a primary care physician, they go to an emergency room when they are suffering from any illness. There are enormous numbers of patients who simply don’t need to be at emergency rooms. Many ED docs refer to them as the “gofer” patients: “Get out of the fucking ER”. This swelling of patients in the ED leads to a number of serious consequences.
When the ED is crowded, wait times go up. The triage process of sorting patients into resuscitation, emergent, urgent, etc., is not a perfect science (these are generally captured in the US by the Emergency Severity Index)[1]. As patients wait longer, their outcomes degrade[2]. As wait times increase, more patients leave without being seen (LWBS)[3]. These patients are generally the same distribution of illnesses as patients who do not LWBS[4,5]. This suggests that they are equally likely to suffer subsequent adverse events, only now, they are not receiving care.
Treating the emergency department as the overflow bin for the health care system has disastrous consequences for patients. First, EDs are designed to perform resuscitation and stabilization. That’s how the physicians and nurses are primarily trained. However, as EDs are currently used, they are essentially performing as souped-up family practice facilities, which degrades their central mission, and may prevent them from providing those services when they are needed.
Additionally, when large numbers of the uninsured rely on the emergency room for primary care, they receive no preventive care. Which means that treatable conditions progress until they become emergencies. That heart attack Romney references? In many cases, insurance would have allowed that individual to be aware of and control hypertension, or arrhythmia, or what-have-you, which would have delayed or prevented that life-threatening event.
When the ED is a large segment of the population’s primary access to medical care, because they cannot be turned away for failure to pay, we have all failed. We have failed economically, in providing adequate opportunity for people to afford medical care. We have failed philosophically, in promoting the idea that it is reasonable for a class of health care providers to be forced to work without remuneration (meaning they must raise the fees for those who can pay). We have failed medically, because the great majority of patients are in the wrong venue to receive appropriate care for their conditions. We have failed politically, in pitting industries and individuals against one another rather than collaborating to maintain a healthy populace and thriving medical engine.
So, Romney is right: it is appropriate that a person who is having a heart attack goes to the emergency department regardless of ability to pay. But he’s literally dead wrong about the system’s ability to handle the crisis he’s promoting with that sentiment.
I’m not endorsing any particular health care/coverage plan. I haven’t seen one yet that I think addresses our systemic problems. I’m not sure there is one. Some of the inequities in the health care system are, I think, insurmountable. And I’m actually kind of ok with that. I don’t think the goal should be to provide all persons with the most possible health care.
But the emergency room is for emergencies. And that is, by my own unpublished data, less than one-third of what goes on there. People are dying because too many people who aren’t dying are presenting for emergency care.
_________________
[1] Emergency Severity Index: A Triage Tool for Emergency Department Care, Version 4,
Implementation Handbook. Agency for Healthcare Research and Quality. http://www.
ahrq.gov/research/esi/esi1.htm.
[2] Ackroyd-Stolarz S, Read Guernsey J, Mackinnon NJ, et al. The association
between a prolonged stay in the emergency department and adverse events in older
patients admitted to hospital: a retrospective cohort study. BMJ Qual Saf
2011;20:564e9.
[3] Fernandes CM, Daya MR, Barry S, et al. Emergency department patients who leave
without seeing a physician: the Toronto hospital experience. Ann Emerg Med
1994;24:1092e96.
[4] Monzon J, Friedman SM, Clarke C, et al. Patients who leave the emergency
department without being seen by a physician: a control-matched study. CJEM
2005;7:107e13.
[5] Rowe BH, Channan P, Bullard M, et al. Characteristics of patients who leave
emergency departments without being seen. Acad Emerg Med 2006;13:848e52.
Winds of Change.
It’s a good thing that I’ve been applying to new positions for the past month and a half. It seems almost certain that I will not have a job at my present institution when my current appointment is up. All PhD researchers must be “cost neutral”. Which means that I must supply 100% of my salary ASAP. Well, that won’t happen by the time my appointment runs out at the end of March.
It also probably means there’s no point in my submitting my R01eq, because even if it were funded on the first submission, it would only cover 50% of my salary at most. I’m in a position most of my tenure track colleagues will not be familiar with: even the gold-standard best grant in the world will not save my job. They’ll simply say: what have you done for me lately?
So I am making plans to leave. And I’m making contacts in other aspects of the industry. I could be doing corporate consulting. Or private consulting. I even spoke to a friend about picking up a few credit hours teaching math at a local community college, which I would enjoy a lot I think.
My computer is out at work. This is the second day. So I can’t really do anything. I got a revision request from the editor-in-chief of a big fancy journal, pre-review. Change up the paper, do another experiment, resubmit. Considering this journal could easily have just desk-rejected, and been happy to move on, it suggests that it has a good chance at eventually competing strongly. The EIC likes it. I know a lot of my readers will disapprove of my being nakedly hopeful about publishing in a major, non-open access journal. But I’m a new investigator still. And that’s the game. This is a big time one-word-name journal. Getting something in there could be career altering.
Anyway, I’m writing this on my phone, which is arduous and embittering. I’ll leave you all with this: now that I have essentially decided that I am not going to keep this job, I feel a little freer. I’ll do what I can to be productive until my time is over. Then I’ll move on. I’m afraid. But I have been in much direr straights than this in my life. And I always come through. Because my life is not really about getting what I want. It’s about accepting what comes, being grateful for what I have, and using my talents to be of service. I’ve been impactful on my science, in my community, and upon those who have sought help from me to recover from alcoholism and addictions. And I have more to give.
Travels.
I will be wandering about the country for a while over the next few weeks. Next weekend I’ll be heading to southern Indiana to spend some time with Jimmy Legs’s family. Then, 10 days later, I’ll be heading to the East Coast for a presentation at East Coasty University. Then I’m taking the train to New York City, to find some decent picante sauce. No, sorry, to meet up with a number of friends for the weekend, including Chicago Joe, who lives in New York now but who will always be Chicago Joe.
And I’ll be hanging out with people from twitter again, and I’m going to hit a few AA meetings in the Big Apple, which should be truly awesome. There are some old, properly broken down cathedrals of sobriety there: nicotine stained walls and coffee brown mottled rugs testaments to more than three-quarters of a century of recovery through the miraculous institution of drunks helping drunks. I can’t wait. I have a good friend there who should be celebrating six months sobriety immediately before my arrival. There will have to be a celebration.
This will be the wrap-up of my project with ECU, at least in terms of what I promised to deliver to them. I’m hoping they will continue to want me to perform analysis and recommend interventions. So far, they contracted me, and gave me a fancy title, to build a tool. The tool is built. I’m finishing the validation this weekend. Then I’ll present it. After that, if they want to use it to analyze their system, they’ll need to continue to contract with me, or buy a software license and hire someone else. Considering the software license is like $21K, I’m hopeful they’ll continue to work with me.
The more things progress where I am, the more it looks like I’ll need a new job. This place is a place of entrenched, aggressive stupidity. I’m applying to lots of jobs. Both in engineering health care systems and in tenure track and other research positions in public health. I even applied to a professorship in systems engineering, but I won’t be competitive for that, I think. Nevertheless, I’m excited by the processes. I don’t have a sterling CV. I don’t have any glamorous journal titles, nor any prestigious grants. But I have a small history of publication and a small history of grant funding. I will hopefully be competitive among people applying for junior positions, although I’ll be 5-10 years older than all of them without anything to show for it.
It will likely be difficult for me to find other serious employment doing exactly what I want. Boo hoo, right? Who gets to do exactly what they want? And even the people who do have to work hard and have enormous headaches about getting their research accomplished and their grants and papers put out there. It’s difficult everywhere. And it’s getting nothing but worse as universities put ever tighter screws on professors. There is an enormous class of university administrators whose entire jobs are to beg for donations and steal overhead from professors. They exist for no other reason than to raise funds to support their jobs. We have created a class of MBA educated panhandlers, and given them the prestige of a university title. It’s disgraceful. And it inhibits both science and education.
Bah. I will not go off on another rant about the university process today. Instead I will stare at a computer screen, not write my grant, and fantasize about three weeks from now, when I’ll be in Gotham having FUN.
How Do You Know When You’re Done?
When I am troubled, one of the best things for me to do is to throw myself into my sobriety. And one of the most important aspects of my sobriety is to carry the message to other alcoholics. I have been given something unbelievably precious, and unfathomably rare. I have been given a reprieve from the psychic, physical, emotional, and spiritual devastation that is active alcoholism. Active addiction. Being free from addiction is a state perhaps impossible to communicate to non-addicts. I sometimes envy normal people, and their privilege not to know the things I know.
Since starting this blog, and coming out of the addiction closet on twitter, it is really kind of amazing the number of people who have reached out to me to say that they or their loved ones have a problem with alcohol, addiction, or more recently, depression. These are pernicious and ubiquitous diseases. And the nature of addiction is to compel us to suffer in shameful silence, cowering from the world. We do not want the world to know we have a compulsion to drink. We can’t bear the idea of the world knowing we married an alcoholic.
This is in part due to the stigma associated with alcoholism and other addictions: that sufferers are simply weak-willed, indulgent, lazy. But it is also due to the very real consequences and presentations of the disease. Alcoholics do bad things. We lie, we steal, we drive drunk. We externalize all our agonies and try to blame others for them. Addiction is more than just a compulsion to consume. It is a compulsion to avoid the consequences of consumption, and to gaslight others into feeling responsible for our failure, malfeasance, and inability to remain sober.
And our loved ones buy into it, all too often. They enable us, or they persist in denial, or they choose not to see the things we so clumsily attempt to conceal from them. Silence becomes a default in the face of overwhelming shame and pain and fear. We worry what others will think, what they will say, if they know we have a problem. And stopping drinking becomes the big reveal: if we stop, then people will know we had a problem! If we recover, then people will know we were sick! It’s as if we refuse chemotherapy lest anyone discover we have cancer.
So how do we come to a point where we can recover? How do we know when we’re done? The tragic answer, of course, is most of us don’t. The great majority of addicts die of complications of addiction. Addiction is terminal. Make no mistake about it. And before we die, we contract into tiny, miserable lives punctuated only by spasms of violence directed at our families, communities. This is a family disease. A social disease. Our reasons not to seek treatment, and the presentation of the illness itself, are all too often based in seemingly social, but deeply anti-social, interactions with others.
I talk regularly with people who want to quit but don’t know how. Who say that they drink in social environments and don’t know how to extricate themselves from that. They don’t want to be the only person at the party not drinking. They don’t want people to talk about them. They don’t think they can afford to take the time they’d need in the acute phase of withdrawal to be away from work, or simply to be a bit out of their minds.
Sadly, many people persist in this state until it’s far too late. They don’t want to take time off work to recover. So they continue drinking until work doesn’t want them. They don’t want their friends or family to know they have a problem, or to have to deal with the transient difficulty of early recovery. So they continue drinking until they no longer have friends or family. Then, alone, there is no reason to stop. And the isolation of the alcoholic claims another promising life.
We’re done when the consequences of sobriety are equal to the consequences of continuing to drink. When we cannot fathom spending another day pouring what has become poison too us into our bodies simply to try to maintain the illusion that it isn’t killing us. When the fear of being labeled an alcoholic in recovery is less than the agony of being an alcoholic in reality.
It starts with reaching out to someone. It starts with deciding that how you feel – how you live – matters more than how you think you look to others. Alcoholics looking to recover get to be selfish. We get to take care of ourselves. Because we will die if we don’t. As our recovery progresses, we turn outward. We start to look to help people. We start to earn what was given to us, when we walked through the fires of withdrawal and shame. We start to be grateful to carry the message.
That’s where I am. I am here. I can help. I stand on firm ground now. Reach for me.
No Resolution.
I sat down with a lot of senior management at my hospital yesterday and talked about how I think I can help the patient flow situation. A number of people seemed pretty impressed. The Chief of Staff, who is new and very clearly competent and no-nonsense, may not have been. He wasn’t unimpressed, certainly. Or, I should say, he didn’t appear negatively disposed towards me. But he also didn’t leap out of his chair and beg to pay me extra money. Which is what I was hoping, of course.
The email I had from him this morning was vague, but I suppose appropriate: “Many thanks for your time and educating us. We have a few things to chew through, including developing the team for pt flow. Will definitely be in touch.” A friend described that as “encouraging”. Is it? I don’t feel encouraged. That feels to me like the words of someone who still isn’t sure I have anything to offer him.
So I remain in the air. I don’t know what my employment situation is, or if LRU is going to get around to offering me a position. I’m completely flummoxed. It’s hard to write my grant not knowing if I’m going to have a job. I’m scared and overwhelmed. I’m tired and frustrated. All the fathomless amounts of money that are wasted here, and I have the skills to actually make a difference in both patient care and hospital economics, and they don’t know if they want me.
It’s dark and frustrating and vile. All of it. I’m so deeply tired of fighting for a job.
It can be difficult, in the frustrating times like this, to look around and be grateful for what I have. But the truth is, I have a lot. For now, I have a job I like, and there’s a good chance I’ll keep it. I have a home and a side consulting gig (which is coming to an end) and a fancy-sounding title (“Adjunct Assistant Professor of Emergency Medicine”) at a well-regarded university. I have the ability to be engaged in my own life. I am not just a spectator as life whizzes on by. I am an effective participant.
Yes there are aspects I can’t control. Yes those concern and disturb me. Yes, I spend a great deal of effort and suffer a great deal of anxiety about all of it. But I have opportunity. I will be ok. Probably. And most crucially of all, I’ll be sober.
Upcycling On.
An incredibly productive weekend has me feeling a bit better. My depressions have been deep, from time to time, even in sobriety, but they last for briefer durations. Reminds me a bit of what my sister Aimee once told me about quitting smoking: the cravings never go away, and they never get any less powerful. They get further between, and the duration diminishes. I still get cigarette cravings, and they’re still astonishingly powerful. But they only last a minute, and they’re weeks or months apart. As opposed to, say, three years ago when they were several times a day and lasted up to an hour.
So I feel like I’m cycling up. Since I wrote the last post, I’ve seen my trainer, which is always good for my mood. She absolutely ruined me with weighted lunges. My ass was sore for days. Then, Saturday, I ran my fastest 10K ever. Still not a race, I remain unsure if I want to do one. But I am aiming for running 10K in less than an hour sometime this year. Saturday I did it in 1:01:13. So I’m only about 2% off my goal. And it’s absolutely true in my experience, that exercise when feeling sad or stressed can ward off serious depressive episodes. And guess what? There’s SCIENCE!*
So a couple of days of vigorous exercise decidedly improved my mood. As did spending most of the weekend working on the validation process for my East Coasty University simulation project. It’s going well and I’m able to come up with good graphs. They’re not all perfect, I’m certainly not done with the validation. But I’m working hard at it and making progress.
And of course, in the midst of writing this post, I received notice that my most recent paper was rejected by a big fancy journal. Sigh. I’ll survive. The reviewer comments were generally complimentary. I’ll turn it around fast and get it back out there. This is a good paper, with a good result. It’ll get published. Last time it went to a diabetes journal. This time, I think I’ll submit to an ophthalmology journal. Maybe it’s time for a jog around the block.
I’m having my big meeting at 3 today with my new chief of staff, hopefully to refocus some of my work on direct hospital impact. It’ll mean more quality work, which I like, and less hard-nosed focus on grants and papers, though I will still aim at producing papers and writing grants. I like the world of science, and academic achievement, even though it’s gruesomely exhausting a lot of the time. I will be pleased to be able to just do some engineering, write it up, and submit it.
So. Resubmitting paper now. Hopefully the next journal will like it.
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* Mata J, Hogan CL, Joormann J, Waugh CE, Gotlib IH. (2012) “Acute Exercise Attenuates Negative Affect Following Repeated Sad Mood Inductions in Persons Who Have Recovered From Depression.” J Abnorm Psychol. 2012 Sep 17. [Epub ahead of print]
Depression and Feedback Loops.
I know I’ve mentioned before that I suffer from occasional bouts of depression. They’ve never been excessively severe, though I have been diagnosed with “Major Depression” in the past. Throughout my childhood and adolescence, depression was an essentially constant companion. I remember, when I was 14, coming to the conclusion that in a conversation, it took someone four minutes to decide they didn’t like me. In a new group endeavor, four days. I don’t remember how I chose those numbers, but the concept has followed me in the back of my mind ever since. Whenever it seems like people are not appreciating my contributions, I return to this.
Depression seems to exhibit itself in me as a strong desire to isolate myself. Fantasies of leaving things behind without telling anyone. Anger. Resentment. Petulance. And a powerful compulsion towards self-destruction. I fantasize about cutting, mostly. And I’ll catch morbid mantras in my head. The latest has been, “My life would be much better if I weren’t in it.” Back when I used to cut, I used to tell myself, over and again: “Love the pain.” In fact, I still use that one. I just use it when I’m running. Long ago, it was: “Death is faster.” Faster than what? It was never clear.
I did, like so many do, treat my depression with alcohol. Because I’m an addict, that didn’t work so well for me. And alcohol is a depressant. Treating depression with alcohol is like treating drowning with lead. I suspect one of the reasons for the incredible renaissance of aspect that occurs for so many in early sobriety, which is often called the “pink cloud”, is that we have stopped flooding our brains with a depressant chemical. But of course, I don’t know the science of it.
I see a psychiatrist every other month for management of my depression. I’m not taking any medicine at the moment. From time to time I’ve taken an SSRI, and they seem to work well enough. But I don’t like how they make me feel. It’s very difficult to describe. Everything becomes memory-foam soft and moss-covered. It’s true that I don’t feel as depressed when I take them. Nor am I creative, or insightful. But I will take them intermittently if things get too bad. I feel like I’m currently approaching that point. I may need to run a course of anti-depressants to unwind the loop I’m in.
There are a lot of feedback loops in mental illness. Consuming a substance, for an addict, triggers a craving for the substance. This leads to dependency, desolation, and eventually death. In depression, I will recruit anything I have handy into the fantasies I have about being unwanted, useless, and unwelcome. My blog traffic is down. Clearly, I’m not writing interesting things. Whether I write about sobriety or science, people just don’t seem to read this as much. I have never generated the traffic that so many other places seem to.
I’ve recently been violating some of my own rules about political interactions on twitter. My rules are simple, when it comes to political and controversial interactions. I have to be able answer yes three times to the question: “Does this need to be said, right now, by me?” If I can’t answer yes three times, I’m supposed to let it pass. I haven’t been doing that. And as a result, I’ve been getting into situations where I come off as a jerk, because I don’t keep my commentary properly circumspect. I’ve been advised by friends that although it’s obvious I’m not being malicious, I’m coming off as an ass. And I appreciate that warning. Because I suck enough at social situations when I’m actually present. On twitter, where I can’t judge tone and facial expression, I’m nearly hopeless.
Isolation is a feedback loop for my depression. The more time I spend alone, the more I feel unworthy of spending time with others. I’ve been doing things that are actually a little more social; I see a trainer in a gym instead of just running. I’ve been going out with friends for dinners and to coffee shops to work on weekends. This weekend there’s a potluck AA meeting at a friend’s house. But these paltry gestures as sociality are insufficient, at the moment, to salvage my overbearing sense of uselessness and separateness.
At parties, I always end up sitting alone, watching people talk. I don’t know how to do it. That’s what the AA potluck is going to be like too. And then, the party is recruited into confirmation of my sense of otherness. Even though I’ve tried to be social, I’ve failed again. It’s lonelier to be in a room full of people who don’t give a shit I’m there (or who wish I weren’t) than it is to be in a house by myself. I’m feeling similarly about twitter at the moment. It’s lonelier than not being there.
I’m mostly sure this is all internal. But I’m not certain.
One of the stable structures in dynamical systems is the periodic orbit. If you have a weight on a spring, and set it bouncing, and plot the position of the weight against its speed, you get a perfect circle. This is a periodic orbit. In the real world, with each bounce, some energy is lost. The circle contracts. And as a contracting circle is plotted against time, it forms a spiral.
Evaluating an Important New Paper.
I got an email last night from the editors of Medical Decision Making, which is a fairly important journal in my field. They publish on all aspects of how decision processes occur, can be improved, and can effect outcomes in medicine. Both at the patient-physician level, and at the level of health care systems. It’s pretty well-regarded. I’ve reviewed for them. They have an exhaustively thorough review process, in my experience, which involves the papers being re-reviewed many times and editors who seem reluctant to make, shall we say, editorial decisions. Papers are not accepted, again, in my experience, until all the reviewers agree nearly 100%, and the paper is in its final form. This process means that getting a paper through their editorial review process generally takes about a year, minimum.
They just issued a special report on modeling, which consists of seven papers laying out industry best practices. I’m going to focus on just the paper about Discrete Event Simulation (DES)*, because that’s what I’m an expert in. From a first read through, this paper is going to be crucial for people working in DES academically, and who intend to publish in the field.
The paper lays out a huge set of best practices, twenty-four in all, which range from common sense to enlightening and brilliant. None of them are bad. These practices will, I agree, do a decent job of separating DES models into rough silos of “good” and “not so good”. Obviously, no system is perfect, but researchers who adhere to these practices will be starting off on the right foot.
The introduction of the paper (which is linked about as the “out” in that vapor trail of hyperlinks), is a straightforward and commonsense description of what DES is, and how it works. My only quibble is the afterthought inclusion of Agent-Based Modeling (ABM) as a subset of DES. This is technically correct, ABM is a subclass of DES models. However, it is so specialized, and has grown into such a robust field of its own, that I feel it warrants separate treatment. ABM is not constrained by the traditional assumptions that go into process modeling with DES. So, from an academic, theoretical perspective, it’s correct to place it there, from a practical, engineering point of view, they’re different things.
The introduction also identifies a massive problem in the field of economic modeling, which DES is often used to inform, which is that:
“Non-constrained resource models—although unusual in other fields that use DES—are required in our field to accord with the common structural assumption made in most health economic models today: that all required resources are available as needed, with no capacity limitations.”
This is why I say that economic models are mostly made-up. The idea of modeling healthcare delivery economics as a resource unconstrained system is absurd on its face, and yet that is the common structural assumption.
The first set of best practices involve when to use DES. And they get it right: DES is excellent for modeling dynamic, constrained resource, queue-based complex systems. They also specifically suggest that if health outcomes are not an output of the model, it should be explicitly justified. I might go the other direction entirely: if health outcomes are a model output, it must be very carefully justified as to how those outcomes are predicted! Predicting human health outcomes with a computer is very hard.
Of critical value too is the section on parameter estimation, specifically with regards to expert elicited data. Frequently, in modeling DES there is no data for some processes. Either because it is unknown, or cannot be measured, or there isn’t time or funding to measure it. This is often overcome with “expert elicited data”, which is fancy-talk for asking people how long they think stuff takes. For example, “How long is it from when you decide you need a radiology consult until you’ve got a radiologist with you in the ED?” This kind of estimation is relatively common in DES modeling, though too much of it and the model is not likely to be of much value. Karnon et al recommend adopting these estimates, and then performing sensitivity analysis around the uncertainty in the estimate. Which is commonsense and not arduous. Often, model outputs will be very robust to these types of estimations, but sometimes not.
Here’s a critical piece, well included, and I was thrilled to read it:
“When modeling clinical practice, it should not be assumed that relevant guidelines are actually applied.”
Meaning, when you ask people what the flow is in a clinical system, and they have guidelines for how flow is meant to go, don’t just believe them. Observe, and chart your own flow. People often take shortcuts, add interstitial processes, or preempt and resume processes which are meant to be uninterrupted. A good engineer does not just accept a clinical flowchart as sacrosanct. We model things as they are, not as they “should be”. This goes to taking data too. We do not care how fast people can do things. We care only how long it ordinarily takes.
Here’s another one I understand but don’t entirely agree with:
“Implementation should account only for the outputs required for validation and final analyses. If individual-level data are required, outputs should be stored as attributes; otherwise, aggregated valuesshould be collected.”
They advocate collecting aggregated data when possible, and storing individuated data only if necessary. While this is good memory management, it is not necessarily good modeling practice in the early stages. We may not know what types of outputs are going to be needed for future analyses. It is good practice to create capacity for capturing individual level data, even if that data is not utilized from the beginning.
There are a number of best practices on computing time issues, which I won’t evaluate because I have never had that problem. However, I can say that none of them strike me as inappropriate. If your model is large enough, or your time horizon long enough, that model runs become prohibitive or limiting, then these would be well heeded. But I feel almost like they’re relics from a time when computers were not nearly as fast as they are now. These may also apply to ABM in a way that they don’t to DES clinical models, for example, when modeling a termite mound at the level of individual insects.
They advocate basic good programming procedures and the use of animation for engaging with non-engineers and programmers. Good work all. It’s a strong paper which has only one glaring omission.
They do not discuss model validation. At all. No best practices on how to demonstrate that the model represents the real world. No means of asserting that the conclusions are predictive. I have my own ideas for this, and will discuss them eventually. Hopefully, in a journal article.
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*”Modeling Using Discrete Event Simulation : A Report of the ISPOR-SMDM Modeling Good Research” Jonathan Karnon, James Stahl, Alan Brennan, J. Jaime Caro, Javier Mar and Jörgen Möller
Practices Task Force -4, Med Decis Making 2012 32: 701, DOI: 10.1177/0272989X12455462
Infactorium 