On unexpected inspiration

By the time I left my doctoral seminar today, I felt a jolt of excitement for and inspiration around my doctoral program at UW - a feeling that has eluded me for the last few weeks to month or so.

Thanks to my good friend and colleague David Pigott, who ended his phenomenal presentation considering opportunities where global health metrics and implementation science intersect (a truly unique arena provided by our program), I once again remembered why I chose this program (and ultimately did so twice). I chose it for its interdisciplinary nature; for its range of options and topical areas; and importantly, for its capacity to substantially elevate my research abilities and leadership to a new level. And to get there, well, it was never going to easy.

Statistics - particularly of the bio variety - and my brain have never meshed well together. I liked math in high school and I love quantitative research, yet statistics has continued to muddle my neurons for years. Prior to starting the PhD proram, I had essentially made it pretty far in my career without making much headway on the foundation, let alone more advanced knowledge, that is critical to most effectively leading research projects or teams. I wanted - I want - to get better at statistical methods and modeling, even though I know I will never be a stats wizard like many of my colleagues and cohortmates. And as mentor once told me, it's very rare to meaningfully learn new things without struggling. I just need to deliberately practice remembering all of this, even if it's for a few minutes each day. Otherwise, I'll risk missing out on a lot of important experiences and opportunities during my program if I keep cycling through the first four stages of statistics grief (denial, anger, bargaining, depression) without carving out more acceptance.

Today I learned...
About some of the interesting implementation science methods and measurement efforts being spearheaded by UW's Professor Bryan Weiner. We actually share a similar background - fierce foci on clinical psychology followed by realizations that the clinical setting didn't quite align with our dispositions - and I want to learn more about how he's bringing behavioral science into health systems frameworks and evaluation.

Today I'm grateful for...
Katie Harris, who has been incredibly generous with her time and expertise as I aim to evolve into less of a bull in an program evaluation china shop. Relearning how to be a student and researcher again hasn't been the most smooth-sailing (let's just say my ship is prone to capsizing and I'm frequently grabbing my bilge pump), but Katie has helped to steady me (and my analyses).

Today's best part was...
Geeking out about malaria treatment coverage measurement and trends with Annie. Second place goes to running with bike lights wrapped around my ponytail ("I'm a bike...but not!") and finally starting to feel better from the nasty head cold that took me down this weekend slides into third. The latter would rank higher if I hadn't lugged around an entire tissue box to classes; I guess there's always tomorrow.

"Boy becomes man becomes doctor" - Nafis Sadat

ROY BECAME A DOCTOR TODAY!

Today I learned...
How much easier analyses are when you have a well-constructed codebook and/or labeled variables in your dataset. While this is far from a new thing learned, I think it's worth mentioning given the extent to which I increasingly appreciate such data management. The amount of time I'm currently spending to hunt down variable names, confirm survey skip patterns, and format data for analysis is a blunt reminder of why research often can take longer than you anticipate...especially when you don't have the incredible benefit well-formatted data and/or team members or collaborators working with you on data-cleaning.

Today I'm grateful for...
Hot lemon water, the very unscientific treatment of choice to battle this head cold threatening to take over my sinus system. Beyond my stock of sinus pharmaceuticals, few things make me feel better than hot lemon water when I'm sick or at the cusp thereof.

Today's best part was...
Celebrating the newly minted Dr. Roy Burstein. I'm struggling to eloquently describe the mixture of awe, pride, and excitement I'm still tingling with. To see him present on his work, some of which I've contributed to and/or supported in one way or another; to recognize the years of analysis, code de-bugging, and revision behind his hour-long presentation; to know that with his successful defense and new role as the team lead at IHME Roy is about to write a new amazing chapter in his career...I couldn't be more proud of my friend and colleague.

Two weeks until Ljubljana!

In two weeks' time I'll be somewhere in a plane en route to Ljubljana for the 2018 European Public Health (EPH) Conference! I'm both excited and nervous, with latter incited by simply how much I need to get done between now and then.

Today I learned...
That post-midterms moment of solace is officially over. The latest biostats homework was a beast (to say the least), and well, it looks like a certain someone will be spending some more time at TA office hours...

Today I'm grateful for...
Others' patience and flexibility. I truly thought I set my alarm for 6 am, but much to my dismay I woke up just before 8 am...and my dear friend Mel was supposed to drop off her dog to stay at my place at 7 am. She would have had every right to be extremely frustrated (and if I were in her shoes, I probably would have been myself), but somehow she wasn't and everything was fine. As someone whose average patience levels are mediocre at best, it was a great reminder about better 'going-with-flow.'

Today's best part was...
Coming home to two dogs who were just so unabashedly happy to see me. That level of enthusiasm and pure adoration for someone doing so little - arriving home! - makes it really hard to remain too discouraged by biostats for too long.

Ahoy, four-day week ahead

Three-day weekends are swell, or at least until you realize you probably still need to squeeze five days' worth of work into the next week. Plus fun social events (I'm hosting the monthly Metrics' get-together on Wednesday), very exciting occasions (someone whose name rhymes with Soy Murstein has a doctoral defense on Friday [!!??!]), and a small dabble into cat-watching for a friend in a pinch.

Today I learned...
If you include multiple quotations within a graph's title in Stata, the title will then break at the quotation marks and create a new line (!?). And suddenly, my graph titles are much more readable...oh the little things.

Today I'm grateful for...
A beautiful afternoon (nearly 60 and sunny in Seattle...in November?!) in which I ran Gabby the dog up to the dogpark and back. She's now gently snoring on my bed and curling up at (or perhaps around) my feet. This dog brings me so much joy, and well, today I'm grateful for you Gabby.

Today's best part was...
Brunch with some lovely friends/colleagues. I miss having them in my day-to-day life, but I suppose catching up over breakfast burritos will suffice for now. 

To GBD and beyond

The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) published today in The Lancet! All papers can be found here: https://www.thelancet.com/gbd

For me personally, it's a somewhat bittersweet occasion, as GBD 2017 will likely be the last GBD iteration (or at least the last for awhile) in which I will have played some kind of substantive role in 'capstone' analytic or production processes. While this is, overall, a good thing (i.e., pursuing a PhD and being involved in GBD production, especially the health-related Sustainable Development Goals [SDGs], would be extremely masochistic), I do miss aspects of it. The phenomenal and brilliant people you get to work with, the thrill of coming up with solutions for a massively challenging scientific undertaking, among others. Of course, I have far less nostalgia for the 80+ hour work weeks during Seattle summers; the mental anguish of trying to multi-task and triage everything at once; the heartbreaking conversations of asking your team to spend yet another late night or weekend rerunning models since something upstream from them and thus outside of their control didn't work; and so on.

In sum, I've had some of the most rewarding times of my career working on GBD, as well as some of the most difficult and trying. I'm honored to have worked with so many stellar individuals over the last three years, and I look forward to seeing what they, from Seattle to Senegal, accomplish going forward. Congratulations to all GBD team members and collaborators!


Today I learned...
The subtle differences between screening and testing, as well as predictive values and similar constructs, for epidemiologic studies and public health programs. Elizabeth, one of my cohortmates, helped me hone in on the differences: for example, my mother has a degenerative eye condition (retinis pigmentosa [RP]), and because it's an inheritable genetic condition, there's interest in determining if/how offspring get the disease. But since RP is fairly rare condition (1 in 4,000 people are thought to have it) and effective treatments remain in pretty nascent stages of development and availiability, recommending formal retina examinations and additional vision tests to test for RP is unlikely to provide substantial benefits at the population level. Instead, the "screening" clinicans use are brief patient histories to identify individuals who know of relatives with RP and then those higher-risk patients are recommended for retina tests (aka people like me). I used to have scans of my retinas in my gmail inbox, but sadly I can't find them anymore; in sum, my retinas are nice and clear, without any black speckles or pigment streaks. The latter would have been here even if I wasn't experiencing clinical symptoms, so it appears I'm RP-free.

Today I'm grateful for...
Nolan Myer, who generously shared his Sounders tickets with this little PhD student. I haven't been to a Sounder game in years, and the whole >60% annual salary reduction thing makes attending sports games a little less likely during my doctoral studies. Thank you so much!

Today's best part was...
Going to the Sounders game with a high school friend (Jared Berbach). Though Jared has lived out here for about three years, we haven't overlapped that much (mainly due to my nutty work schedules). We have now hung out twice in the last two months (!!), so hopefully we can maintain this positive trajectory for the remainder of 2018 and 2019.

By one's bootstrap(ping)s

If I'm not dreaming in attributable risk and cumulative incidence equations tonight, some major rethinking of my studying methodologies may have to occur...

Today I learned...
What bootstrapping is!...or at least conceptually. I haven't successfully (or unsuccessfully, I suppose) run any code to implement bootstrapping, but that's up next on the docket. I'm mildly (aka tremendously) horrified to admit that, even after all of these years, I didn't quite understand what bootstrapping was (in brief: you take a random sample of your study population x times, with replacement so you get the same n as the original study population, and then ta da, you produce a distribution of sample means based on bootstrapping!) and why it could be helpful for an analysis (e.g., estimating 95% confidence intervals). I must say, it was very satisfying to leave biostats class today feeling like I really learned something (potentially) useful for my future research pursuits.

Today I'm grateful for...
Living in a state where all voting is by mail and thus I had the opportunity to vote whenever it fit best into my schedule. This year I wanted to hand in my ballot after I finished my own midterm on November 6, but I just couldn't wait any longer.

Today's best part was...
Receiving a truly heart- (and head-)warming text message from Marissa Reitsma, a friend/colleague whom I've had the true pleasure of getting to know better and working with over the last few years. Receiving an unexpected kind word or two is always lovely, but when it comes from someone you greatly admire and respect as a person, researcher, and well, a badass and strong female, it's that much more meaningful. While it's still early yet in my PhD, I'm fairly sure I'd like to pursue an academic career and seek a faculty position somewhere in this crazy world. I very much care about supporting early-career researchers and providing mentorship where and how it's appropriate, and well - the receipt of a thoughtful, affirming text from Marissa this afternoon brought tears to my eyes and offered a fierce neural hug to my strung-out synapses. Academia and related activities aren't for the faint of heart, literally (three words: free office coffee) and of course figuratively. I occasionally think back to college me and then the early-to-early-ish career model, and wonder how those versions would see me now: a little less idealistic, a bit more decisive, and comparatively, tough as nails. Now, in absolute terms, said nails would be a far cry from earthquake-proof or of diamond-level tenacity; I still have a lot of learning and skin-toughening ahead. Yet I think it's equally important to take time to appreciate the small steps of progress - those little things, after all, may end up being big things. 

I do not think it means what you think it means

As I go through stacks of lecture notes and work through different epidemiology formulas, I keep circling back to this particular side – and thus why good, precise scientific writing and phrasing matters.

In this case, if you weren't paying attention to what was actually being calculated, the easiest interpretation would be there is a 65% greater risk associated with male sex...the act, rather than the category of self-identification of male and female.

Sure, revising to "Risk of drug overdose mortality for males was 65% higher than for females" involves a few more words (and sometimes every character matters) but that kind of excess is probably better excess misinterpretation. But hey, maybe that's just me and my scientific writing zealot ways.

Today I learned...
Well, in theory, this was relearned, but my understanding of it is much better now after studying it a bit more. Relative risk, attributable risk, and population attributable risk – all of which underlie the debate (as highlighted by this Vox article) and ire around this summer's alcohol study (Professor Spiegelhalter's Medium blog post provides a good example of said fury). I plan to speak more to this in a future entry – full disclosure: I wrote or revised a lot of the first submission version of the paper with Max Griswold (lead author) and Emmanuela Gakidou (senior author) – but some main takeaways for now are:

1. The primary message was that, when you accounted for all risk-outcomes with strong causal evidence for alcohol use, the protective effects found for a few causes (i.e., cardiovascular diseases, diabetes for females) with low/moderate alcohol consumption were offset by increasing risk for cancers at similar levels of consumption.
2. Findings on the relative risk for overall health loss and alcohol consuption were meant to provide additional information to the broader debate around alcohol use and potential health benefits – that, despite the prevailing view that 1-2 daily drinks are beneficial to health outcomes, imbibing those bevvies actually don't promote healthier outcomes like you think they do. Bodies aren't silos where, after consumed alcohol is broken into its various bits (yes, that's the scientific terminology), they're only circulated through the cardiovascular system (moderate alcohol benefits hurrah!) and completely sequestered from potentially having negative effects on the liver, colon, etc. It's not how the current formulation of human bodies operate, and thus we shouldn't be viewing the associated risks for health outcomes in similar silos.
3. The paper was never meant to promote the total absention of alcohol consumption; rather, it sought to emphasize how population-level initiatives to reduce alcohol use, which may include efforts that promote abstention in some groups, could have a large impact on improving health outcomes and reducing disease burden. Whether those benefits outweigh the societal and individual costs of enjoying alcohol is up to decision-makers, clinicians, and individuals to weigh in on. I, for one, certainly enjoy my beer, and I don't plan to eliminate my consumption until or unless particular health states (e.g., pregnancy) or needs (e.g., unknown health challenges in the future) deem it as important. Here's the thing: I don't view drinking beer as beneficial to my physical health, and when I have a beer, I'm not drinking it because it's heart-healthy. I drink beer because it's tasty; I enjoy it with friends, family, and well, honestly by myself after a long day; and I view it as a comparatively "better" vice than guzzling soda (which I don't consume), smoking (tobacco-free is me), and other less-than-healthy dietary habits (e.g., I rarely, if ever, eat bacon and processed meats, which were classified as group 1 carcinogens in October 2015). 
4. In my opinion, the phrasing used in press releases – "No safe level of alcohol" – ultimately drove the widespread outry and misconceptions around the study. To the broader public (and I would argue most everyone), claiming there is no safe level of something suggests something much more sinister or scary than claiming there is no healthy level of something. For instance, when I discussed the paper and its press coverage with my mother, she indicated that she would have had very different reaction to the study if the lede had been "No healthy level of alcohol" rather than the phrasing "safe." Her view was that "no safe level" implied any exposure was toxic or dangerous, akin to nuclear radiation or mercury poisoning, whereas "no healthy level" would have de-emphasized the health-promoting benefits of alcohol use – what the main message was meant to be – without suggesting any amount was immediately ruinous for your health. Perhaps my rant above about the importance of good, precise scientific writing and phrasing had some earlier origins...

Today I'm grateful for...
The ending of daylight saving time, and that beautiful, beautiful extra hour of sleep last night.

Today's best part...
Was waking up feeling like I slept in until 8 am and realizing it was technically 7 am by today's clocks. Yes, today I'm doubling down on the wonderful thing called the end of daylight saving time.

On second-guessing

Over the last few days I've thought a lot about about practice of second-guessing – the act of criticizing or questioning actions, decisions, and outcomes – and how the role that second-guessing is playing out in my life right now.

Here's the thing: second-guessing is quite beneficial to scientific inquiry and review. Questioning results and why they look the way they do; examining if x outcome really happened because of y and not z data artefact; and deliberating alternative interpretations or outcomes, given a set of known and unknown factors – these are not only attributes of a good researcher, but also behaviors actively encouraged to become a better one. It's a type of critical thinking that, when channeled well, contributes to strong science.

Yet, as I've found at various points in my life and certainly at present, the ability to optimally deploy this mentality without it seeping into less helpful areas of life can take concerted energy and psychological viligance. When those mental resources are spent and/or particularly stressed, what is generally a strength can quickly become disadvantageous. For me, my ability to "second-guess" scientific results and identify potential anomalies, patterns, and the like has been an asset over the course of my career. Even when I was working in more research-adjacent roles, this ability was quite useful for finding 'red flags' ranging from typos to major discrepancies between key results, figures, and messaging. This kind of critical mindset is a strength until it isn't. Perhaps like many good things, maximizing a strength or skillset is not necessarily about always exercising it, or firing on all cylinders for every situation. Instead, it's likely to be more about recognizing when and how such strengths should be used – and then cultivating other abilities to better complement existing strengths.

For me, particularly in the places where professional and personal dimensions intersect, one of my largest challenges has been knowing – and then trusting – in myself to understand what is the best or right thing for me to do. I have a people-pleasing streak 10,000 miles wide, and a desire to successfully deliver for whatever my team (work) or people (non-work) ask of me, which then translates into (and/or reflects) a deep-seeded fear of letting people down. Call it a gender thing (yes, I was a born of the female sex and I identify as a woman), a personality trait, a reflection of my upbringing, or some constellation of these forces. It's who I am, with all its positive attributes and less-than-ideal characteristics. The detours along the path to finally deciding to do a PhD were certainly shaped by this: the internal conflicts of prioritizing myself and my educational pursuits versus contributions for my teams and organizational affiliations; and the struggles of genuinely recognizing what I needed to do for myself and future, even if that risked (actually or in perception) letting people I deeply cared about down in the process. And while I've made substantial gains over the years, I certainly haven't mastered keeping the second-guessing at bay – or perhaps better said, channeling such second-guessing toward its best uses in my life.

Good thing that, just like research, we're all works in progress.


Today I learned...
Before people figured out scurvy was caused by vitamin C deficiency, they associated the disease's occurrence with leaving land and its remission with returning from sea. The presence of land was then viewed as the main driver of scurvy...which led crew members to bury themselves in dirt up their faces upon arriving on shore in an effort to maximize their "land" treatment.

Today I'm grateful for...
Melody Miles and her beautiful, thoughtful writing (as featured in her blog) on life's transitions, ups and downs, and so on. Something she shared yesterday really resonated with me and a lot of what I've been feeling lately:

The truth is not all my work is completed and my heart cringes at knowing I’m leaving things undone....My heart wants a few more days – or maybe a few more months - of the same. Even though I’ve prepared for this ending, the feeling of familiarity always seem to be more enticing that the feeling of the unknown.

*

I know in my heart of hearts leaving is the right thing for me to do. But that doesn’t mean my heart doesn’t ache inside. It doesn’t make the crazy feelings go away or the heavy cloud of change any easier. This work of saying goodbye, staying open, and inviting a new life to happen to me is probably the hardest work of my life.

Today's best part...
Was receiving a (somewhat) random text from a friend/former colleague about how much she loved this blog. It meant a lot, especially since I'm not exactly sure how all of this could or should be received; my aims continue to evolve, both for myself and for others, should they choose to take anything away from this little side project. Today, well, I think it would be pretty great if someone, anyone comes across this, recognizes themself in one way or another (yes, I'm using themself, as I'm trying to do a better job with gender pronouns), and finds a bit more strength or confidence to pursue what they're discovering is right or best for them. Yes - that'd be pretty darn great.