rivka

Q. How much money is it, and who's paying?

A. I'm being funded by the U.S. National Institutes of Health. NIH put out a call for research proposals addressing "clinical decision making in life-threatening illness," and I responded with a proposal to study how people with HIV make decisions about starting anti-HIV medicines.

I applied under a grant mechanism called "R21," which is designed to support exploratory research aimed in novel directions. The big advantage of an R21 for someone at my career stage is that you're not expected to have tons of pilot data. The R21 is for compiling tons of pilot data, which you then use to justify a larger grant next time.

R21s provide two years of funding. NIH is going to be sending me $125,000 for direct costs in the first year and $100,000 in the second year. ("Direct costs" means money spent directly on research. "Indirect costs" are when your university tacks on 50% extra for grant administration, facilities, et cetera.) The direct costs will cover 50% of my salary and benefits, 50% salary for a research assistant, 5 or 10% of Lydia's salary (I forget) as my "senior advisor," compensation for research participants, miscellaneous supplies, some computers (I think we asked for a desktop for me, and one laptop each for me and my assistant), and travel (two trips to North American scientific conferences for me and one for my assistant).

Q. What are you actually studying?

A. "Cognitive biases and interpretive schemas in antiretroviral therapy decision-making."

See, there's this goofy idea in medical-decisions research that people make decisions about which treatments or health behaviors to adopt by collecting impartial information about benefits and costs and weighing them in a rational manner. If the benefits outweigh the costs, they agree to the treatment.

I think that bears no resemblance to how many people make medical decisions. I think that people tend to filter incoming medical information through a series of mental frameworks that govern their interpretation of what the world is like and how it works. Depending on the nature of those filters, they may reflect incoming information accurately, or they may act like powerful distortion lenses which twist or bias the information beyond recognition. Medical decisions may then be based on a warped accounting of costs and benefits.

For example, if part of your mental framework for understanding HIV is the belief that HIV originated as part of a U.S. government conspiracy to eliminate undesirables (this is an extremely common belief among African-Americans in the U.S.), that framework may well bias your opinion of federally-approved and state-funded treatments recommended by the doctor you're seeing at a public health clinic. Or, for a different example, if you have a basic conviction that "nothing good ever happens to me - my life is hopeless," you may pay little heed to your doctor's glowing picture of medication benefits, and focus instead on the potential for severe side effects.

I'm going to be studying whether and how these cognitive biases and distorted reasoning processes affect HIV-positive people's decisions to accept or reject an offer of antiretroviral therapy.

What makes this study "novel," in NIH terms:

(1) Oddly enough, no one's ever done a rigorous study of why some people refuse ART. People have done open-ended interviews, but not quantitative research.

(2) "Conspiracy theories" about HIV have been studied in the general population and linked to health behaviors, but they haven't been studied among people with HIV. On the one hand, you'd expect those people to be better educated about HIV. On the other hand, you'd expect them to be more open to explanations that none of this is their fault. It's an interesting question.

(3) I'm applying cognitive theory (as in, the theoretical foundation of cognitive-behavioral therapy for mental illnesses) to medical decision-making in a non-psychiatric population. Other people have certainly applied cognitive principles in working with medical patients, but typically only those who are referred for "adjustment problems" or similar - not in medical patients considered generally. So this is a novel application of theory to problem.

Q. What will this mean for your career?

A. It's hard to overstate how important this is for my career. This is a big deal. The ability to attract federal research funding is perhaps the single most important quality an academic scientist can have. True, this is only a small grant - but then, I'm a new junior faculty member. Any NIH funding is prestigious, especially in this era of shrinking federal research dollars.

What makes this different from all the research projects I've worked on before is that I am the Principal Investigator. This is my funding, not anyone else's. I'm solely responsible to the U.S. government for the financial and scientific conduct of the study. I'll be making all of the decisions about how the study is run and how the money is spent. That means that the lion's share of the credit will go to me as well. I've written big portions of Lydia's grants, but at the end of the day she's the PI and the credit and control are hers. In this study? They'll be mine.

This grant will make it much easier to change jobs if I want to. And unless I mess things up, it's designed to smooth the way for my next grant. The whole idea of an R21 is that it's supposed to allow me to collect data which I can then use to support my future requests for research money. In this case, for example, the logical progression would be that I'd use the data from this grant to support a much larger research proposal in which I outline a plan for improving medical decision-making by changing this kind of irrational or biased reasoning.

So this is a Big Deal for my academic career. But also: I think this is an important project which has the potential to make valuable contributions to science. I think this is research that Should Be Done. I am so excited to have the opportunity to make that happen.