Focused Nonchalance

Focused nonchalance is, I believe, the ideal attitude to cultivate when preparing for and taking a high-stakes exam.

While much much easier said than done, the goal of attitudinal preparation is to strive for a state of flow when answering multiple-choice questions: focused and potentially even joyful as you take an exam, marshaling all of your cognitive resources without falling prey to anxiety and self-doubt.

Flow, the now widely-phenomenon phenomena akin to being in “the zone,” was first described in the 90s by the prominent psychologist Mihaly Csikszentmihalyi in Flow: The Psychology of Optimal Experience:

In normal life, we keep interrupting what we do with doubts and questions. ‘Why am I doing this? Should I perhaps be doing something else?’ Repeatedly we question the necessity of our actions, and evaluate critically the reasons for carrying them out. But in flow there is no need to reflect, because the action carries us forward as if by magic.

While the optimal experience and apparent effortlessness of flow as it is most popularly described is probably out of the reach most students taking a multiple-choice test, my point in this discussion is to state firmly that achieving focused nonchalance or even a flow state is not dependent on your actual test-taking skills and prowess or the fraction of questions you get right easily, but is instead a reflection of your attitude and preparation. (Don’t get me wrong, if you always do well on exams and are a natural narcissist, this will likely all come easier). Csikszentmihalyi never argued that flow necessarily meant you were doing awesome; even in the title, he suggests that flow leads to an optimal experience. Nonetheless, that optimal experience goes a long way on a long and stressful examination.

 

Hitting the Wall

Many people who put in a considerable study effort eventually hit a score wall or plateau where more and more effort seems to yield minimal or even worsening score results.

Your specific goal, whatever it is, is awesome and I hope you get it, but you also need to realize that goals are only helpful as a means of motivation, not something to tie your entire self-worth into. Otherwise, the wall is crippling. A friend’s performance, peoples’ forum posts—absolutely none of that matters.

Putting aside the reality that people presumably do have a natural maximum performance range and the fact that the tendency to focus on learning fringe esoterica is unlikely to pay dividends test by test, I think a significant fraction of the mutable wall comes from two places: overthinking and fatigue.

 

Overthinking

Overthinking a question is a symptom of underconfidence. When you overthink and question yourself it’s because on some level you believe that you are insufficiently prepared to determine which facts are critical within the information provided to derive a correct answer. Therefore you start searching for hidden clues to avoid making a “silly” mistake.

The solution is to believe that at any point you are as prepared as you can reasonably be and that you should use the skills you have at that moment to answer to the best of your actual ability. Going hunting or dowsing for tricks isn’t going to help you if you don’t really know what it is you’re looking for.

The components of a question that matter to you only matter because you actually know what to do with them and what they signify. If you change your answer from what you would otherwise pick due to a hunch, you’re guessing. If you want or need to guess that’s fine, everyone does with some frequency, but then guess happily and move on. However, changing what you believe is the best answer just because you wonder if some detail might make a difference but aren’t sure is unlikely to consistently lead to better results.

Overthinking and dumb mistakes are actually two sides of the same coin: one tends to happen when you try to prevent the other. So you oscillate back and forth, even from question to question within a single block. When you check your answers, either in a tutor mode scenario or at the end of a block, the questions you get wrong are a head-slapping frustration-fest instead of learning opportunities.

This frustration is (naturally) compounded by being emotionally invested in your performance. This is why you need to believe that you’re going to do as well as you can. Agony helps no one.

When you’re stumped by a question, the answer isn’t to be sad or angry at yourself. The response should be, “Ah, here’s one of those irritating questions that I’m designed to get wrong. Time to narrow down as possible, guess, and move on.” Even if you know that you used to know the answer, you’re still human.

Your job isn’t to get the all the questions right; that’s an outcome you can’t control. Your actual job is to take each question individually, apply your knowledge and reasoning to it, and pick what you feel is the most likely answer.

 

Guess. Guess again. Guess better.

When you’re down to two choices, try to see if one answer might feel more right. Often, you will like one answer better but won’t be able to “rule out” a second choice. This second choice sometimes seems like it could be correct. Most high stakes exams including the USMLE use a “single best answer” format. This means that other answers don’t all have to be wrong, just that one of them stands out as better (i.e. “the best”). You don’t technically have to know the right answer, you just have to pick it.

Medical school sadly may not contribute very much to your 10,000 hours toward becoming a great doctor as Malcolm Gladwell popularized in Outliers. But it does give you a lot of mileage on the goal of being a great MCQ test taker.

So, the ability to instinctively and comfortably guess the correct choice is another reason to do tons and tons of practice questions from a reputable source. You can develop your innate question sense by practicing and practicing. Using low-budget or alternative questions can be a bit dangerous, as some of these resources over-test minutia or try to trick you in ways that are not typical of the real USMLE.

 

There’s wrong, and then there’s wrong

I remember that when I’d get questions wrong on UWorld, a lot of the time I would say, “oh wait, that doesn’t count, I knew that one.” But the fact is that there is more than one way to get a question wrong. Most people think of really being “wrong” when they’re totally clueless, but that typically makes up a minority of cases. Many times you will actually know (or tell yourself you “know”) the fact being tested even when you get it wrong in question format. Doing questions means continuing to pair up facts with answers, and it takes time.

One of the difficulties many of my former students had with studying through questions is that getting questions wrong is demoralizing. Again, the bottom line is that when you’re studying over the long term with UW or any qbank, your goal isn’t to get questions right; your goal is to learn. There’s almost as much to learn from the questions you answer correctly as the ones you get wrong.

 

Building the Routine

As you get closer to game day, however, the need for simulation outshines the learning benefit of savoring each question in a pressure-free study session between looking at Instagram stories. Taking several blocks in succession and not being able to check answers or take large breaks is mentally different than normal studying. The difficult questions wear on you, shake your confidence, and, psychologically, it’s hard to maintain peak performance and concentration. What you want is to achieve Flow but what you are is nervous and miserable (even on a practice NBME).

Athletes train in similar circumstances as their competitions so that they don’t get nervous on game day. Wholehearted simulation is key. I am generally a huge proponent of tutor mode, but this does mean that as you get closer to test day you want to fix your habits and strain your test muscles so that the big day is just another day:

2 weeks out at the minimum is when you want to get your sleep and other habits in line. But being mindful of your daily practices should start now. You’ll need to start doing test mode and doing two or three block chunks in a row so that you get used to working long stretches.

Never forget that the real thing can really feel terrible. It’s long and you never get any positive reinforcement. The questions you had to guess on will weigh heavily in your mind. This is all test psychology. How it feels doesn’t actually need to matter; chances are you are doing exactly as well as you normally do, and that’s what you need to tell yourself as you go through the day to make that true.

Remember, the goal is focused nonchalance. Don’t forget: “this test is a poorly constructed hurdle” is a better mindset than “this test determines my future.”

The Radical Idea to Forgive all Student Loans

This interesting article in New York Magazine about the proposed economic benefits of forgiving all of the outstanding $1.4 trillion in student loans has been making the rounds recently:

According to the Levy Institute paper, authored by economists Scott Fullwiler, Stephanie Kelton, Catherine Ruetschlin, and Marshall Steinbaum, canceling all student debt would increase GDP by between $86 billion and $108 billion per year, over the next decade. This would add between 1.2 and 1.5 million jobs to the economy, and reduce the unemployment rate by between 0.22 and 0.36 percent.

So, the macroeconomic upside of canceling all student debt would be substantial. The primary (supposed) downsides of such a policy would be a higher deficit, the potentially regressive distributional consequences of debt forgiveness, and (relatedly) the unfairness of rewarding certain well-off borrowers who don’t “deserve” it. Of course, all of these critiques would apply more powerfully to the recently passed tax cut bill. Few people would argue that increasing Harvey Weinstein’s after-tax income was a laudable public policy goal. But no one thinks that we should judge the merits of a tax cut on the basis of whether it rewards any unsavory individuals.

Forgiving $1.4 trillion in debt sounds nuts, but as a convenient near-perfect foil, we instead have a $1.5 trillion tax cut that probably won’t do a whole lot to help anyone who needs it.

The government theoretically profits from the Direct loan program, but the currently rising and soon to be endemic rates of default now predict that the government will start losing a lot of money in the near future.

What most people don’t realize when it comes to the alarmingly rapid rise of student loan default is that the most common culprits are not big borrowers attending expensive private schools (though that happens too, and certainly the need to repay large amounts of debt can be crippling and limits consumption). It’s actually people who borrow less than $10,000. It’s the people, many of whom who never completed a degree program or who received technical training at an unsavory for-profit “institution” like Trump University, who are unable to find the good steady work needed to pay off even a relatively small loan.

As with tax breaks, the biggest winners of the definitely-not-going-to-happen universal loan cancellation would, at least on paper, be high-debt high-income professionals like business school graduates and physicians. But unlike a tax break, not needing to use IDR would result in the same return of 10%+ from every borrower’s income, year after year—a much bigger and likely much more meaningful change, and it would also mean that those who default would finally be able to take steps to rebuild their credit.

Brevity: A Flash Fiction Handbook

I finally had a chance to sit down and enjoy Brevity: A Flashfiction Handbook by David Galef.

This was particularly fun because:

I’ve published six stories by Mr. Galef in Nanoism, my unusual journal that exclusively features Twitter fiction, the longest running of its kind. Keeping it in the family, I’ve actually published even more (10!) by his son, Daniel Galef.

Nanoism is featured in the chapter discussing microfiction. Galef defines nanofiction in the book basically exactly as I did when I started publishing in 2009: Twitter fiction, stories of 140 characters or less (i.e. teeny teeny teeny tiny stories). As the book includes examples of flash fiction’s many forms and styles, two pieces from Nanoism’s library of almost 800 stories also made it into the book (on page 123).

Aspiring writers of very short stories would do well to check out Brevity in addition to The Rose Metal Press Field Guide to Writing Flash Fiction which came out back in 2009. Good stuff.

Trump hasn’t killed PSLF yet

There are a lot of headlines talking about what Trump is doing to PSLF.

But, to be clear, Trump isn’t doing anything to PSLF.

What Trump has done is release a budget proposal, as the sitting president does every year. This proposal is meant to signal policy goals for the administration, but nothing in it is binding. Presidents don’t make budgets; Congress does. President Trump made similar student loan requests for 2018 as he has for 2019, and they were roundly ignored last year. President Obama recommended capping PSLF during his last years in office, and that was ignored as well.

Don’t get me wrong, I don’t think PSLF is going to last forever. It’s going to be much more expensive than the government realized, and pulling out the rug from “rich” doctors may one day prove to be relatively good optics for budget savings.

But, there’s a big difference between PSLF being shuttered in the future (or even next year), and PSLF going away for those are already counting on it.

PSLF is still available, and there’s no reason to ignore it.

Make no mistake, Trump absolutely does want to kill PSLF. However, this is the actual language of the Trump FY2019 budget proposal, and it’s pretty clear that it does not affect old borrowers (emphasis mine):

Reforms Student Loan Programs. In recent years, income-driven repayment (IDR) plans, which offer student borrowers the option of making affordable monthly payments based on factors such as income and family size, have grown in popularity. However, the numerous IDR plans currently offered to borrowers overly complicate choosing and enrolling in the right plan. The Budget proposes to streamline student loan repayment by consolidating multiple IDR plans into a single plan. The single IDR plan would cap a borrower’s monthly payment at 12.5 percent of discretionary income. For undergraduate borrowers, any balance remaining after 15 years of repayment would be forgiven. For borrowers with any graduate debt, any balance remaining after 30 years of repayment would be forgiven.

To support this streamlined pathway to debt relief for undergraduate borrowers, and to generate savings that help put the Nation on a more sustainable fiscal path, the Budget eliminates the Public Service Loan Forgiveness program, establishes reforms to guarantee that all borrowers in IDR pay an equitable share of their income, and eliminates subsidized loans. To further improve the implementation and effectiveness of IDR, the Budget proposes auto-enrolling severely delinquent borrowers and instituting a process for borrowers to consent to share income data for multiple years. To facilitate these program improvements and to reduce improper payments, the Budget proposes to streamline the Department of Education’s ability to verify applicants’ income data held by the Internal Revenue Service. These student loan reforms would reduce inefficiencies and waste in the student loan program, and focus assistance on needy undergraduate student borrowers instead of high-income, high-balance graduate borrowers. All student loan proposals would apply to loans originating on or after July 1, 2019, except those provided to borrowers to finish their current course of study.

“…except those provided to borrowers to finish their current course of study” further supports that students in the middle of the course of study will get grandfathered into PSLF.

So, new borrowers starting in 2019 at the earliest would be part of the new program.

And by new, I mean the US government’s definition of “new,” which really means having no federal loans prior to this date.

So:

  • Current students need not panic.
  • Former students currently in repayment need not panic.
  • Future borrowers who plan to only attend college need not panic (because the new proposal is actually pretty favorable to undergraduate loans).
  • Future borrowers who plan to attend expensive graduate schools like medical school should cross their fingers.

And, none of this matters if Congress does this year what they did last year and ignores the problem. Student debt is a hot-button bipartisan issue. Whatever reform, if any, does get passed is unlikely to look like a carbon copy of the Trump plan.

 

Concussion Protocol

Shaun King reacting to Josh Begley’s short reverse-highlight reel “Concussion Protocol” in The Intercept:

It’s not a headache. It’s not “getting your bell rung.” You don’t have a bell. It’s a traumatic brain injury.