My new book: Medical Student Loans

My second book, Medical Student Loans: A Comprehensive Guide, is now out. It’s a novella-length treatment of student loans specifically for physicians and written to cover the topic for all levels: premeds, medical students, residents, and attendings. It’s especially helpful for graduating MS4s and by its nature also covers important basic financial literacy in a hopefully non-threatening way.

In other words, I hope you like it.

Despite years of writing about student loans on this site, it was a ton of work to put this together and finally get it out to the world. To celebrate, I’ve made it completely free to download from Amazon until the end of Sunday, June 25.

MSL will also be part of the Kindle Unlimited program for the next three months. You can get a 30-day free trial if you need another way to read it for free.

Consider it your first few hours of CME.

Standard Ebooks

Standard Ebooks is an awesome long overdue idea:

Standard Ebooks is a volunteer driven, not-for-profit project that produces lovingly formatted, open source, and free public domain ebooks.

Ebook projects like Project Gutenberg transcribe ebooks and make them available for the widest number of reading devices. Standard Ebooks takes ebooks from sources like Project Gutenberg, formats and typesets them using a carefully designed and professional-grade style guide, lightly modernizes them, fully proofreads and corrects them, and then builds them to take advantage of state-of-the-art ereader and browser technology.

What a great project.

Explanations for the 2017-2018 Official Step 2 CK Practice Questions

The updated 2017-18 official “USMLE Step 2 CK Sample Test Questions” PDF, released in May and available here.

The PDF set is completely unchanged from last year. You can read the complete explanations for last year’s set here.


As for the updated multimedia questions found only in the online version:

Block 1

7. A – Classic Moro reflex, entirely expected and normal until it disappears around age 4 months. If you have never seen a newborn before, also note that the mom is concerned about delayed milestones at two weeks of age, which is a red flag for BS: babies aren’t even smiling socially yet by two weeks.

Block 2

3. D – Pill-rolling resting tremor of Parkinson’s disease secondary to loss of dopamine neurons in the substantia nigra.

18. A – I’m going to point out that a normal healthy kid with no cardiac history or symptoms and no family history of sudden cardiac death for a pre-sports physical is probably going to have a benign exam no matter what you think you hear. HOCM is what you want to exclude theoretically, but here we don’t have a real systolic murmur, just a little vibratory flow murmur at LLSB.

33. E – This one is a bit silly. The lung exam is normal outside of the super common basilar crackles. Everything except for PE you would expect to hear a more impressive auscultation abnormality. But for this question: B and C take longer than 3 days. D we would expect fever, productive cough etc. Bronchitis would be possible, but still more often to have at least productive cough if not fever. PE, on the other hand, classically has a nonproductive cough, hypoxemia, and tachycardia. All three are present. And then they mention her med: OCPs, which are an important predisposing factor for PE in young women for whom it is otherwise a rare entity. Young lady on OCPs is a classic set-up for an STD question (who needs condoms?) or a PE question, one of the two.

Block 3

12.1 D – Statistical significance (a low p-value) does not equal clinical significance. A favorite teaching point when it comes to interpreting literature.

12.2 C –A & D are conjectures: the kind of statements people drop inappropriately in the conclusion of a weak paper to make it sound important. E is an exclusion criterion. B is the opposite: including 0 is equivalent to something not being significantly different.

Navient is still lying to borrowers despite lawsuit

Unsurprisingly, Navient is still lying to borrowers despite the ongoing lawsuit (for misleading borrowers) from the Consumer Finance Protection Bureau.

I was talking to a fellow resident last week. She has almost a half million dollars in student loans from medical school and has been repaying in IBR. She recently got married, and her husband, also a resident, thankfully doesn’t have any student loans himself. Unfortunately, this also means that next time she recertifies her income, her payments are going to basically double thanks to the addition of his additional income. Once he becomes an attending, they would go up even further.

Given the possibility (and desirability) of public service loan forgiveness for her given her long training and very high loan burden, which would result in more money forgiven than she borrowed in the first place (due to negative amortization during residency), her goal should thus be to minimize payments in advance of this goal. I recommended she switched to Pay As You Earn (PAYE) to reduce her payments now and file her taxes separately from her husband next year (they weren’t married for tax purposes this year).

And here comes the lie: she called Navient for guidance, and the customer service representative told her she was ineligible for PAYE because she held a loan from 2009.

Anyone who knows anything about federal repayment programs or has the capacity to do a simple Google search would know that the limitations for PAYE eligibility have nothing to do with the year 2009. They are the following:

To qualify for the PAYE Plan you must also be a new borrower as of Oct. 1, 2007, and must have received a disbursement of a Direct Loan on or after Oct. 1, 2011. You’re a new borrower if you had no outstanding balance on a Direct Loan or FFEL Program loan when you received a Direct Loan or FFEL Program loan on or after Oct. 1, 2007.

So, nothing before 2007 and at least something after 2011. In other words, 2009 was a great vintage for PAYE. Full bodied and expensive with more than a hint of scut.

From the Consumerist:

The lawsuit alleges that for years Navient engaged in a series of illegal and deceptive practices, including providing borrowers with incorrect information, processing payments erroneously, and failing to address customers’ complaints.

Sounds familiar.

As always, it’s difficult to know if the servicer customer service reps are willfully ignorant or malicious, but they are routinely wrong (and seemingly proactively so).

My advice to anyone ever calling a servicer with a question is to already know the answer before you ask it. Find some official government verbiage to back up your interpretation. You should be looking for confirmation, not advice, and if the answer you receive isn’t the answer you’re expecting, find out exactly why. If the person you’re talking to doesn’t know, then get them to give you to somebody else.

More Open Access Journal Shaming

There seems to be a never-ending shaming parade of “peer reviewed” open access journals that exist to extract one-time lump sum payments from desperate authors in exchange for a publishing credit and poorly formatted PDF.

“The conceptual penis as a social construct” in Skeptic Magazine takes it the next level, by also lampooning an entire discipline of academic thought. The article’s approach, summarized by the authors:

We didn’t try to make the paper coherent; instead, we stuffed it full of jargon (like “discursive” and “isomorphism”), nonsense (like arguing that hypermasculine men are both inside and outside of certain discourses at the same time), red-flag phrases (like “pre-post-patriarchal society”), lewd references to slang terms for the penis, insulting phrasing regarding men (including referring to some men who choose not to have children as being “unable to coerce a mate”), and allusions to rape (we stated that “manspreading,” a complaint levied against men for sitting with their legs spread wide, is “akin to raping the empty space around him”). After completing the paper, we read it carefully to ensure it didn’t say anything meaningful, and as neither one of us could determine what it is actually about, we deemed it a success.

This one is a fun ride.

I actually have a case report in an Open Access journal back from my I’m-going-to-be-an-interventional-radiolgoist days (it wasn’t all that good, and my colleague did most of the work, bless him). We submitted but didn’t pay—I think they may have been desperate for articles to publish and just put it up. Case Reports are almost unpublishable now outside of these types of pay-to-publish journals, which creates a bizarre counter-incentive to trying to share interesting one-offs with other physicians and scientists.

I wish—in addition to a robust mechanism for consistently sharing negative results—that there was a better mechanism for sharing research outside of peer review, which is expensive, inefficient, and, in many cases, broken.

Academic publishing is stuck in the pre-digital era. All we’ve done is move physically printed journals online behind paywalls. Comments, updates, additions? Sorry, no. Journals are static, even though science is not. It’s ripe for a big investment by a billionaire to change the status quo. Gates, Zuckerberg—you guys listening?