Book Review: Pay Yourself First & Changing Outcomes

I recently started a 30-day Kindle Unlimited free trial, which gave me a chance to pick up a bunch of Kindle titles (to read on my phone).1 I used the opportunity to take a look at a large fraction of the (mostly self-published) books on medical school advice and physician finance.

My first review is a combo of two sibling books written by financial planners of “TGS Financial Advisors.” These folks specialize in “servicing” physicians; they’re CFPs and not MDs.

The first, Pay Yourself First, is geared toward doctors just out residency/fellowship (potential clients for their $5000/year fee-based advisor service). The second, Changing Outcomes, is directed toward mid-career physicians (who presumably could fork over even more money). This is amusingly reflected in the price, as Changing Outcomes costs a bit more.

Both books are short and share large portions verbatim. Pay Yourself First focuses on convincing you to save more and not spend too much of your new-found income. Changing Outcomes begs you to save more and stop spending so much. The actual financial advice is physician-directed though almost entirely not physician-specific.

The covers are nice, and they paid Kirkus a few hundred bucks for a blurb, so they’re taking the “book as native advertising” concept seriously. There are a few typos and whatnot, perhaps less than average for self-published. I think most recent medical school grads with their massive student loan burdens are more in tune/fearful of their financial future than older docs of the more lucrative medical past, but the discussion of why a high savings rate is the foundation of building wealth and retirement security is nicely written.

A few of my favorite passages.

Here at the beginning of your career your assets are probably smaller than those owned by the average public school teacher. Asset poor and cash flow rich; in your first years of practice, everyone will want a piece of that cash flow.

This is a hidden cost of medical training that most non-physicians simply cannot understand. Not only have you studied longer than any other professional, incurred hundreds of thousands of dollars in education loans, and deferred a serious payday until your mid-30s, you have also lost precious years of potential compounding on your savings.

When you finally start making money, you’re already way behind. You have tons of debt and haven’t saved nearly enough, and those valuable years of compounding interest are gone forever.

Unfortunately, the relationship of wealth to happiness is asymmetric. Moving up is often only temporarily rewarding. But losing ground—suffering even a limited reduction in socio-economic status—is durably painful.

Lifestyle inflation is much easier to avoid than reverse.

Spending on possessions has the most transient effect on happiness, while spending on relationships and experiences has more durable emotional benefits. Unlike status based on earning or spending, research suggests that attaining $1 million of net worth is associated with a permanent increase in confidence and self-esteem.

Having enough money to tell the hospital admin to do something profane to themselves: Priceless.

Outside of these general themes, there is almost zero detail. This is not a DIY book, so other than the inspiration, the books are pretty much useless. Hint: They think you should get a financial advisor.

Overall, the you-need-an-advisor sell isn’t particularly egregious, but it is a bit amusing as it comes after discussion of how low-cost low-fee index fund investing is the right choice (something you definitely don’t need an advisor to set up). Fee-based financial advisors are essentially life coaches who focus on your money. You really only need one if you can’t be trusted to not sabotage yourself.

Verdict: If you need convincing to save more and spend less, either one is a pretty well-written plea and is a fine free read if you have KU. Otherwise, save your money and look elsewhere, like WCI or Bogleheads’.


Review: ExamGuru Shelf Exam Question Bank

Updated 5/16/2015 to reflect new prices, new discount code, and some additional changes.

ExamGuru is the brand new and currently only question bank geared specifically for the third year NBME shelf exams. While the product itself is new, the company is not: it’s a new brand of the COMQUEST family, one of the two big players in the osteopathic question bank market (for the COMLEX exams, which are analogous to the USMLEs). It was released to the general public this week, but I had early access in order to write this review. I was also able to secure a discount for readers, so if you sign up using the code BW15 , you’ll get 15% off whatever package you get, and I’ll get a few bucks.

Before we get started with the actual review, full disclosure: I wrote a small number of questions for this question bank as a freelancer several years ago. These were sold on a per-question basis; they are no longer my intellectual property, and I have no financial stake in the company or its success outside of the time-limited coupon above.

Size and Cost

The ExamGuru question bank is divided into separate shelf exam products, each with a goodly number of questions (as of the time of this post): family medicine (375), internal medicine (412), ob/gyn (369), pediatrics (406), psychiatry (395), and surgery (399). Each question comes with the detailed explanations we’ve come to expect from medical school question banks: 1) Concept/question explanation 2) Detailed answer choice explanations, including explanations of the incorrect options, and 3) Take home point.

You can buy a subscription for a single shelf product at a time: 1 month for $49 $37 and 3 months for $99 $79. Alternatively, you can buy all six products for a length of time ($129 for 1 month up to $379 for the year). Given that buying a month of each product would add up to almost $300, it would seem that the product is priced to encourage you to either buy a few products for a month each or just shell out for the whole year, which would allow you to the use the bank both as a shelf study resource and as an alternative/secondary Step 2 CK qbank.


The website imitates the FRED software you’re intimately familiar with (and also has an option to change the layout to the one used on Osteopathic examinations for DO students). Everything is accessed via the website itself (no downloads or creepy UW spying/tracking), and the site is responsive: it works appropriately on your computer or your smartphone.

Peer percentage correct for each question is provided a la other competitors. Questions are also rated by difficulty, though I’m not sure how this was calculated; oddly, it seemed like most of questions I did were graded as “hard” in their software. I wasn’t sure if this was simply chance or reflects how they’ve self-graded the difficulty and the relative proportions of each within the qbank. Additionally, EG does provide good actionable data about your performance, including a breakdown by question task (establishing a diagnosis, management, etc), which may be a nice way to pick apart areas of weakness you didn’t know you had. If you’re getting the diagnosis questions but missing the management ones, then presumably it’s time to focus on the “next best step” and drugs of choice.

Question Quality

The question quality is good for its first iteration, but it’s not yet at the UW level of polish. This isn’t surprising: I remember using USMLERx back when it was a newer product, and it was awful and a total waste of time and money. The EG house style in particular a bit spotty and could use more homogenization: Multiple question writers and their particular quirks remain surfaced, and occasional aspects, particularly when it comes to the final stem and answer choices, sometimes stray a bit from what you’d actually see on game day. Buzzwords are overemployed and are even sometimes “in quotation marks” whereas nowadays these terms are more likely to described rather than simply called out. Explanations range from relatively short to long & fluffy, sometimes casual “Don’t forget XYZ on test day” and sometimes stiff.

Topics and narratives are fine overall, but some of the questions slipped through without matching the official question writing guide (which I’ve discussed before). A random example: a question about cirrhosis with blatant over the top SBP contained unbalanced answer choices (1 antibiotic choice versus multiple diuretics). That’s probably too easy and not reflective of the standards. I’d argue the question should have been a bunch of antibiotics asking you to know which type is used to treat SBP, or an even combination of both. One answer choice that stands out from the list is to be avoided. On the flip side, the family medicine section has some really great rash/skin questions, which are high yield and not well represented elsewhere.

EG also still needs a copy editor. Shelf questions are often long but almost never because of fluffy prose (only extraneous details!), and comma errors remain (inappropriate comma use before a coordinating conjunction used in a phrase will always be my pet peeve). Again, not necessarily substantive criticism but certainly one that signifies a lack of polish in its first iteration. The material is there, but these little differences do detract a little from question experience, which otherwise is well designed to approximate the real deal. As above, the software is solid.

Update: The EG CEO informs me that they brought on a copy-editor to deal the issues I raised in this review. He also tells me they’ve updated a lot of questions from user feedback. I haven’t personally taken a look again, but if nothing else, most question-banks generally get better over time, not worse.

On the whole, these are mostly nitpicks. But to me, the level of polish of a product is really important if you’re going to spend a lot of time with it. Errors and inconsistently can detract from the experience and distract from your education. 2 That said, ExamGuru is probably one of the best things to come around for the Shelf exams for a while and breathes some new life into the static review lineup. The mistakes I found during my review were nearly all ones of style, consistency, and grammar. These are the things that are easiest to fix gradually. The core content I saw was just fine.

So my overall impression is that this a supplemental product, not a UWorld replacement. While the important topics are covered and the explanations are generally thorough (sometimes a bit lengthy, I’d argue), the overall quality is not yet up to the consistent quality of UW. The main benefit of EG is that it adds some meat to the UW bones, which are nearly ideal for Step 2 CK but a bit thin for several of shelf exams. UW is still I think a critical component of shelf review, but there’s definitely space for another question source. And on the whole, I think ExamGuru is a better question source than the usual alternatives (e.g. PreTest) in terms of depth, ease of use, powers of software, etc. I’d much rather do dedicated shelf questions in a simulated USMLE environment on my computer or phone (yes, EG is mobile enabled) than thumbing through a book or shelling out for another Step 2 qbank.


So should someone use or buy this product? Depends. If I were a third year again, I would for family (maybe peds and ob/gyn as well). Certainly not internal medicine, UW had plenty of that for me to chug through. Ultimately, as readers of this site are well aware, I believe strongly in doing questions, even as a core study method. UW just doesn’t have a very satisfying number of questions for several of the shelf exams (it’s well-pruned for Step 2 CK). Financially, it either makes sense to buy 1-3 of the shelves for the one-month period to use during a dedicated review push or, if you want more, just get the whole set for the year (ouch). I don’t think the quality or consistency is at the UW level but it’s a tailored source of questions in a friendly NBME style package that you can use on your computer or on your phone. And that’s a great start.

If you do end up using the EG product, shoot me an email or comment and let me know how it holds up to thorough use.

Book Review: Medical School and the Residency Match

There’s a new residency guidebook on the scene, Medical School and the Residency Matchand the reviews on Amazon are great. So I’m reviewing it.

This time, instead of being written by a residency consultant (like this or this), the book is written by a group of post-match medical students. As such, it’s a refreshingly honest take and not full of the usual spiels. On one hand, books written by program directors (this is probably the best) may be more authoritative, but they are sometimes over the top and not relatable or easily actionable. For one, what people say they want and what they actually want aren’t necessarily the same thing. Secondly, there isn’t a single path to success. Sometimes it’s nice to be reminded that people like you have been doing just fine, thank you. Continue reading

Book Review: The White Coat Investor

I just finished reading James Dahle’s The White Coat Investor: A Doctor’s Guide To Personal Finance And Investing for the second time. I recommend it as a great first finance book for medical students, residents, and even attendings. Physicians are notoriously terrible at personal finance, and as a profession we are routinely preyed on by those in the financial services industry. Given the massive and enlarging amount of debt students are incurring to get the modern MD, we owe to it ourselves to put some time into our finances and our understanding of money, debt, investment, risk, and retirement. WCI is a great place to start (and the website is a treasure as well).

The biggest take home message is unsurprising to anyone who has thought seriously about getting out of debt, accumulating wealth, or read Mr. Money Mustache and similar folks online: Dahle says, “live like a resident.” This very convincing argument is essentially that best thing you can do for your long term financial wellbeing is to continue living like a resident when your salary increases as an attending. Delay the gratification. Do not “grow” into your new income. The difference between what you earn and what you spend is what you save. What you save is what allows you to “buy” your retirement, a down payment on a house, and fun toys. WCI also has a nice treatment of retirement accounts, mutual fund investing, etc as well as some basic coverage of asset protection, business structure, and income taxes. For some of the more complex topics, the book helps you figure out if and how important these are to you right now and suggests further reading.2

One limitation of the book is its particular perspective/bias. The author is a married male physician with a stay at home wife, and multiple areas of the book are slanted for physicians in the same shoes. Consequently he accounts less well for couples with dual incomes, dual student loans, etc. As an example, the chapter on residency finance in particular literally assumes the physician resident has non-working spouse in his argument for why a resident shouldn’t buy a house. While I agree that most residents probably shouldn’t buy a home (although we did), these broad generalizations are tied to very specific advice that may or may not be applicable to the general reader. Along the same lines, a few comments peppered throughout are essentially thinly veiled advice to keep your non-physician spouse’s spending in check.

The book’s treatment of student loans was insufficient when it came out and now somewhat out of date (e.g. private refinancing for residents isn’t mentioned, because it wasn’t available at the time; PAYE is not discussed, etc). Finance books are full of numbers and examples, but what the right choice is for you depends on your options and your numbers.

“Live like a resident” is important advice—a dollar saved is actually more than a dollar earned (due to taxes)—but the argument that you can only achieve the “good life” and spend money on things that bring you joy after your financial house is well in order isn’t going to work for everyone, either practically or emotionally. Keeping up with Joneses is always a losing battle, but the emphasis on conspicuous non-consumption and driving old cars as the pathway to financial independence is occasionally tiresome. Active reading is required; question your assumptions but take away what you want.

On a related note, for those looking for a completely free first finance booklet, try William Bernstein’s (another MD) “If You Can,” which is somewhat condescendingly written for “millennials” but nonetheless distills the essentials of saving, mutual fund investing, and distrusting people who want to fleece you.

App Review: Quest

I am one of those supremely unproductive people who frequently spends hours researching distraction free writing programs and other workflow micromanagement with zero sense of irony. Nothing helps.

Anyway. One app I do use extensively is the Apple’s default Reminders app, which I’ve long used as both an actual todo list as well as a repository of other random tidbits, blog post ideas, things I want to read and buy etc. I’ve researched (and tried) several todo list apps, but none have stuck. Reminders is ugly, but it’s free, it works quickly, and has the features most anyone really needs.

That just changed last week, because now I’m using Quest.


The overall scheme is similar to Clear (okay, it pretty much copies it), which I didn’t fully embrace, mostly because I thought Clear was colorfully ugly and I didn’t feel like importing all of my items. But Quest is cute app with great idea: it gamifies the to-do list, letting you “level up” for checking off items, with adorable graphics and simple gameplay elements superimposed on a solid todo list app experience.

questQuest allows you to organize your tasks into multiple lists as well as add time-sensitive reminders (just like to Reminders app). The main missing feature it lacks is contextual location reminders, which is a feature of the default Reminders app that has always sounded like a fantastic idea but that I’ve never actually used (e.g a reminder to give your wife a hug that activates when you get home).

My biggest feature request is the ability to grade the difficulty of your ‘quests’ — just as not all monsters are of the same difficulty to vanquish, completing your grocery shopping or calling a plumber doesn’t deserve the same experience/reward as crafting a thoughtful blog post or finishing a research manuscript. But I’ll still keep using it for the adorableness/nostalgia factor alone.