Old Guard Medical Wisdom? Rest

03.26.21 // Medicine, Reading

From Rest: Why You Get More Done When You Work Less:

Neurosurgeon Wilder Penfield, for example, warned medical students that unless they cultivated other interests, “your specializing will expose you to an insidious disease that can shut you away from all but your occupational associates” and “imprison you in lonely solitude.” Penfield’s mentor, William Osler, warned that without care, “good men are ruined by success in practice,” and that “ever-increasing demands” can leave even the most curious person “worn out, yet not able to rest.” It was essential to develop “some intellectual pastime which may serve to keep you in touch with the world of art, of science, or of letters.”

These statements came from an era when residents literally lived in the hospital and Osler’s famous surgical colleague William Halstead’s work ethic was fueled by cocaine.

And even they thought it was important for doctors to be well-rounded, have hobbies, and get a life.

Honestly, I’m more interested in what you do for you than what boxes you’re just checking to impress me.

A Chance for Meaningful Parental Leave During Residency

03.24.21 // Medicine, Radiology

Last year, the ABMS—the umbrella consortium of medical specialties—waded into the established toxic mess of medical training schedules with a new mandate to provide trainees with a nonpunitive way to be parents, caretakers, or just sick:

Starting in July 2021, all ABMS Member Boards with training programs of two or more years duration will allow for a minimum of six weeks away once during training for purposes of parental, caregiver, and medical leave, without exhausting time allowed for vacation or sick leave and without requiring an extension in training. Member Boards must communicate when a leave of absence will require an official extension to help mitigate the negative impact on a physician’s career trajectory that a training extension may have, such as delaying a fellowship or moving into a full, salaried position.

6 weeks over the course of an entire residency may not seem like much given the vagaries of life, but it’s a better floor than many programs currently offer. A graduation delay sucks, and it’s the kind of punishment for living your life that causes many doctors to put off big milestones like starting a family. Medical training already takes a long time, and ~1 in 4 female physicians struggle with infertility (and in that study, 17% of those struggling would have picked a different specialty).

This issue is being addressed across medicine, but we’re going to discuss it in the context of radiology because I am a radiologist.

The American Board of Radiology’s recent attempt at how such language should look has drawn some ire on Twitter. Here is their email to program directors that’s been making the rounds:

They proposed that a program “may” grant up to 6 weeks of leave over the course of residency for parental/caregiver/medical leave as a maximum without needing to extend residency at the tail end. The language here doesn’t even meet the ABMS mandate, which again states that a program “will” provide a “minimum” of 6 weeks (and explicitly states that said 6 weeks of leave shouldn’t be counted against regular sick time).

The ABR could have simply taken the straightforward approach of parroting the ABMS mandate. They could have—even better—taken the higher ground with an effort to trailblaze the first generous specialty-wide parental leave policy in modern medicine.

Instead, they have advocated for a maximum of six weeks, because any more and they feel they wouldn’t be able to “support the current length of required training.” As in, if a mom gets 3 months off to care for a newborn then the whole system falls apart.

I think they realized it would be prudent to ask for feedback first and then make the plan because a new softer blog post removes any specific language:

We need your input to develop a policy that appropriately balances the need for personal time including vacation as well as parental, caregiver, and/or medical leave with the need for adequate training.

It is important to realize that the ABR is not restricting the amount of time an institution might choose to allow for parental, caregiver, and/or medical leave, nor are we limiting the amount of vacation a residency program might choose to provide. These are local decisions and the ABR does not presume to make these determinations. However, above a certain limit (not yet determined), an extension of training might be needed to satisfy the requirement for completion of the residency.

Of course, in the original proposal, the ABR literally did want to limit program vacation (to 4 weeks, see above).

After the mishandling of the “ABR agreement” debacle and the initial we-can’t-do-remote-testing Covid pseudo-plan and now this, I hope the ABR will eventually come to the conclusion that stakeholders matter and that we can make radiology better by working together as a community.

Radiology is a “male-dominated” field, but it shouldn’t be. A public relations win here could make all the difference.

Plenty of Slack

I think there are more than six weeks of slack in our 4-year training paradigm, and it’s hard to argue otherwise.

When the ABR created the Core Exam and placed it at the of the PGY4/R3 year, they created a system where a successful radiology resident has proven (caveat: to the ABR) that they are competent to practice radiology before their senior year. It created a system where the fourth year of residency was opened up largely to a choose-you-own-adventure style of highly variable impact.

We have ESIR residents who spend most of their fourth-year doing IR, and we have accelerated nuclear medicine pathway residents that do a nuclear medicine fellowship integrated into their residency. There are folks early specializing into two-year neuroradiology fellowships during senior year, and others who take a bevy of random electives that they may never use again in clinical practice.1

We have many programs with a whole host of extracurricular “tracks” where residents might spend protected time every week doing research, quality improvement, or clinician-educator activities. I would know, I did all three during my residency. We have residents doing research electives and all kinds of other interesting things that may worthwhile but have no positive impact on their ability to practice radiology clinically, which is the primary purpose of residency training.

A hypothetical example: Take a research track resident with one half-day protected time every week for 40 weeks a year (say because of 8 weeks of night float and 4 weeks of vacation). That’s 20 days a year of reduced clinical activity. 20 working days is basically a month. If they have their R1 year to just focus on learning radiology before taking call, then over the next three years that resident would be “missing” 3 months of clinical time. But no one is seriously arguing that these tracks should postpone residency graduation.

We already have a system where there are minimum case requirements for residents to complete residency training. Last I checked, the ABR is certifying radiologists in the domain of clinical radiology, not their number of peer-reviewed publications or ability to do a sick root cause analysis.

Radiology residency may be four years after a clinical internship, but it’s clear that there is no standard radiology training program clinical “length” despite that fixed duration. Some residents are already doing far fewer months.

No one is adding up diagnostic work hours and saying you need 48 weeks/yr * 52 hours/wk * 4 years = 9,984 hours.

It’s not a thing, and it shouldn’t be.

Competency-based Assessment and Reasonable Limits

The core problem is that we have time-based residencies masquerading as a proxy for competency. You don’t magically become competent when you graduate. Competency is a continuum. Hiring trainees for a set number of years is convenient. It’s easy to schedule. It’s easy to budget. But it’s an artifact of convenience, not a mission-critical component of clinical growth.

There are R3 residents who are ready for the big leagues, and there are practicing doctors who should honestly move back down to the minors. No one is going to argue that a little more training makes you worse. But the logic that more is better gets us to the unsustainable current state of affairs, where doctors are accumulating more and more training to become hyper-specialized in the least efficient way possible while non-physician providers bypass our residency/fellowship paradigm to do similar jobs with zero training.

We all get better with deliberate practice. The question isn’t: is more better? The question is how much less is still enough for independent practice?

Obviously, the ABMS member boards like the ABR don’t exactly have the power to force institutions to change policies directly, and they probably don’t want to. But they do set the stage by mandating the criteria for board eligibility.

I would argue that the ABR should set a minimum threshold and no maximum. If a program is happy with that resident’s progress and they pass the Core Exam, then consider the boxes checked. Let everyone be treated with dignity and then give the programs the flexibility to compete in the marketplace of support.

When my son was born, I was able to take 4 days of sick time and then went straight into night float. That’s bullshit. You want to see motivation? Tell an expecting resident that if they’re a total champion that they can spend as much time as they need with their baby without delaying graduation.

Less than 6 weeks is unacceptable. And while a 6-week minimum is an improvement, I think the true minimum consistent with current training practices that should also have a chance of being implemented is three months.

I’d love to see six months or more. I don’t think that’s going to happen as a minimum, and there’s a very reasonable argument against it as underperforming residents really may need some of that time back. It would be nice to see language that demands 3 months, has no maximum, and strongly encourages programs to work with residents on a case-by-case basis to ensure they are ready for graduation with however much time they have.

But the first step is to have a minimum that doesn’t punish women who want to stay home with their infants until they’re done cluster feeding. Convince me otherwise.

Fairness

The ABR doesn’t use the language of “fairness” in their email, but I suspect the perception of fairness is at play. It’s almost always at play when older doctors consider policies that might benefit younger physicians. It’s the I-did-it-this-way-and-I’m-amazing-so-it-must-be-an-integral-part-of-the process. It’s the hazing.

Right now, some lucky residents across the country get varying degrees of time “off” thanks to PD support in the form of research electives, reading electives, and program staff simply looking the other way. We need to standardize a fair minimum that enables programs to provide a consistent humane process and not just put trainees solely at the mercy of their PDs and local GME office.

Yes, it’s true that if you allow parents time to be parents or people to take care of loved ones or people time to recover from illness that some residents will work fewer months than others. Every resident has their unique experience, but a policy change will also mean that every resident may not have a similar “paper” experience. That’s a fact.

Some people will say, that’s not fair. That it’s not fair to single residents or non-parents. That it’s not fair to the able-bodied. Or to those whose aging parents are healthy or have the resources to support themselves.

But let me provide a counterpoint:

I don’t think fairness means that every single resident has to have the exact same experience. They already don’t. I think fairness means we treat humans with the respect and compassion that every person deserves. I want to live in a world where everyone gets time to be a parent, even if yes, that world means that some doctors may have a career that is a few months shorter.

I think fairness means not punishing people when life happens just because making people jump through hoops makes it easier to check a box.

If you’re ready to practice, you’re ready.

If we need to reassess the validity of an exclusively time-based (instead of competency-based) training paradigm in order to do that, then let’s get to it.

The ABR is accepting feedback until April 15.

Patient Satisfaction: A Danger to be Avoided

03.16.21 // Medicine

Doctors intuitively know that the Yelpification of medicine is bad. But it’s not just toxic to the physician-patient relationship and bad for burnout, it’s actually dangerous.

The outsized and misplaced importance of patient satisfaction scores is a perfect embodiment of Goodhart’s law, well-paraphrased as “when a measure becomes a target, it ceases to be a good measure.”

If you make patient satisfaction scores a critical target—and they are—you will see consequent mismanagement. This is so blatantly apparent when it comes to urgent care and pain management that, if anything, high satisfaction scores are likely a more meaningful signal of poor care.

If a patient comes to an urgent care for a URI and wants antibiotics, they will be most “satisfied” when they receive the prescription they didn’t need. And all that over-treatment is not without risk.

Even outside of quality metrics, profit-centered health care businesses need patients to make money, and the “customer” is always right.

A study published in JAMA is a great example of the obvious negative externalities of prioritizing patient satisfaction scores. It analyzed a large number of telemedicine visits for URI:

72 percent of patients gave 5-star ratings after visits with no resulting prescriptions, 86 percent gave 5 stars when they got a prescription for something other than an antibiotic, and 90 percent gave 5 stars when they received an antibiotic prescription.

In fact, no other factor was as strongly associated with patient satisfaction as to whether they received a prescription for an antibiotic.

Another study out of UC Davis study analyzed a >50,000 person national Medical Expenditure Panel Survey and found that patients who were most satisfied had greater chances of being admitted to the hospital, had ~9% higher total health-care costs, and 9% higher prescription drug expenditures. Of course, if you’re a for-profit entity (and most “non-profit” hospitals certainly are), higher costs and more prescriptions often just mean more profit. A win-win-win.

But even worse, death rates also were higher: For every 100 people who died over an average period of nearly four years in the least satisfied group, about 126 people died in the most satisfied group.

Moreover, the more satisfied patients had better average physical and mental health status at baseline than the less satisfied patients, and the association between patient satisfaction and death was strongest among the healthiest patients. Perhaps the “worried well” should be worried.

The push to satisfy patients at all costs is no secret. But some doctors are fighting back, like Dr. Eryn Alpert, who sued Kaiser Permanente in 2019:

A doctor who refused to prescribe patients unnecessary opioids has sued Kaiser Permanente, alleging the way the company used patient satisfaction scores hurt her career and incentivized doctors to over-prescribe painkillers.

…

By requiring its employee physicians to achieve certain patient satisfaction scores in departments where those scores are closely related to a physician’s willingness to prescribe opioids, other addictive medications, and to order unnecessary medical testing (e.g. labs, radiology) in response to patient demand, Kaiser’s intent was to increase its profits so that … its executives and physicians would receive higher bonus compensation.”

These sorts of individual fights happen quietly all over the country, but the opiate crises may have created an opportunity for doctors to put the focus back on patient outcomes.

Do no harm in many cases means doing less, but the combination of short visits and Press Ganey pressures makes it harder for doctors to do the right thing. Healthcare may be a business, but patient care isn’t.

This article was originally published in Physician Sense in October 2019.

Physics is now just another Core Exam section

03.12.21 // Radiology

Probably the biggest news in radiology over the past year (at least for residents) was the announcement that the upcoming and all future ABR examinations were moving to an online remote/virtual format. That’s worked out pretty well so far.

One bit of nice unexpected news that was announced very quietly this week was that the ABR Core Exam, the first and only meaningful component of the radiology exam certification cycle, would no longer have a separately-graded physics section that could—by itself—prevent overall exam passage. Physics will still comprise an unchanged amount of the test but will be graded as just another section along with all the rest: a component for overall passage but not a section that examinees can “condition” and be forced to retake at a later time.

Holding physics somewhat apart was a holdover from the pre-Core Exam era when there was a completely separated dedicated physics exam.

The ABR made this decision during the grading process just last week. I’m sure that recent examinees would have really appreciated this information during their studies, but timing aside I fully support the ABR’s choice here. Strong move. What’s next?

Explanations for the 2020 Official Step 3 Practice Questions

03.08.21 // Medicine

Here are my explanations for the November 2020 update of the official practice materials.

My explanations for the 2018/2019 set are here. The one before that, which I explained here, was revised in November 2017.

The asterisks (*) signify one of the 71 new questions.

You can find my thoughts on preparing for Step 3 here. Since writing that post, the only substantive change in the exam has been the ability to schedule CCS on a nonconsecutive day. In short, I think the free materials and UWorld should be enough for most folks. If you want book recs, they’re in that post. If you need another question source, I haven’t tried any of them, but you can get 10% off BoardVitals if you’re interested by using code BW10.

As for this free 137-question practice exam, Blocks 1 and 2 are “Foundations of Independent Practice” (FIP). These should take up to 1 hour each. Blocks 3 and 4 are “Advanced Clinical Medicine” (ACM). These should take up to 45 minutes each. Total practice time should be no more than 3:30 if taken under test-day conditions.

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Leadership and Resident Satisfaction

03.02.21 // Radiology

It’s residency Rank Order List season, and I thought I’d share a paper published in AJR from 2016 titled, “Radiology Resident’ Satisfaction With Their Training and Education in the United States: Effect of Program Directors, Teaching Faculty, and Other Factors on Program Success.”

It was a small study where the authors surveyed 217 radiology residents.

Of that group, 168/216 (77.8%) of residents were satisfied overall with their residency programs.

You’re always going to have some sour grapes, and it’s not possible from the data to figure out how much of that fraction might be related to noncontrollable factors like the city, the stresses of dealing with student loans, or other factors. But as the authors noted, that’s a big difference from the golden era:

This is lower than reported in similar previous national surveys conducted by the American College of Radiology, which reported a 97.8% level of job satisfaction of radiology trainees in 2003, and 97.6% level of job satisfaction in 1995.

Like with internet comments and product reviews, convenience surveys always lean toward the dissatisfied. But the data are still interesting because they can highlight the causes for dissatisfaction, even if they play an outsize role compared to the general community.

The three sub-categories with the greatest correlation with overall satisfaction were satisfaction with the program director and administrative office, daily workstation experience, and faculty.

So basically everything.

But of the three, the program director and administration were by far the most dominant. I suspect it’s more of a break not make scenario:

The factor with the greatest correlation to satisfaction with the program director and administrative office is how approachable and responsive the administration is to resident concerns.

A good program director may help make a program, but a bad one can definitely tank one.

A good PD is both a boss and an advocate. While not all trainee complaints are necessarily fixable (or even reasonable), accountability, transparency, and attentiveness aren’t something to take for granted in program leadership. Culture colors everything.

It might be impossible to change the culture of the hospital. It might be impossible to reduce RVU pressures on faculty or improve mediocre teachers. So the survey is actually good news because the program leadership is far more mutable.

There was one throwaway statistic they reference from a 2003 study that ties into the daily workstation experience/faculty components:

A survey with 132 junior radiologists revealed that 68% of the responders left academia after an average of 3.28 years because of low pay and lack of academic time.

That was almost 20 years ago, and the RVU pressure and lack of academic time have gotten worse since then. I wonder what that number is now.

My group is extremely stable, but I’ve seen a ton of turnover amounts young attendings in both academia and private practice. I don’t think enough practices of any variety are willing to allow for a Goldilocks approach between productivity and revenue.

The ABR dreams of a low-cost world

02.23.21 // Radiology

The February 2021 issue of the BEAM features a short article with the title, “Board, Staff Working Together to Control Expenses.”

As the Board of Governors discussed these new [remote] exam tools, one of the perceived potential benefits was the intuitive opportunity to decrease costs and, by extension, reduce fees. However, there are persistent barriers to fee abatement at the time of this writing, including the absence of proven success of the new exam structure; a lack of dependable forecasts of the future steady-state expense structure; the inherent long-term nature of established financial obligations related to exam center equipment and leases; and the unexpected short-term development costs of the virtual exam platform software.

Proven success? Check.

Does any stakeholder believe that ~$50 million in cash reserves isn’t enough to deal with “a lack of dependable forecasts of the future steady-state expense structure” [sic]?

They continue (emphasis mine):

ABR senior leadership is committed to working with the board to control costs. We are optimistic that this is achievable as we close in on the “new normal,” but we don’t know the extent of potential cost reductions, nor when they might be achieved. The less visible infrastructure elements of board functions, ranging from cybersecurity to volunteer support, are critical to customer service for our candidates and diplomates, as well as fulfillment of our core mission. Despite these obstacles, the board members view themselves as responsible stewards of ABR resources, both financial and otherwise. In this vein, they consistently challenge each other, and the ABR staff, to reduce costs and, subsequently, fees, to the extent possible.

Transparency, transparency, transparency. Anything less is just self-love.

A $310,284.24 PSLF Success Story

02.19.21 // Finance

People often ask me if I know anybody who has successfully received public service loan forgiveness (PSLF). For the past couple of years, my answer has been that I’ve seen multiple verified examples of PSLF but didn’t know anyone personally (in real life). That’s mostly because I graduated in 2012, so my former classmates are still at least a year away.

That changed recently because last month a colleague of mine had his loans forgiven. He’s given me permission to share some illustrative parts of his story and provided me with a very detailed timeline. It’s a good case study, and I’ve added references to relevant background/discussion throughout.

Without further ado, here is his (annotated) story:

8/94 – First Stafford loan (FFEL) disbursed ($2,625). The local bank immediately sells the loan to Sallie Mae after collecting the origination fee.

You’ll notice that he is a nontraditional physician who went to school initially back in the 90s but then went back to pursue medicine in the 00s. The Federal Family Education Loan (FFEL) program was created in 1992 as a public/private partnership where “federal” loans were given by private banks in exchange for generous fees from the federal government and a guarantee against cases of default. FFEL supplied 80% of federal student loans until 2008.

8/95 – University converts to the Direct Loan system.

The Direct Loan program, which we all currently enjoy, coexisted with FFEL in the 90s. However, individual borrowers didn’t get to choose. The school picked either FFEL or Direct for its federal aid. At this time, due to a combination of purportedly better customer service (and marketing), most schools chose FFEL.

5/98 – Undergraduate graduation followed by consolidation under the Direct program ($11,118, subsidized loans only)

This was an optional step for convenience at this point but the beginning of a very helpful pattern. PSLF didn’t exist yet (announced in 2007) but astute borrowers will know that the federal government is only interested in forgiving loans that it actually holds (Direct loans). The only way to make FFEL loans qualify for modern income-driven repayment plans and PSLF is to consolidate them into a Direct Consolidation loan. The same consolidation necessity also applies to the now-defunct “low-interest” Perkins loan program that was shuttered in 2015.

5/05 – Consolidation of undergraduate and (non-medical) graduate school loans under the Direct program ($45,437 subsidized, $24,599 unsubsidized). Direct loans assigned to ACS/Xerox Education Services (“DL Servicer”) for servicing, the only Direct Loans servicer at the time.

So after finishing graduate school, he re-consolidates to add his grad school loans to his original undergrad consolidation loan.

9/07 – President George W. Bush signs the College Cost Reduction Act of 2007, establishing the Public Service Loan Forgiveness Program (PSLF)

In 2007, the Democrats held the House and Senate. The CCRA passed in the senate 78 – 18, and Bush signed the law. It’s hard to imagine any bill like this not being voted strictly along party lines these days. For further reading, see the first PSLF chapter of my book, available free online here.

7/10 – Consolidates new FFEL medical school loans under the Direct program ($69,707.25 subsidized, $171,973.74 unsubsidized). The consolidation waived the 6-month grace period and signing up for automatic payments lowered the interest rate by 0.25% to 6%.

While his older loans were Direct Loans, his medical school chose the FFEL program. You can see what so many people got this wrong. He informed me that back in May 2010, someone from the AAMC actually came to his school to talk about PSLF and what to do to qualify (including consolidation). This was rare golden advice back in the day, as most borrowers either kept the wrong loans (FFEL, Perkins) or used the wrong payment plan (graduated or extended). By consolidating after graduation, he was able to waive the otherwise mandatory 6-month grace period and enter repayment early. Read more about the importance of Direct consolidation here.
The interest rate of federal loans changes every year depending on the yield of a 10-year treasury note. During my era, for comparison, it was always 6.8%.

8/10 – Began repayment using the original Income-Based Repayment (IBR) Program.

The original IBR was the first modern-day plan within the income-driven repayment (IDR) umbrella, later joined by PAYE and REPAYE. Income-contingent repayment, the less generous original, dates back to 1993. IBR had payments of 15% of discretionary income, capped payments at the 10-year standard repayment amount if income rose sufficiently, and also allowed for loopholes like utilizing “married filing separately” to lower payments and maximize forgiveness.

9/11 – ACS/Xerox (“DL Servicer”) loses Direct servicing contract and loans were transferred to another servicer, which canceled automatic payments without notification and resulted in a “late” payment.

While there have been recent plans to consolidate all federal loan servicing with a single company (again), for most of the PSLF-era there have been multiple servicers (e.g. Navient, Nelnet, FedLoan, Great Lakes, etc). Of all the services, only FedLoan processes payments for those intending to utilize the PSLF program.
Submitting an employment certification form (ECF) for PSLF automatically switches borrowers to FedLoan, but back in the day, being bounced around wasn’t all that uncommon either. In fact, my loans were transferred to a new servicer a year after I graduated. Each time this happens, you’ll have to set up a new account and auto-pay must be re-established. It’s common to lose a month during the process, and sometimes the servicers themselves might place you on an administrative forbearance if they couldn’t get the job done in the interval between monthly payments.

1/12 – Submitted first employment certification form (ECF) for potential PSLF, triggering the automatic transfer of servicing to Pennsylvania Higher Education Assistance Agency (PHEAA, “MyFedLoan”). The transfer process takes greater than 1 month, resulting in a missed opportunity for a monthly payment.

When you file for your Direct consolidation, you are able to choose your servicer. If you are considering PSLF at all, you want to select FedLoan to prevent any delays from an unnecessary transfer down the road.
Additionally, while you would think that the transfer of your payment records would be easy-peasy, it isn’t. Apparently, at least in the recent past, actual paper was involved. Achieving PSLF on-time relies on a correct payment count, and the source of many folks’ incorrect payment counts is the payment information from old servicer accounts prior to the transfer. While FedLoan is objectively not a good company, they do better with their own counting.

1/14 – Employment verified but payment counts were inaccurate. Submitted complaint with bank statements to show the error. While there was no response, it seemed to be fixed in later iterations.

Incorrect payment counts are a common headache source for borrowers and are often off by years due to small errors in the data. And while it’s easy to request a manual recount, they’ll tell you upfront that the process might take two years. For obvious reasons, they also prioritize those who are closer to the 120 payment number.
When there are payment count or processing issues and FedLoan doesn’t fix them promptly, there are now a few ways to call in bigger guns. You can file a complaint with the Office of Federal Student Aid here and with the Consumer Finance Protection Bureau here. If neither one of those works, then contact the FSA Ombudsman.

6/15 – Residency complete; employment verified.

While it’s considered good practice to submit ECFs annually, at the minimum you want to do so as you leave a qualifying institution. You don’t want to be trying to track down someone at HR willing to sign your form years down the line.

6/16 – First fellowship complete, employment verified.

He’s doing a great job.

11/16 – Switched from IBR to the new Revised Pay as You Earn (REPAYE) payment plan created through an executive order by President Barack Obama in 2015. Annual income verification timing was moved to the end of the calendar year, and one qualifying monthly payment opportunity was lost; 2017 payments now based on 2015 (trainee) income.

Note that because he didn’t meet the eligibility criteria for PAYE, REPAYE was his only chance to lower his payments from 15% to 10% of discretionary income, resulting in significant savings.
During the switch, his annual recertification timepoint moved later in the year. Recall that payments are based on your most recent tax return, which is in turn based on the previous year’s income, so there is a considerable lag between when your income goes up and when you start paying for it with regards to student loans.
You should expect to always lose a month when switching between repayment plans. Your interest also capitalizes, though that is irrelevant with regard to loan forgiveness. With IBR, in particular, the lost month was specifically included in the process.

6/17 – Second fellowship complete; employment verified.

The more training you do, the better deal PSLF becomes. Because of the lag in payment increases, some physicians will almost certainly receive loan forgiveness after never making an attending-sized payment.

8/17 – Graduate school (MPH) enrollment triggers automatic deferment (without notification), another month lost while the deferment waiver was submitted and processed.

Most people who are full-time students cannot meaningfully make student loan payments on prior debt (and they’re usually taking on more!), so any time you become a full-time student, the system is set up so that you are automatically placed on an in-school deferment.
You can waive this and continue repayment on loans from prior schooling, which is very helpful for PSLF for those who go back to school but are still working full-time at a qualifying institution. (But no, in case you’re wondering, you can’t simply waive this on new/current loans and start making qualifying PSLF payments on those new loans while still in school even if you somehow were also working full-time.)

8/18 – Employment verified with 4 payments not appropriately counted; request submitted for a manual recount (which would take almost 2 years to complete).

Two years is what FedLoan considers par.

3/20 – President Donald Trump signs the Coronavirus Aid, Relief, and Economic Security (CARES) Act, essentially canceling the final 7 payments and neutralizing the effects of the prior errors.

The CARES act (which included 0% interest and $0 payments) has benefited a lot of people. In addition to helping keep less fortunate borrowers financially afloat, it’s also been a boon for those going for loan forgiveness, in particular those near the end of their journey currently enjoying larger salaries and consequent larger payments. Further discussion here.
An intern is often looking at $0 payments anyway. A resident may be saving a few hundred bucks per month. But many attendings are saving thousands of dollars per month through the CARES act forbearance, which counts these no-pay months as qualifying payments for PSLF.

10/20 – FedLoans sent notification that 120 payments had been reached (during the CARES forbearance); PSLF application/final ECF submitted, but an employer error on the application results in a 1-month delay.

The language of the CARES act was clear, but some folks were still petrified that somehow the CARES act forbearance wouldn’t count for PSLF. It does.
The HR department has a tendency to sign these forms incorrectly. Every signature should be legible and every date completely clear for an ECF to be accepted.

1/21 – PSLF application approved. $82,438.65 subsidized and $227,845.59 unsubsidized forgiven.

Congratulations!
(Note that subsidized loans are no longer given out for graduate school like medical school, but regardless the interest is only subsidized while still in school.)

Verdict

In the end, this story demonstrates most of the classic PSLF teaching points. It’s a real program. It can be administratively complex, especially for older borrowers, but it boils down to making sure you have Direct Loans and picking an IDR plan. Everything else is just optimization to maximize forgiveness by paying as little as possible over the course of the 120 qualifying payments, keeping records, and complaining if someone else messes something up.

It can provide a very large amount of tax-free loan forgiveness.

However, for some borrowers, this forgiveness does not result in significant cash savings given the relative compensation differences between academic positions and private practice.

People who borrow in the neighborhood of 1x their annual salary or less can feel more or less confident in picking whatever job they want and know that they will be able to service their debt. For these people, PSLF is a great benefit of pursuing your passion for public service but not a reason to take a job you don’t want. For those that borrow 2x or more, PSLF is a real reason to consider a qualifying job.

The ABR’s virtual Core Exam worked

02.17.21 // Radiology

Last year as the pandemic spiraled out of control, the ABR resisted—as they have for years—calls for disseminated exams away from their centers in Chicago and Tuscon. The lack of a foreseeable endpoint and pressure from advocates was finally enough for the ABR to make the switch. And to their credit, when the ABR came around, they went all the way: all exams are to be virtual from this point forward.

And guess what? It worked.

Apparently, it worked really well.

And I, for one, am not surprised.

People I’ve spoken to were overall very pleased with the remote experience. Were there rare technical difficulties? Sure. But reports are that the ABR was generally responsive and helpful in aiding candidates when issues cropped up, and multiple residents I spoke to gave ABR customer service high marks.

So while perhaps they shouldn’t have needed the worst pandemic in a century to make these changes, credit where it’s due: the ABR successfully pulled off the transition to at-home testing.

The ABR’s testing centers, though physically inconvenient, were always pretty nice compared with most commercial centers. But the ability to take the exam from a location of your choosing with no travel required and your choice of preferred snacks, clothing, thermostat settings, and bathroom is pretty nice. Having the exam over three days also probably helped with test-fatigue.

Future Fix Requests

There were a few complaints the ABR should address in future administrations:

Answer choice ~~strikethrough~~. This was a common request, and it’s a common feature including one available on the USMLE exams that residents are all used to.
Cine clip optimization. This has been a longstanding complaint, but in this case, at least sometimes clips are presented in a separate window from the question and answer choices. They should be embedded the same way as normal images with easily controllable playback speed and the ability to manually scroll.
Remove the 30 question auto-lock. The need to lock previously seen questions makes perfect sense at the end of a 60-question block and whenever a candidate takes an optional break. But I’m not sure I buy any justification for auto-locking mid-section. This is a true functional change from prior exam administrations that has a negative impact on those who would like to review all related questions before moving on. It’s also difficult to know how much time to allot to question review when you break up 120 questions into 4 blocks instead of two, making time management more difficult.
Announce the section order. This was a big complaint I heard and one I agree completely with. For years the ABR has avoided publicizing the section order (e.g. Breast, then Cardiac, then GI) despite keeping it consistent across testing administrations. While people obviously aren’t supposed to discuss the exam, in the real world this has meant that candidates taking the exam later always know what sections are coming on which days, allowing them to cram most effectively. Unless every candidate has a randomized order, keeping this information semi-hidden in this setting just isn’t appropriate and should be a no-brainer to fix. Knowing you’re going to have ridiculous radioisotope safety microdetails on a specific day means you can prepare for that much more effectively and seriously jeopardizes the exam integrity. Again, this is not a new issue.

The Core Exam is still the Core Exam

Ultimately, the biggest complaint—no surprise—wasn’t the software but the test itself. It’s not as though the content magically became more on-point just because you got to wear pajamas.

If I were to limit myself to one content suggestion, it’s this:

I feel very strongly that the ABR’s reduction of physics and radiation safety to nonsense microdetails does our specialty a disservice. Residents constantly complain that the test material seems random and is not found in most review materials. This means either the Core Exam treats this material poorly or that the residents are studying the wrong information.

The problem is that this material is important. The ABR needs to make it clear what information candidates should know and release it as a packet of specific information like non-interpretive skills (NIS). In its current form, the combination of physics/radiation biology/radiation safety/nuclear medicine/RISE is a limitless almost black-box from which residents have no idea what to focus on or what material is high-yield. The end result is that most radiologists are taught low-yield or confusing information from physicists and end up with a poor understanding of these concepts. Candidates simply don’t really know what they should know and so don’t really know anything.

MR safety and contrast safety are included in the NIS study guide already (in addition to mission-critical information like the ACGME core competencies and how to create a “Culture of Safety”). The vast majority of the information I just described is also “non-interpretive” and needs to be included.

Choosing the Best Solo 401k

02.09.21 // Finance

What’s a Solo 401k?

A Solo 401k, officially known as an Individual 401k, is a 401k retirement account available to businesses with no employees (other than the owner or the owner’s spouse). It is the most common retirement used by the self-employed. Of note for someone like me, who runs a very small writing and self-publishing enterprise, you can have more than one 401k account even if you still only have one personal contribution limit. So even though I also have a work-sponsored account with my employer as a radiologist, I finally got around to opening up an individual 401k last year.

Why a Solo 401k?

For someone like my wife, who runs an independent psychiatry private practice, it’s the best/easiest way to fund a retirement account.

But even if you maximize the personal contribution limit (currently $19.5k in 2021) with your work account, having a solo 401k for your side hustle still gives you extra tax-advantaged space by allowing you to contribute ~20% of profits from your business up until the $58k per account annual contribution maximum (in 2021).

So it’s a great option if you’d like more tax-advantaged retirement space for contributions if you make any money outside of an employed position (like any of those places that send you 1099 forms at tax time). Physician surveys, moonlighting, consulting, writing, etc are all common sources.

A solo 401k can also give you a place to roll over old accounts from previous jobs to a new account, making everything easier: fewer accounts to manage, less difficulty rebalancing, and the ability to choose a no-cost provider with access to excellent low-fee funds.

Why not a SEP IRA?

The short answer is that the individual 401k is a newer and better option in almost every way:

Many people are able to put more into the 401k account every year (because the IRA only allows for the employer/profit sharing contribution and not an employee contribution), and the i401k also allows access to the features we’ll talk about below like Roth contributions, 401k loans, and catch-up contributions for those above the age of 50.

The 401k is also often the better choice because it allows you to also take advantage of the Backdoor Roth IRA (see the detailed post on WCI if you need some background). Pre-tax money in another IRA runs afoul of the pro-rata rule, which means using a Simple IRA or SEP IRA prevents you from truly maximizing your tax-advantaged retirement space.

The main benefit of the SEP-IRA is that it can be expanded to make retirement accounts for employees should your business grow in the future.

For someone like me, choosing the Individual 401k is a no-brainer.

Main Individual 401k Providers

There are comparison tables out there that may or may not be up to date, but while all companies get the main task of giving you a place for your money, the main difference between the various companies is in the details of what their plans allow. Things on the table:

Roth contributions. All companies allow for traditional pre-tax contributions, but only some permit Roth contributions
Rollovers. Some accounts won’t let you roll over old accounts or only permit rollovers from certain account types (like 401ks but not IRAs)
401k loans. You can actually borrow against your own retirement savings. Not something I intend on using but nice to know it’s there.
Fees. Most are free to open and maintain and only charge fees for trades (typically $0 for mutual funds and ETFs, meaning that these accounts are essentially free for the passive investor).

So here are the main companies and the relevant information for our purposes. Spoiler alert, I chose E*TRADE and have been pleased so far (no affiliate relationship).

Vanguard (Allows Roth contributions but no rollovers or 401k loans. $20 annual fee for each different Vanguard fund in the account until you hold more than $50k with Vanguard, very limited investment offerings; Vanguard is a wonderful company for just about everything except their i401k offering)
Fidelity (No Roth. No electronic deposits, must send a paper check—are you kidding me?)
TD Ameritrade (Irrelevant, will be merged into Schwab shortly)
Charles Schwab (No Roth or 401k loans)
E*TRADE (Permits Roth and Traditional pre-tax, accepts rollovers from everywhere, and allows 401k loans)

So after comparing all the plan documents from the major players, only E*TRADE has all of the features that one can ask for from a straight vanilla plan.

My particular needs: I wanted both pre-tax and Roth options, particularly because I wanted an easy way to roll over a combination of after-tax Roth 403(b) accounts and pre-tax employer matches from my internship and residency as well as a random IRA from my residency position (created by the county hospital that had me contributing to a pension that I would ultimately never qualify for). Consolidating accounts from my old employers into a single place where I had full control was something I considered mission-critical to simplify my finances.

The one nice thing that’s missing but isn’t currently relevant to me at this point is the lack of nondeductible after-tax contributions and in-service withdrawals, the combination required to utilize what’s called the Mega Backdoor Roth IRA. Unfortunately, no company lets you do that with a cookie-cutter plan. You would need to get a bespoke plan with a company like mysolo401k in order to enable the mega backdoor.

Also, none of the main free players give you checkbook control, which would allow you to basically use your solo 401k to invest in all sorts of weird one-offs like angel investing or buying real property. I’m pretty firmly in the set-it-and-forget-it passive investment camp when it comes to my retirement savings, so that’s also a nonissue for me (as it is for almost everyone). The most common choice for those who want checkbook control is probably Rocket Dollar (that’s an affiliate link), but that flexibility isn’t free. If one is looking for some extra cash for an investment property down-payment, for example, taking out a 401k loan is probably an easier option.

The Mega Backdoor Roth

I spent a lot of time confirming none of the big players would help you achieve the Mega Backdoor Roth IRA. I even tried to see if I could customize the E*TRADE plan document myself to permit it but no dice.

Ultimately, no current vanilla plan allows for all the factors needed to utilize the Mega Backdoor Roth. In the context of a solo 401k, this only comes into play when the profits of your business aren’t enough to get you to the $58k annual account limit via profit-sharing BUT you do have enough income and extra cash on hand to want to make up the difference (you can only contribute up to the $58k max or 100% of net compensation, whichever is lower). If you’re running an independent private practice or a big business, your profits may be enough to make this moot.

To enable the MBR you’ll need customized plan documents such as what you can get at mysolo401k or Rocket Dollar (the former is cheaper, the latter would earn me some money). Expect to spends hundreds but not thousands per year to have this kind of account.

Perhaps some competition in this space will eventually result in this filtering down to common providers.