Don’t forbear your loans during residency (if you can help it)

05.17.21 // Finance

The most fiscally responsible thing you can do as a resident with student loans is either enter an income-driven repayment (IDR) program like REPAYE, PAYE, or IBR or (rarely) refinance privately. Please see basically any chapter of the book.

Everyone is currently enjoying a 0% federal interest rate, but that’s set to expire this fall. No one gets a permanent pass on student loan management.

But not everyone is willing or able to do the most fiscally responsible thing. There are many reasons trainees forbear their student loans during residency and fellowship. Some live in high cost of living areas like San Francisco or New York and feel they can’t afford to live and spend a few hundred dollars a month on their loans. Others have families or other obligations that require the redirection of their salary. Still a third group could potentially make payments but is frankly unwilling to because they want to use that money to actually live their life, especially those that are tired of putting said life on hold during school and training while their non-medical colleagues continue to enjoy a higher cost-of-living lifestyle and share well-curated streams of filtered vacation photos (at least pre-COVID).

I’m not judging, but I can say this: very few residents should ever forbear their loans.

Not because it’s not financially responsible (though it’s not), but because if you’re not planning on making payments you should at least look into mitigating the growth of your loans. Government forbearance is the worst of all worlds: none of the perks of an income-driven repayment plan or possible loan forgiveness in a reasonable time frame while also stuck with the high-interest rates of federal loans.

These are the IDR perks you lose during forbearance:

Interest continues to accumulate on all loans (even subsidized loans, if you have any).
You get no IDR-derived interest subsidy and you get no 0.25% autopay rate reduction.
Then, at the end of the forbearance period, the accrued interest capitalizes and gets added to the principal (mean you don’t just owe more money then but your loan will also grow faster in the future).

In other words, the longer you forbear, the worse things get.

If you can stick it out in IDR instead:

All monthly payments during residency count towards the 120 monthly payments (10 years) needed for public service loan forgiveness. Even if calculated at $0/month.
Even if you switch to forbearance later, the qualifying payments you make still count for PSLF (they don’t have to be consecutive). Since your remaining loan balance after 120 payments will be forgiven, it is in your best interest to have these payments be as small as possible, so don’t waste your low-pay years as a resident unless you need to.
Any unpaid interest on any subsidized loans from college is forgiven for the first 3 years
50% of any unpaid interest on all loans is forgiven if in REPAYE.
You get a 0.25% rate discount for enrolling in autopay
Interest will never capitalize again after entering repayment unless you change plans or you lose your partial financial hardship (for IBR and PAYE).

Those are good reasons to not forbear.

It’s also usually unnecessary. Being proactive means almost no one needs to forbear during their intern year: you’ll likely enjoy $0 payments during your PGY1 year (based on when you were a broke student) and very low payments (based on working only part of the year you graduated) during your PGY2.

So, plan for IDR first. If times get tough in the future, forbearance is only a phone call away.

Student loan debt predicts burnout

05.14.21 // Miscellany, Radiology

From “Predictors Between the Subcomponents of Burnout Among Radiology Trainees” by Le et al. in JACR.

In summary:

Debt level < $200,000 was associated with lower [emotional exhaustion] scores among upper-level trainees and was the only predictor of burnout that significantly affected multiple years of training.

I suspect there is a dose-response above that debt level as well.

Uncertainty breeds despair. Make sure you develop a student loan action plan.

Residency and the Craftsman Mentality

05.12.21 // Medicine, Reading

From Cal Newport’s excellent Deep Work: Rules for Focused Success in a Distracted World:

Whether you’re a writer, marketer, consultant, or lawyer: Your work is craft, and if you hone your ability and apply it with respect and care, then like the skilled wheelwright you can generate meaning in the daily efforts of your professional life.

You don’t need a rarified job; you need instead a rarified approach to your work.

Let’s add “physician” to Newport’s list.

One of the more disheartening aspects of medical school is the siloing of medical specialties such that different breeds of doctors appear to compete in the hospital and medical students come away with the idea that one specialty should spark passion in their hearts (and that they will be professionally unhappy if they then don’t match into that one specialty).

It doesn’t have to be this way.

The satisfaction of professional growth and a job well done can transcend specialty choice. If the results of the match weren’t what you wanted, apply yourself to developing a craftsmen’s mentality. Get good at what you do, take pride in it, and passion can follow.

The One Thing

04.30.21 // Reading

From The ONE Thing: The Surprisingly Simple Truth Behind Extraordinary Results:

When everything feels urgent and important, everything seems equal. We become active and busy, but this doesn’t actually move us any closer to success. Activity is often unrelated to productivity, and busyness rarely takes care of business.

You can become successful with less discipline than you think, for one simple reason: success is about doing the right thing, not about doing everything right.

Maybe a collection of bland truisms, but…it’s amazing how enticing the pull of doing urgent but unimportant things can be.

Regulatory controls and not-so-free markets

04.26.21 // Miscellany

Not just doctors but all sorts of students and professionals scrambled to figure out how to deal with their high-stakes exam during the pandemic. Lawyers were no exception. Some states had new lawyers take the bar remotely. But a few states just got rid of it altogether and allowed diplomas from accredited schools to stand on their own.

NPR’s Planet Money, “Most People Can’t Afford Legal Help. 1 Reformer Wants To Change That” is an interesting quick discussion of slowly changing legal regulations that has plenty of parallels with medicine:

The National Conference of Bar Examiners, which helps states administer the bar, argues that the bar remains important in protecting the public. “Every high-stakes profession, including engineering, medicine, aviation, and others, relies on licensure to ensure that practitioners meet minimum standards of fundamental competency, and the practice of law is no exception,” the organization said in a statement.

But Gillian Hadfield, a law professor and economist at the University of Toronto, argues there’s no evidence that the bar actually protects the public. She thinks not only it is time we reevaluate use of the bar exam — it’s time to completely revamp how we regulate the practice of law in the United States.

The bar exam, she says, is one part of a broader system that raises the cost of legal services and contributes to an “access to justice crisis” in the United States. “My estimate is well over 80% of Americans who need legal help can’t get it because it’s too expensive,” Hadfield says. “And the main reason for that is a crazy regulatory system. The bar exam is part of that.”

…

It’s kinda like cafe baristas getting control of the coffee market by using the regulatory system to prevent restaurants, Keurig machines, and gas stations from providing you coffee. They’re like, “It’s for your safety! You could get burned or poisoned! The coffee will be worse!” Meanwhile, a cup of coffee costs $20.

Post-Match Personal Finance Checklist

04.19.21 // Finance

Post-Match Fourth Year is a time of impending change, and there is no better time for a soon-to-be physician to learn the basics of personal finance and get their financial house in order before residency.

There are a lot of things you can do, but here are my top 5:

1. Learn the basics of personal finance and make a student loan action plan

There’s some core information that every functioning adult simply needs to know.

The are many resources for the former and very, very few that are comprehensive enough to make sure you’re doing the latter correctly. You can do both with my book, which includes chapters on the psychology of money, how interest works, taxes, and retirement at the level a new intern should understand. It’s available in print and ebook (Amazon, Apple Books), and the full text is available cost-free and advertisement-free (i.e. completely free) right here.

Early steps will almost always involve federal consolidation after graduation, and you will not forbear/defer your loans.

2. File your Taxes

The deadline was extended to May 17 if you haven’t already, but if you don’t owe taxes, you can file at any time without penalty. So do it! Your taxes are used to determine your student loan payments in income-driven repayment plans like PAYE, REPAYE, and IBR.

3. Consider what kind of insurance you need

If you are married and especially if you have kids, you simply need life insurance. The policies for life and disability insurance that you get from your employer are usually not large enough to provide for dependents and aren’t portable. Getting insured while young and healthy locks in future security. No one enjoys spending money on something they hope to never use, but that’s the nature of insurance.

If you own a home, you’ll need home owner’s insurance, and if you rent an apartment, you’ll need renter’s insurance.

You’ll definitely need auto insurance if you own a car, and need to make sure that the personal liability benefits are high (replacing the car is the cheap part; paying for healthcare and property damage, not so much).

At some point before the end of training, you’ll also want umbrella insurance, which is a cheap liability policy-of-last-resort in the rare event that you are on the hook for more than the limits on your home or auto policy (these cost around a few hundred a year for 1 mil policy but do require robust underlying home and auto policies).

Ignorance may be bliss, but insuring against catastrophe will help you sleep better.

4. Learn about and consider purchasing disability insurance

See my longer article about buying a DI policy during medical school. A post-match fourth-year student is eligible to buy a small doctor policy that is portable to all future jobs and can scale with future income increases. Any disability policy must be purchased through an agent, and it may be worth it to contact one now and see if a policy is affordable to you now. You may have access to different discounts at different points of training, and a good agent can walk you through all of your options, the benefits and costs of specific “riders,” and be available to you as your situation changes.

You want to purchase a policy as early as it’s affordable for you but not later than your final year of training. I partner with the fine folks at LeverageRx and Pattern.

5. Get at least a vague handle on budgeting

It can be really helpful to use a service like YNAB or Mint to create a real bonafide budget to follow, especially if you’ve ever carried credit card debt, want to be more purposeful in your spending, or need to save up for some big purchases. But I know not everyone is going to do that. What’s easier for many people is to determine your reverse budget.

You figure your actual take-home pay (your paycheck after taxes and any retirement, FSA/HSA contributions, etc). Then, determine your fixed expenses, which are the things that happen no matter what like rent and student loan payments, and your mandatory variable expenses (e.g. utilities). The last category is the hardest because they may change month to month, so estimate high, not low. Note that you’ll want a 3-month emergency fund, and any retirement contributions that receive a match from your employer should also be considered mandatory. The difference between what you bring in and the costs you know you’ll need to account for is the maximum amount of money you can “spend” every month.

You should, of course, spend less, and you’ll need to if you want to afford things like travel, but you should never spend more unless you’ve already saved up for it. Figuring out how to plan for the big stuff as well as get deeper insights about your current spending habits are two of the big benefits of software like YNAB. You might consider setting up different folders in your savings account (or even different savings accounts) in order to hold money for special purchases like a wedding or vehicle. Then you can plan for those big-ticket items as an amortized monthly expense.

One key to making budgeting easier mentally and psychologically is a big gap between your income and your expenses. That’s why choosing wisely for the big fixed expenses like housing and transportation is so critical.

Explanations for the 2021 Official Step 1 Practice Questions

04.17.21 // Medicine

This year’s set was updated in February 2021 (PDF here).

The asterisks (*) signify a new question, of which there are only 2 (#24 and 53). The 2020 set explanations and pdf are available here; the comments on that post may be helpful if you have questions.

The less similar 2019 set is still available here for those looking for more free questions, and even older sets are all listed here. The 2019 and 2020 sets, for example, differed by 36 questions (in case you were curious).

Scheduling Slack

04.15.21 // Medicine, Reading

From Alan’s Weiss’ classic Getting Started in Consulting:

Medical consultants advise doctors never to schedule wall-to-wall appointments during the day, because inevitably there are emergencies, late patients, complications on routine exams, and so forth. These create a domino effect by day’s end, and some very unhappy scheduled patients. Instead, they advise some built-in slack time that can absorb the contingencies. If not needed, slack time provides valuable respite.

Ha.

I read this book years ago when I was a resident and came across this passage when reviewing my Kindle highlights the other day.

Perhaps there are consultants in real-life operating as Dr. Weiss suggests, but this common-sense approach to sustainable medical practice is not what many large health systems employ.

In my wife’s old outpatient academic practice, lunchtime wasn’t respite. It was an overbook slot, and her schedule was so jam-packed that there were always patients clamoring to squeeze in.

In order to make that all work, the average doctor spends 1-2 hours charting at home per day.

Contrast that with her current solo practice where she has complete autonomy: her patients aren’t scheduled wall to wall, and she has time for the inevitable emergencies, hospitalizations, collateral phone calls, prior auths, and the other vagaries of modern medical practice.

I’m proud of the practice she’s built—during a pandemic no less!—but it’s crazy that even academic medicine has become so corporatized in its paradigm that it was easier to craft her own business in order to practice on anything approaching the terms that would best serve her patients and herself.

Attending

04.08.21 // Medicine, Reading

A few separate passages I’ve combined from Dr. Ronald Epstein’s Attending: Medicine, Mindfulness, and Humanity:

Altogether, I saw too much harshness, mindlessness, and inhumanity. Medical school was dominated by facts, pathways, and mechanisms; residency was about learning to diagnose, treat, and do procedures, framed by a pit-of-the-stomach dread that you might kill someone by missing something or not knowing enough.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking; and no one had a road map.

The great physician-teacher William Osler once said, “We miss more by not seeing than by not knowing.”

The fast pace of clinical practice—accelerated by electronic records—requires juggling multiple tasks seemingly simultaneously. Although commonly thought of as multitasking, multitasking is a misnomer—we actually alternate among tasks. Each time we switch tasks we need time to recover and, during the recovery period, we are less effective. Psychologists call this interruption recovery failure, which sounds a bit like those computer error messages we all dread. We increasingly feel as if we are victims of distractions rather than in control of them.

Outside of the OR (and not always even then), it’s rare to find an environment that promotes the space for deep focus and self-awareness. Mindfulness, insofar as a daily approach to medical practice, is something that goes against the grain of one’s surroundings.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking.

I like that. Medicine is generally ripe for Monday-morning quarterbacking (and radiology in particular due to the permanent, accessible, and objective nature of the imaging record).

But doctors don’t work in vacuums. We are humans.

Consider for a moment the discipline of human factors engineering:

Human factors engineering is the discipline that attempts to identify and address these issues. It is the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use. A human factors engineer examines a particular activity in terms of its component tasks, and then assesses the physical demands, skill demands, mental workload, team dynamics, aspects of the work environment (e.g., adequate lighting, limited noise, or other distractions), and device design required to complete the task optimally. In essence, human factors engineering focuses on how systems work in actual practice, with real—and fallible—human beings at the controls, and attempts to design systems that optimize safety and minimize the risk of error in complex environments.

(I first found that passage plagiarized on page 8 of the American Board of Radiology’s Non-interpretive Skills Guide.)

Despite the rise of checklists and evidence-based medicine, humans have been almost designed out of healthcare entirely. Rarely is anything in the system—from the overburdened schedules, administrative tasks, constant messaging, system-wide emails, the cluttered EMR, or the byzantine billing/coding game—designed to help humans take the time and mental space to sit in front of a patient (or an imaging study, for that matter) and fully be, in that moment, a doctor.

Organization Habit Loops

04.05.21 // Reading

From Charles Duhigg’s The Power of Habit: Why We Do What We Do in Life and Business:

That’s when [Alcoa CEO Paul] O’Neill’s education in organizational habits really started. One of his first assignments was to create an analytical framework for studying how the government was spending money on health care. He quickly figured out that the government’s efforts, which should have been guided by logical rules and deliberate priorities, were instead driven by bizarre institutional processes that, in many ways, operated like habits.

Healthcare in a nutshell, from the tippy top of Medicare and the FDA down to the hospitals and institutions. It’s all path dependence. We are where we are because of where we’ve been, but we’d never choose to be here doing it like this in the first place.

Bureaucrats and politicians, rather than making decisions, were responding to cues with automatic routines in order to get rewards such as promotions or reelection. It was the habit loop—spread across thousands of people and billions of dollars.

This has always been true, but the optimist in me always hopes that a big event—like a generation-defining pandemic—might shock people into cohesive collective action focused on outcomes instead of the typical saber-rattling over competing values.