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.

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.

The good-reason-to-be-a-doctor police

02.05.21 // Medicine, Reading

From Insider’s Pre-Med Guidebook: Advice from admissions faculty at America’s top medical schools:

Every year, hundreds of thousands of students pursue premedical studies at four-year universities across the United States and the world, and they, too, want to become physicians for a myriad of reasons. Many will find their reasons to be mature and well-reasoned. These students will find the motivation and strength to succeed as pre-med students, medical students, and physicians, and they will live happy and productive lives. Others will pursue medicine for reasons that are immature, underdeveloped, or untested. For these students, there are two major possibilities: they will struggle through their pre-medical studies and drop out, or they will end up dissatisfied with their life-long careers as doctors.

Before you pursue medicine as a career, you must be sure medicine is a good fit for you. If your motivations are poor or false, you will not have the drive to succeed during the long and difficult road ahead. You will lose time, money, and the opportunity to pursue whatever your passion truly is. If your motivations are genuine and well-developed, you will find this path to be easier and infinitely more rewarding. Not only that, but your passion will shine through the activities you pursue. Medicine is a pursuit that is simply too long, too difficult, too costly, and too important to pursue for the wrong reasons.

I would like to call bullshit on these bland truisms.

Someone show me some data.

I think there are plenty of folks who choose medicine for the “right” reasons and then get burned and churned through the medical training gauntlet. It’s hard, and the difficulty varies for different people for different reasons. It’s specious to argue that unhappiness with a medical career stems from flawed motivation as opposed to, say, a toxic training paradigm or a flawed healthcare system.

And, I think there are lots of folks who choose medicine because it’s a challenging well-compensated job where you generally have a meaningful positive impact on other humans on a daily basis.

Your pure soul can be exclusively motivated by humanistic altruism but actually have zero idea what it’s actually like to be a doctor day in and day out. Because shadowing isn’t the same as doing it for years.

You can be passionate about “medicine as a career” for all the “right” reasons even though the “career” you’ve chosen is actually a broad umbrella under which there lies a huge variety of professions from diagnostic radiology to general surgery to psychiatry?

I’ve never been convinced by the idea that good successful doctors are mostly a bunch of 18-year-olds who have a singular understanding of their lifelong “passion” let alone a meaningful understanding of medicine.

I’ve known wonderful failed pre-meds who would’ve made excellent physicians but didn’t make it through the gauntlet, and I’ve met plenty of self-satisfied doctors who got through but probably shouldn’t have.

Show me some data that the process selects for the right reasons and not just the right boxes checked.

Medical Curriculum Development is an Oxymoron

02.02.21 // Medicine

A few separate paragraphs I’ve tied together from Curriculum Development for Medical Education:

The difference between the ideal approach and the current approach represents a general needs assessment.

[A] curriculum can be written, starting with broad or general goals and then moving to specific, measurable objectives. Objectives may include cognitive (knowledge), affective (attitudinal), or psychomotor (skill and behavioral) objectives for the learner; process objectives related to the conduct of the curriculum; or even health, health care, or patient outcome objectives. The development of goals and objectives is critical because they help to determine curricular content and learning methods and help to focus the learner. They enable communication of what the curriculum is about to others and provide a basis for its evaluation. When resources are limited, prioritization of objectives can facilitate the rational allocation of those resources.

The first step in designing a curriculum is to identify and characterize the health care problem that will be addressed by the curriculum, how the problem is currently being addressed, and how it ideally should be addressed.

What percentage of core medical curricula simply exist, and then goals and objectives are grafted on after the fact to link up with the things that are already happening?

When is the last time any medical school went back to first principles? 1910?

Most States Don’t Actually Require COMLEX Exams

01.31.21 // Medicine

Update 2/11/2020: The NBOME ~~cancelled~~ indefinitely postponed COMLEX Level 2-PE. Not sure why they needed the extra shame of waiting two weeks to cave to reality. Here’s the refund waiver link for students who already paid.

On the heels of this week’s USMLE Step 2 CS cancellation and the immediate bold non-cancellation of the COMLEX Level 2-PE (Restarting April 2021? Are you joking?), I thought it’d be worth sharing some information about which states actually require the COMLEX for osteopathic licensure. You see, many DO students already take and pass the more common USMLE exam required for allopathic physicians/MDs.

While schools impose their own graduation requirements and traditionally DO residences may have their preferences, most states don’t care if a DO student passes the COMLEX or the USMLE.

The American Osteopathic Association (AOA) released this licensure summary back in May 2020 (currently unavailable for public consumption save through the magic of the Wayback Machine, h/t Mustafa Basree). The summary is this:

In 44/50 states, DO students can complete the USMLE exams for licensure.
5 more states (CA, MI, OK, WV, and PA) are more complicated. These often have requirements that are clearly in need of an update (such as permitting the substitution of the defunct FLEX exam for older doctors but with no mention of USMLE). MI, OK, and WV may give reciprocity (i.e. get licensed in one of the usual 44 and you may be able to transfer). Pennsylvania also requires a dedicated OMT exam if you haven’t passed Level 2-PE. The language here sometimes says “similar” requirements and sometimes says “equal requirements.” I have no idea what constitutes what here, but certainly wanting to work in these states would be a reason to finish the COMLEX series for now.
Only Florida actually specifically demands a full suite of COMLEX scores.

Given that Step 2 CS is canceled, the world has changed. SOMA, the largest osteopathic student association, has already called for a single licensure exam, but students are—at best—the bottom of the stakeholder food chain. I encourage physicians to lobby their state medical boards to modernize their rules and legislate away redundant requirements. I encourage the entire DO community to put pressure on the AOA to change the COCA accreditation requirements that require students to take the COMLEX in order to graduate.

I’m not saying that the COMLEX shouldn’t count (of course it should); I’m saying it shouldn’t exist.

If the USMLE is enough for MDs, it should be enough for DOs as well. Let the market decide. I don’t think the NBOME, a broadly despised organization, is doing osteopathy any favors here.

Whenever possible, I hope DO organizations, schools, and students walk away from the offerings of the NBOME and put pressure on the organization to reform itself into nonexistence. A system of two separate but otherwise analogous licensing exams is wasteful and expensive (and profitable). Osteopathic principles and manipulative medicine are not sufficient justification for complete redundancy, and there is no future where COMLEX overtakes the USMLE. Just add in a short dedicated OMM exam and call it day. Practically, I don’t think there’s a future where most traditionally allopathic program directors ever accept COMLEX in place of USMLE without bias until at least Step 2 CK becomes pass/fail. The NBOME might be holding on specifically for that future, at which point no one will care who takes what.

For now, students who are able to graduate without taking COMLEX Level 2-PE due to the pandemic and don’t need to practice in the exception states but who have taken USMLE Step 1 and Step 2 CK can finish out the series with Step 3 and call it a day. I hope folks doing this opens the common sense floodgates, but organized medicine doesn’t change easily.

In the 21st century, I’m not convinced physicians are best served by maintaining distinct osteopathic and allopathic pathways at all. A physician is a physician, and the easiest way to get rid of the unfair DO stigma is not to make it a PR issue—but to make it a non-issue. I understand there’s a lot of history here (though much of it not so positive) and plenty of strong feelings. However, even if one buys the argument that the underlying educational philosophy is sufficiently different to warrant different degrees, that’s no justification for perpetuating a separate-but-equal system for licensure given that post-graduate training has already merged and the vast majority of states don’t care.

The eventual outcome is the same. As we all know, it’s the residency training that really makes the doctor.