Diganostic FOMO

05.24.21 // Medicine, Radiology

From Suneel (brother of Sanjay) Gupta’s Backable: The Surprising Truth Behind What Makes People Take a Chance on You:

Apply the following quotation to why doctors don’t want to make the call:

If the fear of betting on the wrong idea is twice as powerful as the pleasure of betting on the right idea, then we can’t neutralize the fear of losing with the pleasure of winning. We can only neutralize the fear of losing with…the fear of losing. Enter FOMO, the fear of missing out. For backers, the only thing equally powerful to missing is…missing out.

Gupta goes on to discuss how potential backers initially too scared to be the first investor eventually pile on to avoid missing out on rare unicorns.

The fear of betting on the wrong idea in medicine manifests through overtesting and hedging. More than our desire to be right, we really don’t want to be wrong. But we can’t use the usual FOMO to our advantage, because medicine isn’t about making pitches or raising money but about directly helping individual people.

We don’t want to miss anything and so are forced to entertain everything, even if that means everyone in the ED gets a CT scan or a radiologist gives an impression a mile long with the words “cannot be excluded” featured prominently next to something extremely scary.

The true solution is this: we need to disentangle the outcome from the process. You can have good outcomes from bad decisions (dumb luck) or you can have bad outcomes after good decisions (bad luck). Luck and uncertainty are part of life, and they’re a big part of medicine. We should expect some bad outcomes even when doing the right thing, and we shouldn’t forget that overtesting and overdiagnosis have their own costs, risks, and harms. Passing the buck to the future doesn’t mean it won’t be paid.

By not making the call, we are making a decision: a decision to abdicate the diagnostic yield of an encounter or examination.

There are absolutely times when uncertainly is prudent. There are true “differential” cases. But the FOMO of diagnostic medicine should be passing up an opportunity to clearly define the next steps in a patient’s care.

Price Transparency and the True Cost of Quality Healthcare

05.19.21 // Medicine

When you read healthcare reviews online, so many of the 1-star reviews relate to prices: patients frustrated by high costs or surprised by high bills. It’s easy to think that price transparency rules will help. One key problem is that healthcare consumers are intermittently if not completely insulated from the true costs of their care due to the filter of commercial insurance. It’s hard to blame people for feeling that their doctor’s time is “worth” a $35 copay instead of the hundreds of dollars they really pay indirectly.

When my family moved from typical employer-provided health insurance to a high-deductible plan, I finally started seeing firsthand how much things really “cost,” and how ludicrous billing gamesmanship practices have become.

I’m a physician, and even I find it striking.

I recently received a bill for hundreds of dollars for an annual well-person patient visit that should have been covered at 100%. If you manage to complain about anything during the intake, you see, you also get billed for a problem visit at the same time.

Is that nuts? Well, yes, of course it is. But this is the world we live in and how institutions pay the bills.

Dr. Peter Ubel had an interesting article in The Atlantic back in 2013 called “How Price Transparency Could End Up Increasing Health-Care Costs” that holds up pretty well. His main thought experiment centers on imaging, which is an easy but sort of plus/minus example.

The same kind of consumer pressure rarely exerts a similar influence on the cost and quality of health-care goods. For starters, most patients have little inclination, or motivation, to shop for health-care bargains. Insurance companies pick up most of the tab for patients’ health-care. A patient who pays a $150 co-pay for an MRI (like I do with my insurance) won’t care whether the clinic she goes to charges the insurance company $400 or $800 for that MRI. The MRI is still going to cost the patient $150. Even patients responsible for 20 percent of the tab (a phenomenon called co-insurance) face a maximum bill of only $160 in this circumstance. That is not an inconsequential amount of money, but it is still not enough money to prompt most patients to shop around for less expensive alternatives, especially when most consumers don’t realize that the price of such for services often varies significantly, with little discernible difference in quality.

To make matters worse, patients often don’t shop for health care in the kind of rationally defensible way that economic theory expects them to. According to neoclassical economics, when making purchasing decisions consumers independently weigh the costs of services from the quality of those same services. If toaster A is more expensive than toaster B, the consumer won’t buy A unless it is better than B in some way—unless it is more durable or has better features—and unless these improved features are worth the extra money.

While some patients shop around for imaging services, many stay within a larger system for all their care or go where their doctor tells them. A more meaningful scenario in a large metro would be to compare broad costs across multiple specialties/types of care across multiple health systems. Say, in Dallas, would you generally pay less at UT Southwestern, Health Texas, or Texas Health? Does that hold true for primary care and specialty care? Are there certain categories of chronic diseases that one network does better or worse with? What about labs and imaging?

Due to network effects, a consumer may not meaningfully be able to choose where to do every little thing, but rapidly comparing systems is perhaps not beyond reach. It would be nice to know, for example, which places are playing games to maximize insurance payouts at patients’ expense and which (if any) aren’t.

Sometimes, however, cost and quality are not perceived by consumers as being independent attributes. Instead, people assume the cost of a good or service tells them something about its quality. For instance, blind taste tests have shown that consumers rate the flavor of a $100 bottle of wine as being superior to that of a $10 bottle of wine, even when researchers have given people the exact same wines to drink. Other studies show that expensive pain pills reduce pain better than the same pills listed at a lower price. Price, then, leads to a placebo effect.

Such a placebo effect is no major concern in the context of wine tasting and pain pills (even if it suggests that consumers could save themselves some money if they didn’t hold this strange belief that higher cost means higher quality). But suppose your doctor asks you to get a spinal MRI to evaluate the cause of your back pain, and you decide to shop around for prices before getting the test. Would greater price transparency cause you to choose an MRI provider more rationally? Or would you instead mistakenly assume that higher price means higher quality? There is reason to worry that price transparency won’t lead consumers to make savvy decisions. It is too difficult for people to know which health-care provider offers the highest quality care.

If patients are not going to make savvy use of price information to choose higher quality, lower cost health-care, some health-care providers, like doctors and hospitals, will probably respond to price transparency by raising their prices.

And there’s the rub: is it a race to the bottom or a slow creep to the top? And if it’s both, how do we predict and influence the outcome? If the growth of debt-fluid corporate and private equity has taught us anything, it’s that competition is fickle, and it doesn’t take much for a dominant position to be abused.

Imagine you direct an MRI center in Massachusetts, and the state government requires you and your competitors to post prices for your services. You consequently find out that the MRI center around the corner from you charges $300 more than you do for their spinal MRIs, and that this increased price hasn’t hurt their business. Imagine, also, that you are convinced that your competitors don’t offer higher quality MRI scans than you do—your MRI machines are just as new and shiny as theirs; your radiologists and technicians are just as well trained. In that case, if patients are not going to be price-sensitive, you are going to raise your prices to match your competitor’s. Otherwise you are just leaving money on the table.

Quality in healthcare is a theoretically important metric but it is so, so poorly measured and understood. Customer satisfaction? Not so good. Outcomes? Highly influenced by patient selection. Healthcare is heterogeneous and complex.

Ultimately, the problem is complex and nuanced, but we should keep this in mind. Efforts to increase price transparency through state and federal law need to be carefully crafted and closely followed. Such laws should include research funding that would enable experts to evaluate how the law influences patient and provider behavior.

Also, whenever possible, price transparency should be accompanied by quality transparency. We need to provide consumers with information not only about the cost of their services but also about the quality of those services, so that they can trade off between the two when necessary. I recognize that this is a huge challenge. Measuring health care quality is no simple task. But if we are going to push for greater price transparency, we should also increase our efforts to determine the quality of health care offered by competing providers. Without such efforts, consumers will not know when, or whether, higher prices are justified.

It’s no surprise that optimizing for cost seems like a reasonable plan given how easy it is to compare versus how hard meaningful quality indicators are to measure.

But price selection in the absence of quality selection creates a perverse incentive for the cheapest lowest-quality-but-just-barely-permissible product.

Underwriting is Noisy

05.18.21 // Miscellany

An example a brief essay “Bias Is a Big Problem. But So Is ‘Noise.” about noise and decision-making in the NYT by Daniel Kahneman and his co-authors in support of their new book Noise: A Flaw in Human Judgement:

Consider another noisy system, this time in the private sector. In 2015, we conducted a study of underwriters in a large insurance company. Forty-eight underwriters were shown realistic summaries of risks to which they assigned premiums, just as they did in their jobs.

How much of a difference would you expect to find between the premium values that two competent underwriters assigned to the same risk? Executives in the insurance company said they expected about a 10 percent difference. But the typical difference we found between two underwriters was an astonishing 55 percent of their average premium—more than five times as large as the executives had expected.

This is why you don’t buy an insurance policy from a captive agent; you purchase through an independent agent who can get quotes from multiple companies. Every decision is subject to bias and noise, and they are separate and independent problems (i.e. both inaccurate and imprecise).

The easiest way to push both in your favor is through multiple independent attempts.

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).