Skip to the content

Ben White

  • About
  • Archives
  • Asides
  • Support
    • Paying Surveys for Doctors
  • Medical Advice
    • Book: The Texas Medical Jurisprudence Exam: A Concise Review
    • Book: Student Loans (Free!)
    • Book: Fourth Year & The Match (Free!)
  • Radiology Jobs
  • #
  • #
  • #
  • #
  • About
  • Archives
  • Asides
  • Support
    • Paying Surveys for Doctors
  • Medical Advice
    • Book: The Texas Medical Jurisprudence Exam: A Concise Review
    • Book: Student Loans (Free!)
    • Book: Fourth Year & The Match (Free!)
  • Radiology Jobs
  • Search
  • #
  • #
  • #
  • #

The disappearing USMLE 2020 practice questions

05.20.20 // Medicine

Update: my explanations for these sets are now available: Step 1 and Step 2 CK.

Earlier this year the NBME released updated 2020 practice materials for both Step 1 and Step 2 CK. There are a bunch of new Step 1 questions and the Step 2 set is entirely brand new (the first meaningful change in several years). I was going to continue my annual tradition of explanations but then noticed that the website reverted back to the 2019 sets.

As is their tendency, the NBME isn’t very quick to manage outdated URLs. The PDFs for both new sets are still accessible:

  • The 2020 USMLE Step 1 Practice Questions
  • The 2020 USMLE Step 2 CK Practice Questions

I don’t know if these will simply come back as official sets soon, but it seems they were likely removed because of COVID-19, so it might be a while.

But they are free highest-quality questions and remain worth your time.

Symbolic Measures and the Silence of the ABR

05.19.20 // Radiology

Earlier today the ACR passed resolution 50 without dissent, a gesture made in response to the recent (and ongoing?) MOC agreement debacle. The thrust of the resolution is that the American Board of Radiology should strive to “minimize power imbalance in decision-making between those professionals and the certifying body by committing to representative, inclusive, and transparent decision-making.” Also that they should consult the ACR before making terrible participation agreements and should also share said agreements in advance for public comment from candidates and diplomates.

Little birdies informed me that the ABR was working hard behind the scenes to spike this resolution. However, when it was presented during the reference committee hearing on Monday and then came up for a vote today, the ABR maintained complete radio silence. Not a peep.

This is, oddly, in strange contrast to recent promises of greater communication and transparency, such as when the ABR President recently said he wanted to “take ownership of flawed or incomplete communications.” Given the opportunity to literally address the entire radiology community and its largest deliberative body, the ABR didn’t say anything. They didn’t argue that they were right. They didn’t admit that they were wrong. They offered no window into the agreement process or any public acknowledgment or response to the many questions and comments that are contained in the resolution or that were raised during the discussion.

Why?

Because they don’t have to.

The core problem with the ABMS member boards like the ABR is that they are completely unaccountable. They may claim “business league” nonprofit status as 501(c)(6) organizations, but they are not accountable to their fields or their diplomates. The ACR has no power over the ABR. So why should the ABR work with them? Why subject itself to a public flogging? Better for that to occur on Twitter, anonymous forums like Aunt Minnie, and yes, right here.

During the reference committee discussion, I offered this testimony:

In its recent apology email to diplomates, the ABR suggested that the new MOC agreement was a slip-up. They wrote, “an error in the creation of the agreement resulted in the posting of an incorrect document, with more restrictive language than was intended.” This statement is at best misleading. The document was not simply a one-off overreach. I would like the members of the college to know that I and all other recent diplomates have been forced to sign similar agreements during our training. I signed a nearly identical agreement waiving my own due process rights in 2013 when I was a first-year resident. And today, despite softening the language of the recent MOC agreement after the public outcry, the current Candidate Agreement containing the exact same problematic language remains completely unchanged. We are leaving our most vulnerable colleagues out to dry.

The ABR is currently starved of external influence and oversight. Their bylaws mandate that nominees for the Board of Governors are solicited internally and elected by 3/4 majority of the current BOG. This insular approach essentially precludes outside perspectives. Once elected, the ABR conflict of interest policy “requires the Governor to act in the best interests of this Corporation, even if discharging that duty requires the Governor to support actions that might be contrary to the views, interests, policies, or actions of another organization of which the Governor is a member, or to the discipline of which the Governor is a member.”

This is deeply problematic. The ABR, by its own bylaws, is unaccountable to radiology and to radiologists. This is why we have our current state of affairs.

What we do matters. We should demand transparency and excellence from any organization that has an impact on our field and our practice. And if the ACR will not take a stand for radiologists then who will? This resolution could be a small first step toward creating a more meaningful working relationship.

Ultimately, this ACR resolution is purely symbolic.

Unfortunately, the ABR’s softening of the recent MOC agreement language was also merely a placating gesture, because it’s functionally similar despite the removal of the most heinous legalese.

There is a massive power imbalance here. In a situation where you can only vote with your feet, you have to be able to walk to wield influence. But doctors can’t strike. And the only people that can meaningfully do so in the current climate are the grandfathered lifetime certificate holders who are optionally enrolled in MOC, and they make up a shrinking fraction of the ABR’s profits every year.

Until the ABR decides that transparency and democracy will help their mission (or their bottom line), they have no need to listen.

But I hope they will. And I hope the ACR will take increasingly strong positions in future years because they’re an important part of the certification narrative that the radiology community needs to hear.

Resident Retirement Contributions and PSLF: Pretax or Roth?

05.18.20 // Finance

Saving for retirement, even as a resident, is a good thing. The absolute amount of money you can likely contribute is relatively small, but it does add up and over time it will compound to a larger amount. However, the most important reason to do so as soon as possible is to start the saving habit.

It’s important to make saving an automatic deeply-ingrained habit. It will serve you well when you make more money and help you make faster progress toward your savings goals of financial flexibility and a healthy retirement. If you think you should wait until you earn more money, the problem is that you can always spend more money, and some folks will simply need higher spending in order to make ends meet based on the decisions they’ve already made with regards to prior spending and borrowing, family planning, and the results of the match. So the most meaningful answer to the question of resident retirement savings is simply yes.

But if you can, let’s discuss the age-old question of pretax vs Roth.

The Options

In a traditional pretax account like the standard option for your work 401k or 403b, money is subtracted from your income in the year of the contribution. So you pay fewer taxes upfront. It then grows tax-free while in the account, and you’ll pay taxes on the distribution when you use it in retirement as if it were income.

Roth accounts are the opposite. You put after-tax money in, meaning you pay regular taxes on that money in the contribution year. The money also grows tax-free while in the account but then is also tax-free when you withdraw it.

Which contribution type is mathematically best has to do with your marginal tax rate during the contribution year while working vs during the withdrawal year in retirement. What’s important to realize is that mathematically, the two choices are equivalent when the tax rates are the same if the amounts contributed are adjusted on a tax-basis (ie, at a 10% marginal tax rate, $1000 pretax contribution is equivalent to $900 Roth, because the Roth has the taxes paid upfront).

The reason behind the idea that a resident should generally use a Roth option is because it’s assumed that you will earn less as a resident than you will want to spend in retirement (potentially true), not that you will simply earn less than you would as an attending (almost universally true).

Retirement Contributions and Student Loans

When it comes to student loans on an income-driven repayment plan, pretax contributions reduce your adjustable gross income, which reduces your discretionary income, which reduces your monthly payments the following year. Because PAYE/REPAYE uses a ten percent discretionary income calculation, every dollar you contribute reduces your payment by ten cents the following year (fifteen cents in the old IBR). If you achieve loan forgiveness via PSLF, then that bonus contribution match is truly extra free money on top of the PSLF windfall.

Additionally, if you are in REPAYE, the lower payments can result in more unpaid interest and thus a slightly better unpaid interest subsidy and lower your effective rate. Conversely, this would only matter if you did not get PSLF. Outside of this rate reduction, remember that lower monthly payments are really a good thing financially: they just mean less progress on your loans and more interest paid over time.

The impact here depends on how much you can contribute. If you have a high-earning spouse and can therefore max out a $19,000 contribution, for example, you’d save an extra $1,900 in payments the following year. That’s not chump change. But if you put $5k away? Just $500, or about $40 a month. Not necessarily anything life-changing there.

In contrast, Roth contributions have no impact.

How Taxes Work

2019 tax brackets Single Married Filing Jointly
10% $0 – $9,875 $0 – $19,750
12% $9,876 – $40,125 $19,751 – $80,250
22% $40,126 – $85,525 $80,251 – $171,050
24% $85,526 – $163,300 $171,051 – $326,600
32% $163,301 – $207,350 $326,601 – $414,700
35% $207,351 – $518,400 $414,701 – $622,050
37% $518,401+ $622,051+

Taxes are progressive. You don’t simply pay your marginal rate on all your earnings based on your total income. You pay the rate on each bucket of money as it fills up. But since pretax contributions are a deduction, they do reduce your taxes at the marginal rate.

So, looking at the chart, a single resident making $55k would be in the 22% bracket, and with the standard deduction, their effective tax rate is about 12%. Let’s say you then, as part of a married couple, wanted to retire on $100k a year? Well, with a $24k standard deduction that would actually get you a marginal tax rate of 12% and an effective rate of about 11% (using 2019 tax brackets as a guide). In this scenario, therefore, pretax could win right off the bat (the marginal rate is what matters here).

There are three important nuances here:

  1. We don’t know what taxes will look like in the future.
  2. Distributions are taxed as income, so not every dollar is taxed the same.
  3. You may need less money in retirement than you think.

We don’t know what taxes will look like in the future

I suspect tax rates will overall be higher in the future, at least at the top marginal rates. The current rates are at historic lows, deficits are rising, and income inequality is reaching a tipping point. That doesn’t necessarily mean they’ll be higher at the level you end up retiring at, but it’s certainly a notch in the Roth column.

Distributions are taxed as income, so not every dollar is taxed the same

As we just discussed, taxes are progressive and each bracket is filled sequentially with rising income. So the first dollar pays almost nothing while the final dollar pays the full marginal rate. In retirement, you can utilize a combination of social security, Roth, and pretax money to minimize your tax burden. You do not need to pay taxes on an income of $100,000 in order to spend $70k after taxes in retirement like you would have during your working years if you have money in both types to utilize. You can use pretax at the lower tax brackets and Roth to fill in the rest to prevent paying the higher rates.

That’s one good reason to do a Backdoor Roth as an attending, even when you earn too much to contribute directly.

You may need less money in retirement than you think.

In retirement, you should have no debt and significantly decreased monthly expenses. No student loans. Real estate taxes, sure, but no mortgage. Probably no car payments, at least for a while. Maintaining a similar quality of life in terms of discretionary spending will be significantly less expensive even with some increased leisure spending.

The Fuzziness and Flexibility of Extra Money

The 10% PSLF “match” has nothing to do with tax savings. It’s extra after-tax money you get to play with the following year due to lower required monthly loan payments. So it’s letting you hold on to money you would have spent. That makes it fuzzy. But it also makes it valuable, because it’s money that you can do whatever you want with. You can certainly invest it by increasing your contribution to your retirement. You could even do that pretax again, getting a token 10% of that amount back the following year. But regardless, the money is a good reason to understand the idea of the time value of money.

The time value of money is the finance principle that money now is worth more than the same amount of money later due to its earning potential (i.e. it can be invested and earn interest). So while it’s possible, like in our above example, for this extra money to merely improve the tax inefficiency of using a pretax account when you hope to spend more in retirement, if it ends up a wash it still may be better to have that money now than later.

One thing to consider, outside of math, is simply where the extra money will help you more. If you do a good job saving for retirement, the few thousand bucks in changes related to tax optimization may not be meaningful because you’ll have more than enough anyway. On the flip side, having smaller IDR payments frees up money now on a monthly basis in these leaner years at the start of your career.

That’s putting money in your pocket to get rid of high-interest debt like credit cards, build up an emergency fund, save a little for an important purchase, make life and disability insurance affordable, or pay for your own HBO subscription (speaking of, have you priced out your options for own-occupation disability insurance yet? Because you need to).  My point is here is that it’s not always prudent to let the tax tail wag the living-your-life dog.

You can, of course, split the difference and invest some of your contribution in your work pretax account (say up to the match) and then whatever else you can afford into a Roth IRA.

Conclusion

It’s literally impossible to know what the correct choice is mathematically. Any calculation involves a ton of assumptions. It’s possible the machines will have taken over and everyone will be on a universal basic income and most tax revenues will come from the immortal cyborg of Jeff Bezos. It’s also absolutely possible that future tax rates will be sufficiently high that Roth becomes the optimal strategy regardless of the extra money pretax contributions can give you right now.

However, that doesn’t necessarily make it the right choice for you. Personal finance is personal. The increased cash flow now may be more valuable in practical life impact than more money later that you may not need or get to utilize.

Personally, if you’re really planning for PSLF, I think pretax makes a lot of sense (though Roth is never bad!). If you’re not planning for PSLF, then, by all means, these are almost certainly some of the best years of your career for Roth contributions. And lastly, if you’re struggling to make your IDR payments and don’t see how you could contribute to your retirement at all, then pretax may make it slightly more feasible for you.

ABR MOC and the Art of the Apology

05.08.20 // Radiology

This week the American Board of Radiology emailed its diplomates in response to the continued concern that its initial fix to the over the top legalese in its agreements was buried so deep that no one could see it as well as the frustration that people who caved early didn’t have a chance to sign the new one.

I know some regular readers are getting bored of all this ABR talk—and we’ll be moving on from this flurry soon I promise—but there’s also a lot to learn here about management and organized medicine.

The ABR, clearly hoping for a gold star, started with this email subject line: “We listened to your concerns about our MOC Participation Agreement.”

Glad to hear it.

Today we’re discussing how to apologize.

Dear Diplomate:
As part of your enrollment in the ABR’s Maintenance of Certification (MOC) and associated interactions with our website, periodic renewals of user agreements are needed to codify the understanding of the limitations of usage of the materials and the extent of liability. This is especially important in establishing the security of the content used in assessment, in order to maintain a secure, valid, and fair process.

In March, an error in the creation of the agreement resulted in the posting of an incorrect document, with more restrictive language than was intended. Specifically, our request for those enrolled in MOC to waive certain legal rights was neither reasonable nor necessary.

I gave the ABR some advice on how to apologize back in 2017. When an accountable organization makes a mistake, they should:

  1. Express regret and acknowledge responsibility
  2. Be transparent and describe the mistake
  3. Give an action plan and steps to correct the problem
  4. Ask for forgiveness

They do a decent (incomplete) job of #3 and #4 in the following paragraphs. But they did a terrible job with #1 and #2.

The ABR is pretending that a Janice or Karen or Peter accidentally uploaded an “incorrect” document that was spuriously created in “error.” While we can all agree that waiving legal rights is stupid and unnecessary, this wasn’t an oversight. In terms of quality parlance such as might have been seen in the ABR’s manual for noninterpretive skills, the creation of the MOC agreement was not a “slip.” It was a bad choice and a manifestation of bad decision making.

It was deliberate. To say otherwise is ludicrous.

Especially so because this language was not new. I actually looked back at my own myABR history and saw that the same BS was in the “Agreement for Candidates and Diplomates” that I signed back in 2013, when I was a busy first-year resident unlearned in the machinations of our radiology overlords.

Perhaps the ABR was coyly suggesting that the language was unnecessary because all recent trainees have already signed away those rights. To wit, while the ABR changed the MOC agreement, they have not changed the Agreement for Candidates and Diplomates, which includes the same language.

Residents are a vulnerable population. Diplomates and organized radiology including the ACR should continue to put pressure on the ABR to fix this issue across the board. Don’t leave the trainees out to dry.

A revised document has since been implemented at https://myabr.theabr.org/moc-agreement. After discussion with counsel, acknowledging that the new language is far less stringent, this will supplant the original agreement for those who have already signed. Alternatively, these individuals may choose to sign the new agreement, but it is not required.

Now diplomates can now choose to sign the new agreement. Misuse of the term grandfathering has been avoided.

In view of the increasing administrative requirements inherent in the daily practice of medical practitioners, the ABR has an obligation to lessen such burdens whenever possible. We apologize for the error and hope to learn from it. No process is perfect, but we can and should continuously improve our processes based not only on internal quality control but also on feedback from our stakeholders, especially the radiology and physics professionals we are privileged to serve.

This is an excellent paragraph.

Sincerely,

Brent J. Wagner, MD
ABR President

Valerie P. Jackson, MD
ABR Executive Director

In short: I don’t know why the ABR is institutionally incapable of giving a real apology.

But more importantly, the ABR only fixed part of the problem. They responded to the loudest voices, but they didn’t even fix the imposition of onerous language on our youngest colleagues let alone address the problematic “processes” and organizational perspective that created it in the first place.

Free Radiology Resources from the ACR RFS

05.08.20 // Radiology

Residents from across the country in the ACR Resident and Fellow Section came together and assembled a nice collection of free radiology learning resources from across the interwebs including lots of videos.

You can help to add more. It’s a Google doc.

Check it out.

 

 

Timeless Advice: The Golden Rule will never fail you

05.07.20 // Miscellany

Kevin Kelly, former editor of Wired and the writer who popularized the 1000 true fans idea, decided to give 68 bits of unsolicited advice on his sixty-eighth birthday. It’s an excellent quick collection, but here are a few great ones that apply especially well to medical training:

Being enthusiastic is worth 25 IQ points.

Promptness is a sign of respect.

To make mistakes is human. To own your mistakes is divine. Nothing elevates a person higher than quickly admitting and taking personal responsibility for the mistakes you make and then fixing them fairly. If you mess up, fess up. It’s astounding how powerful this ownership is.

And one particularly timely one:

When crisis and disaster strike, don’t waste them. No problems, no progress.

Living Happily in a World You Don’t Understand

04.30.20 // Miscellany

Morgan Housel, discussing the problematic narrowness and personal bias of most people’s mental models:

I don’t know what I don’t know. No one does. But we can’t walk around confused all day. Nassim Taleb says “I want to live happily in a world I don’t understand.” Which is exactly what we do. We take the world we live in and try to make a coherent story out of it based on the mental models we’ve developed during our lifetimes.

The takeaway: we are more likely to be influenced by our past than to truly learn from it. We are prone to overfitting life lessons to overly specific details instead of taking away useful general principles.

When this is over and we’re making decisions about how to best function in a post-COVID world, how much do you want to bet that people will say, “Yeah, but that was different. Those were special circumstances,” as a way to revert back to bad practices.

The ABR’s Thoughts on Doing the Right Thing

04.30.20 // Radiology

In response to concerns about exam administration, the American Board of Radiology has now released a “Statement on Delivering Remote Exams” to their Coronavirus updates page:

In response to queries, delivering our exams remotely is problematic. We have investigated many options, but the inability to adequately control image quality, the testing environment, and security would significantly threaten the fairness, reproducibility, validity, and reliability of the testing instrument across candidates.

A challenge? Sure. Problematic? A pure cop-out. To be absolutely clear, the ABR has already used remote testing in the past. It was just on their terms due to their mistake. There is nothing about ABR exam administration that cannot be effectively recreated in a remote setting, especially under these unprecedented circumstances.

We want to give exams that fairly and accurately assess a candidate’s knowledge and experience.

We’ve long since moved past wants and desires here. Nobody wants to be dealing with this, but forcing nationwide travel is by far the greatest threat to fair and accurate candidate assessment.

We pledge to remain flexible and responsive to candidate needs, and we appreciate everyone’s patience as we all go through the pandemic’s effects together.

Being “responsive to candidate needs” and also rejecting the idea of remote testing are 100% incompatible. This is absolutely a public health issue, and a head-down blinders-on approach is unacceptable for a health-related organization purporting to act in the public’s interest.

The ABR’s Revised New MOC Agreement

04.29.20 // Radiology

Last week, people were upset about the heavy-handy liberty-destroying verbiage of the ABR’s new MOC agreement. Some people complained. At least one cranky fellow wrote a blog post about it, and then two days later the ABR backtracked and promised to remove the language about waiving various rights.

They did, in fact, do that. But, oddly, they didn’t release the full text on their website as people requested (and certainly not a track changes-type comparison or an explanation). Those who already signed the old agreement thus can’t see the new agreement for which they are automatically being “grandfathered.”

(It’s perhaps also worth noting that the ABR ironically used the term grandfathering incorrectly. Grandfathering is when old people get to keep using old rules despite subsequent changes. The ABR does this literally every day when lifetime certificate holders are exempt from MOC. Automatically making a new agreement retroactive is the opposite of grandfathering.)

Regardless, here is the new agreement (with commentary, natch).

I UNDERSTAND AND AGREE that by enrolling in the American Board of Radiology (ABR) Maintenance of Certification (MOC) Program, I am subject to the policies and procedures of the program and agree to hold myself to the highest ethical standards in the practice of my specialty.

Deal.

I UNDERSTAND AND AGREE that the ABR MOC program is designed to monitor my professionalism and professional standing, lifelong learning and self-assessment, assessment of knowledge, judgement [sic] and skills and improvement in medial [sic] practice.

Yes, they really misspelled judgment and medical.

I UNDERSTAND AND AGREE that as a diplomate of the Board, I have the responsibility to supply the Board with information adequate for the Board’s proper evaluation of my credentials, moral, ethical and professional standing. I authorize any hospital or other medical or professional organization, or person who may have information relevant to its evaluation of my certification and/or enrollment in the MOC program to provide such information upon request. IF requested by the Board, I will sign and promptly return appropriate consents for release of information addressed to specific persons or entities.

This is a less scary wording of what amounts to the same material. As in, you will cooperate with ABR investigations and aid the ABR in information gathering about you when your privacy rights prevent the ABR from doing so without your consent.

They no longer mention things like waiving FERPA but presumably, all of the details still apply here. If you agree to let them do whatever they want, then you will be signing away those same rights during an investigation if requested. While this sounds bad, it’s hard to imagine the ABR being able to revoke certification from bad actors without this information unless they always wait for state boards and hospitals to act first and then just follow suit.

I UNDERSTAND AND AGREE that any communications made to the Board regarding my certification and/or enrollment in the MOC program may be made in confidence and will not be made available to me under any circumstances. I hereby release from liability any hospital, medical staff, medical or professional organization, person, or the Board of Governors from liability for acts performed in good faith and without malice in connection with the Board’s request for information.

This is also essentially the same. We can’t try to punish whistleblowers.

I UNDERSTAND AND AGREE that should information be received which would adversely affect my certification and/or enrollment in the MOC program, I will be so advised and given an opportunity to rebut such allegations. However, I will not be advised as to the identity of any individual or entity who has furnished adverse information concerning me, and that all statements and other information furnished to the Board in connection with such inquiry shall be confidential, and not subject to examination by me or anyone acting on my behalf. I also agree that I will not use any litigation process, subpoena or other means to attempt to cause any disclosure of adverse information received by the ABR regarding my character or certification.

Whistleblowers can maintain anonymity. I know this was troubling to many people but doesn’t actually bother me that much with the exception of theoretical reports that are not made in good faith. It’s common practice for good faith reports to be protected from liability. But malicious and false reports, once discovered, are typically not immune, and if the motivation behind a report were to become suspect, I’d like to see that language put in. It’s also hard to imagine being able to robustly rebut allegations if “all statements and other information” are confidential.

I CONSENT to have my name and demographic data, including type and date of all ABR certifications and maintenance of certification status included in any list or directory in which the names of diplomates of the specialty boards are published.

Uncontroversial and unchanged.

I AGREE the Board is not liable for any incorrect information provided to the medical community or to the public regarding the status of my certificates, and I further agree that I will promptly notify the board of any errors or omissions in such information.

CYA, meaning unchanged.

I UNDERSTAND AND AGREE that the continued validity of my certificate will be contingent upon my meeting the requirements of the Maintenance of Certification Program (MOC) administered by the Board, as amended from time to time.

I.e, unless the ABR one day loses a lawsuit, you will always need to pay ABR’s MOC tax to remain board-certified.

I UNDERSTAND AND AGREE it is my responsibility to stay informed regarding all aspects of the MOC program and understand that the Board does not have any responsibility to provide individual diplomates with notice of changes to MOC policies.

This is also largely unchanged and is a petty cop-out. The idea is presumably to prevent diplomates from pleading ignorance when they don’t fulfill some component.

I UNDERSTAND AND AGREE that it is my responsibility to notify the ABR of any changes in my mailing address, phone number and email address. All changes made by me via the website shall be accepted as legally binding, and will become the property of the ABR.

ABR, you can’t just seize my property just because I enter my address in your system…

I’m kidding, more or less. What this actually means is that the ABR can legally sell your contact info to the highest bidder (gross).

I UNDERSTAND AND AGREE that it may be necessary for the ABR to revise and update this Agreement at a later date, and that I may be required to sign the updated agreement, which will replace and supersede the terms of this agreement.

We can have an internet discussion again when that happens.

Summary

This is shorter and more readable. All the truly heinous stuff has been removed. Is it perfect? Of course not. Is the effect in some cases the same despite the softer language? You bet. Is it much better than it was last week? Undeniably.

Why the ABR is burying their fix is beyond me. They should, in fact, delete all the recent agreements and ask all diplomates to sign this new version. Everyone deserves to see what they’re signing, and the other agreements (even if “grandfathered”) should not continue to exist.

The Overtautness of American Healthcare

04.29.20 // Medicine, Miscellany

Siddhartha Mukherjee, author of the excellent Pulitzer Prize-winning The Emperor of All Maladies, writing for The New Yorker (emphasis mine):

To what extent did the market-driven, efficiency-obsessed culture of hospital administration contribute to the crisis? Questions about “best practices” in management have become questions about best practices in public health. The numbers in the bean counter’s ledger are now body counts in a morgue.

Deep, deep burn.

We’ve been teaching these finance guys how to squeeze,” Willy Shih, an operations expert at Harvard Business School, told me, emphasizing the word. “Squeeze more efficiency, squeeze cost, squeeze more products out at the same cost, squeeze out storage costs, squeeze out inventory. We really need to educate them about the value of slack.”

Medicine is a business, but it shouldn’t be run as just another business.

Everyone loves analogies with Toyota. There’s even one in this story, though it’s one that doesn’t usually make it into your average managerial or quality training, where people just love their black belts in Six Sigma, Lean, and tossing around those Japanese terms like Kaizen and Kanban. As Mukherjee argues, there’s a wide gulf between actually helping professionals take care of human beings and the complex dance of people and parts that requires and just ordering the fewest and cheapest widgets sourced from a factory in China.

What you really want to measure, model, and establish is the capacity to build something when a crisis arises. And this involves human as well as physical capital. We need to measure talent, versatility, and flexibility. Overtaut strings inevitably break.

Not only have they broken, but they’ve been unraveling for years.

Older
Newer