Ben White

The Trajectory of American Education

08.03.20 // Miscellany

From “Our Educational Colonialism” by Chris Arnade:

Yet it is the kids sitting in middle row I have the deepest sympathy for because they are the most harmed, and the ones you hear the least about. They are mostly working class kids who don’t really fit into the back row because they are very disciplined, eager, and want do what they are told, and especially want to do the right thing. Which now means going off to college to better themselves, so they go off to college to better themselves, regardless of the cost.

They buy into our faux educational meritocracy the most, swallowing it hook, line, and sinker. They buy the dream peddled by every successful person they have ever run across or heard, from Obama down to the middle school guidance counselor: Education is the pathway to a successful and meaningful life.
[…]
So they apply for loans and eight years later that child is a young adult with 100K in debt working in a government bureaucracy five hundred miles away and missing the weekly family backyard BBQs.

When I researched the history of student loans, one of the most striking currents underlying our educational debt crisis is the sad fact that student loans basically function as a subsidy for universities paid as a crippling tax on a generation of young Americans.

Education is wonderful, so is bettering yourself by getting as much of it as possible. But done on your terms and because you want it for your reasons. Not because you, your community, and everyone else you know, is competing with the Chinese, or the Germans, or the Indians. So you have to take countless standardized tests so you can win a golden ticket to ship off to Princeton and hang with others who are good at taking standardized tests, to then be taught more stuff, to then go to grad school to learn even more stuff, so you might, if you are lucky, get to go to San Francisco and live in an a small room hundreds of miles from your family to start in a firm trading bonds, or helping Google sue someone, or running from teaching one introductory writing course at one school to another introductory oratory course at another school, or maybe so you can write papers for a non-profit funded by a billionaire arguing that we need more education. That isn’t good.

What we have now is a top-down educational system that intellectually strip mines America and humiliates everyone. What we need is a democratic educational system that provides pathways to dignified lives for everyone. That provides Shakespeare and differential topology to those who see the beauty of each, but also provides skills to those who would rather focus on things like music, mechanics, nursing, parenting, farming, or whatever.

Education is wonderful. But right now we have an educational arms race, and we’ve forced people to mortgage their brains and futures to get degrees that simply function as overpriced old-fashioned card punches: just a ticket to enter the workforce.

Student Loans Virtual Noon Conference

07.29.20 // Finance, Medicine, Radiology

I gave a virtual noon conference today for MRI Online. It requires a free registration, but it’s one of a collection of great radiology lectures available for free. This is week 19 of the series.

My talk is permalinked here. It starts with discussing a brief history of student loans in the US as well as a pretty detailed discussion of PSLF including dispelling some myths including an explanation of the high rejection rate.

If you listen and notice me laughing at the beginning, that’s because my Zoom session crashed when I attempted to share my screen and I had to restart. Audio cuts out here and there but is nearly 100% intact, pretty good for a Zoom call. And if you listen to any of my podcasts or other talks this past year, you can safely assume I’m sleep deprived (babies are cute) compounded today as I ended up covering the early morning 6 am shift, but it definitely has some really some useful nuggets for those who like audio/video. It’s no substitute, however, for sitting down for a few hours and reading my ad-free totally-free book in whatever format you choose.

One participant asked a great question that I incompletely answered during the Q&A at the end. It was, essentially, what happens to student loan debt after a divorce in a community property state like Texas? The answer is that it usually goes back to the individual borrower, but, that’s only because all assets and debts that happen before the marriage remain individual property and revert back to the individual while all things that happen during the marriage are shared equally. Since most people in the US have just undergraduate loans and most people get married after college, most people won’t have to deal with their spouse’s loans after a divorce. But certainly not all, and this is more likely to be an issue for doctors, who may enter school married or get married while in school. Timing is everything.

Panglossian Medical Fallacies

07.23.20 // Medicine

From Dr. Benjamin Mazer’s “Medicine’s dangerous optimism – Lessons from Dr. Pangloss,” published in The Journal of the Royal Society of Medicine.

Consider the story of Dr. Pangloss, the fictional “professor of metaphysico-theologico-cosmolo-nigology” in Voltaire’s satirical eighteenth-century novel Candide. Dr. Pangloss is remembered for declaring that we live in the “best of all possible worlds.” Pangloss could find logical explanations for the pain and turmoil he saw around him. No one suffered without a good reason. In the face of healthcare’s overwhelming complexity, doctors can also inadvertently resort to assuming our current situation is the best we can hope for.

I am defining Panglossian optimism as the unproven assumption that an observed outcome is the necessary outcome.

That’s the delightful set-up. He discusses four such fallacies:

  1. Favorable outcomes are attributable to medical care, unfavorable outcomes to a lack of it
  2. Arduous training and examination are what produce good doctors
  3. Physician outcomes predict patient outcomes
  4. A sufficiently popular intervention cannot be tested

I particularly love #2. It is, in part, the fallacy of hazing as a constructive and formative practice.

If evaluating applicants is currently too challenging without a Step 1 score, then a Step 1 score must be necessary to evaluate applicants. This is not a sound assumption. A tool that does not select for the qualities we desire inserts bias and noise into the process, making it less efficient.

We also encounter faulty Panglossian reasoning in debates over whether residency duty hours should be restricted for patient and trainee wellbeing. Many experienced physicians imagine their skills molded in the cauldron of inhumane work hours. It is true that they worked inhumane hours, and that many possess excellent skills. The Panglossian assumption is that the latter derives from the former.

For those dejected by the state of high-stakes exams, the arduousness of the journey to attendinghood, or the feebleness of so much of our tautological medical science, his conclusion:

We rationalize the irrational in times of perceived helplessness. By creating an environment more hospitable to questioning and change, we may be less drawn to false comforts.

So, when you are done, or, when you have a position of authority: be part of the solution.

Review: Orbit CME

07.20.20 // Medicine, Radiology, Reviews

It was always a good idea, but in this new world where conferences and live events are canceled for the foreseeable future, Orbit CME is a great idea.

(I previously got temporary free access to Orbit for the purposes of writing this review over a year ago, and I’ve got the usual reader discount affiliate link combo for you here: $20 off any plan. As there aren’t any ads here, these types of win-win situations for good products are one of the only ways I earn money through my writing. So there’s your COI disclosure.)

Orbit is a web browser plug-in that promises to automatically track and quantify the qualifying educational activities you do every day on your computer and then provide you with effortless legit AMA PRA Category 1 CME (often including the somewhat more challenging “self-assessment” SA-CME that some fields require that you typically get for answering questions during each lecture at a medical conference or other interactive activity).

How does it shape up?

Pretty darn well. In order to deliver the value of your subscription, you need to have the abilities/privileges to install the orbit browser plug-in (which is currently only available for Google Chrome). This plugin monitors your browsing and triggers whenever you visit a website that might come in handy for CME, like UpToDate, PubMed, Radiographics, or Radiopaedia. It measures your time with that active browser window, and generates an entry in your CME log. You can then choose which entries to actually spend a credit on to get the CME for it, in case you need certain types (like medical ethics in Texas or MQSA, Cardiac CT, fluoro, etc).

For example, while the hospital PCs only had internet explorer installed until recently, I had no problem using Chrome with the plugin when I worked at imaging centers or from home. As a radiologist, I earned CME so fast just from my usual day-to-day work that even if only using it on my home PC I would have been able to get the entire year’s worth of credits within a month or so, at which point I just uninstalled the plug-in.

Every once in a while I would have random difficulty logging into the plug-in (which does require logins periodically to make sure you’re still you), but otherwise, the process was completely seamless. CME is provided through Tufts, and you can download detailed CME logs for submission to various bodies that require such things.

You can also post external CME to the Orbit site allowing you to track all of your CME in one place and generate one report containing everything you’ve done. Very handy.

When I first discussed the product with the Orbit founding team back after finishing fellowship, I couldn’t help but feel that the price was too steep and thus not worth it ($360/yr for 25 credits; $600/2yr for 50 credits). But then I saw how truly effortless it was and how much a hassle the documentation burden of CME can be. If you enjoy conferences, it’ll always be possible to get enough CME through the activities you plan on pursuing anyway. If you’re in academics, you may acquire enough through your work activities like tumor boards and grand rounds to not need anything else.

But for those who don’t—and certainly in the current COVID world we live in where nothing is happening except remotely—I would rather pay to have my CME automatically generate itself than to do so via a virtual meeting (or some other laborious educational activity). I’ve got an infant and a preschooler, a busy practice, and a bunch of hobbies that are struggling for a minute of sunshine. I do CME every single day I work, and this gives me credit for that. Even if you get CME from other places like I do, there was something especially nice about not needing to bother tracking it down or keeping personal records because Orbit gives you everything you need anyway. If you have an academic/educational/CME fund, it’s definitely money well spent. It also works for PAs and NPs in addition to physicians.

The product was initially designed by a radiologist for radiologists, and it is absolutely perfectly suited to our workflow. But it also works well for many other specialties, and they have a handy table here telling you what kind of CME plugin can get you relative to the demands of your specialty society.

I’ll be subscribing again.

 

How to be a First Year Radiology Resident

07.02.20 // Radiology

This is a brief companion post to my original post on approaching the radiology R1 year. This is what you need to do to succeed in radiology and life:

Be a decent human being and use common sense.

If that’s not enough to go on, here’s a longer list:

  • Be on time
  • Be excited
  • Be nice
  • Be dressed
  • Take responsibility
  • Do what you’re told
  • Read cases, not just books. Be hungry.
  • But…um, also read books, not just cases. Practical knowledge is often different from book knowledge, but you’ll eventually need both to succeed
  • Be knowledgeable. If you can’t know radiology, then Know the Patients. Know the Histories. Know the Priors.
  • Again, always look at the priors and read the prior reports. Prior reports will teach you more than your attendings will face to face.
  • Proofread. Please, please, please. A report is a radiologist’s will manifested. Who do you want to be?
  • Anatomy is the foundation on which all else is built.
  • Develop a search pattern.

Real expectations for a first-year resident in July: are you ready?

In addition to the important life skills I outlined above, I want to stress that really no one expects you to actually understand radiology at this point, but you are expected to learn fast. What you can do—even on day one, even if you don’t actually know anything—is learn the details of the exams: especially patient history and priors. Look at this before you read out because this is literally your one chance to save your attending time and effort. A junior resident is graded more on attitude and attention to detail than on fund of knowledge.

Anyone who cares about what they’re doing can craft reports (almost) free of transcription errors, template mistakes, and missing comparisons.

It’s not uncommon to hear from your chairman or program director during orientation that they want you to have a life and be well-rounded. Like, they’re not asking you to do anything crazy, just an hour or two of reading per night. If you were worried that a deep belly laugh might escape to your great embarrassment, then you are not alone. In an ideal world, you would read every night from textbooks and articles and then rapidly move onto writing your own and contributing to the great growing body of truly meaningful radiology research.

Well, sometimes life happens.

While I like knowing things and doing my job well, I wouldn’t have exactly described myself as a radiology residency completionist. I didn’t necessarily read as much as some people suggested was prudent, and I’ve certainly never enjoyed and found meaning in trying to memorize long differentials for all the things that can occur in a given area when A) those differentials often include things that are radically different either clinically or by appearance and thus would never be confused and B) I have the ability to, you know, access the internet when I’m stumped by an unusual finding.

Keep in mind, this little list was generated from my own experience (in hindsight) and ruminations. The intrinsic variability across programs and training means that parts of my perspective may not or should not apply to you.

But I suspect if you do all of the above to start each of your rotations you’ll be on the right foot.

The ABR Comes Around

06.25.20 // Radiology

The American Board of Radiology announced earlier this week that they would indeed be joining the civilized medical world and moving to a virtual exam solution for all future exams and maintaining the current proposed February and June dates for next year’s administrations:

We appreciate the constructive feedback regarding our 2020 exam schedule and recognize the significant impact that test postponements have had on our candidates, their loved ones and families, and their training programs. We have seen and heard legitimate concerns from candidates, program directors, department chairs, and other stakeholders, and have considered many options to safely administer our exams in the least disruptive fashion while preserving their integrity. Our deliberations and decisions were largely based on our obligation to accommodate those most affected by the pandemic. The health of candidates, volunteers, staff, and the public is our highest priority. In consideration of these concerns, the ABR is moving all currently unscheduled and future oral and computer-based exams to virtual platforms beginning in the first half of 2021, which is the earliest we can confidently deliver these exams without potential delays.

Good for them.

Seriously, I mean that.

But.

And I don’t want to be needlessly negative (or do I?), but as I argued back in April, have said multiple times since, and was then subsequently joined by the entire field of Radiology and its many member organizations, this outcome was the only defensible choice. Nationwide travel for an exam is simply an untenable position right now. Hell, doing so for a computerized test was barely defensible before the pandemic.

Despite all the hemming and hawing and the repeated stance that virtual solutions were simply “not practicable,” the ABR will be moving forward with one of those unpracticable solutions anyway in 2021. It was inevitable, which makes the drama and delay wholly unnecessary.

If the ABR had read the writing on the wall back in March when the world shut down, they still may have not been able to keep the original June date. But they likely could have salvaged the initial backup November date for which every residency program in the country already planned around. That date was closer to the usual timeline and was likely fairer for the senior residents, who will now be forced to re-study and potentially re-broaden their practice as they return from early IR specialization or mini fellowships.

Despite the ABR’s official stance, the Core Exam is not a test you could just pass on the merits of radiology skill alone. The evaluations practicing rads take, the Certifying Exam and OLA, are both easier.

On the one hand, good on the ABR for at least planning to do the right thing. I look forward to seeing how they decide to accomplish this mission, one they originally said they simply couldn’t do. There are a lot of self-imposed boxes to check because “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 all candidates.”

But, on the other hand, the situation was ridiculous. There was a bona fide revolt before the ABR came around to what should have been an obvious choice in the first place. Now that we’re here, the move away from centralized testing should be permanent.

It goes to show that while the ABR has added responsiveness to its toolbox, they have not yet independently demonstrated sound stewardship of our field. Stakeholders need to be willing to fight for every important issue.

I hope this is a turning point for the ABR and its testing mandate. I know the radiology community stands ready to provide constructive dialogue to help improve initial certification and MOC.

Talking about Life, Finance, and Student Loans

06.24.20 // Finance, Miscellany

I recorded an episode of Dave Denniston’s Freedom Formula for Physicians Podcast earlier this year and it’s up this week. I had fun, and we actually covered a lot more personal stuff compared to my usual writing.

You can listen here (or on your favorite podcast app—I recommend Overcast).

The Machinery of Skepticism

06.16.20 // Miscellany

Carl Sagan, famous astronomer and author of Contact and Cosmos (among others), writing about “The Burden of Skepticism” way back in 1987:

It seems to me what is called for is an exquisite balance between two conflicting needs: the most skeptical scrutiny of all hypotheses that are served up to us and at the same time a great openness to new ideas. Obviously those two modes of thought are in some tension. But if you are able to exercise only one of these modes, whichever one it is, you’re in deep trouble. If you are only skeptical, then no new ideas make it through to you. You never learn anything new. You become a crotchety old person convinced that nonsense is ruling the world. (There is, of course, much data to support you.) But every now and then, maybe once in a hundred cases, a new idea turns out to be on the mark, valid and wonderful. If you are too much in the habit of being skeptical about everything, you are going to miss or resent it, and either way you will be standing in the way of understanding and progress. On the other hand, if you are open to the point of gullibility and have not an ounce of skeptical sense in you, then you cannot distinguish the useful ideas from the worthless ones. If all ideas have equal validity then you are lost, because then, it seems to me, no ideas have any validity at all.

Some ideas are better than others. The machinery for distinguishing them is an essential tool in dealing with the world and especially in dealing with the future.

That summarizes so much.

Flywheels and Doom Loops

06.15.20 // Miscellany

Jim Collins, author of Built to Last and Good to Great, talking on The Knowledge Project:

What we found is that the most durable results happen as a series of good decisions that accumulate one upon another over a very long period of time, that create a massive compounding effect. And just like investing, where it’s buy quality assets you would presume to hold forever, then largely do and let them compound, this is the idea that you get a really good thing and you build strategic compounding over a very long period of time, and then you end up with this spectacular result.

He calls that the “flywheel effect.” And, as you might expect, there’s an opposite phenomenon:

Let me just describe the inverse of the flywheel, which is the doom loop. Something happens that produces disappointing results. And it could be that it was a random event or something just happened that was out of your control or something that you just made a mistake or you bungled something, whatever. You get disappointing results. But unlike really understanding why that happened so that you can correct, what happens is a company reacts without understanding. “Oh my gosh, we had disappointing results,” and often what happens is they panic. They look for a new direction or a new program or a new leader or a new acquisition or a new technology or something, and because that never really produces a great result, it produces a burst of false hope, but it’s like drinking a sugar drink as opposed to getting back to your core training. It doesn’t give you any accumulated momentum, which then creates another negative inflection, more disappointing results, which then more reaction without that understanding. Then another new direction, new fad, new program, new whatever, and then another failure to build momentum, more disappointing results, and then you’re in the doom loop.

If you’re honest, how many quality initiatives have you seen as a true flywheel of progress and not just a spoke in the doom loop?