Anticipatory Grief, Anxiety, and—of course—COVID-19

04.06.20 // Miscellany

David Kessler, co-author of one of the classic books with Kübler-Ross detailing the 5 stages of grief, interviewed in the Harvard Business Review:

Understanding the stages of grief is a start. But whenever I talk about the stages of grief, I have to remind people that the stages aren’t linear and may not happen in this order. It’s not a map but it provides some scaffolding for this unknown world. There’s denial, which we say a lot of early on: This virus won’t affect us. There’s anger: You’re making me stay home and taking away my activities. There’s bargaining: Okay, if I social distance for two weeks everything will be better, right? There’s sadness: I don’t know when this will end. And finally there’s acceptance. This is happening; I have to figure out how to proceed.

He goes on to discuss ways to manage pandemic anxiety, including focusing on the present, mindfulness, etc.

And then the bombshell: He’s adding a sixth stage (Finding Meaning) to the classic five.

And, I believe we will find meaning in it. I’ve been honored that Elisabeth Kübler-Ross’s family has given me permission to add a sixth stage to grief: Meaning. I had talked to Elisabeth quite a bit about what came after acceptance. I did not want to stop at acceptance when I experienced some personal grief. I wanted meaning in those darkest hours. And I do believe we find light in those times. Even now people are realizing they can connect through technology. They are not as remote as they thought. They are realizing they can use their phones for long conversations. They’re appreciating walks. I believe we will continue to find meaning now and when this is over.

There will be a pre-COVID and post-COVID world, and they will not be the same. The question is how much of this tragedy can act as a hard reset, enabling us to stop the distraction, infighting, and isolation and start making progress on the things that really matter to us as individuals, as a society, and as a species.

Student Loans & The CARES Act

04.01.20 // Finance

The new CARES act pauses student loans for six months without interest. A few important facts:

This is a pause (administrative forbearance) until September 30, not a typical forbearance. No capitalization will occur.
You don’t need to do anything. It’s automatic for those currently in IDR.
These $0 “payments” count for PSLF and long-term IDR loan forgiveness.
You can call your servicer to request a refund for any payments made on March 13 or after.

There are a bunch of folks going for PSLF asking if they should pause their auto-payments to avoid making an extra unnecessary payment. Yes, it’s possible you could get charged and then subsequently reimbursed if you have an early April payment as the servicers try to rapidly implement the law. Folks are already reporting that their payment due amounts are now showing $0, and the servicers have until April 10 to implement the new law. It’s also already been stated that all benefits will be applied retroactively, so delays will not impact you in the long term—but you being impatient and foolhardy could.

Personally, if going for PSLF, I would absolutely not make any active changes to save money upfront unless you absolutely need to cashflow-wise. I am deeply suspicious in situations like these that the more you mess with the more likely it is for something bad to happen, requiring more work on the tail end. PSLF requires on-time monthly payments; if you call and get placed on a forbearance due to trying to pause payments, then you will not be in repayment status and these months may not count. Or, trying to manually pause autopay and then make a manual payment at the last second if you don’t see an account update is a massive hassle and places an additional burden on a company that was already strained by its day to day operations before the pandemic. I would just wait and let the servicer do their job.

Outside of the CARES act itself, if you’re PSLF bound and your income has fallen substantially, consider recertifying your income now with pay stubs to lock-in lower payments for when the $0 period expires.

What is the impact?

For most of the non-PSLF-bound, it’s just a pause. You can choose to not make payments for six months (or more, it could always be lengthened later), and there will be no penalty at all. Nice flexibility, but it doesn’t really change the natural history of your loans unless you choose to continue making payments during the pause. If you are fresh off of a capitalization step like consolidation or the end-of-grace period, then you have no unpaid accrued interest and so any optional payments you make will go straight to the principal, which is neat.

For PSLF, how much this will save you in the long run depends on where you are in the repayment process.

For graduating medical students:

Many folks consolidating at the end of school will earn $0 payments for their first year, so your monthly payments will not change. There will be no interest accruing for a while, but this will only be relevant should you eventually take a non-qualifying job. So, basically, it’s quite possible this will have literally no impact on you. For anyone considering PSLF, it’s just another reason to consolidate ASAP, because a full six month grace period could be an even bigger waste.

For those certain they don’t want PSLF, there is now a potential reason to wait to consolidate. A 6-month grace period after graduation will be longer than the CARES act 0% period (at least for now), so waiting until the very end will result in a token amount of increased accrued interest during the last couple of months that will then capitalize. But if you wait you can eek out extra months of $0 payments if you wait to consolidate because you’ll start your IDR cycle later and get a full year of low payments based on last year’s taxes (stacked after the CARES act instead of overlapping it). Ultimately that would result in a full year of the optimal unpaid interest subsidy in REPAYE, likely saving you real money. While waiting does make sense outside of loan forgiveness, I ultimately caution most residents with average or high debt to simply rule out PSLF early in residency.

For residents:

You will save a small amount of money because your monthly payments are generally low to begin with. Certainly not going to hurt, and it’s a good chance to take that extra cash and pay down any high-interest (e.g. credit card) debt you may have previously been unable to make progress on.

For attendings:

Attendings in PSLF will save a lot of money. An average physician debt holder capped at the 10-year-standard could easily save $12-18k thanks to six $0 qualifying payments during their high-paying attending years.

Unintended Consequences

As always, the macro and micro don’t match the way politicians or most people would intend or anticipate. Payment pauses are just the minimum viable cashflow bandaid, a step that will ultimately do little for most borrowers nationwide, who already struggle with student loans at baseline with a 10%+ delinquency/default rate.

Meanwhile, while physicians and other high-earners are certainly not immune to job loss from the COVID pandemic, the actual monetary benefits of this policy disproportionately benefit those with large loans and large incomes.

It’s just not enough.

It’s not enough to prevent an absolute economic crush on young Americans, especially if they are largely left behind in the recovery like they were in 2008.

Student loans—like so many other critical issues from our infrastructure and healthcare system to campaign finance and legislative reform—are crying out for a cohesive, coherent, and complete overhaul, and the developing public health and economic disaster should be a wake-up call.

WCI’s Continuing Financial Education 2020

03.31.20 // Finance

I was very much looking forward to traveling to Las Vegas to speak at WCICON20 earlier this month but ended up unable to because of the whole devastating pandemic thing, but Jim and crew have released the conference e-course today. I and several other folks who couldn’t make it in person recorded our talks for inclusion after the fact, so there are over 34 hours of lecture worth 10 hours of CME.

Due to horrific computer glitch, I lost audio during my original recording and had to the majority of it again a second time while juggling my infant and 4-year-old, so I welcome you to check it out and see if you can feel the undercurrent of my electronically induced suffering. The struggle is real.

The course is included in the conference fee, so even if you went in person you should still check it out and hear the extra talks. I already enjoyed the talk from Morgan Housel (author of the upcoming The Psychology of Money) earlier today.

For everyone else, the cost is $100 off through April 21 with code CFEINTRO (which is already embedded in this totally monetized affiliate link).

Coronavirus: The Hammer and the Dance

03.23.20 // Medicine

Another excellent follow-up from Tomas Pueyo about the need to stop doing half-assed mitigation measures.

On one side, countries can go the mitigation route: create a massive epidemic, overwhelm the healthcare system, drive the death of millions of people, and release new mutations of this virus in the wild.

On the other, countries can fight. They can lock down for a few weeks to buy us time, create an educated action plan, and control this virus until we have a vaccine [ed: or treatment].

Governments around the world today, including some such as the US, the UK or Switzerland have so far chosen the mitigation path.

That means they’re giving up without a fight. They see other countries having successfully fought this, but they say: “We can’t do that!”

We can do better together with decisive action and cohesive government intervention/support.

Humans are a communal species. While we need to be alone, right now, we should act together.

Maxims for Academic Medicine

03.17.20 // Medicine

Highlights from Joseph V. Simone’s “Understanding Academic Medical Centers,” published way back in 1999 (hat tip @RichDuszak):

Institutions Don’t Love You Back.

A wise colleague once told me that job security was the ability to move to another job (because of professional independence).

Institutions Have Infinite Time Horizons to Attain Goals, But an Individual Has a Relatively Short Productive Period.

There is little incentive for an institution to rapidly cut through the bureaucratic morass. An institution will always outlast a dissenting individual, regardless of the merit of the case.

Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers.

Generous.

Institutional Incompetents and Troublemakers Are Often Transferred to Another Area, Where They Continue to Be Incompetent or Troublemakers.

They force others to pick up the slack or repair their mistakes, reducing everyone’s efficiency. If this continues for long, those who are consistently unproductive may become the majority because the competent learn that the institution sees no virtue in hard work and collaboration.

Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader.

Examples of such criteria include a long bibliography, scientific eminence, institutional longevity, ready availability, a willingness to not rock the boat, or to accept inadequate resources. Choosing leaders is not a science, but it is surprising how often management skills, interpersonal skills, and experience are undervalued.

See: Academic Medicine & The Peter Principle.

In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People.

Some hesitate to recruit a person who is smart enough and ambitious enough to compete with them. Others want a position filled at any cost because of “desperate” clinical need or other institutional pressures. If that approach continues for long, the third-class people will eventually dominate in numbers and influence and ultimately chase away any first-rate people that remain.

In Academic Institutions, Muck Flows Uphill.

Leaders often try to ignore or deflect the unpleasant mess, but the longer it incubates, the harder it will be to sanitize.

See: the dropped balls nationwide with current COVID-19 pandemic.

Personal Attitude and Team Compatibility Is Grossly Underrated in Faculty Recruiting.

A faculty member may be very productive personally but create an atmosphere that reduces the productivity of everyone else.

Annoying people are the black holes of camaraderie and joy.

Moral Humility & The Ethical Career

03.13.20 // Miscellany

From Maryam Kouchaki and Isaac H. Smith’s “Building an Ethical Career”

So how can you ensure that from day to day and decade to decade you will do the right thing in your professional life?

The first step requires shifting to a mindset we term moral humility—the recognition that we all have the capacity to transgress if we’re not vigilant. Moral humility pushes people to admit that temptations, rationalizations, and situations can lead even the best of us to misbehave, and it encourages them to think of ethics as not only avoiding the bad but also pursuing the good. It helps them see this sort of character development as a lifelong pursuit.

We all have a personal opportunity to make being good an active choice. I’ve always loved the view that being an ethical person isn’t a character trait but an endless series of (often challenging) conscious choices. We see so many examples of people who are good in some capacities but not others precisely because it’s sometimes easier and sometimes harder to make what are—at least in hindsight—clearly right or wrong choices.

Preparing for ethical challenges is important, because people are often well aware of what they should do when thinking about the future but tend to focus on what they want to do in the present. This tendency to overestimate the virtuousness of our future selves is part of what Ann Tenbrunsel of Notre Dame and colleagues call the ethical mirage.

Counteracting this bias begins with understanding your personal strengths and weaknesses. What are your values? When are you most likely to violate them? In his book The Road to Character, David Brooks distinguishes between résumé virtues (skills, abilities, and accomplishments that you can put on your résumé, such as “increased ROI by 10% on a multimillion-dollar project”) and eulogy virtues (things people praise you for after you’ve died, such as being a loyal friend, kind, and a hard worker). Although the two categories may overlap, résumé virtues often relate to what you’ve done for yourself, whereas eulogy virtues relate to the person you are and what you’ve done for others—that is, your character.

I often wonder how many of my goals or projects fall firmly into the wrong camp.

Many factors go into choosing a job—but in general people tend to overemphasize traditional metrics such as compensation and promotion opportunities and underemphasize the importance of the right moral fit. Our work and that of others has shown that ethical stress is a strong predictor of employee fatigue, decreased job satisfaction, lower motivation, and increased turnover.

And this brings us to a nice medical dovetail. How many physician jobs now exist within a bureaucratic or corporate structure that is counter to how we feel a physician should be forced to practice medicine and that is counter to the best interests of both the practitioner and patient? How did we ever let a 15-minute appointment become normal? For anything?

And lastly, helpful litmus tests: publicity, generalizability, and mirror:

Three tests can help you avoid self-deceptive rationalizations. (1) The publicity test. Would you be comfortable having this choice, and your reasoning behind it, published on the front page of the local newspaper? (2) The generalizability test. Would you be comfortable having your decision serve as a precedent for all people facing a similar situation? (3) The mirror test. Would you like the person you saw in the mirror after making this decision—is that the person you truly want to be?

These are important things to consider before any big decision. Yes, they’re basically all the golden rule—but how often do you forget to use it?

Coronavirus & Distance

03.12.20 // Medicine

There have been lots of good articles about the novel Coronavirus and the embarrassing state of America’s public health response.

This one from Vox has some excellent charts.

This one on Medium breaks down some of the underlying relationship mechanics of social distancing measures and spread as well as how one estimates the number of hidden (but transmitting) cases in a population (which does require some assumptions).

Here’s what I’m going to cover in this article, with lots of charts, data and models with plenty of sources:
— How many cases of coronavirus will there be in your area?
— What will happen when these cases materialize?
— What should you do?
— When?

When you’re done reading the article, this is what you’ll take away:

The coronavirus is coming to you.
It’s coming at an exponential speed: gradually, and then suddenly.
It’s a matter of days. Maybe a week or two.
When it does, your healthcare system will be overwhelmed.
Your fellow citizens will be treated in the hallways.
Exhausted healthcare workers will break down. Some will die.
They will have to decide which patient gets the oxygen and which one dies.
The only way to prevent this is social distancing today. Not tomorrow. Today.
That means keeping as many people home as possible, starting now.

Important reading.

OLA Makes Sure Radiologists Have Evolved

03.04.20 // Radiology

From “Focus on DR,” which appeared in the most recent January 2020 edition of the ABR’s newsletter, The BEAM:

Over time, diagnostic radiology has evolved, and imaging techniques and exams have changed. Computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound improved and replaced many traditional exams. The practice of many diagnostic radiologists now consists of work that was not tested on the exams they took for initial certification. A way to see that radiologists have evolved along with their practices and acquired these new skills is needed. Such a system must be meaningful, yet not be onerous for physicians to complete.

This is a fascinating statement. Fascinating because those radiologists with initial certifications that reflect a bygone era of “traditional exams” are in fact grandfathered from the very system “needed” to confirm that they’ve evolved.

Fragmentation and the Family

02.25.20 // Finance, Medicine

Affluent conservatives often pat themselves on the back for having stable nuclear families. They preach that everybody else should build stable families too. But then they ignore one of the main reasons their own families are stable: They can afford to purchase the support that extended family used to provide—and that the people they preach at, further down the income scale, cannot.

[…]

For those who have the human capital to explore, fall down, and have their fall cushioned, that means great freedom and opportunity—and for those who lack those resources, it tends to mean great confusion, drift, and pain.

From conservative columnist David Brooks’ “The Nuclear Family Was a Mistake” in The Atlantic.

Even in medicine, we are seeing a disturbing trend. While the mean and median student debt are rapidly increasing due to high tuition rates, this is actually partially masked by the increasing percentage of medical students graduating with no debt. This suggests that a greater fraction of students come from means and have family support to cover medical school’s incredible cost. And those without that family support are either not getting in or are looking elsewhere.

It doesn’t stop at admission. These disparities and resource differences play out in specialty selection as well:

Over just a six-year period, the number of debt-free graduates almost doubled. And, overall, more competitive specialties like ophthalmology, ENT, urology, radiology have substantially more debt-free graduates than family medicine. Yet, we know we have a specialization problem in medicine. Free tuition at NYU isn’t going to change this massive headwind. The system needs retooling from far, far earlier.

The Slow Death of Contrast-Induced Nephropathy

02.20.20 // Radiology

There are few things less evidence-based since medical antiquity than contrast-fear and contrast-management. We are slowly, slowly, as a field trying to correct long-held mistakes based on bad correlative science.

Intravenous iodinated contrast media are commonly used with CT to evaluate disease and to determine treatment response. The risk of acute kidney injury (AKI) developing in patients with reduced kidney function following exposure to intravenous iodinated contrast media has been overstated. This is due primarily to historic lack of control groups sufficient to separate contrast-induced AKI (CI-AKI; ie, AKI caused by contrast media administration) from contrast-associated AKI (CA-AKI; ie, AKI coincident to contrast media administration). Although the true risk of CI-AKI remains uncertain for patients with severe kidney disease, prophylaxis with intravenous normal saline is indicated for patients who have AKI or an estimated glomerular filtration rate less than 30 mL/min/1.73 m² who are not undergoing maintenance dialysis. In individual high-risk circumstances, prophylaxis may be considered in patients with an estimated glomerular filtration rate of 30–44 mL/min/1.73 m² at the discretion of the ordering clinician.

From the new “Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation.”

The risk of CI-AKI (née CIN) with iodinated contrast for GFR > 45 is zero and for 30-44 probably close to zero as well. If your patient would benefit from intravenous contrast, there are few reasons to avoid it when it will provide meaningful clinical value.

In related news, having one kidney does not matter for contrast safety if that kidney is functioning.