Ben White

The 2019 ABR Core Exam Results, the Board Prep Arms Race, and Where It All Went Wrong

08.25.19 // Radiology

On August 15, the ABR released the 2019 Core Exam results, which included the highest failure rate since the exam’s inception in 2013: 15.9%.

(Side note: due to a “computer error,” the ABR decided to release the aggregate results before sharing individual results with trainees, resulting in entirely unnecessary extra anxiety. This itchy trigger finger release is in stark contrast to the Certifying Exam pass rates, which have never been released.)

 

Year Percent Passed Percent Failed Percent Conditioned Total Examinees
2016 91.1 8.5 0.4 1,150
2017 93.5 6.3 0.2 1,173
2018 86.2 13.0 0.8 1,189
2019 84.0 15.9 0.1 1,191

So what happened?

 

Option 1

One potential explanation is that current residents are less intelligent, less hard-working, or less prepared for the exam despite similar baseline board scores in medical school, similar training at their residency programs, and now very mature and continually improving board preparation materials. This would seem unlikely.

If it really does simply chalk up to resident “caliber” as reflected in minor variations in Step scores, then I would volunteer that we should be concerned that a minimally related test could be so predictive (i.e., so what are we testing here? Radiology knowledge as gained over years of training or just MCQ ability?).

Option 2

Another explanation is that—despite the magical Angoff method used to determine the difficulty/fairness of questions—the ABR simply isn’t very good at figuring out how hard their test is, and we should expect to see large swings in success rates year to year because different exams are simply easier or harder than others. This is feasible but does not speak well to the ABR’s ability to fairly and accurately test residents (i.e., their primary stated purpose). In terms of psychometrics, this would make the Core exam “unreliable.”

The ABR would certainly argue that the exam is criterion-based and that a swing of 10% is within the norms of expected performance. The simple way to address this would be to have the ABR’s psychometric data evaluated by an independent third-party such as the ACR. Transparency is the best disinfectant.

Option 3

The third and most entertaining explanation is that current residents are essentially being sacrificed in petty opposition to Prometheus Lionheart. The test got too easy a couple years back and there needed to be a course correction.

 

The Core Prep Arms Race

With the widespread availability of continually evolving high-yield board prep material, the ABR may feel the need to update the exam in unpredictable ways year to year in order to stay ahead of “the man.”

(I’ve even heard secondhand stories about persons affiliated with the ABR in some capacity making intimations to that effect including admitting to feeling threatened by Lionheart’s materials/snarky approach and expressing a desire to “get him.” I wouldn’t reprint such things because they seem like really stupid things for someone to admit within public earshot, and I certainly cannot vouch for their veracity.)

If you’re happy with how your exam works, and then third parties create study materials that you feel devalue the exam, then your only option is to change (at least parts of) the exam. This may necessitate more unusual questions that do not make appearances in any of the several popular books or question banks. This is also not a good long-term plan.

This scenario was not just predictable but was the inevitable outcome of creating the Core exam to replace the oral boards. If the ABR thought people “cheating” on the oral boards by using recalls was bad, replacing that live performance with an MCQ test—the single most recallable and reproducible exam format ever created—was a true fool’s errand.

A useless high-stakes MCQ test based on a large and unspecified fraction of bullshit results in residents optimizing their learning for exam preparation. I see first-year residents using Crack the Core as a primary text, annotating it like a medical student annotates First Aid for the USMLE Step 1. Look no further than undergraduate medical education to see what happens when you make a challenging test that is critically important and cannot be safely passed without a large amount of dedicated studying: you devalue the actual thing you ostensibly want to promote.

In medical school, that means swathes of students ignoring their actual curricula in favor of self-directed board prep throughout the basic sciences and third-year students who would rather study for shelf exams than see patients. The ABR has said in the past that the Core Exam should require no dedicated studying outside of daily service learning. That is blatantly untrue, and an increasing failure rate only confirms how nonsensical that statement was and continues to be. Instead, the ABR is going to drive more residents into a board prep attitude that will detract from their actual learning. Time is finite; something always has to give.

If I were running a program that had recurrent Core Exam failures, I wouldn’t focus on improving teaching and service-learning. Because on a system-level, those things are not only hard to do well but probably wouldn’t even help. The smart move would be to give struggling residents more time to study. And that is bad for radiology and bad for patients.

The underlying impression is that the ABR’s efforts to make the test feel fresh every year have forced them to abandon some of the classic Aunt Minnie’s and reasonable questions in favor of an increasing number of bullshit questions in either content or form in order to drive the increasing failure rates. Even if this is not actually true, those are the optics, and that’s what folks in the community are saying. It’s the ABR’s job to convince people otherwise, but they’ve shown little interest in doing so in the past.

There is no evidence that the examination has gotten more relevant to clinical practice or better at predicting clinical performance, because there has never been any data nor will there ever be any data regarding the validity of the exam to do that.

 

The Impossibility of True Exam Validity

The ABR may employ a person with the official title of “Psychometric Director” with an annual base salary of $132,151, but it’s crucial to realize the difference between psychometrics in terms of making a test reliable and reproducible (such that the same person will achieve a similar score on different days) and that score being meaningful or valid in demonstrating what it is you designed the test to do. The latter would be if passing the Core Exam meant that you were actually safe to practice diagnostic radiology and failing it meant you were unsafe. That isn’t going to happen. It is unlikely to happen with any multiple-choice test because real life is not a closed book multiple-choice exam, but it’s compounded by the fact that the content choices just aren’t that great (no offense to the unpaid volunteers that do the actual work here). Case in point: there is completely separate dedicated Cardiac imaging section, giving it the same weight as all of MSK or neuroradiology. Give me a break.

The irony here is that one common way to demonstrate supposed validity is to norm results with a comparison group. In this case, to determine question fairness and passing thresholds, you wouldn’t just convene a panel of subject matter experts (self-selected mostly-academic rads) and then ask them to estimate the fraction of minimally competent radiologists you’d expect to get the question right (the Angoff method). You’d norm the test against a cohort of practicing general radiologists.

Unfortunately, this wouldn’t work, because the test includes too much material that a general radiologist would never use. Radiologists in practice would probably be more likely to fail than residents. That’s why MOC is so much easier than initial certification. Unlike the Core exam, the statement that no studying is required for MOC is actually true. Now, why isn’t the Core Exam more like MOC? That’s a question only the ABR can answer.

I occasionally hear the counter-argument that the failure rate should go up because some radiologists are terrible at their jobs. I wouldn’t necessarily argue that last part, with the caveat that we are all human and there are weak practitioners of all ages. But this sort of callous offhand criticism only makes sense if an increasing failure rate means that the people who pass the exam are better radiologists, the people who fail the exam are worse radiologists, and those who initially fail and then pass demonstrate a measurable increase in their ability to independently practice radiology. It is likely that none of the three statements are true.

Without getting too far into the weeds discussing types of validity (e.g., content, construct, and criterion), a valid Core Exam should have content that aligns closely with the content of practicing radiology, should actually measure radiology practice ability and not just radiology “knowledge,” and should be predictive of job performance. 0 for 3, it would seem.

So, this exam is lame and apparently getting lamer with no hope in sight. And let’s not get started on shameless exercise in redundant futility that is the Certifying Exam. So where did everything go wrong? Right from the start.

That’s the end of the rant. But let’s end with some thoughts for the future.

What the Core Exam SHOULD Be

To the ABR, feel free to use this obvious solution. It will be relatively expensive to produce, but luckily, you have the funds.

Diagnostic radiology is a specialty of image interpretation. While some content would be reasonable to continue in a single-best-answer multiple-choice format, the bulk of the test should be composed of simulated day-to-day practice. Unlike most medical fields, where it would be impossible to objectively see a resident perform in a standardized assortment of medical situations, the same portability of radiology that makes AIs so easy to train and cases so easy to share would be equally easy to use for resident testing.

Oral boards aren’t coming back. The testing software should be a PACS.

Questions would be cases, and the answers would be impressions. Instead of having a selection of radio buttons to click on, there would be free text boxes that would narrow down to a list of diagnoses as you type (like when you try to order a lab or enter a diagnosis in the EMR; this component would be important to make grading automated.)

The exam could be anchored in everyday practice. One should present cases centered on the common and/or high-stakes pathology that we expect every radiologist to safely and consistently diagnose. We could even have differential questions by having the examinee enter two or three diagnoses for the cases where such things are important considerations (e.g., some cases of diverticulitis vs colon cancer). These real-life PACS-based cases could be tied into second-order questions about management, communication, image quality, and even radiation dose. But it should all center around how radiologists actually view real studies. It could all be a true real-world simulation that is a direct assessment of relevant practice ability and not a proxy for other potentially related measurables. Let’s just have the examinees practice radiology and see how they do.

The ABR has argued in the past that the Core exam cannot be ported to a commercial center, which is largely the fault of the ABR for producing a terrible test. But at least that argument would finally hold water if the ABR actually deployed a truly unique evaluative experience that could actually demonstrate a trainee’s ability. The current paradigm is silly and outdated, and radiology is uniquely positioned within all of medicine to do better. The exam of the future should not be rooted in the largely failed techniques of the past.

 

Once in IDR/IBR/PAYE/REPAYE, Always in IDR/IBR/PAYE/REPAYE

08.11.19 // Finance

“I got married” or “My income went up” and “they MADE me change repayment plan because I didn’t qualify anymore.”

No no no. They cannot make you do this. You are never forced to leave a federal repayment plan once you have been accepted for it, ever (unless you are not making your payments or don’t submit your annual income certification).

When in an Income-Driven Repayment (IDR) plan like IBR, PAYE, or REPAYE, payments may change annually—but the plan does not. People are more aggressive in negotiating their cable bill than they are in dealing with student loans servicers! Switching the acronym of your payment plan not only capitalizes your accrued interest but can easily cost could thousands or even tens of thousands of dollars.

If you lose your personal financial hardship while enrolled in IBR or PAYE, your interest capitalizes, but you’re not kicked out of the plan, and you are not forced to choose a new plan. Because you “no longer qualify” for the plan, your payments are capped at the 10-year standard repayment amount. “No longer qualify” is deliberating confusing phrasing. Yes, at this point, if you were to freshly apply, you would not qualify and would not be accepted into the plan. But guess what? You’re not applying, you’re just recertifying your income to determine your monthly payment amount. It doesn’t matter if you get married or if you win the lottery. Your plan is your plan until you choose otherwise. You don’t need to “qualify” anymore: once in IBR, always in IBR. Once in PAYE, always in PAYE.

People are being told during their annual income recertification that they need to switch from IBR and PAYE to REPAYE once they lose a PFH, and that is incorrect. All switching does is unnecessarily subject borrowers to uncapped higher monthly payments. The problem is, once you’ve switched to REPAYE on this bad advice, you can’t switch back (because you don’t qualify, see what they did there?).

You can never tell if this is ignorance or malevolence, but given that this is generally coming from FedLoan in the context of borrowers planning for PSLF, a “mistake” like this that results in borrowers spending more per month and getting less forgiven does look pretty suspicious.

Bottom line: This is just wrong. If you file your forms on time and make your monthly payments, your plan will never change.

Don’t let anyone tell you otherwise.

Utopia for Realists

08.09.19 // Miscellany

Rutger Bregman, author of Utopia for Realists and the Dutch historian from the viral video calling out billionaires at Davos (“taxes taxes taxes, all the rest is bullshit in my opinion”), talking to Ezra Klein in Vox:

We should never underestimate capitalism’s extraordinary ability to come up with new bullshit jobs.
…
We could theoretically live in some kind of dystopia where we’re all just pretending to work and sending emails and writing unnecessary reports, and the robots are doing all the real, valuable work.
…
Now, who are these people? They often have wonderful LinkedIn profiles, went to Ivy League universities, have excellent salaries. They work in marketing, finance, etc. Still, at the end of the day, if you give them a beer or two, they’ll admit that their job is perfectly useless. If we actually rewarded people for the value of the work they do, I think that many bankers would earn a negative salary while many nurses and teachers will be millionaires.

And then dovetailing healthcare into this pretty wide-ranging discussion on automation, universal basic income, and the depressing way we value/pay people who are essentially a drain on the system (not through welfare but through wealth extraction):

Economists talk about how it’s some kind of problem that government is not efficient enough compared to the private sector, but I think that’s actually the point. The point of the future is that we can have a huge amount of inefficiency because that’s what makes life meaningful. Good care is inefficient. You actually have to talk some to someone to have the meaningful relationship. If you want to make health care more efficient, you usually destroy it.

What if healthcare didn’t have to be an industry anymore? It’s really a mind-blasting thought.

Measles is the original measles vaccine

07.31.19 // Medicine, Reading

Measles is the original measles vaccine. It’s a natural method that’s been around for centuries. It was good enough for my mother and my mother’s mother and her mother before her.

Unlike synthetic vaccines, which are modified by scientists in underground labs to reduce their potency, measles is completely organic.

From “I’m vaccinating my child the natural way–with measles” in McSweeney’s.

This may be excellent satire, but it could just have easily been lifted from an actual blog written by an actual flesh-and-blood idiot.

FedLoans instructs borrowers to commit fraud

07.29.19 // Finance

I keep hearing of cases of FedLoan Servicing providing blatantly false and dangerously misleading advice to borrowers when it comes to submitting their annual income recertification.

In fact, it’s so clearly wrong that I wondered if the people reporting it were simply mistaken or confused until I’d heard it repeated so many times. It concerns how to file your recertification when utilizing the Married Filing Separately “loophole” in IBR or PAYE.

The quick background: as you may know, federal student loan borrowers must submit their income annually in order to partake in any of the income-driven repayment plans including IBR, PAYE, and REPAYE. If the borrower is married and files their taxes jointly with their spouse (which is the common choice), then their family income is used to calculate their monthly payments. But if they file their taxes separately, then their payments under IBR or PAYE would be based on just their own income and ignore their spouses. This is considered a bit of a loophole, which is why the newest payment plan REPAYE takes into account household income regardless of tax filing status.

So here’s the fraud part. There’s generalized incompetence, and then there is this: FedLoan is actually telling borrowers who have correctly filed their taxes separately that in order to ignore spousal income—even in IBR or PAYE—that they need to check a box saying that they are “married but cannot reasonably access [their] spouse’s information.”

This is simply not true and does not follow any of the rules. What it does do is clearly misuse a niche box that was provided to help estranged spouses or sufferers of domestic violence.

In fact, this very kind of fraud was anticipated by commenters and addressed by the government, because some folks were worried that simply allowing for “self-certification” of spousal status would give people the chance to reopen the MFS loophole that REPAYE closed by simply pretending that they’re not really married.

From the Federal Register:

The commenter also suggested that borrowers who want to evade the requirement will not bother to have their spouse keep separate income information, but will falsely claim that they have no access to such information instead. According to the commenter, if the Department simply accepts such claims, some borrowers will unfairly benefit, and if the Department contests borrower claims that their spouse’s income information cannot be accessed, it will lead to controversies and lawsuits at great expense to taxpayers.

We note that the strategies suggested by the commenter who raised concerns that some borrowers might try to evade higher payments by hiding income or falsifying the certification form would be fraudulent. We expect that most borrowers would be deterred from falsifying information on a Federal application form by the significant penalties that can be applied.

So there you have it. FedLoans is—for absolutely no reason—essentially forcing borrowers to commit fraud in order to rightfully exclude spousal income. People have been submitting their annual recertifications incorrectly under this specific direction for years and repeatedly so, and FedLoan is apparently still giving this advice on a regular basis.

My personal advice (as an individual citizen who thinks fraud is a thing to be actively avoided) is to simply not follow whatever particular variant of this incorrect advice you receive from whatever random representative you speak to. Instead, ask for someone higher up to set things right. There are definitely people in the organization that know that this is incorrect, so don’t give in and do the wrong thing. I would hope that this practice will become universally known as the fault of the loan servicers and not your personal failing, but the risk isn’t worth it.

Now, if you file taxes jointly and think you are being clever by checking that box in order to lower your payments, don’t do that. That’s definitely unequivocally fraud.

In a broader context, this is just another example of why you should not get your loan advice from a loan servicer. They have no fiduciary duty to actually help you, have been and continue to be sued for being awful at doing just that, and the current administration has done everything in their power to remove all momentum in addressing this problem.

Read a (free) book. Scour the web. Talk to an advisor. Whatever. Just don’t trust a servicer at face value.

You don’t need to submit a PSLF ECF when you first start a new job

07.23.19 // Finance

You need at least one Employment Certification Form per employer for PSLF. A good rule of thumb is to submit annually to help make sure that FedLoan is counting your eligible payments correctly, and it’s a perfectly good idea to submit your first ECF a few months into a new job.

 


But, as you can see on the form, its purpose is to describe a period of qualifying employment that has already occurred and that FedLoan can thus use to mark each payment you made during the same period as eligible for and counting toward the 120 needed for PSLF.

As such, you need not try to submit a form the second you start a new eligible job such as your intern year. I’m looking at you, interns in July. You totally can, but it’s sorta meaningless outside of initiating the transfer to FedLoans if they’re not already servicing your loans. The main exception is if you’ve taken a job that you’re not sure qualifies and you want some official guidance before you keep working there. In which case, sure, fire away. In general, it makes sense to submit your first ECF after making a few months of qualifying payments.

Note that switching servicers can sometimes make other bureaucratic things like switching repayment plans complicated, so it’s advisable not to submit your first ECF near when your income recertification is due. Wait until that’s fully processed first. So, if you entered repayment in June or July and want to make sure things are moving in the right direction, then you could file an ECF sometime in the fall if you’re eager for some news.

You should absolutely submit your ECFs annually, but you should at the very least submit one at end of your tenure with each institution. You don’t want to be trying to get old employers to fill out things retrospectively or to have FedLoan reach back into the distant past to try to count up your payments for the first time. Experience has shown that counting is not really their strong suit.

Teachers sue the Department of Education over PSLF

07.22.19 // Finance

Earlier this year the DOE mostly lost a lawsuit against the American Bar Association about PSLF. In that case, the government lost because it didn’t play by its own rules when it changed some complicated details about case-by-case employment approvals and then tried to inflict those changes retroactively on borrowers. It was pretty blatant and they lost.

In other news, I’m a doctor and not a lawyer, so that’s my personal layman’s take.

Anyway, the American Federation of Teachers just sued the DOE as well. But this one is a much tougher sell. Here’s the actual complaint. Their argument? That the government-contracted servicers did an egregiously bad job managing students’ loans and misled borrowers to such an extent that the government should be held liable for their servicer’s mistakes and bound to make serious changes to the administration of the program in order to uphold its original intent.

Pages of Tears

The claims are certainly factually true and seem reasonable in a common-sense way. Reading these Kafkaesque stories of blatant, repeated, and irredeemable bureaucratic failure is as outrage-inducing as it is depressing. There’s no doubt that the administration of loan servicing in general and PSLF specifically is not what Congress had in mind when it passed the bill. The government servicers have done a terrible job across the board, but especially so when it comes to helping borrowers navigate income-driven repayment and PSLF. This is not helped in any way by the fact that formal guidance was really limited from the department itself for the first several years of the PSLF program. The first ECF wasn’t even available until five years in.

It’s comparatively easy for more recent graduates and pundits to roll their eyes at all these teachers and the other 99% of folks rejected in that first batch of PSLF applicants and point out that they didn’t qualify. Of course they didn’t! But the argument is that we are effectively punishing citizens who could have otherwise earned a rare entitlement for trusting what they reasonably believed was official advice.

Ultimately—generalized day-to-day incompetence aside—the problem is that all of these borrowers who are angry about not qualifying for PSLF in fact do not qualify for PSLF. They didn’t do the right things. Some have the right loans but used the wrong payment plan (the issue that was temporarily addressed when Congress passed the temporary “TEPSLF” expansion). But Congress has not attempted to address the “wrong loan” (usually FFEL) component nor made changes to how the program or loan servicing is handled that could address the disaster on the ground. For her part, secretary Betsy “I’ve-never-visited-a-school” DeVos‘s solution was to try to give all of the business to one unqualified company instead of several and put her friends at Navient (current defenders of a federal lawsuit for sucking) in the shortlist (fwiw, that proposal mercifully died).

The Crux of the Case

So back to this lawsuit. The crux of the suit hinges on the argument that the Department of Education is responsible for the servicer’s incompetence, and basically argues that all borrowers deserve PSLF if they were misled by one of the contracted federal loan servicers.

And that takes us to the recent lawsuit that the department mostly lost against the ABA. I say mostly lost, because of the various counts brought against the department, the DoE did win a key victory. In a case where the servicer made a mistake and incorrectly approved a borrower’s ECF (employment certification form), the Department of Education fixed the mistake years later and removed years of PSLF eligibility from someone who thought they were in great shape. This was deemed totally kosher by the court. As long as the mistake was not a final agency action, the government wasn’t held responsible for fixing a “contractor’s error.”

These PSLF denials are not a matter of the posthoc rule changing the DoE lost about earlier this year. The relevant rules haven’t changed, and people are largely correctly rejected (with the exception of FedLoan’s inexplicable inability to count as high as 120). It’s basically a matter of abysmal customer service. And terrible customer service may not be enough.

From the ABA suit decision:

Moreover, although the Department previously confirmed to [the plaintiff] that his employment was eligible, an agency’s attempt to correct a “mistake in interpreting and applying its own recently promulgated regulations” does not necessarily trigger the APA’s prohibition on retroactive rules.

So, with the repeated caveat that I’m totally not a lawyer, it’s going to be a tough sell to convince the court that the bad actions and terrible advice from servicers should mandate a broad rewriting of the program architecture or large swath of additional forgiven loans. It’s probably going to rely on a really sympathetic ear who wants to go out of their way to favor the plaintiff.

Hope?

However, even if it fails, this case may still be a good PR move to stoke some high-visibility outrage. It would be more likely for these issues to be fixed by another act of Congress than for the court to swoop in and save the day. Though, along those lines, even the administration of another temporary expansion would be no small logistical feat given the slow-motion trainwreck that is FedLoan Servicing.

The Coming Changes to USMLE Scoring

07.18.19 // Medicine

In March of this year, there was the InCUS: Invitational Conference on USMLE Scoring. The results page is here, and the summary report is here.

Invitational? That means that the only people invited were stakeholders who are deeply entrenched in the status quo and/or directly profit from the USMLE system. Namely, the Association of American Medical Colleges (AAMC), American Medical Association (AMA), the Educational Commission for Foreign Medical Graduates (ECFMG), the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).

Absent? Regular humans like students, residents, or even much in the way of program directors, educators, etc. No big surprise. When a growing body of students and educators advocated for removing Step 2 CS because it was an easy superfluous reduplicative and expensive waste of time, the NBME just made that harder to pass. They’d much rather just change the paper you get at the end of the other tests than introspect or make a structural change.

So, the NBME has always said they didn’t like people using the score to evaluate medical students (but have spent an awfully long time letting people do just that):

Said another way, the exams were developed as medical licensure examinations and not as academic achievement exams.

The outcome of this big convening of masterminds? Well, the recommendations are extremely vague but give the impression that eventually removing the three-digit USMLE score is a likely component.

Recommendations specific to USMLE:
1) Reduce the adverse impact of the current overemphasis on USMLE performance in residency screening and selection through consideration of changes such as pass/fail scoring.
2) Accelerate research on the correlation of USMLE performance to measures of residency performance and clinical practice.
3) Minimize racial demographic differences that exist in USMLE performance.

Recommendations to the UME-GME transition system:
1) Convene a cross-organizational panel to create solutions for the assessment and transition challenges from UME to GME, targeting an approved proposal, including scope/timelines by end of calendar year 2019.

Indeed.

 

One of the unintended consequences of more medical schools moving to pass/fail amidst increasing medical school enrollment and flat residency spot numbers has been the increasing importance of the USMLE and the shadow curriculum it has created.

If Step 1 matters but your coursework does not, then you’d be better off in a correspondence course that let you spend all your time preparing for Step 1 and ignoring anything your school actually wants you to do. On the flip side, if the USMLE were to suddenly be pass/fail, then residency programs may be evaluating applicants with literally no comparative data from which to judge candidates.

Point #2 from the blockquote is fascinating in its awkward tardiness because everyone knows the correlation with most clinical performance is negligible, and no meaningful research would likely ever state otherwise. USMLE scores correlate with written boards’ pass rates, which themselves also do not correlate with clinical performance. It’s turtles all the way down. None of these tests actually test what they purport to. The whole system is in shambles from the SAT on up. They all measure a degree of general intelligence and preparation, but…who cares.

Despite the mea culpas about mental health, failing students, blah blah blah, not discussed at all—of course—is whether or not the USMLE sequence should even be maintained as is. There’s a painful failure of vision in a conference solely focused on…scoring.

For example, is CS something the NBME should be doing in the first place or isn’t that what an accredited medical school is for? Or, are Step 1, 2, and 3 testing sufficiently different things to do justify three different exams, and if they are, do all three really play a distinct role in the licensing process? One could easily argue that Step 2 CK is much more meaningful to clinical practice and residency performance than Step 1, which mainly has the benefit of a) being hard and b) having scores universally available during the residency application process because it’s taken earlier.

Feel free to submit your comments on these meaninglessly vague preliminary recommendations here.

Tuition Dollars at Work

07.15.19 // Finance, Medicine

From Dr. Daniel Barron’s “Why Doctors Are Drowning in Medical School Debt” in Scientific American’s Observations blog.

Each year, only 41 percent of applicants are accepted into medical school. Because demand outstrips supply, medical schools have the economic upper hand and, because lenders invariably approve loans to cover tuition, schools can effectively set the price of tuition to be whatever they want. College kids who don’t like it need not apply—somewhere in the remaining 59 percent, an applicant is willing to pay.

[…]

Each year a class of new doctors graduates with a total of $2.6 billion in loans, with a median student debt of $194,000. And no one—not even the regulator tasked with protecting students—can say where this money goes.

He interviews the dean that made NYU tuition-free, who provides some interesting quotations. Also, if you read the article, please note that the Barrons need a new accountant.