The ABR’s new Online Longitudinal Assessment (OLA)

02.02.19 // Radiology

It was super duper gratifying to receive my first OLA email from the ABR this past month. OLA (Online Longitudinal Assessment) is the ABR’s new longitudinal MOC (Maintenance of Certification) process, where diplomates take 52 questions every year instead of a big test every decade.

I took the Certifying Exam in October and received my passing result in November, so the month-long break prior to needing to “maintain” my brand new certification from the ABR feels just about right. Yes, a thousand folks need to maintain a piece of paper they haven’t actually received in the mail yet. I can appreciate why folks fresh off their q10-year MOC victory are irritated at needing to immediately participate in more MOC. Promises are being broken left and right. But, hey, money.

Adding insult to injury, as a neuroradiologist, I still have to sit for the exorbitantly expensive ($3,270) neuroradiology subspecialty exam this October. Which means that I need to maintain my first certification in between getting my second.

The final irritant in this system of paying $340/year (forever) is that the ABR, which is a nonprofit sitting on a war chest of ~$48 million, didn’t apply for (i.e. pay for) ACCME accreditation, so the hours spent doing OLA questions don’t count as official CME. (Update Feb 2020: Now they do, reducing your SA-CME burden from 25 to 15 hours over the 3-year period for MOC attestation)

The Actual OLA Experience

The current OLA paradigm is that 2 questions are released every week (104 a year) and “expire” after 28 days. So while you can log in and batch around 8 questions a month, you won’t be able to do it less often without losing some expired questions. Since you only need 52 questions and can do around 8 a month, you could actually get away with doing it almost bimonthly.

I took my first 8 questions this week and got them all right. They were straightforward, reasonable, and relevant to practice (at least in neuroradiology). My initial impression is that OLA questions are more like what the Core exam should be. You get between 1-3 minutes per question, the website was pretty slick (at least on a desktop), and I did all 8 in around 5 minutes. Can’t complain there. This is clearly a better system and more logical way to fulfill the spirit of MOC than taking an exam full of (even more) irrelevant material every decade.

You get to choose your practice profile and thus what types of questions you receive. I originally chose general diagnostic radiology and neuroradiology, but out of my first 8 questions, 7 were neuro and only 1 ended up being general, and the general question concerned GI fluoroscopy, which I detest, so I switched to 100% neuro. Maybe it’ll help with the subspecialty exam.

Things the ABR should improve:

Mobile experience. I’ve heard complaints about display issues on phones. You only get a minute for most questions, so it needs to work.
Lower the price. At the current rates, this is far more expensive than any commercial qbank. And that’s what this is. The ABR makes a lot of profit for a non-profit.
Increase question shelf-life. Why do questions expire after 28 days? So arbitrary. Let the radiologists hold themselves accountable. How about 90?
Get official CME accreditation. This feels like apathy and laziness. I know it’s not straightforward or cheap to be a CME-granting organization with the ACCME. But again, this is an expensive process, but it would be far more reasonable if it counted for CME. (Update Feb 2020: They don’t give you hours per se, but they do reduce the obligation for SA-CME for MOC; you’ll still have to satisfy your state requirements)

And finally, how about you let everyone take the certifying and subspecialty exams using the OLA software instead of flying out to Chicago to waste their time?

Step 1 keeps you safe from the dangers of fun

01.31.19 // Medicine

If students were to devote more time to activities that make them less prepared to provide quality care, such as binge-watching the most recent Netflix series or compulsively updating their Instagram account, this could negatively impact residency performance and ultimately patient safety.

That’s Peter Katsufrakis, MD, MBA, president and CEO of the National Board of Medical Examiners (NBME) and Humayun Chaudhry, DO, MS, president and CEO of the Federation of State Medical Boards, responding in Academic Medicine to a student-written article concerning how Step-prep has consumed medical education that advocated for a pass/fail Step 1.

There was a backlash, and they tried to backpedal on this comment (emphasis mine):

During the editing process of our manuscript, we added a statement about excessive use of Netflix and Instagram which was unfair and inappropriate. As leaders of the USMLE, we believe that students, medical educators, and the public deserve our respect. Our statement was inconsistent with that belief, and we are deeply sorry.

Yeah, right. Make no mistake, their glib response to actual student concerns is exactly what they meant to say. Humor is often the dull dagger of truth, seemingly softer and more palatable than direct honest communication but ultimately more damaging.

However, the disrespect is by far the lesser evil here. Students and residents are rarely respected on an intellectual level by administrators. Their perspectives are viewed as myopic and ill-informed. The real issue here is dismissal.

Students have valid concerns. Residents have valid concerns. Trainee complaints are often dismissed by their superiors as the whining of a coddled generation (whether decades ago or today), and then those graduates go on to perpetuate both the toxic culture and broken system it engenders.

The biggest problem in medical education is the uncanny ability of doctors to pay-it-forward instead of being agents of change.

Pitfalls of Private Equity Takeovers

01.28.19 // Medicine, Radiology

You may have heard about this absurd story in the NYTimes a few months ago: An academic journal pulled a legitimate article comparing practice characteristics of groups that take on private-equity funding and those that do not. Why? Because a PE firm put the squeeze on their editor, that’s why:

In an interview, Dr. Hruza [the incoming president of the American Academy of Dermatology and board-member of United Skin Specialists, the largest PE-backed derm practice in the country] said he did not ask that the paper be taken down. He did, however, confirm that he expressed his concerns to Dr. Elston, the editor, after it was posted. Two days later, Dr. Elston removed the paper.

From the reporting in the times, this situation is absurd. If people have quibbles with the conclusions of a peer-reviewed article, then they should write a commentary. You don’t get to line-edit someone else’s manuscript.

Dermatologists account for one percent of physicians in the United States, but 15 percent of recent private equity acquisitions of medical practices have involved dermatology practices. Other specialties that have attracted private equity investment include orthopedics, radiology, cardiology, urgent care, anesthesiology and ophthalmology.

PE firms are following the money. However, their primary objective of extracting profit doesn’t necessarily equate with an understanding of how to actually run a successful, responsible, and sustainable medical practice.

Dr. Konda, [the paper’s lead author], said he first grew interested in the topic when several of his trainees went to work for private equity-backed practices and told him of clinical environments that emphasized profits at the expense of patient care.

With that preamble, check out this interview with radiologist and former PE analyst, Kurt Schoppe, MD on Radiology’s Nearest Threat, Commoditization, and the Misguided Notion That You Will Be Paid for Everything You Do.

Lots of excellent responses, but these three quotes give you a nice flavor of private-equity takeovers in broad strokes:

One of their favorite marketing lines is “physician-owned or physician-operated.” That’s really a misdirection because, frequently, they set up a holding company under which the physician group is a wholly owned subsidiary. Yes, the physician group is owned and operated by physicians, but it is not controlled by physicians because, as a wholly owned subsidiary, the parent corporation, or the holding company, is going to have absolute control. That holding company is not majority-owned by the physicians. The wording on the contracts is going to be such that the PE firm or the corporate entity is going to have control over the parent entity when it needs it.

…

What I’m getting at is no matter what the marketing says, no matter what they are telling people when they are selling services, these entities must make money for their owners/investor as their primary objective. Changing the economics of radiology group ownership is not fundamentally about the patients or saving money for the payers. They do these things to make money for their investors. This is not a negative judgement, it’s just a fact. If physicians want to sell their practice, if someone is only 4 or 5 years from retirement, and they only have a 4- or 5-year hold on their contract after they sell their group, well, that is just logical. From a purely personal economic point of view, it makes sense for them to sell, because they are not looking at a 15- to 20-year timeline.

…

The people who need to look out for this are the people in training, the people coming out of training, and the younger physicians in the group who have a 15-, 20-, 30-year timeline. If your goal when you came out of medical school was caring for patients, positively affecting the health care environment, or doing things for the greater good, I think you are better able to do that as a physician group in which you decide, as a group, how much money you need to make, what sacrifices you choose to make, and for whom you will charge less. If you cede control of your decision-making to a group that will only be motivated by its ability to make returns for its investors, you’ve put someone else in that conversation who does not necessarily share your values and ethics as a physician.

Anyone joining a hot-bed field like dermatology or radiology needs to understand the business model of your chosen profession and evaluate the health of both the practice and local market you consider joining.

While partners may get short-term windfalls in some buyout scenarios, non-partner employees are the primary profit source. Spending time in a partnership-track without eventually being a partner is a waste if the position becomes untenable and you need to start fresh somewhere else.

NRMP Says: Rank Them How You Want Them

01.24.19 // Medicine

President and CEO of the NRMP, Mona M. Signer, talking with Medscape:

I certainly understand why applicants and programs engage in post-interview communication, but applicants and program directors shouldn’t create their rank-order list on the basis of post-interview communication from the other party. They ought to create their rank-order list based on their true preferences. Applicants should rank the programs where they want to train in order of preference, not where they think they will match. Program directors should rank applicants in order of preference, not the applicants with whom they think they will match. The matching algorithm works best when Match participants rank each other in order of true preference.

YES. Seriously people. I would also add that people shouldn’t create their ROL based on communication (or assurances) during the interview, either.

After all these years, some students and programs still think there should be other considerations to the ROL. But there aren’t. It shouldn’t really matter what the other side wants in this system. It matters what you want. It’s your list.

From “The Residency Match: Interview Experiences, Postinterview Communication, and Associated Distress” in the Journal of Graduate Medical Education:

In terms of postinterview communication, more than 70% of respondents indicated that they wished such communication were explicitly discouraged, and more than half said they wanted programs to bar candidates from notifying them of a high rank in order to avoid match manipulation.

There are no positives to the ego-stroking, play-acting, and intermittently grossly-misleading game that programs (and applicants) play. Everyone wants to be loved and get their top choices, but the only communication that should really have any impact (or be permissible) is new information:

My spouse early-matched to a program at your institution.
My mother has become ill, and I truly hope to end up in your city so that I can help take a greater role in her care.
I just won the lottery, and there is a significantly increased risk of me not completing your grueling program.

Though the NBME allows everyone to dance, the best advice will always be rank them how you want them.

Review: Proscan’s MRI Online

01.09.19 // Radiology, Reviews

MRI Online (now Medality) is an advanced (MRI-focused) online radiology video platform offered by Dr. Stephen J Pomeranz, who is primarily a musculoskeletal radiologist. Just one dude. This in contrast to most online offerings in radiology, which are typically recorded board reviews or CME lectures from the big popular courses at places like Stanford, Hopkins, Duke etc. Multiple folks talking about multiple topics. Those production values tend to be relatively low because they’re typically recorded from normal in-person talks with the best of intentions (but without the best of audio engineering).

I was recently offered the chance to check out MRI online. I had the intention of spending time with it to help with studying for the certifying exam, but then I ended up not studying. That’s a separate story.

Anyway.

Content

There are several different kinds of content: “Mastery series” lectures are divided into digestible 5-10 minute chunks. “Lecture series” are more typical hour-long lectures (some of these are a bit older). “Courses on Demand,” which are recordings of in-person case reviews (my least favorite). And lastly, “Power Packs,” which are interactive PACS-integrated cases with questions and explanations (but no video).

Platform

MRI Online uses the Teachable platform, which is basically what every new course you’ve seen advertised on Facebook uses. Teachable is simple to use, especially well-suited for video courses, and produces a clean product, so there’s no secret why.

There are pre- and post-tests available, but these tend to be short little multiple-choice deals (often text-only). Nothing special there. This is definitely not aiming to be a q-bank.

More importantly, Teachable videos have the ability to be sped up, so you can pick your pace accordingly.

What separates MRI Online from just about every other product out there is that the case review components are integrated with an online PACS. You can review the cases (scroll through stacks, multiple sequences, window/level, etc.), read them cold, and then essentially go through them with Pomeranz or with a written explanation. It’s interactive. It’s practical. It’s reflective of real practice. It’s basically like being a resident or fellow, except that you’re on your own pace, the cases are carefully curated, and your teacher isn’t too busy to teach. It’s pretty neat.

Pricing

Pricing is a bit of a mixed bag.

The in-training price is actually pretty reasonable ($50/month or $500/year). In particular, if you have plans to do an MSK mini- or real fellowship, going through MRI Online would be a great introduction and much less painful than Requisites. For cost reasons, I think any trainee is probably going to buy on a month by month basis when they have time and not to fork out for the year.

(Talk about responsive, the price for fellows used to be $100/month. When I pointed out that fellows don’t really make significantly more than residents, they dropped the price a week later.)

While there’s also a lot of content for neuro (and some prostate), I think most people probably wouldn’t need to buy more than a month if their focus is non-MSK. Proscan tells me they’re adding tons more non-MSK content this year, so I imagine that’s likely to change.

The price for folks out in practice gave me a bit more sticker shock at first: $150/month or $1500/year. That said, you do need CME, lots of practices do provide CME funds, and course reviews and conferences are generally even more expensive and not amenable to pajamas. MRI Online provides real ACCME CME credits, which for the price are actually a bargain depending on how hard you pound your subscription.

I wouldn’t pretend to have the ability to compare and contrast any of the huge number of course reviews that exist in radiology, but MRI Online is definitely better than a lot of conference talks I’ve gone to at RSNA, ASNR, WNRS, ABCD, and WXYZ.

Here’s where the usual negotiated discount/affiliate stuff comes in:

Code BEN10 gets you 10% off.

The annual subscription also includes a free MRI anatomy atlas as well as free attendance at a 3-day MSK MRI course held annually in Cincinnati. They tell me the vast majority of subscribers are annual, not monthly.

Free Samples

There’s a free online MSK mini-course with a sample of cases (that you would need to sign up to take).

There are also sample videos for each course (e.g. shoulder, hip) that you can watch without logging in, as well as sample cases for basically every course. You’ll get a history, review the cases in the diagnostic viewer, then answer a multiple-choice question about them. The explanations have annotated lesions and a relatively concise readable description.

They also provide a full free 7-day trial, which is a real steal for trainees or for focused test-prep.

Bottom line is that there are plenty of no-risk opportunities to check it out. There’s lots of totally free content and no bait-and-switch in sight. I wish more companies were this transparent.

Conclusion

MRI Online is actually an impressive and pretty expansive product, particularly for MSK, but also with hours of content for neuro and body. In addition to solid review, I’d definitely consider signing up again if I changed practices and needed to expand my toolset.

What I read in 2018

01.06.19 // Reading

This is the fifth time I’ve published my book diet for the year (though admittedly a few days late). It’s a pretty eclectic mix this year, and I’m happy to report I did manage to squeeze in a few classics amidst my steady diet of not-so-classics. Not gonna lie, Gilgamesh (humankind’s earliest surviving written story) is kinda awesome. I did fail in my promise to myself to stop reading anything approaching pop-pseudo-psychology and self-help. I keep telling myself it’s because it’s background for all the writing on the topic I have planned, but it’s really a poor excuse.

This number is also totally inflated because I decided to include a few things from Audible that not only did I not “read” but aren’t exactly even books. Audible recently started giving members two free “Audible Originals” downloads every month, which are a combination of short books, plays, and…episodic treatments of a theme? Either way, they’re neat! (And audible is still offering two free books when you sign up.)

The 4-Hour Workweek by Timothy Ferriss (This book is so frequently referenced and has generated so much copycat drivel that I’m shocked I hadn’t read the actual source before. Unfortunately, you can’t be a practicing physician in 4 hours a week, and most of the other insights I liked have remained unchanged since the time of the ancient Stoics.)
The Doctors Guide to Smart Career Alternatives and Retirement by Cory S. Fawcett (I wouldn’t mind retiring to write books either; writing them while gainfully employed is hard work!)
The Year of Living Danishly by Helen Russell (I wouldn’t want to live in Scandinavia, but I would like their social benefits please)
Brevity: A Flash Fiction Handbook by David Galef (Nanoism and I get a shoutout and a couple of reprints in the final chapter, which is neat)
So Good They Can’t Ignore You by Cal Newport (Along with Deep Work, Newport has written two of the least cringe-worthy entries in the productivity/self-help genre. I don’t regret reading either one.)
American Sniper by Chris Kyle
What I Talk about When I Talk about Running by Haruki Murakami
SP4RX by Wren McDonald (‏One thing that I love about graphic novels is how different art styles can inform and reflect the story. Grabbing a random new one off the shelf is always fun when I take my son to the library)
Can’t and Won’t (Stories) by Lydia Davis (it took me over a year reading this book in small chunks to get through it. Had high hopes, as I tend to enjoy (and of course publish) very short stories. Ultimately many of the shortest ones felt empty, while the longer ones generally felt somewhat plodding and maybe even indulgent?)
Island by Aldous Huxley (a treatise on the benefits of Buddhism and magic mushrooms loosely masquerading as a story. Brave New World it is not.)
Dockwood by Jon McNaught (beautiful, unique art, almost like a nearly silent film; very short graphic novel (really two graphic short stories) but so quietly depressing).
Mooncop by Tom Gauld
In Real Life by Cory Doctorow and Jen Wang
How to Live a Good Life by Jonathan Fields (ugh. answer = buckets)
Catch Me if You Can by Frank W. Abagnale (fascinating)
Stephen Colbert’s Midnight Confessions (Weak. I did almost belly laugh once though. I also read it in Barnes and Noble for free, so well worth the price of admission).
The Punch Escrow by Tal M. Klein (awesome near-future techno-romp)
Spell or High Water by Scott Meyer (Magic 2.0 #2)
First Man: Reimagining Matthew Henson by Simon Schwartz
Buzz! by Ananth Panagariya and Tess Stone
An Unwelcome Quest by Scott Meyer (Magic 2.0 #3)
Fight and Flight by Scott Meyer (Magic 2.0 #4) (Ugh this was so weak compared to the first three.)
Ikigai by Francesc Miralles and Hector Garcia (I told myself I wouldn’t buy any more terrible self-help Audible daily deals, but I’m a sucker for Japanese wisdom. This was really terrible but at least mercifully short)
If On a Winter’s Night a Traveler by Italo Calvino (a unique trip, novels within novels *inception horn*)
The Elements of Style by Strunk & White (I think this my third re-read)
You’re Never Weird on the Internet (Almost) by Felicia Day
The Machine Stops by E. M. Forster (published in 1909! probably the inspiration for WALL-E)
Consciousness and the Brain by Stanislas Dehaene (not the fastest or easiest read, but a fascinating one nonetheless. His writing for a general audience is much more palatable than his papers from the 90s and early 2000s I read during one of my college seminars).
The Time Machine by H. G. Wells
Infinite by Jeremy Robinson (I thought this was an awesome sci-fi thriller thingie)
See You in the Cosmos by Jack Cheng (highly recommended, particularly if you liked the Curious Incident)
What Do You Care What Other People Think? by Richard P. Feynman
Caves of Steel by Isaac Asimov (Robots #1)
The Sky Below by Scott Parazynski
The Naked Sun by Isaac Asimov (Robots #2)
The Robots of Dawn by Isaac Asimov (Robots #3)
You Do You by Sara Knight (her first book was far funnier and superior)
Out of Spite, Out of Mind by Scott Meyer (Magic 2.0 #5)
Gilgamesh: A New English Version by Stephen Mitchell
The Stars My Destination by Alfred Bester (I read this so many years ago that it took me a few chapters to realize I’d already read it! A true science fiction classic)
Andrea Vernon and the Corporation for Ultrahuman Protection by Alexander C. Kane (fun!)
Outcasts of Order by L. E. Modesitt, Jr. (I don’t know if I’m just getting older, but the writing in this subseries is more repetitive and the characters more two-dimensional than I seem to remember. Nonetheless, Modesitt may always be my guilty pleasure.)
Children of Time by Adrian Tchaikovsky (really good! Arthur C. Clarke Award winner)
Edgedancer by Brandon Sanderson
The Year of Less by Cait Flanders
No Time to Spare by Ursula K. Le Guin
Misbehaving by Richard Thaler
Oathbringer by Brandon Sanderson (Stormlight Archive #3) (#4 please…)
Harpoon: Inside the Covert War Against Terrorism’s Money Masters by Nitsana Darshan-Leitner
Capital Gaines by Chip Gaines (If I could see deep inside myself, I’d still never know why I read this)
Never Split the Difference by Chris Voss (This is an excellent [the best?] book on negotiating. Probably should be a must-read for every graduating resident)
One Doctor by Brendan Reilly (This is a beautiful doctor memoir. It really is lovely. Reilly also deftly weaves in the frustrations and issues with the changes in the practice of American medicine deftly and with excellent perspective).
You Need a Budget by Jesse Mecham (by the creator of the software of the same name)
Bushido Online: The Battle Begins by Nikita Thorn (I can’t fully express how utterly silly and fun this book is. It’s a LitRPG. I didn’t know what a LitRPG was before, but it’s basically a book where the action and character development occurs like a roleplaying game. People have hitpoints. Gain abilities. Go on quests. It’s just so adorably goofy.)
Bushido Online: Friends and Foes by Nikita Thorn
The Coming Storm by Michael Lewis
Girls and Boys by Dennis Kelly
Thunderhead by Neal Shusterman (Arc of a Scythe #2)
Boomerang by Michael Lewis
Atomic Habits by James Clear
Laid Waste by Julia Gfrorer
“Surely You’re Joking, Mr. Feynman!” By Richard P. Feynman (I feel like if I had a spirit animal, it would have been Feynman.)
This is Going to Hurt by Adam Kay (a diary version of the medical coming-of-age tale. You know the end before it starts, but it’s still a good ride with some laugh out loud funny bits. It was also neat to make sense of how training works in the UK)
Twain’s Feast by Andrew Beahrs
No Land’s Man by Aasif Mandvi
The Impossible Fortress by Jason Rekulak
I am Number Four by Pittacus Lore (not great even as far as super-powered YA goes, but when I discovered that Lore is a pen-name for a group of writers including literature’s greatest modern liar [James Frey], I was curious).
Zero G by Dan Wells
The 21 Irrefutable Laws of Leadership by John Maxwell (Why do I keep reading this tripe??)
Victorian Secrets by Stephen Fry
The Consuming Fire by John Scalzi (The Interdependency #2)(I really enjoyed this one. Has some echoes of Asimov’s Foundation but written with foul-mouthed contemporary style and pacing)
Out of My Mind by Alan Arkin (um, this was odd and meh)
Friday Night Lights by H. G. Bissinger

I’ve read some long books over the years, but Sanderson’s 1248-page epic Oathbringer was a monster.

I have so many unread books on the shelf it’s almost embarrassing (I practice the art of Tsundoku), and also I really want to finish writing book #4 this year—I need to get to work!

Student Loans Books: Free Forever

12.08.18 // Finance, Writing

When I began the project that eventually resulted in my two books on student loans, my long-term plan was to sell them temporarily, recoup some of the incredible time (and opportunity cost) burden of putting them together, and then eventually release them for free.

I’m happy to say that day is finally here.

From now on, you can always download the Kindle, epub, and pdf versions of Medical Student Loans and Dealing with Student Loans for free right here.

To receive your copy, you’ll need to sign up for my email list, and if you’re not interested in actually hearing from me again (which is totally fine), then just hit the unsubscribe link in the very first line of the email. (Okay, I admit I still haven’t actually started my newsletter yet, so I don’t have any gauge of how good it will be; the plan is quarterly [maybe?] starting 2019, 2020? Who knows?).

In order to subsidize the cost of giving these downloads away, I may occasionally bring on a sponsor. I want you to know that there could even be a single ad on a single page of this site (up from the current number of zero), but there will be absolutely no tracking or cookies or anything of any kind. Ever. Because that makes the internet worse.

But most importantly, I’m happy these books are free for the long term. I wrote them first and foremost to help as many people as possible, and making them free forever is the biggest part of that. While they say “student loans” in the title, these are also a good introduction to personal finance for young doctors and other professionals.

So, learning about student loans and basic personal finance will cost you a few hours and not a dime. And, if you’re on the fence about the time, let me leave you with a quote from a recent review by Dr. James Dahle, author of The White Coat Investor:

[Dr. White] does a fantastic job though; I wish I had written the book. But more than that, I wish every medical school required it to be read before you could receive your first student loan.

Download your copy today.

Journey to the ABR Certifying Exam

11.28.18 // Radiology

If there is little information online about the ABR Core Exam, there is essentially none about the Certifying Exam. After several years, the only nuggets on the grapevine were that it was easy, nobody has ever failed, and you might as well do all your selected modules in the field of your fellowship.

All of that is probably true. But just as diagnostic imaging for pulmonary embolism in the ER is always indicated, more information is always better, right? (more…)

Kosher(ish)

11.19.18 // Miscellany

Some of you may have noticed that things have been a little bit quieter than usual around here. While I’m still writing (and have plenty more in store), my attention was divided recently on a new passion project my wife and I just launched.

It’s called Kosher(ish), and it’s basically the first part of a new Jewish lifestyle brand and blog. Because why not? Also, because there aren’t enough fun things for us to dress our son in for the holidays, and Hanukkah isn’t the only one that deserves a t-shirt or some paper goods!

(We only have a few items for this 2018/5779 Hanukkah season, but if you’re in the market, time is running out to receive your order for the holiday.)

It’s not easy to balance a dinosaur-and-train-loving three-year-old, this sprawling website, a half-finished book, a new job, and a new venture! In the meantime, I have some exciting news about my student loans books coming soon and a bunch of great posts to close out the year.

Most of all, thanks as always for reading.

Retort of the week

11.13.18 // Medicine

Do you have any idea how many bullets I pull out of corpses weekly? This isn’t just my lane, it’s my [expletive] highway.

Pathologist Dr. Judy Melinek, responding on Twitter to an NRA tweet admonishing doctors to “stay in their lane” and stop discussing gun control.