Here are my explanations for the new NBME 2018 USMLE Step 1 Sample Test Questions. This year there are 51 new ones (marked with asterisks).
Like in years past, the question order here is for the PDF version (not the FRED-simulated browser version). This facilitates using these explanations in future years when they change the available question set (because the old ones are always available via archive.org). The multimedia explanations are at the end.
Man, I really really wanted to like the reMarkable ($100 off with that link).
The reMarkable, if you haven’t heard of it yet is a large format e-ink device the bills itself as a Paper replacement. It’s billed as a large touchscreen enabled Kindle with a fast refresh rate and a bundled non-battery-powered stylus that supposedly mimics the texture of paper.
And if the software running this thing was anywhere close to the level of polish in a Kindle or your typical smartphone device, then this thing would be pretty awesome.
But it’s not, so it’s pretty much not.
The packaging was slick and got my hopes up a lot.
The screen is pretty nice. A big almost notebook size e-ink display, though without the backlight that folks may have gotten used to on recent Kindle generations. The 300 PPI of the high-end Kindles is substantially better than the 226 PPI of the ReMarkable, so it doesn’t even look as crisp as other modern e-readers. As a radiologist, I was hoping the device would be good for reading image-rich books and journal articles, but the images aren’t crisp enough and the contrast is washed out. The refresh rate when drawing is impressive but the delay when redrawing the screen to change pages in a book is sloooow.
The surrounding is less nice. The plastic frame does jive with the lightness of the device but it belies a build quality far below, say, an iPad or even a Kindle. The front buttons, in particular, are flimsy and loose without firmness or a satisfying click. The little-nubbed pen feels like a cheap but works exactly as billed. It has a satisfying paper scratchiness on the screen.
The software is incredibly weak. The design is hobbled to function as a serviceable paper sketching/drawing app with a buggy, slow, underpowered e-reader bolted on than a real e-reading device. Page turns are slow. Documents are barely searchable. Annotations only sorta work. Unlike Kindle, you can’t, say, export your highlights—they’re basically saved an image overlay, so useless for most people’s purposes unless you are editing/marking up a PDF (as if it were actually on paper). They also have a tendency to shift on the page, making them nonsensical. Underlines should not be strikethroughs. Only non-DRM ebooks in epub or pdf formats work, and the reMarkable doesn’t yet support the new epub3 format. It also doesn’t parse epub files properly, mutilating the majority of the formatting. No links, no footnotes.
You can only sync ebooks via the app, and the app is buggy. I found I was routinely unable to add files to the reMarkable via the app normally, but that I was usually able to add via the iOS “open in reMarkable” extension (which means the files are compatible, just the platform sucks). The organization schema are just a few folders, and book covers aren’t even displayed (the last page visualized is), which makes seeing your collection at a glance a homogenous mess.
There is no in-book search. No parsing of the table of contents. No internal linking.
It shows PDFs like a stack of pictures, not complex files combining images and—of course—text.
Someone who wants to sketch digitally but wants a more paper-like feel than an iPad or a Wacom might enjoy this device.
Anyone hoping for large-format super Kindle is going to be extremely disappointed.
Update: I went back to just using Workflowy for all drafting. It’s just so easy and awesome.
There were two developments that led to me implementing new workflows to get my writing done. I’ve been interested in different writing environments and different tools for longer than I’ve actually done any significant writing but always fell into the typical trap of spending more time researching what to use than I ever spent actually using anything other than the built-in post editor for WordPress and Microsoft Word.
The first was the birth of my son 3 years ago. I don’t know what I used to do with all of that time, but it became clear that with priorities of being a father and then being a physician that I would need to be more deliberate in carving out a niche for writing.
The partially-related second development is that I started to do a lot more writing on my iPhone. To write effectively on the phone, you need a tool that allows you to get words down quickly and keep your snippets and thoughts organized. Another big plus is solid syncing so that you can switch back and forth on the same project on other devices seamlessly.
Last year, I had a two-app system. WorkFlowy for my snippets, lists, and braindumps. I previously wrote about how I used this awesome free service (with completely optional paid upgrades) to write my second book. Then when it was time to sit down and really flesh out that manuscript I used Ulysses. I even had my entire to-do list in Workflowy for a while.
This worked great. But I found that my post snippets and drafts were numerous enough that they started to get cluttered and lost in my tangle of multi-layered WorkFlowy outlines. I use the app for so many different things that it took time to find the right place to put the right snippets, and I didn’t have the time to sit down and use the Web app to re-organize frequently enough. Workflowy is awesome for unstructured data entry, but it was less good for building up multiple drafts simultaneously, which was especially tricky because I was using it for so many different things that I had to navigate through frequently. These extra seconds sometimes meant either losing organization or losing a thought I wanted to transcribe.
The simple solution was staring me in the face the whole time: Bear.
Now, it didn’t actually have to be Bear. It could have been any decent note app. Byword, iA Writer, and even the built-in notes app would all work the same. Bear just happens to be a particularly well-crafted one that is super responsive, a pleasure to use, and has a robust tagging system (and was perhaps coincidentally the one I was testing out when I figured out my new plan). Bear is completely free to use and $15/year for premium features like cross-device syncing.
What I needed to optimize for my phone writing workflow was an app for long projects which is well organized and synced to my computer (Ulysses). An app for lists and brain-dumping and especially for building up lots and lots of snippets for longer works (WorkFlowy). And—and this was the surprise/revelation—an app just for blog posts.
I think most people intuitively want to use fewer apps. The view of so many app reviews and so much productivity writing is that if you just find the right system or best workflow that everything in your life magically falls into place. The truth is that putting the hours in and developing good habits are what gets results. The tools are just lubrication.
So originally, I wanted to find the right thing that works for everything. Ulysses is basically perfect for that. But I wear different kinds of writing hats and write different kinds of things on my phone so having Bear dedicated to fleshing out a limited number of brewing blog posts is extremely efficient for me, even if it also results in a little additional clutter on the home screen.
After years of pretending that people could actually fail (“condition”) individual exam sections other than physics in its convoluted two-stage exam scoring process, the ABR has decided to simplify things going starting this year in 2018.
From now on, there are three scoring outcomes:
Conditioning physics means re-taking just physics. Failing means re-taking the whole thing.
This means that your performance on any individual section (except physics) is irrelevant so long as the average score across all sections meets the passing threshold of 350. No surprise there. For followers of last year’s mammography kerfluffle, you’ll remember that the ABR acknowledged that the results of the mammography section in isolation literally had no bearing on a single examinee’s passage result. Whether or not it was really technically possible to condition a non-physics section, no has ever conditioned a section other than physics since the Core Exam’s inception.
Scoring is still cloudy, however, because the passing threshold of 350 is a meaningless number without any measure of the preparation required or the percentage of questions you must answer correctly in order to achieve that score. It’s purportedly derived from the sum of the Angoff method scores for each section based on what the expert panel believes a “minimally competent” radiologist should know. So, whatever. This does mean, however, that strong sections can make up for weak sections. Consider this is your license to ignore GI and GU fluoroscopy.
While this sounds like a big positive development, I believe this is basically just a paper change. The ABR is just acknowledging outright the reality on the ground for the past several years: The large gap between overall passing performance and the true failure threshold for all non-physics sections is so large that in practice no one could actually fail an individual section.
Frankly, I wouldn’t be surprised if the one person per year who should have conditioned a non-physics section was just given a score of 200 on the offending set in order to pass via an informal secretive score floor. Who knows.
But at least it’s simpler and more straightforward now.
The new budget just passed ponied up an extra $350 million to help those ineligible for PSLF due to repayment plan technicalities. Here is the language, followed by the translation.
From the recently passed budget (aka Consolidated Appropriations Act, 2018), SEC. 315 (pages 1008-1010):
For an additional amount for ‘‘Department of Education—Federal Direct Student Loan Program Account’’, $350,000,000, to remain available until expended, shall be for the cost, as defined under section 502 of the Congressional Budget Act of 1974, of the Secretary of Education providing loan cancellation in the same manner as under section 455(m) of the Higher Education Act of 1965 (20 U.S.C. 1087e(m)), for borrowers of loans made under part D of title IV of such Act who would qualify for loan cancellation under section 455(m) except some, or all, of the 120 required payments under section 455(m)(1)(A) do not qualify for purposes of the program because they were monthly payments made in accordance with graduated or extended repayment plans as described under subparagraph (B) or (C) of section 455(d)(1) or the corresponding repayment plan for a consolidation loan made under section 455(g) and that were less than the amount calculated under section 455(d)(1)(A), based on a 10-year repayment period: Provided, That the monthly payment made 12 months before the borrower applied for loan cancellation as described in the matter preceding this proviso and the most recent monthly payment made by the borrower at the time of such application were each not less than the monthly amount that would be calculated under, and for which the borrower would otherwise qualify for, clause (i) or (iv) of section 455(m)(1)(A) regarding income-based or income-contingent repayment plans, with exception for a borrower who would have otherwise been eligible under this section but demonstrates an unusual fluctuation of income over the past 5 years: Provided further, That the total loan volume, including outstanding principal, fees, capitalized interest, or accrued interest, at application that is eligible for such loan cancellation by such borrowers shall not exceed $500,000,000: Provided further, That the Secretary shall develop and make available a simple method for borrowers to apply for loan cancellation under this section within 60 days of enactment of this Act: Provided further, That the Secretary shall provide loan cancellation under this section to eligible borrowers on a first-come, first-serve basis, based on the date of application and subject to both the limitation on total loan volume at application for such loan cancellation specified in the second proviso and the availability of appropriations under this section: Provided further, That no borrower may, for the same service, receive a reduction of loan obligations under both this section and section 428J, 428K, 428L, or 460 of such Act.
Mhmmm, almost English.
This Republic-passed bill signed by a Republican president includes a seemingly random $350 million for temporarily expanding PSLF. (The Dems, of course, were pushing for $2 billion.)
Even while the ultimate fate of PSLF remains hotly debated, there are additional funds to allow individuals with Direct loans to have their payments under the “Extended” and “Graduated” plans count toward the 120 necessary monthly payments for PSLF forgiveness. Normally, only payments made while in an income-driven repayment (IDR) or the standard plan count toward PSLF.
A lot of people who gave up on the idea or were told they don’t qualify should go back and do some basic arithmetic to see where they stand.
All of the other requirements still apply: as in, you’ll need Direct (not FFEL) loans and have had made 120 on-time monthly payments while working full-time in a qualifying public service job with a qualifying employer. A new application form will be released in the next 60 days.
An unusual caveat is that this particular expansion is first-come, first serve. This makes some sense when you consider that this expansion is really about trying to further the spirit of the original program; these new inclusion criteria are not part of the master promissory note but are really just throwing frustrated borrowers a bone.
See more about the TEPSLF program here.
You may recall the ACGME recently nixed its 2011 rule that mandated a 16-hour shift maximum for interns after “minimal” differences were noted in a study of surgical residents. I discussed those results here and the ACGME change here. Even in that study, the surgery trainees were basically less happy.
So, the ACGME didn’t wait for it, but now the results of a similar study in a cohort of presumably less self-flagellating medicine residents.
The study was designed to test the persistent leadership belief that the old days of infinite work were not only better for learning and patient care but also better tolerated by residents:
We prespecified four hypotheses regarding trainee education: that interns in flexible programs would spend more time involved in direct patient care and in education, that trainees and faculty in flexible programs would report greater satisfaction with their educational experience, and that interns in flexible programs would have noninferior standardized test scores to those in standard programs.
So, iCOMPARE randomized 63 internal medicine residency programs to flexible (read: long) or standard shifts. Both groups had the theoretical “80-hour” workweek cap. Standard programs adhered to 16-hour shift caps for interns and 24-hour caps for residents, while flexible programs “did not specify limits on shift length or mandatory time off between shifts.”
Contrary to the prevailing hypothesis, the flexible residents spent no more time on patient care.
However, the “flexible” (euphemism) program interns were “more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65)”
One thing that was similar was the high-rate of burnout:
Reports of burnout were high in each group. The interns in each group had a similar likelihood of having high or moderate scores on the Maslach Burnout Inventory subscale for emotional exhaustion (79% in flexible programs and 72% in standard programs; odds ratio in mixed-effects logistic-regression model, 1.43; 95% CI, 0.96 to 2.13), high or moderate scores on the depersonalization subscale (75% and 72%, respectively; odds ratio, 1.18; 95% CI, 0.81 to 1.71), and low or moderate scores on the personal accomplishment subscale (71% and 69%, respectively; odds ratio, 1.12; 95% CI, 0.84 to 1.49)
3/4 are miserable. It’s hard to divide an 80+ hour pie into something that isn’t too many hours a week.
I think the conclusion sums up the state of medical training fantastically:
There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied.
So, whose happiness matters more?
In the wake of last year’s impressive technical failure during the Core exam, the ABR has decided to try something new.
On Monday, when registration opened for the 2018 Core Exam, the ABR decided to not send all candidates the email at the same time. Instead, swathes of people had their invites delayed by several hours.
By the time these lucky folks received their invites, the Tucson test dates were completely filled (possibly because the Tucson experience is slightly nicer but maybe also because Chicago was the site of last year’s cluster). Additionally, the Chicago hotel block was completely booked for the first test dates.
This is an amazing illustration of managing expectations.
Yes, by screwing up something as easy and seemingly straightforward as sending an email literally as soon as possible during the testing process, the ABR has again angered a lot of people. But, but, they’ve also made sure to lower expectations in advance this year. Now, assuming they can administer the exam people have paid them for, everyone will just be pleasantly surprised that they can actually take the miserable two-day pain-fest from start to finish.
Clever.
Why is the United States such an outlier? Structural barriers may be to blame. The U.S. health care system famously incentivizes procedures and pills over a holistic approach. That might be especially true with antidepressants, which the National Institute of Mental Health concedes are increasingly prescribed for “off-label” uses, meaning conditions like insomnia, pain, eating disorders, and migraines, rather than depression. This tendency to prescribe, and specifically to prescribe antidepressants, contributes to the aura of “they might help, and they probably won’t hurt,” despite warranted debate over their effectiveness for depression. A system that encourages such practices is at odds with a prescription of “get outside and move for half an hour most days” for depression.
Of course, the real answer is that doctors do tell patients to exercise.
What is this famous “incentivization” for pills over a holistic approach? A psychiatrist does not get paid for prescribing a medication. There are no kickbacks in the 21st century. Complexity in note-writing is a documentation burden, and certainly needing to evaluate labs etc might result in higher billing per visit, but the “incentivization” as such could better be framed: there isn’t much time in a 15-minute med check slot to do anything other than offer an Rx.
As the husband of a psychiatrist, the real story here is patient expectation: a lot of people don’t want to get a lecture on sleep hygiene; they want a sleeping pill.
I’ve been reading Jim Dahle’s White Coat Investor blog for years. And by “blog” I mean watching the WCI empire grow from blog to book to advertising magnate to website network to now e-course.
The newest WCI endeavor is a video course on the Teachable platform called “Fire Your Financial Advisor.” Because of the site you’re currently reading, I was invited to review the course a couple months back when it was first released. Which means I got it for free. In this case, it also means if you buy it for yourself after clicking that link that I also get a few bucks.
But lest that dissuade you: I don’t think this course is for everyone. Or even most people?
But before we get to the review, there’s a special deal in honor of Match Day:
Instead of the normal $499 for the course, now through Sunday, March 18 (at midnight), the course is $425 and you get a signed copy of The White Coat Investor book thrown in for free. There’s a no-questions-asked 7-day money-back guarantee, so there’s no risk (though no free book until then either). Just enroll here if you’re interested and enter coupon code MATCHDAY18 at checkout.
The WCI course is unsurprisingly like a more interactive and version of the WCI book and website with a lot of video (a good chunk of which is reading from a teleprompter with bluegradient background). Though scripted, the delivery is solid but not flawless. There’s also an audio bug (which they are in the process of fixing) that plays the mono audio as single channel stereo (i.e. it comes out of only one of two speakers). The default speed was a bit slow for me but easy to change, either for the whole course or on a per video basis (I’m always a 2x kind of guy).
The big plus side to this particular course, as opposed to most books and finance websites, is that the lessons include a game plan that once completed will result in a real on-paper financial plan for you and your family such as you would get from an actual financial advisor. Actual financial advisors also cost money, often a lot of money (either upfront or in fees), and thus the big-ticket price for admission here is far more reasonable in comparison. A course like this is an investment in yourself.
The thing about financial literacy is that anyone, and especially a high-income professional, should be literate enough to understand and evaluate the work of their financial advisor. It’s the people that blindly trust their advisors and don’t know what they’re paying for that get fleeced. I don’t care if he’s an old buddy from your fraternity days or your best friend’s neighbor’s cousin. So even if you never plan to spend $499 (or even $425) on a course, you should learn enough to know what’s happening in your financial life even if you ultimately decide to outsource it.
So, the theoretical niche for this product or people who want to become financially savvy and are willing to spend a good chunk of change to guilt themselves into becoming so but thus far have not had the motivation required to read very much on the subject. Sound like you? Read on!
Section 1 is the introduction. Section 2 is mostly background and discussion of how financial advisors get paid. Section 3 is about insurance. Section 4 is about housing. All of these are well covered in the White Coat Investor book.
Section 5 is about my favorite topic, student loans, and is substantially enlarged and updated relative to the old book. Since this is my area of greatest focus, I noticed a few minor factual mistakes: one toss away error is that medical residency does not qualify for the graduate fellowship program deferment. It’s really just forbearance as an option for residents who can’t make payments. It’s also not possible to start making PSLF payments during the last few months in school as he mentions (must be working full time, cannot consolidate in-school status loans). The simplified advice to switch from REPAYE to PAYE when you become an attending is often true but not necessarily great blanket advice, as it depends entirely on if your attending income will break you past the 10% payment cap. Plenty of folks in academics will never experience this problem. And switching from REPAYE to PAYE doesn’t require the same decreased vs. full standard payment as switching from IBR does.
Dahle offers a solid overview of the basics, enough to figure out what your options are, but not necessarily always enough to really evaluate those options. He does cover PSLF well. When it comes to student loans, there are a lot of details. Some may say a whole book’s worth. While the course absolutely gets the big picture right, the bottom line is that the student loan component here probably isn’t worth the price of admission.
Section 6 is “living like a resident” and basic personal finance. Important stuff.
The remainder of the course (Sections 7-12) is really where the class differs from most books and gets you to the point where you should feel comfortable handling your own finances. That’s because Dahle walks you through how to set your goals, make your budget, and even use Excel to crunch your own numbers (which he makes much less intimidating than it sounds). He goes over asset allocation and estate planning. All of this is part of writing your detailed financial plan, which he also walks you through as you go. As in, he helps you do the things your financial planner would sit down with you to do for a lot of money.
This information is not supersecret copyrightable stuff. No one has a monopoly on it, and you can find it in many places in print and online, including on Dr. Dahle’s site and in his book. This course is selling convenience, and most of all, accountability. If you spend $400-$500 on an online course, I imagine you will take it seriously. And that shouldn’t be discounted out of hand. Guilt and shame can be powerful motivators.
That accountability doesn’t come cheap, however, and the kind of person ready to plunk down several hundred dollars for an online video course may also be motivated enough to read some books and fish around online. Of course, with the 7-day guarantee, the unscrupulous learner could take the whole course and then ask for a refund.
Price aside, there’s no denying that the course is well-made and convenient. If you want a doctor-to-doctor one-stop-shop to hold your hand as you go through finally understanding personal finance, then this is it.
While you could go through the videos in few hours, it will take several more to really do the class assignments.
And, if you do, it would be money well spent.
I had known Dr. Lown as a doctor and a patient; now I got to know him as an activist. We agreed that the health care system needed to change. To do that, Dr. Lown said, “doctors of conscience” have to “resist the industrialization of their profession.”