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A 280-character Twitter is stupid

11.09.17 // Writing

A lot of people place their hopes on tech companies to save the planet and make literally everything better. At least the tech companies like to pretend they will.

And then you realize how silly so much of it is and how poorly run many of these companies truly are, with so many of them desperately scrambling for their share of our attention paid via advertisements and tracking which we collectively despise.

Twitter is not as big as Facebook and will never make as much money. They don’t have as much data about you as an individual and thus cannot target you for ads with the same gusto. The growth solution, from Twitter’s thinking, is that the 140-character limitation is really holding the service back.

To the contrary, the 140-character limitation is probably Twitter’s only unique selling proposition. Twitter with longer tweets is just like a Facebook newsfeed with more strangers and fewer actual friends. The brevity and speed have been an integral part of the service since its inception. While the original limit was due to the technical limitations of text messages, it nonetheless became part of the character of the service (see what I did there?). It’s definitely a pro/con, but it is unequivocally a true differentiating factor. I’m sure this has been tested and debated for months if not years, but that doesn’t mean it’s the right long-term decision. Platform growth and health don’t always align. MySpace was doing “great” for a while too.

I wrote little stories crammed into tweets every day for over 7 years. 1This is weird, I know. I started one of a handful of publications that feature and even pay authors for tiny stories that fit in a tweet.

For me, the constraint has always been the whole point.

Nanoism will always have a 140 character limit. Constraint is the USP of the platform. We’re not a Facebook publication for a reason.

— Nanoism (@nanoism) November 9, 2017

This isn’t to say someone couldn’t start a compelling 280-character limit fiction venue, but would it really be Twitter fiction? Twitter was inspiring as a creative venue for the same reason that people enjoy (if are also occasionally aggravated by) the linguistic acrobatics required to fit their thoughts into the short form. It’s challenging and often surprising.

Of course, I will fully admit that most of the 140-grumblings surely come from longtime users with emotional attachments, particularly writers. I don’t doubt that most people will be able to simply say what they want to say more easily with a longer limit, and that such engagement may—potentially—lead to more usage and advertising revenue.

But I’ll leave it to John Dingell (91-year-old former Congressman from Michigan):

99% of you people don’t even deserve 140 characters.

— John Dingell (@JohnDingell) November 7, 2017

See? No constraints and this post is way too long. Which is another way of saying that @nanoism will always have a 140-character limit.

SmashUSMLE

09.30.17 // Medicine

Longtime readers know that I don’t do ads, guest posts, or push products. I do however share a coupon or referral code or two for something people might actually want if it results in someone saving money (and not just me making a few bucks).

Which brings us to SmashUSMLE. The bottom line is that if you’re interested, the coupon code BW10 saves you 10%.

I don’t think most people need to be interested at this point.

While SmashUSMLE has Step 1 and Step 2 CK qbanks, it’s essentially billed as a curriculum-replacement tool with hundreds of hours of video lectures. It’s got all the trappings: It has the FRED qbank software. It has accelerated video playback options. It has a phone app.

It’s competing with pricey options like DIT and Kaplan. And while it’s cheaper than both of those, it still costs a fortune ($395 for 1 month, $795 for 3 months). There is a 15-day free trial, however, so if you were planning on doing an expensive course, you wouldn’t lose anything by trying. 15 days is actually a really generous trial; you could get a lot of value for free if you remember to cancel it if you don’t think it’s worth the dough. The solo qbank product option is cheap ($59.99 for a month), but the competition on that front is really stiff.

From my brief review sampling, the qbank lacks polish. Questions use the clinical vignette format but do not ape the USMLE house-style particularly well. A UWorld replacement it’s not.

As for the videos, I would never ever personally be interested in buying a video course, so my intrinsic bias probably precludes a fair assessment. Like DIT, they follow First Aid. The style is pure casual whiteboard—like a friend trying to teach you in a room in the back of the library—which I imagine is nice and approachable for students feeling overwhelmed. But, again, these felt a bit on the unpolished side of the spectrum. I’m not sure I could imagine spending the 100+ hours it would take to watch them all even at 2x speed. The free sample online is representative, so you can make your own decisions.

 

 

Department of Education decides that loan holders aren’t really consumers and that students don’t need protection

09.23.17 // Finance

Last month Betsy DeVos’ (Trump’s) Department of Education ended their cooperation with the Consumer Finance Protection Bureau, because, you know, the CFPB was “overreaching” in trying to actually protect student loan borrowers.

Shocking that the same DOE that wanted to consolidate the entire servicing industrial complex into one giant government contract with a shortlist that included a company currently being sued by the CFPB for defrauding students would now be cutting ties with the agency charged with dealing with exactly this kind of detritus.

Best Small Fictions 2017

09.22.17 // Reading

Got my contributing editor’s copy of The Best Small Fictions 2017 in the mail the other day.

Nanoism had another finalist this year, to accompany our finalists and winners from 2015 and 2016. Great little collection of very short stories.

Surprises All Around

09.20.17 // Radiology

A VA branch is under investigation for poor quality radiology care (and for firing the whistleblower in retaliation):

As many as four to five times a day, Leskosky said, he found serious errors in prior readings, despite just four other radiologists being on staff. In one particularly egregious case, a radiologist missed a 17-centimeter tumor in a patient’s pelvis.
…
In private practice, radiologists may miss key findings once or twice in a lifetime, Leskosky said.
…
A large part of the problem, Leskosky said, is some of the other radiologists on staff were flipping through 50 to 60 patient scans a day, instead of the industry recommended 25 to 30 and, as a result, missing critical findings.

Losing a 17-cm tumor is a pretty aggressive miss, but 1) people in private practice absolutely miss a key finding more than once or twice per lifetime and 2) there is no “industry” to recommend a work-level (let alone one that’s used in practice).

Firing the whistleblower, however, is a pretty egregious no-no, and I’m pretty sure I’ve done some online modules at the VA about that being against the rules.

All said, the “industry” does need better PR though, because there are a lot of radiologists in practice who would love to read just 25 cases a day.

The Single Student Loan Servicer That Wasn’t

08.31.17 // Finance

InsideHigherEd on the rapidly abandoned plan to consolidate all student loan servicing into a single monolithic “too-big-too-fail” mega contract:

DeVos has taken heat since May from members of Congress and representatives from the loan-servicing sector over the plan to pick a single servicer that would hire subcontractors to collect loan payments. Department officials at the time argued that the plan would make oversight of servicers by the government more efficient.

But the proposal found critics among both Republicans like Senator Roy Blunt of Missouri, who argued that the system would remove choice and competition, and Democrats like Massachusetts Senator Elizabeth Warren, who warned against creating a federal contractor “too big to fail.”

Blunt and Warren were part of a bipartisan group of senators who introduced legislation ahead of the department’s announcement Tuesday to block the single-servicer plan. Their bill would instead require the participation of multiple loan servicers.

Instead, 2019 will still see the consolidation of the different servicer websites to a single portal that interacts with the borrowers (which was the original Obama-era plan already in motion). Everything else will remain separate. How that will happen basically remains a mystery, but the site itself will be developed and managed by the Office of Federal Student Aid.

Hopefully, they don’t take any tips from Navient, because their website is singularly terrible.

Medscape resident survey, embarrassingly interpreted, again

08.28.17 // Medicine

Medscape’s newest resident compensations survey is out and discussed in “Most Residents Say They Deserve Big Raise, Survey Shows.”

The main thrust is fine, discussing that today’s residents feel more underpaid than generations past, which is no surprise given the proliferation of mid-levels who work alongside them making considerably more (and likely combined with the envy caused by their better-off friends parading happily on social media [when #YOLO, #FOMO can be devastating]).

But then this:

Resident salaries in 2017 vary considerably by specialty. Trainees in hematology lead the pack, at $69,000, while family medicine residents bring up the rear, at $54,000.

The gender gap in resident pay is negligible. Men averaged $57,400 or 1.2% more than women, who received $56,700.

Ugh. Who writes up these Medscape survey articles? I even wrote about the same misleading fake resident gender pay gap back in 2014.

To summarize:

All trainee salaries are based on PGY year and location. There are absolutely no differences between specialties or genders of trainees of the same seniority. Any differences are related to the differing duration of training between specialties as well as the geographic spread of the relatively small sample.

Ultimately, any attempt to differentiate annual salaries by specialty is intrinsically misleading. Any differences that can be created between genders or specialties are simply reflective of different numbers of respondents at different levels of seniority within the PGY scale. The difference between a family practice resident and a “hematology resident” is that almost every family medicine resident finishes in three years while any hematology fellow will be at least a PGY4 or higher. The fact that hematology “led the pack” and not—let’s say—cardiology or gastroenterology just means of the respondents of the survey, slightly more senior hematology fellows answered compared to their other IM-fellowship peers.

There is a real gender wage gap in medicine, but it does not apply to residency. As I discussed almost exactly three years ago, any differences in gender pay during training are related to the known disparities in gender representation among certain fields, particularly surgical specialties (which have longer training lengths and thus get “paid more”). Now, if we want to talk about the “gender surgeon gap,” that would be a different and worthy story. Because there are fields in which women are underrepresented—that’s the story when it comes to residency. Not a misinterpretation of the statistics.

This sort of willfully misleading interpretation has no place on a website that caters to physicians. Medscape should know better. And, reading some of the comments suggests that some readers (primarily the nonphysicians) do latch on to these “differences” despite simply being a distraction from the real issues at play.

Mammogeddon 2017: The Conclusion?

08.05.17 // Radiology

From the ABR’s July 19 email:

Some of you are wondering why it has taken so long for the ABR to provide a solution. We apologize for the delay as we know this has been stressful for you. More than 450 candidates were affected by this situation. The cause of the problem was not initially apparent, and it was important for us to have time to investigate, review preliminary scores of all candidates, obtain direction from our board members and some program directors, and devise a solution that was most appropriate for all stakeholders, including you, your program, and your patients.

The ABR board also received input from the breast imaging community, which feels it is imperative for residents to be tested on breast content at some point in the certification process. The board members considered requiring a breast module on the Certifying Exam for those who did not receive the module on the Core Exam. However, all were concerned that more than two years of delay would require you to study again for the breast module.

The board feels strongly that we must administer the content as soon as possible, and that we should not require travel, other expenses, or additional resources, which is aligned with what we have heard from the breast imaging community. Therefore, we decided that we should trust you to take the online module in a setting of your choice. In addition, the breast module has been carefully edited to ensure that all findings are visible without the need for a high resolution monitor.

[…] We will schedule residents who need to take the breast imaging module at specific times on two dates: September 7 and September 18, 2017. You will select your desired start time when you register.

Still missing: what actually happened in Chicago, what the technical glitch was, how they’ve taken steps to prevent this from happening again, how this module is graded, how “hard” it will be to pass, if it’s actually possible to fail, and a finally—what happens if someone actually manages to fail.

It is interesting that you can take it anywhere you want but that you still must take it at specific times—presumably a compromise to prevent cheating/sharing of the exam content without resorting to using an official testing center. The real exam is proctored with a bathroom monitor, but the fabled mammo content is on the honor code. To me, this is highly suggestive of lip service to an apparently deeply hurt mammography community.

And, speaking of testing centers, the ABR recently released the following narrative about why they haven’t been able to disseminate the exam:

These delivery requirements have proven to be insurmountable obstacles for the numerous commercial testing vendors that we’ve engaged over the years. It’s important to remember that the vast majority of these vendors’ clients deliver text-based question exams with little or no multimedia content.

[…]

Just last year, we engaged two prominent commercial testing vendors to explore our goal of delivering the diagnostic radiology initial certification exams at local testing centers. Both vendors were given in-depth details of our exam delivery needs and asked to provide a proposal for our consideration […]

…but neither was interested.

I like that they’ve finally publically responded to these perennial requests.

I imagine these two were Prometric and Pearson VUE, because (despite the claim of “numerous” vendors) there are only a handful of large commercial testing centers around that could possibly furnish the exam. I suppose it’s possible the big two passed in years past. I have no doubt that the ABR’s demands for administration are not worth the time and expense for most vendors to meet given the low exam volume. The follow-up question, however, is whether or not it’s possible to write a Core exam that can be disseminated.

For example, the video portions of the exam are small in number and generally useless outside of cardiac MR (which, if we’re being honest, plays a comically outsized role on the test). The multi-slice scrolling capacity is rarely used and usually only a handful of images anyway. Mammo and radiographs could be selected that do not require high-resolution high-filesize images. The ACR in-service exam, of note, was able to snag a contract and is also image-based.

We are committed to making the initial certification process as facile as possible. While our past efforts have not been successful, we will continue to pursue our goal (and your wish) of delivering diagnostic radiology exams in local commercial testing centers. As we all know, technology is constantly evolving, and perhaps local exam delivery will become more feasible in the future.

I don’t doubt that the exam the ABR created couldn’t be ported to Prometric as is. Shucks, it didn’t even work in Chicago. But couldn’t we have a Core Exam that was functionally equivalent but wasn’t so off-putting? Exams need to be written with the administration in mind from the onset, not just as an afterthought.

Perhaps putting our hopes in the possibility that bandwidth and memory will be so cheap one day that testing companies won’t find our poorly written and conceived exam so unpalatable isn’t the best plan.

Switching from REPAYE to PAYE after residency

07.29.17 // Finance

From a reader:

Incoming PGY1. Your posts are tremendously helpful! My question is, why aren’t all residents (or at least the majority) doing REPAYE and then switching to PAYE at the end of their training? I feel like I am missing a key pitfall or something. Is it a pain in the ass to switch? Are new residents scared they will not be able to switch? Or is this just information not everyone has? I understand some people are not eligible, have a large spousal income, have private loans, etc etc…But just wondering why this isn’t a more ‘popular’ way to go about it?

Both REPAYE and PAYE calculate payments based on 10% of your discretionary income. But because PAYE monthly payments are capped at the amount that would be due for the standard 10-year repayment, PAYE payments can be lower than REPAYE payments for high earners. PAYE also allows for the married-filing-separately loophole that REPAYE closes.

The first thing we do as human beings when considering any big important action is to look around and see what everyone else is doing. (One imagines that, overall, this is a helpful survival mechanism.)

The downside to this approach is when the crowd is wrong. Or, when the crowd is right, but you’re different in some critical way.

So, the first/main reason people aren’t all switching from REPAYE to PAYE? They haven’t had a chance to yet.

Reason 1: Too Fresh

The switch probably will be popular over the next few years, but REPAYE is still pretty much brand new and a lot of current residents who should be aren’t on it. It was released at the end of 2015 (which is mid-cycle for almost everyone’s annual recertification), so really only students graduating in 2016 (i.e. new PGY2s) even had the option to pick it when they first selected a repayment plan.

Reason 2: Too Mislead

Another reason is that even for the more industrious residents who considered switching when it came time for their annual recertification, it seems that a lot of servicers have been misleading borrowers about the ability to switch out. For example: Yes, you can switch back from REPAYE to IBR or PAYE or even Navient is still lying to borrowers despite lawsuit.

Reason 3:  Too Ignorant or Lazy

Most borrowers choose and set-it and forget-it strategy to student loans, which means that they don’t critically re-evaluate their decisions or maximize their strategies. I’d like to think most people fall into the reason #1 camp, but the reason #3 group is one of the reasons why I wrote a book about it. A lot of folks are just lost.

Reason 4: They Actually Don’t Need To

A final big reason is that many borrowers won’t benefit from switching to PAYE: it depends on what happens after training. Switching only makes sense if you’re trying to minimize payments for PSLF. Otherwise, having smaller payments just means paying more over the life of the loan. Additionally, the accrued interest will capitalize, which is not relevant for PSLF but is for everyone else. For PSLF purposes:

And even for those PSLF-bound:
– A lot of people don’t need to. It isn’t that easy to break past the pay cap for a lot of docs. Thus, if you’re single, have a non-working spouse, or have a spouse with a similar debt to income ratio, PAYE isn’t going to make a big difference unless you are in a high paying specialty. There are definitely attendings who will continue to earn a REPAYE interest subsidy throughout their 10 years of qualifying payments, even with spousal income (particularly heavy borrowers).
– Similarly, depending on their spouse, many won’t gain enough in lower payments by filing separately to offset the tax penalty of switching to PAYE in order to file taxes separately worth it.

The real take home

As you approach the end of training, it’s time to sit down and make your real repayment plan. You may have been in REPAYE because it was the no-brainer choice while in training, but now—with a new job and a salary increase on the horizon—you’ll have the information you need to figure out if you should stay the course, switch to PAYE or IBR, or prepare to refinance privately.

How I wrote my second book

07.23.17 // Writing

I published my second book a little over a month ago. It took about 11 months from conception to release, clocks in at around 45,000 words, and the bulk of the first draft was written (actually dictated) on my iPhone using Siri and an app called WorkFlowy. A significant fraction of that was “penned” walking down a quarter-mile long sky-bridge that attaches the decrepit parking garage I park in to the hospital I work in, which I typically traversed a few times a day as a resident.

 

 

(Mmhmm, dictation errata.)

The workflow basically went like this: dictate fragments and ideas while walking. Lots of them.

Some of these started off as headings and things to cover later in further detail ( especially those parts that require crunching numbers). Other parts were fully fleshed out (sometimes with placeholders for the data I didn’t have offhand). Back at my computer, I intermittently organized these entries into categories using the browser/web-version of Workflowy.

Workflowy—which is a note-taking/outlining/list-making platform—is perfectly suited to this because it allows for an endlessly large and endlessly nested hierarchal outline. (It’s a freemium app; it’s free but you can pay for upgraded features. That link is a referral that doubles the number of list items you can add per month. Using that would add to my maximum as well, but I already have more than I need). I use Workflowy for basically everything I write: post ideas, drafts, quotations, rapid to-do lists, etc. You can expand and collapse different levels of the outline with the click of a bottom and drag/drop to reorganize elements on the fly. It’s basically frictionless.

So, I spitballed the first half of the book based on a latent outline I had in my head and the topics I knew I would need to cover. Once I had some volume on paper [sic], I went back in and plotted out the chapters I would include and then nested everything I had already written in their proper locations. I had approximately 10,000 words dictated before I organized all these fragments into chapters. The outline format makes it easy to generate new content and then filter and clump it together in batches, so then I knew where the gaps were.

As I got the core content done and it was time to synthesize the disparate elements, flesh out certain paragraphs and arguments, etc, I then transferred the whole outline into Ulysses: the only distraction free writing environment I’ve ever used meaningfully (I also wrote my Texas JP exam book in it). Ulysses allows you to create a smart-folder with multiple separate text documents (“sheets”) in it while displaying them all in a sidebar on the left. So I transferred all the primary chapters into their own sheets within this larger group. Then I begin the process of fleshing out the writing, fixing innumerable dictation errors, adding examples, figuring out all the data I needed, crunching the numbers, and trying to limit repeating myself too much (it’s easy to have an epiphany and dictate what you think is an amazing well-argued point only to realize you’ve already said it twice).

 

 

The Ulysses’ sheet system allowed me to keep all my chapters in separate places to move effortlessly back and forth between them, keeping the format simple with Markdown instead of the usual poorly-implemented Word styles (this is particularly helpful when trying to format e-books, as well as preventing me from wasting my time fiddling with formatting when I should be writing). Ulysses isn’t great for complex data like tables, so as a consequence, those had to wait until the final push. When I was done writing, I exported the whole thing into Microsoft Word for the final additions, table of contents, etc.

The folks who make Ulysses finally released a fantastic iOS version during this process, which I could theoretically use for my next project from the very beginning. The mobile app is a separate purchase but well worth it. Once I move a project into Ulysses, I can now edit it on my phone or on my computer and the iCloud sync works perfectly every time. But I’ll probably still use Workflowy for the initial draft; it’s just so flexible that nothing I have beats it. On the other hand, I’m slowly revamping my “Guide to Fourth Year” and doing it on straight on Ulysses (because I had the initial drafts already written from the old blog posts).

Ultimately, Medical Student Loans: A Comprehensive Guide was a bit scarier to write in some ways than my first book. The JP book was in some ways straightforward: distil a large amount of known boring material into a reasonable amount of condensed material with the hopefully right balance of precision, clarity, concision, and humor. I knew there was a small but underserved market of people (i.e. all physicians who need a Texas license), and I felt that there were several workable but no good options.

No one needs a student loan book. There is no mandatory test. I’m competing with a bunch of free websites and a few mostly crappy books that I am confident no one is actually buying or reading. The vast majority of these don’t tailor well to doctors, but enough cover the issues well enough such that a dedicated person can learn enough in a couple hours to feel like they can (in many cases correctly) make reasonable decisions.

All that said, I believe strongly that more young docs and docs-in-training need the material in this book. Many if not most graduating students don’t understand their loans or even have the basic financial literacy foundation to make sound decisions about them (or any other financial decisions for that matter). That is why I wrote the book, and I’m glad I did!

Overall, it was a big fun project that took way longer than I’d planned. On to book #3!

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