Medical training return on investment

02.07.17 // Finance, Medicine

Some fun (but not new) light reading for those debating whether pursuing medicine was a mistake: UC Berkeley’s Nicholas Roth’s The Costs and Returns to Medical Education.

Overall, of the specialties included, rad onc and radiology topped the scale and endocrinologists bottomed it. The data is from 2009, so some of the assumptions are out of date (as well as pre-dating the imaging reimbursement crunch and subsequent fall in radiology reimbursement, for one). In particular, how student loans are handled makes the data presented significantly less terrible than the reality for some specialties. But it’s still worth reading for several reasons, including:

After Congress passed the 1997 Balanced Budget Act, which capped government payments to hospitals for residents, hospitals added over 4,000 more residents than the government would support. This suggests that market forces are at work as hospitals try to hire residents until the marginal value of an additional resident is zero. It also suggests that hospitals profit from additional residents long after the point when our government stops funding resident education.

I didn’t know that, but it jives perfectly with the narrative all residents believe that hospitals benefit from our cheap labor despite the ludicrous claims that it “costs more” to educate a trainee.

Back to the numbers though, and ultimately, the provided calculated rates of return for the investment in medical school and training is fraught with misleading specificity. Career duration can change the entire calculus (he uses a retirement age of 65). From chron:

Although the overall physician population has grown 188 percent between 1970 and 2008, according to the AMA, the physician population over age 65 has grown by 408 percent in the same period. Economic factors may be keeping many physicians on the job longer, according to data from The Doctors Company, a medical malpractice insurance firm. The company found that the portion of physicians reporting satisfaction with retirement plans has dropped 18 percent since 2006, and the average age at which an internist retired had increased from 62 in 2002 to 70 in 2009.

When considering the costs of becoming a doctor, one must add up the real costs of attending school, lost wages during school, decreased wages during residency, and interest on student loans. Roth uses $36,369.68 as the annual tuition and fees (now it’s probably closer to $47,500 according to the AAMC). He does not count for living expenses, which is fair since everyone’s got to live, but students usually borrow this cost and his treatment of loans is suboptimal. He uses the wages of an intern to approximate lost wages during school (which is probably low for what most doctors could earn in other fields). He uses the average wage of a same-aged person with a college degree to calculate the opportunity cost of not working during school (again, probably low, given that physicians are typically better than average students and likely destined for better than average nonmedical careers overall as well). He also gives us free money:

In 2011, approximately 88.8% of professional degree students received some sort of aid. Of those students, the average aid awarded amounted to $27,500. xxix When weighted, the total aid for all students on average amounts to $24,420 annually.

I know almost no medical students who receive aid anything like that unless we’re grouping student loan “aid” in here. While there are the occasional folks with full rides, most scholarships are small, and most aid given for professional students is actually in non-medicine fields. This probably shouldn’t have made it into the analysis.

I also consider interest payments on student loans. Creditors offer many different types of loans to students, and this makes it very difficult to infer a general loan payment structure. For my purposes, I assume that a typical student accrues $100,000 in interest payments from loans for medical school. I assume that this student pays $5,000 in interest payments annually during the first three years out of medical school and $12,140 annually for an additional seven years.

These sums do not include payments on the original principle; they only include interest payments. These assumptions are similar to a sample repayment schedule presented by AAMC. This repayment schedule assumes an initial Federal Stafford loan of $160,000 dollars with public service loan forgiveness with an assumed $100,000 starting salary after residency

Essentially all loans are DIRECT loans now, but it’s still impossible to handle all loan possibilities with one plan. But this assumes basically a three-year residency followed by PSLF. Given that 44% of graduating students are considering PSLF, assuming that the average doctor isn’t really on the hook for their student loans is misleading. The total loan amount is also now too low, as are the likely annual payments as an attending.

So that’s the dealbreaker. Student loans have changed a lot since interest rates have risen. He assumes no interest payments followed by 100% PSLF adoption, which severely underestimates the cost of attendance to basically 100k even. That’s not realistic for the 60% of doctors who don’t plan to attempt PSLF and would even less useful if PSLF is eventually capped as has been proposed.

It would have been nice to see the payback method used as well (the measure of time to break-even point on an initial investment (it’s intuitive and easier to understand for most folks). But using Net Present Value (NPV) is a great way to present the value of an investment in medical training. Unfortunately, the assumptions are everything: the initial investment cost and the discount rate change the game:

It would seem that the interest payments weigh heavily on the net present values of medical education investments, although these values remain substantively positive.

Specifically, these correlations suggest that physicians receive increases in earnings that overcompensate for the opportunity costs of additional training. This assumes, of course, that additional years of residency and fellowship training result in higher earnings than lesser-trained physicians. The correlation between median earnings and the years of training necessary for the specialties I analyzed, however, is only .4588. While this correlation is significant, it reveals some inconsistencies between further training and earnings. If further training does not result in increased earnings to justify that training, then some physicians may find it profitable to avoid specialization.

Case in point: Infectious disease and endocrinology. You lose three years of attending income only to make less than if you hadn’t specialized in the first place. You are effectively taxed against your academic and clinical interests.

As Roth notes, the assumptions used and the relative costs etc change the number. But in the past several years, the only trend has been more cost to training at overall higher interest rates than were available in the 2000s. This change only exacerbates the cost of choosing a specialty with a bigger duration-to-income ratio.

It’s nice to see a mathematical illustration of what everyone implicitly knows. While Roth’s investment outlook is sunnier than reality, the comparison between different specialties is still relatively meaningful.

The average doctor with average debt is still doing okay. But a doctor choosing a less than average remunerative field with greater than average levels of debt is a different story. That private college + private medical school graduate passionate about rheumatology better be planning on starting their career in academia and hoping PSLF stays just the way it is. The orthopod? They’re just fine.

And if medical schools continue to get more expensive and options for forgiveness are capped, we’re not that far off from the point when some fields will no longer make financial sense at all.

The danger (?) of intravenous contrast media

02.01.17 // Medicine, Radiology

Another study piling on the mounting evidence that at least modern contrast agents put into people’s veins (and not arteries) for CT scans might not be bad for your kidneys after all.

The biggest single center study of EM patients was just published in The Annals of Emergency Medicine, which studied 17,934 patient encounters and compared renal function across 7201 contrast-enhanced scans, 5499 non-con scans, and 5,234 folks with no-CT.

6.8%, 8.9%, and 8.1% were the rates of AKI respectively. As in, folks who received either no contrast or no CT imaging were more likely to have a significant rise in creatinine than people who got contrast. As in, contrast was protective (statistically). Using different cutoff guidelines for AKI, the three were all statistically equivalent.

Practice patterns here still get in the way. Patients with low GFRs are more likely to get fluids prior to receiving contrast, possibly explaining the pseudo-protective effect of contrast. Patients with poor renal function are less likely to get contrast in the first place, reducing the power for evaluating contrast’s effects on those with CKD. However, controlling for baseline GFR didn’t change the story: there wasn’t an increased risk associated with receiving intravenous contrast in this controlled retrospective study regardless of underlying renal disease.

Historically, randomized controlled trials designed to elucidate the true incidence of contrast-induced nephropathy have been perceived as unethical because of the presumption that contrast media administration is a direct cause of acute kidney injury. To date, all controlled studies of contrast-induced nephropathy have been observational, and conclusions from these studies are severely limited by selection bias associated with the clinical decision to administer contrast media.

Maybe with all this mounting evidence it’s time to do an RCT.

CFPB sues Navient (even the feds aren’t happy with their own student loan servicers)

01.21.17 // Finance

The Consumer Finance Protection Bureau is a nonpartisan government agency that was created after the 2008 financial crisis to help protect us from evil banks, credit card companies, predatory lending practices, etc.

They announced this week that they’re suing Navient, the biggest federal (and private) student loan servicer for defrauding borrowers and being generally terrible.

You may or may not really know or care about loan servicers, but they’re the middlemen who send you emails about making payments and take your money. Even when you take federal loan money, most people end up shuttled to one of the several private servicing companies who manage the payments. It should come as no surprise that handling that money is profitable and that unsavory companies stand to profit more if people send more money their way.

In short:

The Bureau alleges that Navient has failed to provide the most basic functions of adequate student loan servicing at every stage of repayment for both private and federal loans. Navient provided bad information in writing and over the phone, processed payments incorrectly, and failed to act when borrowers complained about problems. Critically, it systematically made it harder for borrowers to obtain the important right to pay according to what they can afford. These illegal practices made paying back student loans more difficult and costly for certain borrowers.

When people talk about trying to do clever (or even sometimes simple) things with payment timing or distributing loan payments, this is exactly why I would be hesitant to encourage them. It makes great sense to try to have extra payments go toward loans with the highest interest rate (and it’s still worth it). It makes sense to make extra payments in REPAYE while earning the interest subsidy to get the best of both worlds by getting free government money while also paying down your debt as aggressively as possible (and probably not worth trying, I’d argue). It makes sense to talk with your servicer to get information about your options and make sure everyone is on the same page.

The problem is that the servicers aren’t good at servicing your debt.

I’m concerned enough about the servicers doing the basics of applying IDR-based interest subsidies for borrowers in general, and they purposely make it difficult to confirm what’s happening on their end by poorly if ever demonstrating this information on loan statements, even while they promise “they’re there” when you call. I’m deeply suspicious of any plan that involves the servicers working in borrowers’ best interests.

I’ve spoken with multiple residents steered away from the REPAYE plan through misinformation into IBR or PAYE. I don’t know how much is malfeasance or just incompetence—the people on the phone are customer service reps, not experts—but it’s nonetheless one of the downsides of having a complex convoluted federal system that even the people charged with handling it are unclear as to how to implement its policies.

Incrementalism

01.17.17 // Medicine

Atul Gawande with another fun New Yorker feature on The Heroism of Incremental Care:

Rescue work delivers much more certainty. There is a beginning and an end to the effort. And you know what all the money and effort is (and is not) accomplishing. We don’t like to address problems until they are well upon us and unavoidable, and we don’t trust solutions that promise benefits only down the road.

Incrementalists nonetheless want us to take a longer view. They want us to believe that they can recognize problems before they happen, and that, with steady, iterative effort over years, they can reduce, delay, or eliminate them. Yet incrementalists also want us to accept that they will never be able to fully anticipate or prevent all problems. This makes for a hard sell. The incrementalists’ contribution is more cryptic than the rescuers’, and yet also more ambitious. They are claiming, in essence, to be able to predict and shape the future. They want us to put our money on it.

But our free-market insurance only wants to pay for 15 minutes of it, of course.

As an American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room. Incrementalists are lucky if they can hire a nurse.

and

The difference between what’s made available to me as a surgeon and what’s made available to our internists or pediatricians or H.I.V. specialists is not just shortsighted—it’s immoral.

When people think about rationing care, they talk about rationing care to people. About grandma not getting a pacemaker or a new hip. They speak disparagingly about Canada or the UK. What people don’t realize is that we also ration care internally within medicine. We just do it based on RVUs.

Then, at the end, he finishes with some jabs at half-baked plans to repeal the ACA and a powerful somber note:

In this era of advancing information, it will become evident that, for everyone, life is a preexisting condition waiting to happen.

How to submit PSLF employment verification

01.09.17 // Finance

The general approach for PSLF is succinctly summarized here. In order to qualify, you’ll need to prove you were gainfully employed at a qualifying institution for 120 payments. That means you’ll need to account for 10 years of working life. The Feds recommend you certify your employment every year, which sounds like a pretty good idea if you ask me (there’s a lot of money at stake here, after all). At the least, you should get a form filled out at the end of your tenure at any institution (preliminary/transitional intern year, residency, other jobs, etc.). You don’t want to be asking random people to look back at employment records buried in some offsite file cabinet from your intern year 9 years ago when it comes time to file for forgiveness. It’s asking for trouble.

The steps are simple:

Download the Public Service Loan Forgiveness Employment Certification Form.
Fill it out. It’s extremely straightforward. Mail, email, or fax it to your former or current employer.
Wait to get it back.
Get it back.
Send it to FedLoans, the official servicer of the federal government (address is on the form).
Fedloan processes the form. If you are not currently serviced by Fedloan, your loans will be transferred from your current servicer. If you already consolidated, you’re probably with Fedloan already. Whether a new development or not, Fedloan will process your forms and update the “qualifying monthly payment” count based on the months of qualifying payments matched to months of verified employment.
Rinse and repeat. Again, it may be beneficial to resubmit annually, but at the least, it’s a good idea to submit an employment verification form after moving on from each qualifying job. A) Paperwork only gets harder over time and B) You want to make sure everything is on track and Kosher before making any more financial decisions that might be based a misunderstanding of where you stand currently on the PSLF track.
After you make that 120th payment, send in the final form. Unless the government has swindled you in a truly magnificent way, get ready to see something magical.

The Calm Company

01.06.17 // Medicine, Miscellany

Amidst desires for simultaneous growth, quality, profit, and patient satisfaction, the delivery of healthcare has gotten more…complicated. But the disconnect between the powers that be and the providers who actually work on the ground has turned work for big hospitals and institutions into something increasingly more like working for a big widget factory.

Spurred by rising costs, healthcare in the US has felt the need to “catch up” with the “best” business practices. Have more meetings. Look at more processes. More management. More managers for the managers we just hired.

A few bits from the intro to the forthcoming book, The Calm Company, on Signal v. Noise, the blog from 37Signals (the company behind the team management software Basecamp):

Work claws away at life. Life has become work’s leftovers. The doggy bag. The remnants. The scraps.

You’d think with all the hours people are putting in, and all the promises of tech’s flavor of the month, the load would be lessening. It’s not. It’s getting heavier.

Technology has been used to add capacity, not to improve workflow. As an example, MyChart is a great tool that allows patients to communicate with clinics and providers without calling repeatedly or making an appointment just for a routine refill or to answer a simple question. But you don’t get paid to answer MyChart messages. They’re added on to your workload. The more you’re willing to meet patients where they are and do things on MyChart, the more unpaid work you do and the more time and energy you lose. That’s a system flaw. This is part of why the average physician spends 1-2 hours at home charting daily. More uncompensated time.

Crazy companies all tend to be especially great at one thing: wasting. Wasting time, attention, money, energy.

The answer isn’t more hours, it’s less bullshit. Less waste, not more production. And far fewer things that induce distraction, always-on anxiety, and stress.

I am routinely impressed at how good healthcare systems are at wasting dollars to save cents. Skimping on cheap patient transporters so that highly paid specialists sit around waiting for the next case to start and then run overtime. Understaffing clinic nurses and MAs, leaving the physicians to deal with more phone triage and data entry. The money in some cases comes from different pots, which sometimes allows departments to seem more profitable or efficient than they really are.

Hospitals make changes like real enterprises do but mostly without the critical reflection to see if process improvements are actually improvements. We tokenize quality through small projects to avoid dealing with foundational infrastructural failures—because those are actually hard.

On-demand is for movies, TV shows, and podcasts, not for you. Your time isn’t an episode recalled when someone wants it at 10pm on a Saturday night, or every few minutes in the collection of conveyor belt chat room conversations you’re supposed to be following all day long.

Employer verification: the lynchpin of PSLF

12.30.16 // Finance

The week of Christmas, the NYTimes published a story about people who anticipated their loans being forgiven this year with PSLF and are now in the midst of a legal battle instead.

The suit, filed in United States District Court for the District of Columbia, says some borrowers received approval on their certification forms, then, years later, the entity servicing their loans reversed course, effectively ousting them from the program.

It did so retroactively, meaning that none of the previous loan payments counted toward the 120 payments needed to qualify for forgiveness. So if the borrowers took a job that qualified, they would have to start again with accumulating the payments.

The silver lining is that—though not 100% clear from the article—it appears these denials were all for jobs that were not 501(c)(3) non-profits. They were for other non-501(c)(3) non-profit jobs, which only count toward PSLF when they provide certain types of qualifying public services and are approved on a case by case basis. I have no doubt there are doctors who are planning on PSLF that will find themselves shocked and disappointed by technicalities, but so far there’s no evidence that the usual employment catchalls (government or 501(c)(3) organizations) for PSLF will be spontaneously denied.

These are eligibility criteria for PSLF-eligible employers:

Government organizations at any level (federal, state, local, or tribal)
Not-for-profit organizations that are tax-exempt under Section 501(c)(3) of the Internal Revenue Code
Other types of not-for-profit organizations that provide certain types of qualifying public services and must not be a business organized for profit, a labor union, a partisan political organization, or an organization engaged in religious activities.

Qualifying public services include:

Emergency management
Military service
Public safety
Law enforcement
Public interest law services
Early childhood education (including licensed or regulated health care, Head Start, and State-funded pre-kindergarten)
Public service for individuals with disabilities and the elderly
Public health (including nurses, nurse practitioners, nurses in a clinical setting, and full-time professionals engaged in health care practitioner occupations and health care support occupations, as such terms are defined by the Bureau of Labor Statistics)
Public education
Public library services
School library or other school-based services

So, it is the private nonprofits offering “qualifying” services that are the category at greatest risk for being denied. If your job isn’t a 501(c)(3) but “should” qualify, submit your employment verification forms annually to prevent wasting your time and money planning for forgiveness that may forever remain out of reach.

What I read in 2016

12.26.16 // Reading

The little one is a bit older and I had marginally less call this year, but I also had to take the boards in June, so reading time definitely benefitted from the flexibility of ebooks on the phone and the magical powers of Audible. Overall, it was a better reading year than 2015.

The Etymologicon by Mark Forsyth (fun language romp)
Stoner by John Williams (quiet, understated, lovely)
The Buddha Walks into a Bar by Lodro Rinzler
The Fault in Our Stars by John Green (of course I cried)
Corsair by James L. Cambias
The Sixth Extinction by Elizabeth Kolbert (Pulitzer winner)
The Rolling Stones by Robert A. Heinlein (1970s sci-fi, not the band)
The Bogleheads Guide to Investing by Mel Lindauer, Taylor Larimore, and Michael LeBoeuf
Water for Elephants by Sara Gruen
The Terrible and Wonderful Reasons Why I Run Long Distances by The Oatmeal
Calamity by Brandon Sanderson (The Reckoners #3)
Medical School 2.0 by David Larson
Pay Yourself First by David Hurd and James Hemphill
Changing Outcomes by David Hurd and James Hemphill
The Cartel by Don Winslow (incredibly gruesome but so good)
Physician Finance by KM Awad
A Doctor’s Basic Business Handbook by Brandon Bushnell
The Year They Tried to Kill Me by Salvatore Iaquinta (to me, the new House of God)
So You Got Into Medical School…Now What? By Daniel Paull
Why Medicine? By Sujay Kusagra
Broadcasting Happiness by Michelle Gielan
Bream Gives Me Hiccups by Jesse Eisenberg
The Alloy of Law by Brandon Sanderson (Wax & Wayne #1)
A Tale of Two Cities by Charles Dickens
Dimension of Miracles by Robert Sheckley (audiobook perfectly narrated by John Hodgman)
The Beautiful Struggle by Ta-Nehisi Coates
My Year of Running Dangerously by Tom Foreman
What They Don’t Teach You at Medical School by Dr. David Kashmer (still feel like that’s the wrong preposition in the title…)
What if? by Randall Munroe
Shadows of Self by Brandon Sanderson (Wax & Wayne #2)
The Jungle by Upton Sinclair (so depressing)
A Little History of Philosophy by Nigel Warburton (this was surprisingly fun)
The Earth Moved by Amy Stewart (apparently earthworms are really important)
Drinking Water by James Salzman (really wanted this to be like Kurlansky’s Salt or Cod, but it wasn’t anywhere near as good)
The Ocean at the End of the Lane by Neil Gaiman
The Marshmallow Test by Walter Mischel
Diet Cults by Matt Fitzgerald
The Hunt for Vulcan by Thomas Levenson (long before we demoted Pluto, we used to think there was a hidden planet Vulcan. Weird!)
Rejection Proof by Jia Jiang
The House of Wigs by Joshua Allen
The Bands of Mourning by Brandon Sanderson (Wax & Wayne #3)
The Emperor of Maladies by Siddhartha Mukherjee (well-deserved Pulitzer winner)
Bricking It by Nick Spalding
The Gene by Siddhartha Mukherjee (between the two, Emperor is better)
Harry Potter and the Cursed Child by J. K. Rowling
The Element by Ken Robinson
The Thirteen Word Retirement Plan by Stephen Nelson
Student Loan Debt 101 by Adam Minsky
The 4 Percent Universe by Richard Panek
Simple Sabotage by Robert M. Galford, Bob Frisch, and Cary Greene (the pdf of the CIA’s declassified original field manual that inspired it is better).
As You Wish by Cary Elwes
Mistborn: Secret History by Brandon Sanderson
The Emperor’s Soul by Brandon Sanderson (Huge winner, great novella)
The Medical Entrepreneur by Steven M. Hacker
Breakfast of Champions by Kurt Vonnegut
Born Standing Up by Steve Martin
The Alchemist by Paulo Coelho (just lovely)
Words of Radiance (Stormlight Archive #2) by Brandon Sanderson
The Wealth of Humans by Ryan Avent (smart writing about technological innovation and societal change)
TED Talks by Chris Anderson
Medium Raw by Anthony Bordain
Animal Farm by George Orwell
Born a Crime by Trevor Noah (was really great as an audiobook)
How to Think About Money by Jonathan Clements
When Breath Becomes Air by Paul Kalanithi
Ready Player One by Earnest Cline (fun homage to classic video games and 80s culture masquerading as a novel)
The Rest of Us Just Live Here by Patrick Ness

Classics I visited included a Tale of Two Cities, The Jungle, and Animal Farm, which were all super depressing. I continue to wonder why I read any of the pop-psych/inspirational/self-help type books given that they are all approximately the same and should nearly always be an essay or two and not drawn out to book length. I also read a bunch of short finance, med student, and doctor books for research/blog purposes, which were almost all meh.

On the fun side, I did catch up on most of Brandon Sanderson’s books while waiting for Patrick Rothfuss and George RR Martin to finish their next books. Now I have to wait for Sanderson’s third Stormlight book as well, which won’t come out for another year (and the last book in Mistborn Era 2 is like two years away).

Did love The Alchemist though. Just a beautiful, lovely little story. And every doctor should read The Emperor of Maladies.

Study shows women are still better at everything

12.20.16 // Medicine

Yesterday in JAMA:

We found that elderly patients receiving inpatient care from female internists had 30-day lower mortality and readmission rates compared with patients cared for by male internists. This association was consistent across a variety of conditions and across patients’ severity of illness. Taken together with previous evidence suggesting that male and female physicians may practice differently, our findings indicate that potential differences in practice patterns between male and female physicians may have important clinical implications for patient outcomes.

and

Furthermore, given that there are more than 10 million Medicare hospitalizations due to medical conditions in the United States annually and assuming that the association between sex and mortality is causal, we estimate that approximately 32 000 fewer patients would die if male physicians could achieve the same outcomes as female physicians every year.

Confirmation bias aside, this general finding does ring true to me.

Reading a bit deeper, though, one physician characteristic that was underplayed was that female physicians saw fewer patients overall (i.e. more were part-time). This might function as a proxy for burnout and its associated poor patient care outcomes. Something to consider for the men who are already in medicine and dragging it down.

When breath becomes air

12.12.16 // Medicine, Miscellany

I actually posted this excerpt once before, but I just finished Paul Kalanithi’s When Breath Becomes Air and was moved anew by his missive to his infant daughter:

When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

Earlier in the book, in conversations with his oncologist about coming to terms with how to spend his life with cancer, this entreaty comes up multiple times:

Find your values.

In his moving memoir (which doesn’t at all belittle fields like radiology), Kalanithi softly and compellingly argues that this is the key to how you live like you were dying.