Ben White

2:1

09.09.16 // Medicine

For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.

That is the conclusion of a paper just published in Annals of Internal Medicine.

Outpatient doctors spend at least twice as long proving they provide medical care for billing and compliance purposes as they do actually providing it. “To Err is Human” is more apt than the IOM ever realized.

MEDSKL

09.02.16 // Medicine

MEDSKL is a new free medical education site with a much greater than average pedigree. It’s a group of 180+ physicians/professors/faculty from medical schools in the US and Canada who are promoting FOAMed (free and open access education) for medical students.

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Its clinical (not basic science) focus is well-suited to third and fourth (and industrious second)-year medical students with brief animated videos, written lectures formatted in a SOAP note format for specific problems (clever), and video lectures. The handful I sampled were polished, high quality, and at a basic unintimidating level.

The educational content is all free. There are a lot of fields represented, but this is clearly a work in progress, and lots of topics have only token coverage. In the future, a paid account will net you self-assessment quizzes, which I imagine is the business model to sustain the project. There are also plans to add official CME this fall.

It’s probably a lot easier to recruit educators for clinical medicine presentations that they’re passionate about than it is to find good basic science educators, who are rare. We now have MEDSKL joining OnlineMedEd in the free clinical medicine lecture series, but no one wants to touch the boring parts of medical school (for free). Still, it’s only a matter of time until these sorts of platforms grow and mature.

I’ve long said that the non-clinical parts of the medical school could be a correspondence course. With the increasingly professional and multimodality online resources available, often for free, this is becoming more and more true. There will be a time not long in the future when the vast majority of schools will have basically nothing to offer students during the basic science years that they can’t get better somewhere else other than friends to commiserate with, a rigid schedule, and an external source of accountability. The current trend of supplanting lectures with TBL/PBL curricula isn’t going to change that one bit.

Prisons and Profit

08.31.16 // Miscellany

Very long but excellent journalism in Mother Jones from Shane Bauer, who spent 4 months working undercover in a Louisiana private prison. Hint: it’s terrible. Here’s one terrible facet from an almost endless number of ways in which this system is failing:

If [an inmate] were sent to the hospital, CCA would be contractually obligated to pay for his stay. For a for-profit company, this presents a dilemma. Even a short hospital stay is a major expense for an inmate who brings the company about $34 per day. And that’s aside from the cost of having two guards keep watch over him. […]

One day, I meet a man with no legs in a wheelchair. His name is Robert Scott. (He consented to having his real name used.) He’s been at Winn 12 years. “I was walking when I got here,” he tells me. “I was walking, had all my fingers.” I notice he is wearing fingerless gloves with nothing poking out of them. “They took my legs off in January and my fingers in June. Gangrene don’t play. I kept going to the infirmary, saying, ‘My feet hurt. My feet hurt.’ They said, ‘Ain’t nothin’ wrong wicha. I don’t see nothin’ wrong wicha.’ They didn’t believe me, or they talk bad to me—’I can’t believe you comin’ up here!'”

His medical records show that in the space of four months he made at least nine requests to see a doctor. He complained of sore spots on his feet, swelling, oozing pus, and pain so severe he couldn’t sleep. When he visited the infirmary, medical staff offered him sole pads, corn removal strips, and Motrin. He says he once showed his swollen foot, dripping with pus, to the warden. On one of these occasions, Scott alleges in a federal lawsuit against CCA, a nurse told him, “Ain’t nothing wrong with you. If you make another medical emergency you will receive a disciplinary write-up for malingering.” He filed a written request to be taken to a hospital for a second opinion, but it was denied.

Eventually, numbness spread to his hands, but the infirmary refused to treat him. His fingertips and toes turned black and wept pus. Inmates began to fear his condition was contagious. When Scott’s sleeplessness kept another inmate awake, the inmate threatened to kill him if he was not moved to another tier. A resulting altercation drew the attention of staff, who finally sent him to the local hospital.

Just gruesome.

Capitalism is pretty great if you want to drive down the price of electronics. It does less well in industries without meaningful competition that traffic in human rights and services. If you can make more money by denying service, then it’s in a company’s best interest to provide the barest minimum possible and stop slashing just before losing business.

Sad thing is, despite how scummy the CCA prisons clearly are, the parallels with the US healthcare system are pretty easy to make.

Step 1 Score Correlations

08.29.16 // Medicine

People often ask me about Step 1 corrections, particularly with regards to the Free 150 120 (for which I’ve posted explanations for several years). The data I’d come across over the years was super old.

Last month, Reddit user Waygzh posted the results of a 208 person survey (with an above average mean score of 245), which includes correlations for UWorld, the Free 150, multiple NBMEs etc.

The spreads are huge and the correlations not particularly good, but it’s the best you’re likely to get. Just don’t get discouraged if the number you see isn’t the number you want. Inspiration is better than deflation.

UPDATE: There’s now a 2017 Reddit survey available here as well.

 

It was the best of exams. It was the worst of exams.

08.26.16 // Radiology

From the awesome and scathing “What Went Wrong With the ABR Examinations?” in JACR:

The new examination format also does a poor job of emulating how radiology needs to be practiced. Each candidate is alone in a cubicle, interacting strictly with a computer. There is no one to talk to and no opportunity to formulate a differential diagnosis, suggest additional imaging options, or provide suggestions for further patient management. The examination consists entirely of multiple-choice questions, a highly inauthentic form of assessment.

Only partially true. Questions can ask you for further management. Additionally, it’s possible to formulate questions (via checkbox) that allow you select reasonable inclusions for a differential. This isn’t the same as having a list memorized but is in some ways more accurate in the world of Google, StatDX etc. Of course, this kind of question isn’t meaningfully present, but multiple choice format itself doesn’t necessarily preclude all meaningful lines of testing.

Another rationale for the new examination regimen was integrity. Yet instead of reducing candidate reliance on recalled examination material, the new regimen has increased it, spawning at least six commercial online question bank sites. The fact that one of the most widely used print examination preparation resources is pseudonymously authored is a powerful indicator that the integrity of the examination process has been undermined, effectively institutionalizing mendacity.

Every board exam has qbank products. Part of why Crack the Core is pseudonymously authored isn’t just the recalls; it’s presumably also related to his amusing but completely unprofessional teaching style. I very much doubt the Core Exam is more “recalled” than anything available for the prior exams. What we should be doing is acknowledging that any standardized test will be prepared for this way via facsimile questions, and there is literally no way to avoid it. It’s not as though Step 1 is any different.

Many of the residents we speak with regard the core examination not as a legitimate assessment of their ability to practice radiology but as a test of arcana. When we recently asked a third-year resident hunkered down over a book what he was studying, he replied, “Not studying radiology, that’s for sure. I am studying multiple-choice tests.” The fact that this sentiment has become so widespread should give pause to anyone concerned about the future of the field.

Yes, this is true. But it also strikes me that the old school boards wrapped a useful and worthwhile skill in a bunch of gamesmanship, BS, and pomp. Nonetheless I can’t dispute that casemanship skills have real-world parallels and that the loss of them may have resulted in some young radiologists sounding like idiots when describing a novel case in front of a group of their peers.

In essence, the ABR jettisoned a highly effective oral board examination that did a superb job of preparing candidates for the real-world practice of radiology and replaced it with an examination that merely magnifies the defects of the old physics and written examinations. The emphasis is now on memorization rather than real-time interaction and problem solving. In our judgment, candidates are becoming less well prepared to practice radiology.

It seems increasingly true that anyone more than a couple years out of residency has now fully fetishized the oral boards. It’s definitely true that traditional case taking skills have rapidly atrophied; residency may feel long but institutional memory is short. Old school casemanship isn’t really the same thing as talking to clinicians, but it certainly has more in common with that than selecting the “best” answer from a list of choices.

It is an important skill/ability to succinctly and correctly describe a finding and its associated diagnosis. Some residents now are still able to get the diagnosis but may struggle with describing the findings appropriately when on the spot. But I don’t how much that matters in the long term and if this lack self-corrects over time. I would be interested in seeing if any of the old vs new debate has would have any impact on the quality of written reports, the fundamental currency of our field in the 21st century. I’ve seen plenty of terrible reports and unclear language from older radiologists, so the oral boards barrier couldn’t have been that formative.

The fact is that neither exam is a good (or even reasonable) metric. Frankly, a closed-book exam in and of itself is inherently unrealistic from daily practice. But any exam that trades in antiquated “Aunt Minnies” or relies on demonstrating “common pathology in unusual ways” are really dealing in academic mind games and not really testing baseline radiologic competence.

The movement to end Step 2 CS

08.22.16 // Medicine

If you hadn’t heard, there is growing movement to end Step 2 CS (because it’s a stupid, expensive, and ultimately ineffective test). You can read about the background and sign the petition here. There’s also a fun additional JAMA editorial.

  • 20,190 MD (ignoring DOs who mostly don’t take it and IMGs, for whom the test was originally designed) students took the test in 2014-15, of which 96% passed. So 807 failed.
  • 817 MDs took a repeat and 86% passed (presumably 10 of these were third attempts or re-attempts from the previous year).
  • So 114 US MDs were caught by the Step 2 CS hurdle, at the maximum.

So that’s a terrible value proposition: offloading an expensive test offered in a handful of locations to students drowning in debt and short on time in order to catch a relative handful of people in a deficiency that is largely contrived. But what happened to those 114, of which half failed for communication skills and half failed for poor [fake] “clinical” skills? How many students are actually prevented from continuing their careers? And for students that fail and then pass (the vast majority), is there any evidence whatsoever that this process has improved their skills?1

I am very curious about the former question. I strongly suspect the latter is completely absent.

The irony is that there are plenty of bad physicians, but none of this testing is well suited to unmasking and dealing with real world deficiencies. The even sadder wrinkle is that there are also clearly physicians in the US who have insufficient English skills to practice medicine properly, so Step 2 CS isn’t even doing what it was originally designed to do well.

If I were an MS1, I’d be praying this momentum snowballs and I could save myself the hassle and additional debt.

Guide to The Core Exam

08.18.16 // Radiology

Below are the current entries in the ABR Core Exam Series:

The Core Exam Experience
Detailed post describing the process of registering for the exam, selecting testing location and lodging, the actual test day experience, and the exam itself including the exam breakdown, scoring, and results

Approaching the Core Exam
Detailed post discussing approaching the exam, study schedules, picking resources, and exam content including physics & non-interpretive skills

Resources for the Core Exam
Breakdown and brief reviews of commonly used Core resources

Core Exam Question Banks Review
Separate reviews of the currently available Core Exam qbanks

Book Review: Crack the Core, Radiologic Physics War Machine, CTC Case Companion
Unnecessarily in-depth reviews of Prometheus Lionhart’s Crack the Core book series

Book Review: Core Radiology
TL;DR – I liked it

Yes, you can switch back from REPAYE to IBR or PAYE

08.15.16 // Finance

There has been a lot of confusion from borrowers whether or not REPAYE, with its partial interest subsidy, is a good choice for people with high future income (e.g. residents). The main concern is what happens after training when salaries increase and the possibility of breaking past the monthly payment cap, which could make you lose money (in the context of trying to minimize payments in anticipation of PSLF). Note: If you’re just trying to pay off your loans in an efficient way, breaking past the cap should be mostly irrelevant–you should be trying to pay down your loans as fast as possible anyway.2

If you call your federal loan servicer but don’t ask the right questions, your servicer may lead you astray in how they answer questions about the terms of the REPAYE program. It’s misleading but technically true: if you are making so much money that you break past the REPAYE cap, you absolutely cannot switch back to PAYE or IBR.

That’s NOT because you aren’t allowed to switch out of REPAYE in general (you are), but because at that point you would no longer have a “partial financial hardship” and thus no longer qualify for those plans to begin with. Your servicer is able to provide information and advice, but don’t for a second think that they don’t have a vested interest (see what I did there?) in your payments. A simple rule of thumb is that if you owe more on your loans than you make in a year, you definitely still quality for your income-driven repayment plan.

What is actually used for payment calculations is not your gross income but your discretionary income: your adjusted gross income minus 150% of the federal poverty line for your family size (e.g. family size of 1, 2, and 3 is &17,655, $23,895, and $30,135 in 2015, respectively). The official rule is that if your calculated monthly PAYE/IBR payment (whichever you qualify for) using 10/15% of your discretionary income is less than the standard 10-year repayment, then you still qualify.

So there is a simple solution for forward-thinking borrowers who want to take advantage of the REPAYE benefits but don’t want to tie themselves to higher future payments: Switch back before you make money.

You can switch from REPAYE to PAYE as long as you still qualify for PAYE. Or you can switch back to IBR instead if you had older loans and didn’t qualify for PAYE to begin with.2 Do this at the end of your training and the problem is solved. (Technically, many people could do it even once out in practice; it all depends on how much you borrowed versus how much you/your family makes per year. You can use the calculator to see what household income you’ll need to break past the threshold.)

Also note that since most people generally use tax-returns and not pay stubs to verify income, there is generally a delay between when your income rises and when your taxes reflect that increase. This isn’t the way servicers would like it, but it’s the reality on the ground. You could be an attending as of July 2016, but when you resubmit income verification in the fall of 2016 for REPAYE, you’ll be submitting your 2015 taxes, which is a combination of your last two PGY years of training.

Note that your unpaid interest will capitalize when you switch out of REPAYE, but if it’s all going to be forgiven in PSLF, this is essentially irrelevant. You’ll also sometimes have your accounts placed in an administrative forbearance for a month during the switch, which can delay your PSLF a bit as well.

The bottom line is that you absolutely can switch out of REPAYE—you just have to be a little bit thoughtful on when you want to switch out to not miss the window. REPAYE makes the most sense for many if not most residents. For people who aren’t going for PSLF (especially if they’ve borrowed smaller amounts and won’t enjoy an interest subsidy), no-cost private refinancing may be a better choice.

This plan-switch information comes from this document and FAQ, and I’ve confirmed this interpretation with Nelnet (one of the federal loan servicers). If you talk to your servicer and they say otherwise, ask them to explain exactly why and we’ll get to the bottom of it. Because they should be wrong.

 

Radiology Core Exam Question Banks Review

08.08.16 // Radiology

[Last updated September 2022]

The following is a review and comparison of the available online question banks for the Core Exam.3

There are currently six contenders: RadPrimer, BoardVitals, Qevlar, Rock The Boards, RadsQuestions, Radiology Cored, and Face The Core. I’ve tossed in Physics 300 at the end, a dedicated physics question app. (Those looking for rapid physics review might also consider the Radiology Core Physics Plus app (there’s a free sample). Reviews are mixed, and it sounds as if the material may not be 100% original intellectual property.)

A newer free resource that I also haven’t meaningfully tried is Aunt Minnie’s question bank. Did I mention it’s free? As of 2022, it contains 716 questions. The cases I’ve looked at are solid; seems like a no-brainer to me.

Because RadPrimer is free for many if not most residents and is big, the other resources have an upward climb to be worth your time and money. I was able to secure reader discounts for BoardVitals and RadsQuestions.

TL;DR: RadPrimer does just fine on its own despite its limitations, and it’s free for most residents. BoardVitals is #2 followed by Qevlar. RadsQuestions is brand new and has a risk-free trial. Face The Core is a reasonable but unnecessary adjunct, which you can buy a la carte per subject (in a world with so many cheaper (and even free) resources, not sure why you’d bother). (Radiology Cored is brand new, let me know what you think.)

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