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Organizational stupidity

09.29.16 // Miscellany

Please read and cherish this incredibly cynical essay in Aeon, “Stupefied: How organisations enshrine collective stupidity and employees are rewarded for checking their brains at the office door.” I’m going to superblockquote a chain of some of my favorite parts. Please tell me this doesn’t describe every hospital you’ve ever worked in:

No matter how hard you search there is little – if any – leadership to be found. What most executives actually spend their days doing is sitting in meetings, filling in forms and communicating information. In other words, they are bureaucrats. But being a bureaucrat is not particularly exciting. It also doesn’t look very good on your business card. To make their roles seem more important and exciting than they actually are, corporate executives become leadership addicts. They read leadership books. They give lengthy talks to yawning subordinates about leadership. But most importantly they attend many courses, seminars and meetings with ‘leadership’ somewhere in the title.

Ha, yes.

But often there are very weak reasons for following ‘industry best practice’. For instance, when the Swedish armed forces decided to start using Total Quality Management techniques, some officers naturally asked: ‘Why?’ The response: ‘This is presumably something we benefit from, since this is what they do in the private sector.’ In other words, we should do it because others are doing it.

Applying methods and policies wholesale because they worked somewhere else without then evaluating those changes is a critical role of most middle managers.

At the outset of our research, we suspected that organisational life would be full of stupidities. But we were genuinely surprised that otherwise smart people would go along with collective stupidity, and be rewarded for doing so. Mindlessly following rules and regulations – even if they were completely counterproductive – meant that professionals would be left alone. Using empty leadership talk would get ambitious people promoted into positions of responsibility. Copying other well-known organisations meant a firm could be seen as ‘world-class’. Launching branding initiatives meant that executives could focus on the easier work of manipulating surface images and avoid the much messier realities of organisational life.

This is just brutal.

Working in a stupefied firm often means blinding others with bullshit. A very effective way to get out of doing anything real is to rely on a flurry of management jargon. Develop strategies, generate business models, engage in thought leadership. This will get you off the hook of doing any actual work. It will also make you seem like you are at the cutting edge.

This is what people are hoping to master when they go back for that MBA.

Literally every business/leadership/whatever book I’ve ever read should have been a few blog posts or a short essay. While a lot of people have been piling on recently and calling BS on the organizational psychology and tedious bureaucracy that compose the contemporary large organization, I’m actually tempted to pull the trigger this time and read the book (if only for the refreshingly direct approach).

Thoughts on studying in medical school

09.26.16 // Medicine

Let’s start with this premise: In the 21st century, the medical school basic science curriculum is probably best learned through guided self-study and likely not whatever your school is trying to teach you (especially if that involves the blind leading the blind via TBL). How much you can fulfill this ideal will unfortunately depend on how cooperative your school is with reality.

Read More →

Nothing > Fitbit

09.23.16 // Medicine

Among young adults with a BMI between 25 and less than 40, the addition of a wearable technology device to a standard behavioral intervention resulted in less weight loss over 24 months. Devices that monitor and provide feedback on physical activity may not offer an advantage over standard behavioral weight loss approaches.

That’s the conclusion of a 2-year 471-participant randomized controlled trial in JAMA of how wearable tracking technology affects weight loss.

Wrinkles: Only 75% completed the study. And both groups did lose weight: 3.5 kg in the “enhanced intervention group” and 5.9 kg in the control.

One wonders if meeting your goals with a wearable might cause some people to skip working out or quit an exercise session earlier than they might otherwise do (at least on occasion). The study also didn’t use one with any of the gamification principles that some people have promoted as making exercise more “fun.”

The public would prefer you to not be tired

09.20.16 // Medicine

The public apparently likes the 16-hour shift cap:

After people hear arguments both in favor and against eliminating the 16-hour shift limit, voters’ opposition holds firm at 86%, 79% strongly opposed,” she said. “Eight in 10 would support decreasing the shift limits for second-year residents from 28 hours to 16 hours as well.

These are results from a probably biased Public Citizen survey, a group that vocally opposes the FIRST and iCompare trials that are testing loosening the shift restrictions in surgery and medicine programs across the country.

What I find confusing is that the contemporary discussion always centers on whether or not shift limits are good for residents and/or for patient care. But this focus is always on the impact of shift length on acute fatigue and sleep-deprivation. Nothing about total shift burden, especially when you know that the residents in these studies aren’t magically conforming to the 80-hour rules that are frequently ignored.

I don’t know about most residents, but one imagines a physician to be a lot more likely to do okay on a long shift if (s)he weren’t chronically fatigued working 80+ hours a week. The focus on shift length I think misses the larger and probably more important issue about general overwork, burnout, and chronic fatigue. It’s like being worried about how fresh the oil is in a car without a transmission.

How/Why to Consolidate Federal Student Loans When You Graduate Medical School

09.19.16 // Finance

When you get federal student loans from the government for medical school, you don’t just get one loan: you get at least one per year. Back in the day when graduate students still received subsidized loans, many borrowers would receive three: one subsidized, one unsubsidized, and often a small “low-interest” (5%) Perkins loan. Now, in practice, holding on to multiple loans doesn’t really affect your daily life much. Your federal loan servicer (the company that takes your payments) will apply your payments automatically across all of your DIRECT loans for you (your Perkins loans, if you have any, will be due separately from the rest).

Consolidating your federal loans into a DIRECT Consolidation from the federal government (as opposed to private refinancing, discussed here) does make things look nice and tidy in that you’ll now have a single loan with a weighted-average interest rate based on the rates of the individual loans it replaced, but this paperwork trick isn’t particularly meaningful in and of itself. Unlike private refinance options, you’re guaranteed to not save a single dime on the interest rate. In fact, a slight rounding change could give you a trivially higher rate (it’s rounded up to the nearest one-eighth of 1%).

But there are definitely a few reasons to consider consolidating your loans, particularly as early as you can, in large part due to government’s newest income-driven repayment plan: REPAYE. (Sidebar: please read this for more info about REPAYE and why it’s generally a good idea of residents if you’re not already familiar with the program). And there’s a double reason if you’re considering PSLF.

In short, starting a consolidation when you finish medical school will do four things to save you money:

  1. Reduce the amount of capitalized interest on your loan, which reduces the rate at which it will grow for a long time
  2. Temporarily increase the amount of your REPAYE unpaid-interest subsidy
  3. Help you achieve loan forgiveness a few months faster
  4. Automatically max out the student loan interest deduction on your taxes for the year

We’ll discuss each of these in detail followed by brief step by step instructions. Stay with me.

Read More →

[Education Needs] Denied

09.13.16 // Miscellany

Sad, no good, very bad, depressing reality reported by the Houston Chronicle:

Over a decade ago, the officials arbitrarily decided what percentage of students should get special education services — 8.5 percent — and since then they have forced school districts to comply by strictly auditing those serving too many kids.

Their efforts, which started in 2004 but have never been publicly announced or explained, have saved the Texas Education Agency billions of dollars but denied vital supports to children with autism, attention deficit hyperactivity disorder, dyslexia, epilepsy, mental illnesses, speech impediments, traumatic brain injuries, even blindness and deafness.

Special education rates have fallen to the lowest levels in big cities, where the needs are greatest. Houston ISD and Dallas ISD provide special ed services to just 7.4 percent Tweet this link and 6.9 percent of students, respectively. By comparison, about 19 percent of kids in New York City get services. In all, among the 100 largest school districts in the U.S., only 10 serve fewer than 8.5 percent of their students. All 10 are in Texas.

An embarrassing and frankly sadistic cover up.

When asked about the drop at a 2010 state Senate Education Committee hearing, [special education director Eugene] Lenz did not mention the target.

“We fundamentally believe it has a lot to do with improving general education,” he said.

Fundamental beliefs sound a lot of like lies and crazy talk.

Also, I thought everyone actually involved in teaching children agrees that the increased emphasis on teaching toward standardized tests/metrics in young children while simultaneously cutting budgets for anything remotely enjoyable was making “general education” worse.

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.

Screen Shot 2016-08-31 at 12.42.16 PM

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.

 

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