If your employer offers matching contributions to a tax-advantaged retirement account, then yes. You should be contributing to the match limit. That’s free money. Obviously, if you’re training in a high cost of living area and surviving on ramen you steal from a roommate you found on Craigslist, then nevermind.
From there, if you have more money, what to do next depends on the status of your loans. (more…)
I sporadically post “best books” recommendations for medical topics, which if you’re reading this you’ve likely also noticed sometimes cover topics that I’m not in expert in and discuss books I haven’t actually read. This is my general methodology, for those curious:
The potential downside to this method is that I am not necessarily a subject matter expert on every topic or every book that I recommend. I also definitely have not read each (or sometimes any) book cover to cover.
The positive side is that I’m not just one guy telling you my personal opinion about what I personally like; I’m instead building a cohesive viewpoint based on a foundation of broader public opinion, somewhat similar to the old-school Wirecutter or US News cars reviews. I’d like to think it’s refreshing to see a reasonable grouping of book recommendations that can be attributed to a single person. I am not an expert in or even a trainee in every field, but I know from the continued popularity of my medical school posts and initial forays that people find these types of recommendations helpful and a one-stop shop anxiolytic.
I could call the series “good books that will likely serve you well,” but that doesn’t have much of a ring to it. These “best books” of course aren’t necessarily really the best books. Or sometimes they are, but they still might not be the best books for you. Nonetheless, the goal of these posts is to provide you with a simple straightforward reasonable selection of books that you can read or “read” without remorse.
[Last revised December 2020)
There are a few good options for refinancing your federal student loans and their unreasonably high interest rates into something more manageable during residency (currently: Laurel Road, SoFi, and Splash, discussed at length here).
Once you’re an attending, even more options enter the fray (enumerated at length here). Ideally though, unless you didn’t know you weren’t planning on going for PSLF, you’d have refinanced earlier in residency to maximize your savings.
But medical students have up until now been relegated to getting loans, not refinancing them. Recently, Laurel Road squeezed the competition into medical school proper: post-match fourth years can now apply for their student loan refinancing.
While you sadly can’t get a better interest rate earlier in your education, it does mean that the minute you get that match letter to prove you have a job, you can start the process. When you apply in March, Laurel Road honors the usual six-month grace period, so nothing changes in that sense compared with your federal loans. They require $100/month payments during training (residency + fellowship) after the grace period (which is much lower than the usual PAYE payment and won’t ever increase in size until attendinghood). By applying in March instead of July, you’d save around four months of capitalized interest.
A numerical illustration:
200k at 6.8% accrues around $1133/month in interest. Refinancing that to 5% would knock the monthly interest down to $833/month, thus saving you $1200 over that brief four month span. Neat.1
Also of potential interest, Laurel Road also offers a referee bonus of $300 for readers of this site if you refinance via one of the links on this page.
I’ve written at length about refinancing your student loans, but the short of it is that payments during residency are thus low to nonexistent, and you can save a lot of money even with a mild interest rate reduction over the life of your loan in terms of interest accumulation. The potential downside is that you give up the option for loan forgiveness, both PSLF and the 20/25 year forgiveness made theoretically possible by IBR/PAYE. For low to average loan burdens or short residencies, that’s not a big loss. If you want to do pediatric endocrinology and borrowed $500k, obviously that’s a bigger consideration.2
If you were planning on forbearing your loans because you won’t have the cashflow to make steady payments, then you should almost certainly refinance regardless. Going for loan forgiveness only make sense when you’ve been making years of low monthly payments during residency. For someone forbearing, refinancing saves thousands over the course of even a short residency.
It’s worth it to sit down for a few minutes with a loan calculator and some ideas about your residency, fellowship, and early attending pay to see how much you’d pay over 10 years of income-driven repayment, 20-25 years of IBR/PAYE, or with private refinancing. For many students, refinancing is the right choice financially as well as the most financially liberating during residency (and much much better than forbearance!). Doing so as early as possible is prudent, especially while interest rates remain low. Don’t forget, if the economy were to tank again and rates drop further, you could always refinance again (all of the student loan companies currently operating offer zero cost refinancing programs without origination fees or points required).
Marie Kondo’s The Life Changing Magic of Tidying Up was arguably the biggest ‘self-help’ book of the year (i.e. NYTimes #1 bestseller). The book’s central premise is something that I think everyone deep down knows and that that my wife and I rediscovered for ourselves while preparing for the birth of our first child. Organizational schemas are great, but nothing you do makes a difference if you have too much stuff. Doesn’t matter how you organize if there are more things that you can physically see or get to.
The KonMari method states that if something doesn’t spark joy, then you get rid of it. It doesn’t matter if it’s in perfect shape or if you bought it with every intention of wearing it but never did. The better condition it is, the happier you will make someone else who will have a chance to use it if you don’t need it.3
One of my favorite parts of the book is how she describes a better way to fold your clothing. Her method is one that is so awesome and simple that I can’t believe it’s not simply the default. It’s genius, and it essentially boils down to folding your clothing down tighter than you would otherwise expect, and in doing so, you can arrange your clothing almost like book shelf so that you can see everything contained within the drawer instead of having stacks where the items on the bottom never get worn because they never get seen. Goop has the illustrated guide here.
My very short story “Turkey on Wheat” is back online, republished in The Story Shack with accompanying art by Hong Rui Choo.
In answering some recent reader emails and doing some mock interviews with fourth-year medical students, I’ve noticed an interview deficiency that’s worth correcting. Residency interviews are generally benign, but you still want to be able to talk cogently about why you’ve chosen the field you have as well about the field itself.
You can start off by knowing that you generally will not be truly knowledgeable about your future in the chosen field after a rotation or two as a medical student. And frankly, if you talk about your future career and your opinions too brazenly, you may come off poorly. If you think back to your interviews for medical school (if you can remember them), then you probably remember how weak your grasp of medicine was. You may have said things that make you cringe now. It wasn’t uncommon for an applicant to tell me that they wanted to pursue “residency” in cardiology or oncology among other simple mistakes. Some didn’t even have a grasp of what residency was! You are probably substantially more informed now than you were then, but the same lessons still apply (especially in the fields that are not core rotations). Your interviews warrant a proper balance of critical thinking and humility.
So, why pick X?
An example: for radiology, it’s common for applicants to say things such as “I like the combination of medicine and technology.” Which is fine, but why? Why would that be meaningful for you? How does that interest in this intersection manifest? It would be just as easy for a urology applicant to say they like the innovative combination of urination and genitalia. Honest radiology applicants could then go to say they prefer patients when they are presented as a stack of two-dimensional images. Surgeons would then counter that they like them in 3D but best when they are anesthetized. None of this sounds that great.
This is all to say, think on it a little harder.
Beyond “why this,” there are some relatively common questions that I think are frequently overlooked opportunities to shine. Asking an applicant about the future of the field, changes to healthcare reimbursement, the push for quality improvement, patient-centered care, medical errors, etc are some of the best ways to see how someone thinks, how they feel, and how they reason through a big issue. You don’t usually memorize answers to these questions, nor should you. But you should think about them, not just for interviews, but also for the career you have chosen and your future within it. Note: You want to be able to answer these questions without potentially offending the interviewer or heavily invoking your political beliefs. You never knew the leanings of the person across the table from you.
For example, in radiology, good topics to think about would be the future of the field, the role of midlevel providers, changes to reimbursement, healthcare utilization, private practice versus academics, quality improvement, how to add “value” both to patient care and the ordering providers, patient-centered care, relationships with referents. You may not have fantastic answers (in many cases no true answer exists), but these questions, if asked, are where you have the opportunity to show critical thinking as it pertains to the field you’ve chosen. Approach these questions with care, humility, and the understanding that the person asking them can see through your BS.
I recently finished “reading” the audiobook of Aziz Ansari’s Modern Love (coincidentally narrated by Aziz Ansari), which is essentially an amusing presentation of real sociological research focused on how dating has changed in the internet era. Made for a good listen in the car on the way to daycare, which has become my primary reading time of late.2
It’s an interesting exercise to take a step back and see how in just a few years the foundation of our relationships and framework for making new ones has completely changed. The sections on international romance, particularly in Japan, were a highlight.
As someone who likes having their biases confirmed, my other favorite part of the book was its discussion of studies that demonstrate how social media is increasingly distorting how we view life satisfaction.
That’s the thing about the Internet: It doesn’t simply help us find the best thing out there; it has helped to produce the idea that there is a best thing and, if we search hard enough, we can find it. And in turn there are a whole bunch of inferior things that we’d be foolish to choose.
Too many choices can be paralyzing and just as depressing as having too few. Seeing other people’s curated images causes us to believe that other people are happier than we are, that their choices are better than ours, and that even if we are happy, maybe we could be happier. And all this in turn makes us sad. Perhaps, the solution:
Spend more time with people, less time in front of a screen, and—since we’re all in it together—be nice to people.
In their newest best practice guidelines in the Annals of Internal Medicine, the American College of Physicians practically begs clinicians to stop chasing phantom pulmonary emboli. Nothing super new here, but they do explicitly call out the big offenders:
Best Practice Advice 1: Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.
Best Practice Advice 2: Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria.
Best Practice Advice 3: […] Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.
When I cover the ER, I am routinely impressed in the low diagnostic yield of a PE CT (for actual PE). When I review the chart in protocoling/interpreting these studies, it’s obvious that a significant portion of these patients are being imaged inappropriately, either because there is already a better diagnostic explanation from the initial history/workup, PE is clinically extremely unlikely, or because a positive d-dimer is being chased out of context. Until recently, this profligate waste was a winner to all involved parties.
Nagging concerns of radiation and systemic waste aside, everybody wins. And over time, the d-dimer turned into a bludgeon against reason, and the ready availability of CT made it psychologically and medicolegally more sensible to image aggressively.
The d-dimer was never intended as a screening test for every single patient with chest pain in the emergency room. A positive dimer in an inappropriately risk-stratified patient should not mandate a follow-up CTA. This is especially the case when the test is originally ordered by a nurse as part of a standing order protocol and not by physician who is actually responsible for the patient’s ultimate care. In my brief two-month stint doing clinical medicine in the ER as an intern, I often absorbed patients from the waiting room who already had an EKG, chest radiograph, and labs including troponins and a dimer. Then we were “forced” to get a PE protocol CT to “work-up” the dimer, even in patients who had obvious other explanations for the test results (e.g. an obvious pneumonia on the radiograph). Not everyone practices this way, but it’s easier to practice thoroughly (defensively) in most of the same ways it’s easier to give antibiotics for viral illnesses.
There is one important and misleading exception to premise of the ACP report. And that’s the notion that CTs ordered in the context of “suspected” PE are exclusively obtained to evaluate for PE (i.e. PE CTAs don’t have diagnostic value outside of evaluating for PE). Some of these patients have clinical symptoms without radiographic findings, and the ordering providers are obtaining imaging to further evaluate the lung parenchyma for signs of occult infection (as well a rib fractures, anything else). CT is a troubleshooting modality in cases where the clinical picture is cloudy. So the angiographic component of the CTA may be partially a “why-not” inclusion to exclude a potentially life threatening PE in a patient that was destined for imaging anyway.
That said, I still feel like I almost diagnose more PE incidentally on abdominal imaging than I do on dedicated PE studies.
Disclaimer: I was a resident who had neither started nor completed the process of getting a job when I wrote this. I was however asked to weigh in on pursuing a radiology job in academics vs. private practice, particularly with regards to how one’s future desires might shape an applicant’s choice of residency program. Overall, I still agree with myself.
There are several considerations to take into account when deciding the merits of a career in private practice versus academics. These are of course broad generalizations, and exceptions are not uncommon.
How much do you like variety versus how much you like the idea of being a hyperspecialized subspecialty radiologist?
Most academic radiologists work exclusively within the realm of their fellowship training. That means that even a single extra year of neuroradiology training will often lead to an academic career in which you essentially exclusively read neuroimaging (with maybe some general call thrown in at some institutions). As a resident, you will likely notice that some of your staff seem to know less about the “extraneous” anatomy and pathology than you do. That’s because at this point, years after they’ve practiced general radiology, that’s often true. It’s not uncommon for body staff to defer to the resident’s interpretation of spine findings on a belly CT or vice versa. Procedures you do, if any, will typically be those related to your subfield. Case complexity is higher overall and intra-system follow-up is more common. As such, the clinical work may be more satisfying as well as more narrow.
Private practice radiology is focused on interpreting studies. In general, subspecialty trained radiologists will still often perform as generalists even if they have a relative focus on their subfield. Even interventional radiologists, who some might assume would be fully clinically oriented, often only spend, say, 40-60% of their time doing IR. It’s become common for the subspecialist to be responsible for the highest level cases, but it’s still generally much less common to have an academic style laser-focused job in PP compared with academics. Case in point: a recent study showed that while almost 50% of current IR job postings were 100% IR, only 15% of PP jobs currently offered 100% IR.
So the go-to guy for pediatrics or musculoskeletal imaging still isn’t exclusively reading those studies. In small to mid-size groups, non-IR radiologists routinely perform many of the procedures you think of when you think of IR (biopsies, drainages, etc). A future exception: over time as more corporate mega-groups take over hospital contracts, the clinical volume can be largely pooled, allowing even the PP subspecialist to focus more on the subfield of their expertise. Given the continued push for “quality” and “value,” particularly as referrers become more comfortable with imaging themselves, this trend will also increase.
Conversely, an academician may pair their narrow clinical focus with a greater amount of nonclinical work. While the private practice radiologist may read a larger variety of studies, the academic radiologist is more likely to be involved in research, administration, or teaching. Both research-track and clinical-track jobs exist (though tenure as such is uncommon). In the end, you have to decide if radiology/study variety or career variety is more important. Again, at the risk of beating a dead horse, these are generalizations. There are people in academics who exist only to “kill the list,” and there are people out in practice who are involved in running practice groups, working with hospital administration, and spending a great deal of time during non-clinical work.
Money is slowly becoming less of a factor for many than it used to be. During the golden age, you worked twice as hard in private practice and made three times more. Now maybe you’re working 50% harder for 20% more. Before reimbursement cuts, it wasn’t uncommon for people to make a lot of cash in PP and then “retire” into a slower-paced academic job (obviously this was also before the job market contraction). Those days are long gone and are never coming back. Groups are merging, and these consolidated megagroups are then snatching up the hospital contracts in large metro areas. Partnership track positions are no longer universal, and even when present, may not always be as meaningful, particularly in private equity-owned groups where it really just signifies a pay increase or smaller groups that don’t have long-term imaging contracts or don’t own imaging centers (and thus have no assets to bargain with except limited intellectual manpower). Hospitals are increasingly directly employing radiologists, and an employee is never paid what they’re worth (otherwise how does the employer profit from them!). This is to say that while you certainly make more in PP, that money doesn’t come for free, and the windfall isn’t as egregious as it used to be. It’s frequently described as a grind.
There are also some unsavory practices that churn and burn new grads out of fellowship, often for “partner-track” jobs where the associate is let go prior to making partner. Likewise, folks in the workup typically make out poorly in a group buy-out situation. This is a result of the desire to maintain or increase revenue amidst falling reimbursement, particularly for established partners who are used to bringing home a certain income. A private equity practice, for example, makes its money when old well-paid partners retire and are replaced by a younger less well-paid generation. As older radiologists retire, it’s possible the nature of these groups may change. That said, many young physicians would rather sacrifice some income for lifestyle. People talk. Make sure you know the nature of the group you sign on with.
Conversely, academics definitely isn’t as easy as it used to be. Changing reimbursement combined with ever-increasing clinical volume has resulted in a push for ever greater RVU generation, even in academics. This has meant an increasingly frenetic pace, particularly for those who are not producing academically enough to get protected time. While pay is generally lower, academic institutions often have great benefits. So salary itself isn’t the only consideration when it comes to true compensation.
So both groups are working harder than they used to. In PP, the grind is generally bigger and you take more call in return for lots more vacation and more money. How much more money depends on a lot on the health of the group, location, what patient population they service, assets they hold, etc. PP radiology was well suited to the era of fee-for-service medicine. In a future of more capitated and “value”-based healthcare, there will be more contraction and consolidation, likely resulting in further erosion of the historical differences over time.
Integrated health systems like Kaiser directly employing radiologists make a lot of sense in the era of bundled payments. So while many people weigh their options between private practice or being employed by an academic institution, a third option of being employed by a non-academic hospital or health network may become increasingly common. Such a job is likely similar to a clinical-track academic job for a bit more pay (i.e. not a bad thing for physicians).
Previously thought undesirable, some VA jobs have emerged as highly desirable jobs with reasonably high pay, an occasional light academic component, and preservation of lifestyle.
While the referring physician is important to all referral-based specialties, the ordering provider is much much more the client for a radiologist than the patient. Service in private practice radiology means making those providers happy. In many cases, that will include non-physicians like NPs and PA as well as chiropractors and other folks. Yes, you’ll spend a lot of time on the phone being nice to people who may be ordering asinine studies and pretending you want to talk to them. Part of the gig.
Academics varies more, but generally, the referrers don’t choose you; you’re just in the system. So the dynamics can be different. At my institution, we have a system that allows us to send important results by a recorded message via pager. Saves us a ton of time. Some orderings docs hate it; we love it. That’s a harder sell on the private side.
In general, academic jobs are much more secure. In large competitive metro areas, even group contracts aren’t necessarily secure in the long run, which adds an additional layer of insecurity.
So what does this mean for your choice of residency? Not very much. Any large academic center, which most people aspire to, will offer you the training you need for either job. You don’t need to know right now. And don’t read the above and think PP has a grim future where only suffering exists (because that’s not true). If people ask you, you can either say you’re not sure, want to get the best training possible, or that you’re most interested in academics (after all, who’s interviewing you?) There are two mild caveats:
Private practice jobs are speed and competency-based. Which means a new hire is prized for being able to work through a list of unread studies quickly without making mistakes. As such, the residencies that best “prepare” trainees for private practice are ones that have good clinical volume (most do) and independent call (a challenging luxury that’s rapidly fading). Many programs have done away with independent call due to demands from EM departments for rapid final reads, no patient-care altering addendums, etc. While on the face of it this is a good thing for patient care, it ultimately displaces responsibility and training. Every radiology resident will eventually have to be able to “make a call” on tough cases. Doing it in the context of independent call means that someone with more experience will eventually back you up and provide quality assurance. This allows you to grow in skill and confidence in a relatively safe environment. If you don’t have this, the end result is that you are never meaningfully responsible for patient care until you’re a fellow or an attending. As an attending, you don’t have the same backup luxury. I’m not convinced this is a good thing: it makes young attendings less trustworthy and often overly sensitive/nonspecific.
There are programs with minimal call.2 These are easy residencies (and at some really big names) but probably not the best clinical training. You can be an exceptionally smart person with great book knowledge and that will take you part of the way—but you can’t teach independence, and you can’t substitute volume. There are also programs that treat the overnight ER shift like a normal workday with attending readouts—which means you never have to make a real decision for yourself. Successfully taking independent call and covering a busy emergency department/hospital is both educational but also signifies to groups that you won’t be useless when you’re hired. Most groups know the kinds of residents a program typically produces, at least on the local/regional level.
So essentially, if you’re interested in private practice (and most residents will need to at least consider entering practice), you want to be at a program that provides the best clinical training. That means good volume (large institution with large geographic radius to draw patients from), good faculty (to teach you), and call (preferably independent). Personally, I think these are important criteria for any job in radiology, but certainly for landing a decent PP job in a crowded market.
A large percentage of residents stay in the same metro area for their first job after completing residency. This is particularly true for private practice, where residents from your program are more of a known variable and there are local contacts who can vouch for you. Academic institutions obviously don’t hire all of their fellows, doubly so at many of the big fellowship factory programs. So while a nice pedigree may help you get a job in academia (potentially at a remote institution), you’re statistically more likely to find a private practice job locally (unless the local market is completely saturated). The more awesome and desirable the place you train, the harder it will be to find a job there. Conventional wisdom is that if you want to practice in a certain municipality, you’re well served by going to the best locoregional academic program. If you know you want to be in academics and want a big name job, then feel free to chase pedigree to your particular desires (just know that the actual training is unlikely to be better; that’s not what the name is for; the name is to open doors with people who have pedigree biases. And maybe for you to do more research). Obviously, fellowship is another chance to play this part of the game.
There’s a new residency guidebook on the scene, Medical School and the Residency Match, and the reviews on Amazon are great. So I’m reviewing it.
This time, instead of being written by a residency consultant (like this or this), the book is written by a group of post-match medical students. As such, it’s a refreshingly honest take and not full of the usual spiels. On one hand, books written by program directors (this is probably the best) may be more authoritative, but they are sometimes over the top and not relatable or easily actionable. For one, what people say they want and what they actually want aren’t necessarily the same thing. Secondly, there isn’t a single path to success. Sometimes it’s nice to be reminded that people like you have been doing just fine, thank you. (more…)