The future of prostate exam training is here, and his name is “Patrick.” Half sensor-embued tush-model and half computer-simulated cartoon-man, Patrick promises to grade medical students on their technique while also “present[ing] a realistic patient encounter” including “software that enables him to interact emotionally with the student.” (Before the exam begins, he tells you how scared he is.) [via Medical Daily]
Atul Gawande1, writing about useless medical care for the New Yorker:
One major problem is what economists call information asymmetry. In 1963, Kenneth Arrow, who went on to win the Nobel Prize in Economics, demonstrated the severe disadvantages that buyers have when they know less about a good than the seller does. His prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.
Interesting, in an otherwise thoughtful and well-written essay (as always), Gawande never once mentions fear of medical malpractice as a component that is driving useless healthcare utilization. His best anecdotal examples come from surgeons and proceduralists, who in private practice have an incentive to operate. The family doc, on the opposite end of the spectrum, doesn’t have a direct monetary incentive to order non-indicated radiological exams.
He also never mentions the “patient as consumer” either. Keeping private paying patients happy is the only real monetary incentive most providers have. The argument he references above is that doctors have the power and are (inherently?) inclined to over-test and over-treat. But anyone who has tried to not give antibiotics to someone with a viral URI knows that patients often go to the doctor to get what they want, not to find out what they need.
From a reader:
What’s your step by step process when answering questions on the NBME shelf exams? I have been reading the question first while highlighting the key words and then reading the answer choices (often glancing back at the words I highlighted to confirm that the answer choice I chose is correct.) With this method, I am sometimes pressed with time and tend to rush towards the end. Could you talk a little about your approach to questions on the shelf?
In the past, I’ve written about some of the ways I break down NBME and USMLE questions, but I haven’t actually written about how I really read one. That may be because the answer is relatively anticlimactic, but here I’ll talk a little bit about my focus on flexibility and speed over rigidity when it comes to approaching Step questions (with a few examples from the 2014 official sample questions). As always, this isn’t necessarily what you should do; it’s just my take. When I used to teach Kaplan MCAT, part of the “method” placed a lot of emphasis on using passage mapping as a consistent approach. If time management isn’t a problem for you, there’s no reason you can’t start/continue using these more involved strategies. But if you don’t have a big system and feel left out when you’re friends are fervently highlighting and using answer-choice first schemes etc, you’re not alone.Read More →
Update 8/5/2015: They’ve now updated to the new 2015-16 question set and removed the old links (they’ve previously kept the old ones working for several years). You can still access cached versions of 2014-15 and 2013-14 for now (cachedview.com is helpful in cases like these). My explanations for the new set are available here.
Here are the explanations for the updated 2014 (effectively 2014-15) official “USMLE Step 2 CK Sample Test Questions,” which can be found here.
Overall, there are only three new questions when compared with last year’s set (#90, 95, and 104), which I’ve marked with asterisks below. The explanations for the earlier 2014 set (effectively 2013-14) set can still be found here (the question pdf is still available online) and are largely identical (though in completely different order).
From Julia Belluz’s portrait of Dr. Oz in Vox, now apparently America’s most famous and most trusted physician:
This setback didn’t slow down Oz in his study of alternative medicine — or his embrace of fame. In the early 2000s, he worked with a reiki healer named Raven Keyes. She told me recently, “My reiki master is the archangel Gabriel. All I have to do is ask Gabriel to activate all the angels, and everybody’s angels come to life.” In the operating room, she said, she’d perch on a stool behind the anesthesiologist and transfer her good energy. “I’m connecting with the divine light within me and allowing myself to absorb the divine light in myself so it expands outward.”
Dr. Oz embodies the tension between personal freedom and professional responsibility. If one-way communication via a television or radio show doesn’t qualify as medical advice or constitute a physician-patient relationship, then how do we define it? Because anecdotes are apparently not uncommon about people who trust Oz via TV more than their actual physicians:
One reported that her dad had a heart attack and five stents placed in his heart, which required him to take aspirin and Plavix to prevent blood clots. “He was watching Dr. Oz, who said Plavix was not necessary, so he stopped taking it. About a month later, he had another massive [heart attack] and coded and had to be shocked back to life.” She continued: “My dad admitted to following Dr. Oz’s advice and not asking his own cardiologist.”
When a personality like Oz speaks about health and is a physician, he or she is essentially doling out medical advice. But right now, we wouldn’t even consider holding them accountable. Oz doesn’t even need to disclose his COIs when it comes to fat busting green coffee bean extract or other natural miracles.
Update: John Oliver weighs in on the most recent Oz controversy, as Oz responds to his critics who want him off Columbia’s faculty.
https://www.youtube.com/watch?v=sXTgxkhHAqo
And if you haven’t already seen it, Oliver’s awesome original Oz segment.
7 pounds 8 ounces of pure awesome.
Ragnar Kristoffersen, an anthropologist who trains Norway’s correctional officers, quoted in a fascinating NYTimes piece about a different kind of maximum security prison:
He leaned back in his chair and went on. “We like to think that treating inmates nicely, humanely, is good for the rehabilitation. And I’m not arguing against it. I’m saying two things. There are poor evidence saying that treating people nicely will keep them from committing new crimes. Very poor evidence.”
He paused. “But then again, my second point would be,” he said, “if you treat people badly, it’s a reflection on yourself.”
The NBME just released the updated 2015 sample questions this past month, and there are no new questions in this iteration (at least in the downloadable pdf version). In fact, six questions have been removed (two from each section), which was done to reflect the decrease in total Step 1 test items starting May 11 from 322 to 308.
I’ve made a note of which questions were removed from the 2014-15 set. Therefore, at this time, my explanations for the 2014-15 set are still current. The question order is the same, but the numbering is off a bit.
If an updated set with new questions is eventually released, the explanations will appear below as they have in prior years.
#20 and #29 from 2014-15 were removed.
#74 and #85 from 2014-15 were removed.
#98 and #130 from 2014-15 were removed.
Again, the still current 2014-15 explanations can be found here.
Paul Kalinithi, writing to his infant daughter in his last op-ed before succumbing to lung cancer:
That message is simple: 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.
It’s a rare thing for us to write to the ones we love before we go, let alone to share such poignancy in order to touch others as well. We don’t write meaningfully to each other very much anymore, especially when it counts most. We could do better.
Last updated July 2020
If you’re a resident with a big load of student loans from the feds at a 6.8% interest rate (or worse), your choice has generally been IBR or forbearance. The mountain of debt compared with your relatively paltry resident salary has put conventional student loan refinancing—which requires a reasonable debt/income ratio—out of reach. If you have an average loan burden (say, $180k) or higher, your IBR payments also only cover around half of the monthly interest accrued (so despite your best efforts, your loans are still growing). If you forbear, they’re growing even faster.
So basically, your loans have been growing at a crappy interest rate, and you’ve been unable to bail to greener pastures.2 Until now.
[This is old post; I’ve removed all the specific company references, as they’re out of date. I’ve moved on from this topic.]
This is how it works:
It seems like all student loan refinancing companies have referral programs to drum up business, whereby you get some cash if you send a friend their way. If you’re interested in refinancing, just do the initial 2-min rate check application and see who gives you the lowest rate. If the offers don’t make sense, then don’t sweat it. Your credit won’t get pulled until you do the real application.
What I found clever about the original company offering is that they not only stood to profit from the extra years of interest accumulation if a new borrower paid the minimum amount during residency, but that they’d found a way to get at physicians early and compete against the other companies on something other than who has the lowest offered rate on a given day. Frankly, I’m surprised others took so long to join in (I talked with one of their directors about this back in 2016!).
One thing that happens if you switch from federal income-driven repayment to private consolidation/refinancing is that your accrued interest will capitalize. This means that if you had loans of $180k with $40k of uncapitalized accrued interest, your new loan amount (that will now be gaining interest) is $220k after refinancing. That can be really bad, but all depends on the rates:
$180k at 6.8% APR accrues $12240 every year in interest.
$220k at 3.5% APR accrues $7835 the first year in interest.
So you’ll have to do the math with the rates you are offered versus the amount of unpaid interest you have sitting around to see how it works out. Online calculators (like this one) make it pretty straightforward. The interest capitalizes at end of your six-month grace period after finishing school or when you consolidate, so if you just recently graduated, this is irrelevant. If you’ve been forbearing, then your interest already has and continues to capitalize, so that downside also doesn’t apply.
Part of what made refinancing so desirable back in 2015 when I first wrote this post was that interest rates were at all-time lows. It was a great time to buy a house too, and it made the 6.8% federal student loan interest rate for graduate students particularly galling. Since then, federal rates dropped a bit and the IDR program added an unpaid interest subsidy to many borrowers through the REPAYE program that many residents can benefit from. In other words, refinancing as a resident was something that lots of residents could have benefitted from in 2015 when DRB was the only party in town. Now, the majority of residents will do better in REPAYE.
You can refinance with CommonBond and get an attending rate + $300 cash back if you apply during your final year of training with a signed job contract.
Otherwise, for residents with average loan burdens, options are limited. Another player that is potentially viable is LendKey ($300 bonus). The maximum loan amount is currently $300k. Additionally, on an average resident salary of $55k, the maximum loan amount without a cosigner would be approximately $75k. To hit even their old maximum of $175k, you’d need an income of $85k. While there is no special resident program, they do offer interest-only payments, which if your loans are a small enough may be entirely reasonable. The interest-only payment on $100k at 5% is around $400/month, for example. Earnest ($300 referral bonus) tells me they are also willing to refinance residents despite their debt/income ratio, but you’d essentially have to have enough income to make full payments on a 20-year (the maximum) term, so it’s a no-go for big borrowers as well.
So if you’re an attending, apply to all of them and see who gives you the best rate. Initial rate checks don’t affect your credit. When you sit down and really apply to several student loan companies to get your finalized rates within a short time frame, it’s considered a single hit on your credit report, so the more the merrier.
For further reading, here is my rundown of all of the medical student loan refinance options.
See this post. Keep in mind, PSLF can only take place after 10 years of monthly payments. If you have a smaller loan burden or a short residency, the amount you can theoretically have forgiven may be low (assuming the program continues; it’s new enough that no one has actually had their loans forgiven yet). PSLF is the best deal for those with long residencies/fellowships (low monthly payments for longer under IDR), with a lot of loans (private school = more forgiven), and low attending salaries (lower IDR payments = more forgiven).
In fact, the desire to do PSLF is the main real reason to not bother doing a private refinance rate check if you aren’t eligible for a good REPAYE rate subsidy. At least, the current PSLF is: recent budget proposals have included a proposed capping PSLF or canceling the program entirely, though all changes are designed to affect only new borrowers. So current residents should be grandfathered into PSLF without a cap and get solid loan forgiveness. Future medical students, however, could one day have the real benefits of this program essentially washed away. Now that giving “rich” doctors and lawyers big wads of cash is a legislative issue with bipartisan support, PSLF may end up being a short-lived panacea for physician debt.
If you’ve heard about getting your loans discharged after 20-25 years (IBR or PAYE), you should probably forget about it. Unless you quit medicine and never make a decent attending salary, all but those with the most egregious student loan amounts won’t get their loans forgiven this way (and even if you did, you wouldn’t save much money given all of those extra years of making payments and taxes due on the forgiven amount). If you make little enough (e.g. part-time academic primary care) to stretch out your loans for 20 years but couldn’t do PSLF, then you might have some amount forgiven, but then you would have spent a ton of extra money over the years on interest, and then forgiven amount is taxed (your marginal tax rate * a multi-hundred thousand dollar loan debt = a huge tax bomb). The best reason to keep your federal loans around at 6.8% or worse is for PSLF or because you can’t yet qualify for something better.2