Ben White

Veterans decide CT lung cancer screening will help them continue to smoke

08.15.15 // Medicine

Linkbait-y title aside, JAMA Internal Medicine has an interesting new too-small too-ungeneralizable study of 35 veterans across multiple VAs. In it, 49% (i.e. 17 patients) admitted that the availability of CT lung cancer screening reduced their motivation to quit. Reportedly, quitting is hard and CT scans are easy.

 

new_attri

Of course, hunting for and even finding lung nodules isn’t going to prevent you from dying from cardiovascular disease or COPD, which together are responsible for over half of all smoking-related deaths. Nor will it touch the various other cancers smoking causes, like squamous cell carcinomas of the head and neck, which I see all the time. CT lung cancer screening for high risk individuals is a no-brainer, the data are substantial, but quitting or never-starting needs to be as well!

 

 

Radiology’s continuing PR problem

08.13.15 // Medicine, Radiology

A couple of months back, JACR published an article with the self-evident conclusion that patients would prefer to hear the results of their radiology studies from their doctor (the ordering provider) instead of a radiologist. Duh! Who wants to hear they have cancer from a stranger who they may never see you again nor have any role in their future care?

Buried in that revelation is far more interesting and depressing data. While many patients don’t really understand the difference between ophthalmologists & optometrists and psychiatrists & psychologists, a substantial portion of patients essentially have no idea what a radiologist even is. The surveyed patients believed radiologists are techs who actually operate the machines and not physicians, and they comically underestimated the length of training:

While 88% of patients were confident they knew what a radiologist is and what one does, 79% thought they were technologists (misplaced confidence!). Only 56% knew radiologists are physicians, and even fewer, 31%, believed that radiologists perform image-guided procedures. On average, they believed that the speciality requires an average training of 6.8 years after high school. Respondents at community hospitals estimated even less time, 5.3 years, which would make radiologists second year medical students.

So even though I think it’s clear that patients would (and probably should) want to hear their results from the ordering physician, it’s even less surprising that they’d want the news that way if the alternative is to hear the results from a nonphysician who just finished their first year or medical school.

 

 

Explanations for the 2015-2016 Official Step 2 CK Practice Questions

08.05.15 // Medicine

Here are the explanations for the updated 2015 (effectively 2015-16) official “USMLE Step 2 CK Sample Test Questions,” which can be found here.

Overall, there are a solid 41 new questions when compared with last year’s set, which I’ve marked with asterisks below. For those who have done last year’s set, a list of the new question numbers is in this footnote1. The explanations for last year’s set can still be found here.

If you’re looking for the answers to the newest June 2016 set, they’re available here. While the order is completely jumbled, there are only two new questions.

Read More →

Guide to Fourth Year & the Match

07.20.15 // Medicine

You should read my new free book on this subject.

Below are links to the original posts that make up my series on fourth year and the match:

For Step 2 CK/CS:

 

The more complete collection of medical school and residency related goodness (Step 3! Student loans! etc) can be found here.

Prime Day is here

07.15.15 // Miscellany

Prime Day is here, and while Wal-Mart is copying the idea, I think only Amazon can make a national news story by unilaterally promoting a sale. And while good discounts on some Kindles, other miscellany, and fabled “lightning” deals every 10 minutes may generate some revenue, I have no doubt that the main thrust of the promotion is to drive new Prime memberships. After all, you can still join Prime and experience the fun with a free 30-day trial (or Amazon Student for 6 months free with a .edu address), and Amazon believes that once you go Prime, you never go back.

Options for Medical School Student Loan Refinancing

07.11.15 // Finance, Medicine

Last updated April 2020.

Medical school is expensive and getting more so every year. Meanwhile, federal student loans are still at above market rates (and many private ones are predatory). Combine the two and a new doctor will borrow more and then pay more for the privilege than at any other time in history.

Over the past two years, historically low interest rates and a rebounding economy mean that private banks have re-entered the student loan business, particularly on the refinancing side.

As a resident, your options are essentially limited. Starting in March of 2015, DRB became the first company to offer a resident refinancing program that is unique, practical, and affordable for residents ($100 a month).

I wrote about refinancing as a resident at length in this post.

Otherwise, here is the complete picture for student loan refinancing.2

TL;DR

There are only a handful of options and the initial applications are short (really short, ~5 minutes or less). Rate ranges are typically concordant and are theoretically as low as the 2%-range variable across lenders. All quote you low rates assuming you’ll auto-debit from a checking/savings account. Initial applications will result in a soft pull on credit (does not affect your credit score) and give you a preliminary rate, so if you have good cash flow and can otherwise afford your loans (i.e. you’re an attending), you’ll do yourself no harm by simply applying for refinancing from each company and seeing which one is willing to refinance you at the best rate:

[This old page is here for archive purposes. I’ve removed the specific company references.]

Summary

Overall, the interest rate ranges offered by these companies are generally comparable. Typically when one lowers their rates, the others have followed quickly followed suit.2 The increasing competition in this space has been excellent for consumers, because the rates offered even a year ago weren’t that much lower than the federal ones. So, if you have several potential options based on your loan burden and your income, you might as well apply to all and see who gives you the best deal.3 Preliminary applications generally take 2-5 minutes, so there isn’t a big time investment in doing your due diligence. There are never any fees or costs to refinancing with any of these players, so you can refinance, keep an eye on the rates, and refinance again if they go down.

Bonuses: As mentioned above, I was able to convince several companies to provide a monetary incentive for you, dear reader, should you choose to refinance with them (in addition to a more standard referral bounty to me). I’m pretty pleased about that, as this allows you to effortlessly support me/this site as well as yourself.

The satisfied patient is the one we’re killing

06.14.15 // Medicine

From a UC Davis study that analyzed a >50,000 person national Medical Expenditure Panel Survey:

The study found that patients who were most satisfied had greater chances of being admitted to the hospital and had about 9 percent higher total health-care costs as well as 9 percent higher prescription drug expenditures. Most strikingly, death rates also were higher: For every 100 people who died over an average period of nearly four years in the least satisfied group, about 126 people died in the most satisfied group.

Interestingly, more satisfied patients had better average physical and mental health status at baseline than less satisfied patients. The association between high patient satisfaction and an increased risk of dying was also stronger among healthier patients.

Despite the proliferation of Press Ganey, I don’t think anyone who has worked in healthcare would find these results surprising. Healthcare may be a business, but there’s still trouble in treating patients like regular customers.

patrick

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]

// 05.28.15

Overkill

05.14.15 // Linked, Medicine

Atul Gawande4, 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.