Guesting about PSLF on the Financial Residency Podcast

Listen to me and Ryan Inman of the excellent Financial Residency podcast nerd out about PSLF and why you should 1) be diligent and 2) ignore the clickbait/majority of what you read online.

Check it out.

I would normally give the disclaimer that I had a cold, but I have a four-year-old and now an infant in daycare, so I’m always either sick, recently sick, or about to be sick. Clearly my verbal tick of the day was “at the end of the day,” so mentally subtract that from your listening and it’s a great episode!

Dealing with Test Anxiety and Demoralization

For as long as I’ve been taking multiple choice question tests, I remember when I’d get a question wrong, a lot of the time I would say:

Oh wait, that doesn’t count, I really knew that one.

But the fact is that there’s more than one way to get a question wrong. Most people think of really being “wrong” as when they’re totally clueless, but that makes up a minority of cases. Many times you will actually know the learning point being tested even when you get the question itself wrong. You got the question wrong because you couldn’t link up the facts you know with how they’re requested through a question stem. Other times you went too fast or got played by a plausible alternative choice. Those are good reasons for why doing high-quality practice questions is a critical component of any exam prep: you need to continually pair up facts in your brain Rolodex with answers as framed on multiple-choice questions. It takes time, and there’s no shortcut.

One of the difficulties some of my former students had with studying through questions is that getting questions wrong is demoralizing. And if you’re using questions relatively early on in your developing mastery of the subject matter, you’re going to get a lot of questions wrong. I would encourage you to consider this bottom line: when you’re studying with any qbank, your goal isn’t really to get questions right; your goal is to learn. There’s almost as much to learn from the questions you answer correctly as the ones you get wrong. You need to see the information in its “native“ environment.

Demoralization and test-anxiety

Unfortunately, for many students, this process of demoralization and self-doubt feeds into test-anxiety. For high-stakes tests like the Step exams, that dread could easily ruin months if not years of your life. It’s a hard cycle to break.

One thing I believe (and I do mean believe, no science/data here) is that when it comes to performing on the big day, the more you care, the worse you do. If each time you’re not sure about an answer shakes your overall confidence, it’s going to be a very long test. Being blindsided by a question doesn’t make you an idiot. Derealization is a helpful skill, because dispassionate nonchalance is a better mindset than “this test determines my future.”

So, you need to start by not beating yourself up. Your specific goal of [insert high number here] is awesome and I hope you get it, but you need to know that goals are only helpful as a means of motivation. Not something to tie your entire self-worth into. When you check your performance and get demoralized, you are doing yourself a disservice. A friend’s performance, peoples’ posts on SDN—absolutely none of that matters.

When you get questions wrong, flag them and do them again. There are lots of reasons to get questions wrong and you need to approach the explanations as a chance to learn, not a chance to be disappointed.

I want to repeat that. The reason a high-quality qbank is such a good tool is twofold. 1) Your knowledge is only helpful (in this narrow artificial context) if it helps you answer a question. The best way to see how to apply it to a question is with a question. 2) The explanation teaches you both the key facts, additional competing/confounding information, and the context/test-taking/pearls/trends/etc.

A lot of people shortchange themselves on #2. They rush through with a focus on getting through them to get more volume instead of savoring the explanations. They get upset when they get a question wrong and don’t use it as a learning opportunity. You should almost want to get questions wrong because then it means you have an opportunity to improve, a potential blindspot to weed out. (Okay fine no one wants to get questions wrong). It’s depth, not breadth.

Emotional valence and overreading

The flip side is when people use that negative emotional valence from being wrong to overread the explanation. They take an exception and turn into a new rule. They generalize too much and try to apply something specific on one question as a generic teaching point to another question where it doesn’t apply (“but last time I guessed X and it was Y; this time it’s X, wtf!”). All of this comes from stress and self-doubt.

Remember, learning is a process. Stop paying so much attention to how you’re doing. Whether you do bad or good or your score changes with each practice exam doesn’t really matter except to help identify things to learn. This is how you’re going to study and you’re going to embrace it. You’re going to take the test one day and do your best on it. Agonizing over the data on the way is just self-flagellation.

As you get close to game day, you can switch to timed blocks to simulate the exam. Get into a groove. Find the confidence to go with your gut, not agonize, not get stressed by a long question stem, etc. If one particular thing seems like you’ll never learn it, then don’t. Your score on any exam you take in your whole life will never hinge on a single topic.

The most intimidating part of taking a high stakes exam like the MCAT or USMLE may be your nerves more than your fund of knowledge.

Reframing anxiety as excitement

During your dedicated review, one way to avoid burnout is to work on reframing your attitude from fear to excitement.

Anxiety is different then dread. It was going to be a disaster, you would feel dread. The fact that you are anxious means there’s a chance it might go well.

Telling yourself that you’re calm or to calm down does not work. You aren’t calm, you can’t calm down. At least not before the event starts. Heightened awareness is a sympathetic response, it cannot simply be tamped down with a little wishful thinking. But that heightened response can be reappraised. When you feel something you don’t like, don’t fight it: re-label it. Consistently.

So.

You’re doing this so you can learn, and–before you know it–you’ll be done.

That is astoundingly exciting. It’s a huge milestone.

You need to study, do your best, and be proud of yourself.

Academic Medicine and the Peter Principle

Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

The Three-legged Stool

Academic medicine is sometimes described as a three-legged stool, where the department/institution is balanced on the three pillars of clinical care, research, and education. There is a pervasive myth that academic physicians can do it all: be an outstanding clinician, an excellent teacher, and a prodigious researcher. The reality is that most people don’t have all three skills in sufficient measure, and even those that do are not given the requisite time to perform meaningfully in all three categories.

While polymaths exist, the idea of the physician-scientist is increasingly intractable in modern medicine. The demands of clinical work have increased substantially with increasingly advanced medicine, increased productivity/RVU expectations, often overwhelming documentation burdens, and greater trainee oversight. Meanwhile, research has gotten more complex at the same time that the grant money has dried up. More and more of the funding pie goes to fewer and fewer people. And, lastly, education is typically taken for granted as something that should just take care of itself, something we expect “clinician educators” to do without faculty development, dedicated time, or even credit.

It’s very easy to have an unbalanced stool. Departments tend to lean in one direction or another precisely because they are aligned to do so and are staffed accordingly. As Arthur Jones of Proctor & Gamble famously remarked, “All organizations are perfectly designed to get the results they get.”

Putting pressure on individuals to do everything—deliver excellent clinical care, teach/mentor students/trainees, and contribute to high-impact research—fails to acknowledge the reality on the ground that doing high-end work in any of these dimensions is hard. Without dedicated time and sufficient support, doing anything successfully for very long is a challenge. Trying to work toward impossible expectations (even self-imposed ones) is a big contributor to burnout. At least a veneer of control, self-determination, and respect are prerequisites–not luxuries–for a successful “knowledge worker”-type career. We could more reasonably expect people in every role to excel at one role, be competent at another, and largely ignore the third.

Hospitals and large academic institutions are not filled by flat teams of equals working on a common mission, they are occupied by layers of committees and bureaucracy. Rising stars often contribute more to their superior’s careers than their own. Progress, change, and new initiatives are choked by a spinning-wheels-grind of proposals, SOPs, committees (and subcommittees), amassing nebulous “stakeholders,” and every other trick in the large organization toolbox that isn’t bad in theory but should never be implemented universally and thoughtlessly. It’s all leadership in the I-attended-a-leadership-conference sense without any true leadership.

Physicians who focus on producing excellent care are derided as “worker bees” while those who believe in education are labeled “doesn’t like research.” And the managers rise to the level of their incompetence and perpetuate the hierarchy.

Meanwhile, the consultants and nonphysician leadership consolidate power outside of the traditional hierarchy. And how can we stop them, when we do such a bad job ourselves?

Measles is the original measles vaccine

Measles is the original measles vaccine. It’s a natural method that’s been around for centuries. It was good enough for my mother and my mother’s mother and her mother before her.

Unlike synthetic vaccines, which are modified by scientists in underground labs to reduce their potency, measles is completely organic.

From “I’m vaccinating my child the natural way–with measles” in McSweeney’s.

This may be excellent satire, but it could just have easily been lifted from an actual blog written by an actual flesh-and-blood idiot.

The Coming Changes to USMLE Scoring

In March of this year, there was the InCUS: Invitational Conference on USMLE Scoring. The results page is here, and the summary report is here.

Invitational? That means that the only people invited were stakeholders who are deeply entrenched in the status quo and/or directly profit from the USMLE system. Namely, the Association of American Medical Colleges (AAMC), American Medical Association (AMA), the Educational Commission for Foreign Medical Graduates (ECFMG), the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).

Absent? Regular humans like students, residents, or even much in the way of program directors, educators, etc. No big surprise. When a growing body of students and educators advocated for removing Step 2 CS because it was an easy superfluous reduplicative and expensive waste of time, the NBME just made that harder to pass. They’d much rather just change the paper you get at the end of the other tests than introspect or make a structural change.

So, the NBME has always said they didn’t like people using the score to evaluate medical students (but have spent an awfully long time letting people do just that):

Said another way, the exams were developed as medical licensure examinations and not as academic achievement exams.

The outcome of this big convening of masterminds? Well, the recommendations are extremely vague but give the impression that eventually removing the three-digit USMLE score is a likely component.

Recommendations specific to USMLE:
1) Reduce the adverse impact of the current overemphasis on USMLE performance in residency screening and selection through consideration of changes such as pass/fail scoring.
2) Accelerate research on the correlation of USMLE performance to measures of residency performance and clinical practice.
3) Minimize racial demographic differences that exist in USMLE performance.

Recommendations to the UME-GME transition system:
1) Convene a cross-organizational panel to create solutions for the assessment and transition challenges from UME to GME, targeting an approved proposal, including scope/timelines by end of calendar year 2019.

Indeed.

 

One of the unintended consequences of more medical schools moving to pass/fail amidst increasing medical school enrollment and flat residency spot numbers has been the increasing importance of the USMLE and the shadow curriculum it has created.

If Step 1 matters but your coursework does not, then you’d be better off in a correspondence course that let you spend all your time preparing for Step 1 and ignoring anything your school actually wants you to do. On the flip side, if the USMLE were to suddenly be pass/fail, then residency programs may be evaluating applicants with literally no comparative data from which to judge candidates.

Point #2 from the blockquote is fascinating in its awkward tardiness because everyone knows the correlation with most clinical performance is negligible, and no meaningful research would likely ever state otherwise. USMLE scores correlate with written boards’ pass rates, which themselves also do not correlate with clinical performance. It’s turtles all the way down. None of these tests actually test what they purport to. The whole system is in shambles from the SAT on up. They all measure a degree of general intelligence and preparation, but…who cares.

Despite the mea culpas about mental health, failing students, blah blah blah, not discussed at all–of course–is whether or not the USMLE sequence should even be maintained as is. There’s a painful failure of vision in a conference solely focused on…scoring.

For example, is CS something the NBME should be doing in the first place or isn’t that what an accredited medical school is for? Or, are Step 1, 2, and 3 testing sufficiently different things to do justify three different exams, and if they are, do all three really play a distinct role in the licensing process? One could easily argue that Step 2 CK is much more meaningful to clinical practice and residency performance than Step 1, which mainly has the benefit of a) being hard and b) having scores universally available during the residency application process because it’s taken earlier.

Feel free to submit your comments on these meaninglessly vague preliminary recommendations here.