From Dr. Benjamin Mazer’s “Medicine’s dangerous optimism – Lessons from Dr. Pangloss,” published in The Journal of the Royal Society of Medicine.

Consider the story of Dr. Pangloss, the fictional “professor of metaphysico-theologico-cosmolo-nigology” in Voltaire’s satirical eighteenth-century novel Candide. Dr. Pangloss is remembered for declaring that we live in the “best of all possible worlds.” Pangloss could find logical explanations for the pain and turmoil he saw around him. No one suffered without a good reason. In the face of healthcare’s overwhelming complexity, doctors can also inadvertently resort to assuming our current situation is the best we can hope for.

I am defining Panglossian optimism as the unproven assumption that an observed outcome is the necessary outcome.

That’s the delightful set-up. He discusses four such fallacies:

1. Favorable outcomes are attributable to medical care, unfavorable outcomes to a lack of it
2. Arduous training and examination are what produce good doctors
3. Physician outcomes predict patient outcomes
4. A sufficiently popular intervention cannot be tested

I particularly love #2. It is, in part, the fallacy of hazing as a constructive and formative practice.

If evaluating applicants is currently too challenging without a Step 1 score, then a Step 1 score must be necessary to evaluate applicants. This is not a sound assumption. A tool that does not select for the qualities we desire inserts bias and noise into the process, making it less efficient.

We also encounter faulty Panglossian reasoning in debates over whether residency duty hours should be restricted for patient and trainee wellbeing. Many experienced physicians imagine their skills molded in the cauldron of inhumane work hours. It is true that they worked inhumane hours, and that many possess excellent skills. The Panglossian assumption is that the latter derives from the former.

For those dejected by the state of high-stakes exams, the arduousness of the journey to attendinghood, or the feebleness of so much of our tautological medical science, his conclusion:

We rationalize the irrational in times of perceived helplessness. By creating an environment more hospitable to questioning and change, we may be less drawn to false comforts.

So, when you are done, or, when you have a position of authority: be part of the solution.

Another year, another set of explanations. As always, the order here reflects that of the new PDF released in February 2020. The official practice material page subsequently reverted back to the 2019 version, but as you can see the 2020 link remains live. (If you’re taking this in 2021, then see those explanations for updated questions #24 and 53)

Last year’s 2019 set is available here, though it was almost entirely a repeat of the 2018 set explained here.

The asterisks (*) signifies a new question, of which there are 36.

Read More →

Update: my explanations for these sets are now available: Step 1 and Step 2 CK.

Earlier this year the NBME released updated 2020 practice materials for both Step 1 and Step 2 CK. There are a bunch of new Step 1 questions and the Step 2 set is entirely brand new (the first meaningful change in several years). I was going to continue my annual tradition of explanations but then noticed that the website reverted back to the 2019 sets.

As is their tendency, the NBME isn’t very quick to manage outdated URLs. The PDFs for both new sets are still accessible:

• The 2020 USMLE Step 1 Practice Questions
• The 2020 USMLE Step 2 CK Practice Questions

I don’t know if these will simply come back as official sets soon, but it seems they were likely removed because of COVID-19, so it might be a while.

But they are free highest-quality questions and remain worth your time.

Another excellent follow-up from Tomas Pueyo about the need to stop doing half-assed mitigation measures.

On one side, countries can go the mitigation route: create a massive epidemic, overwhelm the healthcare system, drive the death of millions of people, and release new mutations of this virus in the wild.

On the other, countries can fight. They can lock down for a few weeks to buy us time, create an educated action plan, and control this virus until we have a vaccine [ed: or treatment].

Governments around the world today, including some such as the US, the UK or Switzerland have so far chosen the mitigation path.

That means they’re giving up without a fight. They see other countries having successfully fought this, but they say: “We can’t do that!”

We can do better together with decisive action and cohesive government intervention/support.

Humans are a communal species. While we need to be alone, right now, we should act together.

Highlights from Joseph V. Simone’s “Understanding Academic Medical Centers,” published way back in 1999 (hat tip @RichDuszak):

• Institutions Don’t Love You Back.

A wise colleague once told me that job security was the ability to move to another job (because of professional independence).

• Institutions Have Infinite Time Horizons to Attain Goals, But an Individual Has a Relatively Short Productive Period.

There is little incentive for an institution to rapidly cut through the bureaucratic morass. An institution will always outlast a dissenting individual, regardless of the merit of the case.

• Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers.

Generous.

• Institutional Incompetents and Troublemakers Are Often Transferred to Another Area, Where They Continue to Be Incompetent or Troublemakers.

They force others to pick up the slack or repair their mistakes, reducing everyone’s efficiency. If this continues for long, those who are consistently unproductive may become the majority because the competent learn that the institution sees no virtue in hard work and collaboration.

• Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader.

Examples of such criteria include a long bibliography, scientific eminence, institutional longevity, ready availability, a willingness to not rock the boat, or to accept inadequate resources. Choosing leaders is not a science, but it is surprising how often management skills, interpersonal skills, and experience are undervalued.

See: Academic Medicine & The Peter Principle.

• In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People.

Some hesitate to recruit a person who is smart enough and ambitious enough to compete with them. Others want a position filled at any cost because of “desperate” clinical need or other institutional pressures. If that approach continues for long, the third-class people will eventually dominate in numbers and influence and ultimately chase away any first-rate people that remain.

• In Academic Institutions, Muck Flows Uphill.

Leaders often try to ignore or deflect the unpleasant mess, but the longer it incubates, the harder it will be to sanitize.

See: the dropped balls nationwide with current COVID-19 pandemic.

• Personal Attitude and Team Compatibility Is Grossly Underrated in Faculty Recruiting.

A faculty member may be very productive personally but create an atmosphere that reduces the productivity of everyone else.

Annoying people are the black holes of camaraderie and joy.

There have been lots of good articles about the novel Coronavirus and the embarrassing state of America’s public health response.

This one from Vox has some excellent charts.

This one on Medium breaks down some of the underlying relationship mechanics of social distancing measures and spread as well as how one estimates the number of hidden (but transmitting) cases in a population (which does require some assumptions).

Here’s what I’m going to cover in this article, with lots of charts, data and models with plenty of sources:
— How many cases of coronavirus will there be in your area?
— What will happen when these cases materialize?
— What should you do?
— When?

When you’re done reading the article, this is what you’ll take away:

The coronavirus is coming to you.
It’s coming at an exponential speed: gradually, and then suddenly.
It’s a matter of days. Maybe a week or two.
When it does, your healthcare system will be overwhelmed.
Your fellow citizens will be treated in the hallways.
Exhausted healthcare workers will break down. Some will die.
They will have to decide which patient gets the oxygen and which one dies.
The only way to prevent this is social distancing today. Not tomorrow. Today.
That means keeping as many people home as possible, starting now.

Important reading.