Atul Gawande with another fun New Yorker feature on The Heroism of Incremental Care:

Rescue work delivers much more certainty. There is a beginning and an end to the effort. And you know what all the money and effort is (and is not) accomplishing. We don’t like to address problems until they are well upon us and unavoidable, and we don’t trust solutions that promise benefits only down the road.

Incrementalists nonetheless want us to take a longer view. They want us to believe that they can recognize problems before they happen, and that, with steady, iterative effort over years, they can reduce, delay, or eliminate them. Yet incrementalists also want us to accept that they will never be able to fully anticipate or prevent all problems. This makes for a hard sell. The incrementalists’ contribution is more cryptic than the rescuers’, and yet also more ambitious. They are claiming, in essence, to be able to predict and shape the future. They want us to put our money on it.

But our free-market insurance only wants to pay for 15 minutes of it, of course.

As an American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room. Incrementalists are lucky if they can hire a nurse.

and

The difference between what’s made available to me as a surgeon and what’s made available to our internists or pediatricians or H.I.V. specialists is not just shortsighted—it’s immoral.

When people think about rationing care, they talk about rationing care to people. About grandma not getting a pacemaker or a new hip. They speak disparagingly about Canada or the UK. What people don’t realize is that we also ration care internally within medicine. We just do it based on RVUs.

Then, at the end, he finishes with some jabs at half-baked plans to repeal the ACA and a powerful somber note:

In this era of advancing information, it will become evident that, for everyone, life is a preexisting condition waiting to happen.

Yesterday in JAMA:

We found that elderly patients receiving inpatient care from female internists had 30-day lower mortality and readmission rates compared with patients cared for by male internists. This association was consistent across a variety of conditions and across patients’ severity of illness. Taken together with previous evidence suggesting that male and female physicians may practice differently, our findings indicate that potential differences in practice patterns between male and female physicians may have important clinical implications for patient outcomes.

and

Furthermore, given that there are more than 10 million Medicare hospitalizations due to medical conditions in the United States annually and assuming that the association between sex and mortality is causal, we estimate that approximately 32 000 fewer patients would die if male physicians could achieve the same outcomes as female physicians every year.

Confirmation bias aside, this general finding does ring true to me.

Reading a bit deeper, though, one physician characteristic that was underplayed was that female physicians saw fewer patients overall (i.e. more were part-time). This might function as a proxy for burnout and its associated poor patient care outcomes. Something to consider for the men who are already in medicine and dragging it down.

About the Exam

The ABPN psychiatry exam is a marathon day-long computerized multiple-choice exam offered once a year with two dates in September. You can apply as early as November but the deadline is February (current dates here) through the “folio” website. You won’t schedule the actual exam until scheduling is opened, usually around 2 months before the exam dates. Results take around 8-10 weeks. In 2016, scores were released on November 30 (so 10 weeks).

Eligibility (see the info document):

• Graduate from a legit medical school
• Have a full medical license
• Finish residency (or be a senior on track to finish it before taking the test)
• Complete 3 Clinical Skills Evaluations (CSE)

Costs:

• $700 application fee when you register to tell them you’re ready
• $1685 examination fee when you schedule the exam with Pearson VUE.

You have 7 years after finishing your ACGME residency to pass the ABPN to become board certified. So you have plenty of tries if things go south (subsequent tries “only” cost the $1685 exam fee).

Exam & Content

You get 50 minutes of break time that you can take between sections. Any breaks you take past the 50 minutes are permitted, but they then eat into your actual test time, which is 8.5 hours.

8 sections are split between Part A+B or Part C questions:

• 110 questions in Part A (Basic Concepts in Psychiatry)
• 110 questions in Part B (Neurology and Neurosciences)
• 230 questions in Part C (Clinical Psychiatry).

So 8 sections of 50-65 questions each for a total of 450 questions over 510 minutes. About 20% is neurology/neuroscience. Tack on a 5-minute intro and 5-minute post-test survey and 50 minutes break time, and the whole day can take up to 9.5 hours. 4 sections are vignette based and 4 sections are pure stand-alone questions (from the format and scoring document):

Stand-alone questions are one-best-answer multiple-choice questions that are not associated with any other questions. Part A and Part B questions are all stand-alone questions. For vignette questions, there are typically two to ten multiple-choice questions linked to a common case that may be presented in a video clip, which may vary in length from one to four minutes, an audio clip, or in a text vignette.

The ABPN does provide one sample video vignette to whet your appetite.

Historically, each Part was graded separately and needed to be passed. Now the test is graded in aggregate; it’s no longer possible to fail a single section and thus fail the exam. In 2016, a 71% correct overall was the passing threshold.

And everything is now DSM-V (from the policy document):

Starting in 2017, all specifications and content of all ABPN computer-delivered examinations will be based solely on DSM-5. No DSM-IV-TM classifications and diagnostic criteria will be applicable.

Board Books

• Psychiatry Test Preparation and Review Manual (“Kenny and Spiegel”) is the favorite overall. It was updated to DSM-V in 2016 and includes 1100 questions (6 tests of 150 questions + 160 case vignette questions). The book does come with online qbank-style access, which is cool and can give you topic-performance feedback as well as access to 8 video vignettes.
• Massachusetts General Hospital Psychiatry Update & Board Preparation, which is a review book coupled with ~400 questions. Succinct material coverage but not updated to DSV-V yet.
• Kaplan & Sadock’s Study Guide and Self-Examination Review in Psychiatry, also not updated to DSM-V yet.

Question Banks

Board Vitals

The most popular question bank for the ABPN is Board Vitals (which also has question banks for other specialties as well). This resource is definitely not error-free, and some users feel that it contains too much esoterica, but it’s still widely used. It’s $139 for a month. Using the code BW10 at checkout also gets you 10% off.

Overall, questions represent the board style pretty well, and the product is a good size (1639 questions). BV was completely updated to DSM-V in 2017. A lot of the “neuro” questions are actually psychiatry, so the neuro coverage is less than you’d guess from when you first log in. As an exclusively web-based product, there is no off-line access. You also need to hit the “show explanation” button to see the explanation for a question, which gets tiring after a while.

There is also a new optional 250 question package (actually 257) based on video vignettes available as an add-on (another $139/month), which is pricey but basically the only a la carte source for this question format currently.

TrueLearn

A new player is TrueLearn, which has products for both the PRITE and the ABPN ($25 off with that link). Questions overall feel harder and have a more basic science/med school type feel than those found in the other resources. The interface is a little more cluttered, but the software is overall solid: you can cross out answer choices and there’s also a “bottom line” summary statement, which is helpful.

Ultimately, TrueLearn is a reasonable second online question source after Board Vitals but overall probably not quite as high-yield yet. Overall, a couple of question sources are likely to be sufficient, so after Kenny & Spiegel and Board Vitals +/- more neuro review depending on your background, most test-takers are probably done question-wise.

Rosh Review

Rosh Review is the third of the big three online qbanks, and they offer a Pass Guarantee. 10% off their certification, child and adolescent, and PRITE products with code RoshPsych10.

Beat the Boards

Is a $1,097 online lecture course with a ~1000 questions and ~50 vignettes. We reached out to them to provide access for this review and were totally ignored. This is really expensive and ultimately unnecessary to pass.

Book round-out:

• Kaufman’s Clinical Neurology for Psychiatrists may be too long to read cover to cover during a limited post-work board review, but it also contains 2000 questions (extras are online) to help round out your neurology review.
• Psychiatry Board Review: Pearls of Wisdom is a change of pace written in a concise Q&A format which was useful as an adjunct, but it’s now a bit out of date and was neither as consistent nor as thorough as the other review books. It does contain a lot of high yield facts organized in a quick-read manner but is crying out for a DSM-V update.
• Unlike for Step 1, First Aid for the Psychiatry Boards isn’t the strongest source for psychiatry review and can be ignored. It purportedly does a passable job for neurology but remains a safe pass unless you just need to have another book.

Thanks to my awesome wife (the esteemed psychiatrist) for help in writing this post.

First, my book recommendations for the core third-year clerkships can be found here. What follows are “best” book recommendations geared for MS3/MS4 elective rotations and sub-internships (“sub-i’s”), including most of the surgical and medical subspecialties. Some of these books are geared for medical students; others more for residents. I’ve done my best to include both when appropriate, including a first buy single resource when possible and alternates and options for further reading when necessary. For more info about methodology, feel free to peruse this.

Let me preface this list by saying that a typical student on a normal rotation in a field outside their main interest does not need to buy anything. Even in a field of interest, many (most?) students will simply wait to buy books until they have a book fund during residency and will nonetheless succeed. No one has a monopoly on medicine and medical knowledge; in this new era of medicine, you don’t need to buy anything simply for your education if there isn’t an important test at the end of it.

As a general rule, you will rarely go wrong reading UpToDate for your typical brownie point efforts (particularly in non-surgical fields). As a matter of gamesmanship, you of course never say, “UpToDate says,” you merely state the information as a fact, occasionally referencing “reading” you did or “studies have shown.” It works well to click on the link to the footnote on anything you feel might net you a gold star, click on the reference, then browse the abstract. Then you could say, “a big RCT in Sweden demonstrated…” and if anyone pushes you on details you didn’t glean from the abstract, you simply say, “good question – I don’t recall – I’ll need to go back and look further.”

It should also be said: your success on your rotations has much more to do with how you function as a human being than how many facts you know.

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After a few years of seeing medical students on their interviews from the other side, here are a few of my favorite new considerations for dos/don’ts during your interviews (note, many of these also apply to your personal statement):

Don’t: Say negative things about other fields.

The fact that you think other fields suck is not the reason people want to hear when they ask you, “Why X?” The biggest problem with field-specific negativity is it often reveals your naivete. An applicant applying to radiology who says they didn’t go into medicine because they don’t like writing long notes and spending the day on the phone calling specialists may sound silly, because of course a radiologist spends all day dictating reports instead of notes and talking to referring clinicians on the phone. Every field has its pros and cons, and in many cases, the overlap between fields can be as substantial as it is surprising. There’s no free lunch in medicine. So stay positive.

Don’t: Spout overly familiar things with your field

You may be familiar with concept of “fourth year swagger”: the horrible disease that strikes when a student finishes their third year and, after being exposed to a few weeks of multiple different specialties, thinks they understand everything about medicine, knows all the ins and outs of various fields, and certainly isn’t just parroting the shit that other people who also don’t know what they’re talking about say to them. If you casually repeat things you read on internet forums, this goes doubly for you.

If you had the chance to interview college students applying for medical school, you may have been surprised at how clueless they are about medicine. But of course they are! And almost certainly you were as well. If you think a med school applicant who wants to do a “cardiology residency” sounds naive, then keep in mind your imperfect grasp of your chosen field. You’ve at most done a few months rotating as a student, potentially as little as none before you made your choice. You have no idea what it would actually be like to do that field day in and day out for decades. The things that excite you now will likely be routine. Other aspects that you hadn’t considered may be your passion. So while you need to articulate why you’ve chosen your field, you don’t want to come across as a know it all. Overconfidence is a vice (unless you’re a general surgeon [ba-dum-dum]).

Do: Be normal if you have an MD/PhD…

People with PhDs need to play the game of both implying future academic productivity with a seemingly earnest desire to master clinical skills and do patient care. You don’t want to fall into the trap of seeming like a scientist who views residency and patient care like an obstacle to doing their true work. Or an awkward serial killer. Or, even worse, someone who is tired of doing research.

Do: Own your problems

You just can’t be embarrassed and don’t need to be nervous. Consider the interview as your chance to see if the program is right for you and less about you auditioning for them. It doesn’t matter if you have (in no particular order) a failure, a leave of absence, a heinous evaluation, a stutter, a disfiguring condition, or a weird laugh. You need to be comfortable and happy with yourself if you want people to be comfortable with hiring you. So own it. When appropriate: offer explanations, not excuses; acknowledge everything, apologize for nothing. If you needed to get better, explain how you have and that you’re still working on it (whatever it is).

I recently came across this guide from UW that I liked that addresses this nicely.

Do: Have “questions” ready

The hardest question you’ll get on the trail very well might be “what questions do you have for me?” It’s the hardest because the real answer is none, and you’ll stop listening the moment you ask anything. Here a few of my favored BS ones to put in your arsenal, particularly helpful for later in the season when you’re tired of pretending you care what a random person thinks about anything.

• What is one thing that surprised you when you came to work here?
• Was there anything you didn’t expect between when you applied and when you started working here? (for a resident interviewer or newish faculty)
• How has this place changed over the past few years?
• Do you foresee any changes coming to the program or department in the near future?

Specific questions about the curriculum, rotations, electives, dedicated research time, etc are all great—IF they haven’t been discussed already in a presentation, aren’t in a printout in your interview folder, and aren’t readily available on the website. Asking about things people think you should know is awkward. If you do or aren’t sure, try to frame them as opinion questions (e.g. “How do you feel about the research track offering? Is there support for this dedicated time among the faculty?”).

Also consider: my thoughts on not screwing the interview process in general.

Let’s start with this premise: In the 21st century, the medical school basic science curriculum is probably best learned through guided self-study and likely not whatever your school is trying to teach you (especially if that involves the blind leading the blind via TBL). How much you can fulfill this ideal will unfortunately depend on how cooperative your school is with reality.

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