The Limitations of Copy and Paste

From “To Kickstart a New Behavior, Copy and Paste” by Kathy Milkman, author of the new book, How to Change, which suggests the best way to master a new skill is to emulate the methods of someone successful.

Happily, it’s easy to turn yourself into a deliberate copy-and-paster. The next time you’re falling short of a goal, look to high-achieving peers for answers. If you’d like to get more sleep, a well-rested friend with a similar lifestyle may be able to help. If you’d like to commute on public transit, don’t just look up the train schedules—talk to a neighbor who’s already abandoned her car. You’re likely to go further faster if you find the person who’s already achieving what you want to achieve and copy and paste their tactics than if you simply let social forces influence you through osmosis.

Kinda maybe sorta.

There is a big, big difference between emulating psychosocial habits (like vegetarianism or fashion) or noncomplex skills (like a workable commute route or some forms of regular exercise) and achieving success in a skill-based habit like practicing medicine or playing an instrument.

For low-stakes or low-commitment behaviors, sure. It’s reasonable to try to save time and give yourself the boost of something that has worked for someone. Copy-paste saves you from analysis paralysis.

But copy and paste is also a guaranteed way to fully embrace survivorship bias. You don’t know if the people you are emulating succeeded because of their methods or despite them. You don’t know if those methods are optimal for you or if the most important aspects of said methods are even those which are externally visible or consciously retrievable from the expert.

A lot of people don’t know why they’re successful, and their attempts to craft a narrative about their successes are fiction.

And when it comes to experts instead of peers, one of the common difficulties for many is that it’s been so long since they’ve been a novice that they literally don’t know what it’s like anymore. Their memories of their early growth are fuzzy and often out-of-date to boot.

As we are back in the middle of USMLE Step season for the medical students among you, I am reminded of this post I wrote in 2014 about the Methods to Success Fallacy.

Being “Backable” for Residency Interviews

After reading stories of match success and failure on social media this spring, I’m already thinking about another set of virtual interviews this fall and contemplating how applicants can shine.

Here are some takeaways from Backable: The Surprising Truth Behind What Makes People Take a Chance on You. While this book and its many examples mostly center on entrepreneurship and how startups can get money from investors, there are some nuggets that cross domains nicely. The interview is in some ways a pitch meeting where you’re selling yourself.

The power of unique perspectives and experience

[Investor Ben] Horowitz responded that great ideas typically stem from an “earned secret”—discovered by going out into the world and “learning something that not a lot of other people know.”

Everyone says the same things in personal statements, is drawn to their chosen fields for the same reasons, and has largely similar clinical experiences. When you have rare real-world experience–frankly in any context or domain–that makes you different.

Share how those insights have changed you and inform your approach to medicine.

Earned insights are rare

What’s the single best piece of advice that would help them succeed?” [Oscar-winning producer Brian] Grazer paused for a moment, then said, “Give me something that isn’t google-able. I want an idea that is based on a surprise insight. Not something I could find through a Google search.”

An idea that stems from hands-on experience is way more backable than the same exact idea if it simply originated sitting behind a desk. But the catch is, without being boastful, you have to make that effort shine through your pitch. It can’t be hidden.

Here’s an open secret: a few months of clinical experience don’t make you an expert in your chosen field just as even less time in other specialties doesn’t make you an expert in those either. Bringing fourth-year swagger to interviews often isn’t a great idea.

That said, real insights–whether about your specialty, health care, or even just being a human being and having a good attitude about showing up to work every day for your patients–are a breath of fresh air. I love when I can tell an applicant has an active mind and thoughtful approach, when I can really see their gears turning.

Why should someone be scared to miss out on you?

As creators, our job isn’t to use FOMO to manipulate backers, but rather to neutralize their fear of taking a bad bet. Though it may sound strange, FOMO can make a risky bet feel safe because it shields us from the risk of being left behind. This feeling of inevitability rarely comes from the argument that we should change the world, but rather from the argument that the world is already changing—with or without us.

If there’s a knock on your record and you’re scared people are going to pass you over, own it. The typical advice is to talk about what you learned after your failure, how you’ve changed, and other such bland platitudes, but the fact is that I expect anyone who has messed up to tell me they’ve grown.

That’s all fine. Go ahead and do that.

But…don’t just approach your candidacy from a position of weakness. What about you is unique or special? Why should a program director be scared to lose you? Why are you backable despite (or because of) that setback?

Connections are powerful

Salman Rushdie once wrote, “Most of what matters in our lives takes place in our absence.” While we’re present for the pitch, we’re most likely absent for the hallway huddles, backroom meetings, and email threads that decide the fate of our ideas. Backers become fierce advocates when they are on the inside of an idea. They crack their own egg and add it to the mix.

Stronger-than-average connections with your interviewer will cause people to go to bat for you in the post-interview huddle. So many interviews are bland Q&A. True connections are rare. If you can get an organic discussion going and the time flies, everybody wins.

Each interaction is an independent variable

We don’t typically win people over in one conversation, but through a series of interactions that builds trust and confidence. Even if the last conversation went poorly, you can use the next one to show them how they influenced your work. This type of follow-up is so powerful that it can often change a backer’s response from no to yes.

You can’t really do this with your interviewer (post-interview correspondence doesn’t carry that kind of power), but you can take each interview as a fresh start.  Don’t let one sour interaction spoil the day.

Interviewing is a skill that requires practice

We’ll spend hours researching, outlining, pulling together slides—but very little time practicing what we’re going to share. The feeling seems to be that if we have the right content and we know it well enough, then there’s no need for practice. But I’ve found that backable people tend to practice their pitch extensively before walking into the room. They practice with friends, family, and colleagues. They’re rehearsing on jogs with running partners, in the break room, and during happy hour. They prepare themselves for high-stakes pitches through lots of low-stakes practice sessions—what I now call exhibition matches.

You need to practice. The common approach is to do practice interviews, often with residents and faculty at your home institution (and potentially online organized on social media). You should do those things.

But I’d take it a step further.

You should talk to strangers. Practice having genuine interactions and conversations with people who don’t know you.  Practice really listening to your patients. Get to know them as the three-dimensional human beings they are.

The easy flow of conversation is a delight to interviewers.

You are a process, not an outcome

The other techniques in this book got me comfortable with content, but I still had to learn to get truly comfortable with myself. I had to learn to let go of my ego—to express, rather than impress.

So much of your identity feels tied to your success in school, the match, and your developing career as a physician. But internal validation is always superior to external validation. You don’t and can’t control outcomes. You–at best–control yourself and your approach.

You will enjoy and likely be more successful in the match process if you are content with yourself, happy to do your best, and try to find a good fit. We call it “practicing” medicine, but living life is also the practice of showing up each day working on being the version of ourselves that we strive to be.

When you receive an interview, your goal is not to impress your interviewers. It should be to express yourself and be open to others so that you can find the best place to live and grow in your practice.

Shallow versus Deep. Prolific versus Profound.

From Rest: Why You Get More Done When You Work Less:

We see work and rest as binaries. Even more problematic, we think of rest as simply the absence of work, not as something that stands on its own or has its own qualities. Rest is merely a negative space in a life defined by toil and ambition and accomplishment. When we define ourselves by our work, by our dedication and effectiveness and willingness to go the extra mile, then it’s easy to see rest as the negation of all those things. If your work is your self, when you cease to work, you cease to exist.

What fraction of doctors (and miscellaneous business workaholics) do you think still believe rest is for the weak and that the ability to slog and hustle is not just good but truly enviable?

Second, most scientists assumed that long hours were necessary to produce great work and that “an avalanche of lectures, articles, and books” would loosen some profound insight. This was one reason they willingly accepted a world of faster science: they believed it would make their own science better. But this was a style of work, Ramón y Cajal argued, that led to asking only shallow, easily answered questions rather than hard, fundamental ones. It created the appearance of profundity and feelings of productivity but did not lead to substantial discoveries. Choosing to be prolific, he contended, meant closing off the possibility of doing great work.

Just like many jobs are bullshit jobs, much of our research is bullshit research. If we reward volume, we disincentive depth.

As Vinay Prasad was quoted in the Atlantic, “Many papers serve no purpose, advance no agenda, may not be correct, make no sense, and are poorly read. But they are required for promotion.”

When we treat workaholics as heroes, we express a belief that labor rather than contemplation is the wellspring of great ideas and that the success of individuals and companies is a measure of their long hours.

And this is one of the tough parts about almost everything written about deep work, rest, the power of no, when to say yes, and everything else in the modern business/productivity/self-improvement genre. The approaches just don’t apply very well out-of-the-box to service workers.

Doctors are primarily service workers. If we work more hours, we see more patients. While there is almost certainly a diminishing return in terms of quality care, there is no diminishing return for billing. A doctor generates more RVUs when they have more clinical hours, and that means more profits for their handlers (until someone burns out and quits).

William Osler advised students that “four or five hours daily it is not much to ask” to devote to their studies, “but one day must tell another, one week certify another, one month bear witness to another of the same story.” A few hours haphazardly spent and giant bursts of effort were both equally fruitless; it was necessary to combine focus and routine. (He lived what he preached: one fellow student recalled that in his habits Osler was “more regular and systematic than words can say.”)

Cramming is bad. Overwork is bad. A reasonable concerted effort over a long period of time is good.

Studying 4-5 hours a day was apparently a reasonable amount to Osler’s sensibility. Olser, if you recall, founded the first residency training program at Johns Hopkins.

Do you remember when the heads of the NBME and FSMB suggested in 2019 that a pass/fail USMLE Step 1 would be bad because students might take the decreased pressure as an opportunity to watch Netflix? Because I do.

Diganostic FOMO

From Suneel (brother of Sanjay) Gupta’s Backable: The Surprising Truth Behind What Makes People Take a Chance on You:

Apply the following quotation to why doctors don’t want to make the call:

If the fear of betting on the wrong idea is twice as powerful as the pleasure of betting on the right idea, then we can’t neutralize the fear of losing with the pleasure of winning. We can only neutralize the fear of losing with…the fear of losing. Enter FOMO, the fear of missing out. For backers, the only thing equally powerful to missing is…missing out.

Gupta goes on to discuss how potential backers initially too scared to be the first investor eventually pile on to avoid missing out on rare unicorns.

The fear of betting on the wrong idea in medicine manifests through overtesting and hedging. More than our desire to be right, we really don’t want to be wrong. But we can’t use the usual FOMO to our advantage, because medicine isn’t about making pitches or raising money but about directly helping individual people.

We don’t want to miss anything and so are forced to entertain everything, even if that means everyone in the ED gets a CT scan or a radiologist gives an impression a mile long with the words “cannot be excluded” featured prominently next to something extremely scary.

The true solution is this: we need to disentangle the outcome from the process. You can have good outcomes from bad decisions (dumb luck) or you can have bad outcomes after good decisions (bad luck). Luck and uncertainty are part of life, and they’re a big part of medicine. We should expect some bad outcomes even when doing the right thing, and we shouldn’t forget that overtesting and overdiagnosis have their own costs, risks, and harms. Passing the buck to the future doesn’t mean it won’t be paid.

By not making the call, we are making a decision: a decision to abdicate the diagnostic yield of an encounter or examination.

There are absolutely times when uncertainly is prudent. There are true “differential” cases. But the FOMO of diagnostic medicine should be passing up an opportunity to clearly define the next steps in a patient’s care.

Price Transparency and the True Cost of Quality Healthcare

When you read healthcare reviews online, so many of the 1-star reviews relate to prices: patients frustrated by high costs or surprised by high bills. It’s easy to think that price transparency rules will help. One key problem is that healthcare consumers are intermittently if not completely insulated from the true costs of their care due to the filter of commercial insurance. It’s hard to blame people for feeling that their doctor’s time is “worth” a $35 copay instead of the hundreds of dollars they really pay indirectly.

When my family moved from typical employer-provided health insurance to a high-deductible plan, I finally started seeing firsthand how much things really “cost,” and how ludicrous billing gamesmanship practices have become.

I’m a physician, and even I find it striking.

I recently received a bill for hundreds of dollars for an annual well-person patient visit that should have been covered at 100%. If you manage to complain about anything during the intake, you see, you also get billed for a problem visit at the same time.

Is that nuts? Well, yes, of course it is. But this is the world we live in and how institutions pay the bills.

Dr. Peter Ubel had an interesting article in The Atlantic back in 2013 called “How Price Transparency Could End Up Increasing Health-Care Costs” that holds up pretty well. His main thought experiment centers on imaging, which is an easy but sort of plus/minus example.

The same kind of consumer pressure rarely exerts a similar influence on the cost and quality of health-care goods. For starters, most patients have little inclination, or motivation, to shop for health-care bargains. Insurance companies pick up most of the tab for patients’ health-care. A patient who pays a $150 co-pay for an MRI (like I do with my insurance) won’t care whether the clinic she goes to charges the insurance company $400 or $800 for that MRI. The MRI is still going to cost the patient $150. Even patients responsible for 20 percent of the tab (a phenomenon called co-insurance) face a maximum bill of only $160 in this circumstance. That is not an inconsequential amount of money, but it is still not enough money to prompt most patients to shop around for less expensive alternatives, especially when most consumers don’t realize that the price of such for services often varies significantly, with little discernible difference in quality.

To make matters worse, patients often don’t shop for health care in the kind of rationally defensible way that economic theory expects them to. According to neoclassical economics, when making purchasing decisions consumers independently weigh the costs of services from the quality of those same services. If toaster A is more expensive than toaster B, the consumer won’t buy A unless it is better than B in some way — unless it is more durable or has better features — and unless these improved features are worth the extra money.

While some patients shop around for imaging services, many stay within a larger system for all their care or go where their doctor tells them. A more meaningful scenario in a large metro would be to compare broad costs across multiple specialties/types of care across multiple health systems. Say, in Dallas, would you generally pay less at UT Southwestern, Health Texas, or Texas Health? Does that hold true for primary care and specialty care? Are there certain categories of chronic diseases that one network does better or worse with? What about labs and imaging?

Due to network effects, a consumer may not meaningfully be able to choose where to do every little thing, but rapidly comparing systems is perhaps not beyond reach. It would be nice to know, for example, which places are playing games to maximize insurance payouts at patients’ expense and which (if any) aren’t.

Sometimes, however, cost and quality are not perceived by consumers as being independent attributes. Instead, people assume the cost of a good or service tells them something about its quality. For instance, blind taste tests have shown that consumers rate the flavor of a $100 bottle of wine as being superior to that of a $10 bottle of wine, even when researchers have given people the exact same wines to drink. Other studies show that expensive pain pills reduce pain better than the same pills listed at a lower price. Price, then, leads to a placebo effect.

Such a placebo effect is no major concern in the context of wine tasting and pain pills (even if it suggests that consumers could save themselves some money if they didn’t hold this strange belief that higher cost means higher quality). But suppose your doctor asks you to get a spinal MRI to evaluate the cause of your back pain, and you decide to shop around for prices before getting the test. Would greater price transparency cause you to choose an MRI provider more rationally? Or would you instead mistakenly assume that higher price means higher quality? There is reason to worry that price transparency won’t lead consumers to make savvy decisions. It is too difficult for people to know which health-care provider offers the highest quality care.

If patients are not going to make savvy use of price information to choose higher quality, lower cost health-care, some health-care providers, like doctors and hospitals, will probably respond to price transparency by raising their prices.

And there’s the rub: is it a race to the bottom or a slow creep to the top? And if it’s both, how do we predict and influence the outcome? If the growth of debt-fluid corporate and private equity has taught us anything, it’s that competition is fickle, and it doesn’t take much for a dominant position to be abused.

Imagine you direct an MRI center in Massachusetts, and the state government requires you and your competitors to post prices for your services. You consequently find out that the MRI center around the corner from you charges $300 more than you do for their spinal MRIs, and that this increased price hasn’t hurt their business. Imagine, also, that you are convinced that your competitors don’t offer higher quality MRI scans than you do — your MRI machines are just as new and shiny as theirs; your radiologists and technicians are just as well trained. In that case, if patients are not going to be price-sensitive, you are going to raise your prices to match your competitor’s. Otherwise you are just leaving money on the table.

Quality in healthcare is a theoretically important metric but it is so, so poorly measured and understood. Customer satisfaction? Not so good. Outcomes? Highly influenced by patient selection. Healthcare is heterogeneous and complex.

Ultimately, the problem is complex and nuanced, but we should keep this in mind. Efforts to increase price transparency through state and federal law need to be carefully crafted and closely followed. Such laws should include research funding that would enable experts to evaluate how the law influences patient and provider behavior.

Also, whenever possible, price transparency should be accompanied by quality transparency. We need to provide consumers with information not only about the cost of their services but also about the quality of those services, so that they can trade off between the two when necessary. I recognize that this is a huge challenge. Measuring health care quality is no simple task. But if we are going to push for greater price transparency, we should also increase our efforts to determine the quality of health care offered by competing providers. Without such efforts, consumers will not know when, or whether, higher prices are justified.

It’s no surprise that optimizing for cost seems like a reasonable plan given how easy it is to compare versus how hard meaningful quality indicators are to measure.

But price selection in the absence of quality selection creates a perverse incentive for the cheapest lowest-quality-but-just-barely-permissible product.