Ben White

How I read NBME/USMLE questions

04.26.15 // Medicine

From a reader:

What’s your step by step process when answering questions on the NBME shelf exams? I have been reading the question first while highlighting the key words and then reading the answer choices (often glancing back at the words I highlighted to confirm that the answer choice I chose is correct.) With this method, I am sometimes pressed with time and tend to rush towards the end. Could you talk a little about your approach to questions on the shelf?

In the past, I’ve written about some of the ways I break down NBME and USMLE questions, but I haven’t actually written about how I really read one. That may be because the answer is relatively anticlimactic, but here I’ll talk a little bit about my focus on flexibility and speed over rigidity when it comes to approaching Step questions (with a few examples from the 2014 official sample questions). As always, this isn’t necessarily what you should do; it’s just my take. When I used to teach Kaplan MCAT, part of the “method” placed a lot of emphasis on using passage mapping as a consistent approach. If time management isn’t a problem for you, there’s no reason you can’t start/continue using these more involved strategies. But if you don’t have a big system and feel left out when you’re friends are fervently highlighting and using answer-choice first schemes etc, you’re not alone. (more…)

Explanations for the 2014-2015 Official Step 2 CK Practice Questions

04.20.15 // Medicine

Update 8/5/2015:  They’ve now updated to the new 2015-16 question set and removed the old links (they’ve previously kept the old ones working for several years). You can still access cached versions of 2014-15 and 2013-14 for now (cachedview.com is helpful in cases like these). My explanations for the new set are available here.

Here are the explanations for the updated 2014 (effectively 2014-15) official “USMLE Step 2 CK Sample Test Questions,” which can be found here.

Overall, there are only three new questions when compared with last year’s set (#90, 95, and 104), which I’ve marked with asterisks below. The explanations for the earlier 2014 set (effectively 2013-14) set can still be found here (the question pdf is still available online) and are largely identical (though in completely different order).

(more…)

America’s Doctor

04.18.15 // Linked, Medicine

From Julia Belluz’s portrait of Dr. Oz in Vox, now apparently America’s most famous and most trusted physician:

This setback didn’t slow down Oz in his study of alternative medicine — or his embrace of fame. In the early 2000s, he worked with a reiki healer named Raven Keyes. She told me recently, “My reiki master is the archangel Gabriel. All I have to do is ask Gabriel to activate all the angels, and everybody’s angels come to life.” In the operating room, she said, she’d perch on a stool behind the anesthesiologist and transfer her good energy. “I’m connecting with the divine light within me and allowing myself to absorb the divine light in myself so it expands outward.”

Dr. Oz embodies the tension between personal freedom and professional responsibility. If one-way communication via a television or radio show doesn’t qualify as medical advice or constitute a physician-patient relationship, then how do we define it? Because anecdotes are apparently not uncommon about people who trust Oz via TV more than their actual physicians:

One reported that her dad had a heart attack and five stents placed in his heart, which required him to take aspirin and Plavix to prevent blood clots. “He was watching Dr. Oz, who said Plavix was not necessary, so he stopped taking it. About a month later, he had another massive [heart attack] and coded and had to be shocked back to life.” She continued: “My dad admitted to following Dr. Oz’s advice and not asking his own cardiologist.”

When a personality like Oz speaks about health and is a physician, he or she is essentially doling out medical advice. But right now, we wouldn’t even consider holding them accountable. Oz doesn’t even need to disclose his COIs when it comes to fat busting green coffee bean extract or other natural miracles.

Update: John Oliver weighs in on the most recent Oz controversy, as Oz responds to his critics who want him off Columbia’s faculty.

https://www.youtube.com/watch?v=sXTgxkhHAqo

And if you haven’t already seen it, Oliver’s awesome original Oz segment.

Explanations for the 2015-2016 Official Step 1 Practice Questions

04.01.15 // Medicine

The NBME just released the updated 2015 sample questions this past month, and there are no new questions in this iteration (at least in the downloadable pdf version). In fact, six questions have been removed (two from each section), which was done to reflect the decrease in total Step 1 test items starting May 11 from 322 to 308.

I’ve made a note of which questions were removed from the 2014-15 set. Therefore, at this time, my explanations for the 2014-15 set are still current. The question order is the same, but the numbering is off a bit.

If an updated set with new questions is eventually released, the explanations will appear below as they have in prior years.

Block 1

#20 and #29 from 2014-15 were removed.

Block 2

#74 and #85 from 2014-15 were removed.

Block 3

#98 and #130 from 2014-15 were removed.

 

Again, the still current 2014-15 explanations can be found here.

Refinancing Your Student Loans as a Resident

03.12.15 // Finance, Medicine

Last updated July 2020

 

If you’re a resident with a big load of student loans from the feds at a 6.8% interest rate (or worse), your choice has generally been IBR or forbearance. The mountain of debt compared with your relatively paltry resident salary has put conventional student loan refinancing—which requires a reasonable debt/income ratio—out of reach. If you have an average loan burden (say, $180k) or higher, your IBR payments also only cover around half of the monthly interest accrued (so despite your best efforts, your loans are still growing). If you forbear, they’re growing even faster.

So basically, your loans have been growing at a crappy interest rate, and you’ve been unable to bail to greener pastures.1 Until now.

There are now two four three players who offer student loan refinancing specifically to residents. Laurel Road (formerly DRB) was the first. They were then joined by LinkCapital (now defunct). Later, Splash Financial and SoFi joined the pack. Then, Splash pulled the plug; and then, they came back.

This is how it works:

  • For Laurel Road, you apply for student loan refinancing whenever you want starting from when you match as an MS4 (they’ll respect the usual 6-month post-graduation grace period, don’t worry). Ditto SoFi.
  • For Laurel Road and SoFi, no set maximum loan amount.
  • All will use a multifactorial process to look at your application, including your FICO scores, your debt and total loan amount, and your medical specialty. They use your specialty to determine the median projected/future income for you and use that instead your current income to calculate your debt to income ratio (DTI).
  • If you meet the requirements, you get to trade your old loans for a new one. For Laurel Road, physician spouses can even consolidate their loans into one.
  • None have origination fees. 
  • For Laurel Road, while in training (residency + fellowship), your monthly payment is $100. SoFi also requires $100 payments but only for training lengths up to 4 years. Splash is $100 for 7 years.
  • After you finish training and begin making real money, you will enter standard repayment. Any interest accrued during the training period will capitalize at this point (but did not compound/capitalize during training).
  • In some ways, these offerings are like income-driven repayment plans in the sense that your payments are low in residency and then ramp up once you finish. It’s not like IDR in the sense that it stays $100 or $75 per month regardless of your fluctuating income as a resident, and the new private loan loses any chance of achieving federal loan forgiveness.
  • None have prepayment penalties. Prepayment can also directly go to your balance and not to uncapitalized interest. If you are already doing IDR, this means that you can put that extra $300 or $400 you’re already used to paying every month toward your loans anyway, only now this money will go further. For example: $500 a month for IDR means you spend $6000 a year on your loans. Depending on your loan amount and your new interest rate, this amount may be enough to completely stop the growth of your loans (instead of merely slowing down the rate of negative amortization).
  • Grace periods are usually honored, as well as a three-month grace period before entering full repayment after residency/fellowship ends, giving you a few cushion months at your new salary.
  • Accrued interest capitalization won’t capitalize again until after residency (which is similar to what happens for many physicians in IBR/PAYE, worse than REPAYE, but better than forbearance).
  • Loans are discharged in the event of death and permanent disability (like federal loans). With Splash, only some loans are forgiven (depending on the underlying funding source, so read that fine print!)
  • Laurel Road offers an economic hardship deferment (in three-month chunks) if things get tough. Other companies will generally grant you a temporary forbearance when needed as well.
  • If you don’t qualify for refinancing (e.g. low credit score), it’s possible to reapply with a cosigner (and still be a part of the resident program).
  • The rates you’ll get as a resident aren’t going to be as good as those of an attending. With most companies, if you want to get lower, then you should reapply when you’re an attending. A trainee applying in their final year with a signed employment contract can get an attending rate.

It seems like all student loan refinancing companies have referral programs to drum up business, whereby you get some cash if you send a friend their way. Laurel Road will give anyone who joins through this page $300 for signing up (the equivalent of three months free, nice). SoFi is offering $300. Splash is offering $300. If you’re interested in refinancing, just do the initial 2-min rate check application and see who gives you the lowest rate. If the offers don’t make sense, then don’t sweat it. Your credit won’t get pulled until you do the real application.

What I found clever about the original Laurel Road offering is that they not only stood to profit from the extra years of interest accumulation if a new borrower paid the minimum amount during residency, but that they’d found a way to get at physicians early and compete against the other companies on something other than who has the lowest offered rate on a given day. Frankly, I’m surprised SoFi and others took so long to join in (I talked with one of their directors about this back in 2016!).

Interest Capitalization

One thing that happens if you switch from federal income-driven repayment to private consolidation/refinancing is that your accrued interest will capitalize. This means that if you had loans of $180k with $40k of uncapitalized accrued interest, your new loan amount (that will now be gaining interest) is $220k after refinancing. That can be really bad, but all depends on the rates:

$180k at 6.8% APR accrues $12240 every year in interest.
$220k at 3.5% APR accrues $7835 the first year in interest.

So you’ll have to do the math with the rates you are offered versus the amount of unpaid interest you have sitting around to see how it works out. Online calculators (like this one) make it pretty straightforward. The interest capitalizes at end of your six-month grace period after finishing school or when you consolidate, so if you just recently graduated, this is irrelevant. If you’ve been forbearing, then your interest already has and continues to capitalize, so that downside also doesn’t apply.

Part of what made refinancing so desirable back in 2015 when I first wrote this post was that interest rates were at all-time lows. It was a great time to buy a house too, and it made the 6.8% federal student loan interest rate for graduate students particularly galling. Since then, federal rates dropped a bit and the IDR program added an unpaid interest subsidy to many borrowers through the REPAYE program that many residents can benefit from. In other words, refinancing as a resident was something that lots of residents could have benefitted from in 2015 when DRB was the only party in town. Now, the majority of residents will do better in REPAYE.

So should I try to refinance?

  • If you have private loans at high rates, this is a no-brainer.
  • If you have federal loans and have been forbearing, then this is also worth pricing out. $75-100 a month to slow down the relentless climb of accruing interest can save a lot of money in the long run, particularly if you have a lot of PLUS loans
  • If you have federal loans and are doing IBR/PAYE to be financially responsible but have no interest/faith in PSLF, then refinancing is also definitely worth considering. As there is no prepayment penalty, you are free to still make your old IBR-sized payments. Those payments will go a lot further at a lower interest rate. So if you know you want to do private practice, then there’s really no big reason to stick with IBR. If you’re in REPAYE, then feel free to apply for private refinance, but only pull the trigger if the rate you’re offered is lowered than your effective interest rate with the REPAYE unpaid interest subsidy.
  • Other than losing PSLF, the main downside to switching from IBR/PAYE/REPAYE is interest capitalization (as above). Because of interest capitalization, you’ll have to do some math based on what rate you’re offered, how much you owe, and how much you plan on paying monthly to figure out if refinancing is worth it for you. This matters more the longer you’ve been making income-driven payments that don’t cover the accruing interest; if you just graduated, then you don’t have to worry about this.
  • If you’re doing IDR temporarily but think you’ll need to start forbearing (having kids soon, etc), then it only makes sense to refinance if you can afford the small token payment.
  • If you are nearing the end of residency, keep in mind that depending on your loan amount and your projected salary, your interest may soon capitalize anyway, IBR or not (i.e. you may no longer have a “partial financial hardship”). You’ll also get a better deal with SoFi if you’re within 12 months of the end of your training and have a signed employment contract.

Other options?

You can refinance with CommonBond and get an attending rate + $300 cash back if you apply during your final year of training with a signed job contract.

Otherwise, for residents with average loan burdens, options are limited. Another player that is potentially viable is LendKey ($300 bonus). The maximum loan amount is currently $300k. Additionally, on an average resident salary of $55k, the maximum loan amount without a cosigner would be approximately $75k. To hit even their old maximum of $175k, you’d need an income of $85k. While there is no special resident program, they do offer interest-only payments, which if your loans are a small enough may be entirely reasonable. The interest-only payment on $100k at 5% is around $400/month, for example. Earnest ($300 referral bonus) tells me they are also willing to refinance residents despite their debt/income ratio, but you’d essentially have to have enough income to make full payments on a 20-year (the maximum) term, so it’s a no-go for big borrowers as well.

So for lower loan amounts, Laurel Road, SoFi, and Splash are potentially joined by LendKey and Earnest. But for an average resident with average debt, LendKey and Earnest’s current offerings probably won’t cut it.

So if you’re an attending, apply to all of them and see who gives you the best rate. Initial rate checks don’t affect your credit. When you sit down and really apply to several student loan companies to get your finalized rates within a short time frame, it’s considered a single hit on your credit report, so the more the merrier.

For further reading, here is my rundown of all of the medical student loan refinance options.

What about PSLF?

See this post. Keep in mind, PSLF can only take place after 10 years of monthly payments. If you have a smaller loan burden or a short residency, the amount you can theoretically have forgiven may be low (assuming the program continues; it’s new enough that no one has actually had their loans forgiven yet). PSLF is the best deal for those with long residencies/fellowships (low monthly payments for longer under IDR), with a lot of loans (private school = more forgiven), and low attending salaries (lower IDR payments = more forgiven).

In fact, the desire to do PSLF is the main real reason to not bother doing a private refinance rate check if you aren’t eligible for a good REPAYE rate subsidy. At least, the current PSLF is: recent budget proposals have included a proposed capping PSLF or canceling the program entirely, though all changes are designed to affect only new borrowers. So current residents should be grandfathered into PSLF without a cap and get solid loan forgiveness. Future medical students, however, could one day have the real benefits of this program essentially washed away. Now that giving “rich” doctors and lawyers big wads of cash is a legislative issue with bipartisan support, PSLF may end up being a short-lived panacea for physician debt.

If you’ve heard about getting your loans discharged after 20-25 years (IBR or PAYE), you should probably forget about it. Unless you quit medicine and never make a decent attending salary, all but those with the most egregious student loan amounts won’t get their loans forgiven this way (and even if you did, you wouldn’t save much money given all of those extra years of making payments and taxes due on the forgiven amount). If you make little enough (e.g. part-time academic primary care) to stretch out your loans for 20 years but couldn’t do PSLF, then you might have some amount forgiven, but then you would have spent a ton of extra money over the years on interest, and then forgiven amount is taxed (your marginal tax rate * a multi-hundred thousand dollar loan debt = a huge tax bomb). The best reason to keep your federal loans around at 6.8% or worse is for PSLF or because you can’t yet qualify for something better.2

When USMLEWorld spying on you is the harbinger of our future despair

03.02.15 // Linked, Medicine

From Cory Doctorow’s How Laws Restricting Tech Actually Expose Us to Greater Harm:

Because while we’ve spent the past 70 years perfecting the art of building computers that can run every single program, we have no idea how to build a computer that can run every program except the one that infringes copyright or prints out guns or lets a software-based radio be used to confound air-traffic control signals or cranks up the air-conditioning even when the power company sends a peak-load message to it.

Why? Because for such a system to work, remote parties must have more privileges on it than the owner. And such a security model must hide its operation from the computer’s normal processes. When you ask your computer to do something reasonable, you expect it to say, “Yes, master” (or possibly “Are you sure?”), not “I CAN’T LET YOU DO THAT, DAVE.”

Which, though actually quite different, reminded me of one reason I always disliked USMLEWorld’s zealous efforts to prevent intellectual property theft. From the official Terms and Conditions:

The UWorld software is designed to access your computer system’s clipboard during use of the UWorld software. While a test is in progress, the UWorld software shall disable all clipboard functions of your computer system (including, but not limited to, copy-paste-print and save-to-disk functions). Furthermore, the UWorld software shall monitor all processes on your computer to determine if there exists any applications that could be used (intentionally or unintentionally) to copy contents. Simultaneous use of such applications (hereafter referred to as “dubious applications”) with the UWorld software constitutes a violation of this agreement.

That’s an amazing amount of system privelige we give to a small software package out of Irving, TX. In the future, how much control will we be willing to give up to companies and governements in order to use the products we want?

Preliminary Medicine vs Transitional Year Internships

02.05.15 // Medicine

I’ve noticed a trend when I talk to applicants on the trail: a significant number of faculty advisors are giving some questionable advice, such as recommending that their students applying to advanced specialties (e.g. derm, ophtho, rads) only apply to preliminary medicine programs because transitional year (TY) programs are too competitive. That, combined with a lot of mystery about internship programs and the fact that most TYs are not at recognizable university-based hospitals, means that applicants are at a disadvantage when it comes to making an informed decision about where to fulfill their internship requirement. I talk with applicants at dinners and lunches who already regret treating their internships like an afterthought and wish they had put more time into researching their options. I’ll address some myths below: (more…)

Should your radiologist tell you the results of your scan?

11.27.14 // Linked, Medicine, Radiology

Probably not. But some interesting lines from Gina Kolata’s article in the NYTimes:

Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford:

At that point the radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

This issue here is not that radiologists aren’t “trained” in what happens next (in many cases, of course they are!)—it’s that radiologists don’t actually do what happens next. If you aren’t going to provide treatment, you probably don’t need to be offering patients their options, particularly if you aren’t privy to their history.

For now — with one big exception — how quickly a patient gets the results of a scan, including M.R.I.s, PETs, CTs or ultrasounds, can be idiosyncratic and depend on the particular doctor and the particular patient.

Yet patients want to hear from radiologists, the groups say. One admittedly unscientific indicator was patients’ comments to the American College of Radiology on Twitter. They said they did not want to wait for results and could not understand why a radiologist would tell a doctor their results but not them, said Dr. Geraldine McGinty, chairwoman of the group’s commission on economics.

Realistically, patients want their results quickly and probably don’t care who tells them. The main issue here is patient scheduling. It’s not fair to patients to have an MRI one day and then have an appointment with the ordering provider two weeks later. Many physician schedules are fully booked with routine follow-ups, leaving no room for add-ons when unexpected scan results come up. In some thoughtfully scheduled clinics, patients have a scan in the morning and are seen that afternoon. That’s ideal.

If a patient then still wanted to speak to a radiologist (leaving aside the issue of the non-reimbursable time spent), I think both the radiologists and the referring clinicians would be much happier having that happen in a context in which the definitive management discussion would happen immediately afterward and not in some yet-to-be-determined future appointment. If the patient finds out before the referring provider, then the system breaks down. And learning you have cancer only to be told you won’t be seen by the oncologist until three weeks later is also not therapeutic. We need to be more thoughtful in how patients are scheduled for follow-up—that’s the crux.

“The chance of your actually seeing a radiologist is almost zero,” said Steve Burrin, a physicist and retired vice president of The Aerospace Corporation. Mr. Burrin, 70, who has lung cancer and lives in Los Angeles, has so many scans — CT, M.R.I., PET — that he decided to take matters into his own hands. Now, he immediately asks for a copy of his scan and tries to understand it himself.

I do though think the current state of patient accessible information is problematic. More and more patients have access to their raw reports, which are written for a physician reader.3 The information, terminology, and certain turns of phrase can be bewildering and frankly misleading to patients. If a patient report states there several “indeterminate renal hypodense lesions” which are “too small to characterize,” that sounds super mysterious. But they’re really just (essentially always) tiny cysts of no clinical consequence.

If the future is centered on more transparency and patient empowerment, it would probably be better if a patient-centered report was incorporated into the medical record with the salient points written in accessible language. This is similar to the approach used by WebMD and Medscape, which are owned by the same company, where there are pages on the same topic with one set of data shown to patients and another set to physicians.

Residency Consultants

11.14.14 // Medicine

I get emails all the time asking for residency application advice. A lot of these come from IMGs, which isn’t surprising: applying to residency in the US from the outside is stiffly competitive, and the support/advice from home isn’t always sufficient. Others are those with competitive dreams or particular needs for residency that make fourth year that much more stressful. To profitably fill that void are the “residency consultants” and their ilk, like the folks who wrote The Successful Match who would also love for you to be their client on not one but two (ugly) consulting websites. A lot of these guys are former associate program directors in fields like internal medicine who applied to residency themselves in a different era. In many cases, the nitty-gritty details and current application climate are probably better known by recently matched fourth years and residents in your specialty of choice, not to mention that being involved in interviewing and selecting candidates in one field at one institution doesn’t necessarily make you an expert in the whole process. Great consultants probably exist, but the credentials they spout are a red herring.

I don’t think US allopathic students who are thoughtful and reasonably competitive for their respective fields generally have a significant need for a comprehensive application review. Depending on how supportive and useful your student affairs department and faculty advisors are, many US MDs who are reaching a bit (but flexible) are also likely doing just fine on their own for the most part. But for others, particularly IMGs, a service and all-around helping hand to go over every nook and cranny of your application, help you fix your mistakes and take the right angles, polish your personal statement, and prepare you for interviews is obviously of value. Given how much you have to pour into ERAS, traveling costs, etc–shelling out for a residency consultant may be too much insult to injury, even for those students who are among those who would benefit the most. I’m generally suspicious of a lot of “advice” (and you often get what you pay for), but there’s no doubt that the perspective, experienced editorial services, and advice you get from qualified people who don’t know/like/love you is going to better approximate the things that will help you when the same sorts of strangers review your application or interview on the big day.

Still, I would make sure to exhaust the diverse community of peers and institutional support before hiring a stranger. And I’m sorry, but I don’t have the bandwidth to help one-on-one.