Leverage & Growth 2021

Last year, Peter Kim (Passive Income MD) put on a free virtual summit comprised of interviews with physicians doing interesting/entrepreneurial things outside of medicine. There were some pretty neat sessions.

I always enjoy talking shop, so Peter and I did an interview for this year’s conference about writing/blogging/self-publishing.

The Leverage and Growth Summit is free and runs from March 22-28 with videos available on Facebook. My interview will be released on Day 2, March 23.

You can register for free by dropping your email here.

There will be an option to upgrade to a “VIP All-Acess Pass” if you so choose in the future. That includes lifetime access to the recordings (normally each only available for 48 hours), invites to speaker Q&As, and additional networking. That VIP pass is $97 before the conference, $147 during the event, and $247 afterward. If you decide to upgrade, that link is an affiliate link and I will earn some money. (If you decide to just enjoy the free conference like I did last year, then no one earns anything except warm fuzzies).


Explanations for the 2020 Official Step 3 Practice Questions

Here are my explanations for the November 2020 update of the official practice materials.

My explanations for the 2018/2019 set are here. The one before that, which I explained here, was revised in November 2017.

The asterisks (*) signify one of the 71 new questions.

You can find my thoughts on preparing for Step 3 here. Since writing that post, the only substantive change in the exam has been the ability to schedule CCS on a nonconsecutive day. In short, I think the free materials and UWorld should be enough for most folks. If you want books recs, they’re in that post. If you need another question source, I haven’t tried any of them, but you can get 10% off BoardVitals if you’re interested by using code BW10.

As for this free 137-question practice exam, Blocks 1 and 2 are “Foundations of Independent Practice” (FIP). These should take up to 1 hour each. Blocks 3 and 4 are “Advanced Clinical Medicine” (ACM). These should take up to 45 minutes each. Total practice time should be no more than 3:30 if taking under test-day conditions.

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The good-reason-to-be-a-doctor police

From Insider’s Pre-Med Guidebook: Advice from admissions faculty at America’s top medical schools:

Every year, hundreds of thousands of students pursue premedical studies at four-year universities across the United States and the world, and they, too, want to become physicians for a myriad of reasons. Many will find their reasons to be mature and well-reasoned. These students will find the motivation and strength to succeed as pre-med students, medical students, and physicians, and they will live happy and productive lives. Others will pursue medicine for reasons that are immature, underdeveloped, or untested. For these students, there are two major possibilities: they will struggle through their pre-medical studies and drop out, or they will end up dissatisfied with their life-long careers as doctors.

Before you pursue medicine as a career, you must be sure medicine is a good fit for you. If your motivations are poor or false, you will not have the drive to succeed during the long and difficult road ahead. You will lose time, money, and the opportunity to pursue whatever your passion truly is. If your motivations are genuine and well-developed, you will find this path to be easier and infinitely more rewarding. Not only that, but your passion will shine through the activities you pursue. Medicine is a pursuit that is simply too long, too difficult, too costly, and too important to pursue for the wrong reasons.

I would like to call bullshit on these bland truisms.

Someone show me some data.

I think there are plenty of folks who choose medicine for the “right” reasons and then get burned and churned through the medical training gauntlet. It’s hard, and the difficulty varies for different people for different reasons. It’s a specious argument that unhappiness with a medical career stems from flawed motivation as opposed to, say, a toxic training paradigm or a flawed healthcare system.

And, I think there are lots of folks who choose medicine because it’s a challenging well-compensated job where you generally have a meaningful positive impact on other humans on a daily basis.

Your pure soul can be exclusively motivated by humanistic altruism but actually have zero idea what it’s actually like to be a doctor day in and day out. Because shadowing isn’t the same as doing it for years.

You can be passionate about “medicine as a career” for all the “right” reasons even though the “career” you’ve chosen is actually a broad umbrella under which there lies a huge variety of professions from diagnostic radiology to general surgery to psychiatry?

I’ve never been convinced by the idea that good successful doctors are mostly a bunch of 18-year-olds who have a singular understanding of their lifelong “passion” let alone a meaningful understanding of medicine.

I’ve known wonderful failed pre-meds who would’ve made excellent physicians but didn’t make it through the gauntlet, and I’ve met plenty of self-satisfied doctors who got through but probably shouldn’t have.

Show me some data that the process selects for the right reasons and not just the right boxes checked.


Medical Curriculum Development is an Oxymoron

A few separate paragraphs I’ve tied together from Curriculum Development for Medical Education:

The difference between the ideal approach and the current approach represents a general needs assessment.

[A] curriculum can be written, starting with broad or general goals and then moving to specific, measurable objectives. Objectives may include cognitive (knowledge), affective (attitudinal), or psychomotor (skill and behavioral) objectives for the learner; process objectives related to the conduct of the curriculum; or even health, health care, or patient outcome objectives. The development of goals and objectives is critical because they help to determine curricular content and learning methods and help to focus the learner. They enable communication of what the curriculum is about to others and provide a basis for its evaluation. When resources are limited, prioritization of objectives can facilitate the rational allocation of those resources.

The first step in designing a curriculum is to identify and characterize the health care problem that will be addressed by the curriculum, how the problem is currently being addressed, and how it ideally should be addressed.

What percentage of core medical curricula simply exist, and then goals and objectives are grafted on after the fact to link up with the things that are already happening?

When is the last time any medical school went back to first principles? 1910?

Most States Don’t Actually Require COMLEX Exams

Update 2/11/2020: The NBOME cancelled indefinitely postponed COMLEX Level 2-PE. Not sure why they needed the extra shame of waiting two weeks to cave to reality. Here’s the refund waiver link for students who already paid.

On the heels of this week’s USMLE Step 2 CS cancellation and the immediate bold non-cancellation of the COMLEX Level 2-PE (Restarting April 2021? Are you joking?), I thought it’d be worth sharing some information about which states actually require the COMLEX for osteopathic licensure. You see, many DO students already take and pass the more common USMLE exam required for allopathic physicians/MDs.

While schools impose their own graduation requirements and traditionally DO residences may have their preferences, most states don’t care if a DO student passes the COMLEX or the USMLE.

The American Osteopathic Association (AOA) released this licensure summary back in May 2020 (currently unavailable for public consumption save through the magic of the Wayback Machine, h/t Mustafa Basree). The summary is this:

  • In 44/50 states, DO students can complete the USMLE exams for licensure.
  • 5 more states (CA, MI, OK, WV, and PA) are more complicated. These often have requirements that are clearly in need of an update (such as permitting the substitution of the defunct FLEX exam for older doctors but with no mention of USMLE). MI, OK, and WV may give reciprocity (i.e. get licensed in one of the usual 44 and you may be able to transfer). Pennsylvania also requires a dedicated OMT exam if you haven’t passed Level 2-PE. The language here sometimes says “similar” requirements and sometimes says “equal requirements.” I have no idea what constitutes what here, but certainly wanting to work in these states would be a reason to finish the COMLEX series for now.
  • Only Florida actually specifically demands a full suite of COMLEX scores.

Given that Step 2 CS is canceled, the world has changed. SOMA, the largest osteopathic student association, has already called for a single licensure exam, but students are–at best–the bottom of the stakeholder food chain. I encourage physicians to lobby their state medical boards to modernize their rules and legislate away redundant requirements. I encourage the entire DO community to put pressure on the AOA to change the COCA accreditation requirements that require students to take the COMLEX in order to graduate.

I’m not saying that the COMLEX shouldn’t count (of course it should); I’m saying it shouldn’t exist.

If the USMLE is enough for MDs, it should be enough for DOs as well. Let the market decide. I don’t think the NBOME, a broadly despised organization, is doing osteopathy any favors here.

Whenever possible, I hope DO organizations, schools, and students walk away from the offerings of the NBOME and put pressure on the organization to reform itself into nonexistence. A system of two separate but otherwise analogous licensing exams is wasteful and expensive (and profitable). Osteopathic principles and manipulative medicine are not sufficient justification for complete redundancy, and there is no future where COMLEX overtakes the USMLE. Just add in a short dedicated OMM exam and call it day. Practically, I don’t think there’s a future where most traditionally allopathic program directors ever accept COMLEX in place of USMLE without bias until at least Step 2 CK becomes pass/fail. The NBOME might be holding on specifically for that future, at which point no one will care who takes what.

For now, students who are able to graduate without taking COMLEX Level 2-PE due to the pandemic and don’t need to practice in the exception states but who have taken USMLE Step 1 and Step 2 CK can finish out the series with Step 3 and call it a day. I hope folks doing this opens the common sense floodgates, but organized medicine doesn’t change easily.

In the 21st century, I’m not convinced physicians are best served by maintaining distinct osteopathic and allopathic pathways at all. A physician is a physician, and the easiest way to get rid of the unfair DO stigma is not to make it a PR issue–but to make it a non-issue. I understand there’s a lot of history here (though much of it not so positive) and plenty of strong feelings. However, even if one buys the argument that the underlying educational philosophy is sufficiently different to warrant different degrees, that’s no justification for perpetuating a separate-but-equal system for licensure given that post-graduate training has already merged and the vast majority of states don’t care.

The eventual outcome is the same. As we all know, it’s the residency training that really makes the doctor.