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.


Residency and the Craftsman Mentality

From Cal Newport’s excellent Deep Work: Rules for Focused Success in a Distracted World:

Whether you’re a writer, marketer, consultant, or lawyer: Your work is craft, and if you hone your ability and apply it with respect and care, then like the skilled wheelwright you can generate meaning in the daily efforts of your professional life.

You don’t need a rarified job; you need instead a rarified approach to your work.

Let’s add “physician” to Newport’s list.

One of the more disheartening aspects of medical school is the siloing of medical specialties such that different breeds of doctors appear to compete in the hospital and medical students come away with the idea that one specialty should spark passion in their hearts (and that they will be professionally unhappy if they then don’t match into that one specialty).

It doesn’t have to be this way.

The satisfaction of professional growth and a job well done can transcend specialty choice. If the results of the match weren’t what you wanted, apply yourself to developing a craftsmen’s mentality. Get good at what you do, take pride in it, and passion can follow.



Explanations for the 2020-2022 Official Step 2 CK Practice Questions

Update: The March 2021 pdf is still identical outside of some minor formatting changes.

The NBME released a completely new set of questions in March 2020, which was the first major update since basically 2015. (The August 2020 pdf is the same.)

The 2019 set, which is completely different, is available and explained here for more free questions!

These are in the order of the PDF linked above.


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Explanations for the 2021 Official Step 1 Practice Questions

This year’s set was updated in February 2021 (PDF here).

The asterisks (*) signify a new question, of which there are only 2 (#24 and 53). The 2020 set explanations and pdf are available here; the comments on that post may be helpful if you have questions.

The less similar 2019 set is still available here for those looking for more free questions, and even older sets are all listed here. The 2019 and 2020 sets, for example, differed by 36 questions (in case you were curious).


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