Last week the FTC announced a proposed rule banning non-compete agreements. You can read the announcement here and the actual rule here. The rule would, if enacted, not just ban all non-competes going forward but nullify previous agreements as well. Non-competes are ubiquitous in medicine and a big factor locking doctors into their jobs, typically by preventing them from practicing in the same geographic region for a period of time after leaving their employer. And, for example, whenever a large organization like an academic medical center or a private equity company buys a practice or otherwise dominates a region, these non-competes form an effective moat against competition by preventing doctors from reorganizing after fleeing.

In some areas/fields, noncompetes are universal and have been functionally unavoidable. Many employers rely on lock-in to mitigate their bad culture and sleazy practices; shifting that power dynamic would I think change things very quickly.

It’s intuitive and straightforward how such a rule would affect employed physicians: you can just quit and hang up your shingle elsewhere. And yes, that means a clinician could join an academic practice for a few years, build up a patient panel, get more comfortable in their skin as an attending physician, and then leave and use that experience as a springboard to a new practice. This is, of course, part of the fear that led to non-competes in the first place. Employers put money into new hires between training, onboarding, early decreased efficiency, marketing, etc. Perhaps in a world without non-competes, employers will be less inclined to invest in their employees; that’s the typical business counterargument. The counter-counterargument also holds water: perhaps, if employers don’t invest in their employees, then their employees will leave. Value shouldn’t be a one-way street.

Too good to be true?

Several immediate reactions have been common. One, that somehow doctors will be exempted because woe is us. Two, that companies will use the magic of lawyers to get around the intent of the law. Three, that practice owners/shareholders (think partners in a large private practice) will be exempted because they are business owners and not employees. Four, that this will be litigated into oblivion.

The announcement had this to say:

Companies use noncompetes for workers across industries and job levels, from hairstylists and warehouse workers to doctors and business executives. In many cases, employers use their outsized bargaining power to coerce workers into signing these contracts. Noncompetes harm competition in U.S. labor markets by blocking workers from pursuing better opportunities and by preventing employers from hiring the best available talent.

So the FTC specifically includes doctors when they think of who this rule will affect.

The language of the rule itself also addresses a few of these concerns:

(1) Non-compete clause means a contractual term between an employer and a worker that prevents the worker from seeking or accepting employment with a person, or operating a business, after the conclusion of the worker’s employment with the employer.

(2) Functional test for whether a contractual term is a non-compete clause. The term non-compete clause includes a contractual term that is a de facto non-compete clause because it has the effect of prohibiting the worker from seeking or accepting employment with a person or operating a business after the conclusion of the worker’s employment with the employer.

So, in theory, clever machinations to functionally bind workers without the use of naughty catchphrases would still be against the law. How easy it would be to prove a functional non-compete in court, how expensive and stressful that process would be for an individual worker, and how aggressive companies will be in toeing the line remains to be seen. How desirable/how effective of a deterrent such schemes would be for employers depends on those answers.

There is an exception for business owners:

The requirements of this Part 910 shall not apply to a non-compete clause that is entered into by a person who is selling a business entity or otherwise disposing of all of the person’s ownership interest in the business entity, or by a person who is selling all or substantially all of a business entity’s operating assets, when the person restricted by the non-compete clause is a substantial owner of, or substantial member or substantial partner in, the business entity at the time the person enters into the non-compete clause.

The FTC defines “Substantial owner, substantial member, and substantial partner” to “mean an owner, member, or partner holding at least a 25 percent ownership interest in a business entity.”

By that language, the ban would still apply to a physician owner in a practice of 5 or more people. Your average radiologist whose group sold to private equity, could, after the contract period, turn around and start working for other groups locally. They could, even, start a new group.

Well?

How is this likely to play out? I have no idea. In reviewing the media coverage, the overall consensus points towards the final rule being similar to the proposal, it not being stopped by congress (democrat-controlled senate), and then being litigated immediately. How long it takes to work its way through the courts and its eventual fate I don’t know. I’m sure plenty of lawyer and journalist ink will be spilled when the time comes to predict the outcome, but that is far outside my circle of competency.

For Radiology:

In radiology, the ability to do teleradiology work has taken some of the bite out of noncompetes, but this would still be a massive change for physicians in general. In particular, if the carve-out for owners/shareholders were to stay a similar size, the proposed rule provides a window into how a post-PE world might look for practices struggling after the sale.

No one has poured through every contract out there, but one of the common post-sale questions for the past few years has been: how can we get out of this? Common refrains: the things we were promised haven’t been provided, we can’t recruit, our rads are being poached to help elsewhere in the organizational umbrella, we can’t earn enough with the cut to make this sustainable. What recourse do the doctors who sold a practice have if things aren’t working out post-sale?

If this rule were to come to pass, there would be a light at the end of the tunnel. A failing group post-sale could run out the clock and conceivably form a new group to compete with the shell entity they’d leave behind (though presumably companies would still mitigate competition through non-solicitation agreements, for example). RadPartners and friends would still be buying the profits from your work and the goodwill of your relationships for several years, but the lack of a noncompete would make it impossible for them to guarantee their long-term stranglehold if/when their management fails. They’d have real skin in the game.

In practice, that could easily just hasten a lot more hospital-employed radiologists as institutions look to bring in rads and secure imaging services in this uncertain world. There are certainly groups out there that would rather work for the hospital they’ve been staffing for decades than the PE company they sold to. But even that trend could be temporary if a group of employed rads could then leave and form a group.

Boom.

The dynamism that such a rule enables is the real deal. The bargaining table permutations are infinite, and that’s exactly why the FTC wants to ban noncompetes.

I finally broke down and bought a pair of Figs so I could try to fit in with the young folk.

But I had to do a little surgery with my seam ripper:

Just because I want to pretend I can pull off squeezing into some joggers doesn’t mean I want four(!) separate branding labels on a pair of scrubs of all things.

Now they’re closer to the fantasy world where the generic hospital scrub pants have regular pockets.

Here are my explanations for the August 2022 update of the official practice materials. (As of 2024, the PDF of these questions is no longer available, but the 2020 set is still archived and nearly identical to the 2022 PDF.)

The asterisks (*) signify one of the only two new questions compared with the prior set.

My explanations for the old 2020 set are here and the 2018/2019 set are here. There were 71 new questions in 2020 vs 2019, so going through that older set may still be worth your time. The one before that, which I explained here, was revised in November 2017.

You can find my thoughts on preparing for Step 3 here. Since writing that post, the main 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 book 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 the popular 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 taken under test-day conditions. (more…)

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

Update: The April 2022 pdf also seems to be unchanged.

The NBME released a completely new set of questions in March 2020, which was the first major update since basically 2015.

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.

(more…)

[The original version of this newly updated/revised post was first published way back on August 19, 2012.]

Chances are, your third-year clerkship grades will hinge more on your NBME Shelf exam scores than on your clinical evaluations. The strategy I advocate is to come off of Step 1 strong by immediately shelling out for the UWorld Step 2 question bank for the entire year. Do the questions for each rotation.1And by do them, I mean do all of them while carefully reading the explanations. Mark all questions you guess on or get wrong and do those again. Rinse and repeat. Take your shelf exams, nervously wait 1-3 weeks for your scores to come back, and soldier on. Then at the end of third year, reset it so you can start fresh and use it to study for Step 2 CK. If you’ve studied for and done well on your shelf exams, UW and Wikipedia should basically be sufficient for Step 2 CK, which for at least the near future will be an extremely important non-pass/fail exam. The best way to perform well on Step 2 CK is to also prepare for and do well on your shelf exams.

While UW is, I believe, indispensable for several of the shelf exams, it is not sufficient. (Related: If you’re in the market for an additional question source, I do have some qbank discounts on the support page.) There are also a variety of online-based curriculum replacements that one can use for longitudinal learning during third year. But for book people, here’s how I would approach each clerkship:

Psychiatry

First Aid for the Psychiatry Clerkship is your must-read. It’s extremely quick, readable, and hits everything. You can read this book in a day if you want to; it’s that short.

The only book you would need after FA is Case Files Psychiatry. It’s a good volume in the series, and some of the cases do a nice job of distinguishing between adjustment disorder in its many forms (recognizing adjustment disorder versus MDD, GAD, acute stress disorder, and PTSD etc is extremely important for the psychiatry shelf). You don’t need more reading beyond that, just UW. Enjoy the psycation.

More than any other shelf, the psychiatry shelf really stresses adverse effects of its medications. Every important drug has its one or two, and you need to know them cold. All of them.

You also need to pay special attention to medical disorders with psychiatric manifestations (depression and pancreatic cancer, Addison’s disease; pheochromocytoma or carcinoid tumors masquerading as panic disorder; etc).

Ob/Gyn

Case Files Obstetrics and Gynecology is your first book of the rotation. When in doubt, you can always get through a Case Files book quickly and know that it will hit the highlights (i.e. common board/pimping questions). It’s an excellent foundation for your rotation, and you should read it as fast as possible.

Many people advocate Blueprints Obstetrics and Gynecology, as it is quite readable and nearly exhaustive. I would caution you that unless your rotation has light hours, many many students don’t have enough time or energy to slog through it. Many of my peers who started with Blueprints never finished a single book before taking the exam. They just didn’t have time. Finishing a single book is the most important thing; you need to have one cohesive point of view. Even Case Files alone is better than 3/4 of Blueprints. Don’t get yourself in trouble. Most OBGYN clerkships are exhausting.

If your school pays for the ACOG/APGO question bank, great. Definitely use it. If not, I’d just read Case Files again and do UW. Always focus on things that might seem similar and be able to tell them apart (placenta previa vs vasa previa vs abruption). You may benefit from a qbank supplement (or even PreTest) if you have time and no APGO access.

Pediatrics

Blueprints Pediatrics is the common favorite (and my wife’s personal favorite as well), and though I personally don’t care for the series, it is certainly sufficient. First Aid is overkill. Case Files Pediatrics (my favorite), patient reading, and UW for me was enough, but if you have the time and drive to read a more thorough text, I think BRS Pediatrics is actually the best.

As far as entries in the series go, Pediatrics PreTest is one of the better ones, and if you need more questions in book format, then it would be a reasonable use of your time (I personally wouldn’t bother).

You probably need two sources. Blueprints or BRS + Case Files is a common combination, if you can stand the cardiology section of BP.

Don’t go overboard on vaccine schedules and developmental milestones. You can sink a lot of time into that for little to no benefit. You should know a couple of big milestones per age group. Know the contraindications for vaccines; don’t learn the actual timelines.

Surgery

As always, crank through Case Files Surgery as fast you can so you don’t look like an idiot. Crush Step 2 / Step 2 Secrets (essentially the same book in different formats, one of which you’ll probably want/have anyway, I prefer the former) can also help you get a rapid-fire overview of surgery in less than a night (and is also a particularly nice way to quickly learn the very basics of the many surgical subspecialties, which are fair game on the shelf). However, the single best rapid review text is actually Dr. Pestana’s Surgery Notes, written by a now-retired faculty from the University of Texas Health Science Center at San Antonio. For years before the official version, a more informal packet was widely used and beloved by students around the world for being extremely quick and extremely high yield (you can find copies of that old standby pdf online).

Then, before slamming into UWorld with all your might, I’ve classically recommended the NMS Surgery Casebook. This dense book has been an essential read for the clerkship: excellent, organized well, good diagrams, and contains everything you need to know. Note, this is not the NMS Surgery textbook. Don’t bother with that thing. The Casebook is the better resource by far. In recent years, many institutions and students have recommended the newer Surgery: A Case Based Clinical Review, which is also excellent. They are analogous, so just pick one. After that, just do questions. Pay special attention to trauma management, which makes up a lot of the test. Many questions hinge on applying the ABCs properly, often comically obviating the need to know definitive management. If you would do two things simultaneously in real life, never forget that one of them technically comes first based on the ABCs.

Many students use Surgical Recall to help prep for pimping and an overall understanding of the day-to-day business of surgery. Surgery Recall is a good book for reviewing the common questions you are likely to receive/knowledge you need to succeed in-person and on the wards/in the OR. It’s a good book to carry in your white coat and pull out when you have a few minutes of downtime. I would not, however, rely on Recall as a primary studying guide when it comes to the shelf. Details about actual surgeries are not on the exam, but the management of surgical patients is. The portions that do apply to the shelf though are full of rapid-fire high-yield facts.

Internal Medicine

The best way to study for IM is to do all of UW Medicine. This will take several weeks but will be worth it. The second most important thing you can do is pay attention on the wards.

The favorite medicine text nationwide is Step-Up to Medicine, which is the best (and the third edition just came out). It’s a bit long, and you may find yourself dropping it in favor of getting through the question bank. Case Files Internal Medicine is decent (helpful mostly if your background is poor and because it’s shorter). First Aid isn’t worth your time. For practical knowledge on the wards, huge swaths of students swear by Pocket Medicine (formerly “the green book,” it’s been changing colors with each edition), though I personally think UpToDate is more interesting and more complete when a computer is nearby.

If you finish UW, do more UW. Nothing else comes close to being what you need.

Family Medicine

I leave Family Medicine for last because it’s one of the more irritating tests to study for. Take it later in the year, and it will be mostly straightforward. Taking it toward the beginning of your clerkships can make it the hardest test of the year given its broad scope and the handful of seemingly random questions on every test. If you have the choice, doing it toward the end of third year makes the test far more reasonable.

Medical students can become members of the AAFP for free and then use the AAFP question bank. I thought these questions were more resident-level than the real thing and didn’t love them, but they are undeniably a solid resource. You can slog through a ton of UW and that would work, but that’s a daunting task for a shorter rotation. To historically prepare via UW, you would ideally get through the OB, Peds, IM, and preventative sections. That’s a lot. UW recently began offering shelf mode, which includes family medicine, so at least that makes the prospect approachable, but this selection is still more tailored than you’d get from months of organic review. Definitely hit up UVA’s free online mini-qbank, which has 125 high-yield questions.

In the beginning of the year, Case Files Family Medicine would help give you the basics. Later in the year, it will likely just remind you of things you already know quite well. The ambulatory section of Step Up to Medicine is certainly a good idea. Some people use Blueprints FM (breadth but not depth) or Step 2 CK review books (try Crush Step 2, if you must). There just isn’t a great resource geared for the clerkship. That said, some students swear by the use of Swanson’s Family Medicine Review, which is written for the FM boards but has a nice case-based question-heavy format that would likely serve you well. If that seems too daunting, reading the pediatrics and ob/gyn sections of Crush Step 2 will at least help you rapidly hit the highlights.

In the end, family medicine is not a discrete field; it’s a combination of everything else: mostly medicine, a good helping of peds and ob/gyn, and even a bit of psych, surgery, and EM thrown in. My advice is to schedule it for later in the year, especially after medicine, which makes it much more manageable.

Questions, questions, questions.

Elective and sub-I book recommendations are here. Some thoughts on how to approach irritating/difficult clinical science questions can be found toward the bottom of this page. Step 2 resources are detailed here.

Looking for information on the preclinical shelf exams?
Anatomy, physiology, biochemistry, and microbiology are here.
Pathology is here.