Review: Sulcus Neuroradiology CAQ Prep

11.12.21 // Radiology, Reviews

The neuroradiology subspecialty exam (aka the CAQ or certificate of added qualification) is a tedious, basically redundant, and expensive waste of time taken by a relatively small number of people every year.

As a result, there are very few dedicated recourses.

In fact, there is only one, and it’s Sulcus.

Based on an informal survey I did of CAQ takers, the Sulcus bank is relatively popular despite what are generally poor reviews online. In my informal poll, almost half of respondents admitted to using it. I chalk this up to the CAQ exam being exceedingly expensive, people not wanting to fail it, and this being the only dedicated product.

Related note: Sulcus also now offers MSK and Mammography programs, neither of which I looked at.

Reviewer Disclosure

Sulcus did not pay for this review nor have they seen it prior to publication.

They did provide me with 7 days of free access. I have a life, so that wasn’t sufficient for me to view the entire product, but it was enough for me to form an opinion. I’m not sure I would have finished it regardless, and I did not purchase the product afterward for further studying.

I also have no discount code for you, dear reader.

Platform

It’s a little clunky, but it works.

You must “create a quiz” as a separate step before you can actually take said quiz.

There is no tutor mode.

The site is technically mobile-friendly but the left sidebar (which is just the question numbers) takes priority, meaning that you need to scroll down past the question navigation to do every single question and read every explanation. Very tedious.

Content

There are a total of 562 questions grouped into 175 cases.

As in, there are several questions per case/diagnosis/image(s). For example, doing my first 5 cases used up 16 questions.

The cases themselves are solid. But when each case has three or sometimes four questions, the first is usually high yield, the second is borderline, and the third is basically just for giggles.

The question format is nothing like CAQ. Most CAQ questions are diagnosis-based.

Many Sulcus questions are multiple-choice “pick the correct statement” nonsense, where you evaluate a bunch of statements and then pick the one that is true. It also contains questions that are negatively framed (“which of these are NOT…”) questions that are garbage psychometrically (in their defense, these still crop on ABR’s exams rarely as well).

You’ll also get a lot of extended multiple T/F questions, where you need to evaluate a whole bunch of statements about the diagnosis and get each of them right in order to be “correct” overall. So, the end result—as other reviewers have alluded to—is mostly irritating/demoralizing.

Extended matching questions are pretty rare but fine.

Overall, the bank trends too much toward hyper-detailed in-the-weeds stuff, making it very inefficient to review in quantity for a busy practicing radiologist. The CAQ is an image-based test mostly of diagnosis, so testing a whole bunch of second-order factoids is not worth your time.

In Sulcus’ defense, I have a suspicion that the CAQ exam has changed significantly over the years. It very well may be that its current format more closely resembled the CAQ of old before changes brought the question style more in line with the modern multiple choice offerings of the Core and Certifying Exams. I support this theory with two points.

No one would choose to write questions like this for no reason.
The current (but clearly out of date) CAQ exam study guide from 2017 suggests that most questions would be part of linked question sets: “After the candidate makes her/his choice, one to three follow-up questions will typically be asked.” This is simply not the case. Most questions are solitary single best answer and do not go on to hammer you on miscellaneous second-order details.

Survey Results

I did a brief survey online and got 38 responses. Of the 18 people who said they used Sulcus, there were only two written comments: “didn’t think was relevant” and “was the highest yield by far.”

I think the reality is somewhere in between.

Pricing

$399.

Free Sample

There is one sample case in a slideshow at the bottom of the main page.

Verdict

Eh, pass.

A decent collection of wide-ranging cases; not a bad learning tool but extremely expensive related to other options and not an efficient CAQ review for the practicing neuroradiologist.

Unless you really have a CME fund to burn and nothing else to spend it on, you don’t need something this tedious and demoralizing to get through for the purposes of passing the CAQ exam. Some regular cases books, like Neuroradiology: A Core Review, will get the job done.

If you really just want a chance to see some pretty solid cases, take some great and some excruciating multiple-choice questions, and really hammer some low-yield esoterica to impress trainees and specialists, then this is an excellent choice.

Review: Doctor’s Orders (Hierarchies in Medicine)

08.28.20 // Medicine, Reviews

Sociologist Tania M. Jenkins compares and contrasts two geographically similar academic and community internal medicine residencies in her book, Doctor’s Orders, which discusses hierarchy in medicine. Her overall thrust:

Amidst a widespread and pervasive emphasis on individual merit in medicine, I found that largely structural advantages and disadvantages, often dating back to childhood differences in social class, are frequently misidentified as differences in individual achievement and motivation among medical graduates, helping USMDs float to the top of the status hierarchy while pushing non-USMDs toward the bottom.

Jenkins lumps everything other than US allopathic grads together as non-USMDs (DO, Caribbean MD, US citizen IMGs, and non-US IMGs)

Hierarchies in status, defined as collective understandings of social worth or prestige, such as those between USMDs and non-USMDs, remain highly informal, as do the processes for climbing the ranks. In fact, as I will argue, it is precisely this informality and the accompanying belief that anyone can become part of the elite with enough work and dedication that allow such status distinctions to persist.

This is part of the pervasive myth of Step 1 as the great equalizer for non-USMDs. The idea that if you absolutely destroyed Step 1 you could go far. Anecdotes abound, because yes, an IMG has absolutely needed to do well on Step 1 in order to successfully match. But, but, these successful IMGs are using Step 1 largely to compete with other IMGs. Many of the dozens of programs they apply to aren’t really considering their applications. The AAMC, which runs ERAS, is happy to take applicants’ money to apply to ever more programs while providing program directors with the tools they need to filter out those very same apps.

It’s the perception of true meritocracy, but insofar as we use standard metrics like exam scores, we use them largely within bins/tiers and not equally across all-comers.

These findings also remind us that artifacts of standardization, like Board exams and program accreditation, should not be confused with indicators of equality in medical education.

No big secret there. In many cases, they also probably shouldn’t be used as indicators of quality either, but that’s a different story.

But I think the most interesting thing about the book is that it focuses on physicians exclusively and ignores the real substantive hierarchal change happening in medicine today, which is rapid rise and expansion of midlevel providers. Take, for example, her brief discussion of the sociological history of modern medicine dating back to Eliot Freidson’s Professional Dominance in 1970:

Freidson, the primary proponent of professional dominance, maintained that as long as doctors held sole control over their gatekeeping functions (such as deciding who could become a doctor and who should be admitted to a hospital), they would continue to exert dominance over paramedical professionals and patients—despite incursions from nonmedical sources.In response, scholars criticized Freidson for being out of touch with the massive macrosocietal changes happening in the healthcare system and instead proposed their own theories of professional decline. One of the more serious challenges to Freidson’s professional dominance theory came from the proletarianization thesis. Proponents heavily criticized Freidson’s contention that the medical profession was impervious to the considerable socioeconomic changes happening around it. These scholars contended that increasing bureaucratization (especially the shift from self-employment to hospital employment) was creating a proletarianized profession, with formerly self-employed practitioners becoming constrained by bureaucratic controls within hospitals.

They predicted that, as medical practice became increasingly bureaucratized and specialized, physicians would become mere salaried employees, lose control over the terms and conditions of their professional work, and thereby become proletarianized. In turn, Freidson strongly criticized proletarianization theorists for overstating physicians’ loss of independence. He rejected the notion that simply by joining a bureaucratic organization like a hospital, “[doctors] become mere cogs in a machine of production.” He pointed to other professionals, like engineers and professors, who have long worked in bureaucratic organizations without having their knowledge and skill “expropriated” by nonprofessional superiors, and he noted that even with increased government and organizational control, physicians look nothing like typical alienated blue- or white-collar workers. While there is no doubt that some aspects of proletarianization have materialized (for example, Medicare, rather than physicians, largely dictates reimbursement rates for specific diagnostic codes), for the most part Freidson remains correct that doctors continue to control the processes of entry and the content of their professional work, suggesting that the professional decline forecast by so many sociologists in the 1980s has not come to pass.

I find this conclusion fascinating because I think it’s largely incorrect (or at the least, incomplete). And I suspect most physicians would agree.

Many doctors do (or at least certainly believe they do) function as cogs in the machine, working within a bureaucracy in which they typically have minimal input, where they control little about the day to day logistics of their jobs, and for which their main leverage for change (if any) is to quit. The process is overall gathering momentum.

While doctors may have maintained control over their fiefdom, they’ve instead been sidestepped by the large healthcare organizations that employ them and increasingly by the legislators who have historically protected them. So that strict control has become increasingly irrelevant and the inflexibility of the residency system even more damaging when organizations willingly and knowingly and sometimes preferentially choose to replace physicians with non-physicians providers as a cost-savings and/or profit-generating measure.

This part of the narrative is supremely complex (book-length to be sure), but physicians have some blame here by not producing sufficient numbers of doctors in the right critical fields to meet demand. Nature abhors a vacuum. We’ve also somehow tried to simultaneously maintain that only doctors can do the vast majority of clinical medical tasks while also training and using physician extenders to do many similar tasks nearly autonomously when it’s convenient for the bottom line. We shouldn’t be surprised that the boundaries get blurred when there is big money at stake and time to compound.

Which brings me to this last point:

The free-standing internship was eventually abolished in 1975, making a multiyear residency required for all medical graduates.

In a world where non-physicians providers increasingly have full practice authority fresh out of school, I think there’s a compelling argument for bringing back the internship-is-enough-to-meaningfully practice. While there are still standalone transitional and preliminary years, it’s not really a pathway to respected independent practice. A medical doctorate should count for something other than just a prerequisite to multiyear residency training. It’s increasingly naive and unsustainable to pretend that a doctor can only learn new aspects of medicine within a residency, or even that a residency is the best way to learn all relevant skills. For better or worse, the marketplace is proving otherwise.

When physicians burn out of their chosen calling, they typically leave clinical medicine altogether. I think one of the big factors at play that we rarely talk about is that the combination of residency and the board certification racket locks many doctors into a narrow specialization (or subspecialization) from which there is no escape.

There are lots of doctors who can’t get a residency or who want to change professions that essentially barred from meaningful clinical work, and that’s an incredible waste.

Review: Orbit CME

07.20.20 // Medicine, Radiology, Reviews

It was always a good idea, but in this new world where conferences and live events are canceled for the foreseeable future, Orbit CME is a great idea.

(I previously got temporary free access to Orbit for the purposes of writing this review over a year ago, and I’ve got the usual reader discount affiliate link combo for you here: $20 off any plan. As there aren’t any ads here, these types of win-win situations for good products are one of the only ways I earn money through my writing. So there’s your COI disclosure.)

Orbit is a web browser plug-in that promises to automatically track and quantify the qualifying educational activities you do every day on your computer and then provide you with effortless legit AMA PRA Category 1 CME (often including the somewhat more challenging “self-assessment” SA-CME that some fields require that you typically get for answering questions during each lecture at a medical conference or other interactive activity).

How does it shape up?

Pretty darn well. In order to deliver the value of your subscription, you need to have the abilities/privileges to install the orbit browser plug-in (which is currently only available for Google Chrome). This plugin monitors your browsing and triggers whenever you visit a website that might come in handy for CME, like UpToDate, PubMed, Radiographics, or Radiopaedia. It measures your time with that active browser window, and generates an entry in your CME log. You can then choose which entries to actually spend a credit on to get the CME for it, in case you need certain types (like medical ethics in Texas or MQSA, Cardiac CT, fluoro, etc).

For example, while the hospital PCs only had internet explorer installed until recently, I had no problem using Chrome with the plugin when I worked at imaging centers or from home. As a radiologist, I earned CME so fast just from my usual day-to-day work that even if only using it on my home PC I would have been able to get the entire year’s worth of credits within a month or so, at which point I just uninstalled the plug-in.

Every once in a while I would have random difficulty logging into the plug-in (which does require logins periodically to make sure you’re still you), but otherwise, the process was completely seamless. CME is provided through Tufts, and you can download detailed CME logs for submission to various bodies that require such things.

You can also post external CME to the Orbit site allowing you to track all of your CME in one place and generate one report containing everything you’ve done. Very handy.

When I first discussed the product with the Orbit founding team back after finishing fellowship, I couldn’t help but feel that the price was too steep and thus not worth it ($360/yr for 25 credits; $600/2yr for 50 credits). But then I saw how truly effortless it was and how much a hassle the documentation burden of CME can be. If you enjoy conferences, it’ll always be possible to get enough CME through the activities you plan on pursuing anyway. If you’re in academics, you may acquire enough through your work activities like tumor boards and grand rounds to not need anything else.

But for those who don’t—and certainly in the current COVID world we live in where nothing is happening except remotely—I would rather pay to have my CME automatically generate itself than to do so via a virtual meeting (or some other laborious educational activity). I’ve got an infant and a preschooler, a busy practice, and a bunch of hobbies that are struggling for a minute of sunshine. I do CME every single day I work, and this gives me credit for that. Even if you get CME from other places like I do, there was something especially nice about not needing to bother tracking it down or keeping personal records because Orbit gives you everything you need anyway. If you have an academic/educational/CME fund, it’s definitely money well spent. It also works for PAs and NPs in addition to physicians.

The product was initially designed by a radiologist for radiologists, and it is absolutely perfectly suited to our workflow. But it also works well for many other specialties, and they have a handy table here telling you what kind of CME plugin can get you relative to the demands of your specialty society.

I’ll be subscribing again.

Review: CaseStacks Radiology Call Prep

06.11.20 // Radiology, Reviews

Before we get to it, the usual disclosure: this is not a paid review, but it is the usual kind where I get to offer a reader discount combined with an affiliate link, a win-win that makes it worth my time to write these reviews for products that I believe in. Coupon code benwhite gets you 15% off.

One of the most difficult things about radiology residency is the transition to call, especially for those programs that still have independent call. You go from generating draft reports that your attending may never read before just telling you what to say to suddenly being responsible for actual words that directly impact patient care. Compounding this stress is the fact that you may not have seen everything that you need to see during your rotations to prepare you for this experience. Reading books and articles and doing questions from casebooks or question banks are all certainly helpful, but they don’t simulate the process of actually opening a case on PACS, working through it, and mentally making a decision.

Enter CaseStacks, a new subscription site created by two Neuroradiology fellows at Wake Forest.

CaseStacks aims to be the way that radiology residents prepare for call.

CaseStack has multiple “courses” of different case types each with a combination of high-end bread and butter and some more complicated pathology, all presented with PACS simulation. Currently available courses are Neuro CT, Neuro MRI, Body CT, Chest CT, MSK Radiographs, Peds Radiographs, Chest Radiographs, and KUB. Several of these are subdivided. For example, Neuro CT includes Nontraumatic Brain, Traumatic Brain, Head & Neck, and Spine. Most also include a combination of “classic” and “practice” modules, the latter adding a combination of more subtle findings and negatives to keep you on your toes.

CaseStacks uses a web-based PACS, so all cross-sectional cases are scrollable, allowing you to really experience the case as you would in real life (can also window/level and zoom/pan). Each case is accompanied by findings, a diagnosis, teaching points, and a “preliminary report” that puts some real words on the page for how you might dictate the case in real life (very neat). Cases also include incidental findings that are invariably present in real life but never included in qbanks or casebooks, which typically only include a few static images and don’t reflect the breadth and variety of a real shift.

There are also 5 assessment modules, which include a combination of unknown cases including normal exams for a self-assessment (or for programs to test you) prior to taking call. This feature isn’t as fleshed out yet. The 5 offerings vary widely in length and do not combine all courses (or have a peds variant), so there is no single assessment that, say, covers neuro/body/chest CT + variety of radiographs. That would be clutch, but they’re not there yet.

The site technically works on mobile but doesn’t play that nicely. You’re better off with at least a laptop size screen.

Cost

They offer plans in 3-, 6- and 12-month increments for cross-sectional, plain film, or everything (“pro”). The pro version is $33.33/mo for a full year (~$400, pricey), and the price goes up to $45.33/mo for the shortest duration (3 months = $135.99). Definitely expensive but possibly a more practical use of your book fund than collecting books you probably won’t read.

Free Stuff

The free sample is a breath of fresh air. You can just navigate to the site, click on courses, and see a few complete cases from each class. No login required to see if it tickles your fancy.

Also free with no login required? Anatomy modules, incidental findings tables, normal head CT findings/variant/mimics (things all residents mistake for pathology at some point), peds radiographs normals by age (extremely helpful, especially for musculoskeletal radiographs). All 100% worth checking out and a great resource for call. Definitely bookmark it. I would have really loved the peds normals my first time taking solo peds call.

Take-Home

If CaseStacks existed when I was an R1 or R2, I absolutely would have paid for the service for a few months before starting call. It would’ve been invaluable for my confidence going into a challenging experience.

Review: The Physician Philosopher’s Guide to Personal Finance

07.05.19 // Finance, Reviews

Back in May, I had the chance to sit down with The Physician Philosopher’s Guide to Personal Finance: The 20% of Personal Finance Doctors Need to Know to Get 80% of the Results.

The Pareto approach is a good conceit and is most of what people need. Real personal finance for most people is two things: simple and behavioral. Save a significant amount of your income by living on less than you earn and then do something really boring with it. Then, stay the course no matter what.

Add in bits about how important it is to buy own-occupation disability insurance from a reputable agent (like these folks, who I recommend) and term (not whole) life insurance, and that’s the meat of the book.

My main beef, unsurprisingly, is the chapters dedicated to student loans. One, there are some factual inaccuracies (e.g. about eligibility criteria for the PAYE program, the fraction of physician jobs that qualify for PSLF, the common misconception that losing a partial financial hardship in IBR or PAYE boots you out of IDR and into the standard plan [it doesn’t, the payments just cap at that amount]), and the notion that all doctors should leave REPAYE after training and switch to PAYE in order to minimize payments [it depends!].

Two, the Pareto principle applies well to most people’s retirement finances but less well to nitty-gritty loan details, especially once you get into PSLF-territory. For the former, there is no evidence that a complicated portfolio outperforms a simple one when it comes to your investment accounts. As author Rick Ferri recently advised on the White Coat Investor podcast:

Regarding your portfolio: make it simple, make it automated, and just let it do its thing. Don’t touch it. That’s the best financial advice I can give. Simplicity, automation, hibernation.

But, there can be a big difference with small details when it comes to loans, which can easily change result in swings of tens to hundreds of thousands of dollars. I see what should be simple mistakes cost thousands constantly. Technicalities are the lifeblood of the system, but I do agree with TPP’s overall thrust though. Luckily, there’s a free book that knocks that particular topic out of the park.

Overall Jimmy is a solid writer and the book is readable and reasonably concise. The first editions of my books had small errors too (okay, I’m sure they all still do—I’m a very fallible human). The beauty of self-publishing is that Jimmy has probably already fixed the errata I found.

It’s a solid book for students, residents, and early career physicians. Just please supplement for loan management.

Review: Proscan’s MRI Online

01.09.19 // Radiology, Reviews

MRI Online (now Medality) is an advanced (MRI-focused) online radiology video platform offered by Dr. Stephen J Pomeranz, who is primarily a musculoskeletal radiologist. Just one dude. This in contrast to most online offerings in radiology, which are typically recorded board reviews or CME lectures from the big popular courses at places like Stanford, Hopkins, Duke etc. Multiple folks talking about multiple topics. Those production values tend to be relatively low because they’re typically recorded from normal in-person talks with the best of intentions (but without the best of audio engineering).

I was recently offered the chance to check out MRI online. I had the intention of spending time with it to help with studying for the certifying exam, but then I ended up not studying. That’s a separate story.

Anyway.

Content

There are several different kinds of content: “Mastery series” lectures are divided into digestible 5-10 minute chunks. “Lecture series” are more typical hour-long lectures (some of these are a bit older). “Courses on Demand,” which are recordings of in-person case reviews (my least favorite). And lastly, “Power Packs,” which are interactive PACS-integrated cases with questions and explanations (but no video).

Platform

MRI Online uses the Teachable platform, which is basically what every new course you’ve seen advertised on Facebook uses. Teachable is simple to use, especially well-suited for video courses, and produces a clean product, so there’s no secret why.

There are pre- and post-tests available, but these tend to be short little multiple-choice deals (often text-only). Nothing special there. This is definitely not aiming to be a q-bank.

More importantly, Teachable videos have the ability to be sped up, so you can pick your pace accordingly.

What separates MRI Online from just about every other product out there is that the case review components are integrated with an online PACS. You can review the cases (scroll through stacks, multiple sequences, window/level, etc.), read them cold, and then essentially go through them with Pomeranz or with a written explanation. It’s interactive. It’s practical. It’s reflective of real practice. It’s basically like being a resident or fellow, except that you’re on your own pace, the cases are carefully curated, and your teacher isn’t too busy to teach. It’s pretty neat.

Pricing

Pricing is a bit of a mixed bag.

The in-training price is actually pretty reasonable ($50/month or $500/year). In particular, if you have plans to do an MSK mini- or real fellowship, going through MRI Online would be a great introduction and much less painful than Requisites. For cost reasons, I think any trainee is probably going to buy on a month by month basis when they have time and not to fork out for the year.

(Talk about responsive, the price for fellows used to be $100/month. When I pointed out that fellows don’t really make significantly more than residents, they dropped the price a week later.)

While there’s also a lot of content for neuro (and some prostate), I think most people probably wouldn’t need to buy more than a month if their focus is non-MSK. Proscan tells me they’re adding tons more non-MSK content this year, so I imagine that’s likely to change.

The price for folks out in practice gave me a bit more sticker shock at first: $150/month or $1500/year. That said, you do need CME, lots of practices do provide CME funds, and course reviews and conferences are generally even more expensive and not amenable to pajamas. MRI Online provides real ACCME CME credits, which for the price are actually a bargain depending on how hard you pound your subscription.

I wouldn’t pretend to have the ability to compare and contrast any of the huge number of course reviews that exist in radiology, but MRI Online is definitely better than a lot of conference talks I’ve gone to at RSNA, ASNR, WNRS, ABCD, and WXYZ.

Here’s where the usual negotiated discount/affiliate stuff comes in:

Code BEN10 gets you 10% off.

The annual subscription also includes a free MRI anatomy atlas as well as free attendance at a 3-day MSK MRI course held annually in Cincinnati. They tell me the vast majority of subscribers are annual, not monthly.

Free Samples

There’s a free online MSK mini-course with a sample of cases (that you would need to sign up to take).

There are also sample videos for each course (e.g. shoulder, hip) that you can watch without logging in, as well as sample cases for basically every course. You’ll get a history, review the cases in the diagnostic viewer, then answer a multiple-choice question about them. The explanations have annotated lesions and a relatively concise readable description.

They also provide a full free 7-day trial, which is a real steal for trainees or for focused test-prep.

Bottom line is that there are plenty of no-risk opportunities to check it out. There’s lots of totally free content and no bait-and-switch in sight. I wish more companies were this transparent.

Conclusion

MRI Online is actually an impressive and pretty expansive product, particularly for MSK, but also with hours of content for neuro and body. In addition to solid review, I’d definitely consider signing up again if I changed practices and needed to expand my toolset.

Review: The Unremarkable reMarkable

04.05.18 // Reviews

Man, I really really wanted to like the reMarkable ($100 off with that link).

The reMarkable, if you haven’t heard of it yet is a large format e-ink device the bills itself as a Paper replacement. It’s billed as a large touchscreen enabled Kindle with a fast refresh rate and a bundled non-battery-powered stylus that supposedly mimics the texture of paper.

And if the software running this thing was anywhere close to the level of polish in a Kindle or your typical smartphone device, then this thing would be pretty awesome.

But it’s not, so it’s pretty much not.

Unboxing

The packaging was slick and got my hopes up a lot.

Screen and Hardware

The screen is pretty nice. A big almost notebook size e-ink display, though without the backlight that folks may have gotten used to on recent Kindle generations. The 300 PPI of the high-end Kindles is substantially better than the 226 PPI of the ReMarkable, so it doesn’t even look as crisp as other modern e-readers. As a radiologist, I was hoping the device would be good for reading image-rich books and journal articles, but the images aren’t crisp enough and the contrast is washed out. The refresh rate when drawing is impressive but the delay when redrawing the screen to change pages in a book is sloooow.

The surrounding is less nice. The plastic frame does jive with the lightness of the device but it belies a build quality far below, say, an iPad or even a Kindle. The front buttons, in particular, are flimsy and loose without firmness or a satisfying click. The little-nubbed pen feels like a cheap but works exactly as billed. It has a satisfying paper scratchiness on the screen.

Software

The software is incredibly weak. The design is hobbled to function as a serviceable paper sketching/drawing app with a buggy, slow, underpowered e-reader bolted on than a real e-reading device. Page turns are slow. Documents are barely searchable. Annotations only sorta work. Unlike Kindle, you can’t, say, export your highlights—they’re basically saved an image overlay, so useless for most people’s purposes unless you are editing/marking up a PDF (as if it were actually on paper). They also have a tendency to shift on the page, making them nonsensical. Underlines should not be strikethroughs. Only non-DRM ebooks in epub or pdf formats work, and the reMarkable doesn’t yet support the new epub3 format. It also doesn’t parse epub files properly, mutilating the majority of the formatting. No links, no footnotes.

You can only sync ebooks via the app, and the app is buggy. I found I was routinely unable to add files to the reMarkable via the app normally, but that I was usually able to add via the iOS “open in reMarkable” extension (which means the files are compatible, just the platform sucks). The organization schema are just a few folders, and book covers aren’t even displayed (the last page visualized is), which makes seeing your collection at a glance a homogenous mess.

There is no in-book search. No parsing of the table of contents. No internal linking.

It shows PDFs like a stack of pictures, not complex files combining images and—of course—text.

Conclusion

Someone who wants to sketch digitally but wants a more paper-like feel than an iPad or a Wacom might enjoy this device.

Anyone hoping for large-format super Kindle is going to be extremely disappointed.

Review: WCI’s “Fire Your Financial Advisor” Online Course

03.14.18 // Finance, Reviews

I’ve been reading Jim Dahle’s White Coat Investor blog for years. And by “blog” I mean watching the WCI empire grow from blog to book to advertising magnate to website network to now e-course.

The newest WCI endeavor is a video course on the Teachable platform called “Fire Your Financial Advisor.” Because of the site you’re currently reading, I was invited to review the course a couple months back when it was first released. Which means I got it for free. In this case, it also means if you buy it for yourself after clicking that link that I also get a few bucks.

But lest that dissuade you: I don’t think this course is for everyone. Or even most people?

But before we get to the review, there’s a special deal in honor of Match Day:

Instead of the normal $499 for the course, now through Sunday, March 18 (at midnight), the course is $425 and you get a signed copy of The White Coat Investor book thrown in for free. There’s a no-questions-asked 7-day money-back guarantee, so there’s no risk (though no free book until then either). Just enroll here if you’re interested and enter coupon code MATCHDAY18 at checkout.

The Review

The WCI course is unsurprisingly like a more interactive and version of the WCI book and website with a lot of video (a good chunk of which is reading from a teleprompter with bluegradient background). Though scripted, the delivery is solid but not flawless. There’s also an audio bug (which they are in the process of fixing) that plays the mono audio as single channel stereo (i.e. it comes out of only one of two speakers). The default speed was a bit slow for me but easy to change, either for the whole course or on a per video basis (I’m always a 2x kind of guy).

The big plus side to this particular course, as opposed to most books and finance websites, is that the lessons include a game plan that once completed will result in a real on-paper financial plan for you and your family such as you would get from an actual financial advisor. Actual financial advisors also cost money, often a lot of money (either upfront or in fees), and thus the big-ticket price for admission here is far more reasonable in comparison. A course like this is an investment in yourself.

The thing about financial literacy is that anyone, and especially a high-income professional, should be literate enough to understand and evaluate the work of their financial advisor. It’s the people that blindly trust their advisors and don’t know what they’re paying for that get fleeced. I don’t care if he’s an old buddy from your fraternity days or your best friend’s neighbor’s cousin. So even if you never plan to spend $499 (or even $425) on a course, you should learn enough to know what’s happening in your financial life even if you ultimately decide to outsource it.

So, the theoretical niche for this product or people who want to become financially savvy and are willing to spend a good chunk of change to guilt themselves into becoming so but thus far have not had the motivation required to read very much on the subject. Sound like you? Read on!

Breakdown

Section 1 is the introduction. Section 2 is mostly background and discussion of how financial advisors get paid. Section 3 is about insurance. Section 4 is about housing. All of these are well covered in the White Coat Investor book.

Section 5 is about my favorite topic, student loans, and is substantially enlarged and updated relative to the old book. Since this is my area of greatest focus, I noticed a few minor factual mistakes: one toss away error is that medical residency does not qualify for the graduate fellowship program deferment. It’s really just forbearance as an option for residents who can’t make payments. It’s also not possible to start making PSLF payments during the last few months in school as he mentions (must be working full time, cannot consolidate in-school status loans). The simplified advice to switch from REPAYE to PAYE when you become an attending is often true but not necessarily great blanket advice, as it depends entirely on if your attending income will break you past the 10% payment cap. Plenty of folks in academics will never experience this problem. And switching from REPAYE to PAYE doesn’t require the same decreased vs. full standard payment as switching from IBR does.

Dahle offers a solid overview of the basics, enough to figure out what your options are, but not necessarily always enough to really evaluate those options. He does cover PSLF well. When it comes to student loans, there are a lot of details. Some may say a whole book’s worth. While the course absolutely gets the big picture right, the bottom line is that the student loan component here probably isn’t worth the price of admission.

Section 6 is “living like a resident” and basic personal finance. Important stuff.

The remainder of the course (Sections 7-12) is really where the class differs from most books and gets you to the point where you should feel comfortable handling your own finances. That’s because Dahle walks you through how to set your goals, make your budget, and even use Excel to crunch your own numbers (which he makes much less intimidating than it sounds). He goes over asset allocation and estate planning. All of this is part of writing your detailed financial plan, which he also walks you through as you go. As in, he helps you do the things your financial planner would sit down with you to do for a lot of money.

Bottom Line

This information is not supersecret copyrightable stuff. No one has a monopoly on it, and you can find it in many places in print and online, including on Dr. Dahle’s site and in his book. This course is selling convenience, and most of all, accountability. If you spend $400-$500 on an online course, I imagine you will take it seriously. And that shouldn’t be discounted out of hand. Guilt and shame can be powerful motivators.

That accountability doesn’t come cheap, however, and the kind of person ready to plunk down several hundred dollars for an online video course may also be motivated enough to read some books and fish around online. Of course, with the 7-day guarantee, the unscrupulous learner could take the whole course and then ask for a refund.

Price aside, there’s no denying that the course is well-made and convenient. If you want a doctor-to-doctor one-stop-shop to hold your hand as you go through finally understanding personal finance, then this is it.

While you could go through the videos in few hours, it will take several more to really do the class assignments.

And, if you do, it would be money well spent.

Brevity: A Flash Fiction Handbook

02.16.18 // Reading, Reviews

I finally had a chance to sit down and enjoy Brevity: A Flashfiction Handbook by David Galef.

This was particularly fun because:

I’ve published six stories by Mr. Galef in Nanoism, my unusual journal that exclusively features Twitter fiction, the longest running of its kind. Keeping it in the family, I’ve actually published even more (10!) by his son, Daniel Galef.

Nanoism is featured in the chapter discussing microfiction. Galef defines nanofiction in the book basically exactly as I did when I started publishing in 2009: Twitter fiction, stories of 140 characters or less (i.e. teeny teeny teeny tiny stories). As the book includes examples of flash fiction’s many forms and styles, two pieces from Nanoism’s library of almost 800 stories also made it into the book (on page 123).

Aspiring writers of very short stories would do well to check out Brevity in addition to The Rose Metal Press Field Guide to Writing Flash Fiction which came out back in 2009. Good stuff.

Book Review: The Hidden Curriculum & The Doctor’s Basic Business Handbook

05.18.16 // Medicine, Reviews

David Kashmer’s The Hidden Curriculum: What They Don’t Teach You At Medical School

is up next on the Kindle Unlimited tour of physician books. I really feel like the title should read “in Medical School.”

Kashmer’s hardest sells in the book are on how valuable he thinks his MBA training was and how great locum tenens positions can be for a young physician’s lifestyle (he owns a locums placement company). It starts with the usual “I’ve made a lot of mistakes doing all the amazing things I’ve done” humblebrag and follows it up with a ton of common sense. I do applaud him for the copy editing and book styling, definitely a notch above the usual.

He also really promotes a company called Provider Lifestyle Experts, a service which helps with dealing with credentialing paperwork for $600/month. Yikes! Only in my wildest dreams could I one day make enough money to think spending over $7000 annually for some light paperwork help was a good use of cash.

There are some generally useful things about contract negotiation, but I think these are better and more succinctly covered by the second book in this review. The practical advice on how to deal with the vagaries of clinical practice sort of sound like marathon advice: At first you’ll be nervous. At some point, you’ll get tired. You may even want to quit. If you trip and fall, well that will probably hurt. How much is hard to say. Is that helpful? Not really. It’s obvious. It’s generally pleasant non-advice. Be nice, work hard, don’t do shady things, and if your job really is a terrible fit, get the hell out of dodge.

Overall: Skip unless it’s free and have 1-2 hours to burn and you got terrible clinical evaluations in medical school and residency (i.e. have no common sense).

Brandon Bushnell’s A Doctor’s Basic Business Handbook: Things I Wish I Had Known When I Got Started

is overall stronger, in that out of the 1 hour it takes to read it, 10-15 minutes are pretty interesting. The book is apparently an extended version of a talk he gave to some orthopedics colleagues.

Chapter 1 is “Ten Points You Need to Know About Contracts.” This is interesting and well written. It’s basically an excellent blog post.

Chapter 2 is an almost joke personal finance chapter: don’t act rich, and get a financial planner (ugh).

This is followed by short chapters covering industry and hospital relationships, basics of coding/billing, marketing. All of this is fine and good basics.

Overall: Good if you know nothing, particularly the first chapter. Worth it on Kindle Unlimited/free. Otherwise pass.