Review: Doctor’s Orders (Hierarchies in Medicine)

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

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 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

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

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

MRI Online 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 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 your 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 BW_ATTENDING gets you 10% off ($135/month or $1,350/year). Residents and fellows, please email mrionlineresident.bw@gmail.com for an extra 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.