Ben White

The Emergency Mind

12.04.23 // Medicine

A passage about the fear of consequences from The Emergency Mind: Wiring Your Brain for Performance Under Pressure by Dan Dworkis MD PhD:

In or out of the emergency department, all emergencies share three common structural characteristics:

• Emergencies involve uncertainty.
• Emergencies have high-impact outcomes.
• Emergencies occur under significant pressure.

Whatever the potential impact of a situation is, fear of this impact can lead to paralysis; you can find yourself unable to make a decision because you are so preoccupied with what the impact might be. Of course, not making a decision is, in and of itself, a decision.

A big part of residency training is just accumulating enough reps that you aren’t paralyzed by indecision, especially when stressed or confronted by novelty.

More broadly: even abdicating a decision to maintain the status quo is itself a decision. There is no escape from time, which will always take us from point A to point B.

The consequences will come. The question is, will you make deliberate choices to achieve the best outcome? Will you reflect on not just your outcomes but also your process to ensure you grow?

 

Private Equity & Piracy Metaphors

11.17.23 // Finance, Miscellany

Time horizons, incentives, and moral hazard: a very enjoyable easy-listening zoomed-out discussion of the Private Equity industry on the Freakonomics podcast.

If you find the discussion of healthcare and PE on this site and others to be too tedious and haven’t learned more about this very large and very important industry, this is a great well-produced episode.

It includes an interview with Brendan Ballou, author of Plunder: Private Equity’s Plan to Pillage America.

(Which is not to be confused with These Are the Plunderers: How Private Equity Runs—and Wrecks—America by the Pulitzer Prize­­­–winning Gretchen Morgenson…there’s a theme here.)

The UnitedHealthcare vs Radiology Partners lawsuit went to arbitration instead of a jury trial last month. Last week, the arbitration panel ruled in favor of RP and its practice Singleton Associates, awarding them $153.5 million.

United, for its part, says it’s not done, and that there are still unaddressed counterclaims. From that Radiology Business article: “We do not agree that Singleton will recover an award from UnitedHealthcare,” the Minnetonka, Minnesota, company said.

// 10.24.23

Two great quick radiology podcasts, well worth your time for a better understanding of radiology in 2023:

First, the state of the radiology residency match and how things look for medical students as well as the radiology workforce, courtesy of Dr. Francis Deng (@francisdeng). I agree with everything he said, and he said it better than I would have. Listen here.

Second, episode 2 of the Texas Radiological Society’s “How Radiologists Get Paid” Podcast: a great discussion of the state of payment policy between Dr. Kurt Schoppe, policy wonk and my colleague across town, and Dr. Lauren Nicola, current Chair of the Reimbursement Committee at the ACR. If you want a better understanding of CMS reimbursement and what “quality” has meant recently in radiology, check it out.

// 09.28.23

Making the Most of PowerScribe

09.24.23 // Radiology

With the recent advances in LLMs, I suspect dictation improvements are one of the things that will be increasingly available in the very very near term future (though how cost-effective those plugins or replacements will be remains to be seen).

In the meantime, PowerScribe is ubiquitous in radiology practices across the country, and it’s the only dictation software I use in my job. It has many flaws, but there are plenty of things we can do to make the most of it.

If you’ve been using PS for a while, you will likely be familiar with at least some of these features, but a lot of radiologists just use it like a stubbornly inaccurate transcriptionist.

Here are some tips for making PowerScribe (360) suck less:

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SAVE Can Save Lots of Interest, Even When in Graduate School

09.19.23 // Finance

Every new student loan plan has created some presumably unintended management strategies (i.e. “loopholes”). Over the years, some features have been removed from newer plans, like the “payment cap” from IBR & PAYE that previously capped your payments at the 10-year standard amount no matter how much money you earned. Others have been codified, like the “married filing separately” loophole that allows you to exclude your spouse’s income when calculating your monthly payments (present with IBR/PAYE, excised from REPAYE, but now back in SAVE).

A small loophole in REPAYE became a big loophole with SAVE based on its 100% unpaid interest subsidy. In the SAVE plan, whatever interest isn’t covered by your calculated monthly payment is entirely waived. Negative amortization is a thing of the past. This is true even for $0 payments, meaning that those with low incomes functionally have an interest-free (0%) loan.

This is a great perk of being in repayment for many borrowers, including medical residents (as I wrote about here).

It’s also an incentive to try to enter repayment as “early” as possible. There are two scenarios where a medical (or other graduate) student can do this:

1. Waive the In-school Deferment for Undergraduate Loans

For regular Direct loans, you cannot enter repayment until you leave school and finish the six-month grace period. You can consolidate after graduation to waive the otherwise mandatory grace period, but you can’t change their in-school status while still in school.

You can waive the in-school deferment for loans from previous schooling. From the Official PSLF FAQ:

Q: If I return to school and qualify for an in-school deferment on my Direct Loans that are in repayment, can I decline the deferment and make qualifying PSLF payments while I’m in school?

A: Yes. You can decline an in-school deferment on your loans that are in repayment status and make qualifying payments on those loans while you are in school. In this case, you must contact your servicer and request that the in-school deferment be removed. Remember, in order for your payments to qualify for PSLF, you must be employed full-time by a qualifying employer while you attend school.

Those graduate students with loans from undergrad can therefore enjoy a generous unpaid interest subsidy for their undergrad loans while completing their graduate studies. For many medical students, 0% undergrad loans during grad school can easily reach five-figure savings.

Also, these extra years of $0 payments during grad school will also qualify for the baked-in long-term currently-taxable (not PSLF) IDR loan forgiveness. Not relevant to most doctors, but certainly relevant to many others.

I wrote about this “loophole” way back in the Further Facets of Income-Driven Repayment chapter of the book.

2. Waive the In-school Deferment for Current PLUS Loans

PLUS loans are technically never in-school status; they’re automatically placed in an in-school deferment.

That in-school deferment is actually optional for PLUS loans. Yes, you can contact your servicer and waive the deferment for PLUS loans. With the current PLUS rate of 8.05%, that unpaid interest subsidy leads to substantial (potentially massive) savings.

Note that you may have to repeat this process every semester as you take out new loans.

Ben Braun has a nice article in Doctored Money about his successful implementation of the PLUS loan method.

Caveat: PSLF

This extra effort and decreased interest have no impact/benefit if you achieve PSLF. PSLF is a time-based program; you don’t get a gold star if the amount forgiven is higher or lower.

This technique would still be a reasonable hedge given the uncertainty of the future even when planning for PSLF.

PLUS to the Extreme

Historically, most students would like to avoid PLUS loans. Their interest rates are always 1% higher than the corresponding rates for standard direct loans (hence the “plus”), and they carry a much higher origination fee (aka “loan fee”), 4.228% instead of the usual 1.057%.

They simply cost more, and needing to take them out also means you’ve borrowed more. Borrowing more money makes people sad.

With this loophole, there’s an argument for trying to skip out on regular loans and just take out PLUS loans. The overall slightly higher rate would be more than mitigated by the 0% rate during school.

Functionally, the government has opened a backdoor into “subsidized” loans (that don’t accrue interest while in school) that used to be available for graduate students until 2012. The irony is that with the SAVE program, PLUS loans are now a much better deal than they’re supposed to be.

Note that there’s an immediate downside to this in that higher loan fee, so there’s actually an upfront cost that’ll take several months to break even on.

Take Home

Entering repayment early isn’t a bad idea at all. It wasn’t a bad idea during the REPAYE era, and it’s frankly a pretty amazing deal with SAVE.

I don’t know how easy it would be for the government to specifically close this loophole, nor how interested they will be in doing so. Some legislators would love to shutter the PLUS program, but I suspect it’s relatively safe. For the conventional loophole implementation, there really isn’t any downside: If you want to put your loans back in deferment while in school, that is always available to you as long as you are enrolled accordingly. So there really isn’t any risk as far as I can tell.

Trying to exclusively use PLUS loans out of order just to benefit from the subsidy is, I think, a much riskier venture. The SAVE program isn’t codified in law, and you can’t convert PLUS loans to conventional unsubsidized loans, so that’s a one-way street I would not personally recommend.

How I Use the Contour Shuttle for Radiology

09.04.23 // Radiology

This post could have been titled:

  • Why and How to Use an Offhand Device for Radiology

Or maybe even:

  • How to Make the Most of All Those Extra Buttons on Your Gaming Mouse or Similar Device

We’ll be talking about using productivity devices to make diagnostic radiology more biomechanically (and functionally) efficient. I was personally more focused on the former (repetitive stress is no joke), but both are important. Even if you don’t want to read more cases per day, reading the same number of cases with less friction is still a win.

This discussion applies broadly, but we’ll be doing so through the example of my current left-hand device: The Contour Shuttle Pro V2, a weird little ambidextrous off-hand device mostly used by video editors:

The principles of optimizing your radiology workflow and customizing tools for manipulating PACS are nonspecific. Whether you use this device, some sort of gaming/productivity mouse, or a combination (with or without the help of AutoHotkey), there is a lot you can do to streamline and improve your day-to-day practice.

(See this post for a thorough breakdown of microphones, mice, peripherals, and other workstation equipment).
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