Ben White

Explanations for the 2022 Official Step 3 Practice Questions

11.02.22 // Medicine

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.Read More →

Perceptions of Radiology MOC

10.21.22 // Radiology

In August, the results of a large ACR survey about radiologists’ opinions concerning MOC were released. The summary:

Similar proportions judged the existing program as excellent or very good (36%), or fair or poor (35%), with 27% neutral. MOC–CC was perceived more often as excellent or very good by those who were grandfathered yet still participating in MOC, were in academic practice, were in an urban setting, were older, or had a role with the ABR. In contrast, MOC–CC was more often judged as fair or poor by those who were not grandfathered, were in private practice, were in a rural setting, or were younger.

It’s a pretty sharp divide. Perhaps it is no great surprise that ABR volunteers and grandfathered academics are among those who view the ABR’s offering most favorably. The whole paper is worth a read, and the survey construction itself was very involved.

I’m not personally involved in any of this work, but the story behind why the survey even occurred (which I’m relaying secondhand) is perhaps the most interesting part.

If you recall, there was an ACR Taskforce on Certification in Radiology that was initially authorized in 2019 and concluded in 2020. You can read my highlights and analysis of their work here.

You also might not recall said task force, because their work apparently marks the only time in history that the ACR Board of Chancellors voted against authorizing a task force to submit their findings as a paper to the JACR. What could have been a paper shared with the broader radiology community was instead buried in a lonely random corner of the ACR website.

This is politics at work, of course.

Behind the scenes, the executive committee asked the task force to water down their language and conclusions, remove certain points, and generally “be nice.” The ACR, trying to repair some historically sour relationships with other radiology societies, didn’t want to be mean to the ABR. It probably doesn’t help when inbred leadership positions across multiple societies read like a game of musical chairs. It was apparently after multiple rounds of softening edits that the task force report was eventually buried anyway.

As a consolation, the board did permit a next-step survey in order to ascertain the true feelings of the radiology community (and not just the task force’s presumably squeaky wheels). The ACR used an outside consultant to help generate a fair survey, and then at the subsequent request of leadership, all “irrelevant” questions concerning the ongoing lawsuit, handling of COVID-19/testing delays, and the kerfuffle over the MOC agreement, etc were excised.

The survey results paper was initially submitted to JACR in 2021 and was—as you may have surmised—also rejected (though please note that the JACR is editorially independent). Much back and forth ensued—largely in order to limit perceived “bias against the ABR”—and the paper you see was finally published a year later.

In the end, thanks to editorial assistance, the limitations section is longer than the neutered discussion.

Joining and Leaving Private Equity: A Radiologist’s Story

10.19.22 // Radiology

Previously in the PE series, we spoke with someone who joined a practice that had previously been purchased (before eventually leaving). In this entry, we’re hearing from someone who joined an independent practice and was an associate in the work-up when the group sold.

Just like last time, I’ve sanitized names and some details. This case study is food for thought, not an indictment of a specific group or corporate entity.

Read More →

Forgiveness App is Live

10.17.22 // Finance

The official application for the Biden student loan forgiveness is now live. Impossible to say if any legal action will block it in the end, but for now the safest thing to do if you qualify is to apply as soon as possible. It’ll take about 2 minutes.

Apply here.

 

Envision: The PE Healthcare Harbinger

10.08.22 // Finance

From Bloomberg, some crazy machinations involving the restructuring of Envision, the massive medical staffing company, in order to pay off debts.

This is because Envision had $7 billion debt from its 2018 leveraged buyout by KKR, and KKR needed to find ways to exploit the paper details in order to restructure the company without getting taken to court and blocked.

“Loose documents have become the norm rather than the exception,” says Damian Schaible, co-head of restructuring at Davis Polk & Wardwell. “If we go into a real recession, we are going to see more and more borrowers and sponsors seeking to exploit document loopholes to create leverage against and among their creditors.”

Here’s the quick summary, which invokes the playbook of spinning off the valuable assets in order to essentially dump the crappy ones:

Envision, which also explored a consensual debt exchange that would have raised less funding, ultimately opted for what is considered one of the most controversial and coercive out-of-court restructurings to date. The [initial] deal…would prove to be just the beginning of a series of maneuvers that eventually allowed the company to restructure the vast majority of its debt but forced creditors to turn against one another.

The strategy rested on two pillars. The first was a drop-down transaction, in which a company’s most valuable assets are moved away from existing creditors and used as collateral for new debt. The second was a series of debt repurchases and exchanges that gave certain creditors priority over others and pushed anyone who declined to participate to the end of the line for repayment.

We always talk about stocks being risky and bonds being relatively safe, but corporate debt is its own beast in this world where overleveraged companies can successfully exploit loopholes to screw over current creditors in order to obtain new financing.

Envision first designated [their profitable ambulatory surgery business] Amsurg as a so-called unrestricted subsidiary, effectively moving it out of reach of existing creditors without violating provisions in the credit agreement that prohibited moving or transferring the asset. The Amsurg assets would then be used as collateral to borrow $1.3 billion from Angelo Gordon and Centerbridge, who’d effectively be stepping ahead of everyone else in the repayment waterfall. Envision could then use the cash raised from the hedge funds to boost liquidity and to repurchase some of its existing debt at steep discounts.

Ultimately, only $153 million of the original loan was left outstanding, as owners of 96% of the debt had exchanged their holdings and waived their rights to litigate the transaction in the future.

Likely a harbinger of things to come. The “bad guys” largely win. And for creditors, better to get pennies on the dollar than nothing.

The years of low-interest easy money did a lot of emboldening and overleveraging, and everyone was eager to deploy capital on dubious deals:

There was a bitter irony in the way most of the company’s creditors ended up competing for crumbs. Four years earlier, when Credit Suisse Group AG sold the debt that financed KKR’s purchase of Envision, demand was so high that a salesperson teased investors with a picture of cake crumbs on a plate. The message then: Hurry up and grab it before it’s all gone.

The Reward of Writing

10.04.22 // Writing

Anne Lamott from her lovely book on writing, Bird by Bird:

Writing has so much to give, so much to teach, so many surprises. That thing you had to force yourself to do—the actual act of writing—turns out to be the best part. It’s like discovering that while you thought you needed the tea ceremony for the caffeine, what you really needed was the tea ceremony. The act of writing turns out to be its own reward.”

I gave a talk about the benefits of writing last year at WCICON21. I didn’t know about this passage back then, but if I had, I would have included it at the beginning.

As the absurdly prolific Brandon Sanderson repeats in The Way of Kings as one of the ideals of the Knights Radiant: “Journey Before Destination.”

Process > outcome.

A reader asked me recently about starting a website, something that happens every so often and a topic I’ve written about before. And my answer in that post, which Lamott so beautifully captures, is that the writing has to be worth it in and of itself.

You think you want to teach others, get a following, sell something, or influence (as a verb). And of course you do! You’re human. I do too. But most people can’t just write for that and keep it going very long. Because while the output can be awesome, the outcome is unknowable. The process is the only guarantee.

It’s Always Your Fault

09.21.22 // Medicine, Miscellany

I came across this brief article (“It’s Always Your Fault“) from 2016 by DHH, who—among other things—was the creator of the web application framework Ruby on Rails and co-founder of Basecamp/37Signals:

There’s a system in place that caused this to happen, and you’re part of that system. Shit never happens in a vacuum. The vast majority of it is a predictable consequence of the way things are. Even if it was “just somebody’s fault”, others put or kept that person there.

The goal is to change the system, and to change the system, you have to change its parts. Have the courage to start with yourself. Absorb as much blame and responsibility you can for what happened, and hopefully some of that introspection will rub off on the other parts of the system. But even if it doesn’t, you’ve still done your bit to improve matters.

In Medicine, we seem to oscillate between blame-game individual-at-fault finger-pointing and Just Culture the-system-is-the-problem.

It’s true we shouldn’t go around punishing people who are trying to learn and doing their best, and equally true that we need to always be looking to address system flaws. It’s also critical to keep in mind how many people working in healthcare are second victims of those mistakes, which prevents healthy introspection in favor of guilty misery.

But I also found his point just a little refreshing. As usual, it’s not either/or, it’s both.

 

Losing the Track is Part of Tracking

09.19.22 // Radiology, Reading

From The Lion Tracker’s Guide To Life by Boyd Varty:

You must train yourself to see what you are looking for.

Perhaps the most concise description of radiology training.

“I don’t know where we are going but I know exactly how to get there,” he says.

Process > outcome.

I think of all the people I have spoken to who have said, “When I know exactly what the next thing is, I will make a move.” I think of all the people whom I have taught to track who froze when they lost the track, wanting to be certain of the right path forward before they would move. Trackers try things. The tracker on a lost track enters a process of rediscovery that is fluid. He relies on a process of elimination, inquiry, confirmation; a process of discovery and feedback. He enters a ritual of focused attention. As paradoxical as it sounds, going down a path and not finding a track is part of finding the track.

Uncertainty is part of life, but a search pattern helps.

Data-driven Personal Finance Takeaways

08.31.22 // Finance, Reading

Some interesting passages and food for thought from Just Keep Buying: Proven Ways to Save Money and Build Your Wealth by Nick Maggiulli (a personal finance book with much more data behind its analysis than average for the genre).

On saving:

And one of the most common financial stressors is whether someone is saving enough. As Northwestern Mutual noted in their 2018 Planning & Progress Study, 48% of U.S. adults experienced “high” or “moderate” levels of anxiety around their level of savings. The data is clear that people are worried about how much they save. Unfortunately, the stress around not saving enough seems to be more harmful than the act itself. As researchers at the Brookings Institute confirmed after analyzing Gallup data, “The negative effects of stress outweigh the positive effects of income or health in general.” This implies that saving more is only beneficial if you can do it in a stress-free way. Otherwise, you will likely do yourself more harm than good.

That’s a counterintuitive claim: stressing about not saving enough does more harm than not saving enough.

On spending:

Researchers at the University of Cambridge found that individuals who made purchases that better fit their psychological profile reported higher levels of life satisfaction than those who didn’t. Additionally, this effect was stronger than the effect of an individual’s total income on their reported happiness.

For example, it has been well documented that people get more happiness buying experiences over material goods. However, what if this is only true for a subset of the population (e.g., extroverts)? If so, then we may be generating spending advice based on the 60%–75% of people who are extroverts to the dismay of introverts around the world.

I suspect Maggiulli is right to point this out. Just like scientists get annoyed when news media take a small experiment or a mild trend in the data and throw up a big bold headline, the idea that all humans benefit from the same things in the same sorts of ways doesn’t pass intuitive muster. For many people, I suspect there are probably plenty of high-impact ways to spend on some things and dumb ways to buy experiences.

On valuing an educational/career investment:

The proper way to find the current value of these future earnings is to discount this payment stream by 4% per year. However, there is a simpler way to approximate this—divide the increase in lifetime earnings by two. This will be roughly equivalent to a 40-year payment stream discount by 4% per year. I prefer this shortcut because you can now do the math in your head. Therefore, a $800,000 increase in lifetime earnings over 40 years is worth about $400,000 today.

Value of Degree Today = (Increased Lifetime Earnings/2) – Lost Earnings While things like taxes and other variables can affect this calculation, it’s still a simple way to check whether a degree is worth the cost.

Food for calculus when considering not just expensive degrees but also lengthy medical training or an additional fellowship.

On the health impact of debt:

For example, research published in the Journal of Economic Psychology found that British households with higher levels of outstanding credit card debt were “significantly less likely to report complete psychological well-being.” However, no such association was found when examining households with mortgage debt. Researchers at Ohio State echoed these findings when they reported that payday loans, credit cards, and loans from family and friends caused the most stress, while mortgage debt caused the least. On the physical health front, a study in Social Science & Medicine found that high financial debt relative to assets among American households was associated with “higher perceived stress and depression, worse self-reported general health, and higher diastolic blood pressure.” This was true even after controlling for socioeconomic status, common health indicators, and other demographic factors.

What makes buying a home even easier is if you can afford it. This means being able to provide 20% as a down payment and keeping your debt-to-income ratio below 43%. I chose 43% because that is the maximum debt-to-income ratio you can have for your mortgage to be considered qualified (i.e., lower risk). As a reminder, the debt-to-income ratio is defined as: Debt-to-Income Ratio = Monthly Debt / Monthly Income

Part of what makes mortgage debt less impactful to mental health is presumably the fact that mortgages feel universal and almost no one you are likely to know (at least early in your professional career) has the money to buy a house with cash.

Nonetheless, I suspect I will have a measurable well-being boost when mine is gone.

On why to invest:

In essence, by investing your money you are rebuilding yourself as a financial asset equivalent that can provide you with income once you are no longer employed. So, after you stop working your 9 to 5, your money can keep working for you. Of all the reasons why someone should invest, this might be the most compelling and also the most ignored. This concept helps explain why some professional athletes can make millions of dollars a year and still end up bankrupt. They didn’t convert their human capital to financial capital quickly enough to sustain their lifestyle once they left professional sports. When you make the bulk of your lifetime earnings in four to six years, saving and investing is even more important than it is for the typical worker.

Fund the life you need before you risk it for the life you want.

The conversion of human capital to financial capital is an excellent way of looking at/arguing for investing.

On being realistic about wealth:

For example, research in The Review of Economics and Statistics illustrates that most households in the upper half of the income spectrum don’t realize how good they have it…households above the 50th percentile in income tend to underestimate how well they are doing relative to others…even households at the 90th percentile and above in actual income believe that they are in the 60th–80th percentile range.

For example, you would need a net worth of $11.1 million to be in the top 1% of U.S. households in 2019. However, after controlling for age and educational attainment, the top 1% varies from as little as $341,000 to as much as $30.5 million. For example, to be in the top 1% of households under 35 that are also high school dropouts you would only need $341,000. However, to be in the top 1% of college educated households aged 65–74 years, you would need $30.5 million.

It’s incredibly easy to find some Joneses to keep up with.

On green grass:

But why does happiness start to decline in the late 20s? Because, as people age, their lives usually fail to meet their high expectations. As Rauch states in The Happiness Curve: “Young people consistently overestimate their future life satisfaction. They make a whopping forecasting error, as nonrandom as it could be—as if you lived in Seattle and expected sunshine every day…Young adults in their twenties overestimate their future life satisfaction by about 10 percent on average. Over time, however, excessive optimism diminishes…People are not becoming depressed. They are becoming, well, realistic.”

Part of the curse of medical training is to coincide with this natural stage of disillusionment.