Updates in the ABR Lawsuit

09.03.20 // Radiology

The back and forth continues. You can see the duel laid out on the lawsuit’s website, but they’re now up to 9 filings, most recently on August 12, when the plaintiff added their “Sur-Reply in Opposition to Motion to Dismiss” (which is an additional response to specific arguments made by the American Board of Radiology in their second motion to dismiss which itself was a response to the plaintiff’s amended complaint after the initial complaint was dismissed).

For those just tuning in, the plaintiff’s main thrust has been to argue that the ABR has abused an illegal monopoly by using their complete market dominance in essentially mandatory (initial) board certification to then force all radiologists to continue paying for the “separate product” of maintenance of certification forever. The ABR has argued that MOC is just part of certification now and is not a separate product, even if it wasn’t before and hasn’t been for the majority of the ABR’s history since its founding almost a century ago.

You don’t have to read much to see why the legal system is terrible, lawsuits take forever, and lawyers make a lot of money. The initial lawsuit was filed in February 2019. The amended complaint was filed in January 2020. And this is all quite possibly going to be thrown out by the judge again without even a hint of a trial after at least two years of the ABR burning through our certification fees to preserve its (new) status quo.

One excerpt from the end of this recent back and forth.

ABR:

If Plaintiff’s conclusion were true, hospitals and other medical organizations would not require certification (which includes MOC) to the degree alleged by Plaintiff. Competing entities would be permitted to offer substandard CPD products at bargain prices, and ABR would be powerless to control the integrity of its certification.

Of course, most hospital credentialing specifically does not include MOC, and such a requirement is even illegal in some states. It’s only “required” in the sense that the ABMS boards are now saying they’ll revoke certification from those who have earned it if they don’t keep paying their annual tithe.

Response:

There is nothing [in the motion] about “substandard CPD products,” “bargain prices,” or “the integrity of [ABR’s] certifications.” While ABR may assert its illegal tying is a justified attempt to preserve the undefined “integrity of its certifications,” that inherently fact-driven affirmative defense relies on facts outside the pleadings, is inappropriate on a motion to dismiss, and is contradicted by Plaintiffs’ well-pleaded allegations that MOC does not benefit physicians, patients, or the public, or improve patient outcomes. For example, ABR does not contend ABR certified radiologists failed to satisfy the “integrity” of certifications before MOC; that the “integrity” of certifications was in decline before MOC; that making MOC mandatory protects the “integrity” of certifications; or that hospitals, patients, and insurance companies had less “trust” in certifications before MOC was made mandatory.

Plaintiff seeks only to break up the captive market ABR has created for MOC by tying it to certifications. Eliminating the illegal tie and making MOC voluntary as promised previously by ABR will allow the marketplace to decide the merits of MOC, as the antitrust laws require.

Presumably, the judge will weigh in again in the coming months. His initial response was to grant the ABR’s initial motion to dismiss.

Sociopaths need data too

09.01.20 // Miscellany, Reading

I just finished John Carreyrou’s Bad Blood: Secrets and Lies in a Silicon Valley Startup, about the fall of Elizabeth Holmes and Theranos, the Silicon Valley Unicorn that pretended to be a pioneer in laboratory testing but was really just a purveyor of bloated promises and outright lies.

A sociopath is often described as someone with little or no conscience. I’ll leave it to the psychologists to decide whether Holmes fits the clinical profile, but there’s no question that her moral compass was badly askew. I’m fairly certain she didn’t initially set out to defraud investors and put patients in harm’s way when she dropped out of Stanford fifteen years ago. By all accounts, she had a vision that she genuinely believed in and threw herself into realizing. But in her all-consuming quest to be the second coming of Steve Jobs amid the gold rush of the “unicorn” boom, there came a point when she stopped listening to sound advice and began to cut corners. Her ambition was voracious and it brooked no interference.

A 19-year-old with a couple of semesters of chemistry under her belt suddenly knows enough science and engineering to demolish the scientific state of the art and maybe even the laws of physics when it comes to fluid dynamics. Even the products themselves kept pivoting as her original ideas were clearly impossible with the current state of technology and the people she brought in to do the actual work rotated through.

It’s bonkers, and it’s so telling that almost everyone investing was a tech billionaire or silicon valley VC with no understanding of science. A cult of personality has no business in healthcare without data. This was Holmes describing the Theranos lab process:

A chemistry is performed so that a chemical reaction occurs and generates a signal from the chemical interaction with the sample, which is translated into a result, which is then reviewed by certified laboratory personnel.

If you heard this in a pitch meeting, would you think future of medicine or middle school book report?

I remember the news when Theranos imploded and I think a lot of people fully embraced the schadenfreude. But reading the detailed story was just so depressing. You shouldn’t be able to run a science company while hiding all the research and data. You know, all the sciency stuff. That’s literally not how science works.

How many thousands upon thousands of hours of smart folks’ time was wasted trying to duct tape vaporware when they could have been making a substantive contribution to their fields. How much money was flushed for someone’s ambition?

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.

Less Certainty, More Inquiry

08.26.20 // Miscellany

Maria Konnikova, psychologist and rapid-onset Poker champion, relaying a story from her mentor and seasoned Poker champion, Erik Seidel:

Seidel doesn’t give me much in the way of concrete advice, and our conversations remain more theoretical than I would prefer. He focuses more on process than prescription. When I complain that it would be helpful to know at least his opinion on how I should play a hand, he gives me a smile and tells me a story. Earlier that year, he says, he was talking to one of the most successful high-stakes players currently on the circuit. That player was offering a very specific opinion on how a certain hand should be played. Erik listened quietly and then told him one phrase: “Less certainty. More inquiry.”

“He didn’t take it well,” he tells me. “He actually got pretty upset.” But Seidel wasn’t criticizing. He was offering the approach he’d learned over years of experience. Question more. Stay open-minded.

A good candidate for the second Golden Rule.

The Power of Pausing

08.24.20 // Medicine, Miscellany

Solitude on its own won’t give us knowledge and compassion—it depends how we use that time with ourselves. But it gives us the opportunity to listen to ourselves, to hear the ideas, inspiration, feelings, and reactions that arise, and hopefully to approach what arises with kindness and compassion even when the thoughts that come up are painful or unflattering.

Moments of pause are especially powerful when combined with gratitude and feelings of love. I had a medical school professor who struggled with the demands of being a mother, doctor, teacher, researcher, and administrator. Finding time to meditate or go on a retreat was a near impossibility for her, but whenever she washed her hands before seeing a patient, she would let the warm water run over her hands for a few extra seconds and think of something she was grateful for—the opportunity to be a part of the patient’s healing, the health of her family, the joy of teaching a student earlier that morning. She was one of the first people to teach me that the power of gratitude can be delivered in the smallest of moments . . . and those moments have the power to change how we see ourselves and the people around us.

If we ever forget the power of pausing, we need only remember the lesson of our heart. The heart operates in two phases: systole where it pumps blood to the vital organs and diastole where it relaxes. Most people think that systole is where the action is and the more time in systole the better. But diastole – the relaxation phase – is where the coronary blood vessels fill and supply life sustaining oxygen to the heart muscle itself. Pausing, it turns out, is what sustains the heart.

From former Surgeon General Dr. Vivek H. Murthy’s lovely book, Together: The Healing Power of Human Connection in a Sometimes Lonely World.

When the pandemic first exploded earlier this year, I naively hoped that it would be a unifying enemy that would help us transcend our differences. That didn’t happen here at least. I think some fortunate people were able to pause, but pausing–like many things–is easier with privilege. When I look at the depressing state of community and political discourse, I think Murthy has it exactly right:

The great challenge facing us today is how to build a people-centered life and a people-centered world. So many of the front-page issues we face are made worse by—and in some cases originate from—disconnection. Many of these challenges are the manifestation of a deeper individual and collective loneliness that has brewed for too long in too many. In the face of such pain, few healing forces are as powerful as genuine, loving relationships.

Recalls and Exam Security

08.20.20 // Medicine, Radiology

Out of all the reasons organizations like (but not limited to) the ABR have used as an excuse to shy away from remote content or historically relied on commercial testing centers, I strongly suspect exam security is the only one that actually matters.

While an individual not cheating on the exam is important for exam integrity, that type of exam security is a relatively straightforward n=1 problem. The real exam security that matters is the security of intellectual property. Nevermind that all these medical organizations use questions largely written and initially vetted by volunteers, losing hundreds of proprietary questions in one fell swoop to some industrious malcontent is the real fear.

The recent utter failure of the American Board of Surgery’s virtual testing also makes the point: once people have seen a significant fraction of the questions for a high stakes exam, it’s back to the drawing board. A doomed effort to administer an exam remotely sets an organization back by months, at the least.

That’s because recalls—people sharing memorized exam content—are a big deal. In fact, news about the universal use of recalled study questions for the radiology oral boards back in 2012 was the driving force behind the creation of the MCQ-only Core and Certifying exams, administered only on-site in bespoke testing centers created by the ABR itself in Chicago and Tuscon that sit gathering dust for most of the year.

While recalls are against organizational policy (and thus certainly something an individual should not do), the focus on recalls as a destabilizing force for the fairness of exams is…lame. Literally every important high-stakes exam including the SAT, MCAT, USMLE, and the various board exams have engendered a massive test prep industry around offering nearly the same thing: questions written–sometimes by the same people!–to exactly simulate those very same exams. Many, including most of the USMLE prep products, use software that even completely mimics the test software down to the pixel.

But I want to posit a fundamental misunderstanding:

A Really Meaningful Modern Test Shouldn’t Rely on Hiding its Content

Imagine a radiology exam had a question demonstrating a benign hepatic hemangioma on CT or MRI. Imagine a second-order question asking about management (nothing). If that information were put into a series of recalls, it would be meaningless. Every radiology resident should get the question correct because it is relevant to radiology practice and unavoidable during normal training. And if the exam, like the USMLE licensing exams or the various specialty board exams, purports to be a measure of minimal competency for safe independent practice, then all the questions should be relevant to daily practice.

If someone has mastered all of the relevant “recalls,” then they would presumably be ready to practice radiology. It’s okay if the fraction of answered questions is high if we expect the questions to reflect things we really want everyone to know. Mastering all of this exam content is exactly what we want trainees to do!

Recalls only matter in two situations:

If exams need to include questions designed to differentiate high-level performance, separating the best from the average. In this setting, questions that should be really challenging become easy, throwing off the balance of exam difficulty. It’s precisely because the designers want to give you brainbusters that the element of surprise is key. But in a world where high-quality informational content is at your fingertips, this component of mastery is increasingly irrelevant. The things we really want people to know quickly, like how to manage a true emergency like a code or how to drop a line, are never satisfactorily going to be assessed with a multiple-choice question. That’s what a real-life training program is for. Performance on an MCQ test is typically only good at predicting future performance on other MCQ tests.
Questions that really really test critical thinking. In this setting, the examinee shortcuts the thought process and arrives directly at the answer, defeating the purpose of the question. While the MCAT contains a fair number of reasoning questions along these lines, this is rarely the case in real life for medical licensing and board exams.

Every question bank for every major test is composed of glorified recalls. Pretending otherwise is silly. If all questions contained important material and the ability to answer them reflected meaningful knowledge and competence, then someone able to memorize the plethora of recalled questions would be exactly what you’d want: qualified.

A brief interview (about my Free 120 explanations)

08.19.20 // Medicine, Miscellany

I did a brief interview with the folks at Elite Medical Prep ages ago that went live today. I can’t believe I’ve been writing up explanations for the NBME practice materials for so long, but, well, I guess I have.

On a related note, if you’re in the market for personalized 1-on-1 tutoring, they’re a good group of folks. Tell them I sent you and they’ll give you $50 off when you purchase 5 hours or more.

Lessons from the American Board of Surgery’s Virtual Board Exam Debacle

08.18.20 // Medicine

Lesson 1: Beware Third Party Services

During the slow drama that has been the delivery of high-stakes during the pandemic, some organizations like the American Board of Radiology resisted agreeing to a virtual exam for so long precisely because they couldn’t control the environment, delivery, and security. Unfortunately, we have some great evidence that offloading exam security to a third-party company can easily fail on those metrics as well.

Just ask the American Board of Surgery, which hired Verificient’s Proctortrack, an “industry leading Online Proctoring / Remote Invigilation solution.” Leaving aside how creepy “invigilation solution” sounds, Proctortrack has a 1-star rating on the app store for being generally awful. And despite the platform’s buzzwords of AI, computer vision, and machine learning, there were both serious mechanical and human failings.

The ABS went from a single day 8-hour exam to a two-day 4-hour exam, just to make sure the platform could handle it. It couldn’t.

ProtorTrack is extremely invasive. It requires download and installation of monitoring software that gives serious access over both your computer and your smartphone. The service also requires a room scan of 360 degrees to clear your workspace of nefarious intent (that last part actually makes sense to me).

So what happened?

Near instantaneous failure. The Room Scan feature failed early, and then examinees were basically left out to dry with poor phone and online customer service. People kept trying to log in and ended up banging their heads against the wall. I’ve heard an estimate that around half of the residents were able to take at least a portion of the test. But the circumstances were less than ideal, with many residents apparently reporting being harassed to complete distraction by the “live” overseas proctors.

Shortly after, the reports of identity theft, unauthorized credit card charges, and inappropriate social media contact began.

Because the test questions were exposed to a fraction of the examinees, those questions are no longer usable. The ABMS boards talk a lot about “their” intellectual property, and while these questions are written by volunteers, we shouldn’t demean the serious effort that goes into crafting and then vetting them. MCQ tests may not be a great measure of medical competence, but that doesn’t mean a lot doesn’t go into making one. Having to throw out a test is a serious setback.

I don’t know what goes into how these organizations make these sorts of operational decisions, but I don’t think it takes a clairvoyant to predict that ProctorTrack might have been a suboptimal choice.

While it might look good to an uninvolved observer, I don’t think a third-party off-site unaccountable organization is the right move for a high-stakes virtual exam. While at home exams require more effort, a residency-based in-person exam with live or focused virtual proctoring would be relatively straightforward. Regardless, video proctoring and screen recording don’t even need to be live, so long as all information is saved and can be reviewed.

It’s also hard to imagine a doctor throwing away their career just to copy some exam questions, which is really what we’re worried about here more than someone cheating to pass.

Lesson 2: Be Flexible

The ABS essentially forced residents to take the test (before they canceled it and told them they couldn’t). Taking a pass this year would use up an attempt and looks bad for programs.

One one hand, that doesn’t sound so bad if it all worked out. But it didn’t. And when things don’t work out, people’s lives are way harder. Dedicated study time, job starts, family planning–everything. Doctors build their lives and programs plan their schedules around these exams. When we live in tough times, it’s best to err on the side of accommodation.

Any board needs to have contingency plans in place that will accommodate a rapid administration to waiting candidates. Write more questions now and have them ready to deploy. Running out of questions after a failed attempt and needing to push things back indefinitely in order to write more is a terrible plan.

Lesson 3: Prioritize Communication

Announcements about the exam were done primarily through Twitter. Emails and website updates came universally after a multi-hour delay. Twitter is fine, but Twitter shouldn’t be used as a replacement for individualized communication. When it comes to a career-defining exam, people should be getting so many emails (or potentially opt-in text messages) that they almost find it annoying.

By the time the ABS finally published a FAQ on its website, days had passed.

When the Resident Association of the American College of Surgeons (RASACS) and ABS hosted a virtual town hall, it was announced within five hours of the event and then limited to in-advance sign-ups of only 400 people, a small fraction of the affected residents.

Take-Home

I don’t want to suggest that doing a virtual exam for the first time in history is a straightforward endeavor.

What I do think is clear is that an organization whose sole purpose is to create and administer tests needs to be nearly flawless on that execution. Offloading tasks to third parties, even the commercial testing centers so commonly used, has long resulted in a suboptimal and often degrading experience. Third-party proctoring is apparently no different. I appreciate that ABMS member boards are not tech companies and will always use contractors to accomplish a variety of tasks, but that does not absolve them of responsibility for the final product.

Lastly, communication and accountability shouldn’t be an afterthought. Just because residents have no power over their respective boards doesn’t mean they aren’t worthy of consideration and respect.

Buying Disability Insurance As a Medical Student

08.12.20 // Finance, Medicine

Let’s start by saying that I’m certainly not the only person on the internet that thinks it’s critical for all doctors to buy true own-occupation disability insurance that protects you in the event that you become disabled and can’t earn your full income. Your earning potential is too high and school is too expensive to not protect. There’s a good chance you’ve already (or will soon) hear about DI all the time because your eyeballs and attention are valuable and disability insurance agents sponsor a lot of podcasts and a bunch of blogs.

And that’s actually basically okay because that helps pay the bills for a lot of meaningful content out there; these folks are paid by the insurance companies (not you), and you need to use one to buy a policy anyway.

I bought my disability insurance policy toward the end of residency, but when I look back at my post-call exhausted driving, occupational hazards (e.g. sharps), and health scares, I feel fortunate to still be healthy and to have gone through the process unscathed. Though we haven’t needed to use it yet, it’s not hard to imagine a scenario where things didn’t pan out so well or where I or my wife developed a condition that prevented us from buying insurance in the future.

I have no doubt that the best answer to the question of “when to buy disability insurance?” is as soon as feasible. And I wondered more about the logistics of buying a physician policy as a medical student, something that no one really talks about.

So I asked Matt Wiggins from Pattern to talk with me and fill in the gaps. He made a video for you, dear reader (good for anyone but especially medical students and residents), and I’ve written a post breaking down how that works in medical school and detailing my thoughts. This isn’t a sponsored post (we don’t do those around here), but I do have a relationship with Pattern if you end up checking them out to get policy quotes. (It never costs anything to see your options; agents get paid a commission if you buy a policy.)

What is disability insurance?

A disability insurance policy will provide you with monthly paychecks if you become unable to carry out the duties of your job due to disability. The more you earn, the bigger a policy benefit you can purchase (and the more it costs in premiums). Disability insurance ensures that you are protected financially when things go wrong and you can’t work the way you used to.

A good policy for a doctor is called an own-occupation policy because it pays the full benefit if you can’t do the same doctoring job you were doing as a physician when you become disabled, even if you can be gainfully employed otherwise. If a surgeon hurts her hands and can’t operate, then she’s fully disabled even if she goes on to make even more money as a consultant or another kind of doctor. The problem with most policies bundled with your employment is 1) they don’t follow you when you leave your job and 2) they typically don’t have as strong a definition as own-occupation or what defines a disability. The practical matter is that a group policy just may not cover you in real life. The sorts of policies residents have while in training are notorious for letting you down when you need them most.

When you buy a policy, you will also choose from a variety of “riders,” which are essentially optional add-ons you can purchase a la carte. Each one makes your policy more expensive but also makes it more flexible. A common example would be a “future benefit increase” rider, which allows you to upgrade to a bigger policy in the future when your income rises without needing to go through medical underwriting. Even if you develop a medical condition that is sure to result in a disability in the future, the company still has to let you exercise the rider.

When is the right time to purchase disability insurance?

So you definitely need it. The question is just the timing. Ultimately, since you can’t predict the future, the real answer is as soon as you are eligible to buy the right kind of policy and can afford it. The first part has a real answer, the affordability part is a little fuzzier.

There are two long-term financial benefits to grabbing a policy early:

— Cheaper rates based on Age and Health (you’re never younger or probably healthier than you are right now)

— Discounts from University or Training-program affiliation (range anywhere from 10-40% off the premium and will typically last the life of your policy even after you leave)

For many, a good solution is to get a very small policy towards the end of medical school. You can lock in $1,000/month in coverage for $20-$40/month, which would at least provide $1,000/month tax-free until you are retirement age should a disability happen to you in medical school. But the main benefit is that this small purchase would lock you into the ability to increase your coverage to much higher levels without the insurance company ever checking on your health again, which can be the difference between being future-proof or not. It’s all about who you are when you buy, not who you become.

How Things Differ for a Medical Student

A resident or attending buying disability insurance is able to buy an own-occupation specialty-specific policy. This is the kind that protects exactly what you do. A pre-match medical student will instead get a generic (internal medicine) policy. If you buy a policy after matching, the rate will be adjusted for the risk category (and procedures etc) of the field they’ve chosen. So an anesthesiologist, a higher-risk specialty, will have a higher rate than a family doc.

But there is some nuance. I asked Matt how that works if you specialize later on, and this is what he said:

When a doctor files an own-occupation claim, the insurance company looks to find out exactly what duties or procedures the doctor is doing at the time of disability, and that is the occupation that is protected. In other words, if a doctor buys a policy in med school and then goes on to an internal medicine residency, followed by a cardiology residency, followed by an interventional cardiology fellowship, they will be protected for the procedures they are doing as an interventional cardiologist even though they bought their policy well before they were an interventional cardiologist and their rates are cheaper than if they had purchased the policy later as an attending IC doc.

Interesting (and not what I would have expected at all).

So, if you’ve chosen a higher-risk field like a surgical specialty or anesthesiology, then you’ll also save money in the long term by getting the rates of a less risky “generic doctor” profession upfront.

Most companies will only offer policies to fourth-year students, who can purchase a benefit of up to $2500/month (which would cost in the neighborhood of $60-$100/month in premiums for men and $75-$125/month for women). Once you match, you’d be eligible to increase the resident benefit (which is 5,000/month across the board). But you don’t have to buy a policy at the maximum you’re eligible for; you can buy one that you’re confident you can afford.

Parting Thoughts

The idea that I could have skipped a couple of burritos and a latte and locked in disability insurance as a medical student is crazy to me. I waited until late in residency when we had more cash flow, but that was I think the wrong approach. I should have purchased a small policy as soon as possible. Even if I couldn’t afford the higher premiums to increase the benefit until later in training, at least I could have guaranteed that flexibility to do so upfront by being more proactive.

You should always comparison shop for DI with independent agents. In addition to Pattern, consider checking out LeverageRx as an additional source. It’s always free to get quotes (because agents are paid by commission from the insurance company). Both are affiliates, so talking to them is an easy way to support my writing.

The Cost, Price, and Debt of Medical Education

08.05.20 // Medicine

From “The Cost, Price, and Debt of Medical Education” in NEJM.

In the 1960s, 4 years of U.S. medical education could be purchased for about $40,000 (in 2018 dollars). By 2018, the average price had increased by 750%, to about $300,000; approximately 75% of students took on loans, and their average debt at graduation was $200,000. In contrast, U.S. college tuition increased by about 250% over the same period.

…between 2010 and 2018, the percentage of medical students graduating with no debt also increased — a happy result if it arose from lower prices or more scholarships, but its occurrence in the absence of those conditions suggests that medicine is increasingly a profession accessible only to the rich.

What a massive increase.

This last part, borne out by the data, is a serious problem. And a few free medical schools and a handful of scholarships aren’t going to reverse the serious financial headwinds discouraging the nonprivileged.

Of course, loan-repayment programs offer nothing to students who don’t finance their education with debt to begin with. But a more fundamental limitation is that because these programs target debt and not price or cost, they risk exacerbating high education prices for all. In theory, students who expect their loans to be fully or partially forgiven become less sensitive to the price of medical education and the price differences among schools. Anticipated debt relief — even partial or uncertain relief — reduces the already weak incentives for medical schools to compete on price and so effectively transfers money to the schools with higher prices.

Price insensitivity is a huge issue across higher education. The investment in a nebulous professional future paid with borrowed funds means that many students just accept the sticker price of whatever their dream is and only consider the consequences after the fact. For medical school, many students are just happy to be accepted. The cost differential amongst choices often only plays a role for those choosing between acceptances from lower-price home state institutions and higher-price private ones.

People often ask if PSLF will be canceled as Trump has proposed or if the government will start forgiving large swaths of student loans as many candidates proposed during the recent Democratic primaries, but that’s missing a key part of the story. Any changes to the details of loan repayment in the absence of an overhaul of higher education funding will not solve the systemic problem.

The cost of medical school–as in the amount of money it takes to train a medical student–is surely high. But is it really 3 times that of a college? Do medical students, in some situations, not also provide value to help mitigate some of those costs? Before the current regulatory climate, they certainly used to. Keep in mind, too, that much of the high-touch clinical teaching is actually performed by residents and fellows, who are essentially paid for by the federal government and not by the institutions that employ them.

I am reminded by this interview with Robert Grossman, the NYU dean that made medical school free:

I mention that each year, N.Y.U.’s 450 medical students paid a total of $25 million in tuition.

“So where does this money go?” I ask Grossman.

“Well, where do you think?” he asks, smiling, raising his hands and shrugging shoulders. I think I know what he’s about to say, but I’m surprised when he says it so bluntly.

“It supports unproductive faculty,” he states coolly.

Unproductive faculty, Grossman explains, are people who draw a monthly paycheck, but don’t write grants, teach, or see patients. Tuition also funds other expenses, but the vast majority of tuition is not spent educating students.

All three–the cost, the price, and the debt–have run away and created a host of pathology within medicine. But if we are to take at face value that the price of medical school is merely a reflection of its soaring costs, then there is some serious fat to trim throughout every step of the process.