Ben White

A Primer on Disability Insurance for Doctors

07.05.24 // Finance, Medicine

Introduction

Disability Insurance is a boring and expensive but critical component of a physician’s financial plan.

While life insurance pays your beneficiaries when you die, disability insurance pays you when you can’t work due to a medical condition. It insures your most valuable asset: your future earnings potential in a profession after you spent years investing in yourself.

Upfront Summary

  • Disability insurance helps you pay for your life (and lifestyle) when you can’t work.
  • You (ideally) want an individual, portable, noncancelable, guaranteed-renewable, true own-occupation specialty-specific policy.
  • You want that policy as soon as you can afford one, and you want to include at least a few “riders” (options).
    • One is a “future benefit increase” option or equivalent phrasing, which will let you buy more insurance as your income increases without needing to undergo additional medical underwriting.
    • Also important is a “partial” or “residual” disability rider, that will pay you if your income falls because you can’t work full-time or perform certain tasks (e.g. a surgeon who can’t operate to make their full income but can still see patients in clinic).
    • Another is a “cost of living adjustment” (COLA) rider, which will help mitigate inflation.
  • You’ll want a big enough policy benefit to help prevent a lifestyle shock should you become disabled while also still being able to save enough for old age (“retirement”), since the policy you choose will likely stop paying benefits around age 65.
  • The whole thing will probably cost more than you will enjoy paying, but you’ll always have the option to cancel the policy whenever you want once you’re financially secure and don’t need the benefits.
  • Before you get that magical policy, you may want to lock in some basal coverage by securing a Guaranteed-Standard Issue (GSI) policy first, which doesn’t require medical underwriting (see below).

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Getting Started in Radiology

06.30.24 // Radiology

Here’s a little compilation of posts from the last few years about getting started as a new radiology resident.

Doing

Approaching the Radiology R1 Year and its short companion post: How to be a First-Year Radiology Resident.

Want something a little more controversial? You Should be Correlating Clinically.

Learning

Book Recommendations for First-Year Radiology Residents (and some further recommendations for when there’s extra book fund to burn).

You can round that out with some more general thoughts on studying during residency. Then try my deeper dive: ultralearning radiology.

Also, residents from across the country in the ACR Resident and Fellow Section came together and assembled a nice collection of free radiology learning resources from across the interwebs including lots of videos.

 

 

Optimizing the Diagnostic Radiology Interface as a Resident

06.24.24 // Radiology

Should new residents worry about workflow efficiency and ergonomics?

Yes.

I don’t think it’s ever too early to start thinking deliberately about what makes you better and more efficient in your job or able to act more sustainably. If anything, spending more time on workflow and ergonomics early on in your career is an investment in yourself.

As a resident, I just used whatever was plugged into the workstation I sat at. This eventually led to wrist pain, which even more eventually led me to finally address my setup as an attending. The physical discomfort became obvious. The hit on my productivity/efficiency for all those years was invisible until I made the changes.

Many people, especially once out in practice, become entrenched in their behavior patterns and find it very difficult (and even frankly overwhelming) to approach changing how they work, even when the change is clearly beneficial.

I would say, on a practical level, that it may take some time after starting residency to know exactly what your needs are, what you like and don’t like about the default approach, and what an ideal workflow may be. But taking the basic step of buying a good mouse and programming it to help use PACS is an approachable and very helpful first step. At least do that, and then you can decide if you need to go down the rabbit hole.

The Approach

In general, you will find things easier especially as a resident if you can have a setup that requires no on-site software/driver installation, given the realities of bouncing around multiple workstations and the difficulties of working with your local IT department. Devices that can store their own settings and function plug-and-play on any computer are often described as having onboard memory.

I think a reasonable approach early on would at least involve some kind of gaming or productivity mouse to store window-level settings and your favorite PACS tools.

As you can see if you dive into my multi-post series, I personally divide these tasks between a left-hand device and a right-hand device and also incorporate dictation controls with Autohotkey. I think this is the optimal approach (and one that some of my residents have even now begun using). A dictaphone-free approach however really does require AutoHotkey to work efficiently, so utilizing this would depend on if you are able to get the executable file onto a workstation in order to run your shortcuts (or if the thing is locked down so tight that you won’t be able to). You may not know until you try or talk to someone local who has.

So, if you decide to take the streamlined approach and try to put all the PACS tools you want on a single device, you may find it helpful to have something with a large number of configurable buttons. A good example would be the reasonably priced UtechSmart VenusPro (a 16-button wireless mouse that includes a 12-button thumb grid). The G604 Lightspeed would be another popular choice (more expensive, adjustable scroll wheel, 6 thumb buttons). I personally use a “vertical” mouse, and I discuss even more mouse options (and everything else) at length in my “best stuff” post. (My hospital mouse is the very inexpensive Zelotes–which I describe how I use here–but it won’t be for everyone.)

Unless your radiology department is more forward-thinking and responsive than most, whatever is plugged into your computer is unlikely to be a good mouse for utilizing PACS. Even if it is, it probably isn’t configured the way you want, so literally any variety of productivity or gaming mouse that you customize yourself will provide some obvious and immediate benefits. The ultimate goal is that you should not need to move your hand off your mouse (or put down your microphone) in order to use a keyboard for routine actions.

If you need to touch the keyboard for every case, I would say you’re doing it wrong.

How Many Buttons Do I Really Need?

Good question. Everyone is different.

Some potentially very helpful shortcuts will vary a little by how your PACS handles measurements and things like zoom/pan. Some PACS automatically incorporate a manipulation tool like zooming into the central mouse wheel click or holding left/right mouse buttons simultaneously, whereas others require a keyboard shortcut. Some PACS will automatically helpfully change what the right click does depending on which PACS tool is active. Others do not. Some PACS delete measurements by double-clicking, and some make you press the delete key. That’s why it can be challenging to completely figure out what you want without some trial and error and becoming familiar with your local enterprise software function.

But here is one version:

Four window/level presets are probably sufficient for most people’s needs (e.g. soft tissue, lung, bone + brain or liver or your fourth favorite).

Some common choices for mouse button shortcuts are the measure tool, the ROI tool, delete, localizer/3D cursor to cross-register findings, and whatever button you need to turn back on power scrolling. Again, the exact details vary by PACS. That’s ~five more.

Most people would find the angle tool or spine labeling to be less important, but obviously in some cases those are in constant use, etc. Some PACS have a dedicated toggleable navigation pane to see priors and image series.

Add those together (~12) and it’s not hard to see how one can go crazy and fill up the thumb grid on one of these mice with all tools you need, even if you aren’t trying to add toggling dictation + previous/next template fields as well (3 more).

I will admit that it can be hard to retain all of these in muscle memory, which is one reason why I like using both hands. I suspect a lot of residents are already learning so much and doing so many new things that a smaller number of inputs may be more likely to fall in the sweet spot of being helpful without being overwhelming–but if you’re willing to put the time and energy in, you can get a ton of mileage from a high-button mouse.

Regardless, there is no world where you wouldn’t rather at least change your window/level settings from your mouse instead of dropping your mouse to hit the numpad on your keyboard instead.

Ultimately, the more things become easy for you to do, the more frustrating it is when some task requires you to break your flow.

Take Home

I’m not suggesting you should go full nerd mode and spend a bunch of money.

But, yes, you should at least get a programmable mouse for work.

From “Writer Math” by Elissa Bassist in McSweeney’s:

If you think a piece is 100 percent done, it’s actually 45 percent done. To get it to 100 percent done, you can’t.

// 06.12.24

The Daylight Computer

05.31.24 // Miscellany

It may just be the marketing, but the newly announced DC-1 tablet from Daylight seems poised to scratch an itch of our times. As summarized by Om Malik:

What the company has created is a beautiful tablet — about the size of a normal iPad Air. It is just a “little less than white,” white, with a gorgeous screen. It is very simple, elegant, and lovely. It has an e-ink like screen, and the matte monochrome paper-like display is optimized for reading, writing, and note-taking. It refreshes at 60 frames per second, a pretty big deal for these kind of displays.

I love at least the idea of this.

Complaining about modern technology, addictive software, and the ills of social media can be is tiresome. But it’s also a real, difficult-to-mitigate problem. So I hope this forthcoming thing works as advertised and becomes a commercial success.

And I would love to see this company, on the heels of that success, expand their offerings to additional form factors (the phone being the obvious next choice) or prove the market enough to inspire more mature companies to enter whatever the term for these “deliberate computing” or “modernized retro” or “neo-vintage” or “tech nostalgist” concepts should be.

Nothing currently available has really done the trick. Even the cheapest FreeWrite devices are comically expensive as an isolated electronic typewriter with extremely small displays, and devices like the reMarkable also have a (purposefully) narrow, limiting use case.

The closest thing would be the tablets by Boox, which have good and pretty fast e-ink screens but don’t quite achieve the advertised frame rate here (which if true would be fast enough to function like a regular monitor), feel just a tad underpowered, and don’t have the fun (if potentially gimmicky?) Amber backlight. I actually have a Boox Palma, which is an awesome little phone-sized version of what the DC-1 should bascially turn out to be minus the stylus support, and it’s overall fantastic. It’s a convenient form factor for reading, runs customized Android so Kindle, Libby, and many other apps all work perfectly, and can do the internet and anything else a phone or tablet can do (minus the phone itself). The screen really is pretty fast (you can technically watch a video in grayscale, though not particularly well), and the backlight temperature can be tuned to a slightly warm color for dark environments. Still, it’s just the slightest bit slow such that no one could mistake it for a truly normal computer with a magic screen.

While Boox has made some solid devices, if the DC-1 can run its customized Android system as well and quickly as in the demos, it might function as the productivity and consumption machine for writing, reading, and potentially drawing that the iPad and other tablets have largely failed to achieve due to either not being able to do enough or simultaneously way too much. Maybe this finds the sweet spot.

As a parent with pre-phone-age children, I would love to see more entries in the not-quite-so-smart phone pantheon. There are things I love about modern phones that make using a purposely old-school device too limiting: maps, streaming music, audiobooks, e-books, email (sigh), and yes, sometimes the Internet. Also a top-notch camera (must. take. photos. of. kids). A future world where there are good phones with paper-like aesthetics combined with a curated but powerful productivity and consumption suite of apps would be great.

Here’s a mini-documentary that describes how the new “LivePaper” display works compared with regular e-ink:

Sometimes it’s the right features–not more features–that make a new product worth it.

Need-Fulfilling Strategies & Future Self-Continuity

05.28.24 // Finance

Via Loaded by Sara Newbomb:

“Specifically, when the future self shares similarities with the present self, when it is viewed in vivid and realistic terms, and when it is seen in a positive light, people are more willing to make choices today that may benefit them at some point in the years to come.” —Hal Hershfield.

Hershfield’s research suggests that the more we visualize our future self as really, specifically being just like us, the better we are able to act on current plans that feel deprivational to provide for the future.

Does your salary come from your employer? Not at all! Your employer is simply renting your time and skills. Your salary is the result of your internal resources being turned into a valuable asset that you lease to your employer in the form of labor. Your skills are the asset. Your salary comes from you.

You are your most important asset-generating resource to nurture and protect.

Just like your future self doesn’t benefit if you go sprinting on the hedonic treadmill, your future self also doesn’t benefit if you burn out so badly that you jeopardize your ability to work in your profession at a high level. You have needs now and in the future, and neither should be ignored.

Newcomb’s nice section on needs starts with our old friend Maslow:

It is quite true that man lives by bread alone—when there is no bread. But what happens to man’s desires when there is plenty of bread and when his belly is chronically filled? At once other (and “higher”) needs emerge and these, rather than physiological hungers, dominate the organism. And when these in turn are satisfied, again new (and still “higher”) needs emerge and so on. This is what we mean by saying that the basic human needs are organized into a hierarchy of relative prepotency. —Maslow, 1943, p. 375

I’m not sure I’ve ever read a single word from the “hierarchy of needs” primary source before.

Then, we combine that with this less staid perspective of wants versus needs:

Every moment each human being is doing the best we know at that moment to meet our needs. We never do anything that is not in the service of a need. There is no conflict on our planet at the level of needs. We all have the same needs. The problem is in strategies for meeting the needs. —Marshall Rosenberg

And she brings that around to personal finance:

How many times have you tried to cut back on a certain expense only to find yourself splurging later? This comes from the fact that what we have called wants are actually needs. The core message of Rosenberg’s work was that every action a person takes is intended (consciously or unconsciously) to meet a basic need, and that our needs are universal. Any one of our needs might feel more important than another in a given situation, depending on the person and the circumstance. On one day, you may feel a powerful need for intimacy. The next, you may desperately seek solitude.

[…]

Very often, when people are trying to make ends meet, their first strategy is to start cutting expenses. While this is a great instinct, and we often do want to cut back on our spending, the problem with this approach is that if you do not take the time to ask yourself what need that expense was meeting, you will find that your new budget is very uncomfortable. Just like a dieter who restricts himself too much only to find himself eating an entire pizza in a late-night frenzy, we can do more harm to our finances than good by ignoring our needs when we cut our expenses.

Her rule of thumb:

If everyone cannot have it at once, it’s a strategy, not a need. Dig deeper to find the real need.

Wants are strategies for filling needs. The need is non-negotiable, but the strategy is mutable.

  1. Yes, I’ve started the process of creating a small dedicated job board just for independent radiologist-owned private practices. With all the corporate noise out there, I’m hoping we can connect radiologists looking for the real deal with those groups who are doing it. Still a ways to go, but feel free to reach out to me at ben@benwhite.com if your group is interested, and I’ll get back to you when things are ready.
  2. Separately, yes, for the first time in this site’s 15-year history, I’ve decided to run a real ad. Not a banner ad (and no images), but starting on June 1st, there will be a single monthly post featuring a limited number of true radiology private practices. I’ve temporarily changed this policy because of the radiologist shortage combined with the current less-than-stellar recruitment/marketing environment. I hope folks find it unobtrusive and even helpful; I’ll reevaluate in a year.
// 05.20.24

The Best Radiology Setup/Workstation Equipment

05.13.24 // Radiology

Here is the updated first entry in a series of posts about radiology tools, ergonomics, and efficiency. This includes the go-to stuff I use every day to practice diagnostic radiology, (briefly) how I use them, and a few alternatives. This series is the result of a lot of research, trial and error, and input from others in the radiology community.

Unnecessary caveat: There is no real best anything. Here’s what I have idiosyncratically landed on as a stable happy set-up that balances efficiency and comfort (and an editorial selection of those favored by others).

We get into more workflow details and justifications in the other posts, but we can summarize my personal approach as a hands-free microphone solution, a vertical mouse with some–but not a comical number of–programmable buttons–and a left-hand device that adds additional hotkey efficiency as well as—critically!—a way to scroll with my nondominant hand in order to spread the love across multiple joints.
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