Dealing with a USMLE Failure

04.19.24 // Medicine

This post is for anyone who is lost and dejected after failing one of the Step exams.

First, I’m sorry that you’re going through this. The path to becoming a doctor is long and hard, but there’s something unique about high-stakes testing that adds stress and uncertainty.

I know this may sound a little odd/dramatic, but I think dealing with a big testing disappointment is ultimately the same as any other grieving process. The world today isn’t the world you wanted to live in, and it takes some time to bridge the gap between where you thought you were and where you currently are. The silver lining is that–unlike losing a loved one or a serious injury–you can still get back on the path.

At the same time, while it would be nice to get the failure notice and be able to immediately double down into an amazingly efficient targeted revision process for your next attempt, you’re also a human being. You’re a human being who deserves to grieve.

Maybe you won’t go through the classic stages of grief like denial, anger, bargaining, depression, and ultimately acceptance. But you might, and there’s nothing wrong with that. Just because there are so many worse things in the world doesn’t magically make this experience not suck. Don’t add insult to injury and beat yourself up for being acutely sad.

(On a related note, I think this would also be a good time to take a serious look at your media diet)

Once you have the timeline for your next attempt and know your school schedule, it’s time to be systematic about how to use that time effectively. That should absolutely include some time initially to reset psychologically. For a week or two, make specific time and force yourself to do some things that you enjoy and find centering. You need a less heavy heart to remember why you are on this pathway and why you’re willing to work hard to get to your destination. You can’t only punish yourself for this disappointment with things that rub salt in the wound.

Next, it’s time to analyze your current performance abilities for areas of weakness, both subject matter and testing approach (see below). It may be tempting to add a bunch of new resources or completely change how you study. In some cases that may be the right choice, particularly if you haven’t been incorporating enough questions or have never heard of spaced repetition, but for many people the answer is doubling down on a limited number of high-yield resources and not breadth. If you were close to passing, you probably don’t need to reinvent the wheel.

You do need to prioritize your mental and physical health (trite but true). Diet, exercise, and sleep are huge performance factors that you have a lot of control over.

The bottom line is that you are allowed to feel sad, and you’re allowed to mourn for the world where your pathway to becoming a doctor was smooth and straightforward and where you never need to question yourself or prepare a story for others. It’s something you can and absolutely will deal with, but there’s no reason to pretend that you don’t deserve to be bummed. That’s just toxic positivity. It does suck, and it is a bummer.

But you also need to believe that you will absolutely get past this. It’s a hurdle. And hurdles are meant to be overcome.

For further test-taking reading:

Radiology Micro Job Board

04.18.24 // Radiology

It’s recruitment season, the radiology job market is hot, and there’s a lot of corporate noise. I’m thinking of maybe starting the world’s smallest radiology job board right here, open exclusively to a limited handful of 100% independent private practices.

If your group is interested in advertising on this site (and also therefore supporting my writing), email me at ben@benwhite.com.

Recruitment is a big challenge. While the ACR subsequently addressed the issue I wrote about here, I originally had the idea because of this.

Relying on “A Guy”

04.08.24 // Miscellany

Incredible story briefly detailed in NYT’s “Did One Guy Just Stop a Huge Cyberattack?” by Kevin Roose:

In the cybersecurity world, a database engineer inadvertently finding a backdoor in a core Linux feature is a little like a bakery worker who smells a freshly baked loaf of bread, senses something is off and correctly deduces that someone has tampered with the entire global yeast supply. It’s the kind of intuition that requires years of experience and obsessive attention to detail, plus a healthy dose of luck.

This could have been an unmitigated disaster. So much of the world’s infrastructure relies on random individuals being generally good or exceptionally thoughtful, in this case, the diligence of some dude who describes himself as a “private person who just sits in front of the computer and hacks on code.”

But, on the darker side: Given the seemingly miraculous nature of this catch, what are the odds there aren’t other backdoors already in place in our key systems?

Show Your Work

04.04.24 // Writing

In Show Your Work, Austin Kleon argues “the best way to get started on the path to sharing your work is to think about what you want to learn, and make a commitment to learning it in front of others.” That’s what I’ve been doing since 2009.

One downside of Showing Your Work is when the showing of the work is the only work you do. I never set out to be a blogger (cringey moniker that it is). Not that there’s anything wrong with this site (I think it’s pretty good?), but it’s undeniably the lower-hanging fruit that I’ve been doing for 15 years while mostly not writing the books and stories I originally intended to write. We could call it productive procrastination.

Now that’s not entirely fair, because it turns out that I also like whatever this is. I like writing short, I always have—I edited a nanofiction literary journal for 14 years for heaven’s sake—and I like curating, sharing, teaching people, helping others, and yes, even being a curmudgeon when the situation calls.

Kleon quotes David Foster Wallace, who said that good nonfiction was like watching “somebody reasonably bright but also reasonably average pay far closer attention and think at far more length about all sorts of different stuff than most of us have a chance to in our daily lives.” Which is I think is both generous and true.

So, I wish more people had websites, took the time to have a position or make something to share/teach, and then put it online.

For anyone considering graduating from transient social media reactions to starting a site to show their work, this gem from Clary Shirky:

The stupidest possible creative act is still a creative act. On the spectrum of creative work, the difference between the mediocre and the good is vast. Mediocrity is, however, still on the spectrum; you can move from mediocre to good in increments. The real gap is between doing nothing and doing something.

Medicine is, on the whole, underserved in the public sphere by its physicians. And the field of radiology, which has made up a significant fraction of my writing over recent years, certainly deserves more independent perspectives online than mine and a handful of others.

Don’t be scared to start small and reduce the barrier to entry for yourself. You can curate more than you generate, as old tech writer Jeff Jarvis advised: “Do what you do best and link to the rest.” (Last year I even added a smaller post-style microblog here to encourage myself to share more.)

I’ve enjoyed writing in my little corner of the internet and have no intention of stopping.

But, maybe there will be another book soon.

Post-match Life Research

03.27.24 // Finance, Medicine

Post-match fourth year is a great usually “less-stressful” time to get your required education in personal finance. My free book is a nice, readable, and to-the-point primer on the essentials of personal finance including student loans. Read (or download it) here. Note that the new SAVE plan has simplified the student loan part for the majority of borrowers going forward.

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Not everyone should try to buy a house during residency. With the recent housing boom and higher interest rates, home ownership is probably out of reach for a larger proportion of residents than at any other time in recent history.

But, if you are considering trying to buy a home as a trainee, you’re likely going to need a physician mortgage. One quick way to get your feelers out to several potential companies at once is LeverageRx, a totally free handy platform that will let you rapidly comparison shop multiple physician loan lenders.

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Senior medical students are also eligible to try to lock in their eligibility for disability insurance. Disability insurance isn’t cheap–and you may not be able to afford it on your current budget–but again this is a great time to at least learn about it and price out some options and see. A small ~$2k/mo benefit medical student policy will often cost in the $40-60/mo range and will lock in future insurability. The folks at LeverageRx and Pattern both offer a great no-cost no-commitment way to see what your choices look like.

It’s always good to price out different options through different agents, and it’s possible the discounts available through your medical school affiliation are better than the ones you’ll have access to as a resident. Also, you’re unlikely to get younger and healthier. It’s worth doing some due diligence.

Life insurance, on the other hand, is straightforward: if you have a spouse or dependents that are relying on you, you need term life insurance.

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(Those are both affiliate links, which means that using them supports this site at no cost to you. My aging book is just free, no strings attached.)

Inconvenient Data, Untellable Stories

03.25.24 // Miscellany

From last year’s “Nutrition Science’s Most Preposterous Result” by David Merritt Johns in The Atlantic (“Studies show a mysterious health benefit to ice cream. Scientists don’t want to talk about it.”):

In 2004, the English epidemiologist Michael Marmot wrote, “Scientific findings do not fall on blank minds that get made up as a result. Science engages with busy minds that have strong views about how things are and ought to be.” Marmot was writing about how politicians deal with scientific evidence—always concluding that the latest data supported their existing views—but he acknowledged that scientists weren’t so different.

The ice-cream saga shows how this plays out in practice. Many stories can be told about any given scientific inquiry, and choosing one is a messy, value-laden process. A scientist may worry over how their story fits with common sense, and whether they have sufficient evidence to back it up. They may also worry that it poses a threat to public health, or to their credibility. If there’s a lesson to be drawn from the parable of the diet world’s most inconvenient truth, it’s that scientific knowledge is itself a packaged good. The data, whatever they show, are just ingredients.

The data are just ingredients.

I got an underdesk elliptical a couple of weeks ago…I think maybe it’s awesome and wish I had gotten one a long time ago. I’m honestly a little surprised I can pedal while thinking.

I tried a few, and this is the one I landed on: very stable, pretty cheap, reasonably quiet.

// 03.11.24

The Government Wants Your Input on Consolidation in Healthcare

03.08.24 // Medicine

The US government–specifically the Department of Justice, Department of Health and Human Services, and the Federal Trade Commission–is asking for public input about consolidation in healthcare.

A summary quote from FTC Chair Lina Khan from an article in the WSJ:

FTC Chair Lina Khan said that while some private-equity investment could be beneficial, too many buyout firms focus on profit to the detriment of medical care. Government regulators have heard numerous reports from doctors and other medical workers about the negative consequences of private equity-driven consolidation.

The comment period runs until May 6, 2024, and you can only submit feedback through this official docket on the Regulations.gov website.Continue Reading

Growing as a New Radiology Attending

03.06.24 // Radiology

When you first get into practice and really want to make a good early impression, you’re going to make some mistakes, and some of them are going to be pretty boneheaded. Everyone has holes in their knowledge, and there are almost certainly things that you should know that you somehow don’t.

Depending on your practice–and how often people see your name–it’s possible you may even burn a bridge or two with an experienced (or headstrong) clinician when you miss some key finding or raise alarm bills that didn’t need to be raised (especially when they end up causing them headaches in counseling their patients or dealing with the ER). You can’t change that first impression, all you can do is learn and improve and do better next time.

The frustrating reality is that an experienced clinician may have less general imaging experience than you do but plenty of targeted experience to answer most of their clinical questions as well if not better than you can when you first get out. Over time though, especially if you practice subspecialized or high-complexity care, you can eventually get to the next level.

With a good feedback loop including clinical follow-up to cement your knowledge, you’ll get more reps per day and spend more time reviewing each case than most clinicians seeing patients can hope to squeeze in. They will always have the patient in front of them and the clinical context that you will lack, so you will need to get better and better and better to become someone who they trust as much as–if not more than–themselves. I won’t pretend to know how many of the clinicians I work with respect me that much.

The End of Training is Just the Beginning

The practical reality is that residency/fellowship training are very important but also not always efficiently structured for practical learning. We tend to focus on the cases that hit the list every day–because there is work to get done–even though they may not be the ones that will teach us the most. We also tend to have research and procedures and other competing interests that distract from raw diagnostic radiology learning. And while reading cases out with an attending means that you get more reps of feedback than when working alone, both that and your limited experience means you will likely read fewer cases per day during training, even as a fellow, than you will as an attending.

For all of these reasons, the first six months (or two years, depending on who you ask) out of training can be a huge source of fear and anxiety but also a huge source of growth (especially if you are in a practice with high-quality colleagues that you can learn from and a healthy environment to get feedback in that will not crush your confidence).

Ultimately, the issue with learning after training is that there is no structure to make you put the extra work in, and you won’t necessarily receive feedback on most of the cases where you have the most to improve.

There’s No Forcing Function for Continuous Improvement

The sources for learning remain essentially the same: double down and read about the things that stress you out or slow you down during the workday, learn from the prior reports (especially when the person who read the case is better than you), and keep adapting your search pattern to incorporate your new knowledge and to address your mistakes.

Sometimes, adjusting your template or creating tailored macros can help you get more mental-checklist reps. For example, someone practicing neuroradiology could create a quick macro “pulsatile” that quickly runs downs the pertinent negatives for causes of pulsatile tinnitus that you invoke when that is the provided history, thereby forcing yourself to actively evaluate those causes on the images, thereby eventually making it an subconscious part of your process.

We could summarize this especially desirable kind of learning as deliberate practice. It’s simple to just get through the stack. Eventually, the muscle routines come no matter what, and you’ll gradually improve over your first five years in practice. But it’s harder to develop purposefully and improve in the specific areas you’re weak in if you don’t take a step back and figure out what are the primary causes of your errors and make sure your learning and working processes specifically address them.

So, The Phone Will Ring

For your entire career, every so often, you’ll receive a phone call asking you to take a “second look” at a case (or just flat out make an addendum). And that’s when you open it and see the obvious miss. Often that’s just human fallibility, but sometimes it will reflect a need to reevaluate your search pattern or recalibrate your chosen spot on the speed-sensitivity curve. That’s how we all (hopefully) get better over time.

Sometimes the finding is a tiny or questionable thing that is really only discernable with clinical context or history. Ideally, you’ll find every tiny Morton’s neuroma or extraforaminal disc protrusion, but sometimes it helps immeasurably to know what the actual history is and where to look. So be it.

And sometimes the doc will tell you what they think, and you’ll look at the images again, and you’ll still think you’re right. Hopefully, you’re humble enough to at least wonder if you could be wrong. That’s where having colleagues you respect can help a lot to be the tiebreaker. And sometimes, yes, the phone call is just a surgeon who wants to operate and needs you to provide an excuse. Even the bad actors can be right, so it still behooves you to treat every request with respect even when the clinician may not be.

This is something we all deal with, and the hardest part of that first year or two can be not taking it too hard. We interpret imaging for so many patients and touch a lot of lives, even though it sometimes doesn’t feel like it.

As much you can, try to remember: The ego matters less than the people behind the pictures.

Luminello Sold to SimplePractice and Now Everything Sucks

03.04.24 // Medicine

Private Equity came for my wife’s psychiatric private practice EHR, Luminello. Luminello sold to SimplePractice, which is owned by EngageSmart, which is owned by Vista Equity Partners Management.

From the press release:

“Both SimplePractice and Luminello were founded by clinicians looking to simplify the business of running an independent solo or small group mental health practice,” said Ken Braslow, MD, Founder, Luminello.

“Today, we remain equally committed to removing the administrative burdens that practitioners face and look forward to combining the strength of our collective experience to serve even more practitioners and their patients.”

Apparently, Luminello’s “commitment” was worth $19.6 million.

In short order, SimplePractice announced they were shutting down Luminello.

In fact, Luminello is being shut down so fast that SimplePractice doesn’t yet have the features needed to run an actual medical practice. They’re pressuring docs to transition despite the reality that SimplePractice is currently mostly used by nonphysician therapists and is half-baked as an EHR: They don’t have labs! They don’t have snippets or dot-phrases! They don’t even have e-prescribe! (You get the idea.)

Communication about the transition has been generally confusing and poor, but here’s the fun daily DocuSign reminder that assumes you’ll take it on faith that SimplePractice is going to work for your practice and are coming along for the ride:

In typical tone-deaf private equity fashion, they’re happy to spend money upfront for a roll-up to buy (instead of earn) some growth but then completely botched the execution because they don’t actually know what they’re doing. Instead, they’d rather anger thousands of doctors by bullying them into switching to a product that literally can’t do many of the things their current offering does while pressuring them in the sleaziest ways possible.

Luminello is flawed, but it ~~works~~ worked. In the meantime, its customers are being told they only have until April to sign on to SimplePractice before their EHR stops working.

Meanwhile, the data export function the docs need to save their records (and, coincidentally, to transition to a different EHR) seems to be magically broken. Their patient information is being held hostage.

Just for fun, the entire lab-ordering tab has disappeared.

Starting a few days ago, for some users, the Luminello calendar began intermittently showing empty appointment slots:

And, just today, the site began alternating between intermittently lagging into unusability and just flat-out crashing:

Now, why spend millions to basically buy customers and then immediately turn around and make all of their lives harder instead of just waiting a few more months until you have feature parity? Why not make switching an easy no-brainer upgrade?

Because, in my opinion, they don’t think it matters.

They don’t seem to care about their customers or about the patients (“clients” in SimplePractice parlance) their customers serve, and–most importantly–they’re relying on doctor’s learned helplessness: they assume a critical mass of physicians using Luminello–many in solo practice–are resigned to the enshittification of healthcare or too busy to actively pick something else.

I hope they’re wrong.