Shaun King reacting to Josh Begley’s short reverse-highlight reel “Concussion Protocol” in The Intercept:
It’s not a headache. It’s not “getting your bell rung.” You don’t have a bell. It’s a traumatic brain injury.
Amazon is now so dominant as a corporate force that even the announcement of a plan to someday enter a new industry is enough to crush stocks.
This happened to Blue Apron last summer after Amazon bought Whole Foods and filed a trademark for a possible meal-kit service a week after Blue Apron’s IPO, whose new stock proceeded to immediately tank.
Now it’s happening to healthcare, as Amazon, Berkshire, JPMorgan partner to cut U.S. healthcare costs:
Shares of UnitedHealth Group Inc (UNH.N), Cigna Corp and health insurer Anthem Inc (ANTM.N) were 4 percent to 7.2 percent lower at the close. Drugstore operators CVS and Walgreen Boots Alliance (WBA.O), as well as Express Scripts, closed between 3 percent and 5.2 percent lower. Drug distributors Cardinal Health (CAH.N), AmerisourceBergen Corp (ABC.N) and McKesson Corp (MCK.N) were off 1 percent to 3 percent. Amazon closed up 1.4 percent.
To be sure, the $69 billion loss in healthcare stock value should rapidly self-correct (unlike for Blue Apron, which does not enjoy a stranglehold on an entire segment of the economy).
But in the announcement, the new venture has zero stated plans outside of using “technology” to reduce costs for their own employees, but they do plan to “share the strategies and technology they ultimately develop to reduce costs for the economy and the government.” It doesn’t matter what Amazon does, just that they plan on doing something.
The fact that Bezos is joined by the biggest bank (JPMorgan) and the biggest non-healthcare insurer (Berkshire) just nicely rounds out the trifecta.
Who knows, maybe they could deign to start by developing a good EMR that also uses standards to make healthcare data completely portable in order to empower patients and reduce confusion, overuse, and duplication. If it’s just Amazon Prime Rx with cheaper mail order prescriptions, I’ll be a bit underwhelmed.
“The ballooning costs of healthcare act as a hungry tapeworm on the American economy,” said Berkshire Hathaway Chairman and CEO Buffett. “Our group does not come to this problem with answers. But we also do not accept it as inevitable.”
Buffet’s still got it.
This is my fourth (and final) post about the little snafu surrounding the mammography portion of the ABR Core Exam last summer.
- I wrote about what happened here.
- I wrote about what the response was here.
- I wrote about the proposed solution here.
Now, we’ll finish with how that do-it-yourself online module went.
Logistically, it went great. By all accounts I’ve heard, people were able to log in from the comfort of whatever chair they were sitting at and take the module. The content was reportedly pretty much as expected for a Core exam mammo section, with the possible surprise for some of the inclusion of physics and non-interpretive skills (which are, after all, folded into every core exam section).
No surprise there, because as you might recall, ABR Executive Director Valerie P. Jackson had told examinees not to worry (emphasis mine):
The ABR has also heard from several residents who are concerned that they now need to completely re-study for the breast imaging module. As the ABR’s executive director, I (Dr. Jackson) personally reviewed the breast questions on the new module to modify any material that might not be visible on a monitor that is not high resolution. Although I am a breast radiologist, I have not practiced any clinical work or studied for an exam in more than three years. I found the content to be straightforward and inclusive of the important breast imaging concepts that candidates will most likely have retained from adequate initial exam preparation. Extensive re-study should not be necessary.
The invitation email went out July 27 and registration closed August 11. The module was offered on September 7 and 18, and the results were available on September 28.
As the make-up module was taken on the honor code, we’ll never know if anybody cheated, but it appears at least that no one was caught. On the plus side, we can applaud the ABR for not trying to install any spyware on examinees. Big brother was not invited to the party.
While the module took place several months after the usual pretest studying frenzy, reviewing the content for just one section, particularly mammography, was a stressful but probably not particularly tall order. I imagine nearly everyone took the section honestly.
Now, if you remember, the amusing part of the entire endeavor is that the ABR has admitted in the past that performance on the mammo module (or any individual section for that matter) essentially does not matter in terms of passing the test. No one has ever failed a single section other than physics in the years since the Core exam was first administered.
So, given several years of history to temper expectations, are the results of the module as expected? Did everyone pass?
Yes and yes.
I actually asked the ABR via email what the results were, and I got the impression that they did not want to tell me the specific truth because after a delay of about six weeks they gave me the default phrasing they love to use when discussing exam results:
In regards to specific details such as passes and fails for the breast category, the results for this breast imaging module were inline [sic] with the results from previous ABR exams.
…which means that everyone passed, which they later confirmed in a follow-up email.
I, for one, do not understand the ABR’s resistance to discussing exam results. For example, while the results for the Core exam are more or less released annually, the results of the Certifying exam have never (to my knowledge) been disclosed publicly (e.g. see the official scoring and results page). One presumes that the most likely explanation is that the certifying exam pass rate is 100% and that the ABR is concerned people might question the necessity and utility of an exam with universal passage (but that they also don’t want to make it hard and anger a bunch of already-practicing radiologists who are doing just fine thank you).
But we’re not fooling anyone here. The issues with both initial certification and MOC are neither unique to radiology nor subtle. Transparency and accountability should be the sine qua non for a medical specialty board. And yet.
Ursula K. Le Guin, one of my very favorite writers, passed away this week at the age of 88.
Le Guin was sometimes referred to as a really good speculative fiction author—which is wrong. She was a fantastic writer who happened to mostly write genre fiction. Her meticulously crafted imaginative work set the stage for younger writers like Michael Chabon and David Mitchell to write literary novels that include the fantastic, something readers now take for granted.
A Wizard of Earthsea was one of my first great loves in fiction of any style (though the new cover art makes me sad). The Left Hand of Darkness is really the shining example of what a good writer can accomplish only within the structure of “science fiction.” Ditto The Dispossessed. And The Lathe of Heaven.
Even her manual Steering the Craft was my favorite book on the mechanics of storytelling for many years (and was apparently extensively revised/rewritten and republished in 2015, which means I need to read it again).
From Harper’s January 2018 index:
Amount the US pharmaceutical industry spent in 2016 on ads for prescription drugs: $6,400,000,000
Number of countries in which direct-to-consumer pharmaceutical ads are legal: 2
$6.4 billion? Holy moly, what a depressing figure. Think about how much healthcare that would buy.
In case you’re curious, our partner in crime is New Zealand.
In case you’re still curious, permitting DTC advertising is a terrible idea that can only be satisfactorily explained by the power of lobbying.
[Since this was written, Splash shuttered their resident-specific program and LinkCapital shut down entirely]
In 2015, DRB (now Laurel Road) began offering private student loan refinancing to medical residents with a set monthly payment of $100. This was substantially lower than what the calculated payment for any resident would be under an income-driven repayment plan like PAYE or REPAYE but apparently too hard on the budget for a lot of residents who continued to forbear.
Not long after, LinkCapital joined the resident refinance ranks ($75 a month, eligible after intern year), followed by the very recent addition of SoFi ($100/month for up to four years of training). But for anyone who felt like every buck counted, private refinancing was still more costly to the monthly budget than forbearing.
Of course, forbearing is actually by far more costly in the long term because accruing interest grows unabated and then capitalizes while the borrower enjoys exactly none of the many wonderful benefits of participating in an income-driven repayment plan like IBR/PAYE/REPAYE.
To be absolutely clear, most residents should not be refinancing their federal loans. The vast majority of residents should be in REPAYE or—if spousal income makes REPAYE untenable—PAYE. But for those who feel forced to forbear in anticipation of a career in private practice, then refinancing is something really worth taking seriously.
Splash Financial has now made it possible for this subselected group of trainees to shave thousands off their loans painlessly: the required monthly payments during training are a token $1. They offer relatively narrow rate ranges for different term lengths from 5-20 years, so you may not even need to complete the really quick application to know if it’s even worth considering. Note that there’s no autopay discount during the training period.
When Splash first started offering their product last summer, they tacked on a hefty origination fee, which is unusual in the refinancing industry, where no cost-refinancing is essentially standard. A few months later and they saw the light, nixing the fee. Now the product is a no-fee no-cost alternative that’s competitive with everyone else and the only one that allows for refinancing without the $75-100 monthly payment during training that even the other resident-friendly companies require. You can, of course, pay more per month like any other company (and the more you pay per month, the less you’ll owe later, so that’s highly recommended).
Student loans are a $1.5 trillion dollar industry, and every student loan company has referral programs. Splash’s program offers $500 for loans greater than $100k.
Unless you are in financial straits now and require loan forbearance but also plan on working at a 501(c)(3) non-profit after training, then forbearance is unlikely to be the right choice for you financially. IDR is the solid option for most people and REPAYE often offers the best rates around for many residents, but that doesn’t apply if you can’t or won’t make the payments. Those just forbearing to free up cash during training probably shouldn’t be forbearing in the first place.
Be aware that with any of the resident refinancing companies the interest accrued during training does capitalize at the end of training, so trying to pay down some of that interest prior to this step is always a good idea.
Putting out my fourth annual reading list means that it’s officially a site tradition. That same year I also started really using Audible, which has been life-changing (no exaggeration) for the commute and chores like laundry. Their current signup promotion is two free audiobooks
- No Country for Old Men by Cormac McCarthy
- From Medicine to Mogul by Dr. Draion M. Burch (truly as bad as it sounds)
- The Good Creative by Paul Jarvis
- Ninety-Nine Stories of God by Joy Williams
- Radical Acceptance by Tara Brach (would be a better blog post)
- Get Smart by Brian Tracy
- The Power of Habit by Charles Duhigg
- The Life-Changing Magic of Not Giving a F*ck by Sarah Knight (fun premise wears out gradually)
- Chaos Monkeys by Antonio Garcia Martinez (funny, scathing view of silicon valley; great audiobook)
- Gateway by Frederik Pohl (awesome classic; swept every SF award back in 1978)
- The One Thing by Gary Keller (big bestseller but really a great one-liner that completely falls apart. Summary? Focus on one thing to get better results)
- The Best Small Fictions 2015 (one of the Nanoism stories I published and subsequently nominated made it into this anthology, which was awesome)
- Fantastic Beasts and Where to Find Them by J. K. Rowling
- Perfect State by Brandon Sanderson
- Algorithms to Live By by Brian Christian and Tom Griffiths
- Deep Work by Cal Newport (literally one of the only self-help books I think is actually really worth reading. Newport is a CS professor and just gets it.)
- How to Create a Mind by Ray Kurzweil
- Physicians: Money for Life by Dennis Postema (so bad)
- Spark Joy by Marie Kondo (you might be better off re-reading the original)
- Norse Mythology by Neil Gaiman (The only decent treatment of the Norse canon outside of Marvel comics?)
- Neverwhere by Neil Gaiman
- Spaceman by Mike Massimino (the audiobook is narrated by the author; being in space sounds fascinating)
- When the Air Hits Your Brain by Frank T. Vertosick Jr.
- On Writing by Stephen King
- Anansi Boys by Neil Gaiman
- Elon Musk by Ashlee Vance
- The Great Courses: Money Managing Skills by Michael Finke
- Smoke Gets in Your Eyes by Caitlin Doughty (about the mortuary business, odd stuff)
- Rising Sun by Michael Crichton
- Alcatraz versus the Evil Librarians by Brandon Sanderson
- The Coaching Habit by Michael Bungay Stanier
- Getting Started in Consulting by Alan Weiss
- Till We Have Faces by C. S. Lewis
- Steal Like an Artist by Austin Kleon
- Starman Jones by Robert A. Heinlein (this was what YA looked like in 1953)
- Texts from Jane Eyre by Mallory Ortberg
- Option B by Sheryl Sandberg and Adam Grant (I thought this was an important read)
- Armada by Ernest Cline (fun—not as good as Ready Player One, but you could tell that going in. Wil Wheaton does a great narration on both)
- A Gathering of Shadows by V.E. Schwab (Shades of Magic #2)
- A Conjuring of Light by V.E. Schwab (Shades of Magic #3—great trilogy)
- The Left Hand of Darkness by Ursula K. Le Guin (best speculative fiction writer of all time?)
- The Five Love Languages by Gary Chapman (obvious insights that yet no one implements effectively in their lives)
- Why Not Me? By Mindy Kaling
- The Subtle Art of Not Giving a F*ck by Mark Manson
- The Doctors Guide to Eliminating Debt by Cory S. Fawcett
- The 7 Habits of Highly Effective People by Stephen R. Covey
- 10% Happier by Dan Harris (makes you want to do a 10-day vipassana meditation retreat)
- White Sand by Brandon Sanderson
- The Doctors Guide to Starting Your Practice Right by Cory S. Fawcett
- Stephen Colbert’s Tek Jansen by people other than Stephen Colbert
- Thinking, Fast and Slow by Daniel Kahneman
- Practice Perfect by Erica Woolway, Doug Lemov, and Katie Yezzi
- The Achievement Habit by Bernard Roth
- Nimona by Noelle Stevenson (graphic novel and national book award finalist)
- Off to Be the Wizard by Scott Meyer
- The Geography of Genius by Eric Weiner
- Things Might Go Terribly, Horribly Wrong by Troy DuFrene and Kelly G. Wilson
- I Will Teach You to Be Rich by Ramit Sethi
- Rest by Alex Soojung-Kim Pang
- The Lightning Thief by Rick Riordan
- The Collapsing Empire by John Scalzi
- Goodbye, Things by Eriko Sugita
- Barbarian Lord by Matt Smith
- Pilot X by Tom Merritt
- Astrophysics for People in a Hurry by Neil deGrasse Tyson
- Artemis by Andy Weir (fun—not as good as The Martian, but you could tell that going in. On the plus side, the audiobook is narrated by Rosario Dawson)
- Scythe by Neal Shusterman
- Rendezvous with Rama by Arthur C Clark (won the Hugo and Nebula back in 1973; I read this as a kid but it almost felt new again)
- On Power by Robert Caro
- The Fountains of Paradise by Arthur C Clark (the space elevator! won the Hugo and Nebula back in 1979)
- The Doctors Guide to Smart Career Alternatives and Retirement by Cory S. Fawcett
- Ubik by Philip K Dick (Do Android’s Dream of Electic Sheep [i.e. Bladerunner] may be Dick’s least weird book. Ubik is definitely not—it’s very very odd.)
- Holidays on Ice by David Sedaris
- The Mongrel Mage by L. E. Modesitt Jr. (I have a soft spot for the Recluce series and its magic of order and chaos since I started reading them as a kid. That said, his editor needs a much heavier hand. If you could Find+Replace every instance of the word “sardonic” out of the book it would instantly be pages shorter.)
- The Daily Stoic by Ryan Holiday (one translated passage of ancient stoic philosophy per day for a year)
The only classics I read this year where classic SF novels from the 70s. Oops.
As a doctor who writes, I try to read most of the books written by docs for other docs. I think I’m going to stop soon.
As research for the site and my second book, I’ve also now read pretty much every book on “physician finance.” These are mostly terrible, and I hope I’m mostly done with that subgenre forever.
The self-improvement/lifestyle stuff is also mostly background for some future site writing and as a genre is really fluffy. Of the lot, Deep Work by Cal Newport was definitely my recent favorite. Even then, one of the issues with literally everything ever published in this vein is that the vast majority of it can not/does not apply to doctors (at least outside of those with substantial academic time) or anyone who is forced to bill time for money instead of creating an outcome, product, or other deliverable. Every book is really talking to creative professionals, “entrepreneurs,” and cubicle drones.
My copy of Brandon Sanderson’s Oathbringer just arrived, so that’s going to need to happen early in 2018 for sure.
Amazon is running a promotion on my book Medical Student Loans: A Comprehensive Guide so that it’s free on Kindle through the end of Friday. If you haven’t already, now would be a great time to check it out and get your finances in order.
Background:
I generally try to spend money deliberately, particularly when it comes to what might be considered “nonessential” purposes. This year that included the iPhone X.
Our son is two and a half, so the main reason I’ve been upgrading my phone annually the past few years is to have the very best smartphone camera possible. My wife has the iPhone 7 and (until last week) I had the 7 Plus. The increased quality of the plus (particularly portrait mode, but also low-light performance and even macro) was so substantial that when we’re out and about we would almost exclusively use my phone for photos. The best camera—the saying goes—is the one you have with you, so the premium to capture my son’s moments has been the primary motivator.
(It’s snowing!)
Also, I like shiny things. And it was also my birthday.
I also do what I imagine is a surprising amount of my writing on my iPhone. I dictated the majority of my second book as well as large portions of my blog posts (including parts of this one) using Siri. I even do a fair amount my typing on the phone directly with my handy Bluetooth keyboard and Ulysses. All in all, I consider having a great phone to be a worthy business expense (obviously, I’m still trying to justify myself).
Design & Screen:
I’m ambivalent about the notch. The speaker, selfie camera, and sensors have to go somewhere. Perhaps one day they can be embedded in the screen, but overall I don’t find it as galling as some reviewers have. My main pet peeve is that so far a lot of apps haven’t been updated to make use of the unusual “ears” or rounded corners on the display. Updated apps will often show the clock on the left and wifi/cell signal/battery indicators on the top. Older apps just pretend all that space isn’t really there leaving a black bar at the top and bottom as if it were the size of a regular iPhone 7/8. Over time this will improve, but I’m not sure how well cross-platform apps or the many apps that are essentially webpage viewers will be able to accommodate the new design.
The new OLED screen is really nice. It’s beautiful, bright, and for some reason, almost a little more paper-like and less fatiguing when reading text on a white background.
Face ID:
Touch ID is better, but Face ID works as advertised (mostly). It works in light and dark, with or with my glasses or even sunglasses. It’s marginally slower than Touch ID but not enough to make a difference in most situations, and the change in notifications mostly makes up for it. Now notifications are private on the unlock screen, only showing the app but not the content/message itself until unlocked by Face ID. Then you can tap the notification to go straight into the app, which is a clever little improvement. Elegant.
My main fail point is when lying down or holding the phone at an exaggerated angle it often won’t engage. I haven’t figured exactly how much face the phone needs to see but my experience has been variable (generally poor) in these situations. Bedtime is not a great time for Face ID. I also had a cold recently and if I coughed or made an odd face while trying to unlock it would also fail (it was a bad cold; this was happening more than you’d expect). Chewing also causes it to fail.
My other irritating corner case pet peeve is that Face ID is terrible for using your phone on a table or desk. With Touch ID, you could keep your phone on the table and unlock it with your index finger, never having to pick it up to look at alerts etc. With the X, you either have to hit the side button and loom over the phone to unlocked it or pick it up.
Camera:
In my limited usage thus far, the main difference for me between the 7 Plus and X has the speed of portrait mode (in addition to the new portrait lighting effects). The problem with fast moving toddlers is that sometimes the lag of portrait mode means losing the best moment by the time the photo is actually taken. It’s almost as fast as a regular photo now, though I have noticed some serious auto-focus glitches with close up portrait mode, which I hope will be resolved soon.
I rarely use the front-facing camera, so I haven’t taken any decent front-facing portrait mode photos yet, though it does work as advertised.
Overall:
I like it. Like every new iPhone I’ve purchased over the past six or so years, the iPhone X is the “best” phone I’ve ever had. But it’s still (just) a magical glass brick. Face ID is still mildly irritating and forces a number of unwelcome behavioral changes, and the bugs are annoying. The X’s design is nice but I think most Apple customers would be better off just sticking with the iPhone 8 Plus for this iteration.
A lot of people place their hopes on tech companies to save the planet and make literally everything better. At least the tech companies like to pretend they will.
And then you realize how silly so much of it is and how poorly run many of these companies truly are, with so many of them desperately scrambling for their share of our attention paid via advertisements and tracking which we collectively despise.
Twitter is not as big as Facebook and will never make as much money. They don’t have as much data about you as an individual and thus cannot target you for ads with the same gusto. The growth solution, from Twitter’s thinking, is that the 140-character limitation is really holding the service back.
To the contrary, the 140-character limitation is probably Twitter’s only unique selling proposition. Twitter with longer tweets is just like a Facebook newsfeed with more strangers and fewer actual friends. The brevity and speed have been an integral part of the service since its inception. While the original limit was due to the technical limitations of text messages, it nonetheless became part of the character of the service (see what I did there?). It’s definitely a pro/con, but it is unequivocally a true differentiating factor. I’m sure this has been tested and debated for months if not years, but that doesn’t mean it’s the right long-term decision. Platform growth and health don’t always align. MySpace was doing “great” for a while too.
I wrote little stories crammed into tweets every day for over 7 years. 1 I started one of a handful of publications that feature and even pay authors for tiny stories that fit in a tweet.
For me, the constraint has always been the whole point.
Nanoism will always have a 140 character limit. Constraint is the USP of the platform. We’re not a Facebook publication for a reason.
— Nanoism (@nanoism) November 9, 2017
This isn’t to say someone couldn’t start a compelling 280-character limit fiction venue, but would it really be Twitter fiction? Twitter was inspiring as a creative venue for the same reason that people enjoy (if are also occasionally aggravated by) the linguistic acrobatics required to fit their thoughts into the short form. It’s challenging and often surprising.
Of course, I will fully admit that most of the 140-grumblings surely come from longtime users with emotional attachments, particularly writers. I don’t doubt that most people will be able to simply say what they want to say more easily with a longer limit, and that such engagement may—potentially—lead to more usage and advertising revenue.
But I’ll leave it to John Dingell (91-year-old former Congressman from Michigan):
99% of you people don’t even deserve 140 characters.
— John Dingell (@JohnDingell) November 7, 2017
See? No constraints and this post is way too long. Which is another way of saying that @nanoism will always have a 140-character limit.