Workflowy redesign

08.04.18 // Miscellany, Writing

This is some niche dorky stuff for a Saturday night, but I’m excited: My digital brain, Workflowy, just got a modern redesign.

For those who don’t know, Workflowy is a totally free (with very optional paid options) outliner/todolist/organizer that allows you to have infinitely nested arbitrarily large outlines/lists. If that doesn’t make sense, just try it. It’s ridiculously simple but very powerful. I even wrote the bulk of my last book in it.

The main downside for me has been that Workflowy’s design has been stuck in yesteryear. I’ve been spoiled by a number of elegant writing environments over the past few years, and I actually do think the extra zen makes a difference. This new design is, as expected, super simple, but the clean lines and font crispen up the experience just enough. Well done!

If you’ve already given Workflowy a try, you can activate the new beta design through the options page here. Now they just need to update the iPhone app!

Burnout may be a misnomer

07.29.18 // Medicine

Simon G. Talbot and Wendy Dean, arguing in STAT that burnout is actually a misdiagnosed consequence of unchecked moral injury:

We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the healthcare ecosystem to a tipping point and causing the collapse of resilience.

The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Which is why the chorus of hollow wellness outreach efforts for trainees and other physicians are so patronizing and eye-rollingly ineffective:

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses “information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water” in response to emotional distress crises.

Approaching the Radiology R1 Year

07.02.18 // Radiology

There’s always a tension between giving specific advice (that doesn’t generalize well across different programs) and broad advice (that can sometimes be almost meaningless), but with that caveat, here are some thoughts about starting radiology training:

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My books about Student Loans are free through the end of July

06.20.18 // Finance, Writing

Last year I published a book about managing student loans for medical students and doctors. Earlier this year I extensively revised that into a new book for a general audience. This week, I updated both books.

And now, I’m giving them away for free (at least until the end of July 2018).

Student loans are now depressingly the largest category of consumer debt outside of mortgages. With another graduating class hitting the workforce, I wanted to make my student loan books available to everyone. These are around 45k words, so they’ll take a few hours to get through, but it’s time well spent.

Amazon doesn’t easily let you give away free books these days, so I’ve discounted them to ~~$9.99~~ $2.99.

To get a copy for free, you can download one from your inbox by signing up below for my forthcoming very infrequent/sporadic email newsletter. And, if you aren’t interested in ever hearing from me again, then just hit the unsubscribe link in the first paragraph of the download email. I don’t have any interest in cluttering your inbox.

[sorry, promotion is over!]

If you’re a medical student or physician, click the box for Medical Student Loans. If you’re anything else, click the box for Dealing with Student Loans. These are essentially the same book adapted for different audiences. You only need one.

Topics include:

Borrowing less and minimizing interest accrual during school
How Federal Loans Work & Federal Repayment Options
Income-driven repayment (IBR, PAYE, REPAYE, and ICR)
Federal “Direct” Consolidation
Forbearance & Deferment
Public Service Loan Forgiveness
Maximizing PSLF
Long-Term (IDR) Loan Forgiveness & Loan Repayment Programs (LRP)
Private Refinancing
Taxes & Retirement

Please consider sharing this. There are very few good resources for student loans and a lot of misinformation. I wrote these books because no one else had. I hope you enjoy them.

Explanations for the 2018-2019 Official Step 2 CK Practice Questions

06.09.18 // Medicine

The NBME recently released an “updated May 2018” official “USMLE Step 2 CK Sample Test Questions,” but these are actually completely unchanged over the past two years since the June 2016 update, which was itself almost unchanged from the 2015 set.

Since it’s been a couple years, I’ve included the explanations below (which are, again, unchanged). You might see the comments on the old post for possible additional questions you may have. The multimedia question explanations are also at the bottom of this page.

Last year, helpful reader Jarrett made a list converting the question order from the online FRED version to the pdf numbers. I didn’t go through in detail to see if the online version order has changed, but the multimedia questions were in the same spots except that the block 3 question had shifted by one, so they may have done a little something.

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The ABR supports nursing mothers

06.05.18 // Radiology

I’ve given the ABR a lot of flak over the past few years at pretty much every opportunity, from their expensive, non-portable, and occasionally questionably-written examination to their fumbling of a technical mishap during last year‘s June examination in Chicago. Today, I wanted to highlight something I think the ABR does well, which is something that other medical boards should strive to do better: support nursing mothers.

I also wanted to give additional props on customer service, because unlike my experiences in the past, when I emailed the ABR recently to confirm their nursing mother’s policy, they responded within an hour with a detailed and thorough response.

These are the ABR accommodations for nursing mothers:

* Your pump must be kept in your locker until needed.
* A private room is available where you can go to pump.
* If you do not have a battery-operated pump, an electrical outlet will be available.
* You will need to provide your own method to store / refrigerate the milk.
* Your break time clock will be updated to reflect a total of 60 minutes of break time. While on break, your exam time will pause and break timer will count down. Once break time has expired, your exam time will begin counting down.
* Any extra time you need beyond the additional time will cut into your regular exam time.
These accommodations are standard at both Tucson and Chicago locations.

So, the ABR provides a private space with an electrical outlet and a bit of extra time (30 min) to accommodate nursing mothers. They do ask that you submit an official-looking ADA form at least three months in advance, but this is only a mild inconvenience because they clarified that they do not require a signed doctor’s note as would be necessary in the case of actual disability.

In years past, the ABR has told candidates that no electrical outlet was available, forcing several budding radiologists to purchase a new battery-operated or rechargeable breast pump, a special pump battery pack, a more expensive multipurpose plug-enabled battery pack, or a hand pump. As of this year, they now guarantee access to an outlet if needed, which means that no one will need to spend any extra money to pump during the exam assuming they have insulated storage and ice packs etc (which they would need for traveling anyway). At this point, the last thing that they could do to improve would be to provide access to a staff refrigerator for storage during the exam.

There is a dearth of women in radiology, and this type of support—while free and requiring only a nominal effort—is nonetheless rare and very meaningful, and I want to give credit where it’s due and applaud the ABR’s improving efforts for inclusivity. One of the perks of the ABR’s choice to administer all examinations at their own locations is that they completely control the experience and the rules.

So while I and others have criticized the ABR for imposing additional travel costs and inconvenience on examinees to fly to one of two testing locations in order to take a computerized exam that should theoretically be distributable, I don’t want to discount the overall good job the ABR does with the exam experience. It’s undeniably substantially better than that of your typical commercial testing center with their prison-like ambiance, inefficiencies, and unpleasant TSA-style pat downs. Accommodations for nursing mothers at most commercial testing centers like Prometric and PearsonVue are typically permission to pump in a filthy public restroom or perhaps your car.

Now, as a comparison: feel free to read how this story of a pediatrician’s experience a couple years back. Or this ACLU post about how the NBME handles nursing. Long story short, even though Prometric locations are required by federal law to have a private room to pump available for their employees, they would never deign to share it with an examinee. Instead, it was:

It is still up to you to find a place suitable to you to nurse; whether it is your car, a restroom, or any other public space accessible to you as an exam candidate

Additionally, many accommodations from boards like the ABIM still require a doctor’s note:

Documentation from a medical provider demonstrating the need for an accommodation – ordinarily, a physician’s letter stating the candidate’s delivery date and the anticipated frequency/duration of sessions to express breast milk will suffice.

That’s just silly.

We’re physicians. The purpose of a board exam is to ensure that trainees and recent graduates are ready for safe independent practice, not an opportunity to play at being a poorly-organized police state.

It’s trivial to give women a quiet room to pump in and the respect that they deserve. It’s not even an accommodation—it’s just the decent thing to do. And I don’t think it’s acceptable in 2018 for most major medical organizations to cede the responsibility for all testing policy implementations to large testing corporations that clearly do not care about service.

While the federal law for nursing mothers was designed to protect hourly employees and doesn’t apply to customers or salaried employees (like residents, sadly), I think a law that was written to prevent the extortion of employees earning minimum-wage is probably a good starting point for the standards we should also expect for physicians and just about everyone else in the country. Good job, ABR.

Fourth Year & The Match

05.21.18 // Medicine

May 2019 update:
This super helpful book was revised for 2019-2020, is still totally free, and even has a new cover. Get it in your inbox by signing up below.

Here’s a new book. It’s called Fourth Year & The Match, and you can get your copy by using this form to (at least temporarily) sign up for my new planned very infrequent/sporadic email newsletter:

If you’d like the book but aren’t interested in hearing from me, just click the instant unsubscribe link at the bottom of the download email. I don’t want to pester you.

And if you want to learn more about this project, keep reading:

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Explanations for the 2018 Official Step 1 Practice Questions

04.20.18 // Medicine

Here are my explanations for the new NBME 2018 USMLE Step 1 Sample Test Questions. This year there are 51 new ones (marked with asterisks).

Like in years past, the question order here is for the PDF version (not the FRED-simulated browser version). This facilitates using these explanations in future years when they change the available question set (because the old ones are always available via archive.org). The multimedia explanations are at the end.

Prior sets/explanations can be found here.
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Review: The Unremarkable reMarkable

04.05.18 // Reviews

Man, I really really wanted to like the reMarkable ($100 off with that link).

The reMarkable, if you haven’t heard of it yet is a large format e-ink device the bills itself as a Paper replacement. It’s billed as a large touchscreen enabled Kindle with a fast refresh rate and a bundled non-battery-powered stylus that supposedly mimics the texture of paper.

And if the software running this thing was anywhere close to the level of polish in a Kindle or your typical smartphone device, then this thing would be pretty awesome.

But it’s not, so it’s pretty much not.

Unboxing

The packaging was slick and got my hopes up a lot.

Screen and Hardware

The screen is pretty nice. A big almost notebook size e-ink display, though without the backlight that folks may have gotten used to on recent Kindle generations. The 300 PPI of the high-end Kindles is substantially better than the 226 PPI of the ReMarkable, so it doesn’t even look as crisp as other modern e-readers. As a radiologist, I was hoping the device would be good for reading image-rich books and journal articles, but the images aren’t crisp enough and the contrast is washed out. The refresh rate when drawing is impressive but the delay when redrawing the screen to change pages in a book is sloooow.

The surrounding is less nice. The plastic frame does jive with the lightness of the device but it belies a build quality far below, say, an iPad or even a Kindle. The front buttons, in particular, are flimsy and loose without firmness or a satisfying click. The little-nubbed pen feels like a cheap but works exactly as billed. It has a satisfying paper scratchiness on the screen.

Software

The software is incredibly weak. The design is hobbled to function as a serviceable paper sketching/drawing app with a buggy, slow, underpowered e-reader bolted on than a real e-reading device. Page turns are slow. Documents are barely searchable. Annotations only sorta work. Unlike Kindle, you can’t, say, export your highlights—they’re basically saved an image overlay, so useless for most people’s purposes unless you are editing/marking up a PDF (as if it were actually on paper). They also have a tendency to shift on the page, making them nonsensical. Underlines should not be strikethroughs. Only non-DRM ebooks in epub or pdf formats work, and the reMarkable doesn’t yet support the new epub3 format. It also doesn’t parse epub files properly, mutilating the majority of the formatting. No links, no footnotes.

You can only sync ebooks via the app, and the app is buggy. I found I was routinely unable to add files to the reMarkable via the app normally, but that I was usually able to add via the iOS “open in reMarkable” extension (which means the files are compatible, just the platform sucks). The organization schema are just a few folders, and book covers aren’t even displayed (the last page visualized is), which makes seeing your collection at a glance a homogenous mess.

There is no in-book search. No parsing of the table of contents. No internal linking.

It shows PDFs like a stack of pictures, not complex files combining images and—of course—text.

Conclusion

Someone who wants to sketch digitally but wants a more paper-like feel than an iPad or a Wacom might enjoy this device.

Anyone hoping for large-format super Kindle is going to be extremely disappointed.

So now I’m using Bear

04.02.18 // Writing

Update: I went back to just using Workflowy for all drafting. It’s just so easy and awesome.

There were two developments that led to me implementing new workflows to get my writing done. I’ve been interested in different writing environments and different tools for longer than I’ve actually done any significant writing but always fell into the typical trap of spending more time researching what to use than I ever spent actually using anything other than the built-in post editor for WordPress and Microsoft Word.

The first was the birth of my son 3 years ago. I don’t know what I used to do with all of that time, but it became clear that with priorities of being a father and then being a physician that I would need to be more deliberate in carving out a niche for writing.

The partially-related second development is that I started to do a lot more writing on my iPhone. To write effectively on the phone, you need a tool that allows you to get words down quickly and keep your snippets and thoughts organized. Another big plus is solid syncing so that you can switch back and forth on the same project on other devices seamlessly.

Last year, I had a two-app system. WorkFlowy for my snippets, lists, and braindumps. I previously wrote about how I used this awesome free service (with completely optional paid upgrades) to write my second book. Then when it was time to sit down and really flesh out that manuscript I used Ulysses. I even had my entire to-do list in Workflowy for a while.

This worked great. But I found that my post snippets and drafts were numerous enough that they started to get cluttered and lost in my tangle of multi-layered WorkFlowy outlines. I use the app for so many different things that it took time to find the right place to put the right snippets, and I didn’t have the time to sit down and use the Web app to re-organize frequently enough. Workflowy is awesome for unstructured data entry, but it was less good for building up multiple drafts simultaneously, which was especially tricky because I was using it for so many different things that I had to navigate through frequently. These extra seconds sometimes meant either losing organization or losing a thought I wanted to transcribe.

The simple solution was staring me in the face the whole time: Bear.

Now, it didn’t actually have to be Bear. It could have been any decent note app. Byword, iA Writer, and even the built-in notes app would all work the same. Bear just happens to be a particularly well-crafted one that is super responsive, a pleasure to use, and has a robust tagging system (and was perhaps coincidentally the one I was testing out when I figured out my new plan). Bear is completely free to use and $15/year for premium features like cross-device syncing.

What I needed to optimize for my phone writing workflow was an app for long projects which is well organized and synced to my computer (Ulysses). An app for lists and brain-dumping and especially for building up lots and lots of snippets for longer works (WorkFlowy). And—and this was the surprise/revelation—an app just for blog posts.

I think most people intuitively want to use fewer apps. The view of so many app reviews and so much productivity writing is that if you just find the right system or best workflow that everything in your life magically falls into place. The truth is that putting the hours in and developing good habits are what gets results. The tools are just lubrication.

So originally, I wanted to find the right thing that works for everything. Ulysses is basically perfect for that. But I wear different kinds of writing hats and write different kinds of things on my phone so having Bear dedicated to fleshing out a limited number of brewing blog posts is extremely efficient for me, even if it also results in a little additional clutter on the home screen.