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A few docs talk about early career financial mistakes

09.12.18 // Finance

A bunch of physician finance bloggers (and me) were asked to weigh in on early career financial mistakes for MDLinx’s relatively new PhysicianSense blog.

Everyone else said don’t buy a house and don’t try to beat the market. I largely agree with both of those sentiments.

I’m not exactly a finance blogger, even though I write about money with some frequency. My answer was instead largely about being purposeful with your time.

Many of us spend our lives reacting. We spend our days constantly reacting to crises, patients, and bureaucracy at work. We react to short bursts of free time or moments of boredom with our phones and social media. We consume media and television like we’re hardwired.

And when faced with financial troubles like student loans or other financial goals, we often react by either shutting down and ignoring our problems or by becoming obsessed with dollars and cents. There’s nothing wrong with moonlighting or trying to carve out some side income—I still do both routinely. But it’s also important to step back and see if and how your efforts are affecting your mood, health, and family.

The need to be cognizant of how you spend your money should be self-evident. The need to be cognizant of how you earn it is less obvious.

Explanations for the 2017 Official Step 3 Practice Questions

09.09.18 // Medicine

Here are my explanations for the 2017 version of the official USMLE Step 3 free question pdf. This is a constant reader request, so enjoy my take on these 137 questions.

You can find my thoughts on preparing for Step 3 here. In short, I think the free materials and UWorld should be enough for most folks. If you want books recs, they’re in that post. If you need another question source, I haven’t tried any of them, but you can get 10% off BoardVitals if you’re interested by using code BW10.

As for this free practice exam, Blocks 1 and 2 are “Foundations of Independent Practice” (FIP). These should take up to 1 hour each. Blocks 3 and 4 are “Advanced Clinical Medicine” (ACM). These should take up to 45 minutes each. Total practice time should be no more than 3:30 if taking under test-day conditions.

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NYU and the slow coming wave of “free” school

08.30.18 // Finance, Medicine

A couple of weeks ago, NYU announced that they were making medical school tuition free for every student. Dean Robert Grossman stated, “This decision recognizes a moral imperative that must be addressed, as institutions place an increasing debt burden on young people who aspire to become physicians.”

My first thought on this news was, Man, Harvard is going to be so pissed that they weren’t first.

The idea of free tuition has been discussed and debated in multiple contexts across Ivy-type schools for years. These institutions are not immune to the burgeoning reality that their educations are financially untenable for most people and crippling for others. With many such schools fostering endowments numbering in the tens of billions of dollars, actual tuition dollars are no longer the bedrock of a healthy world-class institution. Over the past ten or so years, Harvard has often led the way on increasingly generous undergraduate financial aid, and many similar schools have made corresponding efforts to make undergraduate education more affordable, but until now, no one has taken meaningful steps to fix graduate schools, many of which are now considered mandatory for advancement across many industries. Even this move is largely a token effort, as every other extremely expensive NYU school will still keep its top-dollar cost in the shadow of this brilliant PR stunt.

As an illustration of the numbers involved in making one small school free:

The annual NYU med tuition was an exorbitant $55k per year, and there are 442 total active medical students, which gives a total cost of $24 million per year. “Paying” this requires (according to NYU) an endowment of $600 million because the school is utilizing the famous 4% rule that would make this massive endowment essentially guaranteed to last forever based on historical stock market returns.

Numbers aside, I do agree with the words of the dean (though I would expand them). There is a moral imperative to fix the cost as well as the delivery of medical education. The length, cost, and inefficiency are all otherwise mutable strong arms that are breaking healthcare and squeezing the joy out of young doctors in training from coast to coast.

NYU will not be the only school to offer free tuition. Other rich schools in and outside of medicine likely have been and certainly will be shoring up their endowments to join the club as is feasible. I anticipate this is the first in a salvo of private schools slowly making various programs free, and this will speed up if/when PSLF is eventually canceled, as the program is basically the only justification for charging otherwise unmanageable amounts of money to students who are destined to never be able to actually service their debt. Beleaguered state schools with their chronically strapped budgets will struggle.

My second thought is that free tuition will now make NYU about as affordable as the best-priced state schools (because the cost of living in New York is otherwise so high). Four years of living expenses will never be cheap, and it’s much harder to scrounge time to be gainfully employed during medical school compared with college. Clinical rotations are inflexible more-than-full-time jobs.

This will also result in, I imagine, a huge increase in applications to NYU. When my wife and I applied to medical school, we only applied to state institutions back in Texas where we were still residents while away for college. We were not keen to spend as much in a single year as we could on the whole package. People like me may now decide to add NYU to the list, especially since NYC is glamorous.

So, good on NYU for being the first to pull the trigger. I hope more schools join their ranks, and I hope most of all that this well-publicized confrontation of medical training costs will lead to a paradigm shift that allows schools and hospitals to rethink the whole process. We can do so much better, for our doctors and for our patients

Student loan books now on iBooks

08.24.18 // Finance, Writing

I’ve been a bit slow on expanding the availability of my two books on student loans, but as of today, Medical Student Loans and Dealing with Student Loans are now available on Apple iTunes/iBooks as well as from Amazon.

Get them here:

  • Medical Student Loans (iBooks, Amazon)
  • Dealing with Student Loans (iBooks, Amazon)

The Med Ed Trifecta

08.20.18 // Medicine

Akhilesh Pathipati, writing “Our doctors are too educated” in the Washington Post (emphasis mine):

U.S. physicians average 14 years of higher education (four years of college, four years of medical school and three to eight years to specialize in a residency or fellowship). That’s much longer than in other developed countries, where students typically study for 10 years. It also translates to millions of dollars and hours spent by U.S. medical students listening to lectures on topics they already know, doing clinical electives in fields they will not pursue and publishing papers no one will read.

We’ve done an amazing job in medicine findings way to fill years with reasonable-sounding and potentially useful activities and then pretending they are not only worthwhile but necessary.

The Hit Points

08.13.18 // Miscellany

Starting in 2003, my secret work/study music has mostly been comprised of hundreds of wonderfully creative arrangements of video game music, largely thanks to a website called OverClocked Remix, which has been steadily curating a massive collection of high-quality pieces for almost 20 years.

Which brings me to this stellar bluegrass rendition of a theme from a Kirby game (that I haven’t played):

My son wants to listen to this song on repeat in the car on the way to school literally every day.

Check out The Hit Points’ complete new album CD for free on their bandcamp. Every piece isn’t a standout, but the overall effort is still just delightful. If you can recognize Guile’s theme from Street Fighter II from your childhood, you’ll immediately agree that it was meant to be played this way.

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.

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