Ben White

What I read in 2016

12.26.16 // Reading

The little one is a bit older and I had marginally less call this year, but I also had to take the boards in June, so reading time definitely benefitted from the flexibility of ebooks on the phone and the magical powers of Audible. Overall, it was a better reading year than 2015.

  1. The Etymologicon by Mark Forsyth (fun language romp)
  2. Stoner by John Williams (quiet, understated, lovely)
  3. The Buddha Walks into a Bar by Lodro Rinzler
  4. The Fault in Our Stars by John Green (of course I cried)
  5. Corsair by James L. Cambias
  6. The Sixth Extinction by Elizabeth Kolbert (Pulitzer winner)
  7. The Rolling Stones by Robert A. Heinlein (1970s sci-fi, not the band)
  8. The Bogleheads Guide to Investing by Mel Lindauer, Taylor Larimore, and Michael LeBoeuf
  9. Water for Elephants by Sara Gruen
  10. The Terrible and Wonderful Reasons Why I Run Long Distances by The Oatmeal
  11. Calamity by Brandon Sanderson (The Reckoners #3)
  12. Medical School 2.0 by David Larson
  13. Pay Yourself First by David Hurd and James Hemphill
  14. Changing Outcomes by David Hurd and James Hemphill
  15. The Cartel by Don Winslow (incredibly gruesome but so good)
  16. Physician Finance by KM Awad
  17. A Doctor’s Basic Business Handbook by Brandon Bushnell
  18. The Year They Tried to Kill Me by Salvatore Iaquinta (to me, the new House of God)
  19. So You Got Into Medical School…Now What? By Daniel Paull
  20. Why Medicine? By Sujay Kusagra
  21. Broadcasting Happiness by Michelle Gielan
  22. Bream Gives Me Hiccups by Jesse Eisenberg
  23. The Alloy of Law by Brandon Sanderson (Wax & Wayne #1)
  24. A Tale of Two Cities by Charles Dickens
  25. Dimension of Miracles by Robert Sheckley (audiobook perfectly narrated by John Hodgman)
  26. The Beautiful Struggle by Ta-Nehisi Coates
  27. My Year of Running Dangerously by Tom Foreman
  28. What They Don’t Teach You at Medical School by Dr. David Kashmer (still feel like that’s the wrong preposition in the title…)
  29. What if? by Randall Munroe
  30. Shadows of Self by Brandon Sanderson (Wax & Wayne #2)
  31. The Jungle by Upton Sinclair (so depressing)
  32. A Little History of Philosophy by Nigel Warburton (this was surprisingly fun)
  33. The Earth Moved by Amy Stewart (apparently earthworms are really important)
  34. Drinking Water by James Salzman (really wanted this to be like Kurlansky’s Salt or Cod, but it wasn’t anywhere near as good)
  35. The Ocean at the End of the Lane by Neil Gaiman
  36. The Marshmallow Test by Walter Mischel
  37. Diet Cults by Matt Fitzgerald
  38. The Hunt for Vulcan by Thomas Levenson (long before we demoted Pluto, we used to think there was a hidden planet Vulcan. Weird!)
  39. Rejection Proof by Jia Jiang
  40. The House of Wigs by Joshua Allen
  41. The Bands of Mourning by Brandon Sanderson (Wax & Wayne #3)
  42. The Emperor of Maladies by Siddhartha Mukherjee (well-deserved Pulitzer winner)
  43. Bricking It by Nick Spalding
  44. The Gene by Siddhartha Mukherjee (between the two, Emperor is better)
  45. Harry Potter and the Cursed Child by J. K. Rowling
  46. The Element by Ken Robinson
  47. The Thirteen Word Retirement Plan by Stephen Nelson
  48. Student Loan Debt 101 by Adam Minsky
  49. The 4 Percent Universe by Richard Panek
  50. Simple Sabotage by Robert M. Galford, Bob Frisch, and Cary Greene (the pdf of the CIA’s declassified original field manual that inspired it is better).
  51. As You Wish by Cary Elwes
  52. Mistborn: Secret History by Brandon Sanderson
  53. The Emperor’s Soul by Brandon Sanderson (Huge winner, great novella)
  54. The Medical Entrepreneur by Steven M. Hacker
  55. Breakfast of Champions by Kurt Vonnegut
  56. Born Standing Up by Steve Martin
  57. The Alchemist by Paulo Coelho (just lovely)
  58. Words of Radiance (Stormlight Archive #2) by Brandon Sanderson
  59. The Wealth of Humans by Ryan Avent (smart writing about technological innovation and societal change)
  60. TED Talks by Chris Anderson
  61. Medium Raw by Anthony Bordain
  62. Animal Farm by George Orwell
  63. Born a Crime by Trevor Noah (was really great as an audiobook)
  64. How to Think About Money by Jonathan Clements
  65. When Breath Becomes Air by Paul Kalanithi
  66. Ready Player One by Earnest Cline (fun homage to classic video games and 80s culture masquerading as a novel)
  67. The Rest of Us Just Live Here by Patrick Ness

Classics I visited included a Tale of Two Cities, The Jungle, and Animal Farm, which were all super depressing. I continue to wonder why I read any of the pop-psych/inspirational/self-help type books given that they are all approximately the same and should nearly always be an essay or two and not drawn out to book length. I also read a bunch of short finance, med student, and doctor books for research/blog purposes, which were almost all meh.

On the fun side, I did catch up on most of Brandon Sanderson’s books while waiting for Patrick Rothfuss and George RR Martin to finish their next books. Now I have to wait for Sanderson’s third Stormlight book as well, which won’t come out for another year (and the last book in Mistborn Era 2 is like two years away).

Did love The Alchemist though. Just a beautiful, lovely little story. And every doctor should read The Emperor of Maladies.

Study shows women are still better at everything

12.20.16 // Medicine

Yesterday in JAMA:

We found that elderly patients receiving inpatient care from female internists had 30-day lower mortality and readmission rates compared with patients cared for by male internists. This association was consistent across a variety of conditions and across patients’ severity of illness. Taken together with previous evidence suggesting that male and female physicians may practice differently, our findings indicate that potential differences in practice patterns between male and female physicians may have important clinical implications for patient outcomes.

and

Furthermore, given that there are more than 10 million Medicare hospitalizations due to medical conditions in the United States annually and assuming that the association between sex and mortality is causal, we estimate that approximately 32 000 fewer patients would die if male physicians could achieve the same outcomes as female physicians every year.

Confirmation bias aside, this general finding does ring true to me.

Reading a bit deeper, though, one physician characteristic that was underplayed was that female physicians saw fewer patients overall (i.e. more were part-time). This might function as a proxy for burnout and its associated poor patient care outcomes. Something to consider for the men who are already in medicine and dragging it down.

When breath becomes air

12.12.16 // Medicine, Miscellany

I actually posted this excerpt once before, but I just finished Paul Kalanithi’s When Breath Becomes Air and was moved anew by his missive to his infant daughter:

When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

Earlier in the book, in conversations with his oncologist about coming to terms with how to spend his life with cancer, this entreaty comes up multiple times:

Find your values.

In his moving memoir (which doesn’t at all belittle fields like radiology), Kalanithi softly and compellingly argues that this is the key to how you live like you were dying.

How to Study for the ABPN Psychiatry Boards

12.05.16 // Medicine

About the Exam

The ABPN psychiatry exam is a marathon day-long computerized multiple-choice exam offered once a year with two dates in September. You can apply as early as November but the deadline is February (current dates here) through the “folio” website. You won’t schedule the actual exam until scheduling is opened, usually around 2 months before the exam dates. Results take around 8-10 weeks. In 2016, scores were released on November 30 (so 10 weeks).

Eligibility (see the info document):

  • Graduate from a legit medical school
  • Have a full medical license
  • Finish residency (or be a senior on track to finish it before taking the test)
  • Complete 3 Clinical Skills Evaluations (CSE)

Costs:

  • $700 application fee when you register to tell them you’re ready
  • $1685 examination fee when you schedule the exam with Pearson VUE.

You have 7 years after finishing your ACGME residency to pass the ABPN to become board certified. So you have plenty of tries if things go south (subsequent tries “only” cost the $1685 exam fee).

Exam & Content

You get 50 minutes of break time that you can take between sections. Any breaks you take past the 50 minutes are permitted, but they then eat into your actual test time, which is 8.5 hours.

8 sections are split between Part A+B or Part C questions:

  • 110 questions in Part A (Basic Concepts in Psychiatry)
  • 110 questions in Part B (Neurology and Neurosciences)
  • 230 questions in Part C (Clinical Psychiatry).

screen-shot-2016-11-05-at-1-43-50-pm

So 8 sections of 50-65 questions each for a total of 450 questions over 510 minutes. About 20% is neurology/neuroscience. Tack on a 5-minute intro and 5-minute post-test survey and 50 minutes break time, and the whole day can take up to 9.5 hours. 4 sections are vignette based and 4 sections are pure stand-alone questions (from the format and scoring document):

Stand-alone questions are one-best-answer multiple-choice questions that are not associated with any other questions. Part A and Part B questions are all stand-alone questions. For vignette questions, there are typically two to ten multiple-choice questions linked to a common case that may be presented in a video clip, which may vary in length from one to four minutes, an audio clip, or in a text vignette.

The ABPN does provide one sample video vignette to whet your appetite.

Historically, each Part was graded separately and needed to be passed. Now the test is graded in aggregate; it’s no longer possible to fail a single section and thus fail the exam. In 2016, a 71% correct overall was the passing threshold.

And everything is now DSM-V (from the policy document):

Starting in 2017, all specifications and content of all ABPN computer-delivered examinations will be based solely on DSM-5. No DSM-IV-TM classifications and diagnostic criteria will be applicable.

Board Books

Question Banks

Board Vitals

The most popular question bank for the ABPN is Board Vitals (which also has question banks for other specialties as well). This resource is definitely not error-free, and some users feel that it contains too much esoterica, but it’s still widely used. It’s $139 for a month. Using the code BW10 at checkout also gets you 10% off.

Overall, questions represent the board style pretty well, and the product is a good size (1639 questions). BV was completely updated to DSM-V in 2017. A lot of the “neuro” questions are actually psychiatry, so the neuro coverage is less than you’d guess from when you first log in. As an exclusively web-based product, there is no off-line access. You also need to hit the “show explanation” button to see the explanation for a question, which gets tiring after a while.

There is also a new optional 250 question package (actually 257) based on video vignettes available as an add-on (another $139/month), which is pricey but basically the only a la carte source for this question format currently.

TrueLearn

A new player is TrueLearn, which has products for both the PRITE and the ABPN ($25 off with that link). Questions overall feel harder and have a more basic science/med school type feel than those found in the other resources. The interface is a little more cluttered, but the software is overall solid: you can cross out answer choices and there’s also a “bottom line” summary statement, which is helpful.

Ultimately, TrueLearn is a reasonable second online question source after Board Vitals but overall probably not quite as high-yield yet. Overall, a couple of question sources are likely to be sufficient, so after Kenny & Spiegel and Board Vitals +/- more neuro review depending on your background, most test-takers are probably done question-wise.

Rosh Review

Rosh Review is the third of the big three online qbanks, and they offer a Pass Guarantee. 10% off their certification, child and adolescent, and PRITE products with code RoshPsych10.

Beat the Boards

Is a $1,097 online lecture course with a ~1000 questions and ~50 vignettes. We reached out to them to provide access for this review and were totally ignored. This is really expensive and ultimately unnecessary to pass.

Book round-out:

  • Kaufman’s Clinical Neurology for Psychiatrists may be too long to read cover to cover during a limited post-work board review, but it also contains 2000 questions (extras are online) to help round out your neurology review.
  • Psychiatry Board Review: Pearls of Wisdom is a change of pace written in a concise Q&A format which was useful as an adjunct, but it’s now a bit out of date and was neither as consistent nor as thorough as the other review books. It does contain a lot of high yield facts organized in a quick-read manner but is crying out for a DSM-V update.
  • Unlike for Step 1, First Aid for the Psychiatry Boards isn’t the strongest source for psychiatry review and can be ignored. It purportedly does a passable job for neurology but remains a safe pass unless you just need to have another book.

Thanks to my awesome wife (the esteemed psychiatrist) for help in writing this post.

Obama thinks about the future

12.04.16 // Miscellany

The New Yorker has a fascinating article about Obama dealing with the fact that Trump won. It’s eminently quotable, but I particularly liked his brief discussion on the futility of trying to “bring back” lost industry through protectionism:

The prescription that some offer, which is stop trade, reduce global integration, I don’t think is going to work,” he went on. “If that’s not going to work, then we’re going to have to redesign the social compact in some fairly fundamental ways over the next twenty years. And I know how to build a bridge to that new social compact. It begins with all the things we’ve talked about in the past—early-childhood education, continuous learning, job training, a basic social safety net, expanding the earned-income tax credit, investments in infrastructure—which, by definition, aren’t shipped overseas. All of those things accelerate growth, give you more of a runway. But at some point, when the problem is not just Uber but driverless Uber, when radiologists are losing their jobs to A.I., then we’re going to have to figure out how do we maintain a cohesive society and a cohesive democracy in which productivity and wealth generation are not automatically linked to how many hours you put in, where the links between production and distribution are broken, in some sense. Because I can sit in my office, do a bunch of stuff, send it out over the Internet, and suddenly I just made a couple of million bucks, and the person who’s looking after my kid while I’m doing that has no leverage to get paid more than ten bucks an hour.

I recently read The Wealth of Humans, in which Economist writer Ryan Avent presents an engaging argument about how things have and are likely to change with increasing automation. I think people are generally pretty quick to believe that robots will eventually replace everything but have nonetheless been far less inclined to think about what that will actually mean. For the economy, for humans, for society as a whole.

Best Books for Elective Rotations and Sub-internships

11.10.16 // Medicine

First, my book recommendations for the core third-year clerkships can be found here. What follows are “best” book recommendations geared for MS3/MS4 elective rotations and sub-internships (“sub-i’s”), including most of the surgical and medical subspecialties. Some of these books are geared for medical students; others more for residents. I’ve done my best to include both when appropriate, including a first buy single resource when possible and alternates and options for further reading when necessary. For more info about methodology, feel free to peruse this.

Let me preface this list by saying that a typical student on a normal rotation in a field outside their main interest does not need to buy anything. Even in a field of interest, many (most?) students will simply wait to buy books until they have a book fund during residency and will nonetheless succeed. No one has a monopoly on medicine and medical knowledge; in this new era of medicine, you don’t need to buy anything simply for your education if there isn’t an important test at the end of it.

As a general rule, you will rarely go wrong reading UpToDate for your typical brownie point efforts (particularly in non-surgical fields). As a matter of gamesmanship, you of course never say, “UpToDate says,” you merely state the information as a fact, occasionally referencing “reading” you did or “studies have shown.” It works well to click on the link to the footnote on anything you feel might net you a gold star, click on the reference, then browse the abstract. Then you could say, “a big RCT in Sweden demonstrated…” and if anyone pushes you on details you didn’t glean from the abstract, you simply say, “good question – I don’t recall – I’ll need to go back and look further.”

It should also be said: your success on your rotations has much more to do with how you function as a human being than how many facts you know.

 

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Buying a house during residency

11.07.16 // Finance

Should I buy a house as a resident?

Probably not.

The American tendency to prioritize owning your house or car can be a bit misguided. When you buy a house with a mortgage, the title may be in your name, but it’s really the bank that owns it. You’re slowly buying it from the bank, paying interest all the while. It’s not that buying a home is a bad idea; it’s that owning a home is not intrinsically good financially. Owning something instead of renting isn’t always better.

Before we discuss the pro/cons, a disclosure: we bought a house when we graduated medical school, and we bought (and sold) a house during medical school as well.

Downsides

It takes on average 4 years to break even on the transactional costs of buying and selling a home. You can’t just compare the monthly mortgage payment on a potential house and the monthly rent for an apartment or house rental and see which is lower. The mortgage will typically be lower, but this masks several things:

  1. Upkeep costs. You’ll need to pay for repairs and maintenance on your house that you wouldn’t be responsible for as a renter
  2. You’ll need to pay taxes and home insurance, which may not have been in your original mortgage projection. This is deductible if you itemize deductions, but note that the “extra” savings on these are related to your marginal tax rate on the difference between these amounts and the standard deduction. An inexpensive house or townhome isn’t going to make a big dent in your tax burden.
  3. You’ll almost certainly lose money to realtors when it comes time to sell. 6% is common (3% to each agent [who then share that with their broker]). With the rest of the closing costs, earmarking 10% is considered a good estimate.

Bottom line: Even if the monthly mortgage payment + the upkeep etc comes out to a better deal than a rental, you’ll still have to take #3 into account. Whether or not the closing costs will make or break the +/- versus renting will depend on how much you sell the house for when the time comes and how long you held the house for (i.e. how much total money you’ve saved vs renting over time). In most cases, selling the house for exactly what you bought it for will actually result in a loss.

Buying a house and planning to sell it after a three-year residency, for example, is essentially investing on margin unless rental prices in your area are super high. You’re just hoping that real estate prices rise fast enough to counteract the costs of a real estate transaction.

Upsides

Conversely, there are some benefits. Your mortgage interest and real estate taxes are deductible, so if your house will cost enough to make your tax deductions bigger than the standard ($9300 head of household or $12600 for couples in 2016), then you can itemize deductions and get some of that money back (essentially reducing your monthly payment). Note that deductions don’t give you a dollar back for every dollar deducted, they merely reduce the income you’re paying taxes on and so save you a fraction of that dollar at your marginal tax rate. But because the standard is always an option, it takes a fair amount of tax to make it all worthwhile. If your itemized deductions add up to 13,000, for example, then you’ll only really save yourself the tax paid on the extra $400: $100 if in the 25% tax bracket that many married residents are likely to find themselves in.

You get to own a house. While upkeep could be a big headache, owning a house and having your own space could be awesome. While owning a home isn’t “priceless,” this part of the value is at least partially a personal calculus. Additionally, sometimes owning is the only healthy option. Some places, particularly small towns, don’t have much of a renter’s market. There may be no houses for rent in the areas convenient to the hospital nor decent apartments. In some unusual cases, you may feel like you don’t have a choice but to buy depending on where you match.

Real estate can also be an investment. Most houses a resident (or graduating medical student, really) can afford probably aren’t your forever home. That said, depending on what your finances will look like when it’s time to upgrade, you could conceivably keep your first house as a rental property (though again this may impair your ability to qualify for another mortgage etc when holding the additional debt). It also assumes you want to deal with being a rental owner/real estate investor, which comes with its pro/cons, costs, and headaches. But buying a home now with a low-interest rate in a good area for rentals may be a viable long-term plan; it depends a lot on the local market.

You can also consider buying and finding a renter for a spare bedroom to help defray your costs. This essentially allows you to be a real estate investor and homeowner all in one with someone else paying part of your mortgage while you still get to enjoy (part of) your home. It’s a good way to hedge your bets.

So if you need to buy a house or simply “need” to buy a house

  • Try to limit your mortgage to 2x your annual income, even if a bank will give you more. Consider 3x to be an absolute limit.
  • 20% down payment is normally considered “good” and will give prevent you from having to pay private mortgage insurance (PMI). Most residents who buy houses do not achieve this.
  • If you have medical school debt (and by odds, you probably do), you may need some variety of physician loan. There are 100% financing varieties as well as ones that require some money (usually 5%) down. Physician loans will allow you to use your match letter as proof of future income so that you can close on a house before you actually earn a paycheck and tend to ignore your student debt in making their approval calculations. LeverageRx is a neat totally free platform I recommend that will let you rapidly comparison shop multiple physician loan lenders (yes that’s a referral link, but check it out).
  • If you aren’t planning on a public service career and loan forgiveness via PSLF, you’d want to see how private refinancing stacks against REPAYE, but you’d definitely want to wait to do any refinancing until after your mortgage clears.
  • Whether an ARM is worth it will depend on how likely it is that you’d keep the house past the fixed-rate limit, how much lower the rate is compared with a conventional 30-year fixed, how much the per-year increase is capped, and if there’s a maximum cap. Any lender can run the options for you so you can see what it means for the specific house you make an offer on. A 5/1 ARM (fixed for 5 years, variable for 25 years) is the most common variety. It’s possible, for example, that a 5-year ARM rate could be 1% less than the 30-year fixed with a 0.5% per-year maximum increase after 5 years (and thus would take a minimum of 7 years before it would overtake the conventional loan’s rate). If you know you’ll hold a house for less than 7 years, then you’re taking on minimal risk in choosing the ARM.1 7-year ARMs also exist if you want a smaller benefit with less risk. In this scenario, I also assume a 15-year is out of the question (because a 15-year fixed loan is more expensive per month but usually has better rates and by far lowest amount of money lost to interest). An ARM is best when you know you’ll only be holding on to a house for the fixed period of time before moving/selling and are confident you’ll be able to sell when the time comes.

The slow growing tide against PSLF

11.03.16 // Finance

Jason Delisle does a nice job describing the majority of the arguments used to suggest that PSLF should be severely curtailed or destroyed in “The coming Public Service Loan Forgiveness Bonanza” for the Brookings Institution.

PSLF will be revised at some point if no other reason than this:

In 2014, the CBO estimated that the Obama administration’s proposal to cap the amount that could be forgiven under PSLF at $57,500 would save $265 million over 10 years (2015 to 2024). The agency recently revised that figure to $6.7 billion.

I don’t think the people making these programs had any idea how much graduate school costs and the incentives they were promoting through potentially unlimited forgiveness.

I still think current borrowers will be grandfathered into the program, and I think politically it is for more likely for forgiveness to capped +/- changes to eligibility rules than for the program to just disappear.

Delisle also lumps all IDR programs together as IBR and says that IBR, PAYE, and REPAYE are functionally equivalent. This certainly isn’t true for pre-2014 borrowers, but also doesn’t take into account REPAYE subsidy or changes to the payment cap (for example) and their effect on the amount forgiven under the PSLF program.

And while he discusses how a cap would help combat the perversion of this program in justifying tuition increases to students, this would really impact longer degrees like law and medicine. A $57,500 cap would still be very enticing to people going for masters degrees in things like social work or speech-language pathology.

You’ll be seeing more like this over the next year (presumably including profiles of rich suddenly loan-free doctors) as the first round of forgiven loans happens in 2017.