[Update: Sorry, I’m no longer offering the print edition]
I finished polishing the print version of my review book for the Texas Medical Jurisprudence Exam and made it available on Amazon last month. It started outselling the Kindle version after a few weeks, which goes to show that—assuming relative costs are reasonable—a lot people still like reading books on paper.
It’s also useful as a non-pharmacological sleep aid.
David Silberswieg, Professor of psychiatry and Academic Dean at Harvard Medical School, writing in the Washington Post about the increasingly underfunded mission of academic medicine:
But while there is a need for oversight, in some political and journalistic quarters there are exaggerated senses of mistrust, attack, mixed messages (if not hypocrisy), and mis-aligned incentives…Ever-increasing regulation brings more and more unfunded mandates and documentation requirements, which while very important to a degree, require extensive amounts of organizational and personnel time, detracting from patient care and increasing professional burn out.
The IOM’s To Err is Human and the resultant quality improvement mandates have done some important things, but fetishizing quality improvement has resulted in countless ways to try to optimize some metrics at the expense of others (as well as other unintended externalities). When you tie reimbursement to a metric, you better be sure that metric is what you really care about. When it’s not, the system suffers (such as the issues that arise with optimizing patient satisfaction).
All of this has resulted in the corporatization of the culture at many teaching hospitals. Endless meetings and initiatives to make processes leaner and to remove waste may be imperative for the responsible, viable running of the teaching hospitals. But the relentless focus on these real concerns increasingly comes up against a point beyond which staffing and funding cuts endanger the academic mission, before endangering patient safety — the point no one wants to reach.
This has been become more and more of an issue during the past four years of my residency. In addition to more documentation, various best practice warnings, mandates, programs, and the unending growth in “vice-presidents” of various manufactured responsibilities, the GME funding dollars are simply getting tighter and tighter. Even our duty hours are now being scrutinized from both directions. A resident still can’t work too much (at least on paper), but the hospitals we work for also want to make sure each is getting their money’s worth for our salary as well. They’re even starting to compete within the system with each other for their share of the pie (if I’m working at hospital A, then why am I call on at hospital B?).
How, then, can we save our academic medical centers, cutting costs and improving efficiency, without compromising the high caliber of care, patient safety, workforce development and discovery? How can we attract, educate, retain and develop our best medical talent, who have spent many years training while incurring crushing debt, and allow them to do their best work on behalf of society?
I’m not sure you can without big changes in the structure and length of medical training from college through residency. With trainees caught within the ever-grinding gears of the bureaucratic machine, the clinical and regulatory missions will absolutely try to kill the academic mission. How can the average trainee learn over a reasonable timespan in an environment of relentless oversight and pseudo-clinical distractors? How can we continue to attract driven and smart people to medicine when the journey and even the destination are becoming more unpalatable? More young physicians want “part time” work (which would often still be considered full time outside of medicine) in order to match the non-medicine lifestyles of their peers. Meanwhile student debt grows unabated. Big things change slowly, and the GME is no exception. But we’re slowly approaching a crossroads.
Rewind. Time for the Jedi Mind Trick. I held the films out. “This patient isn’t an operative candidate. I don’t know if you could even biopsy this mass. It’s really in there.” I prayed his ego would take the bait. The radiologist turned and snatched the films from me then threw them up on the lighted wall on his left. “Oh yeah, I can hit this, no problem. I’ll do it tomorrow, about 9.” And that, folks, is the Art of Medicine.
From Salvatore Iaquinta’s very funny internship memoir, The Year THEY Tried to Kill Me. The closest thing to a modern The House of God since…The House of God.
Got to put on my writer/editor hat and be a guest on WNPR’s Colin McEnroe Show to talk about Twitter Fiction, Nanoism, and read a few tweet-sized tales. This was my very first radio interview (and live is tough, oof!). My part is toward the beginning, with Colin introducing me around the 6:45 mark. But you should at least listen to the very beginning, because their intro sketch bit is the best part of the show.
is up next on the Kindle Unlimited tour of physician books. I really feel like the title should read “in Medical School.”
Kashmer’s hardest sells in the book are on how valuable he thinks his MBA training was and how great locum tenens positions can be for a young physician’s lifestyle (he owns a locums placement company). It starts with the usual “I’ve made a lot of mistakes doing all the amazing things I’ve done” humblebrag and follows it up with a ton of common sense. I do applaud him for the copy editing and book styling, definitely a notch above the usual.
He also really promotes a company called Provider Lifestyle Experts, a service which helps with dealing with credentialing paperwork for $600/month. Yikes! Only in my wildest dreams could I one day make enough money to think spending over $7000 annually for some light paperwork help was a good use of cash.
There are some generally useful things about contract negotiation, but I think these are better and more succinctly covered by the second book in this review. The practical advice on how to deal with the vagaries of clinical practice sort of sound like marathon advice: At first you’ll be nervous. At some point, you’ll get tired. You may even want to quit. If you trip and fall, well that will probably hurt. How much is hard to say. Is that helpful? Not really. It’s obvious. It’s generally pleasant non-advice. Be nice, work hard, don’t do shady things, and if your job really is a terrible fit, get the hell out of dodge.
Overall: Skip unless it’s free and have 1-2 hours to burn and you got terrible clinical evaluations in medical school and residency (i.e. have no common sense).
is overall stronger, in that out of the 1 hour it takes to read it, 10-15 minutes are pretty interesting. The book is apparently an extended version of a talk he gave to some orthopedics colleagues.
Chapter 1 is “Ten Points You Need to Know About Contracts.” This is interesting and well written. It’s basically an excellent blog post.
Chapter 2 is an almost joke personal finance chapter: don’t act rich, and get a financial planner (ugh).
This is followed by short chapters covering industry and hospital relationships, basics of coding/billing, marketing. All of this is fine and good basics.
Overall: Good if you know nothing, particularly the first chapter. Worth it on Kindle Unlimited/free. Otherwise pass.
John Oliver turns his incisive gaze on scientific studies:
Fantastic as always, with some great “TODD” talks too.
From the NYTimes piece about a new synthetic polymer that could be used medically to keep topical medications on the skin, maintain moisture in conditions like eczema, and—of course—to temporarily reduce wrinkles:
A Harvard colleague, Dr. Mathew Avram, who was not associated with the company or its product, said he had tried second skin, putting it under his eyes.
“It does work,” he said.
“But it was a little depressing,” he added. “I didn’t realize I had those bags.”
Is this going to replace some surgeries, make us all feel worse about the superficial effects of aging, or both?
Despite the rave reviews from family, friends, and readers on Amazon, I thought David Larson’s Medical School 2.0: An Unconventional Guide to Learn Faster, Ace the USMLE, and Get into Your Top Choice Residency overall falls prey to the common trap of the self-help genre: overpromise and underdeliver.
It’s unapologetically the approach to medical school as if written by Tim Ferriss (of the 4-Hour Workweek fame), which is fine I suppose, but therefore it harkens from the same spiritual family of life hackers that purport to teach you how to make six figures while banging the best-looking people in every city as you travel the world with two pairs of pants and some merino wool socks in a small Tom Bihn backpack. Even though the content is usually fine, the constant hyper-selling (you too can be like me!) sort of makes your eyeballs feel cheap.
On the whole, the book is clearly self-published. The first 13% is all introductory fluff. Larson repeatedly and irritatingly uses ALL CAPS to signify emphasis. There are a lot of grammatical, typographic, and miscellaneous errors (e.g. using “deep-seeded” instead of “deep-seated,” using “I.E.” when he meant “E.G.,” “your” vs. “you’re” etc). But most of all, it just needs an editor. It’s too long and fluffy. It plays the typical self-help book game of giving you a few pages of information with ten times more verbiage in an attempt to convince you of how great and revolutionary the plan is and how it will benefit you.
Much of the self-help/life-hacking genre is a silly follow the leader game, whereby an individual makes money by trying to sell their success methods to other people (a fraction of which then try to do the same). The real problem is that while success may be sexy, achieving it almost never is. Anyone who purports to teach you the secret to achieving your dreams is mostly selling snake oil (or a book or a pricey online e-course). The good thing is that many of these books, this particular book included, actually have reasonable advice buried beneath the hype. It’s not earth-shattering, but it is solid. The bottom line is something I used to tell my students all the time: You can’t learn everything. No matter what, you will have to pick and choose what to learn, and it might as will be the stuff that matters. Limit your resources. Don’t let your overachieving peers drag you down. If it’s not high yield for step one and you don’t otherwise know that it’s going to be on your unit exams, then you probably don’t need to know it. How Larson thinks you should study finally makes an appearance at the 48% mark (hint: it’s flashcards and spaced repetition, such as many students do with Anki). In catchphrase parlance, that’s “study smarter, not harder.”
So, other than discussing how to study, the book includes exactly 0% of the other parts of medical school: any real specifics about study resources, what to do with the summer after first year, anything specific to the boards, anything about clerkships, anything about applying for residency, etc etc. This is just about how to study, which means in many ways it’s not really about medical school at all. If you want to know about medical school itself, you’ll have to look elsewhere.
There’s also a bunch nutritional pseudoscience and wellness stuff, which is +/-. Maybe I’m too cynical.
If you need someone to help you orient your mindset as you begin medical school, then this book will do the trick. The study methods are fine. Although, while the “typical” med student Larson refers to does exist (the “gunner”), it’s a bit of a straw man to compare his method against. Most people I knew in med school where nothing like what he describes.
All that griping aside, I do think Larson genuinely thinks medical students are making themselves miserable and is trying to offer his perspective of a reasonable approach to prevent throwing four years of your life away, and for that, I do applaud him. The mindset aspect of the book may very well be the most helpful thing about it.
Overall: If you want an in-depth discussion of how to stay sane making flashcards, go for it.
From FiveThirtyEight’s article, What Would Happen If We Just Gave People Money?, discussing the results of the MINCOME experiment in Canada in the 1970s where families received a basic income, no strings attached:
Families receiving MINCOME had fewer hospitalizations, accidents and injuries, Forget found. Mental health hospitalizations fell dramatically. And the high school completion rate ticked up during the years of the experiment, with 16-to-18-year-old boys, in particular, more likely to finish school. Younger adolescent girls were less likely to give birth before age 25, and when they did, they had fewer kids.
The program brought most recipients above Canada’s poverty line. And the employment effects in Dauphin were modest. “For primary earners — those with full-time jobs — there was virtually no decline” in work, Forget said. “Nobody was quitting their jobs.” Cash from the government eased families’ economic anxiety, allowing them to invest in their health and plan over a longer horizon.
The idea of a basic income (instead of means tested “welfare”) is gaining traction. Several countries (Canada, Finland, Switzerland, Kenya, etc) are planning modern experiments of their own. Politics and logistics aside, how else will our economies function when much of the conventional labor force is inevitably replaced by machines?
If you’ve seen the headlines, then you know that this open letter to the CDC from three medical students and Martin Makary at Johns Hopkins has gained a lot of media attention. In it, they argue that the CDC should allow doctors to list medical error as a cause of death. So far so good.
Then they argue, through the power of contrivance, that medical error is the third leading cause of death after heart disease and cancer but above COPD (emphasis mine):
We define death due to medical error as death due to 1) an error in judgment, skill, or coordination of care, 2) a diagnostic error, 3) a system defect resulting in death or a failure to rescue a patient from death, or 4) a preventable adverse event. The prevalence of death due to medical error leading to patient deaths has been established in the literature. From studies that analyzed documented health records, we calculated a pooled incidence rate of 251,454 deaths per year.(1) If we project this quantity into the total number of deaths in the year 2013 (2,596,993 deaths), they would account for 9.7% of all deaths in the nation.
Wait, what? All of the medical error data is slightly bullshitty, and doubling down on it to “calculate a pooled incidence rate” for this purpose is no different. Medical errors that occur before death do not necessary cause that death (correlation and causation). Some patients who die “due” to medical error are so sick that the medical error is not the prime (or even secondary) culprit. Perhaps being on death’s door and requiring high level and Herculean care is a risk factor to experiencing medical error. Not all bad surgical outcomes, hospital acquired or postoperative infections are “errors” even if someone labels them as “preventable.”
The accompanying article in BMJ is longer but doesn’t help with the underlying math (emphasis mine):
A literature review by James estimated preventable adverse events using a weighted analysis and described an incidence range of 210 000-400 000 deaths a year associated with medical errors among hospital patients.16 We calculated a mean rate of death from medical error of 251 454 a year using the studies reported since the 1999 IOM report and extrapolating to the total number of US hospital admissions in 2013.
Associated. I have to imagine that this “analysis” is for dramatic effect, to spur popular outrage and official (re)action. It’s like projecting the cancer risk of CT scans based on the atomic bomb survivors exposures, dividing to estimate the risk of a single CT, and then multiplying to get the total risk of all CTs. Sure, it could be right by coincidence, but it’s certainly not rigorous or even definitely based in reality.
The premise that we should actually know if we kill someone is important and makes sense (though telling people to actually put down “medical error” on a death certificate for their patients given the malpractice climate might be a tough sell and means that I imagine in real life it would often be reserved for egregious cases). I personally think that while this sort of presentation may generate discussion, it actually cheapens an important topic within medicine. Medical error is important and we must do more to track it, but tying a number to it in this manner is almost arbitrary.