Book Review: The White Coat Investor

09.09.15 // Finance, Reviews

I just finished reading James Dahle’s The White Coat Investor: A Doctor’s Guide To Personal Finance And Investing for the second time. I recommend it as a great first finance book for medical students, residents, and even attendings. Physicians are notoriously terrible at personal finance, and as a profession we are routinely preyed on by those in the financial services industry. Given the massive and enlarging amount of debt students are incurring to get the modern MD, we owe to it ourselves to put some time into our finances and our understanding of money, debt, investment, risk, and retirement. WCI is a great place to start (and the website is a treasure as well).

The biggest take home message is unsurprising to anyone who has thought seriously about getting out of debt, accumulating wealth, or read Mr. Money Mustache and similar folks online: Dahle says, “live like a resident.” This very convincing argument is essentially that best thing you can do for your long term financial wellbeing is to continue living like a resident when your salary increases as an attending. Delay the gratification. Do not “grow” into your new income. The difference between what you earn and what you spend is what you save. What you save is what allows you to “buy” your retirement, a down payment on a house, and fun toys. WCI also has a nice treatment of retirement accounts, mutual fund investing, etc as well as some basic coverage of asset protection, business structure, and income taxes. For some of the more complex topics, the book helps you figure out if and how important these are to you right now and suggests further reading.1

One limitation of the book is its particular perspective/bias. The author is a married male physician with a stay at home wife, and multiple areas of the book are slanted for physicians in the same shoes. Consequently he accounts less well for couples with dual incomes, dual student loans, etc. As an example, the chapter on residency finance in particular literally assumes the physician resident has non-working spouse in his argument for why a resident shouldn’t buy a house. While I agree that most residents probably shouldn’t buy a home (although we did), these broad generalizations are tied to very specific advice that may or may not be applicable to the general reader. Along the same lines, a few comments peppered throughout are essentially thinly veiled advice to keep your non-physician spouse’s spending in check.

The book’s treatment of student loans was insufficient when it came out and now somewhat out of date (e.g. private refinancing for residents isn’t mentioned, because it wasn’t available at the time; PAYE is not discussed, etc). Finance books are full of numbers and examples, but what the right choice is for you depends on your options and your numbers.

“Live like a resident” is important advice—a dollar saved is actually more than a dollar earned (due to taxes)—but the argument that you can only achieve the “good life” and spend money on things that bring you joy after your financial house is well in order isn’t going to work for everyone, either practically or emotionally. Keeping up with Joneses is always a losing battle, but the emphasis on conspicuous non-consumption and driving old cars as the pathway to financial independence is occasionally tiresome. Active reading is required; question your assumptions but take away what you want.

On a related note, for those looking for a completely free first finance booklet, try William Bernstein’s (another MD) “If You Can,” which is somewhat condescendingly written for “millennials” but nonetheless distills the essentials of saving, mutual fund investing, and distrusting people who want to fleece you.

Oliver Sacks’ last essays

09.08.15 // Miscellany, Reading

Oliver Sacks, writer of “neurological novels” and one of my favorite authors, died on August 30 from metastatic ocular melanoma. His last three essays are now available, “Sabbath” in the New York Times, “Urge” in the New York Review of Books, and “Filter Fish” in the New Yorker.

Longform has links to 11 of his best essays, including the titular works from An Anthropologist on Mars and The Man Who Mistook His Wife for a Hat. He was a titan of medical and compassionate writing.

Oh, the late night snacking is why we’re fat

09.06.15 // Miscellany

The Washington Post recently ran “Why eating late at night may be particularly bad for you and your diet,” which discusses emerging research that after dinner snacking is bad for you. The thrust of the article is that calories consumed at night result in more weight gain than the same number of calories consumed earlier in the day. Likewise, even on a calorie-controlled weight loss diet, subjects lost more weight if they didn’t eat before bed. Proposed reasons are multi-factorial, of course.

There sorts of data always make for great popular science reading. If making this one change is the first step someone can use to finally make a positive impact in their health, that’s great. But otherwise, it’s just another in the ever-growing list of “things we do wrong” including eating processed food, salt, gluten, not enough protein, “GMO,” insufficiently paleo, blah blah blah. How does a normal person know when to start? Especially when as a country we conflate eating “healthy” with losing weight, and most of the discussion in the media and online is total BS.2 Eating healthy is great. Being a healthy weight is great. Exercise is also independently great. These things don’t necessarily go together.

I for one would probably never change my gluttonous meal to be lunch instead of dinner.2I also don’t eat breakfast! And the ability to maintain a change is much more important than the power of the change itself.

App Review: Quest

09.02.15 // Reviews

I am one of those supremely unproductive people who frequently spends hours researching distraction free writing programs and other workflow micromanagement with zero sense of irony. Nothing helps.

Anyway. One app I do use extensively is the Apple’s default Reminders app, which I’ve long used as both an actual todo list as well as a repository of other random tidbits, blog post ideas, things I want to read and buy etc. I’ve researched (and tried) several todo list apps, but none have stuck. Reminders is ugly, but it’s free, it works quickly, and has the features most anyone really needs.

That just changed last week, because now I’m using Quest.

The overall scheme is similar to Clear (okay, it pretty much copies it), which I didn’t fully embrace, mostly because I thought Clear was colorfully ugly and I didn’t feel like importing all of my items. But Quest is cute app with great idea: it gamifies the to-do list, letting you “level up” for checking off items, with adorable graphics and simple gameplay elements superimposed on a solid todo list app experience.

Quest allows you to organize your tasks into multiple lists as well as add time-sensitive reminders (just like to Reminders app). The main missing feature it lacks is contextual location reminders, which is a feature of the default Reminders app that has always sounded like a fantastic idea but that I’ve never actually used (e.g a reminder to give your wife a hug that activates when you get home).

My biggest feature request is the ability to grade the difficulty of your ‘quests’ — just as not all monsters are of the same difficulty to vanquish, completing your grocery shopping or calling a plumber doesn’t deserve the same experience/reward as crafting a thoughtful blog post or finishing a research manuscript. But I’ll still keep using it for the adorableness/nostalgia factor alone.

Making MS3 Clerkship Study Schedules

08.16.15 // Medicine

This is another reader request and companion post to Studying for Third Year NBME Shelf Exams.

Let me start by saying that I’ve never personally utilized a detailed schedule as a binding contract. My ability to master my personal will with regularity is limited, and the day-to-day variability of a clinical workload makes strict planning difficult. You never know when you just don’t have it in you to work another moment.

That being said, there is some utility to making a rough outline in order to give yourself an idea as to how much time you have to complete various tasks, how many resources you can reasonably get through, and particularly, how much time to allot for dedicated question review at the end of the rotation prior to the shelf exam. You do not want to shortchange your time for questions. The details of your personal schedule will vary based on your clinical workload, the make-up/pain level of your clinical sites, and rotation length. Some schools do surgery in 8 weeks, others in 12. Length matters. Talk to students in the class above yours to get an idea of what kind of schedule to expect rotation to rotation.

Making your schedule

The first step is to determine how many UW question sets you think you can do a single evening, assuming you’re working a normal schedule and are trying to achieve a measured pace and not kill yourself. I prefer to do tutor mode, and you may decide that you can reasonably achieve two full sections an evening with time for detailed review. Extrapolate based on your experience study for Step 1 to know what your speed and stamina can stomach.3

Let’s say you want to budget for 1 UW section (~44 questions) a night.

Divide the number of questions in the relevant subject of the Step 2 CK qbank by 44 to determine the number of days it will take you to complete the relevant questions.
Then multiply this number by ~1.5 to determine the amount of time you need to give yourself total including time review the questions you missed.
Then subtract this number of days from the total number of days you have in the rotation. This gives you time remaining you have to dedicate to reading books.
Don’t forget to allow yourself some days off from studying. You might only “budget” on studying four or five days a week, because this will give you a cushion if you get behind, get tired, or get busy.
Pick your resources (I have my recommendations here), and then split your remaining time accordingly. You can divide this time by the relative length of each book (keeping complexity and page density in mind).
Then divide the number of pages of each book by the number of days you plan to spend reading it to get your daily allotment.

An example:

Let’s say you have a six week psychiatry clerkship.

At around 150 questions in the UW set, if you do one section a day, you need around 3 days to get through the UW questions.
Multiply by 1.5, and you should give yourself 5 days to master the UW material.
Round up and that gives you a week, leaving you five weeks to get through Case Files (477 pages) and First Aid Psychiatry (240 pages).
If you give yourself two weeks for Case Files, that’d around 47 pages daily for 10 days of reading (with weekends off). Give yourself another three weeks to read First Aid twice and you’ll read about 30 pages a day. Very doable.

This method will also allow you to determine what number of resources is reasonable/doable for you given your particular restraints. You can figure out if you have time to read a book twice or how to account for your desperate desire to read every book your classmates have mentioned. And while some days you may read more and others less, this method can help you keep on pace. Just make sure that if you start to get behind that you trim the fat: It’s more important to finish a single good resource than to pick away at parts of several, and you always need to give yourself time for questions.

Veterans decide CT lung cancer screening will help them continue to smoke

08.15.15 // Medicine

Linkbait-y title aside, JAMA Internal Medicine has an interesting new too-small too-ungeneralizable study of 35 veterans across multiple VAs. In it, 49% (i.e. 17 patients) admitted that the availability of CT lung cancer screening reduced their motivation to quit. Reportedly, quitting is hard and CT scans are easy.

Of course, hunting for and even finding lung nodules isn’t going to prevent you from dying from cardiovascular disease or COPD, which together are responsible for over half of all smoking-related deaths. Nor will it touch the various other cancers smoking causes, like squamous cell carcinomas of the head and neck, which I see all the time. CT lung cancer screening for high risk individuals is a no-brainer, the data are substantial, but quitting or never-starting needs to be as well!

Radiology’s continuing PR problem

08.13.15 // Medicine, Radiology

A couple of months back, JACR published an article with the self-evident conclusion that patients would prefer to hear the results of their radiology studies from their doctor (the ordering provider) instead of a radiologist. Duh! Who wants to hear they have cancer from a stranger who they may never see you again nor have any role in their future care?

Buried in that revelation is far more interesting and depressing data. While many patients don’t really understand the difference between ophthalmologists & optometrists and psychiatrists & psychologists, a substantial portion of patients essentially have no idea what a radiologist even is. The surveyed patients believed radiologists are techs who actually operate the machines and not physicians, and they comically underestimated the length of training:

While 88% of patients were confident they knew what a radiologist is and what one does, 79% thought they were technologists (misplaced confidence!). Only 56% knew radiologists are physicians, and even fewer, 31%, believed that radiologists perform image-guided procedures. On average, they believed that the speciality requires an average training of 6.8 years after high school. Respondents at community hospitals estimated even less time, 5.3 years, which would make radiologists second year medical students.

So even though I think it’s clear that patients would (and probably should) want to hear their results from the ordering physician, it’s even less surprising that they’d want the news that way if the alternative is to hear the results from a nonphysician who just finished their first year or medical school.

Explanations for the 2015-2016 Official Step 2 CK Practice Questions

08.05.15 // Medicine

Here are the explanations for the updated 2015 (effectively 2015-16) official “USMLE Step 2 CK Sample Test Questions,” which can be found here.

Overall, there are a solid 41 new questions when compared with last year’s set, which I’ve marked with asterisks below. For those who have done last year’s set, a list of the new question numbers is in this footnote2. The explanations for last year’s set can still be found here.

If you’re looking for the answers to the newest June 2016 set, they’re available here. While the order is completely jumbled, there are only two new questions.

Guide to Fourth Year & the Match

07.20.15 // Medicine

You should read my new free book on this subject.

Below are links to the original posts that make up my series on fourth year and the match:

For Step 2 CK/CS:

The more complete collection of medical school and residency related goodness (Step 3! Student loans! etc) can be found here.

Prime Day is here

07.15.15 // Miscellany

Prime Day is here, and while Wal-Mart is copying the idea, I think only Amazon can make a national news story by unilaterally promoting a sale. And while good discounts on some Kindles, other miscellany, and fabled “lightning” deals every 10 minutes may generate some revenue, I have no doubt that the main thrust of the promotion is to drive new Prime memberships. After all, you can still join Prime and experience the fun with a free 30-day trial (or Amazon Student for 6 months free with a .edu address), and Amazon believes that once you go Prime, you never go back.