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.
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.1 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.2 And the ability to maintain a change is much more important than the power of the change itself.
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.
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.
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.
Let’s say you have a six week psychiatry clerkship.
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.
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!
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.
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.
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, 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.
Last updated April 2020.
Medical school is expensive and getting more so every year. Meanwhile, federal student loans are still at above market rates (and many private ones are predatory). Combine the two and a new doctor will borrow more and then pay more for the privilege than at any other time in history.
Over the past two years, historically low interest rates and a rebounding economy mean that private banks have re-entered the student loan business, particularly on the refinancing side.
As a resident, your options are essentially limited to refinancing with DRB (now Laurel Road), LinkCapital, Splash Financial, and SoFi. Starting in March of 2015, DRB became the first company to offer a resident refinancing program that is unique, practical, and affordable for residents ($100 a month). SoFi’s new offering is similar (only up to 4 years). LinkCapital’s resident program requires a little less at $75 but isn’t available to interns. Splash Financial originally only required a $1 token monthly payment during training and was thus a true forbearance alternative, but they’re now doing $100/mo payments as well.
I wrote about refinancing as a resident at length in this post.
Otherwise, here is the complete picture for student loan refinancing.2
There are only a handful of options and the initial applications are short (really short, ~5 minutes or less). Rate ranges are typically concordant and are theoretically as low as the 2%-range variable across lenders. All quote you low rates assuming you’ll auto-debit from a checking/savings account. Initial applications will result in a soft pull on credit (does not affect your credit score) and give you a preliminary rate, so if you have good cash flow and can otherwise afford your loans (i.e. you’re an attending), you’ll do yourself no harm by simply applying for refinancing from each company and seeing which one is willing to refinance you at the best rate:
Laurel Road (formerly DRB) is the rebranded refinancing arm of the Connecticut-based Darien Rowayton Bank and was one the first big players to return to the student loan game along with SoFi. They were the first company to offer a program specifically geared toward residents (where payments during residency are $100/month regardless of the total loan amount or your income). Laurel Road refinances 100% of private and federal loans with a minimum of $5000 and no maximum, no origination fees, offer fixed and variable interest rates, and flexible loan term lengths. Refinancing after applying through the referral link above would net you $300 dollars.
LinkCapital joined DRB as only the second company to actively court residents for refinancing. You have to wait until you finish intern year to apply, and unsurprisingly, the resident rate won’t be as a good as the attending rate (but still likely better than the federal one). The token monthly payment is $75 instead of DRB’s $100/month, so it’s nominally more flexible. Similarly, accrued interest won’t capitalize until the end of the residency/fellowship period. They also have a unique model where the resident rate automatically goes down 1.4-2% when you reach attendinghood, so refinancing as a resident is partially just an enticement to lock down a guaranteed good rate in the future regardless if interest rates go up in the interim. Trainees in their final year with a signed employment contract automatically qualify for the attending rate as well. The minimum amount is $15k with a maximum loan of $450k with the usual standard offerings: fixed & variable, multiple term lengths (7, 10, 15 and 20-year), cosigners if needed, etc. As of August 2018, Link is no longer offering referral bonuses.
SoFi (which stands for “Social Finance”) was the first company to make a name for itself in the current game of loan refinancing and by far the most likely to send you pre-qualification letters in the mail. The “social” refers to the fact the company originally funded loans at select institutions using money invested by school alumni. Since then the company has grown and begun using conventional financing, but they still claim that some community money makes it into every loan.
SoFi finally began offering a resident refinance program in October 2017, which involves reduced $100/month payments during training (only up to 4 years) with eligibility after matching. They will also refinance senior residents with an employment contract in hand while also offering a one-year deferment on payments. So once you’ve signed on for that private practice job, you won’t have to wait until you’re actually making the money to try to refinance, but you also won’t be on the hook for the larger payments until you can really afford them, which isn’t a bad middle ground.
Minimum loan amount of $5k, variable and fixed rates, and must have graduated from an “eligible” school (depending on where you went, there is rarely an origination fee, which is otherwise not typical among these options). $100 welcome bonus.
LendKey (formerly known as cuStudentLoans, where “cu” stood for credit union) is the only lender to offer interest-only payments. You can do the math with your own loans to see where that leaves you, but if you didn’t borrow too much, it could be even less than IDR (making it potentially affordable as a resident). While one should theoretically always put extra money toward paying down loans, having an interest-only option gives you some month to month flexibility, particularly if you’re transitioning from resident-money to attending-money and want to refinance—but don’t want to start paying a ton immediately. No origination fees, variable and fixed options available. The maximum loan amount has been increased to $300k, which makes LendKey viable for most borrowers. They quoted to me that an annual income of around $75k would be required to refinance their old maximum of $175k. If you apply with a cosigner, LendKey advertises their straightforward co-signer release program, which will help your parents get off the hook after 12 months of payments. And you get $300 for using the above link to refinance.
CommonBond is unique in that they offer a “hybrid” 10-year rate plan which is fixed for the first 5 years and then variable for the last 5 (essentially analogous to a 5-year ARM [adjustable-rate-mortgage]). While hybrid rate range doesn’t look particularly impressive, the hybrid rate will fall somewhere between the variable and fixed rates and helps mitigate the anxiety of committing to a full variable rate (particularly if one hopes to be aggressive in paying down the loan and not keep it long into the variable rate period). No origination fees, but there is an accepted/eligible school list.
Trainees in their final year can receive are eligible for an attending rate with a signed job contract.
Another few unique facets: they also allow you to refinance and take on your parents’ Parent PLUS loans to get your parents off the hook. They also offer academic deferment if you decide to go back to school for that MBA. And lastly, they promise to fund the education of a child in need for every loan they refinance. They also agreed to reimburse readers with $300 for using the above link.
Earnest has some interesting unique features compared with the other players. The main one is totally arbitrary term limits (up to 20 years). You want 10.5 years? You got it! What this means is that you can choose a term length and pay that monthly amount, or you can decide on an exact monthly amount that works for you (and then pay that over the resultant calculated term). In practice, this also makes Earnest a potential option for refinancing during residency. For example, if you refinanced a $100k loan at 4% for 20 years, your monthly payment would be $606. Smaller loans make this option more feasible obviously, but remember you can always pay down faster than your term-length, so really the goal here is to get the shortest term that you can afford/get approved for now and pay down aggressively as soon as possible.
Other interesting features are biweekly payments (to help cut down on accrued interest) and the ability to quickly refinance/change between fixed and variable rates without charge or penalty. If you choose the variable and get skittish, you can lock down a reasonable fixed before it’s too late. Likewise, if your income increases such that it would be easier to pay down more if needed, you could switch to a variable rate and take on that risk. Additionally, if you need to lower your payments because of tough times, they offer rapid refinancing at a longer term to make it happen (of course you’ll also pay more and probably have a worse rate, but hey). Loans start at $5,000, no origination fees. Most but not all states are eligible.
Referral bonus is $300.
Splash Financial is one of the newest players on the block and one of the handful of companies refinancing residents. They used to offer the lowest required monthly payment during training of any company: $1. Now it’s the more common $100/month. The maximum training period is 7 years. Rates vary by overall term length (including the training period), so how good a deal you get as a resident depends on how long your program is and how aggressive you’re willing to be when you finish training. Of course, you could always try to refinance again if you find that speed too much to bear. Splash originally tried to enter the market with an origination fee, but they’ve since seen the light and nixed it, so—like the other companies—Splash is a no-cost refinance. The referral bonus is $300 for loans above $30k. Unlike most lenders, please note that sometimes there is no forgiveness for death or disability (it depends on the underlying funding source for your particular offer), so you need to read the fine print before you sign.
ELFI, which stands for “education loan finance,” is a product from SouthEast Bank. Terms from 5-20 years, $15k minimum, no set maximum. Usual no fees. No resident program, but they do offer (but do not guarantee) a deferment to match your grace period if you have one. There is also an approved school list. $100 welcome bonus.
Citizens Bank offers new student loans in addition to loan refinancing. The maximum loan amount is now 300k (used to be $170k). Product is otherwise typical: No origination fees. Fixed or variable. Co-signer release available. Nothing special/unique, and I’ve also never seen them offer a welcome bonus to anyone.
Credible isn’t an actual lender, it’s a student loan refinance marketplace. When you apply through Credible, you apply to up to 7 lenders simultaneously, which would be a nice time savings and an easy head to head comparison. That said, several big players aren’t on their list, so you’d have to (and should) apply to those separately. Most residents needn’t bother, as DRB and LinkCapital aren’t included (though College Ave, one of their lenders, does offer 2 years of interest-only payments; also requires $75k household income). Neither are SoFi and LendKey, for example. Nonetheless, it’s undoubtedly still the fastest way to check out multiple companies at once. $300 bonus for using the link.
Purefy is another middleman and currently links up borrowers to PenFed and Citizens Bank. Their rate calculations use your credit score and degree more than current income. In my testing, the CB rate was a half point lower through Purefy than through Citizens Bank directly, which is a huge difference. Go figure. Given that the CB website also leaves something to be desired, it’s definitely worth taking the two minutes to add Purefy to the initial rate checks, as they were able to offer one of the lowest rates around.
FRB is a private bank that entered the refinance game recently to lure high-income earners toward their banking business. In order to do that, their rates have thus far been lower than the competition. The FRB student loan is really just a gigantic personal loan, and as such, can be a little more flexible in its amount and what it pays off for you. It also means you may not be able to refinance again. Minimum of $60,000 and maximum of $300,000.
Another cool part:
First Republic will rebate the interest that has been paid against the loan, up to 2.00% of the original loan balance if the loan is paid in full within 48 months.
The downside? You must live “near” one of their physical branches to qualify: San Francisco, Palo Alto, Los Angeles, Santa Barbara, Newport Beach, San Diego, Portland (Oregon), Boston, Palm Beach (Florida), Greenwich or New York City. How near is near? Put your zip code into their website and find out if you qualify.
It’s also a personal loan and not a student loan, which means that it’s not discharged on death or permanent disability etc. That might make you very uncomfortable, so only pursue FRB if you’ve already purchased good disability and term life insurance.
Overall, the interest rate ranges offered by these companies are generally comparable. Typically when one lowers their rates, the others have followed quickly followed suit.2 The increasing competition in this space has been excellent for consumers, because the rates offered even a year ago weren’t that much lower than the federal ones. So, if you have several potential options based on your loan burden and your income, you might as well apply to all and see who gives you the best deal.3 Preliminary applications generally take 2-5 minutes, so there isn’t a big time investment in doing your due diligence. There are never any fees or costs to refinancing with any of these players, so you can refinance, keep an eye on the rates, and refinance again if they go down.
Bonuses: As mentioned above, I was able to convince several companies to provide a monetary incentive for you, dear reader, should you choose to refinance with them (in addition to a more standard referral bounty to me). I’m pretty pleased about that, as this allows you to effortlessly support me/this site as well as yourself.