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ACP begs clinicians to stop ordering so many CTs for PEs

10.05.15 // Medicine, Radiology

In their newest best practice guidelines in the Annals of Internal Medicine, the American College of Physicians practically begs clinicians to stop chasing phantom pulmonary emboli. Nothing super new here, but they do explicitly call out the big offenders:

Best Practice Advice 1: Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.

Best Practice Advice 2: Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria.

Best Practice Advice 3: […] Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.

When I cover the ER, I am routinely impressed in the low diagnostic yield of a PE CT (for actual PE). When I review the chart in protocoling/interpreting these studies, it’s obvious that a significant portion of these patients are being imaged inappropriately, either because there is already a better diagnostic explanation from the initial history/workup, PE is clinically extremely unlikely, or because a positive d-dimer is being chased out of context. Until recently, this profligate waste was a winner to all involved parties.

  • The ordering clinician could feel their anxiety and liability washed away.
  • The patients could feel that they were getting a complete and thorough workup and were relieved when their tests were negative.1Don’t discount patient satisfaction and demand as important components of this trend, especially given the superimposed fear of a litigation in the event of a rare miss.
  • The radiologist and hospital got paid.

Nagging concerns of radiation and systemic waste aside, everybody wins. And over time, the d-dimer turned into a bludgeon against reason, and the ready availability of CT made it psychologically and medicolegally more sensible to image aggressively.

The d-dimer was never intended as a screening test for every single patient with chest pain in the emergency room. A positive dimer in an inappropriately risk-stratified patient should not mandate a follow-up CTA. This is especially the case when the test is originally ordered by a nurse as part of a standing order protocol and not by physician who is actually responsible for the patient’s ultimate care. In my brief two-month stint doing clinical medicine in the ER as an intern, I often absorbed patients from the waiting room who already had an EKG, chest radiograph, and labs including troponins and a dimer. Then we were “forced” to get a PE protocol CT to “work-up” the dimer, even in patients who had obvious other explanations for the test results (e.g. an obvious pneumonia on the radiograph). Not everyone practices this way, but it’s easier to practice thoroughly (defensively) in most of the same ways it’s easier to give antibiotics for viral illnesses.

There is one important and misleading exception to premise of the ACP report. And that’s the notion that CTs ordered in the context of “suspected” PE are exclusively obtained to evaluate for PE (i.e. PE CTAs don’t have diagnostic value outside of evaluating for PE). Some of these patients have clinical symptoms without radiographic findings, and the ordering providers are obtaining imaging to further evaluate the lung parenchyma for signs of occult infection (as well a rib fractures, anything else). CT is a troubleshooting modality in cases where the clinical picture is cloudy. So the angiographic component of the CTA may be partially a “why-not” inclusion to exclude a potentially life threatening PE in a patient that was destined for imaging anyway.

That said, I still feel like I almost diagnose more PE incidentally on abdominal imaging than I do on dedicated PE studies.

Private Practice vs. Academic Radiology

09.21.15 // Medicine, Radiology

Disclaimer: I was a resident who had neither started nor completed the process of getting a job when I wrote this. I was however asked to weigh in on pursuing a radiology job in academics vs. private practice, particularly with regards to how one’s future desires might shape an applicant’s choice of residency program. Overall, I still agree with myself.

There are several considerations to take into account when deciding the merits of a career in private practice versus academics. These are of course broad generalizations, and exceptions are not uncommon.

Variety

How much do you like variety versus how much you like the idea of being a hyperspecialized subspecialty radiologist?

Most academic radiologists work exclusively within the realm of their fellowship training. That means that even a single extra year of neuroradiology training will often lead to an academic career in which you essentially exclusively read neuroimaging (with maybe some general call thrown in at some institutions). As a resident, you will likely notice that some of your staff seem to know less about the “extraneous” anatomy and pathology than you do. That’s because at this point, years after they’ve practiced general radiology, that’s often true. It’s not uncommon for body staff to defer to the resident’s interpretation of spine findings on a belly CT or vice versa. Procedures you do, if any, will typically be those related to your subfield. Case complexity is higher overall and intra-system follow-up is more common. As such, the clinical work may be more satisfying as well as more narrow.

Private practice radiology is focused on interpreting studies. In general, subspecialty trained radiologists will still often perform as generalists even if they have a relative focus on their subfield. Even interventional radiologists, who some might assume would be fully clinically oriented, often only spend, say, 40-60% of their time doing IR. It’s become common for the subspecialist to be responsible for the highest level cases, but it’s still generally much less common to have an academic style laser-focused job in PP compared with academics. Case in point: a recent study showed that while almost 50% of current IR job postings were 100% IR, only 15% of PP jobs currently offered 100% IR.

So the go-to guy for pediatrics or musculoskeletal imaging still isn’t exclusively reading those studies. In small to mid-size groups, non-IR radiologists routinely perform many of the procedures you think of when you think of IR (biopsies, drainages, etc). A future exception: over time as more corporate mega-groups take over hospital contracts, the clinical volume can be largely pooled, allowing even the PP subspecialist to focus more on the subfield of their expertise. Given the continued push for “quality” and “value,” particularly as referrers become more comfortable with imaging themselves, this trend will also increase.

Conversely, an academician may pair their narrow clinical focus with a greater amount of nonclinical work. While the private practice radiologist may read a larger variety of studies, the academic radiologist is more likely to be involved in research, administration, or teaching. Both research-track and clinical-track jobs exist (though tenure as such is uncommon). In the end, you have to decide if radiology/study variety or career variety is more important. Again, at the risk of beating a dead horse, these are generalizations. There are people in academics who exist only to “kill the list,” and there are people out in practice who are involved in running practice groups, working with hospital administration, and spending a great deal of time during non-clinical work.

Money, Time, & The Future

Money is slowly becoming less of a factor for many than it used to be. During the golden age, you worked twice as hard in private practice and made three times more. Now maybe you’re working 50% harder for 20% more. Before reimbursement cuts, it wasn’t uncommon for people to make a lot of cash in PP and then “retire” into a slower-paced academic job (obviously this was also before the job market contraction). Those days are long gone and are never coming back. Groups are merging, and these consolidated megagroups are then snatching up the hospital contracts in large metro areas. Partnership track positions are no longer universal, and even when present, may not always be as meaningful, particularly in private equity-owned groups where it really just signifies a pay increase or smaller groups that don’t have long-term imaging contracts or don’t own imaging centers (and thus have no assets to bargain with except limited intellectual manpower). Hospitals are increasingly directly employing radiologists, and an employee is never paid what they’re worth (otherwise how does the employer profit from them!). This is to say that while you certainly make more in PP, that money doesn’t come for free, and the windfall isn’t as egregious as it used to be. It’s frequently described as a grind.

There are also some unsavory practices that churn and burn new grads out of fellowship, often for “partner-track” jobs where the associate is let go prior to making partner. Likewise, folks in the workup typically make out poorly in a group buy-out situation. This is a result of the desire to maintain or increase revenue amidst falling reimbursement, particularly for established partners who are used to bringing home a certain income. A private equity practice, for example, makes its money when old well-paid partners retire and are replaced by a younger less well-paid generation. As older radiologists retire, it’s possible the nature of these groups may change. That said, many young physicians would rather sacrifice some income for lifestyle. People talk. Make sure you know the nature of the group you sign on with.

Conversely, academics definitely isn’t as easy as it used to be. Changing reimbursement combined with ever-increasing clinical volume has resulted in a push for ever greater RVU generation, even in academics. This has meant an increasingly frenetic pace, particularly for those who are not producing academically enough to get protected time. While pay is generally lower, academic institutions often have great benefits. So salary itself isn’t the only consideration when it comes to true compensation.

So both groups are working harder than they used to. In PP, the grind is generally bigger and you take more call in return for lots more vacation and more money. How much more money depends on a lot on the health of the group, location, what patient population they service, assets they hold, etc. PP radiology was well suited to the era of fee-for-service medicine. In a future of more capitated and “value”-based healthcare, there will be more contraction and consolidation, likely resulting in further erosion of the historical differences over time.

Integrated health systems like Kaiser directly employing radiologists make a lot of sense in the era of bundled payments. So while many people weigh their options between private practice or being employed by an academic institution, a third option of being employed by a non-academic hospital or health network may become increasingly common. Such a job is likely similar to a clinical-track academic job for a bit more pay (i.e. not a bad thing for physicians).

Previously thought undesirable, some VA jobs have emerged as highly desirable jobs with reasonably high pay, an occasional light academic component, and preservation of lifestyle.

Service

While the referring physician is important to all referral-based specialties, the ordering provider is much much more the client for a radiologist than the patient. Service in private practice radiology means making those providers happy. In many cases, that will include non-physicians like NPs and PA as well as chiropractors and other folks. Yes, you’ll spend a lot of time on the phone being nice to people who may be ordering asinine studies and pretending you want to talk to them. Part of the gig.

Academics varies more, but generally, the referrers don’t choose you; you’re just in the system. So the dynamics can be different. At my institution, we have a system that allows us to send important results by a recorded message via pager. Saves us a ton of time. Some orderings docs hate it; we love it. That’s a harder sell on the private side.

Security

In general, academic jobs are much more secure. In large competitive metro areas, even group contracts aren’t necessarily secure in the long run, which adds an additional layer of insecurity.

Your residency choice

So what does this mean for your choice of residency? Not very much. Any large academic center, which most people aspire to, will offer you the training you need for either job. You don’t need to know right now. And don’t read the above and think PP has a grim future where only suffering exists (because that’s not true). If people ask you, you can either say you’re not sure, want to get the best training possible, or that you’re most interested in academics (after all, who’s interviewing you?) There are two mild caveats:

1. Volume & Autonomy

Private practice jobs are speed and competency-based. Which means a new hire is prized for being able to work through a list of unread studies quickly without making mistakes. As such, the residencies that best “prepare” trainees for private practice are ones that have good clinical volume (most do) and independent call (a challenging luxury that’s rapidly fading). Many programs have done away with independent call due to demands from EM departments for rapid final reads, no patient-care altering addendums, etc. While on the face of it this is a good thing for patient care, it ultimately displaces responsibility and training. Every radiology resident will eventually have to be able to “make a call” on tough cases. Doing it in the context of independent call means that someone with more experience will eventually back you up and provide quality assurance. This allows you to grow in skill and confidence in a relatively safe environment. If you don’t have this, the end result is that you are never meaningfully responsible for patient care until you’re a fellow or an attending. As an attending, you don’t have the same backup luxury. I’m not convinced this is a good thing: it makes young attendings less trustworthy and often overly sensitive/nonspecific.

There are programs with minimal call.2In many of these, the fellows take all the general call, which sucks for the fellows! These are easy residencies (and at some really big names) but probably not the best clinical training. You can be an exceptionally smart person with great book knowledge and that will take you part of the way—but you can’t teach independence, and you can’t substitute volume. There are also programs that treat the overnight ER shift like a normal workday with attending readouts—which means you never have to make a real decision for yourself. Successfully taking independent call and covering a busy emergency department/hospital is both educational but also signifies to groups that you won’t be useless when you’re hired. Most groups know the kinds of residents a program typically produces, at least on the local/regional level.

So essentially, if you’re interested in private practice (and most residents will need to at least consider entering practice), you want to be at a program that provides the best clinical training. That means good volume (large institution with large geographic radius to draw patients from), good faculty (to teach you), and call (preferably independent). Personally, I think these are important criteria for any job in radiology, but certainly for landing a decent PP job in a crowded market.

2. Location

A large percentage of residents stay in the same metro area for their first job after completing residency. This is particularly true for private practice, where residents from your program are more of a known variable and there are local contacts who can vouch for you. Academic institutions obviously don’t hire all of their fellows, doubly so at many of the big fellowship factory programs. So while a nice pedigree may help you get a job in academia (potentially at a remote institution), you’re statistically more likely to find a private practice job locally (unless the local market is completely saturated). The more awesome and desirable the place you train, the harder it will be to find a job there. Conventional wisdom is that if you want to practice in a certain municipality, you’re well served by going to the best locoregional academic program. If you know you want to be in academics and want a big name job, then feel free to chase pedigree to your particular desires (just know that the actual training is unlikely to be better; that’s not what the name is for; the name is to open doors with people who have pedigree biases. And maybe for you to do more research). Obviously, fellowship is another chance to play this part of the game.

 

Book Review: Medical School and the Residency Match

09.17.15 // Medicine, Reviews

There’s a new residency guidebook on the scene, Medical School and the Residency Match, and the reviews on Amazon are great. So I’m reviewing it.

This time, instead of being written by a residency consultant (like this or this), the book is written by a group of post-match medical students. As such, it’s a refreshingly honest take and not full of the usual spiels. On one hand, books written by program directors (this is probably the best) may be more authoritative, but they are sometimes over the top and not relatable or easily actionable. For one, what people say they want and what they actually want aren’t necessarily the same thing. Secondly, there isn’t a single path to success. Sometimes it’s nice to be reminded that people like you have been doing just fine, thank you.Read More →

Switching from IBR to PAYE

09.16.15 // Finance

Update 2/2016: The DOE newest repayment plan, REPAYE is now available. For many if not most residents, REPAYE is probably a better choice than PAYE. I wrote about the pros and cons of REPAYE at length in this post. While the benefits and numbers are a bit different, the process of changing plans is the same.

For eligible borrowers, PAYE is just plain better than IBR.2By IBR, I mean the IBR that applies to nearly all borrowers that are not current MS1s. IBR for new borrowers (without any loans predating July 1, 2014) is very very similar to PAYE.

  • The mandatory monthly payment is capped at 10% of discretionary income instead of 15%
  • Loans are forgiven after 20 years instead of 25 (not relevant to most practicing physicians)
  • Capitalized interest is limited to 10% of the original loan amount (that’s neat).
  • Both are qualifying payments towards the 120 needed to qualify for PSLF
  • Like IBR, the government pays interest on subsidized loans for 3 years (at this point only relevant for those with subsidized undergraduate loans, as grad subsidies are gone)
  • Loans forgiven after the 20 years are taxed as income (just like IBR). Loans forgiven as part of PSLF are not considered taxable.

The financial requirement for PAYE is the same as IBR: you must demonstrate a “partial financial hardship” (i.e. the percentage/calculated monthly amount is less than the 10-year standard repayment for your loan balance), so the only difference is if your loans are eligible. You’re eligible for PAYE if you have no loans before October 1, 2007 and got at least one loan disbursement on or after October 1, 2011.

The oft-reported “downside” of income-driven repayment plans is that you will “pay more interest” over the longer term length. This is a bit of a red herring, as you are always free to send more money over to pay off your loan faster. IBR/PAYE plans allow you the flexibility to not need to make big payments; they don’t prevent you from taking prudent measures to pay down your debt. And if you’re planning on gunning for PSLF, then you won’t actually be making payments for that longer term length anyway!2It’s also not as though you could probably afford the standard repayment as a resident….

  • If you are recent graduate, you should select PAYE as your payment plan and call it a day.
  • If you have loans from October 2007 or older, you aren’t eligible for PAYE and need to stick with IBR.
  • If you have no interest in PSLF (cynicism, short residency, smallish loans, private practice bound, etc), then you should probably refinance as soon as possible. The main substantial benefit of keeping federal loans is the possibility of loan forgiveness. Outside of that, private refinancing will save you money, and two companies now allow you to refinance as a resident.

If you’ve been out of school for a few years, you can potentially switch from IBR to PAYE. You apply to switch in the same process you use to update your loan servicer of your annual income. You go to studentloans.gov, pull in last year’s taxes, update family size, etc. Changing plans is just another choice instead of pick just “recalculating” your payments.

However, to switch from IBR to PAYE, this annoying thing happens:

If you leave this plan, you will be placed on the Standard Repayment Plan. If you want to change to a different repayment plan, you must first make at least one payment under the Standard Repayment Plan, or one payment under a reduced payment forbearance (you may request a reduced-payment forbearance if you can’t afford the Standard Repayment Plan payment).

This was presumably done to stop people from immediately jumping ship from IBR to PAYE. In practice, the “reduced-payment” requirement is $5. So you don’t need to shell over a few thousand to cover a month’s standard repayment. However, by switching out of IBR for the month, all of your accrued interest capitalizes. If you’ve been out for a few years making the typical negative amortizing IBR payments during residency, you may have a sizable chunk of accumulated interest sitting around.

A simple example:

  • $200k loan @ 6.8% accrues $13.6k per year
  • Assuming a $400/month IBR payment, the annual unpaid interest is $8800
  • After 2 years of residency, that’s $17.6k accrued interest. After 3 years it’s $26.4k.
  • Switching from IBR to PAYE after two or three years results in a new loan balance of $217.6k and $226.4k respectively. From that point on, the annual interest then increases to $14.7k and $15.4k.

So in this example, your monthly payment is reduced from $400 in IBR to around $266 under PAYE, which is great from a cashflow perspective. But now your loans are growing faster than ever (both from the capitalized interest on top of the fact you are paying down less of it).

By cutting those payments down from 15% to 10%, you’ll be taking an even bigger hit in terms of your loan growth. Keep in mind however that the interest that accrued while you were in school capitalized when you graduated, so you don’t have a ton to worry about if you’re fresh out of school or relatively close.

Which means: the reason to switch from IBR to PAYE is really best only to double down for PSLF. In order to maximize the gains of public service loan forgiveness, you want to spend the least amount possible during your 120 qualifying payments. The spiraling balance is then irrelevant because it’s going to be forgiven.

Over the long term, you lose some of that low-payment benefit for two reasons:

First, your “reduced” payment doesn’t count toward the 120 you need for PSLF. So you’ll have to make another as an attending, which could be as high as the 10-year standard repayment amount. In the example above, that’d be somewhere around $2-3k.3As a resident with the salary described above, that washes away over a year of the difference, but the more you earn, then the more you’ll save (until you cap at the standard repayment). Alternatively, you could pay the full standard repayment when you switch, but that’s guaranteed to be the 10-year amount as opposed to an income-driven amount, which may be significantly lower depending on your future salary.

Second, you’ll also lose a bit if your attending salary becomes high enough that you’re maxing out at the 10-year standard repayment and thus are paying more to handle a portion of that extra capitalized interest. In the example above, the extra $1000 will cost you around $13 a month; far less than you saved making the switch.

On the flip side, because PAYE prevents further interest capitalization due to its 10% cap, if you do lose your partial financial hardship due to your high income, at that point an IBR will capitalize a greater amount of accrued interest and then start costing more as well.

Well that’s boring. Technical details aside, the conclusion goes something like this:

  • If you want to go for PSLF, do PAYE if you can, as soon as you can
  • While your loan grows faster if you have to switch from IBR due to capitalized interest, it’s doesn’t matter if you’re doing PSLF. Even with an extra payment at the end, you’ll still just pay less money and get more forgiven.
  • Switching from IBR to PAYE just to have lower payments will definitely result in your paying a lot more in interest over the course of your loan if it’s not forgiven and you stick it out for the complete term length (which you probably shouldn’t).
  • If you don’t want to try to get your loans forgiven, then you should just refinance them at a lower rate (like yesterday).

Submit your ERAS!

09.15.15 // Medicine

If you’re an MS4, submit your ERAS today. Be the early bird.

And, when you’re done with that, you might prepare for the rest of the season with the Guide to Fourth Year.

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.4i.e. If you’re not saving enough to max out your 401(k) or 403(b) to start investing in a taxable account, then tax loss harvesting is thus irrelevant to your short term plans.

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.2I love Kale as much as the next guy, but eating it, even in juice form, does not actually result in spontaneous weight loss. 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.

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.

questQuest 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.3If you can’t remember, then pay attention during your first clerkship!

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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).
  6. 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.

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