Ben White

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.1

  • 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!2.

  • 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.3 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).

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.4

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.2 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.3

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.

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.

 

new_attri

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.