When Breath Becomes Air by Paul Kalanithi - A Scrub Notes Book Review

"When Breath Becomes Air" is a memoir written by neurosurgeon Paul Kalanithi. The book is a poignant look at the human spirit in both the pursuit of excellence as well as in coming to terms with its own impermanence.

Kalanithi was a Stanford neurosurgery resident when he found himself becoming fatigued, with worsening pain and decreasing weight. A routine chest x-ray discovered multiple lung masses, which were soon proven to be metastatic lung cancer. The book was borne of Kalanithi's other passion, literature, as well as his unfortunately unique perspective as both a healer and now a patient at a time when he was poised to be at the peak of his talents.

The first half of the book details Kalanithi's upbringing and path into medicine. His first love was literature, which he pursued all the way to a master's degree. However, upon further reflection, he felt a desire to pursue medicine after grappling with the question of the intersection of "biology, morality, literature, and philosophy." Since he had initially pursued literature, Kalanithi took two more years to complete the pre-med requirements and then apply to medical school. Accepted at Stanford, he was a fast rising star in the neurosurgery world, despite grueling 100 hour weeks year after year.

The diagnosis, coming near the end of his training, shatters Paul's identity. After striving for close to a decade to become an attending neurosurgeon, his diagnosis is his undoing. He rapidly transitions from physician to patient, and has to learn to let go, to trust in others to have his best interests at heart. The book shows how he meditates that cancer in particular is pernicious in that it makes one mortality both immediate and yet still remote: no longer a hypothetical, but not an immediate reality. Everyone has an answer to what one would do with their last day, but what about one's last decade?

Kalanithi then details the long road back to completing his training, the successes and failures of his treatment, and how he learned to live and ultimately succumb to his fate on his own terms. He died in 2015, leaving behind his wife Lucy and their newborn daughter.

For me, the last part of the book was the most moving, an epilogue written by Lucy about Paul's last days. She charts the uncertainty of his final hours and how he was resilient even while facing the unknown. His final wish was that they see the book to fruition, in which they clearly succeeded.

The book reads like what one would expect of a memoir of a first-time author, but Kalanithi's first rate intellect shines throughout. Even though he never uses the label, it is clear that Kalanithi was a humanist at heart. He does touch upon his wavering relationship with religion. For a reader who questions both their path in healthcare or wants a glimpse of how even the best laid paths can abound with uncertainty, "When Breath Becomes Air" will not disappoint.

Do Medical School Rankings Matter?

This is a guest post / repost from Smart Money, MD on the topic of whether going to a highly-ranked medical school matters:

Some of us are overachievers. Some of us are overachieving doctors. What if you’re in-between? Let’s say that you’re an overachiever, and you want to become a doctor.

Should you go all the way up top and get that medical degree from a top private institution? Does it even matter? With tuition costs skyrocketing, you can easily spend $60,000 annually on tuition alone for each year in medical school. Add another $10-$15k in room and board, and you will be about a quarter million in the hole by the time you get out. In contrast, medical school tuition in 2016 for UT Houston for in-state resident is only about $20,000 annually. That’s a big difference.

These are considerations that are rarely taught or even discussed. If you are planning to go to medical school, it does pay to consider the consequences thoroughly before you proceed.

Does a prestigious degree help get you a better job?

It depends. It depends on where you plan to work. In clinical medicine, you can either work at an academic institution or in the private sector. Many job situations in the academic world require teaching, research, or involvement in administration. If I were a departmental chair looking to bring on a clinician-researcher, I’d want someone who not only can practice medicine well, but also has strong writing skills, coherent presentation abilities, and innovative characteristics. If two candidates had similar track records with similar recommendations and charisma, I might lean towards going for the gal with the Ivy-league degree, especially if I am running an Ivy-League department.

If I needed a doctor in the private sector, the institution that granted the degree is unlikely going to matter much at all. Yale? Great. Wayne State? That’s okay with me. You just need to be ethical, hard-working, and reasonable to deal with. For all other qualities, the verification process in each state and governing medical board can do the rest.

DO DOCTORS FROM PRESTIGIOUS INSTITUTIONS MAKE MORE MONEY?

It depends again. To understand this question, you should understand how doctors make money to see whether an Ivy-League degree will translate to higher dollars. This is also contingent upon how you are using your medical degree, whether you are practicing medicine, performing administrative work, or consulting. Remember, you don’t have to be a doctor to get rich. Or you shouldn’t become a doctor if your main goal is to become rich.

If we are considering doctor worth from revenue alone obtained through clinical practice, insurance companies make no distinction between where you obtained your degree. U.S. grad, international grad, it doesn’t matter. As long as you pass your boards (sometimes you don’t even have to do that!), you’re golden. From clinical practice alone, you’re not going to make more money having gone to a top college or medical school. Period.

Now having that special degree CAN get you more business, depending on which part of the country you practice medicine. This is particularly true (and sometimes annoyingly so) in the New England area. Patients in New Caanan Connecticut do (in general) care where you obtained your degree. They may or may not even be highly educated, but the high concentration of Ivies in that region predisposes this behavior. Unless you have significant street cred and have been working in the area for a long time, your patient may doctor shop your degree.

OKAY, I SANK $200,000+ INTO AN IVY-LEAGUE MEDICAL DEGREE, WHAT AM I GOING TO GET IN RETURN? 

Many of us, under the guidance of family, friends, or schooling, end up enrolling in well-known [read: expensive] private universities and medical schools.

DESPITE the equivocal conclusion by Smart Money MD.

Don’t fret. You’re not totally screwed. If you have a good inheritance coming your way or an alternative means to fund the process, you’re actually in great shape.

If the above doesn’t apply to you, don’t fret either!

STEP 1. PAT YOURSELF ON THE BACK.

Congratulations. It is not easy getting in. It is SIGNIFICANTLY more difficult to get in medical
school than law school, business school, or college. Kudos to you.

This is a fact. By numbers alone. There are simply fewer number of available positions in medical school. The Class of 2018 Stanford Graduate School of Business has 417 new students. Last I checked, the Stanford medical school had fewer than 90 students per class. I think the acceptance rate in the medical school was about 2-3%, while the business school acceptance rate was 6%. If you compare these numbers to that of an average public medical school and public business school, you’ll see that the class sizes will be larger and the acceptance rate will also be higher.

STEP 2. YOU’VE GOT A LIFETIME OF PRESTIGE ATTRIBUTED TO YOUR NAME.

Yup, your mother can brag about her daughter at every holiday party. Your distant relatives will direct their children to you for advice. Your alma mater will also hit you up for donations every single year. You can volunteer with your local alumni group and have “exclusive parties”.
You have a lifetime of memories and connections to potentially successful friends and colleagues.
This is not a bad situation to be in.

STEP 3. CLEAR YOUR MIND AND GET TO WORK.

Get yourself back into the real world. Don’t let anything else cloud your judgment. You’re probably not even that smart. Your coworker at the hospital who came from Portugal probably is one the smartest gals in her country. She memorized Harrison’s twice to pass her country’s exams. Oh yea, she also repeated residency in the U.S. and passed all of her U.S. board exams…in English.
That’s right, her native tongue is Portuguese, and she learned Spanish as her secondary language. English was her third language.

Get yourself out of debt if you funded your education through loan sharks. If I dug myself out of debt, so can you. Save up your money. Figure out how much you are worth.

Figure out what makes you happy. Then work to get there. Easy peasy.


Smart Money MD, an ophthalmologist run financial website, focuses on proper management of medical trainee debt, lifestyle, time, and getting the most out of your hard-earned degree.


I can only second what Smart Money said above. In the grand scheme of things, getting into medical school is a much bigger deal than which medical school you get into. For most residency programs, what you get on USMLE Step 1 will carry much greater weight than your medical school. However, all else being equal, more prestigious medical schools will have more famous faculty, who will be better able to plug you into opportunities to advance your career as well as make phone calls on your behalf when it comes time for Match Day or even beyond with jobs. For more competitive training programs, specialties, or jobs, this may make a huge difference. To decide, ask yourself what type of training and career you want, then find a medical school training program that will you make you happy. Good luck!

Age-Appropriate Screening Guidelines

As you encounter patients in a primary care setting, you play an important role in preventative medicine. Specifically, you must ensure that your patients are receiving appropriate screening given their age, gender, and risk factors. Especially after the implementation of the Affordable Care Act, preventive services have taken on an even greater importance.

 The main body that puts together guidelines in the United States is the U.S. Preventive Services Task Force, or USPSTF:

The U.S. Preventive Services Task Force is an independent panel of experts in primary care and prevention who systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. These reviews are published as U.S. Preventive Services Task Force recommendations on the Task Force Web site and/or in a peer-reviewed journal.

Often, the USPSTF guidelines are complemented by recommendations by specialty societies, such as the American Cancer Society or the American College Radiology. Be careful though: sometimes the guidelines may be contradictory, such as what age to start breast cancer screening with mammography. For a comprehensive list, visit the USPSTF website or download their app.

The selected guidelines below cover some of the most common recommendations:

Women

Age	Recommendation	Grade
Puberty - 24	Chlamydia/Gonorrhea if sexually active	B
21 - 65	Pap smear every 3 years (if combined with HPV testing, can be every 5 years after age 30)	A
40 - 49	Individual decision for screening mammogram based on relative benefits vs risks	C
50 - 74	Biennial screening mammography	B
50 - 75	1) Annual screening with fecal immunochemical test (FIT) 2) screening every 10 years with flexible sigmoidoscopy and annual screening with FIT 3) screening every 10 years with colonoscopy 4) screening every 5 years with CT colonography.	A
55 - 80	Low dose lung CT if one has a 30 pack-year smoking history, currently smokes or quit within the last 15 years.	B

Men

Age	Recommendation	Grade
50 - 75	1) Annual screening with fecal immunochemical test (FIT) 2) screening every 10 years with flexible sigmoidoscopy and annual screening with FIT 3) screening every 10 years with colonoscopy 4) screening every 5 years with CT colonography.	A
55 - 80	Low dose lung CT if one has a 30 pack-year smoking history, currently smokes or quit within the last 15 years.	B

Several interesting or unexpected exceptions to screening guidelines exist. For all, there is no specific recommended screening for skin cancer for the general population. That being said, one should still protect themselves from excessive skin exposure and follow up on any unusual skin findings. For men, the USPSTF recommends against screening for testicular and prostate cancer with PSA. For women, no screening for ovarian cancer exists presently. Women who have a strong family history of breast or gynecologic cancers should be screened for BRCA-1/2 and referred for genetic counseling if the tests are positive.

If there are other screening guidelines you feel should be included on here, please comment below or contact me. For more detailed information, check out Current Practice Guidelines in Primary Care for 2017:

Medical School Student Loan Consolidation And Refinancing: A Primer

Today's post is a repost from Future Proof, MD covering the basics of medical student loan consolidation and refinancing:


If you are like the majority of medical school graduates out there, you're probably saddled with a good amount of student debt. I know I am. If you are like me, you may have gathered multiple loans from several different lenders over your many years of schooling. Now that you're finally done with school and entered the workforce, you may have been bombarded with emails inviting you to consolidate/refinance your loans. So let's talk loan consolidation/refinancing.

First, let's address what consolidation and refinancing are.

• Consolidation allow you to combine multiple loans into 1 loan, resulting in just 1 monthly payment instead of many. For example, if you have only federal loans and go through federal loan consolidation, you will end up with 1 bill but your interest rate will simply be a weighted average of all the different interest rates of the loans you consolidated.
• Refinancing, on the other hand, allow your to consolidate your loans as above. But the difference is that your new interest rate will be dependent on your credit score and history rather than what the interest rates on your old loans were. In essence, you are applying for a new loan with new terms to pay off your old loans - analogous to a "balance transfer" between credit cards. In reality, "consolidation" and "refinancing" are used interchangeably. If you are getting an offer to "consolidate" your loans through a private lender, they're talking about refinancing. For the purpose of our discussion, I will use the term "refinance".

PROS:

• 1 monthly payment. This is probably the biggest benefit of refinancing your loans. Instead of making multiple monthly payments to multiple lenders, you get 1 bill and 1 payment.
• You may qualify for a lower interest rate. The standard interest rate for federal student loans are fixed at 6.8%. If you have good credit and income, it's likely you will qualify for a lower interest rate. I say "may" because when I went through SoFi (the largest student loan refinancing lender) to check what they would do for me, my refinancing offer was less than generous (see figure).
• You can lower your monthly payment. This can result from you getting a lower interest rate on the new loan, by renegotiating your repayment term (15 or 20 years instead of the standard 10 years for a standard repayment plan), or a combination of both.
• Choice of variable vs. fixed interest rates. Choosing a variable interest rate will benefit those who are planning to pay off their student loans rapidly.

CONS:

• Refinancing your loans with a private lender will make you ineligible for federal loan forgiveness programs such as Public Service Loan Forgiveness (PSLF), and other benefits such as Income Based Repayment (IBR), deferments and forbearance.
• Your interest rate may go up if you choose a variable interest rate plan. Most variable interest rate loans have a cap as to how high the interest rate can reach, but it's usually more than the standard 6.8% fixed you would get through the government.
• It's a permanent decision - if you ever leave the federal system, there is no recourse if you decide later that you've made a mistake.
• Fees - this is a minor consideration for those with a large loan balance, but there may be fees associated with a private loan refinancing application.
• So after considering many of the above factors, I ended up consolidating my loans through the government. I am currently on Income Based Repayment (IBR) with plans to eventually qualify for Public Service Loan Forgiveness.

Head on over to Future Proof, MD to see the table with statistics on medical education debt loads as well as many other great posts on personal finance for medical professionals. 


For those of you currently in medical school, I would also add that I strongly encourage you to seek out grants, stipends, and scholarships to supplement your financing. There are many tied to specific student backgrounds (i.e., if you come from a minority group), or for those willing to perform public or military service for some time after finishing training. Personally, I can attest to this being a very valuable approach as a single scholarship application that I knocked out one weekend evening ended up covering my tuition for an entire semester! Another example is author Ramit Sethi who funded his entire Stanford undergraduate education on scholarship money alone. If you need a primer on personal finance overall, his NY Times bestselling book I Will Teach You To Be Rich is a great place to start:

Humerus Anatomic Neck vs. Humerus Surgical Neck

One of the most popular posts on this site was a deep dive into the difference between Pope's Blessing and Claw Hand. Who knew anatomy could be so contentious? Admittedly, today's post is likely much less controversial, but I always found the distinction between the anatomic neck of the humerus and the surgical neck of the humerus to be confusing. Well, prepare yourself for today's shallow dive into the subject. Hopefully this will help clarify the distinction between the two. If it's already clear to you, congratulations - at least one of us will benefit from this exercise!

The anatomic neck of the humerus refers to the location of the physeal plate during development. During growth, bone forms at the physeal plate as the child ages. Once the child reaches maturity, the plate closes, usually during puberty. Different growth plates will close at different ages, with well-characterized ranges known for various bony structures. This pattern of plate closure can be used to assess a child's bone age, which can then be compared to their chronological age to assess for any delay in maturation. Returning to the humerus, the anatomic neck is mostly notable as a defined landmark but has less clinical application.

The surgical neck of the humerus refers to the narrowing of the humerus in the proximal diaphysis. The neck abuts the quadrangular space, a potential space formed by the margins of the triceps, teres minor, teres major, and the medial humerus margin (3 Ts + H, as opposed to the more medial triangular space formed by those same 3 Ts, but no H). Since this region is more prone to fracture, that means fractures in this area are more likely to damage the contents of the quadrangular space, namely the axillary nerve and posterior humeral circumflex artery.

By BDB - You can find the picture here. Traced and colored the picture using adobe illustrator., Public Domain, Link

To memorize the difference between the two, you can try a few different ways. First, A for anatomic comes before S for surgical, and the anatomic neck is more proximal on the humerus than the surgical neck. Second, the surgical neck is more often fractured and more likely to have surgical complications, so the name is associated with its clinical relevance.

And that's pretty much it! For me, learning anatomy was much more helpful when I could attach a narrative about some clinical situation in which that anatomy was relevant. Start with a basic framework of the location from a book like Netter's Anatomy and then search for clinical scenarios that help solidify the terminology in your mind. Hope this helps!

 

ACGME Increases Shift Length For Interns

The American Council of Graduate Medical Education, or ACGME, recently announced that it was reversing course and lengthening the longest shift an intern can work in a hospital from 16 to 24 hours. The ACGME governs the structure of all accredited residency training in the United States, so this change will have broad-ranging effects. While PGY-2 residents and above were already allowed to work these longer shifts, interns had been protected from them since 2010. Here are various summary articles:

• ACGME Statement
• NPR
• Business Insider

However, since 2010, concerns have arisen that the shortened shift actually detracts from intern training as they are required to hand off patients frequently in order to abide by the 16-hour restriction. Often times, a complex patient may require care past the 16 hour mark, which the trainee could not participate in while still complying with the rule.

Another concern was the hand-offs themselves. Especially in July, interns are still learning how to manage patients on a very basic level. Asking them to hand off a complex patient to another intern at the same early training stage is a recipe for error, since clinically relevant information may be omitted or underplayed, leading to errors in the provision of care.

Ostensibly, the ACGME attributes its change to the following reasons:

In keeping with this philosophy, the changes are supported by testimony from a wide range of physician specialty educators and intended to:

• place greater emphasis on patient safety and quality improvement;

• more comprehensively address physician well-being;

• strengthen expectations around team-based care; and,

• create flexibility for programs to schedule clinical and educational work hours within the maximums currently utilized in the US.

These revisions were developed as part of the ACGME’s periodic review of all program requirements to ensure that professional preparation of physicians adequately addresses the evolving and growing needs of patients. 

The trade-off though is a return to the era of the over-worked, fatigued intern. Historically, residency was a brutal training process with no restrictions. The first attempt to curb work hours was set in motion by the death of Libby Zion, an 18 year old girl who was under the care of minimally supervised, overworked trainees. Her father Sidney's anger at her death led to the ACGME instituting its first series of work hour reforms. Even those changes were slow to come around: the commission formed after Zion's death recommended changes including an 80 hour work week restriction in 1989; the ACGME instituted those changes in 2003, fourteen years later.

There have been several minor revisions since 2003, including the move to the 16 hour intern limit in 2010. The debate will continue over striking the appropriate balance between clinical exposure and the physician's personal health. As a medical student, you should inquire with prospective training programs about how they plan to manage the change, as well as ask current program trainees how the program actually functions. In more demanding specialties, such as neurosurgery or orthopedics, there are many programs that have trainees working longer than the hours they actually log. Ultimately, the ACGME is not an enforcing body and cannot assess whether each resident actually works the number of hours they say they do, so it is up to you to ensure the training program you join matches your expectations.

Regardless of whether you join a relaxed program or a stressful one, your best bet to make sure you are as prepared as possible to handle patients clinically on your own. Despite different specialties, intern experiences have a lot of overlap. The following resources below should help you be better prepared for the first day when you round by yourself as a full MD:

• Pocket Medicine by Marc S. Sabatine
  A handy guide that easily fits into a white coat pocket, Pocket Medicine has long been essential reading for interns, especially those on medicine wards. This small book is chock full of practical tips and broad differentials for common clinic findings.
  
  
  
  
• First Aid for the Wards by Tao Le, Vikas Bhushan, et al.
  From the authors of First Aid for USMLE Step 1, the bible of Step 1 prep, comes this book about rotation-specific advice. While intended for MS3 students, it still contains lots of useful information for interns, especially those who will rotate among various specialties, such as transitional interns.
  
  
  
  
• Intern by Sandeep Jauhar
  While not a technical guide like the two prior books, this memoir by Dr. Jauhar gives a good sense of what it feels like to be an intern, especially the sense of disorientation one may feel at times.
  
  

Good luck! If you are or recently were an intern, what was your experience like? What do you think of the proposed changes?

Amazon Fire Tablet Deal

We have previously written about tablets for medical students, and why you might want one. If you're not sold on a top of the iPad Pro, consider this deal for an Amazon Fire Tablet Essentials Bundle (16GB):

Simply enter the code FIREBUNDLE at check out and get the 16GB version, case, and a screen protector for less than you would spend for the tablet itself. If you do get any kind of tablet, a case or cover is a must. Think about it: between carrying it to and from the classroom, library, or wards, the various fluids and substances in a healthcare setting, and the possibility of others using it, the tablet is prone to falls. As we discussed recently, you should also consider the pros and cons of getting a warranty.

In addition to a case, you should consider a Bluetooth keyboard. I'm personally a huge fan of the Kensington keyboard/case combo I got for my iPad Air 2, the Kensington Key Folio Thin X3:


It works great, is backlit, and last for almost a solid *year* on a single charge via microUSB. It has proven invaluable for taking notes and making the device more functional. The combination practically serves as a laptop replacement for most light to moderate computing tasks. Not to mention weighing a ton less! For any medical student with limited carrying / storage space, such a compact solution is a definite plus. 

Should I Get A Warranty For My Device?

Many medical students will end up purchasing various devices such as tablets over the course of their training. When purchasing the device, a question that inevitably arises is: should I purchase additional coverage for any damage to my device? Admittedly, this topic is indirectly related to medical education. However, given that many of you are on limited budgets, it is a fair issue to consider. Buying a warranty vs. saving your money and being careful both have merit. Consider your own situation specifically before making a final decision

Why You Should Get A Warranty

As a medical student, your device is going to be more mobile and in more varied environments than someone who merely uses their device to binge on Netflix. Not only should definitely buy a case to protect your investment from minor scratches, wear, and tear, you should definitely consider a warranty in the event that your device is lost or stolen. Another major factor to consider is your own track record with devices. If you often drop items or otherwise damage them, you should be more inclined to purchase an extended warranty.


Why You Should Avoid A Warranty

Given the ever-shortening upgrade cycle in tech, you will most likely upgrade your device by the time you may incur any damage worthy of replacement. As prices are generally falling over time, the money saved up front may be enough to cover a brand-new replacement device. A rule of thumb for determining whether a warranty is worthwhile is to calculate the implied risk. The formula is simple:

100 x (Insurance Premium / Item Cost)

For example, if a device costs $200 and the extended warranty costs $40, then the implied risk is 100 x $40 / $20, or 20%. Now, ask yourself: is there a 20% or greater chance that I will break this device or otherwise invoke this policy? If so, you should buy the warranty. If not, then save your money and avoid the policy. Need a tie-breaker? Well, do you have children that will ever use the device? That alone probably makes the warranty worthwhile!

Where To Purchase A Warranty

After weighing the pros and cons above, let's say you decide to opt for a warranty. For simplicity sake, purchasing the warranty offered at the time of your purchase is probably easiest. For example, let's say you were purchasing an Amazon Fire Tablet:

You can purchase additional protection for 2 to 3 years from Amazon, provided by SquareTrade:

Looking at reviews online, SquareTrade is well reviewed with reasonable prices. Similarly, for Apple products, an AppleCare service plan / warranty is also a reasonable option.

Have you purchased an extended warranty before? What has your experience been like? Please leave comments below!

Scrub Notes Interview with Dr. James Dahle of White Coat Investor

From our recent post Financial Advice for the Future Physician, some of you may have taken the time to explore White Coat Investor more thoroughly. Those who did likely found it to be a very valuable resource in planning their financial future. Dr. Dahle, who runs White Coat Investor, was kind enough to participate in an interview with Scrub Notes about his site and other advice:

Dr. Jim Dahle
Source: WCI

SN: What inspired you to pursue a career in medicine? 

Dr. Dahle: The first time I thought about a career in medicine was a career survey of some kind in junior high where "doctor" was one of recommendations it had for me. Obviously my parents were encouraging. I was very much interested in science and in helping people but I didn't really formally commit to it until it was time to study for the MCAT. I don't know how much the prestige or money was motivating for me but I was fascinated by the subject matter and I knew that I enjoyed helping others so medicine was a natural fit.

SN: What led you to create White Coat Investor? 
Dr. Dahle: I started really diving deep into personal finance and investing topics midway through residency. I got sick of being ripped off by all kinds of financial professionals and decided I better start learning this stuff myself. After a few years of reading books, interacting on internet forums, and reading blogs I realized that I was spending more time teaching than learning and that I knew more about this stuff than the vast majority of my peers. That was also a period of time when I was very interested in developing sources of passive income. So the blog was started both as a hands-on experiment at generating passive income and a way to get this knowledge into the hands of my colleagues. It turned out the income, once it eventually came, wasn't nearly as passive as I had hoped, but I did end up making a big difference in the lives of literally hundreds of thousands of my colleagues, so that was rewarding in and of itself.

SN: What has been the most surprising part of running the blog? 
Dr. Dahle:  I guess the most surprising thing was just how much vitriol it would attract from commissioned salesmen masquerading as financial advisors. Real financial advisors are generally very supportive of what I'm doing, but those who saw doctors as easy marks are finding them to be not so defenseless any more.

SN:  What is the best piece of advice you have for medical students? 
Dr. Dahle:  I have lots of advice for medical students, but I probably ought to limit this to financial advice. I guess the most important is to remember that what you do those first few years out of residency with your finances are going to determine the course of your financial life. So really focus on getting those years right. That means living like a resident for 2-5 years after residency in order to pay off student loans, jump start your retirement savings, and save up a down payment on your dream house.

SN: What are your top financial predictions for the next four years? 
Dr. Dahle:  My crystal ball is incredibly cloudy. I have found predictions are extremely difficulty, especially about the future. That said, with the Republicans in control of all 3 branches of government, I expect tax rates will go down a bit. The market will fluctuate. Interest rates will change. Those who spend a little bit of time and effort learning about personal finance and investing will reap great dividends of happiness in their lives.

SN: Thank you for taking the time to chat with Scrub Notes!

For more great financial advice for healthcare professionals, head on over to White Coat Investor. You can also check out Dr. Dahle's book on Amazon:

Applying Behavioral Economics to Patient Care

Psychologist Daniel Kahneman, along with his frequent collaborator Amos Tversky, are the fathers of the field of behavioral economics. Kahneman was awarded Nobel Memorial Prize in Economic Sciences in 2002 for his work (Tversky was deceased, and thus not eligible). To bring his work to a broader audience, he published "Thinking, Fast and Slow" in 2011:

The basic premise of the book is that our brains actually function via two systems, which he terms System 1 and System 2. System 1 is instinctive, utilizing heuristics to make decisions quickly. A heuristic is a 'rule of thumb', a device to boil down complex information to a simple choice. In other words, it acts as an approximation, that is usually 'good enough' for the situation at hand. System 2 is calculating and rational; it functions more like a computer, coolly processing inputs and trying to generate the optimal decision as an output.

Kahneman's work points out the biases inherent to both of these systems. His most famous result may be prospect theory, which basically shows that humans do not value incremental changes in probability equally, and that they are susceptible to whether those changes are framed as gains or losses. Another big point that Kahneman makes is that our "selves" really consist of two separate entities: our experiencing selves, and our remembered selves. For example, think about a strenous hike or other physical activity you did. In the moment, your experiencing self may be in agony from the stress and pain; however, your remembering self may view it as a very cherished memory because of the overall payoff.

What does this have to do with medicine? Everything! Both patients and doctors suffer from these biases. While the biases are part of being human, that does not mean we should simply accept making poorer decisions because of them. As a physician, here are some things you can do to mitigate these biases from how you decide.

Gathering A History

When you first meet a patient, you will necessarily have to make an initial assessment. That 'subjective' portion, the S in SOAP note, is the lynch pin for the rest of your encounter. If you have bad information, you will order the wrong exams, make the wrong diagnosis, and implement the wrong plan.

Garbage in, garbage out.

Therefore, getting a precise history is critical. However, to do this, you must combat both your own biases and the patient's. The big one to combat here is recall bias. For example, patients with a history of cancer who present with abdominal are more likely to over-emphasize or recall factors that may suggest a mass as the underlying cause of their pain. Do not disregard this history, but do try to correlate it with objective data, such as a CBC to check for anemia, or imaging.


Ordering Tests

The explosion in objective data one can acquire on a patient has been a major boon to healthcare. However, there is a downside to such tests. This bias is on the provider's side. Whether it is an anchoring/recall bias (the last patient with shortness of breath had a pulmonary embolism, so now every future patient with SOB has a PE) or satisfaction of search (one abnormal test result precluding ordering other relevant tests), these biases can lead to either the under- or over-utilization of appropriate testing modalities.

One way to guard against this is to understand treatment algorithms at great length. While there is a tendency to avoid 'algorithmic thinking' in medicine, the notion is often misapplied. One can go beyond algorithms only after they have fully mastered them, and can confidently assess that the current patient does not fit the algorithm. This is a wholly different matter from simply ignoring an algorithm altogether.


Making a Plan

Finally, once all the history and data have been gathered, and an assessment, it is time to come up with a treatment plan. As Kahneman's book title implies, this is a good time to think slowly. Have all the patient's problems been addressed? Does every abnormal lab value have either an explanation or a plan to address it? A good treatment plan will also include some way to assess its own effectiveness, whether that is by scheduling a follow up exam or test, or some other objective measure. A plan without follow up is simply wishful thinking.

Ultimately, the practice of medicine is a human practice, subject to human biases. However, as our understanding of these biases advances, it behooves us to mitigate these biases to the best of our abilities. If we are to do no harm, we must ensure that we unblind ourselves to the harm our biases may cause.

The New and Improved Amazon Rewards Card

Regular readers of this site likely realize that we're big fans of Amazon. In addition to using e-books and being a Prime Student member, another way to maximize your Amazon benefits is by having an Amazon Rewards credit card.

Previously, the card paid 3% back for all purchases made on Amazon and 1% everywhere else. The new card now pays 5% back on all Amazon purchases for Prime members, 2% at restaurants, gas stations, and drug stores, and 1% everywhere else. It remains free, with no annual fee.

The card becomes another payment option in your Amazon account. After the monthly balance is paid off, the reward points automatically show up on the Amazon checkout page. Simple!

For a limited time, Amazon is offering a $70 instant bonus upon approval. If you are looking for a new stethoscope or maybe even a new tablet device, that would go a long way towards it! Following on the last post though, if you already carry credit card debt, make sure to pay off all your balances first before pursuing new lines of credit and make sure to pay off your balance *every* month.


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Financial Advice for the Future Physician

Dr. Jim Dahle runs the popular healthcare-professional blog White Coat Investor. One of his posts detailed 8 Financial Tips for students looking into a medical career:

Choose the cheapest school you can get into

The decision of which school to attend will have a greater impact on your finances for the next 5-20 years than any other decision other than who/if you marry and what specialty you choose to practice. Choose wisely. I’ll give you a hint–Most medical schools in this country provide a pretty comparable education. Most of what you learn in medical school will come from what you teach yourself and the pearls dispensed to you freely by interns, residents, and other doctors you come into contact with. Little of that learning is dependent on the school you choose. Thus, choose the cheap state school if you can get into it. Don’t forget that costs aren’t limited just to tuition and fees, but also to the local cost-of-living. That school in Boston, New York, or San Francisco is going to cost you a lot more than the one in Omaha or Albuquerque.

Consider the merits of “scholarship” programs carefully

There are several organizations that would like to pay for your medical school in exchange for a commitment. The military Health Professions Scholarship Program is the best known, but the US Public Health Service, Indian Health Services, and other private deals also exist. None of these programs is a “scholarship” in the traditional sense of the word, and many a “scholarship winner” has later realized he would have been much better off, personally and financially, if he hadn’t been awarded the “scholarship.” As a general rule, use these programs only if your career goal is to be a military doctor or a rural primary care doctor. Choosing them for the money is almost surely a mistake you will regret.

Personally, I can attest strongly to his first piece of advice. Choosing a cost-effective medical school has meant the difference between graduating essentially debt-free versus graduating with loan repayments stretching out as far as the eye can see. As life progresses, your costs will increase, so that "manageable" monthly repayment will become increasingly burdensome, especially if you are interested in purchasing a house or having a children as you near the end of the long road of medical training (or already have those obligations!)

For the rest of his tips, check out Dr. Dahle's post 8 Financial Tips for Pre-meds and Medical Students.

Why Not Watching Enough College Basketball Is My Greatest Regret: Guest Post

Leah Kroll is a medical student at NYU. She writes about her life as an MS4 in this post from MotivateMD:

I made it through the rigors of pre-med. I made it through (almost all of) med school, with a few scars to show for it. And now that I’m a big, bad MS4, I finally have the time and the distance to reflect on all the literal blood, sweat, and tears it took to get here... I am a loud and proud Duke Blue Devil. It was my dream school despite my born-and-raised New Yorker parents saying, “South of the Mason-Dixon line? Absolutely no way!” My 4 years there surpassed my wildest expectations. But I failed to live all of my Duke dreams out. 

I’m proud of the person that I have become as a result of persevering through the MCAT, Steps 1 and 2, clerkships… you get the picture. But throughout all of this, since the moment I decided to go into medicine, the pressure to succeed has been a heavy weight dragging me down. I had to have a 4.0 every semester in college or I wouldn’t get into medical school. I had to run myself to the bone trying to excel as a medical student or I wouldn’t be a good residency applicant. I had to get at least XXX on Step 1 or I would be worthless. 

At Duke, basketball is king and I went to as many games as I could in the beginning. But as my medical school aspirations grew stronger, the number of games I attended dwindled to a pathetic 1 during my senior year season. Looking back on the night we won the NCAA tournament during my freshman year, I remember 2 things: 1. The electric rush of taking part in the ultimate Duke experience 2. Taking myself out of the party when the clock struck midnight so that I could retreat to my all too familiar spot in the library. My organic chemistry midterm was in 2 days and I had to get an A.
Every year at Duke, a good chunk of the undergraduate student body (The Cameron Crazies) sets up a tent village outside Cameron Stadium. For months, students live in these tents hoping to score tickets to the main event of the year: Duke Vs. UNC. My non pre-med friends tented every year. We pre-meds never did. After all, would we get enough sleep in the tents to study as much as we needed to? We had to keep our grades up. 

I got that A in organic chemistry. But, at what cost? 

We take the best care of our patients when we take the best care of ourselves. My relationships and interests outside of medicine keep me happy, healthy, and well-rounded. They help me be a better doctor. Regularly watching Duke basketball with my college friends, for example, has kept me sane as I grapple with the rigors of medical school. 

If my memory serves me correctly, organic chemistry came up in medical school just once: a 3-day metabolism and biochemistry unit in my first year. Other than that, my knowledge of electron pushing has not made any contribution to my medical training. Duke Basketball, however, has come up many times with my patients. It’s something that really excites me, and the people I meet in the hospital can relate to that. It makes me stand out from the assembly line of faces and scrubs poking and prodding hospital patients all day. 

Rooting for a basketball team brings all sorts of people together, and it’s that one common goal that serves as the glue. Cheering for a team is not unlike rallying around our patients to help them beat their illnesses. That’s how Duke basketball makes me a better doctor- it reminds me how to connect with almost anyone. 

I only wish I had participated more in my college years. I would have been happier then and it would make me a better doctor now. As hard as it may be to remember when pursuing a profession that requires us to compete and claw our way to the next step, there is such a thing as holding on to academic excellence too tightly. Albus Dumbledore said it best: “It does not do to dwell on dreams and forget to live, remember that.” Wise guy, that Dumbledore.

Looking for more inspiration as you journey through your health professions career? Check out MotivateMD.

Medical Student New Year's Resolutions for 2017

Happy 2017! Hopefully everyone had a restful and happy holiday season. As the new year is upon us, it is commonly a time for resolutions. Some are personal; some, professional. For me personally, here's to cutting out soda! As research has shown, there is a link between sugary drinks and metabolic disease. Hopefully I can make some personal progress in that direction.

What about you? While your personal goals are unique, most likely we all share professional goals as a healthcare professional student. Study harder. Do well on tests. Figure out what we are doing with the 'rest of our lives.' Setting these goals is very important. However, that is only part of the story. A goal is nothing but a destination. What we need is a roadmap to that destination, or a plan. What would that look like? Let's take a look at the three goals mentioned above and see what concrete steps we can take towards them in 2017.

Study Harder

Ah yes, the eternal hope of the conscientious student. Study harder. The goal is omnipresent, but what does it actually mean? You could study more hours. You could isolate yourself as much as possible as you study. Both fit but is that what we want? Not exactly. What most people mean by study harder is actually to study more effectively. This will differ from person to person as everyone learns in a different manner. Some learn better by reading only, others by taking notes, still more by listening / reviewing lecture audio/video. Regardless of how you like to study, there should be two main objectives: studying for mastery, and studying for testing purposes.

Studying for mastery is a component of lifelong learning. This means that after your review, you have a deep, fundamental understanding of the concept. The upfront cost may be more, in terms of time and effort. However, in the long run, this method is more effective because once you master something, you do not have to go back and relearn it. The idea remains embedded in your knowledge base, much like riding a bike. How do you master a topic? The best way I know how is to actually teach the topic. Seek out or create opportunities. Struggling with anatomy? Volunteer to be an anatomy lab TA - the responsibility will force you to either master the material on your own, or seek out help from others so that you are competent enough to teach.


Do Well On Tests

This is also a very generic goal. Aside from a standardized test like USMLE Step 1, every medical school test will be unique. Discussing non-standardized tests first, you can of course try the steps mentioned above, mastering the entire topic. However, sometimes learning everything A to Z just isn't feasible. At this point, it is important to find out what are the objectives the course instructor wants to emphasize. Look at the syllabus, review old tests if available, and ask senior peers. If all that fails, you should *gasp* just ask the instructor what is important. Trust me, they will be happy to see you being pro-active and striving to fully grasp the essence of the material. While you cannot directly ask "What will be on the test?", you can certainly say something like "There is a lot of material to cover. What are the most important points you see students miss in your experience? What is most important practically?" Only a sadist would actively lead you away from material that will come up on the test.

Standardized tests like the USMLE are a different story. For those your best bet is to study common resources like First Aid and do review questions. Lots of review questions (such as Kaplan QBank). Ideally, you want to do these questions in a similar setting to the actual test. For example, if your test is on a Saturday morning at 8am, you went to spend several Saturdays before the test, waking up before 8, figuring out your pre-test routine, and then doing several sections to best simulate what the test will be like. Remember, for people looking at US residencies, your Step 1 score is the biggest objective determinant of how programs will assess you for interviews, for better or worse. Therefore, it behooves you to put as much concerted effort into preparing for this test as possible.

Figure Out My Career

Despite stressing about tests, they will come and go. Ultimately, the tests are simply a means to an end. It is up to you to define what that 'end' is. What type of medical career do you want? Primarily outpatient? Inpatient? Urban vs underserved community? Domestic vs. international? Medical vs. surgical? While some students go into medical school knowing exactly what they want to do, an equal number have no idea. And that's okay! School is a time for exploration. If you have too fixed a mindset, you may miss out on another opportunity that is an even better fit for you. I recommend perusing Iserson's Getting Into A Residency for not only practical tips about applying but also for a framework about how figure out which specialty you should be applying for.

Questions about the process? Please comment below or use the contact page above. Have a fantastic 2017!