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!