Monday, January 23, 2017

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:



Thursday, January 19, 2017

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.


Sunday, January 15, 2017

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.


This post contains affiliate links, which means the blog receives a commission if you make a purchase using those links. For more info, please read the full disclaimer.

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