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Cavalcade of Risk #149: Single Best Answer
As I mentioned earlier, I’m starting to rev up the studying for the licensing exam. A lot of the studying takes the form of practice questions. They’re actually a lot of fun to do: they force you to think actively about the clinical scenario, keep you on your toes, and make it near-impossible for your eyes to glaze over as you semi-consciously read the same page for the 10th time in a row as your eyelids begin to feel heavy, droop, and you start to….
Yikes! Where was I? Right! The Cavalcade is back! Since I’m sure that most of you don’t believe me when I say that doing practice questions is actually fun, I’m going to use this opportunity to try to convince you. With the aid of sophisticated, peer-reviewed psychometric techniques (or not), I have converted each entry into a USMLE-style “single best answer” multiple choice question. Let’s see how you do!
Cavalcade of Risk: Step 1[49]
Instructions: For each of the following test items, select the one answer that best answers the question posed in the stem.
From Boomer at Boomer&Echo: Which of the following behaviours of financial advisors correlates with the lowest risk of defrauding investors?
a) Claiming to have secret/exclusive insider tips that “your broker doesn’t want you to know.”
b) Counseling clients that investments with higher expected returns tend to be riskier.
c) Offering to move your money offshore to avoid taxation.
d) Pressuring you into making a hasty decision on an “exploding offer.”
e) Charging abnormally high membership fees.
From Ken Faulkenberry at the AAAMP Blog: If shares of the Notwithstanding Blog Internet Empire (NBIE) earned a 8% return in 2011 and exhibited a beta of +1.2 relative to a benchmark of shares in all medical blogs that collectively earned a 5% return, then:
a) The alpha for NBIE in 2011 was +2, making it a good investment.
b) The alpha for NBIE in 2011 was +3, making it a good investment.
c) The alpha for NBIE in 2011 was -3, making it a bad investment.
d) The alpha for NBIE in 2011 was -6.8, making it a bad investment.
e) The alpha for NBIE in 2011 cannot be calculated with this information.
From Van R. Mayhall III at the Insurance Regulatory Law Blog: Which of the following statements DOES NOT accurately characterize insurance company insolvency:
a) Most state-based insurance guaranty associations are more comparable to private member-based associations than true state agencies.
b) Insurance companies are subject to unique state-based insolvency protocols in lieu of entering the federal bankruptcy system.
c) Payouts from state insurance guaranty associations are subject to statutory caps.
d) Insurance guaranty associations are intended to provide “bailout” financing to prop up faltering insurers.
e) None of the above.
From Emily Holbrook at Risk Management Monitor: The shoe-shopping website Zappos.com recently earned positive press for:
a) Losing your examiner’s personal information, along with that of millions of other customers.
b) Locking out customers from your examiner’s home country for 4 days after a data breach.
c) Being named in a potentially-class action lawsuit seeking damages as a result of a data breach.
d) Having “some analysts” criticize the company’s response.
e) Having “some analysts” praise the company’s response.
From Jason Shafrin, the Healthcare Economist: Medicare’s new value-based purchasing initiative, which aims to reduce payment to “low-quality” doctors, currently uses treatment costs for which of the following chronic diseases as an element of its cost measure (as distinct from its quality measure):
a) Hypertension
b) Alzheimer’s disease
c) Diabetes
d) Lung cancer
e) Breast cancer
From Louise Norris at Colorado Health Insurance Insider: Colorado’s Medicaid program has recently undergone much change and provoked a great deal of controversy. What happened at the end of 2010 to put Colorado’s Medicaid program on better financial footing?
a) Successful negotiations to lower the fee schedule for physicians’ services.
b) A 55% increase in enrollment relative to 2007.
c) A one-time $13.7 million grant from CMS.
d) New dedicated revenue from a sales tax increase.
e) The introduction of Medicaid Managed Care programs.
From Dr. Jaan Sidorov, the Disease Management Care Blog: Which of the following is an accurate characterization of Dr. Sidorov’s assessment of Health Insurance Exchanges (HIEs) and recent Kaiser Health News commentary on the subject?
a) The left is doing their best to nurture this fledgling institution to maturity in anticipation of the PPACA’s full rollout.
b) It’s reasonable for consumers to spend more time shopping for consumer electronics than for health insurance.
c) Government-run HIEs will eventually match the ease-of-use and “cool” factor of iPhone apps and online purchasing aids.
d) Multiple insurance options on HIEs include variations in provider tiers, out-of-pocket costs, and exclusions.
e) Consumer expectations for HIEs will eventually be exceeded.
From Julie Ferguson at Workers Comp Insider: Doctors’ deaths differ from the deaths of other Americans in that:
a) Doctors often choose to forgo lifesaving chemo, radiation, and procedures.
b) Paradoxically, doctors often do not have access to the full range of lifesaving technologies as the rest of society.
c) Non-physicians tend to be more ready to accept death.
d) Doctors have a cultural bias against accepting death that isn’t shared by society at large.
e) Non-physicians who choose to fight their disease are often pressured by friends and family to be serene in the face of death.
Answer Key
Of course, since you read all the entries, you don’t need one! But just in case: B; A; D; E; C; C; D; A.
Examiner’s Notes
As always, it’s an honour and a pleasure to host the Cavalcade of Risk! If this is your first time at the Notwithstanding Blog, or if you’re coming back after a prolonged absence, I encourage you to take a moment and poke around some of other posts here. From health care policy to health professions training (i.e. medical school), I’ve got it covered.
The 150th(!) Cavalcade will be hosted on February 8th at My Wealth Builder.
Cavalcade of Risk #135: Independence Days Edition
July 2011 has given us many causes to celebrate, and we’re not even half-way in! Early July is when we see Canada/Independence/Bastille Day celebrations in Canada, the United States, and France respectively. This past Saturday was the first day of independence for the brand-new Republic of South Sudan. And today, for the 135th iteration of the Cavalcade of Risk blog carnival, I am pleased to present nine incredibly informative and insightful submissions (plus one of my own) for your edification.
In recognition of all of the countries with July independence days, we’re going to be running a carnival sideshow at this blog carnival today. Interspersed with the submissions will be a small number of flags with trivia-esque hints for countries with July national days; the names of the countries will be at the end of the post. Hopefully this will be an entertaining mid-July “trivial pursuit” to accompany the serious business of risk discussed in the submissions!
This country's neighbours include Suriname and Brazil. (is this a trick question?!)
Two related posts from Jacob Irwin and a guest blogger at My Personal Finance Journey discuss the perils of e-commerce and sharing financial information online. Jacob dissects an example of a common ‘phishing’ scam, and the red flags that should cause one to be suspicious of an email that seems designed to separate you from your personal information (and eventually, your money!). His guest blogger, Les Roberts, talks about how to stay safe while shopping online, and discusses some of the basic technical aspects of secure online transactions.
Tom Drake at the Canadian Finance Blog has a comprehensive post addressing what he claims is the conventional wisdom regarding life insurance: buy term and invest the difference. He argues that while the strategy has its obvious appeal, it’s highly sensitive to the assumptions used in the term vs. permanent comparison. Well worth a read!
No, it's not an American flag, though their capital is named for one of America's Founding Fathers.
Hank Stern, writing at InsureBlog, notes in the context of recent floods in North Dakota that sometimes taking a risk with your insurance coverage can be justified, but as with the analysis in the previous post, that it all comes down to how robust your assumptions are. Come to think of it, isn’t that the case with just about anything?
This country currently leads the world for longest stretch without an official government. You might say they've been waffling for the past year or so.
Wondering about health insurance exchanges? Dr. Jaan Sidorov (aka the Disease Management Care Blog) took one for the team and dove into the depths of the details of Utah’s already-existing exchange. He notes that setting up an exchange is far more complicated than one might think at first glance, and that it’s unlikely that they will be functional in every state of the union come the 2014 deadline. He also ponders the potential for exchange listing/delisting to be used as a quasi-extra-legal cudgel (my words, not his!) by state insurance regulators seeking additional ways to force insurers into line.
“Oh no they didn’t!” is a common refrain from business owners wondering how that absurd claim could have been paid out by their workers’ compensation carrier. Nancy Germond has a clear and concise explanation of why, “oh yes they did!“, along with an interesting history of how workers’ comp came to be in the first place. Read on at Allbusiness.com.
Do you remember the Dodd-Frank bill? Thought it only applied to big banks and high-falutin’ investment securitization shenanigans? Van Mayhall III has a post at his Insurance Regulatory Law blog reminding us that the new provisions of the law could also affect larger insurance companies and their affiliates in ways that management will want to be aware of well in advance of anything going wrong.
St. Thomas isn't just one of the US Virgin Islands. This equatorial namesake, however, has a "princely" companion.
At Colorado Health Insurance Insider, Louise Norris asks whether eligibility criteria for the newly-established federal high-risk health insurance pools is hampering enrollment. Colorado is an interesting vantage point from which to observe this: the twenty-year-old program “CoverColorado” is very similar to the new federal one. The differences between the two programs’ eligibility rules generate good insight into where the federal program is going wrong in attracting enrollees.
If you asked this country for a date in 1995, you might find the time being pushed up unexpectedly.
Workers Comp Insider Julie Ferguson and I seem to have been on the same wavelength for this blog carnival! I recently wrote a post arguing that the problem of poor price transparency in health care may be an objection to the use of consumer-directed health plans now, but that early adopters will pave the way forward for the rest of us. The chicken-and-egg issue is not all that intractable! Julie Ferguson, on the other hand, has a far superior post addressing the same topic. She points out the immense price differences for the same medical services that exist across state lines and across street intersections alike, and provides links to seven (count’em!) different resources for employers and individuals to use to get the best bang for their medical buck.
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This brings CoR-135 to a close. Thank you to all of the submitters for their quality posts on risk, and thank you to Hank Stern for his tireless work managing the behind-the-scenes logistics of every edition of this blog carnival. It really is an honour for this callow medical student to be invited to sit at the grown-ups’ table and host the Cavalcade!
The next edition of Cavalcade of Risk will be hosted by Jacob Irwin at My Personal Finance Journey on July 27th.
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For those of you who tried your hand at the national flags-and-trivia sideshow, the answers are here.
The first one was something of a trick question. It’s France! French Guiana sits atop the northern coast of South America, and is every bit a part of France as Paris or Nice, and as such France has land borders with Brazil and Suriname. Bastille Day: July 14.
It’s not an American flag, but there is a reason it sorta-kinda looks like one. Liberia was established as a place to which to “repatriate” black Americans in the early 19th century, the idea being that they could live a life of greater freedom there than in the antebellum United States. James Monroe was one supporter of this effort: the Liberian capital is Monrovia, after him. Proclamation of independence from the United States: July 26.
Next up: Belgium! It’s been quite a while since they’ve had an official government, and the country is wracked by political tensions between the Flemish and Walloon communities. Oath of the first King of the Belgians: July 21.
St. Thomas in Portuguese is Sao Tome (can’t figure out accents, sorry!), and the flag is that of Sao Tome and Principe, a small island nation located along the Equator in the waters west of Gabon and Equatorial Guinea. Independence from Portugal: July 12.
Prior to 1995, the Pacific island country of Kiribati was split by the international date line. Makes inter-state time zone differences in the US seem incredibly convenient by comparison, doesn’t it? After kinking the IDL a bit to the east to accommodate the entire country on one side, Kiribati was positioned to be the first country in the world to see each new day. Independence from the UK: also July 12.
Cavalcade of Risk #112: The Cavalcade Gets Schooled
It truly is an honour to have been asked to host the 112th edition of the Cavalcade of Risk blog carnival! After all, I am but a lowly, economics-trained fledgling first-year medical student who has been blogging here for less than six months (still considerably longer than my time as a med student to date!) and who still has the occasional blog formatting issue or two.
The excitement surrounding the start of medical school is far from wearing off; as a result of that continued excitement, I decided to take the Cavalcade with me to classes. Remember: everything you read here is fair game for the final (and the licensing exam)!
Cavalcade of Risk #112: Medical School Edition
Behaviour and the Brain
The workers' comp adjuster described this case as "a major headache."
Brains are important. There are several pre-clinical courses that deal with them, and not just because the subject has a starring role in the licensing exam (and on the menu at the Bistro Zombie). The brain is the seat of our behaviour, emotion, rational capacity, and risk assessment capability. Even with this fascinating organ working at full tilt, dealing with risk rationally can be difficult. Of course, we humans are far from perfectly rational, which makes for even greater challenges. GrrlScientist links to a TED talk in which a researcher tries to gain insight into the root of human irrationality by examining decision-making in monkeys. [CONGRESS JOKE DELETED]
Regulatory Compliance
Perhaps the most fun part of medical school orientation is the parade of sessions required by law, by the university, or by the medical school, for little other purpose than to be able to check off a box and say “the students are aware of the policy.”
If legislation had animal mascots, you would be looking at the HIPAA Hippo and the Son of HIPAA Hippo HIPAA Hippo
Of course, some of this compliance information is actually high-stakes. For instance, this year’s HIPAA training session included a portion on medical identity theft red flags. However, as well-trained and as eagle-eyed as the medical students are, you are your best first line of defence when it comes to preventing medical identity theft. Ryan from CashMoneyLife has a post that explains how patients can both detect and protect themselves from medical identity theft.
Physiology
The Physiology of the Medical Student
“Phys” is all about how stuff works. The typical first-year physiology course is a detailed overview of how the body works under normal conditions. It’s easy to take for granted the complexity and intricacy of the processes that keep us alive, in part because most of the time, it all works without any effort on our part (knock on wood).
Protecting the normal physiology of business partnerships is the subject of the next post. Jacob at My Personal Finance Journey explains how a combination of buy-sell agreements and properly-structured life insurance contracts can be used to make small business partnership succession go much more smoothly with much less effort at a stage where there will already be so much in flux.
Histology
The upperclassmen tell me that we look at a lot of slides in histology. As you can see, I'm trying to get a head start.
Histology, the study of tissues, typically involves lots of staining, sketching, and microscopy. While advances in technology means that some slides are digitized for ease of review, there’s still plenty of opportunity to get your hands dirty with “the real deal,” just like the Disease Management Care Blog did with his submission to this week’s Cavalcade. Dr. Jaan Sidorov has found the National Association of Insurance Commissioner’s “Blank” proposal defining the medical-loss ratio, stained it, and put it under the digital microscope for all to view.
Pharmacology
Is it just me, or do four of these look like they're glitter-filled?
I’ve always been impressed by the ability of nearly every physician I know to rattle off drug names (and their indications, side effects, etc.) with seemingly perfect, instantaneous recall. I’d imagine that the months-long pharmacology course in year 2 has something to do with that. “Better living through chemistry” can be tricky to achieve if you don’t know your chemicals.
Jason Shafrin, the Healthcare Economist, describes one set of efforts to improve the benefits of pharmacological therapy by involving pharmacists more directly with the patient’s medication therapy management.
Pathology
Not to be confused with "path-ology," a course taught at schools of engineering and urban planning.
“Path” examines how the body’s structures respond to a variety of stimuli, usually bad ones. It seeks to answer the questions “what’s going on here? What’s wrong? What do these cells do when we [injure/mutate/slander] them?” In this vein, the ever-intrepid InsureBloggers emerge from their basement labs to look at one state’s new PPACA-created Pre-existing Condition Insurance Pool, and provide a concise and focused overview of its pathologies.
Anatomy
I’m fortunate to be able to use so much of the material from my undergraduate vertebrate anatomy class to review terms for medical school anatomy. Despite the fact that, in college, we worked on cows and cats instead of humans, the similarities between the vertebrates are such that a comparative approach to anatomy can yield great dividends. For instance, courtesy of National Geographic TV, I know of a whale anatomist who works out of a human medical school in New York City.
First-year anatomy: a whale of a good time? Or the course that will have you sitting in lab all sad and blubbering?
Joel, our next poster, uses the techniques of comparative insurance anatomy to arrive at this tongue-in-cheek “Plea For Car Insurance Reform.” As with the vertebrates, insights from one area of the insurance world may be able to tell you something about the others.
Biostatistics and Epidemiology
The Notwithstanding Blog would like to remind all visitors to wash their hands and observe universal precautions during their visit
Biostats teaches medical students how to use quantitative tools at a basic level. Being able to critically evaluate new biomedical research is a crucial tool for those of us entering medicine at this time of seemingly-exponential change. Epidemiology more broadly examines health status and disease in the aggregate, including surveillance of epidemics and monitoring of health trends. Careful use of the tools of these fields can allow one to make reasonable predictions about the future of wellness trends and epidemics, or, if you’re Louise of Colorado Health Insurance Insider, the future of PPACA-grandfathered insurance plans.
Extracurriculars
The range of extra-curricular activities at SUMS (Sorta Urban Med School) seems nearly endless. There are running clubs, research opportunities, student government positions, specialty interest groups… the list goes on. However, one set of time-honoured activities among medical students is health outreach and education within the local community. Many medical schools are located in or near areas in which there are major problems with access to healthcare and accurate health information; students can and do rise to the challenge of filling those gaps as best as they can.
These outreach projects can range in tone from the humour-filled to the gravely serious. Julie Ferguson at Workers’ Comp Insider shares a feel-good breast cancer awareness video, along with some other chuckle-inducing medical parody videos. David Williams, host of Cavalcade of Risk #113 in two weeks, posts a guest piece about the lies and dangers of so-called “pro-ana” websites.
Material unrelated to the course that nevertheless shows up on the final because it’s the professor’s niche research interest
"Syllabus? What syllabus?"
One of the risks of starting medical school, with its concomitant classes and extra-curricular activities, is that it will affect your blogging output. Nonetheless, I plan to stick around. I invite all of you CoR readers to poke around the rest of this site. If you like what you see (and even if you don’t), I’d love nothing better than to have you stick around with me!
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Cavalcade of Risk #113 will be hosted at the Health Business Blog.
Intern work-hour limits and licensure
Arguably the biggest highlight of the ACGME’s proposed new resident work-hour policy (discussed earlier here) is the limitation of intern work-hours to 16, reduced from the current 24+4. Dr. Vineet Arora at FutureDocs points out that this proposed new regulation fundamentally changes the “contract” of post-graduate medical education, in which things are supposed to pick up, in terms of quality of life, after the PGY-1 year.
This got me thinking about licensure. These new rules seem predicated at least in part on the assumption that newly-minted doctors will complete at least three years of post-graduate training, thereby becoming “board-eligible” in the specialty in which they trained. Medical licensure, at least in most states, doesn’t make that assumption.
According to the Federation of State Medical Boards, only 17 US states and territories require more than one year of post-graduate training; the remainder require just completion of intern year before allowing graduates to practice medicine independently and without supervision (all this applies to graduates of Canadian/US medical schools only).
I haven’t seen any claims about how the new rules would affect the educational experience and practice-ready status of internship graduates, but I don’t think it’s too much of a stretch to think that there would be some… in which direction, I wouldn’t know. I also can’t find any numbers on how many physicians stick out a shingle and start seeing patients after only 1 year of postgraduate training, but I can’t imagine it being too high, especially since board-certification seems more and more to be a pre-requisite for hospital jobs/privileges, and employment with larger medical groups.
What this means is that the presumably small number of physicians who go on to practice with only one year of post-graduate education under their belts might not have as much experience as they would have under the current rules. This probably won’t be much of a big deal in the grand scheme of things. It does, however, prompt me to ask whether the ACGME should consider its policies in light of the fact that graduating interns are allowed to practice independently in most states. If not, maybe (and I must stress “maybe”) it’s time for state medical boards to start insisting on residency completion before granting licenses to practice.
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In other news, Cavalcade of Risk has been posted this week. It includes my earlier discussion of the new ACGME proposed rules, subject to the admonition, conceded and well taken, that the post might be a bit too tangential to the topic of risk.
Grand Rounds and Health Wonk Review are up
Both are pretty brief this week. Grand Rounds can be found here, and Health Wonk Review — edited with the intent of the Framers in mind — can be found here.
If you’re short on reading time, I would say that the posts on the Copenhagen medical museum and on pay-for-performance are the Grand Rounds “can’t-miss,” and from Health Wonk Review I would recommend the two posts on cancer statistics and the post entitled “Wonkiest of All.”
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The Notwithstanding Blog 
Health Wonk Review, and other matters
Julie Ferguson at WorkersCompInsider hosts the latest edition of Health Wonk Review, which is chock-full of insightful, thought-provoking pieces from across the health wonk spectrum (and occasionally from a clueless amateur like myself).
Avik Roy, now blogging at Forbes, has a quick summary of each published submission at his site. About my piece, he writes
That wasn’t quite what I was trying to say; I guess that wasn’t one of my better-written posts. I’ll use this space to clarify.
My concern is not the political leanings of bioethicists per se, so much as it is their seemingly widespread disdain for the ideal of patient autonomy. I offered political leanings as one possible explanation, but I really don’t think that Leon Kass is any better on this score than his liberal counterparts.
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On a completely different note, I’ve written before about the intersection (or lack thereof) between medical education and business education, but Ted Bacharach at Placebo Journal Blog sums it up far more eloquently and concisely than I ever could hope to.
Read the whole thing (not much longer) here.