The Nobel Prize that Keeps Affecting My Life

Doctor's graduate from medical school every year - but not all of them will practice medicine.  Thousands of them will never get the chance.
CNN wrote a great article entitled: Why your waiter has an MD that explains the problem.

Here's the gist of it:
All med-school graduates who want to practice in the USA have to complete a "Residency Training Program."  If you want to specialize in anything such as Anesthesia, Psychiatry, OB/GYN, Family Practice, Surgery etc… you need to complete a 3-5 year residency and then pass your specific specialty board exams.  After that you can do EVEN MORE training called a “fellowship” to be a sub-specialist; such as a vascular surgeon, a child psychiatrist, or a pediatric oncologist. 

There are a few problems with this system.

In 2012 :
38,377 doctors applied to residency training programs in the United States:  there are only
24,034 slots available.

1^st – 14,000 doctors who graduated from medical school and passed their general medical boards – will not be able to practice in the USA because they didn’t get into a residency.

2^nd – How do you decide who goes to which residency?  Let’s say I wanted to be a dermatologist.  I applied to 45 different dermatology residencies.  I interview at 8 of them. 
Those 8 programs have interviewed anywhere from 15 to 100 applicants.  Every residency wants the best applicants, and every applicant wants the best program (or sometimes any program).

What is the best way to decide who goes to which residency?  Everyone knows you (the applicant) are interviewing at 7 other places - and you know they are interviewing another 50 people for the spot you want.  Who picks?  If you aren't picked by your top choice - do you then apply late to your second choice?

How do you make it fair and most advantageous for all parties involved?

SWITCH GEARS!

A while ago I read the book “A Beautiful Mind” – the biography of John Forbes Nash.   I blogged about it because it was interesting and insightful - and I got to see the life of a genius with schizophrenia.  There was an entire chapter devoted to his mentor – Lloyd Shapely.

Shapely was a genius of game theory. 
(He and John Nash and two others even invented their own game called “So Long Sucker.”)

Shapely did a lot of theoretical mathematics in game theory – like figuring out how to give the best result for all players when everyone is competing against each other.

 – Which brings us back to the problem of 38,000 doctors applying for 24,000 residency slots.

Let’s say one residency can accept 2 applicants per year.  They interview 20 candidates each year and then rank those 20 doctors from first choice to last choice.

Those applicants have interviewed at 15 different residency programs, and have ranked them from first choice to last choice.

How do you match them up?  How do you make sure that after you’ve weeded through 38,000 applicants applying to 4,427 residency programs offering 24,000 slots – that every had the best result?

How do you make sure that there is not a residency and an applicant that would both prefer each other over what they ended up with?

Let’s say Stanford Dermatology has 3 slots.

I ranked them as my #1 choice, and I am their #20 choice.

I ranked UCLA as my #2 choice and I am their # 5 choice.

I ranked Texas as my #3 choice and I am their #2 choice.

Where do I go?  Do I go to Texas because it's the best match?  Just becuase the combined ranking score at Texas (3+2) is less than UCLA (2+5) or Stanford(1+20)?  What if Stanford’s top 19 picks ranked some place else as their #1? Do I become Stanford's #1 pick because I'm the only guy left who really wants them?

Whose list takes precedence?  Does Stanford send out 3 letters of acceptance, wait to see if they get rejections, and then try to fill the slots with the next 3 people on their list?

There is a system called the National Resident Matching Program (NRMP).  It’s designed to take every applicants rank list, and every residency programs rank list – and match them up. The applicants choice is considered first, then the Residency's.

Many applicants think - Can I beat the system?  How can I get into a better program than I’m really qualified for?  Could I rank programs at the top of my list that I have no chance of getting into – and then hope that the system will feel sorry for me and give me the first program I have a shot at (which is my REAL 1^st choice but I ranked it low to game the system?)

You may think I’m kidding.  I’m not.  I had friends in medical school trying to play this game with their training sites and med-school rotations.  They tried to beat the system, to play the game.

Luckily – the Matching system (NRMP) is based on Shapely’s theories about game theory.

A man named Alvin E. Roth proved that the NRMP was both stable and strategy-proof.  It gave everyone the best possible outcome, and it was impossible to “win the game” or “beat the system” by some strategy.

It is in everyone’s best interest to be completely honest in their rankings.  You have the best chance of getting your 1^st choice, and so on down the list.  It is true for the applicant, it is true for the residency.

This seems to make perfect sense – but how hard was it to make that system?  How do you allow for so many variables.

Some residencies only have 1 slot, some have 20.  Some applicants only rank 1 program, some rank 30?

That is why Shapely and Roth are winning the Nobel Prize this year.  Their combined efforts have developed a perfect system.  It can’t be beaten, tricked, swindled, twisted, or played.  Everyone uses the exact same strategy.

3 years ago I applied to 10 programs.  I interviewed at 5 programs and made my "rank list."  On “Match Day” every graduating medical student found out where they were working for the next few years.  I found out I was moving to Reno, my first choice.

2 months ago I applied for a “sub-specialty fellowship.”  I interviewed last month.  I submitted my “rank list” last week.

January 9^th 2013 is “Match Day.” It’s the day I find where I’m training for the next 2 years (if I matched at all).

December 8^th 2012 is the Nobel Prize Ceremony.  That’s the day that Roth and Shapely will give their Nobel Lectures.  I’ll be listening, and silently thanking them for making my life, education, and career - much easier.

To Dr. Roth and Dr. Shapely – thank you.


P.S. (Random Fact) - The Nobel Prize in Economics is not actually a Nobel Prize.   There are Nobel Prizes in Physics, Chemistry, Physiology/Medicine, Literature, and Peace.
It's actually awarded by the Central Bank of Sweden and is called "The Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel"

Studying For Tests: My Two Decades of Evolving Study Techniques

Last week I took the PRITE exam.  (Psychiatry Resident In Training Exam)

I still have more tests to take in the future: Child Psychiatry Board Exam, General Psychiatry Board Exam, etc...
I may be a doctor, but I only got here by becoming an expert test taker first.  Which means I had to learn how to study.
I am not the smartest or best test taker by far.  I did not glide through medical school, and I was not in the top of my class.  I worked hard, constantly evolving my study skills to meet the latest challenge.  Here is my journey.

ELEMENTARY SCHOOL

 - I almost never studied.  It was so bad that when there were spelling tests and two words were pronounced the same (red, read) I'd have to ask the teacher to use the word in a sentence because I had never looked at the list.
I only studied when there was a competition.  When I was in a Geography competition I spent hours and hours at home memorizing all the countries.

HIGH SCHOOL

 - I studied a little for classes, but I knew there was one test that mattered most: The ACT.  I checked all the colleges I wanted to go to - and figured out what ACT and GPA I would need for a scholarship.  My GPA would take consistent work - but the ACT was a single test with HUGE results.  That's why I needed to figure out how to take it.  I took it my freshman year - I didn't get the score I wanted.
I took a review course and took it my sophomore year - still too low.  I took it again my Junior year - too low.  I took another review course and then took it again my junior year - 1 point too low.
I took it for the fifth time my Senior Year - NAILED IT!

I earned the scholarship I needed to be able to pay for college, and off I went.

COLLEGE

 - This is where I learned the necessity of study groups.  I walked into a physics class and quickly discovered - I didn't get it.  I could go to lecture and read the book and it still made no sense.  So about the 2nd week of class I paid attention to who was bored, but always knew the answer.  Two guys in the front (Jake and Pete) were always joking together, but when the teacher called on them - they answered everything right.
I walked up to them after class and asked if I could study with them. 
They already had a study room reserved 3 days a week at the same time for the whole semester.
All 3 of us aced Physics.
I then took Calculus.  I couldn't find a good study group so I went to the math tutoring center.  I sat there every afternoon for 4 months.  I used the same tutor every time.  He got paid by the school, I learned calculus, and thanks to him I aced that course.
Then came Genetics, Anatomy, Physiology, Organic Chemistry, Evolution, Pathophysiology, etc...
That's when I found my perfect study partner - Kyle.
He was more "bookish" than I was.  I knew the lectures.  I knew what the teachers liked, what topics they cared about and what lecture facts they were most likely to test.
Kyle new the book.  He knew the concepts, the underlying theory.  We sat in study rooms and wrote on white board for hours and hours - recreating metabolic pathways and memorizing names, equations, and formulas.  If not for him, I never would have passed those classes.
For a "pre-med" there is one test that determines the rest of your life: The MCAT.
It is the test to get into medical school.  I couldn't just take it 5 times to get the score I needed, because med school's don't just get your top score, they get all your scores.  They want someone who took it once and nailed it.
So - I decided to study for 1 year with a group of eight guys.
We took the formal practice exam nine months before the real thing.  We all scored too low.  We then met EVERY Saturday and practiced.  We reviewed practice questions, took practice tests, quizzed each other, wrote practice essays.  We worked, and worked, and worked.  One year later - I had my high score, and I was accepted at multiple medical schools.

MEDICAL SCHOOL

 - This is where I learned the art of note taking and an exact / never changing schedule.  By this time I was married with a child and I would have two more children before the end of medical school.  I needed family time, and I needed it to be dependable and predictable.
So I car-pooled with three classmates.  We left at 6:30 a.m. and came home at 5:30 p.m.  Whether we had classes or not - we were at school for 11 hours a day.  Saturday mornings I spent at the library from 9-12... always.
I learned that there was WAY too much material to review.  I needed one place to put all the pertinent information.  ONE page of notes for each test.
My first year the page looked like this:

By second year it looked like this:



I had to have a faster way to review, and to know what was important for the test.
We had study groups every day.  We always got together the night before a test to review again.  We always invited our friend Joel (the smartest guy in the class who lived near us) to join us.  He would give us the info we never thought to learn.  He would know the answers to questions no one had asked, and no one cared about...except the professor.  I learned enough to pass from my study group, I learned enough to do WELL from Joel.
When the 11 hours got too boring - I found a way to make studying more fun.  When studying anatomy I purchased flash cards with every muscle, bone, artery, vein, and organ labeled.  I'd place the cards all around the edge of  a pool table - and start a game.  Every shot I took - I'd memorize everything on the card under the cue before I took the next shot.  My games of pool took a long time - but I aced my anatomy tests.
I also learned to relax and recoup.  After EVERY test, we'd play basketball.  About 15 guys showed up every time, and we'd play for an hour or two. (you have to do something to stay sane.)

In medical school, there is a test that MUST be passed to go to residency -  the General Medical Boards.(USMLE or COMLEX)  It's actually three tests, each about one year apart, hundreds of questions, hundreds of dollars to take each.
I studied for each one for six months.  I bought the books, I listened to the review lectures, I took the practice tests.  I spent thousands of dollars on review materials, travel, hotels, and the tests themselves.  I didn't get the highest scores, but I passed every single test the first time. 

RESIDENCY

 - It finally happened.  I got to the point where I can read a book and understand the material and remember it.  I now have 4 kids and a very busy position in my church.  I really don't have time to get together for study groups.  So I read.  I have a book with me EVERYWHERE.  I have one at work to read between appointments.  I take one to the DMV while I wait in line, read it on my lunch breaks, and keep one on my night stand to read before going to bed.
That way I can always play with my kids, and when they move on to something else - I can read. 

Why do I mention all of this?  Today I spoke with a sophomore in college whose grades are slipping.  He told me "I've never had to study and I just don't really know how."

This is what I told him.  You start by looking for new solutions.  You go to the tutoring center, you ask people if you can study with them, you make routines and schedules, you find a way.

I didn't make it through school unscathed.  I never had a 4.0 in high school or college.  I almost failed a course in med-school (the week after my 2nd baby was born).  I am not the smartest, or the brightest.  I'm smart "enough," and I learned how to study.  That is the "secret" of my success.