The Hidden Costs of Medical Student Debt

I just chanced upon reading this insightful article from the New York Times Blog, about (as its title implies) the hidden costs of medical student debt. The author (Dr. Pauline Chen), a practicing doctor somewhere in the U.S., offers a personal recount of her experiences of indebtedness out of the aspirations of becoming a doctor. The truth is, indebtedness for medical students has been the norm for many decades but has quickly increased over the past decade or so. I think the statistics offered by Dr. Pauline Chen are valid: over 80 percent of each medical student class will graduate with debt, and the average debt per student is $158,000.

This figure may not seem much given the purported salaries of doctors, but in reality, I think there are many misconceptions that need to be debunked (disclaimer: I do not work in the field of medicine). First of all, not all doctors are created equal. Depending on what field they specialize (e.g. internal medicine, pediatrics), their paycheck may range from $80,000 to millions per year. I think it would be ignorant to assume all doctors are filthy rich; I'd bet the vast majority do not make more than $200,000 per year.

Aside from the problems of the attitude toward personal debt brought up by Dr. Chen, I think there are a significant number of other problems that warrant attention. These problems --both individual and societal-- are the culprits behind the skyrocketing medical expenses and...colossal debt for students. A number of them are specific to the United States:

1. Length of required commitment -- normally 12 years from beginning to end; 4 years of premed in college + 4 years of med school + 3-4 years of internship
2. High levels of stress -- being given the responsibility over someone's livelihood is no laughing matter and will cause stress when things (inevitably) go awry
3. Uneven supply and demand distribution -- the American Medical Association places quotes on the number of graduates admitted into and graduate from medical schools each year. The result is a huge demand for doctors but little supply.
4. Misaligned incentives -- unfortunately, good doctors often do not stay in their specialty practice long enough to make a difference. They tend to pursue high-income venues like plastic surgery instead.
5. HMOs -- these have infinitely both complicated and raised the costs of medicine in the United States. Healthcare insurance is no longer being used as your average insurance -- you don't call up your auto insurance company for an oil-check of your car, do you?
6. Bottleneck in certification process -- see #3 above.

Did you know that I did not always want to major in economics? When I first arrived in college, I was unsure about what career path I would take. Medicine seemed like a legitimate path back in those days -- after all, both my parents studied medicine (although they are not doctors). It took a rigorous course in genetics to make me realize that medicine was not for me. I wanted to become a doctor and follow many of my friends to medical school, but I ultimately realized that I could not deal with being stuck in education for another decade.

In addition, another reason for my unwillingness to pursue the medical route pertains to point #2 (above). It is the responsibility over the lives of others. Practicing medicine is difference from experiments -- there is no turnarounds if you screw up. If you do screw up, someone will most likely die. I am a pretty sensitive person (if that is not already obvious) so concern over this will consume me. Call me a coward, but I do not want the burden of knowing that I could have saved someone by administering a different treatment...that I was responsible for the death of a patient.

[When I started this post, I believe I had another intention altogether about what to write.]

Enabling the Dreams of Others

For voracious readers out there, the title of this post is a reference to the book The Last Lectureby the late Carnegie Mellon professor Randy Pausch. It is an amazing book -- made more so as it was written from the perspective of a person dying of cancer. After reading the book, I really wish I had met Randy before he passed away (though you can see his lecture here). But this will not be a book review; instead, I am borrowing from Randy to elaborate the ideas in the chapter of his book of the same name ("Part IV: Enabling the Dreams of Others").

I believe that the element of "kindness" has become increasingly rarer in the society we live in. As discussed previously, our society has become enamored with the trappings of wealth and power. Money has been transformed from a medium facilitating exchange of goods to a means of validating our self-worth and, to make matters worse, in measuring ourselves to our peers. This preoccupation with money has led us to become selfish individuals who look at the world as a zero-sum game: the giving to others lessens what we have. I know of this attitude very well, because I am guilty of it.

When I see homeless individuals on the street corner, my immediate reaction is to avoid them or, if that is not possible, ignore them. Sometimes I do give them spare change, but the resulting feeling is the same -- being slightly disgusted with myself at this perceived coldness. I can rationalize all I want about the reasons for my actions: (1) homeless people are lazy, (2) they'll just use whatever I give them to buy alcohol or drugs, (3) it will give them false hope, and (4) whatever I give will only provide marginal benefits. But when I reflect upon my actions, the (damning) conclusion I see is an obvious lack of kindness toward others. Whatever happened to empathy and compassion that the Bible talks about? I would be a hypocrite to not admit that I am a lesser Christian for not following through on the teachings in the scripture.

Self-deprecation aside, the truth is that in our daily interactions, there are always opportunities to be kind to others. Whether this is tipping the nice cashier or holding the door for the person behind you, there are daily instances of these episodes by which we can be kind to someone else. This "other" person could be a complete stranger but when someone is in need, their affiliation/relationship with you should not matter. I wouldn't be wrong to argue that as kindness is identical to altruism (yes there are nuanced differences), our actions should be labeled as such if there were ulterior motives. For example, if you hold open a door because you are romantically interested in the person behind you, you aren't really being kind, are you?

Yet we are going to take this a step further, to the realm of hopes and dreams. Superficially, this is always desiring to help others when you are in the position of doing so. For example, if someone is looking for employment in your company, you can contact the hiring manager and/or refer this individual. Sometimes companies offer bonuses for successful referrals -- so it's a win-win situation. Or you can start by agreeing to become someone's professional reference, or writing a positive letter of recommendation. The basic rule of thumb is this: if you are ever have the power to do something, you should put it to good use. Outside of career employment, you can introduce potential lovers to one another or just offer help when someone needs it. The foundation is desiring to become an enabler for another -- even if the path they chose eventually diverges from their original intention. We are to offer help, not to judge.

At the heart of it, enabling the dreams of others takes an attitude of helping others and applies it to younger generations. It's about being an inspiration, a model figure that eventually inspires others to do the same. In The Last Lecture, Pausch uses the example of a former student "Tommy" who offers Pausch's students a once-in-a-lifetime opportunity to tour the studios of LucasArts (of Star War renown). He reasons that Tommy did it in gratitude for how Pausch helped guide and inspire him while he was a student -- that Pausch "enabled" his dream. On a practical level, it's about being involved in the local community or in your family to help younger siblings. One should never underestimate the potential of even the softest touch of kindness.

[I think eventually I will be posting something more focused on Pausch's book. It's a truly amazing book that offers many wise anecdotes.]

iPhone 5 Spotted in the Wild?

I can be a hypocrite sometimes and this might be true in the case of Apple products. After slamming the company over the fanaticism of its customers (e.g. trading a kidney or going into debt for a iPad 2), I am starting to warm up to some of its products. While a Macbook is out of the question, I have already floated the idea of getting the iPad 3 when it arrives...in November 2011. Now I've just read about the soon-to-arrive iPhone 5 and thinking to myself, should I spring for it?

As reported by this article ("Appolicious"? what a horrible name!), an alleged iPhone 5 was caught in the wilderness of San Francisco yesterday. A tipster apparently caught sight of an iPhone model different from his own iPhone 4, snapped some pictures, alerted the website 9to5Mac, and the rumor mill exploded. Although the open secret has long been that the iPhone 5 will arrive in two months -- in the month of September-- Apple has managed to keep a close lid on its specifications. But here we have it, someone outside of the company has glimpsed the new iteration of the iPhone.

Unfortunately, not much useful information could be derived from the "leak", aside from a larger and curved screen. The tipster reported what he saw to have the screen size comparable to the HTC EVO (which has a 4.3 inch screen) and also "thinner" as well as "wider" than the current iPhone 4. None of these revelations are groundbreaking news -- there were already rumors (coming from component manufacturers) that screen size might be different this time, and Apple is known to obsess about thinning their devices.

But what makes this post interesting is my new openness to the iPhone 5. Because as you see, my birthday is in September and I am thinking of finally upgrading from my trusty Nokia e71x. As a tech geek, I have long been fascinated with getting a new phone and I'm getting sick of waiting of the newer and better devices. The biggest reason is the lack of competing products from others: Android devices suffer from lag due to non-native integration of the OS into the hardware, HP is being timid with webOS phones, Blackberries stink, and Windows Phone 7s are being slow to release. I am hoping to at least try the Nokia N9 though, before making a decision.

Romans 8: "More Than Conquerors"

31 What, then, shall we say in response to these things? If God is for us, who can be against us? 32 He who did not spare his own Son, but gave him up for us all—how will he not also, along with him, graciously give us all things? 33Who will bring any charge against those whom God has chosen? It is God who justifies. 34 Who then can condemn? No one. Christ Jesus who died—more than that, who was raised to life—is at the right hand of God and is also interceding for us. 35 Who shall separate us from the love of Christ? Shall trouble or hardship or persecution or famine or nakedness or danger or sword?36 As it is written:

“For your sake we face death all day long;

we are considered as sheep to be slaughtered.”[l]

37 No, in all these things we are more than conquerors through him who loved us. 38 For I am convinced that neither death nor life, neither angels nor demons,[m] neither the present nor the future, nor any powers, 39 neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord.

The overall passage of Romans 8 ("Life through the Spirit") discusses the difference between living by the Holy Spirit and living according to the flesh. Yet in the former, there will be suffering in the present -- for future glory. Our assurance is that the Spirit will help us through our struggles and suffering because, after all, our God is gracious and loving.

I am singling out the above section from Romans 8, because it is an awesome reminder of who we are and the hope we live for. Although at times we may feel the weight of the world on our shoulders, or perhaps pressure from our culture/peers to conform, the reality is that we live for something much greater. And even more importantly, we are loved by God. This is a love that never fails, always hopes, and always perseveres. This passage provides complete evidence of how God acts in our lives and reminds us of who "has our back". God, the Creator of the universe and giver of life, is this person.

In particular, I am enthralled by the imagery evoked by verse 38. There is absolutely nothing that separates us from the love of God that is found in Jesus Christ -- not demons, not time, not even death! If that does not lend hope for Christians, then I do not know what will.

Book Review: The Girl with the Dragon Tattoo

Last week (yes, there is a lag going on) I finished reading the best-selling novel The Girl with the Dragon Tattoo by the Swedish author Stieg Larsson. I starting reading the book because my roommate owns it and, ever looking to build my literature repertoire, I thought it would be a good choice. It turned out to be a fantastic book -- something Swedish other than Ikea!

The Girl with the Dragon Tattoo is the first book of a trilogy that was left unpublished by a now-deceased Stieg Larsson. It's a very good thing that Larsson's heirs elected to have the works translated and published. There are two protagonists (at least in the first book) for the series: Mikael Blomkvist, a journalist and reporter, and Lisbeth Salander, a gifted hacker and very capable personal investigator. Because it is the first of a trilogy, The Girl with the Dragon Tattoo serves as an introduction to both protagonists and also to the antagonists. Larsson is clearly a very capable mystery-novel author, as this book is composed masterfully and keeps the reader on the edge. I would present JK Rowling's Harry Potter series as a fitting analogy, except Larsson's works are much darker and mature in content.

To give a short synopsis, The Girl with the Dragon Tattoo opens with Mikael Blomkvist being accused of libel against the powerful financier Hans-Erik Wennerstrom. Mikael is sentenced due to having published a damning article on Wennestrom, which the court ultimately finds to consist of unfounded lies. Mikael is forced to quit his position as a part-owner of the magazine Millenium, but is immediately offered an arcane opportunity to research into the disappearance of the niece of another powerful business magnate, Henrik Vanger. While all this is going on, we are also introduced to Lisbeth Salander, an antisocial female hacker who has suffered abuse at the hands of her guardians. She is characterized as incredibly head-strong, determined, and vengeful. Hers and Mikael's paths eventually cross for work purposes, and they quickly develop a hybrid bond that consists of mutual acceptance and physical intimacy. The story ends with a shocking revelation about the Vander family's history and, through Salander's help, Mikael restores his public image.

Larsson's work is clearly intended for adult audiences. While the writing is never explicit, it is not censored to exclude graphic imagery such as physical torture and sex. The author does not seem to be fazed to include them -- which lends authenticity to the work overall. For example, there are incidences of rape and incest that are not for the faint for heart. In addition, the motifs symbolized by the character (e.g. Salander as representing an idealized, strong-willing and independent woman). What makes Larsson's effort so good is the right mixture of the adult elements that is balanced by comical occurences sprinkled throughout the novel. I like the change in scenery from the other works I recently read.

Plot development is also masterfully carried out by the author. The reader is shuffled back and fourth between the two protagonists, in addition to flashback of each respective protagonist. This create the effect that makes it easy for a reader to become immersed in a character: to feel what the character is feeling, and to see what the character is seeing. I found myself at times being annoyed of the shuffling process -- only to realize later that the annoyance was due to my increasing attachment to a certain character. In a way, Larsson teases the reader by introducing bits and pieces about each protagonist until their two independent stories start converging together. The result is synergy: we like each character even more than before, since they complement the other character extremely well.

One thing I really like is the inclusion of unique cultural elements into a novel. In The Girl with the Dragon Tattoo, the setting is Sweden (duh) and the character are model representatives of their country. Larsson seem to have taken the initiative to include as much detail of Sweden as possible -- perhaps to further enthrall the reader into the novel. For example, we are told of the severe cold in the winter as well as the popularity of small wooden cabins near bodies of water. Where do you find this in the United States? The extent of cultural integration brings to mind another great novel: The Kite Runner by Khaled Hosseini.

Overall, I must say I was very impressed by The Girl with the Dragon Tattoo. Normally this can be hinted by the speed at which a book -- positive correlation between liking the book and reading sped. At times the scenes may have been a tad too dark or too explicit, but the novel is clearly the work of a literary master.

Cuisine Fix: Pork & Squash Stir Fry

[Let me preface this post by noting that I cooked this dish before the "Eggs & Tomatoes" dish. This one is a little complicated, has more photographs, and therefore I waited until now to post.]

Most of the dishes I will be blogging about are stir fry dishes, namely because they are quick, easy, and healthy. This one is no exception: a stir fry of pork meat with squash and mushrooms. Total preparation time is about 10 minutes (twice as long as the previous stir fry).

As shown by the photograph above (see, I remembered to document this time), this dish consists of only 4 ingredients. The beauty of stir fry is that you do not need many ingredients to cook up a good dish -- and the only equipment needed is a wok and a stove. There is no messing with the oven, or with any other pots and pans. The ingredients shown are as follows: sliced onions, sliced mushrooms, diced pork meat (that I had previously marinated in soy sauce and frozen), and sliced squash. Squash isn't my ingredient of choice to be honest; my parents grow squash and insisted I take one.

And once again, the ratio of ingredients is not terribly important: there's a lot of squash and little meat simply because I wanted to cook all the squash. [Maybe it's also to compensate for the hot dogs I had been chowing down prior.] Onions are used as the saute base and mushrooms were there because I found them in the fridge. All in all, maybe I did not think things through while preparing this dish -- it's more of being forced to cook because some ingredients were going bad, rather than cooking with a passionate desire...

Instead of the usual white rice, I elected to also make pasta to go with this stir fry. Pasta-making has to be one of the easiest things to cook: all you do is boil water, put in the pasta, cook it, and then add some pasta sauce. I personally am not a huge fan of pasta but, hey, sometimes you need a little variety in the staple food.

The steps I took to prepare this dish (strictly the stir fry) are:

1. Add a few (4/5?) tablespoons of cooking oil to the wok
2. Once the oil is heated, add in the sliced onions and begin sauteing them
3. After onions start to bronze, add in the meat (to avoid any undercooking)
4. Add some salt and soy sauce and cook until the meat is ready
5. Add in the mushrooms and squash together
6. Put the lid on, lower the heat, and let it simmer for 3 minutes. The key here is to have the squash soften and become tender
7. Stir, remove from heat, and serve

If you followed the instructions, your dish should look something like this:

I am a huge fan of boiled corn, so I added half a cob to my dish as a side. As you can see, I like to keep things simple and just have the pasta with the stir fry. It was pretty good!

Automobile: Insurance (Part 2)

And here we are, the final part of the mini-series on the woes of automobile transfer to the state of Virginia. I think the issues I have discussed reflects the norm, rather than the exception, of dealing with the Department of Motor Vehicles (DMV) in any state. But that is now the past and now I move on to examining the nuances of obtaining auto insurance.

Until yesterday, my auto insurance has been together with my parents with the insurance company Liberty Mutual. We have been with this company for many years and their rates were very good in the state of Maryland. But upon inquiry of their rates in Virginia --which turned out to be quite high-- I opted to shop around with other insurance companies. I applied an economic methodology (or just logical) of getting as many quotes as possible, and then selecting the best one in terms of price and coverage.

The Background/Vehicle Profile

I drive a 2008 Honda Civic, an LX-model with 4 doors. I first received my driver's license since the age of 16 and have a spotless record. The only blip could be a speeding ticket (caught by a camera) received last year. I also am considered a good student, with at least a 3.0 GPA from college. But I am not yet 25 years old, an age gap that commands high premiums from insurance companies.

The Playing Field

I looked into a wide range of insurance companies, from the big names to the no-named ones. I tried to select two choices with each company: one at minimum coverage possible (which allowed a straight, skeleton comparison of premiums) and one at the desired coverage. Desired coverage includes a 50/100/50 liability ratio (explained in detail later) for insured and non-insured, in addition to a $500 collision as well as comprehensive deductible. I tried to apply as many discounts as possible, given my background. Minimum coverage is 25/50/25 liability ratio and no other coverage. My cost-per-month results for the Honda Civic are as follows in Arlington, Virginia:

• Geico -- $86.35 for desired, and $42.84 for minimum
• AllState -- $73.83 for desired, and $27.5 for minimum
• State Farm -- $63.6 for desired (did not bother to get a minimum quote)
• Liberty Mutual -- $150 for desired
• Progressive -- $85.35 for desired, and $40.01 for minimum
• Nationwide -- $77.60 for desired, $40.63 for minimum
• 21st Century -- $105.78 for desired, $91/23 for minimum
• Esurance -- $74.14 for desired
• Costco -- $120 for desired

The Decision

From the results above, AllState and StateFarm appeared to be my best options in terms of cost-to-price. AllState had the best priced (by far) of the barebones insurance. However, you should never opt for the barebones package unless finances are really tight or another exceptional reason. My explanation is a no-brainer, with the current rates of medical expenses and car repair costs, you will likely be bankrupt if you get into any accident. Period. $25,000 sounds like a lot of money, but it's a drop in the bucket if either you get insured or someone else is.

Ultimately, I picked StateFarm and loaded up on the coverage. My final premium is about $77 per month, which includes: 100/300/100 liability ratio, $0 deducible for comprehensive damage, $500 deductible for collision, $1000 medical expense, and towing reimbursement of up to $100. This price also included renter's insurance (for my apartment) as StateFarm offers a sizeable discount -- which turned out to be only an extra $2 per month. I was very satisfied with how things worked out. It also helps StateFarm has an office closeby!

The Policy Jargon

After talking with multiple agents and reading on this topic, I feel that I have a pretty good command of the definitions for each coverage topic. You can read about each topic on any insurance company's website (e.g. State Farm's), or you can read my interpretation of each:

• Automobile liability. This is divided into two categories, property damage and bodily injury damage. Both categories are normally the same. To illustrate, my 100/300/100 liability ratio is $100,000 per person for bodily injury ($300,000 total per incidence) and $100,000 for property damage. This topic comprises the bulk of the insurance premium.
• Medical expenses. Think of this as specialized coverage for any medical expenses. $1000 may seem little, but it's specific for medical-related costs and hence easier to file claim on.
• Underinsured motorist. As its name implies, this is when you get into accidents with those without sufficient coverage or no auto insurance at all. By law, liability ratio for this is the same as the automobile liability. But the premium is much less.
• Collision. When you get into a collision with a moving or non-moving object (God forbid!) and your car is damaged, this is what you'd use. Normally there is a deductible, which comes out of your pocket before the insurance company starts paying. After "Automobile Liability", this it typically the second most expensive premium.
• Comprehensive. Any other damage than collision, be it theft, fire, etc. This is actually one of the most affordable premiums and I strongly recommend decreasing your deductible to $0. The different in cost is about $20 from $500 deductible, and the peace of mind is worth it in my book.
• Towing and Labor. Used when your vehicle is disabled and needs to be towed. Insurance covers the first portion of the costs, and you are responsible for the rest. This thing costs only a couple of bucks, so you should definitely have it.
• Miscellaneous (e.g. rental coverage). I do not regard these as necessary, as is the case of reimbursement for rental cars. To each his/her own though...