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The Coming Bear Market: Part II How to Prepare
Issue #492, October 16, 2017

Some Observations on Cemeteries
Issue #Interim Bulletin #491A, October 12, 2017

The Coming Bear Market: Part I: The Myth of Buy and Hold Forever
Issue #491, October 09, 2017

The Market makes New Highs
Issue #490, October 02, 2017

The Importance of a New High
Issue #489, September 25, 2017

A Little Insurance: Wealth, War and Wisdom
Issue #488, September 18, 2017

Some Observations
Issue #487, September 11, 2017

How to be Successful in Your Career
Issue #486A, September 07, 2017

How NOT to Buy a Home
Issue #486, September 04, 2017

This Week in the Market
Issue #485, August 28, 2017

Is the “Trump Bump” Running Out of Gas?
Issue #484, August 21, 2017

Gold is on the Move
Issue #483, August 14, 2017

The Importance of Estimation
Issue #482, August 07, 2017

Buying Art and Collecting: Part II of II
Issue #481, July 31, 2017

Buying Art and Collecting in General, Part I of II
Issue #480, July 24, 2017

Physicians need to be More Forceful: Follow-up
Issue #479, July 17, 2017

Physicians need to be More Forceful
Issue #478, July 10, 2017

Your First “Real” Investment
Issue #477, July 03, 2017

Leasing a Watch: Don’t
Issue #476, June 26, 2017

The Importance of Your Children having a Job
Issue #475, June 16, 2017

The Problem with Medical Student Debt is—the Med Schools
Issue #474, June 12, 2017

Critters and Varmints in your Home and Yard
Issue #473A, June 07, 2017

Leveraged ETFs
Issue #472, May 29, 2017

Leasing a Vehicle: Don’t!
Issue #471, May 22, 2017

Issue #470, May 15, 2017

More on Buying Jewelry
Issue #469, May 08, 2017

Buying Jewelry: Gold, Diamonds and Pearls
Issue #468, April 30, 2017

Thomas Sowell: Part III of III
Issue #467, April 24, 2017

Thomas Sowell: Pat II of III
Issue #466, April 17, 2017

Live Close to Where You Work
Issue #465, April 10, 2017

Medtronic in Hospital Management
Issue #Interim Bulletin #464A, April 07, 2017

Thomas Sowell: Part I of II
Issue #464, April 03, 2017

A Political Contribution a an Investment: Part II of II
Issue #463, March 27, 2017

A Political Contribution as an Investment: Part I of II
Issue #462, March 20, 2017

Buffett Selling Vacation Home
Issue #461, March 13, 2017

Advanced Placement (AP) ourses
Issue #460, March 06, 2017

The Importance of a Credit History
Issue #459A, March 02, 2017

A Credit Card Scam
Issue #459, February 27, 2017

The Electronic Health Reord
Issue #458, February 20, 2017

Issue #457, February 13, 2017

Platinum and Palladium
Issue #456, February 06, 2017

Economic Outlook for 2017: Part II of II
Issue #455A, February 02, 2017

Economic Outlook for 2017: Part I of II
Issue #455, January 30, 2017

A Story From Vegas
Issue #454A, January 25, 2017

Land Donation Deals and the IRS
Issue #454, January 23, 2017

The Theory of Gambler’s Ruin
Issue #453, January 16, 2017

Student Loans: But Wait, There’s More!
Issue #452, January 13, 2017

A Second Home
Issue #Interim Bulletin #451A, January 04, 2017

The Consumer Confidence Index
Issue #451, January 02, 2017

Social Security
Issue #450, December 26, 2016

My Outlook for 2017: Part II of II
Issue #449, December 19, 2016

My Outlook for 2017: The Market
Issue #448, December 12, 2016

Medicine in 20 Years
Issue #447, December 05, 2016

Higher Interest Rates
Issue #446, November 28, 2016

Trump and the Markets: The Bad and Ugly
Issue #445A, November 23, 2016

Trump and the Markets: The Good
Issue #445, November 21, 2016

Negative Trends: The Suits aren’t Makin’ Steel
Issue #444, November 16, 2016

The New DOJ Fiduciary Rule
Issue #443, November 07, 2016

Barron’s Conference, Part IV of IV
Issue #442, October 31, 2016

Barron’s Conference, Part III of IV
Issue #Interim Bulletin #441A, October 26, 2016

Barron’s Conference, Part II of IV
Issue #441, October 24, 2016

Barron’s Conference, Part I of IV
Issue #440, October 20, 2016

This Newsletter
Issue #439A, October 12, 2016

Memoirs of US Grant: Vol II
Issue #439, October 10, 2016

More Points on Collecting, Investing and the Economy
Issue #Interim Bulletin #438A, October 05, 2016

Personal Memoirs of US Grant
Issue #438, October 03, 2016

Ideas for a High School Part-Time Job
Issue #Interim Bulletin #437A, September 29, 2016

Collecting, Investing, and the Economy
Issue #437, September 26, 2016

Free College
Issue #436A, September 22, 2016

A Military Commitment to Pay for Med School
Issue #436, September 19, 2016

When a CD isn’t a CD
Issue #435, September 12, 2016

I Made a Mistake
Issue #Interim Bulletin #434A, September 07, 2016

What is Your Spare Time Worth?
Issue #434, September 05, 2016

Credit Cards and Bonus/Loyalty Points
Issue #433, August 29, 2016

The Write-off of Student Loans
Issue #Interim Bulletin #432A, August 25, 2016

412 Retirement Plans
Issue #432, August 22, 2016

Join the Club
Issue #Interim Bulletin #431A, August 18, 2016

The Case for Precious Metals and Hard Assets
Issue #431, August 15, 2016

When the US went off the Silver Standard
Issue #430, August 08, 2016

Why NOT to Open a Restaurant
Issue #429, August 01, 2016

Some Tips on Life Insurance
Issue #428, July 25, 2016

More Observations on Negative Interest Rates
Issue #427, July 18, 2016

Issue #426, July 11, 2016

Is a PhD Worth It? Part II of II
Issue #425, July 04, 2016

Is a PhD Worth It? Part I of II
Issue #424, June 27, 2016

Avoid Part-time real Estate Agents
Issue #423, June 20, 2016

Issue #422, June 13, 2016

The Problem with Auction Reserves
Issue #421, June 06, 2016

Make Full Use of Your Capital Investments
Issue #420, May 30, 2016

The Fed’s Announcement
Issue #419, May 23, 2016

Quit While You’re Ahead: A True Story
Issue #418, May 16, 2016

The Precious Metals
Issue #417, May 09, 2016

Negative Secular Trends: Part Ii of II
Issue #416, May 02, 2016

Negative Secular Trends: Part I of II
Issue #415, April 25, 2016

Not Winning is not the same as not Losing
Issue #414, April 19, 2016

Behavioral Economics: Part II: Weaknesses
Issue #413, April 11, 2016

Behavioral Economics: Part I: Valid Points
Issue #412, April 04, 2016

The Most Important Books I’ve Read
Issue #411, March 28, 2016

Secret to Success: Take Risks and do Things Differently
Issue #410, March 21, 2016

The Over-Priced Food Presentation Hustle
Issue #409, March 14, 2016


By Robert M. Doroghazi, M.D., F.A.C.C.

Negative Secular Trends: Part Ii of II

Issue #416, May 02, 2016

        Last week and this week’s letters are a summary of my Commentaries on “Negative Secular Trends in Medicine” in The American Journal of Medicine from January through May (see below).
    Almost 10 years ago, Wall Street legend Barton Biggs noted that when he started on Wall Street in the 60s, the best doctors, lawyers and investment bankers made about the same, because it required similar intellectual ability, hard work and integrity. He quickly noted that was no longer the case. My Commentaries explore the reasons why I believe Medicine is losing its competitiveness for the smartest kids in the class.
The ABIM and Over-reaching Bureaucracy
    Prior to 1990, Board certification in Internal Medicine and its sub-specialties was good indefinitely. At that time, in a completely arbitrary move with no data to support their decision, the ABIM mandated that physicians must be retested, at quite considerable time and expense, every 10 years to maintain their Board Certification. Physicians who had completed all required training, already demonstrated their expertise by passing all required exams, and obtained the required amount of yearly Continuing Medical Education, were required to be retested.  No state requires lawyers to retake the Bar Exam, and no European country requires physicians to retake the Board exams.
    In 2014, the ABIM then proposed, again supported by no scientific data, that physicians obtain 100 Maintenance of Certification (MOC) points (hours) every 5 years, and perform 1 MOC activity every two years. Physicians with time-limited certification would suffer their board certification to lapse. It was estimated the new requirements would cost the average Internist $23,607 in time and money over 10 years, with a cumulative cost of 32.7 million physician hours and $5.7B to all participants.
    What made the debate especially acute was the accusation of financial impropriety at the ABIM, that the new MOC requirements were undertaken only to generate fees. Physicians finally had what I call a “Popeye moment”, saying “this is all we can stands, we can’t stands no more”. A lawsuit was filed, an online petition received more than 23K signature, an alternative organization was founded, and the argument spilled into the lay press. The ABIM backed off, but has, unfortunately, rolled back only some of the controversial changes.
Prolonged Training Periods
    If someone starts med school at age 25 and pursues a subspecialty such as Cardiology, they could be elected President of the United States before being eligible to sit for their Board examination.
    Compare this to their college contemporaries. The average Law School grad has ¼ less debt, and could easily make partner by the time a physician finishes training. MBAs fare even better. They often finish school by age 28 or 29, and come out with barely half the debt. Moreover, they could easily have realized $1,000,000 in earnings, and hold a responsible, even prominent, corporate position with the possibility to earn many times what a physician makes, while a physician is still in the minor leagues. The best and brightest young men and women, who can do what they want, will increasingly choose a career other than Medicine.
    Several arguments are routine made to rationalize the need for more training. First is the explosion of medical knowledge, estimated to double every 7-10 years. To take this specious argument to its illogical conclusion, within a generation physicians won’t live long enough to complete their training (I make that argument with trepidation, that someone will take it seriously).
    Some worry that if physicians are pushed through too quickly they will lack maturity. Do med schools now accept people who they know lack maturity? A 25 year old can serve in the US House of Rep. A 22 year old can lead men into battle. If it is expected that a 26 year old with a physician-quality intellect be mature, they will be mature.
    What I find most disturbing about this entire discussion is that the ABIM (and other similar regulation-setting bureaucracies, see above) made the decisions to prolong training periods with little or no scientific evidence. Dr. Joseph Alpert and I previously showed that shortening training periods improves the value of a medical education as an investment by $250K on a one-for-one basis for every year saved.
    My recommendations:
    1) Shorten pre-medical training: A) skip the 4th year of college. B) Consider a combined 6-year undergrad-MD program. Studies show these grads do as well on standardized tests as those who attended college and med school for 8 years. This is the standard in the UK and Europe.
    2) The 4th year of med school has become vestigial and probably can be dropped.
    3) General training can be shortened for those who pursue a subspecialty.
    4) Specialty training can be shortened for those who pursue a further subspecialty. Ex: Cardiology could be shortened by 1 year for those who pursue EP training.
    If the time required to train a physician can be shortened by 4 years, it will increase the value of a medical education by $1,000,000. The smartest kids in the class, who we want to provide our medical care in the future, will take notice. 
    The impact of an article is determined by how often it is used as a reference, or how often it is viewed or downloaded. I hope you find these topics interesting and important enough to have the articles downloaded so you can read them. Your hospital or medical school librarian should be able to help. If this is not an option, feel free to contact Boone Hospital Center librarian Judy Feintuch at   .(JavaScript must be enabled to view this email address)  Judy has been extremely helpful on this project: I couldn’t have done the literature search without her.
    1) Doroghazi RM. Negative Secular Trends in Medicine: Student Debt. Amer J Med. 2016;129(1):8-10.     
    2) Doroghazi RM. Negative Secular Trends in Medicine: High CEO Salaries. Amer J Med. 2016;129(2):e1-2. 
    3) Doroghazi RM. Negative Secular Trends in Medicine: The ABIM Maintenance of Certification and Over-reaching Bureaucracy. Amer J Med. 2016;129(3):238-239. 
    4) Doroghazi RM. Negative Secular Trends in Medicine: Prolonged Training Periods. Amer J Med. 2016;129(4):352-353.
    5) I will have the exact reference for the Summary article when it’s available.
    The precious metals, and all commodities, have been on fire and are on the verge of breaking out. Likewise, nothing goes straight up: they are due for a rest (or even a pullback). More on this in the near future.
    My pun of the month. I found a dead rabbit in my garden. “It had a bad hare day”.
    At older son John’s insistence, I finally read The Great Gatsby by F(rancis). Scott Fitzgerald, named after distant relative Francis Scott Key, who wrote the Star Spangled Banner. I read the book in less than 24 hours.
    RMD comment: the last line is “So we beat on, boats against the current, borne back ceaselessly into the past”. It immediately reminded me of the last line of Voltaire’s Candide: “That is very well said’, responded Candide, ‘but we must tend our garden”. 
    Going into the last day of the 1959 season, the Milwaukee Braves (who won the pennant in 1957 and ’58 with Aaron, Mathews and Spahn), LA Dodgers, and SF Giants, were all in contention for the NL pennant. Dad and I saw the Cardinals sweep a doubleheader from the Giants at Old, Old Busch Stadium (just 6 years before, it was still Sportsman’s Park, home to the Cardinals and the Browns). The Dodgers won a playoff against the Braves, and went on the beat the White Sox, led by MVP Nellie Fox and Cy Young winner Early Wynn.
    RMD comment: In the left field bleachers we were 50 feet or less from Giant centerfielder Willie Mays, who had earlier signed a contract for $100K per year. I remember at the time doing the math. 154 games into $100K = $649.35 per game. Bleacher prices had just been raised from 90 cents to $1, and dad and I were lucky to make $3 for cutting a lawn. Money has always fascinated me.

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