Academic vs PP practice

[Random Anesthesiologist]

A comment by pgg in another thread got me thinking... What are some big practice differences between academic anesthesiology and private practice?

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[ProwlerturnGas]

Here are the differences that I care about: I make double what I made in academics. I do my own cases instead of watch an SRNA fumble through things.

 

[aneftp]

Here are the differences that I care about: I make double what I made in academics. I do my own cases instead of watch an SRNA fumble through things.

Either u got paid very low in academia or ur private practice pays a lot

Cause most academic places hover around in the low to 300s (plus probably around a $50k benefits package).

So "double" means you are raking 700k

 

[deleted162650]

I think the main diff is that in PP you tend to care more about things that are . . . Important.

No agonizing over stupid minutia like an internist or adhering to 50yo dogma.

Just focus on what is gonna make a difference to your anesthetic - the rest is noise.

 

[ProwlerturnGas]

Either u got paid very low in academia or ur private practice pays a lot

Cause most academic places hover around in the low to 300s (plus probably around a $50k benefits package).

So "double" means you are raking 700k

Haha. I wise I made that in academics. Seriously...I might have stayed. So when I say double now, I actually mean a little over double

 

[VA Hopeful Dr]

I think the main diff is that in PP you tend to care more about things that are . . . Important.

No agonizing over stupid minutia like an internist or adhering to 50yo dogma.

Just focus on what is gonna make a difference to your anesthetic - the rest is noise.

Not an anesthesiologist, but do work in PP FM, and this is key. Its amazing how mindsets change when you don't have a hospital paying your salary no matter what.

 

[pgg]

Everybody needs Versed
OB airways are difficult
Everyone on dialysis needs a K drawn
Can't use vent for PPV with a LMA
LMAs and GERD

Been a while since we had a dogma thread.

In defense of my fellow academics though, I have to say that I think almost all of the ones I know don't buy the well-debunked dogma. Maybe our tower isn't ivory colored enough.

 

[urge]

A comment by pgg in another thread got me thinking... What are some big practice differences between academic anesthesiology and private practice?

The line has become very blurry in the last few years. Many academic programs are being run like PP with residents instead of nurses. No non clinical days, no office, nothing. Many academic attending do cases alone too.

You have to give lectures and write a lot of evaluations but other than that there are academic programs that are just like PP.

 

[aneftp]

The line has become very blurry in the last few years. Many academic programs are being run like PP with residents instead of nurses. No non clinical days, no office, nothing. Many academic attending do cases alone too.

You have to give lectures and write a lot of evaluations but other than that there are academic programs that are just like PP.

Yup. And that's why this post will get various responses. Pros vs cons.

There are some very nice academic places with guaranteed non clinical day off each week. Out the door by 3pm if not on call or late. Calls start at 7pm. One weekend every 8 weeks. Those are good academic places

Than there are academic places call is q7. 1 weekend call every month. No non clinical days off. Expected to work to 5pm daily. Plus giving lectures and attending meetings etc.

Same with private practice (60-65 hour work weeks vs 45 hour weeks).

And of course the compensation.

I am at a stage in my career I am ok with making 300k plus benefits and taking 12 weeks off and working reasonable 45 hours a week in private practice. But those at getting harder and harder to find.

 

[Noyac]

Everybody needs Versed
OB airways are difficult
Everyone on dialysis needs a K drawn
Can't use vent for PPV with a LMA
LMAs and GERD

I assume you are describing academics here?

Because I haven't checked a K in a long time on dialysis pts, haven't put an OB to sleep in a while and don't remember having trouble with their airway either. I don't even ask about GERD much anymore and everyone gets LMAs if the case is suitable. Nobody gets versed. But is still don't turn on the vent with an LMA. No need as far as I can see.

 

[2Fast2Des]

Does everyone in PP get the same prop/roc/tube formula no matter what as we do in academics? Its frustrating for those of us who want to do PP after residency and learn various techniques except attendings want the same plan for every pt, especially too because the surgeons dictate anesthetic plan. Of note I've had my attending cancel a toe/foot wound debridement on a guy on dialysis for K of 5.5, which was going to be done as MAC to begin with... Wonder if that is normal?

 

[vector2]

I imagine canceling a MAC on an ESRD K5.5 in PP happens about once every 3 eons.

As for residency, as a CA-2 or 3 you need to be aggressive in broadening your armamentarium on those (hopefully rare) days where you have some garbage ASA-1 cases and you're with a staff who trusts you. Young, healthy guy not tolerating a moderate MAC? You should be able to run a deep MAC/spontaneously ventilating propofol GA and be slick enough with your titration and airway placement that the guy doesn't move, doesn't obstruct, doesn't go apneic, and stays gag/bloody nose-free. Prone MAC looks relatively safe and feasible? Do it. Lap chole and you're banned from using midaz, prop, roc, fent, neostig, and glyco? Figure it out. Long case and you've never used a vec drip before? Read about it and hang one. Feel like your ultrasound skills aren't up to par? See if you can wheel the patient back early, induce, and use U/S to practice placing your second IV in a basilic, cephalic, or deep brachial vein.

Also, if you don't have an official airway rotation, you should plan out days where you're going to do all your cases without DL'ing (asleep fiber, fast trak, lightwand, mcgrath etc).

Your staff should be down with allowing you to do these things if they're not too cost-prohibitive to the dept budget and you are prepared enough so you don't significantly slow down the room. If your staff is still unwilling, you should make this known to your PD and to ACGME during your yearly survey and/or site visits.

 

[Planktonmd]

Everybody needs Versed
OB airways are difficult
Everyone on dialysis needs a K drawn
Can't use vent for PPV with a LMA
LMAs and GERD

You are describing CRNA anesthesia not academia!

 

[Planktonmd]

But is still don't turn on the vent with an LMA. No need as far as I can see.

You don't like pressure support???

 

[sevoflurane]

Besides the coin and quality of life, I find that in PP you are able to practice in all aspects of anesthesia if you wish to do so.
Peds, Neonates, Regional, Cardiac, Neuro, Trauma, OB, etc. My experience is that academic anesthesiologists are compartementalized to a large degree.

 

[deleted162650]

^^ that's very true. One of the reasons I decided against academics.

 

[ZzzPlz]

Besides the coin and quality of life, I find that in PP you are able to practice in all aspects of anesthesia if you wish to do so.
Peds, Neonates, Regional, Cardiac, Neuro, Trauma, OB, etc. My experience is that academic anesthesiologists are compartementalized to a large degree.

Are you saying that in PP, anesthesiologists have overall better quality of life? I'd argue that academia comes with better hours, less call and a better lifestyle. Of course there are exceptions.

 

[sevoflurane]

Are you saying that in PP, anesthesiologists have overall better quality of life? I'd argue that academia comes with better hours, less call and a better lifestyle. Of course there are exceptions.

All I know is my experience.... which has been 10-13 weeks a year and >90% MGMA + 1/7 weekends.

Writting papers and teachinng residents all day long would suck the life out of me.
Some people dig it, just not me.

 

[ZzzPlz]

Sounds like a sweet gig

 

[Robotic Wis-Hipple]

All I know is my experience.... which has been 10-13 weeks a year and >90% MGMA + 1/7 weekends.

Writting papers and teachinng residents all day long would suck the life out of me.
Some people dig it, just not me.

Yeah, that job is like hitting the lotto. We will be lucky to get a PP job that doesn't succumb to the AMC takeover little lone one with 12 weeks vacation. From what I've seen 6 weeks is the avg offered anymore. It's pretty much at the point that academics pays within 10% of PP and has better benefits and less hours. Caveat is I haven't actually started fielding offers or interviewing just yet.

 

[deleted162650]

Sevo's sweet gig came at the cost of location (although his current location ain't half bad). Good gigs are still plentiful if you know which rocks to look under.

 

[deleted547339]

I imagine canceling a MAC on an ESRD K5.5 in PP happens about once every 3 eons.

As for residency, as a CA-2 or 3 you need to be aggressive in broadening your armamentarium on those (hopefully rare) days where you have some garbage ASA-1 cases and you're with a staff who trusts you. Young, healthy guy not tolerating a moderate MAC? You should be able to run a deep MAC/spontaneously ventilating propofol GA and be slick enough with your titration and airway placement that the guy doesn't move, doesn't obstruct, doesn't go apneic, and stays gag/bloody nose-free. Prone MAC looks relatively safe and feasible? Do it. Lap chole and you're banned from using midaz, prop, roc, fent, neostig, and glyco? Figure it out. Long case and you've never used a vec drip before? Read about it and hang one. Feel like your ultrasound skills aren't up to par? See if you can wheel the patient back early, induce, and use U/S to practice placing your second IV in a basilic, cephalic, or deep brachial vein.

Also, if you don't have an official airway rotation, you should plan out days where you're going to do all your cases without DL'ing (asleep fiber, fast trak, lightwand, mcgrath etc).

Your staff should be down with allowing you to do these things if they're not too cost-prohibitive to the dept budget and you are prepared enough so you don't significantly slow down the room. If your staff is still unwilling, you should make this known to your PD and to ACGME during your yearly survey and/or site visits.

Where are you that you still have lightwands? Are you "that guy" who stocked up or were you just making a point?

 

[aneftp]

Does everyone in PP get the same prop/roc/tube formula no matter what as we do in academics? Its frustrating for those of us who want to do PP after residency and learn various techniques except attendings want the same plan for every pt, especially too because the surgeons dictate anesthetic plan. Of note I've had my attending cancel a toe/foot wound debridement on a guy on dialysis for K of 5.5, which was going to be done as MAC to begin with... Wonder if that is normal?

U push roc in a 15 min lap appy/choly u will kill your wake up time which hurts turnover time. I guess u can push 20mg of roc but it depends on the airway.

Are you saying that in PP, anesthesiologists have overall better quality of life? I'd argue that academia comes with better hours, less call and a better lifestyle. Of course there are exceptions.

Again. There is no straight answer.

There are very nice academic jobs. Why do u think people stay for decades for "lower income"

There are very nice private jobs as well.


And than again there are crappy academic jobs. (Hint if it's posted on gas work with multiple job opening on gas work....it probably not a good academic job!)

Of course there are crappy private jobs as well. In my opinion the groups especially those with super parents that "just sold out" tend to have the crappiest jobs. Cause those super partners were fat lazy cats who barely took call. Collected the cash from the AMC and than try to find suckers who will take most of the weekend calls for them.

 

[pjl]

U push roc in a 15 min lap appy/choly u will kill your wake up time which hurts turnover time. I guess u can push 20mg of roc but it depends on the airway.


Again. There is no straight answer.

There are very nice academic jobs. Why do u think people stay for decades for "lower income"

There are very nice private jobs as well.


And than again there are crappy academic jobs. (Hint if it's posted on gas work with multiple job opening on gas work....it probably not a good academic job!)

Of course there are crappy private jobs as well. In my opinion the groups especially those with super parents that "just sold out" tend to have the crappiest jobs. Cause those super partners were fat lazy cats who barely took call. Collected the cash from the AMC and than try to find suckers who will take most of the weekend calls for them.

Sugammadex FTW. You can push all the roc you want.

Jobs are all about tradeoffs. PP vs academic, you just have to decide what is important to you, and you can have it. Just comes at a little price of the things that are not important to you.


Sent from my iPad using SDN mobile app

 

[aneftp]

Sugammadex FTW. You can push all the roc you want.

Jobs are all about tradeoffs. PP vs academic, you just have to decide what is important to you, and you can have it. Just comes at a little price of the things that are not important to you.


Sent from my iPad using SDN mobile app

I'll let others be the Guinea pigs for sugammadex.

The first rule in medicine is don't be the first guy to use the drugs. (Trust me my sister is physician and she's pretty high up in the fda food chain as one of the higher up medical officers with new drug and testing)

But we can agreed trade offs in private vs academic.

 

[Ignatius J]

I'll let others be the Guinea pigs for sugammadex.

The first rule in medicine is don't be the first guy to use the drugs. (Trust me my sister is physician and she's pretty high up in the fda food chain as one of the higher up medical officers with new drug and testing)

But we can agreed trade offs in private vs academic.

Europe has been using it for years. Trust me- we aren't the firsts.

 

[confusingleaf]

Yup. And that's why this post will get various responses. Pros vs cons.

There are some very nice academic places with guaranteed non clinical day off each week. Out the door by 3pm if not on call or late. Calls start at 7pm. One weekend every 8 weeks. Those are good academic places

Than there are academic places call is q7. 1 weekend call every month. No non clinical days off. Expected to work to 5pm daily. Plus giving lectures and attending meetings etc.

Same with private practice (60-65 hour work weeks vs 45 hour weeks).

And of course the compensation.

I am at a stage in my career I am ok with making 300k plus benefits and taking 12 weeks off and working reasonable 45 hours a week in private practice. But those at getting harder and harder to find.

ugh that second academic gig you're describing--that's what i'm starting. constrained by spouse's job to stay in the area, and feeling rather trapped. down the rabbit hole i go...

 

[vector2]

Where are you that you still have lightwands? Are you "that guy" who stocked up or were you just making a point?

the latter

 

[signumvitalis]

lap appys/choles take 15 mins in PP? :0 I never would have known this.

Residents like me are so out of touch with the 'real world' outside their academic institution. Or am I just slacking? :-/

 

[Ignatius J]

lap appys/choles take 15 mins in PP? :0 I never would have known this.

Residents like me are so out of touch with the 'real world' outside their academic institution. Or am I just slacking? :-/

One of the biggest myths you will hear is that private practice is this crazy accelerated pace. What it is to me is just a smattering all over. You will see one surgeon take out a gallbladder in 10-15 minutes and you will see another make a 2nd year surgery resident look good. And everything in between. Some go, go, go. Some "Hey, can you find out where the hell Dr. Soandso went because we are prepped and ready". Some nice. Some jerks. Some arrogant. Some as down-to-earth as they come. Some type A. Some more laid back.

Btw, 7 minutes skin to skin is the quickest appy I've seen.

 

[2Fast2Des]

I imagine canceling a MAC on an ESRD K5.5 in PP happens about once every 3 eons.

As for residency, as a CA-2 or 3 you need to be aggressive in broadening your armamentarium on those (hopefully rare) days where you have some garbage ASA-1 cases and you're with a staff who trusts you. Young, healthy guy not tolerating a moderate MAC? You should be able to run a deep MAC/spontaneously ventilating propofol GA and be slick enough with your titration and airway placement that the guy doesn't move, doesn't obstruct, doesn't go apneic, and stays gag/bloody nose-free. Prone MAC looks relatively safe and feasible? Do it. Lap chole and you're banned from using midaz, prop, roc, fent, neostig, and glyco? Figure it out. Long case and you've never used a vec drip before? Read about it and hang one. Feel like your ultrasound skills aren't up to par? See if you can wheel the patient back early, induce, and use U/S to practice placing your second IV in a basilic, cephalic, or deep brachial vein.

Also, if you don't have an official airway rotation, you should plan out days where you're going to do all your cases without DL'ing (asleep fiber, fast trak, lightwand, mcgrath etc).

Your staff should be down with allowing you to do these things if they're not too cost-prohibitive to the dept budget and you are prepared enough so you don't significantly slow down the room. If your staff is still unwilling, you should make this known to your PD and to ACGME during your yearly survey and/or site visits.

There's some attendings who wont even let CA3's push drugs for induction... While the small handful let you try cool new things (aka not prop/roc/tube). Sometimes I draw up different drugs or bring in some of the equipment you mentioned because if you ask the night before, its a good chance we'll get shut down to do the "standard" thing and hope that maybe they'll say yes if its in front of them. Doesn't help when surgeons are trying to drape while you're getting your second IV/A-Line/Central-line to speed up start time for the marathon case...

 

[sevoflurane]

Sevo's sweet gig came at the cost of location (although his current location ain't half bad). Good gigs are still plentiful if you know which rocks to look under.

My current is a bonified 3/3.
But yeah... My last gig was a good 2/3- location was a PITA.

I don't get all the negative job comments on here.
Being fresh out from the job hunt, I had 4 offers with great PP gorups that were all 3/3 gigs.

Bringing that 2/3 to a 3/3 has been a life changer for me.

These jobs are out there. You just have to find them.

 

[deleted171991]

Doesn't help when surgeons are trying to drape while you're getting your second IV/A-Line/Central-line to speed up start time for the marathon case...

That's where the old great attendings come in. One of the (g)oldies in my program used to kick out the surgeons from the room, until the anesthesia resident was all done. No cleaning, no draping, this is a teaching institution, go get a coffee and come back in 30 minutes. That's how it should be in an academic place, except as a CA-3.

 

[Scotty_G]

Sevo are you in the Pacific NW?

 

[deleted162650]

My current is a bonified 3/3.
But yeah... My last gig was a good 2/3- location was a PITA.

I don't get all the negative job comments on here.
Being fresh out from the job hunt, I had 4 offers with great PP gorups that were all 3/3 gigs.

Bringing that 2/3 to a 3/3 has been a life changer for me.

These jobs are out there. You just have to find them.

Sevo,

I need to make it up there this next year. It's been 2 seasons since I've seen snow. Just a general lack of it 2 years ago and this year between a job switch, new home purchase, and a preggo wife there was zero opportunity. You down to catch a few laps this coming season?

 

[Doctor4Life1769]

That's where the old great attendings come in. One of the (g)oldies in my program used to kick out the surgeons from the room, until the anesthesia resident was all done. No cleaning, no draping, this is a teaching institution, go get a coffee and come back in 30 minutes. That's how it should be in an academic place, except as a CA-3.

That would require the attending to have balls to speak up to the surgeon.

 

[sevoflurane]

Sevo,

I need to make it up there this next year. It's been 2 seasons since I've seen snow. Just a general lack of it 2 years ago and this year between a job switch, new home purchase, and a preggo wife there was zero opportunity. You down to catch a few laps this coming season?

You bet. Direct flight from your neck of the woods. I'll pick u up at the airport.

 

[aimedicine]

That would require the attending to have balls to speak up to the surgeon.

Surgeons are not gods, they are just people...

 

[deleted162650]

You bet. Direct flight from your neck of the woods. I'll pick u up at the airport.

Cool, I'll make it happen. Alternatively, if you ever wanna hit up that other big mountain a few hours south of you let me know. Family has a condo there.

 

[Noyac]

You don't like pressure support???

I don't have any issue with it. Just haven't found the need to use it often. I've maybe turned it on with an LMA twice in the past year.

 

[kidthor]

That would require the attending to have balls to speak up to the surgeon.

Not many of my attendings told the surgeons to wait... they just danced and played the game.

Of the very few who did tell the surgeons to wait, they were all peds attendings. I distinctly remember a pushy surgeon being told to sit in the corner and be quiet or leave the room. He sat in the corner and pouted. Then my attending took her time teaching me her intense A Line technique. It was great (and entirely, fully, completely appropriate).

 

[Noyac]

Sevo,

I need to make it up there this next year. It's been 2 seasons since I've seen snow. Just a general lack of it 2 years ago and this year between a job switch, new home purchase, and a preggo wife there was zero opportunity. You down to catch a few laps this coming season?

Oh boy, bring your legs!
Sevo has been banging out hot laps on the best mountains in the lower 48.
Maybe I will join you kids? What do you think?

 

[Doctor4Life1769]

Surgeons are not gods, they are just people...

You don't need to convince me...

 

[Doctor4Life1769]

Not many of my attendings told the surgeons to wait... they just danced like and played the game.

Of the very few who did tell the surgeons to wait, they were all peds attendings. I distinctly remember a pushy surgeon being told to sit in the corner and be quiet or leave the room. He sat in the corner and pouted. Then my attending took her time teaching me her intense A Line technique. It was great (and entirely, fully, completely appropriate).

Where I was, it was the opposite. Surgeons were patient and taught their residents. Our attendings were not that way

 

[deleted162650]

Oh boy, bring your legs!
Sevo has been banging out hot laps on the best mountains in the lower 48.
Maybe I will join you kids? What do you think?

Let's do it! We'll talk cases on the lift and write it off as CME.