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[Twiggidy]

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well you'll definitely be covering a lot of weekends and nights if you wish to do cardiac. or you'll take a pretty significant pay cut...

the key factor are your surgeons. i understand not wanting to be on pager call but it's much better than being stuck in the hospital and with the right surgeons, even if you are called in for a dissection, it could only be about a 3 hr case which is speedy in the world of CV anesthesia. And CV emergencies are more rare than the after hours pain calls you'll probably get. Most CV anesthesiologist do it because they love doing hearts. It's not the pay and it's not the schedule.

 

[AdmiralChz]

And CV emergencies are more rare than the after hours pain calls you'll probably get.

I would think it’s easy to say, “call back during business hours or, if it’s an emergency, call 911” for a pain clinic. CV emergencies are life-threatening surgical cases, pain calls can wait until the morning.

Some great advice on this thread. Bottom line (and I advise this for all medical students) - do something you ENJOY, chasing perceived money is a fool’s errand. Mid level issues pervase all of medicine due to inaction, all you are doing is trading one set of negatives for a different but equally pressing one.

Can you escape the OR with pain, have more standard hours? You bet, but instead of dealing with nurses and hospital administration you’re haggling with insurance companies, PCPs who want out of the narcotic prescribing business and an often tough patient population. For me these things break any advantage the specialty provides, but for others they truly enjoy the patient interaction and change a good chronic pain plan can enable.

 

[AKMD_1984]

the key factor are your surgeons. i understand not wanting to be on pager call but it's much better than being stuck in the hospital and with the right surgeons, even if you are called in for a dissection, it could only be about a 3 hr case which is speedy in the world of CV anesthesia. And CV emergencies are more rare than the after hours pain calls you'll probably get. Most CV anesthesiologist do it because they love doing hearts. It's not the pay and it's

I would think it’s easy to say, “call back during business hours or, if it’s an emergency, call 911” for a pain clinic. CV emergencies are life-threatening surgical cases, pain calls can wait until the morning.

Some great advice on this thread. Bottom line (and I advise this for all medical students) - do something you ENJOY, chasing perceived money is a fool’s errand. Mid level issues pervase all of medicine due to inaction, all you are doing is trading one set of negatives for a different but equally pressing one.

Can you escape the OR with pain, have more standard hours? You bet, but instead of dealing with nurses and hospital administration you’re haggling with insurance companies, PCPs who want out of the narcotic prescribing business and an often tough patient population. For me these things break any advantage the specialty provides, but for others they truly enjoy the patient interaction and change a good chronic pain plan can enable.

yeah, you have to pick your poison.

Thats why I am a firm believer in the FIRE movement, more so than pain or cardiac. I firmly believe that true happiness does not only come from intellectual stimulation in pain, cardiac, ICU, peds etc.... but accomplishing financial security so you can negotiate from a point of strength, be able to walk away from shi**y jobs and carve out a position of your own liking. And if does not work out, have the balls and ability to walk out.

 

[Timeoutofmind]

Yes sir. Anesthesia overall has more satisfaction than pain. Pain is frustrating and you need to have the right temperament for it.

I am actually starting a pain practice on the side for a few reasons. I work full time as an anesthesiologist but I do have a fellowship in pain. I was doing mix anesthesia and pain working for a hospital but after CDC guidelines came out in 2016, pain practices became a major dumping ground from PCPs because apparently 'they cant write any meds'. I got tired of arguing with the patient that their PCP lied, got tired of PCPs for being lazy and got tired at the environment in pain medicine and the lack of good, reliable, permanent options. PP was never an option when I was starting out as I did not have the means or finances, and eventually I realized hospital employment is not the answer because of bureaucracy and ***** administrators and CEOs at each level.

So with that in background, I just filed for my own corporation, and will start seeing patients hopefully when my credentialing etc is done in January. I don't care about quantity of patients or money - I just want to break even and establish a high quality practice - thats my 6 month goal. And from then, build a reputation, expand and move forward. Hopefully, down the line, I will use that as leverage and sell it to a hospital or merge with another practice on my terms as opposed to being a straight employee. Lets see how it goes...

you know, currently I make close to 500 k with 11 weeks off working FT anesthesia...but the problem is the quality of time off. I worked July 4, will be working thanksgiving and and Christmas day. Essentially either i am on call or working 4 out of 6 holidays a year. Our practice belongs to AMC, but staffing is an issue.
Having two random weeks off in October is not the same as having long weekends and holidays off. When nov and dec schedule came out two weeks ago and I saw my name on the holidays, I had a meeting with my chairman and regional director about this non-sense. Thats one thing I will tell you - if you dont like being told what to do, maybe anesthesia is not the right field for you. Unfortunately the chairman has his hands tied because we have two or three physicians that are not team players so the rest of us have to take the brunt. I was made a promise that next year I will be taking less call on holidays...

Anyways, its quality vs quantity. And if you calculate the amount of time you spend working weekends on call plus back up (I work at least 1 weekend a month in house - either Saturday and Sunday first call and the other weekend day as back up) and at least one friday in house. Sometimes we work 2 weekends a month. So if on average, your'e working 1.5 weekends a month in house, thats 36 hours of additional time per month. Not counting weekday inhouse call or backup. Im being very conservative. Multiply that by 40 hour work week (because my paystub says that I am paid hourly based on 40 hour work week which is bogus - i work close to 55-60), and then 12 months that the pain guy is NOT doing - so that what counts as quality of life. At least for me. Family time is important...my kids are young - i have two boys under 3, and i dont want to miss out more than i already do. And holidays and time off matters. Again depends on the type of person you are.

Im 35 now - my student loans are already paid off, I purchased a house last year, and I just crossed 1M in net worth which i am very grateful about. My goal is 5 Mil of NW. So after a few years, I will re consider options and if I can afford to take a paycut for quality of life, I will either do full time pain or ASC anesthesia or half and half.

So again my friend, decision to do pain vs cardiac is not just based on what you like right now, but what you will like 5, 10 and 15 years down the road...always give yourself the option.

This is an interesting post to me for a number of reasons
A lot of people dont get the profound difference between a pain practice and OR practice
A pain fellowship is more like a hunting license
You have to create your own destiny
You are competing with all sorts of random neurologists, spine surgeons, radiologists, PM&R etc who all dabble in pain
You need to do something to stand out from the crowd
You need to have your hands in several different buckets and be creative and forward thinking.
Its not just gonna come to you
My job could not be more different then your post. On the one hand I am just blessed. But also, in fairness, it takes some intentionality and insight to craft a practice.

Major midwestern city, my first choice location wise when searching for jobs
I do no afterhours paperwork
Work around 40 hours a week
make > 500K
Minimal/zero narcs and disability
Virtually zero after hours calls
Take off whenever I want, usually like 8 weeks or more a year

Its really about how you set up the practice, managing your staff and patients expectations, and dealing with other doctors, streamlining EMR and dictation use, delegating tasks, understanding how to get out of stuff and get what you want with the admins, informal social networking, etc

These are soft skills and judgment calls

You also need to cast a broad net when searching for jobs and understand and be very clear upfront about what the important aspects are of a pain practice when interviewing and clarify all of this up front (e.g. I insisted that it says in my contract I dont do any inpatient consults, etc)

 

[AKMD_1984]

This is an interesting post to me for a number of reasons
A lot of people dont get the profound difference between a pain practice and OR practice
A pain fellowship is more like a hunting license
You have to create your own destiny
You are competing with all sorts of random neurologists, spine surgeons, radiologists, PM&R etc who all dabble in pain
You need to do something to stand out from the crowd
You need to have your hands in several different buckets and be creative and forward thinking.
Its not just gonna come to you
My job could not be more different then your post. On the one hand I am just blessed. But also, in fairness, it takes some intentionality and insight to craft a practice.

Major midwestern city, my first choice location wise when searching for jobs
I do no afterhours paperwork
Work around 40 hours a week
make > 500K
Minimal/zero narcs and disability
Virtually zero after hours calls
Take off whenever I want, usually like 8 weeks or more a year

Its really about how you set up the practice, managing your staff and patients expectations, and dealing with other doctors, streamlining EMR and dictation use, delegating tasks, understanding how to get out of stuff and get what you want with the admins, informal social networking, etc

These are soft skills and judgment calls

You also need to cast a broad net when searching for jobs and understand and be very clear upfront about what the important aspects are of a pain practice when interviewing and clarify all of this up front (e.g. I insisted that it says in my contract I dont do any inpatient consults, etc)

Appreciate your post and sharing the type of practice you have. Personally speaking, giving up anesthesia to do 100% pain is and most likely will never be an option. Some pain guys are so far removed from being anesthesiologists that I wonder why they even went through an anesthesia residency. Would have been better for them to do neurology, PMR or even psych. Those are much easier routes to go into 100% outpatient pain medicine and far more related than OR general anesthesia. I think if you are dead set on practicing pain - best is to go through psych, since one can incorporate addiction medicine and practice pain medicine which is in high demand. Bread and butter procedure in pain can be learned even if you are a fellowship trained psychiatrist.
In most areas there is 10x shortage of addiction physicians per 100,000 persons. The DEA, police, and other law enforcement agencies view a psychiatrist much more kindly than a 'pain physician'. Unfortunately that is due to being involved in pain pills and overall bad reputation that pain docs have. Again, thats just my take - we can spend hours debating this topic.
As for my own niche, marketing and type of patients: I have always practiced in conjunction with ortho/spine/vascular surgeons and oncologists. At times neurologists for headache management. Rheumatologists for refractory joint pain. Bottom line is, the patients have to be legitimate. I do not take cash paying patients or patients without a PCP. I never prescribe medications first visit and actually first visit is when i decide if i will take on the patient in my practice. Again, being an independent physician and not under pressure of making it a profitable venture either for a hospital or scummy PP guys will allow me to have a low risk and clean practice, with high over sight. I am OK with inpatient pain medicine and consults also and find that easy work, interesting, and impactful as well (helps speed up discharge from hospital etc - which is a true value to the hospital). It helps with marketing and presence in the community too.
I intentionally do not advertise myself to PCPs because an overwhelming majority of them are just looking to dump their opioid patients to the pain physician.

 

[Status Sciaticus]

This pretty much sums up why my wife didn’t do pain although she had the fellowship offered to her.

If you like to stomp out pain, you can do plenty of that on an acute pain service. It is majorly rewarding even though it’s temporary. Lots and lots of needle jockeying on a fast ortho/trauma day,

One big thing for me that was mentioned above is that my time is 100% mine when I leave the hospital.

I’ve practiced anesthesia with 700k+ and 12-14 weeks off. Hard to do that in pain, but I am sure it is possible.

I don’t think I’ve ever taken any less than 10 weeks off a year ever since I started doing anesthesia.

Work hard, play hard mentality isn’t for anyone... long nights on call, disaster cases, etc.... My wife came home last night after dealing with a magnum through the chest that exploded the liver plus cardiac injury 30 units of products through a Belmont, median sternotomy, etc.

what part of the US is this 700k + 14 weeks off anesthesia practiced? Asking for a friend.

 

[10KHertz]

Hey guys,

I’m a CA-2 and have been struggling with fellowship options. I’ve narrowed it down to pain vs cardiac (yes, i know. They’re extremely different) and am having a hard time deciding. Have talked to a lot of different mentors, senior residents going into both the fellowships, and alumni from my program as well.

In terms of cardiac, I enjoy the academic stuff about it (learning about the procedures, physiology, TEE, etc) and at this stage in my training don’t mind the middle of the night emergencies. i have a few concerns though. Namely, while I don’t mind the high stress, middle of the night emergencies as a resident with great attending back-up, is this something I will end up getting burnt out by and will it still be this fun/exciting without an attending behind me. I genuinely enjoy the OR environment, too. The other concern I have is about fellowship itself. nearly all the mentors I have have trained at Duke for fellowship and they seemed miserable during their training. I don’t want that for myself (even for a year)and I’m curious if all programs are that bad.

When it comes to pain, I love the procedures, I like learning about different pain syndromes, and I really don’t mind clinic or the patient population. The schedule is a huge plus, but what I’m worried about is that we don’t get a huge amount of exposure to pain (especially advanced interventional procedures) so I’m worried I’d be going into pain fellowship somewhat blind. It also feels so different from anesthesiology (which it is) and I worry I’d be leaving a huge knowledge base behind in my career as a pain management physician.

that’s it in a nutshell - thoughts?

A couple salient points regarding a career in Pain:
1. You are dealing with patients with up to 25% of psychiatric and personality disorders. You need to be comfortable with diagnosis and treating these misunderstood patients.
2. You will be wearing lead-gowns daily for years... know your spine health and understand radiation risks (we pain guys have increased risk period) and ways to minimize it.
3. Finally know the cost of entry into the field. Being independet is increasingly difficult in this ACO environment.

good luck.

 

[deleted697535]

Can i ask a q re pain fellowship?
Like what regulates it? Is there an exit exam or cert of completion. With cardiac theres an exam in Echo and number of scans etc which is at the end of the fellowship year and makes it a bit more legit. With pain what is to stop you doing 6 months of it, learning some skills and away you go?

I do apologise for my ignorance in this field!

 

[AdmiralChz]

Can i ask a q re pain fellowship?
Like what regulates it? Is there an exit exam or cert of completion. With cardiac theres an exam in Echo and number of scans etc which is at the end of the fellowship year and makes it a bit more legit. With pain what is to stop you doing 6 months of it, learning some skills and away you go?

I do apologise for my ignorance in this field!

Actually, pain is more legitimate in this realm than cardiac. There is a board exam administered by the ABA and is an approved subspecialty with its own CME and what not.

While the echo exam is the de facto board exam for Cardiac it’s not actually a separate board and does not have subspecialty status with the ABA (I think only Pain, CCM and maybe Peds are). And in fact, anyone including a lay person can take the advanced echo exam (“Testamur”) but only those with the requirements (fellowship, number of exams) can apply for certification. This takes FOREVER and even now after almost 16 months only ONE of my co-fellows has the certification and the rest including me are still waiting.

There SCA is actively pushing for a formal board exam, but apparently this was denied like 10 years ago.

 

[sevoflurane]

NBE is notoriously slow to push out advanced certificates. Zzzzzz....
16 months is ridiculous.
I think they meet twice a year.

 

[AKMD_1984]

Can i ask a q re pain fellowship?
Like what regulates it? Is there an exit exam or cert of completion. With cardiac theres an exam in Echo and number of scans etc which is at the end of the fellowship year and makes it a bit more legit. With pain what is to stop you doing 6 months of it, learning some skills and away you go?

I do apologise for my ignorance in this field!

There’s an exam for it, it costs $2000 to take it and it’s about 4 hours long. It’s 200 questions over 4 hours. You have to finish an ACGME accredited residency and boarded in primary specialty and then a need a ACGME approved fellowship in pain to be able to sit for it.

 

[AdmiralChz]

NBE is notoriously slow to push out advanced certificates. Zzzzzz....
16 months is ridiculous.
I think they meet twice a year.

Yeah. At 6 months they had a fire or flood or something (not kidding!). At 10 months I had to redo my entire log because they didn’t like the format. At 11 months I had to send another letter from my program. At 12 months it was complete, “in the hands of the committee” which meets once or twice a year.

This is why very few if any jobs formally require NBE certification in lieu of just a fellowship (or experience, or nothing).

 

[PieOHmy]

This pretty much sums up why my wife didn’t do pain although she had the fellowship offered to her.

If you like to stomp out pain, you can do plenty of that on an acute pain service. It is majorly rewarding even though it’s temporary. Lots and lots of needle jockeying on a fast ortho/trauma day,

One big thing for me that was mentioned above is that my time is 100% mine when I leave the hospital.

I’ve practiced anesthesia with 700k+ and 12-14 weeks off. Hard to do that in pain, but I am sure it is possible.

I don’t think I’ve ever taken any less than 10 weeks off a year ever since I started doing anesthesia.

Work hard, play hard mentality isn’t for anyone... long nights on call, disaster cases, etc.... My wife came home last night after dealing with a magnum through the chest that exploded the liver plus cardiac injury 30 units of products through a Belmont, median sternotomy, etc.

where are you makign 700k with 14 weeks off in anesthesia.
geez

 

[sevoflurane]

where are you makign 700k with 14 weeks off in anesthesia.
geez

Middle of nowhere, soul crushing, crappy middle America.
On Q2 weekends towards the end.
Not sure if it was worth it given my current situation.

 

[sevoflurane]

Example: 2 hearts by 3pm = 4k then 250/hr plus blocks $ after 3pm and call stipends on top of that.
$500 minimal call in (epidurals from home)...medicaid negotiated up to 50/unit.

 

[sevoflurane]

All subsidized by the hospital.

 

[sevoflurane]

Vacations were ALWAYS taken to LEAVE that town.

Financially responsible move, but a lot of drawbacks.

 

[dchz]

Vacations were ALWAYS taken to LEAVE that town.

Financially responsible move, but a lot of drawbacks.

Is this now sold to an AMC?

 

[mja75]

I recommend you chose the setting where you feel happier aka following your gut. For me, I was clearly happier in the pain clinic and now as an attending, I've only gotten happier with my choice. The mental health benefits of having a weekday, no call schedule cannot be overstated. Time is the ultimate currency.

 

[deleted697535]

So what did you decide?