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Panacea Financial Contract Review
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GravelRider said:
So because hospitals and AMCs skim money, you should too? When the practice was being formed at the beginning, were the original partners giving part of their professional fees to someone wanting to buy a new boat? That is essentially what you are asking someone on a partnership track to do. What percentage of the excess professional fees of partnership track folks would you estimate are used to build and maintain the business?

Then when someone suggests that when evaluating a potential partnership opportunity, you should sit down and review the books and finances of that partnership with a lawyer or accountant, the partners on here come out with pitchforks screaming GTFO! Tell me, do you think in the business world when someone is considering investing and becoming a partner of a business that they don’t sit down with lawyers and accountants before making a decision? It seems to me that many of these anesthesia businesses are a little too insulated from free market economics…with the whole exclusive contract stuff. It seems to me that many partnership tracks exist to inflate the salaries of existing partners and not to build and grow a business.

The only time I ever made <$500k salary is when I was lied to on a fake partnership track. I learned a lot of lessons then and one of those lessons is to be wary of Ponzi scheme partnership tracks. Anything less than absolute clarity on where your money is going and what you are buying into is a huge red flag.

To be clear, I am not opposed to some sort of nominal “buy-in” or risk-taking on the part of a potential partner, but it’s kind of like porn where you know the **** opportunities when you see them…and the vast majority are ****. Most people are much better off taking a well-paying employed position than taking a huge risk with your time and optimism on what is more likely than not to be a scam. I wish it weren’t that way, but it is.
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if you are making >500k and you are happy, you are doing great no matter what model you are in..
 
OptionOffense said:
Whatever nomenclature you want to use to make you feel better. Its a house of cards. I dont wanna be your partner. Pay me market rate plus 20% just to have to endure the complaining of your flimsy exclusive contract where you have to endear yourself.
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our partner track docs make more than 20% above market rate. Then when they become partner they make a lot more. Sounds like a win win for everybody.

our house of cards has worked for > 50 years, don't see it ending any time soon.
 
Mman said:
our partner track docs make more than 20% above market rate. Then when they become partner they make a lot more. Sounds like a win win for everybody.

our house of cards has worked for > 50 years, don't see it ending any time soon.
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That’s a win win for sure. But many groups push you to sub 300k with a trash schedule while on the track….

If I got above market rate with a reasonable schedule, I’d be on board. It just seems like a rarity.
 
kidthor said:
That’s a win win for sure. But many groups push you to sub 300k with a trash schedule while on the track….

If I got above market rate with a reasonable schedule, I’d be on board. It just seems like a rarity.
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I can't believe any any Anesthesia group would have the audacity to offer sub 300k. Even academic shops can barely get away with that nowadays.
 
kidthor said:
That’s a win win for sure. But many groups push you to sub 300k with a trash schedule while on the track….

If I got above market rate with a reasonable schedule, I’d be on board. It just seems like a rarity.
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everyone works the same amount of call from day 1 and gets the same case mix depending on particular fellowship
 
Southpaw said:
A cardiac attending MAY be comfortable caring a BMI 70 eclamptic patient with known placenta percreta (with imaging showing invasion into the bladder) but the OB attending is more in tune with the requirements of the case. Also, having worked with both cardiac attendings and OB fellowship trained attendings, if I were to ask the actual OB/GYNs who they prefer working with, they choose the OB fellowship trained anesthesiologist. That has to count for something.

I generally agree with you that an OB year is a waste of a year, but I know for a fact that when hospital administration asks the OB/GYNs who they want to staff their OB floor they'll ask for OB fellowship trained anesthesiologists.
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Completely opposite in my neck of the hills but I understand all centers aren't the same. I may argue it may have more to do with personality traits versus actual skill level. Cardiac folks tend to be more regimented and don't prefer to color outside the lines and that tends to rub some other specialties the wrong way whereas the CV/thoracic/vascular surgeons like people who do things the same way all the time because it makes them comfortable in their cases.
 
Mman said:
our partner track docs make more than 20% above market rate. Then when they become partner they make a lot more. Sounds like a win win for everybody.

our house of cards has worked for > 50 years, don't see it ending any time soon.
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when you stop endearing yourself to everyone, we will see how fast that house of cards comes crumblin' down.
 
Hoya11 said:
if you are making >500k and you are happy, you are doing great no matter what model you are in..
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It depends. Depends on location, what you are doing for that 500k, what benefits comes along with it. is it sustainable? prob not. I would not work 50 hours per week at breakneck speed with 8 weeks off for that. Am I doing great? sure. Is it enjoyable? NOPE
 
OptionOffense said:
when you stop endearing yourself to everyone, we will see how fast that house of cards comes crumblin' down.
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I have a hard time calling it a house of cards when nearly every doc we have is a partner, all of whom were on a partnership track prior to that. But you can call it whatever you want. I assure you we won't be putting up ads for you to respond to. When generally get 3-5x applicants per spot that we hire for.
 
OptionOffense said:
What are the chances that whoever publishes that data is in cahoots with whoever pays physicians?
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I think it’s a survey of all nonacademic physician practices so it includes PP groups, AMCs, hospital employed, everyone. Participation is voluntary and I don’t know the response rate. I think my group participates.
 
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Mman said:
I have a hard time calling it a house of cards when nearly every doc we have is a partner, all of whom were on a partnership track prior to that. But you can call it whatever you want. I assure you we won't be putting up ads for you to respond to. When generally get 3-5x applicants per spot that we hire for.
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I was a partner in a group with a buyin early in my career. 20% of gross collections for 2 years, then partner. When everyone or almost everyone is a partner, the “buyin” of 1 or 2 partner track employees split evenly among 15-20+ partners adds only a very small amount to the income of partners. But it is a big chunk of the income for the new hire. Not worth it in my opinion. The only way to make it worthwhile is to have a lot of people in the “partner track” either through continuous group expansion or through churning.
 
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GravelRider said:
3 years to get someone up to speed? You need to recruit better.

But yeah, agree to disagree. Nominal buy-ins and some risk-taking on potential partners is fine. 3+ year partner tracks that inflate the pay of partners are Ponzi schemes. You also forget to mention that your potential partner CAN’T take out loans to start a practice or take on the risks of building a new practice because we live in a world of exclusive contracts.
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No.

3 years to expand to a volume that can account for double the revenue so we operate at 200% of before.

As you know, anesthesia does not recruit or bring in business. Surgeons do. To scale up, you need to let the surgeons know "hey we plan to eventually to offer 2 rooms instead of 1 on Monday-Friday". You don't start that immediately, maybe just Tuesday and Weds 2 rooms since now the surgeon is doubling the volume so he has to find patients. His group may need to make a new surgeon hire of their own.

And yes - you are skimming off the top of your new hire's revenue. Because you invested hundreds of thousands into forming this group and equipment and licensing over the past few years. Also to run a business, you need to keep cash reserves instead of paying out partner distributions completely. Or else another Covid happens and you close shop.

Or you guys can just go ahead and work for an AMC and line their pockets with your "fair" day 1 wage that never grows. Physician owned is the less of 2 evils. Clearly the physician owned model isn't for you though. I don't think its much of an ask to justify an investment of 3 years at market rate ($425) to have equity to split collections and double your income ($800+). Let me repeat that: you would work for 3 years making the same anywhere else, but this group would allow you to split equity after 3 years...It may be more of an ego thing for you guys.

You should apply to work at Tesla, then walk into Elon Musk's office and tell him you can do everything he does so he should have to split the profits 50/50 with you. Don't forget you weren't there all those years Tesla was hemorrhaging cash and about to go under.

Don't worry this real life group isn't struggling for labor, they fulled the spot within a week.
 
nimbus said:
People do all sorts of mental gymnastics to justify it but I think we can all see that it is just stealing.
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Of course it is stealing. If you cant explain your operation to me like I'm 10, you're stealin'. Anesthesiologists enjoyed the reputation of being very unsavory and sleezy back in the day. very deservedly.
 
USCTrojan11 said:
No.

3 years to expand to a volume that can account for double the revenue so we operate at 200% of before.

As you know, anesthesia does not recruit or bring in business. Surgeons do. To scale up, you need to let the surgeons know "hey we plan to eventually to offer 2 rooms instead of 1 on Monday-Friday". You don't start that immediately, maybe just Tuesday and Weds 2 rooms since now the surgeon is doubling the volume so he has to find patients. His group may need to make a new surgeon hire of their own.

And yes - you are skimming off the top of your new hire's revenue. Because you invested hundreds of thousands into forming this group and equipment and licensing over the past few years. Also to run a business, you need to keep cash reserves instead of paying out partner distributions completely. Or else another Covid happens and you close shop.

Or you guys can just go ahead and work for an AMC and line their pockets with your "fair" day 1 wage that never grows. Physician owned is the less of 2 evils. Clearly the physician owned model isn't for you though. I don't think its much of an ask to justify an investment of 3 years at market rate ($425) to have equity to split collections and double your income ($800+). Let me repeat that: you would work for 3 years making the same anywhere else, but this group would allow you to split equity after 3 years...It may be more of an ego thing for you guys.

You should apply to work at Tesla, then walk into Elon Musk's office and tell him you can do everything he does so he should have to split the profits 50/50 with you. Don't forget you weren't there all those years Tesla was hemorrhaging cash and about to go under.

Don't worry this real life group isn't struggling for labor, they fulled the spot within a week.
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You haven’t read a single one of my posts, but that’s fine. Your post is pretty funny, though. Shall I call you Elon?

You seem to have a skewed view of how many anesthesia groups actually started all those decades ago. They certainly weren’t taking out loans and “hemorrhaging cash” to get started, as you suggest.

Why would I apply to work at Tesla? It’s really not the same thing as being on a partnership track at an anesthesia group, so I’m not sure what that’s about? But since you brought it up, do you think the early investors said “here, take a billion dollars. I’m going to take you at your word that this thing is going to pay off” or do you think there were countless meetings with lawyers and accountants reviewing plans and finances before that billion dollar check was written?

Since you haven’t read my posts, I’ll summarize my thoughts for you: My problems with partnership tracks are a lack of transparency. The vast majority of them are scams, but good for you for finding one that isn’t. Because most of them are scams, most people are better off taking a well-paying employed position than taking a gamble on a opaque partnership track that will leave them with less money and less optimism than if they had just taken the employment job. If you can find a partnership job where there is complete transparency on what you are investing in and you can accurately risk stratify what the gamble is then go for it.
 
Endee said:
Texas has the third most AAs of any state in the country.
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TX - HB3878

Relating to the requirement to obtain a license to practice as an anesthesiologist assistant; providing an administrative penalty; authorizing fees.
www.billtrack50.com www.billtrack50.com

I thought it failed…. Are they supervised 4-1? Can you mix aas and crnas on a care team? Maybe our hospital won’t credential them…
 
OptionOffense said:
Of course it is stealing. If you cant explain your operation to me like I'm 10, you're stealin'. Anesthesiologists enjoyed the reputation of being very unsavory and sleezy back in the day. very deservedly.
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Back in the 1990s the term as “anesleaziologist”.
 
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OptionOffense said:
For a while, a lot of practices hired a regional team or guy who did the regional for every one on the schedule. That was his job. I always found that unfair cuz that is an easy job. So if youve been at that job you wont be good at regional. Usually it was these regional fellowship guys who really cannot do anything else but blocks. (can barely intubate-ive seen it).
But i agree, generally speaking cardiac folks are usually not the greatest regionalists or anything else. Cardiac is too easy. The plan and case is always the same.
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Every time I check in to this thread, you post something even more ridiculous than before.

Sometimes I can't tell if you say dumb stuff to be provocative or because you actually believe the literal truth of what you're writing.

OptionOffense said:
Dude I did cardiac anesthesia in my former life. I know. Stop with this. I find General stuff harder. you have to be on your toes more. A potpourri of regional, chidlren, trauma cases, OB, difficult MACS, full stomachs Spinals for Orthopedics recovery room issues.
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I'm going to dust off the SDN Profile-O-Matic here ...

If I had a nickel for every crusty old guy who half-proudly, half-defensively says he "used to do cardiac" I'd have enough for a Snickers bar. Inevitably it's someone who's not fellowship trained, who quit doing cardiac (or were nudged away from cardiac by their group) because they couldn't or wouldn't invest the effort to become proficient with TEE. And by "proficient" I don't mean able to get a 4 chamber and transgastric short axis view and then swing the monitor around so the surgeon can look at it while he tells the perfusionist how to come off bypass. I mean actual quantitative assessments and thorough exams at a consultant level by someone who's at least a Testamur in TEE.

Which is fine. If those guys want to step away from cardiac because at their stage it's not worth the effort to up their game, more power to them. It just gets old hearing some of them pontificate about what they "used to do" while they're clearly straight-up clueless about what fellowship trained people bring to the table.


I'll concede that general work is more exhausting than doing two hearts in a day solo (assuming one starts and finishes those hearts during daylight hours). I totally agree that covering a mix of general & high-turnover endo 1:4 can be a busy, busy, draining day. You've got to be efficient and skilled in a number of ways. But it's laughable to say that cardiac trained people can't do a "difficult MAC" or some GI. I've worked at quite a few places at this point and the great majority of hearts in this country aren't being done by people who only do hearts. That may be the standard at most academic places, but most groups the heart people do hearts a day or two per week and everything else the other days.

And trauma?!? Ell oh ell. You single out trauma as difficult but label cardiac as formulaic and "plan and case is always the same"?!? Dude, I've done combat related trauma in tents and trauma centers that would turn your "used to do cardiac" hair white, and it honestly ain't all that complicated.

Spinals for ortho made the tough stuff list?!? You cannot be for real.
 
amyl said:

TX - HB3878

Relating to the requirement to obtain a license to practice as an anesthesiologist assistant; providing an administrative penalty; authorizing fees.
www.billtrack50.com www.billtrack50.com

I thought it failed…. Are they supervised 4-1? Can you mix aas and crnas on a care team? Maybe our hospital won’t credential them…
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They’ve been trying to get a licensure bill passed however Texas is one of the few states where AAs can operate under the principle of delegatory authority. There are hundreds of AAs in Texas and one (soon to be two) schools. They work in every major city especially Houston, Dallas, Austin, and San Antonio.

Yes you can supervise them 4:1 and yes you can mix and match them. This is how it is across the country.
 
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pgg said:
Spinals for ortho made the tough stuff list?!? You cannot be for real.
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Some of them are hard. You are going through concrete dude. You can't be for real.
 
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amyl said:
Re: AAs - Can you explain? They aren’t licensed but can practice under what principle?
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Some states have their medical practice act worded in such a way that allows a physician to delegate tasks to appropriately qualified personnel. This section of the statute has been used to authorize AAs to practice in some states: currently Texas, Michigan, and Kansas. All that is required in these states to bring in AAs is hospital approval. I believe the total number of states that have MPAs that would allow this are around a dozen, but I don't know all of them off hand.

I think Texas has like 300 or 400 AAs working. I'm surprised if you're in Texas and didn't know AAs worked in that state.
 
amyl said:
It’s worded weird I guess - so do they have a license?
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License no. Ability to practice, yes. A license would be better which is why Texas AAs and the TSA have been trying to get a licensure bill passed for years now. But it has nothing to do with the ability to work in any hospital in TX--they already can. It's more just security. Delegatory authority can be giveth and taketh away.
 
Almost half my interviews in Texas for residency were about AA and lobbying. It was actually very eye opening.
 
OptionOffense said:
I would rather not see the person that is screwing me on a daily basis.
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Your ego so large that you can't take a job where you make the same $ as your dead end AMC job because the other guy built a successful practice that he will cut you in on after 3 years...got it. And you have no responsibility for billing, building or any admin work. Don't know but that's an enticing gig to me.

If someone is collecting profits, I'd prefer it to be my partner and myself over some MBA in a suit that you bend over for.

You did nothing to invest in or build this but expect to be cut in from day 1...

Also if you struggle with spinals, probably better for you to stay at your dead end gig anyway.
 
It seems, in general, call generates a large portion of anesthesia compensation? Is that accurate?

Reading this thread it seems like the difference in pay between a call-taking position and a non call-taking position is pretty big, but I also feel like I typically see people who say they have call 1x per week. Does that mean that the 1 call day (really just night if you would already be working that day) generate that much income?
 
Gilakend said:
It seems, in general, call generates a large portion of anesthesia compensation? Is that accurate?

Reading this thread it seems like the difference in pay between a call-taking position and a non call-taking position is pretty big, but I also feel like I typically see people who say they have call 1x per week. Does that mean that the 1 call day (really just night if you would already be working that day) generate that much income?
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Yes, we can't find enough people willing to take call. It seems as people get older (and richer?) they are less tolerable to surgeon demands at night. We do tons of non emergent cases at night and it gets old fast. It also messes up your sleep cycle and I feel horrible for 2 days after a night of call. Not sure if the extra money is worth it.
 
DrNut said:
Yes, we can't find enough people willing to take call. It seems as people get older (and richer?) they are less tolerable to surgeon demands at night. We do tons of non emergent cases at night and it gets old fast. It also messes up your sleep cycle and I feel horrible for 2 days after a night of call. Not sure if the extra money is worth it.
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So just to clarify: 1 call day a week for an anesthesiologist generates 100k or more of income? That seems higher than I would expect for any surgeon. Is it just a factor of that you are essentially guaranteed to be working on anesthesia call?
 
Gilakend said:
It seems, in general, call generates a large portion of anesthesia compensation? Is that accurate?

Reading this thread it seems like the difference in pay between a call-taking position and a non call-taking position is pretty big, but I also feel like I typically see people who say they have call 1x per week. Does that mean that the 1 call day (really just night if you would already be working that day) generate that much income?
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We do 1-2 overnights/month on average. But we also have 2nd, 3rd, 4th calls which are our biggest/longest days. People who don’t take call or give away all their call take a disproportionate hit in income.
 
Gilakend said:
So just to clarify: 1 call day a week for an anesthesiologist generates 100k or more of income? That seems higher than I would expect for any surgeon. Is it just a factor of that you are essentially guaranteed to be working on anesthesia call?
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Ortho and NS get 3k stipend/night for trauma call.
 
Gilakend said:
So just to clarify: 1 call day a week for an anesthesiologist generates 100k or more of income? That seems higher than I would expect for any surgeon. Is it just a factor of that you are essentially guaranteed to be working on anesthesia call?
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There are multiple ways of being paid, but call is usually incentivized in some way. It’s not a matter of generating income, but rather incentivizing it so people actually do call. If there was no pay differential, who in their right mind would do call? I suppose other ways of incentivizing it would be with time…for example pre- and post-call day(s) off.
 
Gilakend said:
So just to clarify: 1 call day a week for an anesthesiologist generates 100k or more of income? That seems higher than I would expect for any surgeon. Is it just a factor of that you are essentially guaranteed to be working on anesthesia call?
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I don't get paid more money to take call because it generates income, I get paid more to take call because somebody has to do it. You pay the people willing to do the work necessary. The daylight stuff generates the money, but is easy to find someone to do. As a group if we don't take the call we can't do the profitable cases during the day.
 
Gilakend said:
So just to clarify: 1 call day a week for an anesthesiologist generates 100k or more of income? That seems higher than I would expect for any surgeon. Is it just a factor of that you are essentially guaranteed to be working on anesthesia call?
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Depends who’s paying that….. there are eat what you kill groups that can generate lots units after 3, especially if it’s generating 2x, 3x units, as a way to incentivize people to take calls.
Some groups don’t generate much or don’t have a busy OB service, then maybe hospital needs to step in to subsidize, because you are tying up a person at night and that person may or may not be able to work the next day.
Everyone has a price for their time.

When you really calculate out the differentials of 100K based on 1 call/week. It’s ~1900 per week more than non call takers. For that extra 1900/week. I sleep less either in-house or even at home. I get to do “emergency” cases, I have to deal with L&D and screaming parturients. I get to spend time in the hospital on the weekends. I’ve interviewed at places that taking weekday calls is actually looked at as a partner privilege. As a employee/junior partner you have the “earn” the right by taking shltting Friday/Saturday calls first. Until you climb that ladder. How fun is that?!
 
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Every group is a bit different in how they slice up the revenue pie..but it's the same pie.

Most have call stipends in some form to entice others to take or tolerate call.

In my group..everyone takes call evenly and if you want to make more then you can take someone else's call. You can get 100 units in a call shift and be done by 10pm..so yea it can be substantial income. A stipend is added as well
 
Zendo said:
Are nights-only positions similar to nighthawks in radiology (some even 1 week on, 2 weeks off) common in anesthesia? If so, do they compensate more?
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I haven't come across one in private practice. But I am curious how some groups design it?
 
Zendo said:
Are nights-only positions similar to nighthawks in radiology (some even 1 week on, 2 weeks off) common in anesthesia? If so, do they compensate more?
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We have a couple guys who used to take 14-15 nights/month of OB call in addition to their regular job. But that was before we implemented rules against overworking.
 
Zendo said:
That's very interesting! Do you mind elaborating what your group draws the line at, and is it because it affects performance at work or just a way of looking out for the wellbeing of the individuals?

Its also impressive that they would even want to add on 14-15 nights on top of the regular amount. I would assume that's a good sign about the work/compensation at your place!
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We can’t work longer than 24 hrs without a 6hr rest. It’s a liability issue. When the lawyer asks at the deposition, “how long were you on duty when the event occurred?” We don’t want the answer to be “33hrs.”


It’s about individual workaholic personality more than compensation.
 
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