Anesthesiologist Looking for a Niche

[sunnysol]

Hi,

I am an older doc, residency trained in Anesthesiology but not board certified and out of practice for 10+ years while attending to a schizophrenic spouse and a lawsuit and operating under the illusion I might be able to retire.

Those problems and the illusion have gone away. I have active licenses in Montana and California and have recently completed a 3 month hands-on clinical fellowship at a "recognized" medical school-associated anesthesia program. I have a good letter from the director of that program and I am feeling comfortable with my basic anesthesia skills but need more experience while I continue to study for qualifying and board examinations.

I am pretty mobile but need a little income for expenses. My practice "gap" and lack of board certification are making it difficult to enter clinical practice. Any ideas how I can get what I need in exchange for the use of what I have?

Could I fit into a vacant residency position? Fellowship?

Thanks

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[psychbender]

After 10+ years out of practice, when not previously board certified, aren't you also out of the window for board eligibility?

 

[coprolalia]

I would recommend checking straight with the ABA. If you are no longer are or never were board eligible (that's the key), you may not be able to find a job (at least with a reputable group that will be able to facilitate billing for services). The ABA may also be able to give you some advice on what the next step is.

-copro

 

[Planktonmd]

Hi,

I am an older doc, residency trained in Anesthesiology but not board certified and out of practice for 10+ years while attending to a schizophrenic spouse and a lawsuit and operating under the illusion I might be able to retire.

Those problems and the illusion have gone away. I have active licenses in Montana and California and have recently completed a 3 month hands-on clinical fellowship at a "recognized" medical school-associated anesthesia program. I have a good letter from the director of that program and I am feeling comfortable with my basic anesthesia skills but need more experience while I continue to study for qualifying and board examinations.

I am pretty mobile but need a little income for expenses. My practice "gap" and lack of board certification are making it difficult to enter clinical practice. Any ideas how I can get what I need in exchange for the use of what I have?

Could I fit into a vacant residency position? Fellowship?

Thanks

If you are interested in a residency or fellowship why don't you send a few letters explaining your situation directly to program directors of a few programs where you might be able to go?

 

[Pilot Doc]

No one is going to hire you unless they meet you. Why would they take a chance on someone with an atypical paper trail and a long absence from practice.

Take a tour of less visited parts of California with a stack of CV's. Drive up to Ukiah and walk your resume into the OR. You need places that have a hard time retaining docs. If you seem solid in person, they might overlook the paperwork issues.

 

[Pilot Doc]

billing for services

BE/BC status doesn't affect billing.

 

[buckhorn]

You got a few separate issues.
1. Board certification is advantageous but by no means necessary to practice anesthesia. The board routinely fails half of the people who sit for the written exam, so there are many Anesthesiologists who are 10+ years out of residency still working on passing the boards. Dr. Jensen's website show a great flow diagram on how you can fail the boards repeatedly and still be eligible to take them again. The board will happily take your money indefinitely until you finally pass their unfair, irrelevant, and misguided exam.

2. Finding a job. Do you feel comfortable doing routine anesthesia cases? If so you should apply for every job you see advertised in the states you are licensed, also you should look at getting some more state licenses. I would talk to the reputable larger Locum agencies. A couple of locum's stints could get your foot in the door of a good permanent position. Places that have difficulty hiring doctors like small communities in the middle of nowhere, the government, academic and malignant places like AMC's that steal from their physicians will be more likely hire someone with less than stellar credentials.

If you are not yet comfortable working you should look for a place where you will work during the day and there is lots of backup anesthesia attending around to help you out if you get into trouble. You might consider a fellowship or an extra year of residency. Plenty of programs directors would love to get an almost fully trained applicant to work for 6 month to a year at resident salary levels. Contact the programs directly they will gladly create this position for you and call it a clinical fellowship in anesthesia.

3. The gaps in practice and the lawsuit can be easily explained a away with good well written paragraph, a lawyer who represents physicians with issues before the medial or the pharmacy board can probably write you an excellent paragraph if you are having difficulty finding the right explanations.

Good luck finding your niche.

If all of the above does not work and you still want to practice anesthesia you might want consider, becoming a FMG. Leave the country apply for work in a new country, You probably can create just about any story to cover up your practice "gaps", they are unlikely to ever find out about your lawsuit and thankfully nobody will care about the ABA.

---------One of my favorite passages quoted by Dr. Jensen.
You can plan all you want to. You can lie in your morning bed and fill whole notebooks with schemes and intentions. But within a single afternoon, within hours or minutes, everything you plan and everything you have fought to make yourself can be undone as a slug is undone when salt is poured on him. And right up to the moment when you find yourself dissolving into foam you can still believe you are doing fine. -Wallace Stegner

 

[Arch Guillotti]

You got a few separate issues.
1. Board certification is advantageous but by no means necessary to practice anesthesia. The board routinely fails half of the people who sit for the written exam, so there are many Anesthesiologists who are 10+ years out of residency still working on passing the boards. Dr. Jensen’s website show a great flow diagram on how you can fail the boards repeatedly and still be eligible to take them again. The board will happily take your money indefinitely until you finally pass their unfair, irrelevant, and misguided exam.

I take exception to this:

http://www.theaba.org/pdf/newsletters/ABA-2008-Newsletter.pdf

Check out the graph on page 18.

I thought the exam was hard but fair.

The pass rate for retakers is abysmal.

For first timers and overall (at least recently) it hasn't been that bad.

 

[buckhorn]

I take exception to this:

http://www.theaba.org/pdf/newsletters/ABA-2008-Newsletter.pdf

Check out the graph on page 18.

I thought the exam was hard but fair.

The pass rate for retakers is abysmal.

For first timers and overall (at least recently) it hasn't been that bad.

The ABA seems embarrassed by how many applicants that fail their exam so they routinely only report passing rate for first time US M.D. ACGME medical school graduates. They conveniently fail to report the lower passing rates of non ACGME medical school graduates.

The ABA pass ratio table on page 18 clearly shows that some years less than 50% of all the applicants taking the test passed.
I do not know how the ABA could ever justify failing over half of the written exam takers, Failing half the people sitting for the exam
serves no purpose other than to shows how arrogant, out of touch and irrelevant the ABA is.

Until the ABA does the right thing and publishes the questions from the written exam with the results and sells the old question from every past exam, the exam will continue to be of no value. It is little more than a misguided, pointless exercise devised to entertain and amuse a bunch of out of touch academics.

If I was very wealthy I would gladly spent the 5 to 10 million it would take to sue the board to force the release of old test questions. Any other reputable exam voluntarily provides questions to prove the exams relevance and integrity.

The oral exam is also a seriously flawed exercise. All oral exams should be taped. The tapes of all exams both passing and failed exams should be available for review by any interested party at no more than a nominal cost. Tapes need not contain the name of the test taker but privacy could be maintained by giving the examinee a unique code number, alternately given the oral costs almost $2000 the oral could be transcribed and the transcript could be available for review by any interested party.

 

[Pilot Doc]

I thought the exam was hard but fair.

How can you say that without knowing where the pass/fail line was?

 

[pgg]

Until the ABA does the right thing and publishes the questions from the written exam with the results and sells the old question from every past exam, the exam will continue to be of no value. It is little more than a misguided, pointless exercise devised to entertain and amuse a bunch of out of touch academics.

The ABA does publish old written exams and the answer keys. They're old, but several of the mid-90s exams are available for download from their web site. The questions are in my judgment absolutely appropriate and fair (though some are a bit outdated now, 10 years later).

Keep in mind that these were the exams administered during the years that ABA pass rates were starting to decline to their sub-50 nadir in 2000. Recall that anesthesiology programs in the mid-90s were filling with whatever warm-body placeholders they could find - it's not at all surprising that many of these people failed. If anything, this implies that the ABA has objective standards and the integrity to stick to them, even when faced with a wave of marginal candidates. So one or more of the following has occurred: the exam has become easier, the passing bar has been lowered, or the quality of candidates has improved.


If you're going to say that the test has inappropriate or irrelevant content, or that the minimum passing score is set too high, you need to provide some argument beyond the usual "I failed so it's unfair" or "Too many takers fail so it's unfair" kind of tearfully angry lament that usually appears on these forums. (Like this angry tool raging against the system ... who took 6 years to finish med school, had multiple Step failures, was fired from his scrambled-into internship, and now claims that his lack of felony drug convictions entitles him to a military PGY1 position. He also thinks that his Step failures were a consequence of how medicine is too "perfectionism" oriented.)

I want my board certification to be something more than a $2000 rubber stamp. I want them to fail people who can't master the material.


Also, please post in a normal sized font like the rest of us. Thanks.

 

[Arch Guillotti]

How can you say that without knowing where the pass/fail line was?

I say it because that was how I felt about the whole thing. I felt that I put a good amount of time and effort into studying for it and passed accordingly. It was hard because I walked out of there feeling like crap but most people I talked to felt the same way. I read very regularly CA1 and CA2 (not so much CA3) and really stepped it up in the months and weeks preceding the exam thus I felt I was as prepared as I was ever gonna be.

Passing was 209 and a 10% failure rate sticks in my mind for some reason.

 

[buckhorn]

The ABA does publish old written exams and the answer keys. They're old, but several of the mid-90s exams are available for download from their web site. The questions are in my judgment absolutely appropriate and fair (though some are a bit outdated now, 10 years later).

Keep in mind that these were the exams administered during the years that ABA pass rates were starting to decline to their sub-50 nadir in 2000. Recall that anesthesiology programs in the mid-90s were filling with whatever warm-body placeholders they could find - it's not at all surprising that many of these people failed. If anything, this implies that the ABA has objective standards and the integrity to stick to them, even when faced with a wave of marginal candidates. So one or more of the following has occurred: the exam has become easier, the passing bar has been lowered, or the quality of candidates has improved.


If you're going to say that the test has inappropriate or irrelevant content, or that the minimum passing score is set too high, you need to provide some argument beyond the usual "I failed so it's unfair" or "Too many takers fail so it's unfair" kind of tearfully angry lament that usually appears on these forums. (Like this angry tool raging against the system ... who took 6 years to finish med school, had multiple Step failures, was fired from his scrambled-into internship, and now claims that his lack of felony drug convictions entitles him to a military PGY1 position. He also thinks that his Step failures were a consequence of how medicine is too "perfectionism" oriented.)

I want my board certification to be something more than a $2000 rubber stamp. I want them to fail people who can't master the material.


Also, please post in a normal sized font like the rest of us. Thanks.

Not that it should make any difference but to answer your ad hominem attack, I am board certified.

We deserve more from the ABA; they are the one and only way that MD's can become board certified in anesthesia. Only when the ABA decides to open up the entire testing process will we know if they are truly accomplishing their mission, "to maintain the highest standards of the practice of anesthesiology and to serve the public, medical profession and health care facilities and organizations."

Since the ABA has a monopoly they need to operate in an open transparent manner. The exam questions needs to be published when the results are released, not over a decade later when they are retired. The ABA oral exam likewise needs to be run in an open transparent manner.

You make a number of unsupported claims about the ABA, Only when the ABA decides to open up the entire testing process will we know what the ABA is up to and why they fail 55% of the exam takers one year and 25% on another year. Without the independent oversight that only a truly open ABA board certification process can provide we will never know the answers to your unsupported claims.

 

[coprolalia]

 

[Pilot Doc]

I say it because that was how I felt about the whole thing. I felt that I put a good amount of time and effort into studying for it and passed accordingly. It was hard because I walked out of there feeling like crap but most people I talked to felt the same way. I read very regularly CA1 and CA2 (not so much CA3) and really stepped it up in the months and weeks preceding the exam thus I felt I was as prepared as I was ever gonna be.

Passing was 209 and a 10% failure rate sticks in my mind for some reason.

I don't know how any of that relates to whether the exam was fair or not. All you know is how hard the questions felt. We don't know how the exam was scored, how passing was cacluated, how questions are evaluated, etc.

I'm not saying the test was unfair, simply that it is impossible to judge its fairness based solely on reading the question.

 

[pgg]

Not that it should make any difference but to answer your ad hominem attack, I am board certified.

I don't recall attacking your character. I did say

you need to provide some argument beyond the usual "I failed so it's unfair" or "Too many takers fail so it's unfair" kind of tearfully angry lament that usually appears on these forums.

Idly curious: did you pass your first attempt? You're awfully angry about the process for someone who hasn't run afoul of the process somewhere.

We deserve more from the ABA

[...]

The exam questions needs to be published when the results are released, not over a decade later when they are retired.

Has it occurred to you that

• No other specialty publishes board questions immediately? Why does the ABA owe us anything other than a fair test?
• Administering a fair exam is facilitated by using questions more than once? Consider the possibility that a question can be validated and refined over years - that new questions can be tested one year and not used for scoring, then used for credit in subsequent years. If you publish all the questions, you have to start from scratch the next year. All the statistics and validation - gone.

The ABA oral exam likewise needs to be run in an open transparent manner.

Sure, I'm open to hearing your ideas how that can be improved. It's the only subjective part of the process. Transcribing each exam and having a third person score it also (blind to the two examiners and the candidate's race/sex/accent) would be nice ... and would also add a great deal to the cost.

You make a number of unsupported claims about the ABA, Only when the ABA decides to open up the entire testing process will we know what the ABA is up to and why they fail 55% of the exam takers one year and 25% on another year. Without the independent oversight that only a truly open ABA board certification process can provide we will never know the answers to your unsupported claims.

I have no reason to disbelieve the ABA-cited reason behind the >50% fail rate in 2000: that a bunch of bottom tier candidates took spots in unfilled anesthesia programs desperate for bodies to warm stools. It's a written test that hasn't changed much in 15 years, in content, scope, depth, or format (minus the K-types) ... at least as far as I can tell.

I'm unmoved by your claim of ABA ... what? Incompetence? Maliciousness? Extortion? Discrimination?

The written exam isn't composed by 5 guys in black hoods and cloaks in a dark underground room. Many, many anesthesiologists contribute to its creation. If you don't like it, nothing's stopping your board-certified self from getting involved in the process.

 

[sunnysol]

Thanks to all of you. I certainly have a lot of new ideas to mull over.

 

[sunnysol]

Surprisingly not. The main hurdle is qualifying by getting a scaled score of 32 on the in-traing exam. After that, the written board, etc. I am working on that but would like to try to maintain/improve my clinical skills.

 

[Jeff05]

you can contact Mount Sinai Department of Anesthesiology in NYC. there is a program managed by the Program Director and residents for simulator based training and re-training.

 

[doerun]

It will take a miracle or a herculean effort to raise you score up to passing. You will have to study every waking moment for two or three year's minimum, to have a chance of passing. Jensen talks about people studying every waking moment for a year and their score going up only ten points.

 

[mille125]

Not that it should make any difference but to answer your ad hominem attack, I am board certified.

We deserve more from the ABA; they are the one and only way that MD’s can become board certified in anesthesia. Only when the ABA decides to open up the entire testing process will we know if they are truly accomplishing their mission, “to maintain the highest standards of the practice of anesthesiology and to serve the public, medical profession and health care facilities and organizations.”

Since the ABA has a monopoly they need to operate in an open transparent manner. The exam questions needs to be published when the results are released, not over a decade later when they are retired. The ABA oral exam likewise needs to be run in an open transparent manner.

You make a number of unsupported claims about the ABA, Only when the ABA decides to open up the entire testing process will we know what the ABA is up to and why they fail 55% of the exam takers one year and 25% on another year. Without the independent oversight that only a truly open ABA board certification process can provide we will never know the answers to your unsupported claims.

I agree with buckhorn to a certain extent. Board certification is used today to deny privileges and benefits to individuals by insurance companies and groups. It was never intended to be used for this purpose. The oral is a completely worthless exercise and is only in existence to make money for the ABA and guarantee its relevance. With all of that said every candidate needs to put in their time and pass the thing. I have seen several very excellent clinicians who lost years of their lives particularly due to the oral exam. I wish the original poster good luck in his journey.

 

[pgg]

I agree with buckhorn to a certain extent. Board certification is used today to deny privileges and benefits to individuals by insurance companies and groups. It was never intended to be used for this purpose.

Who cares what the original intent was?

Medicine is more complex today than it was back when a diploma, internship, an unrestricted state medical license, and a room in a building were all you needed to deliver the day's standard of care.

We need some method of specialty and subspecialty certification. Certification requires examination. We can quibble over how that should be done - multiple choice vs essay written exams, oral exams in various formats, etc. But it needs to be done, if for no other reason than to protect the public from underqualified hacks claiming skills and knowledge they don't have. No one is better equipped to administer this certification than each specialty's professional society - and that's why every specialty's professional society does so.

The oral is a completely worthless exercise and is only in existence to make money for the ABA and guarantee its relevance.

The exams produce a few million dollars a year of gross income, minus substantial administrative costs. No one's getting rich off them, least of all the oral examiners who could certainly earn more warming a stool than traveling and pimping candidates. I don't believe the ABA is hosting parties in Vegas with the proceeds.

With all of that said every candidate needs to put in their time and pass the thing. I have seen several very excellent clinicians who lost years of their lives particularly due to the oral exam. I wish the original poster good luck in his journey.

Agreed. Whatever you think about the exams, they're obviously worth passing. Griping optional.

 

[mille125]

Who cares what the original intent was?

Medicine is more complex today than it was back when a diploma, internship, an unrestricted state medical license, and a room in a building were all you needed to deliver the day's standard of care.

We need some method of specialty and subspecialty certification. Certification requires examination. We can quibble over how that should be done - multiple choice vs essay written exams, oral exams in various formats, etc. But it needs to be done, if for no other reason than to protect the public from underqualified hacks claiming skills and knowledge they don't have. No one is better equipped to administer this certification than each specialty's professional society - and that's why every specialty's professional society does so.

All of the things that you have mentioned are interesting and idealistic. However, I do not feel that doctors should be reprimanded and/or decredentialed because someone is not board certified. It is interesting that an insurance company can threaten to not list a non board certified doctor but in the same breath attempt to direct patients to the nearest walmart clinic staffed by PA's and wave a patients copay. To put this much importance on a board exam is to neglect and nullify all of the training that you received in residency and fellowship. The last five doctors that I know who lost their medical licenses were board certified
Why even do residency at all? Why not just go from SAT to Steps1-3 to board exam and skip all of the nonsense?



And even though the board examiners are not overcompensated, dont kid yourself. The ABA does make money off this exam for doing essentially nothing.

 

[jetproppilot]

Hi,

I am an older doc, residency trained in Anesthesiology but not board certified and out of practice for 10+ years while attending to a schizophrenic spouse and a lawsuit and operating under the illusion I might be able to retire.

Those problems and the illusion have gone away. I have active licenses in Montana and California and have recently completed a 3 month hands-on clinical fellowship at a "recognized" medical school-associated anesthesia program. I have a good letter from the director of that program and I am feeling comfortable with my basic anesthesia skills but need more experience while I continue to study for qualifying and board examinations.

I am pretty mobile but need a little income for expenses. My practice "gap" and lack of board certification are making it difficult to enter clinical practice. Any ideas how I can get what I need in exchange for the use of what I have?

Could I fit into a vacant residency position? Fellowship?

Thanks

You were good enough at some point in the past.

Albeit a long time ago.

You sound motivated.

Theres gotta be some way to whip you into shape for at least some kinda gig.

Lemme give you an analagy.

I'm a pilot but am not current.

I've got single engine, multi-engine, instrument, commercial, and high altitude ratings.

I've gotta respectable amount of time in turboprops.....mostly Cheyennes but some BE200 and C90 time.

But I'm not current.

In order to become current I'd haffta go up with an instructor, shoot a buncha different approaches (ILS, VOR, GPS), do some landings, do some holds, ..........

you get the picture.

I don't see your scenerio much different, especially in this buyers market concerning our profession.

I don't see you as a lost cause and I wish you all the best and hope you can find some way to bring yourself up to speed.

 

[pgg]

All of the things that you have mentioned are interesting and idealistic. However, I do not feel that doctors should be reprimanded and/or decredentialed because someone is not board certified. It is interesting that an insurance company can threaten to not list a non board certified doctor but in the same breath attempt to direct patients to the nearest walmart clinic staffed by PA's and wave a patients copay. To put this much importance on a board exam is to neglect and nullify all of the training that you received in residency and fellowship. The last five doctors that I know who lost their medical licenses were board certified
Why even do residency at all? Why not just go from SAT to Steps1-3 to board exam and skip all of the nonsense?



And even though the board examiners are not overcompensated, dont kid yourself. The ABA does make money off this exam for doing essentially nothing.

I agree that insurance companies should have absolutely NO business dictating the qualifications of a care provider. That's an entirely different fight, however.

The bottom line is that some entity must provide credentialing services for anesthesiologists. Who do we want to do it?

If I understand you correctly, you think it should be residency programs. I strongly disagree; a bunch of disconnected, loosely regulated groups of attendings who "teach" differing local practices, have differing knowledge levels, set different standards of their trainees ... not to mention have the inherent conflict of interest that arises when the people doing the credentialing have a financial interest in keeping marginal residents around to keep rooms running ...

I think credentialing should be as objective a process as possible - nationally standardized, unbiased, without conflicts of interest, preferably run by a public professional association of the specialty in which membership is open to all. Which is exactly what we've got. (Not that there's no room for improvement, particularly WRT the oral exam.)


Someone posted a link to a journal article here recently, in which the authors discuss the selection process for anesthesiology residencies. And what the meat of that paper showed, right there in Figure 1, is that they SUCK at giving objective evaluations to their residents. Every single resident achieved a score between 6 and 8 in every single category ... and yet the ITE scores they reported ranged from the 1st percentile to the 98th+. That figure is downright comical in demonstrating their absolute inability to stratify their own residents into good and bad. I doubt this program is unique. In fact, since this paper hails from a university program where ~75% of their residents scored over the mean on the ITE, I'd guess this is actually a solid program. Yet you're arguing that these same attendings are capable of objectively determining whether or not their residents become credentialed.

Suffice it to say that I disagree.

 

[Pilot Doc]

Every single resident achieved a score between 6 and 8 in every single category ... and yet the ITE scores they reported ranged from the 1st percentile to the 98th+.

Well, that just reinforces my bias that ITE type tests are pretty meaningless. And I have always done well on standardized tests.

 

[pgg]

Well, that just reinforces my bias that ITE type tests are pretty meaningless. And I have always done well on standardized tests.

So all of the residents in a class of ~20 get identical subjective evaluations (scores of 6-8 on a scale of 1-10, eight categories for ~160 data points, with zero outliers) but have widely varying scores on an objective written exam, and you think the problem is the test?

Maybe if at least one of the residents in that study had received a poor (or even average!) evaluation from the faculty, in even one area, I could buy your argument that the faculty were doing their jobs and that the written exam was just dartboard randomness.

 

[mille125]

So all of the residents in a class of ~20 get identical subjective evaluations (scores of 6-8 on a scale of 1-10, eight categories for ~160 data points, with zero outliers) but have widely varying scores on an objective written exam, and you think the problem is the test?

Maybe if at least one of the residents in that study had received a poor (or even average!) evaluation from the faculty, in even one area, I could buy your argument that the faculty were doing their jobs and that the written exam was just dartboard randomness.

You missed my point by a bit so let me restate


1) The oral exam should be scrapped because it serves not purpose.
2) The written exam has some role but its usage and application to real life is lacking. It has too much weight in the current system.
3) Evaluations and performance in residency needs to be streamlined (as you stated).

I dont know why people continue to say that this exam helps weed out "bad apples". These docs are already practicing!!! I feel that enough weeding out has occurred during the process of movement through premed and med school. Over 90% of the starting wannabes have dropped by this time. My point is that we should help the remaining warriors become the best docs that they can be. Making individuals repeat a board exam is not the answer. I know of three docs who failed the exam once and then subsequently passed. They are not failures in life. It all seemed rather pointless.



It is also interesting that internal medicine now has a 95-98% pass rate as another way to suggest that all of these applications to board scores are ridiculous. In anesthesiology the failure rate is 10 fold higher.