Bay Area Locum market

[ambiturner]

1) Don't underestimate people's net worth outside of their W2 income. Family money is a real thing. Also don't underestimate 2 physician incomes or a spouse that works in tech or VC.
2) People work a lot to make extra income, this includes our specialty and others.
3) People who were in the Bay Area 10 years ago or before got here at the right time, even if it was still expensive at the time. That million dollar house they bought in '09 and we thought "that's wild" now has a value of 3-4 million (depend on where it is). They can still afford their mortgage but if you try to move next door you're coming in a triple or quadruple the mortgage, unless you're rich (see #1)

It'll be interesting to see how this plays out as time progresses because you are basically asking new grads to live in a place on a 400-500k salary, which of course is good money, but the houses cost 3 million dollars or more. As said about, you can ask people to lower their expectations and live in 2b condos that still may cost you 1.8 million or take you chances in an area that's gentrifying.

Is East Palo Alto still holding out against gentrification? Always was amazed it resisted the Silicon Valley creep.

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[Zekchar]

1) Don't underestimate people's net worth outside of their W2 income. Family money is a real thing. Also don't underestimate 2 physician incomes or a spouse that works in tech or VC.
2) People work a lot to make extra income, this includes our specialty and others.
3) People who were in the Bay Area 10 years ago or before got here at the right time, even if it was still expensive at the time. That million dollar house they bought in '09 and we thought "that's wild" now has a value of 3-4 million (depend on where it is). They can still afford their mortgage but if you try to move next door you're coming in a triple or quadruple the mortgage, unless you're rich (see #1)

It'll be interesting to see how this plays out as time progresses because you are basically asking new grads to live in a place on a 400-500k salary, which of course is good money, but the houses cost 3 million dollars or more. As said about, you can ask people to lower their expectations and live in 2b condos that still may cost you 1.8 million or take you chances in an area that's gentrifying.

I too am interested in how this plays out. My husband and I bought 7 years ago in an up and coming city in the Southeast that has had a housing cost explosion. Now the chairman has expressed trouble with recruiting. Its hard to recruit top talent from the northeast pipeline when new grads cant buy a home since physician mortgages cap at 1Mil. While that may be a lot of money, the houses that are in a desirable area are now 1.5Mil and the alternative is to live 20-30 min away from what makes the city a desirable place to be.

 

[Twiggidy]

Is East Palo Alto still holding out against gentrification? Always was amazed it resisted the Silicon Valley creep.

You can easily get into a 2 million dollar bidding war in EPA

 

[Twiggidy]

I too am interested in how this plays out. My husband and I bought 7 years ago in an up and coming city in the Southeast that has had a housing cost explosion. Now the chairman has expressed trouble with recruiting. Its hard to recruit top talent from the northeast pipeline when new grads cant buy a home since physician mortgages cap at 1Mil. While that may be a lot of money, the houses that are in a desirable area are now 1.5Mil and the alternative is to live 20-30 min away from what makes the city a desirable place to be.

Yep. This is how it happens.

If you say this is Atlanta you're going to ruin my day. I put ATL on my radar but Mrs may not be feeling it.

 

[deleted941485]

if you aren’t making over 1M/year minimum. You don’t really have any business living in the Bay Area. It just isn’t worth it. What ever perceived advantages it has are completely wiped out by the sheer cost of living there

I have a buddy who is a neurosurgeon. Lives in lower Manhatten in the financial district. Pays about 8000/mo for his 2 bed apartment and travels constantly throughout the 5 boroughs covering. His salary? 550K/year. No bonuses. He will never own a place and if he does it won’t be nearly as nice as a luxury apartment. The best thing he could do is move.

 

[nimbus]

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One of the biggest benefits of working in CA has been doing our own cases. MAC/Envision is proposing a “Collaborative Anesthesia Team” model on their website.

Medical Anesthesia Consultants Medical Group, Inc. (MAC)

As of Jan. 1, 2023, Medical Anesthesia Consultants (MAC) will no longer provide anesthesia services in the Northern California region.

www.macmgi.com

“ACT vs. CAT Models of Care

The Anesthesia Care Team model (ACT) is a more compressed version of the ICU model.The ASA defines the ACT model as “care that is led by a physician anesthesiologist who directs or supervises care of qualified anesthesia personnel and meets the ASA Guidelines for the Ethical Practice of Anesthesiology.” The anesthesiologist may delegate monitoring and some appropriate tasks, but retains overall responsibility for the patient.

This practice of anesthesiology includes the evaluation and optimization of preexisting medical conditions, the perioperative management of coexisting disease, the delivery of anesthesia and sedation, the management of postanesthetic recovery, the prevention and management of periprocedural complications, the practice of acute and chronic pain medicine, and the practice of critical care medicine. This care is personally provided, directed, and/or supervised by the physician anesthesiologist.

The Collaborative Anesthesiology Team model (CAT) is local, optimal teams of CRNAs, physician anesthesiologists or both. It is the anesthesiology version of “the right provider, at the right time, for the right patient.”

The best mix of providers is based on the following factors:

• Resources (i.e., the characteristics of the local available providers)
• Needs of the patients and facility
• All anesthesia providers are licensed, but they’re not all the same. There are no care teams designed predominantly around licensure, they’re designed based on creating value for patients

Fundamentally, the CAT is based on the idea that if true professional collaboration is to exist, each needs to recognize the other’s autonomy, which includes statutory independence, followed by specific model decisions being made at the local level. This allows effective interprofessional collaboration to occur. Collaboration and autonomy are not mutually exclusive – in fact, they are both necessary if anesthesiology professionals are going to meet the challenges of the future.

The CAT is a model that respects both major professions in anesthesiology, CRNAs and physician anesthesiologists. They are not the same – they have different professional backgrounds and licenses. However, the professions do have significant overlap in the scope of services offered.

There continues to be an ongoing push for medical progress, not only for progress in our profession itself, but more importantly for the sake of future patients. The bottom line is that during and after COVID-19, the country needs all anesthesiology professionals to make their full contribution to patient care. That’s what maximizes value. Collaborative anesthesiology teams, whatever their makeup, are the future.”


CAT is even worse than ACT. It’s a terrible idea in my opinion.

 

[ambiturner]

One of the biggest benefits of working in CA has been doing our own cases. MAC/Envision is proposing a “Collaborative Anesthesia Team” model on their website.

Medical Anesthesia Consultants Medical Group, Inc. (MAC)

As of Jan. 1, 2023, Medical Anesthesia Consultants (MAC) will no longer provide anesthesia services in the Northern California region.

www.macmgi.com

“ACT vs. CAT Models of Care

The Anesthesia Care Team model (ACT) is a more compressed version of the ICU model.The ASA defines the ACT model as “care that is led by a physician anesthesiologist who directs or supervises care of qualified anesthesia personnel and meets the ASA Guidelines for the Ethical Practice of Anesthesiology.” The anesthesiologist may delegate monitoring and some appropriate tasks, but retains overall responsibility for the patient.

This practice of anesthesiology includes the evaluation and optimization of preexisting medical conditions, the perioperative management of coexisting disease, the delivery of anesthesia and sedation, the management of postanesthetic recovery, the prevention and management of periprocedural complications, the practice of acute and chronic pain medicine, and the practice of critical care medicine. This care is personally provided, directed, and/or supervised by the physician anesthesiologist.

The Collaborative Anesthesiology Team model (CAT) is local, optimal teams of CRNAs, physician anesthesiologists or both. It is the anesthesiology version of “the right provider, at the right time, for the right patient.”

The best mix of providers is based on the following factors:

• Resources (i.e., the characteristics of the local available providers)
• Needs of the patients and facility
• All anesthesia providers are licensed, but they’re not all the same. There are no care teams designed predominantly around licensure, they’re designed based on creating value for patients

Fundamentally, the CAT is based on the idea that if true professional collaboration is to exist, each needs to recognize the other’s autonomy, which includes statutory independence, followed by specific model decisions being made at the local level. This allows effective interprofessional collaboration to occur. Collaboration and autonomy are not mutually exclusive – in fact, they are both necessary if anesthesiology professionals are going to meet the challenges of the future.

The CAT is a model that respects both major professions in anesthesiology, CRNAs and physician anesthesiologists. They are not the same – they have different professional backgrounds and licenses. However, the professions do have significant overlap in the scope of services offered.

There continues to be an ongoing push for medical progress, not only for progress in our profession itself, but more importantly for the sake of future patients. The bottom line is that during and after COVID-19, the country needs all anesthesiology professionals to make their full contribution to patient care. That’s what maximizes value. Collaborative anesthesiology teams, whatever their makeup, are the future.”


CAT is even worse than ACT. It’s a terrible idea in my opinion.

I read that whole piece of adminspeak and still don’t know what CAT is, so it has to be bad. I’m assuming it means the anesthesiologists do the monster cases every day while the CRNAs chill in the easy rooms?

 

[Dr. Rude]

I read that whole piece of adminspeak and still don’t know what CAT is, so it has to be bad. I’m assuming it means the anesthesiologists do the monster cases every day while the CRNAs chill in the easy rooms?

You forgot to add that anesthesiologists are available as the fire department, resource people for the CRNAs to ask questions and then document “case discussed with Dr. X” in the record. Last but not least, the liability sponge.

Any group of docs that signs up for this deserves what they get.

 

[deleted941485]

I read that whole piece of adminspeak and still don’t know what CAT is, so it has to be bad. I’m assuming it means the anesthesiologists do the monster cases every day while the CRNAs chill in the easy rooms?

They just don’t have the balls to say it. They know it will spark backlash.

 

[pgg]

I read that whole piece of adminspeak and still don’t know what CAT is, so it has to be bad. I’m assuming it means the anesthesiologists do the monster cases every day while the CRNAs chill in the easy rooms?

You forgot to add that anesthesiologists are available as the fire department, resource people for the CRNAs to ask questions and then document “case discussed with Dr. X” in the record. Last but not least, the liability sponge.

Any group of docs that signs up for this deserves what they get.

This is, essentially, the military model.

Daily schedule gets made by an anesthesiologist, where the complex cases and sick patients are generally triaged to anesthesiologists, with the B&B stuff generally going to CRNAs. The CRNAs are mostly independent, with the caveat that they're required to discuss ASA 3+ patients with an anesthesiologist. Our malpractice environment in the military is pretty great, despite some recent Feres Doctrine erosion, and none of us really worry about any liability/risk involved with helping out if something goes south.

It works out OK and I actually prefer practicing in this environment doing my own cases solo (+/- with a resident) over the over-leveraged 4:1 supervision rodeos (plus covering OB, plus covering preop, plus covering regional) that I sometimes do as a locums.

 

[throwawaybayarea]

If someone reading this thread is interested in an opportunity to join a fair, physician-owned, physician-only group in the Bay Area, send me a message. We are looking for strong clinicians interested in either part time or full time work.

 

[vector2]

This is, essentially, the military model.

Daily schedule gets made by an anesthesiologist, where the complex cases and sick patients are generally triaged to anesthesiologists, with the B&B stuff generally going to CRNAs. The CRNAs are mostly independent, with the caveat that they're required to discuss ASA 3+ patients with an anesthesiologist. Our malpractice environment in the military is pretty great, despite some recent Feres Doctrine erosion, and none of us really worry about any liability/risk involved with helping out if something goes south.

It works out OK and I actually prefer practicing in this environment doing my own cases solo (+/- with a resident) over the over-leveraged 4:1 supervision rodeos (plus covering OB, plus covering preop, plus covering regional) that I sometimes do as a locums.

Do you find the CRNAs in the military, on average, stronger than the ones you work with in PP or academics?

Even our experienced CRNAs not infrequently get into trouble with airways or with hemodynamics, but I'm guessing different pt populations lead to different problem frequencies.

 

[drmwvr]

You can easily get into a 2 million dollar bidding war in EPA

Been out of the BA for 2 decades so I don't know if you're serious, but when I left, EPA made East Oakland look like Salt Lake City.

 

[drmwvr]

Do you find the CRNAs in the military, on average, stronger than the ones you work with in PP or academics?

Even our experienced CRNAs not infrequently get into trouble with airways or with hemodynamics, but I'm guessing different pt populations lead to different problem frequencies.

I suspect swinging a dead cat would contact mostly ASA 1's in the military....I'd be happy to be corrected on that...

 

[Twiggidy]

Been out of the BA for 2 decades so I don't know if you're serious, but when I left, EPA made East Oakland look like Salt Lake City.

I'm sure there are pockets of EPA that are better than others but I kid you not the flippers are selling homes for 2 million there. And I hear you about East Oakland. The only zip codes I'd trust in the East Bay are Rockridge and Berkeley Hills.

 

[drmwvr]

The only zip codes I'd trust in the East Bay are Rockridge and Berkeley Hills.

So that hasn't changed...

 

[chocomorsel]

I too am interested in how this plays out. My husband and I bought 7 years ago in an up and coming city in the Southeast that has had a housing cost explosion. Now the chairman has expressed trouble with recruiting. Its hard to recruit top talent from the northeast pipeline when new grads cant buy a home since physician mortgages cap at 1Mil. While that may be a lot of money, the houses that are in a desirable area are now 1.5Mil and the alternative is to live 20-30 min away from what makes the city a desirable place to be.

How big of a house do you get for 1-1.5 million?

 

[vector2]

I too am interested in how this plays out. My husband and I bought 7 years ago in an up and coming city in the Southeast that has had a housing cost explosion. Now the chairman has expressed trouble with recruiting. Its hard to recruit top talent from the northeast pipeline when new grads cant buy a home since physician mortgages cap at 1Mil. While that may be a lot of money, the houses that are in a desirable area are now 1.5Mil and the alternative is to live 20-30 min away from what makes the city a desirable place to be.

Even if there wasn't a cap I wouldn't be feeling great about buying a 1.5m house with 0 down.

 

[pgg]

Do you find the CRNAs in the military, on average, stronger than the ones you work with in PP or academics?

Even our experienced CRNAs not infrequently get into trouble with airways or with hemodynamics, but I'm guessing different pt populations lead to different problem frequencies.

There are a few factors that are hard to disentangle.

I think, on the whole, that the military CRNAs are taken from a better qualified pool of people, and they get better training. The civilian world will train and graduate any warm body that can clear a tuition check. Getting into a military SRNA program used to be fairly competitive, though I get the impression it's less so the last few years. But they still run a fairly rigorous program and they will cut people who don't meet the standard. It's rare to see a really bad one get through.

The flip side to that is that military CRNAs, like military physicians of all kinds, are very heavily tilted toward junior level experience. Not a lot of gray hairs who've been doing it for a couple decades, because the system is built to churn through new grads who then leave as soon as their service obligation is up. A few stay around as civilian contractors after leaving active duty.

Since any of them could wind up all alone overseas as part of a forward surgical team, they get trained with a more independent mindset. I think this produces a better graduate than the programs that are part of the ACT model pipeline. But it does produce some that are reluctant to ask anesthesiologists for help - it's not uncommon to see them ask a CRNA buddy for help with a difficult case or airway, not the anesthesiologist assigned to "consult" duty.

Although they're required to consult an anesthesiologist for ASA 3+ patients, this is really informal and the physician doesn't sign the chart anywhere. Also, the person making the ASA determination is the CRNA so at least in theory they can sidestep that requirement by just making someone an ASA 2.

We definitely get a whole lot of ASA 1-2 active duty patients, but the majority of our patient population is actually family members and retirees. While not as sick/fat/neglected as the average civilian practice, with fewer wrecks that the VA system, we do see a fair bit of pathology. Most of which gets triaged by the anesthesiologist doing the scheduling to a physician +/- resident team. The CRNAs just aren't doing big vascular cases (fistulas and toe amps are about where their "vascular" cases top out). Or cranis, or thoracic stuff. Ex-lap add-ons, sure, but not the septic SBOs. We don't do hearts any more but when we did it was 100% physician. So it's a little hard to directly compare them to the civilian practices I've worked where they do those cases in an ACT model.

I find the level of tension between anesthesiologists and CRNAs varies hugely between different ACT practices. Some places it's awful, and some places it's a good setup with true medical direction that leaves some flexibility for them to do things their way, but no doubt who's ultimately setting the edges of what's OK. In general the relationship is good in the military. Part of that is probably the shared overall mission as we are similar cogs in the warfighting machine. Part of it is that the arrangement keeps us out of each other's way.

Do they get into trouble with airways and hemodynamics, sure.

Yesterday I did a medically directed case at one of my locums jobs. Standard old COPD'r with CHF getting GA for a hip fracture. Baseline BP 190/100. We talked about light volatile and a phenylephrine infusion. Yet ... still let the BP drift to 100/ then 90/ then 82/ while waiting for incision to stimulate the patient, with the gtt off. 2% sevo. Solid CRNA ... but I don't get how or why that happens. Patient did fine, woke up quickly and comfy in PACU. I didn't check troponins. Again proves you can get away with a lot. Usually.

Bottom line after this long-winded stream of consciousness ramble - in the great big picture of the grand scheme of things, I think there are fewer military CRNAs that are scary outliers, and I think they exit training much more well rounded and capable. The ceiling is probably lower since 90% leave forever after a few years and are replaced with new grads, who are largely solid. I've run into some new grad civilian CRNAs that were simply helpless and needed July CA1 level attention and supervision.

 

[Zekchar]

How big of a house do you get for 1-1.5 million?

3-4 bedroom, 2-3 bathroom, ~2200-2700 square feet, on a 5,000 square feet plot

 

[pgg]

3-4 bedroom, 2-3 bathroom, ~2200-2700 square feet, on a 5,000 square feet plot

Geez

Do you have to turn sideways when walking around the side to get in the back yard, lest your elbows scrap the neighbor's house?

This American infatuation with building detached single family homes on postage stamp lots bewilders me. Is it really better than a townhouse or even an apartment?

 

[chocomorsel]

Geez

Do you have to turn sideways when walking around the side to get in the back yard, lest your elbows scrap the neighbor's house?

This American infatuation with building detached single family homes on postage stamp lots bewilders me. Is it really better than a townhouse or even an apartment?

Agree 100%. What’s the point of such a small lot? Makes no sense. I don’t do anything less than 0.25 acres. Otherwise what’s the point? May as well get a townhouse and my smaller lots were townhouses.

 

[nimbus]

Geez

Do you have to turn sideways when walking around the side to get in the back yard, lest your elbows scrap the neighbor's house?

This American infatuation with building detached single family homes on postage stamp lots bewilders me. Is it really better than a townhouse or even an apartment?

Even if it’s basically a detached/freestanding condo, you can avoid some noise issues, some communal problems (plumbing, electrical, roofing, exterior maintenance) and some HOA issues by not sharing walls.

 

[nimbus]

3-4 bedroom, 2-3 bathroom, ~2200-2700 square feet, on a 5,000 square feet plot

That’s about the same as Southern California if you don’t need to live in an upscale doctor neighborhood. Still safe with good schools, full of teachers, accountants, software engineers, etc.

 

[Zekchar]

That’s about the same as Southern California if you don’t need to live in an upscale doctor neighborhood. Still safe with good schools, full of teachers, accountants, software engineers, etc.

Everybody has their priorities.

I think we can agree that the best bang for your buck is to move to the rural midwest where the salaries are highest and cost of living cheapest. Yes, you can put the money saved towards retiring early or traveling to place of culture on your weekends. That isn't for me and life is too short for such an existence.

I think we can agree that the worst bang for your buck is to move to San Francisco where salaries are low-median and cost of living is the most expensive. Housing is tough, retirement, is tough, and with the current state of San Francisco, the cultural endeavors may be a bit tough as well.

There exists everything in between and that's where I decided my husband and I live. We have city cultural and culinary luxuries available to us. We avoid the snow and have access to beaches. The pay is median and the cost of living is median. I may work 3-4 years more before retiring early, but I will have enjoyed my time along the way.

Anything in extremes is bad (sub-optimal). Find yours and respect that others will have different priorities and thus lifestyles.

 

[nimbus]

Everybody has their priorities.

I think we can agree that the best bang for your buck is to move to the rural midwest where the salaries are highest and cost of living cheapest. Yes, you can put the money saved towards retiring early or traveling to place of culture on your weekends. That isn't for me and life is too short for such an existence.

I think we can agree that the worst bang for your buck is to move to San Francisco where salaries are low-median and cost of living is the most expensive. Housing is tough, retirement, is tough, and with the current state of San Francisco, the cultural endeavors may be a bit tough as well.

There exists everything in between and that's where I decided my husband and I live. We have city cultural and culinary luxuries available to us. We avoid the snow and have access to beaches. The pay is median and the cost of living is median. I may work 3-4 years more before retiring early, but I will have enjoyed my time along the way.

Anything in extremes is bad (sub-optimal). Find yours and respect that others will have different priorities and thus lifestyles.

I agree completely. I live in a very HCOL area too. Just commenting on home prices. It sounds like a lot of places are catching up to California in terms of housing costs.

 

[GassYous]

I agree completely. I live in a very HCOL area too. Just commenting on home prices. It sounds like a lot of places are catching up to California in terms of housing costs.

I just saw an acquaintances place who lives near philly and their backyard is larger than most of our public parks

 

[nimbus]

I just saw an acquaintances place who lives near philly and their backyard is larger than most of our public parks

How long is the driveway? Could be snow shoveling involved.