Change to Anesthesia after IM Subspecialty. Is it worth it?

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stohn_jamos

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Hello all,

I'm an allergy/immunology fellow about to finish training, but I'm not sure I made the right specialty choice. I do love A/I, but the amount of pre-charting kills me. Additionally, if you want to practice as a true specialist in this field, you have to be at an academic center. Theres not a lot of resources or patients to do the interesting things (HAE, drug allergy, immunodeficiency) in private practice. I will admit, my hours are awesome (8-5 with no call or weekends) but compensation isn't much more than hospitalist or general IM for private practice and is abysmal for academic. For these reasons, I'm having some regrets with my career choice.

I had a strong interest in anesthesia in med school and was gonna choose anesthesia or internal medicine. I choose medicine due to CRNA's and wanting to avoid surgeons as well as the options for IM sub-specialization. Nowadays, I have a lot of close friends in anesthesia who love it. I can see the value in getting your work done early and leaving it all at the hospital. Additionally, the lack of longitudinal patient relationships, inbox, and clinic is appealing.

I know the grass is always greener. If you guys had to do anesthesia again, would you? What are some cons in the attending day-to-day job that I'm not anticipating (if it's even possible to get into the residency at this stage of the game)? Other procedural IM subspecialties don't really interest me as much (GI/Cards/Pulm), but I know this is the more logical jump.
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If you like hands on patient care, minute to minute management of patient physiology, doing procedures like a-lines, central lines, IV’s, etc etc then you might like it. Im in pain mgmt but I stay up on my anesthesia in case I decide to go back. The downside is taking call, although this is controllable. In fact controllability is one of the great lifestyle factors in anesthesia. There is a wide variety of practice structures for you to choose from but the short and long of it is that you can choose more time off for less money or vice versa. I know many who do one week on, one week off schedules and still make a great wage. How old you are and whether you have debt are things you should seriously factor into this. I know several people who went from IM to anesthesia and they are much happier.

At the same time things can be better as an attending. I would maybe try finding a good job in your current field and see if you can stand it first.
 
TeslaCoil said:
If you like hands on patient care, minute to minute management of patient physiology, doing procedures like a-lines, central lines, IV’s, etc etc then you might like it. Im in pain mgmt but I stay up on my anesthesia in case I decide to go back. The downside is taking call, although this is controllable. In fact controllability is one of the great lifestyle factors in anesthesia. There is a wide variety of practice structures for you to choose from but the short and long of it is that you can choose more time off for less money or vice versa. I know many who do one week on, one week off schedules and still make a great wage. How old you are and whether you have debt are things you should seriously factor into this. I know several people who went from IM to anesthesia and they are much happier.

At the same time things can be better as an attending. I would maybe try finding a good job in your current field and see if you can stand it first.
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Thanks for advice. I went straight through all the school (younger age) and lack of debt (college was free, able to pay down med school debt by moonlighting) are a huge driving factor in considering this. I was never huge into procedures in residency but now I find myself missing it. I think it's different when procedures are your job vs an add-on to your job that makes life more difficult (like in IM).
 
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Take your Allergy/Immunology career and run. You would be taking a massive hit in lifestyle by switching to anesthesia (busy nights, weekends, holidays). To have an anesthesia career that matched your current lifestyle, you wouldn’t be making much more money than you already are. You’ll also have to commit to 3 more years of residency. Figure out a way to get more efficient with charting and stop looking at your neighbor’s lawn.
 
stohn_jamos said:
Thanks for advice. I went straight through all the school (younger age) and lack of debt (college was free, able to pay down med school debt by moonlighting) are a huge driving factor in considering this. I was never huge into procedures in residency but now I find myself missing it. I think it's different when procedures are your job vs an add-on to your job that makes life more difficult (like in IM).
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How much money can you make per year in immunology?
 
GravelRider said:
Take your Allergy/Immunology career and run. You would be taking a massive hit in lifestyle by switching to anesthesia (busy nights, weekends, holidays). To have an anesthesia career that matched your current lifestyle, you wouldn’t be making much more money than you already are. You’ll also have to commit to 3 more years of residency. Figure out a way to get more efficient with charting and stop looking at your neighbor’s lawn.
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Honestly man, thank you for this advice. I welcome your opinions/experience.
 
TeslaCoil said:
How much money can you make per year in immunology?
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Average per MGMA is $360K for private practice but I see numbers all over the place, more reallistially it's probably around $300K even. I've seen as low as $250K or as high as $400K. Anecdotally I've heard of people making $400K pls, but I doubt this is common. You can augment income by speaking for drug companies or doing more "procedures" like intralymphatic immunotherapy, which is cash pay only, and I plan to learn/do.
 
My understanding, and someone can correct me, is that the GME will only pay for so many years of training. This usually isn't an issue because when people switch after IM or during general surgery, there are still several years of that balance left. For you, though, having done, what, 6 years of training? This may be something that makes it harder for you to get a spot somewhere, if the department has to pay for you without the usual GME subsidy.

Also, I would echo what the others have said. I love what I do, but if I did it 8-5, M-F, I don't think I'd make more than the numbers you're throwing out for A/I. A lot of the money in anesthesia comes from working at times when other people don't want to work.
 
cchoukal said:
My understanding, and someone can correct me, is that the GME will only pay for so many years of training. This usually isn't an issue because when people switch after IM or during general surgery, there are still several years of that balance left. For you, though, having done, what, 6 years of training? This may be something that makes it harder for you to get a spot somewhere, if the department has to pay for you without the usual GME subsidy.

Also, I would echo what the others have said. I love what I do, but if I did it 8-5, M-F, I don't think I'd make more than the numbers you're throwing out for A/I. A lot of the money in anesthesia comes from working at times when other people don't want to work.
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Thanks for the advice man. I honestly didn't know that. I imagine matching to a CA-1 spot would be harder as well and decrease my chances immensely.

Also, I was unaware that much of anesthesia compensation is due to call. It makes sense that if the surgeons are working late hours, you guys are too.
 
TeslaCoil said:
If you want to make the avg anesthesia salary of around 450-550k you’ll be working ~60 hrs a week and taking call.
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Lmao what this is so untrue. Get with the times dude. I make that much work 40 hrs a week and my job is pretty average w2. What you said was true maybe in 2012. All my friends that work 60 hours a week are making 700k minimum.
 
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sevo00 said:
Lmao what this is so untrue. Get with the times dude. I make that much work 40 hrs a week and my job is pretty average w2. What you said was true maybe in 2012. All my friends that work 60 hours a week are making 700k minimum.
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Whatever you say bro. I know many in this type of sitch. Depends on many factors. Im not denying you could find a 40 hr/wk job making 450k. I still dont think thats the average.
 
In anesthesia the money is in the calls, weekends, late nights and less desirable locations.
Culture varies greatly from practice to practice. Allergy/immunology has more chance to be your own boss. Idk if I’d start over if I were you - probably not
 
TeslaCoil said:
Whatever you say bro. I know many in this type of sitch. Depends on many factors. Im not denying you could find a 40 hr/wk job making 450k. I still dont think thats the average.
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Bro its def the average. And im in a big metro area. If you go to less desirable prob make even more. You have no idea what averages are. You’re same guy that thinks every pain doc is making 700k and jobs are plentiful.

Serious it’s like you never actually heard of data reports and surveys. All of your info only comes from the few friends in your city you talk to. You do realize the internet is free right and you can just search for actual statistics?
 
stohn_jamos said:
Thanks for the advice man. I honestly didn't know that. I imagine matching to a CA-1 spot would be harder as well and decrease my chances immensely.

Also, I was unaware that much of anesthesia compensation is due to call. It makes sense that if the surgeons are working late hours, you guys are too.
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There are so many possibilities.

I work in an MD only group approaching 70 MD’s. My first call duties are like q3 months and I don’t do weekends often if at all (maybe 2 weekends in a year?).

ASC’s (ambulatory surgery centers) are easy to find and can be 7-3 with some later days. 400k is probably normal.

2 weeks on 2 weeks off for 600k+ is common. Nocturnist makes a ton more. I know someone making 1 mil doing this.

The typical full time position should be 40 hrs/week. But smokes and mirrors has made it closer to 48-50/month for a full time position.

There are a ton of low paying jobs that tend to be easy, but I personally know of jobs approaching 800k right out of residency for an efficient ACT model.

I love anesthesia and will die by that notion. No other specialty is as interesting and diverse.

Big cardiac cases with TEE certification possibilities/combined CC jobs, fast efficient ortho cases with a lot of needle jockying, boring 6 hour cases where you can multi task your cme’s for the year, pediatric, vascular, regional anesthesia, trauma, OB…. and when your shift is over you are done.

Once the patient is anesthetized some chill music goes on and you interact with a room full of people that you know very well. It’s fun.

No other specialty has the ability to cut back as you progress through your career.

The flexibility to go 1/2 time with no call is amazing, fulfilling and can keep you engaged into your late 60’s if you so desire.
 
sevo00 said:
Bro its def the average. And im in a big metro area. If you go to less desirable prob make even more. You have no idea what averages are. You’re same guy that thinks every pain doc is making 700k and jobs are plentiful.

Serious it’s like you never actually heard of data reports and surveys. All of your info only comes from the few friends in your city you talk to. You do realize the internet is free right and you can just search for actual statistics?
Click to expand...
Jobs in pain and anesthesia are most definitely plentiful. I never said every pain doc is making 700k but seasoned partners make 700k easily. Some practice owners are clearing a million easy.
 
I rationalize repeating residency because it's only 3 years (similar to if I were to do another fellowship in GI or cards). I know plenty of IM subspecialty switching after already doing one fellowship. Also know a guy who did anesthesia directly after IM residency.

The charting is what's killing me the most. It will undoubtedly get better after I exit training, but might also get worse with more volume? The lack of the extra duties to clinic is appealing too (no inbox, prior auths, etc). Could always just do hospital medicine I suppose, but the in/out aspect of anesthesia, procedures, acute management is appealing.

How grueling is the residency?
 
Negatives. Need to be personable and deal with bad patients and surgeons and patients knocking on heavens door.

Doing a case at 3am sucks. As you get older it really messes with the next day.

I hate feeling like a 🧟‍♂️
 
sevo00 said:
Lmao what this is so untrue. Get with the times dude. I make that much work 40 hrs a week and my job is pretty average w2. What you said was true maybe in 2012. All my friends that work 60 hours a week are making 700k minimum.
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So you’re working a 40hr week and clearing 500k? Thats pretty good. Maybe I’ll go back to the OR. How much call are you taking?

Can anybody else confirm this is the norm nowadays?
 
cchoukal said:
My understanding, and someone can correct me, is that the GME will only pay for so many years of training. This usually isn't an issue because when people switch after IM or during general surgery, there are still several years of that balance left. For you, though, having done, what, 6 years of training? This may be something that makes it harder for you to get a spot somewhere, if the department has to pay for you without the usual GME subsidy.

Also, I would echo what the others have said. I love what I do, but if I did it 8-5, M-F, I don't think I'd make more than the numbers you're throwing out for A/I. A lot of the money in anesthesia comes from working at times when other people don't want to work.
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My understanding is that CMS locks you in for payment based on your first residency. So, if anesthesiology, you get four years funding. fP, three years funding etc. if you do a second residency, it is almost always without CMS fund support. However, most residency program funding numbers are locked in from 1996 or 1997 and have not changed, so any expansion of the residency is funded by the program. So, it’s not a big deal to add an unfunded resident because the majority of programs have unfunded positions they have accumulated since 1996.
Not 100% sure I’ve got that completely accurate, but I believe it is something like that. So, in short, I don’t think most programs feel penalized if they take someone who may be partially or completely unfunded.
 
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sevoflurane said:
There are so many possibilities.

I work in an MD only group approaching 70 MD’s. My first call duties are like q3 months and I don’t do weekends often if at all (maybe 2 weekends in a year?).

ASC’s (ambulatory surgery centers) are easy to find and can be 7-3 with some later days. 400k is probably normal.

2 weeks on 2 weeks off for 600k+ is common. Nocturnist makes a ton more. I know someone making 1 mil doing this.

The typical full time position should be 40 hrs/week. But smokes and mirrors has made it closer to 48-50/month for a full time position.

There are a ton of low paying jobs that tend to be easy, but I personally know of jobs approaching 800k right out of residency for an efficient ACT model.

I love anesthesia and will die by that notion. No other specialty is as interesting and diverse.

Big cardiac cases with TEE certification possibilities/combined CC jobs, fast efficient ortho cases with a lot of needle jockying, boring 6 hour cases where you can multi task your cme’s for the year, pediatric, vascular, regional anesthesia, trauma, OB…. and when your shift is over you are done.

Once the patient is anesthetized some chill music goes on and you interact with a room full of people that you know very well. It’s fun.

No other specialty has the ability to cut back as you progress through your career.

The flexibility to go 1/2 time with no call is amazing, fulfilling and can keep you engaged into your late 60’s if you so desire.
Click to expand...

As a former IM refugee, people who go into allergy are not exactly looking to bang out aortic dissections at 2am or cover ICUs with sick patients on ECMO. Allergy had the reputation for being the “lifestyle field” (interpret that as you wish). It was competitive because there were few spots and the pay for the workload was pretty good. You can make more money doing Cards or GI, but you’ll work for it.

The guy should stay in Allergy and give a well-rested laugh at his Anesthsiologist neighbor as he drives by to go in for call on a Saturday morning.
 
GravelRider said:
As a former IM refugee, people who go into allergy are not exactly looking to bang out aortic dissections at 2am or cover ICUs with sick patients on ECMO. Allergy had the reputation for being the “lifestyle field” (interpret that as you wish). It was competitive because there were few spots and the pay for the workload was pretty good. You can make more money doing Cards or GI, but you’ll work for it.

The guy should stay in Allergy and give a well-rested laugh at his Anesthsiologist neighbor as he drives by to go in for call on a Saturday morning.
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See I say things like this about pain medicine and I get chastised by everyone on here.
 
GravelRider said:
As a former IM refugee, people who go into allergy are not exactly looking to bang out aortic dissections at 2am or cover ICUs with sick patients on ECMO. Allergy had the reputation for being the “lifestyle field” (interpret that as you wish). It was competitive because there were few spots and the pay for the workload was pretty good. You can make more money doing Cards or GI, but you’ll work for it.

The guy should stay in Allergy and give a well-rested laugh at his Anesthsiologist neighbor as he drives by to go in for call on a Saturday morning.
Click to expand...
My last 2am dissection was a few years ago 🙂.🍀

I can NOT do clinic. 😬🔫

I’d rather do call at 1/2 time FTE a few times a year for equal pay. You don’t have to do cardiac, but you can… if you like.

Options are limitless.

Anesthesia >>>> in my book.
 
I would encourage you to shadow an anesthesiologist in your free time so you can make an informed decision. One of my pet peeves (I’m not saying you in particular ) are when people in the medical field tell me anesthesia is such a chill specialty and we don’t really do much. Most people even in the medical field have no idea what our job entails.

I’m also curious as why you chose allergy over a field like pulmonary/critical care which has more similarities to anesthesiology than allergy.
 
amyl said:
In anesthesia the money is in the calls, weekends, late nights and less desirable locations.
Culture varies greatly from practice to practice. Allergy/immunology has more chance to be your own boss. Idk if I’d start over if I were you - probably not
Click to expand...


30-40% of my income is from call stipends and collections from cases I do while I’m on call. Our evenings, nights, and weekends are heavily incentivized. Income would take a huge hit if I stopped taking call. I give up a noncall weekday day each week and it barely affects my income but wouldn’t give up any call.

Also I find the OR uncomfortably cold most of the time.
 
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Simba1711 said:
I would encourage you to shadow an anesthesiologist in your free time so you can make an informed decision. One of my pet peeves (I’m not saying you in particular ) are when people in the medical field tell me anesthesia is such a chill specialty and we don’t really do much. Most people even in the medical field have no idea what our job entails.

I’m also curious as why you chose allergy over a field like pulmonary/critical care which has more similarities to anesthesiology than allergy.
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I did a whole anesthesia rotation in med school and liked what I saw, but didn't commit due to recommendations/opinions from older attendings (lots of doom/gloom at that time and wishing they'd have been on the other side of the curtain). Shadowing now is a good recommendation, I'm interested to see how my perspective has changed.

At the time I was choosing my fellowship, I wasn't interested in PCCM. I liked (and still do) seeing clinic and to @GravelRider's point, wanted a chill lifestyle. I did an allergy rotation too of course. The regrets I have now can only be attained after completing the fellowship and seeing what it's really like. I agree that the choices I've already made say a lot about my goals/personality and help elucidate if I'd even be a good fit for the job (which is good, you guys know what kind of person it takes!).

I truly appreciate all the insight from people actually practicing anesthesia. It's helping me realize this might just be a "grass is always greener / what if" moment rather than something I'd actually want to pursue and do day in/day out.
 
stohn_jamos said:
How grueling is the residency?
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The residency is grueling at most good programs. I did 16 liver transplants. A 26 hour long peds heart transplant one time. Was basically on call every other weekend, and at least once a week on the weekdays. Of course we’re talking in house call, and you are working most of that time. Our calls were 24 hours. You go in work a routine OR day until 3-4 PM then your call shift starts until the next morning at 6 am. My pgy-4 year i was carrying 4 beepers. All of this hell prompted me to go into pain management. OB calls were a special type of hell in our program where you could easily do 5 or 6 sections and umpteen epidurals in one shift. One of our ICU rotations was mixed medical and surgical. It was the worst place on earth.
 
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TeslaCoil said:
So you’re working a 40hr week and clearing 500k? Thats pretty good. Maybe I’ll go back to the OR. How much call are you taking?

Can anybody else confirm this is the norm nowadays?
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Yes. I take 2-3 calls a month. And if I do one 24 hr Ob call then that means the rest of that week I only have to work 16 more hours. There’s plenty of extra opportunities to make extra too since we are short staffed. And this is in a top 5 metro area east coast
 
TeslaCoil said:
The residency is grueling at most good programs. I did 16 liver transplants. A 26 hour long peds heart transplant one time. Was basically on call every other weekend, and at least once a week on the weekdays. Of course we’re talking in house call, and you are working most of that time. Our calls were 24 hours. You go in work a routine OR day until 3-4 PM then your call shift starts until the next morning at 6 am. My pgy-4 year i was carrying 4 beepers. All of this hell prompted me to go into pain management. OB calls were a special type of hell in our program where you could easily do 5 or 6 sections and umpteen epidurals in one shift. One of our ICU rotations was mixed medical and surgical. It was the worst place on earth.
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Sounds horrific hahahah
 
sevoflurane said:
My last 2am dissection was a few years ago 🙂.🍀

I can NOT do clinic. 😬🔫

I’d rather do call at 1/2 time FTE a few times a year for equal pay. You don’t have to do cardiac, but you can… if you like.

Options are limitless.

Anesthesia >>>> in my book.
Click to expand...
Yea 1/2 anesthesia FTE is not equal pay to AI private practice with a busy shot center. The allergists in my area work 4 days a week have a referral backlog of months and are clearing high 6 to low 7 figures with 0 EMTALA.
 
chessknt said:
Yea 1/2 anesthesia FTE is not equal pay to AI private practice with a busy shot center. The allergists in my area work 4 days a week have a referral backlog of months and are clearing high 6 to low 7 figures with 0 EMTALA.
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The ones I know were making a paltry living seeing a blizzard of patients in the office doing mind numbing work. Sold to private equity for a pittance because they couldn’t deal with all the private practice hassles.
 
Arch Guillotti said:
The ones I know were making a paltry living seeing a blizzard of patients in the office doing mind numbing work. Sold to private equity for a pittance because they couldn’t deal with all the private practice hassles.
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Yea if it is run poorly they arent going to do well. I work ~2.5 days/wk in clinic + 1 bronch day and am shooting mid to high six figures after expenses. Before I used to be employed and pay was way lower for clinic work. I think there is huge variance the same way there is for anesthesia but the big difference is you arent dependent on hospital admin with outpatient work.
 
chessknt said:
Yea 1/2 anesthesia FTE is not equal pay to AI private practice with a busy shot center. The allergists in my area work 4 days a week have a referral backlog of months and are clearing high 6 to low 7 figures with 0 EMTALA.
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Sorry i thought I read 300k? If allergy is making that much I would def not do another residency. Not worth it.
TBH, i’ve never seen an allergy guy doing bronchs or a bronch “day”?
Is that a thing?
 
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sevoflurane said:
Sorry i thought I read 300k? If allergy is making that much I would def not do another residency. Not worth it.
TBH, i’ve never seen an allergy guy doing bronchs or a bronch “day”?
Is that a thing?
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No I am PCCM but have worked very closely with allergists in the outpt setting and am somewhat familiar with their setup.
 
stohn_jamos said:
I rationalize repeating residency because it's only 3 years (similar to if I were to do another fellowship in GI or cards). I know plenty of IM subspecialty switching after already doing one fellowship. Also know a guy who did anesthesia directly after IM residency.

The charting is what's killing me the most. It will undoubtedly get better after I exit training, but might also get worse with more volume? The lack of the extra duties to clinic is appealing too (no inbox, prior auths, etc). Could always just do hospital medicine I suppose, but the in/out aspect of anesthesia, procedures, acute management is appealing.

How grueling is the residency?
Click to expand...

Go enjoy your life. Develop some hobbies. Find a good practice in a nice part of the country that respects your training. Work no nights, no holidays, and no weekends. Enjoy your relative high income. Develop good rapport with your staff.

There is a 0% chance I’d go do an anesthesiology residency were I in your shoes. Like Gravel said, give the middle finger and laugh at your anesthesiologist neighbor as he heads in for a Saturday call as you start yet another work-free weekend.
 
chessknt said:
Yea 1/2 anesthesia FTE is not equal pay to AI private practice with a busy shot center. The allergists in my area work 4 days a week have a referral backlog of months and are clearing high 6 to low 7 figures with 0 EMTALA.
Click to expand...

Is this still quite possible in major metros these days? I have a friend who was looking for A/I jobs in SoCal like 2-3 years ago. Couldn’t find anything like this and ended up just taking an employed job with Kaiser
 
sloh said:
Is this still quite possible in major metros these days? I have a friend who was looking for A/I jobs in SoCal like 2-3 years ago. Couldn’t find anything like this and ended up just taking an employed job with Kaiser
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I would guess not but the same is true for most of medicine in those areas.
 
Pay can be variable. Some academic salaries I've seen are as low as $200K. Most employed physicians start at $250 - $350K and include some sort of productivity bonus. There are private practices that are plentiful still but harder to get into and have some sort of buy in, which is a grind in itself. I know there are some allergists on SDN who might be able to comment/offer a perspective. Do I just have post-training blues @hotsaws ?

The lesson I'm learning is that there's no free lunch. You trade one problem in a career in medicine (notes) for another (call). I'm gonna take a swing at my allergy/immunology life, appreciate my lack of call/nights/weekends/OB patients, and see where it takes me. I appreciate the input from you anesthesiologists!
 
stohn_jamos said:
Pay can be variable. Some academic salaries I've seen are as low as $200K. Most employed physicians start at $250 - $350K and include some sort of productivity bonus. There are private practices that are plentiful still but harder to get into and have some sort of buy in, which is a grind in itself. I know there are some allergists on SDN who might be able to comment/offer a perspective. Do I just have post-training blues @hotsaws ?

The lesson I'm learning is that there's no free lunch. You trade one problem in a career in medicine (notes) for another (call). I'm gonna take a swing at my allergy/immunology life, appreciate my lack of call/nights/weekends/OB patients, and see where it takes me. I appreciate the input from you anesthesiologists!
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Really? $250k was easily attainable as a new grad hospitalist 15 years ago in desirable major metro areas. My primary care friend is breaking $500k and barely hitting 35 hours a week most weeks in a wealthy northeastern suburb.
 
GravelRider said:
Really? $250k was easily attainable as a new grad hospitalist 15 years ago in desirable major metro areas. My primary care friend is breaking $500k and barely hitting 35 hours a week most weeks in a wealthy northeastern suburb.
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There's the rub.
 
GravelRider said:
Really? $250k was easily attainable as a new grad hospitalist 15 years ago in desirable major metro areas. My primary care friend is breaking $500k and barely hitting 35 hours a week most weeks in a wealthy northeastern suburb.
Click to expand...
 
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