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

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Gern Blansten said:
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 unfounded resident because the majority of programs have unfounded 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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That’s my understanding as well.
 
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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@chessknt is spot on with the assessment of what allergy looks like

Feel free to DM me and I'd be happy to talk in more detail. Training burnout is real and that is likely what you're feeling. My day to day practice is great. There really isn't any need to prechart or anything like that. I get it and I did it initially (out of habit and neuroticism, mostly). Once you're in practice and get the hang of it, you don't really need to pre chart. You're not getting many complex, multidisciplinary care referrals. You're mostly getting straight forward patients and probably not even getting records sent for most of them anyway. Call is a joke, pretty much none of us do hospital consults. I guess if you're in a small practice, you might be fielding patient calls after clinic more often. If you're in a bigger group and especially if there are midlevels, your call burden will be minimal, very minimal. The inbox of an allergist is probably better than most outpatient fields. We don't order a ton of imaging or labs compared to other fields. Hours are normal and controllable. Most work 4-5 days. The earning potential is good. Your anesthesia buddies will make more initially but your earning potential is probably higher than you think. You're also have good potential to have plenty of autonomy as an A/I doc. Still plenty of solo practitioners and privately owned groups.

I think anesthesia is an appealing field but I can't imagine how you could ever consider giving up a career as a subspecialist with a great lifestyle and solid earning potential to go back to training. The thought of it makes me think you are just burned out and engaging in some kind of escapism or grass is greener syndrome. On a practical level, it's pretty crazy. You just spent 5 post grad years training and you would attempt to spend another 4 or so training to change fields this late in the game? I wouldn't consider it a negative to not have to deal with complex PID, HAE, or that type of stuff on a day to day basis -- I love dealing with bread and butter AR, asthma, rashes, food allergy, etc. The patients almost all get better, they are grateful, the reimbursement is good, and you mostly have positive pt encounters all day. Those complex things aren't always as fulfilling. PID can be interesting but you're correct that you pretty much have to be at a large pediatric hospital to see the rare stuff. HAE is meh -- the pts can be difficult to deal with (for whatever reason), the meds are expensive and require paperwork, the actual management is pretty straight forward (controller + abortive, options often dictated by insurance coverage rather than personal choice). Drug allergy is either pretty straight forward or you're dealing with some multidrug intolerance BS.

If you were a med student deciding between A/I and anesthesia, this would be a different conversation. I actually think anesthesia seems like a great field and I wouldn't try to talk anyone out of it. In fact, if I was back in med school knowing what I know now, anesthesia is probably a top 5 field in my opinion. I don't really have anything negative to say about anesthesia. But you're at the finish line of 5 years of post grad training in a desirable field...I don't see any reason to give that up. I get it. I've looked at the grass on the other side and thought it was greener. I have friends in great fields like derm, ENT, ortho, and I've thought "man, should I have done that..." but I have never thought about going back into training. I don't know if I have another second of training left in me. The whole system of training is so toxic and burdensome. Getting out of that bubble and going into private practice was such a breath of fresh air. Don't get me wrong, there's BS to deal with...but I think this is true of any field and I think we have it pretty good.
 
hotsaws said:
@chessknt is spot on with the assessment of what allergy looks like

Feel free to DM me and I'd be happy to talk in more detail. Training burnout is real and that is likely what you're feeling. My day to day practice is great. There really isn't any need to prechart or anything like that. I get it and I did it initially (out of habit and neuroticism, mostly). Once you're in practice and get the hang of it, you don't really need to pre chart. You're not getting many complex, multidisciplinary care referrals. You're mostly getting straight forward patients and probably not even getting records sent for most of them anyway. Call is a joke, pretty much none of us do hospital consults. I guess if you're in a small practice, you might be fielding patient calls after clinic more often. If you're in a bigger group and especially if there are midlevels, your call burden will be minimal, very minimal. The inbox of an allergist is probably better than most outpatient fields. We don't order a ton of imaging or labs compared to other fields. Hours are normal and controllable. Most work 4-5 days. The earning potential is good. Your anesthesia buddies will make more initially but your earning potential is probably higher than you think. You're also have good potential to have plenty of autonomy as an A/I doc. Still plenty of solo practitioners and privately owned groups.

I think anesthesia is an appealing field but I can't imagine how you could ever consider giving up a career as a subspecialist with a great lifestyle and solid earning potential to go back to training. The thought of it makes me think you are just burned out and engaging in some kind of escapism or grass is greener syndrome. On a practical level, it's pretty crazy. You just spent 5 post grad years training and you would attempt to spend another 4 or so training to change fields this late in the game? I wouldn't consider it a negative to not have to deal with complex PID, HAE, or that type of stuff on a day to day basis -- I love dealing with bread and butter AR, asthma, rashes, food allergy, etc. The patients almost all get better, they are grateful, the reimbursement is good, and you mostly have positive pt encounters all day. Those complex things aren't always as fulfilling. PID can be interesting but you're correct that you pretty much have to be at a large pediatric hospital to see the rare stuff. HAE is meh -- the pts can be difficult to deal with (for whatever reason), the meds are expensive and require paperwork, the actual management is pretty straight forward (controller + abortive, options often dictated by insurance coverage rather than personal choice). Drug allergy is either pretty straight forward or you're dealing with some multidrug intolerance BS.

If you were a med student deciding between A/I and anesthesia, this would be a different conversation. I actually think anesthesia seems like a great field and I wouldn't try to talk anyone out of it. In fact, if I was back in med school knowing what I know now, anesthesia is probably a top 5 field in my opinion. I don't really have anything negative to say about anesthesia. But you're at the finish line of 5 years of post grad training in a desirable field...I don't see any reason to give that up. I get it. I've looked at the grass on the other side and thought it was greener. I have friends in great fields like derm, ENT, ortho, and I've thought "man, should I have done that..." but I have never thought about going back into training. I don't know if I have another second of training left in me. The whole system of training is so toxic and burdensome. Getting out of that bubble and going into private practice was such a breath of fresh air. Don't get me wrong, there's BS to deal with...but I think this is true of any field and I think we have it pretty good.
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Appreciate the real talk and advice. I DM'd you!
 
Leinie said:
Inclusive of call?
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40 hours is inclusive of in house call, but I’ve only been working 30 hours recently because it’s been so slow. I have in house weekend call, for which I get the whole next week off as post call. The only thing is I have home call during the week about once per week, which is compensated extra, and I’ve only been called in for a grand total of 2 hours ytd.
 
Dantrolene FC said:
40 hours is inclusive of in house call, but I’ve only been working 30 hours recently because it’s been so slow. I have in house weekend call, for which I get the whole next week off as post call. The only thing is I have home call during the week about once per week, which is compensated extra, and I’ve only been called in for a grand total of 2 hours ytd.
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What part of the country ?
 
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?
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Sounds like it would be worth it to pay for a scribe or some new note-writing AI software.

For real, not worth going back to training. Go out, work, make some money, feel out your job market. You can make a big difference in people's lives AND sleep in your own bed every night and weekend, attend all your kid's special moments, and fulfill some entrepreneurial aspirations with boutique services if you need more than just bread and butter allergy and immunology. (I'm writing this from the lobby of the allergy/immunology clinic because my son just got his weekly allergy shots).
 
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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Averaging 50-52 hrs/week. Mostly solo cases. Took ~7 weeks off last year. Made just over $750K.

Taking 10 weeks off this year. Probably just under 50hrs/week so far this year. On track for just under $750K.
 
TeslaCoil said:
What kinds of cases are you doing?
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Just about anything and everything except transplant. Not a ton of regional anesthesia, as the majority of outpatient ortho stuff happens at a different facility not staffed by our group.
 
abolt18 said:
Sounds like it would be worth it to pay for a scribe or some new note-writing AI software.

For real, not worth going back to training. Go out, work, make some money, feel out your job market. You can make a big difference in people's lives AND sleep in your own bed every night and weekend, attend all your kid's special moments, and fulfill some entrepreneurial aspirations with boutique services if you need more than just bread and butter allergy and immunology. (I'm writing this from the lobby of the allergy/immunology clinic because my son just got his weekly allergy shots).
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I know of an allergist using the passive listening AI software. I think that will be standard or at least common in no time. Haven't tried it yet because, frankly, documentation is not a burden. I just use a regular dictate to note program, analogous to dragon. I can see 25+ patients in a day plus easily clear out my inbox without spending much extra time in clinic. I rarely would be here more than 15 minutes after the last shot patient leaves. I could be quicker if I weren't generally social and chatty with staff, patients, and reps. If the AI stuff were accurate and not much more costly than Dragonesque type stuff, I would be fine adopting it. Overall, documentation really shouldn't be much of a burden in our field.
 
Yeah I feel for you guys doing clinic. The amount of documentation needed has really increased recently. The messaging inbox is good for patient but really cumbersome for physician. Plus it’s still only 30 min for each visit.

I feel grateful that we don’t have to document that much in anesthesia and we don’t have to deal with insurance companies.
 
Simba1711 said:
Yeah I feel for you guys doing clinic. The amount of documentation needed has really increased recently. The messaging inbox is good for patient but really cumbersome for physician. Plus it’s still only 30 min for each visit.

I feel grateful that we don’t have to document that much in anesthesia and we don’t have to deal with insurance companies.
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Probably better off doing GI if you want to avoid an inbox and still make money. They don’t really do clinic anymore.
 
secretasianman said:
Hard to have respect for GI when the the goal is to scope everything and they’ve clearly sold out as a specialty.
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One of the more disappointing transformations I've seen was a GI that came to my hospital fresh from fellowship. He initially cared about lot about doing a good job, came up to speak to me in the ICU regarding patients on whom I consulted him, included real information and recs in his notes. Within a year, though, I was scoping with him as he described the amazing setup they had ("It's the future of GI!"), where they employed an army of NPs in clinic to find any reason to stick a scope in someone. One doc would be assigned to the clinic daily to be a resource for the NPs. The rest were in endo, scoping four days a week. One night when he was called for an emergent upper GI bleed, he screamed into the phone (on a recorded line), "I don't ****ing care, I'm not coming in to scope him!" Great guy.
 
psychbender said:
One of the more disappointing transformations I've seen was a GI that came to my hospital fresh from fellowship. He initially cared about lot about doing a good job, came up to speak to me in the ICU regarding patients on whom I consulted him, included real information and recs in his notes. Within a year, though, I was scoping with him as he described the amazing setup they had ("It's the future of GI!"), where they employed an army of NPs in clinic to find any reason to stick a scope in someone. One doc would be assigned to the clinic daily to be a resource for the NPs. The rest were in endo, scoping four days a week. One night when he was called for an emergent upper GI bleed, he screamed into the phone (on a recorded line), "I don't ****ing care, I'm not coming in to scope him!" Great guy.
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Well FFS medicine basically pushes people to this. Every GI I have ever met outside of academia is exactly like this. I sent someone to a GI with a dilated esophagus who was clearly chronically aspirating and before they even had the swallow study they had already done an EGD (and a colon too because why the **** not). When the swallow study showed severe aspiration only the NP was following the pt with no further thought or workup since the procedure had been farmed. Until FFS medicine dies and we see cogntiive work reimbursed at parity this will continue to happen. Oncology is the same way with selling chemo, allergy with selling shots, cards with ordering every form of ancillary testing in existence etc.

I am sure if CVLs reimbursed at 8x the anesthesia startup rate suddenly everyone would need one for every surgery.
 
Might be program specific, but even in fellowship I didn't do much pre-charting in A/I, occasionally for very complex immunodeficiency, eosinophilia, etc. patients but those were generally the exception not the norm. I do very little in private practice, generally no more than scanning over their last PMD note, often times I don't even need to do that. Most bread and butter allergy notes are very straightforward and to the point. Charting burden is definitely way less than PMDs, probably less than almost all other specialties.

Allergy is a great field, especially as an attending. Focused visits, generally brief notes, patients tend to get better, decent pay, great lifestyle, tons of new treatment options (biologics) for most of the conditions we treat that can be life changing for patients who have suffered for years. The list goes on and on. Most private practices only see basic immune deficiency if any at all (CVID, SAD), and anything more significant gets sent to academic centers. Our days can be busy, but I'd be lying if I said allergy wasn't one of the lowest stress fields in medicine if not the lowest.

One of the few downsides is that all these new treatments generally need prior auths which generates a lot of paperwork, but this is true for virtually every specialty and a good office staff goes a long way to help this.

I am on call roughly every other week but probably average no more than 1 call a week, usually minor things. No hospital coverage so I NEVER have to work evenings, weekends, or holidays (other than phone call which is minimal) which is amazing.

You'd probably make more money in anesthesia but would need to survive another brutal 3 years of training with residency level pay and likely have significantly more hours, call responsibilities, and stress. I don't know if there's a dollar amount I'd take to go back for 3 MORE YEARS of residency, but it would quite literally probably need to be in the 7 figure range for me to even consider it.

IMO - go into private allergy practice, make good money taking care of grateful patients with a great lifestyle, and never look back.

Feel free to DM me.
 
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