Finished residency in June 2017, now four months in to my first private practice job. I remember gaining some good knowledge over the years on SDN, figure it is a good time to pay it back. Ask me anything yall
Four months in to first job after residency, ask me anything
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Hi, thank you for your generous offer to advise! And congrats to your new job 🙂
I have a broad question as a current prelim IM intern: What do you think I should take away most out of my IM year in preparation for CA-1 and beyond? For context, I'm in a ward heavy program with 4.5 months of general wards, 3.5 months of MICU, 1 month CCU; no other scheduled consults or any anesthesia month. Thanks!
1)Do you feel like your residency did a good job of preparing you for private practice?
2)Do you feel like you know more, less or about the same as your co workers?
3)If you have sizable loans are you paying them off quickly?
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What part of the country are you in ?
What is your mix of supervision and doing your own cases?
Do you have a say in what kind of cases you do ?
What is your mix of supervision and doing your own cases?
Do you have a say in what kind of cases you do ?
As much ICU, cardiology, pulmonology, renal as you can. Having an excellent groundwork of physiology prior to CA-1 year is important to build of off. Start reading a little from baby miller or another text and try to finish it throughout the year and you'll be set. Don't stress too much about starting CA-1 year, you're there to learn anesthesia. Most attendings assume you know nothing and build off of that.
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THANKS! and congrats!
so on my residency interview rounds, obviously step scores are paramount...but how much did your (step 3, basic, ITE) scores play into hiring? is this something that you lead with or is it assumed that by the time you get to the point of interviewing, you've cleared these to satisfaction? do they even go on a CV?
did you get faculty mentorship/business connections to help you search or was it more of a cold-calling type of situation?
how was your actual interview process? multiple days? extreme "negotiation"? was there wining and dining? ive heard that there is, especially if you're a "big fish, small pond" candidate..but that might be folklore.
so on my residency interview rounds, obviously step scores are paramount...but how much did your (step 3, basic, ITE) scores play into hiring? is this something that you lead with or is it assumed that by the time you get to the point of interviewing, you've cleared these to satisfaction? do they even go on a CV?
did you get faculty mentorship/business connections to help you search or was it more of a cold-calling type of situation?
how was your actual interview process? multiple days? extreme "negotiation"? was there wining and dining? ive heard that there is, especially if you're a "big fish, small pond" candidate..but that might be folklore.
1.) I do with some caveats- anesthesiologists (regardless of subspeciality) are doing more 'offsite' cases. What I mean is GI endos/CVC/EP etc... I was exposed mostly to rare and generally big,long, and bloody cases at my residency (big academic center) which was fascinating and overall great training; however coming out with little offsite anesthesia experience was perhaps a detriment for me, like most new grads. Just takes some getting used to that's all.
2.) Compared to some of my older co-workers, I feel like I know more about recent evidenced based anesthesia, US-guided nerve blocks, ERAS techniques, opioid sparing techniques, etc. I am but a wee pipsqueak compared to some of my more seasoned co-workers when it comes to some other things. Overall I feel as though I am competent compared to my coworkers. It is important to join a practice, which will let you grow on the job and have co-workers who you can bounce ideas off of. I have already learned A TON in the first few months of being an attending.
3.) My general financial philosophy is to pay them off ASAP for peace of mind more than anything. I have ~$340k and hope to have them paid off in under 5 years, which is absolutely reasonable with a non-extravagant lifestyle.
I can't honestly say how much those factors played in my ultimate success as a candidate. I passed the basic (don't know my percentile) and was anywhere from 50th-90th %ile on the ITE. I had no faculty connections as I trained in a region of the US away from home, and my job is back home in the Midwest. I do know that my current employer called my faculty references (program director was required, then two others) who all told me they received calls.
I interviewed for two jobs- both of which had very similar interview experiences. I was taken out with my wife to a nice, local restaurant with a few other anesthesiologists, the group president/CEO and casually got to know them. They were mostly selling the practice during the dinner at both places, but I treated as a residency interview dinner. One place footed the bill for airfare and put us up in a high end hotel. The following day was meeting with HR directors to go over benefits/pay/etc, touring the hospital(s), meeting some other staff. I was left in rooms with anesthesiologists to pick their brain for maybe 15 mins at a time. I definitely took advantage of that time and asked some tough questions.
One place was willing to negotiate small things (moving expenses, a small signing bonus), the other negotiated nothing. Pay is hard to negotiate in anesthesia as most practices reimburse based on units produced, which is hard to change between providers.
Overall very pleasant experiences.
-I'm in the Midwest, in a bigger city, desirable practice
-I do about 80% of my own cases - vascular, surg oncology, ortho, gyn, uro, EP, OB, acute pain/regional, etc...overall very similar load to residency of cases - whipples, HIPECs, big liver resections, major aortic vascular, just no CT/peds/chronic pain (thank goodness). As I said above, about one day a week of endo, radiology, CVC.
-I do get a say in what TYPE of cases I can generally do, but being new I don't typically request cases. The docs who make the schedule are typically very fair - they spread out the less desirable rooms evenly over time.
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appreciate the info! do you mind sharing examples of the questions you asked?
-Do you think the scheduling is fair? Do the more established partners get preference of cases? My practice uses blended units for both payer mix as well as what you are doing intraop. 1U/15min in the OR regardless whether you are doing an EGD or a heart transplant - no extra compensation for additional procedures done. There are some practices, in which the more established docs do the private insurance spines only and the new grads do the MEDICARE/CAID high turnover rooms and you make less money.
-Is there ample opportunity for new grads to do big cases to further my learning?
-Is there a culture of support and help? ie will I be able to run ideas by people without getting labeled incompetent? Will there be help if I have an intraop emergency?
-Is there an imminent threat of buyout or practice change?
-Post-call work?
-How flexible is leaving early/days off if absolutely needed?
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I don’t have anything to contribute but just wanted to say nice thread guys.
Very impressed with the questions from the young guns.
Very impressed with the questions from the young guns.
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Is there anything you wish you did different CA3 year to better prepare you for working out in the real world?
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How much you making? That's the only important question.
True true but to add. How much are you making and many hours are u pulling in each week to make that income.
It’s the pay per hour that matters most
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How did you find the job? Contacts? Cold calling? Online? Other? @noise115
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As much regional as possible - very useful and something to differentiate you from the older docs who may not have had as much training using US.
Looking back, I think I (as many residents do) get caught up in doing the biggest, baddest cases out there. What gets forgotten is simple skills and fundamentals you learn as a CA-1, such as smooth extubations, safe inductions, etc. Work on those and try to be as independent as possible.
Haha well it's essentially eat what you kill but probably around $400-500k/year minus buy-in. That's 1ish weekend a month, 1 full night of call/week with some longer days mixed in.
I am originally from the general area and knew it was a quality practice and hospital. I didn't necessarily have connections other than "Hey I'm from around here". I cold called both places I interviewed at and both were very receptive. It's always worth a 3 minute call to see if a job is available for you!
To add, that is including the cost of insurance/'mandatory' retirement/malpractice/disability/etc...
Hours worked are similar to residency, just no lecture in the morning, no preop-ing inpatient's afterward. I get in around 6:45 for any case. Leave around 3-5pm most days I'm not on call.
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must have not been a work horse residency.
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That's funny considering another active thread is touting my current program as a workhorse program and those are our hours.
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Obviously being proficient in all regional techniques is desirable but do you find yourself using or expected to know some of the more "advanced" blocks like QL or lumbar plexus? I never saw the partners at the hospital I'm working for next year doing them but it's my understanding they're relatively new
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It's all a matter of perspective. My program also calls it self a workhorse program, but we are so far below the 80 limit that I find the term workhorse hilarious.
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@noise115 Thanks for the info! It seems like you're pretty happy with your set up thus far. Do you find that your other residents in your class feel similar? Also, what brought you into straight private practice as opposed to a fellowship? What fellowship do you feel is most marketable right now?
It was probably middle of the road...like most residencies it was highly dependent on which rotation I was on.
Not expected to use the newer blocks such as QL or PECS (are these even considered new anymore?) but I am happy I am proficient in them. I am able to teach some of the more established docs who are willing and eager to learn what I learned. Over the past year or two my practice started transitioning from paravertebrals to PECs; however most of the regional docs had never even seen the block, so it has been extremely useful to have that skillset
About half of my class is in fellowships and the other in PP. Most of my graduating class is pretty happy where they are at, but it is truly just person dependent. I think anyone would be frustrated if they had expectations of making 500+ while working 40hr/wk or less - so setting your expectations realistically is important.
I went in to private practice for a few reasons. I was initially going to do a fellowship (even applied, but withdrew my application before rank order list was due), but ultimately it was for personal reasons. Desire to be back by family, ready to be done training, ready to be more autonomous in my practice, etc...No real epiphany moment. I think I would have been happy doing a fellowship as well, but I'm glad I went in to private practice, although it was a REALLY tough decision. I decided doing a fellowship for 'job security' (one of the big reasons I was considering a fellowship, unfortunately) was a bad idea. I may regret this in the future, but at this point the future of medicine and anesthesiology is hard to predict so why try?
I'm not sure which fellowship is most marketable right now. CT, CC, peds, chronic pain will always have a need and niche. Regional/OB/Neuro, etc are frankly a waste of time if you desire a private practice job. If you can't do a crani/complex spine, complex OB, and most regional (outside of some exotic blocks) then your residency has failed you, in my opinion. Not saying those fellowships are bad, would love to learn more about all subspecialties in that depth.
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Those are some ridiculously amazing residency hours. Jealous!
How do you do your 'smooth extubations'? Do you just pull them deep?
Does your job have partnership track or are you making what you do for rest of your life if you work there?
What is CVC? Central venous catheter? Like line placements and stuff?
What in your opinion are complex crani/spine, obs that residents should be doing? I'm at a large OB, neurosurg, spine center but most of them feel very straight forward. It feels like the "complex " OBs are done by Ob fellow or cardiac anesthesiologists. (the ones requiring embolizations in IR before going to OR for C sections.. or the ones with bad heart failure and phtn). And for cranies, I would love to do some awake crani but we barely ever do any here.. other than that they all seem the same.. what complex cranis are you referring to? (I'm trying to decide soon if i should do a fellowship or not)
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curious to what makes a program a workhorse program. I dont even think we get close to 80 hours a week here. A bad week with no call is right around 60 hours, but some people think its too much lol
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It's all opinion. Workhorse in my opinion is program puts you to work a lot more than educating. You dont need to work 80 hrs a week. If you are stuck in the hospital for 70 hrs a week, how many people are going home to read? How beneficial is it for a resident to do his/her 200th lap chole? On residency interviews programs often talk about how many cases they do a year, but often people forget those institutions are also the ones w a large residency class + fellows. I'm actually a bit jealous of the small programs now with 5 residents who get assigned to cool/educational cases instead of just having a program staff a resident into almost every room for cheap labor so attendings can double cover.
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Agreed. People who trained at workhorse progs will espouse the merits of being in the OR so much by claiming that those hours allowed them to deal with more unexpected complications and hairy situations that arose in ASA1-2 cases. I think that's mostly a bunch of nonsense, though. One can have reasonable hours throughout 60-80% of residency and still learn how to be deft in an emergency as long as subspec peds, cardiovascular, liver/trauma, ICU, code pager rotations are complex, challenging, and relatively fellow-free.
-I only pull tubes deep if I am extremely concerned with bucking on waking up; otherwise good amount of narcotics, low dose propofol infusion (20ish mcg/kg/min), LTA during intubation all work okay. Get the patient breathing spontaneously as soon as you can. Some patients are just going to cough regardless of what you do. I use LMA's ALOT more now than during residency - ENT cases especially.
-Sorry, CVC is the local lingo for cath lab/ep
-Those kind of OB cases typically will not come to a private practice hospital, but you should be prepared for typical OB pathology (accretes, previas, pre-E, morbidly obese, etc).
-All-day spines requiring transfusions on chronic pain patients, awake crani's, emergent cranis. Not just two level lumbar laminectomies. Obviously a fellowship will allow you to dive deeper into the nitty gritty and expose you to some rarer cases. I would say a neuro fellowship is useful if you want to stay in academia (at least from my limited exposure thus far).
I think my program was middle of the pack. 0545ish-1700 on noncall days. One day a week 0545-1900. One 1500-0700 night/week. Two weekends a month. Obviously CT, transplant and ICU, etc were a little more time intensive. But overall probably 65hours/week. Workhorse to me has more to do with what you do while you're at work than hours.
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545 is really early for general!!. i guess thats why you go home early
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Are those hours really that amazing? What are yours?
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On general months I get in at 630-645 on avg . Leave at 6-7 on avg non call today's.
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Please refrain from calling yourself a “provider”. If you will not respect your education and training, nobody will.
My goodness, this is why I avoid SDN and will probably continue to do so. Just relax a little, it's an online forum. My training is well respected because I am good at what I do and hold myself in high esteem, not because I flaunt that I am a physician. I am just trying to have a nice conversation and help residents, who are in the position I was in a last year to ease the transition.
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Sorry to offend you. That was not my intent. I’m just trying to maintain the distinction btw midlevels and physicians. If we refer to ourselves in a generic term like the midlevels and administrators refer to us, then we continue to blur the line btw the two. With midlevels claiming that they are equal or even better than you, no matter what your training is, you are just making their claim more believeable since you both are called “provider”.
And trust me, your training is only respected by you.
It is your actions, your performance, and how you carry yourself that is respected. Training is low on that scale. Everyone has what they claim to be excellent training, even the midlevels. Back to the Dunning-Kruger Effect.
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Do you feel like that offer was among the highest available out there or did you come across jobs with even greater earning potential?
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That's on the high end among starting pp jobs
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Jobs in the northeast are around 250k-300k so op is balling.
I only applied to two places and got offers from both, so my sample size is fairly limited. I think both places had similar compensations, I may have chosen the place with less earning potential even. I decided to go with the practice, which seemed stable and well run rather than go for the potential of earning more money.
I think this is a fairly common amount of money (pre-tax) for the amount of work I am doing. I base this off what my co-residents have told me they are making in different regions of the country (excluding the obvious outliers such as NYC, California, other highly desirable places to live).
No offense taken,I understand and respect your sentiment. Sometimes you just need to chill and realize I am just having a casual conversation with other like-minded individuals. I assume no one respects
I would say if you're making 250k pre-tax then either the market is highly competitive or you're getting boned, unfortunately. Again, co-residents of mine in Northern California (not SF), Denver, Minneapolis, PNW, etc are making ~350K/year or potentially more per their word. Could be vastly different on the east-coast - I have no exposure to the job market there.
I'm obviously not very good at posting, I was saying I assume no one respects the training itself; however the doctor who comes from the training. That is entirely up to the individual physician.
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Why do I need to “chill”? All I did was ask you politely to refrain from calling yourself a provider. It was for your own good as much as it is for the good of the medical profession.
D
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Competitive market... Unfortunately
