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I wanted to give my two cents to current fellows looking for their first job. I have seen questions popping up about this, and I have learned a lot from this forum so I wanted to give back. And I know the process can be overwhelming and it is hard to get specifics from people, so I really wish I would have known a lot of this starting out.
Obviously people will disagree with things here, but I think generally speaking you will find this to be true to your experiences.
1.
Oct/Nov/Dec is the time to be pedal to the metal with the search. You would be very surprised how many months it takes for concrete stuff to materialize, and how things can fall through as they are approaching completion.
2.
It is really super important to be very proactive and cast a wide net. I know a lot of people in pain who have finished fellowship in the last 1-3 years. The guys with the most prestigious CVs really did not necessarily get the best jobs. It is more about putting in the time to make the connections and explore opportunities
My basic methodology was to contact all the following:
1. Reps from all four SCS companies and let them know the areas I was looking. They put me in contact with their local reps in those areas, who put me in contact with job opportunities
2. VAs in the cities I wanted
3. Academic positions (with residencies/fellowships) in the cities I wanted
4. Googled/Google-mapped the cities I wanted and called the recruiters for the hospitals/hospital systems within about an hour drive of the cities I wanted (usually only a couple per city)
5. Talked to any alumnus of your institution or other contacts you have through other pain fellows or co-residents etc in the cities you want to go to try and speak with anyone actually practicing pain in the city. They will give you invaluable info about the layout and major players
6. It is impossible to find all the private practice opportunities that exist in a city you want, as they are so many and not straight forward to find. But sometimes there is a major player or two that are easy to find online.
I think it is super important to follow up on every lead. Any time someone told me they were not hiring, I asked if they knew who was in the area, for instance. You would be really surprised how helpful some people were and the specifics I found out in this way.
I found a lot of the best opportunities were 30min to an hour outside of the cities I was looking, not really a bad commute at all, especially if you live a little bit on the edge of the city.
3.
Some generalities are that if you want to do a mix of OR and pain or even some acute pain service stuff, you will have the best chance in academics, and a little bit less so but still definitely possible in hospital employment. Academic positions can be uber chill lifestyle or pretty rigorous due to research and administrative requirements it is hard to generalize, I know people in both positions. The good thing about academics is it is kind of CV building/prestigous or a spring board to administration in the right setting.
4.
I think private practice these days is truly the wild west. There are great opportunities, especially if you are not risk-averse, savvy, and are potentially willing to put some money in, but it is really very hard to know what you are getting into ahead of time and you have to do a lot of due diligence. There are a lot of raw deals/tough people out there who will take advantage of you as a new grad. Especially in desirable cities. Many pyramid type things where a few major players who got in earlier make money off everyone elses backs. You need to ask many direct questions about percentage of collections vs production vs RVUs, buy-in opportunities to surgi-center versus practice, specifics with your benefits, how are the referrals going to be generated/split up, etc etc. Discuss your offers with people you know in private practice and this board.
The other two issues with private practice are: Not just in pain, but in all fields, there is a demonstrable, significant shift toward physician employment in the last several years for a variety of economic reasons. The main issue is that hospitals have powerful political lobbies, and if you do the same injection in a hospital vs a private practice office, it pays many times more in the hospital. And also all the increasing regulatory requirements "meaningful use, etc" are very hard for mom and pop shops to do versus easier for hospitals with more infrastructure. I did find a few healthy groups, but many seemed to be struggling to survive for these reasons. Was kinda depressing actually... I think the issue with this, though really, is that it drives many of them to have to do what they can to survive, and even though people complain about "not being your own boss" "hospital administrators" etc, you will have a much greater chance of not being pressured to do things you dont agree with/like in a hospital employee setting, then in most private practices. At least that is what I found. And most of your referrals are internal, so there is much less pressure to please referrers in ways you may not want to (opioids etc).
5.
I found that, with very few exceptions, jobs posted online or via recruiters were not good at all when actually looked into. Makes sense I think, that they are having to post it so tough to fill...
6.
In terms of money, dont bring it up until they do generally, but at least wait till the second or third conversation. MGMA 50% for pain is around $440,000 if you can believe it, for pay. BUT The MGMA average is a little deceptive...because a few of the big dogs are raking it in and skewing the curve up despite the small number of them, and many of the docs are not seeing those average numbers as a result. But think about what your benefit package is worth as part of the offer you are getting too...these can add up to 50-100K sometimes, and some private practices offer OK looking salaries but almost no benefits. But basically no one will shell 440K over right off the bat in private practice, because it is more about the potentially very large gains to be had when you actually invest in the business, if you can find a good deal like this among all the bad ones, versus just getting a huge salary. But for academic jobs I wouldnt go any lower than 250, and for hospital employee positions, start with the 50% MGMA number to get the negotiations going in a good place (and tell them/show them this is what most pain docs earn to back it up), and shouldnt be less than 300 at the lowest. But then again, you just gotta take what you get in the end, especially if you have family or geographic limitations, regardless of what the average numbers are.
7.
For hospital employment it's usually RVU based. 6500 rvus is very doable, and up to 10000 is not uncommon when u are a few years in of your setup is efficient.
65$ is a reasonable amount per RVU (called a conversion factor) when u are new and bringing no new business to the table. I got more than this, and many do, but that's all location (rural v metro) and negotiation specific.
If u do the math 65x6500= around 420K.
8.
Pain can be an awesome field, or a terrible one, all depending on your practice. It is much more variable then other fields of medicine in this regard.
Do the hard work up front!
Obviously people will disagree with things here, but I think generally speaking you will find this to be true to your experiences.
1.
Oct/Nov/Dec is the time to be pedal to the metal with the search. You would be very surprised how many months it takes for concrete stuff to materialize, and how things can fall through as they are approaching completion.
2.
It is really super important to be very proactive and cast a wide net. I know a lot of people in pain who have finished fellowship in the last 1-3 years. The guys with the most prestigious CVs really did not necessarily get the best jobs. It is more about putting in the time to make the connections and explore opportunities
My basic methodology was to contact all the following:
1. Reps from all four SCS companies and let them know the areas I was looking. They put me in contact with their local reps in those areas, who put me in contact with job opportunities
2. VAs in the cities I wanted
3. Academic positions (with residencies/fellowships) in the cities I wanted
4. Googled/Google-mapped the cities I wanted and called the recruiters for the hospitals/hospital systems within about an hour drive of the cities I wanted (usually only a couple per city)
5. Talked to any alumnus of your institution or other contacts you have through other pain fellows or co-residents etc in the cities you want to go to try and speak with anyone actually practicing pain in the city. They will give you invaluable info about the layout and major players
6. It is impossible to find all the private practice opportunities that exist in a city you want, as they are so many and not straight forward to find. But sometimes there is a major player or two that are easy to find online.
I think it is super important to follow up on every lead. Any time someone told me they were not hiring, I asked if they knew who was in the area, for instance. You would be really surprised how helpful some people were and the specifics I found out in this way.
I found a lot of the best opportunities were 30min to an hour outside of the cities I was looking, not really a bad commute at all, especially if you live a little bit on the edge of the city.
3.
Some generalities are that if you want to do a mix of OR and pain or even some acute pain service stuff, you will have the best chance in academics, and a little bit less so but still definitely possible in hospital employment. Academic positions can be uber chill lifestyle or pretty rigorous due to research and administrative requirements it is hard to generalize, I know people in both positions. The good thing about academics is it is kind of CV building/prestigous or a spring board to administration in the right setting.
4.
I think private practice these days is truly the wild west. There are great opportunities, especially if you are not risk-averse, savvy, and are potentially willing to put some money in, but it is really very hard to know what you are getting into ahead of time and you have to do a lot of due diligence. There are a lot of raw deals/tough people out there who will take advantage of you as a new grad. Especially in desirable cities. Many pyramid type things where a few major players who got in earlier make money off everyone elses backs. You need to ask many direct questions about percentage of collections vs production vs RVUs, buy-in opportunities to surgi-center versus practice, specifics with your benefits, how are the referrals going to be generated/split up, etc etc. Discuss your offers with people you know in private practice and this board.
The other two issues with private practice are: Not just in pain, but in all fields, there is a demonstrable, significant shift toward physician employment in the last several years for a variety of economic reasons. The main issue is that hospitals have powerful political lobbies, and if you do the same injection in a hospital vs a private practice office, it pays many times more in the hospital. And also all the increasing regulatory requirements "meaningful use, etc" are very hard for mom and pop shops to do versus easier for hospitals with more infrastructure. I did find a few healthy groups, but many seemed to be struggling to survive for these reasons. Was kinda depressing actually... I think the issue with this, though really, is that it drives many of them to have to do what they can to survive, and even though people complain about "not being your own boss" "hospital administrators" etc, you will have a much greater chance of not being pressured to do things you dont agree with/like in a hospital employee setting, then in most private practices. At least that is what I found. And most of your referrals are internal, so there is much less pressure to please referrers in ways you may not want to (opioids etc).
5.
I found that, with very few exceptions, jobs posted online or via recruiters were not good at all when actually looked into. Makes sense I think, that they are having to post it so tough to fill...
6.
In terms of money, dont bring it up until they do generally, but at least wait till the second or third conversation. MGMA 50% for pain is around $440,000 if you can believe it, for pay. BUT The MGMA average is a little deceptive...because a few of the big dogs are raking it in and skewing the curve up despite the small number of them, and many of the docs are not seeing those average numbers as a result. But think about what your benefit package is worth as part of the offer you are getting too...these can add up to 50-100K sometimes, and some private practices offer OK looking salaries but almost no benefits. But basically no one will shell 440K over right off the bat in private practice, because it is more about the potentially very large gains to be had when you actually invest in the business, if you can find a good deal like this among all the bad ones, versus just getting a huge salary. But for academic jobs I wouldnt go any lower than 250, and for hospital employee positions, start with the 50% MGMA number to get the negotiations going in a good place (and tell them/show them this is what most pain docs earn to back it up), and shouldnt be less than 300 at the lowest. But then again, you just gotta take what you get in the end, especially if you have family or geographic limitations, regardless of what the average numbers are.
7.
For hospital employment it's usually RVU based. 6500 rvus is very doable, and up to 10000 is not uncommon when u are a few years in of your setup is efficient.
65$ is a reasonable amount per RVU (called a conversion factor) when u are new and bringing no new business to the table. I got more than this, and many do, but that's all location (rural v metro) and negotiation specific.
If u do the math 65x6500= around 420K.
8.
Pain can be an awesome field, or a terrible one, all depending on your practice. It is much more variable then other fields of medicine in this regard.
Do the hard work up front!
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