Are You Ready For Private Practice? (
BY JETPROPPILOT)
"(
ADDENDUM: I wrote this a cuppla years ago. Its got alotta useful information in it for you. I'm bumping it for the benefit of my CA-3 colleagues who may have missed it and are gonna be on their own in a few months.)
I'm starting a thread that I hope will be useful for the current and future CA-3s out there. At the end of this year, CA-3s, your life will take a dramatic change. You will have clinical responsibilities where your decision is the final decision. You will be faced with the new dillemas of becoming a team player in a
group practice, where every decision/opinion/action you take will be scrutinized, with the end result being whether you become a partner or not. And you and I know your goal is to become a partner.......job security being the primary objective; major c-notes being the secondary objective.
Problem is, in academia where most of you currently reside, there is no guidance for emerging practitioners....academia will guide you up to and including your last case as a resident. Thats it. After that last anesthetizing case you perform, AMFYOYO. See ya. Youre on your own. Buh-bye.
My last case at Tulane (circa June 30th, 1996) was a 3 hour hysterectomy. After I was done, I went to my locker and cleaned out my stuff.. That was it. No........"So Bill, whats the practice that you're going to like? Group? Hmmmm....we've got a few former private practice dudes around here....why don't we have you talk with them to give you a little perspective of private practice life, OK?"......
.....nothing to that effect happened. And I venture to say most residencies out there are similar in that minimal advice is given to finishing-senior-residents.
This is a problem with academia, Dudes.
Things need to change in academia....most graduating residents matriculate into a private practice model and yet this IMPORTANT fact is ignored in your training. You are not prepared clinically, emotionally, and business-wise for such a career jump....a jump that we all make. Hopefully some academic-deities will read this and realize the
existent black hole in their residency program.
My goal is to recruit my fellow private practice dudes (Mil, Noy, UT) to post here in an effort to guide you through the right way to matriculate into a private group from residency, with the ultimate goal being you hit partnership (read: 6th round NFL draft pick salary).
And here, I'll take a bit of a tangent for med students/interns.
This kinda info may not be for you.
Maybe you're an individualist destined to secure power in your practice of medicine.
I respect that.
I'll also tell you that if you've selected anesthesia as a specialty you're probably not destined for stardom. Yeah, if you really want it you can become a
John Tinker/Alan Kaye/Michael Roizen. But most of us out here making our living at this profession are flying under the radar. By definition we are the offensive line of medicine. We are the players that nobody really cares about.
You're either comfortable with that or you're not.
And if you are not, you probably need to select another specialty.
Deep-six your anesthesia selection and go for heart surgery. Transplant. Family Practice/Pediatrics/Internal Medicine in a rural area where youre da man. Something that you can potentially have your name in the paper for.
And because of the (egocentric) personalities I've seen here on SDN and because of my periodic exposures to unhappy anesthesiologists, I'm gonna string this out a bit..... and I want you to think about this long and hard.....
if you select anesthesia to pay your bills you will never be more than a supporting actor. The Brad-Pitt-of-surgeons will always steal the thunder. They are the glory boys. You are the (metaphorically) short, bald dude on
Seinfeld.
A crucial aspect of the perioperative environment?
Absolutely.
The lead role?
Absolutely not. You are the offensive lineman. The punter that comes on in a crutch and kicks a fifty-six-yard punt. Or a field-goal kicker. You are Morten Anderson. Mr. Carney of the New Orleans Saints. Grammatica.
Again, get comfortable with this. And if this makes you uncomfortable take another route that'll satisfy your needs.
Are you comfortable being a sixth-round offensive lineman for the Tampa Bay Buccaneers?
Yes?
Great.
Then hear me out cuz you can personally benefit
greatly. You can be in the top tier of reimbursement in the physician milleau.
TOTALLY different ballgame out here compared to the academic environment you are used to, folks.
Out here its about accomodating surgeons (without giving a "kiss-ass" impression), providing superior patient care, and getting the cases done as fast and efficient as possible.
Thats it.
Pretty simple s h it, huh?
Kinda like poker in that it takes a few minutes to learn but a lifetime to master.
So I'll start with a few suggestions and I'm sure my colleagues will chime in with
ARE YOU READY FOR PRIVATE PRACTICE suggestions.
1) Now that you're employed by
C-NOTE ANESTHESIA, LLC, its important, at least initiallly, to lose your individuality. Don't take that the wrong way. No, the group doesnt want a robot. They picked you, so thats a good thing. What a group
doesnt want out of a new-hire is a dude/dudette who is inflexible, who insists on doing a certain situation a certain way..
...but heres a very important kicker....
they arent gonna point this out to you. You either figure this out on your own and get accepted, or....uhhhhhh....you fall into the
unliked, inflexible category.
Clandestine profiling going on???....
Absolutely.
You may never hear a negative comment until your pink slip is presented. You either make the grade or you don't. On your own.
Most successful private groups are successful for a cuppla reasons: they are deft at anesthesia, and they know how to keep people happy. Successful anesthesia groups are
able, amicable, and available.
You're used to putting the IJ in a CABG before induction but your new group typically does it after? Time for you to adapt to the
group way.....you like a tube for knee scopes but the group exclusively uses LMAs? Youre used to regional for fem-pops but your new group does all GA??....same message....unless patient outcome is affected, fall into line....
Your new group will expect you to fall into line, not make waves, all the while with a smile on your face. Make conversation with the ortho dude during the 11pm hip ORIF. Make the impression that no matter what the request, you're happy to do it. Being a new-hire is not the time to take a stand about an issue. If presented with something weird, like a 2am BTL,
do it. Then the next morning, call one of the senior partners and ask them if what occurred is normal. If it is not, the senior partner will address it. Not your turf right now. Later when you are a partner, yes. Now, no.
2)
Make yourself irreplaceable. Private practice is all about speed, efficiency, and proficiency. Don't waste time. Don't do twenty minute pre-ops. Don't take twenty minutes to do
anything. If you are taking twenty minutes right now to do an A-line/central line/epidural/etc, work on it NOW. Make yourself da masta. Problems? Seek out a deft attending and watch how he does it. Emulate him.
You are a CA-3 now. You need to
concentrate on making yourself better,
right now. Pick up the pace on your labor epidurals. Yeah, nobody gives a s h it how long you take right now....but come July on your first month with
C-Note Anesthesia LLC, if you leave the main OR to go put in an eoidural and you return 45 minutes later,
thats a problem.
More optimistically, if you leave the main OR for a labor epidural and you are back on the floor 15 minutes later, the senior partners will notice that.
3) There are a handful of procedures that we private practice dudes do
every day. And the more deft you are at those procedures as a new hire, the better you're gonna look.
Central lines, A lines, epidurals, spinals, interscalene blocs, axillary blocks, and of course intubations, are the crux of our procedural world. The better you are at those procedures, the better you're gonna look. Make an effort
right now, as a resident, to optimize your skills. Think about
speed, something your academic-attendings won't emphasize........believe me, they should be emphasizing speed...but thats another thread altogether.......
....are you at a residency where thats impossible? Where you do three interscalenes annually and yet the group you joined does three interscalenes daily?....
its all good.......just be prepared to humbly learn from your senior partners. Watch them. Learn from them. Emulate them. All the while thinking about the Holy Grail....
4)
Accept the fact that for at least the first year of private practice, you need to just go-with-the-flow. Don't make waves. Don't cancel cases unless you are
absolutely sure its gonna affect patient outcome. Don't complain about your schedule. Don't make enemies with surgeons/CRNAs/circulators/administrators.
Gotta orthopedist wanting to do a hip ORIF on an ICU patient in florid pulmonary edema (yep, a situation I remember)? Well you gotta step up to the plate and say
absolutely not.
Conversely, gotta true urgent-yet-not-emergent case being postponed 2 more hours because of NPO issues, with the surgeon sitting in the doctors lounge? Step up to the mike. Call for the patient.
5)
So You're on call today. You are running the board.
Anticipate. Think ahead. Dr Smith the orthopedist just started a knee scope. How long does he take? 30 minutes? If he's got a case to follow, have you sent for the next patient? If the next case requires intervention by you (i.e. epidural for TKA), make sure everything is
finished before Dr. Smith is done with his knee scope. Have the to-follow knee replacement in the holding area, epidural in and dosed before he is finished.
Go to the front desk frequently. Ask "has anybody pre-opped?" That one question will keep you informed if you've been busy doing something else......
HAS ANYBODY PREOPPED???....if the answer is yes then you may be behind the eight-ball already. It is difficult, but doable, to stay ahead of an OR schedule. But thats your job. Thats how you can make yourself invaluable.
Staying ahead of the OR schedule.
6)
Be flexible. Hmmmmm....senior partner going to Las Vegas in November and needs you to switch a cuppla calls?
"No problem, dude" is the right answer. I'm not implying that you incur abusive behavior, but hey, this is real life....and people periodically need to switch schedules. Make it a point during your partnership-trek to be flexible. Cuz this is the kinda s h it thats remembered come your partner-anniversary day
So thats a good start, albeit introductory. Theres a million things we need to cover on this subject, and I want my resident colleagues out there to hear the salient ones concerning
successful private practice matriculation.
REAL WORLD info. Period. No holds barred. Love it or leave it. Thats how it goes down out here.
MIL, NOY, UT et al,
chime in with your wisdom.
Jet MD, LMFAO"
laugh
I wouldn't enjoy this forum 10% as much without the oldies. I have learned here as much as from my own mistakes.
