IM / Anesthesia combined residency - Practice Set up?

[KeikoTanaka]

Hey all,

I have a question I haven't been able to find an answer to.

With a combined IM/Anesthesia residency program, how do graduates of these programs ultimately end up combining the two practices?

Is it possible to work as an OP PCP general internist with moonlighting in the OR?
Can you do OP PCP work as well as pain management, all from the same office?
Do most just end up working full time anesthesia as the pay is higher? Money isn't as important to me, I like variety, and I like maintaining relationships with people.

Thanks guys

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[IMGASMD]

Don’t know anyone who’s doing this. But I’d imaging you do OP PCP gig then work in OR as an employee. Or work as employees for two different jobs. It gets little tricky when you want to set up your own office or becoming a partner into a practice.

You can always just joining someone else’s practice and work as an employee. I work full time as an anesthesiologist, do have a side gig as a hospitalist. It’s tricky since I do have 24-hr calls, and even though I have post-call off, there are emergencies that may need me to stay. So I only work on weekends to keep up some skills.

If I had to set it up and money is no concern, I would do it as anesthesia mommy track/shift work. Maybe M-W-F 12 hour shift, then either open my own private practice or work for someone as OP internist.

If you want to go through a pain fellowship on top of that, I’d say just do anesthesia go to pain. You only have so many hours in a week, you will only want to work so many hours. If you have “three” different hats, I don’t think it’s good for you nor your patients.

 

[sunshinefl]

Hey all,

I have a question I haven't been able to find an answer to.

With a combined IM/Anesthesia residency program, how do graduates of these programs ultimately end up combining the two practices?

Is it possible to work as an OP PCP general internist with moonlighting in the OR?
Can you do OP PCP work as well as pain management, all from the same office?
Do most just end up working full time anesthesia as the pay is higher? Money isn't as important to me, I like variety, and I like maintaining relationships with people.

Thanks guys

Maybe practice where the fields overlap? Like critical care or pain management?

 

[GravelRider]

Combined IM/anesthesia is a dumb idea and a waste of time. It may improve your knowledge, but it does not improve your chances of getting a job. It is impractical. You will end up practicing one or the other. If you try to be both a PCP and an anesthesiologist, you will just end up being mediocre at both. That doesn’t do you or your patients any favors. Figure out what you want to do in the least amount of time spent training as possible.

I would be willing to hear an argument about how combined IM/anesthesia may be beneficial for someone pursuing a career in critical care, but I still think it’s a waste of time there as well. It is definitely not needed for a career in pain.

 

[Twiggidy]

Combined IM/anesthesia is a dumb idea and a waste of time. It may improve your knowledge, but it does not improve your chances of getting a job. It is impractical. You will end up practicing one or the other. If you try to be both a PCP and an anesthesiologist, you will just end up being mediocre at both. That doesn’t do you or your patients any favors. Figure out what you want to do in the least amount of time spent training as possible.

I would be willing to hear an argument about how combined IM/anesthesia may be beneficial for someone pursuing a career in critical care, but I still think it’s a waste of time there as well. It is definitely not needed for a career in pain.

Ditto this. It's a whole lotta residency for little gain.

I think many of these combined tactics are ways people are trying to keep their options open in case they hate OR anesthesia, which I don't blame them really, but it's still a waste of the better years of your life. One residency. One fellowship. Move on.

 

[getdown]

Combined IM/anesthesia is a dumb idea and a waste of time. It may improve your knowledge, but it does not improve your chances of getting a job. It is impractical. You will end up practicing one or the other. If you try to be both a PCP and an anesthesiologist, you will just end up being mediocre at both. That doesn’t do you or your patients any favors. Figure out what you want to do in the least amount of time spent training as possible.

I would be willing to hear an argument about how combined IM/anesthesia may be beneficial for someone pursuing a career in critical care, but I still think it’s a waste of time there as well. It is definitely not needed for a career in pain.

But at least you can consult yourself for "patient optimization" and then clear them. Double billing?

 

[Guillemot]

IMO Time would be better spent doing a CC fellowship after an anesthesia residency or a CC fellowship after an IM residency.

 

[step213]

I don’t want to get into any arguments here- I’m a combined resident and I’m very happy with my choice. For an extra year I feel like I’m much more well rounded- I’m doing a cardiac and then a critical care fellowship at the same shop I did residency (so yes I’m in the minority of people who don’t mind training a little longer). Again very happy for with my training - definitely not for everybody nor even for the majority. But for a small minority of applicants this is a great opportunity - my knowledge base is wider then attendings in either specialty and have become the person to come with “curbside” questions. I don’t mind but if this kind of stuff annoys you then that could also be a problem.

Lastly I will say mastering two specialities is hard work- you’ll have to maximize your learning opportunities while on different rotations while constantly reading and learning on your own. Luckily case volume is not an issue at my residency but do realize that just going through the motions in residency won’t make you “good” - I’m a hard worker but even I was surprised by the amount of dedication it has taken to do two specialties at once.

 

[KeikoTanaka]

I don’t want to get into any arguments here- I’m a combined resident and I’m very happy with my choice. For an extra year I feel like I’m much more well rounded- I’m doing a cardiac and then a critical care fellowship at the same shop I did residency (so yes I’m in the minority of people who don’t mind training a little longer). Again very happy for with my training - definitely not for everybody nor even for the majority. But for a small minority of applicants this is a great opportunity - my knowledge base is wider then attendings in either specialty and have become the person to come with “curbside” questions. I don’t mind but if this kind of stuff annoys you then that could also be a problem.

Lastly I will say mastering two specialities is hard work- you’ll have to maximize your learning opportunities while on different rotations while constantly reading and learning on your own. Luckily case volume is not an issue at my residency but do realize that just going through the motions in residency won’t make you “good” - I’m a hard worker but even I was surprised by the amount of dedication it has taken to do two specialties at once.

Thank you for your input! You plan on working inpatient in an ICU, yes? Would working OP be possible at all for your training

 

[IMGASMD]

I don’t want to get into any arguments here- I’m a combined resident and I’m very happy with my choice. For an extra year I feel like I’m much more well rounded- I’m doing a cardiac and then a critical care fellowship at the same shop I did residency (so yes I’m in the minority of people who don’t mind training a little longer). Again very happy for with my training - definitely not for everybody nor even for the majority. But for a small minority of applicants this is a great opportunity - my knowledge base is wider then attendings in either specialty and have become the person to come with “curbside” questions. I don’t mind but if this kind of stuff annoys you then that could also be a problem.

Lastly I will say mastering two specialities is hard work- you’ll have to maximize your learning opportunities while on different rotations while constantly reading and learning on your own. Luckily case volume is not an issue at my residency but do realize that just going through the motions in residency won’t make you “good” - I’m a hard worker but even I was surprised by the amount of dedication it has taken to do two specialties at once.

7 years to do two specialities and two sub specialities. Most likely will have an academic jobs forever. If that works for you, more props to you!

To op: dont think step213 will ever do “general medicine” tho.

 

[deleted171991]

I don’t want to get into any arguments here- I’m a combined resident and I’m very happy with my choice. For an extra year I feel like I’m much more well rounded- I’m doing a cardiac and then a critical care fellowship at the same shop I did residency (so yes I’m in the minority of people who don’t mind training a little longer). Again very happy for with my training - definitely not for everybody nor even for the majority. But for a small minority of applicants this is a great opportunity - my knowledge base is wider then attendings in either specialty and have become the person to come with “curbside” questions. I don’t mind but if this kind of stuff annoys you then that could also be a problem.

Lastly I will say mastering two specialities is hard work- you’ll have to maximize your learning opportunities while on different rotations while constantly reading and learning on your own. Luckily case volume is not an issue at my residency but do realize that just going through the motions in residency won’t make you “good” - I’m a hard worker but even I was surprised by the amount of dedication it has taken to do two specialties at once.

So extra 2 years of unnecessary training (1 in residency and 1 in fellowship), just because you couldn't make up your mind about what you wanted to be when you grew up.

You may want to calculate the Future Value of $500K gross/$350K net that you did not get to make/save for your retirement, 30 years from now. Even at an only 2% annual increase in real value (stock market returns minus inflation), you wasted more than $600K on 2 years of education. Good luck rationalizing that.

Nobody will give a crap that you run circles around your anesthesiologist colleagues. The bean counters just need a body, not a genius.

 

[Twiggidy]

So extra 2 years of unnecessary training (1 in residency and 1 in fellowship), just because you couldn't make up your mind about what you wanted to be when you grew up.

You may want to calculate the Future Value of $500K gross/$350K net that you did not get to make/save for your retirement, 30 years from now. Even at an only 2% annual increase in real value (stock market returns minus inflation), you wasted more than $600K on 2 years of education. Good luck rationalizing that.

Nobody will give a crap that you run circles around your anesthesiologist colleagues. The bean counters just need a body, not a genius.

I did think that also when I read the post. If you go into private practice you have to really ask yourself if that half million was worth it. 250k hurts enough. You would almost be required to take an academic spot just to make the extra training worth it because as you so delicately said, no one in the private practice world really cares how many fellowships you have.

 

[step213]

Thank you for your input! You plan on working inpatient in an ICU, yes? Would working OP be possible at all for your training

lol my very first line is i don't want to start an argument and yet some of the replies are seriously personal. FFP most of the time i appreciate your posts but really the way your phrased that reply was just rude considering you don't even know me. I did make up my mind - im going to be doing academic CVICU/cardiac anesthesia - i hope to sprinkle in some micu.

I get money IS important and its a big sacrifice that not everyone can make. I'm lucky to be fine with what I have - i'll leave it at that.

You could work OP if you wanted to.. but that is definitely not in my plan. I think you need to find a niche and master it - i don't plan to spread myself too broad. You could have a pain practice and also provide primary care to your pain patients which i think would be a very holistic way to care for a population that is often marginalized.

OP if you have specific questions you can PM me.

 

[deleted171991]

Good luck with that. You'll work almost as much as in PP (academic bean counters are the new slave drivers), while being paid a lot less and with less vacation. Academia is not the cushy nice life it used to be. Heck, even the VA is not what it used to be.

Money is not that important to me either, so I get it. Most families would disagree, especially a spouse who helped through 7 years of postgraduate training.

I was rude. That was on purpose. There are very few people who can say the extra 2 years were worth throwing out more than $600K; it's a huge bet. You will not get my respect for that, sorry. You should see how much I disrespect myself.

 

[2Fast2Des]

I guess if you won the lottery or no loans to where money is no object then sure add more training galore. But how does it feel that a CRNA\PA\NP can do all of those of things you spent so much of your life working to be? With no extra training and they're better than you. Sure I'll be jealous of the brain you have but certainly not of all that work

 

[GravelRider]

Thank you for your input! You plan on working inpatient in an ICU, yes? Would working OP be possible at all for your training

No. Working as outpatient PCP and an anesthesiologist is not going to happen. While there is some overlap between inpatient medicine like ICU and anesthesia, outpatient medicine is a different thing entirely. How are you going to set it up anyway? Work part time anesthesia and then open up your own primary care clinic 2 days a week? Your clinic will be bankrupt in about a month because you can’t support an office staff and pay rent working 2 days a week as a solo practitioner. Maybe you’ll get an outpatient internist job and moonlight as an anesthesiologist? Sorry, I don’t want someone who moonlights anesthesia a couple days a month taking care of me or my family in the operating room. I would choose an independent CRNA over someone in that scenario any day.

Honestly, you need to sit down and figure out a practical job path. I have both IM and anesthesia board certifications and the IM board certification does nothing for me other than provide a talking topic on job interviews. If anything, it stopped me from doing a fellowship because I had serious training fatigue after my anesthesia residency. For someone like you, I would recommend getting into the best IM program you can get into and plan on doing a fellowship where you get a good mix of inpatient and outpatient medicine...pulm/CCM and cardiology come to mind. Forget anesthesia.

 

[deleted171991]

Just to give you another perspective: I am an anesthesiologist and (currently surgical) intensivist, but I love IM. I love IM so much I would go back for a year of MICU fellowship, in a great center, if I could easily (and if it allowed me to sit for the ABIM CCM boards). But I wouldn't go back for 2 more years, and I couldn't care less about outpatient medicine. Doing IM-Anesthesiology is simply wasteful. Same goes for IM-Peds (just do Family Medicine) and most combined residencies (even if combined with a fellowship).

 

[repititionition]

Just to give you another perspective: I am an anesthesiologist and (currently surgical) intensivist, but I love IM. I love IM so much I would go back for a year of MICU fellowship, in a great center, if I could easily (and if it allowed me to sit for the ABIM CCM boards). But I wouldn't go back for 2 more years, and I couldn't care less about outpatient medicine. Doing IM-Anesthesiology is simply wasteful. Same goes for IM-Peds (just do Family Medicine) and most combined residencies (even if combined with a fellowship).

why do you not/have you not move to a mixed med/surg ICU practice?

 

[deleted171991]

why do you not/have you not move to a mixed med/surg ICU practice?

Because I'm married, and my wife has her own career that's important to me, so I don't want to relocate.

In my area, there are no mixed ICU opportunities for people who practice both anesthesia and critical care. I am not ready to give up anesthesia just yet.

 

[step213]

Because I'm married, and my wife has her own career that's important to me, so I don't want to relocate.

In my area, there are no mixed ICU opportunities for people who practice both anesthesia and critical care. I am not ready to give up anesthesia just yet.

Thanks FFP for the reply earlier as i said before I've always appreciated your posts.

I'll say from what i understand there are few places in the country that both doctors want to live in AND you can do both mixed SICU/MICU. I'll say that in the SF bay area there is an option to do it (both private: Kaiser/private hospitals and academic (stanford/UCSF/county) so they are out there - although this area has such a famously high COL that very few doctors who live else where would be willing to relocate to. I'm always fearful of saying where i live cause people on this board will call me bat **** crazy for living here - so i'll make a preemptive response that I'm very fortunate that my partner, who will always be the primary earner in our family - even once I'm an attending, affords us to have a very nice life here and his career is tied to this area. If exact pay is very important - im not sure what academic shops in other parts of the country pay but I hear we are very well compensated as positions here start with pay almost as much if not more then private practice jobs else where (>400K).

From the previous comments above: there is the perception that we are doctors so our salaries must be "significant", so the sooner we jump on that gravy train the better. Some of us probably marry other professionals in other fields and I was surprised to find, from watching my partner's own career, that the executives in the corporate world - that are like really at the top of their game - can bring down impressive numbers that make physician salaries look quite meager. I bring this up cause i feel that people make judgements based on salary/earning potential - and while this is important for some fortunate people - this isn't as important when making decisions. I find some people who are non-traditional like myself, don't put as much emphasis on the $ especially if they were successful in their previous careers.

I'm not going to get into whether or not medicine training would benefit you for MICU cause i would say there are no definitive answer. But I will say there are a couple of anesthesia fellowships where you will do quite a bit of MICU and mixed SICU/MICU as well, my training program being one of them. So perhaps doing an extra year of MICU fellowship would not be needed if this is the type of practice that would interest you.

 

[deleted171991]

My fellowship rotations were about 50% MICU (by my design), so that's not the issue. I only brought it up so that people understand that I am the unusual surgical intensivist who likes MICU and internal medicine (many of the good ones do, in my experience). So the reason I don't recommend a combined residency is not that I don't like IM.

@step213, thank you for your kind words and for your informative post.