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I had been meaning to post this thread for a while, but was dealing with oral boards. @ateria radicularis magna's post compelled me to post a few thoughts. I followed some similar posts from a few years ago, and thought they were very beneficial, and could use an update. So, here we go.
I started seriously searching in August of my fellowship year after my anesthesia written boards were done. My wife (non medicine) and I cast a very very large net geographically, primarily looking at small-medium sized cities (population 40,000-200,000 ish) from coast to coast. My spouse and I had a number of discussions about pros and cons of different locations. Initially, I thought we had a good understanding of where we both wanted to end up, but found that this did shift some over time much to my frustration. Particularly if you are moving to a new city, or region you haven't been to before (which we were planning), recognize that things may change during your searching process. Try not to get frustrated, and keep an open mind, and do your best to be flexible.
I knew I was not bound for academics. I was open to either hospital employed or private practice. I really did not feel I had the skill set, nor the time to invest to learning how to fully establish my own clinic (power to those with the drive to do this during fellowship). I knew I was staring down the barrel of learning pain medicine, and also studying for my oral boards. These have each taken up huge swaths of time.
Preference was for 100% pain, or 80-90% pain with 10-20% anesthesia. I did not find many split anesthesia jobs with this balance. In the areas I was looking there were multiple anesthesia practices looking to hire another pain medicine practitioner with a 60-70% anesthesia 30-40% pain split. In addition, partnership was often not offered, or was a possibility after a very vague track (if you hang around for 10-15 years, maybe you'll bring some account which will make a huge difference). In anesthesia groups, there was rarely any incentive for pain production. These groups were salaried, and you just made what you made regardless of how much work you did. Vacation was a small plus with 6-8 weeks, but with nights/weekends/holidays expected as part of anesthesia coverage. I decided against most of these jobs.
I used several websites to search. Gasworks, Practicelink, and DocCafe tended to show a few pain jobs in undesireable locations, and as I looked over the period of a several months I saw that the same few listings repeat themselves over and over and over again. I also checked the ASIPP website a few times. Listings were not as frequent here, but there were a few private practice jobs. I started looking at LinkedIn a few months into my search and found that there were more academic jobs being listed here, but not that many private jobs. Could be useful for folks looking to practice in that fashion.
A staff member did but me in contact with a practice which was useful, but few folks from my fellowship have gone into private practice in the locations I was looking so there was not much in the way of connections I could utilize.
Eventually, I gave up on job search websites, and started cold calling practices and hospitals. This was incredibly awkward at first, but I got more comfortable with it over time. I would pull up a town I was interested in on google maps, and than googled "pain medicine, pain management, interventional spine, orthopedics, hospitals, and neurosurgery" (separately obviously) to find practices in an area. I made a spreadsheet to keep track of who I had spoken with.
Posting on this board is useful as well. I posted a few times about challenges with the search and people were kind enough to reach out to me with some offers.
Some tips. If calling a private practice, ask to speak with, the practice manager, and give them your number and email. Most responded, a few dusted me. If cold calling a hospital system, just call the operator and ask to speak with physician recruitment. Cold calling hospitals netted me zero interviews. As I was searching during COVID, it seemed many locations were focused on weathering the COVID waves, and weren't looking to expand their pain service lines (mind you this was primarily in a variety of "blue" states).
I realize that this is very much of N=1, and that many people with anesthesia training have likely joined orthopedics practices, but I found that of the 6-7 orthopedics practices I cold called, almost all of them were looking for someone with PMR background. Interestingly, I also saw many more offers of the job websites for an individual with physiatry background. I did reach out to a few of these to see if they would be flexible in interviewing someone with an anesthesia background, but they were not. Private practices also tended to hire along background lines. So if the practice was founded by physiatrists, they tended not to take on individuals from outside specialties, although there were exceptions to this rule scattered here and there. Again, I recognize this is not always true, just my experience.
Your time on the interview trail is valuable. Chances are, you only have four weeks off, maybe five with meeting days scattered in during fellowship. Nobody wants to sacrifice a weekend day to interview for the most part. Be prepared to try and squeeze in a number of phone calls and discussions during business hours.
I would be wary of jobs stating that "they may be looking," or looking for a candidate to start far before your fellowship is complete. I took four of these interviews as they were in locations I wanted to end up, but only one actually panned out favorably. Still, it can be beneficial to speak with these people in order to get a sense of what different job opportunities look like.
After lining up interviews, I was very surprised how superficial they were. In each scenario, I sent over my CV, had a brief phone screen with the practice owner, and then was invited to interview. I paid for my own travel and hotel each time except for the hospital employed position I interviewed with. Interviews tended to be 45 minutes to an hour during a lunch break or immediately after work. Most practices allowed some time to shadow in C-arm and in clinic which was beneficial. Only 2/9 interviews took me out to lunch/dinner as part of the process. Feel of the clinic was huge during these interactions. One physician I interviewed made me cringe every time both he and his practice manager opened their mouths. Morale seemed low and I got a weird vibe from the practice. Trust your gut.
Have a list of questions. Some things I took from this board, and from other folks I spoke with as well
-Malpractice (claims vs occurance based)
-Partnership vs employed?
-If partnership is to be considered, is this an equal partnership, or a senior/junior partnership model (senior partner retains > 50% ownership of corporation while juniors each have a much smaller piece of pie).
-Timeline to partnership, metrics for partnership, buy in for partnership?
-Sign on bonus, moving, CME (Most jobs only offer CME)
-If buy is offered, what are you buying into? Professional corproation? ASC? Real estate? What is the timeline like for each of these.
-%patient on narcotics
-Where are cases being done (in office vs ASC vs hospital OR)
-Health insurance (for self and or family?)
-How much time spent at different clinics?
-Do you have an income projection for over time?
-Percent overhead
-Blend of patients (medicaid, medicare, private).
-In house billing or third party?
-Vacation/sick time.
-Are there PAs/NPs? How are they utilized
-Advanced procedures? Are these things you are comfortable doing?
This is just a starting place. Practices should want to talk to you about these issues and should hopefully be transparent. Do be careful about how you phrase questions. Try to sound like you want to explore issues, but don't be demanding. I got a very angry email from a practice when I started asking questions about partnership. Recognize that some do not believe that new grads merit consideration for full partnership.
Practices seemed to be more interested in interviewing/hiring closer to November/December. Before this point, there was a lot of uncertainty in the air. I would strongly recommend finding a contract review lawyer around this time such that you aren't scrambling to obtain one when you start getting contracts. After you start getting contracts, review yourself, and have past fellows, other pain docs review. If you do this before your lawyer, you'll save a few bucks by weeding out crappy contracts. Asking questions was very useful here. Once you understand the nuts and bolts of the contract, forward it to your lawyer for review to make sure the legal stuff is all set.
Regarding salary - If you are considering private practice, MGMA kinda goes out the window. Most offers were $260,000-300,000 with some kind of bonus that often wasn't great. Practices were not willing to negotiate base at all. Some were willing to toy a little with bonus, but not much.
Highest starting salary I saw was $600,000 for middle of nowhere (town of 18,000, three hour drive to nearest airport). Just couldn't bring myself to do it.
A funny parable about a hospital employed position. I could only find one hospital employed position in the areas I was interested in living. I interviewed with a variety of C-suite executives and chiefs of divisions. All of whom were excited about bringing a new pain doc on board, and promised I would be busy right a way with a 100% non-narcotic practice. None of them had any idea what procedures a pain doc in their system would actually be doing. Three weeks after I interviewed, they emailed me stating they had run the numbers again and there actually wasn't enough business to support another pain doc. Oops.
Overall, I found a job that seems like a reasonable starting place that checks a lot of boxes for my wife and I. Current partners don't seem terrible, but it's a weird feeling knowing that I may just be getting screwed. There were many worse jobs were the screwing seemed much more intense. Our field seems to reward those who are willing to start their own practices and take ownership of such rather than being an associate or a hospital employee. I'm not there right now. Will see where things go.
The process took much MUCH longer than anticipated. Some of that may have been COVID. One of my cofellows ended up taking a split anesthesia/pain job. The other took an absolutely terrible pain job in an urban location he had strong ties to. Market tough in the locations I was looking. To those who had an easy experience, with this, lucky you.
Open for questions, and hopefully someone finds this useful.
I started seriously searching in August of my fellowship year after my anesthesia written boards were done. My wife (non medicine) and I cast a very very large net geographically, primarily looking at small-medium sized cities (population 40,000-200,000 ish) from coast to coast. My spouse and I had a number of discussions about pros and cons of different locations. Initially, I thought we had a good understanding of where we both wanted to end up, but found that this did shift some over time much to my frustration. Particularly if you are moving to a new city, or region you haven't been to before (which we were planning), recognize that things may change during your searching process. Try not to get frustrated, and keep an open mind, and do your best to be flexible.
I knew I was not bound for academics. I was open to either hospital employed or private practice. I really did not feel I had the skill set, nor the time to invest to learning how to fully establish my own clinic (power to those with the drive to do this during fellowship). I knew I was staring down the barrel of learning pain medicine, and also studying for my oral boards. These have each taken up huge swaths of time.
Preference was for 100% pain, or 80-90% pain with 10-20% anesthesia. I did not find many split anesthesia jobs with this balance. In the areas I was looking there were multiple anesthesia practices looking to hire another pain medicine practitioner with a 60-70% anesthesia 30-40% pain split. In addition, partnership was often not offered, or was a possibility after a very vague track (if you hang around for 10-15 years, maybe you'll bring some account which will make a huge difference). In anesthesia groups, there was rarely any incentive for pain production. These groups were salaried, and you just made what you made regardless of how much work you did. Vacation was a small plus with 6-8 weeks, but with nights/weekends/holidays expected as part of anesthesia coverage. I decided against most of these jobs.
I used several websites to search. Gasworks, Practicelink, and DocCafe tended to show a few pain jobs in undesireable locations, and as I looked over the period of a several months I saw that the same few listings repeat themselves over and over and over again. I also checked the ASIPP website a few times. Listings were not as frequent here, but there were a few private practice jobs. I started looking at LinkedIn a few months into my search and found that there were more academic jobs being listed here, but not that many private jobs. Could be useful for folks looking to practice in that fashion.
A staff member did but me in contact with a practice which was useful, but few folks from my fellowship have gone into private practice in the locations I was looking so there was not much in the way of connections I could utilize.
Eventually, I gave up on job search websites, and started cold calling practices and hospitals. This was incredibly awkward at first, but I got more comfortable with it over time. I would pull up a town I was interested in on google maps, and than googled "pain medicine, pain management, interventional spine, orthopedics, hospitals, and neurosurgery" (separately obviously) to find practices in an area. I made a spreadsheet to keep track of who I had spoken with.
Posting on this board is useful as well. I posted a few times about challenges with the search and people were kind enough to reach out to me with some offers.
Some tips. If calling a private practice, ask to speak with, the practice manager, and give them your number and email. Most responded, a few dusted me. If cold calling a hospital system, just call the operator and ask to speak with physician recruitment. Cold calling hospitals netted me zero interviews. As I was searching during COVID, it seemed many locations were focused on weathering the COVID waves, and weren't looking to expand their pain service lines (mind you this was primarily in a variety of "blue" states).
I realize that this is very much of N=1, and that many people with anesthesia training have likely joined orthopedics practices, but I found that of the 6-7 orthopedics practices I cold called, almost all of them were looking for someone with PMR background. Interestingly, I also saw many more offers of the job websites for an individual with physiatry background. I did reach out to a few of these to see if they would be flexible in interviewing someone with an anesthesia background, but they were not. Private practices also tended to hire along background lines. So if the practice was founded by physiatrists, they tended not to take on individuals from outside specialties, although there were exceptions to this rule scattered here and there. Again, I recognize this is not always true, just my experience.
Your time on the interview trail is valuable. Chances are, you only have four weeks off, maybe five with meeting days scattered in during fellowship. Nobody wants to sacrifice a weekend day to interview for the most part. Be prepared to try and squeeze in a number of phone calls and discussions during business hours.
I would be wary of jobs stating that "they may be looking," or looking for a candidate to start far before your fellowship is complete. I took four of these interviews as they were in locations I wanted to end up, but only one actually panned out favorably. Still, it can be beneficial to speak with these people in order to get a sense of what different job opportunities look like.
After lining up interviews, I was very surprised how superficial they were. In each scenario, I sent over my CV, had a brief phone screen with the practice owner, and then was invited to interview. I paid for my own travel and hotel each time except for the hospital employed position I interviewed with. Interviews tended to be 45 minutes to an hour during a lunch break or immediately after work. Most practices allowed some time to shadow in C-arm and in clinic which was beneficial. Only 2/9 interviews took me out to lunch/dinner as part of the process. Feel of the clinic was huge during these interactions. One physician I interviewed made me cringe every time both he and his practice manager opened their mouths. Morale seemed low and I got a weird vibe from the practice. Trust your gut.
Have a list of questions. Some things I took from this board, and from other folks I spoke with as well
-Malpractice (claims vs occurance based)
-Partnership vs employed?
-If partnership is to be considered, is this an equal partnership, or a senior/junior partnership model (senior partner retains > 50% ownership of corporation while juniors each have a much smaller piece of pie).
-Timeline to partnership, metrics for partnership, buy in for partnership?
-Sign on bonus, moving, CME (Most jobs only offer CME)
-If buy is offered, what are you buying into? Professional corproation? ASC? Real estate? What is the timeline like for each of these.
-%patient on narcotics
-Where are cases being done (in office vs ASC vs hospital OR)
-Health insurance (for self and or family?)
-How much time spent at different clinics?
-Do you have an income projection for over time?
-Percent overhead
-Blend of patients (medicaid, medicare, private).
-In house billing or third party?
-Vacation/sick time.
-Are there PAs/NPs? How are they utilized
-Advanced procedures? Are these things you are comfortable doing?
This is just a starting place. Practices should want to talk to you about these issues and should hopefully be transparent. Do be careful about how you phrase questions. Try to sound like you want to explore issues, but don't be demanding. I got a very angry email from a practice when I started asking questions about partnership. Recognize that some do not believe that new grads merit consideration for full partnership.
Practices seemed to be more interested in interviewing/hiring closer to November/December. Before this point, there was a lot of uncertainty in the air. I would strongly recommend finding a contract review lawyer around this time such that you aren't scrambling to obtain one when you start getting contracts. After you start getting contracts, review yourself, and have past fellows, other pain docs review. If you do this before your lawyer, you'll save a few bucks by weeding out crappy contracts. Asking questions was very useful here. Once you understand the nuts and bolts of the contract, forward it to your lawyer for review to make sure the legal stuff is all set.
Regarding salary - If you are considering private practice, MGMA kinda goes out the window. Most offers were $260,000-300,000 with some kind of bonus that often wasn't great. Practices were not willing to negotiate base at all. Some were willing to toy a little with bonus, but not much.
Highest starting salary I saw was $600,000 for middle of nowhere (town of 18,000, three hour drive to nearest airport). Just couldn't bring myself to do it.
A funny parable about a hospital employed position. I could only find one hospital employed position in the areas I was interested in living. I interviewed with a variety of C-suite executives and chiefs of divisions. All of whom were excited about bringing a new pain doc on board, and promised I would be busy right a way with a 100% non-narcotic practice. None of them had any idea what procedures a pain doc in their system would actually be doing. Three weeks after I interviewed, they emailed me stating they had run the numbers again and there actually wasn't enough business to support another pain doc. Oops.
Overall, I found a job that seems like a reasonable starting place that checks a lot of boxes for my wife and I. Current partners don't seem terrible, but it's a weird feeling knowing that I may just be getting screwed. There were many worse jobs were the screwing seemed much more intense. Our field seems to reward those who are willing to start their own practices and take ownership of such rather than being an associate or a hospital employee. I'm not there right now. Will see where things go.
The process took much MUCH longer than anticipated. Some of that may have been COVID. One of my cofellows ended up taking a split anesthesia/pain job. The other took an absolutely terrible pain job in an urban location he had strong ties to. Market tough in the locations I was looking. To those who had an easy experience, with this, lucky you.
Open for questions, and hopefully someone finds this useful.
