Observations of a recent grad

[TecmoBowl]

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Hi,

I thought I'd like to share what I"m seeing when I go out to look for private practice jobs leading to partnerships in the more competitive geographical niches. Hopefully, others can shed some light as well.

So, some of the places that advertise ultimately end up going with "the cheaper option"- CRNAs, or part-timers/day-time folks, all so they don't have to "share the pot" with another M.D. Ultimately, this speaks to the greed of private practitioners, and points to the fact that Physicians don't look out for their specialty, or their peers, but like any other person, only care about $$. This has happened to me twice (maybe I suck, but most don't think so).

I don't mind really, but do these idiots realize they're screwing over the specialty? It'll show more and more to hospitals that Anesthesia is "easy" and can be done by anyone and that Physician Anesthesiologists are expendable- whether it's true or not to what extent is not the issue here.

Most importantly as programs flood the marketplace, those entrenched, i.e., the senior partners or whatever, will be presented a milieu of options, but will ultimately choose what puts more $$ in their bank- and that is not us, Physicians, or at least they will be getting us at a "wholesale" price, unless laws dictating contracts and exclusivity are changed. They should change. There is not too much that ultimately sets apart most of us in delivering a good anesthetic- I mean come on really.

Essentially, our own people will be the ones screwing us all over. That is the truth.

 

[panetrain]

😱 😱😱I have brought this point up on several of my posts. I think it is important to shed some light on what is currently going on this field and what will only worsen in the future. I have seen way too many applicants over the past few years as well as current medical students view anesthesiology as a cushy residency/high pay/open market/great lifestyle. I have no doubt that these ostensible perks play a key role in their decision to pursue this field. This is all changing very quickly and these perks are melting away faster than the polar ice caps.

Hi,

I thought I'd like to share what I"m seeing when I go out to look for private practice jobs leading to partnerships in the more competitive geographical niches. Hopefully, others can shed some light as well.

So, some of the places that advertise ultimately end up going with "the cheaper option"- CRNAs, or part-timers/day-time folks, all so they don't have to "share the pot" with another M.D. Ultimately, this speaks to the greed of private practitioners, and points to the fact that Physicians don't look out for their specialty, or their peers, but like any other person, only care about $$. This has happened to me twice (maybe I suck, but most don't think so).

I don't mind really, but do these idiots realize they're screwing over the specialty? It'll show more and more to hospitals that Anesthesia is "easy" and can be done by anyone and that Physician Anesthesiologists are expendable- whether it's true or not to what extent is not the issue here.

Most importantly as programs flood the marketplace, those entrenched, i.e., the senior partners or whatever, will be presented a milieu of options, but will ultimately choose what puts more $$ in their bank- and that is not us, Physicians, or at least they will be getting us at a "wholesale" price, unless laws dictating contracts and exclusivity are changed. They should change. There is not too much that ultimately sets apart most of us in delivering a good anesthetic- I mean come on really.

Essentially, our own people will be the ones screwing us all over. That is the truth.

 

[urge]

Thanks for sharing.

When you internalize the idea that "money makes the world go around", you will find peace.

 

[TecmoBowl]

It seems extremely unfair to say the least that just because a Group has exclusivity with a hospital, others are locked out of practicing in the area.

My question(s)- I know individual practitioners have pursued legal means to be able to work at a specific hospital or what not. I know there's a famous case of this, just can't recall the name. How does that work?

What if I were to go to the hospital CEO/Board and tell them, hey look, I can work for you, I'll buy my own malpractice coverage etc., and negotiate my own contract with the hospital. I could tell them I'm peds trained, do Adult hearts etc., so I'm much more advantageous to the hospital than the group you have in place and so on and so forth to sell myself to them instead? I actually see this type of offers from individual practitioners becoming new grads' only possible entryway into the market niche.

Capitalism is... great?

 

[TecmoBowl]

Thanks for sharing.

When you internalize the idea that "money makes the world go around", you will find peace.

I'm not sure whether you're being sarcastic or what, but money doesn't make MY world go around, but I find that it does for a significant percentage of people, and because of that, other people/innocent bystanders get screwed over. I don't mind working for lower wages etc., it's just a certain sense of morality and equity I expect, especially from us Physicians, "the bastions of morality" (cough...choke!)

It's basically the "older boomer generation people" screwing over the younger generations. You'd think they'd want us to make quite a bit, since our taxes will be supporting their welfare!

BY THE WAY, THIS IS WHAT I'M ENCOURAGING OTHER GRADS/NEWER ANESTHESIOLOGISTS TO DO- TO GO STRAIGHT TO "THE TOP" AND PRESENT AND SELL THEMSELVES- CLEARLY, OUR COLLEAGUES DON'T HAVE OUR INTERESTS IN MIND (SHOULD THEY?), SO DO WHAT'S BEST FOR YOU AND GO AFTER WHAT YOU WANT- CAPITALISM!!

 

[AnesNavy]

BY THE WAY, THIS IS WHAT I'M ENCOURAGING OTHER GRADS/NEWER ANESTHESIOLOGISTS TO DO- TO GO STRAIGHT TO "THE TOP" AND PRESENT AND SELL THEMSELVES- CLEARLY, OUR COLLEAGUES DON'T HAVE OUR INTERESTS IN MIND (SHOULD THEY?), SO DO WHAT'S BEST FOR YOU AND GO AFTER WHAT YOU WANT- CAPITALISM!!

Point well taken. 😎

 

[Pilot Doc]

My question(s)- I know individual practitioners have pursued legal means to be able to work at a specific hospital or what not. I know there's a famous case of this, just can't recall the name. How does that work?

The case you mention, whose name I neither recall nor feel like googling, was in the early 80's. An OB anesthesiologist sued a hospital under an anti-trust theory that the hospital was using it's monopoly power in OB anesthesia to restrict the market for OB anesthesia through it's exclusive contract with the anes group. (Basically the same theory that Microsoft got into trouble for when they made everyone who bought windows buy MS Explorer as well. They had a monopoly in the OS market and were trying to leverage that into the browser market.)

Anyway, the case made it to the supreme court where teh plaintiff lost on a pseudo-technicality in that the hospital that he sued did not have a monopoly on OB services - they only had about 20%(?) of the local market. The overall point?

1) In an urban market with a lot of hospitals, there's no obvious barrier to exclusive contracts
2) In a rural market where one hospital (or hospital system) has a monopoly you might be able to break an exclusive contract if you have a spare few million to litigate the issue.

 

[coprolalia]

Hi,

I thought I'd like to share what I"m seeing when I go out to look for private practice jobs leading to partnerships in the more competitive geographical niches. Hopefully, others can shed some light as well.

So, some of the places that advertise ultimately end up going with "the cheaper option"- CRNAs, or part-timers/day-time folks, all so they don't have to "share the pot" with another M.D. Ultimately, this speaks to the greed of private practitioners, and points to the fact that Physicians don't look out for their specialty, or their peers, but like any other person, only care about $$. This has happened to me twice (maybe I suck, but most don't think so).

I don't mind really, but do these idiots realize they're screwing over the specialty? It'll show more and more to hospitals that Anesthesia is "easy" and can be done by anyone and that Physician Anesthesiologists are expendable- whether it's true or not to what extent is not the issue here.

Most importantly as programs flood the marketplace, those entrenched, i.e., the senior partners or whatever, will be presented a milieu of options, but will ultimately choose what puts more $$ in their bank- and that is not us, Physicians, or at least they will be getting us at a "wholesale" price, unless laws dictating contracts and exclusivity are changed. They should change. There is not too much that ultimately sets apart most of us in delivering a good anesthetic- I mean come on really.

Essentially, our own people will be the ones screwing us all over. That is the truth.

Excellent post, Tecmo.

Again, I'll ask... Are we training doormats or decision makers?

Answer: Learn to be a good politician early in your training. People are not always looking out for your best interests. Past residency, professional life is more about how good and savvy of a business person you are, as well as how invested you are in being politically active in protecting your rights.

-copro

 

[ProRealDoc]

the Hyde Decision 466 US 2 1984 it deat with an OB anesthesiologist in Louisiana suing for an antitrust violation. Hospitals have used this decision to enter into exclusive contracts with groups.

Anesthesia groups argue that the power is in the numbers and being a solo practitioner puts you at a disadvantage and gives the hospital the power to screw you. Others as tecmobowl see this as a way for greedy partners to screw the young guys out of fair compensation.

Probably the truth is somewhere in the middle.

 

[BLADEMDA]

In the Mid 1990's the job market sucked. A young new graduate could expect to earn CRNA income for 36-48 months while working 60 hours per week. Senior Partners routinely screwed over young graduates while earning mega level pay. Then, in the late 1990's the job market opened up. A new graduate was earning twice CRNA pay and expecting a 24-36 month track. The hours worked declined as well.

Perhaps, we may see a return the bad old days but I doubt it. The new graduate is still earning twice CRNA pay and the tracks are mostly fair.
But, you need an "edge" to get the job. You need something to make you stand out from the crowd.

Also, the stock market collapse of 40% has caused many senior guys to reevaluate retirement plans. This means more years at work and the need to rebuild the nest egg. The net result is less job openings and more desire to hire Midlevels whenever possible to save money.

 

[Frank Rizzo]

Also, the stock market collapse of 40% has caused many senior guys to reevaluate retirement plans. This means more years at work and the need to rebuild the nest egg. The net result is less job openings and more desire to hire Midlevels whenever possible to save money.

That pretty much describes the job market in most urban markets at the moment, at least the markets in the midwest.

 

[foxtrot]

This is also going on in the anesthesia/pain management world too. Most of the groups I have interviewed with in the South are extremely greedy and seem to be out to screw over the new grad. It is sickening. When did medicine become so corrupt? It is very disheartening. It seems to be more and more difficult to find people and groups who do the right thing and act in a fair manner.

 

[maceo]

1. Life ain't fair.
2. Although there may some variation based on state law, Hospitals absolutely do have the right to contract with whoever they want.
3. It is extremely difficult for a flock of new grads to break an existing group.
From the hospitals stand point:
a.) better the devil you know.
b.) It is almost impossible for a new group to provide better quality uninterrupted service from day one without hiring some or most of the existing group. Most groups have noncompetes for their employees (owners) for exactly this reason. Hospitals are generally unwilling to risk their main cash cow (the OR) without major upside.
c.) much more likely the hospital will approach the existing group and squeeze them saying that: "We can replace you for far less with new or recent grads or experienced underemployed anesthesiologists or an AMC)". The group will usually do the math and acquiesce.
4. The above does not apply to very small hospitals or hospitals that are dissatisfied with the quality of their anesthesia group and are looking to make a change.

I wish you best of luck. I was underemployed during the bad 90's.
The sad part is you ain't seen NUTHIN yet. In my area the large regional residency program's senior residents have all signed contracts for good jobs with decent terms for partnership. Most of them inked months ago. The Job Crunch hasn't even begun yet. WHEN it hits you will see groups offering jobs for new grads at CRNA wages (maybe +10%) with NO hope of partnership. The hospital only cares about getting the cases done for the least cost. If this mechanism gets it done so be it.

i agree life isnt fair and certainly the anesthesia market is not. there are crooks everywhere. BUt i see groups being booted out of hospitals all the damn time. it happens very frequently. sheridan, anesthetix et al under cut exisitin groups frequently.

get a job in academics put your 20 years in and you wont have to worry about it.

 

[TecmoBowl]

Hey,

I'm at the San Diego Echo conference and just mingling with people, and I'm discovering that Bull&**T goes on everywhere! NAPA especially, and the guy with Hackensack in New Jersey...these guys are BAD people from what I'm hearing...not my opinion, just what I"m hearing out here from people who have worked there. For instance, a Cornell trained grad with Peds fellowship and TEE experience worked hard two years and quit as he learned there was no serious, or sincere possibility of a partnership position. That being said (don't nail me to the cross here) there's an element of ethnic preference in the urban East Coast, though they screw their own as well. Read between the lines as you may wish to...I'm learning I was born innocent and lived with a sense of trust in people, but life experience is giving me tough lessons.

I'm also getting the drift that academics may be the way to go, especially if with some satellite hospital of a major academic institution.

I've been seriously contemplating a return to school....LAW SCHOOl. I'd like to bring down groups like NAPA or practices where unethical Labor is being practiced. Should I do this? I know I can practice both Medicine and Law. For example, would a worker in a group have a legitimate case against a practice entity if he was being asked to work straight from 6-30am to 4pm without a pause for food or bathroom? Is it a reasonable complaint? I don't know...I would argue the Group was putting patients and my client under undue duress and jeapordy.

I went to med school to be a Doctor, and now I find myself surrounded in a world of sleaze balls- Doctors are just as greedy as the Wall Street execs who brought the world down, and Doctors are willing to screw over other young doctors. It's not what I pictured life in Medicine would be like. So, if all of us younger docs are ultimately getting screwed over, then maybe we should all start hedging our bets and become a counter-threat by pursuing legal careers that deal with this and Medical Malpractice on the side- and bring balance to the force!!

Now, I'm off to the bar..after the gym. I need to keep myself in shape so I can continue to be a workhorse for the fat senior partners/babyboomin' jagoffs who are screwing over my generation, and drink so I can forget that fact, and sue the group after they drive me to a heart attack!!!! No Medicare in my practice...I don't want to take care of that generation at all- for all I care since I have very little regard for that generation of people as whole. I mean how they left the world that was given to them on a platter speaks for itself. They're the generation that has brought down civilization- the only good thing they accomplished is Civil Rights....so much anger in me that I never had before...or maybe it's just disappointment.

Oh, and by the way, the market will be even tougher because H1B1 visa stays have been extended, and will have unintended consequences for us U.S. Citizens. I.e., the private groups like Hackensack will hire just the visa people and U.S. people with the lure of a partnership and spit them out- to replace them with other H1 people. A possibility to consider also...

 

[TecmoBowl]

1. Life ain't fair.
2. Although there may some variation based on state law, Hospitals absolutely do have the right to contract with whoever they want.
3. It is extremely difficult for a flock of new grads to break an existing group.
From the hospitals stand point:
a.) better the devil you know.
b.) It is almost impossible for a new group to provide better quality uninterrupted service from day one without hiring some or most of the existing group. Most groups have noncompetes for their employees (owners) for exactly this reason. Hospitals are generally unwilling to risk their main cash cow (the OR) without major upside.
c.) much more likely the hospital will approach the existing group and squeeze them saying that: "We can replace you for far less with new or recent grads or experienced underemployed anesthesiologists or an AMC)". The group will usually do the math and acquiesce.
4. The above does not apply to very small hospitals or hospitals that are dissatisfied with the quality of their anesthesia group and are looking to make a change.

I wish you best of luck. I was underemployed during the bad 90's.
The sad part is you ain't seen NUTHIN yet. In my area the large regional residency program's senior residents have all signed contracts for good jobs with decent terms for partnership. Most of them inked months ago. The Job Crunch hasn't even begun yet. WHEN it hits you will see groups offering jobs for new grads at CRNA wages (maybe +10%) with NO hope of partnership. The hospital only cares about getting the cases done for the least cost. If this mechanism gets it done so be it.

Buddy, we're all in this thing called "life" together- but I'd like to point out one thing that I'm sure you must have realized by now. All the hospital administration will ever care about is only one thing, one bottom line- MONEY! And for that, they will trust a "new devil", they will be willing to loose you without regard to your mortgage, loans or service to the institution. I've seen it and hear of it often.

The only advice (I do say that with some degree humbleness since I am still a young padowan) that I can give to the ummm older people, is that be careful in the way you manage your practice and finances. If you're not willing to open the doors for us newer people in the workforce, and go with cheaper options like CRNAs/Part-timers etc., if you don't open the doors, we'll be breaking down the walls and bring down the house. You can't hold back the flood that's coming your way- the flood of numbers and if you mistreat us and leave us jaded, things will get worse in terms of group stability. The same people you turn away might be the ones low ballin' you down the line, and since we would be younger, we'd have a lot less to loose.

 

[BLADEMDA]

Buddy, we're all in this thing called "life" together- but I'd like to point out one thing that I'm sure you must have realized by now. All the hospital administration will ever care about is only one thing, one bottom line- MONEY! And for that, they will trust a "new devil", they will be willing to loose you without regard to your mortgage, loans or service to the institution. I've seen it and hear of it often.

The only advice (I do say that with some degree humbleness since I am still a young padowan) that I can give to the ummm older people, is that be careful in the way you manage your practice and finances. If you're not willing to open the doors for us newer people in the workforce, and go with cheaper options like CRNAs/Part-timers etc., if you don't open the doors, we'll be breaking down the walls and bring down the house. You can't hold back the flood that's coming your way- the flood of numbers and if you mistreat us and leave us jaded, things will get worse in terms of group stability. The same people you turn away might be the ones low ballin' you down the line, and since we would be younger, we'd have a lot less to loose.

Funny. I enjoyed the post. Reality is far different in the PP world. You need EXPERIENCE after Residency (1-3 years) to really get good at your trade. You need efficiency in your skills and thinking to work at a busy practice. Delaying cases for any reason including lack of skill is frowned upon in a busy operating room.

Doubt a new graduate can match the skill set of a good PP guy. Plus, you need to learn what the surgeons want and expect.

If the hospital likes the existing group they won't risk trying someone new for a few bucks. They would rather deal with the devil they know; so, they just reduce the subsidy and increase staffing demands.

Sorry, but unless the existing group is really expensive and won't negotiate or really crappy you don't stand a chance at getting the contract.

 

[jetproppilot]

Hey,

I'm at the San Diego Echo conference and just mingling with people, and I'm discovering that Bull&**T goes on everywhere! NAPA especially, and the guy with Hackensack in New Jersey...these guys are BAD people from what I'm hearing...not my opinion, just what I"m hearing out here from people who have worked there. For instance, a Cornell trained grad with Peds fellowship and TEE experience worked hard two years and quit as he learned there was no serious, or sincere possibility of a partnership position. That being said (don't nail me to the cross here) there's an element of ethnic preference in the urban East Coast, though they screw their own as well. Read between the lines as you may wish to...I'm learning I was born innocent and lived with a sense of trust in people, but life experience is giving me tough lessons.

I'm also getting the drift that academics may be the way to go, especially if with some satellite hospital of a major academic institution.

I've been seriously contemplating a return to school....LAW SCHOOl. I'd like to bring down groups like NAPA or practices where unethical Labor is being practiced. Should I do this? I know I can practice both Medicine and Law. For example, would a worker in a group have a legitimate case against a practice entity if he was being asked to work straight from 6-30am to 4pm without a pause for food or bathroom? Is it a reasonable complaint? I don't know...I would argue the Group was putting patients and my client under undue duress and jeapordy.

I went to med school to be a Doctor, and now I find myself surrounded in a world of sleaze balls- Doctors are just as greedy as the Wall Street execs who brought the world down, and Doctors are willing to screw over other young doctors. It's not what I pictured life in Medicine would be like. So, if all of us younger docs are ultimately getting screwed over, then maybe we should all start hedging our bets and become a counter-threat by pursuing legal careers that deal with this and Medical Malpractice on the side- and bring balance to the force!!

Now, I'm off to the bar..after the gym. I need to keep myself in shape so I can continue to be a workhorse for the fat senior partners/babyboomin' jagoffs who are screwing over my generation, and drink so I can forget that fact, and sue the group after they drive me to a heart attack!!!! No Medicare in my practice...I don't want to take care of that generation at all- for all I care since I have very little regard for that generation of people as whole. I mean how they left the world that was given to them on a platter speaks for itself. They're the generation that has brought down civilization- the only good thing they accomplished is Civil Rights....so much anger in me that I never had before...or maybe it's just disappointment.

Oh, and by the way, the market will be even tougher because H1B1 visa stays have been extended, and will have unintended consequences for us U.S. Citizens. I.e., the private groups like Hackensack will hire just the visa people and U.S. people with the lure of a partnership and spit them out- to replace them with other H1 people. A possibility to consider also...

ENTITLEMENT kills the spirit, Dude.

I learned the hard way, and almost lost the partnership opportunity of the century (at least in my microcosm) because of my ENTITLEMENT issues early in my career.

Luckily I quickly learned that even after all my training I wasnt ENTITLED to S HIT.

Funny thing, life is.

Life lessons.

DESERVED?

Absolutely.

ENTITLED?

Absolutely not.

Throw your weight around early right outta residency and you're gonna be given a pink slip.

At least in private practice.

 

[Jeff05]

what's the ethnic preference in urban east coast?

as far as hackensack and other groups...every ca3 in the area knows which groups will treat you right and which won't. everyone knows hackensack will work you to the death and likely not make you partner. those who want to make a couple of extra bucks and roll the dice will go there.

it's the wild west out there. that's the world we live in. still more civilized than the 99.99999999999999999% of this ****ty planet. if you don't want to deal, stay in academics. if you want to play, roll the dice and make the money.

 

[TecmoBowl]

All right, wellll...a buzzed and hence, an honest answer. The ethnic preference in the East Coast, i.e., peri-NYC/NJ based only on the observations of my non-jewish friends is what I was referring to, but the Israelites are screwed royally too. I guess ultimately neither race, religion or moral upbringing are any barriers to greed, even at the expense of screwing over another person.

Blade, as far as being skilled enough to suck surgeons' dicks etc., I think everyone by their CA-3 year learns what's needed. Nobody is talking about "canceling cases" etc., so if that's all that old folks can hang their hats one, then, well, get ready to go back to fellowships or whatever and truly earn your credibility.

Like our founding father Mr. Hamilton, I believe in the old concept of "MERITOCRACY"!!!! That's it, and that's that. I believe there are many unscrupulous people out there, many backdoor deals- hypothetically, let's say NAPA (North American Partners in Anesthesia) pays off or rewards a hospital CEO with whatever, just so they can get the contract for a hospital, staff it with some people in the short-run, advertise on gaswork, recruit some H1B1 visa people who'll just shut the **** up and work for whatever, and you get the drift....Many groups out there like that. Is that entitlement??? NO! Not at all! I'm just calling it like I see it! The public may be right to see Doctors as greedy, because, it's clear to ME that they are. I want nothing but equity and "MERITOCRACY"!

Blade, or MilitaryMD (read your elitist posts as well) or whoever that reads this, your jobs are not secure! We, the newer, younger people are your threat.

I was having this conversation over a few mojitos that brought some clarity to my thoughts- I always dreamed of being a doctor, and I have achieved that dream. But maybe it's my destiny to become a Lawyer, because I cannot stand to see the inequity that's out there. My goal may be to go back to Law School, and over the course of three years, build a case against groups like NAPA. That would be a big accomplishment in my life- to blow open the gates for younger Doctors, to restore hope in "MERITOCRACY"! To NAPA- just because you're on top of the hill, doesn't mean you'll stay there. Those guys should be and will be under fire. Attack them.

 

[treasurefull2]

All right, wellll...a buzzed and hence, an honest answer. The ethnic preference in the East Coast, i.e., peri-NYC/NJ based only on the observations of my non-jewish friends is what I was referring to, but the Israelites are screwed royally too. For full disclosure, my family members are Jewish though I'm not. I have renounced my religion because I'm ashamed and I want nothing to do with the terrorist state of Israel, whose majority of representatives in the U.S., happen to care about nothing but the $$$$$$. **** them. Ultimately, I'm an American, not an Israeli, and so, my allegiance is to the prosperity of the U.S., not Israel....well, Jeff enough to address that part of your question.

Blade, as far as being skilled enough to suck surgeons' dicks etc., I think everyone by their CA-3 year learns what's needed. Nobody is talking about "canceling cases" etc., so if that's all that old folks can hang their hats one, then, well, get ready to go back to fellowships or whatever and truly earn your credibility. In the 1 1/2 years since Residency in an Academic place, the only case I've cancelled is an elective Gyn procedure in a 60-some yr old patient in a wheelchair with acute chest pain, unknown functional capacity and no echos on her record. Buddy, that's what board certification is all about! You're not the only intelligent dude out there!

Yeah I know it's a game out there Jet, but it's disgusting brother! It's "us" screwing over "us"!!!!! As far as "entitled"???? Hell no, I don't think I, nor anyone out there is entitled to anything. Like our founding father Mr. Hamilton, I believe in the old concept of "MERITOCRACY"!!!! MERITOCRACY! MERITOCRACY! MERITOCRACY! That's it, and that's that. I believe there are many unscrupulous people out there, many backdoor deals- hypothetically, let's say NAPA (North American Partners in Anesthesia) pays off or rewards a hospital CEO with whatever, just so they can get the contract for a hospital, staff it with some people in the short-run, advertise on gaswork, recruit some H1B1 visa people who'll just shut the **** up and work for whatever, and you get the drift....Many groups out there like that. Is that entitlement Jet??? NO! Not at all! I'm just calling it like I see it! The public may be right to see Doctors as greedy, because, it's clear to ME that they are. I want nothing but equity and "MERITOCRACY"! I don't throw my weight around at all man, in fact, I'm the most laid back person in the OR you'll ever run into and the surgeons are bummed that I'm even looking for another job because of my efficiency. Though we have techs, I turn over my own room, clean up everything myself all so I can finish my room 40 minutes earlier than everyone else....only to be rewarded with more cases!!! yippppppeeee!!! Anyway, any fit individual can be good at being fast and anyone with half a brain who actually paid attention in Residency can go ahead with 98, okay 99.99% of cases.

Blade, or MilitaryMD (read your elitist posts as well) or whoever that reads this, your jobs are not secure! We, the newer, younger people are your threat.

I was having this conversation over a few mojitos that brought some clarity to my thoughts- I always dreamed of being a doctor, and I have achieved that dream. But maybe it's my destiny to become a Lawyer, because I cannot stand to see the inequity that's out there. My goal may be to go back to Law School, and over the course of three years, build a case against groups like NAPA. That would be a big accomplishment in my life- to blow open the gates for younger Doctors, to restore hope in "MERITOCRACY"! To NAPA- just because you're on top of the hill, doesn't mean you'll stay there. Those guys should be and will be under fire. Attack them.

You're a pretty ****ing ignorant guy...

 

[coprolalia]

You're a pretty ****ing ignorant guy...

Come on, dude! Lighten up. This thread is an instant classic!

tecmobowl, your problem is that your mindset is stuck in the peri-NYC way of thinking. Sober up, and move somewhere else.

Until then, awesome post, my man! Your honest, thoroughly entertaining stream-of-consciousness post reminds me of Jerry Maguire's "memo".



-copro

 

[tracheatoedoc]

I've been doing this fo about 10 years now. The job market is better than ever. I'd estimate that over the last 10 years salaries have increased 33%. I expect the relative shortage of MDAs to continue. Programs are producing 1200 grads a year compared to 1600 mid 90s.

Fee for service pactice may be stagnant or worse, but I haven't been ffs for 5 years or so.

I live in the midwest. Big hospitals are still hiring. They never were a great deal because of their more desirable location.

Are you guys talking about a particular market?
NYC and Chitown never paid 50th percentile packages as a rule.
As far as I know NYC has always paid about 60% of what you could do anywhere else.
Buy some skis and move to Reno or Salt Lake City.

 

[BLADEMDA]

Blade, or MilitaryMD (read your elitist posts as well) or whoever that reads this, your jobs are not secure! We, the newer, younger people are your threat.

Hey Tecmo,

You young guys are not my "threat." Obama, socialized medicine and the AANA in that order are my concerns. So, in a way you are correct. Due to the heavy partisan nature of Obama and the Democratic party big changes are coming to our country; most likely, in the form of increased socialism and the welfare state mentality.

Some may like the socialistic frame work offered by the left wing. Becoming the next France or Sweden is not something I am looking forward to, but, I will deal with it when it arrives.

Sorry to disappoint you again but if the administraton were to buy into rhetoric (like your claim of doing it better for less money) they would go with the AANA/CRNA propoganda of Independent Nurse Anesthesia with one MD (A) per ten Nurses. That would save the most money as every provider would be an employee of the hospital. Of Course, the Independent CRNA would demand more and more money over time so the cost savings wouldn't really materialize (not to mention the increased morbidity).

Similarly, you would start out "hungry" for work and money but over 5 years are likely to demand higher wages in order to align youself with the national average. Plus, a person such as yourself believes he is superior to his peer group so you are likly to want MUCH higher $$$ over time.

You need to stay in academics or branch out somewhere else in the USA.
But first, you need to learn a little humility and respect towards those above you; otherwise, you will find yourself moving from job to job in search of utopia. The only "threat" you pose is to your own career.

 

[TecmoBowl]

YO,

Blade, agree with you regarding AANA sleazy tactics. By the way, for those who don't know, go look up what DNPs (Doctors, that's right Doctors, of Nursing Practice) programs are up to. Your CRNAs the very people brought on and nurtured by private practice folks, are the ones who'll be introducing themselves to patients as Doctor so and so....after 2 to 3 yrs of going to DNP program and getting a "PhD in Nursing" WTF?! 2 yrs for a PhD....heck even the grad students should be pissed about this!!! Another example where private practitioners are willing to sell our profession out. I'd like to join a private practice, but only as long as it's 100% docs. That's another issue all together.

Med Students, do you guys/gals know the next round of Medicare cuts to come due? By 2010, an even more drastic cut in Medicare reimbursement is to be proposed. In fact, it was the Dems who saved us from the 10.5% cut in payments this past July. Go look up how they voted on the bill...HR 6331...not sure of the number. BUT FOR ALL YOU JAGOFFS OUT THERE, STAY POLITICALLY AWARE, CONTRIBUTE TO THE ASAPAC, AND TAKE AN INITIATIVE- GET, AND STAY INVOLVED. PAINT A BETTER PICTURE OF YOURSELF TO THE COMMUNITY. This is the $hit they don't teach us in Med School- you have to carry yourselves a certain way to re-establish public faith in us as Physicians, and more so with Anesthesia I believe. PM&R is hopeless...relax, just kidding! I love getting hate mail!!

Blade, I'm realizing why I went into Medicine, to truly help people...and along the way somewhere, I got lost, maybe we all did. Don't get me wrong, the financial incentives are HUGE, but not the main or only thing. I've seen families (U.S. taxpaying families) ruined because they couldn't pay their bills, my own friends' parents freaking out after loosing jobs because they're worried about health care. I don't know that universal healthcare will be such a bad thing, at least, we'll get paid for what we do! It may bring down the $$ of NAPA or whatever, but for a majority of the doctors, it may actually help them out. What do I care what $*&tsinger at Hackensack takes home? I'm not seeing any of it! Universalize for God's sake. At that point, Anesthesia will have to universalize into a large group(s) for the sake of negotiations. Consolidation for the sake of bargaining power.

 

[urge]

Hey,

I'm at the San Diego Echo conference ...

Me too. Wanna meet?

 

[maceo]

the guys at hackensack and the surrounding area's party is almost over. The sheridans, napas. anesthetix, are all knocking at the doors of all the hospitals in the area. The 50 attendings at hackensack all making 400plus/ and the select partners 20 or so making 850-1 million plus are coming to an end soon, it will be really funny when that happens. Sheridan is already in jersey city.

 

[urge]

Unequal partnerships will die in the next few yrs. Notice the "unequal". Good partnerships will stay alive. A lot of young guys like us don't beleieve in that system. Some of the thinking behind these guys is "I got screwed so I have the right to screw you". That's not going to fly with me. I would rather work for an AMC than a shady pp group. A lot of my graduating residents are taking that approach too.

 

[tracheatoedoc]

the guys at hackensack and the surrounding area's party is almost over. The sheridans, napas. anesthetix, are all knocking at the doors of all the hospitals in the area. The 50 attendings at hackensack all making 400plus/ and the select partners 20 or so making 850-1 million plus are coming to an end soon, it will be really funny when that happens. Sheridan is already in jersey city.

.

Why is that funny?
These anesthesia management companies often can't deliver.
They end up bringing in a series of losers and surgeons get frustated.
This just happened at a nearby hospital. Amsol sells itself as an anesthesia solution and the hospital learns that there are an amazingly large number of bad anesthesiologists.

 

[urge]

.

Why is that funny?
These anesthesia management companies often can't deliver.
They end up bringing in a series of losers and surgeons get frustated.
This just happened at a nearby hospital. Amsol sells itself as an anesthesia solution and the hospital learns that there are an amazingly large number of bad anesthesiologists.

I bet all brand new, either AMC or Private, practices start like that. If you are hiring at random from the available pool you will find quite a few that are always looking for jobs, for a reason. Over time the "weaker" MDs are weeded out. That has nothing to do with the management.

 

[coprolalia]

Do you guys think that the greedy people will eventually get burned? I mean, you can only sustain a practice (or AMC) so long with inferior players, right?

Then again, there are crappy surgeons and crappy hospitals out there that cater primarily to underserved areas with a high Medicare/Medicaid payer mix that essentially puts money coming in first and quality second. And, with hospital subsidies, I'm not sure there's an incentive for some practices to "open the books" so to speak. Not sure that people with private insurance go to those places as a "first choice" anyway. I imagine that situation is ripe for abuse among ALL senior level staff in every specialty. That, and the fact that there are geographical areas that people are tied to with a glut of practitioners makes for easy pickings.

Am I off-base here? Or, is this a fair assessment of the situation?

-copro

 

[maceo]

Unequal partnerships will die in the next few yrs. Notice the "unequal". Good partnerships will stay alive. A lot of young guys like us don't beleieve in that system. Some of the thinking behind these guys is "I got screwed so I have the right to screw you". That's not going to fly with me. I would rather work for an AMC than a shady pp group. A lot of my graduating residents are taking that approach too.

i said this before.. who would you rather be screwed by? people you see everyday or people you never see?

 

[maceo]

.

Why is that funny?
These anesthesia management companies often can't deliver.
They end up bringing in a series of losers and surgeons get frustated.
This just happened at a nearby hospital. Amsol sells itself as an anesthesia solution and the hospital learns that there are an amazingly large number of bad anesthesiologists.

what are you talking about? anesthesia is not rocket science s hit nurses can do it. and do it well. Who cares if the surgeons are happy or not? just as long as the hospital is making money. Seriously, your post is not reality. Napa and sheridan and ahp have been in business a LONG time

 

[maceo]

Unequal partnerships will die in the next few yrs. Notice the "unequal". Good partnerships will stay alive. A lot of young guys like us don't beleieve in that system. Some of the thinking behind these guys is "I got screwed so I have the right to screw you". That's not going to fly with me. I would rather work for an AMC than a shady pp group. A lot of my graduating residents are taking that approach too.

they are dieing already.. rebursements have gotten so bad that these people would have to pay new grads like 150 to make a decent profit.. so they kind of wither away and AMC comes in

 

[Coastie]

Law School?

Are you serious?

All right, wellll...a buzzed and hence, an honest answer. The ethnic preference in the East Coast, i.e., peri-NYC/NJ based only on the observations of my non-jewish friends is what I was referring to, but the Israelites are screwed royally too. For full disclosure, my family members are Jewish though I'm not. I have renounced my religion because I'm ashamed and I want nothing to do with the terrorist state of Israel, whose majority of representatives in the U.S., happen to care about nothing but the $$$$$$. **** them. Ultimately, I'm an American, not an Israeli, and so, my allegiance is to the prosperity of the U.S., not Israel....well, Jeff enough to address that part of your question.

Blade, as far as being skilled enough to suck surgeons' dicks etc., I think everyone by their CA-3 year learns what's needed. Nobody is talking about "canceling cases" etc., so if that's all that old folks can hang their hats one, then, well, get ready to go back to fellowships or whatever and truly earn your credibility. In the 1 1/2 years since Residency in an Academic place, the only case I've cancelled is an elective Gyn procedure in a 60-some yr old patient in a wheelchair with acute chest pain, unknown functional capacity and no echos on her record. Buddy, that's what board certification is all about! You're not the only intelligent dude out there!

Yeah I know it's a game out there Jet, but it's disgusting brother! It's "us" screwing over "us"!!!!! As far as "entitled"???? Hell no, I don't think I, nor anyone out there is entitled to anything. Like our founding father Mr. Hamilton, I believe in the old concept of "MERITOCRACY"!!!! MERITOCRACY! MERITOCRACY! MERITOCRACY! That's it, and that's that. I believe there are many unscrupulous people out there, many backdoor deals- hypothetically, let's say NAPA (North American Partners in Anesthesia) pays off or rewards a hospital CEO with whatever, just so they can get the contract for a hospital, staff it with some people in the short-run, advertise on gaswork, recruit some H1B1 visa people who'll just shut the **** up and work for whatever, and you get the drift....Many groups out there like that. Is that entitlement Jet??? NO! Not at all! I'm just calling it like I see it! The public may be right to see Doctors as greedy, because, it's clear to ME that they are. I want nothing but equity and "MERITOCRACY"! I don't throw my weight around at all man, in fact, I'm the most laid back person in the OR you'll ever run into and the surgeons are bummed that I'm even looking for another job because of my efficiency. Though we have techs, I turn over my own room, clean up everything myself all so I can finish my room 40 minutes earlier than everyone else....only to be rewarded with more cases!!! yippppppeeee!!! Anyway, any fit individual can be good at being fast and anyone with half a brain who actually paid attention in Residency can go ahead with 98, okay 99.99% of cases.

Blade, or MilitaryMD (read your elitist posts as well) or whoever that reads this, your jobs are not secure! We, the newer, younger people are your threat.

I was having this conversation over a few mojitos that brought some clarity to my thoughts- I always dreamed of being a doctor, and I have achieved that dream. But maybe it's my destiny to become a Lawyer, because I cannot stand to see the inequity that's out there. My goal may be to go back to Law School, and over the course of three years, build a case against groups like NAPA. That would be a big accomplishment in my life- to blow open the gates for younger Doctors, to restore hope in "MERITOCRACY"! To NAPA- just because you're on top of the hill, doesn't mean you'll stay there. Those guys should be and will be under fire. Attack them.

 

[coprolalia]

Law School?

Are you serious?

I think he's drunk... or hung-over.

Problem with law school after being a doctor is that there'd be WAY too much temptation to become a plaintiff's attorney, especially if all you care about primarily is money. WAY too much.

-copro

 

[TecmoBowl]

Me too. Wanna meet?

yeah sure. when? where? Don't lure me out into the open to lynch me!! I'm just a frustrated young guy that's all...tired of politicians, lawyers, insurance companies, and now my fellow Doctors! But yeah sure, tell me how.

 

[IN2B8R]

Enjoyed reading your post. The hiring process of many groups/AMC's reminds me of a title of an old movie: sex, lies and video tapes. Moral of the story when seeking a new job: believe no one. Trust no one. Take nothing for granted or as an article of faith. Promises in this business are more often broken than they are kept. And at the end of the day, the worst part of all about getting screwed by a new job is the following: medical school loans do not disappear, families get displaced, hard earned friendships are often flushed down the drain, and hard work is never rewarded. I honestly cannot see how becoming a lawyer is going to compensate for the above tragedies/loses. Good luck with your future endeavors.

All right, wellll...a buzzed and hence, an honest answer. The ethnic preference in the East Coast, i.e., peri-NYC/NJ based only on the observations of my non-jewish friends is what I was referring to, but the Israelites are screwed royally too. For full disclosure, my family members are Jewish though I'm not. I have renounced my religion because I'm ashamed and I want nothing to do with the terrorist state of Israel, whose majority of representatives in the U.S., happen to care about nothing but the $$$$$$. **** them. Ultimately, I'm an American, not an Israeli, and so, my allegiance is to the prosperity of the U.S., not Israel....well, Jeff enough to address that part of your question.

Blade, as far as being skilled enough to suck surgeons' dicks etc., I think everyone by their CA-3 year learns what's needed. Nobody is talking about "canceling cases" etc., so if that's all that old folks can hang their hats one, then, well, get ready to go back to fellowships or whatever and truly earn your credibility. In the 1 1/2 years since Residency in an Academic place, the only case I've cancelled is an elective Gyn procedure in a 60-some yr old patient in a wheelchair with acute chest pain, unknown functional capacity and no echos on her record. Buddy, that's what board certification is all about! You're not the only intelligent dude out there!

Yeah I know it's a game out there Jet, but it's disgusting brother! It's "us" screwing over "us"!!!!! As far as "entitled"???? Hell no, I don't think I, nor anyone out there is entitled to anything. Like our founding father Mr. Hamilton, I believe in the old concept of "MERITOCRACY"!!!! MERITOCRACY! MERITOCRACY! MERITOCRACY! That's it, and that's that. I believe there are many unscrupulous people out there, many backdoor deals- hypothetically, let's say NAPA (North American Partners in Anesthesia) pays off or rewards a hospital CEO with whatever, just so they can get the contract for a hospital, staff it with some people in the short-run, advertise on gaswork, recruit some H1B1 visa people who'll just shut the **** up and work for whatever, and you get the drift....Many groups out there like that. Is that entitlement Jet??? NO! Not at all! I'm just calling it like I see it! The public may be right to see Doctors as greedy, because, it's clear to ME that they are. I want nothing but equity and "MERITOCRACY"! I don't throw my weight around at all man, in fact, I'm the most laid back person in the OR you'll ever run into and the surgeons are bummed that I'm even looking for another job because of my efficiency. Though we have techs, I turn over my own room, clean up everything myself all so I can finish my room 40 minutes earlier than everyone else....only to be rewarded with more cases!!! yippppppeeee!!! Anyway, any fit individual can be good at being fast and anyone with half a brain who actually paid attention in Residency can go ahead with 98, okay 99.99% of cases.

Blade, or MilitaryMD (read your elitist posts as well) or whoever that reads this, your jobs are not secure! We, the newer, younger people are your threat.

I was having this conversation over a few mojitos that brought some clarity to my thoughts- I always dreamed of being a doctor, and I have achieved that dream. But maybe it's my destiny to become a Lawyer, because I cannot stand to see the inequity that's out there. My goal may be to go back to Law School, and over the course of three years, build a case against groups like NAPA. That would be a big accomplishment in my life- to blow open the gates for younger Doctors, to restore hope in "MERITOCRACY"! To NAPA- just because you're on top of the hill, doesn't mean you'll stay there. Those guys should be and will be under fire. Attack them.

 

[Lasvegas]

I will add one small item to this thead.

When I started my training a few years ago I began looking at gaswork.com now and then just to see what kind of jobs were out there ect, and to see what I could learn from the varied types of offers.

On average 3 years ago gaswork showed a total of US job offers at around 2,100. That number has kept going down during that time to where it is today at just over 1,500.

This seems like a fast drop to me considering the studies state that more and more surgs are being done and that anes need is on the rise and will continue.

It also points to the fact one poster already mentions - that in these bad times older docs are staying longer to repair damaged retirement accounts. This means less and less jobs for the new grads.

 

[cozmopak]

I've read a lot of apocalyptic prophecies on this forum in regards to the future of anesthesiology. Why is it, then, that some of the top students at my medical school are entering the field this year? I've heard that it has become more competitive than ever to match into anesthesiology. Have we been duped? Is the future outlook really that grim?

 

[foxtrot]

All I know is that the current job market sucks for new grads. If anyone knows of any fair practices that hiring please pm me.

 

[Jeff05]

anesthesia is attracting top applicants not because it has suddenly become so much more interesting or fulfilling in the last 6 years. it's because salaries have been relatively high.

right now is the END of this cycle of increased anesthesia compensation. again, salaries will fall during the next several years. so yes, all those who went into anes hoping to graduate and get 350 to start with a 3 year partnership track to 600 have been duped. that time is OVER. for now.

I've read a lot of apocalyptic prophecies on this forum in regards to the future of anesthesiology. Why is it, then, that some of the top students at my medical school are entering the field this year? I've heard that it has become more competitive than ever to match into anesthesiology. Have we been duped? Is the future outlook really that grim?

 

[maceo]

All I know is that the current job market sucks for new grads. If anyone knows of any fair practices that hiring please pm me.

i agree. I was just talking to a recruiter who called me about a job. I said i was not interested and asked her just incidentally how the market was. and she said its really really tough now. Maybe its winter and nobody is leaving their jobs and it will pick up this summer. bUt im thinking and she agreed that the field is getting saturated.

 

[CrazyJake]

My faculty advisor told several of us planning to enter Anesthesia earlier this fall that he expects it to be 'very difficult for us to find jobs in 4-5 years when we're finishing....it will stay that way for another 5-8 years after that, no one will go into it again, and it will cycle back for the mid-latter part of our career's.'

Hope he's wrong, but he's been around the field for a while and seems to be pretty in tune with how things go.
Still planning to go into the field despite his thoughts...for what that's worth.

 

[Bluemirage]

Weird to hear these stories about the pessimism of Anesthesiology jobs currently and in the future. In the March 2009 ASA Newsletter, they wrote an article about the RAND study (presented during the Jan 2009 ASA conference on Practice Management) which showed that the U.S. is currently experiencing a shortage of anesthesiologists which, if current trends continue, will worsen by 2020. They also forecast a surplus of CRNA's. I hope the findings in this study is accurate and that the current state of the job market is a temporary result of the economic crisis.

My faculty advisor told several of us planning to enter Anesthesia earlier this fall that he expects it to be 'very difficult for us to find jobs in 4-5 years when we're finishing....it will stay that way for another 5-8 years after that, no one will go into it again, and it will cycle back for the mid-latter part of our career's.'

Hope he's wrong, but he's been around the field for a while and seems to be pretty in tune with how things go.
Still planning to go into the field despite his thoughts...for what that's worth.

 

[positraction]

Always room at the top end of the ladder according to my sources. If you are well-trained, learn the latest technology and techniques, stay ahead in the field, there will always be a place to work in this field. Time changes everything. 1995 was the nadir. Jobs were tight in 93-94 but people still got them. Many ran away from anesthesia for fear of no jobs (or not their perfect job) but then it really opened up again. If you want to do it and you're good, nothing can stand in your way. Time will heal the discrepancies. Future is what you make of it...

 

[bulgethetwine]

Always room at the top end of the ladder according to my sources. If you are well-trained, learn the latest technology and techniques, stay ahead in the field, there will always be a place to work in this field. Time changes everything. 1995 was the nadir. Jobs were tight in 93-94 but people still got them. Many ran away from anesthesia for fear of no jobs (or not their perfect job) but then it really opened up again. If you want to do it and you're good, nothing can stand in your way. Time will heal the discrepancies. Future is what you make of it...

Good win one for the Gipper speech.

It IS cyclical. It should improve (and will probably get worse, first). But it's just another example a la The Pig and the Python, of how the Gen Xers have the most educational debt in history, inherit a polluted planet, and are funding the social security system for all the bloated Baby Boomers... the same Boomers who have amassed enormous wealth is real estate which has, you guessed it, f trucked the Xers again in the form of unaffordable housing in big cities.

All orchestrated by a government run by.... Baby boomers!

Well done fat old dudes !

 

[foxtrot]

Always room at the top end of the ladder according to my sources. If you are well-trained, learn the latest technology and techniques, stay ahead in the field, there will always be a place to work in this field. Time changes everything. 1995 was the nadir. Jobs were tight in 93-94 but people still got them. Many ran away from anesthesia for fear of no jobs (or not their perfect job) but then it really opened up again. If you want to do it and you're good, nothing can stand in your way. Time will heal the discrepancies. Future is what you make of it...

I disagree. Even if you are fellowship trained (and I am) the market is still really bad. All you have to do is look at gasworks to know that there are no jobs out there. Many of the locum jobs are drying up. Even when you call the recruiters, most of them have hardly anything. Most of the academic centers are in hiring freezes. I am not even going to talk about the private practice market. I am not being doom and gloom. I am talking about reality here.

 

[Colba55o]

My faculty advisor told several of us planning to enter Anesthesia earlier this fall that he expects it to be 'very difficult for us to find jobs in 4-5 years when we're finishing....it will stay that way for another 5-8 years after that, no one will go into it again, and it will cycle back for the mid-latter part of our career's.'

Hope he's wrong, but he's been around the field for a while and seems to be pretty in tune with how things go.
Still planning to go into the field despite his thoughts...for what that's worth.

And this guy is your faculty advisor? I thought their job was to try to support, not discourage 😕
Ive expressed the same concerns about job security to many faculty and they have all reassured me that at the very least I will find a decent paying job.

 

[positraction]

Good win one for the Gipper speech.

It IS cyclical. It should improve (and will probably get worse, first). But it's just another example a la The Pig and the Python, of how the Gen Xers have the most educational debt in history, inherit a polluted planet, and are funding the social security system for all the bloated Baby Boomers... the same Boomers who have amassed enormous wealth is real estate which has, you guessed it, f trucked the Xers again in the form of unaffordable housing in big cities.

All orchestrated by a government run by.... Baby boomers!

Well done fat old dudes !

Eventually, old fat dudes will be replaced by sleek, overconsumption conscious, Gen Xers who are smart enough to turn things around. Maybe it take a downturn in the economy (big time) to get people to realize that you don't need to "own" so many toys or big mansions and you don't need to consume yourself into gluttony. Most overfed Americans just need to take a trip to a third world country and see that happiness is not just having a bunch of stuff and consuming just to ward off emptiness.

Back to thread. I think robotics will eventually take over the operating room and only the gifted who are tech-saavy will prevail. Give it 50 years or so, but it starts in the next 20. Those who have skills, knowhow and advanced technology will be the masters of the new domain. Just hope to get my foot in the door and glue myself to the carpet when they start pulling. At least that way, I'll be along for the ride.

 

[maceo]

I disagree. Even if you are fellowship trained (and I am) the market is still really bad. All you have to do is look at gasworks to know that there are no jobs out there. Many of the locum jobs are drying up. Even when you call the recruiters, most of them have hardly anything. Most of the academic centers are in hiring freezes. I am not even going to talk about the private practice market. I am not being doom and gloom. I am talking about reality here.

I tend to agree with you. There are still jobs out there, but i think the market is getting saturated based on talking to recruiters. even if you are fellowship trained.