I have to weigh in on this thread because I think there are some good and valid points all around. I agree that there is a lot of "doom and gloom" when discussing physiatry in CA, and part of that is because there are not a lot of Academic training programs here, and certainly not a lot of what is typically considered "good" ones. When I was interviewing for fellowships years ago, and I casually mentioned that I was thinking about working one day in CA, the automatic response was "Oh, I guess you're not interested in Academics". The resulting private practice free-for-all leads to some interesting practice dynamics.
That point aside, there are some peculiarities about practicing here. First and foremost is the aforementioned "Sun Shine Tax". This is a crowded, saturated, and highly competetive market, and a lot of people (physicians or otherwise) want to move here. If you want to work in sunny CA, you should expect your overall income as a physician to be on the order of 25% - 30% less than many other areas of the country. This combined with a much higher cost of living and high tax rate makes being a physician in CA less financially viable certainly. But you're a doctor. Its not like you're going to be poor...
The posts above regarding insurance companies' hold over practices is dead on. California is a heavily managed care state, and that's without even taking into account Kaiser. There are a lot of other powerful HMO's and they have a near strangle-hold over not only the job market, but the overall referral base. California is also (despite mainstream media's depiction of fame and fortune) a very poor state, especially in the Inland areas. ACA/Obamacare equivalent here is called California Covered, and they reimburse if I'm not mistaking about 68-70% of what medicare does. Most physicians (of all specialities) do not accept this in my area, and it makes multidisciplinary care or overall care-coordination difficult, especially for patients whose employer or insurance companies changed without their consent/knowledge.
With regards to the referral base, PM&R suffers from under-exposure here. The PMDs really have NO idea what you do, and in many cases, have become accustomed to referring to other specialities (neurology, anesthesiology, ortho/neurosurg, etc). The only thing they are really sure that you do is the typical "functional restoration" for deconditioned, medically or surgically complex patient's (i.e. the same thing they try to dump on you in the inpatient setting). Trying to get through to the referral base, whether through grass roots, door-to-door meetings or even mass marketing takes time, effort, is often fruitless and unsatisfying. As someone mentioned above, they have no reasons to trust you or change their behavior and referral patterns built up over years of complacency, and this is perhaps one of the most frustrating things for a young physician or newly minted out-of-training doc to understand, especially if you come from a heavily academic background where you had exposure, respect, and did not have to fight for your business. That being said, noone said being a doctor was going to be easy. It takes time, effort, blood, sweat and tears to build a practice anywhere. My best advice is to simply be a good doctor. Take care of your patients and they'll eventually take care of you. Remain true to your ethics and your principles, and over time, people will notice and will come around.
Some tips for people considering moving here:
1) Apply for your CA state license early. Many jobs wont even talk to you unless you already have one. This is because it take FOREVER (up to 9 months in some cases) to get a darned license.
2) Have a good reason to be here. One of the most common issues people had when I was looking was that they didn't know WHY I would think about moving here, and thus why I would consider staying on long-term. Unbelievably, apparently people in CA don't realize that the rest of the world fantasizes about moving here.
3) Worker's comp works differently here than in other states. There is a system called the MPN, and unless you are on the networks, you cannot see their patient's. As with applying for a license, getting approved by MPNs takes time, and there is a lot of resistance against credentialing new physicians. Given that many clinics here are heavily work comp based, this will definately affect your ability to get a job.
4) If you are an interventionalist, don't forget that you are required to have a darned Fluoro License to practice here. This requires passing an examination, and again, the whole process takes quite a bit of time.
5) There is an unusual process called "proctoring" here, where you need to technically be proctored by a physician of your specialty before your credentialing can be confirmed. Its utter BS and everyone knows it, and ultimately a way for older physicians to exert power and control the market for when other physicians try to make a move in their territory. Again, if you are an interventionalist, a MSK or pain specialist, this process (and by extension, obtaining long-term hospital priveledges) can be a headache. There really are no other physiatrists who do what I do in my community. When I tried to get proctored for my pain cases, the hospital would not accept an anesthesiologist as a proctor because they were not in the same specialty. When I asked the local physiatrist to proctor me, he looked confused, as he was a general physiatrist and stated that he knew nothing about what I do.
I disagree with the above posts that you cannot have a good job, location, pay, and lifestyle. I happen to have all of the above. Getting a job anywhere, especially a good one is most certainly an arduous process that requires compentance, persistance and strength of will, a willingness to "play the game" and an ability to network. As with any geographic location or market, there is also a strong component that is strictly luck and timing.
