The amount and toughness of call as a surgical attending

[Doc mu]

I’m wondering about how much call each major surgical specialty entails and how “hard” that call is. Theoretically, the answer is extremely variable; you can even avoid call all together by doing all outpatient work and only doing minor surgeries. But, that would likely reduce your income drastically and it’s hard to compare each specialty to each other like that.
Therefore, to compare, let’s say you earn exactly at the median in every surgical specialty.

On average, how would you rank optho, urology, ENT, gen surg & ortho in terms of amount & difficulty of call?

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[eyeeye_captain]

First, going fully outpatient, minor surgeries, with no hospital call pays substantially better in ophtho, not worse. My busiest OR day pays like a slow clinic day, and complex surgery only gives you a small bump that really doesn’t account for the extra time spent. Surgery for the thrills, clinic for the bills.

Second, I don’t think anybody beats ophtho here. You can (and I think most do) avoid hospital call mostly or entirely, so no trauma or rounding. There are very few things that can’t be seen the next day in the office. Patient phone calls after hours aren’t high volume, and most (or all) weeks you won’t see anybody overnight but maybe on the weekend.

It’s possible to be bad. I have a buddy who takes call at a Level 1 who spent something like 40 hours between the ER, floor, and surgery on top of clinic one week recently. Does get paid, but not at close to median salary rates. This is an outlier for us, thankfully.

 

[Doc mu]

First, going fully outpatient, minor surgeries, with no hospital call pays substantially better in ophtho, not worse. My busiest OR day pays like a slow clinic day, and complex surgery only gives you a small bump that really doesn’t account for the extra time spent. Surgery for the thrills, clinic for the bills.

Second, I don’t think anybody beats ophtho here. You can (and I think most do) avoid hospital call mostly or entirely, so no trauma or rounding. There are very few things that can’t be seen the next day in the office. Patient phone calls after hours aren’t high volume, and most (or all) weeks you won’t see anybody overnight but maybe on the weekend.

It’s possible to be bad. I have a buddy who takes call at a Level 1 who spent something like 40 hours between the ER, floor, and surgery on top of clinic one week recently. Does get paid, but not at close to median salary rates. This is an outlier for us, thankfully.

How do you make more on E/M codes than surg?

 

[TexasMed22]

My guess for call burden:
gen surg (worst) > urology > ortho = ENT > ophtho (best)

 

[eyeeye_captain]

How do you make more on E/M codes than surg?

You don’t. The difference is volume. An average surgery pays about what 5 average patients with visit/imaging/procedures will. I work half day surgical blocks where I can do around 4 cases, which I don’t typically fill completely. One complicated case can take that down to 3 max. A half day in clinic is 30+ patients. Math says give me the clinic.

It’s possible to make more in the OR if you have cash pay stuff like LASIK or premium lenses for cataracts, but that’s not the case for retina.

*Disclaimer: this is from a retina perspective, not necessarily the case for general folks or other ophtho subspecialties

 

[TheLesPaul]

You don’t. The difference is volume. An average surgery pays about what 5 average patients with visit/imaging/procedures will. I work half day surgical blocks where I can do around 4 cases, which I don’t typically fill completely. One complicated case can take that down to 3 max. A half day in clinic is 30+ patients. Math says give me the clinic.

It’s possible to make more in the OR if you have cash pay stuff like LASIK or premium lenses for cataracts, but that’s not the case for retina.

*Disclaimer: this is from a retina perspective, not necessarily the case for general folks or other ophtho subspecialties

agree with disclaimer, this is subspecialty specific. for me, surgery is much more profitable than an average clinic visit including imaging/minor procedures. so I have 2.5 OR days/week -- and clinic is the penance I pay to be able to operate.

 

[Smurfette]

My guess for call burden:
gen surg (worst) > urology > ortho = ENT > ophtho (best)

Based on after hours case tracking at multiple hospitals:
Gen surg > ortho > urology >> ENT >>> ophtho

 

[LucidSplash]

I feel there are several surgical specialties left out of this discussion.

 

[operaman]

Yeah ent varies a bit depending on the hospital and how you handle things. Generally speaking not too bad most places, but even slow call still sucks.

For ent it really depends on how your shop manages acute airway and whether you trauma. My institution has a nice system for airway and I don’t do trauma so that makes it easier. Our hospitalists admit everything too so even non urgent operative cases that come in overnight you can just admit and see in the morning. Hardest part for me is balancing call with my regular clinical practice.

Count me in as part of the clinic pays way more than OR crowd. OR is much more fun though! Clinic it’s just the function of volume that adds up, plus I do a lot of procedures in my clinics.

But even without procedures, I can generate more revenue in an hour sometimes than a multi-hour OR case. For example, total laryngectomy is about 30 wRVUs and takes a few hours and typically has a 5-7 day hospital stay. I can cram 12 new patients with simple hearing loss into one hour and it’s 31 wRVUs and no hospital stay, no rounding. In dollars it’s about $2k for the hour and for the operation. My typical clinics generate about 100-150 wRVUs which you can also do in a busy OR day, but it’s not easy.

 

[Doc mu]

Yeah ent varies a bit depending on the hospital and how you handle things. Generally speaking not too bad most places, but even slow call still sucks.

For ent it really depends on how your shop manages acute airway and whether you trauma. My institution has a nice system for airway and I don’t do trauma so that makes it easier. Our hospitalists admit everything too so even non urgent operative cases that come in overnight you can just admit and see in the morning. Hardest part for me is balancing call with my regular clinical practice.

Count me in as part of the clinic pays way more than OR crowd. OR is much more fun though! Clinic it’s just the function of volume that adds up, plus I do a lot of procedures in my clinics.

But even without procedures, I can generate more revenue in an hour sometimes than a multi-hour OR case. For example, total laryngectomy is about 30 wRVUs and takes a few hours and typically has a 5-7 day hospital stay. I can cram 12 new patients with simple hearing loss into one hour and it’s 31 wRVUs and no hospital stay, no rounding. In dollars it’s about $2k for the hour and for the operation. My typical clinics generate about 100-150 wRVUs which you can also do in a busy OR day, but it’s not easy.

So would you disagree with everyone above saying ENT has one of the easiest on calls?

 

[operaman]

So would you disagree with everyone above saying ENT has one of the easiest on calls?

No I think it’s probably easier relative to the others in most cases. All comes down to how many truly emergent and operative things you manage. ENT only has a handful of things that need you to go in late at night and potentially operate. Many things can be handled with a phone call and seen the next day.

That said, I would still forfeit a sizable portion of my salary to never take call again.

 

[Doc mu]

No I think it’s probably easier relative to the others in most cases. All comes down to how many truly emergent and operative things you manage. ENT only has a handful of things that need you to go in late at night and potentially operate. Many things can be handled with a phone call and seen the next day.

That said, I would still forfeit a sizable portion of my salary to never take call again.

You're really sending mixed signals xD, if you very rarely have to go in and you mostly just answer a few phone calls at night why would you forfeit $$$ to never take call? it seems like free money to me tbh

 

[TexasMed22]

Based on after hours case tracking at multiple hospitals:
Gen surg > ortho > urology >> ENT >>> ophtho

Is this data based on residents or attendings? I know ortho residents get dunked on, but attendings out in the wild seem to rarely have to come in after hours

 

[Doc mu]

Is this data based on residents or attendings? I know ortho residents get dunked on, but attendings out in the wild seem to rarely have to come in after hours

I have a good experience in ortho (ex-resident), even though they dont usually come in at night (though it does happen sometimes) they usually do the cases that came in the night before after the next day's clinic/OR and so "after hours"

 

[anonperson]

Is this data based on residents or attendings? I know ortho residents get dunked on, but attendings out in the wild seem to rarely have to come in after hours

The fracture etc eventually has to be operated on. May not happen that night but often is added on the next day after their scheduled cases or after office hours. Or added onto a weekend.

If there is already a lineup on Saturday for example, you may be stuck operating on a Saturday afternoon etc.

 

[operaman]

You're really sending mixed signals xD, if you very rarely have to go in and you mostly just answer a few phone calls at night why would you forfeit $$$ to never take call? it seems like free money to me tbh

Because I already make far more than I can spend and I’d rather have time and sleep than more money at this point.

Like I could easily add a Saturday morning clinic each week and make an extra 250k+ a year, but I’d rather have my weekends. Same for call - id rather not be tethered to the hospital at all.

I’ve worked very hard to sculpt my schedule into one that allows me a great quality of life, and it’s an ongoing work in progress. Currently I work long mornings and no afternoons most days, so I’m usually out the door before 3pm on non call days. Long days for me are out by 5pm. No weekends. With this it feels like I’m not even working since none of my friends are free before 3pm anyhow, so M-F I have what feels like full days doing whatever I want. Sure, I could see more patients and make more money, but why if I already have way more than I need? Free time while I’m still kinda young and healthy and able to do anything I want is worth far more than an extra 200k a year going in to my brokerage account.

 

[Smurfette]

Is this data based on residents or attendings? I know ortho residents get dunked on, but attendings out in the wild seem to rarely have to come in after hours

Attendings "out in the wild" in places without residents. All those fractures need to be fixed and they get worked in where they can...often after hours if the OR schedule is full.

 

[mikeGR]

Re: general surgery. This varies greatly. Some specialties are turning into shiftwork (such as ACS/trauma), where technically there is no "call" (it's like the hospitalist or anesthesia shifts) or you may never get called in even if oncall (i.e. breast, endocrine, plastics etc) depending on local culture. Other specialties can have brutal call (i.e. vascular or thoracic or transplant or general surgery without an ACS team at a busy hospital).

At the end of the day, regardless of the specialty, there will be avenues to pursue as much call as you want (with some tradeoffs).

 

[Doc mu]

Re: general surgery. This varies greatly. Some specialties are turning into shiftwork (such as ACS/trauma), where technically there is no "call" (it's like the hospitalist or anesthesia shifts) or you may never get called in even if oncall (i.e. breast, endocrine, plastics etc) depending on local culture. Other specialties can have brutal call (i.e. vascular or thoracic or transplant or general surgery without an ACS team at a busy hospital).

At the end of the day, regardless of the specialty, there will be avenues to pursue as much call as you want (with some tradeoffs).

I have yet to meet breast/endo GS out in the community that don't take GS call, tbh it would be somewhat unfair to not share the pain with their collegues too

 

[mikeGR]

I have yet to meet breast/endo GS out in the community that don't take GS call, tbh it would be somewhat unfair to not share the pain with their collegues too

It's not that uncommon if you don't need the extra work. As a rule, being in a call pool is completely voluntary. However if you're not, there's no one to cover you when you're away (which is not a huge problem in some specialties). You pick your poison.

 

[droliver]

I have yet to meet breast/endo GS out in the community that don't take GS call,

I work with 4 different breast oncologists, none of them take surgery call.

In community hospitals, I think Gen Surgery and Orthopedics by far have the most work associated with call even if they don't always operate on someone urgently in the middle of the night, while vascular surgery and cardiac have the most urgent operating on call.

 

[DoctwoB]

Urologist here. There is a ton of variability based on practice setting, desire, etc.

Many urologists in my community take no hospital call, just cover their clinic pager. Many hospitals in the area do not have urology coverage as they do not want to pay for it and try to treat and street or transfer when indicated.

Many do take hospital call, and receive a hospital stipend for said call. How much the stipend is depends on your local market dynamics. How busy call is will vary. I cover call Q4 at a medium sized hospital, get paid quite well for it IMO. Most nights go by without a phone call. It's pretty rare for me to come in to operate at night, usually a torsion or truly septic stone, every now and again a difficult cath. More common is a later day or two from a few add-ons that came in, most commonly kidney stones.

Overall i'm very happy with the trade off, even happy to take my partner's call weeks when they want. Maybe that will change when i'm older, but honestly i could even see myself moving to 0.5 FTE but keeping my call schedule and still making a pretty good income as i slow down rather then giving up call altogether. .

 

[TexasMed22]

Urologist here. There is a ton of variability based on practice setting, desire, etc.

Many urologists in my community take no hospital call, just cover their clinic pager. Many hospitals in the area do not have urology coverage as they do not want to pay for it and try to treat and street or transfer when indicated.

Many do take hospital call, and receive a hospital stipend for said call. How much the stipend is depends on your local market dynamics. How busy call is will vary. I cover call Q4 at a medium sized hospital, get paid quite well for it IMO. Most nights go by without a phone call. It's pretty rare for me to come in to operate at night, usually a torsion or truly septic stone, every now and again a difficult cath. More common is a later day or two from a few add-ons that came in, most commonly kidney stones.

Overall i'm very happy with the trade off, even happy to take my partner's call weeks when they want. Maybe that will change when i'm older, but honestly i could even see myself moving to 0.5 FTE but keeping my call schedule and still making a pretty good income as i slow down rather then giving up call altogether. .

About how many times, in an average year, do you need to physically come into the hospital when on call in your experience? Attendings so often talk about coming in "often" or "rarely", but these terms seem super subjective so I'd love to hear numbers if you don't mind sharing

 

[Doc mu]

I work with 4 different breast oncologists, none of them take surgery call.

In community hospitals, I think Gen Surgery and Orthopedics by far have the most work associated with call even if they don't always operate on someone urgently in the middle of the night, while vascular surgery and cardiac have the most urgent operating on call.

I always thought, stones, trauma, appendicitis, perforations, obstructions, bleeding...etc all meant you had to go to the OR STAT, is this no longer the case?

 

[Doc mu]

Urologist here. There is a ton of variability based on practice setting, desire, etc.

Many urologists in my community take no hospital call, just cover their clinic pager. Many hospitals in the area do not have urology coverage as they do not want to pay for it and try to treat and street or transfer when indicated.

Many do take hospital call, and receive a hospital stipend for said call. How much the stipend is depends on your local market dynamics. How busy call is will vary. I cover call Q4 at a medium sized hospital, get paid quite well for it IMO. Most nights go by without a phone call. It's pretty rare for me to come in to operate at night, usually a torsion or truly septic stone, every now and again a difficult cath. More common is a later day or two from a few add-ons that came in, most commonly kidney stones.

Overall i'm very happy with the trade off, even happy to take my partner's call weeks when they want. Maybe that will change when i'm older, but honestly i could even see myself moving to 0.5 FTE but keeping my call schedule and still making a pretty good income as i slow down rather then giving up call altogether. .

Sounds sweet I had Urology on my radar for a very long time until my father got cancer and the intraop radiation you guys constantly blast scared me away

 

[DoctwoB]

About how many times, in an average year, do you need to physically come into the hospital when on call in your experience? Attendings so often talk about coming in "often" or "rarely", but these terms seem super subjective so I'd love to hear numbers if you don't mind sharing

A lot depends on how you count it since my clinic is attached to the hospital, meaning I'm "coming in" every day when I go to work.

So a normal week without call i go in 5 times, maybe a 6th to round on an inpatient though usually the on call person will handle that.

On call, I will usually go in on the weekends at least once to round on the consults from the week or any leftover inpatients I or my partners have.

In terms of additional trips into the hospital for a middle of the night case/foley (or a Saturday afternoon case after i rounded in the morning) i'd put that at on average once per week of call, maybe twice.

 

[Doc mu]

A lot depends on how you count it since my clinic is attached to the hospital, meaning I'm "coming in" every day when I go to work.

So a normal week without call i go in 5 times, maybe a 6th to round on an inpatient though usually the on call person will handle that.

On call, I will usually go in on the weekends at least once to round on the consults from the week or any leftover inpatients I or my partners have.

In terms of additional trips into the hospital for a middle of the night case/foley (or a Saturday afternoon case after i rounded in the morning) i'd put that at on average once per week of call, maybe twice.

Wow, ngl that still sounds really bad and urology is supposed to be one of the easiest surgical specialties when it comes to on-calls! Looks like you really can't run away from night work in surgery

 

[DoctwoB]

Can't speak for the general surgeons, but in urology we have relatively few "drop everything and go to the OR" type of emergencies

A truly septic kidney stone needs drainage immediately. These are actually pretty rare. Far more common is the patient with a kidney stone and possible infection but is not truly septic. Those can be added on for a stent at the end of the day, or for the next day if coming in overnight.

A torsion has to go to the OR right away to save a testicle. I get maybe 2-3 of these a year.

A priapism or paraphimosis or a patient in acute retention where they can't get a foley rarely need the OR, but do need to be addressed before the next morning. It's amazing how having ER docs and nurses who actually are willing to try at foleys and not call urology for everything makes a huge difference.

I wouldn't worry about radiation in Urology if i were you. The fluoro doses involved in spot images for kidney stone cases (vast majority of our exposure) is absolutely miniscule. I would argue (and have ran the numbers) we are at higher risk from orthopedic injury by wearing lead in those cases then we are at risk from radiation. While it may look similar to cardiology or IR running their Cine runs, the radiation doses involved in those procedures are actually about 2 orders of magnitude higher.

 

[TexasMed22]

A lot depends on how you count it since my clinic is attached to the hospital, meaning I'm "coming in" every day when I go to work.

So a normal week without call i go in 5 times, maybe a 6th to round on an inpatient though usually the on call person will handle that.

On call, I will usually go in on the weekends at least once to round on the consults from the week or any leftover inpatients I or my partners have.

In terms of additional trips into the hospital for a middle of the night case/foley (or a Saturday afternoon case after i rounded in the morning) i'd put that at on average once per week of call, maybe twice.

Sorry I guess I needed to be more specific than I was. My question was basically: "how many times, per year, on average, do you need to come into the hospital to do something overnight". Sounds like 1-2x per week of call, though not sure how often you're on call.

 

[Doc mu]

Can't speak for the general surgeons, but in urology we have relatively few "drop everything and go to the OR" type of emergencies

A truly septic kidney stone needs drainage immediately. These are actually pretty rare. Far more common is the patient with a kidney stone and possible infection but is not truly septic. Those can be added on for a stent at the end of the day, or for the next day if coming in overnight.

A torsion has to go to the OR right away to save a testicle. I get maybe 2-3 of these a year.

A priapism or paraphimosis or a patient in acute retention where they can't get a foley rarely need the OR, but do need to be addressed before the next morning. It's amazing how having ER docs and nurses who actually are willing to try at foleys and not call urology for everything makes a huge difference.

I wouldn't worry about radiation in Urology if i were you. The fluoro doses involved in spot images for kidney stone cases (vast majority of our exposure) is absolutely miniscule. I would argue (and have ran the numbers) we are at higher risk from orthopedic injury by wearing lead in those cases then we are at risk from radiation. While it may look similar to cardiology or IR running their Cine runs, the radiation doses involved in those procedures are actually about 2 orders of magnitude higher.

Maybe I misunderstood, I thought you said before that you have to go in and operate on / assess a case at night once or twice per week (so around 4-8 times a month), if most emergencies are very rare why go in so frequently?

How much radiation exposure is there in Urology?

My family from both sides first and second degree have a very troubling cocktail of cancer so I think this would reasonably sway my decision. Is it more or less compared to other specialties?

forums.studentdoctor.net

Check this thread out people said Urology has one of the highest radiation exposures in medicine (including the ancient sdn sage urologist @cpants )

 

[LucidSplash]

I’m starting to get derm vibes here.

 

[sloh]

I’m starting to get derm vibes here.

Isn’t urology (and ophtho) supposed to be the “derm” of surgical specialties? Haha.

 

[DoctwoB]

Maybe I misunderstood, I thought you said before that you have to go in and operate on / assess a case at night once or twice per week (so around 4-8 times a month), if most emergencies are very rare why go in so frequently?

How much radiation exposure is there in Urology?

My family from both sides first and second degree have a very troubling cocktail of cancer so I think this would reasonably sway my decision. Is it more or less compared to other specialties?

forums.studentdoctor.net

Check this thread out people said Urology has one of the highest radiation exposures in medicine (including the ancient sdn sage urologist @cpants )

I meant that on my weeks on call i might go in once during the night on average. twice is also including daytime on the weekend. So I'm every fourth week. So maybe I go into the hospital one night a month. I get paid quite well to do so (in addition to any billing i do from consults/procedure done during call). Many urologists choose not to take hospital call as holding the pager isn't worth the money to them, which is totally fair. In that case they are only going in to care for complications from their own patients.

As for radiation exposure, Cpants is right that compared to specialties that never see a fluoroscope we have more exposure. He is wrong in equating the exposure involved though. My average fluoroscopy time during a ureteroscopy procedure is about 20 seconds. The average time for a cardiac cath is 16 minutes, so somewhat less them 60 fold higher. Angioembolizations are even worse. Cine/angio runs use high dose rates, so interventional cards and IR and vascular will get significantly higher exposure. Why? we are usually taking spot images at lower dose/pulse rates. I don't know about ortho but bones are easy to see on Xray so imagine it is somewhere between uro and endovascular specialties.

Last study i saw put surgeon radiation exposure (with a higher fluoro time then i see) at 0.018 mSv per ureteroscopy. do 100/year and you're at 1.8mSv, or about 40-50% above background radiation.

 

[Doc mu]

I meant that on my weeks on call i might go in once during the night on average. twice is also including daytime on the weekend. So I'm every fourth week. So maybe I go into the hospital one night a month. I get paid quite well to do so (in addition to any billing i do from consults/procedure done during call). Many urologists choose not to take hospital call as holding the pager isn't worth the money to them, which is totally fair. In that case they are only going in to care for complications from their own patients.

As for radiation exposure, Cpants is right that compared to specialties that never see a fluoroscope we have more exposure. He is wrong in equating the exposure involved though. My average fluoroscopy time during a ureteroscopy procedure is about 20 seconds. The average time for a cardiac cath is 16 minutes, so somewhat less them 60 fold higher. Angioembolizations are even worse. Cine/angio runs use high dose rates, so interventional cards and IR and vascular will get significantly higher exposure. Why? we are usually taking spot images at lower dose/pulse rates. I don't know about ortho but bones are easy to see on Xray so imagine it is somewhere between uro and endovascular specialties.

Last study i saw put surgeon radiation exposure (with a higher fluoro time then i see) at 0.018 mSv per ureteroscopy. do 100/year and you're at 1.8mSv, or about 40-50% above background radiation.

Your posts are always extremely informative, thanks a lot!

 

[LucidSplash]

Isn’t urology (and ophtho) supposed to be the “derm” of surgical specialties? Haha.

Mohs derm is the derm of surgical specialties.

 

[operaman]

I’m starting to get derm vibes here.

I remember watching my derm attending as an M4 go in to see an inpatient consult. All the residents came along too since it was such a rare occurrence.

Attending kept trying to scan his badge at every one of those hand motion sensors that open doors.

 

[cpants]

I meant that on my weeks on call i might go in once during the night on average. twice is also including daytime on the weekend. So I'm every fourth week. So maybe I go into the hospital one night a month. I get paid quite well to do so (in addition to any billing i do from consults/procedure done during call). Many urologists choose not to take hospital call as holding the pager isn't worth the money to them, which is totally fair. In that case they are only going in to care for complications from their own patients.

As for radiation exposure, Cpants is right that compared to specialties that never see a fluoroscope we have more exposure. He is wrong in equating the exposure involved though. My average fluoroscopy time during a ureteroscopy procedure is about 20 seconds. The average time for a cardiac cath is 16 minutes, so somewhat less them 60 fold higher. Angioembolizations are even worse. Cine/angio runs use high dose rates, so interventional cards and IR and vascular will get significantly higher exposure. Why? we are usually taking spot images at lower dose/pulse rates. I don't know about ortho but bones are easy to see on Xray so imagine it is somewhere between uro and endovascular specialties.

Last study i saw put surgeon radiation exposure (with a higher fluoro time then i see) at 0.018 mSv per ureteroscopy. do 100/year and you're at 1.8mSv, or about 40-50% above background radiation.

I think urology call can vary, but in most places not too terrible. My call pain sounds similar to DoctwoB. Helps to have a good relationship with the hospitalist service. True emergencies are rare, but kidney stones in the middle of the night are very common. You don't want to get bothered at 2AM every time someone shows up with renal colic who needs intervention.

Agree that the health risks of the radiation exposure are very low. OP in the thread was asking in comparison to other specialties and we do have higher exposure than most. I think it depends how much stone work you do and how many complicated cases. I certainly think the risk is not high for malignancy, but I do know a couple of urologists who got radiation-associated cataracts in their 50's. I wear leaded glasses in the OR, but agree might not be necessary, especially if you don't do a lot of stone work.

 

[akwho]

I remember watching my derm attending as an M4 go in to see an inpatient consult. All the residents came along too since it was such a rare occurrence.

Attending kept trying to scan his badge at every one of those hand motion sensors that open doors.

I have a similar derm memory from residency. I was intern on SICU wearing dirty scrubs getting crushed and about 6 people walked in wearing fancy clothes looking well rested. I thought they were hospital admin at first. Then they start buzzing around a patient's room making a big commotion and asking for things like gauze, and tape that are all stocked in every patient's room in the same spot. Then I hear the attending make a pronouncement, "I need an 11 blade for a skin biopsy, STAT!" like he was asking for the sword of excalibur. It was a zoo for about 20 minutes until they left never to be seen in the SICU again.

Btw my attending rating for getting crushed on call:
Tier 1: Gen Surg/Neuro surg/vascular
Tier 2: Ortho & Ob
Tier 3: Uro
Tier 4: ENT = PRS

My resident rating for getting crushed on call at a Level 1:
Tier 1: Gen surg = neuro surg = ortho
Tier 2: vascular
Tier 3: uro=ENT=optho=PRS
Tier 4: non surgical specialities with caps on their services

 

[Dunkthetall]

I have a similar derm memory from residency. I was intern on SICU wearing dirty scrubs getting crushed and about 6 people walked in wearing fancy clothes looking well rested. I thought they were hospital admin at first. Then they start buzzing around a patient's room making a big commotion and asking for things like gauze, and tape that are all stocked in every patient's room in the same spot. Then I hear the attending make a pronouncement, "I need an 11 blade for a skin biopsy, STAT!" like he was asking for the sword of excalibur. It was a zoo for about 20 minutes until they left never to be seen in the SICU again.

Btw my attending rating for getting crushed on call:
Tier 1: Gen Surg/Neuro surg/vascular
Tier 2: Ortho & Ob
Tier 3: Uro
Tier 4: ENT = PRS

My resident rating for getting crushed on call at a Level 1:
Tier 1: Gen surg = neuro surg = ortho
Tier 2: vascular
Tier 3: uro=ENT=optho=PRS
Tier 4: non surgical specialities with caps on their services

 

[Pir8DeacDoc]

Yeah ent varies a bit depending on the hospital and how you handle things. Generally speaking not too bad most places, but even slow call still sucks.

For ent it really depends on how your shop manages acute airway and whether you trauma. My institution has a nice system for airway and I don’t do trauma so that makes it easier. Our hospitalists admit everything too so even non urgent operative cases that come in overnight you can just admit and see in the morning. Hardest part for me is balancing call with my regular clinical practice.

Count me in as part of the clinic pays way more than OR crowd. OR is much more fun though! Clinic it’s just the function of volume that adds up, plus I do a lot of procedures in my clinics.

But even without procedures, I can generate more revenue in an hour sometimes than a multi-hour OR case. For example, total laryngectomy is about 30 wRVUs and takes a few hours and typically has a 5-7 day hospital stay. I can cram 12 new patients with simple hearing loss into one hour and it’s 31 wRVUs and no hospital stay, no rounding. In dollars it’s about $2k for the hour and for the operation. My typical clinics generate about 100-150 wRVUs which you can also do in a busy OR day, but it’s not easy.

Just to put this in perspective for anyone reading this. These aren't realistic real world numbers for most people.

If you average 125 wrvu per clinic and do clinic four days a week for 45 weeks a year (7 weeks vacation) at a typical wrvu pay- that's gross pay of 1.5 million a year. Not including any surgery days at all. That's 99th percentile for an ent. We don't produce this kind of volume or pay as a general rule.

 

[OtoHNS]

Just to put this in perspective for anyone reading this. These aren't realistic real world numbers for most people.

If you average 125 wrvu per clinic and do clinic four days a week for 45 weeks a year (7 weeks vacation) at a typical wrvu pay- that's gross pay of 1.5 million a year. Not including any surgery days at all. That's 99th percentile for an ent. We don't produce this kind of volume or pay as a general rule.

Apparently, laryngologists are rich AF.

 

[operaman]

Just to put this in perspective for anyone reading this. These aren't realistic real world numbers for most people.

If you average 125 wrvu per clinic and do clinic four days a week for 45 weeks a year (7 weeks vacation) at a typical wrvu pay- that's gross pay of 1.5 million a year. Not including any surgery days at all. That's 99th percentile for an ent. We don't produce this kind of volume or pay as a general rule.

Well it’s only recently I’ve been able to open up the volume like that. My first two years out I only had 2 rooms so I had a hard time exceeding 100 RVU /clinic, but since one of my senior partners retired and we haven’t hired another doc, I’ve got lots of rooms and have been able to bump up the volume a bit.

They’re very procedure heavy which is what drives them up. Laryngology(me) and Rhinology both have very highly valued codes for clinic procedures, and Lary can stack them together because the strobe code 31579 doesn’t have any restrictions on billing alongside other procedures like our beloved 31575 does. So very common to have multiple codes per visit in addition to the E&M depending on the cc. That x20-30 patients per clinic and yeah you generate some pretty crazy numbers pretty fast.

Definitely not common for general ent though - you really need a sub specialty practice where most all patients are coming in needing all those strobes+ done, or a rhino practice where the highly paid surgery codes combine with the highly paid unilateral debridement code to generate massive RVUs. Other places I’ve seen high RVU are busy FP recon folks - their surgery codes are massively overvalued and stackable, or busy open skull base where you can also stack some highly valued codes.

I’m dreading the inevitable devaluing of my codes with time though as has happened for some time in our field. For now, I think Lary and rhino have the best revenue potential in an RVU based system. What I don’t know is how much that translates into actual dollars in terms of reimbursements, so hard to say if PP collections-based laryngologists are killing it too.

 

[sloh]

I don’t know is how much that translates into actual dollars in terms of reimbursements, so hard to say if PP collections-based laryngologists are killing it too.

Wouldn’t this be pretty easy to find out?

 

[LucidSplash]

Wouldn’t this be pretty easy to find out?

Not if you don’t know the private practice overhead. Or the reimbursement from the various insurance contracts.

 

[operaman]

Wouldn’t this be pretty easy to find out?

Yeah surprisingly much harder than you would think. At the institutional level they keep insurance payment rates very hush hush. Then there’s actual collections of course. I suppose you could potentially get your average actual collections but so far when I’ve tried to get this my admins have no idea. And then of course there’s the overhead costs that are also hard to pin down at a big institution and which usually aren’t shared.

That said, you can see the RVU to real dollars disparity in aggregate revenue data, but even this is hard to determine what’s a reimbursement issue and what’s a rev cycle issue. I wish I could get the data though - the only way I’d leave my current gig would be starting my own PP here and I’d love to know how well my RVU magic money converted into real money in this payor mix.

 

[droliver]

Tier 3: uro=ENT=optho=PRS

Plastics call in residency is actually one of the worst. As opposed to gen surgery or orthopedics, it’s usually one resident covering multiple hospitals with lots of urgent/emergent interventions that aren’t put off, peds patients to deal with, and the possibility of having to go to the OR for 6-8 hrs for microsurgery hanging over your head every night. You also normally had to work the following day as well.