Three years out, AMA

[noise115]

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I’m now in my third year out from residency in a private practice job. I did this a year or two ago and got some great questions from residents- go ahead and ask anything your little student or resident hearts desire. I’ll answer over the next few days.

I did no fellowship, heavy residency emphasis on regional (my own choice) at a large, well regarded academic program.

My job: large, physician owned group in Midwest. Split my time doing regional service, OR at large level 1 academic trauma hospital (no anes residency- major vasc, neuro, spine, surg onc, trauma), ASCs (mix of healthy peds, ortho, plastics, gyn, etc), occasional OB.
-6 weeks vacation
-production based compensation
-1 weekend every 4-6 weeks (ish)
-1ish night/week with postcall day off 95% of the time
-I do 60% own cases in OR, typically do regional 5-10 days/month- very high volume for abd, thoracic, ortho, trauma pts.

 

[Jesus1]

What procedures comprise 95% of what anesthesiologists do in an average private practice (I count intubation as a procedure).
How necessary is fellowship post residency if you want to go into PP in the midwest/south?
What general advice do you have for residents on improving procedural skill?

 

[noise115]

What procedures comprise 95% of what anesthesiologists do in an average private practice (I count intubation as a procedure).
How necessary is fellowship post residency if you want to go into PP in the midwest/south?
What general advice do you have for residents on improving procedural skill?

It depends on your practice makeup, but airway is the staple of our specialty. iv’s, arterial lines, central lines are very important. Ultrasound guided nerve blocks and epidurals for pain control, spinals for both pain control and primary anesthetics. Trans-esophageal echocardiogram, among many others.

My practice is mostly comprised of airway, ultrasound guided nerve blocks/catheters, thoracic/lumbar epidurals, arterial lines, central lines

 

[Cath Up]

Thank you!

1. Compensation?
2. Are you glad you attended an academic residency, despite no apparent interest in academics? What was the trade off for you with regards to this decision?
3. What is your favorite type of case to work? Why?
4. If you couldn't be an anesthesiologist, what specialty would you choose?

 

[Rocky222Balboa]

Thanks!

1. Are you a partner or employee?
2. Any tips for thriving in private practice (besides being good at procedures?)
3. Do you anticipate any major changes to your setup in the next 5, 10, 20 years?
4. Did you have trauma in your residency?

 

[noise115]

Thank you!

1. Compensation?
2. Are you glad you attended an academic residency, despite no apparent interest in academics? What was the trade off for you with regards to this decision?
3. What is your favorite type of case to work? Why?
4. If you couldn't be an anesthesiologist, what specialty would you choose?

1.) depends on hours worked (more or less), for the past few years $400-450k (60-65 hrs/wk or so if I had to guess)

2.) I loved my residency, and am very glad I went to an ‘academic’ institution. It kept every door open for me. I strongly considered doing a fellowship and staying in academics - I love teaching- but ultimately family reasons prevailed and thus I ended up in private practice. I still work at an academic center, with many of the complex cases I liked, but I get to preform the anesthesia myself!

3.)I love regional anesthesia and the creativity it can allow- especially in complex traumas. In the OR, I like big open abd cases (whipples, liver rsx) or big spines due to the intricate fluid management and pain management.

4.) I love our specialty, but if I had to chose another, maybe palliative care or IR? Palliative as it is similar to acute pain management in the hospital, IR as it is heavily procedure based.

 

[noise115]

Thanks!

1. Are you a partner or employee?
2. Any tips for thriving in private practice (besides being good at procedures?)
3. Do you anticipate any major changes to your setup in the next 5, 10, 20 years?
4. Did you have trauma in your residency?

1.) Partner

2.) If you’re in residency, focus on the basics. Airway management is paramount- you will be out on an island at times and need to be nearly perfect at induction and emergence. Be flexible, hard working, reliable (I cannot stress these qualities enough, and they go for medical school, residency and especially after!) Be willing to learn- the first year or two of private practice is almost like a mini fellowship! Don’t be afraid to ask for help (and if you are afraid, then maybe that’s not a great group to join!)

3.) Nothing I can anticipate, but I’m sure changes will come. We are a fairly stable and large group, so not much from a leadership/ownership standpoint.

4.) I went to a residency with an extremely robust standalone trauma hospital, so I got probably more than my fair share.

 

[Rocky222Balboa]

1.) Partner

2.) If you’re in residency, focus on the basics. Airway management is paramount- you will be out on an island at times and need to be nearly perfect at induction and emergence. Be flexible, hard working, reliable (I cannot stress these qualities enough, and they go for medical school, residency and especially after!) Be willing to learn- the first year or two of private practice is almost like a mini fellowship! Don’t be afraid to ask for help (and if you are afraid, then maybe that’s not a great group to join!)

3.) Nothing I can anticipate, but I’m sure changes will come. We are a fairly stable and large group, so not much from a leadership/ownership standpoint.

4.) I went to a residency with an extremely robust standalone trauma hospital, so I got probably more than my fair share.

Thank you again! Just curious, what do you mean by perfect at inductions? Do you mean in terms of speed, hemodynamic stability, etc?

 

[noise115]

Thank you again! Just curious, what do you mean by perfect at inductions? Do you mean in terms of speed, hemodynamic stability, etc?

Not speed, safety. Minimize laryngo-/bronchospasm, extreme hypotension. You’ll occasionally run into difficult airways, which is expected, but you should be adept at managing routine airways

 

[kidthor]

What are your benefits like and did you have any vesting period?
W2/1099?
Do you miss academia in any way?
When you say midwest do you mean urban midwest or rural? Are you a midwesterner or did you just end up there / do you like it?
On non-call days when do you usually get out of the OR?
Do you think you'd stay at your group forever, or could something cause you to try something new?
Are you RVU based or just you're available for a time block based?
What is your RVU pay (blended?)?
Do you have any gamesmanship for the "good" cases?
Do people in your group get any bump if they were fellowship trained?

PS I'm an underpaid academic pondering greener pastures, hence the many questions!

 

[noise115]

What are your benefits like and did you have any vesting period?
W2/1099?
Do you miss academia in any way?
When you say midwest do you mean urban midwest or rural? Are you a midwesterner or did you just end up there / do you like it?
On non-call days when do you usually get out of the OR?
Do you think you'd stay at your group forever, or could something cause you to try something new?
Are you RVU based or just you're available for a time block based?
What is your RVU pay (blended?)?
Do you have any gamesmanship for the "good" cases?
Do people in your group get any bump if they were fellowship trained?

PS I'm an underpaid academic pondering greener pastures, hence the many questions!

-Benefits are comprehensive and robust, excellent retirement. 2 year buy-in period.
-I definitely miss academia- there is a more group mentality involved. Department meetings, educational meetings, etc. But I have grown to love private practice as well- autonomy, great friendships with partners and other docs, more customizable lifestyle, able to be as current on research as I want to be and conduct my own research if desired.
-Grew up about 2 hours away from my practice. In a middle sized city- a couple hundred thousand, major hospital system service a region with 1+ million people.
-Non-call our days are typically around 3-5pm out, but I can always ask to be out early if needed which is 90% honored.
-Blended RVU, essentially time in OR. 15 min intervals are compensated the same regardless if you’re doing a cataract or a lung transplant. Flat time rate for things like OB, regional, medical direction, ICU, etc...
-Only gamemenship is to minimize turnover as we only get paid while in the OR, but a very neglible pay difference. Overall, no though. Equal scheduling for the most part.
-Fellowship trained folks have a slightly lower buy-in, but otherwise no.

It’s an interesting contrast between academics and PP. Overall, compensation and lifestyle and similar to my co-residents who are in academics. I do think I am in a great group, with plenty of autonomy, great breadth/depth of cases...not sure how common this is.

 

[kidthor]

-Benefits are comprehensive and robust, excellent retirement. 2 year buy-in period.

I would personally be a little irritated with the lack of benefits for a couple years (when I could get it somewhere else from day 1). Was this any concern of yours?

 

[noise115]

I would personally be a little irritated with the lack of benefits for a couple years (when I could get it somewhere else from day 1). Was this any concern of yours?

I should’ve been more clear, benefits are the same for potential partners and partners outside of some retirement fund options

 

[hununuh]

How did you find the current job? What other jobs were you looking at? (Location, compensation package, workload), what was the job search/interview process like compared to the residency interviews? Thanks

 

[Detective SnowBucket]

Would you recommend current medical students go into/stay away from anesthesia? Any predictions for the (near) future of the profession?

 

[NICMAN]

I am just going to throw this out there—-you can earn $450k a year and not have to work 65 hours/week. There are jobs where you can have a similar practice as the original poster and only have to work 45 hour weeks.

 

[propofabulous]

I am just going to throw this out there—-you can earn $450k a year and not have to work 65 hours/week. There are jobs where you can have a similar practice as the original poster and only have to work 45 hour weeks.

How would you recommend one go about finding these jobs?

 

[deleted162650]

How would you recommend one go about finding these jobs?

It’s all about who you know. Talk to your attendings, and the residents/fellows that have graduated from your program. Work hard in residency so when people call up your PD and other friends in the program and say “Hey, we need to hire somebody at Premier Anesthesia Gig LLC, who you got for me?”, your name is the first one they think of.

 

[secretasianman]

Geographic arbitrage. Don’t be picky about location and you can find those jobs I guess...

 

[noise115]

How did you find the current job? What other jobs were you looking at? (Location, compensation package, workload), what was the job search/interview process like compared to the residency interviews? Thanks

Current job is in a location close to family, desirable academic center to work at for me. I interviewed for two other jobs, one academic and another PP. I eliminated academics due to high research requirement, and my current job seemed more organized. It also provided what I thought was a fair compensation and scheduling model between partners(something I find to be VERY important when looking at jobs).

Interview process was much more laid back, a lot of what the group does it calling references, looking at recommendations, etc so it doesn’t involve you. I went out to dinner the night prior with a few other docs. The next morning, went to the office and met with HR to go over pay, benefits, scheduling, etc, then toured the hospital. No real ‘interview’ to be honest.

 

[noise115]

Would you recommend current medical students go into/stay away from anesthesia? Any predictions for the (near) future of the profession?

It’s very hard to predict what will come next, but i think the role of an anesthesiologist will change. Into what, I don’t know. Likely more comprehensive care, preop fine tuning, postop care, etc. It will possibly become more subspecialized (like every specialty seems to be doing), reducing the need for ‘generalists’.

I would recommend it to a medical student, but they must understand the role of anesthesiologist by doing a month or two of work during their third or fourth year. My opinion on the future is just that, mine. Everyone has differing views on what will happen, how they like the field now, etc...

 

[noise115]

I am just going to throw this out there—-you can earn $450k a year and not have to work 65 hours/week. There are jobs where you can have a similar practice as the original poster and only have to work 45 hour weeks.

Very true, this is after benefits are taken out, but your point remains. I chose a practice that may pay a little less, but it is in an extremely desirable area to live, with a tons of great non-compensation perks. The 65hr/wk is an estimate, and now that I am partner that number will go up. But I would say 50-60hr/wk and 400-500k/yr is about what you should expect in the current climate.

 

[noise115]

Geographic arbitrage. Don’t be picky about location and you can find those jobs I guess...

Correct. The other PP group I interviewed for offer more money for less work, but it was poorly organized, more volatile leadership, and in a less desirable location. I chose to take the stable group with a good location, and am happy for it.

 

[26B]

How necessary is fellowship post residency if you want to go into PP in the midwest/south?

I am wondering the same!

 

[Justice4all]

Not essential. Majority of my co-residents were able to secure solid jobs without fellowships in the midwest.

 

[zizzer]

Thanks for doing this!

1. What specific advice do you have for a new graduate in regards to transitioning to being the only anesthesia provider in an OR rather than having somebody else to help (resident, AA, or CRNA)?

2. As a related question, how available is help when you need it? How does this work if the other members are tied up in their own ORs?

3. Is there always somebody dedicated to not be in an OR to handle PACU things, breaks, and help with OR emergencies?

4. Anything specific you wish you would have focused on in residency before starting? What kinds of things did you have the most difficulty with at the beginning?

 

[Detective SnowBucket]

@noise115 this thread is real doom & gloom over anesthesia, what do you think about it?

 

[noise115]

Not essential. Majority of my co-residents were able to secure solid jobs without fellowships in the midwest.

Not necessary! I do everything but hearts, ICU, sick peds. Those I would need a fellowship for (and don’t have a desire to do anyway!)

I have friends with no fellowship, who graduated with me, who are doing hearts.

Im not sure how this will look in the future however.

 

[noise115]

Thanks for doing this!

1. What specific advice do you have for a new graduate in regards to transitioning to being the only anesthesia provider in an OR rather than having somebody else to help (resident, AA, or CRNA)?

2. As a related question, how available is help when you need it? How does this work if the other members are tied up in their own ORs?

3. Is there always somebody dedicated to not be in an OR to handle PACU things, breaks, and help with OR emergencies?

4. Anything specific you wish you would have focused on in residency before starting? What kinds of things did you have the most difficulty with at the beginning?

1.) I don’t have a great answer for this, it is an opportunity to hone your craft and become more consistent in your abilities. If it is truly something that is bothersome, maybe the academia route would be better.

2.) that is practice dependent, but for the most part you should have plenty of help. That’s a major question I asked while on interviews, and something I’ve found to be quite valuable in practice, especially for things like awake fiberoptics, difficult traumas, difficult t-epi’s. I’ve never felt ashamed to ask for help or to pick someone’s brain on a difficult case, and that should be the case wherever you end up. We have a ‘float’ doc or two who are supervising midlevels who is free to help at our two major hospitals. There are some one room ASC’s, where you are alone (which is why I emphasized be good at the basics!)

3.) See number 2, yes

4.) Again, focus on the basics. Smooth inductions, smooth emergences. Techniques to make things easy and safe consistently. Regional anesthesia is the future (imo) and it would be silly not to take advantage of your attendings who are adept. Go out of your way to do regional. Other than that, ask as many questions as you can, do as much as you can!

 

[venacontracta]

When looking at a job at an eat what you kill, production based group, there will obviously be a range of compensation of partners based on how aggressively people pursue units. Given that there's no one firm number, what is the normal way to describe expected compensation in this sort of group and to think about what the compensation will be when obviously "it depends"?

 

[deleted162650]

When looking at a job at an eat what you kill, production based group, there will obviously be a range of compensation of partners based on how aggressively people pursue units. Given that there's no one firm number, what is the normal way to describe expected compensation in this sort of group and to think about what the compensation will be when obviously "it depends"?

Just give a range. I’d probably leave out the outliers and just give a 25-75th percentile to eliminate unrealistic expectations.

Or you could just figure out the average number of units worked and give the average compensation based on that.

The key with this model is to make sure scheduling is fair and balanced.

 

[noise115]

When looking at a job at an eat what you kill, production based group, there will obviously be a range of compensation of partners based on how aggressively people pursue units. Given that there's no one firm number, what is the normal way to describe expected compensation in this sort of group and to think about what the compensation will be when obviously "it depends"?

It’s tough because some partners give away all of their call (highly incentivize so easy to get rid of) and some gobble it up. I would say 25-75th %ile would be 350-500 then some wild outliers. Overall, you will get compensated well if you work hard anywhere you go. I was very concerned with salary numbers as a med student or resident, but it all falls into place well if you join a fair practice and aren’t a ***** with your finances (don’t buy a mil dollar house right off the bat, don’t buy a $60k car right off the bat, pay off your debt, etc)

 

[noise115]

Just give a range. I’d probably leave out the outliers and just give a 25-75th percentile to eliminate unrealistic expectations.

Or you could just figure out the average number of units worked and give the average compensation based on that.

The key with this model is to make sure scheduling is fair and balanced.

Scheduling is very crucial! Not just for compensation but for your interest and development of skills. Being stuck doing Endo all day sounds terrible.

 

[Mikkel]

Scheduling is very crucial! Not just for compensation but for your interest and development of skills. Being stuck doing Endo all day sounds terrible.

I wish I was in Endo all day, 30 MAC cases is a lot of units...

 

[noise115]

I wish I was in Endo all day, 30 MAC cases is a lot of units...

Ha! To each their own, sounds like a soul-crushing day to me.

 

[riskonic]

Can you speak more about the buy-in process? How much was the buy-in? Is this something you have to pay post-tax, in addition to your loans? Did your income significantly increase once you made partner? Seems kind of unfair to ask a resident who already has debt to take on more debt.

Thanks for this thread!