VA Ruling

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For people who are not "in-network", meaning most recent grads, that's the only way. And don't think the leads we got from residency or fellowship were much better (except if academic). There are so few good jobs and so many docs... One can choose between a predatory PP or a predatory AMC, except that the AMC is more transparent.

Doesn't the PD usually help CA-3s secure a job before they finish residency?

 

[deleted171991]

Doesn't the PD usually help CA-3s secure a job before they finish residency?

Don't count on it, especially for classes of 20+ graduates. Your best chance is to become friendly with a well-connected attending (see who's active locally in the state ASA), and hope that s/he will pick up the phone for you.

 

[GravelRider]

I hear everything you are saying, but when you say "most have become pyramid schemes" I fundamentally disagree. You don't have the knowledge of that many groups to say that. I don't have the knowledge. Nobody does. I'm just telling you there are still lots of good groups out there. You can say there are bad groups out there. There are. I agree. But there are also good groups out there.

And it is like stocks and bonds in that working for an AMC might have less potential downside than joining a private group (like a bond), but it also has substantially less potential upside (like a stock).

I'm not here to tell people what to do with their lives. It's a personal decision. I'm just saying based on my experience and my knowledge that if I lost my job tomorrow, I would go join another private group on a parter track. That's what I would do, no questions asked.

I don't pretend to know the percentage of democratic vs pyramid scheme groups out there. We can agree that there are a fair number of dishonest private practices out there. Maybe their influence on the market is larger than their collective numbers (though, I doubt it). We can also agree that we all probably know someone who has had a bad experience with a private practice or at least a near miss with one. This information is out there and maybe it's just like the fake news epidemic, but I doubt it. I have friends in a different market than mine who have cardiac and peds fellowships and they passed up on private practices and joined an AMC/academics because something didn't feel right when they were interviewing at the private practice. I'm sure if you left your current practice, you wouldn't want to join another group without having a pretty good idea of what is in store for you.

I was also responding to this prevailing notion that somehow those of us in the younger generation don't want to work, and that we want lifestyle and everything handed to us. We don't know what it's like to hustle. I've heard the con-men partners in my group say this when they were explaining to people the high turnover and lack of an ability to recruit new grads. Their excuse was that this newer generation just doesn't want to work as hard. This is completely false. The newer generation wants transparency, honesty, and to know how they are being valued.

 

[Mman]

I have friends in a different market than mine who have cardiac and peds fellowships and they passed up on private practices and joined an AMC/academics because something didn't feel right when they were interviewing at the private practice. I'm sure if you left your current practice, you wouldn't want to join another group without having a pretty good idea of what is in store for you.

I wouldn't necessarily say your friends experience with something not feeling right means those groups were phony in any way. Sometimes you just don't click with a group. That's OK and doesn't mean everything wasn't on the up and up. But then again I also don't recommend people just interviewing for random jobs they saw posted that they know nothing about. I mean you can do that, but just know it's a roll of the dice.

I also have no complaints about new grads not wanting to work. Our most recent hires have all been great. I do think, however, that now compared to 20-30 years ago you have more physicians that want a "lifestyle" job compared to in the past. We have docs that have approached us asking for mommy track type stuff with no call and no weekends. They want nothing to do with partnership. They just want normal working hours and a decent paycheck and we have hired a few of those (some new grads, some nearing retirement that just want to coast for a little while). Now I wasn't around working in the OR 30 years ago, but from what I've been told it's a relatively new phenomenon to have docs seeking out such arrangements, and it's not always women that want it.

 

[AdmiralChz]

Don't count on it, especially for classes of 20+ graduates. Your best chance is to become friendly with a well-connected attending (see who's active locally in the state ASA), and hope that s/he will pick up the phone for you.

The flip side to a large residency is a huge, often national base of alums who can help with contacts. Also a large residency implies a large faculty who may be able to offer contacts as well given differing backgrounds.

Not all private practices are run by Darth Vader or Voldemort, I'm really excited and eager about my post-fellowship job. If PP doesn't work out for people, there are tons of academic jobs as well and that shouldn't be so readily dismissed.

 

[BLADEMDA]

Great news. See you guys next year, same time and place when the AANA attempts to lower the standard of anesthesia care at the VA once again.

The Chiefs at all the VAs should consider going MD only from this point on. Replace all CRNAs with MDs and have them sit their own cases. This will dilute the call even more and eliminate the issue of CRNA supervision entirely because they won't be in the system to begin with.

If the VA supervises 2:1 then the move is cost effective. If 3:1 supervision is the model then it may cost a few more dollars to eliminate the CRNA issue (but not much more money since 3 CRNAs plus one MD supervising is equivalent to 2.5 FTEs of MDs doing their own cases)

Our veterans deserve the best care. Eliminate the ACT model and go "all MD" throughout the system wherever feasible.

 

[BLADEMDA]

Wednesday, December 14, 2016


I Should Have Been A CRNA

http://www.blog.greatzs.com/2016/12/i-should-have-been-crna.html

 

[Planktonmd]

The Chiefs at all the VAs should consider going MD only from this point on. Replace all CRNAs with MDs and have them sit their own cases. This will dilute the call even more and eliminate the issue of CRNA supervision entirely because they won't be in the system to begin with.

If the VA supervises 2:1 then the move is cost effective. If 3:1 supervision is the model then it may cost a few more dollars to eliminate the CRNA issue (but not much more money since 3 CRNAs plus one MD supervising is equivalent to 2.5 FTEs of MDs doing their own cases)

Our veterans deserve the best care. Eliminate the ACT model and go "all MD" throughout the system wherever feasible.

This will never happen!
Nurses in the VA are very powerful and they will never allow this to happen.

 

[turnupthegas]

This might be a dumb question.

Does working for an AMC look bad if you're later trying to move to a private practice partnership track position?

(providing you can find an honest group )


Sent from my iPhone using SDN mobile

 

[Noyac]

This might be a dumb question.

Does working for an AMC look bad if you're later trying to move to a private practice partnership track position?

(providing you can find an honest group )


Sent from my iPhone using SDN mobile

It doesn't help!

 

[aneftp]

It doesn't help!

Why doesn't it help?

What's the difference between working at true private practice as employer W2 and being abused and switching to another private practice?

Oops. You get to pay your own malpractice tail if u get screwed with true private practice W2 fake partnership track.

 

[deleted162650]

Oops. You get to pay your own malpractice tail if u get screwed with true private practice W2 fake partnership track.

This is often repeated on here, and I don't really get it. Unless your new job is gonna be in a different state, just take your malpractice policy with you. You as an individual are insured - not the group you work for. Just pay your own premiums until your new group takes over paying for it - or just continue to pay it on your own. Or is my state somehow different than all the others in this regard??

 

[Noyac]

I didn't say it hurt. All I said, was it doesn't help.

 

[aneftp]

This is often repeated on here, and I don't really get it. Unless your new job is gonna be in a different state, just take your malpractice policy with you. You as an individual are insured - not the group you work for. Just pay your own premiums until your new group takes over paying for it - or just continue to pay it on your own. Or is my state somehow different than all the others in this regard??

That's assuming a lot of things to be able to carry your own insurance to another practice or group.

Cause you may want to join either a hospital/academic/large AMC based practice that is self insured.

Sure. Continue to pay the premiums at $15k-20k a year. That's real smart when joining another practice that uses its own malpractice policy.

I take it as a huge red flag if private group doesn't offer to pay employee tail especially partnership track. My sister group North makes it fair. Leave before one year. You pay your own tail. Leave between years 1 and 2. Group And employee split the tail. After two years group pays the full tail. That way it ensures both sides are happy. Thus if you don't become partner after 2 years group pays your tail and you move on.

 

[deleted162650]

Cause you may want to join either a hospital/academic/large AMC based practice that is self insured.

Well sure, if you're switching to a practice environment that doesn't require private malpractice coverage then you're stuck with the tail.

Sure. Continue to pay the premiums at $15k-20k a year. That's real smart when joining another practice that uses its own malpractice policy.

In my state premiums are nowhere near that much (thanks tort reform). It's closer to 8k/year at maturity. Again, a "group" malpractice policy is really just a discounted rate for the group, but each individual is still covered under their own policy. When I switched jobs (same state) I just took my policy with me and my group just absorbed the premiums into their "group" policy as they were with the same insurer (the overwhelming majority of docs in my state all use the same malpractice carrier). It's still technically my policy though - if I wanted to take on a side gig outside my group I'm still covered.

I realize not everyone's situation is amenable to this sort of arrangement, but I don't want people thinking that a job switch automatically means having to fork over a tail.

 

[pgg]

I didn't say it hurt. All I said, was it doesn't help.

That surprises me. I would think that a couple years of experience (+ board certification) would be looked upon favorably by any group.

Assuming the job wasn't a 7-3 surgicenter ASA 1-2 ortho gig, of course ...

 

[aneftp]

Well sure, if you're switching to a practice environment that doesn't require private malpractice coverage then you're stuck with the tail.



In my state premiums are nowhere near that much (thanks tort reform). It's closer to 8k/year at maturity. Again, a "group" malpractice policy is really just a discounted rate for the group, but each individual is still covered under their own policy. When I switched jobs (same state) I just took my policy with me and my group just absorbed the premiums into their "group" policy as they were with the same insurer (the overwhelming majority of docs in my state all use the same malpractice carrier). It's still technically my policy though - if I wanted to take on a side gig outside my group I'm still covered.

I realize not everyone's situation is amenable to this sort of arrangement, but I don't want people thinking that a job switch automatically means having to fork over a tail.

Yes, I agree with you that a job switch doesn't automatically mean forking over a tail.

But you betcha if I'm am an employee on a partnership track, i'm gonna want the group to pay my tail. They screwing you already by having you take less income up front as a "buy in". You get double screwed if you don't become partnership and scrambling for a job.

Do you work out west or in the southwest where MD are mainly self employed?

 

[MirrorTodd]

My group has traditionally been MD/DO only but over the last few years we've been forced to hire CRNA's to meet the site demands of the hospital because we have not been able to recruit enough docs. We practice in a major city making well above the numbers I see people on this forum quoting. But we work a lot. The days are long and you can work all night when on call. And I find that most new grads just do not want this lifestyle. They would much rather work for an AMC making much less. We've actually even had a few applicants ask if they can work for us as an employee with fixed hours and no calls. So to answer your question- we've found it impossible to stay MD/DO only, unfortunately.

Pardon my French, but that's ****ing insane. Immediately post grad is the time to hit the ground running. Why are so many people so lazy nowadays? I truly hope there are still groups like yours when I am finished with military medicine.

EDIT: upon further reading, it makes sense now.

 

[Noyac]

That surprises me. I would think that a couple years of experience (+ board certification) would be looked upon favorably by any group.

Assuming the job wasn't a 7-3 surgicenter ASA 1-2 ortho gig, of course ...

I think you are reading too much into my post.
It was meant to have some humor.

But also, I wouldn't say it helps in the sense that people are looking for AMC employees to fill their vacancies.

In reality, it doesn't matter one way or another.

 

[aneftp]

I think you are reading too much into my post.
It was meant to have some humor.

But also, I wouldn't say it helps in the sense that people are looking for AMC employees to fill their vacancies.

In reality, it doesn't matter one way or another.

Frankly someone working in real academics medicine (not the quasi fake academic centers where attendings works like dogs) for a long time is a bigger of a red flag than someone working at an AMC.

My brother group hired a guy with big credentials from academics (top residency on eastern seaboard. Top cardiac fellowship as well). Been in academics for 8 years. The usual 1 nonclinical day a week off. Supervising all the time. Teaching.

His transition to private practice didn't go well doing solo MD cases on the west coast doing Ob, Gi, ortho along with cardiac. He could handle the big cases but the pace of quick ortho or Gi cases got to him. One of the downsides of being "instituionize" in academics and trying to get out in the real world hoping to make real money.

I guess the same can be said for VA employees after decades trying to transition back to private practice.

 

[Ronin2258]

A few people in my VA group moonlight out to keep skills up.

I would consider a couple of night shifts like that, but health problems are taking a bit of a turn for not good.

I did like the speed that we moved where I trained, which was two different private practice groups, and I try to keep that going during my day time hours.

I still do my own cases (scheduled to do so tomorrow,) but I am also at a busier VA that I have the opportunity to teach residents, and they take the academic cases. I can't just sit on my butt like some of my colleagues in the office when I work with them. Most are CA-1s, and I feel like I should be giving them information. Part of the reason I came was to teach, so I can keep my knowledge base up.

As for our CRNAs, we are most fortunate here. NONE of them want the independent practice, and are thankfully not part of the AANA. We only have 4 anyway, and we cover 10 rooms and two remote sites.

 

[Noyac]

As for our CRNAs, we are most fortunate here. NONE of them want the independent practice, and are thankfully not part of the AANA. We only have 4 anyway, and we cover 10 rooms and two remote sites.

I have to believe that this is the sentiment of a large portion of crna's. Unfortunately, they are in such a militant group that they either fear speaking up or are beat down when they do. It is sad.

 

[deleted162650]

Yes, I agree with you that a job switch doesn't automatically mean forking over a tail.

But you betcha if I'm am an employee on a partnership track, i'm gonna want the group to pay my tail. They screwing you already by having you take less income up front as a "buy in". You get double screwed if you don't become partnership and scrambling for a job.

Do you work out west or in the southwest where MD are mainly self employed?

I'm West Coast. I wouldn't say most docs are self-employed but the group structure certainly seems to be different than what's common on the East Coast/SE. More of an old school arrangement I suppose. While many groups still have some sort of buy-in, compensation is still largely production based. AMC presence is very rare (confined mainly to very undesirable locales and 1 notable sell-out). Hospital employment is actually illegal here (although Kaiser gets around that and has a solid presence). I know you are fairly familiar with my general market.

 

[DrCommonSense]

I had at least one interview where I was told that "we are looking for fresh grads, because they accept lower salaries". I hadn't even asked about compensation yet. I appreciated the honesty. Others just stopped talking to me once they saw I was not wide-eyed and gullible. They were not looking for competent anesthesiologists, they were looking to make money on their employees' backs.

Gaswork is choke-full of bad jobs. For the uninitiated, the way to recognize those is that the announcement is up for many-many months, if not years. They are fishing for suckers. It doesn't cost them much, especially if they use a recruiter. They just lie in waiting, like the predators they are. They are smart, so they tend to delete and repost the job announcements, to seem fresh for the untrained eye. Just by watching one's state for years, one can learn a lot about the crap out there. One can even see when they found a sucker, the job goes away for a year or two, then it always comes back (and that's how one knows it's a bad one).

I never really knew what the rat race was, as a doctor, until I moved to the US. It's sad. By the time young grads realize what they signed up for by choosing this specialty, there is no turning back.

Damn man that is depressing but so true.

Unfortunately, with militant CRNA and huge AMCs supposed by PE/VC groups + big hospitals, how can this ever get better?

The squeeze appears to have just started.

 

[DrCommonSense]

I have to believe that this is the sentiment of a large portion of crna's. Unfortunately, they are in such a militant group that they either fear speaking up or are beat down when they do. It is sad.

Yeah or these CRNAs aren't openly admitting it but give their dues/support to the CRNA PACs while having their head CRNA push it strongly where he can for independence.

It has to be a majority or they wouldn't be militantly pushing for it.

 

[Noyac]

Yeah or these CRNAs aren't openly admitting it but give their dues/support to the CRNA PACs while having their head CRNA push it strongly where he can for independence.

It has to be a majority or they wouldn't be militantly pushing for it.

It may be a majority. I'm not arguing that point. I just said there was a large portion. That to me could be 30-40%.
But none of the AANA decision makers are in this group I'm sure.

 

[pgg]

Just because many CRNAs don't want to be truly independent and on their own, and are genuinely glad for our support and backup, doesn't mean they don't also quietly support and cheer the AANA's efforts to give them the option of working that way. Everyone likes options.

 

[aneftp]

Just because many CRNAs don't want to be truly independent and on their own, and are genuinely glad for our support and backup, doesn't mean they don't also quietly support and cheer the AANA's efforts to give them the option of working that way. Everyone likes options.

Yup agree. The AANA basically wants Crna's to have their cake and eat it too.

Work 40 hours a week ($150-180k) "supervise" with breaks no nights no weekends. Newer grads not completely comfortable due to lack of case while Srna can get "seasoned" on the job training for a couple of years.

Work "independent" more money. Punt the harder cases after a "collaborative" discussion to the MD.

It's the best of all worlds for Crna's.

 

[DrCommonSense]

Yup agree. The AANA basically wants Crna's to have their cake and eat it too.

Work 40 hours a week ($150-180k) "supervise" with breaks no nights no weekends. Newer grads not completely comfortable due to lack of case while Srna can get "seasoned" on the job training for a couple of years.

Work "independent" more money. Punt the harder cases after a "collaborative" discussion to the MD.

It's the best of all worlds for Crna's.

Yeah all while cutting the anesthesiologist salaries, increasing their risk and making their extra training worthless in terms of monetary compensation.

Sounds like a lose lose for anesthesiologists and a win win for CRNAs.

Reminds me of feminism.