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deleted684261

I was just researching the SDN and came upon multiple threads with many good advices. I just compiled them for my own benefit on Word and I thought I would share them as well. Most of the advices are out of context as it is copied and pasted from threads but it is not hard to figure out the topic once you read them. None of these advices are mine and sorry I couldn't credit individuals who commented these. Here it is.


1. Questions: You should ask everything. I wouldn't hold back. vacation, salary, partner salary, benefits, bonuses, who pays what(malpractice, health, etc.). How many people have completed the partnership track and what percent were made partners. This is a biggy. Some groups will keep you until partnership then let you go. If they don't have close to 100% then be weary. I would be very careful before signing a contract with anything more than 2 yrs to partner, 1yr would be ideal but unlikely. Ask about the sites and number of locations. How much time running from one site to another if they do more than one site. Hours per day on average.

2. Question they will ask: Everything. What cases do you do? How do you do them? What cases are you uncomfortable with, comfortable with, like to do, etc.? Why are you interested in their group, town, hosp., etc.? Are you planning to buy a house? Do or have you worked with CRNA's and what is your opinion? blah blah blah

3: Malpractice: Ideally you would have them pay it and it would be a "Claims made" policy ( I think this is right, someone will correct me if I am wrong, JET!) so that you don't have to buy a tail if you leave or are let go. If not try to get them to commit to paying your tail if you leave. Good Luck.

4. Loans: If you have outstanding student loans, try to get them to pay some of it. Also unlikely but you gotta ask. If not then you can consider withholding from your check the loan amount for them to pay and then you don't pay taxes on that option.

5. Billing: This is very important. Do they pay you a salary or do you bill on your own and collect and everything else. I really dislike the later but I understand the need to bill on your own in some groups. If you will be "Eating what you Kill" then you want to know who makes tha daily assignments. It should be evenly distributed. If not you will get the medicare/caid and no pays.
Do most groups have second interviews? If a place wants to hire after the first interview, should I be suspicious?
Most groups I interviewed with did invite me back for a dinner/interview session with the entire group, although others offered after one interview only. I would say of those that offered after one interview only, half were suspicious and I confirmed later on through various contacts that those groups were "hurting to hire someone." It's difficult to know if you don't live in the city you are applying to. Always give yourself time to think about an offer. A group that pushes you to make a decision quickly is probably one that needs to be avoided.
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Anesthesia Private Practice Primer

Employment Models


-Employee: of the hospital, of the private group? Someone is almost assuredly making

money off of your work. How are you paid? Salary? Hourly? Are your hours/

responsibilities well defined or vague? Is everyone in the department an employee, or are

there partners? Does everyone get paid the same? Mommy track/part time available?

-Employee with production: base salary plus production bonus (with either private

group or hospital employment)

-Partnership track: how long? Is there a cash buy-in? Who decides (and what

determines) if you become a partner? Are all partners equal (in salary, vacation, benefits,

case mix, schedule, call schedule, voting rights)? What is the track record of the group

with regards to making people partners? Lots of “two years and out” people in their

history?

-Locums

-Solo Practitioner

Compensation

-Money: Salary? Hourly wage? Salary plus production? 100% production? Profit

sharing? Is it equal? 1099 vs W2?

-Models:

-Straight salary

-Straight hourly wage

-Salary plus production (how is this calculated?)

-100% production aka “eat what you kill” (how is this calculated-units, hours? Are the

units blended? Who makes the schedule?)

-Equal split of profits (everyone gets paid the same, but it varies each month depending

on how much was billed. Does everyone do the same amount of work/hours/case mix?)

-Are there stipends for call, backup call, subgroup call, etc.

Benefits:

-insurance (malpractice, disability, life, health, dental, umbrella)

who covers malpractice tail/nose?

-Retirement-vehicles, time to 100% vesting, matching, profit sharing

-Vacation-how much? How chosen/assigned? How taken (i.e. day by day, hourly, week

at a time)?

-Business expenses (licensing/DEA, society memberships/journal subscriptions, travel,

CME, moving expenses, interview expenses, cell phone/internet, etc)-are they covered/

reimbursed?

-Leave (maternity, FMLA, disability, sick days, personal emergencies)-how is it handled?

Practice Models

-MD only

-Medical direction of midlevels (AA, CRNA)

-meets the 7 criteria for med direction: pre-op eval, anesthetic plan, present for critical

portions (induction, procedures, emergence, etc), immediately available, physically

present for emergencies, monitor case at frequent intervals, post op care

-max 4:1 ratio

-reimbursed 50% of billing

-Medical supervision of midlevels

-does not meet the 7 criteria listed above, or participating in > 4 cases simultaneously

-reimbursed at lower rate

-“Collaborative” (side-by-side practice) with midlevels (who gets what cases and who

decides this? Do you help each other out with emergencies? What is your liability for

their cases? Is the surgeon “supervising” the midlevel (i.e. is this an opt-out state?)

Clinical Practice:

-Sites: how many? Do you practice at all of them? What kinds (hospital, office, ASC,

pain clinic, ICU)? Does everybody practice everywhere? Are some sites “cushier” than

others? Who decides who practices where?

-Case mix: General, OB, peds, CV, regional, thoracic, vascular, neuro, trauma, out-of –

OR (radiology, GI, ED, cath lab, etc), ICU, pain

-How many OR’s? How many procedures/year? How many deliveries?

-are there “sub-groups” within the group/department? Who decides who’s in each group?

Do subgroups require fellowship/certification?

-Does everybody do everything? Are there enough cases of each type to keep

everybody’s skills up (especially peds, CV, TEE, procedures)?

-Is there high risk OB? High risk peds? Complex CV cases?

-Can you do ICU or pain as well as anesthesia? Does the group control or have anything

to do with this? Does the group run the ICU? Does the group run a pain clinic? If so,

how do they value your ICU/pain time? Will you be a solo ICU or pain practitioner

outside of the group? Will the hospital employ you directly for these things while you

remain a part of the group?

-Coverage: what are you responsible for?

-OR hours: what are they? How late can they go? Who runs the OR schedule? How

many rooms are you contracted for at specific times of the day? Can the surgeons

schedule whatever they want whenever they want (i.e. 3 am lap chole, Sunday morning

total knee, etc)? How are emergencies handled? When are midlevels always available

(do you have to relieve them at 3 pm, are they in-house at night, etc)?

-Who covers ICU? Codes? Airways (ED, code, ICU, etc)?

-Do you cover a pain service? Acute/chronic? Consults?

-Anesthesia schedule:

-who makes it (same person every day, third party scheduler, different person everyday,

etc)? What determines when you leave? Who picks what rooms/cases you do? Do you

finish your room(s) no matter what? Do you hand off cases?

-Call: where (in-house, from home)? What kind (general, subgroup, backup)?

-MD only groups may have many people on call each night, depending on services

provided, number of rooms they are contracted to cover, OB/trauma service, etc.

-Equipment: Does the hospital/group have the equipment you need to do your job?

US? TEE? Airway carts/equipment? Specialized peds instruments? Does everything

work? Who fixes equipment (and how available/reliable are they)? Is there an EMR?

Anesthesia EMR?

-How does the group practice?

-Where did they train? Are they BC/BE? Are they fellowship-trained? Are they

dangerous? Are they spread too thin?

-Do they help each other out? Cover for each other? Start rooms for each other?

Respond to emergencies? See your pre/post-op patients?

-How’s their relationship with the surgeons? What happens if you cancel cases?

Contracts:

-Employment Contracts:

-Do you get one? What are your duties/responsibilities?

-Is everyone’s the same?

-Compensation/benefits-get specifics

-Leaving: when/why/how can you be fired or quit? Is there a minimum time you have

to stay? How much notice do you have to give prior to leaving? Is there a non-compete

clause (and is it binding or ever enforced)? If you got a sign-on bonus, do you have

to pay it back? Do they have to warn you before terminating you? Is there probation/

remediation? Can you be fired with/without cause? Who makes hiring/firing decisions

and how are they made?

-Have an employment lawyer look it over. Money well spent.

-Hospital Contracts:

-does the group have them? What are the coverage responsibilities? Are they exclusive

to your group (or do other groups also provide anesthesia services at your facililties)?

How long have they been in place? Are multiple facilities’ contracts tied together or

negotiated separately? How long are they for? Who negotiates them for your group?

Does the group contract with multiple hospital/clinic systems or just one? Does the

group get a stipend from the hospital? If so, why and how much? Are there other

anesthesia groups locally? How big are they? Do they get stipends? Do large anesthesia

management companies (AMCs) provide anesthesia services locally?

Group Dynamics:

-Private Group: What is the group structure? Are their officers or an administrative

board? How/how often are these selected? How are group decisions made (by officers,

by full group vote, by board vote, by individuals, etc)? Who gets to vote (full partners,

employees, locums)? Are there committees? Are you required to serve on them? How

frequently does the group (or the board) meet? On a schedule, or only when they need

to? How is discipline handled? Is the group collegial? Do they meet socially? How

transparent is it? Can everyone see the books/schedule? Is the schedule flexible? Do

partners work for each other? How is this reimbursed (fixed rate, personal negotiations,

etc)?

-What is the relationship with midlevels (employed, subcontracted, hospital-employed,

private group, etc)? Is it collegial/professional/adversarial/hostile?
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Bbones post is spot on, but keep in mind asking all these questions may seem like a red flag to a group. Try to split up who you ask questions regarding the stuff that really matters (lifestyle, pay) so it doesn't sound like you only care about that. A lot of answers should be in a contract, or should be discussed when a contract is offered rather than up front.
Your goal should be to ensure the group are people who you trust and can tolerate working with, and that the system is one you will do well in.

Interviews can be massaged into a one or two month span if you do it right, most offers will have a 1 month limit, but if you are truly serious, they may extend for certain reasons. Hopefully the "right" group gives offer before the "ok" groups offer is past due. If you are close to a deadline feel free to call the "right" group and let them know, a few friends locked in with a contract only to see better opportunities come up.
I personally would have chosen differently if I had all my offers on the table at the same time, but someone up above musta been watching out for me since I am happier here than I would have been there, even before they were replaced by amc.


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How much money are they gonna take from you?
Who writes the schedule?
Blended units?
Group attrition?
Surgeons?
If partners, are there superpartners?
Exclusive contract with hospital for how much longer?
Does hospital stipend the group?
Non-compete?
Are the books open?
Any litigation within the group?
Who does their billing, and how much do they pay?
Do the CRNAs think they are docs or are they good to work with?
How many rooms if supervising?
Who puts in the labor epidurals?
Where does the group get their own health care?
How easy to get good equipment from the hospital?
How are the bureaucrats?
Who manages PCAs?
Who puts in a central line middle of the night for an ICU admit in shock?
Any intensivists, hospitalists in house?
How are the patients worked up before surgery?
How much loot per day of work?
Turnover time?
Vaca?
What would the group like to improve?
Talk to some surgeons.
Forget about money and find out how happy people are.
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case mix
Payor mix/subsidy
Call
Opportunities to earn extra income... sell vaca or take xtra call
Do orthopods want regional?
Trauma? Heavy OB? Do you sleep at night?
Home call?
Always off post call?
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I like to know who has left the group, and the reason. Also, if the group is willing to provide the contact information for the people who have left, so you can follow up and inquire as to the reason for leaving.
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There are the questions you really want to know, and the questions you should ask. Asking a lot about the schedule and pay makes you potentially less desirable, depending on how you do it. When you want to see what the daily life is like, just ask to look at a few days schedules to see what the case mix is, and you can see start/stop times, and likely # of anesthesiologists on per day and out order. That will at least give you a glimpse, and you aren't stretching truth much since case mix is important, and you can make sure you aren't doing all cases you hate, or none of the type you like.

What you should know is how you get paid, and how they get paid. Employee vs partnership, production vs blended unit production vs group production divided by number of guys or any complex grouping of the same. If eat what you kill, who assigns cases. Are you getting a salary or a % of production or partner. Are there intangible buy in time things to consider (working all holidays/more call, etc.). Is there a monetary buy in (consider up to ~10k to be a no). Equity of partners (superpartners?). Time to partnership, if a partnership track. If any prior failed partner candidates (obtain contact info for these to contact them and ask questions, or find info on your own).

Also important is why are they hiring. Is there a retiree, cutting back, growing services, fired partner...

Tough to figure out if there are relationship issues with surgeons/anesthetists/administration, but make effort there.

Activity of group on hospital boards/committees is important for strength of group.

In the end your decision is going to be based 90% on trust, so get a feel for the type of people they are. Make sure you are a human that is interesting to talk to and is well mannered enough to get along with the surgeons/staff and they should be happy enough with you. They will be looking for a good fit based on personality more than any other characteristic you can control. Your skills and background check will be obtained by contacting your staff at your program, and all sorts of other back door ways.

Some groups interview in a very sloppy way, others plan it out. We plan ours to look sorta sloppy, but is rather thought out. We have a few partners who shoot the ****, make friends, and provide a comfortable presence to see how you manage conversation on an overall level with nonthreatening people. We have one guy who gives the numbers talk where we answer all those questions that you are uncomfortable asking but need to know. We have one guy as the "tougher to converse with guy." We have a few who sell the group, and we have a few who check things on the back end. Our goal, and theirs should be to give you a realistic picture of the practice and expectations so you don't come, realize you hate it, and leave. Just be yourself (or at least your best self) and if they don't like you, you are probably better off elsewhere anyways. Every group has a feel, find one that matches you.

Places where our interviewees have gone wrong:
-Changing vapor levels for a partner during case multiple times, despite partner resetting it where they wanted it.
-Treating secretaries at home program disrespectfully
-Poor work ethic at home program.
-Insisting we hire both her and a potential fiancée (ok that was more of a supply/demand mismatch, but...)
-Terrible manners at dinner, like embarrassed to be seen out with them bad
-Bragging about skills, and mediocre ones at that.

Some get it right, and those are offered positions. This is a very important future relationship that deserves a HUGE allotment of resources on the hiring end to make the best fit person get the job. A wrong choice can poison group and jeopardize a contract
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One other thing that has become increasingly important is to find out about the financial strength of the hospital/surgery centers that the group covers. More and more hospitals are going broke or being absorbed by larger institutions. You don't want to find a great job and group only to have the bottom fall out due to institutional issues beyond your control.
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Can someone explain what the significance is of a group offering an option to buy into their billing company? Is this a rare or expected option? Is this something most partners would opt for? Thanks
Larger groups form can their own billing company, hire in house personnel.
The good is that it represents another corporate entity to shelter income and run expenses through. Also the billing company can be a potential source of revenue by doing billing for other practices.
The danger is that if the partners in the clinical practice are not all members of the billing company there will likely be an incentive to filter revenue to the billing company and charge the affiliated practice more than market rate. Also the billing company is a great place for hiring family members of some of the docs who may or may not be qualified.
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Where to find jobs


For anesthesia, gaswork.com is the dominant player. After that, try
practicematch.com
healthecareers.com
practicelink.com
medworking.com
doccafe.com

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Look carefully at the benefits. Make sure your malpractice coverage has a tail, you get money for education/CME, and ask about overtime. Get everything in writing and have a lawyer look it over. And yes, agree with Mil, find out more details about payer mix and billing. Very important, that essentially is what it is all about.

If you are concerned about being a newbie attending, ask what provisions they have in case you run into trouble. Is there an anesthesiologist available to help with difficult airways, etc. What is call like in terms of how many are on, what their duties are, etc. How is the call schedule determined? Feel out if you are going to get abused because you are new. Is there profit-sharing potential? Can you leave? Can they fire you and do they have to have cause? The list goes on and on. It's not easy to ask these kinds of questions. I would recommend checking the place out, and then if you are still interested, you can always ask by phone or visit again.

Getting a contract in hand is essential - that will outline a lot, and whatever is missing from there, you can follow-up on.


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And don't be shy....ask EVERYTHING that Gas told you to....be pushy if you have to....

I didn't ask all the right questions when I came to my current gig because:

1) I didn't know any better
2) I was timid about it
3) I assumed that most people were like the folks that I served with in the Navy


...and because of the above...I suffered for a LONG time.
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The OR manager will have a case list of everything done in the previous year.

The list will contain:

- cases performed
- type of insurance
- time per case

Will that information, a billing company can calculate for you what the generated/collected revenue was for the year minus billing fees.

If that number is higher than your compensation package, then the hospital is making money on you....if not, you're income is being subsidized.

You have to ask yourself if you want the hassle of working for yourself, and making more money, and having control over what you do....versus working for the hospital.
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Holy Cow, there are a ton of questions you need to ask and I can't scratch the surface here so PM me with any questions you have or ask them here and we can go through it.

Most of the questions that Gas mentioned will be answered in the contract.

One thing I would ask is why are the anesthesiologists hospital employees? What happened to the last group if there was one that lead to the hospital employee model?

Who knows your salary, surgeons etc? The board will have to approve the salary and if any surgeon/physician is on the board, then they will all know your salary (even though it is illegal for them to disclose it) and you will hear about it from time to time since you will be making more than some of the surgeons.

Who does the billing for the group? What's the AR (accounts receivable), collections, how many days in AR (60 or less is pretty good from what I can tell)?

Are you in-house for call and if not is there any talk of you being in-house? Why did the last 3 members leave? Can you speak to them? How supportive is administration to the anesthesia dept? Will they go to bat for you? Any stipend for medical director? Has there been any salary changes in the last 5 yrs? Are all benefits (mal practice, health ins, retirement, etc) included in the salary or do they cover them in addition? This is covered in the contract.

You need to be cordial and interested during the interview. The particulars can be worked out after the interview.
 
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SaltyDog

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With regards to #3: If you pay your own policy, it's portable. If you leave the group (as long as you don't leave the state) then you just keep your policy and take it with you to the next gig. No tail necessary, and your premiums are tax deductible.

With regards to #4: Sorry, but that's not a thing. If a PP group is paying your loans, they still have have to report that as income for you and it still gets taxed. The only way to get loan repayment is to work for some kind of community health program in an underserved are and that is alllllllllmost non-existent in the anesthesia world.

Your interpretation of a lot the advice is a little off. You're on the right track in a funny train so to speak.
 
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FFP

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I was just researching the SDN and came upon multiple threads with many good advices. I just compiled them for my own benefit on Word and I thought I would share them as well. Most of the advices are out of context as it is copied and pasted from threads but it is not hard to figure out the topic once you read them. None of these advices are mine and sorry I couldn't credit individuals who commented these.

It would have been nice to give credit where credit was due. Let me fill in the blanks. (Click on the up-arrows for respective links to the original posts.)
 
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