Write your own ideal contract

[EtherMD]

I got something in the mail yesterday like this: 370k hospital employed, + sign on bonus. Only catch: middle of nowhere.

What do you think? Are they desperate? Can you talk them into 400k, or 425k?
​

Yes. If they don't get anyone for $370,000 then they would consider $400,000. Benefits? You need a good benefit package as this is worth $60-$70,000 per year. Forget the "sign-on" bonus game and demand a yearly salary that works for you every year. Average good Partnership income (private practice) is around $375,000 plus benefits so this hospital is offering very competitive terms for a new graduate willing to relocate to the middle of nowhere.

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[Planktonmd]

It wont be higher.


Trust me I have spken to groups before before accepting my current fate that is now. I dont like my arrangement right now. there is aboslutely no stability and my work business changes very abruptly and without notice. i can prolly make more with much less work if i joined a group. I am constantly either looking for cases, asking people to do their cases or taking peoples calls which they are happy to give up. the calls are what makes me maintain my income to an acceptable level in the upper limits of average. But i guess i have to live with this instablility to have my independence and freedom. i suppose i can maintain this income level if ive done it for four years. The only thing that can change is that a group can come and take over. But we cover the place pretty good that the hospital wont do that. Plust its not that type of culture.

Man, I admire your ability to keep your independence, but do you think you can still do this type of work when you get older?

 

[Coastie]

I misread the post; Note my edits. I thought you said 375k was 25th %, not upper 25th percentile.

Too low for you? Almost everyone that I finished Residency with is making this amount or more (first tier program). I would never accept a partnership track where the end result was not at least $375,000. Why bother with a track? AMC's pay $325-$350,000 per year (health care and malpractice as benefits but not retirement or disability). I know of several openings right now for new graduates. My numbers are real world or the AMC's wouldn't be offering those numbers would they?

 

[2ndyear]

Yes. If they don't get anyone for $370,000 then they would consider $400,000. Benefits? You need a good benefit package as this is worth $60-$70,000 per year. Forget the "sign-on" bonus game and demand a yearly salary that works for you every year. Average good Partnership income (private practice) is around $375,000 plus benefits so this hospital is offering very competitive terms for a new graduate willing to relocate to the middle of nowhere.

I get some of these, and read a lot of these on gaswork as well. Usually I see call that is q2-3 for these rural places. I'd imagine you're not going in much, but I've been on q2 home call before and never really got used to being tied to the pager. Thoughts?

 

[EtherMD]

I get some of these, and read a lot of these on gaswork as well. Usually I see call that is q2-3 for these rural places. I'd imagine you're not going in much, but I've been on q2 home call before and never really got used to being tied to the pager. Thoughts?

Yes. That is what a job interview is all about. I view a job as money vs. lifestyle/hours. If you make less money but have a great lifestyle then is that okay? Or, are you willing to work hard for more money? Do you want a job that is in-house once a week with the next day off (working hard) or do you want one with call from home every third night (very little work at night)?

These are personal decisions and there are no wrong answers. I have a friend who makes more money than me per hour in the hospital but I have a bigger W-2 each year. Who has the better job?

 

[Pilot Doc]

What do the partners owners among you think of the following scenarios:

Scenario A: Partner salary $500K, typical new employee salary $250K (W2, group pays beneits). 2 years to partnership.

Scenario B: New grad salary $500K (same as partner), partnership buy-in at two year of $500K. This gives the group the same financial benefit, but includes an incentive to take the person as a partner. A hybrid system ($375K salary, $250K buyin) would be possible as well.

Scenario 'A' very plausible but what are YOU bringing to the GRoup? What advanced set of skills/knowledge sets you apart from the herd? You want a 90th percentile job then show why YOU are the one to be hired. Sorry, but this is when the rubber hits the road. After all those years of hard work in school DO THE EXTRA 12 months so YOU get the job.

Scenario 'A' very plausible but what are YOU bringing to the GRoup? What advanced set of skills/knowledge sets you apart from the herd? You want a 90th percentile job then show why YOU are the one to be hired. Sorry, but this is when the rubber hits the road. After all those years of hard work in school DO THE EXTRA 12 months so YOU get the job.

The numbers I chose are arbitrary. Pick any set that you feel are 50th percentile, market rates for new grad and partner. In scenario A, the partnership is making a substantial amount by paying the new grad less than he earns. They therefore have an incentive to continually hire new grads and fire them just before making partner. Plenty of groups do this and none of them will admit to it. It can be hard to smoke them out.

In scenario B, the partnership still gets to rake in the cash from a new grads sweat, but they only get it if they retain the new grad as a partner. That equalizes the playing field. The group, if they play honestly, still gets their $$ and the new grad either gets partnership or a fairer compensation for their time and trouble.

 

[granolabar2]

zippy2u, if you don't mind sharing, what do you pay in malpractice yearly? (or what can a new grad expect to pay if their group doesn't cover it?)

 

[mille125]

What doesn't seem fair is the possibility of working 2 years 364 days and the next morning being told you will not be made a partner.

How about an arrangement where I am 'evaluated' for 6 months, and then a partnership decision is made. If yes, then I can continue to work for the full pre-partner income period (2-3yrs) with guaranteed partnership, or I can leave to pursue partnership elsewhere. Would this stipulation be difficult to achieve in most practices?

The 'ideal' contract I posted was the best I currently hope to achieve in most areas of the contract. I certainly don't expect to get everything listed. It's ALL up for negotiation. If I had to prioritize, I would do it as follows (most to least important):

Suitability to the practice, quality of the partners, warm, friendly, cooperative atmosphere at work.
Salary/partnership interval/partnership income value.
Potential for career growth within the practice, ASC, hospital, etc.
Location (small/medium city in Southeast, aesthetically pleasing surroundings, stuff to do indoors and outdoors).
Call schedule
Benefits
Vacation

There is never any guarantee for partner nor should there be. This is true of law firms, accounting firms, etc. It is a hard cruel fact of life. This theoretical contract actually gives you the option to take vacation at a price from your salary. If you work 52 weeks per year it would be your own decision.


If I were you a would spin your MBA experience into a positive and suggest that you may be able to help the group negotiate with hospitals on contracts, etc. This would definitely be viewed as a positive.

 

[mille125]

zippy2u, if you don't mind sharing, what do you pay in malpractice yearly? (or what can a new grad expect to pay if their group doesn't cover it?)

it varies from state to state....in my state (TEXAS) 200k/600k has a mature rate of 18K....you would likely only pay a few thousand dollars in the first few years.........

 

[bubalus]

Scenario 'A' very plausible but what are YOU bringing to the GRoup? What advanced set of skills/knowledge sets you apart from the herd? You want a 90th percentile job then show why YOU are the one to be hired. Sorry, but this is when the rubber hits the road. After all those years of hard work in school DO THE EXTRA 12 months so YOU get the job.

So what fellowships are going to bring your CV to the top of the pile (fields and institutions)? Obviously being able to fit a groups needs, but what are your thoughts in more general terms. CV? CCM? Regional?

Thanks.

 

[urgewrx]

What do the partners owners among you think of the following scenarios:

Scenario A: Partner salary $500K, typical new employee salary $250K (W2, group pays beneits). 2 years to partnership.

Scenario B: New grad salary $500K (same as partner), partnership buy-in at two year of $500K. This gives the group the same financial benefit, but includes an incentive to take the person as a partner. A hybrid system ($375K salary, $250K buyin) would be possible as well.

In scenario B, the partnership still gets to rake in the cash from a new grads sweat, but they only get it if they retain the new grad as a partner. That equalizes the playing field. The group, if they play honestly, still gets their $$ and the new grad either gets partnership or a fairer compensation for their time and trouble.

Pilot Doc, I still cannot make any sense of your logic for Scenario B. If the new hiree is making 500k, same as partners, why would anyone want to be partner? Specially if it means paying 500k for no difference in salary.

The reason partners earn more money than they actually "make" (bill for services they provide) is because they are skimming the top of every new employee. People, including us, want to be partners so they can skim all the younger guys behind them.

Understand this: Anesthesiologist are not self sufficient any more. There is no way for those guys earning 500K to make that amount by themselves. They either get a hospital subsidy or they skim the new guy. Scenario B is impossible in real life.

 

[EtherMD]

Pilot Doc, I still cannot make any sense of your logic for Scenario B. If the new hiree is making 500k, same as partners, why would anyone want to be partner? Specially if it means paying 500k for no difference in salary.

The reason partners earn more money than they actually "make" (bill for services they provide) is because they are skimming the top of every new employee. People, including us, want to be partners so they can skim all the younger guys behind them.

Understand this: Anesthesiologist are not self sufficient any more. There is no way for those guys earning 500K to make that amount by themselves. They either get a hospital subsidy or they skim the new guy. Scenario B is impossible in real life.

Scenario B is not going to happen in 99% of Groups. Unless you wrote the text book or invented the technique you are not getting scenario B.
If you can get scenario A take it. Do your research and ask a lot of questions. If a Group lies about firing new graduates regularly they are opening themselves up for a major lawsuit. If you ask for full disclosure they are obligated to tell you the truth. So, ask "how many people didn't make partner?" Why? Who made partner most recently and can I meet that person? Any Group with a big history of firing new graduates right before partnership should be avoided like the plague. A Group should dismiss a new graduate within the first 13 months of work. This allows both sides to move on and look for the right fit. Or, the Group should notify the employee/new graduate of problems and discuss possible solutions over the next 6 months. Both sides need to work together to avoid ugly suprises at the end of the track.

 

[zippy2u]

I don't pay my own malprac insurance, the boss man does. He says it's about the high 20s for 1million/3million in Florida. Boss man should go with 250/750 but that's his headache not mine.If the state would let me and the hospitals, I wouldn't have malpractice insurance. I'm a firm believer that any form of insurance makes it easier for the lawyers to sue you. LOL, the lawyers even want nurses employed by the hospital to have liability insurance. Regards, ---Zippy

 

[EtherMD]

So what fellowships are going to bring your CV to the top of the pile (fields and institutions)? Obviously being able to fit a groups needs, but what are your thoughts in more general terms. CV? CCM? Regional?

Thanks.

I have been beating this drum for months. The best 12 months of your career from a financial persepective is the fellowship year. This ONE YEAR sets you apart from the herd and really helps you to stand out. Those of you wanting maximum opportunities for location and pay should do the year.
In my opinion, I will list the fellowship that Groups want in 2007. This means that these areas are in "demand" right now and command a premium.

1. Cardiac- TEE certified Anesthesiologist. Every Group wants one or two of these for the difficult heart/valve cases. We all do the cases but TEE certification makes you legitimate in the eyes of the surgeon. Also, good P.R. for the Group. This does not make much money for the Group but a necessary "evil" for many practices. Of course, this means the Group does hearts and a lot of difficult valve cases.

2. Pain- Still hot right now. Pain Anesthesiologists still command a premium and some might list this as number 1. For me, a close call but with more Pain Docs available these days and the fact that many of them want less O.R. call because of "clinic" days. Regardless, Pain is a smart choice.

3. Critical Care- USA is getting older, fatter and sicker every day. We need more ICU docs and hospitals like Anesthesia trained Intensivists. You will find less Groups doing ICU but those that do want a fellow trained Anesthesiologist. Those that don't still value your training and appreciate your unique knowledge and experience.

4. Peds- If you want to be the "go to" person for the sickest kids in a large metropolitan Group then Peds is valuable.

5. Neuro/Regional- Medicare is not paying for catheters post-operatively. Most older guys learn these techniques quickly. If you like Regional then do a lot U/S guidance in your fellowship.

 

[urgewrx]

If a Group lies about firing new graduates regularly they are opening themselves up for a major lawsuit. If you ask for full disclosure they are obligated to tell you the truth.

Perhaps we should have a sticky thread where reviews of good and bad groups can be shared. That way we wouldn't have to depend on their "honesty" or lack of it. Kind off like scutwork.com but for groups. What do the SDN mods think?

 

[Pilot Doc]

As for why would you want to be partner if you made 500K as an employee, you only get that deal for 2 years. It would be up or out.

But let's change the scenario a little. (If you don't like these numbers, cut them X% to suit you - the absolute values don't matter)

Partners make $400K. Initial offer to new employee is $200K. Counteroffer from employee is $300K for two years with $200K buy-in. Net salary (assuming tax issues could be avoided) to employee is $200K/yr, net profit to group is still presumably $400K (2 years * 400-200).

The advantage of this is that it's a self-enforcing contract. if you get screwed you don't have to invest $50-100K in a lawsuit that has marginal chances of success.

Any reason a reasonable group wouldn't take this offer?

 

[EtherMD]

As for why would you want to be partner if you made 500K as an employee, you only get that deal for 2 years. It would be up or out.

But let's change the scenario a little. (If you don't like these numbers, cut them X% to suit you - the absolute values don't matter)

Partners make $400K. Initial offer to new employee is $200K. Counteroffer from employee is $300K for two years with $200K buy-in. Net salary (assuming tax issues could be avoided) to employee is $200K/yr, net profit to group is still presumably $400K (2 years * 400-200).

The advantage of this is that it's a self-enforcing contract. if you get screwed you don't have to invest $50-100K in a lawsuit that has marginal chances of success.

Any reason a reasonable group wouldn't take this offer?

Okay,

Let's say I am selling a "hot" car that stays on the lot an average of 5 days.
I have sold every one that comes in within a week and got full MSRP. You offer me "invoice" for the car. I say "No." You counter with $300 over invoice. I still say No and tell you to look somewhere else or come back next year because the market dictates the terms.

This is your scenario "B". What you think is "fair" is not relevant to the deal.
The market dictates the terms and if a job pays well there will be many applicants. I would rather hire a new graduate on the Group's terms than his.
As long as most new graduates agree to the terms (and they do) then those that insist on scenario "B" will be working with Johan or Sheridan. Currently,
the market thinks a 2-3 year partnership track with usual terms (see my previous post) is acceptable. Those wanting to earn 80th percentile or more are happy to accept those terms.

There is a Group that has a six year partnership track because the partners earn 95th percentile. They expect a fellowship trained, Board Certified Anesthesiologist to accept a six year track. While they have gotten a few confused, foolish new graduates it takes this Group longer than most to fill a position. Most of the older partners had a 24 month partnership track. Yet, because they earn 95th percentile they expect the new guy to be an employee for six years.

I highly recommend you avoid terms like that at all costs. But, a reasonable partnership track with decent pay is worth enduring to be part of a good Group.

 

[urgewrx]

I know of some graduates who took jobs in NYC paying ~180K plus full benefits. In New York City!!!
​

 

[EtherMD]

I know of some graduates who took jobs in NYC paying ~180K plus full benefits. In New York City!!!
​

I assume CRNA's in NYC make that much or more. I also assume these new graduates were promised a pot of gold at the end of their track/slavery.

 

[urgewrx]

I assume CRNA's in NYC make that much or more. I also assume these new graduates were promised a pot of gold at the end of their track/slavery.

Yes and no.

Yes, CRNA's make ~150K.

No, It's an employee track. Granted, salary raise every year. Bonus when Board Certified. By 5 years they expect ~300k.

 

[EtherMD]

Yes and no.

Yes, CRNA's make ~150K.

No, It's an employee track. Granted, salary raise every year. Bonus when Board Certified. By 5 years they expect ~300k.

What can I say? The significant other must be making a lot of money or they plan on sharing an apartment with another couple.

 

[bubalus]

Thanks, Ether. That was what I was thinking you'd probably say, but it's nice to hear it from someone on the hiring side.

 

[denied]

Anesthesia Management Company. They are have the hospital contract and hire the MD's and CRNA's. They usually get 15-20% off the top as a management fee. The rest is used to pay anesthesia providers.

The 15-20% they tell you about is just the beginning of how they will screw you, if you ever get acess to the books you will see that that AMC is taking much more. Beyond the basic unfairness of working for some out of town liar who bribed the administration to give him the contract. You get to do all the work and the AMC owners will pay you as little as possible. Anything told to you by an AMC owner should be considered a lie until proven other wise. AMC absentee owner don't practice anesthesia but are working 24/7 dreaming up ways to steal money from their employees, the patients their employees treat and the hospital that gave them the contract. If you care about earning a fair salary and being treated fairly you will be wise to avoid work for an AMC liar.

 

[objdoc]

1. Cardiac- TEE certified Anesthesiologist. Every Group wants one or two of these for the difficult heart/valve cases. We all do the cases but TEE certification makes you legitimate in the eyes of the surgeon. Also, good P.R. for the Group. This does not make much money for the Group but a necessary "evil" for many practices. Of course, this means the Group does hearts and a lot of difficult valve cases.

2. Pain- Still hot right now. Pain Anesthesiologists still command a premium and some might list this as number 1. For me, a close call but with more Pain Docs available these days and the fact that many of them want less O.R. call because of "clinic" days. Regardless, Pain is a smart choice.

3. Critical Care- USA is getting older, fatter and sicker every day. We need more ICU docs and hospitals like Anesthesia trained Intensivists. You will find less Groups doing ICU but those that do want a fellow trained Anesthesiologist. Those that don't still value your training and appreciate your unique knowledge and experience.

4. Peds- If you want to be the "go to" person for the sickest kids in a large metropolitan Group then Peds is valuable.

5. Neuro/Regional- Medicare is not paying for catheters post-operatively. Most older guys learn these techniques quickly. If you like Regional then do a lot U/S guidance in your fellowship.

With due respect: a fellowship year may not always be worthwhile. Sure, if you want to do some hearts, or all hearts, then TEE certification would be great. But, spending a year on this in a non-ACGME fellowship? New grads right now can still sit for the TEE exam. I would agree that this is the best fellowship option, but it isn't necessary. Most anesthesiologists don't want to do hearts, so this is useful only if you plan to do many of them for a large portion of your career.

CCM is the intellectual foundation of our specialty, and but most of us don't want to attend in the ICU, and most groups don't want someone to attend in the ICU. The incentive to train isn't there. I think that the ABA should integrate this into the residency, but that's another discussion.

Pain makes sense if you want to do pain. I'm not sure where this subspecialty will go in a few years, but it seems like it will get saturated due to all the interest now. I have come across many pain fellowship trained attendings who found they didn't care for it, and don't practice pain medicine. Sure it's interesting, but many go towards anesthesiology because they don't want to have long term patients and run a clinic.

Peds - great fellowship, if you like peds. You will be the go-to person for the sickest kids. Doesn't make sense if you want to do only community peds cases.

Neuro/Regional - you don't need a fellowship for this, maybe some learning on the job, and some CME if you feel deficient. Certainly not a year for this unless you are planning an academic career.

I would add Ob as something groups look for, as no one else really wants to do these cases, and it is good PR for the group to have a fellowship trained 'director' of Ob anesthesia...

Unless you are planning an academic career, or have J-1 issues, or plan to have a sharp focus on your practice (greater than 1/2 hearts, pedi, pain, or OB), a fellowship has a large opportunity cost in lost income, lost time on a partnership track, lost experience in cases you don't spend a year doing. It has been said on these forums in the past that working hard at your residency, and studying hard for the boards, is the best approach to becoming a skillful and well-rounded anesthesiologist. Your first couple of years in practice will still be learning experiences, more varied and realistic then another year of supervised practice, i.e. pgy-5 year...

 

[The_Sensei]

With due respect: a fellowship year may not always be worthwhile. Sure, if you want to do some hearts, or all hearts, then TEE certification would be great. But, spending a year on this in a non-ACGME fellowship? New grads right now can still sit for the TEE exam. I would agree that this is the best fellowship option, but it isn't necessary. Most anesthesiologists don't want to do hearts, so this is useful only if you plan to do many of them for a large portion of your career.

CCM is the intellectual foundation of our specialty, and but most of us don't want to attend in the ICU, and most groups don't want someone to attend in the ICU. The incentive to train isn't there. I think that the ABA should integrate this into the residency, but that's another discussion.

Pain makes sense if you want to do pain. I'm not sure where this subspecialty will go in a few years, but it seems like it will get saturated due to all the interest now. I have come across many pain fellowship trained attendings who found they didn't care for it, and don't practice pain medicine. Sure it's interesting, but many go towards anesthesiology because they don't want to have long term patients and run a clinic.

Peds - great fellowship, if you like peds. You will be the go-to person for the sickest kids. Doesn't make sense if you want to do only community peds cases.

Neuro/Regional - you don't need a fellowship for this, maybe some learning on the job, and some CME if you feel deficient. Certainly not a year for this unless you are planning an academic career.

I would add Ob as something groups look for, as no one else really wants to do these cases, and it is good PR for the group to have a fellowship trained 'director' of Ob anesthesia...

Unless you are planning an academic career, or have J-1 issues, or plan to have a sharp focus on your practice (greater than 1/2 hearts, pedi, pain, or OB), a fellowship has a large opportunity cost in lost income, lost time on a partnership track, lost experience in cases you don't spend a year doing. It has been said on these forums in the past that working hard at your residency, and studying hard for the boards, is the best approach to becoming a skillful and well-rounded anesthesiologist. Your first couple of years in practice will still be learning experiences, more varied and realistic then another year of supervised practice, i.e. pgy-5 year...

I agree with this post 100%!

 

[EtherMD]

With due respect: a fellowship year may not always be worthwhile. Sure, if you want to do some hearts, or all hearts, then TEE certification would be great. But, spending a year on this in a non-ACGME fellowship? New grads right now can still sit for the TEE exam. I would agree that this is the best fellowship option, but it isn't necessary. Most anesthesiologists don't want to do hearts, so this is useful only if you plan to do many of them for a large portion of your career.

CCM is the intellectual foundation of our specialty, and but most of us don't want to attend in the ICU, and most groups don't want someone to attend in the ICU. The incentive to train isn't there. I think that the ABA should integrate this into the residency, but that's another discussion.

Pain makes sense if you want to do pain. I'm not sure where this subspecialty will go in a few years, but it seems like it will get saturated due to all the interest now. I have come across many pain fellowship trained attendings who found they didn't care for it, and don't practice pain medicine. Sure it's interesting, but many go towards anesthesiology because they don't want to have long term patients and run a clinic.

Peds - great fellowship, if you like peds. You will be the go-to person for the sickest kids. Doesn't make sense if you want to do only community peds cases.

Neuro/Regional - you don't need a fellowship for this, maybe some learning on the job, and some CME if you feel deficient. Certainly not a year for this unless you are planning an academic career.

I would add Ob as something groups look for, as no one else really wants to do these cases, and it is good PR for the group to have a fellowship trained 'director' of Ob anesthesia...

Unless you are planning an academic career, or have J-1 issues, or plan to have a sharp focus on your practice (greater than 1/2 hearts, pedi, pain, or OB), a fellowship has a large opportunity cost in lost income, lost time on a partnership track, lost experience in cases you don't spend a year doing. It has been said on these forums in the past that working hard at your residency, and studying hard for the boards, is the best approach to becoming a skillful and well-rounded anesthesiologist. Your first couple of years in practice will still be learning experiences, more varied and realistic then another year of supervised practice, i.e. pgy-5 year...

I disagree. The big Groups value a fellowship and this gives the advantage to the person who completes one. Remember, there are a limited number of very high paying positons out there and my vote is for the fellowship trained individual. I can tell you this is how many Groups think and if you want to improve the odds of landing that 90th percentile job do the extra 12 months.
Again, you don't NEED a fellowship to get an average job. But, if you want one that pays much better than average right out of training do the extra 12 months. You won't regret it.

 

[EtherMD]

The 15-20% they tell you about is just the beginning of how they will screw you, if you ever get acess to the books you will see that that AMC is taking much more. Beyond the basic unfairness of working for some out of town liar who bribed the administration to give him the contract. You get to do all the work and the AMC owners will pay you as little as possible. Anything told to you by an AMC owner should be considered a lie until proven other wise. AMC absentee owner don’t practice anesthesia but are working 24/7 dreaming up ways to steal money from their employees, the patients their employees treat and the hospital that gave them the contract. If you care about earning a fair salary and being treated fairly you will be wise to avoid work for an AMC liar.

Wow, we have issues with AMC's don't we? AMC's are my enemy more than the AANA. That said, I hear decent things about Sheridan. Comments?

 

[denied]

Wow, we have issues with AMC's don't we? AMC's are my enemy more than the AANA. That said, I hear decent things about Sheridan. Comments?

I interviewed with Sheridan and it did not take long to see that they are a fundamentally dishonest greedy company that is out to screw you. Other than the J-1 visa waver H-1B indentured servants who can't quit their employee turn over is very high rivaling that of your local fast food restaurant. Like many AMC they go through employees so fast they have their own placement agency. I was promised a year end bonus but they refused to define the criteria of awarding the bonus or disclose who got the bonus last year, a red flag that the bonus was a lie.

Sheridan probably needs all those lawyer to get out of all the legal problems that they create. The lies of their recruiters, the broken contacts with employees, The numerous hospitals who have seen the light and dumped Sheridan when the got tied of the constant physician turn over and bad service Sheridan provides. Sheridan even screws their former stock holders since it was a publicly traded company that went private via a controversial sham buy back of outstand shares at below market value that spurred a big lawsuit.

Do your self and your career a favor and steer clear of Sheridan or any other AMC.

 

[powermd]

Pain seems like the only fellowship that makes economic sense. Pain is reimbursed well enough that you not only pull your own weight, but make $$$ for the group. Cardiac/CCM lose money the more time you spend in the subspecialty. You are only desireable to the group as a marketing tool. I believe they are in high demand and are well paid right now, but it doesn't sound like a very secure situation to me. Of course, reimbursements could drop for pain procedures, but that is a risk we all face as anesthesiologists no matter what we're doing.

I wasn't considering a fellowship until this discussion; now I am pretty much sold on the idea. I am seriously considering pain, although there is very much that I like about cardiac too.

I have been beating this drum for months. The best 12 months of your career from a financial persepective is the fellowship year. This ONE YEAR sets you apart from the herd and really helps you to stand out. Those of you wanting maximum opportunities for location and pay should do the year.
In my opinion, I will list the fellowship that Groups want in 2007. This means that these areas are in "demand" right now and command a premium.

1. Cardiac- TEE certified Anesthesiologist. Every Group wants one or two of these for the difficult heart/valve cases. We all do the cases but TEE certification makes you legitimate in the eyes of the surgeon. Also, good P.R. for the Group. This does not make much money for the Group but a necessary "evil" for many practices. Of course, this means the Group does hearts and a lot of difficult valve cases.

2. Pain- Still hot right now. Pain Anesthesiologists still command a premium and some might list this as number 1. For me, a close call but with more Pain Docs available these days and the fact that many of them want less O.R. call because of "clinic" days. Regardless, Pain is a smart choice.

3. Critical Care- USA is getting older, fatter and sicker every day. We need more ICU docs and hospitals like Anesthesia trained Intensivists. You will find less Groups doing ICU but those that do want a fellow trained Anesthesiologist. Those that don't still value your training and appreciate your unique knowledge and experience.

4. Peds- If you want to be the "go to" person for the sickest kids in a large metropolitan Group then Peds is valuable.

5. Neuro/Regional- Medicare is not paying for catheters post-operatively. Most older guys learn these techniques quickly. If you like Regional then do a lot U/S guidance in your fellowship.

 

[RSX]

I'm thinking of a Peds fellowship. Do you guys know the demand, average salary, lifestyle of peds anesthesiologists? You will be working with the sickest kids, therefore you pretty much have to work in a Children's hospital right? Otherwise, non-sick kids can be handled by non-fellowship trained docs. So are there peds only groups?

 

[objdoc]

Wow, we have issues with AMC's don't we? AMC's are my enemy more than the AANA. That said, I hear decent things about Sheridan. Comments?

AMC's seem to make sense. Economies of scale, and all that. I'm sure there are some more reputable than others...

 

[urgewrx]

Which fellowship makes you more marketable?

Depends where you look. For example, open an anesthesia journal and you will see many ads for peds and regional, month after month, usually from big name academic places. If you look in gaswork, you will see many jobs for general, some cardiac, some pain and, some OB.

Should you do a fellowship?

The most important thing is to know what you want to be doing comfortably for the next 30 yrs. If you see yourself in a surgicenter, or living in a small town, there is no reason to do a fellowship. If you like academics or are interested in certain group that you know does specalized cases, then a fellowship would be worthwile.

Keep in mind a fellowship is really expensive. You will be paid like 50k when you could have been making 250k. That is the price of a home in many places. It's also one year of partnership that you loose. And you will be taking crap from people when you could be out there calling the shots.

 

[urgewrx]

I have come across many pain fellowship trained attendings who found they didn't care for it, and don't practice pain medicine.

There are tons of these.

 

[morpheus md]

With due respect: a fellowship year may not always be worthwhile. Sure, if you want to do some hearts, or all hearts, then TEE certification would be great. But, spending a year on this in a non-ACGME fellowship? New grads right now can still sit for the TEE exam. I would agree that this is the best fellowship option, but it isn't necessary. Most anesthesiologists don't want to do hearts, so this is useful only if you plan to do many of them for a large portion of your career.

CCM is the intellectual foundation of our specialty, and but most of us don't want to attend in the ICU, and most groups don't want someone to attend in the ICU. The incentive to train isn't there. I think that the ABA should integrate this into the residency, but that's another discussion.

Pain makes sense if you want to do pain. I'm not sure where this subspecialty will go in a few years, but it seems like it will get saturated due to all the interest now. I have come across many pain fellowship trained attendings who found they didn't care for it, and don't practice pain medicine. Sure it's interesting, but many go towards anesthesiology because they don't want to have long term patients and run a clinic.

Peds - great fellowship, if you like peds. You will be the go-to person for the sickest kids. Doesn't make sense if you want to do only community peds cases.

Neuro/Regional - you don't need a fellowship for this, maybe some learning on the job, and some CME if you feel deficient. Certainly not a year for this unless you are planning an academic career.

I would add Ob as something groups look for, as no one else really wants to do these cases, and it is good PR for the group to have a fellowship trained 'director' of Ob anesthesia...

Unless you are planning an academic career, or have J-1 issues, or plan to have a sharp focus on your practice (greater than 1/2 hearts, pedi, pain, or OB), a fellowship has a large opportunity cost in lost income, lost time on a partnership track, lost experience in cases you don't spend a year doing. It has been said on these forums in the past that working hard at your residency, and studying hard for the boards, is the best approach to becoming a skillful and well-rounded anesthesiologist. Your first couple of years in practice will still be learning experiences, more varied and realistic then another year of supervised practice, i.e. pgy-5 year...

Agree with above, doing a fellowship with the sole intention of padding your resume is not the best of ideas. This is probably true more so of pain mangement than anythng else. I fail to see how a pain management fellowhip will make you more marketable as an anesthesiologist....cardiac, peds, regional yes, but chronic pain is a different animal altogether. It may make a slight difference all else being equal at a very few groups, but that is no justification to go that route if you are not 100% into it.

 

[Trisomy13]

I'm thinking of a Peds fellowship. Do you guys know the demand, average salary, lifestyle of peds anesthesiologists? You will be working with the sickest kids, therefore you pretty much have to work in a Children's hospital right? Otherwise, non-sick kids can be handled by non-fellowship trained docs. So are there peds only groups?

Not necessarily. Any hospital that has a high-volume peds-cardiothoracic surgeon will have a need for a fellowship trained peds anesthesiologist. And that doc will want someone to split call and vacations ;-)

 

[EtherMD]

Okay,

Let me get this straight. Most of you are in training or just a few years in practice (less than 5). Yet, you think that you are "qualified" to tell the large Groups and those with many years of experience whether a fellowship is beneficial? The tail does not wag the dog and many of you are way off base on the subject. I will say it again: If you are looking to make 90th perecentile income or more and live in a nice, desirable location do the extra 12 months as the odds of getting that job is much higher than without the fellowship.

How many of you know a lot of Groups earning 90th percentile or more? I do and most consider a fellowship very beneficial in the hiring process. After all, would a Group rather hire another person with 12 months of work experience with Sheridan or a fellowship trained person that helps fill a necessary void in the Group? Who would you hire if you were running the Group?


I am sorry for those of you who could not afford to do the fellowship or chose to "skip" it. However, those of you willing to acquire extra skills like TEE certification, Critical Care certification, etc. will find many experienced Anesthesiologists recognize the extra sacrifice you made. I view it as a major plus just like most major Groups.

 

[EtherMD]

There are tons of these.

I know many Board Certified Anesthesiologists that don't like anesthesia and don't want to work. So what? Pain Management offers the energetic individual many options for just 12 months of extra training. Your starting pay is higher, the odds of landing a 90th percentile job is high and when you get older you can open your own pain practice with no call.

Many Groups will let you do 30% or 50% pain if that is your preference.
But, if you despise Pain Management pick another fellowship. Being the "best" in one area is a major plus these days for a new graduate. A well trained fellow should be able to function as an experienced attending in that area from day one.

 

[EtherMD]

Which fellowship makes you more marketable?

Depends where you look. For example, open an anesthesia journal and you will see many ads for peds and regional, month after month, usually from big name academic places. If you look in gaswork, you will see many jobs for general, some cardiac, some pain and, some OB.

Should you do a fellowship?

The most important thing is to know what you want to be doing comfortably for the next 30 yrs. If you see yourself in a surgicenter, or living in a small town, there is no reason to do a fellowship. If you like academics or are interested in certain group that you know does specalized cases, then a fellowship would be worthwile.

Keep in mind a fellowship is really expensive. You will be paid like 50k when you could have been making 250k. That is the price of a home in many places. It's also one year of partnership that you loose. And you will be taking crap from people when you could be out there calling the shots.

I want you to keep a few things in mind. You may get tired of living in the sticks and want to move back to civilization. If you end up with a 50th percentile job instead of the 90th percentile job how much money did you "lose" by not doing the fellowship over 30 years? Millions!
Even academic centers pay fellowship trained people more money and are more likely to promote them. So, take the crap for 12 more months and then enjoy the fruits of your labor.

 

[ravanbj]

I have a difficult situation...Need advice...

I have 2 choices:

1. I can start a pain fellowship this July and then look for jobs and see what happens....

OR

2. I have a job offer in a medium sized city in California. 1st year $300,000, 1 yr partner. But this is a 1099 fee for service group. It is extremely fair with absolutely no cherry picking. My close friend is a partner to confirm it. They have a fair way to dividing all case and types of insurance. basically you are paid a set fee per units regardless of type of insurance. They are averaging between $400-500k based on number of calls and more or less vacation. You only get paid when you work, but the job is very flexible. great practice doing all dins of cases.

What to do???? I like pain but I like anesthesia. I could be happy doing both. I am drawn to pain for the chance to have my own practice, have more respect, and make more money (hope for between $500-700k). Plus treated with respect. Obviously the negatives are that I have to take another year for fellowship and it will take at least 2 maybe 3 yrs to make partner in most pain groups. Opening my own practice will take at leasat 2 yrs to make money. If I join the anesthesia group I calculate that I could save $1 million in 3yrs....

What would you guys do?

 

[morpheus md]

Okay,

Let me get this straight. Most of you are in training or just a few years in practice (less than 5). Yet, you think that you are "qualified" to tell the large Groups and those with many years of experience whether a fellowship is beneficial? The tail does not wag the dog and many of you are way off base on the subject. I will say it again: If you are looking to make 90th perecentile income or more and live in a nice, desirable location do the extra 12 months as the odds of getting that job is much higher than without the fellowship.

How many of you know a lot of Groups earning 90th percentile or more? I do and most consider a fellowship very beneficial in the hiring process. After all, would a Group rather hire another person with 12 months of work experience with Sheridan or a fellowship trained person that helps fill a necessary void in the Group? Who would you hire if you were running the Group?


I am sorry for those of you who could not afford to do the fellowship or chose to "skip" it. However, those of you willing to acquire extra skills like TEE certification, Critical Care certification, etc. will find many experienced Anesthesiologists recognize the extra sacrifice you made. I view it as a major plus just like most major Groups.

I may or may not be qualified, but I certainly know people who are. I am at a top tier residency, with a strong pain program, whose pain graduates secure desireable spots in private practice and academics. NO ONE I have spoken to that is associated with my program has recommended doing a pain fellowship to add leverage for your anesthesia career. So while you do have more experience as an anesthesia attending, I submit to you that your sample size is still n=1, and must therefore be taken with a grain of salt, even on a residents' message board.

If you do think that the subjective opinion of one attending is significant, I can tell you that I have friends who are private practice attendings, in particular one very well established at a great spot in West LA, who finds the concept of doing a pain fellowship with the intention of not practicing pain completely absurd. Everyone is entitled to their opinion...

 

[Duckie24]

Let me get this straight. Most of you are in training or just a few years in practice (less than 5). Yet, you think that you are "qualified" to tell the large Groups and those with many years of experience whether a fellowship is beneficial?

Hello, Kettle?

This is The Pot. You're black.


This is EXACTLY my point in the other threads where you want all of us young'ns to solve all of the problems in our field! So, thanks for making it for me, especially since you are one of the ones who doesn't seem to want to accept it.

Seriously, on another note, I enjoy all of your posts and think you have great ideas and would be a great advocate for our field. Believe me, I will be taking your fellowship advice to heart. And I'll be right there fighting the good fight too.

 

[EtherMD]

I may or may not be qualified, but I certainly know people who are. I am at a top tier residency, with a strong pain program, whose pain graduates secure desireable spots in private practice and academics. NO ONE I have spoken to that is associated with my program has recommended doing a pain fellowship to add leverage for your anesthesia career. So while you do have more experience as an anesthesia attending, I submit to you that your sample size is still n=1, and must therefore be taken with a grain of salt, even on a residents' message board.

If you do think that the subjective opinion of one attending is significant, I can tell you that I have friends who are private practice attendings, in particular one very well established at a great spot in West LA, who finds the concept of doing a pain fellowship with the intention of not practicing pain completely absurd. Everyone is entitled to their opinion...

I NEVER said do a Pain Fellowship. In fact, I listed CARDIAC as number one.
I am mearly pointing out that someone without "connections" stands a much better chance of getting a 90th percentile job after the completion of a fellowship. While my opinion is only "1" as you have so kindly pointed out I ask everyone to think about the job market as COMPETITION based. If I can hire a fellowship trained individual INSTEAD of someone without one shouldn't I? A top tier program really helps but I prefer a top tier program and a fellowship. Since the job pays well (90th perecentile) and the track is fair (24 months) why not get the person who helps fill the "void"? My bet is that after a few years in practice you will come to the same conclusion.

Again, don't do a fellowship you hate or will never use. That is absurd. Instead, see if you can find one that develops your skills in an area of interest so you can be the "expert" from day one. A few program directors may let you combine Regional with Neuro or Peds since these areas are not "official" specialties.

In the real world "connections" always trumps skill and knowledge. But, most jobs are going to be filled by the most qualified candidate with good personal skills.

 

[EtherMD]

Hello, Kettle?

This is The Pot. You're black.


This is EXACTLY my point in the other threads where you want all of us young'ns to solve all of the problems in our field! So, thanks for making it for me, especially since you are one of the ones who doesn't seem to want to accept it.

Seriously, on another note, I enjoy all of your posts and think you have great ideas and would be a great advocate for our field. Believe me, I will be taking your fellowship advice to heart. And I'll be right there fighting the good fight too.

Hey Duckie,

You want to be the "average" duck. So, no fellowship required and you can join the other birds looking for the best meal on the pond. The smart people will want to get their "ducks lined up" so they can get a leg up on the competition. After all, there are only a FEW jobs paying 90th percentile or more so best of luck.

Meanwhile, the CRNA's are getting the DNAP and you don't understand why you need more legal qualifications.

 

[johankriek]

I\OR

2. I have a job offer in a medium sized city in California. 1st year $300,000, 1 yr partner. But this is a 1099 fee for service group.
?

fresno?..

 

[urgewrx]

A few program directors may let you combine Regional with Neuro or Peds since these areas are not "official" specialties.

Ether, man. You gotta keep up with times. Ped is an official ACGME accredited subspecialty since 2 or 3 years ago.

Younglings, see how experienced people don't always know what they talk about.

 

[xjohns1]

so, for those of you who have experience with hiring, do groups that do NOT do critical care place any added monetary value on an applicant with cc fellowship training? i.e., if you aren't in or appling to a group that practices critical care, is there any real financial advantage in pursuing a cc fellowship? thanks for the input.

 

[militarymd]

so, for those of you who have experience with hiring, do groups that do NOT do critical care place any added monetary value on an applicant with cc fellowship training? i.e., if you aren't in or appling to a group that practices critical care, is there any real financial advantage in pursuing a cc fellowship? thanks for the input.

I've hired a number of folks over the last year (replacing folks who should NOT be doing anesthesia)

Subspecialty training gets you to the top of the list.

Experience moves you to the top.

However, nothing gets you more cash because we pay EVERYONE the same.

Having said that, we passed on a fellowship trained guy and went with an average guy (both BC) because teh average guy "fit" in better with the rest of the guys/gals already here.....personality counts..

 

[mille125]

I have a difficult situation...Need advice...

I have 2 choices:

1. I can start a pain fellowship this July and then look for jobs and see what happens....

OR

2. I have a job offer in a medium sized city in California. 1st year $300,000, 1 yr partner. But this is a 1099 fee for service group. It is extremely fair with absolutely no cherry picking. My close friend is a partner to confirm it. They have a fair way to dividing all case and types of insurance. basically you are paid a set fee per units regardless of type of insurance. They are averaging between $400-500k based on number of calls and more or less vacation. You only get paid when you work, but the job is very flexible. great practice doing all dins of cases.

What to do???? I like pain but I like anesthesia. I could be happy doing both. I am drawn to pain for the chance to have my own practice, have more respect, and make more money (hope for between $500-700k). Plus treated with respect. Obviously the negatives are that I have to take another year for fellowship and it will take at least 2 maybe 3 yrs to make partner in most pain groups. Opening my own practice will take at leasat 2 yrs to make money. If I join the anesthesia group I calculate that I could save $1 million in 3yrs....

What would you guys do?

I will preface by saying that I am a practicing pain management doc (less than 5 yrs). I believe that I am the only practicing full time pain management doc currently on this thread (I may be wrong but that is my impression). This seems like a very difficult decision but it really isnt.

If you truly love pain, you should absolutely do the fellowship. The fellowship prepares you for a 100% pain practice (spinal cord stimulators, E&M management, radiofrequency, IDET, etc.). You will soon find that comprehensive pain management is NOT a two day a week job (even though the anesthesia groups will have you believe this). You will also find that comprehensive pain management is much more than epidural injections. Only a fellowship can prepare you for this. Pain management is very rewarding. However, you really need to love what you are doing. I am 100% satisfied. However, even I have a few days where I never want to return. Everyone in the business does. I also have many handwritten letters from grateful patients and referring doctors who tell me that I have made a difference in their lives. This more than makes up for the bad days. Success in pain management is similar to batting in the major leagues. If you are batting 333 you are very successful. If this doesnt sound like your cup of tea, I suggest that you run away from a pain fellowship and dont look back. The disgruntled pain attendings are the ones who thought that "they could make themselves like it," or "the money will cure all ills". I will tell you right away if you make 1 million per year on pain and your heart is not in it, you will be very disgruntled. Chronic pain patients have a way of wearing on the unfocused and uninterested physician.


As far as 500-700K, I guess that it is possible but not probable. 90th percentile for pain management is about 580-600K. I know of a few who make 1 million plus per year. The vast majority of us (myself included) are near the anesthesiology group partnership salary as far as revenue from the practice. However, you do have an opportunity to invest in surgery centers which can increase your profits. You also have very limited call.

Finally, your group contract sounds pretty good. I would talk to your friend in the group that you know. If you are starting at 300K without a fellowship, many times there is some catch (ie very frequent or demanding call, very abrasive personalities, etc.). If your friend tells you that it is a good group and you trust him/her, then I would sign if you are not truly interested in pain. However, if my above story moved you, then you should do a pain fellowship.

I hope that this helps.

 

[Noyac]

so, for those of you who have experience with hiring, do groups that do NOT do critical care place any added monetary value on an applicant with cc fellowship training? i.e., if you aren't in or appling to a group that practices critical care, is there any real financial advantage in pursuing a cc fellowship? thanks for the input.

NO

 

[Duckie24]

Hey Duckie,

You want to be the "average" duck. So, no fellowship required and you can join the other birds looking for the best meal on the pond. The smart people will want to get their "ducks lined up" so they can get a leg up on the competition. After all, there are only a FEW jobs paying 90th percentile or more so best of luck.

Meanwhile, the CRNA's are getting the DNAP and you don't understand why you need more legal qualifications.

Ether, read carefully what I wrote. I said I was planning on doing a fellowship. I understand where you're coming from, I want to set myself apart.