Need wisdom on first job: Bigger cases or small community hospital?

[hckyplyr]

Let me preface this and say prior to marriage and two young children, my goal was to get out of residency (no fellowship) and do big cases, grow my procedurals skills, case knowledge, efficiency, etc. Now that I have two little ones, priorities have changed. I'm a "work to live" type of person, and I rather be home/doing things I enjoy/family time than being at work. I'm deciding between two different positions:
FYI. I've had to EDIT job 1 details after I've gotten more accurate info. So I apologize to everyone who has already commented with my inaccurate information.
1. Affiliate hospital of my residency, 16 ORs, mostly bread and butter cases. Minimal peds, busy OB, minimal vasc, no neuro (spine yes), no trauma
-Hours: Around 55 when working NO call, M-F. Not required to take weekend or weekday call
-100% physician only cases. OB: you have a CRNA
-Pay: Eat what you kill, looking at around $450k projected (withOUT call), $25k sign on. If taking minimum call (6 weekends/yr and 1 weekday call a month) salary gets to low $500s
-Vacation: 8-9 weeks, unpaid
-Working with many people I know/went to residency with, many seasoned attendings around for help if needed.
-Benefits: 403b 6% match (NO match for job 2), 457b (non-governmental)
-Always has job openings
-Opportunities to do LOCUM work around area

2. Small community hospital with 4 ORs with small ASC. Bread and butter. Minimal peds (same as above), No trauma, No OB, No vascular, No neuro (spine yes)
-Hours: Around 40
-2:1 supervision, doing own cases on call. Trying to hire another doc so physicians can possibly do own cases during day. (Big maybe)
-Pay: 1st year with bonuses $570k, then $525k year
-Call: Every 5th week (week at a time), with <5% nightly calls on weekdays, about 2 cases a weekend. Physicians live >45 min away bc emergent cases so rare and no OB.
-Call pay: $300/hr if called in
-Benefits: 403b (no match), 457b (non-governmental)....Same benefits as other job
-Vacation: 13 weeks
-Very rarely have job openings

In reality, both places are pretty "bread and butter" heavy, with exception of first job likely doing more sick patients and OB. I feel like a bit of a sell out if I went straight to a community center. Also, if I need help/questions there's not really any other anesthesiologists around but myself. However, if I truly wanted big cases (cardiac, peds, transplant) which happen at an academic center, those are mostly given (at least at my residency) to fellowship trained people anyway. I'm really torn, and I'd love to hear the experience from seasoned vets who can pass down some wisdom about what you would do/recommend. Thank you greatly

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[abolt18]

Let me preface this and say prior to marriage and two young children, my goal was to get out of residency (no fellowship) and do big cases, grow my procedurals skills, case knowledge, efficiency, etc. Now that I have two little ones, priorities have changed. I'm a "work to live" type of person, and I rather be home/doing things I enjoy/family time than being at work. I'm deciding between two different positions:

1. Affiliate hospital of my residency, 16 ORs, mostly bread and butter cases. Minimal peds, busy OB, minimal vasc, no neuro (spine yes), no trauma
-Hours: 50-70. Not required to take weekend or weekday call, but generally hours are longer M-F when not on call
-100% physician only cases. OB: you have a CRNA
-Pay: Eat what you kill, looking at around $425k projected (with call), $25k sign on
-Vacation: 8-9 weeks, unpaid
-Working with many people I know/went to residency with, many seasoned attendings around for help if needed.
-Benefits: 403b (no match), 457b (non-governmental)....Same benefits as other job
-Always has job openings
-Opportunities to do LOCUM work around area

2. Small community hospital with 4 ORs with small ASC. Bread and butter. Minimal peds (same as above), No trauma, No OB, No vascular, No neuro (spine yes)
-Hours: Around 40
-2:1 supervision, doing own cases on call. Trying to hire another doc so physicians can possibly do own cases during day. (Big maybe)
-Pay: 1st year with bonuses $570k, then $525k year
-Call: Every 5th week (week at a time), with 45 min away bc emergent cases so rare and no OB.
-Call pay: $300/hr if called in
-Benefits: 403b (no match), 457b (non-governmental)....Same benefits as other job
-Vacation: 13 weeks
-Very rarely have job openings

In reality, both places are pretty "bread and butter" heavy, with exception of first job likely doing more sick patients and OB. I feel like a bit of a sell out if I went straight to a community center. Also, if I need help/questions there's not really any other anesthesiologists around but myself. However, if I truly wanted big cases (cardiac, peds, transplant) which happen at an academic center, those are mostly given (at least at my residency) to fellowship trained people anyway. I'm really torn, and I'd love to hear the experience from seasoned vets who can pass down some wisdom about what you would do/recommend. Thank you greatly

Not a seasoned vet, but to me it's option #2 or #3 (the job you haven't looked at yet that has big cases AND more money/vacation).

 

[TheLoneWolf]

If you are a work to live guy as you reported, take job 2. More money, fewer hours, more vacation. Almost never hiring.



If you really hate it, you can always quit and join the bigger hospital which is always hiring.

 

[Urzuz]

You are asking us to weigh your family life and professional life, which only you can do. But if you want some quick facts regarding your professional life:

1) straight out of residency, doing your own cases is the only way to get really good and slick, develop your own practice habits, etc, no matter what anyone else says.

2) you will feel fulfilled professionally 1000x more doing your own cases, getting to know the surgeons/circulators/techs well, etc. Generally speaking, in physician only practices, you are also viewed and treated like a physician (rather than a lunch break monkey for nurses in supervisory roles)

3) your skills will atrophy going into an ASC immediately. If you know you want to do only outpatient for the rest of your life (let’s say you’re older or don’t have many years of practice left, etc) then it may be a decent option. But if you’re relatively young and have 20+ years of working ahead of you and there’s a chance you may end up in a different practice, you’re starting off on the wrong foot. We have had YOUNG physicians join our group (<10 years out) who didn’t know how to do an adductor canal block and needed help from another partner, all because they joined a Cush supervision job straight out of residency. This is downright embarrassing and all of your partners will view you as a 🤡

4) you’re earning way more in the second practice, no two ways about it

 

[Southpaw]

2 and not close. You could always go back to 1 if desired. They’ll be hiring indefinitely w that package.

 

[Maz777]

40 hours vs. 50-70. Easy call to make here.

Job 1 is horrendous. 425k is garbage for those hours. Unpaid vacation.

Supervision sucks but Job 1 doesn't make up for that. At least you can do the occasional solo case on call. Or just have a CRNA take lunch while you induce by yourself.

 

[NICMAN]

I would never take #1

#2 is cushy but you have to weigh all the factors.

I personally think my #3 is better though. Take a closer look at what we are offering.

You know how to contact me ;-)

 

[deleted875186]

Wouldn’t even consider #1 based on the pay and hours with how much better #2 is. Supervising 2:1 is ok, you can be involved more, and doing your own cases on call or after hours keeps things up. As you said, in reality skills will atrophy no matter what even at a larger center because they have specialist teams that do cases.

 

[GassYous]

Wow 50-70 hours for 425 and no 402k match lol. No wonder they are always hiring.

 

[Hoya11]

Let me preface this and say prior to marriage and two young children, my goal was to get out of residency (no fellowship) and do big cases, grow my procedurals skills, case knowledge, efficiency, etc. Now that I have two little ones, priorities have changed. I'm a "work to live" type of person, and I rather be home/doing things I enjoy/family time than being at work. I'm deciding between two different positions:

1. Affiliate hospital of my residency, 16 ORs, mostly bread and butter cases. Minimal peds, busy OB, minimal vasc, no neuro (spine yes), no trauma
-Hours: 50-70. Not required to take weekend or weekday call, but generally hours are longer M-F when not on call
-100% physician only cases. OB: you have a CRNA
-Pay: Eat what you kill, looking at around $425k projected (with call), $25k sign on
-Vacation: 8-9 weeks, unpaid
-Working with many people I know/went to residency with, many seasoned attendings around for help if needed.
-Benefits: 403b (no match), 457b (non-governmental)....Same benefits as other job
-Always has job openings
-Opportunities to do LOCUM work around area

2. Small community hospital with 4 ORs with small ASC. Bread and butter. Minimal peds (same as above), No trauma, No OB, No vascular, No neuro (spine yes)
-Hours: Around 40
-2:1 supervision, doing own cases on call. Trying to hire another doc so physicians can possibly do own cases during day. (Big maybe)
-Pay: 1st year with bonuses $570k, then $525k year
-Call: Every 5th week (week at a time), with <5% nightly calls on weekdays, about 2 cases a weekend. Physicians live >45 min away bc emergent cases so rare and no OB.
-Call pay: $300/hr if called in
-Benefits: 403b (no match), 457b (non-governmental)....Same benefits as other job
-Vacation: 13 weeks
-Very rarely have job openings

In reality, both places are pretty "bread and butter" heavy, with exception of first job likely doing more sick patients and OB. I feel like a bit of a sell out if I went straight to a community center. Also, if I need help/questions there's not really any other anesthesiologists around but myself. However, if I truly wanted big cases (cardiac, peds, transplant) which happen at an academic center, those are mostly given (at least at my residency) to fellowship trained people anyway. I'm really torn, and I'd love to hear the experience from seasoned vets who can pass down some wisdom about what you would do/recommend. Thank you greatly

I will break the trend and say Id prefer Job #1.

I could not be so married to a small little place wanting to do a gallbladder or appy at 9pm here and there.

Those little places come with a lot of home call.

If I am going to do small ASC level cases, I'm not taking call. When I leave, I'm out. Thats the sacrifice in my mind.

With Job #2 you lose your skills, probably lose a lot of future job opportunities when that little place gets taken over and you havent done real anesthesia ever as an attending, and your still on call 20% of your life. And when you get called in its for little BS. Also future very uncertain at such a small place in the long term. Current partners may be downplaying the call.

At Job #1, all those wise experienced attendings, why dont they go do job #2? Why do they stay? Good people is a good sign.

If I were you I would just do 1099 and make my owns schedule and work at various places during the day.

IE 2 10hr shifts at hospital A, 2 10hr shifts at an ASC, maybe one day off.

 

[DirtDocMD]

5 more weeks vacation? $100k more per year?? 10-20 less hours per week??

Obviously, it’d be better if you did your own cases. Honestly, at 2:1 supervision, I don’t see how the practice is saving any money??? It’d be cheaper just to have Docs.

As it stands, you take #2. If it doesn’t pan out, there will likely ALWAYS be a job at #1.

 

[abolt18]

Take job number 2 and use 4 of your vacation weeks to go do locums gigs at places with sick patients where you so your own cases.

 

[JiPo]

Take job number 2 and use 4 of your vacation weeks to go do locums gigs at places with sick patients where you so your own cases.

That sounds good in theory, but I don't know if it is such a good idea to take on sicker patients at a place you are not familiar with and possibly without much back-up after months of doing easy cases.

 

[Greenbayslacker]

Let me preface this and say prior to marriage and two young children, my goal was to get out of residency (no fellowship) and do big cases, grow my procedurals skills, case knowledge, efficiency, etc. Now that I have two little ones, priorities have changed. I'm a "work to live" type of person, and I rather be home/doing things I enjoy/family time than being at work. I'm deciding between two different positions:

1. Affiliate hospital of my residency, 16 ORs, mostly bread and butter cases. Minimal peds, busy OB, minimal vasc, no neuro (spine yes), no trauma
-Hours: 50-70. Not required to take weekend or weekday call, but generally hours are longer M-F when not on call
-100% physician only cases. OB: you have a CRNA
-Pay: Eat what you kill, looking at around $425k projected (with call), $25k sign on
-Vacation: 8-9 weeks, unpaid
-Working with many people I know/went to residency with, many seasoned attendings around for help if needed.
-Benefits: 403b (no match), 457b (non-governmental)....Same benefits as other job
-Always has job openings
-Opportunities to do LOCUM work around area

2. Small community hospital with 4 ORs with small ASC. Bread and butter. Minimal peds (same as above), No trauma, No OB, No vascular, No neuro (spine yes)
-Hours: Around 40
-2:1 supervision, doing own cases on call. Trying to hire another doc so physicians can possibly do own cases during day. (Big maybe)
-Pay: 1st year with bonuses $570k, then $525k year
-Call: Every 5th week (week at a time), with <5% nightly calls on weekdays, about 2 cases a weekend. Physicians live >45 min away bc emergent cases so rare and no OB.
-Call pay: $300/hr if called in
-Benefits: 403b (no match), 457b (non-governmental)....Same benefits as other job
-Vacation: 13 weeks
-Very rarely have job openings

In reality, both places are pretty "bread and butter" heavy, with exception of first job likely doing more sick patients and OB. I feel like a bit of a sell out if I went straight to a community center. Also, if I need help/questions there's not really any other anesthesiologists around but myself. However, if I truly wanted big cases (cardiac, peds, transplant) which happen at an academic center, those are mostly given (at least at my residency) to fellowship trained people anyway. I'm really torn, and I'd love to hear the experience from seasoned vets who can pass down some wisdom about what you would do/recommend. Thank you greatly

#2. Can always switch to #1 if you really hate it in a year or two, but I suspect the $$ will be hard to ignore.

 

[kidthor]

#2 no question.

#1 sounds awful. 50-70hrs a week at 425K is not reasonable at all.

 

[secretasianman]

#2 hands down

 

[Status Sciaticus]

I'm first year out, and I would pick #2 hands down. Why would I take on more difficult cases, get paid less, ruin my sleep overnight (OB), and take less vacation? So my skills dont atrophy? Screw that. If I want to keep up a certain skill, I will find a way to do so. And if I dont need to use a certain skill, I dont need to use it.

For example, we all did livers and transplants in residency. I don't do either of those now. Do I need to do them if the place I am working at or looking to work at doesnt do them? Obviously not. If I want an ASC lifestyle, I'm going to focus on skills conducive to that lifestyle. You dont need to do cases on patients with EF of 10%. Send that crap to the academic center.

I know people who just dont do OB because they dont want that drama. I'm sure their management of OB has atrophied. But if theyre not going to do those cases, do they need to do them?

 

[vector2]

#2 and then offer to do a few weeks of locums at #1 for $300/hr

 

[GoSoxGo]

You are asking us to weigh your family life and professional life, which only you can do. But if you want some quick facts regarding your professional life:

1) straight out of residency, supervising junior residents doing complex cases is the only way to get really good and slick, develop and then pass down your own practice habits, etc, no matter what anyone else says.

2) you will feel fulfilled professionally 1000x more teaching residents how to do anesthesia, getting to know the residents/students/surgeons/circulators/techs well, etc. Generally speaking, in large academic health systems, you are also viewed and treated like a physician (rather than a private practice all star who is beaming after singlehandedly getting an ASA 2 through a lap chole safely)

3) your skills will atrophy going into an private practice immediately. If you know you want to do only outpatient for the rest of your life (let’s say you’re older or don’t have many years of practice left, etc) then it may be a decent option. But if you’re relatively young and have 20+ years of working ahead of you and there’s a chance you may end up in an academic practice, you’re starting off on the wrong foot. We have had YOUNG physicians join our group (<10 years out) who didn’t know how to lead a team or teach others or multi-task or care for ASA 4's, all because they joined a Cush solo job straight out of residency. This is downright embarrassing and all of your colleagues will view you as a 🤡

4) you’re earning way more in the second practice, no two ways about it

 

[hckyplyr]

I feel bad changing information now since everyone was so kind and helpful. Unfortunately the several people I initially talked to were not accurate. For job 1: After more in depth talking to people. Job 1 with NO call is around 55hrs week, making about $450k. If taking call (6 weekends/yr and 1 weekday call a month) salary gets to low $500s (and more hours obviously). Also, job 1 with 403b match 6%. This definately gets the financial aspect closer, but still more hours at job 1, less vacation.

 

[hckyplyr]

40 hours vs. 50-70. Easy call to make here.

Job 1 is horrendous. 425k is garbage for those hours. Unpaid vacation.

Supervision sucks but Job 1 doesn't make up for that. At least you can do the occasional solo case on call. Or just have a CRNA take lunch while you induce by yourself.

I changed the financial info for job 1 since it was inaccurate. Giving CRNA breaks so I can induce/extubate is a great idea.

5 more weeks vacation? $100k more per year?? 10-20 less hours per week??

Obviously, it’d be better if you did your own cases. Honestly, at 2:1 supervision, I don’t see how the practice is saving any money??? It’d be cheaper just to have Docs.

As it stands, you take #2. If it doesn’t pan out, there will likely ALWAYS be a job at #1.

I made changes to job 1 403b and salary now that I have new info. Still more hours, less pay and vacation though. Thanks for help

Take job number 2 and use 4 of your vacation weeks to go do locums gigs at places with sick patients where you so your own cases.

Something I definitely considered, I still have to work out if they will let me LOCUM at local places though

 

[teacher2md]

1) straight out of residency, supervising junior residents doing complex cases is the only way to get really good and slick, develop and then pass down your own practice habits, etc, no matter what anyone else says.

I'll disagree with this. I've now done both supervision and solo for my first two jobs, and they're both challenging in their own ways. But doing things solo is the only way to really hone your craft in terms of speed and 'slickness'. Supervision is challenging because you're having to learn how to pick your battles, how to ask that things are done without seeming like you're in charge (even though you are?), how to give breaks and lunches to multiple rooms while also being readily-available for help. Maybe supervising residents is much better, I wouldn't know.

2) you will feel fulfilled professionally 1000x more teaching residents how to do anesthesia, getting to know the residents/students/surgeons/circulators/techs well, etc. Generally speaking, in large academic health systems, you are also viewed and treated like a physician (rather than a private practice all star who is beaming after singlehandedly getting an ASA 2 through a lap chole safely)

My professional relationship with surgeons is better as an MD regularly doing my own cases, because I'm in the room taking care of the patient with them.

Also, this user seems to be conflating all private practice jobs as easy ASC jobs. You just need to find a better PP job. For instance, at my job we do peds, OB, regional, neuro, thoracic, and open heart cases, trauma, in addition to all all the ambulatory stuff. Academia is so specialized, that there probably aren't many who do all of these types of cases on a regular basis.

3)We have had YOUNG physicians join our group (<10 years out) who didn’t know how to lead a team or teach others or multi-task or care for ASA 4's, all because they joined a Cush solo job straight out of residency. This is downright embarrassing and all of your colleagues will view you as a 🤡

This may be true. It probably was a rough adjustment for people who are accustomed to doing solo anesthesia for 20 years to now have to learn all of the 'other' skills that are required to supervise multiple rooms.

We've all heard plenty of the inverse complaint --someone who supervised for decades who is rusty with solo care.

 

[Beeftenderloin]

You are asking us to weigh your family life and professional life, which only you can do. But if you want some quick facts regarding your professional life:

1) straight out of residency, supervising junior residents doing complex cases is the only way to get really good and slick, develop and then pass down your own practice habits, etc, no matter what anyone else says.

The only part of this that’s truly unique to academics is the passing down of practice habits. I’m PP, 100% solo, doing open AAAs, hemi-arches, low EF/redo cardiac surgery, big surg onc belly whacks, lots of thoracic, lots of cranis, occasional awake crani.

2) you will feel fulfilled professionally 1000x more teaching residents how to do anesthesia, getting to know the residents/students/surgeons/circulators/techs well, etc. Generally speaking, in large academic health systems, you are also viewed and treated like a physician (rather than a private practice all star who is beaming after singlehandedly getting an ASA 2 through a lap chole safely)

Where I did residency the attending surgeons treated my anesthesia attendings like garbage and most of them took it on the chin. Where I did fellowship the surgical attendings barely interacted with the anesthesia attendings. Where I am now I get respected/treated like a physician to the point where it makes me a little uncomfortable at times. Regarding the lap chole bit, I’ll refer back to above.

3) your skills will atrophy going into an private practice immediately. If you know you want to do only outpatient for the rest of your life (let’s say you’re older or don’t have many years of practice left, etc) then it may be a decent option. But if you’re relatively young and have 20+ years of working ahead of you and there’s a chance you may end up in an academic practice, you’re starting off on the wrong foot. We have had YOUNG physicians join our group (<10 years out) who didn’t know how to lead a team or teach others or multi-task or care for ASA 4's, all because they joined a Cush solo job straight out of residency. This is downright embarrassing and all of your colleagues will view you as a 🤡

I think you’re creating a false dichotomy that you’re either in academics doing real cases on sick patients or you’re atrophying in private practice. This is silly. There are high acuity private practice jobs and high acuity academic jobs and low acuity private jobs and low acuity academic jobs. I can recall examples of all 4, even in my relatively brief time doing anesthesia. And folks who are all tied up in academics are some of the most atrophied folks I’ve seen in terms of anesthesia capabilities. Someone who only does cardiac/thoracic, only OB, only liver, etc and hasn’t done any other area of anesthesia in years is somehow better because they have associate prof in front of their name? Or the inverse of that, the generalists that don’t do hearts, neuro, liver, peds, regional or OB because those are all done by sub-specialists? I don’t buy it. Sounds like something academics like to tell graduating residents to convince them to ignore the PP money so they’ll stay on and fill out the call schedule (while also justifying their decision to do the same). Nothing wrong with staying in academics. But only do it if you like teaching and/or it’s the right fit. You’ll have no trouble finding high acuity in PP, right up to VADs, transplants, etc.

 

[Hoya11]

#2 no question.

#1 sounds awful. 50-70hrs a week at 425K is not reasonable at all.

Lots of people taking about these salaries in the 500s but around me 425 with 6 weeks vacation for a call taking position if the market .. maybe some SDN inflation going on

 

[DocVapor]

I'm a few years out with a little one at a small-medium facility no hearts, no heads, but vascular, Ortho spine, healthy peds, and moderately busy OB. Plus a small ASC.

Take the #2 position all day every day and never look back. Enjoy your nights in your own bed never getting yelled at by the pregnant meth/fentanyl/etc addicts screaming for an epidural that isnt going to "work."

Bank the extra money you make compared to the other job. The faster you bank that money the sooner you can let ALL your skills atrophy.

 

[Urzuz]

You are asking us to weigh your family life and professional life, which only you can do. But if you want some quick facts regarding your professional life:

1) straight out of residency, supervising junior residents doing complex cases is the only way to get really good and slick, develop and then pass down your own practice habits, etc, no matter what anyone else says.

2) you will feel fulfilled professionally 1000x more teaching residents how to do anesthesia, getting to know the residents/students/surgeons/circulators/techs well, etc. Generally speaking, in large academic health systems, you are also viewed and treated like a physician (rather than a private practice all star who is beaming after singlehandedly getting an ASA 2 through a lap chole safely)

3) your skills will atrophy going into an private practice immediately. If you know you want to do only outpatient for the rest of your life (let’s say you’re older or don’t have many years of practice left, etc) then it may be a decent option. But if you’re relatively young and have 20+ years of working ahead of you and there’s a chance you may end up in an academic practice, you’re starting off on the wrong foot. We have had YOUNG physicians join our group (<10 years out) who didn’t know how to lead a team or teach others or multi-task or care for ASA 4's, all because they joined a Cush solo job straight out of residency. This is downright embarrassing and all of your colleagues will view you as a 🤡

4) you’re earning way more in the second practice, no two ways about it

Yikes. I don’t think this turned out being as nearly as funny/witty as you expected it to be while writing it. In any event, let me indulge you and enlighten you in the process.

I trained at a big name academic center (think one of the names that people throw around as having the best anesthesia residency in the country) with attendings that literally pioneered multiple aspects of anesthesia care. After having been out in practice now, I can confidently say that if I were having surgery, I would (in a heartbeat) pick an anesthesiologist who trained at a middle-of-the-road, no name residency, who has at least part of the time been doing their own cases for the last 15 years, over a lifelong academic anesthesiologist who never left the ivory tower after 15 years. And it’s not even close.

Don’t get me wrong - working at an academic center, teaching residents, pushing research forwards etc is extremely important, and it takes a very unique skill set that not many people have. I have the utmost respect for those attendings that stay at academic centers and take their job of teaching seriously (not all of them do). But if we’re talking strictly about the average anesthesia skill set of an average lifelong academic anesthesiologist versus an average lifelong private practice anesthesiologist, they are worlds apart.

As an aside, you clearly have no concept of what life is like outside of an academic center if you think that every private practice is filled with ASA 2s undergoing lap choles.

 

[Arch Guillotti]

As an aside, you clearly have no concept of what life is like outside of an academic center if you think that every private practice is filled with ASA 2s undergoing lap choles.

Very true. May not do hearts or livers or sick kids or whatever but many sick complicated patients in private practice oftentimes with limited resources.

 

[anaesthetic]

You are asking us to weigh your family life and professional life, which only you can do. But if you want some quick facts regarding your professional life:

1) straight out of residency, supervising junior residents doing complex cases is the only way to get really good and slick, develop and then pass down your own practice habits, etc, no matter what anyone else says.

2) you will feel fulfilled professionally 1000x more teaching residents how to do anesthesia, getting to know the residents/students/surgeons/circulators/techs well, etc. Generally speaking, in large academic health systems, you are also viewed and treated like a physician (rather than a private practice all star who is beaming after singlehandedly getting an ASA 2 through a lap chole safely)

3) your skills will atrophy going into an private practice immediately. If you know you want to do only outpatient for the rest of your life (let’s say you’re older or don’t have many years of practice left, etc) then it may be a decent option. But if you’re relatively young and have 20+ years of working ahead of you and there’s a chance you may end up in an academic practice, you’re starting off on the wrong foot. We have had YOUNG physicians join our group (<10 years out) who didn’t know how to lead a team or teach others or multi-task or care for ASA 4's, all because they joined a Cush solo job straight out of residency. This is downright embarrassing and all of your colleagues will view you as a 🤡

4) you’re earning way more in the second practice, no two ways about it

As an aside, you clearly have no concept of what life is like outside of an academic center if you think that every private practice is filled with ASA 2s undergoing lap choles.

Big yikes. I trust nearly all of my partners in PP with doing my anesthetic for any surgery. I trust close to zero academic anesthesiologists where I trained with the same for my family and me.

We do both care team and solo thoracic, cardiac, transplants, VADs, complex spine and neuro in addition to the usual other surgical subspecialties at a busy, big metro level I trauma center.

All of my partners (including non-cardiac) are pretty slick and are excellent clinicians. I can say the same for about 1-2% of the attendings who trained me. It’s kind of hard to “hone your craft” if all you’ve done for a decade or two is sit on your a** supervising two rooms and let the residents/CRNAs do everything.

 

[GoSoxGo]

Yikes. I don’t think this turned out being as nearly as funny/witty as you expected it to be while writing it. In any event, let me indulge you and enlighten you in the process.

I trained at a big name academic center (think one of the names that people throw around as having the best anesthesia residency in the country) with attendings that literally pioneered multiple aspects of anesthesia care. After having been out in practice now, I can confidently say that if I were having surgery, I would (in a heartbeat) pick an anesthesiologist who trained at a middle-of-the-road, no name residency, who has at least part of the time been doing their own cases for the last 15 years, over a lifelong academic anesthesiologist who never left the ivory tower after 15 years. And it’s not even close.

Don’t get me wrong - working at an academic center, teaching residents, pushing research forwards etc is extremely important, and it takes a very unique skill set that not many people have. I have the utmost respect for those attendings that stay at academic centers and take their job of teaching seriously (not all of them do). But if we’re talking strictly about the average anesthesia skill set of an average lifelong academic anesthesiologist versus an average lifelong private practice anesthesiologist, they are worlds apart.

As an aside, you clearly have no concept of what life is like outside of an academic center if you think that every private practice is filled with ASA 2s undergoing lap choles.

Wasn't meant to be witty or funny, was merely taking an extreme point like you did but in the opposite direction. The only way to get really good and slick is to do your own cases. You will be 1000000x more fulfilled professionally if you do your own cases. No respect from anyone unless you are in the room the whole time. Yada yada yada. Just as ridiculous as saying there are no sick patients or VAD's in private practice (thank you to you and the last few posters for confirming this).

The point is, good anesthesiologists are good - a guy ahead of me in residency was a badass; he went into private practice and does his own cases and I'm sure is one of the best in his group. He would be the same if he was in my academic department. But he probably likes doing his own cases. I personally enjoy supervising and am fulfilled. Get along great with surgeons. Everyone is different. There's bad clinicians in private and academics. But these silly blanket statements about average skill sets are ridiculous. What are you basing this one? How fast you can get a patient off to sleep if we had a race? Your understanding of pharmacology since you trained at such an amazing place?

 

[Urzuz]

Wasn't meant to be witty or funny, was merely taking an extreme point like you did but in the opposite direction. The only way to get really good and slick is to do your own cases. You will be 1000000x more fulfilled professionally if you do your own cases. No respect from anyone unless you are in the room the whole time. Yada yada yada. Just as ridiculous as saying there are no sick patients or VAD's in private practice (thank you to you and the last few posters for confirming this).

The point is, good anesthesiologists are good - a guy ahead of me in residency was a badass; he went into private practice and does his own cases and I'm sure is one of the best in his group. He would be the same if he was in my academic department. But he probably likes doing his own cases. I personally enjoy supervising and am fulfilled. Get along great with surgeons. Everyone is different. There's bad clinicians in private and academics. But these silly blanket statements about average skill sets are ridiculous. What are you basing this one? How fast you can get a patient off to sleep if we had a race? Your understanding of pharmacology since you trained at such an amazing place?

I appreciate you clarifying your post.

However I encourage you to talk to attendings that have practiced in both models and ask them what they think regarding their ability to develop their skills and actually get “good” at their craft. What does being a good anesthesiologist mean to you? Yes, speed and proficiency are two important aspects of being a good anesthesiologist (lines, blocks, inductions, wake ups, etc). But it’s also being able to recognize and diagnose problems as they evolve/progress. There is no other way to say it - unless you are doing those procedures yourself and you are there seeing the evolution of problems yourself, you cannot be as good as someone that does those things constantly, day in and day out. Are there outliers on either side of the argument? Sure. There may be people who have been intubating and putting in lines for the last fifteen years by themselves and it still takes them 20 minutes to put an arterial line. And there may be people who have supervised since the day they finished residency and they can still be extraordinarily facile when it comes to those procedural things, and they may be very vigilant and be able to detect nuanced issues that evolve during the course of a surgery.

I’m sure academic anesthesiologists would also be able to talk circles around most private practice anesthesiologist when it comes to the latest therapies for treating ARDS patients in the perioperative setting, or rattling off the physiologic derangements of an ESLD patient who is undergoing a liver transplant.

But ask yourself how each would fare in the others’ shoes. I have no doubt that a 15-year private practice anesthesiologist who has been at a tertiary care center would have no problem adjusting to the life of an academic anesthesiologist (when it comes to actual care of patients). They may struggle with teaching or publishing papers, but they would be able to care for the vast majority of patients with ease and it wouldn’t disrupt the workflow of the OR. However, I know for a fact that the converse isn’t true - lifelong supervising anesthesiologists can and do flounder and do disrupt the workflow of busy private practices if/when they try to make the switch.

I’m basing the above on the experience of seeing both sides of the coin and coming to my own conclusions. If you’ve only ever been in a singular practice setting, your head is in the sand and you have no idea how things work outside of your bubble.

Sorry if you’re offended by any of the above.

 

[GoSoxGo]

I appreciate you clarifying your post.

However I encourage you to talk to attendings that have practiced in both models and ask them what they think regarding their ability to develop their skills and actually get “good” at their craft. What does being a good anesthesiologist mean to you? Yes, speed and proficiency are two important aspects of being a good anesthesiologist (lines, blocks, inductions, wake ups, etc). But it’s also being able to recognize and diagnose problems as they evolve/progress. There is no other way to say it - unless you are doing those procedures yourself and you are there seeing the evolution of problems yourself, you cannot be as good as someone that does those things constantly, day in and day out. Are there outliers on either side of the argument? Sure. There may be people who have been intubating and putting in lines for the last fifteen years by themselves and it still takes them 20 minutes to put an arterial line. And there may be people who have supervised since the day they finished residency and they can still be extraordinarily facile when it comes to those procedural things, and they may be very vigilant and be able to detect nuanced issues that evolve during the course of a surgery.

I’m sure academic anesthesiologists would also be able to talk circles around most private practice anesthesiologist when it comes to the latest therapies for treating ARDS patients in the perioperative setting, or rattling off the physiologic derangements of an ESLD patient who is undergoing a liver transplant.

But ask yourself how each would fare in the others’ shoes. I have no doubt that a 15-year private practice anesthesiologist who has been at a tertiary care center would have no problem adjusting to the life of an academic anesthesiologist (when it comes to actual care of patients). They may struggle with teaching or publishing papers, but they would be able to care for the vast majority of patients with ease and it wouldn’t disrupt the workflow of the OR. However, I know for a fact that the converse isn’t true - lifelong supervising anesthesiologists can and do flounder and do disrupt the workflow of busy private practices if/when they try to make the switch.

I’m basing the above on the experience of seeing both sides of the coin and coming to my own conclusions. If you’ve only ever been in a singular practice setting, your head is in the sand and you have no idea how things work outside of your bubble.

Sorry if you’re offended by any of the above.

Not offended at all and appreciate the discussion.

I just talked to one of our more senior attendings who did academics right out of residency for seven years, then private practice for about ten years in a major city, and then returned to academics for the last five years or so. He did admit it took him some time to get used the private practice efficiency when he first left academics; part of this was that the surgeons went so much faster. But he caught up and was fine. He's one of our best generalists. Asked him whether he thought academic groups are better clinically than private ones. He said thirty years ago he would have said yes, but now he thinks it's a wash. If he had to pick an average clinician from either group to care for a family member he'd lean more towards academic dept because the private group has a few more anesthesiologists he wouldn't trust (ie have explicitly said they refuse to change their practice or learn anything new). Anecdotal, for sure.

We have two somewhat junior faculty in my department who are both very talented and hardworking and are both leaving academics for private practice (location, money and vacation reasons). Will take them a bit of time to adjust, but once they do they will be fine. If you can simultaneously cover a lung transplant and an emergency CABG/MVR overnight with two CA-2's you can adjust to fast private practice surgeons with sick patients. If you're motivated. Of course other colleagues of mine wouldn't be able to adjust. Depends on the person, as you said indirectly.

Not sure what you are getting at with anticipating the evolution of problems and detecting nuanced issues. If they happen right after the procedure then I'm there. If it's anticipating what will go wrong - if I'm covering a VATS with a CA-2 and a kidney transplant with an intern, you better believe I have to recognize and diagnose when things go wrong. You think I just induce and help line up and then go to my lab for the day?One could argue I'd have to be a bit better than even you at anticipating land mines, especially when I have three or four rooms with sick patients and traveler CRNA's. Pontificating about ARDS physiology doesn't help in these scenarios.

If the crux of your argument is that switching from academics has a lag time in terms of efficiency, I will agree with that. But is this a major factor in selecting a job? And of course as you admit the reverse is true, if you've only ever done your own cases and decide you want to switch to academics there will be a similar lag.

A good anesthesiologist to me is someone who gets sick patients through surgery safely. Not sure what it means to you - you start off saying it is about detecting nuances and problems early, but seem to conclude it's about not floundering around and disrupting the workflow of a private practice. I'll admit I've only worked in academics so am surely biased. Have you ever worked in academics?

 

[deleted875186]

My two cents ….

More respect as an anesthesiologist at a smaller community hosptial compared to the big city hosptial I trained at. Not even close.

You do sick patients in a community hosptial, and at times it’s more difficult than in the big academic center. You have to decide if case is appropriate for the hosptial, and you have limited backup.

Also, supervising residents can be stressful I imagine. I have never done it, but have little desire to do it.

 

[pgg]

Take job number 2 and use 4 of your vacation weeks to go do locums gigs at places with sick patients where you so your own cases.

That sounds good in theory, but I don't know if it is such a good idea to take on sicker patients at a place you are not familiar with and possibly without much back-up after months of doing easy cases.

This is what I did when I was in the military.

Fresh out of residency they sent me to a tiny hospital. It was me and 3 CRNAs and all we did was basic ortho, basic gen surg, low-risk low-volume OB, and ... not much else. Some OMFS. At one point the case load was so low the clowns in admin started booking outpatient vasectomies and wisdom tooth extractions in the main OR just to fudge the utilization numbers up a bit. No joke, it was that slow.

A few years later I moved to a bigger military hospital. It has a residency program but compared to the outside world, the acuity and case load are fairly low there. Hours were pretty good on the whole. Call burden wasn't bad, 2 or 3 in-house calls per month. Pay was poor - "half a day's pay for half a day's work crammed into an 8 hour day" ... but they didn't do hearts and as a CT-trained guy I had to look elsewhere.

Both places, I did a lot of moonlighting locums work. Sometimes I had to burn vacation time and travel to do it. Yes, it really IS harder working at a new facility. You don't know the people or where stuff is. But the only way to get confident and good at anything is to do difficult stuff.

The obvious downside - it can get to be a real grind when you spend a lot of your time off from cushy job #1 working busy job #2.


OP shouldn't worry about taking on sicker patients, even if only part time. He (?) finished residency, is safe, will do fine. Efficiency and comfort will come but there's no substitute for hours in the OR with sick patients. New grads should get them wherever they can.

 

[cchoukal]

I would echo the point made above about the new info on job #1: 55 hrs a week without call is 5 11-hr days, every week. That's M-F, 7am to 6pm. That is a serious grind and definitely worse than taking call and having some pre/post call time off.

 

[hckyplyr]

All great comments and pearls, all of which I greatly appreciate. Like I mentioned, hospital call is 10 weeks a year (one week at a time). If you're called in with a PP model, you get compensated based on case, time and block units. For the hospital employed positions (like job 2), should there be a call stipend just for taking home beeper call, plus a $/hr rate if called in? I've heard hospital admin is trying to take away the compensated call. To me that means I'm just working for free if I'm called in.

 

[NICMAN]

The going rate for night float (5 weekday-nights plus 2 weekend-nights) should be around $20,000 and/or some variation of a week off plus a premium payment for the 80 hours worked.(eg $50/hour to hold the pager and $300/hour if called in plus post call time off).

If they say the 10 weeks is included in your salary then you are being underpaid. I would ask for premium payment for times when you are called in to reduce the risk of call over utilization by the hospital with now downside risk on their part (they have set fixed costs whether you work one hour or 12 hours).

 

[vector2]

I appreciate you clarifying your post.

However I encourage you to talk to attendings that have practiced in both models and ask them what they think regarding their ability to develop their skills and actually get “good” at their craft. What does being a good anesthesiologist mean to you? Yes, speed and proficiency are two important aspects of being a good anesthesiologist (lines, blocks, inductions, wake ups, etc). But it’s also being able to recognize and diagnose problems as they evolve/progress. There is no other way to say it - unless you are doing those procedures yourself and you are there seeing the evolution of problems yourself, you cannot be as good as someone that does those things constantly, day in and day out. Are there outliers on either side of the argument? Sure. There may be people who have been intubating and putting in lines for the last fifteen years by themselves and it still takes them 20 minutes to put an arterial line. And there may be people who have supervised since the day they finished residency and they can still be extraordinarily facile when it comes to those procedural things, and they may be very vigilant and be able to detect nuanced issues that evolve during the course of a surgery.

I’m sure academic anesthesiologists would also be able to talk circles around most private practice anesthesiologist when it comes to the latest therapies for treating ARDS patients in the perioperative setting, or rattling off the physiologic derangements of an ESLD patient who is undergoing a liver transplant.

But ask yourself how each would fare in the others’ shoes. I have no doubt that a 15-year private practice anesthesiologist who has been at a tertiary care center would have no problem adjusting to the life of an academic anesthesiologist (when it comes to actual care of patients). They may struggle with teaching or publishing papers, but they would be able to care for the vast majority of patients with ease and it wouldn’t disrupt the workflow of the OR. However, I know for a fact that the converse isn’t true - lifelong supervising anesthesiologists can and do flounder and do disrupt the workflow of busy private practices if/when they try to make the switch.

I’m basing the above on the experience of seeing both sides of the coin and coming to my own conclusions. If you’ve only ever been in a singular practice setting, your head is in the sand and you have no idea how things work outside of your bubble.

Sorry if you’re offended by any of the above.

Not offended at all and appreciate the discussion.

I just talked to one of our more senior attendings who did academics right out of residency for seven years, then private practice for about ten years in a major city, and then returned to academics for the last five years or so. He did admit it took him some time to get used the private practice efficiency when he first left academics; part of this was that the surgeons went so much faster. But he caught up and was fine. He's one of our best generalists. Asked him whether he thought academic groups are better clinically than private ones. He said thirty years ago he would have said yes, but now he thinks it's a wash. If he had to pick an average clinician from either group to care for a family member he'd lean more towards academic dept because the private group has a few more anesthesiologists he wouldn't trust (ie have explicitly said they refuse to change their practice or learn anything new). Anecdotal, for sure.

We have two somewhat junior faculty in my department who are both very talented and hardworking and are both leaving academics for private practice (location, money and vacation reasons). Will take them a bit of time to adjust, but once they do they will be fine. If you can simultaneously cover a lung transplant and an emergency CABG/MVR overnight with two CA-2's you can adjust to fast private practice surgeons with sick patients. If you're motivated. Of course other colleagues of mine wouldn't be able to adjust. Depends on the person, as you said indirectly.

Not sure what you are getting at with anticipating the evolution of problems and detecting nuanced issues. If they happen right after the procedure then I'm there. If it's anticipating what will go wrong - if I'm covering a VATS with a CA-2 and a kidney transplant with an intern, you better believe I have to recognize and diagnose when things go wrong. You think I just induce and help line up and then go to my lab for the day?One could argue I'd have to be a bit better than even you at anticipating land mines, especially when I have three or four rooms with sick patients and traveler CRNA's. Pontificating about ARDS physiology doesn't help in these scenarios.

If the crux of your argument is that switching from academics has a lag time in terms of efficiency, I will agree with that. But is this a major factor in selecting a job? And of course as you admit the reverse is true, if you've only ever done your own cases and decide you want to switch to academics there will be a similar lag.

A good anesthesiologist to me is someone who gets sick patients through surgery safely. Not sure what it means to you - you start off saying it is about detecting nuances and problems early, but seem to conclude it's about not floundering around and disrupting the workflow of a private practice. I'll admit I've only worked in academics so am surely biased. Have you ever worked in academics?

In the spirit of Christmas, let me just commend both y'all for taking a back and forth which could've easily just been overcome with pettiness, vitriol, and name-calling (like so many other threads in this forum) and turning it into a productive discussion where the audience got to see good points regarding attending skill in both private practice and academics.

 

[nimbus]

If you can simultaneously cover a lung transplant and an emergency CABG/MVR overnight with two CA-2's

Is this a thing nowadays? Admittedly I was a resident a long time ago but we were 1:1 for lung transplants.

That said, I did academics for a year after residency and supervising residents was definitely more stressful than doing my own cases in PP.

My own take is that people should do academics only if they have a real drive for teaching and/or research and not because it is the lesser of two evils. Otherwise they are doing a disservice to the residents and to their department. If you don’t love teaching and you don’t have a pet topic you’d love to investigate further by the end of CA-3 year, do not do academics. You’ll be a lot happier in PP where the expectations are much different. If you’re not a teacher or a researcher in academics, you will be a 2nd class citizen of your department.

 

[Justice4all]

Academics has changed. Only handful of programs are truly about education and research. The rest are just PP limited by ACGME rules.

 

[Iso4ane]

The only part of this that’s truly unique to academics is the passing down of practice habits. I’m PP, 100% solo, doing open AAAs, hemi-arches, low EF/redo cardiac surgery, big surg onc belly whacks, lots of thoracic, lots of cranis, occasional awake crani.

You’ll have no trouble finding high acuity in PP, right up to VADs, transplants, etc.

I curious to hear more details about this gig. IF i wasn't in academics, this sounds like the gig I want.

 

[Beeftenderloin]

I curious to hear more details about this gig. IF i wasn't in academics, this sounds like the gig I want.

I usually have 2-3 higher acuity days per week doing the type of cases mentioned (with lots of “healthy” outpatient CABGs and valves as well), then the rest is lower acuity stuff like simple gyne, ortho, GI, etc. Not doing VADs/transplant at my shop but the big tertiary center a few suburbs over has a private anesthesia group and private cardiac surgery group doing heart transplants, LVADs and lots of MCS.

 

[GoSoxGo]

Is this a thing nowadays? Admittedly I was a resident a long time ago but we were 1:1 for lung transplants.

That said, I did academics for a year after residency and supervising residents was definitely more stressful than doing my own cases in PP.

My own take is that people should do academics only if they have a real drive for teaching and/or research and not because it is the lesser of two evils. Otherwise they are doing a disservice to the residents and to their department. If you don’t love teaching and you don’t have a pet topic you’d love to investigate further by the end of CA-3 year, do not do academics. You’ll be a lot happier in PP where the expectations are much different. If you’re not a teacher or a researcher in academics, you will be a 2nd class citizen of your department.

Occasionally. We usually try to be 1:1 for lungs, sometimes have a second CRNA room with a straightforward case. But overnight we only have one cardiac person on call so sometimes you get unlucky and have two cardiac cases simultaneously.

Agree: re enjoying teaching and/or research.

 

[aafisahar]

Academics has changed. Only handful of programs are truly about education and research. The rest are just PP limited by ACGME rules.

"Healthcare is a ****ing meat grinder. People go in one end, and meat comes out the other. All we do is turn the handle."