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Here's some fairly interesting spam I got today regarding physician happiness. It surprising to me how many people describe themselves as unhappy or worse at work, and it makes me think I might have a pretty damn good gig going. This survey also makes me think about the viability of non-medical careers for MDs, which is likely something I'll do a video and/or presentation on in the future.

Physician happiness, in 5 charts

Fewer than half of physicians said they were happy at work in 2022, a significant drop from before the pandemic, according to Medscape's 2023 Physician Lifestyle and Happiness Report. See the trends, charted.
www.advisory.com www.advisory.com


In other news, my financial advisor approached me about appearing on stream, so he'll be doing a live Q&A at some point in the near future when our schedules mesh. I'll keep you guys apprised of that, because he has been extremely helpful to me. He represents Larson Financial, which is a company that only work with physicians as clients, so they're fairly tuned into the weird post-residency jump in salary we experience, the massive student debt loads, etc. For the record, there won't be any money changing hands on either side for this experience. It's purely educational, though I'll say I've been happy with his services and hope he gets some additional business out of the deal.
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MilkmanAl said:
Critical care is pretty cool! It requires an extra year of fellowship after training, so the additional commitment isn't as damning as some other fellowship tracks. You get to care longitudinally for the sickest people in the hospital, and if I do say so myself, anesthesiologists make the best intensivists due to how much time we spend training to manage catastrophes. The more long-term, maintenance care is what the fellowship is good for.

Unfortunately, if you're looking to avoid academic practice, your options may be limited. At least in my area, anesthesia-led ICUs basically don't exist outside of large tertiary care centers. In fact, I don't know of any, other than the two major academic institutions in town. Maybe that's different elsewhere and someone else can weigh in accordingly? My hospital would support a dedicated ICU team, but they're just now transitioning to that and are using pulm docs. You might be able to wrangle a tele ICU position, as I think that's what more remote, smaller locations are moving toward these days.

Also a bummer is that you're probably going to take a pay hit to focus on critical care. (That would likely not be the case for telehealth, but I digress.) When there are pulmonologists available to work for $300k-350k, it's tough for hospitals - especially smaller ones - to justify the cost differential to pay you anesthesia money. You might find a group somewhere that rotates people through the ICU and the OR as part of their contract with the hospital, so the pay doesn't suffer, but again, I don't know of any places locally that function that way.

Matching is going to be a strange beast from here on out. Anesthesia has been absurdly competitive in the last 2 matches compared to how it was historically. With Step 2 presumably being the new Step 1 in terms of sorting competitiveness, that'll absolutely be critical to score well on, as you say. Research is always a plus to your app, but if you're content to match in the Midwest or mid south, I'm going to wager that you're fine without it, changes in specialty competitiveness notwithstanding. Otherwise, just button up your app the best you can. Knock out good clinical grades, get decent letters, prep smartly for your interviews, and apply broadly. Oh, and tell them I sent you! That'll get you matched, for sure.
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Hey! I've been debating between the EM vs IM vs Anesthesia path to CC myself. Anesthesia/cardiac/CC seemed pretty appealing, and you definitely go into fellowship with a great headstart in the physio and procedural department.

However, I want to /be/ an Intensivist preferably at an academic institution as I want to get involved heavily with teaching, with a touch of research. Would you still recommend the Anesthesia pathway over the PulmCC path in these conditions? Anesthesia seems like a more "fun" path as it's overall more interesting than IM and gives you a lower burnout fall back point but I feel like while Anesthesia has it's advantages in CC so does IM and they may be harder to pick up down the road

Thanks!
 
GotToGetThatGPAUp said:
I want to /be/ an Intensivist preferably at an academic institution as I want to get involved heavily with teaching, with a touch of research. Would you still recommend the Anesthesia pathway over the PulmCC path in these conditions?
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Yeah, I'd honestly recommend going through anesthesia for critical care, regardless of what you ultimately want to do with that training. To reiterate what I mentioned previously, you're going to be quite a bit better at the emergency management and resuscitation portions of the job with an anesthesia background than anything else. If/when you decide to leave the academic world, your income potential will be quite a lot higher than with IM, too.
 
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GotToGetThatGPAUp said:
Hey! I've been debating between the EM vs IM vs Anesthesia path to CC myself. Anesthesia/cardiac/CC seemed pretty appealing, and you definitely go into fellowship with a great headstart in the physio and procedural department.

However, I want to /be/ an Intensivist preferably at an academic institution as I want to get involved heavily with teaching, with a touch of research. Would you still recommend the Anesthesia pathway over the PulmCC path in these conditions? Anesthesia seems like a more "fun" path as it's overall more interesting than IM and gives you a lower burnout fall back point but I feel like while Anesthesia has it's advantages in CC so does IM and they may be harder to pick up down the road

Thanks!
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Anesthesia.

Honestly, don't do critical care. But, even if you do, go the anesthesia route. You'll be so much more comfortable with pharmacology, codes, and procedures compared to IM.

I would also consider which of the three specialties you would most be content with if you decide not to go critical care. I would argue anesthesia is the best job market, the happiest people, and the most fun of the three. Obviously I'm biased.

I've watched a CA-1 teach a IM trained pulm crit fellow to do an Aline. I've watched CA-3 on call bail out EM and IM trained crit care on airways. Unless you go to a weak program, I really think it is also the best route to CC.
 
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I agree with basically all of that. I'd also add that as CA2s in the unit, we were the line coaches for everyone from pulm and nephrology fellows (dialysis catheters) down to the rotating EM residents.
 
Hey all, a question for you: I ran across the updated pediatrics residency requirements, and at first glance, they look absolutely awful for the future of pediatrics. Between doing away with critical and other advanced care training and allowing for institutions with limited/inadequate resources to start training programs, my impression is that we're massively dumbing down the profession. That sure doesn't seem like it'll allow pediatricians to compete with mid-level providers very well. Am I missing something, here? What's the buzz?

I talked about it last night on stream (link below, spread out over the first hour or so, if you're interested), but I'm trying to see if my take is off-base. It seems awful for docs and future trainees.
 
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MilkmanAl said:
Hey all, a question for you: I ran across the updated pediatrics residency requirements, and at first glance, they look absolutely awful for the future of pediatrics. Between doing away with critical and other advanced care training and allowing for institutions with limited/inadequate resources to start training programs, my impression is that we're massively dumbing down the profession. That sure doesn't seem like it'll allow pediatricians to compete with mid-level providers very well. Am I missing something, here? What's the buzz?

I talked about it last night on stream (link below, spread out over the first hour or so, if you're interested), but I'm trying to see if my take is off-base. It seems awful for docs and future trainees.
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It just seems like the MD profession as a whole has gone dramatically done. The AMA doesn't lobby for physicians like they should meanwhile midlevels consistently get more autonomy and power within the medical field. The way this is headed is no distinct difference in the ability to care for patients with MD's compared to midlevels. The difference will ultimately come down to patients and who they choose to be treated by. I hope I am wrong and it doesn't come to this...
 
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Quite frankly, it looks like peds residency is angling toward pediatricians being midlevels with a whole bunch of experience and background education. I simply don't understand the elimination of subspecialty care. If you're supposed to be an expert at referring your patients out (???!?!?), shouldn't you know some basics of those specialties to which you're sending people and which conditions warrant specialty care? This does not compute.
 
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MilkmanAl said:
Quite frankly, it looks like peds residency is angling toward pediatricians being midlevels with a whole bunch of experience and background education. I simply don't understand the elimination of subspecialty care. If you're supposed to be an expert at referring your patients out (???!?!?), shouldn't you know some basics of those specialties to which you're sending people and which conditions warrant specialty care? This does not compute.
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That would make going into peds a liability. If you're new and you miss something your peers with experience would have spotted due to them having more training couldn't you get sued?
 
Yeah, it definitely means that. Precedent would be radiologists missing a read and getting sued. After reading a little more, some seem to think this change is to legitimize ridiculous fellowships like the one for pediatric hospitalists. How do we make a year fellowship for teaching pediatricians how to be pediatricians worthwhile? Don't teach them anything but outpatient medicine in residency! Flawless plan!
 
MilkmanAl said:
Yeah, it definitely means that. Precedent would be radiologists missing a read and getting sued. After reading a little more, some seem to think this change is to legitimize ridiculous fellowships like the one for pediatric hospitalists. How do we make a year fellowship for teaching pediatricians how to be pediatricians worthwhile? Don't teach them anything but outpatient medicine in residency! Flawless plan!
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Who is spear heading this? That extra training is what makes parents take their kids to a peditrician vs family medicine.
 
It's straight from the ACGME, and my understanding is the changes are already made. Someone correct me if I'm off-base, though. I'm at a loss as to how these are positive changes.
 
Don't mean to change the subject, but curious on your thoughts on general vs. peds anesthesia. I've heard you don't really need any of the fellowships to do those specialties aside from maybe cardiac, but I was curious if you can keep doing adult anesthesia following a pediatric anesthesia fellowship. Is this entirely uncommon or is it just workplace dependent? M2 here. Thanks.
 
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cjmurph14 said:
Don't mean to change the subject, but curious on your thoughts on general vs. peds anesthesia. I've heard you don't really need any of the fellowships to do those specialties aside from maybe cardiac, but I was curious if you can keep doing adult anesthesia following a pediatric anesthesia fellowship. Is this entirely uncommon or is it just workplace dependent? M2 here. Thanks.
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Dude, I'm sorry, I totally missed this question. Sorry about that. Peds is a decent choice for fellowship, as it definitely increases your employability in general and also opens up work at children's hospitals, if that's your thing. To be clear, you can absolutely still do adult anesthesia after a peds fellowship. In fact, I'd say that's the case for most people. You might funneled preferentially toward the pediatric cases in your practice, but you'll still be a generalist.

As for my personal opinion on the fellowship, it sure seems like a lot of effort to make your life more stressful. Pediatric anesthesia can get dicey in a hurry, and some of those kids in children's hospitals are *crazy* sick. There's not really a pay incentive to go peds, either. I'm happy to keep my peds exposure to sports injuries and ENT, thanks.

I actually came here to congratulate everyone on matching and to encourage and sympathize with those who didn't. Emergency medicine appears to have eaten the fattest of phalluses this year, so there are at least a fair few spots there. Also, don't discount the possibility of opportunities outside of personal clinical practice. Consulting, expert witnessing and other legal advising, medical directorship of clinics or outpatient services (dialysis and hospice come to mind), medical spas, insurance reviews, and a bunch of other career paths are great options that are actually fairly lucrative. You may need to eat a prelim year to qualify for a medical license for some of those, but there's always hope. There are always *good* options when you have a MD. Wherever your paths take you, congrats on finishing med school, and best of luck on your next steps.
 
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Very naive MS2 here with a high interest in anesthesia. Thanks for keeping this thread going and being an active responder.

Given the difficulty in finding LOR authors, is it worth trying to get one from an anesthesiologist outside of a teaching environment if it's solely shadowing? I met a PP guy in my neighborhood that is an alum from my school and we chat regularly, but I don't envision using my elective to rotate with the hospital he works at (I don't even know if that hospital group allows students to rotate).

Not sure he's even open to the idea yet, but want to gauge the reality of whether or not exploring that path would be worth it over the next few months/as I start my rotations.
 
My impression of rec letters is that pretty much everyone in anesthesia understands that it's a very revolving-door sort of situation in the OR. As long as you have at least a couple days' worth of experience with someone and are willing to sit down and chat with them so they can get a few personalized pearls to include about you, getting a LOR shouldn't be a huge deal. That said, it'd behoove you to get involved in an anesthesia interest group and seek out a few people you click with during your rotations. Also, it looks like anesthesia is getting remarkably more competitive over the past few years, so maybe getting involved with some anesthesia research would be a good way to both pad your resume and get a letter or two.

If you know a guy in the anesthesia community, I'd definitely try to get involved with him professionally in some capacity. That could mean just some shadowing, or it might mean a rotation, if that's a possibility. Either way, he may have some connections that could be useful for you. Anesthesia is a really small community, so it's quite likely he can help you out.

Good luck on your road to the best specialty ever (totally not biased). Hopefully that was useful info or at least confirmation of what you suspected. I'm happy to answer any other questions you can think up.
 
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MilkmanAl said:
My impression of rec letters is that pretty much everyone in anesthesia understands that it's a very revolving-door sort of situation in the OR. As long as you have at least a couple days' worth of experience with someone and are willing to sit down and chat with them so they can get a few personalized pearls to include about you, getting a LOR shouldn't be a huge deal. That said, it'd behoove you to get involved in an anesthesia interest group and seek out a few people you click with during your rotations. Also, it looks like anesthesia is getting remarkably more competitive over the past few years, so maybe getting involved with some anesthesia research would be a good way to both pad your resume and get a letter or two.

If you know a guy in the anesthesia community, I'd definitely try to get involved with him professionally in some capacity. That could mean just some shadowing, or it might mean a rotation, if that's a possibility. Either way, he may have some connections that could be useful for you. Anesthesia is a really small community, so it's quite likely he can help you out.

Good luck on your road to the best specialty ever (totally not biased). Hopefully that was useful info or at least confirmation of what you suspected. I'm happy to answer any other questions you can think up.
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Thanks for the crazy quick reply! I've cranked out a couple non-gas projects so far and having a gas project in the works (albeit, more of a surg project). My conversion to the gas gang has been a recent development, but the aforementioned bloodbath the match has become has me anxious even before starting my rotations about what all I'll need to do.

And thanks for the advice! I'll slow-roll the idea to him next time I see him and see if he's open to it, or as you mentioned, knows someone else who might be.

My school doesn't have a home program, but there's a new residency in the area and the PD is an alum of our school. Is it worth cold-emailing them directly if I have their contact info, or would that be jumping the gun too early at this point?
 
Cold calling is never a bad idea, but I'd do it fairly close to the time when you'll want to set your rotation up. Like, if you're a year out from the potential rotation, you'll get lost in the shuffle. Maybe float the idea a few months before set-up time in case they need to get some clearances and credentialing stuff done with the hospital ahead of time, and then send a "Hey, remember me?" email when you're actually in the process of setting up your schedule.
 
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We had an OB patient with untreated moyamoya this morning. I sleepily placed her epidural after a planned labor induction got rolling, and I found that little tidbit in her chart while documenting the procedure. The nurse - a really good, experienced OB nurse, for the record - and the patient didn't mention anything about it, and when I asked the OB doc, she kind of brushed it off as something she noticed but didn't give much thought to. I work at a medium-sized community hospital, and while we supposedly don't do any planned high-risk OB, an untreated cerebral vascular malformation is about as high-risk as an OB patient gets, in my book. She definitely has no business being at the hospital, and we have protocols in place to get these patients through our pre-op clinic for more testing, evaluation, and if necessary, care transfer. Of course, all of that gets dashed if the physicians don't recognize danger when they see it, so now we're stuck with this laboring mom who's at extremely high risk for a stroke in a facility that barely has a functioning NICU and will struggle to handle a massive peripartum bleed.

The moral of the story is that whatever specialty you choose, try to keep your scope of knowledge at least broad enough to recognize impending doom. It gets really easy to laser focus on your field, but you have to maintain some understanding of everything else to take good care of your patients. At the very least, have the balls to just punt to someone else when you see something you don't recognize. Don't know WTF moyamoya is? Look it up. Ask anesthesia. Ask vascular surgery. Ask SOMEONE. Don't just let it cruise by unattended, because then you set up yourself and everyone else involved in the case for catastrophic failure.
 
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I care of these patients regularly for revascularization and associated procedures. They are someone I would absolutely not want to manage at a community type hospital, and I would think labor and delivery would be extremely high risk. They can have bad outcomes in experienced centers with experienced physicians.
 
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Thanks to my newborn basically never sleeping, my social media activity has been markedly decreased over the past few months and virtually non-existent over the past month. Fortunately, due largely to the magic of sleep, I'm looking to turn that around. With any luck, I'll be back to regular content creation and streaming effective immediately. I generally try to steer away from pure self-promotion and provide some value with each post, but I figured I'd toss out an update given my recent absence.

With that in mind, this is crunch time for lots of you. Whether you're starting med school, residency, or a new job, you're about to make a huge transition. As always, I'm open to any questions about those issues. For tonight's stream, the plan is to stave off the forces of Hell in Diablo 4 and discuss a really interesting neurosurgical case I did recently. The rest will be open time for catching up on current events and addressing any questions you may have. I hope to see you there from 8-10P Central time. Links are in the first post of the thread. Cheers!
 
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do you have any concerns about the future of the field with regarding to PE taking over a lot of practices?
 
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MilesDavisTheDoctor said:
do you have any concerns about the future of the field with regarding to PE taking over a lot of practices?
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Private equity takeover is a constant threat to all medical practices. However, many hospitals are figuring out that while slashing costs via doc salaries saves some money up front, it ultimately costs much more in lost productivity (cancelled cases and appointments, poor throughput, etc.) and to restaff once everyone leaves. Patient care almost always suffers somehow, usually through quality, timeliness, or both, and in this era of ubiquitous social media, multiple strongly negative reviews are awful for business. My hospital, in particular, bit on the PE strategy for the ER and got massively burned. They have straight-up told our group that they have no interest in forcing us out in favor of a potentially cheaper corporate option because of that failure. Like everything else, this trend will ebb and flow. We'll never be free of the threat of corporate takeover, but hopefully we'll get to a point where enough institutions have been burned by crappy care and mass exoduses post-buyout that they'll lean against that option.
 
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Well, it's job search time for lots of senior residents, and the "Is this a good contract?" threads are cropping up on message boards across the land. My experience is that med schools and residencies alike go out of their way to obfuscate earning potentials for a variety of reasons, so please do your due diligence in uncovering what fair market value and reasonable contract terms in your area are. I am definitely not a contract lawyer or legally savvy in any capacity, but I am happy to (very superficially) address any contract clauses that seem questionable. Of course, I strongly advise you to seek professional assistance in that matter, but it's sometimes nice to have someone with an eye towards the clinical side of things have a look (vs. only addressing the legalese). I'll likely talk about contract terms live at some point in the near future. Also, you can find some rather useful (though admittedly a bit outdated) salary info here: Discord - A New Way to Chat with Friends & Communities
 
Hey all, long time, no see! This year has been absolutely brutal for me, but hopefully it's been a bit better on your end.

Anyway, I'll be discussing all things finance surrounding medicine and medical education, so if you're interested and want to throw in your two cents, please join! I'm not a financial expert at all, so this'll very much be a "do as I say, not as I do" and "learn from my mistakes" sort of deal. I can use all the help I can get.

8P Central on the YouTube and twitch channels in the first post.

Edit: Finance talk postponed to 1/24, per the hosting Discord server's request. I'll still be on tonight if you want to chat, though.
 
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Congrats, everyone, on rank list submission! Hopefully there are lots of first-choice matches up in here!

On another note, in honor of all the folks about to start new jobs in July, I'll be talking about things to look for in a contract and private equity/corporate involvement in healthcare staffing tonight at 8 Central. Come hang, share your rank lists, dish the dirt on programs, blow off some steam, and maybe learn something in the process. See you then!

 
Good luck tomorrow, everyone. Remember that whatever happens in the match, you have amazing, lucrative, fulfilling career options ahead of you, even if they're not strictly speaking in medicine but here's hoping you all match what you want where you want!
 
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Okay, folks, spill it! Where did you match? Happy? Not happy? What rank did you get? Regardless of the above, huge congratulations on taking the next huge leap in your career. Best of luck to everyone! I'm available for questions any time, as always.
 
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