Can't decide

[Low Flow]

CA3 considering two job options:

Stay at university hospital where I did residency
- 95% supervision of residents/anesthetists.
- no OB, peds, cardiac, regional without fellowship.

Private practice group in town
- two year partnership track, 10-12 weeks vacation once partner.
- busy OB service.
- 95% physician only cases, including blocks, healthy peds.
- no major vascular, cardiac, transplants. Mostly ASA 1-2s.
- probably more demanding call than university hospital because OB.

Overall compensation between the two is probably minimal but would favor the private group in the long run. I'm struggling with the choice between doing all of my own cases/procedures and supervising. I'll admit I do get bored with the downtime of a long, stable case. It would be nice to be the attending who can come/go as they please. The university job probably has an easier call schedule too given lack of OB. On the other hand, I do love regional, and I enjoyed OB for the most part. I fear I would lose those skills quickly without practicing them. I'd imagine it's easier to go from solo cases to supervising later in my career than vice versa.

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[deleted875186]

No brainer for me, do your own cases. Supervising CRNAs stinks, and supervising new residents is probably even worse.

 

[sevo00]

You don’t want your first job to be one without OB or regional. I’d take a pay cut to continue doing my own cases

 

[nimbus]

No regional or OB without fellowship? Seriously?? The university apparently has a lot of faith in their own graduates.

What cases will you actually do at each hospital? Neither job seems good from a case mix standpoint.

 

[IMGASMD]

Number 2.
No crna.
Better vacation.
OB and regional.

All the stuff I need right now in my practice.
You just need to tell me how often the call is, I am there….

You really need/should do your own cases for at least a while. It’s different when you are a resident, I don’t cares how independent you are as a ca3. The mindset is different.

Talked to a partner recently, who has an offspring also went into anesthesia, then did a neuro fellowship. His criticism of his own kid is that they never did their own cases. They’ve always had someone else “available” during their training. Food for thought.

 

[Urzuz]

Sitting your own “long, boring, stable” cases hits different when 1) the parking meter (unit generation) is running the entire time, and 2) you don’t have an attending looking over your shoulder and if anything goes sideways it’s on you to figure it out.

Definitely option #2.

 

[POW16]

#2 as long as call frequency/intensity is not super high.

 

[pocafx]

I’ve been practicing about 3 months. Md only. I haven’t done cv, vasc, thoracic but want to. I am doing OB, regional, and all generals. Being the only anesthesia person in the room is definitely eye opening and good experience. Also learning the private practice way. Lots of things different than academic center

 

[GassYous]

I had a pretty rigorous residency, saw everything, did everything and I gotta tell you, the first year was not easy. Making the tough decisions yourself, sick patients crashing, dealing with the politics, it's quite a ride. Number 2 and it's not even close.

 

[vector2]

It's not even a question. Most people don't finish their career at their first job and I would be very loath to hire a generalist who hadn't been doing any OB or regional.

 

[nimbus]

I had a pretty rigorous residency, saw everything, did everything and I gotta tell you, the first year was not easy. Making the tough decisions yourself, sick patients crashing, dealing with the politics, it's quite a ride. Number 2 and it's not even close.

It's not even a question. Most people don't finish their career at their first job and I would be very loath to hire a generalist who hadn't been doing any OB or regional.

The learning never stops and the learning curve remains steep in the first few years out of residency. People get more savvy over time. I agree it’s not a good idea to take a very limited job early in your career. As much as possible, the OP should find a job where they can refine and improve the skills they acquired during residency.

 

[Harpoon1]

don't fret if you like the university setting where you are, there are definite benefits to it. I took the #2/PP route myself but I think the whole you gotta do OB / regional , etc etc. is getting slightly overdone here.
are you a hard worker?
are you a team player?
Those are more important at dictating your professional success than this decision for your first job. If you are that worried about losing OB/regional skill cover some calls at another facility every once in a while. This shouldn't be a fear based decision but a "best fit" decision on where you actually want to work everyday (and OB sucks).

 

[Ashers]

2.

I took that route. Do I regret it? Only the part where I did ob. If you like ob, it sounds fine. I went into my first job knowing I hated it. I didn't get to do thoracic and vascular because "those are cardiac cases" at the level 3 trauma center I worked, even though I was willing. Except the ruptured diaphragmatic hernia I had in the middle of the night on new years with a regular gen surgeon... That was fun.

Make sure call is a schedule your can tolerate. I was told 1 thing, and experienced another, because I was "young and liked to work."

 

[rakotomazoto]

Give #2 a try for all of the reasons mentioned already. Your alma mater will most likely take you back later on if you totally regret your choice and want to switch at some point, although I think it's unlikely that you would want to once you have had a little taste of private practice.

 

[Maz777]

Easy call. Do your own cases. Supervision sucks. That's a good amount of vacation. If the call frequency is even, go PP.

 

[deleted875186]

Wow, a consensus, truly rare for one of these threads

 

[Mehd School]

Grass is always greener. I did option #1 and that went to **** so now I'm a month out from joining option #2. Except I only get to do my own cases 2 days a week. But I'll do hearts, blocks, OB etc. What your academic place is doing is not real anesthesia. Not letting a board certified anesthesiologist put a needle in an armpit or a back because they didn't complete an extra unnecessary fluff year is asinine.

 

[anbuitachi]

#2. unless u want to be a lifer at #1, u want OB and especially regional experience.
for OB, if epidural doesnt work, worst case is you redo it.
for regional, you dont want patient to scream in pain if your blocks dont work. bad look

 

[coffeebythelake]

I’ve been practicing about 3 months. Md only. I haven’t done cv, vasc, thoracic but want to. I am doing OB, regional, and all generals. Being the only anesthesia person in the room is definitely eye opening and good experience. Also learning the private practice way. Lots of things different than academic center

Probably the number one thing.. surgeons who don't take 4 hours to do a lap chole

 

[IlDestriero]

2 unless the call is ridiculous.

 

[repititionition]

Academics will always take good people back. Good PP jobs will often not look at people who have been in academics too long because they understand the issues that come with it. See all the posts above.

While the PP is arguably also quite limited in what you’ll see and do (ASA 1-2, no vascular, etc), at least you’re still using peds, regional, and OB skills. Do yourself a favor and take the PP job at this point in your career.

 

[TexBlazer2106]

Decisions like this are largely personal and how your career fits in your life/family goals is unique to you.

That being said, I'm a few months into an MD-only PP job after training at large institutions and working at one for 2 years as an attending, and I love it. It's much more fulfilling and affirming as an anesthesiologist than what I'd experienced before.

 

[Gern Blansten]

The unanswered question is how long until group number 2's senior partners sell to private equity firm and completely change how the group operates? If they sell in a year and a half, you likely get none of the share and are left with a job that is not what it was advertised as. I have seen it happen fairly often. Senior partners who are close to retirement get all of the benefit (nice lump sum payout) and a nice guaranteed salary to finish out their career and the junior non-partners are left in the cold.

 

[Twiggidy]

I find it interesting that the overall compensation between and academic practice and a private practice with busy OB is minimal.

 

[agammaglobulin]

I find it interesting that the overall compensation between and academic practice and a private practice with busy OB is minimal.

I'd guess if you broke it down to hourly pay, the PP pays more. Likely the academic place has significant less vacation - never heard of academics giving 10-12 weeks off.

 

[Twiggidy]

I'd guess if you broke it down to hourly pay, the PP pays more. Likely the academic place has significant less vacation - never heard of academics giving 10-12 weeks off.

Ah yes. That’s true.

I would just make sure when I’m not on vacation that I’m not doing a ridiculous amount of call

 

[ambiturner]

I find it interesting that the overall compensation between and academic practice and a private practice with busy OB is minimal.

My academic job is one of the highest paying in the area if you include benefits. That says more about the area market than my job in particular though. But the traditional, partnership track jobs are hurting these days, associates wanting more money thus lower buyin going to partners and stagnant reimbursement = lower pay.

 

[Katheudontas parateroumen]

Just started as an attending so I don’t have as much perspective as some on here.

I’d say go where you feel supported. It’s vitally important to still have some mentorship as your first couple years as an attending are still steep learning curves. You want to be in a good environment. Starting out with your residency program, obviously assuming you actually liked it, is a natural transition. Get some experience under your belt and you can easily move on if you don’t like it. Also, just from a small small sample size, academics are usually long term type jobs that have very little turn over so it really could be your “forever” job if you wanted it to be. At which point it wouldn’t matter so much you don’t experience here and there doing certain types of cases. Also, since it’s your residency program, you probably have some leeway saying “hey, I wanna be solo today” I’m sure. And of course you can continue to learn from all the specialty attendings. Also, I’m sure on call at night, there’s no super sub specialists other than maybe cardiac and peds, so it’s on you to do as much you want. All is to say, the academic one isn’t so bad.

Right now I supervise CRNAs and in the near future residents. I have already needed to bail them out a few times. So skills are not as sharp as a do it yourself place, but don’t degrade all that much… and I haven’t done anesthesia is over year since my icu fellowship.

Good luck!

 

[Agast]

If you really want to work at the place you trained, I think you should leave for a few years and then come back. Otherwise it’s hard for people to see you as their attending peer, and not a super senior resident. I think that’s true for all specialties. You don’t want to get dumped with the bs department responsibilities.

 

[Reveler]

It sounds like the resounding chorus is pointing you toward #2. I entertained similar scenarios while considering my first contract (still in fellowship btw). The landscape is constantly changing, and positioning yourself to be the most successful should your personal or professional situation change is important. Especially early in your practice. The academic shops I'm familiar with tend to cause some procedural (and mental?) atrophy as attendings mostly watch everyone else do stuff (especially when not doing peds, OB, regional, etc.). Not saying that you couldn't do stuff as the situation arises later in your career, but when COVID hit, I remember most of my young attendings lamenting not being able to jump ship and take other jobs for fear they couldn't take care of peds, OB, sit their own cases ("I haven't put in an a-line in 10 years!"), etc.

Besides, do you really want to watch sweaty CA1s fumble through failed procedures only to jump in at that last minute to save them over and over and over and...

 

[Reveler]

If you really want to work at the place you trained, I think you should leave for a few years and then come back. Otherwise it’s hard for people to see you as their attending peer, and not a super senior resident. I think that’s true for all specialties. You don’t want to get dumped with the bs department responsibilities.

This is a good point. I see this a lot where I trained. There's definitely a weird tenure problem where all the schedule makers shaft the youngins bc they see them as basically CA4s/5s. They inevitably always get the fresh CA1s while the old guys get the long all day cranis and sit on their a** in the office and drink coffee.

 

[kidthor]

Unless you have a burning drive to do academics I would do job #2. I’m in academics (due to having a particular research interest) and do about 1/3 supervising residents, 1/3 supervising CRNAs, 1/3 solo.

My solo days are absolutely the best, no question - it’s comparatively relaxing and fulfilling. I know the patients are getting good care and we all trained in anesthesiology to provide anesthesia (a shocker, I know).

Supervising residents can be rewarding because they are generally eager to learn and I like being able train intelligent, hardworking doctors who want to be good future anesthesiologists. There are a few bad apples, but it’s very rare. I also give some lectures which is good because the residents are engaged and interested, but it does take a lot of work to make a good talk, and it’s all 100% uncompensated time.

Supervising CRNAs often sucks. Yes sometimes it gets you a bit of down time. But more often you’re hustling while you don’t know what’s going on in the room and you know it’s inferior care, yet you play along as if it’s somehow ok. Luckily most CRNAs I work with currently are nice people, but honestly a good number of them are sloppy and careless and cause bad outcomes. At prior institutions some were outright hostile and dangerous. Plus academic places often want you to go 1:3 or 1:4 - which causes you to run around like an idiot. Want to simultaneously supervise an ultra sick EVAR, a bloody ortho onc case, then be expected to also supervise a prone ERCP under “MAC” on a completely different floor? Unfortunately this is common in academics.

Another few downsides to academics…. The benefits are generally getting much worse. At my shop we have 4 weeks of vacation, no academic funds, no meeting days, a retirement vesting period of several years - oh and they stopped contributing during COVID… the main requirements are 50 hr clinical weeks with a collateral expectation to teach occasional lectures for free and publish here and there in your spare time.

So yeah - I’d recommend the private practice job. It sounds like you’d continue to build your skills doing you own cases, the acuity is manageable, the vacation is good. If it’s a “true” private practice where you can actually be a partner/owner then you can control your own destiny. Take it!

 

[Simba1711]

I would be a fan of the private practice option as well. Some things to look out for before signing the contract is whether the call is split evenly. This means the same number of calls per month between non partners and partners. Also, whether non partners are forced to take more weekend call especially the Friday call which is post call. How is the pay structured? is it straight salary, based on rvus, or hourly. I would steer away from salaried in this market especially if they don't pay you hourly beyond a certain time. Finally, how do they decide the assignments for the next day.

if you had a really enjoyable experience at your academic practice I wouldn't necessarily rule it out. No ob would be a plus IMO. In addition, you can still do blocks in an academic practice for vascular and general cases. The surgeons might be more open to blocks in an academic setting as well. In private practice, there are cases I don't do a block even though the patient would benefit because turnover time is emphasized or the surgeons want to do their own block so they can bill.

 

[GassYous]

Surgeons cannot bill for blocks, it would be part of their global payment.

 

[zizzer]

#2. Doing your own cases is waaaay better. I feel way busier when I'm working with CRNAs actually on the rare times I do. Sure, you're stuck in the OR when doing your own cases, but it's more satisfying and you usually get some down time to relax a bit when things get stable. I'd be a bit concerned with the case mix either way, but missing out on ASA 3-5 cases is probably better than missing out on OB and regional. I'm sure you'll encounter sick patients occasionally at the private practice job.

 

[psychbender]

I always enjoy how some people in academics assume that no sick patients are seen in the community. It many cases, it's actually more challenging dealing with these patients without the robust subspecialty support and overabundance of extra hands. Go with option 2, do you're own cases, really come into your own as a specialty consultant. Later, if you decide that you do want to teach, you'll be a better instructor having worked outside the university system for a while.

 

[Angus Avagadro]

Uni job sounds sucky. Academics are highly sub specialty oriented, cases, call,etc . If you want to be a generalist, the PP job sounds good. It's good you can sit your own cases. Check out their support staff for turnover, blocks etc. Also, if you do your own blocks, find out what they do. Is anyone available to mentor you if need be? I'm dating myself, but in the Era of carotid endarterectomy, we had a surgeon who wanted cervical plexus blocks for all his cases. No surgeons where I trained wanted local. Didnt know about that and was assigned that room shortly after I arrived. I had to do some fast reviewing and a little puckering for my first one.