Thread for fellows looking for first jobs

[ateria radicularis magna]

What should a fellow watch out for in the current job environment ? Things are changing fast. Are there groups out there taking advantage of new grads or can everyone in our field pretty much be trusted with a handshake ?

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[lobelsteve]

12 days early for April fools.

 

[gaspasser127]

What should a fellow watch out for in the current job environment ? Things are changing fast. Are there groups out there taking advantage of new grads or can everyone in our field pretty much be trusted with a handshake ?

There’s no speciality in medicine (or industry in the world) where everyone can be trusted with a handshake.

I feel like when I was going thru the process of finding a job a few months ago my best advice came from my attendings.

Ultimately I ended up going with a hospital employed position where I felt like I was going to be the least individually screwed over (which means everyone is equally getting a little screwed).

 

[ateria radicularis magna]

There’s no speciality in medicine (or industry in the world) where everyone can be trusted with a handshake.

I feel like when I was going thru the process of finding a job a few months ago my best advice came from my attendings.

Ultimately I ended up going with a hospital employed position where I felt like I was going to be the least individually screwed over (which means everyone is equally getting a little screwed).

That’s an interesting perspective. Do you feel like the larger groups that are backed by investors are a strong choice for a new graduate coming out of fellowship? They seem to have a lot of administrative support and access to industry leaders.

 

[drusso]

There’s no speciality in medicine (or industry in the world) where everyone can be trusted with a handshake.

I feel like when I was going thru the process of finding a job a few months ago my best advice came from my attendings.

Ultimately I ended up going with a hospital employed position where I felt like I was going to be the least individually screwed over (which means everyone is equally getting a little screwed).

They will never love you back.

 

[myrandom2003]

Handshake but get it in writing.
-make sure partnership has specific metrics to hit, not something vague.

Just get everything spelled out and make sure the contract spells out a peaceful exit if not for cause.


If your going to a hospital, then it’s usually take it or leave it. I feel that if you join a hospital, I would like to quote something Putin said in a February to ?Ukraine translated to English: “You may like it, you may not, but you’ll have to endure it, my beauty”.

 

[NJPAIN]

They will never love you back.

View attachment 352083

Very true but the commitment to have your own practice in a competitive market is immense. You need to pound the pavement, be available, be social, sponsor the little league, send your kids to Cotillion AND practice medicine. You know that better than anyone. We all don’t have that.

A perfect example from another forum is a pain doc with a HUGE practice in the south was struggling over how to discharge a patient who had a stim trial but terrorized his staff. Clearly he was fearful of the bad press that would be spread by this patient. All about optics,

 

[drusso]

Very true but the commitment to have your own practice in a competitive market is immense. You need to pound the pavement, be available, be social, sponsor the little league, send your kids to Cotillion AND practice medicine. You know that better than anyone. We all don’t have that.

A perfect example from another forum is a pain doc with a HUGE practice in the south was struggling over how to discharge a patient who had a stim trial but terrorized his staff. Clearly he was fearful of the bad press that would be spread by this patient. All about optics,

I agree. But, LOOK at that physician compensation model design. It's no accident that it looks that way. What does that communicate about the VALUE of physician work? It's cheaper by the pound? I wonder how the CEO comp model is designed? Show me your spreadsheets and I'll show you your values.

 

[ateria radicularis magna]

Some of the bigger groups are selling new grads on seeing no clinic patients and instead doing all procedures ordered by several nurse practitioners.
Should a new grad jump in bed with one of these big groups?

 

[drusso]

Some of the bigger groups are selling new grads on seeing no clinic patients and instead doing all procedures ordered by several nurse practitioners.
Should a new grad jump in bed with one of these big groups?

Can you give specific examples so people can follow up with the decision-makers/owners?

 

[ateria radicularis magna]

Something about a “diagnostic arm “ (nurses) and a “surgical arm” (doctor).
Is this is a good move for a new grad ready to launch his or her career?
How about ancillary services? Should new grads jump on the ancillaries train or stay far away?

 

[MitchLevi]

ABSOLUTELY NOT

 

[RoloTomassi]

Definitely not. New grads need to hone their differential diagnostic skills, PE, image reading, what injection worked/ didn't work and why, see side effects and complications, collaborate with other specialties, and a million other things. Clinic isn't always fun but it's a necessary part of the job.

 

[bedrock]

Definitely not. New grads need to hone their differential diagnostic skills, PE, image reading, what injection worked/ didn't work and why, see side effects and complications, collaborate with other specialties, and a million other things. Clinic isn't always fun but it's a necessary part of the job.

Exactly. It’s morally wrong to be a block jock doing endless and usually inappropriate procedure because the midlevels don’t evaluate or order the correct procedure.

But it’s also terrible for your professional development as you aren’t perfect and all knowing just because you completed a one year fellowship.
You need to see patients longitudinally for several years, evaluating them, understanding when you made the wrong diagnostic and procedural decisions, etc, before you are truly a qualified pain attending.

 

[NJPAIN]

Something about a “diagnostic arm “ (nurses) and a “surgical arm” (doctor).
Is this is a good move for a new grad ready to launch his or her career?
How about ancillary services? Should new grads jump on the ancillaries train or stay far away?

I know exactly whose mouth that came from PM - KOL for every product on the market.

 

[ateria radicularis magna]

Exactly. It’s morally wrong to be a block jock doing endless and usually inappropriate procedure because the midlevels don’t evaluate or order the correct procedure.

But it’s also terrible for your professional development as you aren’t perfect and all knowing just because you completed a one year fellowship.
You need to see patients longitudinally for several years, evaluating them, understanding when you made the wrong diagnostic and procedural decisions, etc, before you are truly a qualified pain attending.

Interesting take.
What about losing out on the access to industry leaders and key opinion leaders in the field?
Don’t you feel like the ceos and cmos will give you a leg up on the competition who may not have access to stellar administrative, management and marketing teams?

 

[ateria radicularis magna]

I know exactly whose mouth that came from PM - KOL for every product on the market.

Seems like new grads are getting this talk track from around the United States. If it’s coming from all these different doctors with all this experience at the top of their field, it must be true, right?

 

[nvrsumr]

As far as injections I’d trust the NP to do them more than order them.

 

[RoloTomassi]

Interesting take.
What about losing out on the access to industry leaders and key opinion leaders in the field?
Don’t you feel like the ceos and cmos will give you a leg up on the competition who may not have access to stellar administrative, management and marketing teams?

They really aren't as special as they want you to think they are.

 

[ateria radicularis magna]

As far as injections I’d trust the NP to do them more than order them.

How about the groups where the NPs order implants? I mean they’re just filtering through patients following an algorithm right? Isn’t this the future of pain medicine/pain surgery?

 

[ateria radicularis magna]

They really aren't as special as they want you to think they are.

Then how do they exist at all? It can’t be cheap to support that much middle management?

 

[bedrock]

Interesting take.
What about losing out on the access to industry leaders and key opinion leaders in the field?
Don’t you feel like the ceos and cmos will give you a leg up on the competition who may not have access to stellar administrative, management and marketing teams?

I think you’re drinking the cool aid.

Most of the key opinion leaders are morally bankrupt and I would never refer my mother or a friend to them.

CEOs will talk about their special marketing and then steal 90% of the extra revenues while you pay 100% of that marketing.

You need to be more circumspect about people involved in pain that don’t truly have the patients best interests in mind, only their own.

 

[ateria radicularis magna]

I think you’re drinking the cool aid.

Most of the key opinion leaders are morally bankrupt and I would never refer my mother or a friend to them.

CEOs will talk about their special marketing and then steal 90% of the extra revenues while you pay 100% of that marketing.

You need to be more circumspect about people involved in pain that don’t truly have the patients best interests in mind, only their own.

That’s interesting to hear, and concerning. How can new grads avoid these people you describe ?

 

[nvrsumr]

I think there is a little sarcasm. Pain does eat their young. Too many needles chasing too few spines.

Work for a hospital. Work for an 800lb ortho group. Take over a retiring docs practice. Start your own. The equitable 4 doc pain practices of 10 years ago are mostly gone.

It’s pretty hard to get the referrals to support 4 pain docs in a competitive market with large vertically integrated hospital systems. I do see some busy 2 doc practices and a few 4 doc ones where they drive across the city, maybe do a little gas on the side at an asc, and at least one doc is “mommy track”

 

[ateria radicularis magna]

I think there is a little sarcasm. Pain does eat their young. Too many needles chasing too few spines.

Work for a hospital. Work for an 800lb ortho group. Take over a retiring docs practice. Start your own. The equitable 4 doc pain practices of 10 years ago are mostly gone.

It’s pretty hard to get the referrals to support 4 pain docs in a competitive market with large vertically integrated hospital systems. I do see some busy 2 doc practices and a few 4 doc ones where they drive across the city, maybe do a little gas on the side at an asc, and at least one doc is “mommy track”

From what I am hearing, the bigger groups are moving away from an emphasis on needles and are more aligned with some of the cutting edge stuff that can really fix the problem rather than just putting a band aid. Doing all these higher skill surgeries doesn’t leave a lot of time to do things that physician extenders can do, right? From what the new grads are getting from the big groups, you have got to practice at the top of the license and not in the middle or bottom of the license talking about BMIs, steroids and prescribing nsaid. If the new grad doesn’t get on board with doing a lot of cutting edge implants, is anyone even going to hire him/her in todays pain marketplace?

 

[Agast]

I hate the term “bandaid” with a passion. Steroids treat inflammation, for inflammatory-mediated pain. I tell my patients it’s more like treating an infection with antibiotics. Finishing your course of antibiotics does not prevent you from getting another infection in the future if you do not change your behavior.

 

[hyperalgesia]

Avoid practices that are owned by a chiropractor, NP, or lawyer. That's my hot TOTD.

 

[DOctorJay]

They will never love you back.

View attachment 352083

Here’s my tip. Run the numbers.

Make a graph like this (it’s not mine in case anyone is wondering).

Understand how you’re being valued at the start of your practice and once you’ve built things up if you’re employed.

 

[Ronin1]

From what I am hearing, the bigger groups are moving away from an emphasis on needles and are more aligned with some of the cutting edge stuff that can really fix the problem rather than just putting a band aid. Doing all these higher skill surgeries doesn’t leave a lot of time to do things that physician extenders can do, right? From what the new grads are getting from the big groups, you have got to practice at the top of the license and not in the middle or bottom of the license talking about BMIs, steroids and prescribing nsaid. If the new grad doesn’t get on board with doing a lot of cutting edge implants, is anyone even going to hire him/her in todays pain marketplace?

Don’t believe everything you hear especially from device reps and the talking heads at conferences. Often the same guys talking about the next great device when they just cashed the check from the previous company. In many cases their case numbers are not that high.

Devices etc are a small part of most peoples practice

 

[Taus]

Don’t believe everything you hear especially from device reps and the talking heads at conferences. Often the same guys talking about the next great device when they just cashed the check from the previous company. In many cases their case numbers are not that high.

Devices etc are a small part of most peoples practices

I find it very strange that it truly seems to be the exact same small group of docs advertising for everyone of these new devices. Also, they seem to be at a conference or course like every weekend. I’m sure it pays well…. But the whole thing just doesn’t sit right with me. Seems odd.

 

[Ducttape]

name me a "cutting edge technology" that "fixes the problem" and i will show you, 10 years from now, a treatment that has been abandoned by those same KOL - for not being cutting edge enough, and for not having valid scientific data to show long term benefit.

 

[ateria radicularis magna]

Well it does seem really nice for these industry leaders to volunteer so much time to teach the new grads and recruit them for their first jobs joining their groups. They spend so much time flying around and doing weekday webinars. That can’t be cheap.

 

[ateria radicularis magna]

I find it very strange that it truly seems to be the exact same small group of docs advertising for everyone of these new devices. Also, they seem to be at a conference or course like every weekend. I’m sure it pays well…. But the whole thing just doesn’t sit right with me. Seems odd.

How can a new grad looking for the first job identify these doctors ?

 

[DOctorJay]

Well it does seem really nice for these industry leaders to volunteer so much time to teach the new grads and recruit them for their first jobs joining their groups. They spend so much time flying around and doing weekday webinars. That can’t be cheap.

volunteering?

 

[ateria radicularis magna]

volunteering?

Isn’t there a law against accepting money from device companies if you are a doctor ?

 

[DOctorJay]

Isn’t there a law against accepting money from device companies if you are a doctor ?

are you familiar with propublica?

Dollars for Docs

ProPublica has compiled the disclosed payments from pharma companies to doctors and other health care providers. Search for your doctor in our interactive database.

projects.propublica.org

run the names you see on linkedin posts through this

 

[buddababa]

Well it does seem really nice for these industry leaders to volunteer so much time to teach the new grads and recruit them for their first jobs joining their groups. They spend so much time flying around and doing weekday webinars. That can’t be cheap.

not sure if you're being sarcastic, but they do get well compensated for their time

 

[ateria radicularis magna]

Wait, so a handful of doctors are given hundreds of thousands of dollars by device companies, and the same doctors are responsible for recruiting new graduates from fellowship for the large pain groups? This can’t be true.

 

[drusso]

I find it very strange that it truly seems to be the exact same small group of docs advertising for everyone of these new devices. Also, they seem to be at a conference or course like every weekend. I’m sure it pays well…. But the whole thing just doesn’t sit right with me. Seems odd.

If you actually run the numbers and factor in the windshield time, then waiting for the plane time, time away from revenue-generating activity, time away from family, etc it's not that rich of a deal. I think that they do it for other reasons and a strong conviction that it is right and necessary.

 

[ateria radicularis magna]

If you actually run the numbers and factor in the windshield time, then waiting for the plane time, time away from revenue-generating activity, time away from family, etc it's not that rich of a deal. I think that they do it for other reasons and a strong conviction that it is right and necessary.

That’s great to hear. For new grads looking for the first job, these doctors are pretty much the only ones they meet and engage with.

 

[lobelsteve]

https://www.linkedin.com/in/shamit-desai-4728ab41/recent-activity/

Recent twitter argument. He was very boastful, arrogant. I did not comment on his tweet about post-op narc mgmt- but I could.

 

[MitchLevi]

Exactly. It’s morally wrong to be a block jock doing endless and usually inappropriate procedure because the midlevels don’t evaluate or order the correct procedure.

But it’s also terrible for your professional development as you aren’t perfect and all knowing just because you completed a one year fellowship.
You need to see patients longitudinally for several years, evaluating them, understanding when you made the wrong diagnostic and procedural decisions, etc, before you are truly a qualified pain attending.

Agree across the board.

Wanted to add the fact I believe midlevels order a lot of unnecessary procedures bc they (1) want to keep that doctor happy and (2) are generally uncomfortable telling pts there's nothing left to do but hurt.

After all, what is it they say about midlevels...Heart of a nurse & brain of a doctor?

 

[ateria radicularis magna]

Agree across the board.

Wanted to add the fact I believe midlevels order a lot of unnecessary procedures bc they (1) want to keep that doctor happy and (2) are generally uncomfortable telling pts there's nothing left to do but hurt.

After all, what is it they say about midlevels...Heart of a nurse & brain of a doctor?

How should a new grad approach the group about his or specific responsibilities with regard to management of mid levels? Seems like a tricky area that one may not really understand until it’s too late.

 

[MitchLevi]

No midlevels until you've been an attending for a few yrs IMO. A new grad isn't ready for that. You need to learn your craft bc trouble shooting your own BS will be difficult, and you don't know enough yet to troubleshoot someone else's. There are tons of little things you learn over time.

The other issue is financial. That PA/NP added to your overhead? If so, who hires the PA? The practice or you? What happens if the PA is slow? Does the practice pay for the PA for the first 12 months, or does the doctor? How does the PA get bonuses, and if the PA goes 200k over his/her overhead does the MD get a piece of that?

You won't be profitable for 18-24 months.

I especially feel no service line with midlevels on the front end scheduling procedures with the MD on the back end.

 

[ateria radicularis magna]

No midlevels until you've been an attending for a few yrs IMO. A new grad isn't ready for that. You need to learn your craft bc trouble shooting your own BS will be difficult, and you don't know enough yet to troubleshoot someone else's. There are tons of little things you learn over time.

The other issue is financial. That PA/NP added to your overhead? If so, who hires the PA? The practice or you? What happens if the PA is slow? Does the practice pay for the PA for the first 12 months, or does the doctor? How does the PA get bonuses, and if the PA goes 200k over his/her overhead does the MD get a piece of that?

You won't be profitable for 18-24 months.

I especially feel no service line with midlevels on the front end scheduling procedures with the MD on the back end.

Great perspective. Control of the new grad by controlling mid level activity and reimbursement is a significant strategy of the large groups.
I wonder what are the top 5 things a new grad should ask a potential first job other than reimbursement questions.

 

[PainDoc2025]

are you familiar with propublica?

Dollars for Docs

ProPublica has compiled the disclosed payments from pharma companies to doctors and other health care providers. Search for your doctor in our interactive database.

projects.propublica.org

run the names you see on linkedin posts through this

Home | Open Payments Data - CMS

openpaymentsdata.cms.gov

more accurate/up to date - run the numbers for Timothy Deer here on open payments

 

[RoloTomassi]

Home | Open Payments Data - CMS

openpaymentsdata.cms.gov

more accurate/up to date - run the numbers for Timothy Deer here on open payments

Child's play. This is someone I know:

 

[drusso]

Home | Open Payments Data - CMS

openpaymentsdata.cms.gov

more accurate/up to date - run the numbers for Timothy Deer here on open payments

This is very illuminating but I wish the Feds broke out which docs generated the most facility fees too. It doesn't show income for Taper KOL's.

 

[ateria radicularis magna]

Just to bring this home a bit. What can a new graduate looking for the first job take away from this open payments database? Avoid the people on it? Seek them out? Do these people generally treat new graduates like colleagues or more like little pieces of a money puzzle?

 

[gaspasser127]

Just to bring this home a bit. What can a new graduate looking for the first job take away from this open payments database? Avoid the people on it? Seek them out? Do these people generally treat new graduates like colleagues or more like little pieces of a money puzzle?

I’m not quite sure what the ProPublica database and new grads looking for jobs have to do with one another.

FWIW, I’ve met a lot of these KOLs this past year during various courses/conference and most of them seem very down to earth and have a genuine interest in teaching - or so it seems. Sure they get paid $$$ by industry for it - but why shouldn’t they?

I bet working for a KOL is a mixed bag and ultimately probably isn’t much different than any other private practice.