You’re done with residency/fellowship. Now what?

You have devoted the last decade of your life to medical school, residency, and fellowship. It’s time to get out into the real world for a REAL job. Where do you want to live? What type of practice would you like?

workhoursdoc
From AMA

Timing is everything.  Start early!

I started my fellowship in August.  During my elective pediatric hearts rotation, I met a team of physicians who were very encouraging and asked if I had a job yet (this was October).  I told them I didn’t have a job yet, but I wanted to stay in California.  Maybe it was my lucky day, but one of the lady docs I worked with sat on the application committee for my current job.  She encouraged me to apply to their anesthesia group.  After going through the proper channels, I got a phone call from the anesthesia group saying they would like to interview me for a position.  I had my interview in November and heard back in December that I had a job.  Everything happened in such quick succession.  When I left residency, I knew I wanted to be in southern California.  Thank goodness I matched into a fellowship spot in Southern California!  It makes it easier if you know what area/region/state you want to practice in.  Keep in mind that some states are more friendly to physicians than others.

2018 Best States to Practice Medicine

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Source: WalletHub

 

After you’ve decided on a location to practice, figure out the type of practice options that are available in the area.

Luckily, I was working in the city that I wanted to be in, so I could easily survey the hospitals and find out who was hiring.

Physician Group Practice Trends: A Comprehensive Review. Journal of Hospital and Medical Management. 2016.

Do your research. 

What type of practice works for you?  Do you want a large academic center with a physician-led team approach to healthcare?  Do you want to practice in a private practice setting in a team or solo?  There are so many practice models out there — I wish residencies explored/explained more of these options.  Fortunately, I knew a solo-practice physician-only model would work best for me.

10 Ways private practice differs from academic anesthesia

Keep in mind the number of hours you want to work.  What are the opportunities for working more or less?  How many vacation weeks will you get?  Is there paid-time-off?  Will you have a salary or productivity-based income?  How many calls/month will you take?  Is there a discrepancy between new hires vs. senior partners in access to vacation/salary/calls/etc.?  Is there fairness in scheduling?  How long will it take to make partner?  What’s the buy-in amount?  Is there a buy-out when you leave/retire?  I didn’t know to ask these questions when I was going through the process of looking for my job.  Don’t forget to ask about retirement options and health insurance coverage.  Also, ask if it’s possible to work at another hospital or surgery center in the area or if there is a non-compete clause in the contract.

The Interview

Bring your best self to the interview.  The people who are interviewing you want to know more about you.  Tell them about your hobbies, lifestyle, goals for the group, plans for the future.  Engage your interviewer and ask them how long they’ve been with the group.  How do they enjoy their time?  Keep in mind that they’re interviewing you because you look great on paper.  They want a chance to get to know you better.  Show them your best self, especially all your hobbies and interests outside of medicine.  Keep the conversation casual and inviting.

The Contract

Read over the contract carefully.  My group has a one year contract that is revisited yearly and is the same for every member of our 250+ physician group.  Before I started, some people recommended a contract attorney specializing in medical contracts to read it over.  I didn’t find it necessary in my case as my contract was the same for every physician in my group and the language was very clear to understand.  Use your own judgement.  If you don’t understand the contract, get some help.

 

What recommendations did you find helpful in your job search and interview?

What additional help can I include in this post?

Interested in Medical School? Start Early.

A friend of mine’s son is just about to graduate from high school.  He’s interested in medical school, and his mom asked me what advice I would give to help him pick a college knowing that he has an interest in medicine.

Keep in mind: I am not a counselor or an advisor.  I am a physician, and this is what worked for me.

My advice:

  1. If you’re interested in medicine…. start early.
    • The college and medical school application process are getting more competitive.  Students are bright, prepared, and eager.  Let’s start with the basics.  Are you sure you’re interested in medicine?  Like really interested?  Sure, the media portrays some glamour lifestyles for physicians… but it’s not all glitz and glam.  You’ll put in at least a decade of extra work vs. your peers who get a job right out of college.  While they’re building their nest egg, you are not.   
    • Luckily, I stumbled upon my interest in medicine at an early age when my family practice physician encouraged me to pursue it.  He proved to be a great mentor as I was able to shadow him and really get a feel of his day and what he does.
  2. Once you’ve decided medicine in your passion… solidify that decision.
    • Volunteer at the hospital.  Observe your physician.  Volunteer to help people.  If this excites you, you’re on the right track.  Put yourself in situations where you can get involved in medicine.  Read and research what medical school is like.  Reach out to a medical school and see if you can get more information: chat with a medical student, find out if anyone needs help with a research project.
  3. Do well in school.
    • This is a must.  Applicants are incredibly competitive and intelligent with tons of extracurriculars on their resumes.  Get good grades.  Do well on your SAT/ACT and then do well on the MCAT.  Your grades and your test scores are the most basic comparison tool for schools to compare applicants.  Doing well gets you noticed.
  4. Get involved and signup for extracurricular activities.
    • Once you’ve put in the work for good grades and test scores… get involved.  This could be anything: sports, clubs, arts/music, babysitting/caring for loved ones, volunteering, job in a lab, travel/cultural growth.  The key is to show that you’re well-rounded and multifaceted all while achieving the good grades.  Once the colleges and med schools have seen your test scores, they’ll next use your extracurricular activities to help separate out the different applicants.  The key is maintaining good grades while all these other activities are happening.  AAMC fact sheet for medical schools.

If you’re in high school and interested in medicine:

  • Get good grades and do well on SAT/ACT (consider college prep courses to help)
  • If you’re able to take honors classes or AP classes and do well, definitely sign up for these.  It’s another way to separate yourself from other applicants.
  • Volunteer at your local hospital and/or doctor’s office
  • Get a job at a research lab or hospital
  • Get involved in extracurricular activities
  • Talk to your high school counselor about career paths
  • Attend career fairs (my school offered a career night in medicine where we got to go into the operating room) and college fairs on getting into medical school
  • Ask a college pre-med what they’re taking and how to do well in college
  • If you’re torn between two schools on your college list, consider taking a good look at the college that may also be linked to a medical school.  There’s a good chance that some of the medical school professors will be teaching some of the upper level physiology or anatomy college courses.  Some of the professors may also sit on the admissions committee to medical school.  Lastly, it may be easier to get involved in clinical research or scientific studies that the medical school professors are working on… and that would be a great way to introduce yourself to medical school staff as well as get a stellar recommendation letter to show off your work ethic and dependability.

If you’re in college and interested in medicine:

  • Get good grades and do well on the MCAT (consider prep course to help)
  • Get a major in something you’re interested in (you do NOT have to be a pre-med major… you just have to take the pre-med prerequisites to take the MCAT and apply for medical school).  Even though I majored in biomedical science (a pre-med major at Texas A&M), I would have done biomedical engineering if I had a do-over.  Science and math have always been my interests…the engineering major would have given me a nice background beyond my pre-med major.
  • Talk to your college counselor/advisor early (freshman year)
  • If you get into an honors program in college (usually based on your SAT/ACT scores), go for it.  Typically the honors classes are smaller and are a fantastic way to build report with your professor as well as get deeper into the subject matter.  Plus, being in the honors program will further help you standout on your application to medical school.
  • Volunteer at the local hospital.  Although you may start out as a volunteer, see if you can get into the OR (operating room) as well as outpatient clinics.  This will expose you to a wide variety of practices: surgery, anesthesiology, pathology, internal medicine, family practice, OB/GYN, specialties, etc.
  • Get involved in extracurricular activities in college.  There are a ton of clubs and interest groups in college.  If you don’t find one you like, start your own!
  • Need a job in college?  Consider getting one in the research lab or at a medical school or in a hospital.
  • Consider doing summer school to get some credits out of the way.  When I was in college, 12 credits was a full-time student.  I always took 15 credits because I thought I could handle it.  (Now I cannot recommend the following…) My junior year in college, I signed up for 21 credits to see if I could handle a medical school work load.  It was a tough semester, but I did it and got a 4.0.  I wouldn’t recommend that route because you need to focus on grades… but it worked for me.
  • Apply to a lot of medical schools (in-state and out-of-state).  I grew up in Texas and at the time they had a Texas match with 7 medical schools.  I only applied to the Texas (in-state) medical schools because I knew that was all I could afford.  Keep in mind your debt burden: a $9,000/yr education vs a $30,000/yr is a big difference.  I chose an option that made the most sense to me — I didn’t want to be in debt forever.  In fact, I highly recommend reading this book: The White Coat Investor: A Doctor’s Guide To Personal Finance And Investing.  If I had that available to me, I would’ve read that in high school… re-read it in college… read it again in medical school… and read it again throughout life.  Yes, I’m constantly revisiting this book because it is that good.
  • Interviews: honestly, I can’t remember if I interviewed for medical school or not (geez that makes me sound old!).  If you do have interviews… put your best foot forward and practice interviews with your friends/parents/professors/etc.  Be positive, engaging, and professional.  Interviewers DO judge a book by its cover.
  • Once you’ve applied to medical school, sit back and wait for your results to roll in.  Honestly rank the schools you would like to go that caters to your learning style/goals/etc.  My medical school (UTMB) was one of the first in the country to incorporate systems-based learning and problem-based learning.
    • Systems-based = learn subject material based on the different organ systems vs. separate anatomy, physiology, pharmacology, pathology, etc.  (I learned based on the cardiovascular/gastrointestinal/genitourinal/neurological system, which included the anatomy, physiology, pharmacology, pathology, etc related to that system.  I thought it was a more intuitive way to learn medicine) .
    • Problem-based learning involved small groups where we would discuss medical cases, labs, clinical problems, etc.  It was a nice environment to express yourself as well as work together in a team.  This is how the real-world works where you talk to your colleagues to work through various medical issues.  It supports professionalism and engages a teamwork mentality.
  • Lastly, thank the people who helped you get here.  It’s easy to overlook your mentors, friends, professors, and family.  As you enter the medical school/medicine world, your family will learn along the way that you made a commitment to a profession that will take priority over them.  You will miss weekends, evenings, date nights, holidays, anniversaries, etc.  Not only will you sacrifice a lot to get to medical school… you’ll continue making sacrifices once you’re out practicing medicine in the real world.

AAMC fact sheet for medical schools

My Training:

My Job:

The physician anesthesiologist vs. CRNA debate

Why is this even a debate?

It seems to me that the CRNA-led debate is financial… once you tease through all the fluff.

So here’s some literature I found:

As an anesthesiologist, I work in an MD-only anesthesia group. This is by choice: I prefer doing my own cases and being responsible for my own liabilities. The times I have required an anesthetic, I have requested a physician anesthesiologist. As a resident, I had very good insurance coverage, so I wanted a physician for my surgery. At that time, I was ok with having a resident anesthesiologist paired with an attending anesthesiologist for my case. My second surgery was done at my current hospital, and we only have MD anesthesiologists. Perhaps I’m biased? I know and I understand the path/journey/training it takes to get to become a physician anesthesiologist. I want someone who is well-trained, independently thinks, vigilant, and knowledgeable.

I’m sure there are great CRNAs out there… but when I was a resident… we used to supervise CRNAs in our final training year…. and it was scary some of things they would do. Who extubates from a trach R&R on 30% FiO2? Yeah, that particular CRNA told me they had 30 years experience. 30 years experience of doing something wrong doesn’t equate to 30 years of knowledgeable experience. And let’s not forget that CRNAs need a 15 minute morning break, 30 minute lunch break, and 15 minute afternoon break and they go home when their “shift” ends (even if it’s in the middle of a complex case). I take a break when I can… I eat lunch and take a bathroom break when I can…. and I choose to stay and finish complex cases for better continuity of care.

Would you want a nurse practitioner or physician assistant solely performing your surgery without a surgeon? I know I would NOT. I think there’s plenty of room for teamwork in healthcare. This is how to improve hospital efficiency and patient care. My fear is if CRNAs gain independence for purely financial reasons. But then, they will have to carry their own liability, cover their own breaks, take night call and discover that they had it so good in a healthcare team.

Opinions from other physician anesthesiologists:

 

Bottom line in my opinion:

  • Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training specifically in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
  • Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school.  The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
  • I will continue to be FOR team-based physician-led anesthesia care.

Not everything is taught in med school

I came across this excerpt from Atul Gawande while browsing the TED articles.

What doctors don’t learn about death and dying

It made me realize that only the basic factoids for a foundation in medicine are taught in medical school.  The article should open the eyes of my peers; it is ok to accept and understand the fragility of life without thoughts of failure.  Compassion, empathy, resourcefulness, etc. aren’t easily teachable concepts or behaviors.  One would hope that aside from understanding things on a cellular to anatomical to physiological to pharmacological level, a basic lesson in emotions, communication, and coping would be equally as important as learning the fundamental medical knowledge to clinically treat patients.

The Operating Room

Welcome to the medical world. It’s not for sissies. You’ve done a great job outlining your experience. Keep up the great work! There is a light at the end of the tunnel…and it is every bit as rewarding as you could imagine!

Life at Hogwarts College of Medicine

Originally written in mid-January

I was about to sit down for a warm pre-dinner snack of daal, rice, and tilapia when my phone buzzed insistently from the tabletop. I stood there for a moment, staring at the screen, until I processed the words, “meet me in 30 min.” I wolfed down my dinner, stuffed my ID badge and white coat into my laptop bag, and dashed out the door into the freezing evening weather.

When I arrived at the hospital, I was sweating profusely into my jacket. I met my research advisor in her office, and she led me into a new world – one of windowless hallways, where there were no lost visitors or rambunctious first-year medical students to penetrate the silence. There were only faceless doctors and nurses, solemn and solitary as they headed toward their mission.

In the operating room, I watched as the anesthesiologists placed their monitors…

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IS ANESTHESIA A CUSHY SPECIALTY?

The anesthesia consultant

Cover image of The House of God

Samuel Shem’s classic novel/satire of medicine, The House of God (published in 1978, more than two million copies sold), follows protagonist Dr. Roy Basch as he struggles through his year as an internal medicine intern. A second physician recommends Basch switch careers to one of six no-patient-contact specialties: Rays, Gas, Path, Derm, Eyes, or Psych. These names translate to radiology, anesthesia, pathology, dermatology, ophthalmology, and psychiatry. These specialties are touted as lower stress choices with superior lifestyles, where time with sick patients is minimized and the physician is more likely to be happy.

Is this true? Is anesthesia worthy of Samuel Shem’s assessment that it’s a cushy specialty?

My answer, after thirty years of anesthesia practice, is … it depends.

Let’s examine each of the six specialties regarding their perceived advantages:

• Radiology involves a career of peering at digital images of X-rays…

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