By Dr. Mike
I needed the flexibility of locum tenens to be able to climb Aconcagua.
A lot of young doctors have been telling me to write about my work experience. So I finally decided to start a blog. Here goes nothing! I finished my anesthesiology residency in 2008 and since then I have done every type of job that can be done after anesthesia residency. Now obviously there are a lot of folks out there that have done more and let me tell you that I would love to hear from you! But currently I do not know anyone who has had the same breadth of experience in such a short time. I completed a pediatric anesthesia fellowship, then did private practice (salaried), Doctors Without Borders (MSF), locum tenens, worked in the Australian/New Zealand system (anesthesia and intensive care), fee for service (eat what you kill) practice, a second fellowship in pediatric cardiac anesthesia, and finally a highly sub-specialized academic practice. Am I crazy? Maybe just a little. But many people I speak with tell me that they wish they could have done the same or at least tried a few different types of practice. I kept changing because I wanted to see it all and do it all and decide for myself what really worked best for me. And I keep finding better and better jobs. If I had never left my first job, I would never have known how much better it could get.
So without further ado, I present my thoughts on 7 different job types available to the attending anesthesiologist. There are of course more; these are just the ones with which I am familiar.
People often talk about 4 major things to look for in a job: location, money, the nature of the work, and the people. I have added safety and flexibility to this list since these are very important to me and hopefully you as well. I have provided an example of how I would score a potential job in each category from 1 to 5 (1 being the worst and 5 being best). Try scoring them in your according to what you think would be important to you.
Safety: This is always my number one issue. Quite simply are your patients safe and are you safe? There are some jobs out there that are just not as safe as they could be and new grads can get pressured into doing things they were taught not to do. I won't get into the details; take caution. Your number one duty is to cause no harm. The highest chance of having a major error or crisis is during the first five years after graduating residency. Here is where a fellowship can be useful. A fellowship gives you a little bit longer in that protected environment where somebody is supposed to watching over your shoulder. You will also learn new and more specialized skills. Whether or not you chose a fellowship, learn how to make and keep your practice safe and carefully examine jobs for potential issues with safety, especially when you are fresh out of training. Once you have at least one or two years of experience, you are less likely to do do unsafe things.
People: It is critical to like the people with whom you work. After a few months/years when work becomes routine, you will like what you do when you like the people. Some groups are simply not fair to new doctors although I think that most are extremely fair. This can make or break a job and I usually know which job feels right by a gut feeling and this comes from meeting the people. Which job had the best people? I think it depends on your own personal culture. I think I found that I had some of my best times in Africa and New Zealand because the culture was new and exciting.
Flexibility: I like flexibility more than most people and I think a lack thereof is what forced me to to look around. By changing jobs every year, I introduced flexibility into the mix. I like being in charge of my schedule. I enjoy doing very long medical missions and mountaineering expeditions and although most jobs won't tolerate long absences, there are ways of getting the time that you need. The winner here is obviously locums although my New Zealand practice was top choice for a permanent job.
Nature of work: Anesthesia jobs are surprisingly different. You may end up doing bread and butter with or without peds/OB/cardiac. Some groups ask you to do pain. Sometimes you may have to do a lot of regional. And sometimes you may have to do ICU. It helps to be doing what you like best and for some people, that means a little bit of everything.
Location: Ideally you need to have your one or two dream cities picked out but you may not always get the job you want or be able to live close to work. Living close to work is the ultimate goal and there is nothing worse than having a long commute twice a day. Desirable locations may have fewer to no jobs so you might have to wait if you choose a stellar location. If that is the case, consider a job that may be nearby or could be a good lead into your dream job. I know many great practices who want a pediatric or a cardiac anesthesiologist and those who have done these fellowships have an advantage. My favorite location so far was my New Zealand job where I lived on the beach and was able to ride my bike 20 minutes to the hospital. The job was home-call and I was able to drive there in 10 minutes. I must say that I really like walking 5 minutes to my current job. The children's hospital where I currently work happens to be in a wonderful neighborhood so I am taking full advantage. I often will not even start my car for a week! Imagine the extra free time you would have.
Salary/Benefits: Last and I think least is the money yet it boggles my mind how often residents will look at this as the main issue. No! Don't do it. All the jobs will have a reasonable salary and you really need to look at all the components of the job. My private practice job was a higher paying job yet I wasn't so happy to be working late every night while working two weekends a month. Imagine if you had a complication because you were working such long hours to make more money. That would not be worth it. There is hidden value in safe practice. And if you can get 3 or 4 out of the 5, you probably won't mind making less money. The top priority (after safety of course) in my humble opinion should always be your happiness.
1) Fellowship (or staying on faculty where you trained)
Wow, who wants to delay gratification yet another year? Seriously, one more year of being under the thumb of the institution, ongoing debt, long hours, and low wages turns most people off immediately. But hold on a second. If you consider that your career should last around 30 years, then 1 more year in the long run is nothing, especially if you carve out a special niche for yourself that you enjoy and can out-compete non-fellowship applicants when the job market is tight. And when it comes to safety, this choice probably beats every option except maybe just staying on as an attending at your home institution where you can get backed up like a resident and still get paid as an attending. These are top notch ways to continue to develop your skills in a more protected environment and for the new grad, this should totally outweigh the loss of income compared to going private. Caution should be exercised for non-acgme fellowships because you might be able to acquire those skills without a fellowship and some fellowships are not required to practice in a certain field. Peds and Cardiac for example are two areas where you still can work without having done a fellowship but it is becoming less common and in order to get a job doing either of these would require proof of significant experience in these areas.
Here is how choosing to prolong your misery but increasing safety scores:
Safety: 5
People: 4
Flexibility: 4
Nature of Work: 5
Location: 3
Salary/Benefits: 1
Overall: A superb option. Just don't overdo it like yours truly. Total score: 22
2) Private (non-fee for service)
This is a non-academic job where you get paid either a pre-determined salary or your paychecks are determined in some other manner completely different than fee-for-service. Generally these jobs will provide you with benefits and you are paid by W2 as an employee of the group or hospital. Depending on the group, you might be doing all your own cases, supervising CRNA's, residents or a combination of all of the above. There may or may not be a partnership track and the group may or may not honor the track. I have heard a few horror stories of firing a physician just before making partner. Fortunately this is rare. The vacation time might be reasonably good (6-8 weeks) although depending on how many are in the group, you could end up working a lot of weekends. It also depends on whether senior partners are taking call and begs the question of whether you are considering a fair group. Some groups have a buy in period of 2-3 years where the salary is less and the call and workload is higher.
Safety: 3
People: 4
Flexibility: 2
Nature of Work: 2
Location: 4
Salary/Benefits: 5
Overall its a good deal if you find the right group and can be rough if you don't. Score: 20
3) Independent Contractor (fee for service)
This is also private practice but the way you get paid and get benefits is totally different and this changes the feel of the group and also changes the way people practice. In a strict fee for service job, you get paid what you personally bill for so if you do two long ASA 1 hernia cases you would make much less than if you did 4 rapid ENT cases or cases where you put in an a-line or an epidural. More complex cases like thoracotomies have more startup units so that all translates to more money. Needless to say, there are some people out there that try to do the cases that bill more units and also may try and put in more regional blocks or invasive lines than they would otherwise do. Fortunately that type of abuse is rare. You get paid as a 1099 which means the money is pre tax and you are responsible for paying estimated taxes each quarter. This can be beneficial as you can write off business expenses off the top before you even get hit with taxes and this can be advantageous if you have a saavy accountant. Rich people are profoundly good at paying less taxes and my dad who isn't a physician would always tell me "it's not what you make but what you keep." Under these circumstances it may make sense to form an S-CORP or an LLC. You will have to set up your own 401k, health benefits, etc since you are considered an independent contractor. This type of job is fine if people play fairly. One concern I have is whether or not there are enough people around on any given day should you need help or a break. In my experience, this type of practice was absolutely fine as there was a very fair system in place where the assignments varied each day based on who was on 1st, 2nd, 3rd, and 4th call and post call. And call was random and equitable as well. Vacation is a little strange as its one of the few jobs where people do not seem to care as much about how much vacation you take. The rational for that is that if you are not working, you are not making money as opposed to the other jobs where people continue to earn the same paycheck even when they are on vacation. You need to factor this as well as the lack of benefits when comparing salaries to a salaried position. A consequence of all of this seems to be that the individuals in these groups are a little more hungry for work and turnovers and downtime can be very painful as you do not make money unless you are doing cases.
Safety: 2
People: 3
Flexibility: 4
Nature of Work: 3
Location: 4
Salary/Benefits: 5
Overall can be good but depends on a fair group. Score 21
4) MSF Doctors Without Borders
Now we get into the fun stuff! I loved working for MSF. I worked in Sudan and Nigeria and spent time in New York, Uganda, and Paris for security meetings. The missions were truly those of a lifetime. Everyone on the mission had a general sense of purpose and adventure and the local people were always delightful and very very grateful for what we did. I saw things that I only read about in textbooks like neonatal tetanus. I had to do much more intensive care, pain medicine, emergency medicine, and minor surgery than a standard anesthesia job. The role of the anesthetist is a bit different in the rest of the world and with MSF your responsibilities are more than back in the USA. Depending on where you go, the missions can range from chill to downright dangerous and very stressful. MSF sets up a huge number of sites where people have been displaced by armed conflict so be aware that this is not your standard run of the mill vacation mission. The living conditions are pretty basic. It was so hot in Sudan that I did not sleep much and I got pretty ill from the food. But even though I suffered, I loved it and had the best experience of my life. I came back a different person and felt more alive than ever. A trip with MSF can take a person jaded by the routines of the american medical system and completely rekindle that passion that drove them towards medicine in the first place. The trips can be exhausting however and you could be the only anesthetist which means taking call 24/7 for your entire time. A mission for an anesthetist or surgeon can be anywhere from 1 to 6 months whereas primary care doctors are required to commit to 6 months minimum. There is very little pay, but it isn't nothing. There is a small monthly salary paid to your US bank account. All your travel, food, and accommodations are paid for. MSF provides very very good international health insurance. Honestly, it was the best I have ever had: cigna international. I wanted to keep it going after I got back but it was ridiculously expensive and they require you to be traveling. You also get a small contribution into a 401k of your choice and local spending money. But the truth is that you only do this for the experience. This type of work appeals only to the very young and older physicians whose children have grown up.
Safety: 1
People: 5
Flexibility: 5
Nature of Work: 5
Location: 1
Salary/Benefits: 1
You would have to decide for yourself how you would score the location because it could be either a 5 or a 1. I gave it a 1 for the risk involved but some might say it was a 5 because they would otherwise never go to such unique places during dangerous times. Also when I talk about risk, I generally mean the risk of having a complication in your practice. In this case, there is not much medicolegal risk in some of these impoverished areas. The patients will be very sick, you will not have other experts around to help, and the equipment and resources are limited which increases the risk of having complications compare to that of your practice in the USA. It should be understood that practicing anywhere in the world in underserved areas can be like this.
Score: 18
5) Locum Tenens
This is a bit of an oddball category. I was told by one of my program chairs not to do this because you do not get any benefits and you are the perpetual "new guy." But I have done locums and I see an advantage when the circumstances are right. Being the new person or the "locums" person can be a negative thing in many places. You may not be assigned to anything complex as nobody will trust you and you certainly will not know your surgeons or where the heck to find equipment when you need it. You may be quite facile with all of your home equipment but odds are that something along the way on a locums job will trip you up. The thing about anesthesia is that we interface with so many different pieces of equipment and technology and there is such a huge variety from one hospital to the next. You may flail with the wrong intravenous catheter as I once did when I used new catheter in small babies and the catheter was much shorter than the needle compared to others I had used. There are many different types of anesthesia workstations, IV tubing sets, and drug delivery systems. Each component by itself is not that complex but when you add it all up and its all new to you it will hit you all at once at the worst time. For example if you struggle with an airway with nobody to help and all the equipment is just a bit off, let me tell you that it gets stressful in a hurry. Think about who will back you up if you have a problem or a complication.
So, why bother? Well, a locums job is not a bad thing either, you just have to understand what you get yourself into. There is nothing that matches its flexibility. You decide your own hours. Take caution however as you may not always get hours when you want. The most common Locums positions available may generally be outside of big cities and may be during holiday seasons. And you may not get enough work or the job may be very short lived so I tend to look at it as a very temporary thing. There have been two situations where the group has asked me to stay on as permanent so locums can be a way to try a group out without making a permanent commitment.
You get paid by 1099 but the payment might be fee for service or could be based on a pre determined hourly wage. You might be paid by the hospital, the group or a third party. There are companies that act as intermediaries between you and the hospital. They pay you and provide your benefits but you don't actually work for them. The pay can be good to very bad and I have seen a downwad trend in the amount people are willing to pay locum physicians so its good to check out what's out there all over the country and keep your standards high.
Safety: 2
People: 3
Flexibility: 4
Nature of Work: 3
Location: 3
Salary/Benefits: 2
I don't think flexibility is truly a 5 because its only flexible when work is abundant and you can freely accept and turn down work. It does not always work this way as mentioned above and you can get stuck with no work in the specific area you want. There is however always work somewhere in the world which means this is an acceptable back up plan.
Score: 17
6) Foreign/Australian/New Zealand
My work in New Zealand was my favorite so this of course will be severely biased. I loved the medical system for its relative freedom from medicolegal issues and production pressure. There are malpractice lawsuits but very uncommon. The ACC (Accidental Compensation Corporation) serves as a taxpayer funded means to pay for injured people. That covers anybody injured
7) Academics