My Journey through Anesthesia...
After graduating my pain management fellowship at NYU in 2007, I wrestled with the idea of going into a full-time pain practice or anesthesiology/pain management hybrid position.
After going on multiple job interviews I realized that I did not want to be a full-time anesthesiologist for the rest of my career. So, I wound up taking a position in the anesthesiology department at Maimonides Medical Center. I opted for this position, as I was offered the chance to build a pain practice from scratch.
I started with one afternoon per week in the pain office and otherwise functioned as a full time anesthesiologist. I took call like everyone else. In fact my first call was on my birthday in the same OB ward where I was born. My parents even kept the anesthesia bill from 1976. They were charged $88.
Anyway, I did it all. Peds (which i dreaded), ruptured AAA repairs, ECT, endoscopy, all while building a pain practice and seeing pain consults between, before and after my OR cases. With the help of my chairman, vice chairman and the orthopedics dept., I had the opportunity to build a regional anesthesia service, test out Onc Q pumps, Exparel, learn TAP blocks, Quadratus Lumborum Blocks and more.
It took about 7 years, gradually building my name and practice while phasing out anesthesia and taking less and less call until I transitioned from a hybrid position, to a full time pain management position. Once this occured, my sleep schedule dramatically improved. So did my job satisfaction. I was finally given the chance to devote all of my time to treating pain patients.
I can only surmise that those of my colleagues who took a full time private practice pain job after fellowship, entered far more lucrative practices.
First week of my attending job
Money is not how I measure success. Don’t get me wrong, money is quite important, but it’s not everything.
I learned this my first week as an anesthesiology attending. We were short staffed and I had to take extra- call, then stay late working the post call day. This went on while having an Anesthesiology Oral Examination and Pain Managment Board Certification Exam looming in the back of my head. In addition, I had a 1 year old that was allergic to sleep and was coming out of a pain fellowship in which I did not administer anesthesia to anyone for a full year. Did I mention that all 3 of us lived in a studio apartment?
True, I was the MOD at the Manhattan VA running the PACU, codes and the inpatient pre-op guru, but that did not prepare me for my first week of my attendingship.
In fact, I was almost ready to quit. I had never been more stressed out in my life. At the end of that difficult work week, came a fat 4 figure over-time check. Coming from residency, this was BIG MONEY. I showed it to my wife and said, "wow thats nice, but not worth my happiness." Don't get me wrong. I was happy to see the check and had no problem working hard. Calls, staying late, etc, but there has to be BALANCE. So my definition of success chaged from that day on.
Dr. Rosenblum's Definition
Looking back, I would say that the most attractive feature to my job was the fact that I was given the platform to build a practice in a way that I see fit. I was never pressured to build a pill mill or block shop. I was basically given a blank canvas and asked to paint my picture. Although my team practice is not a practice that I soley own, I do have a lot of autonomy. I have the satisfaction of walking into an office every day, that I know, my partners, staff and I built from scratch.
So when the fellows, residents and even some attendings ask advice as to what type of pain job they should look for, here’s what I say:
Are you willing to give up your skills as anesthesiologist? And if so, when would you do this?
I worked very hard for three years to learn the art of anesthesia. I took a difficult Anesthesia Written and Oral Exam. Coming out of residency, I knew I wanted to be a pain doctor however, I wanted to get a strong foundation in anesthesiology. It’s a great specialty, has a lot to offer, and although I am not practicing it at this point in time, I know that I can always fall back upon it if I decide to do so. For years, I administered anesthesia to ASA 3, 4 patients. This experience at NYU, and then Maimonides gave me a strong backbone to which I can always turn to in the event that the world of pain medicine falls apart or becomes less appealing to me.
Do I want to practice in a private practice or in academic practice?
In academics you have the benefits CME activities, research, residents/fellow teaching etc. If you go the private route, would you be satisfied doing your job and going home with little opportunity to teach, and little opportunity to test your hypotheses with IRB approved studies.
Do you want to practice in a multi specialty practice or in a strictly pain management practice?
- Multi specialty groups such as mine, have the advantages of leveraging the different specialties. For instance, my anesthesiology group benefits from the procedures that I bring to the ambulatory surgical center. We provide the surgical center with reembursement for pain management procedures in the form of a facility fee, and my group benefits from the direct pain reimbursement as well as the collections from the anesthesia on the cases that I do. Being part of a large group has the benefits of an economy of scale as well, as greater purchasing power. If I was on my own, It would not be very easy to purchase other pain practices or afford the beautiful state of the art office where I work.
Should I start up a pain practice from scratch?
- This is a question that I asked myself, many, many, many, many, times. And fact, I still wonder. My friends who have done this are quite happy, as we do have a wonderful specialty that can still be lucrative. In this day and age it is quite challenging to start your own practice. Faced with high overhead, increasing regulations and and diminishing reimbursement, I advise caution when heading down this route. If you are a multitasker and have the stomach, it may be a good idea. What holds me back is my current satisfaction with my group, and the large upfront investment. This varies tremendously depending on how you set it up. Then there are the stresses of managing, bills, staff, legal , compliance, etc.
Am I interviewing for a legit practice?
- Unfortunately, not everyone has high moral character. You need to be very careful with who you get into bed with. I have met doctors at conferences who report being fired from private practices because they refused to perform procedures that they felt were not indicated. There are practices out there in which the referral patterns include recommendations from referral sources that request interventions or meds that you may not agree with. There also practices were physicians are pressured to perform injections or give medications by lawyers who have alterior motives, or they are asked for interventions just because they are highly remibursed as opposed to medically indicated. I would caution anyone from taking these jobs.
- Don't get stuck in a practice where you can't sleep at night. Don't focus on surgeons as your only referral source. You should not have to feel like you are obligated to refer a patient for surgery who really does not need it, or has not exhausted conservative therapy.
My final job advice is to look for a practice in which the physicians are all of the same head. You want to find ethical people who are playing the long game. In my pain practice, many patients are treated as if they have a temporary problem. While we cannot always solve the problem, this philosophy avoids me from giving unnecessary medications, sending patients surgeons prematurely, or giving more injections than I need to.
If you keep the patient happy and do the right thing for the long term, most of them will appreciate you. The drug seekers won't, but that is ok. You will still be doing right by them.
Instead of building a practice where I automatically send a patient to surgery if the third epidural does not work, I treat the patient as a partner in the healing process and hope that over time, the patient will modify activities to help themselves. Surgery does have a role, but I do not advocate it in order to receive more referrals from the surgeon. My plan is to play the long game. I’ve built a reputation among my patient as being the "doctor that does not give up." This has lead to a majority of my referrals coming from other patients.
In my opinion, this is what you should look for when looking into pain practices. If the physicians, staff and patients all seem happy, then you may have found the right practice.
I hope this essay helps you in all of your careers.
Dave Rosenblum, MD