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cancerman51

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HELL NO!

I tried everything humanly possible to go down the academic path. Fought constantly to get research time during residency, which made me persona non grata at my program. Looked hard at research fellowships, but the reality of having a family made that impossible unless I worked 6 days a week.

So I joined a group practice.

One of my initial fears was that i would miss the academic environment, case variety etc, and not have access to the same expertise on the consult end.

However, I haven't found any of that to be true. my dermatopathologists are getting me results in 24-48 hours, I havent found any test that I can't get, nor any specialists that I can't tap for help. the case variety is nearly the same, except that I get far, far, far fewer delusions of parasitosis, nutjobs, and entitlement syndrome patients.

I never wait for nurses any more, I have MA's that handle all of my correspendence. I don't have a complete troll of an administrator who tells me when I can or can't take vacation. They have bought me all the equipment i've asked for, and usually have it for me within a week.

The fact of the matter is that the further I get from academics, the happier I am. Right now, i focus on delivering great care to my patients, and the environment totally supports that.

I am not missing the fight anymore. Trying to do research felt more like walking naked through a live shooting range with a target painted on my back.
 
I do have some call, a week at a time, several weeks out of the year. I got paged 3 times the last week i took call, which wasn't too bad. The surgeon takes his own call.

I asked for a new dermlight to replace my busted up POS from residency. they ordered me a DL3 today.
 
So happy for you Cancerman!!! Also very appreciative of your honesty about the difficulties in pursuing academics. Your opinions and insights are always profound and help guide junior residents like myself wrt career planning.
 
Cancerman, what kind of private practice are you in? Large/small multispecialty, or derm only?

What are your insights about the differences (pros & cons) of the various practice types when you looked for a job?

What do you think about documentations/notes/time spent on paperwork?

Thanks in advance! I'm glad you're happy with your choice!
 
I'm in a multispecialty group. My primary site is a satellite clinic, and i'm the only derm there, but there are about 10 derms + Dermpath and Mohs in my department.

I definitely found the multispecialty group way more appealing. I have pretty much the same access to ENT, Optho, Plastics, etc that I had as a resident. Except for autonomic sweat testing there isnt much that I can't get testing wise. Certainly don't have any problems getting useful tests. 50% of my path comes back the next day.

I'm aggressively working to minimize my documentation time. During residency, i had 20 minutes per patient, but documentation was tedious, and I had to return all the patient phone calls and sent out tons of letters. I'm at 4 patients per hour right now, and I think my face time with each patient is unchanged. The keys so far are:
1. I don't return phone calls. MA's do that. The difference this makes is immeasurable.
2. I'm moving toward 0 dictation. I am developing templates for common problems that capture truly relevant information. The MA's start the appropriate one. I have about 12 different ones now for common scenarios. Using these, my documentation for warts, hairloss, or acne takes less than 30 seconds for me to complete. The others are still a work in progress. Even on days where I fall behind on documentation, it usually only takes me about 15-25 minutes to document half a day of patients now.
3. Letters are only for very special cases
4. MA's generate the outgoing letters for external consults. These are identified and triggered by prompts in the templates.
5. I have a surgical intake process for scheduling patients that identifies in advance all the pacer/defib/heart/joint/high risk site patients and triages them appropriately. The MA's are now doing this quite easily and documenting this for every patient now.

We work pretty hard each week to identify waste (processes that don't add value to the patient encounter) and error prone processes and then test various alternatives until we have fixed the problem and then move on to the next.
 
Sounds like a sweet set up. Good for you cancerman. I've always enjoyed your insightful post even back when you where on the dermboard.
 
I forgot to mention that I need a hummer sized wheelbarrow to take my paycheck to the bank
 
Seems like the MA's are making the huge difference
 
cancerman51 said:
HELL NO!

I tried everything humanly possible to go down the academic path. Fought constantly to get research time during residency, which made me persona non grata at my program. Looked hard at research fellowships, but the reality of having a family made that impossible unless I worked 6 days a week.

So I joined a group practice.

One of my initial fears was that i would miss the academic environment, case variety etc, and not have access to the same expertise on the consult end.

However, I haven't found any of that to be true. my dermatopathologists are getting me results in 24-48 hours, I havent found any test that I can't get, nor any specialists that I can't tap for help. the case variety is nearly the same, except that I get far, far, far fewer delusions of parasitosis, nutjobs, and entitlement syndrome patients.

I never wait for nurses any more, I have MA's that handle all of my correspendence. I don't have a complete troll of an administrator who tells me when I can or can't take vacation. They have bought me all the equipment i've asked for, and usually have it for me within a week.

The fact of the matter is that the further I get from academics, the happier I am. Right now, i focus on delivering great care to my patients, and the environment totally supports that.

I am not missing the fight anymore. Trying to do research felt more like walking naked through a live shooting range with a target painted on my back.
Click to expand...

Thanks for the great post cancerman. Towards the end of residency and also leaning towards private practice for many of the reasons you cited above.

The one thing that is hard to believe is your case variety being nearly the same!? I always thought of the pros you listed for PP, but thought the negatives were fewer exciting cases, fewer uncommon/complicated patients and also missing grand rounds. Are you really seeing things like gvhd, ctcl, erosive lp, BP/PV/PF, SJS, genodermatoses etc on a semi-regular basis like in residency? Theres not a day that goes by that I don't see at least 1-2 in this type of category plus occasionally something really rare that I've never seen before which I feel that I may miss. Some PP attendings have complained to me that their clinics are 98% skin checks.
 
Kaushik said:
👍

I agree. Seems like it's better to pass on the nurses who think they're equivalent/superior to you and just go with the MAs who don't seem to come with the ego...
Click to expand...

I'm not sure that he meant it that way (but I could be wrong). I think the difference (at least the way I'm reading it) is that he used to be a resident, but now he's not. So the helpers (i.e., nurses or MA) will actually do their job since they will be more accountable. A resident complaining that a nurse is unhelpful isn't going to accomplish anything. However, now that he's a practicing dermatologist, if his MAs aren't meeting his needs, (presumably) he can get new ones. This would probably be true even if they were nurses.

Of course, in a general dermatology practice you really only need MAs. Nurses don't justify the additional expense.

The setting change also matters. With all of the bureaucracy associated with academic settings, getting rid of unhelpful staff is difficult even for attendings. It's also hard to reward the ones who do work hard. As a result you find that staff (MAs and Nurses) are generally less helpful and hard working in academic settings than they are in most non-academic settings. This is probably a bit of an over-generalization, but it's not far from reality.
 
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doctalaughs said:
Thanks for the great post cancerman. Towards the end of residency and also leaning towards private practice for many of the reasons you cited above.

The one thing that is hard to believe is your case variety being nearly the same!? I always thought of the pros you listed for PP, but thought the negatives were fewer exciting cases, fewer uncommon/complicated patients and also missing grand rounds. Are you really seeing things like gvhd, ctcl, erosive lp, BP/PV/PF, SJS, genodermatoses etc on a semi-regular basis like in residency? Theres not a day that goes by that I don't see at least 1-2 in this type of category plus occasionally something really rare that I've never seen before which I feel that I may miss. Some PP attendings have complained to me that their clinics are 98% skin checks.
Click to expand...

To say that I see the same amount of gvhd, ctcl, erosive lp, BP/PV/PF, SJS, genodermatoses as an entire academic department would be preposterous. And definitely would not have seen 1-2 of those a day in residency. But when i compare my calendar now, to my calendar as a resident, i would say that
I do not expect to see GVHD or CTCL often
I only saw SJS once during all of residency, so hard to compare to that
I see fewer skin checks now
I see more new rashes now

I also suspect private practice is different than being in a multi specialty clinic
 
Your group bought you a dermscope for free, without taking it out of your paycheck? Not to be rude, but that boggles my mind. I'm interviewing with privates and multispecialties as well, but I don't think anyone would buy me a scope that I could keep as my own private instrument.
 
DermMatch said:
Your group bought you a dermscope for free, without taking it out of your paycheck? Not to be rude, but that boggles my mind. I'm interviewing with privates and multispecialties as well, but I don't think anyone would buy me a scope that I could keep as my own private instrument.
Click to expand...

HAH! The acquisition of the 3Gen DL3 is old news. I decided I want dermascopic images of lesions that I biopsy to build a collection of images and to use for serial monitoring in patients, particularly lesions in cosmetically sensitive images. So i asked on Monday for the 3Gen photo system. Just got approved yesterday and should be here in time for Xmas.
 
I think I last posted on this board 1000 years ago, but cancerman's post brought me back! Shout out to CM - we posted on the old ezboard together, and I actually think someone introduced you to me as CM at a AAD 4-5 years ago.

I'm a typically cynical MD/PhD who said they were going to do research when I entered my high powered (certainly according to them) program. First let me say this - every single brilliant dedicated cool MD/PhD colleague I entered with, except for 1, has now left the tower.

I did not expect to stay. I wasn't dishonest, but I bet on my dept offering me a 5 figure salary, beating my head with a stick on the way out. But amazingly they gave me what I needed when I asked for it. They supported me. Some of the senior research faculty turned out to have personality disorders, but most didn't, and took my side when I needed it.

I'm now publishing papers in major research journals like I did as a graduate student. I forgot how much I loved science but it's great - challenging, painful, confounding, exhilarating. I'm so thankful to the group here that they gave me a chance to do this (although I'm still waiting for the bottom to drop out and to end up in PP).

Some of my colleagues make twice as much as I do. But they work 4 times the hours (truth). I wouldn't trade right now. I simply wouldn't do it. Maybe someday, but lots of life left for that.

It can work. I would recommend this - understand how people who stayed, stayed. What they got. See if you could stay for within 10% of that, because that's probably negotiable. Be honest you need cash. And enjoy yourself....
 
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I did not expect to stay. I wasn't dishonest, but I bet on my dept offering me a 5 figure salary, beating my head with a stick on the way out. But amazingly they gave me what I needed when I asked for it. They supported me. Some of the senior research faculty turned out to have personality disorders, but most didn't, and took my side when I needed it.
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Congrats man! That is awesome. What you found is the key. I would have stayed in those circumstances also. Being on fellow pay scale for another 3-5 years was the killer for me.
 
I should qualify and say my department was unusually supportive and this is not the rule.

If you really want to do basic science, find someone who got a job (asst prof, not the deep dark black hole of 'clinical instructor') in the last 2 yrs or so at your school of love. Buy them at least 3 cocktails.

Wait.
 
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