Residents In a Room

Episode Number: 55

Episode Title: Ask a Private Practice Attending

Recorded: August 2023

(SOUNDBITE OF MUSIC)

VOICE OVER:

This is Residents in a Room, anofficial podcast of the American Society of Anesthesiologists where we go behind the scenes to explore the world from the point-of-view of anesthesiology residents.

There's no such thing as achieving ideals in the real world, but there's such a thing as getting close.

That respect aspect of being in a workplace is probably the biggest thing that I'd be looking for.

I want to be at a place that has respect for what anesthesiologists need to take good care of their patients.

Finding a place that really values the patient experience.

For me, it's the culture of the workplace that would be the most important.

DR. BETH HALL:

Welcome back to Residents in a Room, the podcast for residents by residents. I'm your host for today's episode, Dr. Beth Hall, a CA3 at University of Chicago. And I'm here at U of C with some fellow residents and with Dr. Smitha Arekapudi, who has worked in private practice, academics, and even as a locums attending. We're going to pick up our conversation about transitioning out of residency. Last month we focused on academic medicine, but today we'll focus more on private practice. Before we begin, I'm going to ask my fellow residents to introduce themselves.

DR. NIKHIL NADLER:

I'm Nikhil Nadler, CA3 at Loyola University Medical Center.

DR. SEAN POWERS:

I'm Sean Powers, CA3 at Loyola University Medical Center.

DR. SHYAM DESAI:

And I'm Shyam Desai. I'm also CA3. I'm at Rush.

DR. HALL:

And Dr. Arekapudi. Tell our listeners a bit about yourself.

DR. SMITHA AREKAPUDI:

Well, thank you, Dr. Hall, for the introduction and thank you for having me. I'm delighted to be here with all of you today. A little bit about me. I have basically, as you suggested, worked in every type of anesthesia practice from MD only fee for service to medical supervision of CRNAs, from surgery centers to level one trauma teaching facilities. I've served as clinical teacher, director of the medical student rotation. I've served as chief of anesthesiology for a large single specialty firm and chair of a department at a community hospital. And my background includes medical school, but it also includes degrees in public health, business, and liberal arts. And so with that, I also possess a wide variety of other experiences. Since a young age, I've been interested in community service and have been pretty active in nonprofit work and social entrepreneurship. And at ASA, I'm a member of the committee on innovation and I'm also a member of a new ad hoc committee on market strategy for anesthesiology.

DR. NADLER:

As a bunch of new CA3's who are looking at the job market right now. Right now it's on fire, from what I understand. But from your perspective, what is the job market like right now? And for those of us who have to work in private practice, what tips for interviewing do you have or anything that we should be looking out for?

DR. AREKAPUDI:

You're correct. There is an excess of demand right now as opposed to supply of physicians available in the marketplace. So that provides a great situation for prospective job seekers in terms of looking for what they may consider as their best fit.

And I think a general framework for approaching these questions is asking yourself a few questions. And I would start with two top questions that are for myself, but they apply to others is: what kind of work do I want to do? Where do I want to live? And those were the most important for me when I started out. When I was in your position not that long ago. It's been over a decade, but it still feels like not that long ago. And the other questions I would ask, which are very critical as well, with whom do I want to work? How do I want to get paid? Or how much? That wasn't--how much wasn't really a consideration as the final consideration, but it does matter, especially if you have loans. And the final question is how much influence can I or do I wish to have beyond the clinical realm?

So when you think of those questions, everybody has their own personal answers to these questions. And so I would say that knowing your own as much as you can know them, sometimes you may not know them or develop it yet. As much as you can know these answers, that's critical to going in with that in mind and saying, does this job, is it applicable to what my needs are? There's no perfect job, there's no perfect position, and there never will be. So the issue there will always be a number of mutual compromises.

My tips for interview, I think in this marketplace, I think people would be more amenable for you to ask more detailed questions. That being said, I will say. In my experience, it's really hard to get to know the culture of a place. And I think working there six months is required at least to really understand things and people, work relationships, and those are all very important things In terms of answering those questions that I talked about at the beginning. I also think you should look out for really understanding what's presented to you in a verbal setting and what's presented to you in the contract and make sure that you're okay with both

DR. POWERS:

So you've worked as a locum as well. It seems like potentially exciting prospect for a new grad. Do you have any thoughts on working as a locum right out of residency?

DR. AREKAPUDI:

I do. I think it might be appearing exciting and it's very interesting that there are locums opportunities proliferating right now. However, I would not for myself and for advice, I would not pursue a locums job right out of training. And the reason for that is you want to go to a place that isn't in the midst of severe change or challenge or crisis for that matter. And often a place that requires locums or a lot of locums is undergoing those things. And so when you're coming out from residency, you want to go to a place generally where you can be an attending who will have a great opportunity to solidify clinical skills and become the most safe, independent, autonomous doctor that you can be. And to do that, I think you need an element of stability, hopefully mentorship, although that doesn't exist everywhere. Having colleagues who hopefully have your back when something unexpected happens because it's a matter of time. It will happen. That's the nature of our field. So I would advise against going into locums out of residency. And the other reason I advise that is that you might be as a locums, given some of the more difficult, challenging cases that other people may not want to have to deal with because they have an opportunity to have someone else who's there to take cases like that. And I'm not saying that that happens all the time, but it can and you might not want to enter practice in that manner. You want some consistency, stability. And that being said, I have worked with people coming straight out of residency in a locum scenario, and many of them did just fine. But I'm giving you a philosophical answer to why you want that, and it might promote your well-being to have those things that I was talking about.

DR. DESAI:

Do you think that private practice settings struggle more to create a positive work environment compared to academic or other settings? Or is it just totally different in terms of kind of the environment setting?

DR. AREKAPUDI:

I don't know that I think about it like that. I think that a work place is a work place, and I don't know that academic medicine is always creating, with all due respect to academic medicine, I'm not sure they're always creating a desirable workplace. So I'm not going to speak to the details of that. But I think that's an interesting question from a general perspective of what is a positive work environment. And I think that also relates to what you're looking for out of a workplace. So I think that a positive work environment involves transparency, a place where you can potentially bring your whole self to work, authenticity of yourself, a place where you have support and you feel that you have that support. Your colleagues, so to speak, have your back. And that's what I mean by bringing your whole self to work, that you feel comfortable that if you have something that you want to communicate, that you could do so in private and that you will feel supported and people can stand by you.

And of course, some of the things that I care about in a workplace I felt go without saying, but maybe they should be said as we continue to evolve such as I want a workplace that. Prioritizes, number one, patient safety approach and quality of care, and that that patient experience is a guiding principle of decision making. And this sounds simple, but it's actually quite a complex thing in operations in practice, so I'll answer it that way. There is a huge challenge right now in the anesthesiology and in general in health care workplace workforce retention. Not just recruitment -- recruitment and retention. And part of that has to do with are we having workplaces that are desirable for workers to work in, whether it be nurses, your facilities staff, your doctors, your other staff. These are questions that are quite complex and apply department by department, and I think it's something to consider. And that being said, I think every doctor and every individual has potential to be impactful because say you have a workplace that you wish could be different, I think that you have a potential to be impactful at the level of individual relationships, and that's where change really happens. So it's something to keep in mind. Be the person who is part of delivering the workplace experience that you hope to get, whether it be in patient care, as a colleague, as a decision maker. There are so many roles, but that's that's the guiding principles by which I hope and try to operate by every day.

DR. HALL:

You are somebody who has had many different roles and a lot of them in leadership. And I just wonder why do you think it's important that anesthesiologists are at the decision making table? And are there different pathways to leadership positions that you think residents should know about now?

DR. AREKAPUDI:

I think it's critical, especially in a time of health care change and health care challenges in this country after Covid, particularly that anesthesiologists be leaders. We're already leaders, even if we don't say we are, in the OR. We set the tone. We are leaders in patient safety and so on. I think it relates to the other question that I talked about, about your ideal workplace. There's no such thing as achieving ideals in the real world, but there's such a thing as getting close or aiming for excellence and success and enjoyment and fun while you do these things, make an impact, and help people. I think that's why most of us, all of us nearly, went into medicine, is to help people.

I think it is about framework, thinking about things in framework. I like to do that as it keeps us focused and the framework I want to talk to you about is: see, believe, think and act. This one framework and you can start thinking this way, but there are many ways to go. But all of these ways focus on the human approach, the human layer to things. So see, you want to paint that picture so they can visualize it. You see it. Then Next in believing. How do you instill a belief in this picture being attainable and desirable in your present or future state of being? And then that third one is see, believe, think. Thinking is how do you empower an individual? Everything is at the individual level, I believe. This is about persuasion really, how do you empower a person to think through to your picture and looking through a new lens so that they can envision your future state? What are the operations principles, the steps to getting there? And then finally, act is the tactics really, what you want to do in terms of tactics. But how do you incentivize? What are the incentives that make you need it, that you want it, and making sure that other people want it and ensuring that they can act differently. And why I go through these steps is we all talk about wanting to do things, okay. But these steps really will help your approach to execution of the matter, really making it happen. I think that's where a lot of health care organizations and even businesses in the world, like people, they have challenges at the execution level. So I think as anesthesiologists, you have a special insight, talents that other people don't possess and may not even have appreciation for. So it's important that you can communicate well so that people understand these things.

That was kind of a very broad approach to your question, but I think there are so many opportunities for leadership and it's necessary for us to be leaders at the table, particularly in what's coming up. We have a lot of technologies coming. We should be the ones determining how, why, and the safety and what and when.

DR. NADLER:

So life as a resident is very different than life as an attending in private practice. What are things that we should be doing now as we're preparing to graduate that can prepare us for a role as an attending in private practice? Coming out of training will be supervising others. What should we be doing now to prepare for that?

DR. AREKAPUDI:

Supervising others is different than maybe what you're doing as a resident and focusing on taking care of one case at a time where you know one patient at a time and your attention is not divided. Supervising others may present new work, new challenges because you have lots of streams of information, lots of variables that you may not have had experience organizing in your mind and taking care of as a resident. But you may have. It's hard to know, depending on your experiences as a resident, as you go to senior levels, you might have ability in supervising others at some residencies.

My thoughts on this question are really have it to do with development of good communication skills and also two other issues that are critical. These skills are critical in every scenario, but become exceptionally critical when you're dealing with people you manage. Self awareness and situational awareness and communication skills. And the challenges there are a continually evolving thing, and it's hard to know when you're in a new place, when you don't know anyone, when you don't know the culture, when you don't know the place. These are things to keep in mind on how to be in any workplace.

When you're managing others, it's a joy to work with a great CRNA who you trust, who you have good communication with, who you know will deliver a great clinical experience and patient experience. And on the flip side, you can have challenging personalities, challenging people who don't meet up with expected skill level and so on. I think what's important here is, sometimes when you're under pressure it can be even more challenging to have self and situational awareness because there's only seconds. So these are things to talk about.

When thinking about communications to take care of the patient at hand and then potentially have the communication privately, depending on the nature of the communication. I think feedback and giving feedback--good feedback is a rare thing. People say you won't hear anything unless you did something wrong, which is important but not enough. So when looking at supervising others, I would say this all has to do with your self development and focusing on your well being, but also that an acknowledgement that these issues are critical in addition to clinical skill. These are components of what you need to be a great anesthesiologist and hopefully you will be landing in a place where that's understood and appreciated. And sometimes you'll find that there are workplaces where the leadership may not possess these skills. So it's incredibly challenging to do this when the culture does not acknowledge and appreciate such an approach. So you have to be careful knowing where you are and that's very challenging. You may not know that this is easy to talk about, but it's hard to actually do. And some places this will not be acknowledged as important or relevant.

DR. POWERS:

Can you talk a bit about production pressures in the private practice setting? And are there challenges we should be prepared to accept?

DR. AREKAPUDI:

This is a timely and important question. In fact, I co-wrote an article for the ASA Monitor with three others in the April edition 2023 about this topic. So you can look at that. I think the most important thing for me personally as an anesthesiologist before anything else, before anything I've discussed on communication, self-awareness, blah, blah, blah, all this stuff, is simply patient safety and delivering an excellent anesthetic with a good outcome. That's my number one goal when I'm at work. And I think the answer to this question revolves around that.

So, there will inevitably in this marketplace be production pressure with pressure from declining reimbursements, rolling out of value-based solutions. That is an ever-present business approach. That doesn't mean that it is the only way. By that I mean the way we do things now may not be the final or only way. Things are evolving. And so I suggest that you would benefit from having an idea of how things can change or how you want them to change, but the reality is if you can always practice with quality and safety first, the rest should fall into place. And sometimes you need to be courageous and bold and say, I stand up and say, no, this we cannot cross this line and this is the reason. And you can do that calmly, confidently and with your expertise, make a great argument as to why. And you have to be willing to do that in a setting of production pressure where you think it will compromise beyond what you think is an acceptable delivery of an anesthetic.

I think of it this way -- not everybody will answer this question this way -- but I say, would I feel good having one of my family members be in this situation as a patient or myself? And that guides me very obviously. And I deliver every day an anesthetic to each patient that I would want delivered to me, or at least that's what I aim for. I hope for that. And so, yes, there is production pressure. I would like to add, you mentioned, I think you mentioned in the private practice setting, I don't think academics are immune right now to this. I think everybody has production pressure.

So you want to talk about what role we can take as anesthesiologists at the macro level. At the macro level, you want to talk about what influence can we have on policy and standards and approach and what does that mean? Asking questions is an art. And I think as you get experienced and even now, you're especially equipped to ask good questions. Asking good questions is an uncommon skill and sets the foundation for all data collection. And so you can make big decisions on what data you want to collect and what's important to collect, and that will play a role in the measures valid and applicable. Are they generalizable to your population and what effect does that have on your practice model? That is an evolving thing and in the moment you focus on the micro things. When you're not in a leadership position, you focus on, am I going to do this anesthetic with safety and excellence?

DR. DESAI:

There's more and more private equity money in medicine kind of in general. And my question to you is how will that impact private practice positions in anesthesia and kind of moving forward, in your opinion?

DR. AREKAPUDI:

There is a lot of private equity money in medicine, and private equity backed national firms have a lot of contracts in this country, and the majority of physicians now in anesthesiology are employed. So this question just relates to, in my opinion, what kind of employment scenario are you going to accept and tolerate? And is what's said verbally or even in writing as long as those agreements are held up, I think your workplace will be what you hope for and experience. Private equity, probably their motivations are business motivations, but business motivations are widespread, not just in private equity. So your general considerations apply whether you take a job with a private equity backed firm or not. So I think it's important for you to determine what kind of workplace and situation you want. And I think our other questions addressed that.

Now, I have a question for you. I think in residency and previously before residency, I didn't have much of a business education or knowledge of the business side of the world or frameworks to look at things. And I think that's missing in most residencies. And I think it's important to educate yourself as much as possible on these concepts, including talking to people, reading, and getting a wide variety of opinions. With that said, I'm curious to know what your future workplaces will be like that would most make you content and happy. And I'm curious to know what features of those workplaces would be for you or what considerations you have. What would make what would be that landing spot?

DR. DESAI:

I think something that I would think of at the top of my list is kind of just I think you alluded to this in some of your answers, just being respected as an anesthesiologist, a part of a group, and not just in terms of being respected while doing cases or with the people that I work with. But kind of in terms of having kind of that work life balance as well. So I know that with the current, at least from what I've heard with the current market in anesthesia and the huge demand for anesthesiologists around the country, that sometimes it's hard to to get vacation time when you want it or to be able to get time away from medicine to do other things, such as being a part of things like this, like a podcast or getting non-clinical times. So just kind of that respect aspect of being in a workplace is probably the biggest thing that I'd be looking for.

DR. HALL:

Building off a little bit of what Shyam said, but going in a little different direction, you talked about a place that has respect for you, and I think I would take it in a different way and that I want to be at a place that has respect for what anesthesiologists need to take good care of their patients. I don't want to be in a position where I feel like I'm alone in advocating for my patients or I'm the only person who has a safety and high quality mindset. I want that to be kind of built into the framework of a place that I'm at. I don't know how I'm going to find that necessarily yet, but I think that to me, that would be very important that, you know, patient safety is first as opposed to profit.

DR. NADLER:

I think for me, it's the culture of the workplace that that would be the most important. I want to see that I enjoy being with the people I'm around for a majority of the day, that we have life outside of medicine and that everything is just enjoyable to go to work. And I have support amongst my amongst my colleagues.

DR. POWERS:

Yeah, I think really finding a place that really values the patient experience and really looks at making sure that a patient that you take care of at your institution wants to keep coming back there because they know they're going to get good care. I think that would be that type of culture just kind of permeates throughout the entire institution, not just only what the patient sees, but what's happening behind the scenes as well.

DR. AREKAPUDI:

Thank you so much. Those were I love your answers. They're so insightful.

I think your comments on respect are so critical and important, and I think that has to do with our value and value added that we bring to the table. And I think these comments on respect are critical because they relate to person-to-person relationships that I talked about earlier. And when you have mutual respect that only builds respect and collaboration. Additionally, respect is based on people's knowledge and understanding of you and your value and your talents and so much more, your personality, everything. And I think this only drives home that we have real opportunity to market ourselves better and educate people about who we are. And that it's important that you can't just be in the or doing a case that you need to be out there and with your colleagues organized and building coalitions. It's so critical. And there are different types of coalitions. So I encourage all of you to be in the ASA and participate in coalition building there, but also a coalition building locally at your hospitals across fields vertically and horizontally at every level.

(SOUNDBITE OF MUSIC)

DR. HALL:

Thank you so much, Dr. Arekapudi for chatting with us today. And to our listeners, thank you for tuning in to Residents in a Room, the podcast for residents by residents. Don't forget to subscribe and follow and join us for the next episode coming next month.

VOICE OVER:

Leverage global, peer-reviewed resources and an engaged community to further your knowledge and skills. Explore the features of Anesthesia Toolbox and recommend it to your Residency Program Director. Visit asahq.org/toolbox.

Join us for residents in a room where we'll share timely info, advice and resources designed to help residents succeed in residency and beyond. Find us wherever you get your podcasts or visit asahq.org/podcast for more.