Residents In a Room

Episode Number: 56

Episode Title: Interview Tips from the Inside

Recorded: September 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.

Emergencies happen. They can be so scary, and it is fair game for a candidate to ask about the support they will have on the day to day.

It's your mission to find a practice that will help support you both in clinical practice and with developing the interpersonal tools to become a leader within the operating room.

DR. DOUG MORGAN:

Hey everyone. Welcome to Residents in a Room, the podcast for residents, by residents. Or in this case, people who were once residents.

I'm Dr. Doug Morgan and I'm here with my colleague, Dr. Camellia Baldridge. And we're hosting this episode sponsored by our Practice US Anesthesia Partners. Today we're going to share some thoughts on questions residents can use during the interview process to better understand the health and structure of a private practice. Our goal is to help residents develop the language to be able to mine salient information from an interview process and really make the interview process a two way street.

Before we jump in, Camellia, why don't you tell the listeners a little bit about yourself?

DR. CAMILLIA BALDRIDGE:

Sure. My name is Camellia. I went to the University of Colorado for medical school and the University of Washington for both residency and a complex neuro fellowship. After graduating, I did what many new grads do. I focused my job search on geography, my perceived collegiality of the practice, and the complexity and breadth of cases was really important to me. This landed me at USAP Washington, where I've been since 2019, and in the years since starting private practice, I've learned much more about the business side of anesthesia and the importance of joining a practice with a good relationship with the hospital. Hence my presence here today.

Doug, can you introduce yourself as well?

DR. MORGAN:

Sure. As I said, my name is Doug Morgan. I'm a physician partner with US Anesthesia Partners here in Washington, specifically in Seattle. I went to medical school at the University of Health Sciences in Kansas City, then anesthesia residency here at the University of Washington, then did a year abroad in Auckland, New Zealand, doing a mix of pedes adult cardiac and ENT anesthesia. I've been with the group since 2008. I've also had the good fortune to wear many hats within leadership in that time. I'm currently on our group's board of directors and I am our thoracic anesthesia chief.

DR. BALDRIDGE:

So Doug and I both sit on our group's recruiting committee and we have the privilege of interfacing with dozens of anesthesia graduates, anesthesia fellows, and also seasoned anesthesiologists who are interviewing for private practice. And in our time on recruiting, we've noticed that experienced anesthesiologists ask very in-depth questions about the structure of our practice and our relationship with the hospital. And many new graduates don't ask any of these questions. So today we want to share with you several questions you can ask during an interview to make sure the practice you join has longevity. And as Doug said, we want to ensure that the interview process is a two way street.

DR. MORGAN:

Yes. So the three topics we will discuss here today, number one, ensuring a symbiotic relationship between the practice and the hospital system; two, the internal processes for quality improvement, mentorship, case review and protocol development so physicians are supported in continually focusing on improved patient care; and finally, the operational or business structure of the practice, meaning the non-clinical employees of the group that support the physicians ability to focus on their clinical practice.

DR. BALDRIDGE:

Doug, interviews are very nerve racking and some residents might feel nervous about asking too many questions. What's your response to that?

DR. MORGAN:

I think there are some obvious things that everyone wants to know and should understand when looking for a job. But the obvious ones geography, income, potential, clinical variety, partnership opportunities, and equality once you've achieved partnership, simple things like benefits, malpractice, vacation, and then the overall culture of the practice. Prioritizing these are very, very important. But asking questions about the next level characteristics about a practice will really help you understand the overall health and sustainability of a practice. You're looking for a place to form a career and build your life. And the practice is looking for a safe, competent, dependable anesthesiologist tor the long term. It is fully appropriate for you to ask questions on the business side of things.

DR. BALDRIDGE:

I totally agree. I think we really focus on the fact that your clinical abilities are going to sky rocket in the first five years. And many people say those first five years can be more difficult than residency itself. But we don't think about how much your understanding on the business side of medicine will also really escalate in those first five years of practice. Personally, I'm very impressed during an interview when a resident asks a question like How would your organization handle losing an insurance contract? Because it shows us that you're already having an appreciation for the business side. Doug, what do you think are some questions a resident can ask to try to understand the relationship that the hospital has with the anesthesia group you're interviewing with?

DR. MORGAN:

Yeah. Think questions like, How long has the group been practicing at their primary facility? How frequently does the group's leadership meet with the hospital's leadership? Does the hospital only meet with the group when there's a problem, or is there a real partnership between the hospital C-suite, meaning the hospital leadership, the OR directors, and the anesthesia group? Are the practice anesthesiologists active in multiple committees at the hospital level? And if so, how involved are those physicians? Are these anesthesiologists helping to draft policies and procedures at the hospital level?

DR. BALDRIDGE:

I mean, I think the crux of what you're getting at is the critical role that anesthesiologists have in maintaining the operating rooms, both functioning and ensuring patient safety. And it's really our responsibility to actively participate in building protocols that impact the delivery of clinical care. And we want to make sure that our patients experience from end to end is being scrutinized and constantly improved. The reality is that some hospitals are going to value this more than others, and you really want to make sure you end up in a hospital system that values your anesthesiologists and works well with them.

DR. MORGAN:

Yeah, exactly. You know, it's important to ensure that we're at the forefront of any conversation about adding additional sites of service or new service lines. If a group isn't already a trusted partner of the hospital, they won't have that opportunity to have a seat at the table. A group with a seat at the table is a group that will likely have a long and collegial relationship with the hospital.

DR. BALDRIDGE:

So what happens if the expectations of one party are not being met by the other? In other words, what are some questions an applicant can ask to try to determine if there's been issues with either the practice or the hospital side of this critical relationship?

DR. MORGAN:

Yeah, unfortunately, right now there's lots of examples of these relationships souring and often it just becomes the hospital system looking for a whole new anesthesia group. This typically means terminating or not or not renewing the contract and opening what's called an RFP, a request for proposal. An RFP is typically then answered by any number of competing anesthesia groups to see if a different anesthesia group would be better able to meet the needs of the hospital. Whether that be first case starts, cost of services, or the ability to provide specific service lines. For residents in an interview, I Think simple questions are things like has the group ever had to answer an RFP with their own hospital or system? Do you, meaning the interviewer, do you feel the group is meeting the needs of the hospital? As a group do you struggle to meet the demands for case starts? Do you have adequate staffing to fulfill those first case start obligations? Does the hospital advertise excellence in services such as cardiac, pedes, code stroke, regional? And if so, is the group able to sustain those service lines with fellowship trained anesthesiologists? Can the group grow as the hospital grows? If the hospital asks the group to help build new ORs or add service lines, will the group be able to meet those needs?

DR. BALDRIDGE:

Those are a lot of really big questions, but it seems like a lot of those are so intimately related to the clinical breadth and the acumen of the group. Part of what makes an anesthesia practice successful, as we've been mentioning, is the group's ability to deliver safe, superior and consistent clinical care.

DR. MORGAN:

Exactly. Kim, what are some programs within a practice that prioritizes high quality clinical care? And what are some questions a resident can ask during an interview to learn about these programs?

DR. BALDRIDGE:

You know, this is something that I think I took for granted when I was a resident applying to private practice because quality improvement programs and things like mentorship are so often built into academic institutions, and it's easy to take for granted that they'll always be there. The reality is not all private practices are going to value quality improvement programs in the same way, because the reality is that these programs take a lot of work, time, dedication, and leadership to maintain. I think first off, for me, an important question to ask is if there's any sort of mentorship program for a new anesthesiologist joining the group. And this can be as simple as pairing an anesthesiologist with an experienced anesthesiologist, similar clinical interests and personality. And you're just trying to establish a support system when you're starting in a new and foreign clinical environment. I think the other important question to ask is about the presence of clinical quality programs within the group. Established QI programs are absolutely paramount to strong working relationships with surgeons, and they should aim to improve our patient outcomes. Again, keep in mind, not every group that has a QI program is going to be created equal. It's perfectly reasonable to dig in and ask questions about QI program and processes during your interview.

DR. MORGAN:

Yeah. Think specific questions could include, Is there a quality improvement leadership structure within the group? And are there any non-clinical support team members dedicated to supporting that leadership? I think you can ask for an example of a recent initiative that was implemented. And then what kind of data is the program capturing and is that data being used to build new best practices? Other things. You know, what kind of reporting tool does the Quality and Risk program have in place? Does the QI leadership meet to review incidents? Does the group have morbidity and mortality conferences? You know, there's often morning times where you can sit down with with other members of your team and review cases that didn't go perfectly. And then who is in charge of protocol development?

DR. BALDRIDGE:

I think these questions are so important because they're paramount to your own continued development as an anesthesiologist when you join a group. And in my time on the recruiting committee, I really am impressed when a graduate asks questions about our own quality programs because it shows that they understand that very important interplay.

DR. MORGAN:

Yeah, and I will add that I think it's a good idea for residents to understand what the support is like in the OR day to day. Some groups run very lean where everyone is in the OR as often as possible, whereas other groups build in a board runner or an individual who is out of the OR and available for clinical help. Coming straight out of residency, you should understand how far away help is when you need it and how the practice that you might join and how their structure influences this ability to offer that clinical assistance.

DR. BALDRIDGE:

Oh my goodness. So true. And emergencies happen. They can be so scary and it is fair game for candidate to ask about the support they will have on the day to day. I encourage residents to ask their interviewer, what is the last emergency you had and how long did it take for help to arrive and what did that help look like? It's completely reasonable and it should really clue you in to the type of support that is built into the practice structure.

So Doug, we've covered so far ways to assess for the symbiotic relationship between the practice and the hospital system, and also some of the internal processes a group may have for quality improvement, mentorship, and day to day support. The last topic that we want to discuss is the operational and business structure of a practice. Most groups will have non-clinical employees that support the physician's ability to focus on clinical practice. What are some of the internal group, organization and leadership structures that you think make a good business model?

DR. MORGAN:

Yeah, well, I mean, we all know how to do anesthesia, but what we haven't been trained on is the business side of our specialty. I think the key takeaways for a resident from an interview would be, How does the practice manage itself? Is everything a vote of the partners or do you have a governance board and committees to help guide decisions? Similarly, do the board or the committee members have term limits? How frequently are these positions turned over, and is there succession planning in place to ensure the future of the practice? Is there business leadership behind the scenes? This can be things like a chief quality officer. It can be a chief financial officer, an HR director, a compliance officer, and to me, the most important one is the business exec. So one individual to help the group interface with the hospital C-suite so that business leaders are talking to business leaders. I think an applicant can ask who manages contract negotiation and renewal with the hospital. This should ascertain if business leadership is responsible for contracts or if the group relies on their anesthesiologist to handle these critical business relationships. Other question, Who handles payer contract and negotiations with the insurance companies? Who handles the billing? Is it in-house or is it outsourced? And how efficient is it? Are the physicians responsible for any part of the billing process beyond just keeping accurate records?

DR. BALDRIDGE:

That is so many topics that, again, I had no idea when I was a resident applying for jobs. I think the other business side topic that I would add is to ask about recruiting. Specifically, ask if the group has support to recruit physicians both locally and outside of the region, and this might be in the form of somebody like a recruiter. And also it's reasonable to ask about recruiting targets and attrition rates to get an idea about the stability of the group.

DR. MORGAN:

So, Cam, we've covered a lot of ground. I think at the end of the day, especially in those first few years of your career, 95% of what you will do daily, you will have already been trained to do. It's your mission to find a practice that will help support you both in clinical practice and with developing the interpersonal tools to become a leader within the operating room.

DR. BALDRIDGE:

We really hope the questions we've posed today will help you find a healthy practice with intelligent and thoughtful clinical quality programs already built in, a symbiotic relationship with the hospital where the hospital values its anesthesiologists and gives them a seat at the table, and also a strong internal business structure that supports physicians so that we can do our day to day clinical work and not worry about all of the business stuff.

DR. MORGAN:

Yeah. We want to thank you, everyone, for tuning in. If anyone has questions or wants to contact either Cam or myself, please feel free to reach out. Our email addresses are on the USAP website and we really hope our listeners learn something valuable today. And we hope you'll tune in to the next episode of Residents in a Room, the podcast for residents by residents, or at least people who were once residents. Thanks, everybody.

VOICE OVER:

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