Time to show some love to the SRNA community with a little opinion piece. As a May graduate, it was about this time of year when I began to get serious about finding a position. Two healthcare providers and a dog ready for anything. I started with the below set of criteria, which are in MY order of importance. No right or wrong, but this how I narrowed the job search.

1.      Type of work – Max scope of practice. Truely not negotiable.

2.      Compensation – High. Yep, I said it. Close second.

3.      Work Schedule – Total hours per week/time off. Distant third.

4.      Location – Warmer than where we are now. More of a bonus.

Type of work: I see so many people say they want to keep up with the skills learned in school, but I don’t see that in practice. In a graduating class of 34, I was the only person to take an independent job. ACT models MAY restrict things like peripheral nerve blocks, pain injections, spinals/epidurals/OB, central lines, preoperative workup, postoperative follow up, and decision making in the plan of care. Even if an ACT model allows these things, it is billing fraud if an MDA is not available at the critical times throughout the case. From my experiences, MDAs generally pushed induction drugs and dictated the plan of care. They said what to use and what not to use. This varied, but included drugs, lines, airways, induction, and emergence. Nothing wrong with an ACT model. But I didn’t train in any ACT models that allowed me to truly practice all of the skills I learned in school, so I don’t understand why the graduates that express a desire to maintain skills sign to an ACT practice. May be a different superseding priority. Maybe other parts of the country have a looser ACT model than what I experienced in the Midwest. More than a few CRNA-only practices didn’t meet my criteria because peripheral nerve blocks were not the standard of care--whether that be the choice of the surgeons or the CRNAs. Maybe they didn’t do OB. Regardless, I wanted a place that would allow me to practice as I saw best for the patient. And I found it.

Compensation: Don’t deny that it’s super important. I could go down the rabbit hole with this one, but I’ll keep it short. CRNAs provide a valuable service and endure a high opportunity cost to get where we are. I want that reflected in my compensation. Keep in mind this is easier when looking at critical access hospitals than the big dogs located in a tropical paradise. Critical access subsidies and no MDA to pay give the advantage to rural facilities. I have an excel sheet with the breakdown of each job offer. Base salary, sign on, and moving allowance is the starting point. W2 or 1099. Big difference. A rough equivalent requires an additional 20-30% from a 1099 contract to break even with a W2 contract. This accounts for malpractice, retirement, taxes, CME, and any other benefits. More on contract breakdown and 1099 specifics in the weeks to come.

I considered 5 weeks of vacation with each contract and everything else as locum time at a modest rate, which at the time was $1,200 per day as a 1099 ($6,000 per week). So a job with 8 weeks PTO would have an additional $18,000 added for assumed locum income. Look at extra call pay and call back pay. Don’t forget any employer retirement matches which could be an additional $10,000 annually.

Work Schedule: Most positions that offer high compensation have a weekly hour requirement greater than 40. Some positions offered options such as 4 10s for $200,000 or 4 12s for $230,000. Some jobs that had an amazing compensation package required 60 hours per week or loads of in-house call. I’m thinking these guys are getting the short stick. They are running a 15 CRNA operation with only 10 CRNAs. The company is saving onboarding costs, orientation time, and benefits. The 10 CRNAs working their tails off are saving the employer so much money as opposed to having 15 CRNAs work a 40-hour week because of the aforementioned costs. Don’t even get me started on turnover. I digress. Point here is to figure out how many hours you are being asked to work each week including OR time, first call, and second call (if applicable). Post call day off? How much PTO, unpaid leave, maternity leave, and sick leave? See if the place is fully staffed or if they have regular turnover. Asking the right questions during the interview stage tells you a lot about this part. A high compensation with high hours usually equates to a low hourly rate.

Location: Very subjective. We lived our entire lives in the Midwest and were not afraid to relocate because the 3 aforementioned points were of greater importance. I inquired about 3 positions in the Midwest as they may have checked the boxes. Two fell short on compensation and the third was lost due to my lack of experience. Ego unharmed. The south and southwest appeared to have a need for rural providers and they offered solid compensation packages. That’s where I focused my attention.

CRNAs are in high demand and when you have the ability to say “No”, you are a negotiating powerhouse. Did I mislead or take advantage of anyone? Certainly not, that’s against my morals. I did however have a good sense of the market and have contracts in hand. I plugged all of this into an Excel sheet and that populated the numbers I needed for each job. When the dust settled, my wife and I moved 1,400 miles into the mountainous southwest where I have a 3 on 1 off critical access position. The CRNAs, and entire crew for that matter, are great. So far, so good.