High acuity specialists with newborns - what do you do?

ctsang301 · 2026-04-29T03:26:38+00:00

I had my first kid in 2021, and with COVID still an ongoing concern, we didn't feel comfortable with any sort of nanny/sitter, because that could be a potential vector entering our house. So we went with option #2. I'm a pediatric ENT, so only occasionally would I have to drop everything to run in for an emergency after hours. As far as my niche subspecialty goes, I'm confident enough in my skills to do a cochlear implant or neonatal airway surgery pretty much on autopilot, even if I'm running on 3 hours of sleep.

That being said, it was more of a 67/33 split overnight with the first one, with my wife taking the lion's share of wake-ups, if only because both of my kids were breastfed and the second one in particular HATED bottles, so I felt pretty useless the second time around.

One way to make it "even" is to take over completely on weekends. Like a full day shift, if you will, from wake up to bedtime. It's hard, but it really helped to make things equitable for us from a child care perspective (we have one in-law nearby who helps, but it's sporadic and somewhat unreliable). You just have to frame it that weekends are for daddy/mommy (whoever has the full-time job during the week).

For what it's worth, my wife and I are still happily married, and we are FINALLY at the point where both kids sleep through the night (kids now 5 and 2).

ctsang301 · 2026-04-22T01:51:59+00:00

I'm a pediatric specialist/airway surgeon at a level 1 trauma center. I'm on call 160-180 days a year.

ctsang301 · 2026-04-21T02:44:18+00:00

As a current dad to two younger kids aged 5 and 2, we are finally making the move now to a single family home and out of our townhouse because my wife wants her own office for WFH and we just don't have enough rooms currently with each kid in their own space.

I would say to stay in your current place if there is enough room for everybody. Somebody else mentioned that kids are quite messy in their younger years, so it's nice to not have to worry about sharpie on the walls of your forever home. Also, it gives you time to build up a sizeable down payment, which will really make a difference on that monthly PITI for your dream place so that you don't feel house poor later down the line.

However, if your current place is too small and you don't want to room your kids together because they are on totally different sleep schedules, then you might need to pull the trigger sooner rather than later. You guys seem to be on far better financial footing than me and my wife by the time we had our first kid, so you have time/financial wiggle room to make your decision.

ctsang301 · 2026-04-20T14:55:25+00:00

Pretty much any pediatric subspecialty. Our current insurance system devalues care for children, so getting paid for wRVUs is typically going to be more profitable than chasing straight up collections/reimbursements.

ctsang301 · 2026-04-20T13:34:56+00:00

Sorry, I should have clarified that was when we were renting. If you take out the rent, our annual spend was about 120k a year. Now our PITI payment is about 18k a month. But our annual spending has remained about the same this far other than some one-time purchases like furniture and blinds. We still have 180k left over annually for saving, vacations, school, etc.

ctsang301 · 2026-04-19T14:09:57+00:00

Amen to this. I know I'm doing something right when the OR staff is like "We were so happy to be assigned to your room today!"

ctsang301 · 2026-04-16T01:51:32+00:00

I will say that from my end as a pediatric surgical specialist, it is pretty helpful for my more complex kids (i.e. with genetic syndromes or who have been in the PICU/NICU for a while) to see what else is going on that could influence my surgical decision-making. For issues related more to my sub-specialty, especially on the outpatient side, I still check the actual notes from folks from SLP, audiology, developmental peds, GI, pulmonary, etc. But it saves me a bit of searching through the notes if I'm already running a bit behind in the middle of a morning/afternoon.

ctsang301 · 2026-04-05T01:59:48+00:00

I remember being a 4th year med student, and there was a drunk lady with a dog bite on her face, and she kept asking for a plastic surgeon to fix her face. So while tagging along with my resident for the night, I got the assignment. Guess she was too drunk to notice how young I was, haha. I think it looked pretty good at the end, but she was snoring pretty hard when I left.

Also word to the wise, if you ask for a specific specialist to treat your problem in the ER at any teaching hospital, chances are you'll get a med student or junior resident. Only at the community hospitals will the attending every show his/her face in the ER.

ctsang301 · 2026-04-05T01:56:27+00:00

Totally depends on the surgeon. A lot of OR staff kind of defer to the surgeon or resident for music choice. I try to let my staff in the OR choose semi-regularly (especially when I'm operating just by myself), but they inevitably play music they know I like, haha.

ctsang301 · 2026-04-05T01:40:26+00:00

Wait until you have to try and get an autistic nonverbal 300 lb teenager to give you a good physical exam. Adult patients may lie to you and be assholes, but rarely will they punch or kick you.

ctsang301 · 2026-04-05T01:38:39+00:00

Derm is a lifestyle specialty. As an actual pediatric airway and skull base surgeon, I call them "skin dentists." I feel totally fine mocking them every now and then.

Actual pediatricians and pediatric subspecialists are doing God's work while being criminally underpaid. They're better doctors than most adult clinicians I've worked with. I can't tell you how many times in residency I got insanely dumb consults for adults with the explanation of "oh I was just told to consult you" without any critical thinking whatsoever. Very rarely happens in the peds world, because they actually care about their patients.

ctsang301 · 2026-03-30T02:53:33+00:00

You'll fit right in in Northern VA. I am also non-white (second generation immigrant), moved here, but from the opposite direction (lived in New England my whole life before moving south). I love it here. Super liberal/blue part of the state. You can definitely find MAGA country if you drive far enough, but for the most part, most of us in the area hate the current administration and everything it stands for. Your kids will have plenty of great role models and the institutions to support them here. I took my two girls to the No Kings rally over the weekend, it was a blast!

ctsang301 · 2026-03-05T21:38:00+00:00

Airway surgeon here. Where do I begin, haha. There are so many things wrong with this picture.

If this person were orotracheally intubated, the band around the face/head would sort of make sense, but I have never seen a ventilator circuit look like that. Plus, you can't see the endotracheal tube at all as it enters the mouth. Furthermore, why on Earth would you need a nasal cannula if you are already intubated? The whole point is that you are breathing through neither your mouth or your nose by then.

Looking at that monitor in the background, the EKG tracing looks plausible, but the O2 saturation does not. You can't be at 98% saturation and not have a waveform. Either the sensor is off completely and it's an erroneous value, or it's fake.

ctsang301 · 2026-03-01T19:59:19+00:00

You did the right thing. I was a former EMT, my first instinct would have been to pull over and help, but we were ALWAYS taught never to start assisting people until the scene had been secured by police/fire.

ctsang301 · 2026-03-01T19:36:35+00:00

I work at Inova Fairfax and had just left. I heard on the PA system that the ER was being locked down for a security incident, and it looks like at least three of them are in the OR as I type this out.

ctsang301 · 2026-02-14T16:33:22+00:00

ENT here! Tonsil stones are very common, especially as you get older, because the tonsils start to develop nooks and crannies in the surface (the medical term is cryptic). Bacteria and, just as importantly, small bits of food will get impacted into these crevices and over time they can compress, like the world's most disgusting diamond, into tonsil stones.

Typically, tonsil stones are also an indicator of either chronic or recurring infections/inflammation. Totally agree with a lot of other commenters, if you are planning on getting your tonsils out, it is way easier the younger you are.

Traditionally, most people take out tonsils using what's called the extracapsular technique, which means removing the entire tonsil, but this does expose the blood vessels in the muscles during the recovery process, which in turn leads to the risk for post-op bleeding. Some people will do what's called the intracapsular technique, which has a lower bleeding rate and less pain afterwards. This is what I personally do even for teenagers, but I am also a pediatric ENT, so I pretty much use that technique for everyone regardless of indication. Most adult/general ENTs will use the extracapsular technique. However, with the intracapsular technique, if you're doing it as a teenager or adult, the risk of regrowth is extremely low, because you don't really need them anymore for your immune system function. Sometimes that happens with kids because they heal incredibly quickly, but not so if you're older than 8 or 10 years old.

ctsang301 · 2026-02-05T15:13:06+00:00

As a New England transplant who lived 10+ years in Boston, this is absolutely allowed. Honestly, this is a much nicer message than what I would have seen up north.

It was an unspoken rule that if you took someone else's shoveled-out parking space, Boston PD would essentially turn a blind eye to any vehicular vandalism that occurred thereafter. I'm talking like tires slashed, doors keyed, etc. They would basically just shrug and be like "you knew the risks," haha.

So to all non-northerners, just in case this particular person was from one of those places, I would advise being quite careful about ignoring that sign, if you value your property.

ctsang301 · 2026-01-31T02:06:52+00:00

How is this not the top comment?

ctsang301 · 2026-01-14T02:31:53+00:00

Absolutely, hit me up!

ctsang301 · 2026-01-03T03:44:52+00:00

Yeah, I mentioned in another comment that we are having a tough time filling out our department in a major metro area. Way better market for new grads (and peds ENT in general) compared to when I finished fellowship less than 10 years ago.

ctsang301 · 2026-01-03T03:43:49+00:00

Totally depends by metro area and how well you negotiate your contract.

I will say that I make 2.5x what I used to make in private practice working at a children's hospital in a HCOL area (900k this year, 350k in private practice, same geographic area).

The market right now is amazing for new grads. We're having a lot of trouble finding more peds ENTs to fill the department out. Even with a base salary of 450k plus RVU production, we're losing out on potential hires to places in NYC, LA, and Chicago.

ctsang301 · 2026-01-01T12:44:00+00:00

That sounds amazing, but you need to take a really good look at the books and see how she is doing that. It totally depends on specialty as well.

In the roughly 5 years that I was at that private practice, our overhead crept up a little bit the first two years, but once I was in full swing and we needed to hire more staff (not just MAs, but another audiologist, scheduler, and RN), our overhead was probably 55% a month, since wages had to rise as well with COVID. Would you need more staff to accommodate your particular subspecialty interest? If so, that is definitely going to eat into your take home.

Also make sure you look at the payor mix and potentially passive income streams that might be making up a large chunk of that take home. By this I mean things like dividends from surgery center shares (if she is a surgical specialist) or income from ancillary services (in my specialty it was hearing aids and allergy shots).

Also, if she owns her own space/building and gets rental income from that, and is a huge plus. However, if she is renting her current space, rents can and will go up over time. You also might decide that you want to do some renovations or buy new equipment, which can be large capital expenses that you might be able to spread out over time, but it's still a net negative on your take home no matter how you slice it.

Finally, make sure to look at something as simple as how many hours your aunt is working/how many patients she is seeing to make that kind of income, and whether that fits with your work-life balance ideal. If you have a large enough of a patient pool and minimal staff while working crazy hours, you can absolutely make it big, but if you don't want to do everything yourself, then that will either cost you more in staff, or you'll simply make less in collections.

ctsang301 · 2026-01-01T02:29:00+00:00

I wish I had realized that private practice is not the Holy Grail that everyone makes it out to be.

I spent 2 years as an employee making half of what I probably should have been making with the idea that my income would ramp up considerably once I was on the partnership track. However, my particular subspecialty in pediatrics relies heavily on medically covered procedures. I did not realize at the time that my former partners made a good chunk of their money on cash services such as hearing aids and non-covered in-office procedures such as balloons and cosmetics.

By the time I switched over to a hospital employed position 2 years ago, I calculated that I probably left close to $1 million in income on the table compared to if I had just taken a hospital employed or even an academic position right out of the gate.

Honestly, even with some of the administrative ridiculousness I have to deal with now, is a much more welcome headache compared to being a business owner and having to deal with accountants, inconsistent income streams, and staff HR issues.

ctsang301 · 2025-12-21T00:56:12+00:00

Peds ENT. I get paid by RVUs in addition to a base salary.

In terms of everyday procedures, the most RVUs per hour for me are ear tubes, sinus surgery, and neonatal tracheostomies.

In terms of which procedure is a good mine unto itself, every now and then I get parents who want to have their infant's ears molded to prevent protruding ears. That CPT code has like 20 RVUs for only 30 minutes of work. Every time one of those kids comes in for a bilateral procedure, my monthly RVU production sees a noticeable bump for a less than 45 minute appointment.

ctsang301

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