Academia lets you have a subspecialized practice, e.g., minimal to no spine if you are cranial focused. I suppose it’s possible to be doing a high volume of complex cranial cases in non academic settings, but you have to build that practice which I imagine is very challenging. You also are less likely to have expertise in all the other areas needed to care for these patients, for example intensivists, ENT, plastics, etc. I disagree that quality of life is necessarily better in non academic settings, I think people underestimate the value of residents, who function as slave labor. Most academic attendings couldn’t find the ED at their institution if they wanted to. In a hospital employed position you are often the first call for neurosurgical patients in the ED, you are putting in EVDs overnight, etc.
The statement that in a hospital employed position you are first call is absurdly inaccurate. Most places have PA’s or NP’s that are first call.
As for why academic positions are highly sought after…that’s the dirty secret. They’re not.
I think it really depends on what you want. Not every place has 24/7 NP/PA in house coverage, but most level I trauma centers do. Most offer letters I've seen have something along the lines of "6 days of first call/month, 8 days of second call/month, etc." Every job is going to have pro's and con's. You can make the argument that doing research, going to conferences, trying to rise up in committees, doing poorly paid consulting work while trying to land the sweet design team gig is a second full time job. At the same time, I'd gladly take a pay cut to never have to talk to another floor nurse or ED doctor ever again. Residents are also undoubtedly better than a PA, especially for call cases (trauma hemicrani, suboccip, shunt failure, etc.) since they can do those cases pretty much independently with you just in the room. All depends on your goals (money, types of cases, lifestyle, disgust/passion for research, etc.)
Residents are better IF you can trust them. If you have a shitty resident, it’ll fuck up any call you take. Imagine having a chief that couldn’t start a crani or a junior that fucks up exam findings that make the difference between an emergency and a case that can get added on the next day.
And you can fire an incompetent APP. Firing an incompetence resident is much harder
The academic market has been rough the last couple of years (outside of spine, obviously). The honest truth is that if you're coming out and you want an academic job, you are a captive audience, and you'll have to take what is available. Having an ego or thinking that you are better than whatever is out there will be a death blow to your career. Nobody wants someone who did a year of locums waiting for something better to roll around. Waiting around just means you will be competing with the next class of people. If there are 5 jobs in your subspecialty, and all of them are bad, then you're screwed. It is that simple. You need a job by the time you finish training. Suck it up and work at getting a better job when you're 3-5 years out. If you pay attention to a subspecialty, you will see this happen constantly.
Many good jobs for new grads are not filled via normal recruitment processes. I would be wary of them anyway. Things that are too good to be true almost always are. One of the most important things to look out for is fake positions: "we need a warm body to cover call at this outlying hospital." If they don't have an honest need for a third skull base surgeon, you're just signing up for pain.
When a chair decides to hire you, the process will move very quickly. If they are faffing around, then you're not getting the job. If you're having a difficult time sealing the deal, then it might be you. People call their friends. The attendings that got called about me were never the ones I expected.
You can make almost anything work if you try hard enough. Only the extremely lucky AND connected get the perfect position right from the start. I'm sorry you didn't get that tumor job at MGH or whatever - better luck next time.
