A (0:00)

Welcome back for another episode of the OB GYN Resident Survival Guide, your audible guide through a variety of topics relevant to OB GYN residents and med students going into the field. I'm your host, Dr. Casey Miller, and today I'm going to walk you through all the different ways that you can practice as an OB GYN attending. Before I jump in, I want to talk about the sponsor of this episode, which is Rakuten. I was late to the game and only found out about Rakuten a year ago. Essentially, it's a free cashback app that pays you back for shopping at stores that you're already buying from. Anyway, at the time of this episode, I'm just browsing their website and I'm seeing cash back offers for 8% at Sephora, 4% at Nike and Staples, 2% cash back at Lululemon and Aloe Yoga, and 7% at Groupon, among hundreds of other cashback offers. When you download the browser extension and shop online, you will automatically be notified about deals and receive cash back with your purchases. It's very easy. Last year I received over a hundred dollars in cash back, which covered about 20 of my absolutely necessary Starbucks refreshers. I know what it's like to be in training and tight on cash. Every dollar counts and this is a super easy way to save when you are spending on things that you would be spending on anyway. If you want to sign up, my referral link is in the show notes. We both get a bonus when you do. All right, let's jump into this episode. I almost didn't pursue OBGYN as a specialty because as a med student I only knew of one practice style and that was kind of the private practice Go, go, go. No free time, always on call model. I hoped that there were different options and I did decide to commit anyway. But it took me a long time to realize that there are so many different ways that you can pract practice in this specialty. As a resident, I was exposed to the academic and county group practice models, but still, when it came to searching for and applying for jobs as a PGY4, I really felt like I was in the dark and I had no idea what to look for, what my options were, and what to avoid. It wasn't until I started applying broadly and interviewing as a resident and as an attending and after talking with other attendings in different practice models that I finally developed a better big picture understanding of all these different practice models for OB GYNs. At least in the United States. All of the information I'm sharing today has been gathered from a process of my own research and interviews and employment over the past two years, as well as from friends and colleagues working in these types of practice settings. So I of course can't speak in depth about what I have not personally experienced as an employee, but I do think that the info I have is a really great starting point for those of you who are looking for attending positions this coming year, or for those of you medical students on the fence about whether or not this job slash lifestyle could be for you. So there are four overarching employment structures for OB GYNs in the United States Private practice, academic practice, hospital owned practice, and county or city owned practice. And within any of those, depending on the location and the positions available, you can work as a generalist, a hospitalist, or as a contractor in a per diem role or a locum role, and I'll go over those later on. Let's go ahead and start with private practice. Private practices are physician owned businesses and revenue comes from office visits, procedures, surgeries and deliveries. Typically there is a practice owner who runs the actual business and then associates which would be the other OB GYNs in the practice. So the owner sees their own patients, but is also responsible for everything that comes with running a business like payroll, hiring staff, marketing, rent payments, or hiring out other people to do that for them. Associates are typically salaried and outside of clinical work aren't really managing the business itself. So the pros and cons really depend on how large your practice is and how many other doctors there are to share the load. Let's talk about some of the potential pros. If you don't want to have a boss or work for anyone else, and you are particularly entrepreneurial, eventually starting a private practice could support a work for yourself lifestyle. However, the counter argument to that is that running a private practice does take a ton of work and you're not only logging clinical hours, but hours running the business itself. For the purpose of this episode, I think most of you listening are not going to be starting your own private practice right out of residency. So I'm going to be speaking from the perspective of being an associate in the private practice. So one pro is that if your goal is to get as much experience and exposure to deliveries, clinic patients and surgeries as possible, the private practice model may be perfect, especially if you're in a smaller group practice, because in that setting the volume is likely going to be high, but there are very few associates to share the load with. Additionally, you would likely assist each other in surgery, which doubles the amount of surgical exposure you'll get when compared to other models where the residents assist the attendings in the operating room. Another pro is the potential for higher earnings compared to some of the other practice models. Depending on how the practice works, you can earn salary plus additional bonus distributions from profit left over in private practice. After all of the expenses are paid, profits go to the physicians as opposed to a hospital or university, and then with whatever's left over to the physicians after that. Additionally, there might be less of a cap on what you can earn in productivity, meaning patients seen, procedures done and babies delivered, et cetera, because the more you work, the more you make, as opposed to other models where your schedule might be fixed and or productivity bonuses aren't included in the contract. Another pro is that you can advertise yourself and your practice to gain more patients and the opportunity for excellent continuity of care. Your patients are your patients, and unless you're on vacation or out sick, they're not seeing anyone else. Let's talk about some potential cons. Like I mentioned before, if you're in a small practice, there is a very high likelihood that you will be working crazy hours. For example, if your Practice only has four other OB GYNs, that translates to either you being on call every four days or on call for one week out of every month. How the call is distributed really depends on the individual practice, but if you imagine 500 patients divided by four physicians, everyone does have to take time off at some point. Those aren't just patients that need to be seen in clinic. Those are patients that are going into the OB emergency room for triage visits. They need to be seen and scheduled for surgeries, cesarean deliveries and vaginal deliveries and admitted for labor. So the smaller the practice, the more thinly spread each one of those providers is going to be. In addition to the hours, you're probably more likely to be pulled in multiple directions in a day. For example, a friend of mine who works in private practice will routinely have a full day of patients scheduled in clinic. However, she'll on her lunch break, go and do a hysterectomy and then maybe leave clinic once or twice to deliver a baby on labor and delivery, catch up on her clinic patients after who've been waiting for her, and then be on call overnight. For the same reasons, your shifts will probably not have set hours, depending on how many people are available to take call after hours and on weekends. Lastly, it's very likely that associates will have to pay their own tail malpractice insurance to As a reminder, tail insurance covers lawsuits that come in the future. For patients that you treated in the past, it might be negotiable, but if it's not, depending on how many years you stay at the practice, you're looking at a bill of tens of thousands of dollars or even hundreds of thousands of dollars that you're paying out of pocket when you exit the practice. Overall, private practice can be great if you want high volume and experience complete care and continuity with your own patients, and if it's important to you that the people deciding how and when you practice are other physicians as opposed to corporate administrators. On the flip side, depending on your practice size, there's a good chance you'll have a pretty crazy schedule and working many hours a week. When you do want to leave the practice, you'll likely have to pay your tail insurance out of pocket. And that's just an important piece of information to find out about and negotiate if possible, before you sign your contract. Next up is academic practice. In academic practice, you are employed by a university teaching hospital, which typically involves a mix of clinical practice, teaching residents and students, as well as research. You're hired as an employee and are not responsible for running the business in any way. Potential pros include having resident support, although that comes with the responsibility and extra time that it takes to teach, it often saves you the attending a lot of work. As you all know, residents write the notes, they consent and prep patients for surgery. They see patients and come up with a plan and tell you the plan, and they overall take the brunt of the clinical work that you would otherwise be responsible for on your own. Now, of course, you're still responsible for supervising everything, seeing patients and reviewing the notes, scrubbing into the surgeries and so on. But that's still still very different from doing it all by yourself from scratch. Secondly, academic hospitals are typically resource rich, meaning that you have access to most if not all the specialists and subspecialist services for both outpatient, inpatient and interop consults when you need them. And having a lot of support is very helpful, especially as a new grad when you're still trying to find your footing. Thirdly, being in an educational environment forces you to stay up to date with evidence based practice guidelines. And that's certainly not to say that practitioners in other environments are not up to date. However, being in an academic role, you will likely be required to participate, at least to some degree with educational lectures and or research in addition to your clinical responsibilities. So if you're interested in leading your own research projects or participating in others academic programs will likely offer you the most support, opportunity and funding to do so. Compared with other models, the last two include the potential for mentorship in your early career and the opportunities for early career development through educational roles. And from a financial standpoint, the university will typically cover your tail insurance if you decide to leave. Potential Cons Teaching residents and students does take a lot of time. If you really are committed to helping people learn, you have to be patient, which means that everything moves slower. Clinic might run over. Surgeries will probably take substantially longer because you need to give the trainees a chance to troubleshoot and basically learn how to do everything from scratch. Another potential con Depending on the group style, there is a potential for a lack of continuity of care with your patients. Oftentimes, the group of physicians you're working with share each other's patients so you might see someone for a new OB visit and then not take care of them for the rest of their pregnancy. Or on the flip side, you might have a handful of prenatal visits with one patient. However, you are not involved with their delivery at all because you're not on call when they're actually admitted to the hospital. You might even be operating on patients that you've never met before. If the volume is really high and there's a backlog of patients that need surgery, cases might get added on to your OR schedule simply because you're the first available surgeon. Another potential downside is that these roles do typically involve added responsibilities like lecturing and advising research or QI projects, as well as submitting regular resident and student evaluations, which can take up a lot of extra time. And lastly, although these roles are typically salaried, the base pay can be substantially lower than other employment structures. For a variety of reasons. Universities generally run on tighter margins than hospital systems or private groups. However, part of your quote unquote compensation is the mentorship and career development available to you by being affiliated with a brand name health system, so to speak. Overall, academic practice could be great if you like to teach or participate in research, and if you feel like you need or want substantial support that comes in the form of trainees and consulting specialty services. However, having to teach and manage other educational responsibilities on top of your clinical work can become very burdensome, especially if you're receiving lower financial compensation compared with other non academic OBGYN roles. All right, let's talk about the hospital owned practice structure. In hospital owned practice, you are employed by a health system. Some commonly known examples include Kaiser Permanente Providence, Trinity Health and Advent Health. You might have heard of these. Essentially the hospital owns the practice, they handle overhead and staffing and you're paid as an employee as opposed to sharing profits like at a private practice. In layman's terms, the hospital owned practice model really is the epitome of corporate medicine and as you can imagine, that has associated pros and cons. Because the corporate business model is very efficient for earning revenue, the budget for physician compensation is usually a lot higher than alternate practice models. Many of these systems will offer higher base salary in addition to sign on bonuses for physicians and still with the opportunity to earn productivity bonuses throughout the year. I have friends that received sign on bonuses anywhere from $15,000 to $200,000. Now those are big flashy numbers, but of course keep in mind that those numbers do come with strings. Usually if you're getting offers like that, you'll have to sign a contract agreeing to stay there as an employee for a certain number of years. Otherwise they would then have to pay all of that back. But if you're okay with that, it's an amazing opportunity if you want to pay off your student loans or buy a house fast. Another potential pro is that in many of these systems you'll have the opportunity for excellent continuity of care because you can have your own quote unquote private patients without having to deal with the pitfalls of private practice and always being available to take care of them. That being said, there are many hospital owned practice models that share patients just like what I talked about in the academic practice model. Lastly, this practice style can be really great for mentorship, particularly in the operating room since these locations are less likely to have residents assisting you in the or, you'll probably co scrub surgeries with other attendings in your group. And some systems even have workflows designed to pair junior surgeons specifically with senior surgeons to allow for continued mentorship and support. Lastly, again with this practice model, typically the hospital will cover your tail insurance. Let's talk about some potential cons. In these models, physicians generally have very little control over department operations. The hospital admin, usually business administrators and not clinicians, set the schedules. They decide who gets to work when and where and who gets to operate when and where and on what kind of patients. This is when you get into issues with clinic schedules being overloaded with 30 plus patients per day for example, because one the primary goal in the corporate structure is profit, the more patients seen and more procedures done equals more revenue for the hospital. And number two, the people who make the schedules don't really have an idea what type of visits take up more time than others because they're not necessarily working with clinicians to make the schedules. For this same reason, it can take a long time for departmental changes to occur due to the multiple layers of admin needed to review requests and approve changes requested by the physicians themselves. Overall, the hospital owned practice model could be a great option if your primary goal out of residency is to pay off your student loans or buy a house and then continue to earn very high wages without having to be in a private practice model. That being said, if the schedules and models in place are not supportive of the physicians when you start, it's probably unlikely that that will change as time goes on, regardless of what the clinicians have to say say about it all right, we are on to the last employment structure for OBGYNs, which include the county and city owned practices. In county or city owned practice you are employed by a local government health system that is run and funded by the government. Examples would be any county hospital or in areas where the county system doesn't exist. The city might own the hospital system and an example of this would be the New York City Health and Hospital System. People call it H and H for short, and they own and run multiple hospitals under the umbrella of H and H. These institutions typically care for more underserved and high acuity populations with complex social needs. One of the biggest pros is being able to advocate for and provide safety net care for vulnerable populations. You really do have the opportunity to make a massive impact on someone's health who may not routinely get good care or any health care at all. Because of the barriers to care faced by many of these patients, you'll likely see much more varied pathology and unique clinical scenarios which does have the potential to lead to rapid growth and development of not only your medical knowledge but your surgical skills. Additionally, because it's government run again, you don't really need to worry about any of the business operations as an employee and you can just focus on your clinical work alone. Additionally, you are likely to have resident support as many of these systems will either have their own residency program or residents from affiliated academic hospitals that rotate there. Lastly, oftentimes these systems are short on resources and staff, but because of that there may be many more opportunities for career development and growth and early in your career, simply because no one else is there to do it or compete for leadership roles. The potential cons are somewhat tied in with the pros as you can imagine because these practices are government funded you're typically working in lower resource settings, you probably won't have quick access to all of the specialists and subspecialists in house, meaning that your complex patients may need to be referred out which might delay their care. You also probably aren't going to have the fancy devices or state of the art facilities available in any of the previously mentioned employment structures, again due to lack of funding and resources. For the same reason, there may be less potential research support, particularly if there is no associated residency program. Like with hospital owned practices, physicians may not have as much control over department operations and when you or your colleagues want change to occur, it will likely have to run through multiple layers of admin before you see any results. Lastly, when it comes to clinic, you might run into the same problem of having way too many patients booked for a day, but for different reasons than with the hospital owned practice model. County hospitals are just more likely to overbook clinic visits because the demand far exceeds the capacity of available providers and the system is designed around access, not efficiency. County systems are legally and ethically obligated to see uninsured and underinsured patients. However, attendance to these appointments might be unpredictable due to transportation and work barriers, housing instability, et cetera. So oftentimes clinics will intentionally overbook to keep the schedules full. However, when all the patients do show up, that really sucks for the physician because then you're stuck seeing 30 to 40 patients in a day. Overall, the county and city owned hospital practice models would be great if you are passionate about helping underserved communities, advocating for vulnerable populations, and teaching students and resident physicians. That being said, working in a lower resource setting can be both frustrating and nerve wracking, particularly when taking care of patients that might be higher risk and really do need those resources and support systems a lot more than anyone else. All right, so far we've talked about the four main employment structures in which OB GYN physicians can practice in the United States private practice, academic practice, hospital owned practice, and the county city owned practice. Next week in part two, I will talk about the different ways that OB GYNs can practice within these structures, either as a generalist, a hospitalist, or as a contractor in locums and per diem roles. I truly hope this was helpful for you. I really just want this to be a jumping off point for those of you figuring out how you want to practice after residency. Please feel free to share this with anyone you know that you think it might be helpful for and I hope that it sparks a discussion within your own programs and circles because I think that the more that this stuff is talked about, the more people will land jobs that are actually a good fit for their interests and goals. There's so much more than what I've mentioned about all these different employment structures. And I would encourage you, if any of them jump out to you, to find people in your own residency programs or that you know of in your own circles to learn more about them, ask your questions, and maybe they'll completely disagree with me and say that, you know, Dr. Miller was way off on this. Let me tell you the truth. That's great, because the more actual firsthand experience someone has, the better they will be able to advise you. Thanks so much for tuning in today. I will see you next week with Part two.