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Hello and 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 medical students going into the field. I'm your host, Dr. Miller, and today I am covering part two of all of the different ways that you can practice as an OB GYN attending in the United States. If you haven't already listened to last week's episode, Part one, I highly recommend pausing this and coming back after you've done so, because that will just help to make this episode make a little more sense. But in sum, we reviewed the four main employment structures for OB GYNs in the United States. Private practice, academic practice, hospital owned practice, and the county or city owned practice models. Today I'm going to talk to you about the different ways that you can actually practice within those employment structures. So you can work as a generalist, a hospitalist, or as a contractor in a locums or per diem role. Let's start with the generalist roles. A generalist is a traditional bread and butter OB gyn. They practice obstetrics and gynecology. They work inpatient and outpatient, meaning they do clinic, surgery and deliveries and take call in the hospital. Overall, this is currently the most common way to practice as an OB gyn. So let's talk about some of the pros. Really, you do get to do everything that you were actually trained to do in residency, both obstetrics and gynecology. There's plenty of procedural variety. You're probably never going to be bored, and ultimately you just kind of get to do the things that you were planning to do and expected to do when you decided to become an OB gyn. So secondly, there is the potential for long term patient relationships depending on your practice style, like the options that we talked about in the last episode. You may start seeing a patient when they are very young as an adolescent. Then you may go on to deliver one or more of their babies. And if you're there for a really long time, you might even end up managing their transition to menopause. Of the different ways that you can practice within the various employment structures, this one probably offers the highest long term income, which again is practice dependent, but specifically in the private practice or hospital owned practice models. But again, that's going to depend on the type of practice that you are working in and the employment structure that you are working in. Lastly, working as a generalist in any of the employment structures that I talked about in the last episode is probably going to give you the most control over management decisions within your department compared with hospitalist or contractor roles. Let's talk about some potential cons. Full time generalists might actually burn out quickly, particularly if you're taking frequent 24 hour calls, because those 24 hour calls are stacked onto the rest of your week, which is typically filled with clinic and oftentimes scheduled outpatient surgeries. Along the same line, your schedule might be unpredictable. From week to week, for example, you're not likely going to have the same set clinic days per week and the same days off per week. One week you might be in clinic Monday, Tuesday, Wednesday, operating Thursday and on call Friday to Saturday, and then the next week be operating on Monday, Tuesday and clinic Wednesday, Thursday, Friday with call Sunday to Monday next. Because a substantial amount of your practice is spent in the outpatient setting, generalists actually do end up doing a lot of primary care. Many of the patients that come to see their gynecologist don't have primary care providers that are already taking care of them. And so some of that responsibility will fall onto you as their provider, specifically making sure that they're up to date on all of their various screening, evaluations, vaccinations, et cetera. And if you like that, that's great. But a lot of people that go into specialties such as ob GYN go into it because they don't actually enjoy the primary care component of primary care. Lastly, and what I view to be the biggest pain point for practicing as a bread and butter generalist is that in addition to your scheduled clinic call and surgeries, you are also responsible for following up on and managing all of the test results that come back into your in basket. This includes any lab studies and imaging results that you order for your patients in clinic. And to do some math, even if you only have three days of clinic in a week, which typically most people are doing more, but let's just say three clinic days a week you see 20 to 25 patients a day. Again, a lot of people are seeing more than that and each patient only has one test that you order. That in itself is 60 to 75 results per week that you need to review and contact the patient about if they're abnormal. And usually you're going to be ordering more than one test per patient that you see. So all of that adds up very quickly. And like I said, when abnormal test results come into your in basket, you do need to contact the patient to inform them of the results and or send them medications and or ask them to book a follow up visit so that you can discuss things further. Depending on the volume of your practice, you may not actually be able to schedule every single patient for a one to two week follow up visit to review time sensitive results. Which means that you're doing all of this on your own time. Your own time meaning time that you are not getting paid. Unless you're squeezing inbox management into your lunch breaks, or in between patients and clinic, or even in the or waiting for your patients to be intubated, this stuff is going to get done either before clinic, after clinic, or on your days off. You might be able to negotiate paid admin time, for example a couple hours a week to work on your inbox, but I definitely don't think that that is a standard part of most employment packages. Unless you're involved with additional administrative roles or leadership positions, you you may also have the nurses and LVNs to help manage straightforward results, but not all practices will have this kind of support and even when they do, there are obviously still limits to what these staff members are capable of doing on your behalf. All of this to say when interviewing for these generalist positions. Just make sure that you ask about these things, find out if admin time can be negotiated into your contract, and get a really good understanding of not only how many patients you'll be exposed expected to see per day in clinic, but what kind of support you have for inbox management. All right, let's talk about the hospitalist role. A hospitalist is an OB GYN that works in the hospital only, meaning no clinic and no scheduled outpatient surgeries. Some hospitalists work as a laborist, meaning they only work on the maternity unit, managing labor triage, postpartum and antepartum patients and procedures are limited to vaginal deliveries, cesareans, or anything necessary for obstetric and postpartum patients specifically. Other hospitalist roles cover both labor and delivery and inpatient gynecology, rounding on the admitted gynecology patients, seeing gyne consults in the ER and performing urgent or emergent gynecologic surgeries. Typically, a hospitalist is employed by a third party company and not the hospital or group practice themselves. So what are some of the pros? Well, because you're inpatient only, there really is limited to no in basket responsibility. You're not responsible for any outpatient labs or studies that need to be followed up on because all of the tests that you're ordering are completed while the patient is admitted to the hospital or in the OB emergency room. If the results that you order don't come back before your shift ends well, then the follow up gets passed on to the person who's coming on shift to replace you. So essentially when your shift ends, it ends. Work doesn't follow you home into your personal time. Another pro is that there are many hospitalist opportunities where your base pay is equivalent to that of a generalist salary. However, you're only working 6 to 824 hour call shifts per month. So if you're willing to do shift work and work really hard for a 24 hour period, but then have multiple days off per month, this will cater to that. Another potential pro is that many of these hospitalist roles do now offer benefits packages and because you're doing shift work, your time off is quite predictable. Even if you don't take call on the same day every week, you probably will get your call schedule for the next three to six months. And so when you're not on call those days, you can guarantee to be off and have to yourself. All right, so what are some of the potential cons? Many hospitalist roles may have fixed call, meaning they deal out your schedule and you don't necessarily have a say when you are or are not working. For example, they need you to work six 24 hour calls per month that they get decide which dates with or without your input, because they might be hiring specifically for certain weekdays or weekends that they don't already have coverage for. Additionally, some hospitalist groups will not allow you to trade call shifts with colleagues regardless of there being no scheduling conflict as a result of the trade. Now, I know I said that one of the potential pros is that the base pay is often equivalent to generalist roles, but there are many hospitalist roles that are well below the base salary that you would be getting paid as a generalist. In fact, many hospitalist roles are poorly compensated for how high the volume or patient acuity is at the institution. Keep in mind you are going to get paid a flat rate regardless of how stressful or busy your shifts are. There is no potential for productivity bonuses for seeing more patients or doing more procedures. So it's very important to have an idea of what the patient volume and acuity is going to be like. Because if they deal with 30 plus triage patients a day and 4,000 deliveries a year, or even if the patient population is in a region with a disproportionate amount of comorbid medical conditions, you're going to want to negotiate a higher pay because your shifts are just inherently going to be harder. Another potential con to consider is that if you are going into a hospitalist role right out of residency, but have a desire to potentially work as a generalist down the line. Depending for how long you work as a hospitalist, there's a good chance that you'll become pretty rusty with your gynecologic surgical skills and even your medical knowledge when it comes to management of clinic patients. Lastly, hospitalist positions result in virtually zero continuity of care. There is no relationship building prior to meeting your patients, and you're typically treating and managing patients that you've never met before, which means that they may be less trustful of you, and you have just a very short period of time to build rapport and that trust with your patients. Moving on to the last category, let's talk about contractors. Now, I don't think people in this role are necessarily called contractors in this industry, but it's just an easy way for me to explain the locum and per diem roles. Basically, they're like the freelancers of medicine. These are temporary positions that usually open up when there are staffing gaps at hospitals or clinics. For example, when someone takes maternity leave or or they might be in the process of hiring more full time physicians because they need more of them. But until they can get some more physicians to sign on full time, they'll open up these short term roles to fill the gaps. The main difference between locum and per diem jobs are that locums are typically short term temporary contracts on a 1099 that may require travel versus per diem rules where you pick up shifts as needed at one hospital system, typically local to you and typically on a W2. One of the potential pros is that if you need a job but your living situation is too uncertain to commit to a long term contract. For example, if your partner is looking for a new job and might have to relocate on an unknown timeline, you can sign a contract for a short period of time for say two weeks or six months or a year. Additionally, there is often higher pay per call shift than salaried staff because you're not paying into benefits or retirement now, overall your salary is probably going to be lower by the end of the year than in a generalist or hospitalist role. But if you're just picking up shifts as a per diem to make some extra cash, the work that you're actually doing on your shifts is probably getting you a little farther financially. Another pro, of course, is your ability to choose your contract based off of your professional interests. Some contracts are for clinic only, whereas some are for full scope generalist roles with Locums. Typically the locums agency that hires you will cover malpractice, travel, housing and credentialing. And oftentimes per diem employers will offer the same, at least for your malpractice and credentialing. Like I was mentioning previously, these roles provide opportunities to supplement your other income. For example, I have a friend that works as a full time generalist but wanted extra cash to save for a house, so she picked up some per diem shifts taking call once or twice a month at a hospital that was near to her home institution. Overall, working as a contractor is really the only way to get complete control over your life and your work schedule. You choose where and when you want to work and for how long. Let's talk about potential cons. Probably the biggest downside to these roles is the lack of benefits. Because you're considered a temporary employee and not working full time equivalent hours, it's too high of a cost to the employer to include this within your compensation. Obviously, health insurance is expensive, so the employee has to be contributing a significant amount of hours of work in order to make the cost worth it to the employer. Something to consider with Locum's roles is that traveling regularly isn't always feasible if you have a family or other responsibilities that anchor you to a specific geographical area. And it can also be challenging and probably pretty tiring to consistently be working with unfamiliar teams, changing hospital systems, and a variety of different electronic health record systems. Lastly, it goes without saying, but because you are paid per hour or per shift or per duration of your contract, your income will only last as long as your contract. So if you really want financial stability and a fixed income, contracting roles probably aren't the best for you. At least not long term. All right, I know that was a lot, but I think it's a great jumping off point for those of you wondering what your options will be when it comes to practicing as an attending OB GYN in the United States. Let's go ahead and recap. The four main employment structures for OB GYNs include private practice, academic practice, hospital owned practice, and the county or city owned practice structures. Within these structures, you can work as a generalist, a hospitalist, or as a contractor in a locum or per diem role. Pros and cons really depend on what your priorities are and every institution, regardless of their employment structure, will differ from the other in terms of what they want from their physicians and how they will compensate them. Although I've only skimmed the surface here, I really hope this episode provided you with some basic information and inspires you to really consider what you think will be the most important to you when it comes to your lifestyle and your work situation after residency. If you have any questions, feel free to email me@infoorcaseymiller.com otherwise, I will see you next week with another episode.