Tuesday, September 8, 2015

In what specialties can a surgeon be autonomous?

I am a medical student who is trying to decide on a field. I am not chasing money but rather autonomy; thus I would prefer to work for myself rather than a hospital. So my question is, which fields of surgery are more amenable to private practice, and which fields tend to require the resources of a hospital or don't work as well without a hospital?

The way things are going; future use of the words “autonomous” and “physician” in the same sentence will be rare, if not unheard of.

Here are some figures from a July 2015 American Medical Association report.
  • Younger physicians were more likely than older physicians to be employed. About 59% of physicians under the age of 40 were employed, versus 46.0% of physicians aged 40-54 and 33.3% of physicians 55 and above.
  • Nearly one-third of physicians are in practices with more than 10 physicians, including 13.5 percent in practices with 50 or more physicians.
  • Multi-specialty practice physicians were more likely than single-specialty practice physicians to report that their practices were hospital owned—44.6% compared to 23.0%.
Who knows what the percentage of employed physicians will be by 2020, but it surely will be higher.

I can think of only two surgical specialties that can be mostly independent of hospitals, otolaryngology and plastic surgery. I am not including ophthalmology because it isn’t really a classic surgical specialty.

The only way otolaryngologists and plastic surgeons can be autonomous is by concentrating solely on cosmetic surgery or working only in an ambulatory surgery center.

Otherwise, you would need a complete operating room—staffed by a nurse, an operating room technician and for some cases, an anesthesiologist—in your office.

Very few surgeons are able to limit their practices to cosmetic surgery directly out of residency or fellowship. Unless you join an established cosmetic surgeon in practice, which would of course limit your autonomy, you will need to be on call for trauma and be available for consults involving problems like pressure sores in hospitals to pay the bills.

My observation as a surgical chairman in community hospitals was that it takes years before the average plastic surgeon is able to develop a reputation and focus solely on cosmetic surgery.

You should also be aware that both of those specialties are highly competitive. In this year's match, only 1 of 299 ENT positions went unfilled, and 364 US seniors had ranked ENT as their preferred choice. For plastics, there are two ways to obtain a position. The NRMP handles an integrated match which filled 144 of 148 positions. There were 162 US seniors who listed Integrated plastics as their preferred choice. The other match is independent of the NRMP and takes residents who have done varying years of general surgery. For that 2015 match, which placed applicants in positions starting in July 2016, 85 applicants submitted rank lists, and 68 of 70 positions were filled. That left 17 candidates unmatched.

Additional reading: A post on KevinMD entitled “So doctor, who’s your boss?


Anonymous said...

Wasn't it mentioned previously in a post in this blog that there were companies that plans to buy out private medical practices to reduce competition? If so, then autonomy and physician will definitely not be seen in the same sentence in the future as mentioned.

Anonymous said...

I think plastics is still going to require a hospital, once you get past simple things, any of the big stuff is going to require a hospital stay. So that sort of gives them a half and half, they still are going to have to require privs and get OR time. The bigger surgeries like the lifts and the like require a day to do.

Skeptical Scalpel said...

Thanks for the comments. I may have been uncharacteristically optimistic in thinking that cosmetic surgery could remain even somewhat autonomous. Maybe it is hopeless.

RobertL39 said...

My sense is that we're not all talking about the same thing in the same way.
The questioner could be an employee of a single or multi-specialty group which was not hospital owned. You would be employed by the group and still do some things at the hospital but not be paid and owned by the hospital.
The questioner could go into complete solo practice in dermatology (which does more and more 'surgery' these days, all of it in the office). Then you would not need a hospital at all.
Or solo private practice is always an option. Good luck with the IT, coding, billing, running the office, and all the other things which are getting much more horrible (as in IMPOSSIBLE!!—does 'meaningful use' ring a bell??) to do alone and so much easier to leave to the IT or business department of your group. That said, I do suspect there are lots of small communities who would love to have a solo surgical practitioner. It's just that it's a tough slog and is not going to get any easier.
Or you could join Kaiser or Geisinger where the insurance company, hospital and doctor group are working together instead of being constantly at odds with each other. This seems the best solution for a longer, less-stressful career.
Hospital-owned practices seem destined to fail as the incentive for the hospital is to keep patients in and provide services (their raison d'ĂȘtre), whereas the incentive for the insurance company (and under the right scenario for the doctor too) is to keep them OUT of the hospital. It seems unlikely that hospitals will be able to change their stripes. Per the NYT they're *just now* realizing that they don't have a clue what anything actually costs them and maybe they need to figure that out! Hard to run a business when you don't know what anything costs.
Maybe it's kinda' like going to college—you know what you want to do until you get there and then everything changes. The only thing the writer can count on is that it will all change. Be flexible, thank you for going into medicine, and good luck!

Skeptical Scalpel said...

Robert, good points. I took the student's email to mean that he didn't want any sort of boss. Joining another doctor or a group has advantages and disadvantages. One of the latter is that someone will be telling you what to do. I have seen so many pairs and groups break up and lots of heartache when the junior member realizes he signed a restrictive covenant and can't practice within 50 miles of where he and his family live.

The Doctor Isn't In said...

Sorry I missed this question.
The only one I can think of is Ophthalmology. They still do 99% of their work in outpatient centers so if you have the cash to set up your own facility you can do implants cataracts laser stuff etc all day long and be autonomous as you like.
Of course getting a match might be a different issue they are the tightest specialty to get into but once the bells ring you have what you want.
Interesting when SS and I started we were autonomous within the mighty walls of the hospital institutions. When we walked down the halls you could almost hear the rumble of GOD's footsteps coming. I remember having elevator doors held open and every staffer saying "Good morning Dr" but now no one cares the medical people look at us surgeons as the scut work folks who will chop out whatever they tell us to and return the patient to them hopefully better then they gave them to us.
The Administration sees us as nothing more then away to increase the utilization of their precious radiology equipment and their overcharged for OR's
Everyone forgets that surgery was around long before medicine and has made the biggest life changing advances in healthcare.
Now that PharmaCos have stepped in we are relegated to "use them when all drugs fail" unless of course it is a life or death situations then of course call the surgeons they can fix everything.....
Dr D

Skeptical Scalpel said...

Ophth isn't real surgery. A drop of blood is considered a hemorrhage in ophthalmology.

The good old days are gone. I'm glad I'm no longer involved.

Unknown said...

I'm a little late on responding here, but I can inject one small note of hope. My husband, a neurosurgeon, is a partner in an orthopedic practice, which is still (fingers crossed) managing to stay clear of a buyout by a hospital. The docs in this group are not employees of the group but partners, which means they can run their practices about as autonomously as it's still possible to do. Also, our accountant in this small(ish) community, who handles many doctors' accounts, tells us that they are starting to see an outflux of docs from those employed practices. Let's hope this trickle turns into a flood.

Skeptical Scalpel said...

Unknown, thank you for comment. That is interesting news. I hope you can keep us posted on further developments.

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