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Hospital-Based Practice

Practice as a Hospital-Based Trauma Surgeon at a Community, University Affiliated Facility
Joan L. Huffman, MD, FACS
Associate Director, Trauma/Surgical Critical Care
Crozer-Chester Medical Center
Upland, PA

Background

The model I will discuss exists within a large community hospital system with five hospital-based residencies, as well as a local university affiliation for surgical residents.

I practice at the largest of five hospitals (the “Mother Ship”), which serves as the tertiary referral center in our county (although we are 30 minutes from a large metropolitan area). We are also a Level II Trauma Center (the only trauma center in the county – the adjacent metro area has seven Level I centers, because each university must have their own). We also house the Regional Burn Center.

There is a varied consortium of staff surgeons – both hospital employees and private practice MDs. Of the 50+ active surgical staff (half of which are clinical teaching staff for the university), there are 5 women: two general/burn surgeons, a plastic surgeon, a cardiothoracic surgeon and myself. 

This amalgamation of different residencies, of different specialties, and hospital/private staff can be a mixed blessing and curse. There are many agendas: academic, financial, professional and personal, which may complement or compete.

Positive Aspects

Personal

(1) I live in a pleasant suburb, with very little crime, excellent schools, half-century homes and mature trees.
(2) I take trauma call from home, and can be at the hospital in 15 minutes.
(3) I am only 30 minutes from a major NE city for dining, cultural activities, professional sports, and have easy access to regional rail lines, Amtrak and an international airport.

Professional

(1) I play an active role in both student and resident education.
(2) I benefit from resident coverage of my patients on nights, weekend and holidays.
(3) I participate in both national and international investigational trials, and reap both the intellectual rewards and travel perks.
(4) I have the university contact to arrange speakers and make professional connections, but do not have to deal daily with academic requirements, or endure tenure track battles.
(5) I have access to a large patient population for data collection, if I wish to prepare abstracts or papers for presentation at local, regional, or national forums, and have little, if any, competition in my pursuits.
(6) Outside of the university confines, I have been able to pursue my “soul work”, in the areas of Palliative Care in the ICU, and Domestic Violence Prevention Education.
(7) There is real sense of collegiality between specialties.
(8) Opportunities for advancement exist within my division, my department, and/or the hospital management milieu.
Compensation

(1) My malpractice is paid by the hospital. In my local geographical area’s current malpractice climate, this is a godsend. More and more private MDs are leaving the area, or even the state, due to inability to obtain insurance.
(2) I have a good health, disability, life insurance and retirement package provided to me at no additional cost (with low cost options for supplementation).
(3) I have a very reasonable vacation, personal, holiday, and conference time allowance, and generous expense reimbursements.
(4) I have office space and equipment (both office and patient clinic area), support staff (and their salaries/benefits) provided by the institution.

Negative Aspects

Personal

(1) An individual who enjoys an active nightlife might find the quiet suburbs too mundane, and the 30-minute drive to “Civilization” as they know it, excessive.

Professional

(1) There is no external stimulus for academic endeavors.
(2) Mentors may not be available (then again, they may not be present at many large academic centers, either!).
(3) It may be difficult to advance in your field outside of the “non-academic” facility.
(4) Advancement is possible within the institution, but difficult, as in all surgical spheres.  In the community atmosphere, discrimination may be more subtle (code word for “covert”), and couched in more polite “politically correct” words or actions.

You can influence the impact of the above noted factors by your own self-motivation.  Members of our facility (including one of the other women surgeons and myself), are members of national organization committees, publish in peer-reviewed journals, and are national speakers.

Compensation

(1) Each hospital based employee (as a single entity) & the private groups (as a group entity), negotiate individually with administration for their compensation packages.  History and politics heavily balance (or unbalance) the outcome.
(2) As a hospital employee I am paid a salary wage, yet must submit a time card.  Ludicrous, of course, since the maximum hours that can be recorded are five, 8-hour days.
(3) There is large variability (and lack of reciprocity) in expectations for time commitments and/or financial compensation in call coverage between hospital based MDs and private MDs providing call within a single service (i.e. trauma coverage)
(4) There is no inducement to build a general surgical practice, outside of my trauma/critical care practice.  Any attempts are seen as an intrusion into the turf and pocketbooks of the private practice MDs.  The private staff has lobbied administration to the point, that there is in fact, a florid discouragement from administration.

Recommendations

The Politics

If you are considering a position at the hybrid facility as a hospital based surgeon, expect to deal with many sets of politics:

(1) The interactions within the hospital based group, both MDs and practice managers;
(2) The interactions between the hospital based group and private practice  physicians
(3) The interplay between those with/without university affiliation and/or free-standing residency affiliation; and
(4) Interaction with administration.

Note: there may be an intricate interweave and overlay of all of the above.

Interviewing & Contract Negotiation

(1) Find out who is hiring you: the chief of your division, the chair of your department, a representative of administration, a hospital practice manager, or any combination of the above.
(2) Ask to meet all the key players that you will interact with in your particular field.  This may include individuals both inside and outside of your own division, and both hospital based and/or private groups.
(3) Neither of these (1 and 2) may be readily discernible to the outsider. Both issues may require careful investigation. A hospital website or regional colleagues may help provide potential contacts.
(4) Consult the AAMC publications for the current salary ranges for your rank, country region and type of facility.
(5) Who you negotiate with depends on who is hiring you (see above).
(6) Have a contract attorney review your contract BEFORE you sign on the dotted line.

Summary

While some of the descriptions are specific to my personal experience, many can be generalized. Despite the obstacles, in all, I enjoy the Ying~Yang experience of this hybrid facility. To rephrase an old Chinese proverb, “Challenge & diversity breed opportunity”. Best wishes in your endeavors if you elect this type of practice.