Career PlanningCareer PlanningCommunity SurgeryCommunity Surgery

CAGS 2007CAGS 2007

Chris VindenChris Vinden

University of Western OntarioUniversity of Western Ontario

Division of General SurgeryDivision of General Surgery

ObjectivesObjectives

Provide an overview of community Provide an overview of community practice and contrast it with practice and contrast it with academic practice.academic practice.

To help residents with the difficult To help residents with the difficult decision of what kind of surgeon they decision of what kind of surgeon they want to be.want to be.

CaveatCaveat

The views presented today are The views presented today are biased to my perspectives, tastes, biased to my perspectives, tastes, personality, philosophy and past personality, philosophy and past experiences.experiences.

Take them with a grain of saltTake them with a grain of salt

Caveat 2Caveat 2

People ChangePeople Change• You will not be the same person in 10 You will not be the same person in 10

yearsyears• Your priorities, goals and ambitions may Your priorities, goals and ambitions may

completely changecompletely change Marriage Marriage KidsKids Family tragedies / trials Family tragedies / trials

• What seems challenging and enjoyable What seems challenging and enjoyable now, may become just a repetitive jobnow, may become just a repetitive job

Academic vs CommunityAcademic vs Community

Usually an irreversible decision. Usually an irreversible decision.

• Very few surgeons start out in Very few surgeons start out in

community practice and end up in community practice and end up in academic centres.academic centres.

• And Vice Versa And Vice Versa

Life Goals vs Career GoalsLife Goals vs Career Goals

Happy Family…. Happy Family…. Financial Security $$$$$Financial Security $$$$$ Enjoy WorkEnjoy Work Enjoy PlayEnjoy Play Early RetirementEarly Retirement AltruismAltruism AcademicAcademic

• National or International reputation: fameNational or International reputation: fame Respected ClinicianRespected Clinician

You cannot be a Great Surgeon You cannot be a Great Surgeon and a Great Dadand a Great Dad

Being Great at something Being Great at something requires Time and Effortrequires Time and Effort

High achievement in one High achievement in one area of your life requires area of your life requires compromise in others.compromise in others.

Community Practice VariesCommunity Practice Varies

Large Community HospitalLarge Community Hospital Medium Sized Community Medium Sized Community

HospitalHospital Small Community HospitalSmall Community Hospital

What do you need to practice What do you need to practice Modern General Surgery?Modern General Surgery?

CT scannerCT scanner Invasive radiologistInvasive radiologist Internal Medicine supportInternal Medicine support Good AnesthesiaGood Anesthesia Surgical specialty supportSurgical specialty support

• Urology, Gynecology, Ortho, PlasticsUrology, Gynecology, Ortho, Plastics

Small Community HospitalsSmall Community Hospitals 1-2 surgeons, 1-2 surgeons, NO CT scanner, No invasive radiologistNO CT scanner, No invasive radiologist Minimal surgical specialty supportMinimal surgical specialty support

• May have to do C sectionsMay have to do C sections• May have to do OrthopedicsMay have to do Orthopedics

Often requires additional trainingOften requires additional training Remote / rural locationsRemote / rural locations Have significant difficulty recruiting surgeonsHave significant difficulty recruiting surgeons

Increasing tendency for Itinerant Surgeons from Increasing tendency for Itinerant Surgeons from adjacent communities to provide servicesadjacent communities to provide services

Medium Sized Community HospitalsMedium Sized Community Hospitals

4-6 general surgeons4-6 general surgeons Population of ~ 100,000Population of ~ 100,000 Open ICU’sOpen ICU’s Often don’t have gastroenterologyOften don’t have gastroenterology Significant portion of income will be Significant portion of income will be

from endoscopyfrom endoscopy Less specialty support, not 24/7Less specialty support, not 24/7

Large Community HospitalLarge Community Hospital

Cities with population of > 250,000Cities with population of > 250,000 7-12 general Surgeons7-12 general Surgeons Some sub specializationSome sub specialization

• Some have done fellowshipsSome have done fellowships Closed ICU’sClosed ICU’s Competition in endoscopy from Competition in endoscopy from

gastroenterologistsgastroenterologists Full complement of specialistsFull complement of specialists Very few “within specialty” tertiary care Very few “within specialty” tertiary care

referralsreferrals

What population is required to What population is required to support one General Surgeon?support one General Surgeon?

Beware Aggregate StatisticsBeware Aggregate Statistics Ontario had 691 General Surgeons in Ontario had 691 General Surgeons in

2005 ( 1 per 17,000 )2005 ( 1 per 17,000 ) BUT many surgeons never retire and BUT many surgeons never retire and

never surrender billing numbernever surrender billing number

RealityReality

““Full time” filterFull time” filter• Does at least 5 appendectomies per Does at least 5 appendectomies per

yearyear• At least 160 billing days per yearAt least 160 billing days per year• Age < 65Age < 65• Gross billings > $150,000Gross billings > $150,000

Reduces number of General Reduces number of General Surgeons in Ontario from 691 to 351Surgeons in Ontario from 691 to 351• Per capita : 34,000Per capita : 34,000

Income DisparityIncome Disparity

Ontario Fulltime Community Ontario Fulltime Community SurgeonsSurgeons• Median income is $110,000 Greater than Median income is $110,000 Greater than

AcademicAcademic• Median income is 26% higher than Median income is 26% higher than

AcademicAcademic• Disposable income is 100% higher Disposable income is 100% higher

After business expenses, income taxes and After business expenses, income taxes and retirement savings retirement savings

Academic FundingAcademic Funding Historically Funding Medical Academic activity Historically Funding Medical Academic activity

has been at Charitable levelshas been at Charitable levels Ontario prior to 2004…Ontario prior to 2004…

• Funding per clinician was < $10,000Funding per clinician was < $10,000• Physicians Academic Salaries were “ self funded” by Physicians Academic Salaries were “ self funded” by

internal taxation schemesinternal taxation schemes• Hospitals supplementedHospitals supplemented• Foundations and endowments supplemented Foundations and endowments supplemented

Since 2004Since 2004• Partial AFP… funding increase to $19,000 per clinicianPartial AFP… funding increase to $19,000 per clinician

Proposed 2008…Proposed 2008…• Proposed AFP funding increase to achieve equality with Proposed AFP funding increase to achieve equality with

non academic physiciansnon academic physicians

Overhead costsOverhead costs

~ $100,000 per surgeon~ $100,000 per surgeon

Community Surgeons pay more rent Community Surgeons pay more rent Community Surgeons have substantially Community Surgeons have substantially

cheaper office labour costscheaper office labour costs• Do not pay union rates. Do not pay union rates.

No Cost benefit to Academic practiceNo Cost benefit to Academic practice

Impact of ResidentsImpact of Residents

Not all residents are equalNot all residents are equal

• Depends on the quality and skill set of Depends on the quality and skill set of the residentthe resident

• Some residents make life a lot more Some residents make life a lot more difficult. difficult.

• Some make life a lot easierSome make life a lot easier

Impact of ResidentsImpact of Residents

PositivePositive• ChallengeChallenge• Enjoy TeachingEnjoy Teaching• Look after SCUTLook after SCUT

NegativeNegative• Slow you down, Junior > Senior > FellowSlow you down, Junior > Senior > Fellow

Approx 25% slower than large community hospitalApprox 25% slower than large community hospital

• Have to watch them operateHave to watch them operate

Community HospitalsCommunity Hospitals Have a sense of CommunityHave a sense of Community Referring Family Doctors participate in careReferring Family Doctors participate in care Much more efficient… time and costMuch more efficient… time and cost

• Less bureaucracyLess bureaucracy• Cost per weighted case is a lot lowerCost per weighted case is a lot lower

Usually better equipped than teaching hospitalsUsually better equipped than teaching hospitals• Computer systemsComputer systems• PACSPACS• OR equipment and scopesOR equipment and scopes

General Surgeons have less competition from General Surgeons have less competition from other specialties for resources other specialties for resources

Downsides: Tertiary Care SnobsDownsides: Tertiary Care Snobs

~ 3% of Patients~ 3% of Patients Like to get Diagnosed in community Like to get Diagnosed in community

hospitals but get Treatment in hospitals but get Treatment in tertiary centrestertiary centres

Usually return to community hospital Usually return to community hospital for management of complicationsfor management of complications

Downsides: Variable Physician QualityDownsides: Variable Physician Quality

Not all doctors are greatNot all doctors are great Higher variability in Quality of Physicians Higher variability in Quality of Physicians

in Community Hospitals. in Community Hospitals.

Downsides: SCUTDownsides: SCUT

Ward workWard work• But Community Nurses take far more But Community Nurses take far more

responsibilityresponsibility PaperworkPaperwork Discharge PlanningDischarge Planning

Downsides: CallDownsides: Call

Usually more frequentUsually more frequent But rarely operate after midnightBut rarely operate after midnight Emergency cases can be squeezed Emergency cases can be squeezed

into the list.into the list. ER docs are reasonable, look after ER docs are reasonable, look after

the bowel obstruction, diverticulitis the bowel obstruction, diverticulitis till AMtill AM

ACADEMIC OBLIGATIONSACADEMIC OBLIGATIONS

Teaching DossierTeaching Dossier Grant ApplicationsGrant Applications Publication PressurePublication Pressure Committee MeetingsCommittee Meetings EvaluationsEvaluations Course PreparationCourse Preparation Rounds, Rounds, Rounds.Rounds, Rounds, Rounds.

INDEPENDENCEINDEPENDENCE

Very few obligations apart from Very few obligations apart from clinical clinical

Holidays without your laptopHolidays without your laptop HobbiesHobbies FamilyFamily Financial IndependenceFinancial Independence Earlier RetirementEarlier Retirement Less HassleLess Hassle

Community SurgeryCommunity Surgery

SatisfyingSatisfying Financially rewardingFinancially rewarding ChallengingChallenging IndependentIndependent

Highly RecommendedHighly Recommended