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2 surgeons working as full time 1 surgeon position, why not done in surgery?

Discussion in 'Surgery and Surgical Subspecialties' started by cardsurgguy, May 1, 2007.

  1. cardsurgguy

    cardsurgguy Senior Member 7+ Year Member

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    During a conversation a bit ago about work life as an attending, I remembered a pediatrics resident at the hospital I worked at saying that when she was done with her residency, she and another pediatrician (I think another peds resident from the hospital who was the same year as her) were going to try to get a job as 1 pediatrician together, where they would make the same salary, have the same number of patients, work the same hours, etc as 1 full time pediatrician, but between the two of them so that each of them would make 1/2 as much as normal, see 1/2 as many pts, and work 1/2 the hours as a full time pediatrician obviously.

    They were trying to do this because they were thinking of starting a family and therefore wanted to work less, and they both had husbands that were successful in their careers and so the wives didn't need to work full time financially speaking


    This got me thinking about something...Why can't this happen in surgery?

    They are doing primary care, where you have longitudinal relationships with patients and are the patients main doctor. As compared to surgery, which is a case by case basis type of specialty. You do a case on a patient, and make sure they are fine post op, and they don't see you again. (obviously there are long term relationships in all specialties with certain pts, but relatively speaking not nearly as much as primary care is my point)

    So it would seem, given the above, that surgery would be the best specialty where something like the 2 for 1 position thing would work out. (Or 3 for 2 etc)

    Pay is higher in surgery than in primary care, so financially one wouldn't have to be in these people's positions with spouses who make good livings.


    Is this not done because of surgeon's preferences and/or not thinking longer hours are not a big deal? (by going into surgery, that's pretty much self selecting out the population like these two who are more lifestyle concerned)


    So what do all of you think? Could something like this work in surgery?
     
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  3. blackdiamond

    blackdiamond 10+ Year Member

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    Some reasons why this would not happen, at least not too common:

    1) Length of residency training often causes greater severity of debtness requiring higher salaries.

    2) Most surgeons are men,thus most are the breadwinners of their families.

    3) The true nature of the field attracts hard-working addicts, who if "share" a position with another attending would be looked down upon.

    4) It's difficult in general to share a position in any job. Employers would have to balance schedules, health benefits, etc.


    I view a career in surgery as a career, not a lifestyle. I want a good,happy family, opportunities to go on my ski vacations, spend time doing anything else other than being in the hospital. I want to be good at my job, take good care of my patients, but there's no need to live in the hospital to accomplish this. Old schoolers who advocate this, from what I've seen, have MISREABLE lives with so much anger and resentment. Why in the hell would I want this for myself? Luckily, there are plenty of opportunities to work as an attending in a less demanding environment. It's out there. You don't need to "split" a job with another attending. The drawback: less pay...which many people are drawn away from.
     
  4. At our institution, we have two breast surgeons that split appointment. One works the first half of the week while the other works the second half.

    They alternate general surgery call with the larger general surgery full time attending faculty. It can work... The arrangement is interesting and does raise some questions.
     
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  5. Eyesore

    Eyesore Member 10+ Year Member

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    One thing to think about is that some costs of being able to practice are still there even if you practice half-time. Licensing costs, professional membership costs, malpractice costs, books, journals, etc. are not cut in half just because you work half-time. This may be obvious but some people may not think about it. So, in fact, the two people sharing a practice are making less than half.
     
  6. Pilot Doc

    Pilot Doc SDN Angel Moderator Emeritus 7+ Year Member

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    The only one of those costs that are significant are malpractice costs. Getting slot coverage is an option. In that case, 2 people split one malpractice policy. The only stipulation is that you can't practice simultaneously. Other overhead expenses are splittable assuming you don't operate, see patients, etc. at the same time. Benefits would be a substantial extra cost - might take 10K out of your half salary.

    So on the whole, the total compensation package of two physicians working half time will be very close to one full-time doc.

    So why don't surgeons do this? Most surgeons, as noted above, aren't interested in working 20-30 hours/week. And, I think more likely, most surgical groups aren't interested in hiring people who want to work such hours.
     
  7. I think some of this may depend on the specialty. There is always the concern of "volume". Exactly how much of any group of procedures should you/do you need to perform in order to maintain skill? How much general surgery should you do if you practice predominantly breast and only take occasional gen-surgery call? Should you take trauma call once every week, month, two months, etc? How much laparoscopy should you be doing in the middle of the night if you don't usually practice that? Is it fair to patients to have coverage by surgeons only skilled in open cholecystectomies because they are part timers and do not practice much laparoscopy? Or, is it worse to have a part time laparoscopist attempt to take out a badly inflamed gallbladder in the middle of the night?

    Of course there is then the issue of the "itinerant" (sic) surgeon...

    I do not claim to know the answers. I have enjoyed training with "part time" attendings. I am grateful for their experience and what I learn... But the questions arise and nobody has the answer though I am sure many have an opinion.
     
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  8. carrigallen

    carrigallen 16th centry dutch painter 10+ Year Member

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    I'm not in a surgical residency, but to me this arrangement would raise questions. I wouldn't want surgeon B taking care of surgeon A's post-op complications. Too much information is lost in signout, and knowing your post-op patient is important. Is that an aortofemoral graft or axillofemoral graft that got occluded at 2 am? Are you going to sign-out counselling a patient about a critical biopsy result? Some post-op patients are sick and I think knowing their baseline is important. Are you going to sign-out communication with peers at morning conference or m&m?

    As a patient, I don't like the idea of coming into an office and never knowing who I would see. As an internist I would probably avoid refering patients to a tagteam duo because unless there is a monolith of responsibility, things get missed or fall through the cracks. The last thing I want is to call a specialist one day, and then have to repeat everything when I call them the next day. I do want a "go-to guy" who can tell me what happened in the OR, what happened post-op, and what the plan is.

    Not only would two people effectively make less money than one, I think two people would actually be less efficient and more dangerous.
     
  9. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    But that happens ALL THE TIME in community private practice. The partners split up call and rounding duties, particularly if they cover more than one hospital, so it is not unusual AT ALL for a different surgeon to so the post-op care for one of his partners.

    But you're right - it can lead to errors. A few weekends ago I was moonlighting and Surgeon A had written an order than the Foley was not to come out for 3 days since the patient had a severe stricture and the Foley had to be placed by a Urologist, who had trouble cysto'ing the guy.

    Surgeon B, A's partner, comes in to round on the guy - post op from a chole, and orders the Foley to come out. Nursing doesn't question the order, and guess who gets the call 10 hrs later when the guy can't pee? Guess who gets yelled at when I call the urologist at 10 pm on a Saturday night? The guy had to go back to the OR for cysto, dilation and placement of a Coude (which I had tried at the bedside unsuccessfully). So it happens but a fact of practice in the community is that you will have your partners taking care of your patient and they will make mistakes just as you will when rounding on theirs.

    Understood - most don't. However, for a non-scheduled visit or for a wound check, drain check, etc. you may NOT see the surgeon who operated on you if you haven't scheduled the visit around their OR schedule. You may see their nurse or again, one of their partners.

    Any rate, probably the real reason surgeons don't often share jobs is as mentioned above: they don't want to and practices don't want to hire those that do...its too much hassle.
     
  10. tussy

    tussy Senior Member 10+ Year Member

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    I know a couple of surgeons that have this sort of "practice sharing" arrangement. It seems to work well for them. I think most surgeons don't do it for all the aforementioned reasons, but it is an option for those that are interested.
     
  11. TaiShan

    TaiShan Member 5+ Year Member

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    The other problem is that you can split work but you can not really split the benefits. I mean, Hospitals/groups will have to pay health insurace for TWO families, pay pension for two people, and pay any other benefits for two even though these two people are only as productive as one.

    If hospitals/groups only pay you flat fees (ala moonlighting) without any other benefits, I am sure you can split work with someone.
     
  12. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    Well, since most surgeons in private practice, unless they are a hospital employee, pay their own health insurance, the issue is moot. Employers (ie, if you weren't a partner) with less than 15 employees are not required to offer you health insurance.
     
  13. Pilot Doc

    Pilot Doc SDN Angel Moderator Emeritus 7+ Year Member

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    Assume a full-time, 60 hr/week surgeon makes $350K with a benefit package worth $50K/yr - total compensation of $400K. Split that by two and you get $150K/yr plus 50K benefits - only $25K less than 1/2 of 375. (And that's a pretty generous benefits package - health insurance alone shouldn't be more than 10-15K)
     
  14. supercut

    supercut Senior Member 7+ Year Member

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    The main reason it doesn't happen is because traditionally surgery is a balls to the walls culture and if you aren't willing to do that, you are typically looked down upon.

    Change comes more slowly in surgery than any other aspect of medicine.

    Kudos to those pioneers who are struggling to make this a more humane profession.
     
  15. cardsurgguy

    cardsurgguy Senior Member 7+ Year Member

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    Several people have raised the benefits issue. That could be worked out. For example, in the situation I cited, if I remember correctly, neither one of them is receiving health insurance since both of their husbands have health insurance for the family. So in a way, the company is saving since they are having a full time position without having to pay health insurance for the employee.

    Retirement benefits, such as the group practice/or hospital system contributing towards a 401k could simply be cut in half.

    Still though you guys are probably right. It most likely wouldn't literally be 50%. Probably a little less. Maybe 45%, who knows. But if you're interested in this setup, chances are it's for lifestyle/family reasons and you probably don't have a huge issue with a little bit less money (especially if you have a spouse who makes a good buck.




    Yeah, I already figured that was a major reason before I posted the thread, I just wanted to see about the logistical issues and if there were any different logistics as compared to other fields. But hell yeah, in terms of the non-logistical issues, such as how you're perceived, the attitude in the field, etc, it would be looked down upon.

    I'm not particularly interested in doing this, it was more of a curiousity type of thing since at least just on the logistics (ie leaving attitude, and specialty personality out of it), it seems that this could happen easier in surgery than in primary care fields.

    Oh well, interesting thing to think about for people who are interested in it.

    After all, 1/2 time, or splitting 3 physicians to take the patient load of 2, or whatever setup is still working around 35-45 hours a week in many cases for a large percentage of surgeons of various fields.:rolleyes:
     
  16. I am not sure where your numbers come from or what specialty....
    60 hr/wk
    350k/year
    etc.....
     
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  17. Pilot Doc

    Pilot Doc SDN Angel Moderator Emeritus 7+ Year Member

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    That's a reasonable number for general surgery. I'd bet that $/hr number is probably 60th percentile.
     
  18. And here I thought everyone was so concerned about med students avoiding surgery as a career in part because lifestyle was so tuff....and European style work hour restrictions on attending surgeons

    well 60hr weeks and $350K/year, things sound pretty good in the US GSurgery world.
     
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  19. -Goose-

    -Goose- 10+ Year Member

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    What?
     
  20. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    I think that's Skylizard's way of saying that he isn't quite so sure about the numbers quoted above. While it certainly is possible to work 6o hrs a week and make $350K per year, that is by no means the average, especially when starting out. Most would be lucky to earn above $300, IMHO (since I often get quoted the average salary for general surgeons when hospital administrators complain that I would be "making more than a general surgeon".)
     
  21. -Goose-

    -Goose- 10+ Year Member

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    Really? Non-fellowship trained?
     
  22. clearly grasps my thoughts. The other issue is that simply working 60Hr/week may be less then easy to arrange....

    Think about M-F, 10Hr/day.
    That gives you a start at 50Hr/week without even taking into account weekends and middle of the night calls, emergencies... appies, choles, colectomies, etc...

    Now, let's take an FP physician, they often work 50+Hr/week. So, where do the scales fall??? Surgery is regarded as having a difficult lifestyle for a reason. The compensation starts out usually at least double what an FP would make. Does anyone really think the average GSurgeon out of residency is making >$300k and working 60Hr/week (only 10 more Hr/week then an FP)?
    The community surgeons I saw were usually cutting skin between 7 & 730am and finishing rounds at 9pm if they were lucky. They told me about their "overhead", etc... Their salaries were closer to $200k and their week was >80Hrs, their call, depending on the group, was Q3 for "new" patients (if lucky), with each taking call the entire weekend on alternating basis, and each covering "their own patients" (i.e. rarely signing out their patient). There are obviously variations on the scheme for coverage, etc... However, surgeons are not generally paid by the Hour. There is billing, collections, "overhead", "RVUs", etc...

    I just don't see the "average" GSurgeon working 60hr weeks for $350K/year. I have to tell you that would be a sweet deal. If that is what you are being offered and there isn't a snake hiding under the rock, you should take it.
     
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  23. cardsurgguy

    cardsurgguy Senior Member 7+ Year Member

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    According to the Occupational Outlook Handbook, which got their data from the Medical Group Management Association (a reputable medical group industry organization), the median "total compensation" for general surgeons is as follows.

    "Less than two years in specialty" - 228,839
    "Over one year in specialty" - 282,504

    (obviously it's good they are giving salaries starting out after residency (as opposed to one lump salary with everybody), but I have no idea why they use less than two years and over one year since there's overlap, who knows)

    Anyways, the statement about "total compensation" is given as

    "Total compensation for physicians reflects the amount reported as direct compensation for tax purposes, plus all voluntary salary reductions. Salary, bonus and/or incentive payments, research stipends, honoraria, and distribution of profits were included in total compensation."


    What kinds of hours this represents, or what the median hours per general surgeon are, who knows, only compensation is given.
     
  24. As I read that, <2 years is just that and >1 year includes all comers i.e. established 18months, 2yrs, 5yrs, 10yrs, etc... it is an average of a big spread...right? and still less then $350k.
     
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  25. cardsurgguy

    cardsurgguy Senior Member 7+ Year Member

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    Yeah, I knew that. I was wondering why they wouldn't just say "less than two years" vs. "over 2 years" since that wouldn't have the 2nd year counting in both salaries.

    Oh well, just raised a point of curiousity for me. Just me being nitpicky and curious about unimportant things as usual...
     
  26. Oh, OK. I didn't read the resource you referenced so I just wanted to confirm I was understanding it correctly. Thank you.
     
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  27. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    It is a bit curious to divide the groups that way.

    The mean salary for those in practice less than two years is probably about right - many general surgeons get a salary guarantee for the first year or two, and it would be fair to say that on the average (ie, discounting rural places or other places with hidden agendas that pay you big bucks), that salary guarantee would be between the high 100s and 250K/year.

    After two years, most general surgeons revert to a pay for performance if they are in private practice - this obviously means they can make much more than they guarantee or much less, if they choose to work fewer hours, bill less creatively or do poorly reimbursed patients or procedures.

    Any any rate, I don't know any general surgeons working 60 hrs a week and making $350; perhaps we are thinking about Ophtho...on second thought, they would likely make more than $350. :D

    Little off topic, but a "trick" I found that some hospitals are doing:

    if you are not BC in your field of specialty and did a general surgery residency before additional training, some places are rewriting hospital by-laws to require anyone not BC in a field other then general surgery (ie, colorectal surgery, CT, etc.) then you are required to take gen surg call.

    Obviously not a problem if you are a BC Vascular surgeon. But if you haven't taken your boards, haven't passed them or are in a specialty (like Surg Onc) which doesn't have boards, you could be in for taking some. Just somethign to consider when perusing contracts.
     
  28. I saw this happen to a hand surgeon at our institution.... I don't know the details but he was taking some sort of extra ED call for about a year.
     
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  29. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    Fortunately, it looks like they are grandfathering those in who signed before the changes but it means there is one less hospital I will be taking my patients to! I don't play that game when I have lots of other options.

    I had a colleague caught in the middle of being offered a position without gen surg call (which is something 99% of us will not do) and then the gen surgeons having the bylaws rewritten so she couldn't get credentialed there.

    One would think the hospital wouldn't want the liabilty of someone doing procedures they haven't done in years (if ever done alone). :confused:
     
  30. FliteSurgn

    FliteSurgn This space for rent. 10+ Year Member

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    As I've said in previous threads, those kinds of numbers (and even much larger numbers) are certainly "do-able". There are some variables though. Overhead is a HUGE drain on the income of most surgeons. I know people that are paying over 50% of their collections towards overhead (office rent, salaries/benefits for personnel, health insurance, malpractice, etc). So, one way to make a huge impact in your income is to really pare down overhead as much as possible. If you are in a mutli-specialty group, this is next to impossible. Those in a MSG are the one's the pay the most. Compare that to a single-specialty group where I've seen overhead ranging from 10%-35%.

    If you're not on salary, the other variable that impacts your potential income is your own ability to produce. In other words, what kind of volume you are capable of performing. How many cases you have referred and how long it takes for you to plow through those cases is the other large factor relating to your potential. A full day for one surgeon might be 3 lap choles, while another might consider that 2 hours of work including turn-over time. The latter surgeon is much more likely to be in a position to increase their income because he/she has the ability to boost production more than the second (assuming similar referring volume).

    For example, my partners all make >$350k (some significantly more) after overhead and before taxes. As a new doc in the practice, I overcame my salary guarantee and began production-based pay after 6 months. I rarely work over 40 hrs/wk on average unless I have some bad call days/nights. Our overhead is about 15%. This is as good as it gets. :cool:
     
  31. cardsurgguy

    cardsurgguy Senior Member 7+ Year Member

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    15%? Wow, that's amazing.

    In 2 years of getting a healthcare management MBA prior to medical school, I've never studied a practice either in the real world or in case studies that has an overhead anywhere near that.
    Generally, an overhead of 25-30% was considered a good overhead that was something to be happy with.

    If you don't mind me asking (if you feel like giving up your secrets), how is it that low??

    Do you have the docs children coming in and doing the administrative functions for $5 an hour allowance??:D
     
  32. For general surgery.... that would be spectacular... I guess attendings will have nothing to fear about those European style attending work hour restrictions... If you can do general surgery, produce adequately, and work 40-50 hours per week... like I said take it if you can get it!!! Granted, I am not a business major and am not practicing general surgery in the community yet. However, it just sounds too good to be true and not likely to be average or common IMHO. I just haven't really heard about that sort of scenario.
     
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  33. Pilot Doc

    Pilot Doc SDN Angel Moderator Emeritus 7+ Year Member

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    You're awfully bitter and confrontational. Maybe you should address that offline. A quick search of FliteSurgeon's post would reveal extensive details about his practice.

    But you probably make a decent point that there really isn't an "average" general surgeon. Lots of surgeons practice in areas where patient demand greatly outstrips surgeons. They have a nice life. Other surgeons practice where you have to fight for scraps; life is not nice. Unfortunately, cost of living is generally inversely proportional to earning power for surgeons as well.
     
  34. I apologize if my reply came accross as bitter. It was not intended that way. I am simply expressing my opinion and did not think it innappropriate. I honestly apologize. I was not being sarcastic but honest when saying, "For general surgery.... that would be spectacular..."
     
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  35. Pilot Doc

    Pilot Doc SDN Angel Moderator Emeritus 7+ Year Member

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    No worries. maybe I jumped the gun a bit. Something about your style just seemed overly aggressive. Sounds like it wasn't intentional.
     
  36. FliteSurgn

    FliteSurgn This space for rent. 10+ Year Member

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    Here are some details on why our overhead is so low. We have a high-volume surgery-only practice with 4 surgeons. We have 4 relatively low paid office workers (schedule cases, answer phones, file, reception, etc.), one collections person, and an office manager that does all of our coding, billing, and finances. We do not have any nurses, medical assistants, etc. We do have 2 PAs though. The PAs generate their own income by billing as assistants during surgery. One of them works completely on production and the other is on salary, but collects enough on assist fees to cover that. Therefore, they are both essentially free to our practice. We live in a cheap malpractice environment and rent is pretty low for our office space. And, no, it isn't in Wyoming or any other BFE location. We are in one of the 50 largest metropolitan areas in America.
     
  37. -Goose-

    -Goose- 10+ Year Member

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    So there IS hope.
     
  38. Interesting number....
     

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