Biggest issues all relate to the integration of the hospital & residents. Describe the hospital for us. Setting? For-profit, non-profit, county? How many beds? Trauma level? NICU level? PICU? Is ICU open/closed?
If the hospital was built (from a systems standpoint) with the residency in mind (i.e. there is a tight inter-dependence of the hospital on the residents), there's less to worry about. If the residency is an add-on to an already functioning community hospital, you have some things you need to think about.
The question is what is the role of the residents and what is the role of the private attending and how dependent will the hospital be on the services of the residents? For example, who will you admit and how frequent? Will those patients be insured or not? If they are uninsured, who will be your specialty consultants who will back up the service for procedures, high risk consults? Are those specialty consults volunteering their service or will they be financially compensated to work on behalf of the residents to care for the patients?
Will the residents be a part of the code team or will they be the code? And if so, will they be given the authority to run the code? And if so, how will they be provided the training and experience? (i.e. who will teach intubations and allow residents to "practice" on their patients?).
How do residents get deliveries? From their own clinic? Or through the call list? Or take all uninsured/unassigned? And, who will deliver the babies with the residents? FP core faculty or volunteer OB attendings on the call list? There's a difference because the community attendings may not want residents involved when they are on the liability bubble.
What is the role of the resident once a baby is delivered? Who catches and who attends neo codes? Are the residents part of that? And if so, are they running it? And if so, who backs them up if they can't get the intubation or resuscitate the newborn?
How many pediatrics beds are there in the hospital? And, if you're a community hospital, will you have pediatric specialty back up? Will you have a PICU? Or will the ER be asked to divert/transfer all critically ill kids to the children's hospital? And if so, what is the residents' role in that? If they divert sick kids, do they evaluate those kids with the EM attending in the ED?
A large part of unopposed programs is how do you access specialty care in procedural disciplines that would be easier to access had there been a fellowship/residency in place. Examples are: If you're at a private community hospital, unopposed, and you admitted a GI bleeder, will GI or Surgery scope this guy? Or teach you how to scope this guy? If they won't teach you to scope, then you must consult. So the question is will this patient (or the hospital by way of paid call) pay GI/Surgery for scoping this guy? Because if GI/Surgery doesn't get paid, they will find all the reasons to NOT scope this patient on your service, while your name (and your attending) is attached as the primary. So, that's a huge liability. If you are in an opposed program, that's not a problem, because there are other residents/fellows who are happy to scope someone. So that needs to be clarified. What patient population will you be working with? Will specialists teach you the procedure? And, if not, will the hospital remove all the disincentives to NOT take care of the patient? Same goes for all procedure disciplines (OB, GI, Pulm/CC, Cards, Gen Surg, Cardiovasc Surg, Ortho).
My bet is that with a class of 4, you are going to be an add-on to a preexisting hospital. If that is the case, you need to make sure that you are NOT the uninsured service. Because all the privates will love it if you take all their non-paying patients, and over time, they will say that they won't support you (or, aren't obligated to support you). So that means that someone has to step in. Either the hospital forces the specialists to take care of your patients (uninsured) which is highly unlikely because the specialists bring in more money to the hospital than FM does. Or, the hospital pays the specialists to take care of your patients. If your inpatient services are a combination of paid and uninsured, that may be different, because now you're more of a player to a new private specialty attending who's looking to build their practice.
These are challenges that most unopposed community programs face, and most will have a way of dealing with it. But for a NEW unopposed program, you better figure these issues out ahead of time, because it can hamper your clinical exposure and liability.
