Small Hospital Vs Big Hospital

[Sparda29]

As a new grad, what is better in terms of long-term career development: working for a small hospital (30 bed facility) or a large hospital (300 bed facility)? I was told about an opportunity at a small hospital where there are only like 5 doctors, awesome DOP. It's a small town with no crime in the northern part of the country and they are willing to wait for someone to get licensed in that state. The recruiter was telling me that working for a small hospital is better for long term career, but I'm not so sure about that?

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[All4MyDaughter]

As a new grad, what is better in terms of long-term career development: working for a small hospital (30 bed facility) or a large hospital (300 bed facility)? I was told about an opportunity at a small hospital where there are only like 5 doctors, awesome DOP. It's a small town with no crime in the northern part of the country and they are willing to wait for someone to get licensed in that state. The recruiter was telling me that working for a small hospital is better for long term career, but I'm not so sure about that?

Does the recruiter have any incentive to mislead you?

 

[Sparda29]

Does the recruiter have any incentive to mislead you?

I don't know, how much do they really make on placing people? I was asking the guy about a listing in NYC when he told me it was a repost, however there was a great opportunity available in said rural hospital.

 

[type b pharmD]

For you Sparda, the smaller environment will provide better career opportunities.

At a large institution, the people who are promoted and given career development opportunities are typically the people in high regard by the establishment, and in the 'large' institution environment, those are the people with extra residencies, fellowships, research experience, teaching experience, and people who head up and succeed on big projects.

If you think you can squeeze your way in and get given some projects, quality improvement, workflow optimization, outcomes/process research, or if you get some credentials behind your name beyond just PharmD , then go for the large institution. Just from reading your posts diligently over the years, I know this is not you Sparda.

In a small environment, you can become well rounded and become known as the local 'expert'. It will probably be more time and effort since you will be using your time in a more varied and less efficient way compared to a large compartmentalized (staffing) institution, but the fact that there will be limited to no competition from other academically minded people in the rural setting means that if you are a true baller, you can probably write your own ticket. Small hospitals typically have a plethora of projects and unfinished QI improvement to do, and you can grab these.

Once youve established yourself as a true expert and hard worker, you'd be the first person that the hospital looks at for DOP, management, starting a clinical service, heading up a big (paid) project, being on formulary and drug use committees , etc



TLDR version: Small hospitals are much better since you will have the opportunity to prove yourself and wont be competing with academics and established players. However, they are much more work, you will have to take on all roles to impress, and there may or may not be a promotion opportunity immediately available.

Might want to talk to Xiphoid about this one , he went to work at a small hospital and after proving himself was offered the option to expand clinical services and become DOP. (i think?)

 

[pharmasaur]

I would also think small hospital. You become part of the family and feel like you're contributing to a team. (that is if you like your co-workers)

At a really large hospital, you're kind of seen as dispensable...there's too many people, easy to get lost in the crowd and you really have to gun it to stand out.

Kind of like small liberal college vs big state school debate. small school has less gadgets and toys but you can really stand out as an individual. big school has more opportunities but more than likely you're a nobody.

 

[Sparda29]

Yeah that's what I figured. Problem is, this hospital would be perfect if I was 35-40 with a wife and kids. Beautiful area of the country in New England on the USA/Canadian border, small town, great views, low taxes, go snowboarding half of the year. But I'm a single 25 year old, don't think I can let go of NYC just yet.

 

[type b pharmD]

Yeah that's what I figured. Problem is, this hospital would be perfect if I was 35-40 with a wife and kids. Beautiful area of the country in New England on the USA/Canadian border, small town, great views, low taxes, go snowboarding half of the year. But I'm a single 25 year old, don't think I can let go of NYC just yet.

Also, knowing you, you might vanish into the culture of slack at such a location, never to be heard from again as far as professional development goes

If I were in your position, I would be trying to make friends with one of the up-and-coming favorites in the department and see if they will hand something off to you to work on and get to building your name, if for no other reason than it may help you 'stay' hired, and not viewed as just a replaceable part.. It is doubtful that you will get promoted without any additional credentials or successes on your CV.

On the other hand, being a staff at a large institution and not having additional credentials, working hard might just be a waste of time. I'd feel more comfortable taking it easy in an anonymous environment.

 

[Sparda29]

Also, knowing you, you might vanish into the culture of slack at such a location, never to be heard from again as far as professional development goes

If I were in your position, I would be trying to make friends with one of the up-and-coming favorites in the department and see if they will hand something off to you to work on and get to building your name, if for no other reason than it may help you 'stay' hired, and not viewed as just a replaceable part.. It is doubtful that you will get promoted without any additional credentials or successes on your CV.

On the other hand, being a staff at a large institution and not having additional credentials, working hard might just be a waste of time. I'd feel more comfortable taking it easy in an anonymous environment.

I've already done this with the clinical pharmacist who is the DOP's favorite in the department. DOP knows I eventually wanna be clinical pharmacist/DOP. Problem is that I work the afternoon-evening shift and I only see the clinical pharmacist and the director for 2 hours out of my shift. I've been doing some of the clinical pharmacists tasks without being asked to do them. Hell, ever since I started working, I have recorded the most interventions in the department, more than the clinical pharmacist as well. No idea how the DOP will react to that.

It's gonna be either:

A: OMG, you're so awesome taking the initiative to help out with the clinical tasks. Here's a nice raise and a promotion to clinical pharmacist.
B: What the hell, no wonder every night is crazy for you guys, you're taking time away from doing order entry to do the clinical pharmacists work. Is she banging you and in return you do her work? Write-up or fired.

 

[KARM12]

It's gonna be either:

A: OMG, you're so awesome taking the initiative to help out with the clinical tasks. Here's a nice raise and a promotion to clinical pharmacist.
B: What the hell, no wonder every night is crazy for you guys, you're taking time away from doing order entry to do the clinical pharmacists work. Is she banging you and in return you do her work? Write-up or fired.

Some how I doubt it will be either of those...

 

[nafcillin]

Type b. I agree with you!

 

[Praziquantel86]

I would not recommend being a patient at a small hospital where Sparda is honing his skills as the sole pharmacist.

 

[Sparda29]

I would not recommend being a patient at a small hospital where Sparda is honing his skills as the sole pharmacist.

 

[rxlea]

He has a point. You need more experience (based on your posts, anyway) before you man the ship.

 

[mustang sally]

Small hospital advantages: you will become jack of all trades. As type b said, if there are projects, clinical work, etc. that needs to be done, guess who's doing it...fancy residency be damned. You will also get to know hospital staff pretty well, which may make it easier (or not) to work with all of the doctors, PAs, etc.

Disadvantages: Limited formulary so may be less exposure to different types of meds (though more than you think, because patients come in on their home meds), less complexity to patient cases than you would see in a major trauma center, fewer other pharmacists around to learn from/shoot the **** with, and oh yeah, do you have to take call at all? Personally I think call sucks, though its probably a good experience in its own right.

 

[Ackj]

Small hospital advantages: you will become jack of all trades. As type b said, if there are projects, clinical work, etc. that needs to be done, guess who's doing it...fancy residency be damned. You will also get to know hospital staff pretty well, which may make it easier (or not) to work with all of the doctors, PAs, etc.

Disadvantages: Limited formulary so may be less exposure to different types of meds (though more than you think, because patients come in on their home meds), less complexity to patient cases than you would see in a major trauma center, fewer other pharmacists around to learn from/shoot the **** with, and oh yeah, do you have to take call at all? Personally I think call sucks, though its probably a good experience in its own right.

This has been my (limited) experience. Smaller hospital, only one person had a pharmD, no residents at all. Good relationships with the docs and most nurses, since there were not very many you got to know them. We actually had 3 patients who came in all the time for Prolastin, so that was cool. Definitely lots of projects available to work on if you took the initiative. Note that this place wasn't extremely small, but definitely on the lower end, like 150 beds or so.

 

[All4MyDaughter]

I just noticed that the hospital in question has 30 beds... That is really really small. I doubt there is much clinical stuff going on, and the diversity of pathology that you see is also likely to be limited. Not sure this is a great place for a new grad to develop his clinical mojo.

And Sparda...yes that recruiter is getting paid (probably a few thousand) to find someone for that hospital. Sounds like it's a tough sell, so he's going to say what he can to convince people. Don't be naive.

 

[spacecowgirl]

I just noticed that the hospital in question has 30 beds... That is really really small. I doubt there is much clinical stuff going on, and the diversity of pathology that you see is also likely to be limited.

Not true! When you're the only game in town, you see everything. No, you're not doing any caths but you see pretty much everything else. Lots of clinic stuff over here.

 

[rxlea]

I just noticed that the hospital in question has 30 beds... That is really really small. I doubt there is much clinical stuff going on, and the diversity of pathology that you see is also likely to be limited. Not sure this is a great place for a new grad to develop his clinical mojo.

And Sparda...yes that recruiter is getting paid (probably a few thousand) to find someone for that hospital. Sounds like it's a tough sell, so he's going to say what he can to convince people. Don't be naive.

Not true! When you're the only game in town, you see everything. No, you're not doing any caths but you see pretty much everything else. Lots of clinic stuff over here.

^^^ this. I saw some weird stuff on my rural rotation and there were only 25beds. Plus, pharmacists have more autonomy. Infectious disease is always fun especially when there are other barriers to consider like cost and a limited formulary. That and your patients not understanding you!

I did a ton on that rotation. It was bomb. I learned way way y more than I thought I would. I even helped examine a patient

 

[Praziquantel86]

Not true! When you're the only game in town, you see everything. No, you're not doing any caths but you see pretty much everything else. Lots of clinic stuff over here.

Out of curiosity, what's everything else? I doubt you'd be seeing transplant (solid organ or heme), most malignancies, surgical disasters, major trauma, MIs, stroke, etc.

I'd imagine a 30-bed shop would be a lot of bread-and-butter type stuff like asthma/COPD, pneumonia, etc. with the high-acuity stuff shipped out. Not saying that's a bad thing clinically or professionally, but it's somewhat disingenuous to say you see "everything". You need to be at a mega-academic center for a lot of that stuff.

 

[spacecowgirl]

Out of curiosity, what's everything else? I doubt you'd be seeing transplant (solid organ or heme), most malignancies, surgical disasters, major trauma, MIs, stroke, etc.

I'd imagine a 30-bed shop would be a lot of bread-and-butter type stuff like asthma/COPD, pneumonia, etc. with the high-acuity stuff shipped out. Not saying that's a bad thing clinically or professionally, but it's somewhat disingenuous to say you see "everything". You need to be at a mega-academic center for a lot of that stuff.

We don't see transplant or major traumas, that's true. Everything else, we see. We send out strokes and MIs if they are candidates for thrombolytics/caths but a lot of people present too late or are not candidates. We do a lot of outpatient chemo here so we see that and then see them inpatient when they are neutropenic. Our census is small but diverse - everything from EtOH withdrawal vented w/propofol to homicidal ideation to routine TKA to respiratory failure to serotonin syndrome to pathological fractures from bone mets.

We deliver babies and do hospice care and everything in between. Do you know the dosing and treatment for neonate meconium aspiration as well as how to treat intractable pain and copious secretions in end-stage cancer? I do

 

[rxlea]

We don't see transplant or major traumas, that's true. Everything else, we see. We send out strokes and MIs if they are candidates for thrombolytics/caths but a lot of people present too late or are not candidates. We do a lot of outpatient chemo here so we see that and then see them inpatient when they are neutropenic. Our census is small but diverse - everything from EtOH withdrawal vented w/propofol to homicidal ideation to routine TKA to respiratory failure to serotonin syndrome to pathological fractures from bone mets.

We deliver babies and do hospice care and everything in between. Do you know the dosing and treatment for neonate meconium aspiration as well as how to treat intractable pain and copious secretions in end-stage cancer? I do

It sure sounds like fun in unicorn land.

EDIT: in the unicorn forest I visited, there was Hanta virus, plague, TB, and rattlesnakes lurking around every corner!!!

 

[joetrisman]

It sure sounds like fun in unicorn land.

EDIT: in the unicorn forest I visited, there was Hanta virus, plague, TB, and rattlesnakes lurking around every corner!!!

Benefit of living in the south west. Sometimes I think I should do my pgy1 up north and then go to fl or south west for pgy2 so I can see some warmer climate related id stuff

 

[All4MyDaughter]

Out of curiosity, what's everything else? I doubt you'd be seeing transplant (solid organ or heme), most malignancies, surgical disasters, major trauma, MIs, stroke, etc.

I'd imagine a 30-bed shop would be a lot of bread-and-butter type stuff like asthma/COPD, pneumonia, etc. with the high-acuity stuff shipped out. Not saying that's a bad thing clinically or professionally, but it's somewhat disingenuous to say you see "everything". You need to be at a mega-academic center for a lot of that stuff.

This is what I meant, but I've also never worked at a small hospital in a rural area. The small hospitals here (city and surrounding) just don't see the diversity/complexity of the bigger ones. That's all I meant.

 

[Its Z]

For you Sparda, go do the small hospital thing.

Thank me later.

 

[Sparda29]

I just noticed that the hospital in question has 30 beds... That is really really small. I doubt there is much clinical stuff going on, and the diversity of pathology that you see is also likely to be limited. Not sure this is a great place for a new grad to develop his clinical mojo.

And Sparda...yes that recruiter is getting paid (probably a few thousand) to find someone for that hospital. Sounds like it's a tough sell, so he's going to say what he can to convince people. Don't be naive.

According to the recruiter, there are only like 5 regular doctors at this hospital.

 

[All4MyDaughter]

According to the recruiter, there are only like 5 regular doctors at this hospital.

You said that in the OP.

 

[Sparda29]

You said that in the OP.

Oh yeah, forgot I mentioned that before.

 

[mustang sally]

We don't see transplant or major traumas, that's true. Everything else, we see. We send out strokes and MIs if they are candidates for thrombolytics/caths but a lot of people present too late or are not candidates. We do a lot of outpatient chemo here so we see that and then see them inpatient when they are neutropenic. Our census is small but diverse - everything from EtOH withdrawal vented w/propofol to homicidal ideation to routine TKA to respiratory failure to serotonin syndrome to pathological fractures from bone mets.

We deliver babies and do hospice care and everything in between. Do you know the dosing and treatment for neonate meconium aspiration as well as how to treat intractable pain and copious secretions in end-stage cancer? I do

The hospital you work at sounds a lot like mine! I agree, between inpatient and outpatient, you can see a lot of things. Again, this is in a rural area where there is nowhere close by to go, not in a city with a lot of other hospital choices.

We don't do transplantations here (obviously), but we have ended up with a lot of transplant patients lately. It's pretty cool to have a more complex patient to work with sometimes.

 

[ucrx]

Did anyone else read this and realize not everybody has the same definition of large and small hospitals? I guess that comes from only working in hospitals that are around 1000 beds or bigger...

 

[xiphoid2010]

Small hospital can provide opportunities to upstarts not given out in larger institutions. A larger hospital will give you a lot more job security but much more structured career options. It's a trade off.

And as others have mentioned, there will likely be some limitation to what you learn (eg, no chemo, no transplant, rare diseases, etc), you will see most of stuff coming through the door. You do build up a very close working relationship. The downside is that it is often an under served area or a long way out, the benefits might not be as killer as some of the bigger hospitals. You will likely find plenty of things that you want to bring up the standard but are limited by tight funding and dated/lower quality of care. But if you build up rapport with the 5 docs, you can almost have a free hand in medical practice. Another draw back is that you will likely be oncall a lot, and must be willing to wear multiple hats when needed. If you just want to put in 8 hrs a day and nothing more, stick with a staffing job in a big place.

Before you take up the offer, do a little digging. Check out their financial situation and why they are hiring. If everything looks ok, a small hospital is a good place to start, build up your skills. After a few years, stay if you feel loyalty to the closely knitt relationship, or transition to a larger setting when opportunity presents.

 

[KARM12]

Benefit of living in the south west. Sometimes I think I should do my pgy1 up north and then go to fl or south west for pgy2 so I can see some warmer climate related id stuff

Doing a PGY2 residency in an urban city and a county hospital, I saw all kinds of crazy stuff. Our patients came from all over the globe with a lot from the Caribbean and Africa...tropical medicine is super fun!

 

[Sparda29]

Did anyone else read this and realize not everybody has the same definition of large and small hospitals? I guess that comes from only working in hospitals that are around 1000 beds or bigger...

1000 bed or more = mega hospital, forget large, lol.

 

[rxlea]

Benefit of living in the south west. Sometimes I think I should do my pgy1 up north and then go to fl or south west for pgy2 so I can see some warmer climate related id stuff

Come here!!!!!!!

 

[BenJammin]

I just don't understand the attitude of "I want to advance my career so let's start big". Every great baseball player started in the minor leagues, every NFL player perfected his skills in college, and big time hospital directors usually started at small hospitals.

 

[Sparda29]

I just don't understand the attitude of "I want to advance my career so let's start big". Every great baseball player started in the minor leagues, every NFL player perfected his skills in college, and big time hospital directors usually started at small hospitals.

Lebron didn't go to college.

Anyway, I think an analogy that would fit this situation better would be a QB out of college being drafted and immediately becoming starting QB (Mark Sanchez, Vince Young, Matt Leinart, Andrew Luck, Robert Griffin III) versus a QB being drafted and learning from the elders (Aaron Rodgers, Tom Brady, Eli Manning).

 

[Praziquantel86]

Lebron didn't go to college.

Anyway, I think an analogy that would fit this situation better would be a QB out of college being drafted and immediately becoming starting QB (Mark Sanchez, Vince Young, Matt Leinart, Andrew Luck, Robert Griffin III) versus a QB being drafted and learning from the elders (Aaron Rodgers, Tom Brady, Eli Manning).

Sorry if I've come across a bit harsh previously in this thread - but I think there are a few things to consider.

First, you won't have backup. The mistakes you make are yours and yours alone - and everyone makes mistakes, it's just a matter of having a safety net available to catch them. You will have limited or no one else there to help you get the swing of things. Having not done a residency and worked for a limited time elsewhere, this is very important.

Second, building a clinical service is something that should be done with experience to bak it up. You've mentioned yourself how limited your rotations were - not having ID or critical care would seem to be a huge hindrance. This snowballs on with point 1 - you can make all the recommendations you want, but you'll have no way to run them by anyone beforehand to see if they're right. Simply put, you don't know what you don't know.

Third, and others have mentioned this, you'll have limited resources in a world where you're trying to learn and grow. You haven't struck me as a self-starter at all, and not having access to journals or a library would add just another barrier to your learning that it seems like you wouldn't overcome.

Just my thoughts, take em for what they're worth.

 

[mustang sally]

First, you won't have backup. The mistakes you make are yours and yours alone - and everyone makes mistakes, it's just a matter of having a safety net available to catch them. You will have limited or no one else there to help you get the swing of things. Having not done a residency and worked for a limited time elsewhere, this is very important.

Second, building a clinical service is something that should be done with experience to bak it up. You've mentioned yourself how limited your rotations were - not having ID or critical care would seem to be a huge hindrance. This snowballs on with point 1 - you can make all the recommendations you want, but you'll have no way to run them by anyone beforehand to see if they're right. Simply put, you don't know what you don't know.

QFT. If you are going to be the full-time pharmacist there, your DOP can make you or break you. I would definitely try to get a handle on the what the DOP situation is as much as possible before taking the job, as he/she will likely be your primary mentor in this situation, the agent of change for the pharmacy, and the one you go to for advice.

 

[xiphoid2010]

QFT. If you are going to be the full-time pharmacist there, your DOP can make you or break you. I would definitely try to get a handle on the what the DOP situation is as much as possible before taking the job, as he/she will likely be your primary mentor in this situation, the agent of change for the pharmacy, and the one you go to for advice.

That pretty much holds for any job. Know who you will be working for and if you can work with that person before you transplant into a brand new environment. Either that or have the willingness risk the consequences if things don't work out.

Either way, things happens very quickly in a small hospitals. We recently got bought, I lost half of my PRN staff, retraining, or the lack of, strains inter-disciplinary relationships. It represents both opportunities and risks. Here a tightly knit family like working relationship can be a double edged sword, when one major player leaves, the next want to go as well. If you lose key players, the pain starts to outweigh loyalty and opportunities. This is one of the major reason why you want to see the company financials, which decided whether you are dishing it or taking it.

 

[mustang sally]

That pretty much holds for any job. Know who you will be working for and if you can work with that person before you transplant into a brand new environment. Either that or have the willingness risk the consequences if things don't work out.

Either way, things happens very quickly in a small hospitals. We recently got bought, I lost half of my PRN staff, retraining, or the lack of, strains inter-disciplinary relationships. It represents both opportunities and risks. Here a tightly knit family like working relationship can be a double edged sword, when one major player leaves, the next want to go as well. If you lose key players, the pain starts to outweigh loyalty and opportunities. This is one of the major reason why you want to see the company financials, which decided whether you are dishing it or taking it.

I suppose that's true. There just are a lot less pharmacists for me to interact with here. My DOP is basically my only back-up and mentor right now.

 

[xiphoid2010]

I suppose that's true. There just are a lot less pharmacists for me to interact with here. My DOP is basically my only back-up and mentor right now.

Are you a part of a system? If so you can call up the pharmacist at another one for a lot of things. Of course your DOP's job is to help handle situations that you can't, so don't feel too bad to call, but learn it.