Career Planning Community Surgery CAGS 2007

1. Career PlanningCommunity SurgeryCAGS 2007 Chris Vinden University of Western Ontario Division of General Surgery

2. Objectives • Provide an overview of community practice and contrast it with academic practice. • To help residents with the difficult decision of what kind of surgeon they want to be.

3. Caveat • The views presented today are biased to my perspectives, tastes, personality, philosophy and past experiences. • Take them with a grain of salt

4. Caveat 2 • People Change • You will not be the same person in 10 years • Your priorities, goals and ambitions may completely change • Marriage • Kids • Family tragedies / trials • What seems challenging and enjoyable now, may become just a repetitive job

5. Academic vs Community • Usually an irreversible decision. • Very few surgeons start out in community practice and end up in academic centres. • And Vice Versa

6. Life Goals vs Career Goals • Happy Family…. • Financial Security $$$$$ • Enjoy Work • Enjoy Play • Early Retirement • Altruism • Academic • National or International reputation: fame • Respected Clinician

7. You cannot be a Great Surgeon and a Great Dad • Being Great at something requires Time and Effort • High achievement in one area of your life requires compromise in others.

10. Community Practice Varies • Large Community Hospital • Medium Sized Community Hospital • Small Community Hospital

11. What do you need to practice Modern General Surgery? • CT scanner • Invasive radiologist • Internal Medicine support • Good Anesthesia • Surgical specialty support • Urology, Gynecology, Ortho, Plastics

12. Small Community Hospitals • 1-2 surgeons, • NO CT scanner, No invasive radiologist • Minimal surgical specialty support • May have to do C sections • May have to do Orthopedics • Often requires additional training • Remote / rural locations • Have significant difficulty recruiting surgeons • Increasing tendency for Itinerant Surgeons from adjacent communities to provide services

13. Medium Sized Community Hospitals • 4-6 general surgeons • Population of ~ 100,000 • Open ICU’s • Often don’t have gastroenterology • Significant portion of income will be from endoscopy • Less specialty support, not 24/7

14. Large Community Hospital • Cities with population of > 250,000 • 7-12 general Surgeons • Some sub specialization • Some have done fellowships • Closed ICU’s • Competition in endoscopy from gastroenterologists • Full complement of specialists • Very few “within specialty” tertiary care referrals

15. What population is required to support one General Surgeon? • Beware Aggregate Statistics • Ontario had 691 General Surgeons in 2005 ( 1 per 17,000 ) • BUT many surgeons never retire and never surrender billing number

16. Reality • “Full time” filter • Does at least 5 appendectomies per year • At least 160 billing days per year • Age < 65 • Gross billings > $150,000 • Reduces number of General Surgeons in Ontario from 691 to 351 • Per capita : 34,000

17. Income Disparity • Ontario Fulltime Community Surgeons • Median income is $110,000 Greater than Academic • Median income is 26% higher than Academic • Disposable income is 100% higher • After business expenses, income taxes and retirement savings

18. Academic Funding • Historically Funding Medical Academic activity has been at Charitable levels • Ontario prior to 2004… • Funding per clinician was < $10,000 • Physicians Academic Salaries were “ self funded” by internal taxation schemes • Hospitals supplemented • Foundations and endowments supplemented • Since 2004 • Partial AFP… funding increase to $19,000 per clinician • Proposed 2008… • Proposed AFP funding increase to achieve equality with non academic physicians

19. Overhead costs • ~ $100,000 per surgeon • Community Surgeons pay more rent • Community Surgeons have substantially cheaper office labour costs • Do not pay union rates. • No Cost benefit to Academic practice

20. Impact of Residents • Not all residents are equal • Depends on the quality and skill set of the resident • Some residents make life a lot more difficult. • Some make life a lot easier

21. Impact of Residents • Positive • Challenge • Enjoy Teaching • Look after SCUT • Negative • Slow you down, Junior > Senior > Fellow • Approx 25% slower than large community hospital • Have to watch them operate

22. Community Hospitals • Have a sense of Community • Referring Family Doctors participate in care • Much more efficient… time and cost • Less bureaucracy • Cost per weighted case is a lot lower • Usually better equipped than teaching hospitals • Computer systems • PACS • OR equipment and scopes • General Surgeons have less competition from other specialties for resources

23. Downsides: Tertiary Care Snobs • ~ 3% of Patients • Like to get Diagnosed in community hospitals but get Treatment in tertiary centres • Usually return to community hospital for management of complications

24. Downsides: Variable Physician Quality • Not all doctors are great • Higher variability in Quality of Physicians in Community Hospitals.

25. Downsides: SCUT • Ward work • But Community Nurses take far more responsibility • Paperwork • Discharge Planning

26. Downsides: Call • Usually more frequent • But rarely operate after midnight • Emergency cases can be squeezed into the list. • ER docs are reasonable, look after the bowel obstruction, diverticulitis till AM

27. ACADEMIC OBLIGATIONS • Teaching Dossier • Grant Applications • Publication Pressure • Committee Meetings • Evaluations • Course Preparation • Rounds, Rounds, Rounds.

28. INDEPENDENCE • Very few obligations apart from clinical • Holidays without your laptop • Hobbies • Family • Financial Independence • Earlier Retirement • Less Hassle

29. Community Surgery • Satisfying • Financially rewarding • Challenging • Independent • Highly Recommended