Types of Ob/Gyn Practices

Private practice

This is the most traditional form of practice, although fewer and fewer Ob/Gyns are employed via this model. (See future article, The Crisis in Private Practice). A private practice is a for-profit business. Typically, the private practice is owned by a group of more senior physicians (“partners”) who hire more junior doctors as well as nurses and medical assistants, a receptionist, an office manager, and perhaps nurse practitioners or physicians’ assistants. Over time, if the partners and junior doctor like each other, the junior doctor will become a partner, typically by buying into the practice. A typical practice will have a defined time by which the partners offer partnership to the junior doctor, often 2 years.

Buying into the practice is beyond the scope of this article, but please note this is fraught with the potential for abuse and the loss of a great deal of money. Please hire a lawyer and an accountant before you buy into a practice. (How To Evaluate a Medical Practice Buy-In)

A private practice may generate additional income for the partners with “ancillary services” such as NSTs, ultrasounds, or mammograms. In this case, the practice would own the equipment needed and directly employ the radiology tech or nurse who performs the service.

In return for “privileges” at a hospital where private doctors can perform surgeries and admit patients, the doctors typically agree to cover “unassigned” patients who present to the hospital with an emergency. “Unassigned” means that the patient is not established with a doctor who holds privileges at the hospital. Usually, every physician who has privileges at a hospital takes an equal share of unassigned call. Historically, unassigned call has been unpaid; however, with the Ob/Gyn shortage, more and more Ob/Gyns are being paid by hospitals for taking unassigned call, above and beyond billing the patients’ insurance for services rendered. $50-100 per hour seems to be a rate I have typically heard for this.

The private practice is also responsible for all of its own patients who present emergently to the hospital. In some private practices, each doctor is responsible for her own patients 24/7. In other practices, the doctors take turns being on call for all the practice’s patients. The latter certainly seems more humane to me and compatible with being a normal human. Sometimes, smaller practices will even cross-cover for each other’s patients so that each practice gets every other weekend off or some such arrangement.

More and more hospitals are hiring Ob/Gyn hospitalists to help private practices out by providing various amounts of backup and call coverage. See “Hospitalist” below.

Academic practice

I don’t need to describe this. Every Ob/Gyn resident knows what this is because you trained in an academic institution of some sort at some point. I have seen more academic positions that don’t really involve having to do research recently – back when I was training, you really had to have active research interests to be considered for an academic job. Now that university / academic health systems have gobbled up community practices, more academic-affiliated jobs seem to be more community-focused.

Employed position (non-profit or for-profit)

In this employment model, a large health care institution, often with affiliated hospitals it owns, employs Ob/Gyn doctors directly. The main benefit of this model is financial security, on average better benefits, such as maternity leave, and not having to deal with the ever-more-complex headaches of running a business. The main downside is that doctors who are employed by others do not have the freedom to run their practices as they like.

For example, in a private practice, you can just decide to close your clinic at 3 PM every day during the summer to take your kids swimming. You can decide if losing that revenue is worth it. In an employed practice, it is unlikely that the clinic administrators you answer to would allow you to do that. More troubling is that, without health care backgrounds over multiple levels of leaderships, administrators can often make unreasonable and unsafe changes to physicians’ work environment without understanding the ramifications, and a great deal of physicians’ time is spent saving them from themselves. However, not having to worry whether practice revenue will cover the nurses’ paychecks, office rent, and electricity bill each month is wonderful.

Most large health care employers are nonprofit. Some are also for-profit. This means that they are owned by shareholders or other investors who expect the clinic administrators to maximize the profit extracted from the patients. Unsurprisingly, this is typically not achieved by being beneficient to patients nor physicians. In my experience, working as a physician cog in the machine for a nonprofit health administrators is frustrating. However, to quote M. C. Gainey ,who played one of “The Others” on the late, great TV show Lost, they are “scientists and humanitarians compared to what…are coming next.” (Venture capitalists, of course)

Employed by the government

Specific (non-academic) government employers include the federally qualified health clinics (FQHCs), veteran’s administration (VA), and the Indian Health Service (IHS), all of which employ Ob/Gyns. FQHCs receive federal funding so that they can survive financially while taking care of complex Medicaid patients, which practices would otherwise lose a great deal of money on, since Medicaid reimbursements are so low. Patients of FQHCs tend to be low-income and many non English speaking. One advantage of working for a government employer is that malpractice is covered by the government. I have heard anecdotally that having to sue the federal government deters frivolous lawsuits.

Hospitalist

An Ob/Gyn hospitalist is one who specializes in providing inpatient care only. The specific job duties vary from hospital to hospital. Some manage gynecologic emergencies; some only obstetrics. Some cover only unassigned patients; some take care of patients from private or employed practices. Shifts are often 12 or 24 hours. The purpose of the OB/Gyn hospitalist is to deliver safe care to patients (without being distracted by clinic duties) and to make life and practice more sustainable for the full-scope Ob/Gyns. Some private practices employ their own hospitalists, and some are employed by the hospital itself.

Benefits are not having to manage an inbox, truly being off while not at work, and having a predictable schedule. The main downside is losing the ability to perform non-emergent gynecologic surgeries. Usually, when you request privileges from a hospital, they will want to see that you have been doing the surgeries you want privileges for, usually over the past year, and DEFINITELY over the past two years. If you go for two years without performing a significant number of cases, you will need to be proctored to re-enter surgical practice. There are two ways to receive proctoring. One way is to pay a tremendous amount of money to a formal clinical re-entry program. (I am unable to find at this time an actual gynecology re-entry program that is up and running.) Another way is to make a deal with a practice that needs help that if they will proctor you at the beginning, you promise to work for them for a  certain time frame or some such trade.

The Society of Ob/Gyn Hospitalists has many resources.

Locum tenens

Locum tenens, or “locums,” is essentially a physician temp job. Given that full scope jobs are often overwhelming and exhausting, and hospitalist jobs sometimes don’t pay very well, more and more Ob/Gyns are making a career out of piecing together locums jobs. As many hospitals are in desperate need of Ob/Gyns, the pay can be quite good. The pay is much better if you can contract directly with a hospital instead of going through an intermediary like a locums agency or recruiter.

I would start with FlexMedStaff to learn more.

The demand for locums Ob/Gyns is most often for obstetrics. Sometimes they will want you to cover clinic and hospital, sometimes just hospital. There are rarer jobs that include elective gynecologic surgery.

Full scope

A traditional Ob/Gyn job is known as “full scope.” There are fewer and fewer full-scope Ob/Gyns, but it is still doable with the right support and often in more underserved areas. Traditionally, a full-scope Ob/Gyn will see patients in the office, perform surgeries on her gynecologic patients, and deliver her obstetric patients, as well as taking a share of call. This is an extremely complex and broad range of responsibilities to juggle, but a number of interventions can make the job bearable: a hospitalist, a skilled and dedicated first assist, mid-levels to see routine patients in the office, and a nursing phone service with numerous protocols to field patient calls at night.  

Tracks

The well-known Kaiser nonprofit health system pioneered “tracking” of community Ob/Gyns, with tracks for office only, hospital only, OB/office, and gynecologic surgery. These jobs are becoming more common and require maintaining expertise in a narrower skill set

Backing up Family Medicine / Midwives

In some jobs, Ob/Gyns only cover and deliver their own patients. In some jobs, you will be asked to provide backup for nurse-midwives or family medicine doctors who are not part of your practice. The advantage of this is that, in an Ob/Gyn shortage situation, these providers are necessary to provide obstetric care in many parts of the country where there are not enough Ob/Gyns. There is really not an upside for Ob/Gyns to this arrangement, though.

First of all, since these other providers are only qualified to take care of lower risk patients, they will cherry-pick the easiest patients to take care of, leaving the Ob/Gyns with a greater share of difficult, high-risk patients who require more time on behalf of the Ob/Gyn and also carry more medicolegal risk; nonetheless, the reimbursement for both groups of patients is the same at this time, making a low-risk OB practice much more lucrative. The same is true for easy gynecologic care – uncomplicated annuals and vaginitis visits certainly reimburse much better per time spent than complex problem gynecology and gynecologic surgery, so the more mid-levels and family medicine providers taking care of these patients, the less profitable the Ob/Gyn practice becomes.

Secondly, it is always more stressful to be called to an emergent situation out of the blue, and these other providers, since they are ultimately not surgically responsible for the safe delivery of babies, may push the risk they take on for their patients beyond what is truly safe.

In short, it is not wrong to ask Ob/Gyns to provide backup for nurse-midwives and family medicine doctors. However, significant compensation is in order for doing so.

Karla Solheim, MD, FACOG