Unless you will be the sole practitioner for the facility, an admittedly rare circumstance, you will need to have an understanding of the case distribution model at your prospective facility. Make sure that the case assignment system has reasonable checks and balances to avoid abuse. This warning is particularly important when a large group has a significant presence.

The best case is having an independent party responsible for assignments. Also, if patient or surgeon requests are frequently made and honored, determine if there is any method to offset your lost income when one of “your” cases is taken from you. Without protection of some sort, lobbying of surgeons, direct advertising to patients, and other tactics have been known to result in an attempt to disproportionately direct patients to one of the competing anesthesiologists or anesthesia groups. This is a recipe for conflict, outlandish behavior, and dysfunctional anesthesia department function. I can hear the sound of consultants pounding on the door!

As with case distribution, assuring fair distribution of call responsibilities is exceptionally important in a solo practice. Sometimes additional calls can be financially beneficial, particularly when starting out in practice and trying to create good relationships with surgeons. In other situations, additional calls may be a problem. In either case, make sure that the opportunities for gaming the system are at a minimum.

In addition to handling after-hours cases, those on call often must manage acute pain management issues such as epidurals and continuous nerve blocks, postanesthesia complications including postdural puncture headaches and persistent nausea or pain, and perhaps even calls from chronic pain patients for prescription refills, implantable pump issues, or other problems. Although many of these issues are common to all practices, as a solo practitioner you may find yourself saving patients from the misadventures of
others or being forced to manage a treatment regimen far different from what you might have prescribed. At least in a group practice, you can weed out problem physicians and reduce your potential liability. You can also establish common protocols for managing specific issues.

In a setting in which the anesthesiologists are in multiple practices and are competing with each other for business, relationships can easily become strained. Assess the history of these interactions carefully. Big warning signs include history of litigation between providers, hospitals threatening to enter into an exclusive contractual relationship, or a parade of consultants having visited the site in the recent past.

Meet with your competitors before applying for privileges to practice. There may be a significant shortage of providers and you will be welcomed with open arms; however, much of the time you will be seen as someone trying to steal food out of the mouths of the other physicians’ children. If your competitors are hostile and you still want to practice, at least you will know the challenges you will be facing.