Anaesthesia Consultant Practice

After concentrating on the formal requirements for a FANZCA, many trainees haven’t given a great deal of thought to planning the rest of their careers. Fortunately anaesthetic consultant practice provides the opportunity to work in a range of different employment structures with the ability to find a good fit between personality and practice environment.

Salaried work

This is the type of work most trainees will be familiar with because most of the consultants they have worked with during training in big hospitals will have been either full-time staff specialists or regular part-time Visiting Medical Officers (VMOs) receiving hourly or sessional rates of pay. In most ways this is similar to being employed as a registrar: the anaesthetist has an employment contract of a specific duration with the hospital, generally on the terms of an Enterprise Bargaining Agreement (EBA) between the AMA and the health service. The rates of pay are listed in the EBA, which is easily accessible through membership of the AMA.

Salaried employees receive many other benefits, also generally specified in the EBA: annual leave, sick/family leave, conference leave, long service leave, sabbatical support, education funding and access to salary packaging. These benefits are typically worth about an extra 30% on top of the base rate of pay for the purposes of comparing pay between employment options.

The strongest aspect of salaried work is its stability and often the support available. Salaried employees can expect to receive their regular pay every fortnight whether they were busy with clinical work or on vacation. Tax and superannuation are dealt with automatically. Well-run departments will provide non-clinical (out of theatre) time for further educational opportunities, research options, teaching or committee work, typically with about 25% of work time being non-clinical.

The rostering of a large department entails a significant amount of rigidity. Salaried employees have limited choice over which day might be a regular day off and when to take leave because everyone’s requests have to be considered and many departments will give priority to more senior staff. On the other hand, taking sick leave is simple as a salaried employee, and the obligation to cover the work falls on the employer.

Large hospitals typically have quite comprehensive values statements, policies and procedures which employees may be required to comply with, and large departments may protocolise aspects of clinical care. As a salaried employee this may constrain not only aspects of your clinical work but even some behaviour outside work such as advocacy or social media activity.

Flexibility in pursuing academic opportunities, research and teaching can be a great strength of full-time staff specialist work at a senior level. Junior consultants will typically rank fairly low in departmental priorities, so in the beginning there might be a lot of endoscopy lists or Saturdays on call or not going to major conferences but over a few years it may be possible to start doing the regular thoracic list you want and to start working on your research ideas.

The availability of new salaried work varies dramatically over time and place. Short-term and part-time VMO positions are typically easy to find, as departments need to cover sabbaticals, maternity or long-service leave. Long-term full-time staff positions are often very competitive, with candidates expected to bring something new or special to the department, such as experience from a fellowship or a research interest in an area the department is keen to develop.

So-called “Zero hour” contracts are a variety of VMO salaried employment where no regular hours are offered in the contract, only irregular offers of work. This is similar to being a casual employee. These arrangements don’t offer many of the benefits of being a regular employee but are convenient for administrators needing to cover staffing requirements with minimal cost. Without regular sessions it is difficult to develop good relationships with other members of the operating room team or to engage in any kind of professional development in a department.

Fee for Service

Most medical care in Australia is done under a “fee-for-service” model: you see your GP, they charge you for the visit and you get some money back from Medicare. In anaesthesia, fees under this model are calculated using the “Relative Value Guide” (RVG) which appears in the Medical Benefits Scheme (MBS) schedule. The MBS schedule lists item numbers which correspond to the description of anaesthesia services and almost all billing is done using these item numbers. The ASA has a parallel set of item numbers which differs slightly from the MBS schedule and which is used instead under some billing agreements. The MBS schedule is available online and the ASA schedule through ASA membership.

A bill for anaesthesia services typically comprises a pre-op consultation item, a “flagfall” item for the particular operation, a time item for the duration of care and optional items reflecting age, ASA score and certain additional procedures such as CVC insertion. Each item has a certain number of units associated with it (this is the “relative value” of the service) and the number of units is multiplied by a unit price to determine the total fee.

Fee for service payments are used for much after-hours work by salaried anaesthetists, and in some cases for all work by VMO anaesthetists in smaller or regional hospitals. Instead of completing a time-sheet, the employee lists the items and unit values of work done and is paid accordingly. For privately insured cases done in-hours by staff specialists, their department typically bills the patient’s insurer using this model and the income generated typically goes to the department for funding activities such as buying teaching equipment which might not otherwise be supported by the hospital.

The most common form of fee for service work is anaesthesia in a private practice setting. This can be a regular list agreed between surgeon or anaesthetist, or irregular work such as when an anaesthetist might agree to be on call for a hospital and to do whatever urgent cases arise with whichever surgeon is doing them, or a surgeon contacts a group looking for someone to provide anaesthesia for a semi-urgent case. Anaesthetists need to be accredited to work at particular hospitals or networks of hospitals, and most will seek accreditation at several.

At best, private work can consist of working regularly on well-paid lists with a team with a high degree of mutual respect and involves developing significant expertise in providing a service exactly tailored to that team and those patients. There is almost complete freedom to tailor the location, time-commitments and proceduralists worked-with in the long term, and there is a great deal of autonomy in clinical practice. In large hospitals, some of the supports typical of a large public hospital are also available, such as a pain service and education and M&M meetings.

On a short-term basis, private work has some constraints which aren’t present in salaried work. If a list runs over, or a patient has difficulties in the PACU, responsibility falls on the individual practitioner to be available. It’s very difficult to call in “sick” with short notice. Most anaesthetists join a group, which can make it easier to find a colleague to help out in a crisis or to hand over responsibility to when going on holiday. A group can generally handle finding cover for any time away, with sufficient advance notice.

Income in private practice is obviously tightly linked to the volume of work done. This makes it necessary to plan for cash-flow requirements such as tax payments and also for times of low income such as following vacations. It can seem unsettling for someone used to a fortnightly salary. When starting out, some people find the intermittent nature of fee for service income stressful and feel a pressure to accept all offers of work. Over time, the more difficult problem can be scheduling enough free time for general well-being and to do the unpaid activities which are still necessary, such as maintaining current knowledge and skills. It is important to be motivated as an individual to keep skills up to date; maintaining a part-time commitment at a teaching hospital can help with this.

The unit price used for billing is a major determinant of income. Medicare, private insurers and other payers such as Workcover stipulate the maximum rebate they will provide per unit. In some cases it might be a condition of engagement that the anaesthetist not charge more than the rebate, however in most settings the anaesthetist will set their own fee and ensure that the patient is informed in advance of any out-of-pocket “gap” they will incur. Most anaesthesia groups will be able to provide this “Informed Financial Consent” (IFC) service which can be complex because of the variety of unit rates and rules imposed by insurers.

Membership of an anaesthesia group also provides the opportunity or even the obligation to be involved in the running of the business to some extent. Similarly, large private hospitals provide the opportunity for committee work or even teaching or research work. There is not the same obligation to be involved in non-clinical activities as in the public system.

Finding private work can be a puzzle for new fellows. Joining an anaesthesia group can often provide work covering leave or new or extra lists with surgeons with whom they have a relationship. Some large private hospitals have open on-call rosters to cover urgent cases or obstetrics. Any one-off work with a surgeon is potentially an opportunity to provide a service which might encourage them to seek you out again. Regular work is often combined with a collegial professional relationship: surgeons entering consultant practice often work with anaesthetists they know from training or public hospital work.

Contract work

Some anaesthesia work is offered as a fixed price for a period of work. Most commonly this is in the form of locum (temporary) work offered through medical staffing agencies. An agency will gladly add your email address to their advertising list and then send frequent offers of short periods of work, typically a few days to a few weeks. The offer will usually include flights and accommodation and a fixed payment per day of $2000-$3500.

This kind of work is well-paid and completely flexible in that there is no on-going commitment. It is highly suitable for filling in a few weeks or months before taking up a longer term job with a fixed start date such as an overseas fellowship.

The quality of support is variable in locum work. Some hospitals and anaesthesia groups value locum anaesthetists highly and treat them well in the hope of possibly attracting long term or permanent workers. Other hospitals might be using a medical staffing agency because there are good reasons why they can’t attract or retain staff.

Depending on the specific payment arrangement used, it might be necessary to register for GST when doing contract work, and it is unlikely that there will be any of the benefits and protections available to salaried employees.

Fixed-payment contract work is also offered by some clinics performing cosmetic work or endoscopy. Often this is with the aim of being able to provide a fixed, low, inclusive price for their services. This kind of arrangement might involve working in a very cost-conscious facility. You should remain aware of your obligations to meet professional standards, regardless of the objectives of the facility you’re working in.

My Experience

The work which fits best with your circumstances will change over time. My personal experience has included work in all three of the payment models described. Before my overseas fellowship I did a locum for an anaesthesia group in country Victoria for a flat fee per day or night on-call. It was certainly a bit lonely working completely independently for the first time, but they were very supportive and hospitable and I ended up doing months of work though I had initially committed to a much shorter period.

After my fellowship I worked as a full time staff specialist in a major hospital for a few years. This provided the opportunity to do high acuity, subspecialised work, to teach and to participate in research. At the same time I did a small amount of private obstetric anaesthesia work which was fee for service and for which I did my own billing, becoming familiar with the details of insurers, rebates, and informed financial consent.

I decided that I did not want to commit to a career as a full time staff specialist. There were aspects of working within a large and fairly impersonal organisation which did not appeal to me. I took two part-time public VMO appointments each for one day per week and joined a private group. My private work picked up over a year or so to a half-time commitment, mostly working with proceduralists whom I trusted and liked. It was a gradual process of taking on new work as it was offered and sometimes handing on work to other group members if I felt I was not a good fit for the surgeon or list. All my booking, billing and other clerical work is done by the group staff. I don’t enjoy doing clerical work much, and medical secretarial staff are better at it than I am and cost significantly less per hour.

Comparing income from salaried public work and fee for service private work is complicated. Fee for service billing depends greatly on the nature and speed of the procedural work. My personal experience is that the average total billing for my private work per hour is a bit more than double the base rate of pay for my public work. Adding 30% to my public base rate to reflect entitlements and deducting 15% from my private billing to reflect group costs and indemnity and income insurance gives a better comparison: private work pays me about 60% more. This is roughly in line with the difference in productivity between the practice settings: public work in a teaching hospital is necessarily slower than working with an experienced team in private who have often been together for a decade or more.

For most people it is not a matter of choosing one specific type of work or even area of practice. Work will be a blend of what you’d like to do and what is available. Anaesthesia work in whichever setting you practise offers the key ingredients which make work fulfilling: a high degree of autonomy and responsibility, making a meaningful difference to people’s lives, and substantial material reward.