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I am a medical student who is trying to decide on a field. I am not chasing money but rather autonomy; thus I would prefer to work for myself rather than a hospital. So my question is, which fields of surgery are more amenable to private practice, and which fields tend to require the resources of a hospital or dont work as well without a hospital?

The way things are going; future use of the words “autonomous” and “physician” in the same sentence will be rare, if not unheard of.

Here are some figures from a July 2015 American Medical Association report.

• Younger physicians were more likely than older physicians to be employed. About 59% of physicians under the age of 40 were employed, versus 46.0% of physicians aged 40-54 and 33.3% of physicians 55 and above.
• Nearly one-third of physicians are in practices with more than 10 physicians, including 13.5 percent in practices with 50 or more physicians.
• Multi-specialty practice physicians were more likely than single-specialty practice physicians to report that their practices were hospital owned—44.6% compared to 23.0%.

Who knows what the percentage of employed physicians will be by 2020, but it surely will be higher.

I can think of only two surgical specialties that can be mostly independent of hospitals, otolaryngology and plastic surgery. I am not including ophthalmology because it isn’t really a classic surgical specialty.

The only way otolaryngologists and plastic surgeons can be autonomous is by concentrating solely on cosmetic surgery or working only in an ambulatory surgery center.

Otherwise, you would need a complete operating room—staffed by a nurse, an operating room technician and for some cases, an anesthesiologist—in your office.

Very few surgeons are able to limit their practices to cosmetic surgery directly out of residency or fellowship. Unless you join an established cosmetic surgeon in practice, which would of course limit your autonomy, you will need to be on call for trauma and be available for consults involving problems like pressure sores in hospitals to pay the bills.

My observation as a surgical chairman in community hospitals was that it takes years before the average plastic surgeon is able to develop a reputation and focus solely on cosmetic surgery.

You should also be aware that both of those specialties are highly competitive. In this years match, only 1 of 299 ENT positions went unfilled, and 364 US seniors had ranked ENT as their preferred choice. For plastics, there are two ways to obtain a position. The NRMP handles an integrated match which filled 144 of 148 positions. There were 162 US seniors who listed Integrated plastics as their preferred choice. The other match is independent of the NRMP and takes residents who have done varying years of general surgery. For that 2015 match, which placed applicants in positions starting in July 2016, 85 applicants submitted rank lists, and 68 of 70 positions were filled. That left 17 candidates unmatched.

Additional reading: A post on KevinMD entitled “So doctor, who’s your boss?”