Rounds to Revenue: Comparing residency in universities and private practice (#457)

In both settings, the veterinary resident is in the middle of a quiet crisis.

But the shape of that crisis, and the forces driving it, look different in a university teaching hospital than in a private specialist practice.

Think of them as two parallel worlds with the same young clinician at the center, pulled by different kinds of gravity.

Who is the Resident?

• In a university teaching hospital.

• The resident is, officially, a learner and a teacher.

• Patients and clients matter deeply, of course, but the stated mission is three-fold: teaching, service, and research.

• The resident is explicitly part of the educational pipeline: undergraduates, vet students, interns, residents, then board-certified specialists.

• Their role includes explaining, demonstrating, supervising, and assessing students, often while also trying to understand the case themselves.

• There’s a constant tug-of-war:

• Am I here to move cases through the service or to slow down enough that students (and I) really learn?

• In a private specialist practice

• The resident (or resident-equivalent trainee) is first and foremost a producer of clinical work.

• The primary mission is service: high-quality, efficient, client-satisfying care.

• Teaching still happens, but it’s usually informal and focused on interns, junior associates, and nurses. Vet students may be present only occasionally, or not at all.

• The resident’s value is measured more directly in terms of caseload handled, revenue generated, and client/referring vet satisfaction.

• Here the tug-of-war feels different:

• Am I here to learn or to earn my keep?

The Shape of the Day

• University hospital

• A typical day for a resident might include:

• Early morning patient rounds with students and interns

• Teaching on the floor: “What’s your problem list? What are your differentials?”

• Family meetings with clients, observed by students

• Interruptions for consults, calls from referring vets, and imaging reviews

• Midday or end-of-day rounds, case presentations, journal clubs, seminars

• Late-night record-writing and emails, sometimes research work squeezed in

• The pace can be chaotic, but there’s a through-line of explicit education: rounds, case discussions, seminars, boards prep.

• The resident is constantly toggling between clinician and instructor.

• Private specialist practice

• A day here tends to be more tightly scheduled and more overtly production-oriented:

• Appointments or procedures booked in defined slots

• Fewer formal rounds, more hallway conversations

• Little or no requirement to deconstruct cases for students step-by-step

• More direct responsibility for efficiency: keeping to time, hitting daily targets, avoiding bottlenecks

• Less protected time for teaching conferences; learning may come from quick debriefs, online modules, or board prep done at home.

• The pace can be just as intense, but it’s more linear: consult, diagnose, treat, move on.

• There may be fewer people in the room, but more direct pressure to keep the room full.

Teaching and Mentorship: Explicit vs Implicit

• University hospital

• Teaching is overt:

• Residents are evaluated on their teaching skills.

• They are expected to explain their reasoning out loud, invite student input, and provide feedback.

• Structured activities (journal club, morbidity & mortality rounds, board review sessions) are built into the week (even if they’re sometimes squeezed).

• This has two sides:

• Strength: Explaining concepts to others deepens the resident’s own understanding. Students ask naive but important questions that force clarity.

• Cost: Time and cognitive energy are consumed by teaching, sometimes when the resident themselves still feels uncertain or behind. Poorly supported teaching can feel like yet another demand rather than a developmental opportunity.

• Private specialist practice

• Teaching is more incidental:

• The resident may work directly under a small number of specialists, often with a see one, do one, do many rhythm.

• Learning happens largely by immersion and imitation: watching how the specialist talks to clients, prioritizes, and treats.

• There is usually less pressure to slow down and narrate reasoning to learners who know little; discussions can be more advanced and concise.

• Again, two sides:

• Strength: The resident may get more direct apprenticeship-style exposure to one or two mentors, with less noise from students.

• Cost: With minimal obligation to teach, the resident loses that powerful forcing function to organize and verbalize knowledge. And if the mentor is absent, uninterested, or too busy, there may be no fallback teaching structure.

Metrics and Money

• University hospital

• Metrics are often academic and institutional:

• Case logs, procedures, board pass rates

• Publication expectations, abstracts, research involvement

• Teaching evaluations from students

• Service productivity, but usually diluted by the broader academic mission

• Money is there in the background (RVUs, budgets, funding), but for the resident it can feel indirect. The pressure is real, but mediated through:

• We need to see more cases to keep the service afloat.

• We need more publications for program strength/rankings.

• Private specialist practice

• Metrics are more clearly financial and operational:

• Revenue per clinician, per day, per service

• Number of consults, surgeries, rechecks

• Client satisfaction scores, online reviews

• Referring vet loyalty and turnaround time

• They may still have research or CE, but the resident feels money more directly:

• Pricing conversations

• Pressure to avoid empty slots

• Awareness of what each procedure and hour is worth

• This can sharpen clinical efficiency and communication skills, but it can also blur the boundary between best medicine and most profitable medicine, especially for a trainee still forming their professional ethics.

Emotional Landscape and Isolation

• In the university hospital

• The resident is rarely physically alone, but can be emotionally isolated:

• Surrounded by students, staff, faculty, administrators

• Juggling multiple audiences in every case: the client, the student, the faculty person, the intern

• Self-criticism amplified by comparison: Everyone else is presenting at conferences / publishing / scoring higher on in-training exams

• However, there are potential buffers:

• Peers in the same program

• Formal wellness resources (however imperfect)

• A culture, at least on paper, that acknowledges training stress and work–life balance

• Whether those supports are actually used or safe to access is another question

• In private specialist practice

• The resident may feel professionally grown up sooner:

• Less overt hierarchy of student–intern–resident–faculty

• More informal atmosphere, smaller team, more first-name relationships

• Clients and referring vets may see them as the specialist faster, even while they’re still training.

• This can be exciting - and isolating:

• Fewer co-residents for mutual support

• Less institutional structure for mental health and wellness

• A subtle expectation to cope like everyone else in a busy, commercial environment

• The quiet crisis here is that distress can be hidden under a veneer of professionalism and productivity for a long time.

Professional Formation: What each environment tends to grow

These are generalizations, but they capture common patterns.

• University teaching hospital tends to grow:

• Comfort with complexity

• Strange cases, multi-disciplinary patients, zebras.

• Didactic and bedside teaching skills

• Explaining, questioning, giving feedback.

• Academic identity

• Comfort with reading, writing, critiquing research.

• System navigation

• Dealing with layers of policy, committees, and institutional politics.

• But may under-develop:

• Real-world efficiency in a high-throughput referral setting.

• Comfort discussing money and value with clients.

• Longitudinal relationships with owners and referring vets.

• Private specialist practice tends to grow:

• Speed, efficiency, and prioritization

• Getting things done in real time, every day.

• Client communication in a market context

• Estimates, value, expectations, conflict management.

• Business awareness

• Staffing, scheduling, marketing, financial realities of specialty care.

• Longitudinal care

• Follow-up, continuity, reputation with referring vets.

• But may under-develop:

• Teaching skills and comfort with novice learners.

• Protected scholarly activity and research literacy.

• Exposure to rare, complex, or low-income cases that don’t make it into private referral hospitals.

What Each Can Learn from the Other

If we name the quiet crisis for residents in both settings, some clear possibilities emerge.

• University teaching hospitals could borrow from private practice by:

• Honoring efficiency and time-management as legitimate learning goals

• Normalizing open discussions about money, value, and access to care

• Providing more longitudinal experiences, not just one-off tertiary referrals

• Private specialist practices could borrow from universities by:

• Building simple, regular teaching structures (mini-rounds, weekly case reviews) even without students

• Protecting a small amount of non-clinical time for reading, board prep, or research projects

• Explicitly defining mentorship responsibilities instead of relying on osmosis

• Most importantly, both settings could:

• Make the resident’s learner identity explicit and protected

• Encourage vulnerability and questions rather than punishing them

• Treat emotional well being as a precondition for good medicine, not an optional add-on

Rick’s Commentary

In the end, the veterinary resident stands at the same crossroads in both worlds.

In the university hospital, the risk is being drowned in complexity and competing missions, losing sight of themselves as a person.

In private specialist practice, the risk is being absorbed into productivity and performance, losing sight of themselves as a learner.

The task for mentors, institutions, and the residents themselves, is to hold onto a simple truth:

A residency, wherever it happens,

should not just produce someone who can do the work.

It should shape someone who knows why they do it,

how they want to do it,

and who they refuse to become along the way.

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