OBGYN Career Paths - Part 2: Generalist, Hospitalist, Locums and Per Diem Roles Explained
If you're an OB/GYN resident or a medical student planning to apply for OB/GYN residency, you've probably already started thinking about what life looks like on the other side of training. Last week, I covered the four main employment structures for OB/GYN attendings in the United States — private practice, academic practice, hospital-owned practice, and county or city-owned practice. If you haven't listened to that episode yet, go back and start there, because today we're building on that foundation.
Today, I want to talk about the different ways you can actually practice within those structures. Specifically: the generalist role, the hospitalist role, and contractor positions like locums and per diem. Each one comes with its own set of trade-offs, and understanding them now — before you're knee-deep in job negotiations — is going to save you a lot of stress later.
The Generalist Role: Traditional Bread-and-Butter OB/GYN
A generalist is what most people picture when they think "OB/GYN attending." You're doing it all — obstetrics and gynecology, inpatient and outpatient, clinic, surgery, deliveries, and call. This is currently the most common way to practice as an OB/GYN.
The pros:
You get to actually do what you trained to do. Both OB and GYN. Procedural variety. You probably won't be bored.
There's real potential for long-term patient relationships. You might start seeing someone as an adolescent, deliver her babies, and manage her menopause transition. That continuity is meaningful.
Of all the practice models, generalist roles — especially in private practice or hospital-owned settings — tend to offer the highest long-term income potential.
You'll generally have more control over management decisions in your department compared to hospitalist or contractor roles.
The cons:
Burnout is real. Full-time generalists taking frequent 24-hour calls — stacked on top of a week full of clinic and scheduled surgeries — can hit a wall fast.
Your schedule can be unpredictable week to week. You might be in clinic Monday through Wednesday, operating Thursday, and on call Friday to Saturday one week — and then an entirely different configuration the next.
You'll end up doing a lot of primary care. Many gynecology patients don't have a separate PCP, which means you're picking up things like vaccination counseling, screening reminders, and chronic disease management. Some people love that. A lot of people who went into a surgical specialty specifically because they didn't want to do primary care... don't.
And the biggest one, in my opinion: the inbox. If you see 20 to 25 patients on each of your three clinic days and order even one test per patient, that's 60 to 75 results per week that need to be reviewed and acted on. Usually you're ordering more than one. Abnormal results mean patient contact, medication management, and follow-up scheduling — and most of that happens on your own time unless you negotiate paid admin time into your contract. Ask about this before you sign anything.
The Hospitalist Role: Inpatient Only, No Clinic, No Inbox
An OB/GYN hospitalist works exclusively in the hospital. No scheduled outpatient surgeries, no clinic. Some hospitalists work as a laborist — focused entirely on the maternity unit, managing labor, triage, postpartum, and antepartum patients, with procedures limited to vaginal deliveries and cesareans. Others cover both labor and delivery and inpatient GYN, including consults in the ER and urgent or emergent gynecologic surgeries. Most hospitalists are employed by a third-party company rather than the hospital or group practice directly.
The pros:
Virtually zero inbox responsibility. You're ordering tests on admitted patients, and if the results don't come back before your shift ends, they get handed off to whoever is coming on next. When your shift ends, it ends.
Many hospitalist opportunities offer base pay comparable to a generalist salary — but you're only working 6 to 8 twenty-four-hour call shifts per month. If shift work appeals to you, that math can work out really well.
Your time off is predictable. You'll often get your call schedule three to six months out, and the days you're not on call are truly yours.
The cons:
Fixed call schedules. The group may assign your shifts without much input from you, especially if they're hiring to fill specific coverage gaps. Some hospitalist groups also don't allow shift trades.
Pay varies widely — and not always in your favor. A lot of hospitalist roles are poorly compensated relative to the patient volume and acuity. You get paid a flat rate regardless of how brutal your shift is, and there are no productivity bonuses. Know what you're signing up for. If the institution does 4,000 deliveries a year with a complex patient population, negotiate accordingly.
If you go straight into a hospitalist role after residency but think you might want to work as a generalist someday, be aware that your gynecologic surgical skills — and your outpatient clinical knowledge — will get rusty over time.
No continuity of care. You're meeting your patients for the first time, often in high-stakes moments, and you have a very short window to build trust. That's something to sit with before committing to this model.
The Contractor Role: Locums and Per Diem
Think of locums and per diem physicians as the freelancers of medicine. These are temporary positions that open up when there are staffing gaps — someone goes on maternity leave, a group is in the middle of a hiring search and needs coverage, you name it. The main distinction between the two: locums are typically short-term contracts on a 1099 that may involve travel, while per diem roles involve picking up shifts as needed at one local hospital system, usually on a W2.
The pros:
Flexibility when your situation is uncertain. If your partner is job searching and a relocation is possible, you can commit to a short-term contract — two weeks, six months, a year — without locking yourself into something you'll need to get out of.
Higher pay per shift than salaried staff, because you're not paying into benefits or retirement. Your overall annual income will likely be lower, but per shift you're doing well.
You can choose your contract based on your professional interests — clinic only, full-scope generalist, whatever aligns with where you are in your career and what’s being offered.
With locums, the agency typically covers malpractice, travel, housing, and credentialing. Per diem employers often cover malpractice and credentialing as well.
It's also a great way to supplement income without a full schedule change. I have a friend who works full-time as a generalist but wanted to save for a house faster, so she picks up one or two per diem call shifts a month at a nearby hospital. It works.
The cons:
No benefits. As a temporary employee, health insurance is typically not included, and that's a real cost to factor in.
Travel isn't always feasible. If you have a family or other commitments anchoring you to a specific area, locums contracts can get complicated — logistically and emotionally.
Working with different teams, different hospital systems, and different EHRs on a rotating basis can be genuinely tiring.
Your income lasts only as long as your contract. If financial stability and a predictable paycheck matter to you, this probably isn't a long-term solution.
The Bottom Line
To recap: within the four main employment structures — private practice, academic practice, hospital-owned, and county or city-owned — you can work as a generalist, a hospitalist, or as a contractor in a locums or per diem role. The pros and cons of each model really come down to what your priorities are. And every institution, regardless of structure, will differ in terms of what they expect from you and how they'll compensate you.
I've only scratched the surface here, but I hope this gives you a foundation for starting to think about what your life after residency could actually look like. What matters most to you — schedule predictability, income ceiling, continuity of care, surgical volume, inbox management? There's no right answer. But the earlier you start asking yourself these questions, the better equipped you'll be when it's time to negotiate.
If you have questions, feel free to reach out at info@drkcmiller.com. See you next week!
Listen to the full episode on the OBGYN Resident Survival Guide podcast.
