Editor's note: This article is part of a series on the various practice models that ophthalmologists can choose to work in. See "The Growth of a Multi-Location Practice" and "Starting a Practice, With a Little Help" for more.
After residency, I wanted to focus on my translational science research and complex anterior segment clinical work. For this reason, I decided on an academic medicine position at the University of Colorado and Denver Health, a level 1 trauma center. Five years later, I decided to move back home to Cape Coral, Fla. It was here that I found myself pivoting to a new type of career and was lucky to be given an opportunity at Tyson Eye, a private practice with multiple locations in southwest Florida. These experiences have given me insights into two very different practice settings. If you are wondering whether to move in one of these directions in your career, here are some of the key components to consider.
The academic setting
On the plus side
At an academic center, there is an overall sense of being part of something bigger than the individual physician. You are expected to participate in lectures and clinical discussions outside of clinic time, and you might be expected to conduct research. Staying up to date with CME activities is easier since many of these opportunities come with CME credit. Additionally, there are usually colleagues who nearby who can help with complex patients.
Conducting translational and basic science research is much easier in the academic setting and allows for cross collaboration with other laboratories — something typically much harder in private practice. And although private practice fellowships offer high quality clinical education, opportunities are more plentiful in the academic setting , and you are more likely to be involved in real-time clinical teaching as well. Academics gives you better exposure to resident and fellow learners.
However …
By necessity, medical institutions’ administrative systems are built for multi-department and multi-science campuses. The strengths of this approach are obvious when you consider the cohesiveness and culture of the academic setting. On the other hand, the organizational priority for cohesion directly impacts doctor autonomy; the freedom to practice as you wish, with the equipment you wish, can take a back seat to the priorities of the medical center. This loss of autonomy can be frustrating, and for some can contribute to burnout.
Further, many hospitals do not provide complete transparency when evaluating a doctor’s fair market value (FMV) and are generally guarded about sharing the data on which they base your take-home pay. Academic centers are also, on average, less transparent about how much money you generate and where the money you generate goes, especially if you are on a work relative value unites (wRVU) system. Hospitals tend to have a heavy administrative burden, and clinical care generates all of the revenue to pay for it. However, physicians don’t always have transparent access to information about where the money they make goes, so it can be difficult for them to know whether they are being undervalued or if administrative costs are exorbitant.
Administrative burden is also skyrocketing. Between 1975 and 2010, the number of physicians in the United States grew 150%, roughly in keeping with population growth, while the number of health-care administrators increased 3,200% for the same period. Despite hiring this army of administrators, doctors now spend more time on a computer documenting than they do examining or talking to patients. The average amount of administrative work for doctors has increased despite thousands of percent more administrators.1
Private practice — not owned by private equity
The truth about administrative burden
Ironically, in medical school and residency, I was taught that if I went into private practice, I would be burdened with all the administrative tasks and responsibilities that this army of hospital administrators take care of on a daily basis. This was far from true in my case, and I think we need to do a much better job of educating medical students and residents about this. My administrative burden has gone down tremendously since joining Tyson Eye despite having much fewer administrators. I believe this is due to it being a physician-owned practice, where administrators’ performance is evaluated by the physician in real time.
In contrast, hospitals tend to have a separate hierarchy of nonclinical administrators, and you get what you get in terms of administrator quality, with very little ability for the doctor to hire and fire based on performance. At Tyson Eye, my schedule is free from nominal tasks thanks to these super-talented administrators, and I now have much more time to engage in strategic decision making and patient care.
More independence, lower overhead costs
In private practice, autonomy is king and there are far fewer barriers to practicing the way you want. This is because private practices have fewer surgeons on average, making cohesion much easier to accomplish without sacrificing autonomy. The dynamics are similar to working for a small company vs a larger one. The layers of bureaucracy you might find in a big company or hospital don’t typically exist in lean and mean private practices.
For instance, let's say there is a new piece of surgical equipment that has recently launched. I may only have to wait a half a day before we as the physicians decide to purchase this piece of equipment. In the hospital setting, this same process could take months or even years to approve. You typically must wait for the right time of year for capital equipment purchase, put together a business case including projected use and revenue, and then present it to a hospital committee of nonexperts. Academics is very much like private equity in this way. If you are in a smaller private practice and determine that this technology would boost patient care while also making financial sense for the practice, you don’t have to justify it to anyone.
Finally, I initially thought clinical research would be better suited for academics, but I was wrong about that, too. Academic centers typically have overhead fees that they charge industry and the government. Usually, these add-on costs are 50% to 70% on top of the requested funding. The overhead costs are much cheaper in private practice, and so grant sponsors can get high quality research done faster and cheaper using this route. Many private practices (like Tyson Eye) even have research departments that take care of the administrative work for clinical research!
Don’t be intimidated by the business of medicine
Business education is much easier to learn than medical education. We have been told that the business of medicine is difficult and that doctors make bad businesspeople. Doctors also make bad electricians and bad lawyers … unless you learn those skills. Having completed an MBA, I can tell you that every doctor I have ever met could easily get straight As in an MBA program or learn the critical business skills necessary to be actively engaged and aware of where the money you generate as a doctor goes and what it pays for.
Private practices are not all created equal, and I certainly have heard of bad experiences from colleagues. However, this has mostly boiled down to a few key reasons: they enter a practice that is a poorly run business, they are employed by a private equity-owned practice and therefore do not have autonomy, or they don’t have a mentor who can guide them on how to effectively run a practice.
I have great colleagues at Tyson Eye and an exceptionally talented mentor in Dr. Toby Tyson. Not only is he one of the best surgeons I've ever seen, but he's also one of the most business savvy people I've ever met. I have been blessed with the opportunity to learn the business side of ophthalmology from him, which has been critically important.
Becoming business savvy is not challenging, but it is near impossible if you don’t have good resources and mentors to learn from, as well as an open-book policy for the accounting at your practice. These key elements will give you the skills to avoid burnout and maximize autonomy, whether you are in academics or private practice.
In the end, what you decide in your career journey depends on what you value the most. There are strengths to both academia and private practice, and an informed decision will foster your success. OM
Reference
- Cantlupe J. Expert forum: the rise (and rise) of the healthcare administrator. Athenahealth. 2017. Accessed September 24, 2024. https://www.athenahealth.com/knowledge-hub/practice-management/expert-forum-rise-and-rise-healthcare-administrator
