“Which practice model is the best?”

It's one of the most common questions residents and fellows ask me. They expect a simple answer. After practicing in academic medicine, a private equity-backed organization, and now a physician-owned practice, I've learned that the question itself is the wrong one.

Every practice model has strengths. Every practice model has weaknesses. The better question is: Which environment will help you become the physician—and the person—you hope to be?

When I completed my fellowship, the decision seemed relatively straightforward. Today, graduating ophthalmologists choose among academic medicine, physician-owned practices, hospital-employed groups, and private equity–backed organizations. Each offers meaningful opportunities and meaningful tradeoffs. My goal is not to convince you that one model is better than another, but to help you ask the right questions before making one of the most important decisions of your career.

Why Has Ophthalmology Changed?

Modern ophthalmology is increasingly capital intensive. Practices invest in optical coherence tomography systems, premium intraocular lens technology, minimally invasive glaucoma surgery instrumentation, femtosecond lasers, ambulatory surgery centers, cybersecurity measures, compliance programs, and electronic health record systems while navigating reimbursement pressure and workforce shortages. These forces helped drive consolidation and created opportunities for outside investment.

Private equity has become one of several established practice models rather than a temporary trend. Understanding why it emerged is more valuable than simply debating whether it is good or bad.

What Each Practice Model Taught Me

• Academic medicine gave me the opportunity to teach, mentor, collaborate, and participate in research. Working with residents continually challenged me to stay curious and evidence-driven. While institutional processes can be slower, and compensation structures differ from private practice, the opportunity to educate future ophthalmologists is incredibly rewarding.

• Working within a private equity–backed organization challenged many of my assumptions. I experienced the benefits of scale, including professional management, infrastructure, technology investment, recruiting, and operational support that allowed physicians to spend more time caring for patients. At the same time, governance structures vary widely, and physicians should understand who makes strategic decisions and how physician voices are represented.

• Practicing in a physician-owned group reinforced the value of autonomy and physician leadership. Decisions about staffing, technology, patient experience, and strategic growth remain close to the physicians delivering care. Ownership also carries responsibility, from recruiting and compliance to capital investments and long-term planning. For many physicians, those responsibilities are deeply rewarding.

There Is No Perfect Practice Model

The biggest mistake young ophthalmologists make is searching for the perfect job. It doesn't exist. Every practice model involves trade-offs. The best fit depends on your professional goals, personality, and desired balance between autonomy, stability, leadership, scholarship, and entrepreneurship.

Finding the Right Fit

Perhaps the biggest misconception among graduating residents is that they need to identify the "perfect" practice before signing their first contract. In reality, your first position is just that—your first. Very few ophthalmologists can predict with certainty what practice environment will best suit them before they have experienced independent practice.

Instead of asking, “Which practice is best?” ask yourself a different set of questions: What type of work energizes you? Do you enjoy teaching and research, or are you happiest focusing exclusively on clinical care? Are you excited by entrepreneurship and the idea of building something of your own, or would you prefer to spend your time caring for patients while others manage the business? How important are autonomy, geographic flexibility, mentorship, work-life balance, and earning potential at this stage of your career?

Your priorities will likely evolve. Early in your career, mentorship and surgical volume may matter more than ownership opportunities. Later, leadership roles, equity, or greater control over your schedule may become increasingly important. The "right" practice is not necessarily the one that offers the highest salary or the most prestigious name—it is the one that aligns with who you are today while allowing room to become who you hope to be tomorrow.

The Future of Private Equity

Private equity is not going away. The forces that fueled its growth—technology costs, administrative complexity, succession planning, and the need for capital—remain real. However, the landscape is evolving.^1,2 Rising interest rates, greater scrutiny of health care transactions, and increasing attention to physician satisfaction have slowed the rapid pace of consolidation seen several years ago.³

At the same time, physician-owned practices continue to demonstrate remarkable resilience. Many independent groups are thriving by remaining nimble, investing strategically, embracing innovation, and preserving cultures centered on physician leadership. Others are adopting hybrid approaches that combine outside investment with meaningful physician governance.

Rather than asking whether private equity will “win,” I believe the better question is how every practice model can evolve to meet the changing needs of patients and physicians. The organizations that succeed over the next decade—whether academic, physician-owned, hospital-employed, or private equity–backed—will be those that invest in people as much as infrastructure, support physician engagement, and maintain an unwavering commitment to excellent patient care.⁴

Advocating for Yourself

Accepting a position is only the beginning of your professional journey. No practice is perfect, and every organization experiences growing pains. Before deciding that a position is not the right fit, give yourself time to build relationships, establish trust, and understand the culture. Many challenges can be addressed through open communication, constructive feedback, and a willingness to become part of the solution.

As your career progresses, don't be afraid to advocate for yourself. If you are interested in teaching, leadership, research, new technology, or greater autonomy, have those conversations with your partners or administrators. The best organizations want their physicians to grow and will often support opportunities that align with both your professional goals and the practice's long-term success.

That said, there are times when moving on is the right decision. If your values consistently conflict with those of the organization, if you no longer feel supported in providing the care you believe your patients deserve, or if opportunities for professional growth simply do not exist despite honest conversations, it may be time to explore other options. Changing practices should not be viewed as failure—it is often a thoughtful step toward finding an environment where you can thrive. Likewise, some physicians eventually discover that they are happiest creating something of their own through physician ownership. Entrepreneurship is not for everyone, but for those who value autonomy, leadership, and the opportunity to shape a practice's future, it can be an incredibly rewarding next chapter.^5,6

Table 1. Comparing Practice Models^7,8

Questions to Ask Before Signing Your First Contract—and Why

1. Who makes the major clinical and strategic decisions? Understanding who sets the direction of the practice will help you determine how much influence physicians have over patient care, operations, and future growth.

2. How are physicians represented in leadership? A strong physician voice in governance often reflects an organization that values clinician input and shared decision-making.

3. What mentorship opportunities are available? Your first few years in practice are critical for developing surgical confidence, clinical judgment, and professional growth. A supportive mentor can be one of the most valuable assets early in your career.

4. How is compensation structured today, and how might it evolve over time? Beyond your starting salary, understand how productivity is measured, whether incentives change, and what opportunities exist for long-term financial growth.

5. Is there a pathway to partnership, equity, or other forms of ownership? Even if ownership isn't important to you today, knowing your future options can help you evaluate the long-term potential of the practice.

6. Are physicians able to invest in the ambulatory surgery center or other ancillary services? Ambulatory surgery center ownership and ancillary services can be meaningful components of professional satisfaction and long-term financial planning, depending on your career goals.

7. How are decisions made regarding new technology and capital investments? Ophthalmology evolves rapidly. Understanding how the practice evaluates and adopts new technologies offers insight into its commitment to innovation and patient care.

8. What is physician turnover, and why have physicians left the practice? Turnover can provide valuable information about practice culture, leadership, and long-term physician satisfaction. Every practice experiences transitions, but understanding the reasons behind them is important.

9. What opportunities exist for professional development beyond clinical practice? If you're interested in teaching, research, leadership, advocacy, industry collaboration, or innovation, find out whether the organization encourages and supports those pursuits.

10. Where do you see the practice in 5 to 10 years? Whether you're joining a physician-owned group, hospital system, academic department, or PE-backed organization, understanding the leadership's long-term vision helps determine whether your own career goals align with the future direction of the practice.

If there is one lesson I hope the next generation takes away, it is this: Don't spend your career searching for the perfect practice. Instead, seek great mentors, meaningful opportunities to grow, and an environment that aligns with your values. Ownership models will continue to evolve, but integrity, curiosity, and a commitment to exceptional patient care never will. Ultimately, the best practice is the one that helps you become the physician—and leader—you aspire to be.⁹

References

1. Chen EM, Cox JT, Begaj T, Armstrong GW, Khurana RN, Parikh R. Private equity in ophthalmology and optometry. Ophthalmology. 2020;127(4):445-455. doi:10.1016/j.ophtha.2020.01.007

2. Braun RT, Lelli GJ, Pandey A, Zhang M, Winebrake JP, Casalino LP. Association of private equity acquisition with Medicare spending and use of ophthalmology services. Ophthalmology. 2024 ;131(3):360-369. doi:10.1016/j.ophtha.2023.09.029

3. Zhu JM, Hua LM, Polsky D. Private equity acquisitions of physician medical groups. JAMA. 2020;323(7):663-665. doi:10.1001/jama.2019.21844

4. Shanafelt TD, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-1832. doi:10.1001/jamainternmed.2017.4340

5. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration among US residents and fellows and the general US working population between 2012 and 2023. Acad Med. 2025;100(12):1486-1498. doi:10.1097/ACM.0000000000006294

6. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking action against clinician burnout: a systems approach to professional well-being. Washington (DC): National Academies Press (US); 2019. doi:10.17226/25521

7. American Academy of Ophthalmology. List of online resources for residents. Accessed August 3, 2026. https://www.aao.org/young-ophthalmologists/yo-info/article/list-of-online-resources-for-residents

8. American Society of Cataract and Refractive Surgery. Practice management. Accessed August 3, 2026. https://www.ascrs.org/clinical-education/practice-management

9. Porter ME, Lee TH. The strategy that will fix health care. Harv Bus Rev. 2013;91(10):50-70. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care

Reena A. Garg, MD, is a board-certified, fellowship-trained glaucoma and cataract surgeon in Washington, DC, and an associate professor of ophthalmology at Georgetown University. She is president of the Washington DC Metropolitan Ophthalmological Society. She reports no financial disclosures.