In my experience, most ophthalmology trainees are inundated with the message that the only options following graduation are: a) join a private practice group b) continue in academic medicine or c) become a salaried employee (e.g at the Veteran’s Administration, Kaiser Health, or similar large institution). Luckily for me, I became aware of the hidden fourth option: d) start your own practice. Let’s look at some pros and cons of each of these options.
Private Group Practice
This is the most common pathway for graduating residents and fellows. Half of my residency cohort and most of my ophthalmology friends chose this route. Typically, you join a private group and work as a W-2 employee for 1-2 years before being offered to buy in to the partnership.
Pros:
More autonomy than academic medicine
More money than academic medicine in the long run
Opportunity to gain equity in the practice
Cons:
Senior partners sometimes treat new associates unfairly
Harder cases given to new doctors
Patients with the highest reimbursing insurances being diverted to senior partner’s schedule. Note: this isn’t common, but does happen with some frequency.
No guarantee that you will be able to buy into the practice
Difficult to know if the practice is behaving ethically unless you know other ophthalmologists in the area
May enter into a “churn and burn” situation by accident (“churn and burn” refers to the practice of hiring a junior associate with a promise of making partner in two years, paying them far less than the revenue they generate over those two years, and then not offering partnership or firing them as their contract nears its end).
Some bureaucracy. The amount of administrative employees and hoops to jump through increases as practice size increases.
Academic Medicine
Pros:
Familiar. As chronic students, every trainee knows where they stand in academic medicine and understands, to a great extent, what will be expected of them
Difficult cases. Academic medical centers tend to get the more challenging cases, which was a pro for me but may be a con for others.
Ability to teach residents and fellows. This may also be a con for some, but I find teaching to be very rewarding.
Not in charge of hiring and firing of employees. You never have to do payroll, deal with problem employees, or settle arguments among support staff.
Cons:
Research. I have never been too interested in basic science research, and this is a con for me. For others, the ability to do research may be so enticing that it may be the whole reason to pursue academic medicine.
Poor reimbursement compared to private practice.
Substantial bureaucracy. If you want a new piece of equipment, you can expect a months-long process to demonstrate need and then gain approval to purchase it.
High administrative burden. This goes hand-in-hand with the prior point. The number of administrators per doctor is highest in academic medicine. As relatively independent people, physicians generally don’t care for other people telling them how to practice their craft.
Not in charge of hiring and firing employees. It is much harder to replace frequently under-performing support staff.
Salaried Employee
Pros:
Stability. As an employee of a large health system, you know exactly when your next paycheck is coming and how much it will be. The benefits package usually ends up being pretty good as well.
Good reimbursement. The starting salary tends to be high (particularly in relatively undesirable parts of the country).
Cons:
Lack of autonomy. You are told when and where to show up as well as how many patients to see.
Cap on reimbursement. Although you may get a cost of living increase and a production bonus, the large administrative staff salaries and other medical departments’ need to be subsidized somehow. Your earning potential will never be as high as it could be in private practice.
Start Your Own Practice
Pros:
Everything is exactly how you want it. From the color of the wallpaper to the number and type of support staff, you make all the decisions.
Cons:
The startup cost is expensive, but not prohibitively so. The average cost to start a new practice is around $300,000 for a comprehensive/anterior segment ophthalmologist. This number will vary based on the brand of equipment you buy, any special requirements (e.g. Schiempflug tomography, OCT-A, etc) but $300,000 is a reasonable estimate.
The Unknown. Fear of the unknown and lack of immediate income stability deter many ophthalmologists from starting their own practice.
I had personal experience in academic medicine (as a resident, fellow, and attending) before starting my own practice. Although the ability to teach residents was appealing, the rather high administrative burden and red tape was a constant thorn in my side. My VA experiences as a resident was enough to deter me from pursuing an employee job once I decided to leave academic medicine. This left me with either joining a small group or starting my own practice.
For me, joining a small group was never very appealing. It was so close to the complete freedom and ultimate autonomy of owning my own practice but still had strings attached. The cons are listed above, and are enough for me to stomach the unknown of opening my own practice.
I was aided in my decision by knowing three people who had recently started solo practice ophthalmology in different parts of the country. They told me that although it was comparatively difficult to start something from scratch, they were happy with their choices and would never go back. This is a refrain I’ve encountered from every solo practice ophthalmologist I’ve met: “I would do it all again.” The same can not be said for my fellow academic attendings, employed ophthalmologists, and some small group practitioners. For me the decision to go solo was relatively easy. No other job would allow me the freedom to practice medicine as I see fit. Now I am only accountable to my patients and my conscience, and I have never been happier.
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