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Cover Stories | Nov/Dec 2009

What Type of Practice Does One Choose?

Physicians and an employment specialist discuss career options.


By Richard M. Awdeh, MD

Joining an academic ophthalmic practice was one of the best and most gratifying decisions of my life. This article shares a few of the decisive points from my interview process in an effort to help current residents and fellows choose a practice.

The most important question to ask yourself when selecting any job is who will be your colleagues? The answer is critical in an academic setting, because ophthalmic departments typically are large practices. It is valuable to get a sense of the department's culture. Are the employees happy? Do they work well with each other?

Because you can only determine so much about a department and its members in an interview setting, it is important to call your friends and colleagues around the country for advice. Speak to the junior faculty or to those who recently departed the practice. Do people generally stay in the department for a long time? You should expect colleagues in your practice to be supportive of you and to demonstrate a commitment to developing you as an academic ophthalmologist.

Finally, assess those with and for whom you will be working directly. An understanding of your role in the organization—both within a particular group and the entire institution—will help you to appreciate your role in the practice and what your future directions may be.

Clearly, if an academic practice is hiring, then there should be a clinical need for your services. Oftentimes, however, a position may be created for you. In either circumstance, you should consider whether there is a demonstrable clinical need by assessing how busy the other doctors in your practice area are, both clinically and surgically. It can be to your advantage if you can offer a specialized area of expertise that the group is currently lacking.

In addition to having a busy clinical practice, most ophthalmologists stay in an academic setting because they enjoy challenging cases and interacting with colleagues. Being in a stimulating environment can ignite research ideas and spawn innovation. Consider the basic infrastructure at your prospective department. Are there weekly grand rounds? Does each subspecialty group meet on a weekly basis to discuss new treatments or difficult cases? Are there journal clubs with the trainees? What are the referral patterns with the "town guys"?

Arguably, one of the most rewarding aspects of joining an academic group is teaching the next generation of ophthalmologists. For a recently graduated trainee, this can be an anxious task but nonetheless rewarding and important to the development of your own skills. Try to determine during the interview process what your responsibilities will be with the residents and/or fellows.

It is helpful, but not essential, to have a specific research project outlined when interviewing for a position. At minimum, have an area of interest that you would like to explore. There is a distinct difference between an applicant who expresses an interest in research and someone who gives specifics and lists possible avenues of funding and their particular deadlines. Have a 1- to 2-year plan and a definite 5-year plan.

Bear in mind your research interests and consider two key options. First, is there an established infrastructure at the facility you are considering, or do you have to build one? If you are interested in optical coherence tomographic (OCT) imaging of the retina, you should know whether an OCT imaging program already exists. Is there access to animals? Are there OCT laboratories at the eye institute? Are others already doing similar projects in this department?

Likewise, are knowledgeable people ready to help with grant/budget writing and submissions? Have other junior faculty recently gone through the process? If so, speak to them! Your odds of success in research are much greater if the underlying infrastructure is already in place.

If your interest lies not in basic science or animal research but in clinical research, focus on funding opportunities, the availability of study coordinators, industry partnerships, and patient volume.

You may have a dream project, but are the collaborators that you need available? A great biomedical engineering project is not going anywhere without biomedical engineers available to help you.

Search your soul before the interview process, not during it. Knowing what drives you and what your career goals are will make the entire process much easier for you and will allow you to assess how a given position will help you achieve your aims.

A nurturing environment is important. Try to identify potential mentors during the interview process. Be proactive about reaching out to them. These professors will be excited that you sought them out.

Joining an academic practice can be a very rewarding experience and offers you the ability to incorporate variety into your career. The aforementioned points should serve as a users guide in helping you check some internal barometers before proceeding down the interview trail.

Richard M. Awdeh, MD, is an assistant professor of ophthalmology at the Bascom Palmer Eye Institute in Miami, Florida. Dr. Awdeh may be reached at (305) 482-5135; rawdeh@med.miami.edu.

By Cristina Boggiano

Finding the right position is a rewarding return for years spent honing your ophthalmic skills. Fielding job offers and choosing which one you will accept is perhaps the most strategic set of decisions you will ever make in your career. Based on my experience as an ophthalmic placement specialist, I have outlined some tactics that will help you prepare for your upcoming transition.

As a senior resident or fellow advancing toward your last year of training, you begin a new phase of your ophthalmic career: joining a private practice or institution. It is during this time that the job search becomes a job in and of itself.

Start off by carefully considering and defining your needs. If married, include your spouse in the process. Take into account important issues like geography, recreational opportunities, and community-based factors. Along with personal interests, consider professional aspects such as patient volume, proximity to a teaching facility, and your ability to perform certain procedures. At this time, it is also important to determine your approaches toward contract negotiations, interviewing, partnership, and salary.

With a properly outlined plan, it is possible to actively pursue all avenues to locate potential employment positions. Understand, however, that this part of the process takes time and resources. The length of time to secure a position ranges from just weeks to about 8 months. If you are set on relocating after training, take extra time to evaluate both the position and practice to ensure they meet your needs and match your interests. Prepare by starting to look for positions early.

An effective way to optimize your job search is to network. Use a hybrid approach of online, phone, and in-person methods. Social-media Web sites, ophthalmic societies and groups, alumni organizations, and ophthalmic meetings present powerful networking opportunities. Job board listings in ophthalmic journals and online abound. You can choose to search on your own or elevate your search by using an ophthalmic recruiter. Rely on this advocate's expertise to find out about positions all over the country that may not be not publicly listed.

Once you have narrowed the field to positions of interest, concentrate on acing the interview. Be amicable and try your best to extract from your conversation with the interviewer the relevant professional aspects of the organization. If you have concerns about this part of the process, contact a mentor or ophthalmic recruiter to coach and prepare you.

Regarding salaries and contract negotiations, by the time you are offered a position, you are close to reaching your goal. Be realistic about salaries for your specialty and the region you are pursuing. Similarly, be sensitive to the economic climate and acknowledge that there is currently heavy competition for available positions. Choosing to enlist the advice of a career advocate, mentor, or ophthalmic recruiter can benefit you during this period.

Securing the right position is a great challenge every year for residents and fellows. Devote yourself wholeheartedly to this endeavor, allow plenty of time for planning and preparation, and when you find the best match, move decisively. When you consider the benefits of finding the right position, the time and resources you devote are a worthy investment in your ophthalmic career and future.

Cristina Boggiano is the founder of The Ophthalmic Associates in Boca Raton, Florida, a firm that specializes in job placement services for eye care professionals. Ms. Boggiano may be reached at (866) 488-6363; fax: (866) 328-7778; cristina@theophthalmicassociates.com.

By Damien F. Goldberg, MD, MBA

As you finish your ophthalmic training and decide to search for a different working environment, you are poised to make a life-altering decision for which residency may not have prepared you. This decision comes at a time that you are juggling patients, surgeries, the Ophthalmic Knowledge Assessment Program, and boards. You are excited to finally get to work, but you may be unsure about what kind of practice you want to join.

Some of you may pursue an academic setting or large hospital group, whereas others will choose between starting or purchasing a practice and joining a private group. When making this decision, it is important to maintain perspective and be aware of some of the benefits and pitfalls.

The upside to starting your own practice is that, from the beginning, you are your own boss, you make all the decisions, and you collect all the profits. The disadvantage is that you assume more risk on office, equipment, and staffing costs, and you make a significant commitment of time with extra administrative work. It is a good idea to prepare a financial forecast, study your market, and closely research the best location for your new office. Starting a practice can be rewarding and will be easier if you find the right experts to guide you. In today's ophthalmic practice environment, having a good business consultant, accountant, and attorney is key. Fortunately, all these advisors can be found at any of the large ocular conferences (eg, the AAO or ASCRS meetings).

Keep your eyes open for opportunities. A friend of mine recently began his practice and found a good way to reducing his start-up office costs for equipment. He became very savvy at identifying online auctions of business liquidations and saved thousands of dollars by picking up discounted office furniture, computers, and printers. Many of these items were in great condition and just a few years old.

The biggest advantage of buying compared to starting a practice is a reduced level of risk. The physical office already exists, and the practice has established goodwill. Insurance contracts are set up, and patients are familiar with the location.

The greatest disadvantages to buying a practice are that you assume considerable debt up front, and it can be difficult to assess the true value of the existing practice. Not uncommonly, a certain percentage of patients will leave because you are not the doctor they are used to seeing. Some patients may have already left, perhaps because the practice was unstable or poorly managed. These factors are not always reflected in the price of the practice. In addition, some established employees may choose to leave or may have already left because of anxiety and insecurity about your managerial style.

I highly recommend retaining the previous owner of the office as a salaried employee to smooth the transition for the patients and staff as well as yourself.

Joining a group practice is probably the easiest transition to make. Insurance contracts are set, the practice is established, and you are offered a guaranteed salary. Frequently, there is an opportunity to become a partner in the future. Upfront financial risks are low, and you do not need to worry about losing patients or staff because no one is retiring. You can learn how to bill medical claims, manage employees, and maintain referrals when starting your own practice, but with a group practice, you do not have to reinvent the wheel. You can employ strategies that an established practice has used for decades.

The biggest disadvantage of joining a group practice is that you do not have full autonomy. The group makes practice decisions, and you may not have voting privileges until you are offered an opportunity to buy into the practice. Although there may be no or a relatively low initial cost to join a group, you may find the partnership contract complex and the buy-in sizeable. All of these details should be made clear from the start.

Fortunately, the same key advisors that can help you get started on your own can also help you to simplify the buy-in and, most often, make the partnership a win-win for both sides.

Damien F. Goldberg, MD, MBA, is in private practice and a partner of the Wolstan & Goldberg Eye Associates in the South Bay region of Los Angeles.Dr. Goldberg may be reached at (310) 543-2611; damiengoldberg@wolstaneye.com.

By Christopher E. Starr, MD

All residents must make two important decisions: whether to pursue a fellowship or not and whether to join a private or academic practice. Some make these choices early in residency, but for many, these decisions are not so easy. I ended up in the second group, even though I had always perceived myself to be in the first. When I started my residency, I firmly believed I was destined to be a retina specialist in private practice. Today, I am a cornea specialist in full-time academics. Although I still get a thrill from listening to retina specialists argue about the intricacies of the retinal pigment epithelium (but don't tell anyone), my decisions to pursue cornea and academics, albeit later than most, were ultimately right for me. This article will share some of that journey and the decisions I made along the way.

Before starting my residency and during my early years in training, I naively was led to believe that full-time academicians were underpaid, underappreciated, bitter people who worked in drab, depressing institutional settings. I also was under the impression that retina specialists were cooler, smarter, funnier, taller, and better dressed than cornea specialists. I now know that none of these things is accurate. In truth I could have been very happy with a career in retina (some of my best friends are retina specialists), but what ultimately gave cornea the edge for me was that, during the routine examination, I could easily see and touch the ocular surface, all while sitting comfortably at the slit lamp. Conversely, the routine retinal examination involves bending, twisting, and contorting (which is bad for your back) and painfully impaling the sclera with metal probes (which is serious for the patient; they do not call it scleral depression for nothing). Last but not least, cornea specialists actually make vision better.

When I finished my cornea fellowship in 2002, I wanted a job in private practice in New York City—the location being the one decision in my professional life about which I never waivered. Even though I was primarily in private practice during the first 4 years after fellowship, I maintained an active role in resident teaching by staffing weekly clinics and surgeries. In time, the luster of private practice waned, and I found myself enjoying my days in the hospital more than my time in the office.

When Donald J. D'Amico, MD, was named the new chairman of ophthalmology at the Weill Cornell Medical Center, he called to tell me that he was coming to New York to build a world-class academic department and asked if I would join him as his residency program director. Without discussing salary or specifics and without any hesitation at all, I said yes. The opportunity to work with some of my favorite people from my residency training in Boston, in the department that first introduced me to ophthalmology as a medical student, in my beloved New York City seemed to be my dream job, and it was (and 3 years later, it still is).

For me, academics trumps private practice in almost every respect. Today the starting salaries and benefits packages in academics are competitive with and, in many instances, better than those in private practice. In private practice, young associates often need to spend 5 days a week seeing patients to make a reasonable bonus, which often leaves little time for anything else. In academics, I mentor and teach residents, fellows, and students; give talks; write articles (some more personal than others); attend meetings; perform research; and collaborate with other faculty members. At the end of the year, I can still receive a bonus, because all of the aforementioned activities are actually valued in academics.

As reimbursement declines, the costs of a medical practice skyrocket, and health care reform and its results loom, starting and operating a successful private practice are getting harder. Physicians must fight for every patient, slowly build a reputation, invest heavily in marketing, go door to door introducing themselves to potential referrers, and comanage patients. At large academic centers, brand recognition, local reputation, and a level of credibility are immediately shared to some extent by new faculty, as is a seemingly endless referral source from the myriad affiliated doctors and departments.

The academic life is not right for everyone. When staffing complex resident cataract surgeries, I occasionally question whether it is even right for me. The bottom line is that, in private practice, I felt like a businessman and did not like it (and was not very good at it, either). In academia, I retain some of the idealism I felt as a young boy dreaming of a future career in medicine. I have the opportunity to help not only patients but also students, other physicians, and perhaps in a small way, the field of ophthalmology.

Christopher E. Starr, MD, is the director of the Ophthalmology Residency Program, co-director of the Cornea, Cataract & Refractive Surgery Fellowship, and an assistant professor of ophthalmology at Weill Cornell Medical College in New York. Dr. Starr may be reached at (646) 962-3370; cestarr@med.cornell.edu.

By Jonathan Stein, MD

Exiting the womb of academia to enter professional practice can be a daunting task for the young ophthalmologist. Until your departure from either a residency or fellowship program, everything has been, for the most part, predetermined. At this point, you make decisions that will affect the rest of your personal and professional lives, including the type, scope, and location of your practice. This article offers some guidance for young ophthalmologists.

One of the first things you need to establish is the level of academic involvement that you desire. Before your residency or fellowship program, your life was spent in some sort of academic forum. Many young ophthalmologists I know find the idea of leaving academia behind unappealing, and a significant number of the physicians dedicated to medicine enjoy the succession of research, teaching, and learning. Identify the level to which you wish to participate in academia—full time, part time, or no time (ie, complete private practice). Part-time levels of participation in all of these areas are very common for the young ophthalmologist. Recent graduates will often seek multiple opportunities within their discipline when they are first emerging from their training program. It is very feasible for the young ophthalmologist to share his or her time between teaching clinics and private practice in the beginning. This serves the mutually valuable end of maintaining the beginner's involvement in training, keeping him or her busy in the clinic and OR, and affording time to start a private practice. As you advance in your career, the times shared between these ventures can be altered.

What will be the scope of your practice? Even within the smaller divisions of academics versus private practice, significant diversity still exists. In academia, you could teach, research, and practice to varying degrees. A full-time commitment to any of these areas is rare; it is much more common to devote a certain percentage of your time to each. Most private practitioners spend some amount of their time at a teaching institution, and the percentage of time allocated to a practice versus teaching residents and fellows is an individual decision. Although it is not essential to commit to such time schedules early in your career, you should have an idea of what your ultimate desires are. The timing of any one individual's decisions varies widely from one professional to the other. Private practitioners need to decide on whether to establish a solo practice or to join a group practice. Each option has its pros and cons. The benefit of a solo practice is that you are your own boss. Furthermore, all successes and failures are the result of your actions alone and do not rely on others. The other side holds true here, too. There are pros and cons to a group practice. Specifically, it is usually easier to get busy in a group practice, as the entity has already been established. Referrals can easily come in from the other existing doctors. Competition, however, can also easily exist. It is important to analyze each individual situation to establish what is the best choice for you.

Perhaps your most important decision is the location of your employment, and this matter requires careful consideration. Certain disciplines within ophthalmology are only possible in select locations. For example, it would be difficult to establish a refractive surgery practice in an impoverished inner city. Similarly, it would be difficult to enter into a career as an ocular tumor specialist in an extremely rural area. Research the local demographics and professional landscape. The more common scenario is choosing a location and practice that needs a specific discipline and is not currently saturated with many similar specialists. You will need to exercise due diligence with regard to these factors in order to make a completely informed decision. Consider your ultimate career goals when choosing your location.

Choosing a practice after your residency or fellowship is stressful. Identify what is important for your career and family. Although it should not be expected, it is not uncommon for many ophthalmologists to change their career path later on. It is important to remember that your general personal goals direct you toward your ultimate destination, no matter which way the path might take you in getting there.

Jonathan Stein, MD, is a clinical assistant professor in the NYU Department of Ophthalmology in New York City, and he is in private practice at Ophthalmic Consultants of Connecticut in Fairfield. Dr. Stein may be reached at (203) 366-8000; steinjonathan@hotmail.com.

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