Andrew G. Lee, MD
Professor of Ophthalmology, Neurology, and Neurosurgery
University of Iowa Hospitals and Clinics
Iowa City, Iowa
The decision to enter academic or private practice is one of the
most important choices that a resident can make. This article compares
the advantages and disadvantages of each career choice.
Academic ophthalmology, like private practice ophthalmology,
generally includes a mix of outpatient clinical medicine and ophthalmic
surgery. According to the American Academy of Ophthalmology (AAO), the
average American comprehensive ophthalmologist spends ?four days per
week in the office performing primarily medical ophthalmic functions
and one day in the operating room? and ?in a typical workweek, the
ophthalmologist will see over 100 patients and perform three or more
major surgical procedures?.
Cataract surgery is the most commonly performed ophthalmic surgery
in the U.S. Refractive surgery, glaucoma procedures, and laser
procedures are also very common. The most common conditions that a
general ophthalmologist in private practice would see include
refractive error, red eyes, cataract, glaucoma, diabetic retinopathy,
and age related macular degeneration.
Residents are typically drawn to ophthalmology as a career because
of the mix of surgery and outpatient medicine; the ability to care for
patients of all ages; and a relatively well paid and positive
life-style.
Scott and Gunderson reported the results of a study of prospective
ophthalmology residents and the factors influencing their career
choice. Table 1 lists the factors that these authors reviewed.
Decision Factors
Here are some of the many factors that will influence your decision as you consider this important career choice:
- Autonomy
- Time
- Continuity ? the degree of continuity of care anticipated with patients
- Routine/Diversity ? extent to which similar or different tasks are preferred
- Family/Leisure ? amount of time spent with family or in leisure activities
- Expertise ? anticipated level of expertise (i.e., general or sharply defined)
- Income ? income level compared to other specialties
- Innovation ? amount of innovation required
- Intellectual ? specific versus theoretical problem solving approach preferred
- Physician Interaction ? amount of time interacting with other physicians
- Manual/Mechanical ? extent to which manual/mechanical activities are preferred
- Pressure ? amount of pressure anticipated dealing with crises, scheduling conflicts, and patient decisions
- Responsibility ? degree of responsibility expected to assume
- Schedule ? regularity of work hours
- Security ? anticipated job security and confidence in income
- End Results ? extent to which work provides opportunity to see end results
- Status ? rating of status compared to other specialties
- Computer/Technology ? extent to which computer based technologies will impact work
- Family Influence ? extent to which family and personal values determine career decisions
Research Results
JR Scott and CA Gunderson, professors in the Department of
Ophthalmology and Visual Sciences at the University of Texas Medical
Branch surveyed a representative sample of practicing ophthalmologists
recently regarding their career path choices. They reported that among
42 individuals, 36% sought careers in academic medicine, 55% in private
practice and 7% in research. The remaining 2% were undecided.
The survey authors noted specific differences between careers in
academic centers versus private practice. Academic centers tend to be
composed of fellowship-trained sub-specialists who generally confine
their practice to their specialty. This is in distinction to the
comprehensive ophthalmologist who might see patients within a wide
scope of practice or even a fellowship trained sub-specialist in
private practice who might still see general ophthalmology as well.
Academic sub-specialists tend to have access to more didactic learning
(e.g., grand rounds) and exposure to residents and fellows in training.
Apples to Apples
The following graphic of career path factors provides a side-by-side
comparison of the relative benefits and characteristics of a career in
ophthalmology: academic versus private practice
|
Factor
|
Academic
|
Private practice
|
|
Autonomy
|
Academic hospitals and clinics tend to have an established
governance and hierarchy for their Departments of Ophthalmology (e.g.
Chair, Vice Chair) that define and limit an individual faculty member?s
autonomy in the business and administrative operations of the clinic. A
written policy and procedures manual typically outlines these
parameters for an academic faculty member and the department.
|
The private practice ophthalmologist generally has more flexibility
and autonomy to decide their individual scope of practice, malpractice,
clinic schedule, and vacation times, business practices and policies,
and administrative structure (e.g., human resources, hiring and firing
staff, physical plant, equipment).
|
|
Time
|
A typical academic clinical ophthalmologist might see patients 2 or
3 days per week and have dedicated time for research, administrative
duties, or teaching. At individual centers an academic physician might
be on a ?clinical track? and be in the clinic 3-4 days per week or on a
?tenure? or ?research? track and see patients as few as 1 day per week.
|
A typical private practice ophthalmologist has 3 days of week of clinic, 1 day for surgery, and 1 day for administrative work.
|
|
Continuity of care
|
Academic physicians with multiple partners in practice might see
their own patients only or rotate care within a division among several
specialists. The fewer days in clinic that the practitioner is
available the less likely to have continuity of care for all patients.
Sub-specialists might only see a particular patient for a specific
problem and then return the patient to the care of their primary eye
doctor once the acute problem is solved.
|
Most private practice ophthalmologists have excellent continuity of
care and may see the same patient from childhood to adulthood and into
the geriatric years.
|
|
Routine/Diversity
|
Although many sub-specialties within ophthalmology see a certain
number of routine (?bread and butter?) disorders on a weekly basis,
academic centers tend to attract more complex, diverse, difficult, and
challenging cases.
|
The average general ophthalmologist sees a number of core and
routine diagnoses including refractive error, cataract, glaucoma,
diabetic retinopathy, and age-related macular degeneration. The most
common surgical procedures are cataract extraction and laser surgeries.
|
|
Family/leisure time
|
This is a highly variable and individual factor. An academic career
can be more time consuming in many respects compared to private
practice in terms of finding ?extra time? for research and teaching in
addition to clinical activities. On the other hand, most academic
centers handle the billing, collections, human resources, accounting,
and clinic operations.
|
Private practice, especially in the first few years might require
the ophthalmologist to assume the roles of business manager, billing
and coding supervisor, book keeper, human resources, chief executive
officer, chief operating officer, and administrator. Although there are
typically less research and teaching requirements
|
|
Expertise
|
In general, academic centers attract sub-specialty trained
physicians who desire a sub-specialization in a specific area of
interest for clinical care or research.
|
Private practice doctors may also have completed fellowship training or may choose to have a particular area of interest.
|
|
Income
|
Academic specialists tend to earn less than their private practice counterparts.*See table here [LINK]
|
The income for a private practice ophthalmologist varies based upon
area of the country, degree of specialization, surgical or non-surgical
practice, years in practice, and clinical volume.
|
|
Innovation
|
Academic specialists tend to be on the ?Cutting edge? of developing
techniques and technologies. Academic centers are more likely to be
participants in clinical trials and new research innovations.
|
Private practice physicians can participate in clinical research and
often are performing innovative and novel techniques in their practice.
|
|
Intellectual
|
The referral pattern and case mix for academic sub-specialists tend
to be more intellectually challenging and complex than in private
practice. The management of patients in the teaching setting with
residents and fellows emphasizes review of the theoretical as well as
practical application of medical knowledge.
|
A private practice in ophthalmology might see a number of
interesting or intellectually challenging cases that the clinician
might choose to manage themselves or refer to a sub-specialist.
Practical management of patient problems is usually more emphasized
than the theoretic considerations.
|
|
Physician interaction
|
Academic specialists tend to be closely affiliated with academic
hospital or university settings that foster more active and frequent
interactions with other specialists.
|
Private practice offices tend to be free-standing or physically
separate from other specialists. Individual specialists however might
practice in a multi-specialty group or setting.
|
|
Manual/mechanical
|
Academic and private practice surgeons may practice a greater or
lesser degree of surgical difficulty. More technically difficult cases
(e.g, re-operations, complex procedures) tend to gravitate towards the
academic setting.
|
A private practice surgeon may choose to manage more or less difficult and complex cases.
|
|
Pressure
|
Academic centers tend to manage more difficult and sicker patients
with more complex problems. This can be intellectually challenging but
stressful.
|
Private practice doctors have to manage a business in addition to
performing their clinical duties. This is a different type of pressure
than in the academic centers.
|
|
Responsibility
|
Academic centers are often the ?court of last resort? for difficult
management issues and the degree of responsibility can be high in these
cases.
|
Private practice physicians may choose to refer out complex cases to
the academic medical center rather than bear the responsibility for
these ?tough? cases.
|
|
Schedule
|
The academic center typically has residents and fellows to cover the
emergent and after hour calls. On the other hand, more emergent (e.g.,
trauma) and complex cases are referred to the academic center.
|
The private practice doctor generally can control the case mix and
call schedule that best meets their individual scheduling needs.
|
|
Security
|
The academic medical center and the tenure system provide a
relatively high degree of job security and confidence of income within
a specific salary range.
|
The private practice physician is dependent on the market conditions
to provide job security and confidence in income. On the other hand,
the private practice doctor may have more control of overhead,
expenses, and income than the academic physician.
|
|
End results
|
The academic center may be in a better position to see the ?end
result? in cases that are referred with no initial diagnosis. On the
other hand, many of these more difficult cases have either ?no answer?
or ?no treatment?.
|
The majority of the ?bread and butter? activities of a general
ophthalmologist (e.g., cataract surgery, refraction, diabetic
retinopathy, glaucoma) have definable and measurable outcomes.
|
|
Status
|
The academic center provides external markers of ?status? including
official titles (e.g., Director, Chief), rank (e.g., Associate
Professor), and affiliation with a prominent and prestigious teaching
institution (e.g, University Hospital).
|
Private practice doctors may choose to have clinical or adjunct appointments or affiliations with teaching hospitals.
|
|
Computer technology
|
Academic centers often have ?economies of scale? that allow
implementation of new computer technologies that might be less
affordable for an individual practice. The centralization and
automation of certain aspects of clinic operations may improve
efficiency.
|
Smaller operations like private practice may be more flexible and up to date in their application of computer technology.
|
|
Family influence
|
Academic centers typically have explicit and written maternity and
paternity leave, health, and other benefit packages. The academic
career may be more amenable to more predictable hours and work schedule
particularly in the research and teaching arenas.
|
Private practice doctors typically have more autonomy and control of
their vacation schedule, leisure time, and benefit packages.
|
Doing the Numbers
The following results are taken from the December 2003, Ophthalmology Management salary survey:
- the ?average personal net income? for ophthalmologists in 2002 was $321,000? (range $30,000 to $4,000,000.
- Salaried physicians earned less than their non-salaried counterparts: $242,000 compared with $367,000 (about 33% less).
- The average income for salaried ophthalmologist associated with an
academic institution (12% of the salaried group in this survey) was
$176,000.
- The average income for the 17% employed by a business was $337,000
and the average income for the remaining 70% employed by an M.D. or
group practice was $229,000. (Half of this group reported being in
practice 14 years or longer.)
The bottom line is that academic physicians tend to earn less than their private practice counterparts.
Coast to Coast
It?s also interesting to see the income variation by region as noted
by the results of the 2001 Medical Group Management Association survey,
which depicts the US salary variation by region:
|
Specialty
|
n
|
Eastern Median
|
n
|
Midwest Median
|
n
|
Southern Median
|
n
|
Western Median
|
|
Ophthalmology
|
42
|
$240,352
|
138
|
$244,361
|
91
|
$236,859
|
114
|
$197,807
|
|
Ophthalmology:
Retina
|
*
|
*
|
22
|
$503,300
|
7
|
*
|
*
|
*
|
Specialization
As you would expect, specialization deeply affects salary as
reported by Allied Physicians. The survey measured base salaries, net
income or hospital guarantees minus expenses and was performed in
March, 2001:
|
Specialty
|
Average
|
Lowest
|
Highest
|
|
Ophthalmology
|
$ 138,000
|
$ 174,000
|
$ 311,000
|
|
Ophthalmology Retina
|
$ 219,000
|
$ 360,000
|
$ 516,000
|
Choosing to enter academic or private practice ophthalmology is a difficult choice for residents.
The academic career in general offers:
- a more intellectually and technically challenging and diverse clinical and surgical mix,
- freedom from many of the ?day to day? business operation details of running a small business (i.e. private practice),
- a certain degree of job security,
- a defined salary range,
- more opportunities for interaction with learners (e.g., residents and fellows) and other specialists, and
- prestige and status associated with a University title and affiliation.
The private practice career offers:
- more autonomy and control of business operation details,
- the potential for higher income, and
- more discretion and decision making leeway in scheduling, leisure time, case mix, and call schedule.
The resident in training should balance the advantages and disadvantages of each choice prior to making a final decision.
References
- http://www.aao.org/aao/about/eyemds.cfm
- http://www.ophmanagement.com/archive_results.asp?article=85973
- Pankratz MJ, Helveston EM. Ophthalmology: The resident?s perspective. Arch Ophthalmol 1992 110:37-43.
- Kay LE, D?Amico F. Factors influencing satisfaction for family practice residency faculty. Fam Med 1999 31 (6): 409-14.
- Weaver SP, Mills TL, Passmore C. Job satisfaction of family practice residents. Fam Med 2001 33 (9): 678-82
- Debas H. Surgery: A noble profession in a changing world. Ann Surg 2002 236 (3) 263-9.
- Gabram SG, Hoenig J, Schroedeer JW Jr., Mansour A, Gamelli R. What
are the primary concerns of recently graduated surgeons and how do they
differ from those of the residency training years? Arch Surg 2001 136
(10): 1109-14.
- Brian RS. Women in medicine. Amer Fam Physician 2001 64 (1):174-7.
- Bergus GR, Randall CS, Winniford MD, Mueller CW, Johnson SR. Job
satisfaction and workplace characteristics of primary and specialty
care physicians at a bimodal medical school. Acad Med 2001 76 (11):
1148-52.
- Mayer, KL, Perez RV, Hung SH. Factors affecting choice of surgical residency training programs; J of Surg Res 2001 98: 71-75
- Xu G, Rattner SL, Veloski J, Hojat M, Fields SK, Barzansky B.
(1995) A national study of the factors influencing men and women
physician?s choices of primary care specialties. J Acad Med 1995 70
(5): 398-404.
- Commonwealth Fund Report. Training tomorrow?s doctors: The medical
education mission of academic health centers. A Report of the
Commonwealth Fund, New York; 2002.
- Scott JR, Gunderson CA. A study of prospective ophthalmology
residents? career perceptions. Med Educ Online [serial online]
2003;8:9. Available from http://www.med-ed-online.org .
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