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 .