Private practice versus academics

[canadianoutlaw]

I suspect most of the forum members (aka "Dahlers") are in private practice (simply because there are more PP doctors in the US). Are there any academic docs out there? I'd be interested in hearing how you justified pursuing academics over private practice from a financial standpoint. In academics, it seems you get paid less yet are expected to work just as hard. Its just that you are expected to produce research (or teaching, etc) (opposed to RVUs, but even that is not necessarily true in some centers) but you are not necessarily directly compensated for the extra work you do. Can anyone speak to this? Were you motivated to do academics because you found: the risk of burnout less? Career satisfaction higher? Job security higher? Schedule more flexible/family friendly? Less fee-for-service and drive to create more "health care"? etc. As a resident, we get zero-to-no exposure to the "real world" of private practice. I guess a lot of it is specialty-dependent so it may be hard to comment on this. But I've never heard the WCI comment on this topic.

[tex]

The answer to your question will be VERY different depending on specialty and location, as well as I'm sure the disposition of person answering. Even within a given city, the pp (or academic) jobs may be very different from each other, and at least in my field the nature of pp vs academic is starting to overlap quite a bit in some places.

FWIW, I'm just out of fellowship, restricted to one city for the job search. Though I would consider myself the "pp type", the handful of small pp groups in town were either too geographically far away to where we needed to be for the wife, of questionable job security (ultralarge for-profit corporation and large non-profit have > 90% of the business in town), or practice medicine pretty differently to the point where I'd probably go crazy.

I chose the non-profit for the quality of medicine practiced, work-life balance, high job security and flexibility to remain in the city if needed, competitive salary tied clearly to the amount of work I do. The more traditional academic job I considered had poor work-life balance and scholarly productivity expectation that was not tied clearly to compensation. Your situation may be completely different, but at least some things to think about. It will take some investigation on your part to see what the jobs you might take are actually like.

 

[conniebird]

I'm in academics - IMO you do academics because you want to, not for the $$.

I can only speak for myself - I do make less than my PP counterparts from residency, BUT I also live in a HCOL city where all MDs are paid less. That said, I make the most in academics for my area. I wouldn't say it's a lot less than PP- I work 4 days a week, average 15 patients per sessions. I have a base salary plus incentive and I do make incentive.

I chose academics because I have a niche that can only be done in academics. I love working with residents and have smart colleagues. I would be very lonely in PP and honestly, I think I would atrophy significantly. I work for a very large health system so the benefits are pretty awesome - the 403b match is more than my max contribution. The system also has higher negotiated insurance reimbursements.

I'm not sure if I would make a lot more in PP for my city and I would def need to say a lot more patients.

It's a personal decision - I was told if you aren't sure, to start out in academics, you can always switch to private later, but it rarely happens the other way around.

[Zaphod]

It definitely depends as you can see above. However, most of the people I know in surgical specialties...we get paid similar/more for significantly less amount of work. Where I trained the attendings worked like crazy, almost like perma residents. Im sure they make decent money, but they are being crushed.

On the other hand I work about 3.5 days/wk, no hospital, call or weekends ever and likely make more than my old attendings or near the tenured/chief levels. Of course I have to pay my own benefits, but I can max a SEP and do a defined benefits pension as well giving me even more space if possible. Just not rounding ever gives me 2-4h/d, do not miss going to the hospital.

I could make more and wouldnt mind that, but I get paid well for time spent and thats really all that matters to me and how I've arranged my life. In my first 6 months I cut whole segments of not worthwhile patient populations/procedures off and focused on what made most $/time spent, etc...I like being in control of what I do and how much I make etc....plus the extra time with the family. Every now and then I feel like I need to make more money, but then I think about the time I have, and the diminishing returns due to taxes and am happy again.

[Hatton]

I have always been in private practice. I think some people in my field (Ob/gyn) do quite well in academics.  They have lucrative side gigs in the realm of expert witnesses. I have been through a trial and my attorney kept referring to the plaintiffs expert as the million dollar woman because she had made that amount as a plaintiff's expert. I don't know how common this is and if academic experts in other fields make this kind of money but they can in Ob.

[jhwkr542]

In my particular city and specialty, the academic docs make the most in the city. However, they work more with longer hours and less vacation and less control over their business.

[Sneezy]

I would say the reasons I've stayed in academia are

1. I like doing "academic" things particularly teaching fellows and residents (and students).  I really enjoy this, have directed a fellowship in the past, and get a lot of satisfaction out of training the next generation.  I also enjoy doing some research.  I also like only doing clinic 2-3 days a week and spending the other time on research/teaching/administration

2. I enjoy being around so many smart people who are also interested in academic things.  I like the conferences and having time to discuss odd/unusual patients in my field.  Call is also much less because of more partners, but time on call is busier than it would be in PP

3. Stability. You read about private anesthesia or ED groups losing contracts.  I'm sure the docs don't g hungry but this is unlikely to happen to clinical faculty at an academic center (at least not this abruptly).

4. Being part of a big enterprise can be helpful with things like EMR and meaningful use.  A practice has to decide which vendors to use, pay for the software and hardware, worry about compatibility with local hospitals, etc.  Being part of a big group (this would apply to large multi specialty practices as well) means someone else is doing the heavy lifting on this.  We still complain just as much, though 

5. The money varies.  My first job I probably made 50-70% of what I'd make in PP.  In my current job it is probably close to 100% of someone who just does clinic while I work less clinical hours.  The guys who are entrepreneurs and build big practices still make more.  I am an "expert" in my fields and make some money doing consulting and expert testimony.  This generally pays less well than you might think (say $300-500/hour) but is interesting and a change from the routine

Downsides include

1. Politics.  I had to move from my first job because of this.  While this worked out great, it wasn't the most pleasant thing to go through

2. Lack of control.  Sometimes the hospital does stupid stuff and there isn't much we can do about it.

3. Lack of respect.  In many academic center, anyone who isn't a multiple-RO1 funded researcher is a second class citizen, even thought the vast majority of revenue and profits are generated by clinicians

 

Overall, I've really enjoyed academics and would do it again, but it isn't for everyone

 

[The White Coat Investor]

I spent my first three years splitting my time between academics and private practice. Choosing between them is a lot more like choosing a specialty and a lot less like choosing a job within a specialty. Things are just so different.

An academic needs to actually like doing clinical work with residents and students. While I liked teaching, I found I missed actually going in and taking the history and doing the exam myself. An academic needs to be patient with the reduced efficiency of an academic environment. When you call a consult, you get a student, then an intern, then a junior resident, and then the chief resident who calls the attending, and then the intern communicates the recommendation to you three hours later. When a private practice doc calls a consult, noone comes in but you get the answer in 2 minutes. An academic always has a project hanging over their head. There is no "just taking care of patients." That's something I dislike about WCI- there is always work to be done and you have to be good about setting boundaries in your life. If your only job is working shifts, then when you're off you're off.

At any rate, if you're not sure what you want, start in academics. Much easier to go from academics to private practice than vice versa. Plus, you're more likely to get PSLF.