We would tread water for hours in high school water polo while holding a ball above our heads. The first to drop the ball would have to swim “suicide laps” across the pool. That feeling — of swimming suicide laps — basically describes how I felt during 14 years of “schooling” between undergraduate, medical school, residency, and fellowship, with the added element of wielding scalpels and delivering babies. When I finally came up for air, I was asked what type of job I wanted, attached to the commonly echoed advice, “pick a job that fits what you want.” The problem was that after so many years of focusing on learning the material, the surgical skills, the patient care, I felt completely uncertain of who I was and what I wanted. Further, I had spent the majority of my learning in the academic realm, so the idea of leaving academics felt frightening and ostracizing.
Recently, I have had to navigate the process of picking between private practice, hospital-employed, academic, and every position in between. I learned the generalizable differences between all of the above (and that there aren’t enough Reddit posts to guide what one should do).
Perhaps the most common choice for burgeoning MDs is between academics and private practice. The bare-bones approach to choosing poses the question, “Do you want to teach and do research?” But here’s the kicker: there are plenty of academic jobs that allow you to prioritize one or the other or neither. Even more confusingly, there are academic jobs that are categorized as “clinical” and yet expect robust teaching and research. One of my mentors was able to secure more research time in a tenure track position, given his robust research productivity and PhD. Another mentor made it very clear to the academic center hiring her that she had no interest in research and would like to remain solely clinical, with resident and medical student teaching. Not to mention that there are certainly academicians who are lackluster researchers and educators. A friend of mine told me he had an academic ICU attending who would excuse himself after rounds to “do rigorous research,” notwithstanding the fact that he rarely published. The key in any scenario is to get it in writing. Regardless of the promises given to you during your interview, nothing is as set in stone as a contract.
There are other considerations, too. It is generally accepted that in academics your pay will be salaried (with or without a productivity bonus, depending on the institution) and that it will likely be lower than your potential salary in a private practice setting. However, academic positions are associated with a progressive increase in salary as your RVU increases (and it is up to you to discuss the salary and professional advancement structure specific to each institution). In academics, there can be a sense of safety in knowing that regardless of your caseload/volume, you’ll be receiving the same salary. On the other hand, you may also end up working equally as hard as someone in non-academics who is making significantly more. Academics are also traditionally associated with administrative work, although the amount of time and days allotted to each clinician is variable, as is how exactly you spend your administrative time. Private practice positions, too, may also require administrative tasks. There are major medical centers whose bylaws require that administrative positions be filled by both private practice and academic faculty.
I’ve personally found that the best way to gauge each institution’s expectations regarding administrative workload is to ask its employees. It may be difficult to truly assess the rigor of each situation even when asking directly, so you may not know the true answer until you yourself are a part of the system. (Not helpful, right?)
In considering private practice, a crucial component is assessing the solvency of a practice. While your earnings may potentially be higher in private practice, the losses and risks to your own financial stability are potentially greater. For new physicians, who will need to build a patient base, a 2–3-year guaranteed salary is often offered in lieu of a production-based salary. Compensation models within private practice models vary; practices may offer a guaranteed salary (by either the practice itself or supported by a hospital), a salary based on revenue, a salary based on RVU production, or some hybrid of all of the above. Be certain you know who is guaranteeing your salary, as this is with whom you’ll have to discuss an exit agreement should you need to leave before your contract is up. Regardless of the model, private practice depends on a production-based model wherein practitioners earn what they heal (or “eat what they kill,” for lack of a better colloquialism). The benefits of private practice may include greater independence and decision-making. You may, for example, have a greater voice in hiring/firing, the setup of your clinic and schedule, the number of patients you see each day, etc. Within a larger academic or hospital organization, it may be difficult to dictate staff, schedules, OR time, etc.
A hospital-employed practice is an interesting example of a hybrid falling somewhere between traditional academics and private practice. Such practices may be production-based or salaried, or any measure in between. While some sense of protection may be incurred by working for a larger entity than a smaller practice, you also lose some of the independence afforded by private practice. Teaching and research are also variable by hospital and are affected by whether a residency or medical school is associated with that particular hospital. In my limited experience, hospital-employed positions are primarily focused on your productivity as a physician.
(As an important side note: COVID-19 has impacted many practices, as well as earning potential at institutions, both academic and private. There have been reports that academic physicians will earn 10–15% less this calendar year; private practices have also suffered due to decreased patient loads. Many practices have had to close entirely.)
The greatest lesson I have learned is that there is no standard for what private practice, academics, or hospital-employed positions look like. Each type of position is developing some fluidity, especially as there is greater demand for positions that fit different types of physicians. There are academic centers that are run like private practices with teaching obligations viewed as secondary to a clinical private practice, and there are academic centers that create paths to promotion based on teaching (counter to the “publish or perish” dichotomy). There are also private practices in which physicians can invest heavily in teaching, and potentially receive a stipend for teaching at a resident level. Even social media has even become a milestone by which some institutions may advance academic faculty.
The most helpful pieces of advice I received throughout my own decision-making process were to never accept the first offer I received, and to ask myself what my career goals were. There is always room for negotiation — whether it be salary, time allocation (clinical/academic/research), OR time, performance metrics, signing bonus, moving costs, call, educational/discretionary funds, licensing, dues, board examination costs, parking, benefits, or retirement plans. An EM friend of mine recently secured a position in academics; the institution was unable to leverage salary, but covered the entirety of her MBA training costs for her remaining semesters until graduation from fellowship. She is saving $20,000 as a result.
Be sure to research what someone in your field should be making. Yes, women are notoriously offered less. Do your homework. Ask about paid time off; does it accrue, or is it use-it-or-lose-it? What does medical/sick leave/ parental leave look like? You should evaluate each position for its malpractice insurance, its benefits, its vacation time and CME, the call schedule, and the non-compete clause or restrictive covenant.
As a final note, it must be acknowledged that asking you to know what you want and who you are at the outset of this process is a tall ask. Try to keep in mind that your first or second or 10th job may not be the “right” fit. As in your training, it's rarely about picking the right job at the right time — it’s much more about your journey and learning about yourself. Personally, I am excited by the opportunity to finally stop treading water, get out of the pool, and seize autonomy in picking which waters to dip my foot into next.
Did you struggle with the decision to choose your practice setting? How did you decide? Share your experience in the comments.
Dr. Muldoon is a minimally invasive gynecologic surgery fellow, a mother to the world’s tallest one year old and a 7-year-old Labrador, a wife to a kind Canadian, and an avid reader and fridge magnet collector. Dr. Muldoon is a 2020–2021 Doximity Op-Med Fellow.
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