• Which Type of Practice Works Best for You?

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    Picking a practice type is a career-defining decision. To help you assess your options, EyeNet invited 3 oph­thalmologists to describe the pros and cons of their practice settings—a private practice, a Kaiser group practice, and an academic-affiliated Veterans Affairs (VA) hospital. (For perspectives on a solo practice, a multisubspecialty practice, and an academic practice, see the 2015 YO supple­ment.)

    Life in Private Practice

    Will Parke, MD, works at a 12-physician practice. The practice, which is retina only, has been around for almost 30 years, with the founding physicians still very much involved.

    What I like about working here. Four things attracted me to this practice, and they remain some of the biggest reasons that I love my job.

    The first is that I respect the clinical skill, judgment, and innovative acumen of my partners, and I enjoy talking ophthal­mology with them. In training, most of us grow accustomed to hanging out with other residents and fellows and comparing notes on a daily basis. I wanted a similar camaraderie in my job.

    Second, the physicians in my group have the freedom and ability to grow their careers in whichever way they like. Some have dug into public policy and professional organi­zation leadership, some into research or device development, others into teaching.

    Third, the group is very collaborative and in­clusive regarding practice management decisions. Right from day 1, I’ve known that if I bring an idea to a board meeting, it’ll receive a serious appraisal.

    The last factor is that we treat our responsi­bility as employers very seriously, and we take great pride in providing rewarding jobs for a large number of people.

    None of these characteristics is necessarily specific to this practice setting, but private practice enables us to mold the structure and culture of our organization to reflect our priorities.

    Downsides to my practice type. Private practice be­comes a daunting place if you don’t strike the right balance in your approach to practice management—proactive and deliberate, but not obsessive. If you’re not careful, it is easy to get lost in the weeds of business minutiae. On the other hand, details do matter, and topics like billing, employee benefits, office leases, or accounting can evolve as quickly as our clinical practices do. Sticking your head in the sand and eschewing tough business decisions is a recipe for unsus­tainability.

    What surprised me most. Coming out of fellowship in an academic institution, I was stunned at how nimble a private practice can be. Big decisions are appropriately made much more deliberately than small ones, but once they are made, they are enacted very quickly. The bureaucratic hurdles are a fraction of what we’re used to in training.

    What my day is like. For clinic, I am in a different loca­tion each day of the week. I usually have 1.5 to 2 days of sur­gery per week. I’ll start either clinic or surgery at 7:30 a.m. but try to arrive a little early for both in order to take care of emails or paperwork. A lunch break is a memory from medi­cal school that I look back on fondly. Surgery usually finishes in the early afternoon and clinic around 5 p.m., after which I try to spend an hour or so on research before heading home.

    In summary. Private practices differ wildly. Rather than decide broadly on private practice versus the alternatives, you should first figure out what you want in your career. Next, check out a few private groups with a culture that will enable you to pursue it.

    Life in a Very Large Group

    Diana R. Shiba, MD, joined a medical group that is part of one of the largest integrated care delivery systems in the United States—Kaiser Permanente. Working for a Permanente medical group has been simply a dream come true. I have incredible work-life balance, great compensation and benefits, and can practice medicine the way I always intended to—without worrying about the business of running a practice. Nationally, there are 18,000 physicians in the various Permanente Medical Groups. In the Southern California Permanente Medical Group (the one I’m part of), we provide care to more than 4.2 million patients a year. In California alone, there are more than 200 ophthalmologists who are part of the same system.

    What I like about my practice. On a personal level, there is a strong emphasis on physician wellness and work-life balance in our practice. For example, I have a flexible sched­ule that allows me to have a day off during the week to spend with my 3-year-old twins, Zoe and Noah. There is paid educational time, which allows us to teach, conduct research, or attend conferences. Our benefits package has competi­tive compensation (it’s more than the package offered by a well-respected private practice) and includes a pension plan. Professionally, I love being able to go to work, log on to our electronic health record (EHR) system, and just concentrate on my patients. I don’t have to focus on coding or running a business, and I have the financial security of knowing that our integrated system is well poised to weather the changes happening in health care. Having access to such a large group of physicians (across all specialties) has also made coordinat­ing care with other specialists easy.

    Downsides to my practice type. I do have less autonomy than a physician in solo/private practice—I cannot just reschedule my clinic and go to the golf course on a whim. There are also multiple levels of management, and implementing a large practice change may take more time than if you work in a private setting with, say, 4 other ophthalmologists.

    What surprised me most about my practice type. I have found that navigating upper management has not been as difficult as I thought it would be. If anything, management has been supportive of my professional growth. I’ve also been impressed with the EHR system we use. With 1 click, I can order or review an MRI, email a patient, or contact a colleague at a distant medical center.

    What my day is like. I start my clinic at 7:30 a.m., with my last patient at 3:15 p.m. I see approximately 24 patients a day, and have a 1-hour lunch. I have a colleague who starts at 9 a.m., and this flexibility allows her time to drop off her son at day care prior to work. At my center, we all have 4-hour blocks of OR time weekly, as well as built-in educational time, and weekends off. I also have administrative time that I dedicate to advocacy work for the medical group.

    In summary. I believe working for a very large medical group has many more pros than cons, and it has enabled me to find happiness on both a personal and professional level.

    Life at an Academic VA

    Roma Patel, MD, MBA, combines resident teaching with independent practice. After completing residency at the University of California, Davis, and a glaucoma fellowship at Duke, I returned to the Sacramento VA where I had worked as a resident. I am currently the chief of ophthalmol­ogy for the Sacramento Mather VA and an assistant clinical professor at the UC Davis Eye Center. Our VA serves as the subspecialty referral center (glaucoma, retina, and cornea) for most of the Northern California region. My clinics are focused on secondary- and tertiary-level glaucoma care, I operate independently on my glaucoma patients, and I teach residents cataract surgery and clinical skills.

    What I like about my practice. I love that I work with close friends and great colleagues, I enjoy teaching residents, and the veterans are wonderful to work with as patients—they are extremely grateful, recognize our team’s ability to provide great care, and have a great viewpoint on life and on what is im­portant.

    In our closed system, patient-related finances are the least of my worries. I can choose the appropriate care for my patient without concern for insurance approval or the ability of my patient to pay for medications or surgical proce­dures. The level of glaucoma pathology is high at the VA, and I feel fulfilled and challenged by uti­lizing the full capacity of my training and skills. As a young mother, I appreciate the perks of not taking primary call and having a stable income with ample guilt-free paid vacation time. Depending on your VA, you can have supported time and funds for research, attending conferences, and attending leadership courses.

    Downsides to my practice type. Working in a VA can be challenging. You sometimes have fewer resources than your colleagues in private or academic practice—less technical and ancillary support, for example. Furthermore, due to employee protections, it is hard to find accountable nonphysicians, but I have begun to build my network. As chief, I have many responsibilities in addition to my patients—I am trying to improve and grow our staff, increase our effi­ciency and access, and I am working on plans for our new eye clinic. As a part-time professor, I am exploring possible minor research projects, and teaching often takes longer than just doing it yourself. It can be hard to balance all of this.

    What surprised me most about my practice type. I have learned that each VA is very different. Much depends on leadership and the structure of physician teams. Those that are closely academically affiliated are often filled with excel­lent physicians and have a higher level of care. Some VAs are structured such that only residents operate—this might not be the best choice for a young ophthalmologist, as you need to nurture your own skills early on in your career. The VA funding is also interesting in that it is easier to get equipment funded than personnel.

    What my day is like. In a typical week, I am in my glau­coma clinic 2 days, in the OR 1 day, have administrative/academic time for 1.5 days, and supervise consult residents at UC Davis for half a day. I start work usually around 8 a.m. Clinical work is finished by 4:30 p.m., but I tend to stay until 6 p.m. for my administrative work. Once I am home, I try to focus on family and home life.

    In summary. VAs across the country are looking for po­tential young leaders. If you are keen to teach residents but not so excited about doing research, it could be the perfect fit. And you would be hard pressed to find a more grateful patient population!

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    D. Wilkin “Will” Parke III, MD, practices at VitreoRet­inal Surgery in Minneapolis. He is a member of the YO Editorial Board. Financial disclosures: None

    Roma Patel, MD, MBA, is chief of ophthalmology at Sacramento Mather Veterans Affairs Hospital and assistant professor of clinical ophthalmology at the Davis Eye Center, University of California. She is a member of the YO committee. Financial disclosures: None.

    Diana R. Shiba, MD, practices at, and is director of government re­lations for, the Southern California Permanente Medical Group. She also chairs the YO Advocacy subcom­mittee and is a board member of the California Medical Association. Financial disclosures: None.

    For more articles, click the section links under “YO Guide Content.”