Choosing a Practice Setting: Will You Work in a Private, Academic, or Hospital-based Setting?

Thorny decisions are the daily diet for practicing neurologists. Even so, one of the most difficult professional choices faced by most physicians will not involve patient care, but a more personal question: Where to begin their careers. The issue quickly transcends the simple matter of geography and rests instead on the choice between settings. Academia? Private practice? Hospital employment? All have their pluses and minuses, says Bruce Sigsbee, MD, FAAN, a current board member and past president of the American Academy of Neurology.

As a retired private practice physician whose first position was in academia, Dr. Sigsbee has paid special attention to this issue. Citing both anecdotal and statistical data that suggests higher turnover rates for doctors in their first years of practice, he advises new physicians to make their initial selections with care. Although changing positions is always possible, the stakes can be high. For example, a false start in the wrong setting could result in uprooting your family to a new location or the loss of a bonus tied to your tenure in the position. If your employment contract includes a restrictive non-compete clause, changing positions can become even more complicated.

And yet, leaving can become imperative if the setting proves to be less tenable than originally thought. It’s not unusual, for instance, for doctors to feel they don’t fit culturally or professionally in their new place of employment. Sometimes the contract itself changes, moving from a very attractive package initially to one requiring more work for less money after the first year. And sometimes the issue isn’t with the work or the physician, but with the physician’s family. If the doctor’s spouse can’t tolerate the new location or the physician’s work conditions, things are bound to get rocky. One last reason physicians sometimes regret their first choice of employment? As Dr. Sigsbee notes, “People come out of training with expectations and things aren’t what you expected at all. You get a lot of training about neurology or your specialty but you don’t get any business training or the basics of the workplace.”

One could argue that the schools should do more to prepare doctors for the realities of the workplace but they are already accommodating an ever-increasing amount of training. Perhaps no solution would be more effective than a combination of self-education by physicians on their employment options and a higher level of selfadvocacy when making their decisions. To help you with that endeavor, here’s a brief primer on each of the three main areas of employment for neurologists.

ACADEMIA

Variety: In 2014, 33 percent of all AAN member neurologists were employed in academia, positions which typically combine three areas of focus: Patient care, research, and teaching. The work can be very appealing for a number of reasons, including the variety of daily duties and the opportunity to focus deeply on a primary area of interest. However, the same level of variety can be the down side, particularly if you’re motivated most by the opportunity to research. In choosing this work, Dr. Sigsbee cautions, “You need to know how much protected time you will have. If they burn up all your time with meetings and teaching and you can’t focus on the research, you won’t do as well.”

Location and Compensation:

For obvious reasons, academic employers are limited in their numbers and their locations tend to be university campuses. Presuming you enjoy an academic setting, this will not pose a difficulty. On the other hand, the cost of living in some sought-after locations can present a problem for physicians just beginning their careers. “In academia, you tend not to be paid as much initially,” Dr. Sigsbee notes. “You work hard at the beginning and it takes a while to get established and get bigger grants. The ramp-up time is hard and you and your family have to be able to tolerate that.” 

Decision:

Lower initial pay and a plethora of sometimes conflicting duties may not be detractors if you dream of finding the next big cure or hearing “Professor” in front of your name. As Dr. Sigsbee says, the down sides can fall away quickly in light of the “enormous intellectual stimulation” of academic work.

HOSPITAL EMPLOYMENT

Growth and Stability: The fastest growing segment of employment for physicians, hospitals employed 22.7 percent of all AAN member neurologists in 2014. Merritt Hawkins, in their 2012 Review of Physician Recruiting Incentives, reported that 63 percent of their search assignments to place physicians were for hospital employment in 2011 and 2012—up from just 11 percent in 2004. Reasons vary for the growth in hospital recruiting but physicians’ affirmative responses center on such motivations as the steady paycheck, often generous signing bonuses, and student debt retirement. Analysts of hospital employment caution that they’ve seen this trend before—in the 1990s when a surge of hiring led to physician over-staffing and rounds of layoffs. But of course, analysts haven’t seen anything approximating the current economics posed by the Affordable Care Act and other drivers of the hiring trend, so it’s difficult to draw parallels between the two periods. 

PRIVATE PRACTICE

On the decline: With 24 percent of all AAN members in 2014 working in private practice or as the owner of a solo practice, this option is not under-represented for employment. But indicators show that it may be on the decline, with practices being bought by hospital groups and solo practitioners turning in their shingles in pursuit of a steadier paycheck elsewhere. Dr. Sigsbee, who worked both as a solo practitioner and in practice with others before retiring, can recommend a sequence before launching out on your own: “It’s much easier to go into practice with others. Once you’ve done that, then maybe it’s a better time to go off on your own.”

Independence vs. Balance: One clear appeal of solo practice and to a lesser degree, practice with others, is the level of autonomy. Not only do you see the patients on your own terms, but you have the opportunity to work with the same patients over a lifetime. In the case of chronic care, this can be either very rewarding, or potentially dull, depending on your tolerance for followup care and your use of advanced practice providers to handle some of the repetitive consults. In either case, you’ll be balancing your patient care with administrative duties, ranging all the way to hiring, billing, and purchasing equipment if you’re in practice for yourself. Having walked this path in the two independent practices he established, Dr. Sigsbee recalls with chagrin “getting absolutely killed by the schedule” when he worked 15- hour days in his first practice. It took four years, but when he changed locations he established new patterns that better served him and his family.

Decision: For most physicians, the choice for private practice will stem from their own personalities and drive for independence. If you choose to practice with others, Dr. Sigsbee would urge another criteria as well: Culture. “You need to understand that private practices can really differ in their dynamics and how they’re set up,” he says. “Some will have a real focus on life balance and some will not. Some groups go off in separate directions after work and some are together all the time, even at family events. You have to decide what kind of person you are and what you want to be involved in before you can make a good decision about which practice to join.”

RETENTION MATTERS TOO

Whichever route you choose for your first (or next) position, you’ll do better if you set yourself up for success. In addition to advocating for your terms of employment (visit AAN.com/careers for articles and webinars on negotiating), consider asking for a mentor or other onboarding support to help you adjust to your first year or two in the position. Then monitor your goals and your satisfaction every few months to be sure you are on track. With careful selection and tracking, you’ll be on the path to the fulfilling career you’ve been preparing for.

THREE STEPS TO HELP YOU CHOOSE YOUR PRACTICE SETTING

Here are three steps to help you discover which practice setting would fit best for you and your family.

1. Take a personal inventory. It’s been a long time since you launched yourself on the path to medical school and residency. Now is a good time to review your goals to confirm what you need in your next position. Start by looking at your long-term goals: What would you like to have achieved before you retire? Now, move the needle back by asking, What stepping stones will help you reach those goals? Finally, review your current needs and interests to identify the best starting point for the next chapter of your career. 

2. Take some tours. If you’re seriously considering one or two facilities for your next employment, or even if you’re still at the beginning stage of your planning, a physical tour can help clarify your thinking. Some organizations (notably hospital systems) will have physician recruiters who can set up a tour and meetings with others on staff. In other cases, you may have to introduce the idea and follow through by requesting to shadow certain aspects of someone’s work. 

3. Meet with other physicians. The AAN Annual Meeting is an excellent venue for casual but directed conversations with physicians currently practicing in the settings you are considering. To prepare, identify the questions you might like to ask of someone currently in private practice, in a specific hospital or academic setting, etc. and then attend social events at the meeting like the Capitol City Celebration or Exhibit Hall Opening Reception, and strike up a conversation with those next to you. A few minutes of conversation is often enough to start a new professional relationship. 

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