FEATURE ›› CAREER PATH

FINDING THE RIGHT Place to Practice Retina

21st century advice for specialists seeking a first job in private practice.

BY SUSAN WORLEY, CONTRIBUTING EDITOR

After completing a successful fellowship, the retina specialist who aims to enter private practice must clear one more major hurdle before launching his or her career: finding and securing a first job. Yet, particularly in the current era of rapid change and uncertainty in healthcare, very few new specialists feel adequately prepared to conduct an efficient job search.

“At this point in your career trajectory, you and your mentors have invested an enormous amount of time in ensuring that you’re the best possible retina surgeon,” says Vincent Hau, MD, PhD, a vitreoretinal surgeon at Kaiser Permanente in California, and founder of the Fellows-in-Training section of the American Society of Retina Specialists (ASRS). “So, now that you’re ready to enter the marketplace, you may be prepared to perform as a clinician, but chances are you’re still in need of real-life lessons on how to be a business person.”

For specialists still honing their surgical skills, the need to suddenly shift gears and begin developing business acumen can be disconcerting. Moreover, there may be an inclination to rush into early career decisions because of pressing financial concerns, such as the need to pay back school loans. However, pausing to develop the critical tools you need to properly evaluate employment options can give you a significant advantage in today’s job market.

“It’s important to take the time you need to thoroughly vet a potential employer,” says Dr. Hau, who has lectured on the topic of early career choices at annual ASRS meetings. “The process may involve considerable research, and a great deal of time spent talking with colleagues and mentors, but due diligence will undoubtedly increase your chances of making a wise choice. I often tell fellows that searching for your first job is much like speed dating. Your exposure to potential employers may amount to a relatively quick series of interviews, ranging in length from a few hours to an entire day or even two. And then, after very limited interaction with each potential partner, you have to decide whom you want to ‘marry’ — perhaps for the rest of your life.”

Hau and other experienced practitioners recommend finding resources to help you develop an internal checklist or evaluation system you can bring to job interviews. Several prominent organizations, such as the AMA, AAO and ASRS offer online business resources, presentations, and tools that can help you get up to speed quickly. Here are a few important points to keep in mind while interviewing.

PREFERRED PRACTICE SETTING

When you begin the search for your ideal job, your preferences with regard to the geographic location and type of private practice (whether large or small, multi-specialty or retina-only) will be among your earliest considerations. Many experienced practitioners say it’s wise to remain flexible with regard to these criteria. Among them is Rizwan Bhatti, MD, who trained and mentored retina fellows at an academic institute at USC for several years before joining a retina-only practice and eventually launching a successful solo practice in Pasadena, Calif.

“Immediately after fellowship, there’s pressure to get a job and start working right away,” says Dr. Bhatti. “When you have a particular geographic area in mind — such as a certain city or a place near your hometown, sometimes it can be difficult to find a good match in that area. If that happens, you have two choices: you can accept a less-than-ideal job in the area where you want to be, or you can take the best job available to you a small distance away or in another part of the country. I’ve seen fellows make both choices. Down the road, people who compromise and take a less-than-desirable job in a preferred area can sometimes wind up frustrated, and usually end up leaving that first job. People who accept the best job, regardless of the geographic area, usually are happier and have better options in the future.”

Dr. Hau advises also keeping an open mind when deciding whether to work with a retina-only, multispecialty ophthalmology, or broader multispecialty group.

VINCENT HAU, MD, PhD

“It’s easy to become accustomed to a certain type of practice during fellowship,” says Dr. Hau. “But it’s important to see what other types of practices have to offer. Because I became familiar with an academic setting during my training, I arranged, through an elective, to do some work in a large retina-only private practice. If you can’t arrange that type of experience, do what you can to investigate other options through research or conversations with colleagues. There are pros and cons to working in each of type of practice, and it’s best to know what they are before making a decision.”

While very few retina specialists enter into solo practice immediately after training, some hope that a first job might give them the knowledge they need to go solo.

“My previous experience in a large multispecialty practice, and later in a small retina-only practice, was integral to my success in solo practice,” says Camille Harrison, MD, who now runs a solo practice in Rancho Mirage, Calif. “When you’re just coming out of fellowship, many facets of working as a clinician in private practice are still new to you. Adjusting to these things while learning how to run a business on your own can be overwhelming. By the time I started a solo practice, I was comfortable in my role as a clinician, and I knew exactly how an office should be set up and managed, so I wasn’t taking on everything at once.

“If you’re thinking about taking a job as a stepping stone, try to find one that will give you exposure to the business side of a practice, with an employer who’s willing to mentor you about running a practice,” Dr. Harrison says. “You’ll want an inside look at the HR process, the hiring and firing, and the way a practice markets their business. And you might consider starting out in another geographic area, so that when you leave, competition isn’t a concern.”

WHAT ABOUT YOUR CONTRACT?

During your job search, you’ll likely feel bombarded by a huge amount of information about the different practices you visit. Visualizing the way each new fact will ultimately affect your contract is one of the best ways to organize this information.

“One of the foremost things to keep in mind while considering options is what your contract will eventually look like,” says John Kitchens, MD, a partner in Kentucky’s largest retina-only practice and director of the Young Physicians Section of the ASRS. “Retina contracts can differ considerably from other standard physician contacts. It’s important to understand how contracts are written, and what to look and listen for during interviews. You’ll want to know, for example, how a practice deals with hard assets such as equipment, and how the practice depreciates those assets. It’s also essential to understand how the practice handles drug acquisition and reimbursement. And you’ll want to learn whether a practice owns its building and facilities. These are just a few of the things that will impact your contract, particularly if you intend to buy into the practice in the future.”

TECH SAVVY PRACTICE?

If a practice is sound, it should be easy to spot evidence of a significant investment in technology. If a practice appeals to you, but doesn’t seem quite up to par in this area, be sure to ask detailed questions about plans for the future.

“You want to make sure you’re going to have the technological support you need to operate smoothly on a day-to-day basis,” says Thomas Stone, MD, fellowship director and partner, Retina Associates of Kentucky. “If you see evidence that a practice hasn’t made an investment in technology, particularly with regard to their imaging equipment, that’s likely to be a red flag. If, for example, you’re the first retina specialist in a multispecialty practice that doesn’t have imaging equipment, you’ll want to know the practice’s plan for purchasing that equipment, and you’ll have to ensure that an acceptable arrangement is written into your contract. If you’re not comfortable with the imaging or any other kind of equipment, make that part of your initial discussion, because it’s something that will affect you all day, every day when you’re seeing patients.”

Dr. Stone adds that the quality of the practice’s EHR system is another good litmus test for determining whether a practice is technologically up to date. Rishi Singh, MD, an information technology medical director and retina specialist at the Cleveland Clinic, concurs.

“When you’re evaluating a practice, a robust EHR system is generally a good sign,” says Dr. Singh. “Such a system allows for a high level of efficiency and financial transparency compared with a paper system, and generally contributes to lower overhead for the practice. Eventually all practices must adopt EHR, so the question is: how far along is a given practice with regard to that transition?”

Adds Dr. Singh, “The technological sophistication of a practice can be very revealing. I once visited a practice with an excellent reputation. I watched some of the physicians loading boxes and charts into the back of a car, and discovered the practice routinely did this to transport data to different destinations. It surprised me that the practice didn’t have a more sophisticated system in place. In my opionion, the degree to which a practice is willing to invest in technology can tell you something more important about that practice than its starting salary or number of locations. In this era of rapid change, obsoletism also can be a concern. Even if a practice appears to be running smoothly, you need to investigate carefully so you can anticipate how it will be running 5 years from now.”

REVENUE AND PATIENT BASE

“If you’re told during the interviewing process that you’ll be expected to grow your own practice, that’s something of a red flag in my opinion,” says Dr. Kitchens. “While everyone in a practice may be expected to bring some patients in, I think when you’re first getting started, it’s important to know that you’ll be fairly busy right away; you don’t want to have to wait to develop your own patient base from scratch.”

Dr. Kitchens says an important related issue is a practice’s method for distributing income. In some practices, he says, each member of the practice is paid strictly according to the number of patients he sees, and there is no shared revenue.

“That can create a hostile environment,” says Dr. Kitchens. “Especially if you feel you must compete with other members in the practice for new patients. In some practices, everything is split equally, and that may work well if all of the doctors in a practice are equally driven. But it might not work well if you’re a newcomer, and after you start, one of the senior members suddenly starts taking 4-week vacations and doing less work. You may be splitting the revenue equally but doing more than your share of the work.

“Each practice has different ways of dividing income and different expectations regarding bringing new patients into the practice,” Dr. Kitchens continues. “Some practices may use a hybrid model for distributing income — half of the income may be split equally and the other half may be based on productivity; so, if you want to work harder and see more patients you can increase your income, and if you like to attend meetings or take a moderate amount of vacation, you may be able to do that without feeling the full financial crunch. It’s important to understand how income and overhead are shared, how these things vary in retina-only and multispecialty practices, and how this will be written into your contract.”

CULTURE AND VALUES

“Based on my own experience and that of my colleagues,” says Dr. Bhatti, “more important than anything else, is joining a practice where people have similar ethics and similar beliefs about patient care. You can have the greatest IT in the country, but if you’re not working with the right people, you’ll have problems. Flip it around and if you’re working with great people and the IT isn’t the best, you’ll find a way to work through that problem. Personalities and values are of paramount importance, because good people will do the right thing over time, no matter what kind of problems you face. A key inquiry should focus on practice turnover.”

Mark Abruzzo, a Pennsylvania attorney who specializes in providing legal counsel to retinal physicians and other ophthalmologists agrees that it’s important to ask about turnover, and also recommends learning as much as possible about the personalities in a practice before accepting an offer.

“Everybody is putting their best foot forward during the interview process,” says Abruzzo. “So it’s wise to find a time, perhaps during a dinner, when you can shift the topic of conversation from business to something more personal. Allow the members of a practice to open up and reveal a little about who they are.”

At the same time, Abruzzo cautions against revealing too much about yourself.

“If you say, ‘I can’t wait to come to this area because my spouse’s family is here and we’ll have someone to watch the kids’, you’ll lose negotiating leverage.”

WHY IS THE PRACTICE HIRING?

Understanding a practice’s motivation for hiring is critical part of learning about its culture and values, says Abruzzo. “When I review an employment agreement, the first thing I want to know is why the practice is hiring. There are too many groups out there who mistakenly believe that if they hire a fourth or fifth doctor, the volume will come. The environment is so competitive today that you can’t just add a new specialist without foresight. You want to know what’s going on in the community, and why a practice might be interested in expanding. Is the practice buying additional offices? If you’re the new person coming into the office, are you replacing someone who’s retiring? If so, that’s often a good situation. Spend time getting insight into the practice’s reason for hiring.”

MAY I SHADOW?

As you near the end of a search, you may want to consider one more precaution.

“Here is some advice that didn’t occur to me when I first came out of fellowship,” says Dr. Harrison. “If you’re seriously considering joining a group, why not ask if you can visit for a few days and shadow one or more specialists in the clinic? I’ve heard so many doctors say that after working in an office for just 1 week, they discovered all kinds of troubling things that they never picked up on during the interview. For example, I’ve heard about technicians who were so inexperienced that they significantly interfered with the day-to-day functioning of the practice. Spending a couple of days in a practice can also give you a better sense of the culture, for example, how the staff interacts with patients. This will help you determine if it’s going to be a good fit for you.”

But will most potential employers agree to a request to shadow?

“If an employer says no to that request, I think you have to wonder what they might be hiding,” says Dr. Harrison. “If my request to shadow were denied, I never would have considered taking the job.” NRP

RESOURCES

›› aao.org/ophthalmologyjobcenter/

›› asrs.org/employment