Next to deciding whom to marry (if at all), where to live, and what to have for dinner tonight, two of the most important questions you’ll face in life are, “What do I want to do with my life?” and “Where do I want to do it?”

As you’re likely preparing to depart your clinical fellowship or are still early in your career as a retinal physician, in all likelihood you have the first question figured out. Chances are it’s the next series of questions that’s racking your brain: Do I want to work in an academic setting or a private practice? Large or small practice? Single-specialty or multispecialty? Do I want to be close to family or far away?

THE CHALLENGE OF THE TRANSITION

The truth is, many possibilities await you as a newly minted retinal physician, and it can be challenging to choose which path (or paths) to follow, especially because so much of your life up to this point has been out of your control.

Whether it’s an internship, residency or fellowship, most new retinal physicians have these programs selected for them, and the switch to choosing their own destiny, as it were, can be daunting. “In training, you would rank programs — ‘I’d like to go here first, there second, there third’ — and you could wind up at any one of the programs you put on your list,” explains Sunir J. Garg, MD, a retina specialist at Mid-Atlantic Retina and Wills Eye Hospital, both in Philadelphia. “There’s a bit of, ‘Geez, it’s not entirely in my control. It’s also just a 1-, 2-, or 3-year commitment, so you figure, ‘Ah, I can do anything for a few years.’”

But, now that the time has come to look for a “real job,” it’s the first time most retinal physicians will make such a major life choice on their own. Many find the prospect overwhelming, says Michael Seider, MD, a retina specialist and ocular oncologist at Kaiser Permanente of Northern California.

“We’re so used to getting the highest score and passing every test that it can be a difficult transition to the work world,” says Dr. Seider. “Everyone knows what the best med school is ­— get in there. Everyone knows where the best residencies are — get in there. Everyone knows where the best fellowships are — get in there. Then you go to get a job, and it’s like, ‘Wait, they’re not ranked? I don’t know what job to take.’”

Dr. Garg agrees. “It’s the first time a lot of us have to ask ourselves where we want to be, potentially for our whole career. It’s like marrying somebody. You go in with the full intention of being with this practice for the rest of your life, with the hope that it works out as you envisioned and intended. Sometimes it does, and sometimes it doesn’t.”

To make the transition easier and increase your chances of making that first job choice a success, these and other now-veteran retina specialists weigh in with their thoughts and advice.

GEOGRAPHY: DO YOU KNOW WHERE YOU’RE GOING?

Generally speaking, it’s important to set reasonable limitations on your job search with respect to two major areas: geography and type of practice.

“Part of your decision depends on where you want to live and, if you have a significant other, where he or she wants to live,” says Dr. Garg. “If you really like to surf, perhaps ending up in Iowa is not your best choice.”

“Geography is usually a limiting factor for many people, and it’s going to be a unique decision for each person,” says Daniel Kiernan, MD, a retina specialist with the multispecialty practice, Ophthalmic Consultants of Long Island, who completed his fellowship in 2011. “I was not geographically restricted, so I interviewed all over the country. But I was paying attention to details like distance to large city, cultural and entertainment options, international airport proximity for travel and visiting family and friends, and also urban versus suburban versus rural.”

One geographic aspect that shouldn’t be overlooked, Dr. Kiernan says, is the relationship between where you wind up living and the offices or clinics where you will be practicing. For this reason, he advises interviewing at every prospective employer’s clinic.

“It’s a bad idea to interview solely at, say, the AAO (American Academy of Ophthalmology) meeting or a retina society meeting and never see the practice where you’re actually going to work, especially if it has multiple locations,” he says. “Definitely look at a map and figure out how far away those locations are and how many of those location or locations you’re expected to work at each week, and what your other responsibilities might be.”

ACADEMIC OR PRIVATE PRACTICE?

Deciding the type of practice to pursue is also important to increasing your chances of a successful long-term choice. In ophthalmology, this generally means taking one of two roads: academic or private practice. The academic path confers certain advantages and benefits that may appeal to certain retinal specialists, says Dr. Garg.

“I enjoyed the research and teaching aspect of it. I enjoyed the liberties that an academic place gives you to focus on patient care with less of the emphasis on the administrative aspect of a practice,” says Dr. Garg, who spent his first year out of fellowship as an assistant professor of ophthalmology at Washington University in St. Louis.

“I enjoyed the collegiality there. I enjoyed having people in other ophthalmologic specialties, including basic scientists, in the same building,” notes Dr. Garg. “Intellectually it was a very vibrant environment where you continue to learn things that you wouldn’t normally be exposed to. And the department was very well-rounded, both in terms of breadth and depth of clinicians, clinician scientists, and basic scientists.”

“One of the benefits of academics is that you get to do a lot of different things,” agrees Dr. Seider. “You can teach, you can do research, and you can do clinical care. It’s fun and has variety.”

PRIVATE PRACTICE: SINGLE-SPECIALTY, MULTISPECIALTY, EVEN YOUR OWN PRACTICE

Choosing the private practice path, meanwhile, means also selecting from such options as single-specialty or retina-only practices; multispecialty practices; and, perhaps, even starting your own solo practice. As with academic practice, these options provide their own opportunities and benefits.

“If you are a very enthusiastic, business-minded individual, you might enjoy private practice more than academics,” says Dr. Kiernan. “You might even throw out your own shingle, which is a pretty reasonable option, especially in a less urban or rural location. Generally speaking, the more urban the location, and the more saturated the market, the harder it’s going to be to start your own practice, especially because the startup costs are going to be higher, too. But I still think it’s always an option for the right individual.”

For his part, Dr. Kieran felt a calling to the multispecialty model of ophthalmology practice.

“I interviewed in both (single- and multispecialty), but I found that I just liked the feel of the multispecialty group,” Dr. Kieran explains.

“There’d be a lot of referrals to me from people within my practice, but I also liked the idea of having a support system around me. If I have a patient with glaucoma or a cataract, I don’t have to reach out too far to get hold of someone I can trust.”

Nevertheless, Dr. Kiernan confesses that he sometimes wonders what it would be like to go back and join a retina-only practice.

“A lot of my friends are in them, and they are very happy and doing very well,” he says. “But it’s a different model, and you have to appeal more to your referral base and be careful about communication, like sending letters, texting, or emails. You have to make sure your referrals get those communications back because it’s not just like somebody you’re seeing, in the same office the same day.”

ALTERNATIVE MODELS OF PRACTICE

For those who appreciate the benefits of both academic and private practice, “hybrid” and other types of practices offer the best of both worlds. Both Dr. Garg and Dr. Seider practice at what could be termed “hybrid academic-private practice” clinics.

“We teach a lot,” Dr. Garg says of Mid-Atlantic Retina. “We have six clinical fellows at a time, and we have anywhere between one to three research fellows. We teach the Wills Eye Hospital residents regularly. We also have a very vibrant research unit, including a busy clinical trials unit. We have good research support that enables us to do a lot of original research. We get to help mentor our fellows and residents on how to conduct research projects so they can learn and develop their own research interests. And then we have a very large, private practice as well.”

Dr. Seider, who has funded research time and serves as volunteer faculty at UCSF, says, “To me, Kaiser Permanente is a good compromise for someone like me who really felt like I wanted to be in academics, but also wanted to focus on my family. I’m still seeing very complex patients and pathology, because nothing gets referred out of our system. In that way, we’re like an academic center. We can leverage the data from literally millions of patients in our system to complete great research projects.”

KNOW THYSELF — AND BE FLEXIBLE

With so many options available, even setting limitations may not be enough to ease a new retinal physician’s transition into the “real world.” In this case, perhaps the most valuable advice such doctors can heed is to know what they want — and don’t want — but also to retain a level of flexibility.

“It comes down to knowing yourself, knowing what your likes and dislikes are, knowing what your strengths and weaknesses are, and making your decision based largely on that,” says Dr. Garg. “It’s a very personal thing.”

At the same time, however, flexibility goes a long way, as circumstances don’t always play out as desired or expected.

“You might be the best candidate in the country for a practice you want to join, but the year you’re looking, they may not need anyone,” Dr. Garg says. “As much as we all have these great plans about what we want, where we want to live, where we envision ourselves, that just may not be available during your application cycle.

“There’s a certain degree of uncertainty and unpredictability in the process, which is just the nature of the beast,” Dr. Garg says. NRP