Retina fellowship is the final step in the lengthy process to become vitreoretinal surgeons. The applications, interviews, and the constant transition to the next phase of training have been mastered. Making the upcoming transition from an apprenticeship (fellow) to a practitioner has many comfortable components (like updating a CV and interviewing). The next step, however, is not a time-limited position. You will not enter a lottery system and “match.” Chance plays a smaller role in the next step; you will have the opportunity to choose your environment. Choose carefully and try to reduce the chances that you will be looking for a new position in a few years.
At the time of this publication, the majority of secondyear retina fellows have secured next year's position. This article will be a review of what you already know. For firstyear fellows, the content of this article will come as no surprise, but it is worth taking time to think about what you want from your career and then taking the necessary steps to make that happen. Also, it may be worth reviewing previous Fellows' Focus articles relating to contracts and negotiations as you proceed through the process.1,2
You will be making many decisions as you begin your search for the ideal job. The best advice you receive will come from your mentors and your peers, so do not hesitate to discuss your opportunities with them. It is likely that they have garnered valuable insights from their own experiences.
LOCATION
Although it may seem obvious, remember that you
must select a location where you and your family can live
and be happy. You may have heard the phrase, “Go where
your spouse will be happy, then you will be happy.” It is
easy to fall into the trap of looking for what you consider to be the best job and sacrifice location. The detrimental
effects of such a decision are likely to ripple through both
your professional and personal lives. Assess locations prior
to investigating job opportunities, and only pursue those
that are in suitable locations. The perfect job, in the
wrong location for you, is not the perfect job. Almost certainly,
practicality will win in the end, and you will have
wasted precious time on a job opportunity that you ultimately
decline because of unsuitable location.
If there is a particular location where you would like to build your life and career, it is never too early to begin exploring opportunities. Make contact with as many of the practices in the area as soon as possible. We all want to be the person who started looking incredibly early and found the ideal job years in advance. Typically, a practice will spend many months in preparation prior to choosing a new associate. You will have a significant head start if you have already spent time meeting the partners and associates.
PRACTICE ENVIRONMENT
In the past, one would simply choose between academic
and private practice and proceed from there. In
2010, the culture is a bit different, requiring more selfassessment
of one's aspirations and motivations. In addition
to traditional academic or private practices, there
are many hybrid practices. Each type of practice has pros
and cons, so it is important to consider these carefully.
ACADEMIC OR
UNIVERSITY-BASED PRACTICE
We are all most familiar with the traditional academic
practice because of our past education. There are many
benefits to an academic practice as a new attending. The
environment is both familiar and supportive, allowing a
more seamless transition and continued growth. The
details of the job will vary but typically include a combination
of clinical, research, and teaching responsibilities with
protected academic time. There is rich opportunity for
intellectual stimulation and multidisciplinary collaboration.
In exchange for the fertile environment within academics, one must relinquish a certain amount of control. The structure of academic departments means that you will not be you own boss; actually, you will likely have several bosses. The ability to implement change may be more difficult and require navigating a complex bureaucracy. Additionally, the financial compensation in academics tends to fall behind that of private practice after 2 or 3 years in practice. In the past, many in academics enjoyed not only the university environment, but also close ties with industry. Recently, these relationships are coming under more scrutiny in true academic practices, and many institutions have implemented policies prohibiting such relationships.
PRIVATE PRACTICE
Most graduating retina fellows join existing private
practices, while a select number of fellows will build their
own practices from scratch in areas of need. Private practices
vary widely in their organization, patient volume,
OR setting, buy-in, size, and scope of specialty. The range
varies from a small retina-only practice to a large multispecialty
practice. From size to scope to contract details
there are many variables, all with pros and cons. Initially
identifying a potential practice will likely center on the
personality of the group and whether you feel you will
mesh with them and therefore be productive. After you
have identified practices you would like to join, a careful
analysis of the details of the contract, compensation, and
partnership opportunities will help ensure you understand
the decision you are making.
Private practice typically offers the most control along with the greatest financial compensation, but these parameters vary highly from one practice to another. Clinical volume tends to be greatest in private practice, and this typically leads to a greater surgical volume as well. There are tradeoffs for the increased compensation, control, and volume experienced in private practice. The patient population tends to be less diverse with limited opportunities for academic stimulation compared with university-based practices.
HYBRID PRACTICE
The hybrid practice is a combination of academic
and private practice. Usually these practices are structured
as private practices, but the members of the
practice are committed to academic endeavors. The
academic interests may be quite varied, frequently
including clinical research and collaborative relationships
with industry. Some of these so-called hybrid
practices outperform their academic peers in many of
the large, prospective, multicenter trials. These practices'
strengths lie in their clinical efficiency and ability
to screen many patients for these studies. Most are
not awarded federal funding nor perform much bench
research, but there are exceptions. Several of these
hybrid practices also teach fellows and residents. In
general, these practices may offer better remuneration
to the retina surgeon compared to a traditional academic
practice.
The increased compensation in the hybrid model is partially due to lower overhead compared with the academic practice, but there are drawbacks. Hybrid practices are unlikely to have in-house statisticians, multidisciplinary collaborators, or funding mechanisms for homegrown studies. There is usually less diversity in diagnoses compared with academic institutions, but it is often greater than traditional private practice. Protected academic time is not common in a hybrid practice, and therefore more time outside of work may be needed to be productive academically.
As you already know, every situation has pros and cons. Spend some time now considering the bigger picture so that, as you get more involved in the job search, you can carefully evaluate the details of those opportunities that suit you best. Ultimately, you should strive for a good fit, but keep in mind that frequently it is the little things that directly affect your happiness and satisfaction.
Darrell E. Baskin, MD; Jeremy D. Wolfe, MD; and Chirag P. Shah, MD, MPH, are second-year vitreoretinal fellows at Wills Eye Institute in Philadelphia, PA, and members of the Retina Today Editorial Board. Dr. Baskin may be reached at darrellbaskin@gmail.com; Dr. Wolfe may be reached at jeremydwolfe@gmail.com; and Dr. Shah may be reached at cshah@post.harvard.edu.
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