So here we are, coming close to the end of our training to become vitreoretinal surgeons, and we now must decide where to begin our careers. For some of us, the choice will be simple, with a decision made years ago during residency to join the practice of a friend or family member. Some of us have a vague idea of what we want and where we will end up, whether it is in private practice or an academic institution. Others are guided by a specific geographic location.

Regardless of where you fit, this decision should not be taken lightly. You are about to sign a complicated contract and begin the journey to the fulfillment of your career goals and aspirations.

Below we summarize some of the advice we have received from family, friends, and mentors regarding how to thoroughly evaluate a potential position. This article is not meant to be an all-inclusive checklist, but rather a vehicle to stimulate the analysis of what you seek and where you will be happy.

PRACTICE SETTING

The most basic choice that will guide job selection is whether to seek employment in private practice or an academic setting. This is a crucial decision that will take an individual down one of two distinctly different paths. We'd be willing to bet that most of us at some point were convinced that we would end up in academics, as this is all we have known for some time. As the years have passed and our training has progressed, however, most of us have realized that private practice is not as diametrically opposed to academia as we had assumed. In fact, in recent years, many practices have evolved into a hybrid of the two models—academic intent in a private setting—in which one is afforded many of the benefits of academics without the standard sacrifices.

Although many of the discussion points below can be applied to both academic and private practice positions, the content of this article is mainly geared to those thinking about joining a private practice.

PATIENT AND CASE VOLUME

Maybe you like the idea of easing into your new job, or maybe you want to hit the ground running. In either case, you should inquire about how busy you should expect to be, both immediately and as you become more settled in.

Some questions to ask: How busy can I expect to be? How many patients does each current partner see per day? How many surgeries and procedures per week? How are new patients distributed among physicians in the practice, and how many new patients would I expect to receive? What is the wait for a new patient visit? What is the geographic draw area, and what is the population of that area? How many referring doctors do you have? How are patients referred into the practice? Ideally, these queries should draw out detailed explanations.

Similarly, it is important to get a sense of the practice's desire and ability to take on a new associate. You may want to ask about the 5-year plan. Is the practice growing, looking to take on new associates, expand to larger offices or a new territory? If expansion is being considered, who will cover those offices? (What you are really asking but not saying aloud: Will I be stuck out in the middle of nowhere with a 2-hour commute?)

PARTNERS, ASSOCIATES, AND OFFICE STAFF

We have been advised that joining a practice can be akin to a marriage of sorts. You will be spending a significant amount time with your colleagues, and it is important to make sure that you will get along with this new “family.” You should meet all of the partners and convince yourself that you would be happy working side-by-side with them. Do you get along with them, and, more important, do they seem fair and have the interests of others in mind? How long have they been part of the practice, and is anyone planning to leave the practice or retire in the near future? It is also important to inquire about former associates and partners, the average turnover rate, and the reason for any departures. To that end, you may want to ask if you can contact individuals who have left the practice.

Also keep in mind that retina specialists rely heavily on comprehensive ophthalmologists and other subspecialists. Find out if the group has good access to glaucoma, neuro-ophthalmology, cornea, general ophthalmology, rheumatology, and internal medicine groups.

Be sure also to vet members of the staff, as they will certainly have a significant impact on your efficiency, productivity, and happiness. First and foremost, make sure there is adequate staff to accommodate another associate, and, if not, inquire whether there are plans to hire. Try to meet as many staff members as possible to evaluate whether they are kind and friendly to patients. Additionally, gauge the job satisfaction level of the staff and the overall turnover rate. It is also important to know what authority you would have in directing employees' functions to meet your needs.

SCHEDULE AND HOURS

Although it is impossible to know exactly how busy you will be and the precise hours you will keep, it is advantageous to have a good handle on your potential schedule. How many patients will you be expected to see daily, at first and over time? How much time is allotted for follow-up and new patients, and how many exam lanes will be available? Are emergencies distributed evenly, or are they typically added to the younger associate's schedule? Does the office have evening or weekend hours, and who will staff those clinics?

Patient flow can have a substantial impact on your efficiency. What sort of technician support will you receive, both during the day and on evening shifts?

Call is an important issue that can substantially affect you and your family's happiness. Ask how the call is split: Is it weighted toward the more junior associates, or is it split equally? How are holidays split? Does the group cover any other practices, trauma, or general ophthalmology call, and, if so, how busy is it, and how is it compensated?

PATHOLOGY

At this point in your training, you undoubtedly know what fascinates you in retina and which types of cases you enjoy seeing in the clinic and the OR. You should investigate whether your potential job will provide you with these experiences. Ask about the commonly seen pathologies; do they see a lot of bad diabetics and perform countless panretinal photocoagulation procedures? Do they regularly operate on bad traction retinal detachments? Do they cover a trauma center where they might see intraocular foreign bodies and ruptured globes? Or are the cases more routine, such as age-related macular degeneration, retinal vein occlusions, and macular holes and puckers? Ask how many anti-vascular endothelial growth factor injections they perform in a regular clinic day. Another angle to glean this information is to ask about the patient population, including the demographic makeup of the area and the mix of insurance coverage.

PRACTICE DEVELOPMENT AND VISION

There are a variety of practice models that can reflect the goals and aspirations of the senior partners. These may range from a high-profile group of thought leaders who are involved in clinical research and with strong participation in major meetings, to a business-savvy group that is efficient and streamlined to maximize lifestyle and minimize overhead, to a smaller, more laid-back group. The culture of a practice should be an important consideration in your job hunt. Does the practice you are looking at reflect your own goals? Inquire how long the group has been in practice, how it has evolved since its inception, where it sees itself in the future, and how you might contribute to that future.

NEGOTIATING A CONTRACT

Contract negotiation may be one of the most confusing aspects of the job hunt. Medical students, residents, and fellows tend to receive a limited education in this regard. You may want to consider hiring a contract consultant, but it is important nonetheless to understand some basic concepts and to ask the right questions. First, the complexity and accuracy of the contract is critical. Is it appropriate, or is it over-complicated? Is it well-written and organized, or is it fraught with mistakes? On a basic level, ask about the structure of the practice. Aside from considerations discussed above regarding schedule and hours, is the practice a corporation, a subchapter-S corporation, a limited liability company, or a limited liability partnership? Is there a restrictive covenant, and, if so, for how many miles does it extend? Who approves time off? What about continuing medical education (CME)? Does time spent on CME count against vacation time? Is it paid for by the group? Will you have a voice in administration of the practice, including hiring and firing? How are business decisions made? What are causes for termination, and can you be fired without written notice? Does it cost you any money if you leave before the end of the defined term of employment? How are you going to be paid? Will you be an employee or an independent contractor?,/p>

SALARY

Salary is a topic that is on everyone's mind when looking for a job, but it can be the least comfortable to bring up. Ask how the salary for an associate and partner is structured. Are associates given a base salary, and what is that salary at the start, at 6 months, and thereafter? Alternatively, is the salary based on productivity, or is there some combination of the two? How is incentive or bonus determined? Are the incentives formulated in such a way that they are attainable? What is the earning potential of a partner? Be sure to ask about benefits, both for yourself and your family, and what is covered (eg, medical, dental, life, malpractice, long-term disability). Last, although this probably seems far in the future at this point, ask how retirement funding is structured.

PARTNERSHIP OPPORTUNITIES

The potential to become a partner in your practice is an important point to consider. Foremost, you should be aware if possibilities to become a full partner exist. If so, what is the buy-in, and when would you be eligible for buy-in? What formula is used to determine your buy-in? What is the buy-in method? Is it salary reduction, an annual sum, pretax or upfront? Is it paid over a period years, vesting? What is the buy-out? What happens when someone retires? Will you be able to become signatory of the lease or able to purchase an office if one is built?

PRACTICE FINANCES

Regardless of whether you plan to become involved in the administrative affairs of the practice, it is critical to understand its underlying financial integrity and philosophy. Ask what the true overhead of the practice is (anything over 55% should be explained) and whether the overhead is trending up or down. If there is any doubt, ask to see financial reports of the practice. Ask about the collection ratio of collectable fees. Who controls the finances of the practice: one of the partners, or a dedicated staff member? Ask what the gross and net income of the group was for the past few years and how profits are distributed at the end of the fiscal year. You also want to find assurance that a profitable practice will continue to be so in the future. Ask how managed care has affected the group and how the practice maintains the business flow in terms of marketing. Do they spend significant energy taking referring doctors out for dinners and giving talks?

OFFICE, OR, AND EQUIPMENT

People's opinions vary considerably regarding the importance of office space and equipment. Regardless of how you feel, you should gather as much information as you can; you may be surprised. Much of this you can do on your own as you tour the facilities. Take a good look at the office. Is it clean? Does it have a modern or more traditional aesthetic? Does the practice own the building, or is it leased? If leased, what are the details of the lease? Be sure to look closely at the equipment, noting anything that is lacking that you consider essential to your ability to care for patients. Consider the condition of the equipment and how up-to-date it is. Do you want to have all the newest gadgets, or are you comfortable with older equipment that gets the job done while saving capital? Additionally, consider whether the equipment is owned or leased. Check out the scheduling system and medical records, specifically whether the practice has paper records or an electronic medical record. Finally, take a very good look at the OR suites. Are surgeries performed at a hospital or an ambulatory surgery center, and what is the condition of each? Is all necessary equipment available?

CONCLUSION

Retina fellows have spent the past decade working to arrive at the point where we can put our experiences to practice. Finding the ideal job is not an easy task, and you will need to invest substantial time and effort. The points noted in this article are not presented as time savers, but rather as things to think about that may help you find your dream job.

Nikolas London, MD; Alok Bansal, MD; and Andre Witkin, MD are second year vitreoretinal fellows at Wills Eye Institute, Thomas Jefferson University in Philadelphia and members of the Retina Today Editorial Board.

Dr. London can be reached at nik.london@gmail.com; Dr. Bansal can be reached at alok.s.bansal@gmail.com; and Dr. Witkin can be reached at ajwitkin@gmail.com.