Among the many decisions a graduating retina fellow faces is whether to pursue a career in academia vs private practice. Most of us have trained entirely in academic institutions up until, and often including, fellowship. As such, it may be an environment we feel most naturally drawn to and stimulated by, surrounded by educators and learners at various stages of training, with departmental rounds, research, and teaching incorporated into each day. On the other hand, some of us have gained exposure to private practice either through fellowship, friends or family members in medicine, or have sought it out on our own, and we may find this environment most appealing. Interestingly, although private practices vary, the decision to pursue this route may not mean completely forgoing all of those things that made our training years so fulfilling. We invited Dr. Carl D. Regillo, MD, FACS, and Dr. Sunir J. Garg, MD, FACS, to share their thoughts on this matter.

- Michael Dollin, MD; Christopher Brady, MD; and John D. Pitcher III, MD

What factors should a fellow consider when deciding on a career in academia vs private practice?

Sunir J. Garg, MD, FACS: Both career paths are very rewarding. Being part of a strong academic department is a lot of fun and is intellectually engaging, and being involved in grand rounds and teaching conferences does help keep your clinical skills sharp. The 2 biggest attractions for me to an academic department are the teaching and research aspects.

Carl D. Regillo, MD, FACS: “Academia" and “private practice" are not mutually exclusive environments. A spectrum of clinical care, teaching, and research can exist to varying degrees in any practice setting. What really matters is how much of each of these activities a fellow desires to have in his or her career, both in the short and long term. An advantage to the private practice setting is that one often has more latitude in choosing how much time one wishes to put into teaching and research. However, these activities might be limited in a very busy clinical care setting, where protected time usually is not built into the typical work week and an infrastructure may not be in place to permit doing certain types of research.

Is research possible in either of these practice settings? What about with regards to industry vs non-industry sponsored studies?

Dr. Garg: As a whole, I think that academic programs are becoming more isolated from industry, partly out of a desire to allow trainees to make decisions without undue influence from industry. Many academic programs have also become more removed from certain pharmaceutical multicenter trials, partly because regulatory environments and investigational review boards at-large institutions tend to be slower and may make it difficult to participate in such studies. As such, a large private practice setting may be better suited for these clinical trials. For those who are interested in a more focused research career, however, academics can be a better platform. Bench research can only be done only in academic departments (or with a pharmaceutical company), and large, National Institutes of Health (RO1) grantfunded research is basically impossible outside of academics, and even then can be challenging due to less research funds available. However, just because you are in an academic program does not mean that these opportunities will be available. If you have a research interest, having a research infrastructure and good mentors at your institution is critical. I did not fully appreciate how important this is until a few years out.

Dr. Regillo: The types of research best suited to private practice are clinical trials and case series studies. However, very small private practices may not have the resources to support a research infrastructure. Also, the culture to promote and facilitate research may not be present in certain private practices, regardless of size. In general, a university-based departmental practice is more likely to foster, encourage, or even mandate some degree of research or teaching. It is also more likely to have some protected time, which can make it easier to pursue research activities.

Can a physician entering private practice still pursue educational and scholarly interests?

Dr. Garg: There are more options now than ever. Many private practitioners are not too far away from a residency program. In a private practice, you can invite residents to spend time with you in the clinic and OR. In addition to Wills residents, residents from some of the other local programs spend time with me in the clinic. You can also volunteer to staff a resident clinic a couple of times a month, for instance. This can be a lot of fun and is a welcome change of pace.

Clinical trials are great. Going to investigator meetings is interesting, and involvement in the trials helps you stay current and engaged in advances in our field. It also can help open up other speaking opportunities in the local area. Additionally, private practitioners generally tend to see many patients and can innovate many aspects of patient care and surgery. Putting these cases together as a research project, either alone or in collaboration with others, is also valuable and interesting.

Dr. Regillo: For teaching, the members of private practices will need to be affiliated to some degree with a teaching institution that has medical students, residents, or fellows. If the doctors in training are not formally part of the practice, then one will need to travel to where the teaching environment is located and carve out time from patient care to staff clinics, give lectures, or mentor in the OR.

What financial aspects, if any, should a fellow consider when choosing between academia and private practice?

Dr. Garg: Within retina, there still exists a fairly large financial disparity between academic and private practice positions. Although the numbers in the first couple of years of practice are similar, over time the curves tend to separate. Although the larger number may appear more seductive, it is important to remember that we are all very lucky to be in ophthalmology, and particularly in retina. We are fortunate that our services are valued by others as well as by society as a whole, and, because of this, we have been fortunate to be well compensated. Even in an academic setting, I was making more money than I ever dreamed was possible. I would encourage people to do what makes them happy and to do what they would look forward to doing in a place they want to be every day. There is no point in saying, “OK, I am going to do this until I'm 60, and then once I retire, I will do what I really want to do."

Dr. Regillo: Although most practice environments, institutional or private practice, have clinical productivity tied into their compensation, private practice is likely to be more heavily weighted to clinical care productivity. There may be no incentives or even financial disincentives to teaching or research in certain practice environments. In the traditional institutional-based academic environments, one's productivity and compensation is often a mix of clinical care, research, and teaching activities along with other roles such as committee participation and leadership positions. That being said, there can be a lot of overlap to these models.

Are there any quality-of-life factors that are more easily attained in academia or private practice?

Dr. Garg: From a research perspective, academia leaves you more time to think. I see patients 5 days a week, and by the end of the day my brain is fried. I think about research while commuting or in the evenings and, weekends. Having academic time built into your schedule to be able to think is helpful. The other potential advantage of being in academics is that patients will come to you just because you are at the “U." In contrast, in private practice, we end up spending a lot of time doing after-hours activities, including dinners, educational programs, or community outreach endeavors. It can be easier to develop professional relationships within an academic department simply because you share office space with others. I made some close friends during my short time at Washington University because we had time and space to develop those relationships. In private practice, that still happens, but that usually happens after working hours.

Dr. Regillo: In a busy private practice setting, research and other academic activities are more likely to be done after hours, although there can be exceptions. Regardless of the practice environment, it is always challenging to juggle a busy clinical practice with research and teaching.

If a fellow realizes a certain career decision was not the best fit for him or her, is it easier to switch from academia to private practice, or vice versa?

Dr. Garg: It is very hard for most of us to know what we really want to do when we are fresh out of fellowship. I was simply happy to have a job and be able to ply my trade. All things being equal, if people are undecided, I think it is worthwhile considering joining a strong academic department from the start. It usually enables you to focus more on your clinical and surgical skills, and you don't have to worry as much about the day-to-day private practice details. For many of us who spent the preceding 14 years in an academic institution, it is a very familiar and welcoming environment. If you find after some time that it is not how you would like to spend your career, most private practices, I think, would be very open to welcoming somebody who spent time in academics but then wanted to join private practice. The move from private practice to academia happens as well, but it is generally less common and can be a bit of a culture shock. However, I know several colleagues who started off in private practice and found that it did not suit them and, after a year or 2, went back into academics and have been very happy.

Dr. Regillo: In general, it is usually easier to switch from an institutional academic practice to a more traditional private practice than vice versa. If one is undecided, it may be best to pursue a traditional academic environment first, but that is only if one is truly dedicated to and adept at all the tasks that may be required. The good news is that the door is never really closed to those who want to be more involved in research and teaching later in their career, and both can be pursed in a variety of settings and at any time. Keep in mind that, just as with patient care, it takes time to be good at all of these activities. There is always a lot to learn, so keep learning about research and teaching just as much as clinical care.

Closing thoughts?

Dr. Garg: Ultimately, I think taking the “best" job, whether in academics or private practice, is the key. Much of this depends on what jobs are available when you start looking. If you have geographic restraints, or your spouse is looking for a specific type of job, your options are going be reduced significantly. Being flexible about what type of setting you are interested in can give you more options. You want the best job you can get. Going into academics or private practice is sort of like saying you are going to buy a car. You want to do your research so you can get a good product that's reliable and fun, and hopefully you don't end up with a lemon.

Sunir J. Garg, MD, is an Assistant Professor of Ophthalmology at Thomas Jefferson University Retina Service and Wills Eye Hospital in Philadelphia. He is in practice at Mid Atlantic Retina Consultants with locations in Pennsylvania and New Jersey. He may be reached at sunirgarg@ yahoo.com.

Carl D. Regillo, MD, is the Director of the Retina Service of Wills Eye Institute and a Professor of Ophthalmology at Jefferson Medical College of Thomas Jefferson University Hospital. He is a member of the Retina Today Editorial Board.

Christopher Brady, MD; Mike Dollin, MD; John D. Pitcher III, MD, are second-year vitreoretinal fellows at Wills Eye Institute in Philadelphia, PA, and members of the Retina Today Editorial Board. Dr. Brady may be reached at christopherjbrady@gmail.com; and Dr. Dollin may be reached at mike.dollin@gmail.com; and Dr. Pitcher may be reached at johndpitcher@gmail.com.