At the start of my second year of fellowship, I started considering what career opportunities were available to me within the vicinity of my fellowship training. I had been in the central Jersey area for many years and had established a strong referral network from colleagues, which I wished to maintain. Once I determined that I did not want to pursue further subspecialty training (i.e., transplant, interventional, etc.), the next decision was academic versus private practice.
My original desire was to join the faculty of my fellowship. Unfortunately, due to budget cuts at the time, there was not enough funding to hire another nephrologist. Fortunately, another opportunity came along in a private practice that seemed to fulfill a lot of what I was looking for.
When evaluating various career opportunities during your general nephrology training, consider what you enjoy and what your long-term career goals are. For me, I enjoyed research, teaching, and case diversity with particular interests in fluids and electrolytes, acid-base, glomerular diseases, and dialysis. Long-term goals included meeting financial targets, teaching, and completing research projects. With this in mind, interests and goals will change over time. As one of my mentors once told me, “I would get bored of my situation about every 10 years, but I was fortunate to find new opportunities to reinvigorate my interest.” Now, 10 years after graduating fellowship, I'm finding the same.
What I enjoy about private practice is the autonomy and flexibility. I am able to essentially set and adjust my schedule, train/optimize staff, and decide on what services I prefer to focus (e.g., outpatient, inpatient, dialysis, teaching, publications, etc.). I am also in direct control of the financials and how revenue is allocated and what insurance plans I choose to accept. Additionally, there are no restrictions on participating in external opportunities such as speaking engagements, advisory boards, medical directorships, or joint ventures with dialysis providers.
I am fortunate in that I am affiliated/contracted with a teaching hospital that does not have an academic nephrology division. This allows me to teach students and residents on their clinical and elective rotations, provide didactic lectures, collaborate with others on research and publications, provide services to indigent patients both inpatient and through their affiliated outpatient clinic (thereby giving me exposure to diverse pathology), and be involved in the nephrology teaching curriculum. This, however, may not be the typical situation with all private practices.
Other things to consider about a private practice include the following:
Geography (pathology seen, competition in the area, reimbursements, revenue stream, lifestyle, etc.). For me in particular, there are several competitive groups in the same area, so essentially, I have to build a “brand” of quality, service, and perhaps most important, availability.
Small groups vs. large groups. This will directly influence call schedule (or lifestyle), partnership track along with buy-ins and buy-outs, ability to change things within the practice (e.g., staff recruitment, rounding schedule, etc., since one's “vote” will be diluted with more physicians in the group), and perhaps most important these days, economies of scale (ability to negotiate contracts with insurance providers and dialysis providers and concentrate shared resources such as billing and benefits).
Finally, it appears that there is a major transition in medicine. The days of “mom and pop” practices are slowly ending. Two main trends are emerging:
1) hospital systems contracting with private practices in some capacity and
2) practices converging into one entity and essentially becoming a corporation such as an IPA (independent practice association) or an ACO (accountable care organization). For example, five small nephrology groups in the central New Jersey region may decide to form an IPA under one tax ID.
As we decide our career choices, there are certainly many options to consider. However, just like any other industry, things are evolving and will continue to evolve. Our goals and interests will evolve with them.