One decision with which many otolaryngology residents struggle, and one we all must make, is whether to pursue a career in private practice or academia. Since most otolaryngology residencies are associated with large academic medical centers, many are lacking adequate exposure to private practice, most residents enter this decision with an incomplete experience, making an informed decision difficult. Additionally, because like begets like, it’s fair to say that most residency training programs carry a bias towards pushing academic career paths.  Nevertheless, the reality is that most people go into private practice given the distribution of workforce needs, and the field needs good people in both arenas.  Like all things, there are merits and drawbacks to both career paths.  The correct decision for you is best determined by a critical self-evaluation of your priorities. What drives you?  What will provide the kind of fulfillment you need to get out of bed excited to go to work every day for the rest of your career? Below is a general summary of some of the advantages and disadvantages of pursuing an academic or private practice career. As a disclaimer, realize that in either group there is often tremendous variability from practice-to-practice. There are even overlapping “hybrid” positions that combine the spoils of each.

Three commonly cited advantages of private practice are greater autonomy, better compensation, and greater career flexibility. However, the extent to which these attributes are realized is somewhat influenced by the type of practice you are in: solo, single specialty, multiple specialty or hospital employed. As a general rule, a smaller practice affords greater autonomy and the potential for higher income while incurring more financial risk and instability. If you are in a solo practice or small single specialty group, you will have the greatest control over your work – making your own schedule, choosing personnel, and deciding on the color of the bathroom wallpaper. Larger private practice groups provide increased job security at the expense of autonomy. While it might sound appealing to hang your own shingles and call all the shots, managed care and the growing costs of running a medical practice have placed increasing strains on small single specialty groups, and there has been a clear movement towards large multi-specialty groups and hospital-based employment. However, if you are able to successfully navigate the gauntlet of solo or single-specialty practice, the rewards can be incredible.

Historically there has been a substantial disparity in financial compensation favoring private practice physicians.  At present, that gap has probably narrowed somewhat: the 2011 median salary (AAMC Careers in Medicine) for all private practice otolaryngologists was $370,631 and the median salary for associate or full professors at an academic institution was $333,000.  Such differences may be even smaller in larger cities, where markets are competitive, though the income ceiling likely remains higher in most private practice opportunities. 

In traditional private practice models, your salary is anchored to your billing and collections.  Therefore, if your collections are good, your salary will be high, and vice-versa.  In order to create a successful practice in this model, you need two things: a high volume of patient encounters and a population that has the means/insurance to create a high collection:bill ratio.  Private practice is generally much more fast paced than academics and the metaphor "time is money" runs pervasive --  you will often see twice the number of patients in clinic, perform a much greater volume of (low complexity, low risk) cases, and OR turnover is frequently minutes instead of an hour. As an otolaryngologist in any practice, your routine has to be molded by not only what is enjoyable, but what is profitable. For example, if you want to build a referral base to become your region’s premier revision thyroid surgeon, you may still end up seeing otolaryngologic allergy and sinus surgery patients in order to financially support that interest.

Beyond patient encounters, a significant portion of income in private practice can also be generated from ownership of outpatient surgical centers, professional or facility fees, and collections from ancillary or integrated services such as audiology, radiology, pathology and anesthesiology.  In many larger groups, these types of relationships may be pre-existing, and if you demonstrate that you’re a “good citizen” (the 3 As – Affable, Available and Able) during the first few years of being a salaried associate of a group practice, you can be given the chance to buy-in to one of these ventures.  In general, this type of financial setup can generate a large amount of revenue - an arrangement that is forbidden in a practice supported by an academic institution.   

The primary motivators for pursuing an academic career include opportunities to regularly perform more complex and specialized surgical cases, to conduct research, and to train the next generation of clinicians and surgeons. These benefits are usually at the expense of income potential and professional autonomy. The bureaucracy and inefficacies of the large medical system can be frustrating. Significant amounts of time and energy are frequently required to accomplish even the simplest tasks and it often seems that many organizational policies have been made by personnel that are far removed from clinical care.

In contrast to private practice where nearly all time is dedicated to clinical care, in academics, continuing education and intellectual pursuits are strongly encouraged. In an academic environment it is not uncommon for the department to support additional advanced training (MS, PhD, MPH, or MBA) and depending upon your employment agreement, 20% or more of your time may be dedicated to research. These positions are commonly subsidized for several years, but most departments eventually require that investigators secure full funding to support research time and costs.

Academic medicine also affords the chance to provide high-level cutting edge care while working alongside well recognized leaders in the field, with greater access to advanced consultations from other surgical subspecialties, radiation oncologists, medical oncologists, radiologists, and pathologists (among others). Compared to private practice, there are less time constraints placed on individual patient visits, allowing the otolaryngologist the flexibility to spend more time with patients when needed. As a general rule the case-load is more complex since basic bread and butter cases are generally cherry picked by community physicians and advanced cases are referred to tertiary-care centers because of high risk, poorer compensation, or lack of adequate infrastructure.

One of the most significant and underappreciated aspects of academic medicine is the stability that comes with being affiliated with a large medical center. Even starting out, many young academic physicians find themselves “booked up” quickly because of the draw of the medical school or university reputation. Furthermore, small fluctuations in patient volume or changes in reimbursement can be absorbed or buffered by the deep pockets of a large medical system. In contrast, a solo practice physician must work hard to fill the clinic and surgical schedule and to manage money effectively in order to be prepared for economic ebb and flow. The sizeable infrastructure of a large medical center provides the clinician with more time to just be a doctor and not have to worry about the system. There is greater protection from litigation. Additionally, the call pool is generally larger, permitting less rigorous call duties.

Evaluate your priorities and determine what drives you. If you receive great self-fulfillment from challenging complex cases, educating the next generation of physicians, or being a part of cutting edge research and patient care, then academic medicine is your calling. If you have an entrepreneurial spirit, enjoy business management, and desire greater control over professional endeavors, you may be more suited for private practice. Both career paths can provide a very comfortable living, and future healthcare reform may continue to significantly alter current compensation trends.  Furthermore, it is not uncommon that personal priorities evolve over time. Luckily, many otolaryngologists have made very successful midcareer transitions to meet changing personal goals and aspirations.