How to Choose a Practice (Private vs. Academic)

William N. Levine, MD, FAAOS | Milton Little, MD, FAAOS

February 9, 2022


Exposure and experiences shape the decisions orthopaedic trainees make as they search for a career following residency and fellowship.  Most programs provide an example of an academic practice, but only minimal exposure to private practice. As mentors, it is important to provide insight into the different practice models so that our trainees can find their best career landing spot. Rather than focus on the global conversation of private practice vs academic practice, we will investigate factors that influence career decisions and how they may be achieved in the perfect job for you.  

1Clinical

Many of us enter medicine to challenge ourselves clinically and the case complexity is impacted by the practice model.  Many academic jobs are tied to tertiary and quaternary referral centers where patients come for physician experience, hospital technological advances, multidisciplinary teams, and exposure to all subspecialities. Hospital-based academic jobs may allow for higher volume experiences with those complex cases and allow physicians to develop a large referral base.

It is important to recognize that many hospitals may contract with private orthopaedic groups to manage specific specialties.  While the group and each physician are considered private, their presence in the hospital allows them to maintain the large referral base, treat complex patients, while still having increased levels of autonomy in terms of practice decision-making.

2Teaching/Education

Resident and fellow education are often the primary reason why an applicant may be seeking an academic job.  Many of us were trainees at academic institutions where we had teachers and mentors who truly impacted our lives.  As an attending, the presence of a residency program provides the opportunity for continuous resident/fellow education if you are chosen to be a member of the teaching faculty (not guaranteed). Additionally, your evaluations as an educator may be a component that is assessed for academic advancement or financial compensation.

Fortunately, with the growing number of “privademic” institutions, residents are also getting exposed to private physicians are who involved in resident education at affiliated hospitals, surgery centers, and clinics.  As a private physician, you can reach out to institutions who are affiliated with your practice or who may have residents who need exposure to your specialty to participate in their education programs.  Additionally, there are numerous organizations, the AO, OTA, WOA, EOA, AAOSM, AOA, AAOS and even industry-funded educational courses where you can still participate in trainee education.  It is important to evaluate the practice and assess how time away for education may impact your earnings and partnership prospects.

3Research Requirements

Most academic jobs have some research requirements and research productivity may be linked to academic promotion, bonuses, and leadership positions.  Academic institutions often have increased funding, research support, and facilities that can nurture research goals. It is important to evaluate the position’s research expectations and reconcile your personal goals with those expectations.

Unless you are participating in a “privademic” institution, hospital-based group, or private practice with trainees, most private positions do not have research requirements or support. In those groups, research is often a personal labor of love.  It can be done, but it may require more leg work with less support.  In contrast, many private groups with fellowships or associated training programs have ample support and opportunity for research advancement.  These groups have been extremely productive allowing someone in “private practice” to continue to build their CV and national reputation.

4Academic Appointment

Academic appointments and promotions are an important aspect of academic positions.  Care must be taken to evaluate the conditions and requirements for achieving academic promotion.  Currently, institutions are developing multiple tracks for academic promotion, and they include tracks which focus on research, education, or clinical advancement.  Our institution (ML) even developed an adjunct track for private physicians who work at the hospital and are part of our training programs.  Inquire about adjunct faculty positions at surrounding academic institutions as that may be a way to achieve an academic appointment if that is something that is important to you while in private practice.

5Pay

The Covid-19 pandemic has had very disparate impact on salaried and non-salaried employees due to the intermittent elective surgery stoppages.  While surgery centers have increased their productivity, hospital based elective surgery has seen some decreases in use.  As a member of an academic practice with a salary, you will be somewhat protected from these catastrophes.  Salaried employees received most, if not all their base salaries despite the decreases in productivity.  Productivity based bonuses may have been impacted, but many physicians were able to remain solvent.

Completely RVU or collections-based practices were impacted severely if they did not evolve other ways of continuing to be clinically productive.  Physicians began to take trauma call and operate out of their comfort zone to maintain income with varied results.  It’s important to recognize that both academic and private jobs may have a salary component as well as a productivity component, so it is important to do your due diligence when researching the job.  Partnership models are very different as well, and a more in-depth investigation into each job should be performed.

6Vacation and Benefits

Both academic jobs and private jobs will have different benefit packages.  Academic positions as non-profit hospitals often cover malpractice, office overhead, disability insurance and may have numerous retirement/pension options.  In contrast, overhead and malpractice may be individually covered in private practice positions and physicians may be responsible for their own disability insurance or retirement. 

The idea of vacation/time away may also be impacted by your practice’s payment strategies.  If you are solely RVU/collections based, time away equals lost income and that may impact your work-life balance.  Salary based academic jobs may not face the same productivity pressure allowing physicians to spend the provided time away with their family.  Additionally, some academic institutions have even implemented faculty sabbaticals to allow physicians to maintain their salary while working on their personal well-being and non-clinical academic pursuits. 

7Conclusion

While there are some inherent differences between academic and private practice jobs, it is important to carefully analyze the job.  Each job has their own inherent positives and negatives, and it is important that physicians reconcile their expectations, their desires, and their job prospects.


DISCLOSURES: Dr. Levine is on the Columbia faculty, serves as Board or committee member for the American Shoulder and Elbow Surgeons, and is on the editorial or governing board for the Journal of the American Academy of Orthopaedic Surgeons. Dr. Levine serves as an unpaid consultant to Zimmer Biomet. Dr. Little Consultant: Globus Medical, Consultant: Depuy Synthes, Committee Member: AO Fellowship Committee; OTA Membership Committee; OTA Diversity Committee; OTA Wellness Committee

Read the AAOS Code of Conduct for Discussion Group Terms, Conditions and Disclaimers HERE.

Copyright© 2022 by the American Academy of Orthopaedic Surgeons

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