Evaluating Practice Models when Searching for a Job, Personal Perspectives of a Pediatric Ophthalmologist

By Aaron Miller, MD, MBA (bio)

When leaving residency and entering fellowship, it is a good time to begin to think about your future practice plans. Will you enter a large multispecialty practice or will you “hang your own shingle” and start your own solo practice? Each option has its advantages and disadvantages. The right one for you will depend on your practice location and personal desires.

There are typically 6 different practice options for a pediatric ophthalmologist:
1. Solo practice
2. Small multispecialty ophthalmology group practice
3. Small pediatric ophthalmology group practice
4. Large multispecialty ophthalmology group practice
5. Academic medicine
6. Multiple specialty group practice including primary care and specialty physicians

Solo Practice: This option gives you the most autonomy and greatest control in your practice growth. However, it is also considered one of the most difficult models to start directly out of fellowship. You will need to secure a bank loan or find other funding options to purchase the essential equipment to open your practice. You will also have to complete all the hospital and insurance contact negotiations well in advance. It takes approximately 6 months to obtain insurance contract approval status so starting during fellowship is essential. Something to look into is a hospital income guarantee depending on your practice location. If you are considering going into an area that is underserved for pediatric ophthalmology (present in many urban and suburban areas), talk with the hospital about providing you with funds to start your practice and a guaranteed income every month. The trade off to this is that you may be requested to cover the ROP for that hospital’s NICU and maintain a presence at the facility for a set number of years.

Small Multispecialty Ophthalmology Group Practice: This is one of the more common practice models in existence. Typically, a group will start as either a general ophthalmology group with a few specialty trained individuals. As they grow, they will have a desire to become more well-rounded and look for a pediatric specialist for them to focus more on adults. Additionally, a group practice will frequently want to offer all types of ophthalmic care to their service area. A common misconception is that a pediatric practice is not able to support itself. What makes a pediatric practice special in this group is that the overhead tends to be much less than others. While the revenue may not be as high as a high-volume cataract surgeon, you cost less with regards to equipment. Additionally, a pediatric specialist will allow the general practice to run more efficiently by taking care of children that typically take more time to examine for the general ophthalmologist.

Small Pediatric Ophthalmology Group Practice: While frequently thought of as one of the most preferred pediatric ophthalmology practice models, it has its own challenges. Finding the right “chemistry” among partners is essential. Sometimes variations in training style and patient management can be difficult to overcome. Additionally, the population size needs to be larger to support multiple pediatric specialists. On the positive side, you are better able to create a pediatric environment in your offices and have colleagues to discuss difficult cases with. There will also be better knowledge in your billing and collections personnel of pediatric coding and reimbursement.

Large Multispecialty Ophthalmology Group Practice: This is the practice model that I currently work in where we have all specialty areas covered among our 46 physicians, of which there are 6 pediatric specialists. The obvious advantages are the ability to negotiate better reimbursement contracts and centralized billing and collection, leaving the physician the ability to focus more on patient care. Call tends to be very busy but is much less frequent due to the size of the group. Many specialty physicians stick to their specialty training area since the other areas have coverage within the group. The downside to the practice model is that it takes much longer to make administrative changes due to the sheer size and adherent additional bureaucracy that exists.

Academic Medicine: Pursuing a career in academic medicine is frequently rewarding to those individuals who enjoy teaching and the research process. There tends to be an easier access to patients and there is an inherent prestige to working at most institutions. It allows you to grow more as a clinician by being exposed to newer concepts and you will always be challenged to be at the top of your game through your resident interactions. However, there are trade-offs. Typically, the more prestige an institution has, the lower the opening pay offer that can be expected. You will also be expected to see ROP in your practice but will have the extra medical-legal protection of the institution. Lastly, with the trend of more institutions going to a production-based salary structure, it is becoming ever more challenging to balance research, training of residents, and patient care.

Multispecialty Group Practice: This is commonly thought of a system modeled after the Kaiser model found in California where a private institution has physicians of all specialties working within it. As a pediatric ophthalmologist, you will be working along with other ophthalmologists along with your primary care physicians and other specialists. As such, you will have a closer access to patients and will form stronger relationships with your referral base. The down-side is that you will commonly be subsidizing the primary care physicians within this model due to the current reimbursement structure in America. There also may be less capitalistic opportunities in this model such as optical or ASC ownership.

As you can see, there are multiple practice models that exist that can be pursued at the conclusion of your fellowship. There are frequently hybrids of these that can exist that I did not discuss such as private practice with an academic appointment. Regardless of which model that you enter, there is not a perfect model for all pediatric ophthalmologists. However, there may be a perfect model to fit your personal desires and practice goals!