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How do you choose a career path? Can you change the one you're on? Unless oncologists have walked both paths, it is difficult to understand the differences between academic and community practice careers beyond differences in call schedules and misconceptions about compensation. Most oncology trainees have little exposure to community oncologists. In many communities the competition between the town (private practice) and gown (academia) has done little to facilitate mutual understanding, and often creates negative perceptions of community practice among academic trainees. Further, even after 2 or 3 years of fellowship, it is rare for trainees to sit with a faculty member and discuss the requirements of a clinical research career. The literature on this topic is helpful but sparse.1
We highlight characteristics that distinguish academic medicine from private practice. Several caveats are necessary for this effort. First, these insights are the personal observations of the authors, who have enjoyed oncology practice in both settings. Second, by academic oncology practice we refer to a clinical research career—in which patient care is a vital component—rather than a laboratory-based physician-scientist. Third, those well into their career might find some of these conclusions to be over-generalizations;certainly there are abundant variations about how practices and academic institutions are organized. Finally, it's the job of the Fellow looking for work to thoroughly explore the particulars—contractual issues, compensation, expectations, space, research and clerical support—and all the other details that contribute to high productivity and job satisfaction.
Most physicians will find more similarities between community practice and academic oncology than differences. Both require careful attention to patient care, close communication with other members of the health care team, service to the hospital and community, and careful time management. The differences that define the environment and feel of each career are summarized in this section and in Table 1.
In community practice, the mission is clear: Create an up-to-date, safe, and efficient office practice to deliver cancer care. This must be a successful business that provides value to patients and payers, and provides excellent patient care. The mission of patient care drives the operational details, such as how many support staff are hired, what information system is used, and whether compensation to the physician is based on seniority or productivity incentives. Because the physicians are usually the owners, the system is commonly adjusted to increase the owners' efficiency, as well as ensure that the owners have time available for other professional activities or for leisure.
The academic mission is complicated by the multiplicity of customers—patients, research funding agencies, and trainees at all levels. To be effective, the academic center must devote resources not only to patient care but also to laboratory and clinical research, to teaching, and to the administration of a large organization. This is a good thing; patients and society benefit from the success of the research mission. However, multiple missions often lead to problems with efficiency and accessibility and to competition for money and resources that can be allocated to investments in patient care.
The structure of community practice is flat. The most common model of community practice is a small corporation in which the physicians are the owners. A doctor joins as an employed associate. After a 2- to 5-year probationary period, the employed physician may be offered an ownership interest (i.e., partnership), and begins to share in the monetary failures and success of the corporation. Mechanisms for decisions about ownership, space, personnel, and finances are specified in the corporate bylaws. Decisions usually require agreement among the shareholders.
Academia is more hierarchical. Everyone has a boss who works under another boss. Expectations and priorities are set by the leadership. Salaries and productivity expectations follow from these priorities. A faculty member may lead a program, but rarely has a voice in larger decisions about the institution's patient care delivery system. As their careers progress, academic physicians may need to shift their focus towards administration and departmental leadership to ensure a stake in the goals or outcomes of their organization. In the meantime, they are still required to obtain grant and patient care revenue, publish manuscripts, and achieve national recognition. To help their doctors meet these career goals and requirements, some academic centers have recently created new patient care or clinical tracks to address burgeoning patient referrals and still give the clinical researcher time to pursue grant funding and to write and publish articles.
The community doctor is the intern, resident, Fellow, and attending all rolled up in one. Most community oncologists care for patients with a variety of cancers. Further, they also perform most of the hematology and coagulation consults in their respective hospitals. Rare diseases or diseases that require resources not available in the community may be referred to a regional academic center.
A small, patient-focused community practice corporation can be organized around the needs of the owners. As a result, the physician-owners can decide when they start and stop seeing patients, to schedule a half-day off, or to otherwise make arrangements to suit their practice style. In the office, there are many levels of support—clerical, nursing, and sometimes nurse practitioners or physician's assistants—meant to increase efficiency of the clinical operation. Furthermore, community doctors often care for people they see in the grocery store, worship with, or sit behind in the car pool lane. For most, this aspect of community practice is personally rewarding, but occasionally this is an awkward intrusion into their private life.
Many find the least pleasant aspect of community practice to be night and weekend call. The frequency and intensity of work “on call” depends on the number of doctors in the practice. In a big practice, it's not uncommon on weekends to do rounds at three or four hospitals and admit patients to a fifth hospital at night.
Patient care in the academic world is different. The academic oncologist usually specializes in one or two specific malignancies. For some, that specialization is very important; for others, it's confining. Academic oncologists see a higher proportion of patients with unusual diseases, patients referred for clinical trials, and patients who may have exhausted conventional remedies who have traveled great distances hoping for a cure. Research is woven into the fabric of academic practice, but is usually much more variably integrated than in the community.
At the academic medical center (AMC), the doctor is “on service”—doing inpatient rounds and teaching—a specified and limited period of the year. Although there is support from interns, residents, and Fellows, the amount of time and energy spent at the hospital during service months may be considerable. The night call at the AMC is likely to be lighter; going to the emergency room in the middle of the night at the AMC is rare, but not unheard of. Further, to make time for research, teaching, and administration, the AMC doctor rarely has office practice more than 1 to 3 days a week, unless on a purely clinical track. Table 2 highlights various aspects of patient care in both environments.
The business of medical oncology is increasingly complicated. Revenue is generated from office visits and hospital consults or follow-up, chemotherapy administration services, and chemotherapy drug charges—and in some practices, from research, imaging, laboratory work, and radiation therapy. It is expensive to fund a practice; oncology practices that administer chemotherapy require five to eight staff per physician to safely administer treatments, bill, answer the phone, draw blood, and perform myriad other functions. The physician-owners are at financial risk for the property they own or rent, as well as the salaries and benefits of their employees. For example, a practice of 10 oncologists who operate an infusion center from their office commonly write checks to cover pharmaceutical expenses for more than $1 million a month. As a result, there is financial risk in private practice; abrupt changes in the revenue stream—delayed collections, loss of a physician from protracted illness, billing failures, employee theft or fraud, or bankruptcy of a payer all have the potential to be financially devastating. The risk is highest in practices that are poorly managed; therefore, it is recommended that businesses with this degree of cash flow consider professional management. It is usually difficult for a newly minted oncologist, entering practice, to understand the complexities of cost of share purchase, ownership of equipment and property, and obligations to retiring owners to be successful professionally or financially. The purchase of legal and accounting advice is often money well spent.
On the other hand, the financial rewards of private practice may be significant. First year associates salaries range from $175,000 to $250,000 nationally. Five years later, at the ownership level, compensation can more than double. These ranges are dependent upon many factors, including the risk one is willing to assume, patient load, ancillary revenue, and the local payer mix and reimbursement. Table 3 summarizes an informal survey that compares recent compensation levels between tracks. These figures are not stable because the reimbursement environment keeps changing from year to year.
The compensation structure of academia is more straightforward. Academic doctors are rarely at financial risk. The patient care–related costs are spread among the hospital and the clinical departments, and may be cushioned by government support. In most academic centers, oncologists do not purchase pharmaceuticals or realize margin from chemotherapy administration because the hospital usually employs the staff and supplies the chemotherapy. Furthermore, revenue from medical oncology is often shared among other departments that may have lower or negative margins. As a result, compensation levels among academic oncologists are lower. The informal survey in Table 3 shows that academic doctors begin at the assistant professor level from $120,000 to $170,000. Complicated compensation formulas incentivize academic doctors who secure research grants or generate large patient revenues. Salaries at the professor level can more than double starting salaries. AMC doctors regarded as national experts often augment their salaries by speaking at conferences, running symposia, testifying as experts, or becoming consultants and members of advisory boards.
Private practice is driven by the relationships between doctors who make patient referrals to one another. More than any other source, a newly diagnosed cancer patient relies on the primary care doctor's referral to see an oncologist. The relationships among doctors can be the source of great collegiality, and are one of the more rewarding aspects of practice. However, it can be uncomfortable when the oncologist is referred a patient who has had an incomplete workup or inadequate treatment, or is requesting chemotherapy when it is not indicated or when it's too late for meaningful therapy. The best physicians in private practice create systems of communication and informal education that promote excellence among the doctors with whom they work. Honest and direct communication is the best way to manage these situations. Community physicians often attend weekly multidisciplinary tumor boards to ensure communication for difficult cases and to bring recent advances in care to a broad group of providers.
The nature of the academic center, where physicians practice together in multidisciplinary environments, reduces practice variation. These groups create systems to ensure that clinical information is collected and critical data is reviewed and re-reviewed. Informal consultations with more experienced colleagues are available. Because AMC consultations often have the advantage of hindsight, AMC faculty may correctly interpret a series of events in retrospect that were difficult to understand as they unfolded one at a time. Managing these potentially emotionally charged situations can be difficult. Academic physician relationships rely on both local physicians and on the institutional reputation for patient referrals. Academic oncologists have close interactions with physicians in their own hospital; extended relationships with colleagues at the national level are common. This local and national network of colleagues is a personal reward of the academic setting.
Academic doctors have career flexibility. If the clinical research track isn't fruitful or personally rewarding, there are other choices, including private practice, academic administration (e.g., running the training program, hospital quality director, etc.), an expanded teaching role, or leaving academia for a corporate role in the pharmaceutical or insurance industry. Peter Drucker, the management theorist who coined the term “knowledge worker” wrote about knowledge workers' second careers.2 The foundation for a second career is laid in the first career. The better the national reputation, the more complete the planning, and the broader the experience in the first career, the wider the choices may be for a second career.
Some doctors don't enjoy private practice or find the physical demands of call to be difficult. Although the second career options may not be quite as broad as for a nationally known academic physician, there are plenty of examples of doctors leaving practice to enter into a clinical academic track or the pharmaceutical industry if they had previously maintained a clinical research record in their community practice. Government positions and organized medicine can attract doctors away from the bedside.
The ultimate career goal should be satisfaction—pride and a sense of accomplishment—whether from building a research program or a community practice. To achieve career satisfaction, there are some common elements.
First, any physician—whether laboratory based, in clinical research, or in a community hospital—must build a reputation based on quality. This is the cornerstone of success in either career track. Reputation is the sum of the quality of the work, the interpersonal interactions with colleagues, and the respect among patients and staff.
Second, satisfaction requires balance between personal and professional lives. Some doctors work 16 hours a day, and others work 7. The hours don't matter; what's important is that a balance is struck that fits the personal needs of the doctor and their family.
Third, it's not about the money. Although one doctor's compensation may be greater than another's, there is little difference between the satisfaction of “rich doctors” and “not-so-rich doctors.” Making early career decisions solely on the basis of income will only intensify the later need for more income and intensify dissatisfaction if the work is not gratifying of its own merit. Conflicts surrounding money split up practices and collegial relationships all too often.
There are some differences in what makes a private oncologist and academic oncologist successful, and some of these are outlined in Table 4. The reputation of a private practice doctor is built on the three A's: affability, availability, and ability. (In the past, there was a fourth A, affordability, but that hardly seems apropos today.) The reputation of a community practice oncologist is inextricably linked to fostering collegial relationships (affability) with primary care doctors and surgeons to build a referral base. In community practice it's exceedingly important to be available for new consults, referring-physician phone calls, talks to the community, and tumor board meetings (availability). The community oncologist has to demonstrate ability: willingness to communicate their status as the local cancer expert among colleagues, patients, and referring doctors. Finally, the community oncologist will benefit from paying attention to the finances of the practice, perhaps not as an expert, but to understand and anticipate problems.
In academia, focusing is essential to success. For some, it's the hardest thing to do; if you can't do it, pick a different career path. The successful academic oncologist will choose one or two areas and become an expert. Clinical work should revolve around research goals. Pressures to increase patient care and teaching should be avoided during the formative phases of a career. A willing mentor can make or break the oncologist in academia. A good mentor will give advice as to protecting time and maintaining focus, and can help turn ideas into funded grants and published papers. Successful academic doctors get involved at the national level on study sections, cooperative groups, and data presentations at research meetings. The gratification of academia is delayed. It may take years to build a research program and a portfolio of articles and projects that influence the standards of oncology practice. Finally, the successful clinical research oncologist must think 5 to 10 years ahead to anticipate technology and plan research projects. Although finances aren't the same concern as in private practice, new academic doctors should require written objectives and review them yearly to make sure that you and your boss are on the same page regarding career advancement.
There is an anticipated shortage of both community and academic oncologists.3 If this proves to be true, Fellows just starting out and established oncologists interested in a career change will have a wide array of choices. A better understanding of the different paths available to young and seasoned doctors will lead to greater personal and professional satisfaction.