Ophthalmology off the Grid
Episode 96

Survive & Thrive: Private Practice vs Academia

In this episode of the Survive & Thrive series, Gary Wörtz, MD, is joined by Nandini Venkateswaran, MD; Dagny Zhu, MD; and guest Preeya Gupta, MD, to talk about one of the big decisions faced by young ophthalmologists: private practice or academia? They weigh the pros and cons of each career path and share their own experiences in navigating this choice.

Gary Wörtz, MD: Open, outspoken. It's Ophthalmology off the Grid. An honest look at controversial topics in the field. I’m Gary Wörtz.

Speaker 2: Welcome to another episode of Ophthalmology off the Grid’s Survive and Thrive series.

Today, Dr. Gary Wörtz is joined by Drs. Nandini Venkateswaran and Dagny Zhu and guest Dr. Preeya Gupta for a discussion on private practice versus academia. They talk about which factors to consider when trying to decide which path to take; plus, they’ll each share their own experiences in navigating this pivotal moment in their careers.

Coming up, on Off the Grid.

Speaker 2: Survive & Thrive is an independent program produced by Bryn Mawr Communications and supported by advertising from Johnson & Johnson Vision.

Gary: Welcome to Ophthalmology off the Grid: Survive and Thrive series. This is Dr. Gary Wörtz along with my cohosts, Dr. Nandini Venkateswaran out of Mass Eye and Ear and Dr. Dagny Zhu at Nvision in California. Today we're talking about private practice versus academia. It's a big conversation. A lot of us decide to go in one direction or the other, and we have a very special guest, I have to say one of my best friends in ophthalmology, Dr. Preeya Gupta. Preeya and I go way back. We've worked on a number of projects together, especially recently, and we'll probably get into a little bit of that, but without any further ado, Preeya, thank you for joining us tonight on Ophthalmology Off the Grid.

Preeya Gupta, MD: Thanks so much for having me guys, and Gary, you are one of my best friends in ophthalmology.

Gary: Ah, you know, it's just so much love. It's great.

So, we're talking about academia and private practice. You and I span that entire conversation. You're at Duke and have been there, I guess, since fellowship, is that right?

Preeya: Yeah, this is my tenth year on faculty.

Gary: Wonderful, wonderful. So, I want to get into...really…because our listenership really spans a wide range, but I feel like a lot of younger ophthalmologists listen to Off the Grid, and probably a lot of ophthalmologists, either…pre-ophthalmology medical students, or ophthalmology residents, or maybe early-career ophthalmologists who are in the middle of trying to decide, what do I do? Should I stay at my institution? Should I go and try to get a real job? At one point in my life, I was going to do an ASOPRS fellowship in plastics and stay at the University of Kentucky and be their plastics guy. That didn't end up happening. I changed my mind kind of last minute and decided to go anterior segment. But Preeya, I would like to know from you, when did it click for you that academics was going to be the way you started your career?

Preeya: You know Gary, I think that sometimes things happen for a reason, and a lot of times it isn't that you magically have all the information that you need to make the perfect decision at the perfect time. So, I did my residency at Duke, and then I did my cornea, refractive, anterior segment fellowship at Minnesota Eye Consultants with Dick Lindstrom and Dave Harden and Tom Samuelson. So, those are two very different environments. Duke, obviously, is a major academic institution. As students, we're very comfortable with academic institutions, we know what they're like, it's kind of where you've been raised. Fellowship was just a very different experience because it's an academically oriented private practice.

So, I really got to see kind of both sides, and I think that ultimately you can't make a wrong decision. The only wrong decision is an uninformed one. And to me, I've always loved being around residents and fellows and teaching and being involved with research. I think that the way it worked out was just that there happened to be an opening at Duke after fellowship, and it's obviously an amazing eye center, amazing collective group of resources. I think for me, early in my career, I didn't have a strong leaning of, "Oh, I have to be an academic," or, "I have to be private practice," and it really was about being in an environment that would support clinical growth when I wanted to or academic work when I needed it. I found that early in my career that the environment that I chose was actually a reasonable balance for that.

Gary: Nandini, you've recently had to make this decision also. I'd love to know kind of what went into your mind when you were thinking about, what do you do when you grow up, if you will? What do you do post-fellowship?


Venkateswaran, MD: Yeah, I remember...I mean it was just under a year ago now, and I remember even talking to Preeya quite a bit as I was trying to make my decision, because for me, I think like she was alluding to, academics is always what I knew, and I did my residency at Bascom Palmer and my fellowship at Duke, and all of my mentors were academicians, and watching how their careers evolved, for me it was kind of identifying people who I wanted to emulate in terms of their career paths or what they were accomplishing and see how I could make that possible, and for me, academic seems like a very safe and a very supportive place to start. I think there's a lot of career security in academics, and there's many opportunities in any academic institution, not only clinically, but also from research standpoint, grant funding standpoint, education standpoint, for trainees. And I think you also have the opportunity to kind of establish a niche or a name for yourself and pick an area that you want to specialize in.

The diversity and the complexity of patients you'll encounter in an academic setting will help you further identify those areas of interest and hone them in, because we all come out of training very excited and enthused to see and do everything, and 10 years down the line that's going to change, and we're all going to find those areas that we want to become "experts" on. So, I thought that was great, and Mass Eye and Ear, I'm primarily at a satellite location, but I'm also operating at the main eye center and seeing patients and working in the ER there as well. So, it's been a nice hybrid model, actually, for me to work in kind of an office-based setting, but also have opportunities to work with trainees in the emergency room and work in the clinic there where patients are sicker or more indigent than in the satellite. So, I really enjoy it so far 2 months in, I can't complain.

Gary: Yeah, and Dagny, you were kind of on the other side. I know it took a little while for you to really get started, but you're at Nvision, a fantastic group practice, or chain of practices, and you're, I think, the youngest owner of one of those centers. Walk me through your thought process on which way to go. Did you know early on that you wanted private practice or was it more of a struggle to decide?

Dagny Zhu, MD: I was really similar to Preeya. I had a really open mind coming out, especially because my number one priority was getting back home to Southern California. I know for some people, geography becomes their number one priority based on where their family is, so when you're trying to go back to somewhere that's pretty saturated, your opportunities are a little bit more limited. So, I kept a very open mind and I interviewed basically everywhere, private practice, academia, and Kaiser, which is a large HMO-based hospital system here that's very popular as well. So, I sort of got to see a little bit of each. But I have to say, when I found the Nvision opportunity, I was scared, because like most residents or new trainees, we got very little exposure to private practice, and all we know is academia. And I was afraid of missing out and losing everything that I loved from academia, namely the opportunity to do real research and also to work with residents and to continue to teach.

But I will say that I have found that even in private practice, these opportunities are still within reach. Like Preeya said, her fellowship was very...it was a private practice fellowship, but very academically oriented. So, your private practice is whatever you make of it. For me, I'm actually very interested in doing research, and so I've had opportunities to collaborate with industry and do sort of some of these post-market investigator-initiated studies. Some of the surgeons at our centers are doing studies on the Vivity lens that just came out. I'm doing studies on the trifocal PanOptix. And so, Dr. Tooma, who is the founder of Nvision, he was in a lot of the FDA trials of a lot of the things that came out.

So, it's actually pretty limitless, the type and amount of research that you can still do in private practice. It's sort of a different type of research. You probably couldn't do basic science research, for instance, as much, but the research opportunities are still there. And for teaching too, I actually have a lot of students who shadow me. A lot of them are med students, and I've had residents rotate with me too. And actually, I recently became a clinical preceptor for one of our neighboring universities, Western University. So, I'm a fourth-year rotation site for them, so, I get to actually have students come in, which is pretty cool. So, I get to keep doing that, which is awesome.

Gary: Yeah, and I want to just take a pause here to...actually, I want to thank our sponsor, Johnson & Johnson. Without them, we're not able to do this, and it's really important that we're able to get these kinds of conversations started. And there's a lot of, like I said, residents out there and early career ophthalmologists who are trying to make these decisions. So, I do want to thank Johnson & Johnson for sponsoring this.

One thing that I found very interesting, because I came into ophthalmology as an outsider, I was exposed to medicine, my father was an internist, so growing up I was kind of exposed to medicine, but ophthalmology was kind of this weird field that I didn't really know too much about. And it seems in other fields of medicine, the thought leaders really come from academia. It's not to say that that's not the case in ophthalmology, but I feel like it's pretty well balanced with some private practice doctors, like Dr. Dick Lindstrom, and some others who are out there, Stephen Slade, Eric Donnenfeld, Warren Hill, the list goes on.

There's a number of private practice ophthalmologists who are really kind of at the top of the KOL or thought leader board, and it is really interesting that private practice can be as academic as you want to make it. When I got out of residency, I really just wanted to go do surgery. I mean people who know me, if you spent much time around me, I like to cut, I like to do cataract surgery, I just like to be efficient and make the most of my time in the operating room. And I really strongly focused my efforts that way, but it wasn't too long when I was in private practice that a lot of the intellectual curiosity that was fostered and developed through undergrad, through medical school and residency, because I was doing research all the way along, not necessarily because I loved it, it was more I felt like I kind of needed to do it, but that muscle...you sort of build those muscles or whatever it is, and I started being curious about things.

And so, not to say that you get the grass is greener effect, where you're wondering, should I have gone into one thing or the other, but I will say that in private practice in ophthalmology, you do have a lot of opportunities, like Dagny was saying. As a matter of fact, Preeya and I just recently published a paper together. So Preeya, why don't you talk a little bit about that, because that was something that you and I just...over a cup of coffee, we were talking about our practices and how we could collaborate, and next thing you know, we've got all these things that we've launched. So why don't you talk a little bit about that?

Preeya: Yeah. You know, you're absolutely right, Gary. I can't emphasize enough to the people out there that are listening that really it is what you make of it, and I truly believe that in academics and private practice, you can be academic, and you can be research minded, and just because you start in one environment doesn't need to mean that you end in that environment. Academic institutions change, private practices change, and I think if I could give everybody one piece of advice before I tell everybody about our awesome paper, it is that, every 3 to 5 years, it's so important for you to sit down and look at what your own personal goals are, look at what your current environment is, and you can always assume that something else is better, but there's going to be pros and cons to everything.

And I think that unless you're actively reflecting on whether or not your environment makes you happy, or are you achieving the goals of what you want, if you don't reflect on that, you're not going to be your happiest, partly because sometimes we just need to accept limitations, and we need to accept that a certain environment can only provide certain things, and I've always believed that things are what you make of it, and you should not let anybody else control your destiny and your happiness, because it really is up to you to perceive everything as it is, and if you don't like it, change it. But our collaboration...yes, Gary and I were…on the phone. Gary knows me well. I'm constantly walking outside.

I think I always have my earbuds in, and Gary can probably hear the birds chirping on the trail. But we were talking about femtosecond laser cataract surgery, and the topic of, why doesn't everybody just feel like this is giving better visual outcomes? We're doing it in a high percentage of our patients. And one thing led to another, a couple of Pub Med searches, we found that actually there's been no studies looking at the femtosecond laser and its impact on managing low levels of astigmatism and what that meant for uncorrected vision. And so, we worked together and out of it created a formula, the Wörtz-Gupta formula, which is freely available, actually, at lricalc.com. We learned things about building a website. Lricalc.com is the blood, sweat, and tears of Gary Wörtz and Preeya Gupta trying to figure out how to speak web designer.

Gary: That's right.

Preeya: But most importantly, such a great illustration of collaboration among colleagues, independent of our own environments. Gary has certain fortes, I had certain fortes, and the fortunate thing is that put together, they all came together so nicely, and those are the things that I really would encourage everyone out there listening…if you're...when I said earlier, things are what you make of it…so, if you're interested in doing academic work but you're in a private practice, reach out to your academic colleagues, and if you don't have all the infrastructure, or vice versa, sometimes in private practice, you have access to certain things technology-wise, etc., that you won't have in academics, because it's a larger institution and there's less control or choice sometimes. And this collaboration to me really just reinforced that if you have an idea, you can see it through to fruition. I really think this was a journey of learning, because after 10 years of academic work, I learned something new.

And then…I mean, Gary and I have a list of five other projects in our pipeline of fun things, and even from here, I feel like it's also a springboard to us working with other colleagues. We have one of our sub-investigators here, but we have our friends and colleagues testing out our formula and giving us real world feedback, and that turns into another larger collaboration. The website itself, we have international users, so it's impacting a number of people in ophthalmology. And when I look at my day to day, those are the things that excite me, surrounding myself with people that are like-minded, that have a high bar for excellence, that value taking great care of their patients. I know that about myself, and so if I'm not in that environment, I change it or I try to put those pieces together so that I can be happy with my day to day. And I think, academics, private practice, there's so many shades of gray in between, that you really can make things what you want.

Gary: Yeah. I also think that...sometimes I think as ophthalmologists or high performing individuals in general, we probably put a lot of pressure on ourselves to try to be excellent at everything, and I do think sometimes we don't leverage the friendships that we have, where Preeya was so helpful to me in this process of, "Hey, let's think about the study design." I had, in my mind, a study design and goals, and as we talked about it, she really helped clarify my thinking on it. It was like, wow, it's a really great way, that just reaching out to a friend who has strengths in other areas, it made the process so much more productive. I think that we're really lucky in ophthalmology that we do have such a collaborative environment between academics and private practice, because it's not that way everywhere. Dagny, What about in your area? You're in Southern California; you're at a big refractive center. Are you able to collaborate with your local universities in residency programs, and/or are you able to collaborate with your partners throughout the Nvision network?

Dagny: Yeah, absolutely. A lot of us partner together. We are a very large private practice group, so there's surgeons practicing all throughout the West Coast, and so there's ample opportunity for collaborations on research projects, but even with local residents, I have residents helping me with my research projects. There's an opportunity because, you'll discover if you're in private practice trying to do research, one of the logistical issues you try to deal with early on is, “How do I get IRB approval?” That's something I never thought about as a resident because I just went to the university IRB.

But once you're in private practice, you realize you got to find an IRB, and there are actually commercial IRBs available which you can apply to, and that's actually what I did, many that I was never aware of before. But the other option is also to collaborate with your colleagues who may be at neighboring universities. So, for example, with a resident or something, you can apply through their university's IRB. I'm actually doing some social media projects, which are kind of cool, and it still needs the IRB for some simple stuff we're looking at, but I'm working with some residents up in Canada, and they actually went through their University of Toronto IRB to get approved really quickly, much faster than I could get probably from a university down here. There's just different opportunities, definitely. Logistically, it helps to collaborate with an academic center, for sure.

Gary: Yeah, and Nandini, you're at the mecca. You're at Mass Eye and Ear, you've got access to I'm sure so many fun technologies. What's it been like starting out in academia? Any surprises? Has it been about how you thought it would be? Anything you're enjoying especially?

Nandini: I think a lot of it is learning to navigate how many resources you have at your disposal. It's actually quite overwhelming to start off, because you're trying to figure out what area do you want to focus on? What sort of research do you want to do? And a lot of research comes from your clinical practice. So, for me, a priority has been kind of building my patient base so I could identify conditions I want to study or think of ways, potentially, to implement new technologies and do investigator-initiated trials. But one of the best things has been to be able to pick the brains of so many smart people around me, even if it's a 5-minute conversation between OR cases or setting up a meeting with the head of my cornea service.

Just trying to get a sense of, what was your career path like? How did you decide what you were going to do when you started? You have a lot of free time your first, at least, 6 months of practice. So that's the time that you can really devote to writing papers, or thinking of research ideas, spending time doing those Pub Med searches to figure out where there's something lacking in the literature. So, for me, it's been a lot of just brainstorming and trying to figure out what it is, and then hopefully as things get busier and I think of more ideas, things will come into fruition.

Gary: Preeya, when you are working with your residents, can you tell which ones are going to be bound for academia, which ones are bound for private practice, and then those who could go either way? Are there certain traits that you see in them?

Preeya: It is interesting. As much as I would like to be able to…

Gary: Predict them all?

Preeya: Yeah, in my crystal ball. There is...kind of like what Dagny said, sometimes the other factors, where your family is or what geographic areas you want to be in, sometimes that plays a role in decisions. But I think that, at least at Duke, a lot of our residents are already fairly academically oriented, and so, if I picked a solely based on that...Now remember, I don't get all of them to go into cornea. So…

Gary: You got to try harder.

Preeya: I got to try harder, absolutely. But I give all of the residents, and our fellows, the same advice, which is, sometimes you get so stuck on academics or private practice, and I really encourage people not to look at it that way and to look at so many more factors. How often do we reflect on what's going to make us happy? Right? We assume we know what's going to make us happy, but when it comes to a real-life decision, like where are you going to live? Where are you going to practice? Who are you going to practice with? We spend more time with our coworkers, often, than we do at home with our families at times. So those are big decisions, and I don't think that you should necessarily get trapped in the, “I got to pick one way or the other,” because knowing what you want and need is really the most important deciding factor.

Dagny: Preeya, I love what you said about how it's really what you make of it. Not all academia is the same, not all private practice is the same, it's really what you make of your own opportunity. And just numbers wise, I mean, most residents are going to go into private practice. That's just where most of the opportunities are. But that doesn't mean they can't be academic like we talked about. There's lots of opportunities there.

Preeya: Absolutely.

Dagny: I'm wondering, for our young ophthalmologists or trainees listening, is there anything about academia that you don't like? Any cons about working in an academic setting? Just so it can help them sort of make their decisions.

Preeya: Yeah, I think as you get further along in your career in academics, I think that one of the things you'll realize is that they're part of bigger systems, and bigger systems tend to make decisions for the average. So, on average, how can we get more people happier than not happy? So, it's not necessarily “How can I get Dr. X to be happiest,” but it's, “How can I get the averages to be well taken care of?” That sometimes, I think, can be difficult, because if you have a specific vision, a specific drive, a specific goal for your patients, or even going down to products, even specific technology that you want to have access to, unfortunately you don't always have control over things like that, whereas if you said, "OK, I want to see this many patients in clinic," you might not be able to, because there might be shared resources, or there might be things where you are part of a bigger system, and it's not really as much about you, no matter how excellent your work is or how much your patients love you.

Things like that are important, but you're still part of a bigger circle. Whereas, in private practice, your circle is smaller, you often have more autonomy and more decision-making, but with that comes often more financial responsibility and more logistical, sort of, organizational kind of things. So right now, when I go to clinic, I don't make a schedule. I show up, I see my patients, I hope that there's enough people to help me get through the day, and you move on. But I think that it goes both ways. So, there's some days where I'm, "Oh, this is great that I don't have to think about all of these logistics," but then there's other times where you would like to change something or you'd like to improve something that's broken and you can't fix it because it's a system issue.

Gary: I'll say that as a private practice partner, I'm able to really, totally optimize my practice lifestyle. I can be as selfish as I want to be. As long as I can fund it, I can do whatever I want. I have full autonomy. The problem comes in when something like COVID hits, and you are on the hook for making sure that all of your employees don't starve. I've got 100 employees potentially, and...maybe not quite that many, but not far off…and if we're shut down, all those people, I'm responsible for, and ultimately it's the doctors who make the revenue, and if we're not operating or seeing patients...So really...it cuts both ways.

There's maybe a higher chance of optimizing your lifestyle, you have a little bit more control over your income in some regard, but also, you're really on the hook. And if things don't go well, you don't have the university there necessarily as a buffer between you and the big, bad world that's waiting for you out there. I do think it's sort of a risk/reward calculation that we have to take into account. I do want to say, during COVID, I've actually...we all had maybe a little more time because we're not running and gunning and going to meetings and traveling everywhere, and I read this really great book called Ikigai: The Japanese Secret to a Long and Happy Life. It's actually by Héctor García and Francesc Miralles, who are both Spanish authors. It's in English. It's a very quick read. It's only about 160 pages long.

For anyone out there who's in the middle of sort of a, not a crisis necessarily, but more just, sort of, a reflecting mood of, “Am I doing sort of what I was meant to do? Am I in the right space for myself?” Basically, the Ikigai is sort of a combination of what you love, what you can be paid for, what the world needs, and what you are good at. It's sort of at this intersection between passion, mission, profession, and vocation. I think a lot of times, we just go to work and we don't think too much about our mission or our reason for being alive and our reason for being put on the earth, and as ophthalmologists, we're working miracles at scale. I mean, as a Christian, I read the Bible, and Jesus did a few miracles, but the ones that really stood out were basically making the blind man see again. At least that stands out to me.

And think about this, there are people who walk into my...I'm not comparing myself, but what I'm saying is, sometimes we take it for granted, what we really do, and it's absolutely mind-blowing. And if we could do this 1,000 years ago or 2,000 years ago, we would be considered as having other-worldly power. Sometimes in the grind of doing a lot of it, though, it wears on you, and you don't remember how special it is. So, I just want to remind everyone out there, if you're listening to this and your burnt out, or you're trying to refigure out why you're here doing this, it's OK to take a step back and really think about the choices that you want to make for yourself. Making a change is...I'm a testament to that. I've been in a number of different practices, and I'm so happy now, but that was after...you’ve got to kiss a lot of frogs. Sometimes where you start is not where you end. I think anyone out there listening, you take agency over your own decisions in your life, and that's, I think, how you figure out how to make a real productive, meaningful life.

Dagny: What was the name of that book? Can you spell the title?

Gary: Yeah, it's I-K-I-G-A-I, Ikigai:…

Preeya: I just put it on my Audible.

Gary: …It's online, The Japanese Secret to a Long and Happy Life. Very good book. It's mindblowing. Love it. So, Preeya, any thoughts, any final thoughts before we wrap up?

Preeya: You know, I'm just excited for all the future ophthalmologists out there. And I think my only advice to them is, don't be paralyzed with the decision. Everything is changeable, truly. There just isn't a thing that you couldn't change if you truly were committed to fulfilling a goal, an ideal, a practice style, whatever it is that, as you said, Gary, makes you passionate, that makes you excited. That is what you should pursue. And that applies to so many areas in our own lives, but unfortunately, it takes us a long time to realize that. I really do believe that if you keep that at the forefront as you're thinking about these decisions, it makes all of the decisions so much less onerous and more palatable and truly puts the power of being happy, in whatever environment you choose, in your own hands…

Gary: That's right. Wonderful. Bloom where you're planted, I love it.

Nandini: Those are wise words.

Gary: Yes, yes, Nandini, absolutely. Well, I think we'll just wrap up there. Preeya, Nandini, Dagny, thank you so much. I love connecting, talking with you all, and I always learn and feel like I'm better for it. So, thanks again. This has been Ophthalmology Off the Grid: Survive and Thrive, sponsored by Johnson & Johnson. Until next time.

Speaker 2: Thank you to our contributors for joining for another episode of the Survive and Thrive series, and thanks to Dr. Gupta for sharing her expertise.

This has been Ophthalmology off the Grid. Until next time.

Speaker 2: Survive & Thrive is an independent program produced by Bryn Mawr Communications and supported by advertising from Johnson & Johnson Vision.

11/20/2020 | 33:32

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