I recently changed jobs. I moved my family and my career across country from a large university in the Midwest, to a large independent group practice in the Southwest. For readers who have changed career positions, you know how involved this process can be: New hospital credentialing, new state licensure, new house, new school for the kids, different climate and weather, different city. I’m often asked why I made the move. The rationale is complex, with both professional and personal motives. Part of this change is the transition from traditional academic neurosurgery to a private practice group; this aspect of my move will be the focus of this essay.
What is Academic Neurosurgery?
Without question, the definition of academic neurosurgery has changed and continues to change. All readers know what a traditional academic neurosurgery program is: The behemoth hospital with a university’s name attached. Readers also easily recognize the opposite end of the neurosurgery practice spectrum: The independent, solo or small group practice. The gray area of “privademic” neurosurgery practices are somewhere in between. All the academic potential can exist at one of these privademic group practices, but there is a stark difference between a private, independent practice and a traditional, employed, academic practice.
What I Like (About the New Practice)
From my first day in the office, when my administrative assistant was looking for direction on building my weekly schedule and running my clinic, I knew I had embarked on a more independent path. No longer was I plugged into the large university, overflowing with patient referrals and with allotted timeslots for my clinic and OR. Now, I had the independence to dictate my patient mix, my schedule and my office administration.
The independence also translates financially. Gone was the salary; instead, I control my own cost center. This independent cost center promotes financial transparency. I know that if I choose to attend a meeting or hire an administrative assistant, these costs affect my bottom line. On the other hand, there is no ceiling on my earnings, and I know that if I see more patients, take more calls and do more cases, I will be financially rewarded.
What I Miss (About Academics)
A large academic institution can be considered a “cushion” or “safety net” for the individual neurosurgeon. Those who have worked at a traditional academic program understand this concept. The cushion refers to multiple aspects of the neurosurgeon’s professional life: Name recognition at the academic center, a constant flow of patient referrals, the safety net of a salary not directly tied to clinical work output, even the concept of risk mitigation for any individual practitioner.
As a part of that academic cushion, we didn’t worry about insurance carriers or collections. With a salary and loose incentive structure, we knew we’d be compensated regardless of the patient’s insurance carrier.
What I Don’t Miss
The salary structure at an academic institution, however, is a double-edged sword. I found the department’s financial center to be more of a black box, opposite now to my individual itemized cost center. I enjoy knowing excess revenue is not spent on a cost I didn’t incur.
I also don’t miss the bureaucracy of administrative policy at the large academic medical center. Nothing hurts job satisfaction like lack of control. I don’t miss asking the question: “Who’s making these decisions?”
While every hospital has its efficiency issues, some are more efficient than others. At the large academic medical center, cases were hard to add on, our first case start times typically landed into mid-morning and turnover between cases was extremely slow. A complex web of contributing factors existed for each issue. Perhaps a salary structure without direct financial incentive for volume creates inefficiency; perhaps smaller hospitals have potential to be more efficient.
Additional Thoughts and Job Transition Pearls
Neurosurgeons change positions for an array of reasons, but in each case, a contract will need to be negotiated. Remember to know your BATNA (best alternative to a negotiated agreement), know your worth and join a group with integrity and trust in your partners. Start the credentialing and licensure process early and be organized throughout the move.
The decision to change jobs relies on a complex set of priorities. Three of the most important professional priorities can be called the “iron triangle:” Practice location, practice type and income. It is extremely uncommon to optimize all three of the iron triangle variables with one position. Choose to optimize two of these variables; give up the third. Academic neurosurgery compared to private practice is just one point in the iron triangle.
I still plan to pursue national leadership, publication and education in my private practice position. Many neurosurgeons at academic institutions may have a personal cost center. All things considered, the distinction between traditional academics and private practice may be more blurred than ever. A more important dividing line may be hospital employment compared to private practice. Hospital employment puts our profession at the mercy of business administrators, whereas private practice empowers physicians. It’s nice to buck the national trend of increasing hospital employment and join a private group practice.
