I will begin this article with a disclaimer: I am an academic vascular surgeon and have been for my entire career. My second disclaimer is that throughout my training and even in most of my practice environments, I have been involved in private institutions as well. I like to think that I am not terribly biased toward or against either venue in particular. My final disclosure is that this entire discussion will revolve around vascular surgery practices.

WHAT DEFINES AN ACADEMIC OR PRIVATE PRACTICE?

If the practice name has the word University in it, you have likely found an academic practice. However, this is not always true, and as Shakespeare wrote, “What's in a name?” If you look at a particular large academic practice in Albany, New York, you will see that the name of the group is very straightforward: The Vascular Group. Nowhere in that name will you find out that every member of that group makes fundamental contributions to academic vascular surgery at every single national meeting. The name of the practice does not reflect the volume of teaching that medical students, residents, and fellows that the members provide. And perhaps the truth of the matter is in that statement. If you find that the institution has a significant teaching component and/or an expectation (or a track record) of publications, you are likely looking at an academic group. The converse is that there are academic groups in which some members are clinical producers and often have limited publications and, sometimes, limited student or resident interaction. There are also private practices that publish extensively and engage in the education of students and residents.

The number of myths surrounding practice types is innumerable, but I will describe a few of them in the following paragraphs.

MYTH ONE

Private practice surgeons have only one goal: making money.

The adage that “money makes the world go around” is true. You cannot provide care without resources, which means money has to come into the picture. The biggest difference in the arena of money between private and academic practices is the degree of control you have in how you make it and how easy (or impossible) it is to track where each cent goes.

In terms of money flow, what you collect has many destinations other than your pocket or retirement account. In both academic and private practice, each dollar goes to several places. These locations can vary greatly from practice to practice. In a “typical” private practice, your collections have to also pay for overhead, ultrasonographers in your office, office staff (assume at least a receptionist, some facility for coding and billing, and filing systems), and fees for licensing and credentialing. In an academic practice, you not only have the same expenses as the private practice, but you also have taxes. Taxes vary from institution to institution, and they often comprise money for the larger department that can be allocated to several missions or other sections within the department. Some amount often goes to the larger university or to the dean. In a private practice, you often start out as an employee and, in one of several methods, become a partner. Generally, you can find out exactly where the money you collect goes in a private practice. That cannot be said of most university practices. As academic medical centers become more cognizant of the financial pressures facing them, academic surgeons are finding themselves increasingly accountable for their workloads and are often benefiting financially from high workloads in the form of bonuses for productivity or a percentage of their collections. All of the above permutations must be explored when considering accepting a position at either type of practice.

In a private practice, you have a little more control in how you practice. Depending on the particular practice you choose, you may find that you have to broaden your scope beyond what you did during vascular training; you may find that you need to take a general surgery call. However, you may be able to restrict your practice to a single territory, such as venous practice. The scope of your practice depends on several factors. Issues such as the density of vascular surgeons, what the larger group wants, and what the local referring and consulting physicians are looking for affect your options. Remember, in private practice, these are your choices, as you are choosing the practice. In academic practice, it is more common to have a “straight” vascular practice, but you often find that you have to be a vascular generalist, doing everything from hemodialysis access to treating thoracoabdominal aneurysms. Regardless of whether you choose an academic or private practice, individual members will become more specialized. In large practices, it is not altogether uncommon to find individual members with niches within vascular surgery.

MYTH TWO

Academic surgeons go into academics because they would rather do research than take care of patients.

I have a major issue with this myth. Academic surgeons are responsible for the bulk of training, so if they cannot operate, how can anyone they train be competent? It is true that academic vascular surgeons often have responsibilities in addition to their clinical practice, but these responsibilities very rarely affect clinical practice per se. Those responsibilities also look different today than they did 10 years ago. Today, “academics” comprises more than the basic sciences. Although academic vascular surgeons continue to greatly contribute to the understanding of the molecular and cellular mechanisms behind every aspect of vascular disease, they are also involved in research into outcomes of procedures, decision making in vascular surgery, and clinical trials. They are also increasingly involved in health policy research and in education. All of these count as academic output.

To turn the tables, there is nothing to say that vascular surgeons in private practice cannot engage in these endeavors. In fact, they often do. Occasionally, minimally invasive or novel therapies are more rapidly integrated into private practices, which tend to be more flexible. Thus, when trials to assess these technologies or therapies are designed, private practices play as large a role as academic practice. Although running a basic science laboratory is not likely feasible without a supporting university, education, health policy, and outcomes research are all actively performed by private practice surgeons today.

MYTH THREE

Once you choose a path, you cannot change it.

This was widely quoted to me when I was a resident and a fellow. I was advised to pursue academics because if I did not start there, I could never get there. This simply is not the case. A dean at a southern medical school is a vascular surgeon whose first job was in private practice. And while in that private practice, she presented and published several important articles that influenced vascular surgical practice. No one would ever consider her transition to academics to be less than thoroughly successful. The converse is true as well. As previously mentioned, private practices are often involved in clinical research, and practitioners may occasionally decide that inquiry drives them more than they anticipated and make the move to academics.

MYTH FOUR

Academic and private practices are diametrically opposed.

Looking at the previous three myths, it should be apparent that the line between private and academic vascular surgery is awfully blurry. This has been a steady change that has occurred during the past 10 years. Each practice looks different. “Academic” and “private” are no longer the distinctions that they once were. Many academic practices are very clinically oriented, with limited academic output. Many private practices have vibrant publications and research output. However, there are several differences that remain. Physicians tend to have more control in private practice. The business of medicine looks more and more like a business every day. Your willingness and enthusiasm toward this fact must play a part in your job choice. The bigger the institution, the slower change is accepted. Much like a ship, the bigger it is, the longer it takes to turn. Academic practices are often part of a larger department, which is itself part of the larger university. This is often the source of the inflexibility that is observed in many academic practices.

FREE ADVICE

No job is perfect, but there is one that will likely be a wonderful fit for your strengths and your desires. Think about where you want to be 1 year after your training. Does the job you are looking at match your mental image? What about at 5 years? How do you feel about changing jobs? It is a lot to digest and a lot to think about. It might help to sit down at a quiet moment (often hard to find during a busy training program) and think about your individual strengths, weaknesses, likes, and dislikes. Take that list with you when you look at positions. When the qualities that you are looking for and those of the job match up, you have found a position that will likely suit you. Do not let the designation make your decision for you. Ideally, this is a position you will hold for a while and enjoy. Take your time looking and making your decision.

Many thanks to Robert Patterson, MD, and Julie Thacker, MD, for their advice in the preparation of this article.

Leila Mureebe, MD, FACS, is Assistant Professor, Section of Vascular Surgery, Duke University Medical Center in Durham, North Carolina. She has disclosed that she holds no financial interest related to this article. Dr. Mureebe may be reached at (919) 681-2550; leila.mureebe@duke.edu.