Although many surgeons ultimately will work in private practice instead of academia, some surgeons—especially those who pursue advanced laparoscopic training—will have a choice between these career paths. The decision is a complex one, particularly in view of changes that the health care reform law will likely bring to surgical practice in the United States. Understanding the benefits of each practice type may better prepare trainees for their eventual landing point.

Generally, a career in academia is centered on research and publishing, as well as education and training. Surgeons in academia often say they feel they are part of a larger surgical culture, contributing not just to individual patients but to the field as a whole.

“For me, it was the fun of having questions and getting answers, making a difference that seemed a little bit bigger than my own wallet,” said Daniel Jones, MD, professor of surgery at Harvard Medical School and chief of minimally invasive surgery at Beth Israel Deaconess Medical Center, both in Boston. Dr. Jones was fortunate to train in minimally invasive surgery (MIS) at a time when these programs were popping up around the country. One private practice group offered him “a ski lift ticket, a golf course pass, and time to do both,” but Dr. Jones felt the advanced laparoscopic skills he acquired in fellowship should be used to make contributions to the field of surgery at large.

“It wasn’t golf and skiing, but it was fun in a different way, and I was making contributions,” he said.

Now years later, Dr. Jones has published books and hundreds of papers, launched surgical skills centers in France and Dubai, and currently sits on executive boards and committees for several prominent national surgical societies.

One of the best aspects of an academic career is coverage by colleagues, added Dr. Jones. “In an academic group practice, you can get coverage for those activities that are valued as collectively important.”

“It also allows a surgeon to go out of town without the fear of losing our practice the next day,” he said.

The collective group is the source of both the advantages and disadvantages of academic life (Table 2). Academic surgeons tend to see rare and challenging cases; they also manage the sickest patients, which community surgeons can refer to them when needed.

Academic surgeons also have a broad network of colleagues to call on. “When a difficult problem comes in, I have a very wide group of colleagues that I can work with or ask to give me feedback, and I think that’s a little bit different than the general practice surgeon,” Dr. Jones said.

In private practice, the benefits and restrictions of the academic group are forgone for the freedom and risk of ownership.

Private practice surgeon Daniel Cottam, MD, finished training in much the same way as Dr. Jones—with advanced skills that were in high demand. He had several job options at prestigious academic medical centers, but chose private practice because the rewards aligned with the demands.

At every academic institution he visited, surgeons had to perform a set number of surgeries. “Everyone had to produce in terms of the number of surgeries to make money for the hospitals or the medical school. That was most important to the administration,” Dr. Cottam said. “Publishing and teaching was something that you had to do but they didn’t pay you or care about it that much.”

Academic surgeons were asked to produce at high volume but weren’t rewarded proportionately, added Dr. Cottam. “And that is nothing against academic physicians; that’s just what happens when you work for a big organization—[they] take the profit from you individually to put it back into the institution.”

When he was interviewing for surgical positions, Dr. Cottam found that private practice surgeons typically made at least double the salary of academic surgeons.

However, the biggest breakthrough for Dr. Cottam, who enjoys research, was discovering that a significant amount of published research is produced in private surgical practices. “When I started looking around at the number of people who were academically active yet were still in private practice, I was astounded,” Dr. Cottam said. “I had just never conceptualized people publishing academic papers outside of a big, fancy medical center.”

That sealed it for him, and now years later, Dr. Cottam runs a very successful 2-physician bariatric practice in Utah and routinely contributes papers to major bariatric surgery journals.

Generally, the main benefit of private practice is control. Surgeons with some degree of ownership in a private practice can usually dictate their income. That may mean doing fewer procedures, abandoning certain operations altogether, or taking longer vacations.

“The flipside is that whenever you’re not working, you’re not making money, but your overhead is still there,” Dr. Cottam said. “But for people who really like to have control, private practice is the only way to go.”

However, control also means hiring and firing, handling human resources issues, and negotiating with insurance payers and hospitals.

“The reality is that when you go into private practice, you have to ask yourself, ‘Is it worth it to spend the additional hours looking over the staff and watching over the bottom line to be successful [and] take that 50% to 200% pay raise?’” Dr. Cottam said.

Although private practice and academic surgeons often say they value different things, Dr. Cottam is convinced that being successful in either arena requires the same skills, whether that means being available to sit on yet another committee or to manage a surgical patient at a community hospital into the wee hours of the night.

“When you see a very successful academic and a very successful private [practice] physician, I doubt the skills are that much different,” Dr. Cottam said. “It’s all about making relationships and being available.”