Better care: Private practice or academic center?


Throughout training, I had an idea. And that idea was — I would be a great academic physician. I had the right training. I had done research from college through fellowship. I had received research grants from medical school through fellowship, published numerous papers and started defining a niche. Everything was going great.

Academia — here I come!

Then attending-hood arrived. I looked for positions in academic centers. I was limited by geographical boundaries but interviewed at two academic traditional academic centers. These sites were traditional academic centers with assistants, associates and full professors with R and K grants. There were students, residents and fellows.

The other center was academic with students, residents, and fellows but less NIH-funded research. There were definitely a lot of people producing research. It was just on their own time with various funding routes.

I debated between the various institutions and finally decided to go with the less traditional academic centers. Here I was a 100% clinical but with the opportunity to teach and perform research. Over the next few years, I focused on my niche (cardio-oncology), practiced general cardiology and performed the research I wanted. It was not the career I had planned in medical school, but I was doing the things I wanted.

Over that time, my medical skills improved in some fields and atrophied in others. I was no longer dealing with arrhythmia. Why mess with hard-to-control atrial fibrillation when the electrophysiologist (EP) was down the hall. I did not have to think heavily regarding ischemic patients because my interventional colleagues would be happy to chime in. By being a general cardiologist at an academic center, my overall cardiology skills atrophied. Sure I was, great at hypertension management (surely better than my interventional or EP colleagues) and heart failure management (though not transplants or those requiring inotropes).

I was getting better and better at cardio-oncology, my chosen niche, but part of me was dying. All those years of training were fading into the ether of time. I did not mind so much as life was comfortable and easy, but it did make me a little sad. So after four years, I decided to move. The reasons for the move was multi-factorial. But here I was, four years later in a new city and now in a private practice group. Not only private practice, but in a remote setting.

Now, I’m one year into my new practice. Over that time I have become a better doctor. I am a more rounded cardiologist. I manage my own antiarrhythmics and perform my own cardioversions. I decide which valve cases need a transesophageal echocardiogram and do it. Then I decide who should and should not get surgery. My skills for determining who should be sent an hour away for either an outpatient or inpatient angiogram has become much more tuned. I listen to the intricacies of the history and look for the subtle changes in the ECG before sending someone for an invasive procedure. I no longer have the interventionalist there for a second opinion. I even am doing my own bedside echocardiograms — a skill I gave up years ago.

One year in and I can tell you that I have become a better doctor. I imagine this is the case with most private physicians. We have to be more of a generalist. We can not huddle into the dark corner of our niche and forget the rest of medicine. We do not have the thousands of resources and people backing us up, allowing for us to shirk our decisions.

This is why I am surprised as to how poorly private practice doctors are seen in academics. The academicians — and society — hold the academic centers up on a pedestal. It is in these houses that the best care is provided. While this may be true for some centers and more specifically some very rare or hard to treat diseases, for the general, run-of-the-mill diseases, I think that private practice docs may be better off. They may provide better care with a higher continuity in that care. No sign offs. No explaining what the history was to five other people. No students and house staff to screw up orders and complicate rounds. In many ways, the private practice is a better place to get care.

So here I am now, in private practice, a more rounded doctor. I can still focus on my niche and my research if I want, but at the end of the day, my clinical acumen continues to grow. Will I ever go back to academics? Only time will tell. But for now, I will stay in my small hospital and enjoy fine tuning my clinical practice.

What do you think? Are academic centers placed on a false pedestal by society? Do you prefer care at the big academic center or the big clinical center?

“Dads Dollars Debts” is a cardiologist who blogs at his self-titled site, Dads Dollars Debts.

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