Becoming a gastroenterologist has been an arduous journey. Choosing the right path—a path offering the right balance of long-term professional goals while accommodating personal needs—can be a daunting task. As a GI fellow, we are under the guidance of the fellowship program and are often not aware of opportunities after graduation. In the past, there were limited options: academic medicine, private practice, and industry. The recent expansion of the healthcare systems and regulatory pressures has led to the emergence of multiple new possibilities of employment within those traditional options. However, in the absence of any formal guidance, it creates more confusion to find the best fit while sorting through the options. This editorial focuses on guiding graduating fellows through common models of practice in gastroenterology.
Traditionally, academic medicine was believed to offer gastroenterologist a significant fraction of work in research and education. The mounting pressure for generating more revenue through clinical care has reduced the time for research and/or teaching in recent years. However, this has not decreased the attention to academic medicine because of the current availability of extensive opportunities with the dedication of variable time for the tripartite mission of clinical care, research, and teaching.
There are multiple pros for pursuing academic medicine. One of the most appealing factors is the opportunity to subspecialize and be an expert in one area of particular interest. This applies explicitly to treating certain rare and/or complex conditions, and also allows for an adequate volume of specialized procedures for advanced endoscopists to maintain their skills. Another captivating aspect of academia is the opportunity to teach and train the next generation of physicians with prospects for research. Those focused on teaching and mentoring without research can pursue a clinical educator track.
One of the significant setbacks in academic medicine is the pay scale compared with the private practice, but academic salaries have also increased recently. Salary can be supplemented by increased clinical work, invited lectures, workshops, and royalties, to name a few. However, not all institutions allow for salary enhancement from these activities. There can be an environment of bureaucracy/inefficiencies in larger systems, which can be occasionally frustrating. Competition to get grants and fundings can also create a stressful working environment. It is vital to negotiate the contract with the protected time for the research activities or other academic endeavors.
With a change in the landscape of medicine, a variety of practice models have emerged in private practice. These can be classified into physician-owned practice and employed position.
Physician-owned private practice
This model varies from the solo practitioner to the mega (>40 physicians) physician group. The solo and small (<5 physicians) private practices are facing several challenges in the current system of complex regulations and are thus either merging into the larger groups or the hospital system. Group practice can be single-specialty vs multispecialty. The earning potential in the physician-owned private practice can surpass most of the models because of the diverse source of earning potential. The sources can include professional fees, facility fees, and ancillary income from services such as anesthesia, pathology, infusions, and radiology. There are few other perks of being in the private practice model. Of these, autonomy in the decision-making process may be a major positive factor. It also has less institutional regulations and bureaucracies.
The primary setback for the fresh graduates avoiding physician-owned private practice is the hassle of practice management for which they receive minimal or no training during the fellowship. With the growing demand for advanced infrastructure for electronic medical records systems, mandatory quality metrics reporting has led to a strain on practice in terms of high cost in time and money. On the other hand, decreasing reimbursement and an increase in nonpatient care workload can lead to burn out and poor satisfaction. The majority of these difficulties in private practice are inversely related to the size of the group, and thus, larger practice and even mega practices are increasing. Being part of the larger practice has quite a few benefits similar to being an employed physician and even allows for subspecialized practice and developing a niche in your area of interest. There is also an increasing trend of partnership with practice management, ambulatory surgery center, and managed care insurance companies. This minimizes the management and leadership part of the responsibility, and physicians can focus on patient care while remaining independent practice.
There is an increasing number of employed physicians in the past few years. The employer can be the hospital, the major health system, or even a physician-owned private practice. With this model, the primary source of income is professional fees, which is usually in terms of a relative value unit. This model provides a sense of financial security to the fresh graduate since initial pay is higher compared with other models, along with the broad spectrum of benefits. But, the trade-off is autonomy and future earning potential since the employee is never going to be paid equal to their worth. There will be no profit for the health system if they pay an employee the exact money the employee brings in revenue.
In recent years, there has been a rise in practices and community hospitals affiliating with teaching institutions to be a part of larger healthcare systems to increase the stability of the practice. These affiliations not only help with building referrals but also increase negotiating power with the insurance companies. This is informally referred to as a hybrid model, and some people even refer to it as “privademics.” This gives the potential for not only mentoring and teaching opportunities but also open doors for clinical research with an overall improvement in financial and professional contentment compared with either academic or sole private practice.
In conclusion, there are multiple options to choose from, and none superior to others. One should carefully consider personal and professional goals before embarking on a career. Evaluating each opportunity with open-mindedness while assessing pros and cons seems an ideal way to find one's true fit.
Author contributions: K. Trivedi contributed to the manuscript in its entirety and is the article guarantor.
Financial disclosure: None to report.