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Residents & Fellows Corner | Mar/Apr '16

If I Could Do It All Again

Regardless of where we are in our careers, there are undoubtedly things we would all do differently if we could—after all, hindsight is 20/20. When I finished my fellowship in 2008, I relocated to join a practice in Arizona. A few years later, I returned to California and joined another practice, where I worked for about 4.5 years. Then, a little over a year ago, I finally started my own practice—an undertaking I wish I had pursued 7 years ago. However, through all of these transitions and experiences, I have come to learn several important lessons that may help my younger colleagues in their own pursuits.


For some reason, as ophthalmologists, we tend to undervalue ourselves and our work. Take cataract surgery, for example. It takes us 14 years of higher education to get to a point where we are adequately trained to perform this procedure. We operate utilizing both hands and both feet simultaneously, while looking through a microscope, and essentially operating underwater. That’s truly amazing, but how do we describe cataract surgery? “No bleeding,” “no sutures,” “6 minutes in and out.” Essentially, what we are saying is: It’s easy.

Most ophthalmologists emerge from training having worked extremely hard and with a great deal of intelligence and expertise to show for it. So, when you get out of residency or fellowship, value yourselves. When Lebron James came out of high school, he understood the value of himself. He did not meet with prospective teams and say, “Gee, that coach seems like a really nice guy. Where do I sign?”


Now, Lebron had an entire team of consultants, lawyers, and agents to help him thoroughly evaluate what was on the table. When I came out of fellowship, I had the wherewithal to realize that I didn’t know a thing about business. There was no Physician CEO course back then. As I was flying around the country checking out job offers, it dawned on me that I didn’t know how to tell whether a practice was truly successful or whether a specific opportunity was good for me. I also didn’t know what the industry standard salary or practice buy-in was for a fellowship-trained associate.

Likewise, when I was sitting at a negotiation table, I didn’t have a leg to stand on. I quickly realized that if I said, “That sounds pretty good, but I think that x, y, and z would be more appropriate,” any potential employer would think, “Who are you to formulate such an opinion?” So, I hired a well-known, respected ophthalmology consultant who did a litany of things to help to set the stage for my first job. It was his job to negotiate the details of my contract, and it was my job to just be pleasant and well-versed in ophthalmology.

Consultants are key, as most young ophthalmologists do not know how to negotiate or assess a business. However, it is important to realize that your consultant is not your friend … or your therapist. They will charge you for the time you speak on the phone with them, so you don’t want to vent about all the things that you are frustrated with in your practice, but they are worth their weight in gold.

So, where did it go wrong? For starters, I ignored the advice that the chairman of my residency program gave me. His departing words to me were, “When you finish up, figure out where you want to live—that is where you should practice.” My fellowship year, I was making $30K and was $0.25 million in debt. Ignoring my mentor’s advice, I asked myself, “Which job is going to pay me the most?” My consultant helped me establish that job and constructed the perfect stage to launch my career. I moved to Arizona and started operating on a high volume of patients. My first year in practice, I did 1,200 cataract cases. By my second year, I was performing more than 2,500 cataract surgeries. Everything was perfect, right? Sure, except I was miserable.

I did not love living in Scottsdale, and I realized that I had to hit the reset button. I moved back to Los Angeles and couldn’t take any of my patients with me, so I was back to ground zero. Interestingly, approximately 76% of us do not end up staying at our first job; a large majority falls into my realm. But every time you hit the reset button, you have to start all over. Figure out where you want to live, and that is where you should practice—what profoundly wise advice.


When we sit down with our first prospective employer, we are likely making around $30K–$50K. So, when he or she says, “Listen, I am going to pay you $200K,” our eyes get big, we get tunnel vision, and we say, “That sounds perfect. Done.” But it is not about the salary. The real question is: What are you working toward? Two years as an associate means nothing. What you really want to assess is what you are buying into and what your buy-in will look like 2 years down the road. Hiring practices often try to sidestep that question by saying, “Oh, we’ll cross that bridge when we get there …” However, it’s important for your consultant to define those terms from the onset; otherwise, you may be wasting away several years of your career at a dead-end job.

Define the buy-in terms. Think of it like buying a house. Could you imagine making that purchase without being told how many bedrooms and baths it has or what the square footage is? Learn what the practice is really worth and establish the buy-in terms as best you can. Determine whether you would have a buy-in into a surgery center or not. In addition to defining these terms, they should be put in your contract. If it is not in writing, it does not exist. Sometimes you will interview with very kind people and will have an innate sense to trust them, but you have to be smart and protect yourself.

All of us, when we start our first jobs think, this could be better, that could be better. You talk to your colleagues from residency and may think that their jobs sound like a better situation. You begin to feel deflated. It’s crucial to look beyond that—the grass is always greener. When you start your first job, make the most of it. Work hard. If you are going to stay with that job and you are talking about a buy-in, the harder you work, the more revenue you produce, and therefore the more weight you will carry at the negotiation table.

For me, I had built up all these reasons in my head as to why I shouldn’t start my own practice. I would have to pay salaries, deal with property insurance, etc., and it seemed like a long, daunting path. So, instead, I had to go out there and start over a couple of times and get to the point where I was so frustrated that I had to do it. There was no other option. As it turns out, all of the seemingly daunting tasks of owning a practice that I had built up in my head proved to be quite trivial. Sure, they are a bit time-consuming, but I do them all with a smile on my face knowing that I directly reap the rewards of all my hard work.


My last piece of advice is probably the most important lesson I have learned in my medical career thus far. When I was with a former practice, we bought another smaller practice, owned by a gentleman who was moving to another country. I adopted all of his patients and was instantly impressed by how committed they were to him. Many of them were in tears at the news that their doctor had left and would no longer be caring for them.

As I started seeing these patients, I came to realize that the retired ophthalmologist was not a great clinician and an even worse surgeon. I had all of his old notes and observed many inaccuracies and possible mismanagement of some cases. His surgical outcomes were quite average at best. However, his patients absolutely adored him. None of them would have ever gone to any other ophthalmologist, no matter how often that doctor lectured, or how many studies he or she had done, or how beautiful his or her practice was. They would have never left this physician’s care for one reason: He was a genuinely nice person. No matter how smart or how good of a surgeon you may think you are, always remember to be kind to your patients. It goes a long way.

Will Christian, MD
Will Christian, MD

Mar/Apr '16