So I don't have any slides, but I just wanted to sort of tell you my story briefly before the Q&A. So I was in academic practice for over 20 years. I was at University of Texas briefly, and then University of Utah for the bulk of my time. And I was an assistant, associate, and full professor, all with tenure. And I was one of those people, I thought, I could never leave. This is what I'll do forever. Everything's great. My job went from a really good job to a not-so-good job to really not-so-good to me saying to my wife, I got to go. I got to go. Everything I liked about academics kind of wasn't working for me. And at one point, I actually went into my division chief's job, and I said, is there anything left here for me to do? And he couldn't come up with an answer. I'd been a fellowship director for seven years. I'd been in the dean's office. I'd run courses for the medical school. I just kind of ran out of stuff to do. And then I went around the country, and I looked at a bunch of other academic jobs both to be faculty or to be chief, and I had a lot of offers. And I came home, and I said to my wife, because all my thinking comes back to me talking to my wife, I said, they have all the same problems. I said, why would I go there to have the same problems I have here? And then I looked at being a chief, and then I said to my wife, it's like buying a heart attack being a chief. And I said, I don't need that either. And then I didn't know what to do. And then I went out with somebody who I didn't know very well for lunch, and he was in kind of a hybrid job. And he had a lot of things that I was looking for. And I remember I came home, and I thought, I'm looking at the wrong jobs. And then I completely abandoned my search to go from a university to a university, and I started looking at other places. So I am technically an employee of Peak Gastroenterology, which is a large private group in Colorado and Wyoming and a few other places. And it is venture equity, so I did kind of go down that rabbit hole. But I'm on permanent loan to Advent Health, which is an enormous hospital system around the country. They have four very large hospitals in Denver. And when we got there, we basically kind of started from zero in terms of setting up an advanced group. And they were very interested in going down the advanced, building an advanced program there. And me and my partners, essentially, like I said, we started from zero. And now we have professorships, we have medical students, we have residents, we have fellows, and we have an advanced fellowship of which I am the director. So people say to me, are you in academics or private? And just for background, I published 41 papers last year. I'm 32 so far this year, so I'm with some people in this room. And I'm editor-in-chief of GIE, and people say to me, are you in academics or are you in private practice? And I say, yes. Yes, I am. Like, you can kind of do anything now. So the world has changed, and I think that this academic versus private distinction is very gray now. It used to be very black and white, and it's very, very gray, and there's a lot of places that you can do all sorts of stuff. Like, technically, I'm in private practice, but if I get a consult, I send the fellow. My life didn't change that much when I went, but I made more money. So just remember, and I'll sit on the panel with my last thought, making money doesn't make you, or having money doesn't make you happy, but not having money makes you sad. So just remember, that's kind of like two ways to think about it. I'm going to go join the panel. All right, so we'll open up to questions. We'll open up to questions to the audience, because a lot of you guys are going to start looking for jobs soon, right? And you guys are finishing fellowship, and you're no longer a first-year fellow. You're at the senior fellow's course now, and you've got to start looking for jobs, and you've got to start looking at where you want to work and what you want to do with your life. And finally, make some money after all these years of training. So we'll open up to any questions. If not, we'll ask each other questions. And if you do a fourth year, you can extend that decision for yet another year. Okay, in the back there. Hi, good morning. I have a question for Dr. Adler. I'm one of the third-year GI fellows here at UIC in Chicago. You mentioned you spent most of your life in academics, and you're still kind of like in a hybrid, academic versus private. But you mentioned when you were looking for jobs after you spent your time in Utah, you found the same problems in academia elsewhere. Could you please, because we are in a point in our career where we are looking for jobs as well in academics and so forth. What are those common problems in academics that we should be aware of, which we might not know at this point in our career? So it's a good question. I'm going to preface this by saying I loved my time in academics. I don't like poo-pooing. Actually, this session shouldn't be called, Which Job is Right for You? This session should be called, Which Job is Right for You Today? Because that's going to change over time. You're going to become a different person over time. You're going to want different things. My kids were heading to college, and I wanted more money. Both my kids go to private college. Both my kids' colleges are $70,000 a year per kid. I wanted more money, and I had hit the ceiling at the University of Utah. I wanted a lot more autonomy. If I wanted a new device or a piece of equipment, well, then I went to value analysis, and they only met three times a year, and the agenda was full. And then maybe I had to wait six months to get on the agenda for the next meeting. And then after the meeting, I waited three more months to get a verdict, and the answer was no. Then I just lost a year to be told no. The University of Utah went from a salaried model, which was very good, to an RVU model. And I remember when they announced the RVU model, I stood up at faculty meeting and said, just so you all realize, we're now in practice. We're all on private practice now. They're paying us based on our productivity. And then a lot of the faculty stopped wanting to work with fellows and do all sorts of academic And a lot of the things about the job that were very attractive kind of went away. And then when I looked at places around the country, they had the same financial crises. They were all RVU model. And they had the same sort of very, very top-heavy administrative structure, where it was very hard to get something done if you wanted to be quick or agile or move fast. For example, as I was flying here yesterday, I was at Denver Airport. And we needed a piece of equipment. And we had run into a little bit of roadblock. And I called the CEO of the hospital. And I said, we need this. And he said, OK. And I said, thank you. And that was it. And now we have it. So it's very, very different when you're outside of that very, very, very top-heavy model. So again, I loved my time in academics. I wanted a lot more autonomy than I was ever going to get there. I'm glad you keep saying that word, autonomy, because that contributes directly to professional satisfaction. And that will prolong your career. We're seeing remarkable levels of burnout among physicians in their 40s. And it's because they feel that they've had their autonomy removed, that they're not in charge of their profession anymore. It's interesting that you started off in academia and went into private practice. I started off in private practice. And within four years of leaving my fellowship program, I was the fellowship site director for Banner Good Samaritan Hospital. The fellowship was based at the VA. And I served in that role with a fellowship program, those three fellows a year for three years each, for 16 years. And then one of my younger partners took it over for the rest of the time. So you can make of your career whatever you want to, as long as you're working in a system that allows that. And if you're not, like you just heard, it's going to be up to you to either make a change or change the environment you're in. If you're in a big health care system, you're in a big corporate behemoth. Those things are really hard to change. You will just bang your head against the wall until your head falls off. And so I applaud that because you just heard, he just made a change and charted his own course. You all have the ability to do that. My feeling is the same in private practice. You have the most autonomy and you have the ability to get things done right away. If I want a different biopsy forceps in my endoscopy center, I tell my nurse manager and it's there the next day. And you can do that. But in a hospital system, oh, sorry, we have a contract with Boston Scientific. That's what you got to use. And you guys have all run into that, right? You want to try something new, you can't get it. Same thing goes for everything in your practice. If you have a receptionist in your hospital system that is being rude to your patients and they come into your visit and they're in a bad mood because they were, it was a two-hour registration process and they had to wait 40 minutes and then they finally get in to see you and I'm like, well, gosh, I was here. I was on time. Why were you late? I've been sitting in the lobby for two hours. That directs, that affects your reputation. In your own practice, you set those rules. You actually see the process work. And you have that benefit to your reputation, so. Can you talk into the mic so that people can hear you virtually? I don't have a mic on my desk, sorry. We can hand you a mic, I think. So I am at the tail end of my career. I've been in three different jobs over 35 years, similar to some of what was discussed up here. And I think the big thing to drive home is, you know, you're out looking for your first job right now. You think you know what you want. You might not really know what you want. But you're going to try to make the best decision that you can and it's really scary. And maybe you have children now. Maybe you don't. But when kids come along, it totally changes your perspective on how much you want to work and where you want to spend your time. So I think, go away from here knowing that no decision ever has to be final. You're a physician. You're employable. Everybody wants you. You can go almost anywhere you want and change your job fairly easily. It's a big decision to make, but what decision you make today really doesn't have to be the last one. So don't be afraid of that. You know, my job, my first job was academics for 10 years at Baylor. That's how some of us know each other here. And I became very frustrated with academia, lack of control, all the things that have been mentioned, and lack of money. And I had two kids by then. So I went into private practice at the same hospital I'm still at, Houston Methodist. And I did that for 16 years. But for some of the reasons that have already been discussed, it became very hard to manage a practice. You know, the income reimbursement was going down. The expenses were going up. It was just difficult. And so a group of us went to work for a hospital system. I worked for Methodist Hospital, which is a little different than working for Kaiser, but maybe similar in some aspects. I definitely gave up control. I gave up control of the money. But they do pretty good at the money. And they pay me well. And they have awesome benefits. You know, I gained a whole lot that I really like at this stage of my career. And one can say the grass is always greener on the other side. No job is perfect. But you make the best of what you have. And hopefully you'll find happiness. And we're going to talk at the end of this thing tomorrow about work-life balance and wellness. And, you know, a lot of achieving that has to do with finding the right job for you at the right time in your life. So no choice has to be the last choice for you. You know? You're very employable anywhere you go. Thanks, Karen. And she said that very humbly as the past SGE president. I did that while I did all those other things. I have a question from the chat. In training with a hybrid model, one of the challenges I've encountered is that while enjoying the benefits of higher salaries and autonomy, there's a correlation of productivity which results in a busy workflow, potentially affecting the prioritization of the academic environment. How do you manage to balance those factors? Is that for me or for? It was a hybrid question, but I certainly think anyone could probably take a stab. I think it just depends on your personality. People who know me know I really, really like to be busy. By Sunday afternoon, I'm ready to do an ERCP on somebody. Yeah, exactly. Anybody. And, you know, if I get in and the schedule is light, I get annoyed. I want to be busy and I want to be full. So these places, they tend to be higher volume and there's a lot more emphasis on throughput and productivity, and for example, that for me was a good fit personality-wise. Whereas I think some people at universities can kind of coast, like if it's a light day, they're still getting paid and they can kind of disappear their office and work on a paper or grant. But I like to work a full day, and if any of you guys follow me on Twitter, dumbest words out of my mouth ever, but please follow me on Twitter. But I often post my schedule, because I think a lot of people kind of like to see that, and I will post my schedule, like here's what I'm doing today to actually show here's how many procedures in the time I'm doing them. I'll just add one thing, and this is on part of my, one of my other talks, but work on your efficiency. When I remember as a fellow, you had free time. You had time to sit down and read and you could go to conferences and that kind of stuff, and you can still do that, but make sure you are not wasting any time, because that doesn't help anybody. Yes, in private practice, you're gonna work as hard as you wanna work. If you work harder, you will earn more money. And a lot of people who go into private practice, they are, I wouldn't say workaholics, but they enjoy what they do. And they have very long careers in general. You know, you have, I've got two partners in Phoenix who are 76 and 75, full schedules. I ask them, Steve, what are you gonna do? What are you doing? He said, my wife doesn't want me around, I have to work. But he loves working. He gets so much gratification about seeing these patients. And I do too, kind of, I still see patients. And I see patients that I've had since I started practice in August of 1993. I still see them. And when they come into the office, we don't talk about their medical problems until we all have discussed our kids. Because I know their kids and they know mine. And that is huge. You don't realize how much satisfaction you get out of that. So I would just say that's some of the benefits that you can get from a career that is satisfying from all the cylinders that we've been talking about. Two questions, actually. First is, with the new model of the practice, what is the big concern about private equity? Because it seems to be where a lot of practice seems to be heading. And a lot of those big private equity firms are buying our practices. And when you talk to a lot of docs, there's somewhat seem to be some innuendos, like this is gonna go bad at one point. And so my question always is, what is the big fear with that? And what is the big concern? And then secondly, when looking at practices, still in the work-life balance, is there a safe minimum number of partners you should look at? I guess everybody takes calls, one in four, one in six. But if you're joining a practice and you have five partners, but two are in their 70s and probably gonna leave soon, is that a big red flag? You're leaving somewhere. I don't like big red flags you should see and not go into, because maybe they're gonna sell their equity and then leave you guys with one in three call. Those are my concerns. Thank you. Great question. I'll start, Doug. You can add on if you like. So private equity is not just in healthcare. It's in all sectors of the economy right now. And you hear varying things about it. Private equity became a thing in medicine around 2010 and started off with practices of dermatology. And now it's in essentially all specialties. It started off in GI in 2016 with a group out of Miami, GI Alliance, which is my group, formed in 2018. There are stories out there, mostly in other specialties, where private equity did not go very well. The physicians didn't have a good idea of what they were getting into. They thought, oh, I'm gonna just take a bag of money and someone else is gonna ruin practice and everything's gonna be fine. And that's the exact wrong way to go about this. No matter what you do as far as partnering with a capital partner, unless you as the physicians retain control of the group, management of the group, you're gonna wish you had. And so when my group, I had a big group in Phoenix. We were doing fine. We were dominant in Arizona. But we saw more opportunity to be national. And so we looked at that and looked at the structure of the governance of the group, who controls decisions and at what level. And you have to actually learn over time what that means for a practice. But once you do, you figure out a good model versus a model that maybe is a little shakier. And you've probably heard of situations where in anesthesia, particularly in dermatology, those transactions haven't gone very well. They have not aged well. In GI, we've been a little bit more fortunate because most of them are going okay. And mine particularly is going quite well. And I think Doug's is doing well also. And so I think the answer is it depends. The criteria you need to pay attention to is, is it physician-led? Is a gastroenterologist or a panel of gastroenterologists in charge of not just the clinical part of it, but the business part of it? That's really important because business decisions affect clinical care. So that's really important. Number two is, what's the ownership percentages? Does a private equity or a financial firm own 75% of the group? Because that's what can happen and has happened to other platforms in anesthesia, dermatology, and a couple of others. Or are the physicians in a majority ownership position? Like I said, we in GI Alliance own 86% of the stock of the group. We let our capital partner have some because they're a partner and they provide capital for us to expand. But those are the important factors. This is a lot, and none of us went to business school, so it's very foreign to us. And most of us don't, we went to medical school so we wouldn't have to learn business. So that's part of it. But a lot of us went to learn business in the School of Hard Knocks. And we got slapped around for years and years until we figured things out. Those are the physicians I think that you need to seek out and ask them very pointed questions. He's probably forgotten more about venture equity than I know, right? So he knows a ton about this, I'm a newbie to this. So I can tell you that I'm actually not that fixated on it. I'm part of a venture equity group, like I have my salary, we have a bonus structure, and I'm kind of focused on that. And I'm learning a lot because I'm new to it. And if it goes, some of my partners, like they're just like, they're losing their minds, they just want it to go, they want it to go, they want that big bag of money. If it goes, great, and if they offer me the big bag of money I'm definitely taking it. But it's kind of on its own, there's a whole process in place, and it doesn't affect me day to day. So like some of my partners are extremely involved, 30, 40, 50% of their time is involved running that aspect, and my job is actually not so much like that. Can I ask, I would like to ask Linda a question real quick since she hasn't had a chance to say anything. So I'm curious about the autonomy at Kaiser, because we hear that it's kind of the golden handcuffs, like it's a pretty good deal, it's a pretty good schedule, but you don't have a lot of say in how things are. It depends on your regional Kaiser. So the way Kaiser is sort of set up, it's under regional leadership, but then each hospital has their, so the benefits, the salaries, a lot of those are set by region. So for example, Kaiser, Southern California is different than Northern California. Salaries are set, time off, maternity leave, paternity leave, all of those things are set on a regional slash state standard, because some of that is legal. Then what happens is the clinical care practice, the nice thing is the GI group, at least in Southern California, there's about 200 of us, we meet routinely, we set clinical standards in terms of what we're gonna practice, all of that is actually led by physicians. As a subspecialist, I think Kaiser's a great way to go, honestly. I'm obviously biased, I've been there for a few years. Because it is physician-run, so going back to the issue about autonomy and decision-making, you really, things that benefit you are when somebody who's been through your type of training help you dictate those clinical decisions that affect your patient care and day-to-day life. I think as a primary care doctor, or frontline doctor on a Kaiser-type system where it's HMO, that is a little harder, I think, to deal with. But for you guys, as subspecialists, Kaiser's not, we practice evidence-based medicine, we adopt things pretty routinely, we do a lot of things that are offered at academic medical centers as well. So we're running short, oh. There was a second part of the question that I don't think we answered, and that is what happens when one or two of your partners leave and you're left with all the call. That can happen in any setting, really. I mean, it depends on your call responsibilities. Sometimes they're mandated for you through your organization, and sometimes you arrange those locally. A lot of groups don't take hospital call anymore, they're purely outpatient. So it really just depends, but the practice setting doesn't really have an impact on that. Yeah, and I was gonna say, I have a friend who trained here at Northwestern, an OB, went to Kansas City, had a call of one and eight. Her contract said shared call. And by the time she was done and leaving, it was one and two, which taught me, and we're gonna hear from Doug Adler about negotiation, and although I don't know how much it means on a piece of paper, but I have always had in my contracts, whatever that means, call not to exceed X. Now, what does that mean? Even today, I'm scheduling ERCPs for tomorrow. So it doesn't really matter, probably, but certainly if you're the only person left, that has impact. So there is some goal to negotiation, so at least you have something on paper. But again, I think we'll hear a little bit more about that. But there's certainly variation in when you have a chunk of your people leave or are over time for whatever reason. So I think time's running up. I just wanna say one last, I feel like I'm defending academics now, because I feel like everyone's left academics, or they, yeah, I mean, the one thing I didn't say in my entire slide talk was money, I realize that, but you still make a decent amount of money. I don't know what the people in private practice are making. I mean, I don't wanna know. He still lives in LA, so he's okay. He's doing okay, he's not starving. I may be young and naive, but at this point, I love my academic career. I felt like this is what my entire medical career was built to do. I went to interventional endoscopy, and now I do interventional endoscopy at an academic center where I see very complicated patients. I go to weekly conferences with the surgeons and the oncologists to discuss these patients who are being referred in from the community, referred from Kaiser, because they don't wanna handle these patients because they're too hard and too difficult. And so maybe my composition is not as good, but I enjoy that part of my career. I enjoy working at the VA where I teach the fellows how to do endoscopy, so I see the fellows go from being able to barely hold a scope to doing these procedures competently at the end of their fellowship. That's very gratifying to me. I mean, certainly there's a research component, which I'd say I'm not very productive in research, but I think when you see the fellows who are engaged and who are motivated to do research, it always helps me be motivated. And I think it's always helpful to be around young people who are energetic and motivated. It keeps me young. And so, I mean, I don't know if I'd sell you on academics because you guys are in academic medicine now, right? But I don't want you guys to forget. Why you started. Why you started. Think about your, read your personal statement again, and think about why you wanted to be a doctor and why you wanted to go to GI. And I'll tell you, most of you guys are writing these paragraphs at the end of like, you want to work in an academic center, take care of these complicated patients. You know? Like, don't forget that. Yeah, and so we're gonna close. I think we are behind, but I think if we can be back here for 10.05 for Sarah to start, and know, like someone said, you start, you know, it's good to get a big infusion of training at the very beginning, and then you can go on with that. But there's lots of options. And I think all of the panelists gave us some really interesting things to think about. And they're all available. And that's one of the fun parts about this weekend is that come grab us, ask us what we like to do. So, thanks for a great session. Okay, I'll send you some more, okay? I'll send you some more.

transition

academic practice

private practice

challenges

autonomy

job opportunities