American College of Physicians: Internal Medicine — Doctors for Adults ®

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When clinical practice isn’t enough, some physicians find new careers

The job market for ex-clinicians is brisk—if you have the right stuff

From the March 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

When Rajiv Patni, ACP-ASIM Member, started a research fellowship at an academic medical center in New York City, he looked forward to indulging his passion for clinical research.

Yet as the months went by, Dr. Patni found almost no time to do research. He had to maintain a hospitalist practice to bring in clinical revenue and to struggle constantly with reimbursement issues. As a result, he had no time to compete for grants that would let him advance as a researcher.

After two years, he called it quits and found a job in the pharmaceutical industry. Today, the 32-year-old physician is much happier in his new career as a medical director for Pfizer Inc. He said that he earns more than he would as a junior faculty member, and gets to spend his days designing and discussing cardiovascular trials. Most important of all, he enjoys what he described as the ultimate luxury for internists: time to think.

"In internal medicine,” Dr. Patni explained, “you're trained to be an intellectual. That's now what industry—not academia—lets you do."

Across the country, physicians like Dr. Patni are taking stock of their careers. Many are dissatisfied with a practice environment that can feel more like a factory than a profession. At the same time, the growth of technology and health care-related industries has given physicians unprecedented opportunities to shop their medical degrees around.

As a medical director for Pfizer Inc., Dr. Patni enjoys the ultimate luxury for internists: time to think.

To be sure, changing careers can bring new types of stress. One West Coast physician who works as a stock analyst starts his day at 4:45 a.m., while a physician consultant now racks up 150,000 airline miles each year. But physicians who have made the switch say they are satisfying interests and tapping into skills that went unused in clinical care—making changing careers a bright possibility for physicians who have the right stuff.

Walking away

Some physicians leave clinical practice because of the changing practice environment. Rheumatologist Victor Sloan, ACP-ASIM Member, for instance, left full-time academic practice in part because he realized that the kind of relationship he wanted with patients had become a thing of the past.

"My late sister-in-law battled lupus for 30 years and saw only two rheumatologists," said Dr. Sloan, 41, an associate director of clinical research at Novartis Pharmaceuticals in East Hanover, N.J. While he always dreamed of practicing in a similar environment, he realized that it wasn’t possible.

“With increasing pressures and patients switching insurance, it's very hard to have that kind of a partnership with patients anymore," Dr. Sloan said. Three years ago, he left practice to work for the pharmaceutical industry.

Not everyone, however, blames the changing practice climate for the decision to leave. Some say they simply wanted to pursue other interests.

Daniel J. Burge, ACP-ASIM Member, said he loved his six years as a solo rheumatologist in Wilmington, Del., and that the time when he told patients he was leaving for a Seattle biotech was "the most traumatic month in my entire life." Yet while he relished his patient relationships, he knew he needed more scientific stimulation than clinical care could provide.

"Paperwork and insurance companies didn't drive me out of practice," said the 39-year-old Dr. Burge, who joined Immunex Corp. as a medical director in 1997 and recently became vice president of clinical development. "It was cutting-edge science that lured me away."

Culture shock and rewards

While their reasons for leaving may vary, physicians who have switched careers agree that leaving practice, particularly to join large companies, often leads to culture shock.

For example, physicians who enter the business world immediately find themselves on a permanent first-name basis with colleagues. "People who have a big thing about being called 'Dr.' won't survive in industry," explained Pfizer's Dr. Patni.

Physicians may find that their boss is not a physician. They have to make decisions as a team, not individually. And far from being the ultimate authority, they are often only one expert among legal, financial and marketing advisers whose views have as much weight as theirs, if not more.

Yet the rewards of making the switch can be great. Physicians are no longer tied to a beeper or taking call at 2 a.m. They often discover more collegiality, particularly in the drug and biotech industries, discussing disease states and different compounds with other physicians and PhDs. Bonuses and stock options can add up to terrific compensation, and for many, the business world offers much more variety that they found in clinical practice.

"The patients you see are challenging, but a lot of times you see the same things day in, day out," said Marlene R. Krausss, MD, who left her ophthalmology practice to start KBL Healthcare Ventures, a venture capital firm in Manhattan.

(Unlike some physicians who switch careers, Dr. Krauss had something of an advantage. Before entering medicine, she had earned an MBA and worked for eight years as an investment banker.)

In business, she explained, nothing stays the same. The companies she analyzes are always different, while the economy is in constant flux. Change creates “a fair amount of anxiety," Dr. Krausss said, "but it's very appealing."

Perhaps most interesting of all, physicians who have left clinical practice say they still feel connected to patient care. Dr. Burge from Immunex, for instance, has received dozens of messages from former rheumatoid arthritis patients who have seen their health improve due to a tumor necrosis factor inhibitor that he helped bring to market.

"They write, 'You've done your job there, now you can come back,' " Dr. Burge said. "I miss my patients, but in practice I benefit maybe a thousand or two thousand individuals. Here, I'm having an impact on tens of thousands."

Even physicians working in financial industries still feel strongly tied to patient care. "When I invest in companies that develop new laser surgery techniques or cardiovascular diagnostic devices, I impact the health care system," said Dr. Krausss. When she evaluates prospective companies, she also questions whether they are actually advancing medicine or just jumping on the me-too medical products bandwagon.

"I'm not sure if that thought goes through the minds of most venture capitalists," Dr. Krausss said.

Growth industry

According to the AMA, more than 3,700 physicians worked in "miscellaneous" nonpatient care sector jobs in 1999. (The AMA defines that category as positions other than administrative, research and teaching jobs.)

Workforce experts point out, however, that AMA figures may not include physicians who have moved to the pharmaceutical, communications, marketing and financial industries. They also say that the figure doesn't reflect practicing physicians who take part-time consulting or advisory board positions that are opening up in many industries. (See “How to sell your medical degree in the job market” .)

Ironically, while some physicians claim that the growth of managed care and the corporatization of medicine drove them away from clinical practice, those same factors actually expanded the nonclinical job market for physicians.

It was managed care, after all, that made it possible for a first wave of physicians to find alternative careers. Back in the 1980s and 1990s, thousands of physicians began to cut back or leave clinical practice to work as administrative executives for provider groups, hospital systems and health plans.

The number of physician executives exploded in the last decade, according to Wes Curry, a spokesperson for the American College of Physician Executives. Before 1988, roughly 25 new physicians joined his organization each month; by the mid-1990s, 300 physicians were joining each month. (The organization now has just over 13,000 members.)

In recent years, however, that growth has tapered off, in part because of consolidation among hospitals and insurers. While there are still plenty of available positions as medical directors and medical affairs vice presidents within health care systems, group practices and insurance companies, many have become little more than cost-cutting jobs. As a result, some physicians in those positions are seeking more innovative opportunities in other industries.

Too, some physician executives are increasingly dissatisfied that they can't move out of clinical administrative positions. "I see a very real glass ceiling for physicians in provider organizations who want to move into operations, or from drug development in the pharmaceutical industry to business strategy," said Gigi Hirsch, MD. "There are some very frustrated physicians who've been pigeonholed on the clinical side and want a change."

Yet even this dynamic in the physician executive market has created new career opportunities for other physicians. Dr. Hirsch, for instance, an internist who spent five years in emergency medicine, is now part of another emerging industry: physician career counseling. She is the founder and chief executive officer of MD IntelliNet LLC, a physician consulting and placement company based in Brookline, Mass. 

Intellectual capital

Workforce analysts say that physicians who are dissatisfied with either clinical practice or an executive slot will continue to find a growing number of both full- and part-time opportunities. That is because the value of practicing physicians' intellectual capital is on the rise.

Robert B. Keet, FACP, is a good example. A 53-year-old practicing internist-geriatrician, Dr. Keet is now medical director for Axolotl Corporation. The Mountain View, Calif., company makes software that allows physicians to securely send authorizations, lab results, prescriptions and clinical memos over the Internet.

Dr. Keet's contract with Axolotl requires him to maintain a part-time practice. "They wanted someone who maintained primarily a clinician's perspective," he explained, something that physicians who leave clinical practice quickly lose. As medical director, Dr. Keet does some marketing to other physicians but also has strong input on product design.

"Axolotl feels strongly that software for physicians is poorly designed even if it's designed by very good engineers," Dr. Keet said. "Engineers don't really understand the complex decisions that physicians face."

That view—that only physicians really know their thought processes and clinical environment—is gaining credence among the software development, communications and device industries, as well as in the marketing departments of any company trying to sell products to physicians.

Yet Dr. Keet also has administrative experience that helped him land his dot-com medical directorship. He dropped down to part-time practice 12 years ago when he became medical director of an independent practice association (IPA) in Santa Cruz, Calif. As part of his job, he oversaw the development of an information system for the IPA's physician network—a system that caught Axolotl's attention. The IPA went on to become a test site for the company’s software, which set the stage for Dr. Keet's move to e-health in 1997. The fact that he earned an undergraduate degree in engineering from Cornell University before entering medical school gave him even more credence in the dot-com world.

David J. Shulkin, FACP, also found his way to e-health through an administrative path. In 1991, he became the University of Pennsylvania Medical Center's first full-time physician administrator, a role that later led him to become the health system's chief medical and chief quality officer. In 1999, he left Penn to become chief executive officer of DoctorQuality.com Inc., a Philadelphia company that provides Web-based physician quality measurement and improvement resources.

Dr. Shulkin said his years as an administrator prepared him to strike out on his own. "I would never attempt to be a CEO of a company that is planning on being successful unless I had the 10 years of management experience at Penn," he said, noting that he went from overseeing a staff of 700 to working with 40 employees.

Managing a medical career

According to Dr. Shulkin, a growing number of his colleagues among that first wave of physician executives are joining other industries. In his view, physicians are becoming more like other professionals in their willingness to switch careers.

"I've always heard from people outside medicine that after spending 10 years in one area, it's time to reinvent yourself," he explained. "Physicians who always thought, 'I'm going to hang out my shingle and retire 40 years later,' are recognizing that there are different ways to contribute during a 40-year career."

Seth Garber, MD, has made two career switches since leaving full-time clinical practice. Starting work as a general internist in a Portland, Ore., Kaiser Permanente group in 1979, he gradually took on more administrative duties until by 1988, he was working in administration full time. Then in 1995, at age 45, he joined the Seattle office of William H. Mercer Inc. as a principal and senior consultant. Today, he advises large health systems and employers.

Dr. Garber said that in his experience, physicians who have switched careers once are much more willing to move again. "It's very liberating to leave your first career and discover that you can do other things," he said. "You realize that you're valuable for skills other than the ones you've been practicing for many years."

Even physicians who do not seek wholesale reinvention are branching out, Dr. Garber said, through less radical change. They are taking on treadmill tests, for instance, or working part time as a nursing home medical director, in order to broaden their clinical skills or managerial experience. (See "Five strategies for physicians to overcome burnout,".)

"In the past, a physician's career just managed itself," said MD IntelliNet's Dr. Hirsch. "Now that career has to be actively managed."

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