AN INTERVIEW WITH DAVID S. COHEN, MD
What is a typical day in the life of an ENT?
Being and ENT surgeon involves a mix of clinical, surgical, research, teaching, and administrative tasks. Generally, most ENT surgeons have clinic days most frequently and perform surgery somewhere between one and three days a week, depending on their subspecialty or system’s needs. Clinical days generally are 9 am–5 pm days where we see a wide variety of patients and medical problems. As a general otolaryngologist, 20 percent of my patients are younger than 12 years old and 20 percent of my patients are older than 70 years old. What I love about my clinical day is that I see a wide variety of problems, most of which can be diagnosed rather quickly. Whether it’s looking in someone’s nose and sinus tracts or looking in someone’s ear and removing ear wax, often times one clinic visit can be all that a patient needs, and we can make a near immediate impact. This is incredibly satisfying—have a patient come in, make a diagnosis, and treat them expeditiously. Also, ENT is a specialty where preventative/lifestyle changes, or medication, can often help patients avoid surgery. Deciding which patients would do better with surgery and which patients would do better with medication or lifestyle change is one of the more challenging facets of our clinical day. I appreciate and cherish this nuance and enjoy approaching each patient’s concerns individually and trying to deliver the best care for them. Our office hours are often predictable and reasonable.
Despite these medical options, ENT is a surgical specialty with a wide range of surgery techniques available. This includes smaller surgeries, like a tonsillectomy or ear tubes, but can also include some very complicated and technically challenging surgery, such as removing head and neck cancers and reconstructing the face. I appreciate the many different surgical modalities that our specialty has, including microscopic, endoscopic (using cameras through small openings), robotic, and open (such as cutting and removing a thyroid gland.)
What are the biggest challenges to practicing in private practice?
The biggest challenge in terms of private practice is often compensation and insurance repayment. Since compensation is tied to clinical and surgical encounters, this leads to challenges including which providers cover what services. Sometimes, a certain insurance refuses a test/exam which requires additional effort made to get that test covered. Also, your compensation is often tied to how many patients you see/operate on, which can create some external stressors that can be challenging.
Making a practice is like starting a company or brand. This involves strategic thinking including brand development, hiring your staff and nurses, which hospitals you want to work at, what equipment you want to buy or rent, etc. This often can be exciting, but at the same time challenging since we are often not taught these skills during our training or upbringing.
What do you like best about practicing in private practice?
With private practice, you are often able to “carve out” whatever type of practice you would like—you do the surgeries or procedures that you like to do and can refer patients for other procedures or problems that you do not want to treat regularly. You also are frequently in charge of your own scheduling, including how many days you have off, vacation, when you do surgery, when you have clinic, etc. On the other hand, generally you are paid based on clinic encounters/surgeries, so if you are taking vacation or doing other things, you often are not getting paid nor making money to support your business.
From your perspective, what is the difference in practicing in an academic versus private practice setting?
Academic ENT often includes a responsibility to produce research or an engagement in activities that promote your center or university. This could be basic science research working on developing new drugs or treatments, or it could be being a professional speaker for a certain subset of ENT illnesses.
Generally, as a private practitioner, you are not expected to produce research in the same way an academician is, and you are not expected to teach as much as an academician is.
From a salary perspective, is there a difference?
As aforementioned, generally private practitioners often made more money traditionally than academicians or hospital-based employees since they can start revenue streams that are not tied to patient care/clinical responsibilities. This includes ownership of surgery centers, hearing aid dispensaries, cosmetic services, or allergy services. The landscape of compensation in medicine is changing, however, and the divide between private practitioners and academicians/hospital-based employees is narrowing as healthcare delivery is evolving.
From a work-life balance, is there a difference?
ENT surgeons and physicians in general will always be challenged to have good work-life balance. As an ENT surgeon compared to other surgical specialties, we often work fewer and more predictable hours than many other surgical fields. Despite this, it is a challenge to be able to balance life outside of work. While the flexibility of private practice allows for certain allowances in terms of work-life balance, there are other stressors that are less prominent in an academic role, such as hiring staff or having other group resources at hand, such as retirement, malpractice, or benefits.
Why did you decide to go into private practice?
For me, I liked being able to practice multiple facets of ENT and enjoy many different sorts of treatment and surgeries that often are limited if you are part of a big group or academic center. Private practitioners are often most interested in the daily practice of medicine e.g. seeing patients and treating them. They are often less attracted to research or administrative activities, although in many hybrid systems these opportunities still exist.
As a resident, how do you know what type of practice is a good fit for you?
I think as a resident it is very challenging to decide what practice setting ultimately is a good fit for you. Many residencies have multiple practice settings in their training, although they tend to be university/academic heavy and often less experience with private practitioners, especially solo practitioners. My advice would be to approach each setting with an open mind and a blank slate, and weight the pros and cons of each practice type. There is no “perfect practice,” but many of your own motivations or personal traits lend you to being more successful in a given system or practice setting.
What words of wisdom do you wish someone would have shared with you in considering an ENT career in an academic/private practice?
Keep an open mind and continue to reflect on your priorities and passions. Try to do more of what you like to do, and less of what you don’t like to do. This is an evolutionary and active process that never stops. If you continue to evaluate where you are, reflect, and move toward your goals, it really doesn’t matter what practice setting you choose—just do something that you are proud to do and that makes you happy/fulfilled.
In retrospect, is there some additional training you would recommend in preparing for private practice/academic practice?
Practice management such as coding, wealth management, loan repayment, disability, and malpractice would be topics I wish I had more information on during my residency training.
About David S. Cohen, MD
David S. Cohen, MD, is a practicing otolaryngologist in Harbor City, California and is affiliated with Kaiser Permanente South Bay Medical Center. He received his medical degree from Keck School of Medicine of the University of California.