Is Your Heart Still In It?
Use our Career Checkup to see how well you're managing your professional life.
By John B. Pinto

As an ophthalmologist, you spend plenty of time thinking about outcomes and practice bottom lines. Unfortunately, working in such a demanding, high-pressure occupation, it's easy to forget your reasons for becoming an ophthalmologist in the first place. For most doctors, those reasons included the promise of job satisfaction, whether as a result of doing their personal best, helping people to see better, the promise of personal wealth and security, or the possibility of becoming a leader in a field that they found intriguing.

Unfortunately, many M.D.s end up a lot less happy than they expected to be. But making changes is never easy. What is easy is to keep doing your day-to-day routine feeling dissatisfied -- even miserable -- and never stop to consider that a change might make a world of difference.

Consultant John Pinto, America's most-published author on ophthalmology business and career management topics, has spent years working with M.D.s across America. In this article he shares what he's learned about job satisfaction from ophthalmologists at all stages of their careers, and provides:

• a description of the typical "life cycle" of an ophthalmology career, to help you keep your expectations realistic
• a quiz to clarify just how satisfied or unsatisfied you really are
• suggestions for alternate ways to "measure" your success
• a list of ways surgeons have changed their career focus to regain some of their lost job satisfaction.

If you're a typical ophthalmologist, you probably manage six or seven support staff, more than half a million dollars of annual cash flow, and the baffling visual apparatus (and personalities) of roughly 3,500 patients. You also manage relationships with scores of third-party payers and hundreds of referral sources.

But there's another, even more important, management issue you may be overlooking: How well are you managing you, the figurative and literal heart of your practice? How do you feel about your career today? Do you still love your work?

Several times a year I'm called by surgeons who have truly reached the end of their ropes, wondering if they should leave the profession altogether. In response, I often quote poet Kahlil Gibran from The Prophet:

"Always you have been told that work is a curse and labor a misfortune . . . If you cannot work with love but only with distaste, it is better that you should leave your work and sit at the gate of the temple and take alms of those who work with joy."

How's your own "joy factor" doing? Unfortunately, I think that even the happiest eye surgeons, more often than most professionals, wake up each morning asking the question, "Why am I not happier?" It's too bad, especially when you consider that many eye surgeons picked ophthalmology because, ideally, it offers more than other specialties: more income, better lifestyle (i.e., less call duty) and almost universally favorable patient outcomes. Happiness should just naturally follow, right?

There's more to success than case volume

Not necessarily. Every eye surgeon gauges his or her professional success a little differently. Circumstances that contribute to one surgeon's perception of wild success may do little to alter another surgeon's sense of failure.

I often ask clients, "On a 10-point scale, how happy are you with your professional career?" You'd be amazed at the answers I hear. It's not unusual for a surgeon who's doing far better than his peers to report that he isn't doing well at all. Some surgeons rank their careers at 3 or 4 on a scale of 10, even though they:

• generate more than $1 million in annual collections and bank several times the average ophthalmologist's $230,000 annual pre-tax income
• have one of the most active surgical practices in town
• have excellent outcomes and good patient rapport
• are ranked among the top eye surgeons by the local general practice community
• have a serene office staff with high morale
• enjoy a stable home life, with a supportive spouse.

So how do surgeons gauge their success? The most common success metric is surgical case volume. Every week in doctor's lounges across the country you can hear the same question: "Who's doing the most cases?" Manufacturers' reps are the chief scorekeepers; they perpetuate the rumor mill regarding who's pulling ahead in the race.

Ironically, surgeons with the highest volume often don't take home the largest pay checks. If you back out optometric co-management fees and the marketing costs needed to drive a top-tier practice, the annual income hero in your town may be someone you'd never suspect -- especially when calculated on a profit-per-hour basis. Also, high-volume doctors may be the most driven, but often they're not the happiest.

Keeping a more realistic score

In reality, there are lots of other ways to keep score in the career success race -- qualitative and existential career measurements that go beyond the raw numbers of dollars or patients or cases. After all, what matters most is how much satisfaction you derive from the work you're doing.

For example, one of the best ways to end up feeling like a success is to excel at a particular aspect of practice that happens to appeal to you. I've seen doctors create tremendous career satisfaction by:

Developing a showcase facility. One eastern doctor sinks more than 15% of every dollar he collects into his award-winning architectural masterpiece (4% to 6% is more typical.) His net profit margin is only about 20%. Yet he's so pleased with his decision to develop a showcase facility to work in every day that he's willing to cut back on other lifestyle costs.

Developing an extraordinary team. Another doctor I know loves his practice team. His large staff contingent is among the brightest I've ever met as a group. And the most expensive -- he spends about 45% of his cash flow on staff wages and benefits (18% to 30% is more typical). But he feels tremendously fulfilled, career-wise.

Trading income for time off. As they say, free time is the ultimate luxury. I know a bachelor doctor who takes 20 weeks off each year. His annual pre-tax income is less than six figures -- but he's one of the happier surgeons I've met in the past 23 years. He's almost never fatigued, and he has plenty of time for travel and other personal interests. (Of course, some would consider him a failure at his career!)

Focusing more on what you love to do. Some doctors who dislike the grind of routine clinical care but relish surgery hire medical ophthalmologists and optometrists. In practices with older patient populations (or patients brought in by consumer advertising) these extenders are well-accepted as a surrogate for most visits with the surgeon, allowing him to do what he loves best. In fact, if patients are satisfied and outcomes are good, the potentially lower profit margins from this practice model may be offset by a higher net profit for the surgeon-owner. After all, his time is being used more productively.

Focusing on practice excellence. For some doctors, reputation among patients, staff and peers is paramount. These doctors invest their own time and money to get outside help with quality assurance initiatives, staff education and satisfaction studies. (Of course, if a practice owner focuses on quality first, the bottom line tends to take care of itself.)

Cultivating superior partner relations. Professional partnerships are at least as complex and prone to disharmony as marital partnerships. If you and your practice partner are killing career satisfaction for each other, it may be time for counseling or divorce, rather than years of continuing struggle. I end up spending a good portion of every client session on dispute resolution, which must precede any meaningful practice business development work.

On the other hand, good partnering, though rare, results in some of the highest levels of surgeon satisfaction I've witnessed around the country. To the extent that it can be learned -- and I believe it can -- the elusive ability to find and cultivate superior partner relations should be on the curriculum of every medical school and residency program.

Keeping the future in perspective

One of the keys to career satisfaction is your sense of what the future will hold. I'll let you in on a little secret that very few surgeons recognize at the outset of their careers: In terms of raw earnings and control, every surgeon is destined to rise and fall. Your income and control will start out low, increase over the course of a decade or more, reach a plateau, remain at that level for some period of time, and then erode and collapse. It's all as natural as birth, growth, maturity, senescence and death. If you have unrealistic expectations about this, you're setting yourself up for major disappointment. You could also end up blaming yourself for normal cyclical career changes that happen to nearly everyone.

Let's examine each phase in turn.

Phase One: Growth

This phase runs from about 30 years of age to around 40. At this stage, all options and nearly all career pathways are still open to you. You're like a stem cell, capable of differentiating into whatever you desire. Your training is over and your professional career truly starts -- probably working for someone else. You have a base salary. Within a couple of years, you're producing enough to enjoy a modest bonus on top of this base.

Around this time you may be offered a partnership opportunity. Before this, for all practical purposes, you were subject to the control of parents, professors or bosses. Once you make partner, in economic and control terms, you're a liberated adult for the first time in your life.

Of course, there's a trade-off; you're now taking on a new set of overseers: third-party payers, referring doctors, the managing partner of your practice, and that surly lead technician they've given you who enjoys bossing you from one exam room to the next all day long. Oh yes, and your patients. They're each, quite literally, your boss. If they're not happy, your practice won't grow and your old college loans (along with your new mortgage and your first child's braces bill) won't get paid.

These new pressures notwithstanding, you're still advancing year-by-year, and probably making more money. Your annual tax bill now eclipses what you once made as a resident or fellow. It doesn't matter if you're rising slowly from $120,000 to $200,000 or quickly to $2 million -- you're still rising. If you've selected the right market to practice in (where the people are and the doctors aren't) and joined the right practice, you're probably set for life. If not, you still have a lot of time to get it right.

The most common mistake made by young doctors who find themselves in the wrong setting -- a bad market, a nasty boss, not enough patients to go around, etc. -- is to wait too long to seek out a better situation, or to sit around passively waiting for someone else to make things better.

Phase Two: Professional Maturity

Sometime during this phase, which runs from around age 40 to age 55, you reach a plateau. Although your surgical density improves every year and your raw output rises as you become more efficient and work-hardened, you reach a point of equilibrium. Your annual output growth is nulled by inexorable fee reductions and (probably) your inability to manage a larger organization.

It's time for midlife crises of various shapes and colors.

At this point doctors start to wonder, "Is this all there is?" "Will I ever perform more than 17 cataract cases in a single session, like Fred?" "Will my collections ever crack the $1 million mark in a year?" "Is it time to start a new family with my technician Mary Lou, who I'm convinced really does love me for who I am -- not for my wealth -- despite the 24-year age difference?" The most fortunate surgeons thread their way through the labyrinth of this career phase relatively unscathed . . . or massively scathed, but at least somewhat happier.

By 45, you're thinking about retiring in your early 50s. By your early 50s you're thinking of retiring in your early 60s. You're beginning to suspect than in another decade you'll be thinking about retiring in your early 70s. And so it goes.

You've climbed high enough on the ladder to enjoy the view. Unfortunately, toward the end of this career phase, you can also see the slide that starts at the top of the ladder and goes back down. What's more, if you work in a competitive practice or market, lots of younger doctors are below you on the ladder trying their best to push you along so they can be on top.

If you're at least moderately successful and emotionally balanced, you'll transit this career phase with pride, great memories and little more than a few invisible bruises. If not, you'll be a prime candidate for career burnout.

Here are some strategies to help you manage your career during this phase:

Ask yourself whether you've chosen the right field and subspecialty interests. It's not too late to go back to law school or taper your practice to the areas you enjoy most.

Don't get strung out or overextended. This can happen in many ways. You might be a solo surgeon with four satellite offices, feeling like a permanent visitor no matter where you're working. You could be in your mid-50s and have a perfectly terrific geriatric practice and decide that it would be swell to be the 18th doctor in town to get into LASIK. You might get so wrapped up making a $25,000 honorarium as a drug company consultant that you drop $250,000 in practice revenue.

Don't back down too fast, or with insufficient planning. Ophthalmology is a business with high fixed expenses. An innocent 10% cut in patient volume can claw 30% from your take-home pay.

Beware of hubris. Perhaps you've managed to cut things close to the edge with extremely aggressive surgical patient selection or billing protocols. But don't keep forcing the odds just to make payments on that ski condo. Remember the old adage . . . pigs get fat, hogs get slaughtered.

Don't get complacent. Be sure to challenge your old assumptions about how to practice medicine and how to run the business. Visit the most successful practices you can find and copy what they do.

Phase Three: Professional Senescence

The last few winding down years (starting at about age 55 or a little later) are poignant and bittersweet for most surgeons. You still have a number of important career decisions to make, such as whether to learn that new surgical maneuver, stick to your old method, or pass certain difficult cases on to others. But for some, this phase feels like the last months of a lion's proud life span; one moment you're at the top of the food chain, the next you're susceptible to depredation yourself.

The happiest surgeons I know at this stage in their career aren't the richest. They're the doctors who are surrounded and sustained by many rich practice relationships, such as:

• the office manager who is just hitting her stride, although she started in the practice 16 years ago as a front desk clerk
• the doctor you handpicked as a junior associate 2 decades ago who has just been appointed managing partner of the group, taking over your old position
• your oldest patients, whose adult children your partners now see for their emerging presbyopia and early cataracts.

In any case, most retiring surgeons seem to be ready for a change. Many of them tell me, with sincerity, that they're winding down their careers at just the right time.

Phase Four: Professional Death

Thousands of patients have announced their retirement to you over the years. Now you stand back and hear yourself say the words, "I'm leaving practice this June." This can happen as early as your 40s, but today it often doesn't happen until after age 70. At this point you have no more professional career pathways left to choose, but a host of new personal pathways suddenly proliferate.

Although my own retirement is decades away, I find myself listening closely to clients in peri- and post-retirement, to find out what strategies help them to manage this part of their lives. Here are a few of the things they've shared with me:

Plan at least 10 years ahead. Don't stick your head in the sand and be surprised at the last moment.

Find out what retirement feels like by taking a sabbatical. Pretend you've retired and just hang out for a few weeks with no responsibilities. (If you're like most doctors, you'll run back to your office after the mock retirement and thank your stars you don't have to leave practice quite yet.)

Don't rush into retirement. Just because your dad retired at 62 doesn't mean you should. If you really like practicing, do it for life. And if that's your plan, live accordingly, with health and stress management habits that will let you go the distance.

Be ready for surprises. You may be happier than you ever thought possible once you give up the responsibility of practice. Or you may find that life is much less satisfying than you expected.

Formulate new goals for yourself, large or small. Plan to visit countries you've never visited and read the books you've always wanted to read. Master a new language. Volunteer to do something you love that will help others. Teach.

Take care of yourself. Do just what you've been advising everyone else to do all these years: Eat right and stay physically active.

Measuring success in every career phase

One day, the career you now loathe or cherish will be past-tense. Until then, only you can judge how successful you are.

Some surgeons will always use income as the core measure of their success. For such doctors, comparing one year to the next as they stride through a 30+ year long career leads to an inevitable sad moment when annual income stalls and then declines. Income growth, maturity, senescence and death is the natural parabolic curve of your career life.

More enlightened doctors may take a more comforting view. Rather than judging their economic success in terms of annual income, they may focus on their net worth, which tends to keep rising steadily throughout a professional career, despite the ups and down of other economic factors.

Of course, the most enlightened ophthalmologists don't worry about whether their incomes or net worth are higher or lower than before; they focus on managing their careers so that they continue to enjoy their work. They get the real payoff -- because job satisfaction goes hand in hand with peace of mind, and that can keep on growing to the bitter end.

John Pinto is president of J. Pinto & Associates, Inc., an ophthalmic practice management consulting firm established in 1979. He's the country's most-published author on ophthalmology business and career management topics. Books he's written recently include the second edition of John Pinto's Little Green Book of Ophthalmology and Turnaround: 21 Weeks to Practice Survival and Permanent Improvement. You can reach him at (800) 886-1235, pintoinc@aol.com, or www.pintoinc.com. Send mail to: 376 San Antonio Ave., Suite C4, San Diego, CA 92016.