Advice on next steps 4–5 years out – prioritizing flexibility & QoL

[Ophthodoc2018]

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Hi all,

Looking for some perspective on next steps.

I’m currently ~5 years out of ophthalmology training. Due to family circumstances, I’ll need to relocate about ~45 minutes outside a major metro area in the next 1.5-1.75 years.

I’ve done well financially working as an employee in a PE-owned group. Current total income is ~$700–800k, including quarterly ASC distributions. I also hold ASC shares and PE equity. By the time I plan to leave, expected net worth should be around ~$2.5-3M. I anticipate selling my ASC shares at exit, and the PE platform will likely flip around that time as well.

At this stage, my primary goals are:

• Flexibility and quality of life
• As much time off as possible
• Covering family/kids expenses comfortably
• Avoiding being locked into work I don’t want to do

I am not willing to join another PE-backed practice.

The options I’m considering:

1. Starting my own solo/small practice
   • Pros: Maximum long-term flexibility, autonomy, ability to shape schedule and scope of practice
   • Cons: Higher upfront burden, operational risk, stress—especially when I may not need to take that financial risk given my current position
2. HMO/Kaiser-type setting
   • I hear mixed things: solid benefits but heavy workload, complex patients, no premium cataract/refractive upside
   • Pension concerns me—unclear how secure it will be long term
   • Unclear if this truly leads to better QoL vs burnout
3. Joining a private practice with potential buy-in
   • Possibly best balance, but worried about cultural fit, future governance issues, and long-term flexibility
   • I don’t mind traveling a bit if the environment is good and it can eventually lead to more control over my time

I’m trying to think more in terms of lifestyle optimization rather than income maximization, given that I should be financially independent enough to prioritize flexibility.

For those who’ve been in similar situations:

• Any regrets starting a practice when you already had “enough”?
• Are HMO-style jobs actually sustainable long term in ophthalmology?
• What should I be looking for (or avoiding) in a private practice buy-in at this stage?

Appreciate any insight.

 

[i-doctor]

I’ve transitioned a couple of times. My thoughts:

You’ve gotten incredibly lucky with P.E. Your income + quarterlies are excellent, way above the norm! But keep expectations low around the next flip/2nd sale. It may never occur, as new P.E. deals have dried up considerably. (Plan for $0 and no flip, just in case.)

—Absolutely a NO to HMO salaried position

—Join a Private Practice YES but only on your terms. You have a lot of experience (and assets). Ask for the working hours/lifestyle you want. Don’t let them make you work harder than you want to.

—Solo practice is always a great solution for the RIGHT person, but not everyone wants to own their own business. Go for it IF you are that type of person. But you need to make sure that you can make arrangements with colleagues to cover on call hours, because you can easily get sucked into becoming a workaholic if not careful.

 

[4ophtho]

Out of curiosity, why not join another PE practice ?

 

[Ophthodoc2018]

Thank you for your input! I realize that I have been really lucky with this PE (it is probably one of the best out there). I inherently don't trust PE and the odds of another PE job working out are slim I feel.

Why do you think the Kaiser HMO ophthalmology jobs aren't a good fit?

 

[i-doctor]

Kaiser people work incredibly hard for less money. Probably the worst income per unit worked of them all. The whole system is run by primary care specialties whose goal is to “equalize” their pay with the surgical specialists. “We’re all one big happy equal family”.

 

[i-doctor]

To clarify, Kaiser is perfectly fine if you just want a paycheck and punch in and out of work! But it comes as cost. Yes, it seems like they give fair compensation, because they indeed have to pay a higher salary to attract an ophthalmologist vs a primary care doc. But the system is designed to pool a large chunk of the profit, which then gets distributed among docs based on seniority (from year end bonuses, profit-sharing, and the pension itself). That’s where the equalization occurs. The problem is that you will wind up contributing a lot more to that shared pool than most other doctors there. Where do you think all of that Premium IOL revenue goes?

 

[Ophthodoc2018]

I was reading that although they cap your schedule to 24-26, each patient is very complex not bread and butter. And call can be very difficult with on call emergencies …

 

[dantt]

The problem is that you will wind up contributing a lot more to that shared pool than most other doctors there. Where do you think all of that Premium IOL revenue goes?

Not much premium iols it kaiser

 

[i-doctor]

Not much premium iols it kaiser

Of course not. No financial incentive to put in, but you still have to deal with all those patients.

 

[eyeeye_captain]

Hmm, I’d always thought of Kaiser as like a better paid VA gig. Maybe I was wrong. I know some likely lifers in their system but not well enough to have talked numbers. Obviously you can make more in the private world.

25 a day? How complex could these patients possibly be? Tertiary care academic uveitis and neuro can do that.

Crazy call? Privately insured patients aren’t the county hospital. I interviewed at a fellowship that had some moonlighting gig with Kaiser where they covered call and got a lot of RDs because supposedly triage calls like flashes and floaters had to wait like a week to be seen. No clue if that’s true, but if they’re capping things at 25 a day, I wouldn’t be surprised. And if that’s the culture, I can’t imagine they’re seeing much after hours.

 

[NYCNative]

Your post is screaming low-overhead solo-practice to me. Many are doing it, reach out to the solo-practice email list-serv. Here is a "turn-key" solution: Medical Practice Consulting & Billing | Independent Practice Partners

 

[spartan25]

I’ll offer a second opinion on Kaiser. I work 4 days a week and see about 20-25 patients per day. I can offer whatever lenses I want to patients. I don’t get any extra reimbursement, but I see that as freeing knowing that I don’t have any secondary incentives when discussing lens options

Benefits are great, 401k match after 1 year, cash balance plan after 2 years. Great employer contribution on HSA.

Starting salary is around 400k which would obviously be a pay cut for you. Everyone’s “enough” number is different

 

[Ophthodoc2018]

I’ll offer a second opinion on Kaiser. I work 4 days a week and see about 20-25 patients per day. I can offer whatever lenses I want to patients. I don’t get any extra reimbursement, but I see that as freeing knowing that I don’t have any secondary incentives when discussing lens options

Benefits are great, 401k match after 1 year, cash balance plan after 2 years. Great employer contribution on HSA.

Starting salary is around 400k which would obviously be a pay cut for you. Everyone’s “enough” number is different

My main worry with Kaiser is that the patients will be complex and I will be doing open globes all night long during on call hours... (I have read previous threads saying this). I even read comprehensive docs were forced to do retinal barrier lasers (which I am not comfortable doing) ...

I don't mind a pay-cut as long as it translates to reduced stress and workload.

 

[Ophthodoc2018]

I’ll offer a second opinion on Kaiser. I work 4 days a week and see about 20-25 patients per day. I can offer whatever lenses I want to patients. I don’t get any extra reimbursement, but I see that as freeing knowing that I don’t have any secondary incentives when discussing lens options

Benefits are great, 401k match after 1 year, cash balance plan after 2 years. Great employer contribution on HSA.

Starting salary is around 400k which would obviously be a pay cut for you. Everyone’s “enough” number is different

Around how many cataract surgeries do you do in a week?

 

[spartan25]

I’m a subspecialist so it’s slightly different, but I’ve never been forced/pressured to see something I don’t feel comfortable with. I referred out a retinopexy today.

I’d say the patients are moderately complex. Less so than fellowship but probably more so than a busy private clinic. But with only seeing 20-25 per day you have the time for counseling, etc. Open globes are rare to have on call (some people with none in 5+ years, others with 1-2 in 10 years)

For cataracts you start with doing 9 per half day out of one room. A lot of bilaterals with only oral sedation. After two years you can do 18 per half day out of two rooms if you choose (not mandatory). And two half days in the OR per week.

I personally am very happy and don’t foresee myself leaving anytime soon. But I know it’s not for everyone. Mostly the lack of autonomy can get to some people. But for pay/benefits and quality of life I think it’s a great option

 

[Ophthodoc2018]

I’m a subspecialist so it’s slightly different, but I’ve never been forced/pressured to see something I don’t feel comfortable with. I referred out a retinopexy today.

I’d say the patients are moderately complex. Less so than fellowship but probably more so than a busy private clinic. But with only seeing 20-25 per day you have the time for counseling, etc. Open globes are rare to have on call (some people with none in 5+ years, others with 1-2 in 10 years)

For cataracts you start with doing 9 per half day out of one room. A lot of bilaterals with only oral sedation. After two years you can do 18 per half day out of two rooms if you choose (not mandatory). And two half days in the OR per week.

I personally am very happy and don’t foresee myself leaving anytime soon. But I know it’s not for everyone. Mostly the lack of autonomy can get to some people. But for pay/benefits and quality of life I think it’s a great option

Out of curiosity, why would anyone working for Kaiser want to do more cases (36 cases a week vs 9 cases a week) if there is no monetary incentive?

Also are all cases are done with oral Valium sedation? What if a patient needs MAC/general?

How many weeks of call do you do in a year? How many times do you have to go in after hours or weekends?

Thanks!

 

[solitude]

does your 2..5-3M NW include revenue for selling your PE/ASC shares? What is your household's annual expense? Unless it's fairly low, you probably don't and won't have "enough" in 1.5 years, but you may have enough to cut back and let the market do the heavy lifting. There's an argument to be made for just keeping on churning for a few more years until you actually hit your number. Then a lot of the things you're worried about become moot, because you can just say no to whatever you don't want to do.

 

[spartan25]

You get a slight pay bump if you do the 18 cases out of two rooms. It’s not significant but some people just like operating more.

There is an ASC if you need MAC or general but it’s used infrequently.

Call is split evenly between the MDs in the group. It ends up being roughly 1 weekday per month and 2-3 weekends per year. Generally don’t have to go in on the weekdays (just schedule in your clinic the next day), and generally go in once on the weekends (stack a mini clinic on Sunday AM with pvds, ulcer checks, hyphemas, etc)

 

[Ophthodoc2018]

does your 2..5-3M NW include revenue for selling your PE/ASC shares? What is your household's annual expense? Unless it's fairly low, you probably don't and won't have "enough" in 1.5 years, but you may have enough to cut back and let the market do the heavy lifting. There's an argument to be made for just keeping on churning for a few more years until you actually hit your number. Then a lot of the things you're worried about become moot, because you can just say no to whatever you don't want to do.

When I said “enough,” I didn’t mean that I never would have to work again. I meant it in a way where I can just cover basic costs and not have to hustle like I am now. We have a pretty low budget. My main goal is to save enough and then get a job to not have to dip into savings.

 

[Ophthodoc2018]

You get a slight pay bump if you do the 18 cases out of two rooms. It’s not significant but some people just like operating more.

There is an ASC if you need MAC or general but it’s used infrequently.

Call is split evenly between the MDs in the group. It ends up being roughly 1 weekday per month and 2-3 weekends per year. Generally don’t have to go in on the weekdays (just schedule in your clinic the next day), and generally go in once on the weekends (stack a mini clinic on Sunday AM with pvds, ulcer checks, hyphemas, etc)

So theoretically you can just stick to 100-125 patients and 9 monofocal cataracts a week forever? Seems enticing haha .

 

[spartan25]

So theoretically you can just stick to 100-125 patients and 9 monofocal cataracts a week forever? Seems enticing haha .

18 per week (2 half days per week). But yes it’s nice