Only about one-third of pediatric cardiovascular practitioners are in private practice.¹ Indeed, a young physician fresh out of fellowship may find entrepreneurship and other aspects of managing a practice daunting. Responsibilities such as competing with behemoth academic institutions, navigating complex Medicare & Medicaid payments and private insurance contracts, keeping up with the rising cost of medical equipment and electronic medical records, and managing personnel while taking care of patients may seem beyond the typical comfort zone of a graduating fellow.

Despite this, becoming a private practice pediatric cardiologist (PPPC) is a choice to consider for those striving for autonomy and offers a unique opportunity for "owning" one's work and its outcomes. The PPPC has the ability to develop a comprehensive operational plan that allows for complete control over practice revenue and possession of tools to develop personalized, high-quality care that meets the needs of the local community. The flexibility to implement changes, untethered by extraneous regulations,² gives the PPPC a sense of authority and satisfaction.

Though being allied with an academic institution is an advantage, a PPPC has the freedom to refer to other tertiary institutions that best meet the needs of patients and their families. Many accredited residency programs have provisions for residents and medical students to rotate in private offices. Clinical faculty appointments may be available for those interested in teaching and clinical research and offer opportunities to collaborate with multicenter research projects and registries, as well as participate in national organizations such as the American College of Cardiology (ACC) state chapters and advocacy groups. Academic pediatric cardiology remains a male-dominated specialty, creating certain challenges for women^3-5 who still receive a lower salary compared to their male counterparts.^4,5 A PPPC has more flexibility to achieve a work-life balance, evaluating personal productivity and self-assigning salary compensation. Private practice offers an opportunity to "own" your success. Taking all factors into consideration, becoming a PPPC is a viable option. Table 1 lists some points to consider when establishing a private practice.

Table 1: Essential Points to Consider When Establishing a Private Practice

1	Patient Population Size	Consider current physician density and market saturation
2	Practice Location	Urban vs. rural
3	Revenue Sources	Private payer vs. Medicaid; Knowledge of reimbursement patterns, payer contracts and fee schedules
4	Management, Organization and Personnel	May hire a consultant to help with the set up
5	Electronic Health Record	U.S. federal mandate includes both incentives for its implementation and penalties for non-adapters

On the other hand, an academic career in the 21st century is becoming increasingly challenging and complicated. Gone are the days when training was an apprenticeship by the "Socratic method;" when the trainee was taking all calls at night; when faculty "ruled the roost," defining direction of care and hospital policy. Today, many academic faculty members are "employees," answering to a variety of non-physician "suits" that may include business administrators, former nurses, and lawyers. Medical schools no longer have the decision-making power or the resources to accomplish the goals of the past, with hospitals, insurers, and the government now driving decisions, policies, and funding. The impact of these changes has resulted in an altered job description for academic faculty; no longer is the "triple threat" a respected and supported goal, with a "meritocracy" and relative value unit generation defining the level of individual success. No longer is teaching or other non-reimbursed time spent, including un-funded research, acceptable. Finally, the job security of academic physicians has also become uncertain.

So, why should one deal with all of these insecurities and unpleasantries? Why not "just take care of patients" in your own private practice? Why bother with academic medicine at all? These questions may be answered by more questions. How much do you value teaching? How much do you value being exposed to and potentially playing a role in "cutting-edge" advancements? How much do you value working with teams of professionals who advance the care of patients with congenital heart disease? How important is caring for the "sickest of the sick" and the most complex cases? Do you wish to see outpatients for the entirety of your career; or do you want the disease spectrum, the ability to specialize, to be a "world expert" and work with unique groups of patients? How important is the pursuit of research questions that your inquisitive mind brings forth? These are the questions that all graduates should be asking themselves in the beginning and throughout fellowship, not merely during the final six months of training. The transition from fellow into academic faculty or a PPPC is rigorous either way; developing an informed plan well in advance of the final year of training is important. This means that fellowship programs need to better prepare trainees for the inevitable transition and that trainees need to take responsibility for their own goals and desires, their intellectual and time input during training, taking every opportunity to be exposed to the widest variety of diseases, procedures, equipment, teaching and research from the very beginning through the final days of training.

In the end, irrespective of what the graduating fellow in pediatric cardiology chooses, it is a privilege to care for patients and their families who depend on their pediatric cardiologists. It is crucial to find your passion and understand what makes you happy. Ultimately, it is this passion that drives you to be more productive and attain peer recognition. Choose wisely.

References

1. Freed GL, Dunham KM, Loveland-Cherry C, Martyn KK, Moote MJ; the American Board of Pediatrics Research Advisory Committee. Private practice rates among pediatric subspecialists. Pediatrics 2011;128:673-6.
2. Litton JS. The Pros and Cons of Private Practice (Physicians Practice website). 2012. Available at: http://www.physicianspractice.com/blog/pros-and-cons-private-practice. Accessed 8/28/2015.
3. Wenger NK. Women in cardiology: the US experience. Heart 2005;91:277-9.
4. Sanghavi M. Women in cardiology: introspection into the under-representation. Circ Cardiovasc Qual Outcomes 2014;7:188-90.
5. Poppas A, Cummings J, Dorbala S, Douglas PS, Foster E, Limacher MC. Survey results: a decade of change in professional life in cardiology: a 2008 report of the ACC women in cardiology council. J Am Coll Cardiol 2008;52:2215-26.

Keywords: Child, Choice Behavior, Consultants, Electronic Health Records, Entrepreneurship, Fee Schedules, Fellowships and Scholarships, Heart Diseases, Insurance Carriers, Internship and Residency, Medicaid, Medicare, Motivation, Outpatients, Physicians, Population Density, Private Practice, Registries, Salaries and Fringe Benefits, Schools, Medical, Students, Medical, Uncertainty, Heart Defects, Congenital

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