Someone asked me what it’s like to practice in NYC. A simple enough question but upon further examination, one I didn’t really know how to answer. I’ve never practiced anywhere else. I love what I do and adore my hometown but would my life have been different if I practiced in Duluth, Minnesota? How does one describe something without a basis of comparison? I decided it was a question worthy of investigation.
Aesop’s beloved fable of The Town Mouse and the Country Mouse goes like this:
“A Town Mouse once visited a relative who lived in the country. For lunch, the Country Mouse served wheat stalks, roots, and acorns, with a dash of cold water for drink. The Town Mouse ate very sparingly, nibbling a little of this and a little of that, and by her manner making it very plain that she ate the simple food only to be polite.
After the meal the friends had a long talk, or rather the Town Mouse talked about her life in the city while the Country Mouse listened. They then went to bed in a cozy nest in the hedgerow and slept in quiet and comfort until morning. In her sleep, the Country Mouse dreamed she was a Town Mouse with all the luxuries and delights of city life that her friend had described for her. So the next day when the Town Mouse asked the Country Mouse to go home with her to the city, she gladly said yes.
When they reached the mansion in which the Town Mouse lived, they found on the table in the dining room the leavings of a very fine banquet. There were sweetmeats and jellies, pastries, delicious cheeses, indeed, the most tempting foods that a Mouse can imagine. But just as the Country Mouse was about to nibble a dainty bit of pastry, she heard a Cat mew loudly and scratch at the door. In great fear the Mice scurried to a hiding place, where they lay quite still for a long time, hardly daring to breathe. When at last they ventured back to the feast, the door opened suddenly and in came the servants to clear the table, followed by the House Dog. The Country Mouse stopped in the Town Mouse’s den only long enough to pick up her carpet bag and umbrella.
“You may have luxuries and dainties that I have not,” she said as she hurried away, “but I prefer my plain food and simple life in the country with the peace and security that go with it.”
Of course, Aesop’s fables always had a moral to the story…
Poverty with security is better than plenty in the midst of fear and uncertainty.
Fable can have two definitions.
The first: a short story, typically with animals as characters, conveying a moral.
The second: a false statement or belief.
This month, we welcome a newly minted crop of young doctors to our profession. They look out on a landscape with more career paths than any OD before them, but at the same time, must embark on a chosen path carrying the heaviest debt load of any of their older colleagues. How do they choose? Not many have the more straightforward option of taking over a family practice. Some live in states with limited scopes of practice. Some want the peace and quiet of a rural community. Many prefer the hustle and bustle of an urban center. Some chose the field because of an entrepreneurial spirit. Others want a stable paycheck without the headache of a small business to run. The choices seem fraught with danger and uncertainty. If one chooses incorrectly does bankruptcy ensue? Does it mean short-term misery for long-term gain? In the age of social media, advice can be misleading. Alternative facts and fake news abound.
At the beginning of my own career 25 years ago, my choices seemed not particularly different, but the advice I received came from trusted and reliable sources. In a certain sense, I had to make more mistakes on my own since I could not Google every possibility of failure ahead of time. If I needed help or advice, I had to make the concerted effort of seeking out a colleague whose opinion I valued, by picking up a phone or writing a letter or making a personal visit. In exchange for my efforts, I received limited but sage and deliberate counsel. There was less confusion. Contemplating what I would have done had I been graduating today, I tried to look for advice online. The multiplicity of opinions is staggering. Frankly, I think I would have been paralyzed with indecision and indecision is the worst enemy of the entrepreneur.
Because I have been happy and successful with my career choices, I feel invested in the success of my younger colleagues. I wish them well in their journey to improve and protect sight and safeguard the health and quality of life of the 40,000 individual patients they are likely to see in a 40-year career. There has been much debate in all fields of medicine as to whether it is better to practice solo, in a group, in the city, in the country, in person, or virtually. First, let’s examine the common assumptions we all make. Next, let’s see what a survey of our colleagues across the country and across various practice modalities reveals. Finally, I am going to postulate that in fact, the choice is a fable. You can draw a moral from it if you like, but I speculate it is a false belief – how you choose to practice will make no difference whatsoever. Happiness and fulfillment in your work stem from the single interaction between the doctor and the patient. How and where that interaction takes place is up to you and as long as the chosen setting gives you the right to control that interaction, happiness will follow.
The Common Assumptions
LARGE URBAN PRACTICE
SMALL RURAL PRACTICE
Doctor earns higher salary
Doctor earns lower salary
Doctor pays more for housing
Doctor pays less for housing
Doctor pays more for commercial real estate
Doctor pays less for commercial real estate
Practice pays higher staff salaries
Practice pays lower staff salaries
Harder to retain patients
Easier to retain patients
Higher cost of advertising
Lower cost of advertising
Easier to maintain anonymity and privacy
Easier to nourish personal relationships
Harder to take weekends and holidays off
Easier to take weekends and holidays off
Hectic, stressful pace
Laid-back, relaxed pace
I always liked gross anatomy lab so let’s do a little dissecting.
National data from Salary.com lists the median salary for an OD to be $118,942.00
New York City, population 8.5 million: $142,849.00
Buford, Wyoming, population 1: $108,365.00
Ft. Collins, Colorado, population 164,000: $115,255.00
Looks like a $34,000 difference from largest to smallest city in the US. That brings us to Assumption #2.
2. Real estate costs
What can that extra 34k buy for us? According to Street Easy, the least expensive neighborhood in NYC boasts housing at $555 per square foot. Assuming the one person who lives in Buford doesn’t want any neighbors, let’s look at housing costs in the middle sized neighborhood of Ft. Collins, where the average square foot will cost you $245.
That $34,000 extra the New Yorker will earn if she moves from Buford will get her a really big shoe closet in NYC and the extra $6900 she earns if she opts for Ft. Collins may buy her an extra cupboard. I don’t know – maybe I wouldn’t need as many shoes if I lived in Ft. Collins? Nah.
3. Staff Salaries
An average optician in NYC earns $53,099.
An average optician in Buford earns $40,278.
An average optician in Ft. Collins earns $42,842.
We get it, staff is more expensive to hire in larger cities but then again, larger cities have a higher proportion of cash paying patients and a higher sales volume.
That one resident of Buford searches Google and comes up with 5 highly-rated optometrists within a half hour drive of home. Wait – Ft. Collins is only an hour and a half drive from Buford – duke it out, docs.
A resident of Ft. Collins comes up with 20 ODs on a Google search. That’s 8200 prospective patients per practice.
My home zipcode in NYC, which boasts 60,000 residents in a 15 block radius, and lists 7 highly rated practices within walking distance, yields 8500 potential patients per practice. That’s a lot of P’s.
I think this is a very old metric. First of all, most optometrists and all physicians, for that matter, are awful at advertising. They just run on inertia when it comes to marketing. Google listings are free and few people use things like the yellow pages (the WHAT?!) anymore. Advertising can certainly be more or less expensive but location would hardly impact its cost. I recently did a financial analysis of my practice, which showed advertising costs to be less than 1% of all expenses. The business class I am taking took that number and compared it to industry standards in all of medicine. You know what? That’s more than most doctors spend, so who cares how the cost of advertising varies by location? No one.
6. Anonymity / Privacy
Colleagues often comment, “It must be nice to live and work in a city where you can disappear into the woodwork.” I guess I was never issued that invisibility cloak because I meet a patient every single time I walk my dog. Three times a day. EVERY TIME. I go to the supermarket and have to worry about how I’m dressed because last time I ran out for milk in shorts, a snotty little teenager whistled and shouted, “Hey, Dr. K! Looking hot today!” Creepy doesn’t even begin to describe it. An evening out to dinner with my husband entails furtive glances and whispered phrases. Yes, we are in love, but inevitably it’s because a patient is seated two tables away. Gives HIPAA compliance a whole new meaning. So what about small towns? Are they any different from medium or large ones? Here are some quotes from doctors in the field.
“I love really KNOWING my patients. Not only my patients, but their families for several generations! Everyone knows everyone, and many are related to each other. When my kids are in the local paper, patients bring me extra copies ‘just in case’.”
Viktoria Davis, Madelia, MN population 2,239
“If you stand on Main Street and pick your nose, by noon everybody knows which nostril it was. Also, if you do have someone unhappy with you or your services for whatever reason, you will run into them- and their family and friends…”
Jim Hutchins, wait for it….. Sleepy Eye, MN population 3,445
“Everyone asks you for money, but you get to actually see where your donations are going. Patients take such an interest in my family. They talk to my kids in restaurants. Some literally come up and take my kid from me in a restaurant and give my wife and I a chance to eat without a 2-year-old screaming. That kind of stuff is great. The cons are similar in nature. Since everyone knows me, my time off is never truly off. I am always a doctor. Even when I’m not at ‘work’.”
James Barton, Andalusia, AL population 8,968
“I love that you build a relationship with your patients in a small town and end up seeing their whole family… (but) when I’m not at work I don’t always want to have to discuss work when I see my patients out in the community.”
Emily LaSalle, Beaufort, SC population 13,445
“What I hated, and most likely self imposed, was running into patients in the mall, grocery store, et al. I am a private person and not interested in sharing all my life with my neighbors/patients.”
Mary Lou French, Downers Grove, IL, population 49,473
“I can’t go to the grocery store without seeing at least one patient most weeks.”
Steven Hepokoski, Maple Grove, MN population 69,576
“I love how my patients are like family and friends. They are more than just patients to me and my practice. They come in expecting to see a doctor who is like their family and genuinely cares about them. Since the community is small and close, good things spread but bad things spread faster, so we have to be very cautious.”
Jennifer Che, San Pedro, CA population 80,065
“I enjoy working with friends and patients who have become like family. It’s nice to help people out in the community – those I engaged at the grocery store, neighborhood, restaurant, church, rotary club, etc. Sometimes being from a smaller community can be challenging since everyone knows everyone elses business.”
Jennifer Fishel, Greenville, NC population 91,495
“Even though it’s a big city (and downtown in a big city) it sometimes feels like a small town. I run into my patients all the time in local shops, going for walks etc. That is a blessing and a curse depending on the patient – haha.”
Mark Ross, Calgary, Alberta population 1.266 million
“I complain endlessly about having no place to hide but really I should just shut up because I love it.”
Viola Kanevsky, New York, NY population 8.538 million
Why don’t we throw assumption #6 in the waste bin?
Weekends and Holidays
In surveying ODs across the country, I found no strict pattern that relates to practice location. Basically, if you want to take time off, just do it. The patients will wait for you. Your life will not. Of over 300 respondents to the survey, the vast majority responded that Optometry offered ample opportunity to balance work and play and most said they took all the time they wanted and lived comfortably. Over 50% took between 2 and 6 weeks annual vacation, saw patients 4-5 days a week, and did not take work home despite being overwhelmingly skewed towards working in solo private practices, which theoretically, are much more management-intensive.
Small towns can have hectic schedules and urban jungles can have slow days but the only rhythm I could find came not from location but from mode of practice. Corporate and group practices tend to push as many patients onto the schedule as possible, regardless of where the practice is located. Satisfaction with work seems to depend less on pace than on perceived autonomy. Perhaps optometrists self-select because the field is largely entrepreneurial but the bulk of complaints from corporate settings focused on insufficient staffing, lack of support and respect from other medical professionals, inability to control one’s own hours, and difficulty finding vacation coverage. Interestingly, despite the fact that ODs often fight about the perceived difference between corporate and private settings, the complaints from private practice owners were almost identical: staff is hard to manage, patients expect service around the clock, and vacation coverage is hard to come by.
Almost every single doctor responding said they wished they had an associate to help them both with patient load and clinical decisions.
So what advice can I give to the young OD about to embark on their career? What would I say to the student contemplating a life in vision care?
I think the news is good. Over 300 ODs surveyed, 40% Millenials, 30% Gen-Xers, and 30% Boomers, here’s the satisfaction survey result:
Almost all responded they were happy with their balance of work to play. The strongest factor that appeared to correlate with high satisfaction was working either solo or in an OD-owned group. Not even vacation time or salary predicted satisfaction as much as this. We are, after all, gregarious beings and birds of a feather flock together. Let’s face it, Optometrists are generally a nice bunch of folks and we enjoy each other’s company.
Back to my original question – what is it like to practice in New York City? I suspect my day is very much like yours. I look forward to work, I look forward to long weekends and time with my kids. I try to avoid patients when shopping for unhealthy snacks and trashy magazines. I wear dark sunglasses in the hopes of avoiding macular degeneration and being recognized by that one patient who Yelped about how much I charged him for his last exam. I ride my bike by the river, I walk my dog in the park, I see the same movies and enjoy the occasional steak dinner, same as my colleagues in Duluth. I may have more cocktails than some and fewer than others. I definitely own more fabulous shoes than anyone needs anywhere, but everyone has to have a hobby. So would my life have been different in Minnesota? I am not picking on Minnesota randomly, by the way. For some reason unknown to me, an inordinate number of optometrists wrote to me from that lovely state, home of my favorite radio program, The Prairie Home Companion. I truly think not. Which brings up the larger question – if we are all really so much the same, which I insist we are, can we not abstain from bashing each other’s choices – be they professional, personal, or political? My advice to the young graduate then is this:
You are embarking on a great career. Keep your sights on one target and one target only: strive for excellence. Excellence in your career, excellence in your business dealings, excellence in your family life. The pursuit of excellence will bring its own rewards. That is what will make you happy, what will keep you satisfied. Where you choose to park your excellent self is immaterial.