Although your chosen specialty will have a major impact on your paycheck and work-life balance, it’s not the be-all and end-all. The setting you choose to work in, whether it’s academic, community, or private practice, also plays a key role.
But what are the differences between these options, and how do you know which one is best for you?
Defining Academic vs Community vs Private
First, let’s define each kind of practice.
Academic hospitals are affiliated with medical schools or universities, and these hospitals require more from you than just clinical practice. In academic hospitals, you’ll also be spending time teaching students and residents and doing research.
Community practice is much broader. People sometimes use the term “community medicine” interchangeably with private practice, but, in reality, they’re comparing academic and non-academic medicine.
In a community hospital, you’re employed by the hospital and take on a more clinical role. You may or may not have residents, and the majority of your work will be based in the hospital and its affiliated clinics.
Private practice differs from academic and community hospitals in the sense that the hospital does not employ you. Instead, you’re either starting your own practice or joining a pre-existing group, but your practice can still be affiliated with community hospitals.
What are the pros and cons of each practice? Let’s break down the most important factors to consider.
1 | Patient Population
We’ll start with the patient population.
Depending on your practice, there are several differences in the types of patients you’ll see, one of which is patient complexity.
In community medicine or private practice, straightforward cases will be the bread and butter of your specialty. That’s not to say you won’t occasionally see difficult cases, but anything too complex will require more specialized care than what your hospital’s resources have to offer.
This brings us to academic medicine. Complex patients are typically referred to larger academic centers, where hospitals have more advanced diagnostic tools and specialized physicians specifically trained to handle these cases.
The other difference is patient variety.
Academic medicine allows you to focus on a subset of patients. For example, as an academic rheumatologist, you can do most of your research on lupus and tailor your practice toward treating lupus patients. You’ll become the expert at your hospital, and colleagues will start referring their patients to you when more specialized care is needed.
However, this doesn’t mean it will all be lupus; when you’re on service at the hospital, you’ll still see a wider variety of patients.
On the other hand, in community medicine and private practice, you can expect a little bit of everything. The general expectation is that you can confidently treat any disease in your specialty.
2 | Schedule
The next big difference is the typical schedule of each practice.
As an academic physician, your responsibilities extend beyond seeing patients. Another major part of the job is teaching students and residents. Some of your time is also reserved for administrative tasks, especially if you’re involved in a committee or take on a role as a director or chair.
If you’re interested in research, you may have protected time for your studies, but this depends on your career goals and the university’s agreement. Some academic physicians realize they prefer research to patient care and ask for more protected time for their projects.
If you’re employed in a community hospital, most of your time will be spent on clinical work since there’s less teaching and research involved. Even if you decide to work on a committee or take on another administrative role, the majority of your work still revolves around seeing patients.
This may sound ideal if you aren’t particularly enthusiastic about research, but clinical work is more intense than the slower-paced life of academia. Also, in community hospitals, you may not have residents or fellows to help shoulder the clinical burden of admitting patients and writing notes.
Private practice is similar to community hospitals since most of your time is spent seeing patients. However, the time dedicated to administrative tasks may vary depending on your type of practice. If you’re part of a group, there’s less administrative burden on you, but if you’re running a solo practice, you’re running the show. This means more of your time will be dedicated to running your day-to-day operations and administration, such as salaries and budgeting.
3 | Autonomy
Another essential difference between practices is the level of independence and autonomy, which is determined by the nature of your work.
If you’re in academic medicine or a community hospital, you’re most likely employed by the hospital. When you’re in private practice, you’re the boss. Both have their pros and cons.
The pros of private practice include independence, less bureaucracy and politics, and higher pay.
In private practice, you choose how you run your practice—no ifs, ands, or buts. Administrative tasks are also more straightforward. For example, if you need new equipment, there are no hospital guidelines to delay or deny your request. You can order whatever you need. Plus, you don’t have to deal with the politics associated with the admin or hospital committees.
Private practice doctors also make more money than their employed colleagues, which we’ll touch on in a second.
While all of this sounds like a pretty sweet deal, working in private practice is not without its cons, which include increased responsibility and financial risk.
When you’re running your own practice, you’re responsible for building it up from nothing and making it successful. This involves learning how to handle your own billing and marketing, how to properly budget for overhead and staff salaries, and more. There’s also a much larger financial risk involved.
Plus, in private practice, your income is dependent on how much you work. When you have a schedule that doesn’t account for vacations or breaks, you’re likely to see these breaks as missed opportunities to earn more money. This increases your risk of burnout and, ultimately, could lead to a poorer quality of life.
Employed positions, whether in academia or a community hospital, have their pros and cons as well.
The pros of being an employee include a more stable income and less responsibility. While your income as an employee won’t be as high as in private practice, its stability is guaranteed.
Plus, as an employee, you don’t need to be involved in many of the administrative tasks required to run a practice. You also don’t have to worry about marketing or budgeting for salaries, enabling you to focus on your specialty.
While more secure than running your own practice, being an employee is not without its drawbacks. The cons of being an employee include politics, less income, and contract-based employment.
As an employee, you answer to hospital administration, which may mean not getting your way. It’s undeniably frustrating to request new equipment and be denied. You’re also only protected for as long as you’re under contract. When your contract ends, you don’t have any long-term guarantees for what comes next.
4 | Pay
Lastly, let’s talk about the differences in pay.
There are two ways to approach this. Academic vs non-academic, and employed vs private practice.
For academics vs non-academics, physicians in non-academic settings can earn as much as $120,000 more a year than their academic colleagues. This is where relative value units, or RVUs, come into play.
RVUs define the value of a service provided by a doctor relative to all other services and procedures. It’s a complex system that factors in all the various clinical work doctors perform, such as appointments, procedures, consultations, and more. The number of clinical tasks required of a physician impacts how they’re reimbursed. 
Since academic physicians have non-clinical duties, such as teaching and research, they have less time available to provide care for patients, resulting in fewer RVUs. The amount of revenue a doctor generates for their hospital is reflected in their pay. Non-academic physicians have more time in the day for clinical tasks, which generates more RVUs for their hospital or private practice.
Now, let’s look at employed physicians versus doctors in private practice.
Physicians in private practice generally make more money than their employed colleagues. In 2022, self-employed physicians reported average earnings of $385,000, whereas employed physicians reported $320,000.
There’s more than one reason for this salary gap.
The first and most obvious reason is that employees in any business aren’t paid their true value. If businesses, in this case, hospitals, are expected to remain sustainable, then they must pay employees less than their actual value to account for administrative costs, overhead, operations, and profit.
Another reason for this gap is a business owner’s ability to adjust their expenses. If you own your practice, you can increase your revenue by optimizing your medical coding, reducing operating costs, and so on.
But don’t dismiss employment just yet. Many employed positions, especially in academic hospitals, make you eligible for public service loan forgiveness—a program that can help you tackle your student loans.
So, while private practice physicians have more opportunities to make significant bank, being employed could mean more money in your wallet early on.
Locum Tenens
Finally, there is one other option for physicians, known as locum tenens.
Locum tenens is Latin for “holding one’s place.” When you work in locum tenens, you’re basically filling a gap at a hospital.
These jobs are ideal for physicians who value flexibility and want to work for shorter periods, enabling them to discover the kind of work they’d like to continue long-term. These opportunities come with more independence and a more competitive salary, with doctors earning almost $33 an hour more than their full-time colleagues.
However, this job is not without its risks. You’re responsible for managing your own personal finances and benefits, such as retirement and insurance. You also may not find the job you want in your desired location. Although locum tenens positions offer flexibility, you’re limited by the opportunities in your area.
In the end, the choice you make regarding your practice depends on a variety of factors. While not all of them are in your control, you still have a lot of say.
If you enjoy teaching and doing research, you may want to stay in academia after training. If you’re more interested in seeing patients and having a stable lifestyle, a community hospital may be for you. But if you’re a risk taker and want to explore your entrepreneurial side, starting your own private practice is likely a better fit.
If you’re interested in learning how different specialties operate in academic, private practice, and community settings, make sure to check out our So You Want to Be series, which breaks down the many different specialties and career paths in medicine.
If you have a suggestion for a specialty or healthcare career you’d like us to cover, leave a comment below.
