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Finding Happiness and Success Outside the Ivory Tower

November 2004

In an effort to broaden the scope of this column to explore other career options available to pulmonogists, I have begun inviting some guest columnists to write about their real-world experiences out in practice. Many of you may have noticed that we have already had our first guest columnist. Russell Klein (september 2004 Entering Private Practice) finished his fellowship a few years ago to join a practice in Southern California. This month, Christine Fukui, Chief of Pulmonary, Hawaii Permanente Group, graciously shares her experiences working for an HMO.

By Chris Fukui

In an earlier column, readers were given an introduction on starting a private pulmonary practice. Alternatives to this and academic medicine include HMO, military, VA and government careers. I would like to share my experience at a large not-for-profit HMO.

In 1980 I was the only one of seven fellows at my institution to enter non-academic practice. Training in a large medical center prepared graduates for careers in research and teaching, and success was measured in NIH grants and scientific papers. I have found that it is possible to find a rewarding and successful career outside the ivory tower of academic medicine.

The 1970s were a time of idealism and service to your community. Private practice, though potentially lucrative, involved running a business, which medical training did not prepare you for. Sometimes serendipity plays a role in one's career. A desire to return to my island home coincided with an ad for a pulmonologist at an HMO. I seized the opportunity to become the only pulmonologist for a population of 130,000.

When selecting a position, one must consider the opportunities provided. This was an opportunity to build a pulmonary practice and program the way I wanted to, from the ground up. There were new services to start, including a pulmonary function lab, fiberoptic bronchoscopy and a respiratory therapy department. To my amazement, interesting, unusual and challenging patients were plentiful in the world outside of academia. Having patients in the ICU, hospital and clinic all in one building made it easy to leave clinic for a few minutes to check an unstable patient in the hospital.

Salary is only one aspect of a benefit package. In 1980, the starting salary was less than $50,000. Now physician salaries in the group are based on MGMA national norms, and have increased. Salary was not a large factor in my decision and in retrospect this was fine. Other benefits to consider when looking at a position include vacation and educational leave. I value the money and even more the time allocated to continuing medical education. Learning does not stop with fellowship and overhead expenses do not continue while I am away. After seven years, opportunities for a sabbatical are offered. In addition, the group offers profit sharing 401K accounts, pre-tax flexible spending accounts for dependent care and healthcare not covered by insurance (like cosmetic and lasik surgery). The medical group covers malpractice, health and disability insurance. There is even life and long term care insurance provided. All of these factors make a position attractive.

When starting a career, mentoring is very important. An experienced pulmonologist can be very helpful at the start of your career. Although there were no other pulmnologists in the group, there was a wonderful and wise thoracic surgeon who taught me much about the practice of medicine, thoracic surgery, and included me in a world that was dominated by men. Two pulmonologists have joined the group, helping the call schedule as well as adding new expertise to the group, and serving as a sounding board for difficult or interesting patients. Three intensivists trained in pulmonary and critical care medicine helped care for patients in the ICU.

There are teaching opportunities in HMO practice. Medical residents and students do rotations on the pulmonary service, and I enjoy the opportunity to be challenged, to teach and to influence young careers. As the medical director of a community college respiratory care program, I also teach respiratory therapy students.

If one is interested in research, HMOs can provide an excellent patient population for clinical research. We are now involved in a multi-center asthma study. Many other physicians have taken advantage of this "captive" population.

With a secure salary and freedom from billing, collecting and running a business there is time for volunteering. I enjoy working with the local chapter of the American Lung Association and American Thoracic Society. Volunteers are always needed for asthma camp, school asthma programs, testifying at the legislature on pertinent bills etc. Thoracic Society dinner/lecture programs are a source of continuing medical education as well as a chance to see old friends. More recently the local Thoracic Society has organized an annual 4-day conference at a local resort with well-known speakers from around the country. Clinicians can have a voice in the ATS in the Council of Chapter Representatives, of which I am a member. It has been important for me to be in a practice that allows me to pursue other interests while continuing to care for patients.

Being active in the medical group and hospital is rewarding with many opportunities for growth. I participate as a member of the Board of Directors of the medical group. My latest interests are in hospital quality and patient safety.

At the start of my career, I could not have predicted what I am doing today, nor the growth of HMOs in providing care to a significant part of the population. In an HMO, I have found a nice mix of patient care, teaching, as well as opportunities to volunteer and contribute to my medical group and hospital. This type of practice is not for everyone, but it has provided me with a long-satisfying, and, I believe, successful career.