The American Medical Association has tracked practice ownership for more than a decade, and over that stretch the share of physicians who are self-employed fell from 53.2% in 2012 to 44.0% in 2022. Among physicians under 45 it collapsed from 44.3% to 31.7%.

That second figure deserves a second look, because it means fewer than 1 in 3 physicians under 45 owns any part of the practice where they work. An entire generation trained for 12 years, went to work for someone else, and mostly never got the chance to choose otherwise.

The collapse concentrated in exactly the places young ophthalmologists are taught to want, and ownership is still standing in the markets they're taught to dismiss.

Where Ophthalmologists Are Told to Want to Practice

Ask a glaucoma fellow where they intend to practice and you'll hear the same short list of major metros, a list that has been stable for 20 years and has almost nothing to do with medicine. These are the cities where the training programs sit, where classmates settle, and where a spouse can find work without anyone calling it a sacrifice.

What never comes up during fellowship is that every one of those cities has more ophthalmologists who want a seat than there are seats, which means the employer sets the terms because another qualified candidate is already waiting. Ownership never enters the conversation, and from the employer's side it never has to.

Desirability gets priced like anything else, and a city everyone wants has no reason to hand equity to a physician who would move there regardless.

What a Desirable City Costs an Ophthalmologist

Consider 2 glaucoma specialists finishing fellowship in the same June.

The first takes an employed position in a major metro where the compensation package looks strong on paper. The practice is owned by a health system or an investor-backed platform, the schedule is set by administration, and the surgical volume flows through a group that decided years ago how the money moves. She's paid well for the work, builds no equity out of it, and the decisions that determine her working life are made in a room she has never entered.

The second takes over a practice in a metro of under a million people and owns the professional corporation outright, which means she sets the surgical schedule, chooses her own equipment, decides which lenses go on the shelf, and keeps what the practice produces after expenses. 10 years later she owns a business with patients, referral relationships, and cash flow behind it.

One of them has a job that pays well, and the other has an asset that pays her whether or not she's the one in the chair.

Bain's Front Line of Healthcare survey found 81% of physicians in physician-led organizations satisfied with their role in strategic decisions, against 50% in health-system-led organizations. A gap that wide comes down to whether anyone asks your opinion before changing how you practice, which is a separate question from what anyone gets paid.

The Objection Ophthalmologists Actually Raise

Nobody chooses a smaller city for the nightlife, and the reasons physicians give for avoiding secondary markets are real ones. Winters run longer, the restaurant scene is thinner, the airport has fewer nonstops, and your college friends are somewhere else. Those are genuine costs and they deserve a genuine answer rather than a brochure.

The honest answer is that most of what physicians fear about smaller markets turns out to be a comparison problem. A metro of 900,000 people has excellent schools, a real hospital system, a symphony, and a 20 minute commute, which looks disappointing next to Manhattan and extraordinary next to the alternative most physicians actually face, which is a 90 minute commute to a practice they'll never own.

What the Ophthalmology Employment Market Does to Your Leverage

There's a mechanic underneath all of this that explains why the same physician gets treated differently in 2 cities, and it's worth understanding before anyone signs anything.

An employer's willingness to share ownership tracks almost perfectly with how hard the seat is to fill. In a metro where 4 qualified candidates apply for every opening the employer never has to offer equity and won't, while in a market where a search drags on for a year and produces 1 candidate, the employer either offers something meaningful or the seat stays empty and the patients go elsewhere.

The whole mechanism runs on substitutability rather than generosity. A physician in a desirable city is substitutable by definition, because the city itself is doing the recruiting, while a physician willing to practice where recruiting is genuinely hard becomes the scarce input in someone else's business, and scarce inputs set terms.

Most young ophthalmologists only ever negotiate in the first kind of market, so they conclude that ownership isn't offered anymore, when the accurate conclusion is that ownership isn't offered where they're looking.

Educational material only. Figures are illustrative and individual results vary. Images are AI-generated illustrations and don't depict actual Verdira practices, physicians, or patients. See our Disclosures.