It has been two years since I took the mantle at the University of Missouri in Columbia, and during that time our faculty roster only has four of the original clinical faculty I inherited from a starting 11. Faculty left for a myriad of reasons including: spousal job opportunities; death; claims of discrimination; disgruntled they didn’t get the chair; wanting to be closer to extended family; and the chair’s preference that the department move ahead without them. It is difficult to accept faculty reasons for leaving, especially when you were hoping they would stay. However, it also provides an opportunity to create a department with the strengths a good academic department should have, covering all subspecialties within ophthalmology.

Dr. Fraunfelder is adding gray hairs at a rate of about 10 per month.
As of July 2016, we will have 22 clinical faculty and 31 total faculty including PhDs. From the Association of University Professors of Ophthalmology Compensation Survey last published in December 2012, this puts our department at about an average size for all academic ophthalmology departments in the United States (The 50th percentile is 24 clinical faculty and 29 total faculty).

It has been an eye-opening two years; however, I am an old soul in regards to academic medicine. I have been going out to recruiting lunches, dinners and fund-raising activities since I was in junior high school. The Dr. Fraunfelder in many circles is my father, who was chair at the University of Arkansas straight out of fellowship in 1970 and then became chair at Oregon Health & Science University a decade later. One of his enduring legacies is the Casey Eye Institute in Portland, Ore., which now boasts almost 70 faculty and is in the top five nationally in NIH funding. What I learned from him during my formative years got me started on this quest to build a center of excellence in mid-Missouri to serve this region with some of the best eye care in the land.

I wish I could take all the credit for the rapid growth of the Mason Eye Institute here in Columbia. The truth is more complex and could not happen without support from the leadership, especially the medical school dean and the hospital CEO/COO. Investment in ophthalmology growth is not always a priority for many health systems because, at best, we may only represent 2 percent of a total health-system budget. Internal medicine and General Surgery make a much larger financial impact.

What ophthalmology can offer, however, is a large footprint in outpatient care. Because we see so many patients during the day, it is not unusual for an eye department to see more patients than family medicine and internal medicine combined. This leads to internal referrals and development of narrow networks that make the whole health-care enterprise stronger. The offshoot benefit is a key reason why eye departments are so important to academic centers and why satellite hospitals of academic centers frequently include an eye clinic as a service for patients.

From a start date of July 1, 2014, I have interviewed and recruited upwards of 50 candidates across all subspecialties of ophthalmology. The success rate in landing candidates we really want is around 40 percent. They come from all regions of the United States, and the reasons for success and failure are legion. Maybe the candidate loves the beach; perhaps their significant other loves to ski; perchance one of the Kardashians sneezed or the Oprah Winfrey Network went out of business. Sometimes you just can’t tell what makes one person rock and another roll. Still, some overarching truths remain that I have learned through trial and error. From new-chair conferences sponsored by the American Association of Medical Colleges (AAMC) and the AUPO, I knew some of these things. Some issues, though, are a unique knowledge that can only be acquired through spending time, money and effort on recruiting on a daily basis. Times are different now and with time, once-universal truths that are taught in MBA schools and new-chair seminars no longer apply. Here, I want to attempt to share with chairs, faculty, recruits and trainees what is in store for us over the next few years, and to impart whatever shred of wisdom is gained through the experience of being a professional recruiter for ophthalmic faculty.

‘The Hateful Eight’

I have identified eight key elements about recruiting that profoundly affect success and failure. Some may be obvious but others reflect the health-care environment that is shifting underneath our feet with health-care reform, political upheaval and scope-of-practice threats. They are in no particular order, and these are not the only factors. These are simply the most important ones from my point of view:
1.    Spouses
2.    Loyalty
3.    Base salaries
4.    Location and extended family
5.    Ambition
6.    Optometry
7.    Search firms
8.    Curriculum vitae

1. Spouses

When I first started, I knew the significant other/spouse was a key person in recruiting. But lip service and stating this out loud is not enough. This is the number-one issue for failure in recruiting, and I have failed in this area frequently despite my best efforts. The problem is that I cannot find the spouse a job. There is no such thing as a power couple. One could argue the Clintons, but I am sure there could be a debate on that. My experience is that one person is usually a much better candidate and much more qualified for an academic position than his or her significant other.

I’ve failed twice in obtaining a psychiatry residency for spouses, once in pediatrics, once in the music school, and could not get an interventional radiology appointment for the spouse of a pediatric ophthalmologist. I am particularly frustrated in not finding a position within psychiatry because there are eight spots at our medical school, and many of the candidates are not competitive for residencies in other specialties. My worst experience was working with the chair of music, who would not take a previously tenured music professor from another institution on the violin for free (the university would cover a spousal accommodation for two years under a special program).

A stay-at-home spouse, who is caring for the kids, frequently puts his or her foot down at a certain point and says, “I’ve been following your training for four to six years and now I’m going to decide where we live.” Even if the candidate loves the department, sees an excellent future  and believes in the leadership, there is no way to overcome a spousal trump card.

 • Recruiting pearl: Create a separate agenda and visit itinerary for the spouses during the visit. Set up interviews in town in their chosen profession and have them tour the city with a realtor before the couple tours together. Have the spouses meet the principals of the schools; take them to the sports facilities in the areas that their kids excel in; show them the performing arts center for children; have your own spouse visit with their spouse when appropriate. Husbands and wives of department chairs can have a profound influence on whether or not a candidate wants to come to your department and stay in your department. Also, personally take them out to coffee and get to know them. A chaperone in the form of your department administrator or executive assistant is a good idea. In my experience, the spouse can be the key driver and is equally important to the candidate in a successful recruitment. It helps if the spouse is an easily employed superstar, but this is as rare as rocking horse manure.

 Times are different now and with time, once-universal truths that are taught in MBA schools and new-chair seminars no longer apply.
2. Loyalty

The point here is that there is no loyalty. This was a difficult concept to comprehend, and it took some time to understand: Just because I spend a few thousand dollars on the recruitment, have a wonderful dinner, spend hours of my faculty time interviewing, campaign on their behalf with other physicians, and take the risk of trusting them with a job offer, doesn’t mean they are going to reciprocate.

One particularly painful anecdote was the recruitment of a plastics specialist who called me the day after we overnighted an offer and he/she said they are considering going elsewhere (which means it was already decided). I had made sure that ENT, plastic surgery, the emergency department, and our current plastics specialist would allow for things he/she wanted to do and had shared a rough draft offer after verbal commitment to our department. A chair loses a lot of reputation points when he puts that much time and effort and public relations into a candidate who says no thank you without preamble. Everyone in the department felt the betrayal.
What I found over the next two years is that this experience is not uncommon. Fellows whom we supported, candidates that we went out of our way for, friends, former trainees and alumni children frequently feel no loyalty to your department. I have seen candidates come and go that we really wanted who didn’t even send us a thank you note or even give the courtesy of returning a phone call.

 • Recruiting pearl: Grace is not present in all people. Are you born with it? Can you learn it? I don’t know these answers; however, I’ve learned not to take it personally. It is not a reflection on me or my department. The way to deal with this is to be careful in your expectations and do not give a rough-draft offer without serious vetting of a candidate and his intentions. Candidates frequently use your offer letter as ammunition for the job they really want.

3. Base Salaries

It has become a bidding war for the best candidates. Talent has a price and we are not yet at an egalitarian state of health-care training where one corneal surgeon is as good as another. Some specialties are especially hard to recruit, as well. Pediatric ophthalmology, as of this writing, has no fewer than eight academic postings on the AUPO website (

According to the AUPO Compensation Study of December 2012, the average base salary for a pediatric ophthalmologist just out of fellowship is $160,000. An established academic pediatric ophthalmologist can expect to make on average around $264,000 in total compensation. If I want to attract a pediatric ophthalmologist or any top-of-their-profession subspecialist, I will need to meet and exceed the average base salaries that our forefathers offered.
This is one of the great paradoxes of medicine occurring right now. Health-care reimbursements are falling but physician salaries are increasing. The challenge for department chairs going forward is not to hamstring your department with bloated base salaries and allow faculty to earn based on productivity.

 • Recruiting pearl:
Incentivize faculty based on research productivity, teaching acumen, clinical productivity, community service and administrative contributions. Paying incentive on top of base salary is the answer, not large base salaries. If the candidates you are recruiting are who you think they are, there should be no issue in being productive enough to earn benchmark salaries and more. Faculty are motivated to eat what they kill. Allow them that freedom but hold them accountable with a conservative base.

4. Location & Extended Family

This is a battle you cannot win. Sometimes it is the priority of the candidate and sometimes the priority of the spouse. One wonders why they are visiting your department if they are sure they want to live in southern California. Perhaps they are just reinforcing their already-held notion that there is no place like home and Aunt Betty is a must-see weekly. Missouri has a 20-percent lower cost-of-living than New York or California. The homes are more affordable, and the commodities at grocery stores cost less. The property tax is low, and the sales tax is negligible. None of this information matters if you have to see the ocean.

I recently was unable to convince a retina/cornea spouse team to come to our program. I’m sure the cornea specialist wanted to come and the retina specialist didn’t. They were not a power couple and the cornea physician was much preferred. For reasons only known to them and the supernatural, they wanted to move to the rural northwest. It is not satisfying to hear after the fact that they regret their decision. There is no going back and there is no second chance. The decision to enter an academic program is a watershed moment in a candidate’s life. If you turn your back on the offer, it is uncommon to get an opportunity again.

 • Recruiting pearl: Listen, be empathetic, try to reason and, ultimately, don’t expect a win if location or extended family is the driver. All candidates have one or two drivers in their decision process and if this is one of them, there is no arguing. Changing a person’s thought process in a couple days is unusual, if not impossible.

There’s no beach in sight of the Mason Eye Institute, but Columbia’s low cost of living and other enticements have helped fuel the center’s substantial growth in the past two years.
5. Ambition

This noun reminds me of the “greed is good” speech Gordon Gecko made in the movie, “Wall Street.” In my view, ambition is good. Ambition trumps location. Ambition can supersede extended family and spouse. Ambition can even overcome salary expectations. Academic medicine frequently attracts those who aspire to train the next generation, discover cures to eye disease, innovate new treatments and collaborate with clinician scientists across the medical spectrum to improve the care of our population. Many recruits are looking for a career instead of a job. They want their career to be extraordinary. When I meet a candidate who wants to be involved in directing the residency program, lead a service, travel abroad and create a new clinic, or negotiate lots of lab space and protected time for research, I rejoice inside. These are candidates who speak an academic chair’s language. Chairs can control space, funds, protected time and academic appointments. We have less influence on spouses, and we can’t help our location.

 • Recruiting pearl: Recruit for what your department needs. If you need a productive glaucoma surgeon, make sure you vet a productive glaucoma surgeon. Great teachers and lecturers are plentiful within our profession, but they know they are great. Appeal to their ambition to be even greater during the recruitment phase, and your department will benefit. Likewise, if you need an NIH-funded PhD researcher, these candidates are obtainable and will speak a language of space and funding that a chair can comprehend. From my perspective, ambition is the most joyous trait a candidate can have.

6. Optometry

Optometry schools have a glut of providers nationwide. As our eye residencies have remained static, optometry schools have increased and graduates are looking for a job. According to the ophthalmology fellowship match, about 70 percent of graduating ophthalmology residents will obtain a fellowship. This indicates that the general ophthalmologist is a shrinking breed and primary eye-care is increasingly becoming the purview of the optometrist. In addition, scope of practice by ODs is a constant issue and depending on the state you live in, they may already be performing procedures that used to be the privilege of only ophthalmologists.

The implications for an academic eye department is that optometrists will play a key role in primary eye-care going forward. I have found during my recruiting that optometry is an asset in our department and I need to employ at least four ODs to help sustain our primary-care enterprise. Ophthalmologists frequently do not want to see patients outside their subspecialty and even our general ophthalmology faculty resist things at which ODs excel. These include contact lenses, refractions, low vision, pediatric care for amblyopia, diabetic eye exams and general eye exams.

 • Recruiting pearl: Optometry will be a key component of general eye care going forward, therefore recruitment of the best ODs to academic centers is of paramount importance. The creation of OD residencies and OD student rotations within academic centers will help ophthalmology and optometry train excellent providers for the patients we care for. Scope-of-practice issues will not go away, but only by working together can we solve the problems that divide us. There is a place for both types of eye-care providers and the optometrists within academic centers are only too happy to refer the surgical and complicated eye diseases to the ophthalmologist most qualified to care for them.

7. Search Firms

To paraphrase “Jerry Maguire,” recruiting can be an “up-at-dawn, pride-swallowing siege.”
I have been underwhelmed by the help provided by head-hunters or search firms. The professionals at these organizations simply do not know as many people as faculty within an academic department do. They are not networking as much as we do and there is no way a search firm could find a candidate for an academic department as well as a department chair could. The candidates suggested to me by the most reputable search firms are almost always not competitive in the areas that a clinician scientist would be competitive in. In addition, medical professionals speak a language and embrace a culture that is understood between medical personnel. A business like a search firm does not speak this language or understand a medical school culture.

 • Recruiting pearl: Do not bother hiring a search firm. There are great job-listing sites with the American Academy of Ophthalmology, AUPO, the Association for Research in Vision and Ophthalmology and many of the subspecialty Listservs. In addition, discussing vacancies with colleagues across the nation will provide you the information you need in a much better fashion and in a language you understand apart from a search firm.

8. Curriculum Vitae

Candidates are not their CVs. Unfortunately, they are usually much less than their CVs. Of course, there are surprises where the CV is average and the candidate is remarkably talented, but the inverse is usually true. In fact, the more impressive the CV sometimes the less impressive the candidate. Beware of the MD/PhD with grants, multiple publications, local awards, an MBA and considering getting a law degree. Some candidates over-train and this doesn’t show a focus on success but more of a focus on being a professional student. Perhaps this is an instance where ambition turns in on itself and eats the host.
Academic departments look for triple threats; teachers; researchers; and clinicians. Triple threats may have an MD or PhD but what is important is how they work within a team; how candidates interact with patients; how they collaborate with faculty and staff. This data cannot be ascertained on a CV alone.
• Recruiting pearl: Spend hours of faculty time interviewing a candidate over more than just one day. Call the chair of the department where the candidate trained and talk directly to faculty and co-residents/fellows who trained with this candidate. You will be surprised what can be uncovered.

After talking to the residency director of a promising candidate, I learned the candidate had to repeat a year and was just not very good at surgery. After talking to a department chair at another program, I learned a candidate was considered a charlatan and a self-promoter. One cannot garner this information on paper. Information is power; learn everything you can about a candidate. One disruptive faculty member can ruin the morale of an entire department.

Our Legacy

To quote the movie, “Jerry Maguire,” recruiting can be an “up-at-dawn, pride-swallowing siege.” There are many disappointments that will occur during the process but the payoff in the end is to know we are all working together to improve eye care in our community. This is our legacy as ophthalmologists. Recruiting and retaining the smartest, most talented, compassionate and collaborative clinician-scientists leads to this reward.

It has only been two years and I think I’ve added some gray hair at a ratio of about 10 grays per month. With these recruiting pearls in my pocket, however, I believe I will be able to set my expectations at the appropriate level. It is my hope the reader, no matter what stage you are in, will also take these pearls into account as they will help ease the transition from recruit to faculty member. An efficient recruitment allows you to seamlessly start to do what we all want the most. That is to provide the best eye care, discover the cures to ocular disease, and teach the next generation of eye physicians and surgeons. REVIEW