Job market in subspecialties

[jasper0asb]

I'll be starting my ophtho residency next year and am consequently starting to think about subspecialties. While it certainly would not be the the only factor in my decision, I really would like to be able to live in an urban area in the future. I understand that the largest cities are quite saturated with Ophthalmologists. Are there certain subspecialties in which it would be easier to get a job in a more sought after location? I've heard that programs are always looking for peds and neuro people because there aren't that many of them out there. Is it then safe to assume that it would be easier to get a job in New York, Chicago, Seattle, Denver, etc if you had done one of these fellowships? I have nothing against small towns and don't mean to offend those who chose to live in one, just not my cup of tea... Any thoughts? Thanks!

---

Members don't see this ad.

 

[JMK2005]

I'll be starting my ophtho residency next year and am consequently starting to think about subspecialties. While it certainly would not be the the only factor in my decision, I really would like to be able to live in an urban area in the future. I understand that the largest cities are quite saturated with Ophthalmologists. Are there certain subspecialties in which it would be easier to get a job in a more sought after location? I've heard that programs are always looking for peds and neuro people because there aren't that many of them out there. Is it then safe to assume that it would be easier to get a job in New York, Chicago, Seattle, Denver, etc if you had done one of these fellowships? I have nothing against small towns and don't mean to offend those who chose to live in one, just not my cup of tea... Any thoughts? Thanks!

Glaucoma, Cornea would be better picks in metropolitan areas where you can incorporate general and subspecialty practice.
Retina and oculoplastics are good choices as well, but you give up general ophthalmology.
Neuro-ophth is time consuming and not very marketable.

 

[wetgangrene]

Glaucoma, Cornea would be better picks in metropolitan areas where you can incorporate general and subspecialty practice.
Retina and oculoplastics are good choices as well, but you give up general ophthalmology.
Neuro-ophth is time consuming and not very marketable.

I don't mean to hijack the thread, as I am actually very interested in hearing more answers as well.

JMK - I definitely understand that retina specialists give up general ophtho, but is it as strictly the case with oculoplastics as well? Is it not possible to personally practice plastics with general? And I'm talking about basically full scope, fellowship trained plastics, not a few blephs in a general practice...

Thanks

 

[dantt]

Glaucoma seems to be a big plus. Cornea not so much. Can anybody else comment otherwise?

 

[Bgladney]

If you are looking for the Major Metros....it really is a crap-shoot right now. Not possible to say what will be needed three years from now.

Jobs in the Metros are almost non-existent. Don't get me wrong....there will be some. The problem is that for every position you apply to, 30 others will also apply. Low volumes and low pay will most likely be the norm.

Working with many candidates who are limiting themselves geographically and are not seeing any options right now.

 

[jasper0asb]

How much of a difference does being willing to take lower paying positions make? While obviously not ideal, my husband is in a lucrative field so I don't really need to make a ton of money. I really do not want to end up living in a rural area. Any one have any other suggestions on how to increase my chances of this?

 

[Dusn]

Being stuck to a certain geographic location starting out is placing yourself in a bad situation. Obviously sometimes you can't help it but, if you can't, then you have to hope that you're lucky.

There may be a group looking to hire in the exact area you're looking at when your finish residency or fellowship or there may not be. It's luck of the draw. Groups that seem to be always looking to hire often have something wrong with them (there's a reason they haven't filled or their new hires seem to be quitting) .

Also when you join a practice, you'll have a non-compete that can be large. So let's say you join a practice in a metro area (and often to do so you'll have to sign a non-compete unless you're in a state that doesn't allow it). Your husband is tied to a job that he can't leave. Your job ends up being miserable and you have to quit or you get fired. Your non-compete may prevent you from practicing in that area again and you need to end your career or hire a really good lawyer.

You have to be much more wary of predatory senior partners when you don't have the luxury of quitting your job and moving elsewhere if you don't like it. They will take advantage of it and offer you a very low salary.

In addition your surgical numbers will be extremely low in metro areas. I've heard of 10 cataracts in a year for starting cornea trained ophthalmologists. Your overhead will be higher. Your patients will be far less grateful, have unreasonable expectations, expect a <5 minute wait time, and will coming to you for a second or third opinion and constantly comparing what you say to what the last ophthalmologist they saw said.

The best fields would probably be glaucoma, peds, uveitis, neuro. But it's all a crapshoot if you're tied to one metro area.

Another option would be to try to get to know your residency attendings really well, do a good job, and try to stay at the same program as faculty or join one of your attendings. You'll have to really impress them. And this is assuming you want to stay in the same place as your residency. People would always rather hire someone that they know -- it's safer.

 

[Bgladney]

@jasper0asb: Finding an opening is going to be the first step.

Easier said than done.

 

[Eyefixer]

@jasper0asb: Finding an opening is going to be the first step.

Easier said than done.

I agree with Bill. As I've mentioned before in my posts, our biggest problem in tight markets is that hospitals and for the most part physician's groups do not need us. As much as other specialties grumble in regards to working for the hospital, these are still opportunities and at the very least they add to the competition for applicants. In LA, for example, your job choices are limited to private practice, Kaiser, VA or academics. Private practices are dying a slow and painful death around here; if you look hard enough, you will probably find a per diem that pays less than $100/hr and come with no benefits and likely no future opportunities. I know a few people who were able to string together 2 or 3 per diem positions into a pseudo-full time; some practices are revolving door always changing associates every 1-2 years (ex: http://ophthjobs.aao.org/jobs#/detail/5237147; this practice has an add up on AAO every 6 months for at least last 5 years); all this is in addition to predatory senior physicians, ever increasing overhead, ever decreasing reimbursement, etc. It is easier to get hit by a lightning then to get a KP position around here; competition is FIERCE. KP now adopted a practice of hiring sub-specialists for comp positions so your subspecialty training is pretty much a waste if you go that route. Academics pays very little and you have to be interested in research; that's not for everyone. I have not seen a VA opening around here in 10 years. So that's it. I don't see this getting any better any time soon.

 

[RestoreSight]

Eyefixer - beyond the excellent observations you made, do you feel some subspecialities have a poorer long term outlook than others in saturated markets? Retina/cornea/plastics in particular?

 

[Eyefixer]

Eyefixer - beyond the excellent observations you made, do you feel some subspecialities have a poorer long term outlook than others in saturated markets? Retina/cornea/plastics in particular?

Retina is in it's own little world. Opportunities are better with retina training, I believe.

Plastics compete with ENT, Plastic surgery, GPs and NPs that are doing fillers but if you are ASOPRS trained your opportunities will be better since there are not that many graduating every year.

Cornea has little advantage in terms of tight market opportunity in private practice. You do have a better opportunity in academics though since you likely won't be hired there if you are comp.

 

[Bgladney]

Retina is in its own world but that does not necessarily make it easier to land something in the Metros. Starting to see many retina surgeons start to worry about reimbursements....especially for injections.

 

[Eyefixer]

Retina is in its own world but that does not necessarily make it easier to land something in the Metros. Starting to see many retina surgeons start to worry about reimbursements....especially for injections.

That has not been my experience around here. Retina practices are growing at a much faster pace then comp practices. Everyone is worried about reimbursements, cataract surgery was already cut as of 1/1/13 by ~10%. That's before 2% recent Medicare cut.

 

[LightBox]

I don't think it's as dismal as everyone says. Though not an ideal job market, there are still opportunities to be had. As everyone says, there are 3 main attributes of an eye job these days: (1) compensation; (2) location; (3) whether your spouse is happy there. It is difficult to get all three!

But my personal opinion is that if you are paid like crap, you won't be happy no matter if you are living in Ibiza. Unless of course your spouse is the main bread-winner anyways.

 

[Adab]

I don't mean to hijack the thread, as I am actually very interested in hearing more answers as well.

JMK - I definitely understand that retina specialists give up general ophtho, but is it as strictly the case with oculoplastics as well? Is it not possible to personally practice plastics with general? And I'm talking about basically full scope, fellowship trained plastics, not a few blephs in a general practice...

Thanks

It depends what you want. Folks doing 1 year non-ASOPRS fellowships can certainly incorporate general ophthalmology into their eyelid, face, and lacrimal practice. Two year ASOPRS individuals can do the same, of course, but the the extra year away from general ophthalmology may significantly decrease the comfort level--though the extra training makes them capable to handle complex orbital pathology. It all depends on what you're comfortable with and how you want to develop your practice. As a side point, as a non-certified subspecialty society, ASOPRS doesn't appear to carry significant weight to patients or professions outside ophthalmology. In the cosmetic realm, the real political battle is plastic surgery vs everyone else. Indeed, a couple years ago a PS society editorial insisted that only plastic surgeons should be doing cosmetic facial surgery, including blepharoplasty (disclosure: this according to an attending of mine--I have not looked for the source).

Hope this helps. The jobs are definitely out there, just realize the "perfect job" doesn't exist. Lowering your expectations is the road to happiness.

 

[ophthope]

As everyone says, there are 3 main attributes of an eye job these days: (1) compensation; (2) location; (3) whether your spouse is happy there. It is difficult to get all three!

But my personal opinion is that if you are paid like crap, you won't be happy no matter if you are living in Ibiza.

1. I'd like to go ahead and put in an advance application to that position in Ibiza.

2. Do you feel like overall it's still pretty easy for a fresh-out-of-residency/fellowship Ophthalmologist to find a good paying job in a suburb or rural area? Just trying to figure out if, outside of Cali and major metro areas the job market is good.

 

[JMK2005]

Doesn't matter what fellowship you do, you can practice general ophthalmology if you want. The difficulty is how you want to market yourself. If they know you do cataracts too, then general ophths are hesistent to send you patients in competitive area. That's the fear anyways.

 

[Eyefixer]

Doesn't matter what fellowship you do, you can practice general ophthalmology if you want. The difficulty is how you want to market yourself. If they know you do cataracts too, then general ophths are hesistent to send you patients in competitive area. That's the fear anyways.

Just out of curiosity, do you know many retina specialists that perform cataract surgery and practice comp?

 

[JMK2005]

I knew of one retina guy who did comp. He practiced in a rural area tho. I aware of another guy who is retina trained, but markets himself as comp.

 

[Eyefixer]

These are very extreme examples likely not applicable to any competitive areas.

 

[JMK2005]

I didn't say it is common.

 

[taehong81]

I agree with Bill. As I've mentioned before in my posts, our biggest problem in tight markets is that hospitals and for the most part physician's groups do not need us. As much as other specialties grumble in regards to working for the hospital, these are still opportunities and at the very least they add to the competition for applicants. In LA, for example, your job choices are limited to private practice, Kaiser, VA or academics. Private practices are dying a slow and painful death around here; if you look hard enough, you will probably find a per diem that pays less than $100/hr and come with no benefits and likely no future opportunities. I know a few people who were able to string together 2 or 3 per diem positions into a pseudo-full time; some practices are revolving door always changing associates every 1-2 years (ex: http://ophthjobs.aao.org/jobs#/detail/5237147; this practice has an add up on AAO every 6 months for at least last 5 years); all this is in addition to predatory senior physicians, ever increasing overhead, ever decreasing reimbursement, etc. It is easier to get hit by a lightning then to get a KP position around here; competition is FIERCE. KP now adopted a practice of hiring sub-specialists for comp positions so your subspecialty training is pretty much a waste if you go that route. Academics pays very little and you have to be interested in research; that’s not for everyone. I have not seen a VA opening around here in 10 years. So that's it. I don't see this getting any better any time soon.

I agree with Eyefixer's statement. For someone that just went through a job search limited to southern california must say that it was pretty tough finding a job. It seems like every open position received tons of application. But I think having a fellowship (cornea, glaucoma, medical retina) does make you more marketable since you can do general ophtho + your subspecialty. Also doing your residency or fellowship in the area of where you want to be does help as you have better opportunity to network. As there are unposted jobs that you find out by word of mouth.

 

[Bgladney]

2. Do you feel like overall it's still pretty easy for a fresh-out-of-residency/fellowship Ophthalmologist to find a good paying job in a suburb or rural area?

There are plenty of opportunities if you are open to smaller communities. Any I define smaller these days as places 250,000 and under.

 

[Bgladney]

Just out of curiosity, do you know many retina specialists that perform cataract surgery and practice comp?

Very very few. It comes down to referrals. A generalist is not going to send you patients if you are doing cataracts.

In the rural rural areas it might be the only way to get by but even then that is extremely rare as you will most likely be as busy as you would like.

 

[Member111111]

This thread is really helpful..so thanks in advance for ur answer..

I am considering glaucoma and uveitis..

what are the job prospects for uveitis? How does anterior vs. posterior uveitis differ in job prospects? Is it better to do a second fellowship in cornea or retina, respectively? Is this a specialty mostly limited to academics or equally represented in private practice?

 

[Eyefixer]

This thread is really helpful..so thanks in advance for ur answer..

I am considering glaucoma and uveitis..

what are the job prospects for uveitis?

If you want to do straight uveitis, you will be limited to academic centers and MAYBE a very large group or two.

How does anterior vs. posterior uveitis differ in job prospects?

Lol. Pretty soon we will have posterior subcapsular cataract physicians vs nuclear sclerotic... Seriosuly though, bad posterior uvieitis usually goes to a retina group to a guy who has done retina AND uveitis training. However, I know a few GOOD uveitis specialists that do all uveitis, anterior and posterior.

Is it better to do a second fellowship in cornea or retina, respectively?

Cornea/uveitis combo is pretty rare. Retina/uveitis is common.

Is this a specialty mostly limited to academics or equally represented in private practice?

See above.

 

[Bgladney]

Don't see much uveitis opportunites out there. It is a bonus for the big practices but not a great demand yet. I am seeing an increase in folks asking about it.

 

[confusedfella]

With regards to the saturation of ophto - I have heard that there is going to be a huge demand of optho in the coming years due to the aging population. So shouldn't it be easy to find jobs in this field?

 

[JMK2005]

With regards to the saturation of ophto - I have heard that there is going to be a huge demand of optho in the coming years due to the aging population. So shouldn't it be easy to find jobs in this field?

demand may be increasing, but not reimbursements. since cataract surgery is elective, it will be lower in the list of priorities.

 

[MullerCell]

I think that demand will likely increase, certainly for subspecialties that see primarily elderly patients like retina. The US population above the age of 65 will double between 2000 and 2030. In addition, 1/3 of physicians are expected to retire by 2020 with recently trained and future physicians likely to work significantly fewer hours during the extent of their practice than MDs trained 30 years ago (more female physicians and more physicians that value work/life balance). However, there are some forces that will likely decrease demand, most importantly the likely changes in physician payment models. If we are in a capitated system, cataract surgery volume will plummet since it is in most cases essentially an elective procedure, and many 20/20-20/30 cataracts are currently being performed. However, other essential treatments will likely increase with an aging population (treatment of retinal diseases, glaucoma, ect).

 

[orbitsurgMD]

The makings of sweatshop practice, courtesy of CMS and the health insurance industry.

 

[dantt]

I think that demand will likely increase, certainly for subspecialties that see primarily elderly patients like retina. The US population above the age of 65 will double between 2000 and 2030. In addition, 1/3 of physicians are expected to retire by 2020 with recently trained and future physicians likely to work significantly fewer hours during the extent of their practice than MDs trained 30 years ago (more female physicians and more physicians that value work/life balance). However, there are some forces that will likely decrease demand, most importantly the likely changes in physician payment models. If we are in a capitated system, cataract surgery volume will plummet since it is in most cases essentially an elective procedure, and many 20/20-20/30 cataracts are currently being performed. However, other essential treatments will likely increase with an aging population (treatment of retinal diseases, glaucoma, ect).

How do surgeons right now manage to get insurance/medicare to pay for 20/20-20/30 cataracts?

 

[ophthope]

How do surgeons right now manage to get insurance/medicare to pay for 20/20-20/30 cataracts?

BAT/glare testing? I always thought it seemed silly too but some people who "see 20/20" on the chart have bad problems with glare. Plus that chart only measures central visual acuity, and if I had a cataract causing issues with my peripheral vision I'm sure I'd want surgery. I don't know how they get them to pay other than showing decreased acuity with glare, but regardless of whether or not they will pay there are plenty of people who see benefit from cataract surgery even if they are "20/30." I just wanted to comment because when I first discovered Ophthalmology I got an uneasy feeling about seeing a 20/30 patient going to the OR, but after asking about it and talking to these patients I understand now. Conversely there are some 20/60 patients who feel like they're totally fine and don't want surgery yet. It's not some scam by greedy eye surgeons. I'm sure that happens in every specialty but in this case there are plenty of legitimate reasons to do the surgery for the patient.

 

[MstaKing10]

perhaps others can comment in more detail but medicare has a "checklist" of criteria that must be met/documented to reimburse for cataract surgery. If these criteria are not met, and a surgeons charts were audited, this could lead to serious ramifications. On the other hand, many patients are now paying out of pocket for premium lenses or all laser cataract surgery, thus, billing through insurance companies may not be necessary (similar to refractive surgery like LASIK or PRK). Of course, the expectations are high and these patients are (rightly so) very demanding.

Back to the OP, with the anticipated shortage of MD's and the ever aging population, do not be overly concerned about job security. You may have to sacrifice a bit (ie. salary) to live in a more desirable location but rest assured there are jobs out there. Other threads have addressed this in the past in more detail.

 

[RestoreSight]

perhaps others can comment in more detail but medicare has a "checklist" of criteria that must be met/documented to reimburse for cataract surgery. If these criteria are not met, and a surgeons charts were audited, this could lead to serious ramifications. On the other hand, many patients are now paying out of pocket for premium lenses or all laser cataract surgery, thus, billing through insurance companies doesn't happen with less strict criteria. Of course, the expectations are high and these patients are (rightly so) very demanding.

Back to the OP, with the anticipated shortage of MD's and the ever aging population, do not be overly concerned about job security. You may have to sacrifice a bit (ie. salary) to live in a more desirable location but rest assured there are jobs out there. Other threads have addressed this in the past in more detail.

Its nice to hear some optimism from time to time.

One thing overlooked in this discussion is "putting in your time" to get ahead in this field. Almost all professions start new hires at a junior level and you are expected to work your way up to a senior level over a number of years. With seniority comes increased pay and control of your time. Obviously medicine is unique in that if you combine premed courses, med school, intern year, residency and fellowship training it takes a long time to even get to the junior level, but that's just how it is. Even in saturated desirable sunny markets you may start out low as a junior, but inevitably opportunities for advancement appear as senior ophthalmologists retire for various reasons, quit, move away and (sadly) pass away. It just requires patience.

 

[glauKomFlecKen]

Just joined SDN, interesting thread. Reimbursements continue to drop for cataract surgery, but can anyone comment on how reimbursements work for premium IOLs? If a patient ops for a toric lens or all laser cataract surgery is it 100% out of pocket or is some of it covered by insurance? What is the comps take home pay compared to a standard medicare reimbursed procedure?

 

[Eyefixer]

Its nice to hear some optimism from time to time.

One thing overlooked in this discussion is "putting in your time" to get ahead in this field. Almost all professions start new hires at a junior level and you are expected to work your way up to a senior level over a number of years. With seniority comes increased pay and control of your time. Obviously medicine is unique in that if you combine premed courses, med school, intern year, residency and fellowship training it takes a long time to even get to the junior level, but that's just how it is. Even in saturated desirable sunny markets you may start out low as a junior, but inevitably opportunities for advancement appear as senior ophthalmologists retire for various reasons, quit, move away and (sadly) pass away. It just requires patience.

Not overlooked at all. Look at my last post. No guarantee in competitive areas that you will be offered partnership at all. Some practices keep hiring new associates every 1-2 years. That's the way they like it. Cheap labor. I sure wouldn't want to continue playing this game when I am >40.

 

[RestoreSight]

Not overlooked at all. Look at my last post. No guarantee in competitive areas that you will be offered partnership at all. Some practices keep hiring new associates every 1-2 years. That's the way they like it. Cheap labor. I sure wouldn't want to continue playing this game when I am >40.

I took this into account before I posted. I haven't yet actively looked for a job, but I have enough friends in the field to know that not all practices are predatory. No one should expect to just walk into a senior position day 1 out of residency. Plus, the option is always available to start your own group practice with like-minded associates looking to avoid predation. It's obviously riskier, but risk equals reward.

 

[Eyefixer]

I took this into account before I posted. I haven't yet actively looked for a job, but I have enough friends in the field to know that not all practices are predatory. No one should expect to just walk into a senior position day 1 out of residency. Plus, the option is always available to start your own group practice with like-minded associates looking to avoid predation. It's obviously riskier, but risk equals reward.

You are right, but please understand that some practices do this by design. Basically, they know you have no chance of becoming a partner even when they promise you gold mountains at the start. They purposely leave partnership clause vague in your contract ("will discuss in 2 years, etc., etc."). If you don't like your initial contract, they just keep going down on their applicant list until someone takes it. In 1-2 years, this junior associate realizes they are getting screwed and leaves. Leather, rinse, repeat.

I would also caution you about starting a practice with another person in a highly competitive area. It is hard enough making one doc busy and profitable off the ground. Two would be progressively worse. Unless your SO is your primary source for income. Then it’s a different story

 

[RestoreSight]

You are right, but please understand that some practices do this by design. Basically, they know you have no chance of becoming a partner even when they promise you gold mountains at the start. They purposely leave partnership clause vague in your contract ("will discuss in 2 years, etc., etc."). If you don't like your initial contract, they just keep going down on their applicant list until someone takes it. In 1-2 years, this junior associate realizes they are getting screwed and leaves. Leather, rinse, repeat.

I would also caution you about starting a practice with another person in a highly competitive area. It is hard enough making one doc busy and profitable off the ground. Two would be progressively worse. Unless your SO is your primary source for income. Then it’s a different story

Haha. I think I should focus more on finding a sugar-mama. That would fix everything.

Is word of mouth or asking for past references the best way to avoid the scenario you outlined above? Are there specific red flags you've come to recognize?

 

[Bgladney]

Ask about past associates and talk with them if you can. Keep in mind that stories have two sides so take what they say with a grain of salt. Now days, with the internet and things, you can see who are the revolving door practices.

Don't forget, in some cases, these revolving door practices are perfect for some. When someone is so focused on being in a location, they might take the position just to be there, knowing they will leave in the future. This "mutual exploitation" sometimes works for both sides.

A vague partnership clause in a contract does to always mean the practice is a predator. Most contracts will outline the timeline when conversations on partnership will start. The vagueness allows both parties to back out of partnership if needed. If you are getting along and doing good work a good practice will offer you partnership.

 

[Eyefixer]

Best jobs are found through word of mouth. If a job is being advertised in a competitive area something is usually wrong but not always.

 

[MstaKing10]

Revolving door practices are usually pretty easy to spot. Contacting those that left is critical in figuring out where things went wrong. There are two sides, but if there is a pattern of hiring new associates every few years, then you as the new associate will likely find yourself in the same situation. Keep in mind that these practice are trying to get as much out of you while putting in very little for your benefit. Thus, in addition to low salary, you will may end up dealing with more call, patients being cherry picked to be lower payers (medicaid or unfunded), getting more complex or difficult patients dumped on you by partners and other such issues.

No hard data to support this, but I have heard that about half (maybe more) of all docs will leave their first job for another. I can't imagine that this would be a mutually beneficial situation unless you were truly looking for a temporary job. If you want to be in the area, then signing a contract with a practice that likely includes a non-compete (most do) would then limit your abilities to work in the area after you left.

Finally, I agree that most contracts are somewhat vague in terms of partnership. But a more concrete metric would be knowing the exact process by which the last few associates later became partners. At the very least, a letter of intent describing how the process of partnership works is useful if for nothing else, for you to know what you are getting into prior to joining the practice.

Ask about past associates and talk with them if you can. Keep in mind that stories have two sides so take what they say with a grain of salt. Now days, with the internet and things, you can see who are the revolving door practices.

Don't forget, in some cases, these revolving door practices are perfect for some. When someone is so focused on being in a location, they might take the position just to be there, knowing they will leave in the future. This "mutual exploitation" sometimes works for both sides.

A vague partnership clause in a contract does to always mean the practice is a predator. Most contracts will outline the timeline when conversations on partnership will start. The vagueness allows both parties to back out of partnership if needed. If you are getting along and doing good work a good practice will offer you partnership.

 

[Bgladney]

but I have heard that about half (maybe more) of all docs will leave their first job for another.

I would venture to say it is closer to 75% leave their first job within 2 years. Some for location and family issues, others due to the practice. Hard to say why this is due to the many different reasons but it is pretty high.

 

[Mirror Form]

Best jobs are found through word of mouth. If a job is being advertised in a competitive area something is usually wrong but not always.

In my job hunting experience, the practices advertising on the AAO's website were generally the most serious ones. Whereas, the ones I heard of via word of mouth were sort of looking but didn't really need anyone in the near future. All the job opportunities I heard of via world of mouth ended up being a complete waste of my time.

 

[orbitsurgMD]

Best jobs are found through word of mouth. If a job is being advertised in a competitive area something is usually wrong but not always.

I guess it depends on the mouth the words come from. Drug reps have a network that sometimes can give you informal leads.

 

[MstaKing10]

In my job hunting experience, the practices advertising on the AAO's website were generally the most serious ones. Whereas, the ones I heard of via word of mouth were sort of looking but didn't really need anyone in the near future. All the job opportunities I heard of via world of mouth ended up being a complete waste of my time.

AAO had solid leads, but also had the most competition and more hit or miss in terms of job/practice quality. I was fortunate enough to have a solid network of attendings that helped in finding some really solid job offers via word of mouth. The practices were definitely looking, not just "seeing what's out there" and all jobs were high quality. I really trusted my attendings and I know they were looking out for me as well so felt more comfortable pursuing those options.

Either way, the more you interview the more you will know what's out there and what you are interested in will become clearer. It goes both ways.